ABSTRACT
There is limited examination about coronavirus disease 19 (COVID-19)–related food handling concerns and practices that cause chemical or microbial contamination and illness, particularly among those with food insecurity. We investigated consumer food handling concerns and practices during the COVID-19 pandemic and whether they differed by food insecurity status. An online survey was distributed among Chicago, IL, residents between 15 July and 21 August 2020 (n = 437). Independent t tests and Fisher's exact tests were used to identify differences in food handling concerns and practices between those with and without food insecurity (alpha = 0.05). Survey items included questions about food handling practices that were considered safe or neutral (i.e., washing hands and produce with water, sanitizing food packaging) and unsafe (i.e., using cleaning agents to wash foods, leaving perishable foods outside) by using 5-point Likert-style scales or categorical responses (i.e., yes, no). Participant responses fell between “slightly” and “somewhat” concerned about contracting COVID-19 from food and food packaging (mean ± standard error [SE]: 2.7 ± 0.1). Although participants reported washing their hands before eating and before preparing foods at least “most of the time” (mean ± SE: 4.4 ± 0.0 and 4.5 ± 0.0, respectively), only one-third engaged in unsafe practices. The majority of participants (68%) indicated that they altered food handling practices due to the COVID-19 pandemic and received information about food safety from social media (61%). When investigating differences in concerns and practices by food insecurity status, food insecure participants were more concerned about COVID-19 foodborne transmission for all food items (all P < 0.001) and more frequently performed unsafe food handling practices than those with food security (all P < 0.001). Results from this study suggest more investigation is needed to understand barriers to safe food handling knowledge and practices, particularly among those with food insecurity.
Keywords: COVID-19, Food handling concerns, Food handling practices, Food safety, Food security, Health communication
Safe at-home food handling practices consistent with government recommendations are essential to reduce risk of foodborne illness, a major public health concern with approximately 9.4 million cases occurring annually in the United States ( 4 ). Prior to the coronavirus disease 19 (COVID-19) pandemic, the prevalence of U.S. consumers performing safe food handling practices has slowly increased over time, albeit in a nonlinear pattern ( 11 ). Evidence suggests that yearly intervals with the highest increases of safe at-home food handling practices coincide with greater media attention about major foodborne illness outbreaks ( 11 ). The demonstrated links between food handling practices, illness, and the media are applicable during the COVID-19 pandemic, as there continues to be substantial media coverage about the COVID-19 pandemic and transmission ( 15 , 29 ). COVID-19 transmission through food handling was considered the top food safety concern for U.S. consumers during the year 2020 ( 14 , 21 , 31 ). Consumer surveys conducted by the International Food Information Council in June and September 2020 reported that during the pandemic, approximately one-third of U.S. consumers expressed concerns about food safety risk during at-home meal preparation, and 85% modified food handling and preparation practices due to COVID-19 ( 20 , 21 ). The food handling and preparation results reported by the International Food Information Council were confirmed by a single longitudinal study that found consumers increased produce washing with mostly water, as well as with soap and vinegar in the United States during the pandemic ( 41 ).
Although current government and international guidelines state there is no evidence that COVID-19 transmission can occur through food and food packaging, preliminary evidence reports that only up to 53% of participants trust food item handling information from a government agency or health care professional ( 44 , 46 ). This disconnect between consumer risk perception with government and clinical recommendations may be partly attributed to (i) challenges associated with safe messaging about safe at-home food handling guidelines directed toward consumers and (ii) easy accessibility to secondary sources (e.g., YouTube) that contain misinformation ( 39 ). Content analysis of YouTube videos about food safety during the COVID-19 pandemic found that 28% of videos recommended washing produce with soap and cleaners and up to 20% of videos suggested food and/or food packaging transmits the COVID-19 virus ( 39 ). Evidence outside the COVID-19 research area asserts that food safety messages are more effective when U.S. consumers perceive substantial risk of contracting the disease through foods ( 25 ). This phenomenon might explain why early reports found participants rinsing foods with bleach and a 20% increase of call data to poison centers from January to March 2020 ( 6 , 16 ). COVID-19–specific food handling practices also differed by sociodemographic factors; higher education level was associated with more frequent washing of produce with soap at the beginning of the pandemic and with using food thermometers during cooking ( 41 ). However, it remains unclear whether food-related socioeconomic vulnerabilities, namely, food insecurity and financial strain, are associated with handling concerns and practices.
