ABSTRACT
Background:
Women are the primary caregivers and cooks in Indian households. Their knowledge of food adulteration determines family health. The study assessed the knowledge of women on commonly adulterated food items available in their kitchens and its associated factors.
Materials and Methods:
A community-based cross-sectional study was conducted among 310 women of Rahi block of Raebareli, India. A 40-item food inventory with their common adulterants was prepared using tool kit modules of the FSSAI. Each correct adulterant identified for a food item was scored one to obtain a cumulative Food Adulterant Identification (FAI) score. The multivariable logistic regression identified the determinants of high FAI.
Results:
The mean age of the women was 37.1 ± 11.7 years. Among 183 study participants, about 59.0% of women had knowledge about food adulteration. Among all the food groups, 288 (92.9%) women knew about adulteration in milk and milk products, 240 (77.4%) knew about adulteration in oils and fats and 230 (74.2%) knew about adulteration in spices. Around 157 (50.7%) and 153 (49.3%) women had low and high FAI scores respectively. The education of secondary-level or higher (AOR 3.4; 95% CI 1.9-6.1), knowledge of food adulteration (AOR 2.2; 95% CI 1.2-4.1), and experience of health issues after consuming food from the market (AOR 2.7; 95% CI 1.3-5.6) were associated with high FAI scores.
Conclusion:
Knowledge about food adulteration in rural India needs to be improved. Prior knowledge about food adulteration and the educational status of women were found to be important determinants for identifying commonly adulterated items.
Keywords: Adulteration, food safety, household products
Introduction
The widespread variations in food consumption patterns among Indian households are reflected in their kitchens.[1] This variation is largely influenced by food production in the region. With a growing population, the demand for food is on the rise. To meet this demand, the food producers often add other substances to the food to increase the overall production.[2] Many producers taking advantage of the situation, add inferior quality and low-cost food for economic gains.[2] This gave rise to food adulteration in the country which compromises the community health. Though the majority of the time, food adulteration is intentional; sometimes unintentional food adulteration does occur.[3]
In many developing countries, including India, the problem of food adulteration is omnipresent. The increasing burden of chronic diseases in urban communities leads to the adoption of healthier lifestyles in the community.[4] This motivates the community to check the nutritional labels of the food products and ensure quality before purchase.[5] The limited access to quality food and a low literacy rate in rural India serves as a platform for the practice of food adulteration to flourish. Most of the food items available in rural areas of the country are produced from unregulated markets, be it milk and milk products, oils, spices, cereals, pulses, etc. These are commonly used and adulterated food items, posing a significant health risk to consumers.[3] The ‘Eat Right’ Toolkit, an initiative of the Food Safety and Standards Authority of India (FSSAI), is a movement to help individuals and families in the community make safe and healthy food choices.[6] Food Adulteration Key Ring, an important component of the “Eat Right” Toolkit, sensitizes the community on detecting food adulteration, especially for those residing in rural areas of the country.
India is one of the most populous countries in the world with more than 60% of the population residing in rural areas.[7] Food is a basic necessity of life. Therefore, addressing the growing threat of food adulteration would primarily safeguard the community’s health. Women are typically the primary caregivers and cooks in Indian households, and their knowledge and awareness of food adulteration are crucial for ensuring the safety and health of their families. There is limited research on the knowledge of women regarding food adulteration in rural areas of India.[8] Therefore, the study aimed to assess the knowledge of women on commonly adulterated food items available in the kitchens in a rural block of the Raebareli district along with determining its associated factors.
Materials and Methods
Study design and study settings
A community-based cross-sectional study was conducted from November 2023 to June 2024 among women residing in villages of the Rahi block of the Raebareli district of Uttar Pradesh. The study participants were women residing in the villages of the study area. The women who refused to consent or were unavailable in the household following two visits were excluded from the study. The study received ethical consideration from the Institute Ethics Committee. A written consent was obtained from the study participants. The confidentiality of the data was ensured.
Sample size and sampling strategy
The sample size was calculated considering the proportion of women having knowledge of food adulteration to be 72%.[5] Assuming an alpha error of 5%, a confidence interval (CI) of 95%, and an absolute error of 5%, the final sample size calculated was approximately 310 study participants. A multistage sampling technique was used for the recruitment of the study participants. In the first stage, 10 villages were randomly selected using the lottery method from the list of villages in the study area. In the second stage, a list of households in each village was obtained from the village health worker, and a total of 31 households with eligible participants were randomly selected. Only one eligible participant from each household was included in the study. For the households with more than one eligible participant, a coin toss was done to select the study participant. None of the participants who were selected through sampling refused to participate.
