User experiences with Food Storage in a Meatsafe (Mesh-Covered Food Storage Cabinets) in an Informal Settlement in Dhaka, Bangladesh

User experiences with Food Storage in a Meatsafe (Mesh-Covered Food Storage Cabinets) in an Informal Settlement in Dhaka, Bangladesh | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article User experiences with Food Storage in a Meatsafe (Mesh-Covered Food Storage Cabinets) in an Informal Settlement in Dhaka, Bangladesh Musarrat Jabeen Rahman, Syeda Nurunnahar, Mahbubur Rahman, Laura H. Kwong, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8234271/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 15 You are reading this latest preprint version Abstract Background Food hygiene is a critical but often overlooked link in fecal–oral disease transmission, particularly in dense informal settlements where environmental contamination and food storage constraints heighten risk. A mesh-walled food storage cabinet, or “meatsafe,” was designed to protect food from insects, animals, and young children while allowing ventilation. A parent randomized controlled trial (RCT) in Korail, Dhaka’s largest informal settlement, documented near-universal meatsafe use but no reductions in food contamination or child diarrhea. This qualitative study explored why a widely adopted hardware solution did not achieve expected health impacts. Methods Guided by the Integrated Behavioral Model for Water, Sanitation, and Hygiene (IBM-WASH), we conducted a purposive, theory-driven study embedded within the RCT. Data collection included 21 in-depth interviews with primary caregivers, 684 structured spot checks, and message-recall assessments among 145 participants. Interview transcripts were thematically coded for barriers and organized into contextual, technological, and psychosocial dimensions. Results Multiple barriers constrained effective meatsafe use. Technological issues included unstable frames, weak latches, sharp edges, mesh gaps, and the use of rexine liners that warped with heat. Psychosocial barriers involved concerns that storing hot food would trap steam and cause spoilage, low recall of behavior-change messages, contested childcare authority, and temporary relocations to villages during certain seasons. Contextual barriers reflected shared kitchens, chronic gas shortages, overcrowding, extreme heat and humidity, rapid food spoilage, flooding, and sewage-contaminated water. A critical behavioral gap emerged: households often cooled food uncovered before placing it in the meatsafe, leaving it vulnerable to flies, rodents, and dust. Conclusions High observed use of the meatsafe without corresponding reductions in microbial contamination or child illness underscores the limits of single-technology interventions in resource-constrained urban environments. Sustainable reduction of foodborne enteric disease in informal settlements will require integrated improvements in energy, water, drainage, and pest control, alongside co-designed technologies that address users’ practical, environmental, and behavioral realities. Food hygiene Complementary feeding Diarrheal disease Informal settlements Bangladesh WASH Food storage Qualitative research Behavior change Randomized controlled trial Figures Figure 1 Figure 2 Figure 3 Introduction Food hygiene occupies a pivotal node in the fecal–oral transmission schematic, the F-diagram ( 1 ), yet it received relatively little emphasis in recent WASH interventions ( 2 – 4 ). A growing body of evidence nevertheless underscores its public health relevance. In urban Bangladesh, children whose households left stored food uncovered had 6.16-fold higher odds of diarrhea than those whose food was covered ( 5 ). In rural settings, consumption of food with high fecal bacterial counts elevated the risk of diarrhea within 24 h ( 6 ), and the presence of Escherichia coli ( E.coli) in food doubled the odds of bloody diarrhea ( 7 ). Trials targeting complementary food hygiene have incorporated varying levels of “hardware” and “software” (behavior-change communication, BCC). Banja la Ukhondo in Malawi delivered 33 participatory BCC sessions over 31 weeks, guiding households to fabricate tippy-taps, dish racks, and pot lids; despite providing no hardware, it reduced self-reported diarrhea by 13 percentage points ( 8 , 9 ). A BCC-intensive hygiene intervention based on hazard analysis and critical control point (HACCP) principles in Bamako, Mali promoted handwashing, utensil cleaning, and reheating during daily home visits over four weeks, and achieved significant reductions in fecal coliforms at critical control points ( 10 ). A similar BCC-only trial in low-income neighborhoods of Dhaka, Bangladesh provided four weeks of daily household visits promoting the same food hygiene practices, which virtually eliminated E. coli, Streptococci , and Clostridium perfringens in weaning foods, with effects sustained for three months after the intervention ( 11 ). While interventions that rely primarily on intensive BCC through frequent promoter contact might reduce contamination levels and diarrheal incidences in the short run, these labor-intensive approaches are not scalable or sustainable ( 12 ). Minimal BCC, coupled with hardware support may have potential for sustained habit formation ( 13 , 14 ). Rather than instructing caregivers step by step, such approaches draw on behavioral economics principles of “nudges,” where subtle environmental cues help shape everyday choices. Nudges have proven effective in shifting related practices in other domains: for instance, painted footprints leading to school handwashing stations increased handwashing ( 15 , 16 ), and children served meals on plates printed with dietary guidance made healthier food selections ( 17 ) Formative research in rural Bangladesh revealed that caregivers typically cook once per day, store food for 4–8 hours, and dislike tight lids that trap steam when food is cooling. Many expressed enthusiasm for a meatsafe, a metal mesh-walled cabinet that excludes insects, domestic animals, and probing of stored foods by young children while allowing food to cool; users reported less spoilage and neighbors inquired where they could obtain one ( 18 ). Accordingly, we evaluated the meatsafe in a randomized controlled trial in Korail, Dhaka’s largest informal settlement. Five spot-check rounds over six months documented near-universal meatsafe usage: 88–99% of intervention households stored cooked food in the meatsafe. The proportion of fully covered dishes rose from 67% at the first visit to 88% at the fifth. Nevertheless, the endline assessment detected no reduction in E.coli among foods stored > 4 h, nor in caregiver-reported child diarrhea (Rahman et al., 2024, in prep.). Several possible explanations may explain these null results. To explore these possibilities, the qualitative inquiry probed the barriers that may have constrained the intervention’s potential efficacy and effectiveness. Guided by the IBM-WASH framework, we examined how contextual, technological, and psychosocial factors interacted to limit the meatsafe’s protective impact ( 13 ). We therefore asked why the meatsafe failed to enhance food safety or child health and what barriers, experienced by only a subset of households and not documented or measured in checklist spot-checks, blunted the meatsafe’s impact? METHODS Intervention Description The intervention supplied a low-cost meatsafe plus one 15–20-minute session of BCC at the first post-intervention visit, when the meatsafes were provided to the household. Our theory of change was that giving caregivers a cabinet intended to ventilate steam and keep out flies and simple instructions for use and basic food hygiene should prompt immediate, routine storage of cooked foods, reducing fecal contamination and lowering childhood diarrhea. Two posters accompanied it: one on correct meatsafe use (immediate storage, regular cleaning, and keeping the cabinet dry) and one on general food hygiene behaviors (thorough cooking, handwashing, and boiling water). The general food hygiene recommendations were drawn from an intervention in Nepal ( 19 ), that built on other prior work to identify key points of contamination risk in the domestic food preparation in process in Mali and Bangladesh ( 10 , 11 ). Field staff visited households fortnightly to collect RCT food samples and inspect meatsafe condition. We aligned the qualitative data collection with the parent RCT’s intervention arm’s post-intervention visits (PI-1→PI-5). Study Setting and Participants We collected data from 1 June 2024 to 30 November 2024 in Korail, Dhaka’s largest informal settlement ( 20 ) ( 21 ). The neighborhood is characterized by its mix of corrugated iron shed structures and a few buildings with brick walls ( 22 ). Access to basic water and sanitation services is limited ( 23 , 24 ), while inadequate drainage and the consequent spread of contaminated floodwater and flooding contribute additional contamination risk ( 20 ). Access to natural gas for cooking arrives late at night, so some households purchase firewood or propane for daytime cooking ( 25 ). All participants were prospectively recruited from households in the intervention arm of the parent RCT. Eligibility was restricted to primary caregivers responsible for household food preparation and storage. Sampling Strategy Sampling drew on the parent RCT’s fortnightly spot-checks of intervention households (those provided with meatsafes) across five post-intervention visits (PI-1 to PI-5; n = 684 observations). Using these existing quantitative data, we retrospectively identified households representing a range of storage practices and contamination levels, and then prospectively conducted new qualitative interviews with eligible caregivers. Sixteen households were selected because they displayed clear challenges: they either did not have cooked foods stored in the meatsafe during spot checks, or their meatsafes showed suboptimal cleanliness or functionality, such as visible dirt, broken doors, or screens. In addition, we also selected households with food samples with E. coli counts ≥ 100 colony-forming units per gram (CFU/g), the threshold of high contamination used by the parent RCT. To provide some contrast, we also selected five households that consistently used their meatsafes as intended, storing cooked foods at all visits and showing no recorded functionality or cleanliness issues. In total, 21 in-depth interviews were conducted with primary caregivers responsible for household food preparation and storage. This comparative sample design, contrasting households with persistent contamination and functionality problems against those with consistently safe use, enabled us to examine behavioral, environmental, and contextual factors shaping the effectiveness of the meatsafe. We continued interviews until thematic saturation was reached, with no new major barriers or enablers emerging in the final transcripts. Data Collection and Analysis Qualitative Data Two Bengali-speaking research assistants (RAs) conducted in-home, semi-structured interviews lasting 30–60 minutes. All interviews were audio-recorded with participants’ informed consent, and RAs completed detailed field notes immediately afterward to capture nonverbal cues and contextual observations. The interview guide, refined through pilot testing in two non-intervention households, covered daily cooking and storage routines, perceptions of the meatsafe, and broader food-hygiene practices. Recordings were transcribed verbatim and then translated into English. To ensure fidelity, translations were reviewed by bilingual researchers familiar with the study context. Two coders (MJR and SN) read each interview transcript and coded broadly for barriers, which was iteratively refined to include any kind of negative experience, opinion, or struggle that the respondent mentioned. Coders compared coding decisions and resolved discrepancies through discussion until consensus was reached. We organized coded segments of any expression of a barrier into the contextual, psychosocial, and technological dimensions of the Integrated Behavioral Model for Water, Sanitation, and Hygiene (IBM-WASH) framework ( 13 ) domains. Draft thematic summaries were reviewed in researcher-team meetings to ensure credibility and coherence. Routine debriefs between the field researcher (MJR) and the study supervisor, followed by wider team discussions with implementation staff, helped maintain methodological consistency, curb individual bias, and refine emerging interpretations. The primary field researcher (MJR), who was familiar with the Korail context but external to the community, also maintained reflexive notes throughout the study to reflect on their role and positionality. Throughout, an audit trail logged every coding and thematic decision, providing a transparent foundation for the final account of barriers and enablers to meatsafe use. Ethical Considerations The study was approved by the University of California, Berkeley Committee for Protection of Human Subjects (Protocol #2024-04-17365) and icddr,b Ethical and Research Review Committees (PR-24022). Written informed consent was obtained before each interview using Bengali-language consent forms signed by the participant and counter-signed by the interviewer as witness. All participants were informed of study objectives, potential risks, and their rights to withdraw at any time prior to giving written consent. No minors were included. RESULTS The following themes emerged most prominently in discussions with participants, at times explicitly linked