key: cord-0948160-vd0zpjnc
authors: Faour-Klingbeil, Dima; Osaili, Tareq M.; Al-Nabulsi, Anas A.; Jemni, Monia; Todd, Ewen.C.D.
title: An on-line survey of the behavioral changes in Lebanon, Jordan and Tunisia during the COVID-19 pandemic related to food shopping, food handling, and hygienic practices
date: 2021-02-05
journal: Food Control
DOI: 10.1016/j.foodcont.2021.107934
sha: 372d9e14ee623e047ba44379882cb35edb4a6275
doc_id: 948160
cord_uid: vd0zpjnc

The impact of the novel coronavirus pandemic (COVID-19) has spanned across the various aspects of life globally. Understanding public reactions is vital for effective risk communication and outbreak control and prevention. The Arab world has diverse cultural, economic, and social structures, so public choices and decisions also vary. To investigate the changes in behavior related to food shopping and handling, precautions measures, and hygiene practices of the public during the pandemic, a web-based survey tool was developed and conducted on 1074 subjects in three Arab countries, Lebanon, Jordan, and Tunisia, using a snowball sampling technique. The results showed a significant reduction in RTE consumption during the pandemic, as shown in the 19.2% and 12.2% rise in the proportion of respondents not ordering hot and cold RTE food delivery, respectively. Compared to pre-COVID-19 times, a substantial increase in behaviors related to hygiene and disinfection practices (22.0% - 32.2%) was observed with a lesser increase (11.2%) in handwashing practices before food preparation. Moreover, public concerns about contracting COVID-19 from food led to almost doubling the number of Tunisians using cleaning agents for washing fresh fruits and vegetables (e.g., soaps, non-food grade chlorine bleach) besides a 16 % and 26.1% increase in use among the Jordanian and Lebanese, respectively. However, a third of the respondents did not follow instructions on labels for the use of chemical products. In conclusion, this study identified culture-specific shortfalls in handwashing and unsafe food handling practices during COVID-19 in the Arab countries and sheds light on the paramount role of coordinated efforts between the local health authorities and the food safety and public health stakeholders in risk communication. To reduce health risks, there need to be rigorous educational campaigns and targeted messages that reach out to the general audience on hand hygiene, the health effects of haphazard use of unsafe chemical compounds on food, and recommendations on following label instructions.

hygiene practices of the public during the pandemic, a web-based survey tool was 23 developed and conducted on 1074 subjects in three Arab countries, Lebanon, Jordan, and 24

Tunisia, using a snowball sampling technique. The results showed a significant reduction in 25 RTE consumption during the pandemic, as shown in the 19.2% and 12.2% rise in the 26 proportion of respondents not ordering hot and cold RTE food delivery, respectively. 27

Compared to pre-COVID-19 times, a substantial increase in behaviors related to hygiene 28 and disinfection practices (22.0% -32.2%) was observed with a lesser increase (11.2%) in 29 handwashing practices before food preparation. Moreover, public concerns about 30 contracting COVID-19 from food led to almost doubling the number of Tunisians using 31 cleaning agents for washing fresh fruits and vegetables (e.g., soaps, non-food grade chlorine 32 bleach) besides a 16 % and 26.1% increase in use among the Jordanian and Lebanese, 33 respectively. However, a third of the respondents did not follow instructions on labels for the 34 use of chemical products. In conclusion, this study identified culture-specific shortfalls in (1) Food shopping and ready-to-eat food purchases, 157