Study tool
A pre-tested predesigned semi-structured questionnaire was administered to the study participants. The questionnaire was prepared after a thorough review of the literature with expert discussion on food adulteration in the local context. The standard national module and state-level tool kit modules were used for questionnaire preparation.[6,9] The questionnaire consisted of three domains: socio-demographics of the study participants, knowledge of food adulteration, and food adulterant identification domain. The food adulterant identification domain consisted of nine food groups, namely cereals and millets, pulses, milk and milk products, oils and fats, sugar and sugar alternatives, salt, spices, and others. There was a total of 40 food items with their common adulterants listed under these food groups.
The questionnaire in the local language was pre-tested in 30 randomly selected women residing in different blocks of the Raebareli district, Uttar Pradesh, India. In the food adulterant identification domain, a few food items and their respective adulterants were modified because of the non-availability of food items in the area and the difficulty in recognizing the names of adulterants due to regional differences.
Statistical analysis
Data entry was done in Microsoft Excel and analyzed using Stata version 15.0 (College Station, Texas, USA). Descriptive analysis was presented as proportion and mean with standard deviation and median with Interquartile range. Each correct adulterant identified for a food item was scored as one and a cumulative Food Adulterant Identification (FAI) score was calculated. Every study participant obtained an FAI score out of 40. Based on the median FAI scores, the study participants were categorized into high and low FAI scores. The determinants of high FAI scores among study participants were identified by a two-step process. In the first step, univariate logistic regression was done to identify independent variables. In step two, the independent variables identified in step one were put into a multivariable logistic regression model to determine the determinants of high FAI scores among the study participants. The P value of <0.05 was considered significant for the multivariable logistic regression model. The results of logistic regression were presented as Crude Odds Ratio and Adjusted Odds Ratio (AOR) with 95% CI and P value.
Results
The mean age of the women was 37.1 ± 11.7 years, most (91.0%) of them were married. The median family size of these study participants was 6 members. Around 194 (62.6%) of the study participants had received education at or below the primary level and 187 (60.3%) belonged to lower socio-economic status. Only 183 (59.0%) study participants knew about food adulteration. Overall, the knowledge and practices adopted to prevent food adulteration were low among the majority of the study participants [Table 1].
Table 1.
Socio-Demographic Profile and Knowledge of Food Adulteration among Study Participants (n=310)
| Variable | Category | Frequency (%) |
|---|---|---|
|
| ||
| Baseline Characteristics | ||
| Age (in years) | < 35 | 165 (53.2) |
| ≥35 | 145 (46.8) | |
| Education | Illiterate | 91 (29.4) |
| Primary | 103 (33.2) | |
| Secondary | 34 (11.0) | |
| High School | 36 (11.6) | |
| Intermediate | 23 (7.4) | |
| Graduate or above | 23 (7.4) | |
| Marital status | Unmarried/divorced/widow/single | 28 (9.0) |
| Married | 282 (91.0) | |
| No. of family members | <5 | 123 (39.7) |
| ≥5 | 187 (60.3) | |
| Socio-economic status* | Upper class | 4 (1.3) |
| Upper middle class | 8 (2.6) | |
| Middle class | 19 (6.1) | |
| Lower middle class | 92 (29.7) | |
| Lower class | 187 (60.3) | |
| Method adopted to check for the quality of food | Physical appearance and smell | 144 (46.5) |
| Checking expiry date | 134 (43.2) | |
| Never checks | 32 (10.3) | |
| Experience health issues after consuming food from the market | No | 129 (41.6) |
| Yes | 181 (58.4) | |
| Checking food labels before purchasing | No | 305 (98.4) |
| Yes | 5 (1.6) | |
|
| ||
| Food Adulteration aspects | ||
|
| ||
| Source of information on Food adulteration | Never heard | 127 (41.0) |
| Friends and Family | 102 (32.9) | |
| Government sources | 54 (17.4) | |
| Social media | 27 (8.7) | |
| Knowledge about health risks associated with food adulteration | No | 308 (99.4) |
| Yes | 2 (0.6) | |
| Adopted any method to prevent food adulteration during storage | No | 307 (99.0) |
| Yes | 3 (1.0) | |
| Knowledge about the government initiative to prevent food adulteration | No | 171 (55.2) |
| Yes | 139 (44.8) | |
| Attended workshop/awareness campaign on food adulteration | No | 306 (98.7) |
| Yes | 4 (1.3) | |
*Modified BG Prasad socioeconomic scale 2022
Among all the food groups, 288 (92.9%) study participants knew about adulteration in milk and milk products, 240 (77.4%) knew about adulteration in oils and fats and 230 (74.2%) knew about adulteration in spices. Approximately 50% of the study participants were able to identify two food items and their respective adulterants in each of these food groups [Table 2 and Figure 1].