to meatsafe use, and at other times, only indirectly or implicitly connected. We describe the results in this section and draw connections to how it affects meatsafe usage in the Discussion. General Food Handling and Storage Practices Prior to receiving the meatsafe, participants stored food by a variety of methods. Cooked food was often placed on the floor with plastic covers or in jute sacks, stacked on wooden or plastic racks in the corners of rooms. Participants said that when raw fish and other perishables were uncovered, they attracted cats and/or cockroaches. Participants explained that they cook the day’s rice, curries and side dishes in bulk late at night, when gas was available, then consumed portions of the stored food throughout the day, usually without any reheating or briefly warmed on a firewood stove. Families who had purchased firewood sometimes cooked a new pot of rice during the day. After receiving the meatsafe, all households began using it as their primary location to store cooked and uncooked food, and other small items. Generally, the top shelf was used to store suji (semolina for porridge), powdered milk, and sugar, and other personal items such as make-up and stationery. The middle shelf held utensils, while the bottom shelf stored cooked food in sealed aluminum containers. Participants lined the shelves with “rexine”, inexpensive, embossed, PVC-coated fabric (vinyl-like and water-resistant). Technological Dimension Storage Stability and Structural Support The metal meatsafe’s lightweight design, while intended to be portable and adaptable, caused many users to report that it wobbled or shifted, especially when full of heavy items. The meatsafe was not trusted as a stable place to store food. Caregivers explained that they avoided storing heavier items, like pots of rice or daal (lentils), in the meatsafe because of the risk of tipping or spillage. So these were instead placed on the floor or under the bed. Instead, families used the meatsafe only for lightweight items. Most families improvised reinforcement methods, indicating that the current design did not adequately account for the environmental conditions of homes in informal settlements. The most common solution was placing bricks or boards underneath the meatsafe to stabilize it on uneven or damp floors.. As one of the caregivers said, We put bricks underneath, otherwise it shakes. The floor isn’t level, and when you open the door, it can tip forward. Many felt that a heavier, sturdier base would have made the product more suitable for their environment, dependable, and convenient. Latch Weakness and Structural Gaps The spot-checks results showed that meatsafe doors achieved high functionality, with the proportion closing well 86.8% at PI-1 and 99% at PI-5. Furthermore, 99.3% of screens had no holes across all five post-intervention visits. However, a few households complained that the latch system was too small, poorly installed, or broke easily. Even when the latch did hold the doors closed, there would still be a 2–3 finger-wide gap between the doors through which pests, particularly cockroaches could enter the meatsafe. As two caregivers shared, ….there’s no proper latch. Cockroaches or rats still can get in. Even if it’s latched, there are gaps. That’s why we can’t store hot food either. My husband tried to tape some parts inside to make it tighter, but still, there’s a gap. Cockroaches sneak in at night. It would be better if it had a bigger, stronger latch… something that locked properly. Some households attempted to reinforce the latch with tape, and many participants tried to close these gaps with cloth, but these makeshift solutions were not durable. Another repeated concern was that children could tamper with the latch or open the meatsafe unsupervised, scattering items or leaving the food vulnerable to flies. Mothers expressed a need for stronger, child-resistant closures. As one of the caregivers explained, My child opens the meatsafe... I tell him not to touch it, but he plays with the latch. If it had a lock or stronger closure, it would be better. Participants shared that they preferred sturdy steel cabinets with higher-quality meatsafes with stronger frames and better latches. Size and Multi-Use Storage Needs The meatsafe was intended to store a day’s worth of cooked food. However, participants’ storage needs were far more diverse. Households often placed biscuits, raw vegetables, powdered milk, spices, oil bottles and utensils in the meatsafe to protect them from pests. A mother of two explained: We store many things in the same space, biscuits, onions, dry food, children’s chips. But we can’t fit everything. If it were bigger, we could keep large cooking pots inside, too. Some households repurposed the meatsafe entirely, storing non-food items such as clothes, cosmetics, medicines, or baby supplies (Fig. 1). Participants reported that they often placed washed utensils inside the meatsafe while still wet. However, they expressed concern that this practice might damage the meatsafe, as the limited airflow created a damp environment and led to moisture accumulation inside. Frequent Cleaning but Persistent Dust Overall cleanliness was strong, with 77.7% of meatsafes rated “very clean,” though this dipped to 66.4% at PI-2 before rising to 84.2% by PI-5 (Table 1). Many caregivers covered the top of the meatsafe with rexine or old clothes (Fig. 2) or made active efforts to clean the meatsafe every few days. However, the neighborhood’s dusty environment, combined with the device’s sharp edges and difficult-to-clean corners, made complete cleanliness unattainable. Reflecting a common concern among participants, one of the caregivers noted, When we wipe it, our hands get cut from the edges. Dirt gets stuck in the corners. If we had a smoother, sturdier rack, it would help… Even after cleaning, dust collects again. Missing Liners and Improvised Solutions Since the meatsafe shelves did not come with a liner, participants initially lined the shelves with newspaper but after they realized that the newspaper would easily tear or get wet they switched to liners of old cotton or chiffon scarves. As one of the caregivers said, The paper liner tears when it gets wet. Then cockroaches come. So, I use cloth instead. I cut up my orna [traditional woman’s scarf] and put it on the shelves. Many respondents also reported lining the shelves of the meatsafes with rexine (plastic-coated fabric) as a superior alternative, citing its reusability, ease of cleaning, and durability. However, many participants were concerned that hot pots could cause the rexine to melt or warp (Fig. 3), meaning they were hesitant to follow the recommended practice of storing food in the meatsafe immediately after it was cooked. This cooling period then would be high-risk, since food that was not fully covered remained exposed to flies, dust, and pests. If it were made of stronger material, I could store hot food without the rexine. Now, I have to let it cool for 7–8 minutes before putting it in. By then, flies might land on it. So, we place the food down on the floor and wait. When the pot cools down a bit, then we put it inside the meatsafe. Psychosocial Dimension Mental Models of Steam and Food Spoilage In the BCC poster on meatsafe use, we advised caregivers to cover cooked food immediately and place it in the meatsafe. However, nearly all participants reported deliberately delaying covering food and putting it in the meatsafe, citing concerns about trapped steam causing food to spoil faster. Two mothers explained: If we touch the container and it is still warm, then storing it then will cause it to spoil. And so, we let the food cool down first. Then we store it, so it stays good. Because if you cover it immediately while it’s hot, moisture collects inside. That’s why I let it cool down a bit first. Then I cover it or store it. Otherwise, the rice turns yellow and sour. Caregivers also noted that condensation formed on the rexine, causing dust to stick to the liner and supporting concerns about hot food storage leading to mold. Temporary Relocation to Natal Villages Some caregivers chose to temporarily relocate to their natal villages during the hot and rainy seasons, when the experienced fevers, colds, and diarrhea to be most common, fuel was in short supply, and flooding was common. Rural settings were viewed as more conducive to recovery, not only due to perceived cleaner air and fewer pests, but also due to stronger family caregiving support and familiarity with local health providers. One participant reflected: Maybe there are some inconveniences during the rainy season here. But in the village, the cool breeze and calm nature make everything feel peaceful. In winter, we can walk around and spend time outdoors, and that keeps us healthy. Our children got sick once in Dhaka, and it was hard to manage. That’s when we felt village life was better. Another shared how extreme weather compounded the difficulty of caregiving in Dhaka: Rainy days bring a different challenge, if it rains heavily in Dhaka, cooking becomes difficult. Water enters the kitchen and makes everything harder. After cooking, cleaning becomes an even bigger burden. Many people live in Dhaka, but when someone gets sick, they go back to the village. Navigating Blame and Vulnerability in Shared Care and Social Pressure While contaminated food, unwashed hands, and open storage were acknowledged as risks for children’s diarrhea, many participants also emphasized prenatal malnutrition, seasonal transitions, and contact with sick peers as contributors to children’s recurring illnesses, especially diarrhea, colds, and weakness: Sometimes the child eats with dirty hands or from the floor. Sometimes it's food left open, or baby food not covered. But also, my child was weak from birth, maybe from what I ate while pregnant. Mothers also cited community exposure from other children, and they tried taking steps to limit the amount of time children play with other children, only to face pushback from grandparents or neighbors. As one mother explained: I try to keep him away from others when they’re sick, but my in-laws say let him play. They feel bad when the child cries. Then I get blamed for being too harsh. Contextual Dimension Fuel Scarcity and Crowded Housing Participants repeatedly emphasized how gas shortages, shared stoves, and minimal living space interfered with adhering to recommended food hygiene practices such as reheating food before serving, boiling water to make it safe for drinking, and properly cleaning cooking utensils. With five to eight families sharing a single stove that received gas for only six hours late at night, households had a narrow window to cook. Families may purchase firewood to in the face of inconsistent gas supply, but they find both gas and firewood to be unaffordable. Caregivers reported being unable to often reheat leftovers or boil water during the day. A 38-year-old mother explained: Seven to eight families share one gas stove. There’s no fixed turn, and often no gas at all. We can’t reheat food. We have to feed our children stale food. Leftover meals were typically stored for hours and consumed without reheating even though mothers understood that reheating would help kill pathogens. As one mother of two children described: If there’s no gas, we can’t cook again. The children cry from hunger, but we have to feed them whatever food is left. Sometimes I buy biscuits, but if there’s no money, they eat stale rice. Furthermore, caregivers could not reliably boil water to ensure its safety. One grandmother noted: Even if I want to boil water for tea or warm the leftover rice, I cannot. The stove has to serve many families. By the time it’s my turn, I’ve already missed the time when the children need to eat or drink. High population density throughout the settlement exacerbated exposure to dust, garbage, and pests in the immediate environment. Families described cockroaches, flies, and rodents crawling over floors, stoves, and uncovered food throughout their neighborhood, not just inside their homes or around the meatsafe. As a 22-year-old mother explained: We live among so many people that dust keeps accumulating all around us. We try to sweep and wipe surfaces, but it’s not always possible. We don’t always have gas to boil water. It’s difficult to follow all the guidelines. Although many participants appreciated the meatsafe for limiting exposure to flying insects and rodents, ants and small cockroaches could still enter through the mesh and other small pests could enter when caregivers opened the meatsafe doors. A few users reported using pesticide in the meatsafe. One explained by saying, No insects were in the food, but we saw small ones inside the meatsafe. We used spray once, and now we clean more often. Seasonal barriers During summer seasons, temperatures and humidity accelerated spoilage of both cooked food and raw ingredients like soaked lentils and chopped vegetables. Several caregivers mentioned that food, especially milk or rice, would be sour by midday if cooked the prior night. One mother described: Because of the heat, food spoils quickly. Sometimes we can’t even eat it. The children fall sick. If we had a sturdier meatsafe, maybe we could store food better in the summer. Women explained that during the monsoon season crossing their flooded courtyard to reach shared cooking areas required them to wade through floodwater contaminated with sewage, making access slow and hazardous but not preventing it entirely. Caregivers still used the kitchens when necessary, though they often reduced