Abstract
Background
Although nutritionally beneficial, honey may harbor Clostridium botulinum spores, posing risks to infant botulism (IB). Infants under one year are vulnerable due to immature gut flora, with IB potentially causing severe symptoms, such as respiratory failure. Despite global awareness, cultural beliefs influenced caregivers’ practices in Palestine. This study evaluated Palestinian parents’ knowledge, beliefs, and feeding practices regarding honey to guide targeted interventions.
Methods
This cross-sectional study (August–September 2024) surveyed 469 Palestinian parents (aged ≥18 years) from 10 West Bank cities, excluding 88 ineligible responses. A validated questionnaire assessed their knowledge, attitudes, and practices. Data were analyzed using the R software (frequency, Chi-squared/Fisher’s tests; p < 0.05).
Results
Most participants were female (89%), under 30 years old (53%), and highly educated (77%). While 58% knew of honey-linked IB, only 32% identified C. botulinum as the causative agent. Notably, 15.8% fed honey to infants aged <12 months and 62.5% introduced complementary feeding at 6–12 months. Age and income-influenced practices, with many believing that honey aids digestion or supplements nutrition.
Conclusions
The findings reveal gaps in knowledge and widespread cultural beliefs about the benefits of honey, which contribute to unsafe feeding practices. Health interventions in Palestine should incorporate these insights to improve awareness and to prevent IB.
Keywords: Honey, infant botulism, West Bank, mothers, Clostridium botulinum
Introduction
Honey, a natural substance known for its nutritional and therapeutic properties, can also contain spores of Clostridium botulinum (C. botulinum), a bacterium that produces botulinum toxin C [1]. Botulinum spores are the main risk factors for infant botulism (IB), as the normal gut flora that can prevent colonization by C. botulinum is not fully developed in infants under one year old, unlike in children over one year old [1–3]. Infant botulism is a term used when a disease affects babies under the age of one. Food-borne botulism results from the consumption of foods that are tainted with botulinum toxin. Wound botulism occurs due to infection of the wound by C. botulinum and the production of toxins at that site [4].
Babies, particularly those younger than one year, can be in danger of botulism if they ingest honey with these spores, causing serious symptoms such as muscle weakness and breathing difficulties that can be life-threatening [5,6]. Constipation is usually the first indication, along with lethargy, difficulty sucking and swallowing, weak crying, hypotonia and general muscle weakness, leading to a floppy appearance. Neurological signs such as drooping eyelids, weakness in eye movement, slow pupil reaction to light, relaxed facial muscles, difficulty swallowing, decreased gag reflex and decreased tone in the anal sphincter may also appear. IB’s severity can range from mild sickness to life-threatening conditions, but the outlook is usually good if hospitalization is prompt due to the gradual onset of the disease [7,8]. To prevent IB, the most effective and currently the only practical measure is to avoid giving honey to infants, a step that both parents and healthcare providers can implement [9].
Despite awareness campaigns highlighting the dangers of feeding honey to infants, caregiver practices still vary widely and are influenced by cultural beliefs and individual perceptions of health risks [10]. This study aims to address the current knowledge gaps by examining how informed Palestinian parents are about the connection between honey and botulism, their views on using traditional honey, and the feeding habits of caregivers. This study aims to aid in creating culturally sensitive public health interventions and educational programs by identifying the factors that impact parents’ choices of infant feeding practices involving honey. It is important to comprehend the cultural beliefs and practices influencing parental views on feeding honey to infants in order to create successful approaches that encourage following international health recommendations, while respecting traditional practices.
This study aims to bridge the divide between worldwide health recommendations and traditional practices, ultimately decreasing instances of IB linked to the consumption of honey in Palestine. Currently, there are no available data on the number of IB cases attributed to honey in Palestine. This absence of information highlights the importance of studies, such as ours, in raising awareness and addressing potential risks associated with honey consumption in infants. The findings of this study, which fill a gap in research on honey consumption awareness for infants less than one year of age in the West Bank, could inform policies and interventions to encourage safer infant feeding practices in diverse cultural regions. This could result in improved child health outcomes and reduced rates of preventable disease.