(2) Hygiene practices 158

(3) Risk perception and knowledge 159 160

Only the first and second themes were included in this paper. 161 162 Theme (1) was designed to explore behavioral changes related to the consumption of ready-163 to-eat foods (RTE) foods by asking respondents to report on a 6-point Likert scale (1= More 164 than twice a week, 5= Never, 6= No access to food delivery) the frequency of ordering RTE 165 before and during the pandemic. In this question, the level 6 option was added to the scale 166 as in some Arab countries, food delivery may not be available, hence, it is statistically 167 inaccurate to count those cases as "never." 168 169 Theme (2): On a five-point Likert scale (1= Never, 5=Always), respondents were asked to 170 report the frequency with which they use the cleaning agents to wash the fresh fruits and 171 vegetables (FFV) before and during the pandemic. The cleaning agents would be in that 172 case formerly selected from a multiple-choice question, and respondents can select more 173 than one choice that applies. Similarly, using the same frequency scale, six statements on 174 the protective measures and hygienic practices before and during the pandemic were 175 designed to investigate respondents' behavioral changes as a result of COVID-19 risks and 176 to identify if there is a disparity compared to their concerns towards food safety. The questionnaire was initially designed in English. To ensure the quality of the translation, 183 native speakers performed a back-translation. The survey and the procedure to be followed 184 were approved by the Ethical Approval Committee of the Institutional Review Board of the 185 University of Plymouth and Jordan University of Science and Technology in Jordan, and the 186 We used a convenience sample of general consumers with various backgrounds in 213

Lebanon, Jordan, and Tunisia. We aimed to collect data from 380-400 people in each 214 country to achieve ten respondents per variable as the lower limit to ensure an acceptable 215 margin of error within each country (Hair et al.,2010; Kotrlik and Higgins, 2001, pp. 46-49) . 216

The survey was conducted as an anonymous online survey through Google Forms, a survey 217 administration app that is included in the Google Drive office suite. It is a cloud-based data 218 management tool used to design and develop web-based questionnaires and provides 219 various options for capturing the data from the multiple answers. 220

The invitation for participating in the web survey was sent via Facebook, LinkedIn, and 221

WhatsApp. In the interest of reaching out to broader participants, the web link was also 222 shared via Email to contacts living/residing in Lebanon, Jordan, and Tunisia. The invitation 223 was posted again as a reminder on several Facebook groups. We did not post in public 224 groups categorized by gender or specific profession to avoid biased sampling. 225

Sampling relied mainly on the snowball technique, i.e., referrals from initial subjects to 226 generate additional subjects. Hence, participants were also encouraged to invite family, 227 friends, and colleagues to participate by forwarding the online survey link. Some of the 228 participants shared the web link on their Facebook page. 229

The survey instrument was distributed in English and Arabic and was open for participation 230 from April 28 to June 2, 2020. On the first page of the web survey, participants were 231 provided with the study details, including their right to discontinue participating at any time. 232

Screening questions were used to ensure that participants were over 18 years and live in 233 one of the three countries. To continue with the survey, informed consent was obtained from 234 participants through a check to the box "Agree" required to confirm reading the consent 235 information for participation and that they are above 18 years and living (residing) in 236 Lebanon, Jordan, or Tunisia". 237

Google Forms does not need to key-in respondent data manually; hence the data coding 238 error is minimized, and data were exported to SPSS 26 for statistical analysis. Cross tabulations and chi-square with Fisher's exact tests were used for proportions tests. 246

We also use the Kruskal-Wallis test to compare the independent ordinal variables related to 247 behavioral changes among the different countries. More than a third (33%) and 31% of the respondents stated that they shopped for food once 275 a week and two to three times a week during the COVID-19 pandemic, respectively. In 276 comparison, 25% purchased food less than once a week. Obtaining food and groceries by 277 supermarkets or food shops' delivery services was not common in the three countries (10%) 278