trips by cooking larger batches at once and then relying on stored food without reheating. This coping strategy lengthened storage duration and increased risk of spoilage. Several caregivers reported that water also flooded their homes, contaminating cooking spaces and soaking stored firewood and clothes. One young mother described: Recent rainfall may have occurred, causing water to accumulate on the roads in this area. While water does not enter the house, it creates significant issues on the roads, restricting movement. Access to the kitchen becomes difficult, and food storage becomes challenging under these conditions. In many cases, caregivers resorted to “batch” during breaks in rainfall, preparing large quantities of food for multiple meals. But this prolonged storage duration also means increased food hygiene risk. Caregivers reported placing utensils, such as the boti (a curved blade for chopping that is held in place on the floor by a foot), and the meatsafe on bricks or wood planks to keep them dry. However, these improvised measures only offered partial protection. Elevating items on bricks or planks reduced direct water contact but did not prevent contamination from dirty floodwater splashing onto surfaces, nor from pests climbing up. As a result, utensils and stored food still carried heightened risk of microbial exposure. Pests like flies, mosquitoes, and rats were especially likely to enter the house when it was flooded outside. As one mother explained: When it rains, rats come in to escape the water outside. They scurry around the floor, trying to get near food. Even if we put the rack on top of bricks, rats sometimes climb up. DISCUSSION The parent RCT showed near-universal use and routine maintenance of the meatsafe, yet no measurable reductions in food contamination or caregiver-reported child diarrhea. While spot checks documented impressive usage metrics, with households consistently storing food in the meatsafe and maintaining cleanliness, our qualitative interviews exposed a critical behavioral gap invisible to quantitative spot check observations monitoring: any storage in the meatsafe vs. immediate storage in the meatsafe. ‘Use’ in our spot-check data refers only to food observed in the meatsafe at the time of the visit, and does not necessarily indicate that food had been placed inside immediately after cooking or that it was allowed to cool outside before being placed inside the meatsafe. Our BCC messaging emphasized immediate storage and food covering but could not ethically advise storing uncovered food inside the meatsafe, given the absence of specific evidence that keeping food uncovered inside the meatsafe would provide the same protection as covering foods with tight-fitting lids ( 26 ). Qualitative findings shed light on the technological, psychosocial, and contextual constraints that may have blunted the meatsafe’s effectiveness and help explain the paradox of high use without corresponding health benefit. Since caregivers refused to cover food when hot due to concerns that condensation induces spoilage, they continued to cool food uncovered, creating the same opportunity for contamination that exists in households without meatsafes. A combination of technological, psychosocial, and contextual factors undermined immediate storage of freshly cooked hot foods in the meatsafe, despite consistent meatsafe use. Technological issues such as unstable frames, weak latches, sharp corners, mesh gaps, and concerns about liners were frequently noted. Psychosocial barriers included steam-spoilage fears, low recall of BCC messages, contested childcare authority, and seasonal relocations that disrupted consistent use. Contextual barriers reflected the broader living environment in Korail, including shared kitchens and stoves, chronic gas outages, batch cooking, overcrowding, extreme heat and humidity, rapid food spoilage, flooding, and sewage-contaminated water. Together, these technological, psychosocial, and contextual constraints influenced both how households used the meatsafe and the conditions under which stored food remained vulnerable. We attempted to study the effectiveness of the meatsafe without first being sure of its efficacy. In addition, we only followed up on meatsafe usage a few months after installation; a longer time horizon might capture further adaptation, or abandonment, of the device. The BCC package also never directly confronted local understandings of how trapped steam induces spoilage of foods; lacking empirical evidence that placing hot food immediately in the meatsafe is safe, we were ethically unable to endorse that practice. In prior studies, extensive formative research allowed time to modify and upgrade the technology of interest ( 27 – 29 ). In our case, we relied on a locally available free-market product and assumed quality. Our evaluation assumed meatsafe effectiveness without first confirming its efficacy. That is, we assessed real-world usage before demonstrating whether the device could reduce contamination under controlled conditions. Future trials should consider lab-based efficacy testing before scale-up. Incremental upgrades, steel frame, child-proof bolt, metal shelves, could boost durability and ease of cleaning but cannot overcome structural and behavioral constraints. Design revisions, smooth, rounded interiors, detachable trays, heat-tolerant liners, would simplify cleaning and reduce warping concerns. BCC should directly engage caregivers’ concerns Persistent external contamination threats—flies, rodents, dust, sewage, and floodwater—likely overwhelmed the meatsafe’s protective function, while contextual pressures such as shared kitchens, chronic gas outages, overcrowding, extreme heat and humidity, rapid spoilage, and reliance on batch cooking further shaped its use and caregivers’ sense of self-efficacy. Mothers described frustration, blame, and limited decision-making power; some noted that in-laws overruled their efforts to limit children’s exposure or scolded them for being “too harsh,” highlighting contested childcare authority. These accounts, though not a systematic measure of agency, show how constrained authority eroded confidence and consistency in protective routines. In communal childcare contexts, such social frictions—combined with the perception that food hygiene was only one of many diarrheal risks—further diluted motivation to prioritize it. Periodic relocation to natal villages also disrupted the repetition and stable environmental cues required for habit formation, which depends on consistent practice in stable settings ( 14 , 30 , 31 ). Limitations It is also important to note a methodological limitation of this qualitative inquiry. Because the interviews were designed to probe barriers, our results disproportionately reflect constraints raised by a subset of respondents, many of whom faced difficulties that were not universally experienced. In practice, the findings presented in this paper represent an intentionally expansive mapping of possible mechanisms and bottlenecks, rather than a quantification of their prevalence. Indeed, quantitative spot checks consistently documented high uptake and visible maintenance of the meatsafe, suggesting that these barriers, while real and important, did not prevent most households from using the device. Future mixed-methods research should more carefully integrate qualitative probing of barriers with quantitative measures of frequency and magnitude, to better distinguish between rare but plausible risks and widespread obstacles to sustained use. Conclusion Echoing the sobering results of recent WASH megatrials, our study underscores that neither hardware nor minimal behavior-change communication on its own is sufficient to solve microbial risk. The meatsafe offered partial protection from flies, rodents, and visible dust contamination but could not overcome the entrenched challenges of poverty, crowding, fuel scarcity, and shared caregiving dynamics that contributed to persistent exposure to fecal pathogens and ongoing risk of diarrheal disease . Importantly, even large WASH megatrials that combined hardware provision (latrines, handwashing stations, safe water storage) with intensive promotion of handwashing, safe feces disposal, and water treatment demonstrated little impact on child growth or diarrhea (Luby et al. 2018; Null et al. 2018; Humphrey et al. 2019). These results indicate that our findings are not a matter of “hardware only” design but instead highlight the limits of household-level interventions, even when paired with behavior-change encouragement. In our trial, as in those megatrials, persistent environmental contamination and structural barriers likely overwhelmed the partial protection that individual devices could offer. To meaningfully reduce foodborne enteric disease in urban Bangladesh, interventions must build on systemic investments in energy, water, drainage, and pest control. Future research should co-design alternative technologies that address both microbial and practical challenges: solar-powered fridges using thermal mass, solar-assisted warming trays with phase-change salts, or hybrid solar-LPG cookers that lower fuel costs. Modular solar micro-grids already piloted in urban slums enable communal refrigeration and lighting; pay-as-you-go solar kits offer scalable household energy. Such transformative options merit testing where simple racks cannot meet microbial safety thresholds. Abbreviations • BCC Behavior Change Communication • cfu/g Colony Forming Units per gram • F diagram–Fecal–oral transmission diagram • HACCP Hazard Analysis and Critical Control Point • IBM WASH–Integrated Behavioral Model for Water, Sanitation, and Hygiene • icddr,b International Centre for Diarrhoeal Disease Research, Bangladesh • PI 1 to PI–5–Post–Intervention visits 1 through 5 • PVC Polyvinyl Chloride • RA Research Assistant • RCT Randomized Controlled Trial • RGHI Reckitt Global Hygiene Institute • SDG Sustainable Development Goal • WASH Water, Sanitation, and Hygiene Declarations Ethics approval and consent to participate This study was approved by the University of California, Berkeley Committee for Protection of Human Subjects (Protocol #2024-04-17365) and the Ethical and Research Review Committees of icddr,b (PR-24022). All participants provided written informed consent prior to participation. Clinical trial number: not applicable. Consent for publication Not applicable. No identifying personal data, images, or videos are included in this manuscript. Availability of data and materials The qualitative transcripts generated during this study and analyzed to support the conclusions of this article are not publicly available due to concerns regarding participant confidentiality in a dense informal settlement context, but de-identified excerpts are included within the article. Additional data may be made available from the corresponding author upon reasonable request. Competing interests The authors declare that they have no competing interests. Funding This study was supported by the Reckitt Global Hygiene Institute (RGHI) under grant number 092000310-UCB-0310. The funder had no role in the study design, data collection, analysis, interpretation of data, decision to publish, or preparation of the manuscript. Authors’ contributions MJR conceptualized the study, oversaw data collection, and drafted the manuscript. SN contributed to data coding and analysis. MR supervised field activities and provided input on study design. LHK contributed to methodological development and interpretation of findings. PJW provided overall supervision, contributed to conceptual framing, and critically reviewed the manuscript. All authors read and approved the final manuscript. Acknowledgements The authors thank the field research assistants, the participating households in Korail, and colleagues at icddr,b for their collaboration and support. Authors’ information MJR is a PhD graduate in International Health from the Johns Hopkins Bloomberg School of Public Health, specializing in social and behavioral interventions in low-resource urban settings. References Wagner EG, Lanoix JN. Excreta disposal for rural areas and small communities. 1958. Humphrey JH, Mbuya MNN, Ntozini R, Moulton LH, Stoltzfus RJ, Tavengwa NV, et al. Independent and combined effects of improved water, sanitation, and hygiene, and improved complementary feeding, on child stunting and anaemia in rural Zimbabwe: a cluster-randomised trial. Lancet Glob Health. 2019;7(1):e132-e47. Knee J, Sumner T, Adriano Z, Anderson C, Bush F, Capone D, et al. Effects of an urban sanitation intervention on childhood enteric infection and diarrhea in Maputo, Mozambique: A controlled before-and-after trial. Elife. 2021;10. Luby SP, Rahman M, Arnold BF, Unicomb L, Ashraf S, Winch PJ, et al. Effects of water quality, sanitation, handwashing, and nutritional interventions on diarrhoea and child growth in rural Bangladesh: a cluster randomised controlled trial. Lancet Glob Health. 2018;6(3):e302-e15. Uddin IM, Endres K, Parvin T, Bhuyian MSI, Zohura F, Masud J, et al. Food Hygiene and Fecal Contamination on the Household Compound are Associated with Increased Pediatric Diarrhea in Urban Bangladesh (CHoBI7 Program). Am J Trop Med Hyg. 2023;108(3):524-9. Islam MA, Ahmed T, Faruque AS, Rahman S, Das SK, Ahmed D, et al. Microbiological quality of complementary foods and its association with diarrhoeal morbidity and nutritional status of Bangladeshi children. Eur J Clin Nutr. 2012;66(11):1242-6. Pickering AJ, Ercumen A, Arnold BF, Kwong LH, Parvez SM, Alam M, et al. Fecal Indicator Bacteria along Multiple Environmental Transmission Pathways (Water, Hands, Food, Soil, Flies) and Subsequent Child Diarrhea in Rural Bangladesh. Environ Sci Technol. 