Methodology
Study design, period and setting
This cross-sectional study targeted Palestinian parents aged >18 years old. Participants were sampled from 10 West Bank cities: Hebron, Jerusalem, Ramallah, Jenin, Tulkarm, Bethlehem, Nablus, Salfit, Qalqilya and Jericho. Data were collected in August and September 2024.
Participants
All participants in this study were Palestinian parents, who residing in the West Bank, who at the time of the research had at least one child older than 12 months old. On the other hand, we excluded the data of parents who did not have at least one child older than 12 months. Accordingly, 88 responses that did not meet the inclusion criteria were excluded.
Research instruments
A total of 469 responses were received after 88 were removed. Alhindi and coworkers agreed to utilize the Arabic and the English versions of the questionnaire in this study [11]. This questionnaire was designed to initially determine the knowledge, attitude and practice (KAP) among mothers on the relationship between honey and botulism in Saudi Arabian infants. The questionnaire was modified to include parents and not only mothers. Participants in the online Arabic version of this study received an introduction explaining the goals of the research, withdrawal process, privacy and data confidentiality. The questionnaire had three primary components.
Demographic section
This section includes the address, age, sex, education level, occupation, monthly income and marital status.
Baby feeding information
This section included a series of inquiries on the duration of breastfeeding, as well as the kind and age of supplemental food introduction.
Attitude, knowledge and practice regarding infant botulism
The name of the causative organism, a few symptoms of honey botulism, and the relationship between honey intake and IB were used to assess paternal knowledge.
Ethics statement
This study was conducted in strict conformity with the Helsinki Declaration. Ref no.: EA/2024/2 was assigned to the study protocol, which was approved by the Ethical Committee of the Institutional Review Board at Palestine Polytechnic University. Participants were given the choice to opt out of participating by selecting the ‘No’ option when they started the online questionnaire and gave informed consent. They were given enough details about the goals and techniques of the research.
Data analysis
All statistical analyses were performed using R Statistical Software (version 4.1.3; R Core Team, 2022) (R Foundation for Statistical Computing, Vienna, Austria). Data were confirmed, coded and input into a personal computer. Frequency and percentage were utilized to show categorical data. Participants in the study were split into two groups depending on whether they provided honey or not, and statistical analysis was carried out using the Chi-squared test and Fisher’s exact test for categorical variables.
We considered a p value <.05 as statistically significant at a 95% confidence level.
Results
Study group characteristics
A total of 469 parents participated in this study. Of the participants, 89% were female, while the majority (53%) were 30-year-old or less. The populations studied were taken from 10 cities in the West Bank: Hebron (23%), Tulkarm (12%), Jerusalem (11%), Salfit (9.6%), Jenin (9.0%), Bethlehem (8.7%), Jericho (8.3%), Ramallah (7.0%), Nablus (6.0%) and Qalqilya (5.1%). A total of 77% of the respondents held a university/postgraduate degree. Seventy-one percent of participants were unemployed. Most study participants (43%) had no monthly income. Table 1 provides further demographic information on the individuals.
Table 1.
The baseline socio-demographic, educational, professional and economic characteristics of the study population.
| Characteristic | N = 469a |
|---|---|
| Age | |
| ≤30 | 250 (53%) |
| >30 | 219 (47%) |
| Gender | |
| Female | 419 (89%) |
| Male | 50 (11%) |
| Marital status | |
| Married | 435 (93%) |
| Divorced | 19 (4.1%) |
| Widowed | 15 (3.2%) |
| Educational level | |
| Preuniversity | 110 (23%) |
| University/postgraduate studies | 359 (77%) |
| Employment | |
| Employed | 137 (29%) |
| Unemployed | 332 (71%) |
| Residence | |
| Bethlehem | 41 (8.7%) |
| Hebron | 110 (23%) |
| Jenin | 42 (9.0%) |
| Jericho | 39 (8.3%) |
| Jerusalem | 51 (11%) |
| Nablus | 28 (6.0%) |
| Qalqilya | 24 (5.1%) |
| Ramallah | 33 (7.0%) |
| Salfit | 45 (9.6%) |
| Tulkarm | 56 (12%) |
| Monthly income | |
| Less than 1880 shekels | 72 (15%) |
| 1880–5000 shekels | 155 (33%) |
| More than 5000 shekels | 42 (9.0%) |
| I do not have a monthly income | 200 (43%) |
| The duration of breastfeeding | |
| Less than a month | 38 (8.1%) |
| 1–3 months | 73 (16%) |
| 4–6 months | 59 (13%) |
| More than 6 months | 280 (60%) |
| No breast feeding | 19 (4.1%) |
| Age of infant (in months) when food was introduced | |
| Before the sixth month | 147 (31.3%) |
| From the age of 6–12 months | 293 (62.5%) |
| After the 12th month | 29 (6.2%) |
n (%).