Food security is ready access to sufficient food to maintain a healthy lifestyle. Prepandemic, more than 1 in 10 households were food insecure ( 7 ). Emerging evidence suggests that rates of food insecurity in the United States rose during the COVID-19 pandemic, especially during the first several months. Studies indicate that about a third of households that were food secure prepandemic became food insecure in the early phase of the pandemic. These rising rates are likely due to changing resources, such as loss of employment, increasing financial strain, and transportation difficulties—factors that can limit food access ( 7 , 19 , 33 ). The rapid changes in food accessibility during the pandemic might impact how new knowledge is delivered to those with fewer resources, particularly among those of lower income. Notably, the transfer and access to public health information is shown to proceed at a much slower rate or to a lesser degree within communities with fewer resources ( 28 , 30 , 34 ). It is important to understand how changes in food handling practices during crises, such as global pandemics, differ between food secure and insecure populations because these events can exacerbate physical, social, and economical challenges among those with already limited resources. With greater public attention on food handling practices during the COVID-19 pandemic and limited investigation of food safety among food insecurity, there is an opportunity to understand if individuals with limited resources have unique food handling concerns, practices, and resource-seeking behaviors.
Although previous studies investigated overall at-home food handling concerns and practices during COVID-19, more granular information is needed to identify the areas of variability for different food handling concerns and practices, especially by food insecurity status. These results can be used to develop tailored messaging for populations with different physical, social, or economical resources. Thus, the study objectives were to (i) summarize the status of food handling concerns and practices of adults in Chicago, IL, and (ii) investigate whether households with and without food insecurity have different COVID-19 pandemic-related food handling concerns and practices.
MATERIALS AND METHODS
Survey development
The COVID-NUTR survey was developed as an online instrument by using the Qualtrics platform (Qualtrics, Provo, UT) and distributed between 15 July and 21 August 2020. The survey contained 79 items formatted as multiple choice, Likert-style scale, or short response and used skip logic to reduce participant burden. Survey items related to food handling were adapted from existing published instruments, and items about medical history, resources, and food-related concerns were developed by investigators ( 8 , 27 , 35 , 42 , 43 ). Of the 79 items, 49 items focused on concerns about food items (9 items), concerns about different types of foodborne contamination (5 items) ( 42 ), and food handling practices to prevent COVID-19 transmission (35 items) ( 35 ). The remaining 30 items included sociodemographic, medical, and dietary intake information, which helped characterize the participant sample and will be used for future secondary analyses ( 8 , 27 ). Items on concerns and practices used a 5-point Likert-style scale that ranged from “not at all concerned” to “extremely concerned,” or from “never” to “always,” respectively; high numbers indicated greater concern or more frequent engagement. Unsafe food handling practices were defined as behaviors that may lead to chemical or food poisoning (i.e., washing produce and meats with cleaning agents, leaving perishables outside for over an hour). Other survey items were formatted as “mark all that apply” and used categorical response options (i.e., yes, no; see Supplemental Table S1).
The survey also collected information about food insecurity. Food insecurity was scored by using items from the six-item short form of the food security survey module ( 43 ). Participants were asked about food access and affordability. The sum of the responses was calculated for each participant; a score of 0 indicated high food security, while a score of 6 indicated very low security. On the basis of the raw score, participants were assigned to one of three categories per the U.S. Department of Agriculture (USDA) cutoffs: (i) high or marginal food security; (ii) low food security; and (iii) very low food security. To characterize the current practices of all food insecure participants, we combined those with low or very low food security to create an overarching food insecure group ( 43 ). Diet data were collected by using the Dietary Screener Questionnaire, which estimates the daily intake of seven dietary components in the past month ( 27 ). These dietary components include fruit (cup equivalents), vegetable (cup equivalents), dairy (cup equivalents), whole grains (ounce equivalents), total added sugar (teaspoon equivalents), fiber (grams), and calcium (milligrams). The content validity of the entire survey was tested among those with expertise in nutrition, survey development, food science, and epidemiology.