Table 2.
Knowledge of Food Adulteration in Different Food Groups. (n=310)
| Food groups | No. of items included in a food group | Knowledge about adulteration | Food items identified as having adulterants (Mean±SD) |
|---|---|---|---|
| Cereals and millets | 5 | 199 (64.2) | 2.5±1.4 |
| Pulses | 2 | 58 (18.7) | 1.0±0.0 |
| Milk and milk products | 5 | 288 (92.9) | 2.1±1.3 |
| Vegetables | 2 | 138 (44.5) | 1.2±0.4 |
| Oils and Fats | 4 | 240 (77.4) | 2.0±0.8 |
| Sugar and sugar alternatives | 4 | 211 (68.1) | 2.3±0.9 |
| Salt | 2 | 119 (38.4) | 1.3±0.4 |
| Spices | 10 | 230 (74.2) | 2.8±1.8 |
| Others | 6 | 131 (42.3) | 2.0±1.3 |
Figure 1.
Box plot showing food items identified as having adulterants in different food groups
The FAI scores of the study participants ranged from 0 to 37. The median (IQR) score for the study participants was 10 (6,14). Around 157 (50.7%) and 153 (49.3%) study participants were categorized as having low and high FAI scores respectively [Figure 2].
Figure 2.
Distribution of Food Adulterant Identification (FAI) score of study participants
The education of secondary-level or higher was associated with the high FAI score of the study participants with an AOR (95% CI; P value) of 3.4 (1.9-6.1; <0.001). There was a significant association between knowledge of food adulteration and high FAI scores with an AOR (95% CI; P value) of 2.2 (1.2-4.1; 0.01). The study participants who had experienced health issues after consuming food from the market were associated with high FAI scores with an AOR (95% CI; P value) of 2.7 (1.3-5.6; 0.01) [Table 3].
Table 3.
Determinants of High Food Adulterant Identification (FAI) Score among Study Participants (n=310)
| Variables | Category | High FAI | Low FAI | Crude Odds Ratio (95% CI) | P | Adjusted Odds Ratio (95% CI) | P |
|---|---|---|---|---|---|---|---|
| Age (in years) | < 35 | 91 (55.2) | 74 (44.8) | Reference | Reference | ||
| ≥35 | 62 (42.8) | 83 (57.2) | 0.6 (0.4-0.9) | 0.03 | 1.0 (1.0-1.1) | 0.82 | |
| Education | Primary or below | 82 (42.3) | 112 (57.7) | Reference | Reference | ||
| Above primary | 71 (61.2) | 45 (38.8) | 2.2 (1.3-3.5) | 0.001 | 3.4 (1.9-6.1) | 0.001 | |
| Marital status | Unmarried/divorced/widow/single | 15 (53.6) | 13 (46.4) | Reference | |||
| Married | 138 (48.9) | 144 (51.1) | 0.8 (0.4-1.8) | 0.64 | |||
| Number of family members | <5 | 59 (48.0) | 64 (52.0) | Reference | |||
| ≥5 | 94 (50.3) | 93 (49.7) | 1.1 (0.7-1.7) | 0.69 | |||
| Socio-economic status | Lower class | 88 (47.1) | 99 (52.9) | Reference | |||
| Above lower class | 69 (56.1) | 54 (43.9) | 1.4 (0.9-2.1) | 0.29 | |||
| The method adopted to check for the quality of food | Never Checks | 13 (40.6) | 19 (59.4) | Reference | |||
| Physical appearance and smell | 57 (39.6) | 87 (60.4) | 1.8 (1.0-2.7) | 0.28 | |||
| Checking expiry date | 83 (61.9) | 51 (38.1) | 0.4 (0.3-1.7) | 0.22 | |||
| Experience health issues after consuming food from the market | No | 41 (31.8) | 88 (68.2) | Reference | Reference | ||
| Yes | 112 (61.9) | 69 (38.1) | 3.5 (2.2-5.6) | 0.001 | 2.7 (1.3-5.6) | 0.01 | |
| Knowledge of food adulteration | Absent | 43 (33.9) | 84 (66.1) | Reference | Reference | ||
| Present | 110 (60.1) | 73 (39.9) | 2.9 (1.8-4.7) | 0.001 | 2.2 (1.2-4.1) | 0.01 | |
| Knowledge about the government initiative to prevent food adulteration | No | 64 (37.4) | 107 (62.6) | Reference | Reference | ||
| Yes | 89 (64.0) | 50 (36.0) | 3.0 (1.9-4.7) | 0.001 | 0.9 (0.4-1.9) | 0.69 | |
Discussion
The study assessed the knowledge of food adulteration among women of low socio-economic status, residing with larger families in rural areas of the Raebareli district. These women are primary caregivers and play a significant role in making food purchase decisions for their families.[10] The present study reported that almost half of the study participants rely on the appearance and smell of the food items to decide on the quality. A study conducted among Belgian and Romanian consumers also reported the freshness and appearance of the food items were considered for judging their quality.[11] Food adulteration affects the quality. Visual identification of food adulteration is difficult, and quality assessment based on appearance jeopardizes the family’s health.[3] More than half of the study participants in the present study reported having experienced health issues after consuming food from the market. Hence, knowing food adulteration and its identification will ensure positive health.