Knowledge, attitude and practice
Parents’ knowledge regarding infant botulism
More than half of the parents (58%) had heard of IB and 62% knew that honey intake was related to IB. However, 321 participants (68%) were unaware that IB was caused by C. botulinum, as shown in Table 2.
Table 2.
The parents’ knowledge of infant botulism.
| Parents’ knowledge regarding infant botulism | N = 469a |
|---|---|
| Did you ever hear about IB | |
| Yes | 272 (58%) |
| No | 197 (42%) |
| Do you know about honey botulism and its relation to honey | |
| Yes | 293 (62%) |
| No | 176 (38%) |
| Do you Know that IB caused by an organism named Clostridium botulinum | |
| Yes | 148 (32%) |
| No | 321 (68%) |
n (%).
Parents’ knowledge of the symptoms and signs of infant botulism
Abdominal pain was the most frequently reported symptom of IB (n = 155, 20%), followed by nausea/vomiting (n = 138, 17%), diarrhoea (n = 113, 14%), high body temperature (n = 111, 14%), difficulty breathing (n = 83, 11%), difficulty swallowing (n = 52, 6.6%) and skin irritation (n = 73, 9.2%). Constipation (n = 35, 4.4%) and neurological symptoms (n = 30, 3.8%) were the least reported by parents, as shown in Figure 1.
Figure 1.
The parents’ knowledge of the symptoms and signs of infant botulism.
Information source for honey botulism
Parents initially turned to reading and general information (n = 152, 31%) as the main sources of knowledge about the risk of honey botulism. The Internet and social networking sites were the next most common sources (n = 106, 22%). Paediatricians (n = 80, 17%) and family members (n = 67, 14%) were also significant sources of information. On the other hand, scientific studies (n = 47, 9.7%), and friends (n = 32, 6.6%) were the least mentioned sources of information on honey botulism (Figure 2).
Figure 2.
The information sources of honey botulism.
Believes and attitudes
Among those who responded, 305 parents (65%) either disagreed or strongly disagreed that honey is an important food supplement. Similarly, 295 parents (62.9%) disagreed or strongly disagreed that honey could be used to treat gastrointestinal symptoms. Approximately, 52 parents (11.1%) agreed or strongly agreed with the statement that honey is an important food supplement, and 44 parents (9.4%) agreed or strongly agreed that honey could treat symptoms of the gastrointestinal tract. In addition, 112 parents (23.9%) were undecided about honey as a food supplement and 130 (27.7%) were undecided whether honey works to treat gastrointestinal symptoms (Table 3).
Table 3.
The percentage of participants with respect to what they believed in honey.
| Strongly disagree | Disagree | Didn’t know | Agree | Strongly agree | |
|---|---|---|---|---|---|
| I believe honey is an important food supplement, N (%) | 161 (34.3%) | 144 (30.7%) | 112 (23.9%) | 37 (7.9%) | 15 (3.2%) |
| I believe honey treat gastrointestinal symptoms, N (%) | 135 (28.8%) | 160 (34.1%) | 130 (27.7%) | 32 (6.8%) | 12 (2.6%) |
Practice
Feeding honey to infants before 12 months of age
Almost 15.8% stated that they gave honey to their infants before 12 months of age, and most of them gave honey from the 8th to 12th months of their child’s life (35, 47%) (Table 4).
Table 4.