2018;52(14):7928-36. Chidziwisano K, Tilley E, Malolo R, Kumwenda S, Musaya J, Morse T. Risk Factors Associated with Feeding Children under 2 Years in Rural Malawi-A Formative Study. Int J Environ Res Public Health. 2019;16(12). Morse T, Tilley E, Chidziwisano K, Malolo R, Musaya J. Health Outcomes of an Integrated Behaviour-Centred Water, Sanitation, Hygiene and Food Safety Intervention-A Randomised before and after Trial. Int J Environ Res Public Health. 2020;17(8). Touré O, Coulibaly S, Arby A, Maiga F, Cairncross S. Improving microbiological food safety in peri-urban Mali; an experimental study. Food Control. 2011;22(10):1565-72. Islam MS, Mahmud ZH, Gope PS, Zaman RU, Hossain Z, Islam MS, et al. Hygiene intervention reduces contamination of weaning food in Bangladesh. Trop Med Int Health. 2013;18(3):250-8. Martin NA, Hulland KRS, Dreibelbis R, Sultana F, Winch PJ. Sustained adoption of water, sanitation and hygiene interventions: systematic review. Trop Med Int Health. 2018;23(2):122-35. Dreibelbis R, Winch PJ, Leontsini E, Hulland KR, Ram PK, Unicomb L, et al. The Integrated Behavioural Model for Water, Sanitation, and Hygiene: a systematic review of behavioural models and a framework for designing and evaluating behaviour change interventions in infrastructure-restricted settings. BMC Public Health. 2013;13:1015. Lally P, Gardner B. Promoting habit formation. Health Psychology Review. 2013;7(sup1):S137-S58. Dreibelbis R, Kroeger A, Hossain K, Venkatesh M, Ram PK. Behavior Change without Behavior Change Communication: Nudging Handwashing among Primary School Students in Bangladesh. Int J Environ Res Public Health. 2016;13(1). Grover E, Hossain MK, Uddin S, Venkatesh M, Ram PK, Dreibelbis R. Comparing the behavioural impact of a nudge-based handwashing intervention to high-intensity hygiene education: a cluster-randomised trial in rural Bangladesh. Trop Med Int Health. 2018;23(1):10-25. Davidson KA, Kropp JD, Mullally CC, Rahman MW. Behavioral nudges and nutrition education in Bangladesh: Experimental evidence comparing food choices in a lab setting to decisions at home. Agricultural and Applied Economics Association; Agricultural & Applied Economics Association Annual Meeting, Washington, DC. 2018. Rahman MJ, Nizame FA, Nuruzzaman M, Akand F, Islam MA, Parvez SM, et al. Toward a Scalable and Sustainable Intervention for Complementary Food Safety. Food Nutr Bull. 2016;37(2):186-201. Gautam OP, Schmidt WP, Cairncross S, Cavill S, Curtis V. Trial of a Novel Intervention to Improve Multiple Food Hygiene Behaviors in Nepal. Am J Trop Med Hyg. 2017;96(6):1415-26. Olthuis K, Mahalingam K, Tartas P-B, Zevenbergen C. Influence of floods on spatial variability of wetslums using geo-information techniques: a case study of a specific human habitat in Korail, Dhaka. Habitats of the World-Biodiversity and Threats: IntechOpen; 2020. Sinthia SA. Analysis of urban slum: case study of Korail slum, Dhaka. International Journal of Urban and Civil Engineering. 2020;14(11):416-30. Chowdhury S. DRINKING WATER QUALITY IN SOME SELCTED SLUMS OF DHAKA CITY, BANGLADESH. International Journal of Engineering Applied Sciences and Technology. 2021;5(9):66-70. Bashar R, Salekin Tonmoy S, Farheen Ria A, Ahsan Khan N. Assessing the Real-Life Socio-Economic Scenario of Established Slums in Dhaka: The Cases of Korail and Sattola. European Online Journal of Natural and Social Sciences. 2020;9(2):455–66. Uddin F, Jahan N. Socio-Cultural Perception and Interpretation of Health and Illness: A Study in the Korail Slum of Dhaka City. International Journal of Science and Research (IJSR). 2021;10(1). Reeda FR. Community Profiles of Informal Settlements in Dhaka: Korail, Ershad Nagar, Kallyanpur (Pora Bostee), and Chalantika. 2024. Parvez SM, Kwong L, Rahman MJ, Ercumen A, Pickering AJ, Ghosh PK, et al. Escherichia coli contamination of child complementary foods and association with domestic hygiene in rural Bangladesh. Trop Med Int Health. 2017;22(5):547-57. Huda TMN, Jahir T, Sarker S, Yeasmin F, Masud AA, Sultana J, et al. Formative Research to Design a Child-Friendly Latrine in Bangladesh. Int J Environ Res Public Health. 2021;18(21). Hussain F, Luby SP, Unicomb L, Leontsini E, Naushin T, Buckland AJ, et al. Assessment of the Acceptability and Feasibility of Child Potties for Safe Child Feces Disposal in Rural Bangladesh. Am J Trop Med Hyg. 2017;97(2):469-76. Hulland KR, Leontsini E, Dreibelbis R, Unicomb L, Afroz A, Dutta NC, et al. Designing a handwashing station for infrastructure-restricted communities in Bangladesh using the integrated behavioural model for water, sanitation and hygiene interventions (IBM-WASH). BMC public health. 2013;13(1):877. Judah G, Gardner B, Aunger R. Forming a flossing habit: an exploratory study of the psychological determinants of habit formation. Br J Health Psychol. 2013;18(2):338-53. Lally P, van Jaarsveld CHM, Potts HWW, Wardle J. How are habits formed: Modelling habit formation in the real world. European Journal of Social Psychology. 2009;40(6):998-1009. Table Table 1. Spot check observations of meatsafe usage across five post-intervention visits (PI-1 to PI-5). Category Condition PI-1 (N=121) PI-2 (N=119) PI-3 (N=118) PI-4 (N=122) PI-5 (N=120) Total(N=600) Door Condition Closes well 105 (86.8%) 115 (96.6%) 117 (99.2%) 121 (99.2%) 119 (99.2%) 577 (96.2%) Some difficulty closing 5 (4.1%) 3 (2.5%) 1 (0.8%) 0 (0.0%) 0 (0.0%) 9 (1.5%) Does not close 11 (9.1%) 1 (0.8%) 0 (0.0%) 1 (0.8%) 1 (0.8%) 14 (2.3%) Cleanliness Very clean 93 (76.9%) 79 (66.4%) 95 (80.5%) 98 (80.3%) 101 (84.2%) 466 (77.7%) Some dirt 26 (21.5%) 38 (31.9%) 22 (18.6%) 23 (18.9%) 18 (15.0%) 127 (21.2%) Considerable dirt 2 (1.7%) 2 (1.7%) 1 (0.8%) 1 (0.8%) 1 (0.8%) 7 (1.2%) Screen Condition No holes 119 (98.3%) 119 (100.0%) 118 (100.0%) 122 (100.0%) 118 (98.3%) 596 (99.3%) One hole 1 (0.8%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 2 (1.7%) 3 (0.5%) Multiple holes 1 (0.8%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 1 (0.2%) The table summarizes observed meatsafe conditions, including door functionality, cleanliness, and screen condition, recorded during 684 structured spot checks among households in the parent randomized controlled trial. Values represent frequencies with column percentages. PI-1 through PI-5 denote post-intervention visits 1–5. PI-1 through PI-5 = post-intervention visits 1–5 Cells show frequency (column-percent); N represents the total number of households observed during each visit. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 06 Feb, 2026 Reviews received at journal 06 Feb, 2026 Reviews received at journal 04 Feb, 2026 Reviewers agreed at journal 26 Jan, 2026 Reviews received at journal 25 Jan, 2026 Reviewers agreed at journal 24 Jan, 2026 Reviewers agreed at journal 12 Jan, 2026 Reviewers agreed at journal 10 Jan, 2026 Reviews received at journal 24 Dec, 2025 Reviewers agreed at journal 22 Dec, 2025 Reviewers agreed at journal 14 Dec, 2025 Reviewers invited by journal 09 Dec, 2025 Editor assigned by journal 07 Dec, 2025 Submission checks completed at journal 07 Dec, 2025 First submitted to journal 28 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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16:44:43","extension":"html","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":113491,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8234271/v1/213c8d4eab329f489051ce7c.html"},{"id":98074110,"identity":"3bf94c69-df49-451a-846f-f9af01f86a09","added_by":"auto","created_at":"2025-12-12 13:25:43","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":485994,"visible":true,"origin":"","legend":"\u003cp\u003eExamples of overload of meatsafes with non-food items along with food items\u003c/p\u003e\n\u003cp\u003ePhotographs illustrate how households used the meatsafe to store multiple categories of items—including cooked food, uncooked food, utensils, powdered milk, spices, and personal items—resulting in overcrowding and reduced space for cooked food storage.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8234271/v1/c2b5343461f61a4e64b678e9.png"},{"id":98428841,"identity":"c2edee17-b1cc-4921-a64c-0be40339925c","added_by":"auto","created_at":"2025-12-17 16:42:27","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":520164,"visible":true,"origin":"","legend":"\u003cp\u003eMeatsafe usage patterns: examples of using cloth to cover the top\u003c/p\u003e\n\u003cp\u003eImages show households placing cloth or rexine on top of the meatsafe to prevent dust accumulation and protect stored items, reflecting routine adaptations made to maintain cleanliness.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8234271/v1/dd4c787a69600944759ceb1a.png"},{"id":98429718,"identity":"28bacd50-717b-4ade-be8d-9de23b79854e","added_by":"auto","created_at":"2025-12-17 16:44:02","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":640481,"visible":true,"origin":"","legend":"\u003cp\u003eRexine sheets to cover the base of the shelves\u003c/p\u003e\n\u003cp\u003eImages show rexine liners added by caregivers to protect the meatsafe shelves. Several households reported concerns about rexine warping or melting when placing hot pots inside the meatsafe.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8234271/v1/99f9526b292ec1f7088a1ffc.png"},{"id":98444782,"identity":"38c000e3-60f9-4e5e-8a72-ce999db78a89","added_by":"auto","created_at":"2025-12-17 17:17:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2963077,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8234271/v1/c0c1030e-1f6b-4072-895f-b6d50ed11c1b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"User experiences with Food Storage in a Meatsafe (Mesh-Covered Food Storage Cabinets) in an Informal Settlement in Dhaka, Bangladesh","fulltext":[{"header":"Introduction","content":"\u003cp\u003eFood hygiene occupies a pivotal node in the fecal\u0026ndash;oral transmission schematic, the F-diagram (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e), yet it received relatively little emphasis in recent WASH interventions (\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). A growing body of evidence nevertheless underscores its public health relevance. In urban Bangladesh, children whose households left stored food uncovered had 6.16-fold higher odds of diarrhea than those whose food was covered (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). In rural settings, consumption of food with high fecal bacterial counts elevated the risk of diarrhea within 24 h (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), and the presence of \u003cem\u003eEscherichia coli\u003c/em\u003e (\u003cem\u003eE.coli)\u003c/em\u003e in food doubled the odds of bloody diarrhea (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eTrials targeting complementary food hygiene have incorporated varying levels of \u0026ldquo;hardware\u0026rdquo; and \u0026ldquo;software\u0026rdquo; (behavior-change communication, BCC). \u003cem\u003eBanja la Ukhondo\u003c/em\u003e in Malawi delivered 33 participatory BCC sessions over 31 weeks, guiding households to fabricate tippy-taps, dish racks, and pot lids; despite providing no hardware, it reduced self-reported diarrhea by 13 percentage points (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). A BCC-intensive hygiene intervention based on hazard analysis and critical control point (HACCP) principles in Bamako, Mali promoted handwashing, utensil cleaning, and reheating during daily home visits over four weeks, and achieved significant reductions in fecal coliforms at critical control points (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). A similar BCC-only trial in low-income neighborhoods of Dhaka, Bangladesh provided four weeks of daily household visits promoting the same food hygiene practices, which virtually eliminated E. coli, \u003cem\u003eStreptococci\u003c/em\u003e, and \u003cem\u003eClostridium perfringens\u003c/em\u003e in weaning foods, with effects sustained for three months after the intervention (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). While interventions that rely primarily on intensive BCC through frequent promoter contact might reduce contamination levels and diarrheal incidences in the short run, these labor-intensive approaches are not scalable or sustainable (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eMinimal BCC, coupled with hardware support may have potential for sustained habit formation (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Rather than instructing caregivers step by step, such approaches draw on behavioral economics principles of \u0026ldquo;nudges,\u0026rdquo; where subtle environmental cues help shape everyday choices. Nudges have proven effective in shifting related practices in other domains: for instance, painted footprints leading to school handwashing stations increased handwashing (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), and children served meals on plates printed with dietary guidance made healthier food selections (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eFormative research in rural Bangladesh revealed that caregivers typically cook once per day, store food for 4\u0026ndash;8 hours, and dislike tight lids that trap steam when food is cooling. Many expressed enthusiasm for a meatsafe, a metal mesh-walled cabinet that excludes insects, domestic animals, and probing of stored foods by young children while allowing food to cool; users reported less spoilage and neighbors inquired where they could obtain one (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAccordingly, we evaluated the meatsafe in a randomized controlled trial in Korail, Dhaka\u0026rsquo;s largest informal settlement. Five spot-check rounds over six months documented near-universal meatsafe usage: 88\u0026ndash;99% of intervention households stored cooked food in the meatsafe. The proportion of fully covered dishes rose from 67% at the first visit to 88% at the fifth. Nevertheless, the endline assessment detected no reduction in \u003cem\u003eE.coli\u003c/em\u003e among foods stored\u0026thinsp;\u0026gt;\u0026thinsp;4 h, nor in caregiver-reported child diarrhea (Rahman et al., 2024, in prep.).