The present study reported that three-fifths of participants were unaware of food adulteration. In contrast, a study among women residing in Ghana reported that around one-fifth of them did not know about food adulteration.[12] Largely, the participants in the study conducted in Ghana were working women with education above the primary level. A study among Lebanese adults reported low food adulteration scores in more than 70% of the study participants.[13] This score considered the knowledge of participants on how a food item can be adulterated, and knowledge of common adulterants and commonly adulterated food items. The comprehensiveness of knowledge assessment resulted in low scores among these participants. In the present study, the study participants did not know about the health hazards of food adulteration which reflect their poor knowledge. This observed lacuna can be addressed by generating awareness in the community about the health hazards of food adulteration. The government of India by introducing FSSAI-labelled food products and the DART (Detect Adulteration with Rapid Test) eBook, empowers the community to detect adulteration and ensure food safety.[14] The foremost barrier in FSSAI labeling is the consumption of unpackaged food items because of lower prices.[15] In low socio-economic communities, the price of food items affects their food purchase behavior.[16] On the other hand, the awareness and accessibility of DART to low socioeconomic communities is itself a challenge.
The majority of the participants in the present study could identify food items of milk and milk products, spices, and fats and oil food groups that could be adulterated. Similar findings were reported in a study conducted in Ghana. The study reported the common adulterated food items were chili pepper belonging to spices, palm oil, and groundnut paste, belonging to fats and oils.[12] The study in Dhaka reported milk powder, fruits and animal protein were the common food items being adulterated.[17] Globally, adulteration of milk is prevalent and more so in unregulated markets. The milk from Egyptian and Chinese markets reported milk adulteration as high as 90% of the sample surveyed.[18,19] A study conducted in India also reported that only 8% of the packaged milk was free from adulterants.[20] To detect milk adulteration various testing kits were made available in the market to be used domestically.[21,22] In rural India unpackaged milk is consumed largely, and people are aware of water being added as an adulterant in milk.[20] All these factors led to knowledge of adulterants in milk and milk products. India is one of the largest producers and consumers of spices.[23] Powdered forms of spices are adulterated for economic gains. Half of the study participants in the present study could judge the quality of food items by appearance and smell, change in color, and visibility of sawdust/powdered bran, which might help the participants to be aware of adulteration in spices.
The present study reported a strong association between higher education and the ability to identify the common adulterants of food items. The education status of an individual affects his understanding and how he perceives the government initiatives to mitigate food adulteration.[24] A study conducted in urban slums with poor literacy also reported that there was a significant difference in the education status among participants making good and poor-quality food purchases.[8] The quality of purchase was assessed by various factors, one of which was the identification of food adulteration. This study included participants similar to the present study in terms of socioeconomic status and educational status.
The present study reported a significant association between people who have experienced health hazards after consuming food from the market and high FAI scores. The people who suffered health hazards were able to identify a greater number of food items being adulterated. This might be due to health hazards like non-communicable diseases, gastrointestinal tract infections and others caused as a consequence of food adulteration.[2] With the increasing burden of non-communicable diseases and unhealthy diets being one of the major reasons for this rise, there is a need for preventive measures to avoid health hazards in the future.[25]
The strength of the study is the robustness in including around 40 food items commonly available in the kitchens of an Indian household. The selection of the food items included in the tool may vary within India based on the availability of region-specific food items. The findings can only be generalized to women belonging to rural communities.
Conclusion
The knowledge of food adulteration in the low socioeconomic community needs to be improved. Since prior knowledge of food adulteration and education status emerged as important determinants for identifying commonly adulterated items, well-curated awareness programs are necessary for these communities. Promoting higher education will ultimately improve the knowledge for identifying adulterants in food items. The findings of this study will help policymakers, health professionals, and educators about the need for interventions to educate women about adulterants that are present in commonly and frequently consumed food items in households in rural areas. This study indirectly provided insight into the need to conduct awareness programs for rural females for quick and easy methods to detect these common adulterants. Further studies are needed to focus on the ability of these women to detect food adulteration.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
References
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