The month of the child’s life when honey or foods containing honey derivatives were provided for the first time.
| The month of the child’s life when honey or foods containing honey derivatives were given for the first time | N = 74a |
|---|---|
| 1–3 months | 10 (14%) |
| 4–7 months | 18 (24%) |
| 8–12 months | 35 (47%) |
| Less than a month | 11 (15%) |
n (%).
Complementary feeding
62.5% of all the parents began giving their child complementary foods at a respective age between 6 and 12 months of their infants.
Factors affecting knowledge, attitude and practice of honey feeding
Effects of parental sociodemographic factors on honey consumption in infants below 12 months of age:
The study identified a statistically significant association between the honey feeding of infants before the age of 12 months and sociodemographic characteristics, such as age groups and monthly income. Sixty-five percent of the 30-year-old age group and 35% above 30 years of age (p = .030) were fed honey to their infants. Parents who said they had a monthly income of less than 1880 shekels or 1880–5000 shekels were more likely to provide honey before 12 months of age (30%) than parents of other financial groups (p < .001) (Table 5).
Table 5.
The sociodemographic characteristics as indicators of the likelihood of giving honey to infants aged less than 12 months.
| Feeding honey before 12 months | |||
|---|---|---|---|
| Yes, N = 74a | No, N = 395a | p Valueb | |
| Age groups | .030 | ||
| ≤30 | 48 (65%) | 202 (51%) | |
| >30 | 26 (35%) | 193 (49%) | |
| Sex | .6 | ||
| Female | 65 (88%) | 354 (90%) | |
| Male | 9 (12%) | 41 (10%) | |
| Address | N/A | ||
| Bethlehem | 1 (1.4%) | 40 (10%) | |
| Hebron | 10 (14%) | 100 (25%) | |
| Jenin | 10 (14%) | 32 (8.1%) | |
| Jericho | 4 (5.4%) | 35 (8.9%) | |
| Jerusalem | 2 (2.7%) | 49 (12%) | |
| Nablus | 5 (6.8%) | 23 (5.8%) | |
| Qalqilya | 6 (8.1%) | 18 (4.6%) | |
| Ramallah | 9 (12%) | 24 (6.1%) | |
| Salfit | 8 (11%) | 37 (9.4%) | |
| Tulkarm | 19 (26%) | 37 (9.4%) | |
| Employment | >.9 | ||
| Employed | 22 (30%) | 115 (29%) | |
| Unemployed | 52 (70%) | 280 (71%) | |
| Education | .3 | ||
| Preuniversity | 21 (28%) | 89 (23%) | |
| University/Postgraduate | 53 (72%) | 306 (77%) | |
| Monthly income | <.001 | ||
| Less than 1880 shekels | 22 (30%) | 50 (13%) | |
| 1880–5000 shekels | 22 (30%) | 133 (34%) | |
| More than 5000 shekels | 9 (12%) | 33 (8.4%) | |
| No monthly income | 21 (28%) | 179 (45%) | |
n (%).
Pearson’s Chi-squared test; Fisher’s exact test.
Effects of parents’ beliefs and understanding regarding giving honey to their infants before the age of 12 months
Of the parents giving honey to infants, 32 (43%) reported high scores for the question ‘I believe honey is a good food supplement’ (p < .001) and 27 (36%) for ‘I believe honey is a good treatment for intestinal symptoms’ (p < .001).
A significant association was found between breastfeeding duration and honey consumption before the age of 12 months. Interestingly, 37 parents who gave honey before 12 months reported breastfeeding for more than 6 months compared with parents with shorter breastfeeding durations. However, no statistically significant association was found regarding the age of complementary food (p = .075) or the status of knowledge of the relationship between honey and IB (p = .059), as shown in Table 6.
Table 6.