Participant recruitment and study population
Participants were recruited through Amazon's Mechanical Turk (MTurk; https://www.mturk.com/) platform, an online marketplace with features that streamline participant recruitment, data collection, and data validation. This tool has been used across research disciplines and is considered to collect reliable data as evaluated by using test-retest and enroll more demographically diverse participants than standard Internet recruitment approaches ( 2 ). MTurk includes over 250,000 Amazon users who can register as “workers” and browse a job board that contains various online tasks created by job posters for compensation. These tasks can include completing surveys. MTurk's filter tools were used to restrict responses to residents with Chicago zip codes. Participants were included in the analysis if they were older than 18 years, provided race data to ensure a racially diverse sample representative of Chicago residents per census data, resided in Chicago, IL, and consented to participate in the study. Exclusion criteria included incomplete surveys (as defined as not completing the survey), repeated entries from a single Amazon worker identification or implausible or missing body mass index values (<16 or >80 kg/m2). Participants were compensated US$10 upon final survey approval.
Statistical analysis and ethics approval
Statistical analyses were performed by using SAS version 9.4 (SAS Institute Inc., Cary, NC). Data for the overall sample and for those with food insecurity were presented as means ± standard errors and frequency (percentage of sample). Independent t tests (continuous) and Fisher's exact tests (categorical) were used to detect differences between food handling concerns and practices between the food insecure and secure groups. P < 0.05 was considered to be statistically significant. The study protocol and materials were approved by the institutional review board for the primary institution (STU00212946), and all participants provided informed consent prior to the study.
RESULTS
Participant characteristics
Residents in the Chicago area (n = 1,627) responded to the MTurk posting, and 1,127 participants were excluded if they declined to participate (n = 5), did not provide sociodemographic information (n = 359), did not complete the survey (n = 468), did not meet the quota sampling that matched Chicago census race data (n = 175), and had duplicate entries (n = 120). Of the remaining 500 participants, 437 (27%) were determined eligible if they provided plausible body mass index values. Mean age of the overall sample was 34.2 ± 0.5 years (Table 1 ). The study sample included adults who identified as male (55%), mostly non-Hispanic White (60%), and completed at least a high school education (94%). Almost half of the study participants reported being food insecure (51%). The number of physician-confirmed or physician-suspected COVID-19 cases was significantly higher among food insecure (n = 97) versus food secure (n = 9) groups (Table 2 ). Additional demographic differences between food secure and food insecure groups can be found in Table 1. The average completion time for this survey was approximately 18 min.
TABLE 1.
Participant characteristicsa
| Variable | Overall sample (n = 437) | Food insecurity (n = 221) | Food security (n = 216) |
|---|---|---|---|
| Age (yr) | 34.2 ± 0.5 | 33.8 ± 0.6 | 34.5 ± 0.7 |
| Gender, n (%) | |||
| Female | 197 (45.0) | 98 (44.3) | 99 (45.8) |
| Male | 239 (55.0) | 123 (55.7) | 116 (53.7) |