\u003c/p\u003e\u003cp\u003eSeveral possible explanations may explain these null results. To explore these possibilities, the qualitative inquiry probed the barriers that may have constrained the intervention\u0026rsquo;s potential efficacy and effectiveness. Guided by the IBM-WASH framework, we examined how contextual, technological, and psychosocial factors interacted to limit the meatsafe\u0026rsquo;s protective impact (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eWe therefore asked why the meatsafe failed to enhance food safety or child health and what barriers, experienced by only a subset of households and not documented or measured in checklist spot-checks, blunted the meatsafe\u0026rsquo;s impact?\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eIntervention Description\u003c/h2\u003e\u003cp\u003eThe intervention supplied a low-cost meatsafe plus one 15\u0026ndash;20-minute session of BCC at the first post-intervention visit, when the meatsafes were provided to the household. Our theory of change was that giving caregivers a cabinet intended to ventilate steam and keep out flies and simple instructions for use and basic food hygiene should prompt immediate, routine storage of cooked foods, reducing fecal contamination and lowering childhood diarrhea. Two posters accompanied it: one on correct meatsafe use (immediate storage, regular cleaning, and keeping the cabinet dry) and one on general food hygiene behaviors (thorough cooking, handwashing, and boiling water). The general food hygiene recommendations were drawn from an intervention in Nepal (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e), that built on other prior work to identify key points of contamination risk in the domestic food preparation in process in Mali and Bangladesh (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Field staff visited households fortnightly to collect RCT food samples and inspect meatsafe condition. We aligned the qualitative data collection with the parent RCT\u0026rsquo;s intervention arm\u0026rsquo;s post-intervention visits (PI-1\u0026rarr;PI-5).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStudy Setting and Participants\u003c/h3\u003e\n\u003cp\u003eWe collected data from 1 June 2024 to 30 November 2024 in Korail, Dhaka\u0026rsquo;s largest informal settlement (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). The neighborhood is characterized by its mix of corrugated iron shed structures and a few buildings with brick walls (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Access to basic water and sanitation services is limited (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e), while inadequate drainage and the consequent spread of contaminated floodwater and flooding contribute additional contamination risk (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Access to natural gas for cooking arrives late at night, so some households purchase firewood or propane for daytime cooking (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAll participants were prospectively recruited from households in the intervention arm of the parent RCT. Eligibility was restricted to primary caregivers responsible for household food preparation and storage.\u003c/p\u003e\n\u003ch3\u003eSampling Strategy\u003c/h3\u003e\n\u003cp\u003eSampling drew on the parent RCT\u0026rsquo;s fortnightly spot-checks of intervention households (those provided with meatsafes) across five post-intervention visits (PI-1 to PI-5; n\u0026thinsp;=\u0026thinsp;684 observations). Using these existing quantitative data, we retrospectively identified households representing a range of storage practices and contamination levels, and then prospectively conducted new qualitative interviews with eligible caregivers. Sixteen households were selected because they displayed clear challenges: they either did not have cooked foods stored in the meatsafe during spot checks, or their meatsafes showed suboptimal cleanliness or functionality, such as visible dirt, broken doors, or screens. In addition, we also selected households with food samples with \u003cem\u003eE. coli\u003c/em\u003e counts\u0026thinsp;\u0026ge;\u0026thinsp;100 colony-forming units per gram (CFU/g), the threshold of high contamination used by the parent RCT. To provide some contrast, we also selected five households that consistently used their meatsafes as intended, storing cooked foods at all visits and showing no recorded functionality or cleanliness issues.\u003c/p\u003e\u003cp\u003eIn total, 21 in-depth interviews were conducted with primary caregivers responsible for household food preparation and storage. This comparative sample design, contrasting households with persistent contamination and functionality problems against those with consistently safe use, enabled us to examine behavioral, environmental, and contextual factors shaping the effectiveness of the meatsafe. We continued interviews until thematic saturation was reached, with no new major barriers or enablers emerging in the final transcripts.\u003c/p\u003e\n\u003ch3\u003eData Collection and Analysis\u003c/h3\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eQualitative Data\u003c/h2\u003e\u003cp\u003eTwo Bengali-speaking research assistants (RAs) conducted in-home, semi-structured interviews lasting 30\u0026ndash;60 minutes. All interviews were audio-recorded with participants\u0026rsquo; informed consent, and RAs completed detailed field notes immediately afterward to capture nonverbal cues and contextual observations. The interview guide, refined through pilot testing in two non-intervention households, covered daily cooking and storage routines, perceptions of the meatsafe, and broader food-hygiene practices. Recordings were transcribed verbatim and then translated into English. To ensure fidelity, translations were reviewed by bilingual researchers familiar with the study context.\u003c/p\u003e\u003cp\u003eTwo coders (MJR and SN) read each interview transcript and coded broadly for barriers, which was iteratively refined to include any kind of negative experience, opinion, or struggle that the respondent mentioned. Coders compared coding decisions and resolved discrepancies through discussion until consensus was reached. We organized coded segments of any expression of a barrier into the contextual, psychosocial, and technological dimensions of the Integrated Behavioral Model for Water, Sanitation, and Hygiene (IBM-WASH) framework (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) domains. Draft thematic summaries were reviewed in researcher-team meetings to ensure credibility and coherence. Routine debriefs between the field researcher (MJR) and the study supervisor, followed by wider team discussions with implementation staff, helped maintain methodological consistency, curb individual bias, and refine emerging interpretations. The primary field researcher (MJR), who was familiar with the Korail context but external to the community, also maintained reflexive notes throughout the study to reflect on their role and positionality. Throughout, an audit trail logged every coding and thematic decision, providing a transparent foundation for the final account of barriers and enablers to meatsafe use.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eEthical Considerations\u003c/h2\u003e\u003cp\u003e The study was approved by the University of California, Berkeley Committee for Protection of Human Subjects (Protocol #2024-04-17365) and icddr,b Ethical and Research Review Committees (PR-24022). Written informed consent was obtained before each interview using Bengali-language consent forms signed by the participant and counter-signed by the interviewer as witness. All participants were informed of study objectives, potential risks, and their rights to withdraw at any time prior to giving written consent. No minors were included.\u003c/p\u003e\u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThe following themes emerged most prominently in discussions with participants, at times explicitly linked to meatsafe use, and at other times, only indirectly or implicitly connected. We describe the results in this section and draw connections to how it affects meatsafe usage in the Discussion.\u003c/p\u003e\n\u003ch3\u003eGeneral Food Handling and Storage Practices\u003c/h3\u003e\n\u003cp\u003e Prior to receiving the meatsafe, participants stored food by a variety of methods. Cooked food was often placed on the floor with plastic covers or in jute sacks, stacked on wooden or plastic racks in the corners of rooms. Participants said that when raw fish and other perishables were uncovered, they attracted cats and/or cockroaches.\u003c/p\u003e\u003cp\u003eParticipants explained that they cook the day\u0026rsquo;s rice, curries and side dishes in bulk late at night, when gas was available, then consumed portions of the stored food throughout the day, usually without any reheating or briefly warmed on a firewood stove. Families who had purchased firewood sometimes cooked a new pot of rice during the day.\u003c/p\u003e\u003cp\u003eAfter receiving the meatsafe, all households began using it as their primary location to store cooked and uncooked food, and other small items. Generally, the top shelf was used to store \u003cem\u003esuji\u003c/em\u003e (semolina for porridge), powdered milk, and sugar, and other personal items such as make-up and stationery. The middle shelf held utensils, while the bottom shelf stored cooked food in sealed aluminum containers. Participants lined the shelves with \u0026ldquo;rexine\u0026rdquo;, inexpensive, embossed, PVC-coated fabric (vinyl-like and water-resistant).\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eTechnological Dimension\u003c/h2\u003e\u003cdiv id=\"Sec12\" class=\"Section3\"\u003e\u003ch2\u003eStorage Stability and Structural Support\u003c/h2\u003e\u003cp\u003eThe metal meatsafe\u0026rsquo;s lightweight design, while intended to be portable and adaptable, caused many users to report that it wobbled or shifted, especially when full of heavy items. The meatsafe was not trusted as a stable place to store food. Caregivers explained that they avoided storing heavier items, like pots of rice or \u003cem\u003edaal\u003c/em\u003e (lentils), in the meatsafe because of the risk of tipping or spillage. So these were instead placed on the floor or under the bed. Instead, families used the meatsafe only for lightweight items.\u003c/p\u003e\u003cp\u003eMost families improvised reinforcement methods, indicating that the current design did not adequately account for the environmental conditions of homes in informal settlements. The most common solution was placing bricks or boards underneath the meatsafe to stabilize it on uneven or damp floors.. As one of the caregivers said,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWe put bricks underneath, otherwise it shakes. The floor isn\u0026rsquo;t level, and when you open the door, it can tip forward.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eMany felt that a heavier, sturdier base would have made the product more suitable for their environment, dependable, and convenient.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eLatch Weakness and Structural Gaps\u003c/h2\u003e\u003cp\u003eThe spot-checks results showed that meatsafe doors achieved high functionality, with the proportion closing well 86.8% at PI-1 and 99% at PI-5. Furthermore, 99.3% of screens had no holes across all five post-intervention visits. However, a few households complained that the latch system was too small, poorly installed, or broke easily. Even when the latch did hold the doors closed, there would still be a 2\u0026ndash;3 finger-wide gap between the doors through which pests, particularly cockroaches could enter the meatsafe. As two caregivers shared,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026hellip;.there\u0026rsquo;s no proper latch. Cockroaches or rats still can get in. Even if it\u0026rsquo;s latched, there are gaps. That\u0026rsquo;s why we can\u0026rsquo;t store hot food either.\u003c/p\u003e\u003cp\u003eMy husband tried to tape some parts inside to make it tighter, but still, there\u0026rsquo;s a gap. Cockroaches sneak in at night. It would be better if it had a bigger, stronger latch\u0026hellip; something that locked properly.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eSome households attempted to reinforce the latch with tape, and many participants tried to close these gaps with cloth, but these makeshift solutions were not durable.\u003c/p\u003e\u003cp\u003eAnother repeated concern was that children could tamper with the latch or open the meatsafe unsupervised, scattering items or leaving the food vulnerable to flies. Mothers expressed a need for stronger, child-resistant closures. As one of the caregivers explained,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eMy child opens the meatsafe... I tell him not to touch it, but he plays with the latch. If it had a lock or stronger closure, it would be better.