Behaviour and knowledge as indicators of the prevalence of honey feeding in infants aged less than 12 months.
| Feeding honey before 12 months | |||
|---|---|---|---|
| Yes, N = 74a | No, N = 395a | p Valueb | |
| Knowing the relation of honey to infant botulism | .059 | ||
| Yes | 39 (53%) | 254 (64%) | |
| No | 35 (47%) | 141 (36%) | |
| Breast feeding | .023 | ||
| Did not receive any | 4 (5.4%) | 15 (3.8%) | |
| <1 month | 4 (5.4%) | 34 (8.6%) | |
| 1–3 months | 11 (15%) | 62 (16%) | |
| 4–6 months | 18 (24%) | 41 (10%) | |
| >6 months | 37 (50%) | 243 (62%) | |
| Age of complementary food | .075 | ||
| <6 months | 20 (27%) | 127 (32%) | |
| 6–12 months | 45 (61%) | 248 (63%) | |
| >12 months | 9 (12%) | 20 (5.1%) | |
| I believe honey is a good food supplement | <.001 | ||
| High scorec | 32 (43%) | 20 (5.1%) | |
| Low scored | 42 (57%) | 375 (95%) | |
| I believe honey is a good treatment for intestinal symptoms | <.001 | ||
| High scorec | 27 (36%) | 17 (4.3%) | |
| Low scored | 47 (64%) | 378 (96%) | |
n (%).
Pearson’s Chi-squared test; Fisher’s exact test.
High score = answered with agree and strongly agree.
Low score = answered with neutral, strongly disagree and disagree.
Discussion
Our study is a cross-sectional study aimed at exploring parents’ knowledge, attitudes and practices in the West Bank regarding honey feeding to their below-12-month-old infants and botulism. The significance of this study lies in the fact that IB is a rare, life-threatening condition that necessitates prompt diagnosis and supportive care, including close monitoring of feeding and breathing requirement [12]. This is particularly important in the context of healthcare challenges in the West Bank, such as delays in accessing hospitals, navigating checkpoints, and financial constraints [13].
During the past century, surveys revealed the presence of C. botulinum in soil and sediments, in addition to food, especially infant foods, including honey, vegetables, fruits and even formula powder [14,15]. However, studies have confirmed that the greatest risk factor for infection with C. botulinum is honey in infants [16], which was identified as a potential source of C. botulinum spores in 1976 when Midura and Arnon described IB for the first time [17].
It is known in our societies that honey is an essential healthy food substance in the treatment and prevention of many diseases, and in fact, its health benefit has been scientifically proven in many studies in treating infections and reducing the risk of cardiovascular diseases by improving lipid profile [18], obesity management [19], glucose tolerance in diabetic patients [20] and many more. In children, in particular, it is mainly used to treat nocturnal cough and urinary tract infections and to improve sleep quality [21–23]. It also has a rule in gastroenteritis treatment by using it as a substitute for glucose in the oral rehydration solution [24].
In this study, over half of the parents (58%) were aware of the risks associated with IB and its connection to honey consumption. This percentage is higher than the findings of a similar study in the Kingdom of Saudi Arabia (KSA), where only 48% of the parents were aware of IB risks [23]. However, it is lower than an Indian study that reported 75% of participants being knowledgeable about IB risks [25]. Only 32% of the participants knew that C. botulinum was the cause of IB, but this was still higher than the KSA study results (6.5%) [23]. Regarding knowledge of IB symptoms and signs, the most commonly known symptoms were abdominal pain and nausea/vomiting (17–20%), followed by diarrhoea, high body temperature, difficulty breathing and skin irritation. However, fewer participants were aware of essential signs such as, difficulty in swallowing, constipation and neurological symptoms (4–6%).
The main sources of IB risk knowledge were the Internet and the reading of general information. Additionally, paediatricians and family members were considered good resources. Most parents had negative beliefs about honey being an important food supplement and useful for treating gastrointestinal symptoms, with only 10% agreeing with this statement. Exploring parents’ attitudes, we found that 62% of the parents started giving complementary feeding to their infants between the 6th and 12th months. Compatible with the recommendations of the World Health Organization [26], only a small percentage (15%) of participants gave their infants honey before 12 months of age. Notably, most of these parents believed that honey is a beneficial food supplement for infants and treats intestinal symptoms, despite the fact that many of them had breastfed their children for over six months. Breastfeeding has previously been considered a risk factor for IB [27]. However, recent studies have found no evidence that C. botulinum can be transmitted through breast milk to infants [7]. Breast milk may help delay C. botulinum colonization by influencing the composition of the gut microbiome. As a result, breastfed infants typically develop symptoms of IB at six months or older [28]. We do not have definite evidence of a link between feeding honey and the breastfeeding period, but we suggest that there are several factors, including believing that honey is a good food supplement and a good treatment for intestinal symptoms, these beliefs come from the customs and traditions of Palestinian society that circulate the benefits of honey from one generation to another and describe it as a treatment for many diseases. In addition to the lack of health education regarding its risks to infants, poor economic situation and honey availability may also contribute to its use as a complementary food. We found an association between feeding infant honey and parents who were unemployed, aged 30 years or younger, and had a family income ranging from 18,800 to 5000 shekels or less.