| Other | 1 (0.0) | 0 (0.0) | 1 (0.5) |
| Ethnicity, n (%) | |||
| Hispanic or Latinx | 69 (29.1) | 57 (25.8) | 12 (5.6) |
| Non-Hispanic or Latinx | 357 (81.7) | 155 (70.1) | 202 (93.5) |
| Race, n (%) | |||
| Asian or Asian American | 42 (9.6) | 10 (4.5) | 32 (14.8) |
| American Indian or Alaskan Native | 8 (1.8) | 7 (3.2) | 1 (0.5) |
| Black or African American | 94 (21.5) | 64 (29.0) | 30 (13.9) |
| Native Hawaiian or Other Pacific Islander | 2 (0.5) | 2 (0.9) | 0 (0.0) |
| White | 261 (59.7) | 122 (55.2) | 139 (64.4) |
| Two or more races | 30 (6.9) | 16 (7.2) | 14 (6.5) |
| Highest level of education, n (%) | |||
| Less than 11 yr of education | 2 (0.5) | 2 (0.9) | 0 (0.0) |
| High school graduate | 23 (5.3) | 12 (5.4) | 11 (5.1) |
| Vocational, technical school, some college | 82 (18.8) | 46 (20.8) | 36 (16.7) |
| College graduate | 232 (53.1) | 117 (52.9) | 115 (53.2) |
| Postgraduate | 98 (22.4) | 44 (19.9) | 54 (25.0) |
| Physician-confirmed or physician-suspected COVID diagnosis, n (%) | 106 (24.3) | 97 (43.9) | 9 (4.2) |
| Food security, n (%) | |||
| High or marginal | 216 (49.4) | NAb | NA |
| Low | 111 (25.4) | NA | NA |
| Very low | 110 (25.2) | NA | NA |
| Have your eating habits changed during the COVID-19 pandemic? Yes | 345 (78.9) | 196 (89.0) | 149 (69.0) |
| Dietary intake, daily | |||
| Fruit (cup equivalents) | 1.0 ± 0.0 | 1.0 ± 0.0 | 0.9 ± 0.0 |
| Vegetable (cup equivalents) | 1.5 ± 0.0 | 1.5 ± 0.0 | 1.5 ± 0.0 |
| Dairy (cup equivalents) | 1.8 ± 0.0 | 1.9 ± 0.1 | 1.6 ± 0.0 |
| Total added sugar (teaspoon equivalents) | 17.8 ± 0.4 | 18.9 ± 0.6 | 15.1 ± 0.5 |
| Whole grains (ounce equivalents) | 0.9 ± 0.0 | 0.9 ± 0.0 | 0.7 ± 0.0 |
| Fiber (g) | 16.8 ± 0.2 | 16.4 ± 0.4 | 15.7 ± 0.3 |
| Calcium (mg) | 1,027.1 ± 12.6 | 1,022.2 ± 24.6 | 941.8 ± 18.8 |
Data are expressed as means ± standard errors or as n (percentage of group). Bold values represent significant differences between the food insecure and food secure groups (P < 0.05).
NA, not applicable.
TABLE 2.
Food handling concerns during the COVID-19 pandemica
| Prompts | Overall sample (n = 437) | Food insecurity (n = 221) | Food security (n = 216) |
|---|---|---|---|
| General concerns | |||
| How concerned are you about getting COVID-19 from your groceries?b | 2.7 ± 0.1 | 3.1 ± 0.1 | 2.3 ± 0.1 |
| How concerned are you about getting COVID-19 from food packaging?b | 2.7 ± 0.1 | 3.1 ± 0.1 | 2.3 ± 0.1 |
| Specific concerns | |||
| How concerned are you about getting COVID-19 fromc | |||
| Fresh fruits and vegetables | 2.6 ± 0.1 | 3.1 ± 0.1 | 2.1 ± 0.1 |
| Canned, frozen, or processed fruits and vegetables | 2.3 ± 0.1 | 2.9 ± 0.1 | 1.7 ± 0.1 |
| Meat | 2.6 ± 0.1 | 3.2 ± 0.1 | 2.0 ± 0.1 |
| Milk and dairy products | 2.5 ± 0.1 | 3.1 ± 0.1 | 1.8 ± 0.1 |
| Fish and seafood | 2.5 ± 0.1 | 3.0 ± 0.1 | 1.9 ± 0.1 |
| Sweet and salty snacks | 2.3 ± 0.1 | 3.0 ± 0.1 | 1.7 ± 0.1 |
| Grains | 2.5 ± 0.1 | 3.2 ± 0.1 | 1.8 ± 0.1 |
| Which, if any, are the most pressing food safety concerns?c | |||
| COVID-19 (viral) contamination | 3.2 ± 0.1 | 3.6 ± 0.1 | 2.7 ± 0.1 |
| Bacterial contamination | 3.0 ± 0.1 | 3.4 ± 0.1 | 2.6 ± 0.1 |
| Contamination from heavy metals | 2.6 ± 0.1 | 3.1 ± 0.1 | 2.0 ± 0.1 |
| Contamination from physical hazards (e.g., glass, rocks) | 2.5 ± 0.1 | 3.1 ± 0.1 | 1.9 ± 0.1 |
| Foods that have the greatest health risks (e.g., high sodium) | 3.0 ± 0.1 | 3.4 ± 0.1 | 2.6 ± 0.1 |
Data are expressed as means ± standard errors. Bold values represent significant differences between the food insecure and food secure groups (P < 0.05).