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e Participants shared that they preferred sturdy steel cabinets with higher-quality meatsafes with stronger frames and better latches.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eSize and Multi-Use Storage Needs\u003c/h2\u003e\u003cp\u003eThe meatsafe was intended to store a day\u0026rsquo;s worth of cooked food. However, participants\u0026rsquo; storage needs were far more diverse. Households often placed biscuits, raw vegetables, powdered milk, spices, oil bottles and utensils in the meatsafe to protect them from pests. A mother of two explained:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWe store many things in the same space, biscuits, onions, dry food, children\u0026rsquo;s chips. But we can\u0026rsquo;t fit everything. If it were bigger, we could keep large cooking pots inside, too.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eSome households repurposed the meatsafe entirely, storing non-food items such as clothes, cosmetics, medicines, or baby supplies (Fig.\u0026nbsp;1).\u003c/p\u003e\u003cp\u003e Participants reported that they often placed washed utensils inside the meatsafe while still wet. However, they expressed concern that this practice might damage the meatsafe, as the limited airflow created a damp environment and led to moisture accumulation inside.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eFrequent Cleaning but Persistent Dust\u003c/h2\u003e\u003cp\u003eOverall cleanliness was strong, with 77.7% of meatsafes rated \u0026ldquo;very clean,\u0026rdquo; though this dipped to 66.4% at PI-2 before rising to 84.2% by PI-5 (Table\u0026nbsp;1). Many caregivers covered the top of the meatsafe with rexine or old clothes (Fig.\u0026nbsp;2) or made active efforts to clean the meatsafe every few days. However, the neighborhood\u0026rsquo;s dusty environment, combined with the device\u0026rsquo;s sharp edges and difficult-to-clean corners, made complete cleanliness unattainable. Reflecting a common concern among participants, one of the caregivers noted,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWhen we wipe it, our hands get cut from the edges. Dirt gets stuck in the corners. If we had a smoother, sturdier rack, it would help\u0026hellip; Even after cleaning, dust collects again.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eMissing Liners and Improvised Solutions\u003c/h2\u003e\u003cp\u003eSince the meatsafe shelves did not come with a liner, participants initially lined the shelves with newspaper but after they realized that the newspaper would easily tear or get wet they switched to liners of old cotton or chiffon scarves. As one of the caregivers said,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe paper liner tears when it gets wet. Then cockroaches come. So, I use cloth instead. I cut up my orna [traditional woman\u0026rsquo;s scarf] and put it on the shelves.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eMany respondents also reported lining the shelves of the meatsafes with rexine (plastic-coated fabric) as a superior alternative, citing its reusability, ease of cleaning, and durability. However, many participants were concerned that hot pots could cause the rexine to melt or warp (Fig.\u0026nbsp;3), meaning they were hesitant to follow the recommended practice of storing food in the meatsafe immediately after it was cooked. This cooling period then would be high-risk, since food that was not fully covered remained exposed to flies, dust, and pests.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eIf it were made of stronger material, I could store hot food without the rexine. Now, I have to let it cool for 7\u0026ndash;8 minutes before putting it in. By then, flies might land on it. So, we place the food down on the floor and wait. When the pot cools down a bit, then we put it inside the meatsafe.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003ePsychosocial Dimension\u003c/h2\u003e\u003cdiv id=\"Sec18\" class=\"Section3\"\u003e\u003ch2\u003eMental Models of Steam and Food Spoilage\u003c/h2\u003e\u003cp\u003eIn the BCC poster on meatsafe use, we advised caregivers to cover cooked food immediately and place it in the meatsafe. However, nearly all participants reported deliberately delaying covering food and putting it in the meatsafe, citing concerns about trapped steam causing food to spoil faster. Two mothers explained:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eIf we touch the container and it is still warm, then storing it then will cause it to spoil. And so, we let the food cool down first. Then we store it, so it stays good.\u003c/p\u003e\u003cp\u003eBecause if you cover it immediately while it\u0026rsquo;s hot, moisture collects inside. That\u0026rsquo;s why I let it cool down a bit first. Then I cover it or store it. Otherwise, the rice turns yellow and sour.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eCaregivers also noted that condensation formed on the rexine, causing dust to stick to the liner and supporting concerns about hot food storage leading to mold.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eTemporary Relocation to Natal Villages\u003c/h2\u003e\u003cp\u003eSome caregivers chose to temporarily relocate to their natal villages during the hot and rainy seasons, when the experienced fevers, colds, and diarrhea to be most common, fuel was in short supply, and flooding was common. Rural settings were viewed as more conducive to recovery, not only due to perceived cleaner air and fewer pests, but also due to stronger family caregiving support and familiarity with local health providers. One participant reflected:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eMaybe there are some inconveniences during the rainy season here. But in the village, the cool breeze and calm nature make everything feel peaceful. In winter, we can walk around and spend time outdoors, and that keeps us healthy. Our children got sick once in Dhaka, and it was hard to manage. That\u0026rsquo;s when we felt village life was better.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAnother shared how extreme weather compounded the difficulty of caregiving in Dhaka:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eRainy days bring a different challenge, if it rains heavily in Dhaka, cooking becomes difficult. Water enters the kitchen and makes everything harder. After cooking, cleaning becomes an even bigger burden. Many people live in Dhaka, but when someone gets sick, they go back to the village.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eNavigating Blame and Vulnerability in Shared Care and Social Pressure\u003c/h2\u003e\u003cp\u003eWhile contaminated food, unwashed hands, and open storage were acknowledged as risks for children\u0026rsquo;s diarrhea, many participants also emphasized prenatal malnutrition, seasonal transitions, and contact with sick peers as contributors to children\u0026rsquo;s recurring illnesses, especially diarrhea, colds, and weakness:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eSometimes the child eats with dirty hands or from the floor. Sometimes it's food left open, or baby food not covered. But also, my child was weak from birth, maybe from what I ate while pregnant.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eMothers also cited community exposure from other children, and they tried taking steps to limit the amount of time children play with other children, only to face pushback from grandparents or neighbors. As one mother explained:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI try to keep him away from others when they\u0026rsquo;re sick, but my in-laws say let him play. They feel bad when the child cries. Then I get blamed for being too harsh.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003eContextual Dimension\u003c/h2\u003e\u003cdiv id=\"Sec22\" class=\"Section3\"\u003e\u003ch2\u003eFuel Scarcity and Crowded Housing\u003c/h2\u003e\u003cp\u003eParticipants repeatedly emphasized how gas shortages, shared stoves, and minimal living space interfered with adhering to recommended food hygiene practices such as reheating food before serving, boiling water to make it safe for drinking, and properly cleaning cooking utensils. With five to eight families sharing a single stove that received gas for only six hours late at night, households had a narrow window to cook.\u003c/p\u003e\u003cp\u003eFamilies may purchase firewood to in the face of inconsistent gas supply, but they find both gas and firewood to be unaffordable. Caregivers reported being unable to often reheat leftovers or boil water during the day. A 38-year-old mother explained:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eSeven to eight families share one gas stove. There\u0026rsquo;s no fixed turn, and often no gas at all. We can\u0026rsquo;t reheat food. We have to feed our children stale food.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eLeftover meals were typically stored for hours and consumed without reheating even though mothers understood that reheating would help kill pathogens. As one mother of two children described:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eIf there\u0026rsquo;s no gas, we can\u0026rsquo;t cook again. The children cry from hunger, but we have to feed them whatever food is left. Sometimes I buy biscuits, but if there\u0026rsquo;s no money, they eat stale rice.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eFurthermore, caregivers could not reliably boil water to ensure its safety. One grandmother noted:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eEven if I want to boil water for tea or warm the leftover rice, I cannot. The stove has to serve many families. By the time it\u0026rsquo;s my turn, I\u0026rsquo;ve already missed the time when the children need to eat or drink.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eHigh population density throughout the settlement exacerbated exposure to dust, garbage, and pests in the immediate environment. Families described cockroaches, flies, and rodents crawling over floors, stoves, and uncovered food throughout their neighborhood, not just inside their homes or around the meatsafe.\u003c/p\u003e\u003cp\u003eAs a 22-year-old mother explained:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWe live among so many people that dust keeps accumulating all around us. We try to sweep and wipe surfaces, but it\u0026rsquo;s not always possible. We don\u0026rsquo;t always have gas to boil water. It\u0026rsquo;s difficult to follow all the guidelines.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAlthough many participants appreciated the meatsafe for limiting exposure to flying insects and rodents, ants and small cockroaches could still enter through the mesh and other small pests could enter when caregivers opened the meatsafe doors. A few users reported using pesticide in the meatsafe. One explained by saying,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eNo insects were in the food, but we saw small ones inside the meatsafe. We used spray once, and now we clean more often.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\u003ch2\u003eSeasonal barriers\u003c/h2\u003e\u003cp\u003eDuring summer seasons, temperatures and humidity accelerated spoilage of both cooked food and raw ingredients like soaked lentils and chopped vegetables. Several caregivers mentioned that food, especially milk or rice, would be sour by midday if cooked the prior night.\u003c/p\u003e\u003cp\u003eOne mother described:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eBecause of the heat, food spoils quickly. Sometimes we can\u0026rsquo;t even eat it. The children fall sick. If we had a sturdier meatsafe, maybe we could store food better in the summer.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eWomen explained that during the monsoon season crossing their flooded courtyard to reach shared cooking areas required them to wade through floodwater contaminated with sewage, making access slow and hazardous but not preventing it entirely. Caregivers still used the kitchens when necessary, though they often reduced trips by cooking larger batches at once and then relying on stored food without reheating. This coping strategy lengthened storage duration and increased risk of spoilage. Several caregivers reported that water also flooded their homes, contaminating cooking spaces and soaking stored firewood and clothes. One young mother described:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eRecent rainfall may have occurred, causing water to accumulate on the roads in this area. While water does not enter the house, it creates significant issues on the roads, restricting movement. Access to the kitchen becomes difficult, and food storage becomes challenging under these conditions.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIn many cases, caregivers resorted to \u0026ldquo;batch\u0026rdquo; during breaks in rainfall, preparing large quantities of food for multiple meals. But this prolonged storage duration also means increased food hygiene risk.\u003c/p\u003e\u003cp\u003eCaregivers reported placing utensils, such as the \u003cem\u003eboti\u003c/em\u003e (a curved blade for chopping that is held in place on the floor by a foot), and the meatsafe on bricks or wood planks to keep them dry. However, these improvised measures only offered partial protection. Elevating items on bricks or planks reduced direct water contact but did not prevent contamination from dirty floodwater splashing onto surfaces, nor from pests climbing up. As a result, utensils and stored food still carried heightened risk of microbial exposure.