and was significantly the least reported among the Tunisians (Table 2) . Besides, there were 279 no substantial differences in the proportion of those who shopped for food once a week or 280 more frequently (two to three times a week) during the pandemic. Family needs, household 281 food mismanagement, or commonly ingrained habits of buying fresh raw foods are likely the 282 reasons; also, the trust that consumers may have in the food shops may confer some distancing and continuous cleaning and hygiene. Like our study, the authors observed that 287 more than a third (39.8%) of the Tunisian consumers performed food shopping once a week, 288 31.0% two or three times a week, 15.0% daily, and 7.5% every 2 weeks, and 3.5% once a 289 month. Also, only a small percentage of Tunisian consumers (2.1%) relied on food delivery 290 or bought their foods online (Jribi et al., 2020). 291 292 Furthermore, our results showed that more than a third (34%) of the respondents reported 293 they would continue food shopping after the pandemic with the same frequency reported 294 during the outbreak. On the other hand, 65% percent of the surveyed subjects will not or 295 were unsure, of those, almost half (47%) were willing to visit food and grocery shops more 296 often when the pandemic is over. From these results, it seems that the moderate and 297 extreme concerns of the surveyed subjects from the risks of being exposed to the 298 coronavirus through eating and buying food, and from touching food packages and exposure Wilcoxon signed-rank test showed that the pandemic had caused a significant change in 305 respondents' food consumption behavior as shown in the reduced frequency of ordering hot 306 RTE foods (Z = -17.798, p = 0.000) and cold RTE food (Z= -13.379, p = 0.000). These 307 changes were commonly observed in the three countries for the hot and cold RTE food with 308 values for Lebanon (Z= -12.444, p= 0.000 and Z= -9.571, p = 0.00), Jordan ( Z= -11.374, p = 309 0.00 and Z = -8.737968, p= 0.000), and Tunisia (Z= -5.598, p= 0.00 and Z= -3.441, p= 310 0.000) (Supplementary materials- Figure 1a -b) . Overall, there was a significant rise from 311 14.1% to 33.3% and 24.4% to 36.6% in the proportion of those who stopped ordering hot 312 and cold RTE food delivery during the pandemic, respectively (Table 3) 

showing a significantly reduced consumption of RTE foods compared to their counterparts. 314

Nonetheless, the Tunisian respondents showed lower consumption levels before and during 315 the pandemic than the Lebanese and Jordanians because online or direct order for RTE 316 food delivery is not widespread in Tunisia where consumers prefer home-made food 317 products for hygiene and taste reasons (Zaibet et al., 2004) . The delivery services for cold 318 RTE food are not very common in the studied countries, explaining the wide gap in the 319 consumption levels between the cold and hot RTE foods. 320 321 J o u r n a l P r e -p r o o f

These data indicate that food choices were affected by fear of food as a potential vector of 322 the COVID-19 virus. This was observed as we explored the frequency of RTE food 323 consumption among the respondents who mainly reported extreme and moderate levels of 324 concern about getting infected from eating food that may be contaminated with the SARS- 19's impact on food purchasing, eating behaviors, and food safety perceptions (IFIC, 2020). 329

The report shows that people were doing less shopping in-person and cooking more. When 330 asked how their food shopping habits have changed over the past month, half of all survey 331 takers reported shopping in-person less, and nearly half (47%) of survey takers said that 332 they were eating more home-cooked meals than one month ago. Nearly 1 in 3 reported that 333 they were ordering less takeout or delivery than usual, while 16% said they were ordering 334 more often than they used to (IFIC, 2020). Likewise, in China, as a result of the increased 335 frequency of food scares in recent years and the increased Chinese consumers' worries 336 about food safety, consumers' confidence in the quality of food was reduced which led to a 337 drop in demand for certain food products (Liu et al., 2013) . 19.264, p=0.000 for the variable "Dispose of all food and RTEs shopping bags", Z=-19.634, 360 p=0.000 for "Dispose of all boxes and packages of food", Z= -21.453, p=0.000 for 361 "Disinfection of food packaging", Z=-19.415, p=0.000 for "Washing hands after touching food 362 bags and packages", Z= -16.334, p=0.000 for "Washing hands after returning home, Z=-363 10.132, p=0.000 for "Washing hands before preparing food". 364

Compared to the pre-COVID-19 times, a significantly higher number of people were 366 practicing handwashing before food handling, when returning home, and after touching food 367 packages during the outbreak. However, this significance is primarily attributed to a 32.2% 368 and 24.1 increase in frequent handwashing practices after touching food packages and bags 369 and returning home, respectively (Table 4 -5). Although frequent hand washing is one of the 370 most campaigned and recommended practices for protection from getting Covid-19, only an 371 11.2 % increase in reported frequent handwashing before food preparation was observed. 372

Additionally, the data show a rise of 22-23% increase in behaviors related to the frequent 373 disposal of the RTE food shopping bags and of food boxes and packages during the 374 pandemic, respectively, besides a 31% increase in disinfection of food packaging before 375 storing at home when compared to pre-COVID times in the three countries (Table 4-5) . 376 377 At the country level, there were significant differences between Jordan and Lebanon 378 regarding disposing of all RTE shopping bags (p=0.004), and between both, Jordan and 379