Scales represent the following: 1, not at all; 2, slightly; 3, somewhat; 4, moderately; 5, extremely.
Scales represent the following: 1, not at all concerned; 2, slightly concerned; 3, somewhat concerned; 4, moderately concerned; 5, extremely concerned.
Food handling concerns during the COVID-19 pandemic
Participants in the overall sample reported feeling some concern over contracting COVID-19 from groceries and food packaging (overall mean for both: 2.7 ± 0.1). When participants were asked to rate the level of concern about COVID-19 transmission from specific food items, they were at least slightly concerned for all food items (Table 2). In general, participants rated less concern about processed food items (i.e., canned, frozen, processed fruits and vegetables, and sweet, salty snacks [overall mean for processed: 2.3 ± 0.1]) than with unprocessed foods (i.e., fresh produce, meat, fish and seafood [overall mean for unprocessed: 2.6 ± 0.1, P = 0.007]). When investigating differences in food handling concerns between those with and without food insecurity, food insecure participants were significantly more concerned about getting COVID-19 from groceries and food packaging (Table 2). Those with food insecurity also reported greater concern for foodborne COVID-19 transmission from fresh and processed fruits and vegetables, meats, dairy, fish and seafood, snacks, and grains than the food secure group (all P < 0.0001).
Food handling practices during the COVID-19 pandemic
In the overall sample, 68% of participants reported changing food handling practices due to the COVID-19 outbreak (Table 3 ). Washing hands before eating (mean: 4.4 ± 0.0) and before preparing foods (mean: 4.5 ± 0.0) were the most frequently reported food handling practices, with participants engaging in these practices most of the time and always, respectively. Yet, many participants also engaged in unsafe food handling practices in an attempt to reduce COVID-19 transmission risks. These practices include cleaning produce with soap (35%), vinegar (29%), hydrogen peroxide (11%), and/or alcohol (11%), and washing meat with vinegar (22%). Approximately one-third of participants cleaned food packaging by using alcohol (34%), hand or dish soap (33%), vinegar (13%), and/or bleach (12%).
TABLE 3.
Food handling practices during the COVID-19 pandemica
| Variable | Overall sample (n = 437) | Food insecurity (n = 221) | Food security (n = 216) |
|---|---|---|---|
| Have you made any changes to how you sanitize your food or food packaging due to COVID-19 outbreak?b | 298 (68.2) | 172 (77.8) | 117 (54.2) |
| How much you perform the following practices to prevent COVIDc | |||
| Avoid foods that could be contaminated with COVID-19 | 2.8 ± 0.1 | 3.2 ± 0.1 | 2.4 ± 0.1 |
| Wash hands before eating | 4.4 ± 0.0 | 4.3 ± 0.1 | 4.6 ± 0.1 |
| Wash hands before preparing food | 4.5 ± 0.0 | 4.3 ± 0.1 | 4.7 ± 0.0 |
| Wash fresh fruits and vegetables with water before eating | 4.5 ± 0.0 | 4.2 ± 0.1 | 4.6 ± 0.1 |
| Wash fresh fruits and vegetables with cleaning agents | 2.7 ± 0.1 | 3.2 ± 0.1 | 2.2 ± 0.1 |
| Leave nonperishable groceries outside for more than an hour | 2.5 ± 0.1 | 3.0 ± 0.1 | 1.9 ± 0.1 |
| Leave meat and dairy outside for more than an hour | 2.1 ± 0.1 | 2.8 ± 0.1 | 1.4 ± 0.1 |
| Wash raw meats with water or cleaning agents before cooking | 2.8 ± 0.1 | 3.3 ± 0.1 | 2.3 ± 0.1 |
| What, if any, cleaning agents do you use to wash your fruits and vegetables? | |||
| Hand or dish soap | 152 (34.8) | 95 (43.0) | 57 (26.4) |
| Hydrogen peroxide | 49 (11.2) | 45 (20.4) | 4 (1.9) |
| Bleach | 31 (7.1) | 30 (13.6) | 1 (0.5) |
| Vinegar | 128 (29.3) | 91 (41.2) | 37 (17.1) |
| Alcohol or ethanol | 49 (11.2) | 42 (19.0) | 7 (3.2) |
| What, if any, cleaning agents do you use to wash your meat? | |||
| Hand or dish soap | 72 (16.5) | 58 (26.2) | 14 (6.5) |
| Hydrogen peroxide | 41 (9.4) | 39 (17.7) | 2 (0.9) |
| Bleach | 28 (6.4) | 27 (12.2) | 1 (0.5) |
| Vinegar | 98 (22.4) | 81 (36.7) | 17 (7.9) |
| Alcohol or ethanol | 45 (10.3) | 41 (18.6) | 4 (1.9) |
| What, if any, cleaning agents do you use to wash your food packages? | |||
| Hand or dish soap | 142 (32.5) | 93 (42.0) | 49 (22.7) |
| Hydrogen peroxide | 46 (10.5) | 39 (17.7) | 7 (3.2) |
| Bleach | 51 (11.7) | 36 (16.3) | 15 (6.9) |
| Vinegar | 58 (13.3) | 50 (22.6) | 8 (3.7) |
| Alcohol or ethanol (including Lysol and Clorox products) | 149 (34.1) | 75 (34.0) | 74 (34.3) |
Data are expressed as means ± standard errors or as frequencies (percentage of group). Bold values represent significant differences between the food insecure and food secure groups (P < 0.05).