\u003c/p\u003e\u003cp\u003ePests like flies, mosquitoes, and rats were especially likely to enter the house when it was flooded outside. As one mother explained:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWhen it rains, rats come in to escape the water outside. They scurry around the floor, trying to get near food. Even if we put the rack on top of bricks, rats sometimes climb up.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe parent RCT showed near-universal use and routine maintenance of the meatsafe, yet no measurable reductions in food contamination or caregiver-reported child diarrhea. While spot checks documented impressive usage metrics, with households consistently storing food in the meatsafe and maintaining cleanliness, our qualitative interviews exposed a critical behavioral gap invisible to quantitative spot check observations monitoring: any storage in the meatsafe vs. immediate storage in the meatsafe. \u0026lsquo;Use\u0026rsquo; in our spot-check data refers only to food observed in the meatsafe at the time of the visit, and does not necessarily indicate that food had been placed inside immediately after cooking or that it was allowed to cool outside before being placed inside the meatsafe. Our BCC messaging emphasized immediate storage and food covering but could not ethically advise storing uncovered food inside the meatsafe, given the absence of specific evidence that keeping food uncovered inside the meatsafe would provide the same protection as covering foods with tight-fitting lids (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Qualitative findings shed light on the technological, psychosocial, and contextual constraints that may have blunted the meatsafe\u0026rsquo;s effectiveness and help explain the paradox of high use without corresponding health benefit. Since caregivers refused to cover food when hot due to concerns that condensation induces spoilage, they continued to cool food uncovered, creating the same opportunity for contamination that exists in households without meatsafes.\u003c/p\u003e\u003cp\u003eA combination of technological, psychosocial, and contextual factors undermined immediate storage of freshly cooked hot foods in the meatsafe, despite consistent meatsafe use. Technological issues such as unstable frames, weak latches, sharp corners, mesh gaps, and concerns about liners were frequently noted. Psychosocial barriers included steam-spoilage fears, low recall of BCC messages, contested childcare authority, and seasonal relocations that disrupted consistent use. Contextual barriers reflected the broader living environment in Korail, including shared kitchens and stoves, chronic gas outages, batch cooking, overcrowding, extreme heat and humidity, rapid food spoilage, flooding, and sewage-contaminated water. Together, these technological, psychosocial, and contextual constraints influenced both how households used the meatsafe and the conditions under which stored food remained vulnerable.\u003c/p\u003e\u003cp\u003eWe attempted to study the effectiveness of the meatsafe without first being sure of its efficacy. In addition, we only followed up on meatsafe usage a few months after installation; a longer time horizon might capture further adaptation, or abandonment, of the device. The BCC package also never directly confronted local understandings of how trapped steam induces spoilage of foods; lacking empirical evidence that placing hot food immediately in the meatsafe is safe, we were ethically unable to endorse that practice. In prior studies, extensive formative research allowed time to modify and upgrade the technology of interest (\u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). In our case, we relied on a locally available free-market product and assumed quality. Our evaluation assumed meatsafe effectiveness without first confirming its efficacy. That is, we assessed real-world usage before demonstrating whether the device could reduce contamination under controlled conditions. Future trials should consider lab-based efficacy testing before scale-up. Incremental upgrades, steel frame, child-proof bolt, metal shelves, could boost durability and ease of cleaning but cannot overcome structural and behavioral constraints. Design revisions, smooth, rounded interiors, detachable trays, heat-tolerant liners, would simplify cleaning and reduce warping concerns. BCC should directly engage caregivers\u0026rsquo; concerns\u003c/p\u003e\u003cp\u003e Persistent external contamination threats\u0026mdash;flies, rodents, dust, sewage, and floodwater\u0026mdash;likely overwhelmed the meatsafe\u0026rsquo;s protective function, while contextual pressures such as shared kitchens, chronic gas outages, overcrowding, extreme heat and humidity, rapid spoilage, and reliance on batch cooking further shaped its use and caregivers\u0026rsquo; sense of self-efficacy. Mothers described frustration, blame, and limited decision-making power; some noted that in-laws overruled their efforts to limit children\u0026rsquo;s exposure or scolded them for being \u0026ldquo;too harsh,\u0026rdquo; highlighting contested childcare authority. These accounts, though not a systematic measure of agency, show how constrained authority eroded confidence and consistency in protective routines. In communal childcare contexts, such social frictions\u0026mdash;combined with the perception that food hygiene was only one of many diarrheal risks\u0026mdash;further diluted motivation to prioritize it. Periodic relocation to natal villages also disrupted the repetition and stable environmental cues required for habit formation, which depends on consistent practice in stable settings (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e).\u003c/p\u003e\u003cdiv id=\"Sec25\" class=\"Section2\"\u003e\u003ch2\u003eLimitations\u003c/h2\u003e\u003cp\u003eIt is also important to note a methodological limitation of this qualitative inquiry. Because the interviews were designed to probe barriers, our results disproportionately reflect constraints raised by a subset of respondents, many of whom faced difficulties that were not universally experienced. In practice, the findings presented in this paper represent an intentionally expansive mapping of possible mechanisms and bottlenecks, rather than a quantification of their prevalence. Indeed, quantitative spot checks consistently documented high uptake and visible maintenance of the meatsafe, suggesting that these barriers, while real and important, did not prevent most households from using the device. Future mixed-methods research should more carefully integrate qualitative probing of barriers with quantitative measures of frequency and magnitude, to better distinguish between rare but plausible risks and widespread obstacles to sustained use.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eEchoing the sobering results of recent WASH megatrials, our study underscores that neither hardware nor minimal behavior-change communication on its own is sufficient to solve microbial risk. The meatsafe offered partial protection from \u003cem\u003eflies, rodents, and visible dust contamination\u003c/em\u003e but could not overcome the entrenched challenges of poverty, crowding, fuel scarcity, and shared caregiving dynamics that contributed to \u003cem\u003epersistent exposure to fecal pathogens and ongoing risk of diarrheal disease\u003c/em\u003e.\u003c/p\u003e\u003cp\u003eImportantly, even large WASH megatrials that combined hardware provision (latrines, handwashing stations, safe water storage) with intensive promotion of handwashing, safe feces disposal, and water treatment demonstrated little impact on child growth or diarrhea (Luby et al. 2018; Null et al. 2018; Humphrey et al. 2019). These results indicate that our findings are not a matter of \u0026ldquo;hardware only\u0026rdquo; design but instead highlight the limits of household-level interventions, even when paired with behavior-change encouragement. In our trial, as in those megatrials, persistent environmental contamination and structural barriers likely overwhelmed the partial protection that individual devices could offer.\u003c/p\u003e\u003cp\u003eTo meaningfully reduce foodborne enteric disease in urban Bangladesh, interventions must build on systemic investments in energy, water, drainage, and pest control. Future research should co-design alternative technologies that address both microbial and practical challenges: solar-powered fridges using thermal mass, solar-assisted warming trays with phase-change salts, or hybrid solar-LPG cookers that lower fuel costs. Modular solar micro-grids already piloted in urban slums enable communal refrigeration and lighting; pay-as-you-go solar kits offer scalable household energy. Such transformative options merit testing where simple racks cannot meet microbial safety thresholds.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u0026bull; BCC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eBehavior Change Communication\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u0026bull; cfu/g\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eColony Forming Units per gram\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u0026bull; F\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ediagram\u0026ndash;Fecal\u0026ndash;oral transmission diagram\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u0026bull; HACCP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHazard Analysis and Critical Control Point\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u0026bull; IBM\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eWASH\u0026ndash;Integrated Behavioral Model for Water, Sanitation, and Hygiene\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u0026bull; icddr,b\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eInternational Centre for Diarrhoeal Disease Research, Bangladesh\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u0026bull; PI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003e1 to PI\u0026ndash;5\u0026ndash;Post\u0026ndash;Intervention visits 1 through 5\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u0026bull; PVC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePolyvinyl Chloride\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u0026bull; RA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eResearch Assistant\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u0026bull; RCT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eRandomized Controlled Trial\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u0026bull; RGHI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eReckitt Global Hygiene Institute\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u0026bull; SDG\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSustainable Development Goal\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u0026bull; WASH\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eWater, Sanitation, and Hygiene\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u003cbr\u003e\u0026nbsp;This study was approved by the University of California, Berkeley Committee for Protection of Human Subjects (Protocol #2024-04-17365) and the Ethical and Research Review Committees of icddr,b (PR-24022). All participants provided written informed consent prior to participation. Clinical trial number: not applicable.\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003cbr\u003e\u0026nbsp;Not applicable. No identifying personal data, images, or videos are included in this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The qualitative transcripts generated during this study and analyzed to support the conclusions of this article are not publicly available due to concerns regarding participant confidentiality in a dense informal settlement context, but de-identified excerpts are included within the article. Additional data may be made available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003cbr\u003e\u0026nbsp;The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding\u003cbr\u003e\u0026nbsp;This study was supported by the Reckitt Global Hygiene Institute (RGHI) under grant number 092000310-UCB-0310. The funder had no role in the study design, data collection, analysis, interpretation of data, decision to publish, or preparation of the manuscript.\u003c/p\u003e\n\u003cp\u003eAuthors’ contributions\u003cbr\u003e\u0026nbsp;MJR conceptualized the study, oversaw data collection, and drafted the manuscript. SN contributed to data coding and analysis. MR supervised field activities and provided input on study design. LHK contributed to methodological development and interpretation of findings. PJW provided overall supervision, contributed to conceptual framing, and critically reviewed the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003cbr\u003e\u0026nbsp;The authors thank the field research assistants, the participating households in Korail, and colleagues at icddr,b for their collaboration and support.\u003c/p\u003e\n\u003cp\u003eAuthors’ information\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;MJR is a PhD graduate in International Health from the Johns Hopkins Bloomberg School of Public Health, specializing in social and behavioral interventions in low-resource urban settings.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWagner EG, Lanoix JN. Excreta disposal for rural areas and small communities. 1958.