Lebanon, and Tunisia and Lebanon (p=000 for both) for disposing of all boxes and covers of 380 food, disinfection of food packaging, and washing hands after touching food bags, after 381 returning home and before preparing food. Furthermore, the Lebanese tended to follow 382 much more frequent precautionary measures and handwashing practices during the 383 pandemic than their counterparts (Table 5) . One-way ANOVA test showed that respondents 384 in Lebanon followed a significantly higher frequency of protective and hygiene practices to 385 guard against the SARS-CoV-2 across all the tested variables. This difference was 386 noticeable in the disinfection of food packages and disposing of food and shopping bags 387 (Table 6) . 388

Locally, many of the information from the international sources (Center for Food Safety and 389

Applied Nutrition, 2020a, 2020b; WHO, 2020) was shared on some local news platforms 390

indicating that there are no reports or evidence of the virus being transmitted through food or 391 food packaging since the route of transmission and infection is primarily respiratory; 392 however, indirect contact with contaminated surfaces and objects would also play a role in 393 transmission (Al Hurra, 2020; Nesan News, 2020; Nidaa al watan, 2020; République 394 Tunisienne Ministère de la Santé, 2020). Thus, to minimize the risk from touching food 395 potentially exposed to coronavirus, handling of packages and goods should be followed by Wilcoxon tests showed a significant increase in the frequency of using different cleaning 419 agents (described in the next section) besides water to wash FFV during the pandemic in the 420 three countries compared to the pre-COVID-19 times (Z= -15.448, p= 0.000). The results 421 also revealed significant differences in FFV washing practices among the three countries (p= 422 0.000). The Lebanese recorded higher levels of use of cleaning agents than the Tunisians 423 and Jordanians (Table 7) . Relative to the pre-pandemic times, the number of Tunisians who 424 always used cleaning agents almost doubled during the pandemic with a 22.3% increase in 425 practice, besides a 16.0% and 26.1% rise in the practice observed among the Jordanian and 426

Lebanese groups, respectively (Table 7) respectively. (Figure 1 ). It is of great concern that more than a third (36%) of the 437 respondents stated that they do not follow instructions or specific guidelines regarding the 438 appropriate concentration while very few (<1%) reported that they relied on their hunch. COVID-19 pandemic has resulted in significant changes in food shopping, food handling, 506 and hygiene practices of the surveyed subjects in Lebanon, Jordan, and Tunisia. The study 507 sample showed a significant rise in their adoption of precautions and hygiene measures for 508 the coronavirus such as disposing of food packages as well as RTE food and grocery 509 shopping bags and disinfecting food packages before storing at home. Although people 510 practiced handwashing much more frequently during the pandemic, the proportion level was 511 lower than expected, particularly before food preparation. Food choices were also affected 512 as seen in the substantial reduction in ordering RTE hot and cold food and food shopping 513 In such a crisis, local authorities shall establish a mechanism to capture and identify 543 misconceptions. It is essential to coordinate efforts with all concerned stakeholders to 544 establish reliable sources of information. Further, local authorities shall communicate the 545 benefits of (a) frequent hand hygiene, (b) health effects of haphazard use of chemicals on 546 food, and (c) importance of appropriate use of cleaning agents, i.e., following use 547

instructions on their labels. This will ensure overall safer practices and reduce health risks. J o u r n a l P r e -p r o o f Total 1074 4.37 1.02 † Mean score of the respondents' attitudes on a 5-Likert scale: 5 "Always", 4 "Often", 3 "Sometimes", 2 "Rarely", 1 "Never" Mean scores in the same column with the same superscript letter are significantly different (p < 0.05) J o u r n a l P r e -p r o o f • Although in-store food shopping frequency was low, reliance on the home delivery for food grocery was not common • The consumption of ready-to-eat foods has significantly decreased during the pandemic • Some hygienic practices increased during the pandemic, but the least reported was handwashing before food preparation.

• The Lebanese showed a higher frequency of protection measures and hygiene practices than did the Jordanians and Tunisians.

J o u r n a l P r e -p r o o f

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