The prevalence of poverty limits the ability to select healthy choices, particularly as food insecurity increases. In addition, studies found an association between lower-income and delayed complementary food introduction [26]. IB diagnosis requires physical examination and laboratory tests, including blood, urine and stool analysis. The cornerstone of IB management is botulinum antitoxins and supportive care, which requires expensive hospital stays of months for complete recovery [12].
The strengths of our study lie in the validity of the results, as participants were given the freedom to choose whether to take part, and we selected responses only from parents with infants aged 12 months or older. This helped to reduce the percentage of incorrect or unreliable answers. The participants were only required to provide relevant personal information. The significant correlation between parents’ knowledge and beliefs and the practice of feeding honey to infants before 12 months of age demonstrates the consistency of our data.
However, our study has some limitations. It was based on a questionnaire distributed on the Internet, which allowed participants to use online resources to answer questions, particularly those related to their knowledge of symptoms. We were unable to gather data from parents without Internet access, leading to a non-random sample and potential societal bias. The questionnaire focused on past practices, some of which may have been forgotten by the mother, in addition, it relies on self-reported data, introducing potential biases.
Conclusions
This research emphasizes important deficiencies in the understanding and behaviours related to honey intake among Palestinian caregivers, especially in terms of the dangers of IB. Although many parents know about IB being linked to honey, there are still many misunderstandings about what actually causes it. The results highlight how sociodemographic factors affect feeding practices and parental beliefs regarding honey consumption. Culturally sensitive educational interventions are crucial in informing parents about the risks of honey for infants under one year of age in order to improve infant health and safety. To address this, culturally sensitive educational initiatives involving respected figures such as doctors and traditional healers are needed. Workshops in familiar settings and the use of local media can increase awareness. It is important to respect the traditional uses of honey while providing evidence of its risks as well as offering safe and culturally accepted alternatives. Free educational materials and sessions, while considering economic challenges, can improve accessibility. Visual aids and regular feedback from parents can enhance effectiveness, aiming to reduce IB risks by aligning health messages with local customs. By connecting traditional customs with health advice, these initiatives could lower the occurrence of avoidable illnesses, such as IB in Palestine.
Acknowledgements
The authors thank all the collaborators who contributed to this research: Omar H. Salloum, Waed Mohsen, Shahd Rajabi, Izzat Melhem, Nour Qurnah, Raneen Ibraheem Jebreen, Majd Ahmad Alhemony, Masa Salehi and Hiba Abu Aisheh.
Funding Statement
No funding was received for this research.
Author contributions
All authors have read and approved the final work. Bashar Yaser Hasan Awad: conceptualization; writing – original draft; writing – review and editing; investigation; methodology; validation; visualization. Farah Bilal Yousef Shahin: writing – original draft; writing – review and editing. Mohammad Yaser Hasan Awad: writing – original draft; writing – review and editing; investigation; validation. Haya Jebreen Mohammed Warasna: writing – original draft; writing – review and editing; investigation; validation, project administration. Amal Mahfoud: writing – original draft; writing – review and editing; project administration. Afnan W. M. Jobran: writing – original draft; writing – review and editing. Tarek A. Owais: formal analysis; methodology; software; writing – review and editing.
Ethical approval
Ethical approval was obtained from the Palestine Polytechnic University Ethics Committee.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Data availability statement
All data generated or analysed during this study are included in this article. Original data set/raw data are available from the corresponding author on reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
All data generated or analysed during this study are included in this article. Original data set/raw data are available from the corresponding author on reasonable request.