\u003c/li\u003e\n\u003cli\u003eHumphrey JH, Mbuya MNN, Ntozini R, Moulton LH, Stoltzfus RJ, Tavengwa NV, et al. 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Am J Trop Med Hyg. 2017;96(6):1415-26.\u003c/li\u003e\n\u003cli\u003eOlthuis K, Mahalingam K, Tartas P-B, Zevenbergen C. Influence of floods on spatial variability of wetslums using geo-information techniques: a case study of a specific human habitat in Korail, Dhaka. Habitats of the World-Biodiversity and Threats: IntechOpen; 2020.\u003c/li\u003e\n\u003cli\u003eSinthia SA. Analysis of urban slum: case study of Korail slum, Dhaka. International Journal of Urban and Civil Engineering. 2020;14(11):416-30.\u003c/li\u003e\n\u003cli\u003eChowdhury S. DRINKING WATER QUALITY IN SOME SELCTED SLUMS OF DHAKA CITY, BANGLADESH. International Journal of Engineering Applied Sciences and Technology. 2021;5(9):66-70.\u003c/li\u003e\n\u003cli\u003eBashar R, Salekin Tonmoy S, Farheen Ria A, Ahsan Khan N. Assessing the Real-Life Socio-Economic Scenario of Established Slums in Dhaka: The Cases of Korail and Sattola. European Online Journal of Natural and Social Sciences. 2020;9(2):455\u0026ndash;66.\u003c/li\u003e\n\u003cli\u003eUddin F, Jahan N. Socio-Cultural Perception and Interpretation of Health and Illness: A Study in the Korail Slum of Dhaka City. International Journal of Science and Research (IJSR). 2021;10(1).\u003c/li\u003e\n\u003cli\u003eReeda FR. Community Profiles of Informal Settlements in Dhaka: Korail, Ershad Nagar, Kallyanpur (Pora Bostee), and Chalantika. 2024.\u003c/li\u003e\n\u003cli\u003eParvez SM, Kwong L, Rahman MJ, Ercumen A, Pickering AJ, Ghosh PK, et al. Escherichia coli contamination of child complementary foods and association with domestic hygiene in rural Bangladesh. Trop Med Int Health. 2017;22(5):547-57.\u003c/li\u003e\n\u003cli\u003eHuda TMN, Jahir T, Sarker S, Yeasmin F, Masud AA, Sultana J, et al. Formative Research to Design a Child-Friendly Latrine in Bangladesh. Int J Environ Res Public Health. 2021;18(21).\u003c/li\u003e\n\u003cli\u003eHussain F, Luby SP, Unicomb L, Leontsini E, Naushin T, Buckland AJ, et al. Assessment of the Acceptability and Feasibility of Child Potties for Safe Child Feces Disposal in Rural Bangladesh. Am J Trop Med Hyg. 2017;97(2):469-76.\u003c/li\u003e\n\u003cli\u003eHulland KR, Leontsini E, Dreibelbis R, Unicomb L, Afroz A, Dutta NC, et al. Designing a handwashing station for infrastructure-restricted communities in Bangladesh using the integrated behavioural model for water, sanitation and hygiene interventions (IBM-WASH). BMC public health. 2013;13(1):877.\u003c/li\u003e\n\u003cli\u003eJudah G, Gardner B, Aunger R. Forming a flossing habit: an exploratory study of the psychological determinants of habit formation. Br J Health Psychol. 2013;18(2):338-53.\u003c/li\u003e\n\u003cli\u003eLally P, van Jaarsveld CHM, Potts HWW, Wardle J. How are habits formed: Modelling habit formation in the real world. European Journal of Social Psychology. 2009;40(6):998-1009.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Table","content":"\u003cp\u003eTable 1. Spot check observations of meatsafe usage across five post-intervention visits (PI-1 to PI-5).\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellpadding=\"0\" width=\"842\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eCategory\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003eCondition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003ePI-1 (N=121)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003ePI-2 (N=119)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003ePI-3 (N=118)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003ePI-4 (N=122)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003ePI-5 (N=120)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003eTotal(N=600)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eDoor Condition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003eCloses well\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e105 (86.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e115 (96.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e117 (99.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e121 (99.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e119 (99.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e577 (96.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003eSome difficulty closing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e5 (4.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e3 (2.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e1 (0.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e9 (1.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003eDoes not close\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e11 (9.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e1 (0.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e1 (0.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e1 (0.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e14 (2.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eCleanliness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003eVery clean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e93 (76.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e79 (66.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e95 (80.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e98 (80.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e101 (84.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e466 (77.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003eSome dirt\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e26 (21.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e38 (31.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e22 (18.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e23 (18.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e18 (15.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e127 (21.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003eConsiderable dirt\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e2 (1.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e2 (1.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e1 (0.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e1 (0.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e1 (0.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e7 (1.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eScreen Condition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003eNo holes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e119 (98.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e119 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e118 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e122 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e118 (98.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e596 (99.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003eOne hole\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e1 (0.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e2 (1.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e3 (0.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003eMultiple holes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e1 (0.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e1 (0.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe table summarizes observed meatsafe conditions, including door functionality, cleanliness, and screen condition, recorded during 684 structured spot checks among households in the parent randomized controlled trial. Values represent frequencies with column percentages. PI-1 through PI-5 denote post-intervention visits 1\u0026ndash;5.\u003c/p\u003e\n\u003cp\u003ePI-1 through PI-5 = post-intervention visits 1\u0026ndash;5\u003c/p\u003e\n\u003cp id=\"_Toc201475846\"\u003eCells show frequency (column-percent); N represents the total number of households observed during each visit.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"tropical-medicine-and-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"tmah","sideBox":"Learn more about [Tropical Medicine and Health](https://tropmedhealth.biomedcentral.com/)","snPcode":"41182","submissionUrl":"https://submission.springernature.com/new-submission/41182/3","title":"Tropical Medicine and Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Food hygiene, Complementary feeding, Diarrheal disease, Informal settlements, Bangladesh, WASH, Food storage, Qualitative research, Behavior change, Randomized controlled trial","lastPublishedDoi":"10.21203/rs.3.rs-8234271/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8234271/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003cbr\u003e\nFood hygiene is a critical but often overlooked link in fecal–oral disease transmission, particularly in dense informal settlements where environmental contamination and food storage constraints heighten risk. A mesh-walled food storage cabinet, or “meatsafe,” was designed to protect food from insects, animals, and young children while allowing ventilation. A parent randomized controlled trial (RCT) in Korail, Dhaka’s largest informal settlement, documented near-universal meatsafe use but no reductions in food contamination or child diarrhea. This qualitative study explored why a widely adopted hardware solution did not achieve expected health impacts.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003cbr\u003e\nGuided by the Integrated Behavioral Model for Water, Sanitation, and Hygiene (IBM-WASH), we conducted a purposive, theory-driven study embedded within the RCT. Data collection included 21 in-depth interviews with primary caregivers, 684 structured spot checks, and message-recall assessments among 145 participants. Interview transcripts were thematically coded for barriers and organized into contextual, technological, and psychosocial dimensions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003cbr\u003e\nMultiple barriers constrained effective meatsafe use. Technological issues included unstable frames, weak latches, sharp edges, mesh gaps, and the use of rexine liners that warped with heat. Psychosocial barriers involved concerns that storing hot food would trap steam and cause spoilage, low recall of behavior-change messages, contested childcare authority, and temporary relocations to villages during certain seasons. Contextual barriers reflected shared kitchens, chronic gas shortages, overcrowding, extreme heat and humidity, rapid food spoilage, flooding, and sewage-contaminated water. A critical behavioral gap emerged: households often cooled food uncovered before placing it in the meatsafe, leaving it vulnerable to flies, rodents, and dust.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003cbr\u003e\nHigh observed use of the meatsafe without corresponding reductions in microbial contamination or child illness underscores the limits of single-technology interventions in resource-constrained urban environments. Sustainable reduction of foodborne enteric disease in informal settlements will require integrated improvements in energy, water, drainage, and pest control, alongside co-designed technologies that address users’ practical, environmental, and behavioral realities.\u003c/p\u003e","manuscriptTitle":"User experiences with Food Storage in a Meatsafe (Mesh-Covered Food Storage Cabinets) in an Informal Settlement in Dhaka, Bangladesh","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-12 13:25:39","doi":"10.21203/rs.3.rs-8234271/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-06T09:46:04+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-06T09:10:54+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-04T06:12:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"315980565134936765488130708765414201316","date":"2026-01-26T09:05:52+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-26T01:23:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"201180408854250751451863306277054853030","date":"2026-01-25T04:57:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"116563600838587209148013626712640010289","date":"2026-01-12T09:21:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"16113515774984124651547560601854792752","date":"2026-01-10T11:21:59+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-24T10:26:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"168210846306088125483759609811566010635","date":"2025-12-22T07:47:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"327366821154824937439467439149233355598","date":"2025-12-14T11:59:17+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-09T07:13:33+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-07T22:51:45+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-07T22:51:13+00:00","index":"","fulltext":""},{"type":"submitted","content":"Tropical Medicine and Health","date":"2025-11-29T04:21:53+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"tropical-medicine-and-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"tmah","sideBox":"Learn more about [Tropical Medicine and Health](https://tropmedhealth.biomedcentral.com/)","snPcode":"41182","submissionUrl":"https://submission.springernature.com/new-submission/41182/3","title":"Tropical Medicine and Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ad1208f8-7896-4db1-b760-42a9e5beee36","owner":[],"postedDate":"December 12th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-20T05:10:16+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-12 13:25:39","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8234271","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8234271","identity":"rs-8234271","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}