Data are expressed as n (percentage of group) of yes.
Scales represent the following: 1, never; 2; sometimes; 3, about half the time; 4, most of the time; 5, always.
Compared with food secure participants, a greater proportion of those with food insecurity reported altering food or food packaging handling during the COVID-19 pandemic (54 and 78%, respectively; P < 0.0001). A consistent pattern emerged when examining food handling practices; those with food insecurity reported washing hands prior to eating and preparing foods at a lower frequency (both: P < 0.0009) but more engagement with unsafe food handling practices (i.e., using cleaning agents to wash foods, leaving perishable foods outside) than the food secure group (all P < 0.0001). Specifically, a greater percentage of the food insecure group used soap, vinegar, and hydrogen peroxide to wash produce, meat, and food packaging (all P < 0.0003; Table 3).
Food handling and diet-related resources during the COVID-19 pandemic
Cross-sectional analyses revealed that more than half of the overall sample received information about food handling to prevent COVID-19 transmission from social media (61%) and newspapers or magazines (64%) at the time of survey distribution (Table 4 ). All participants felt the following information would be most helpful: (i) how to safely shop for groceries in person; (ii) how to practice safe habits with delivery foods; and (iii) how to eat healthily on a budget. Compared with those who are food secure, more participants with food insecurity used social media (75 versus 46%), YouTube or online videos (48 versus 30%), and blogs (15 versus 9%).
TABLE 4.
Food handling resources during the COVID-19 pandemica
| Prompts | Overall sample (n = 437) | Food insecurity (n = 221) | Food security (n = 216) |
|---|---|---|---|
| What resources have you used to learn about food safety to prevent COVID-19 contamination? | |||
| Newspapers and/or magazines | 237 (54.2) | 120 (54.3) | 117 (54.2) |
| Social media (such as Instagram, Twitter, Facebook) | 266 (60.9) | 166 (75.1) | 100 (46.3) |
| Research studies | 176 (40.3) | 81 (36.7) | 95 (44.0) |
| Radio and/or podcast | 98 (22.5) | 55 (24.9) | 43 (19.9) |
| YouTube or online videos | 169 (38.7) | 105 (47.5) | 64 (29.6) |
| Blogs | 53 (12.1) | 34 (15.4) | 19 (8.8) |
| Your doctor or health care providers | 143 (32.7) | 72 (32.6) | 71 (32.9) |
| Family or friends | 188 (43.0) | 90 (40.7) | 98 (45.4) |
| Do you feel that the following food resources would be helpful to you during the COVID-19 pandemic? | |||
| How to safely shop for groceries in person | 269 (61.6) | 132 (59.7) | 137 (63.4) |
| How to safely order, receive, handle takeout or delivery food | 225 (51.5) | 120 (54.3) | 105 (48.6) |
| How to unpack groceries at home | 214 (49.0) | 104 (47.1) | 110 (50.9) |
| How to eat healthfully on a budget | 263 (60.1) | 141 (63.8) | 122 (56.5) |
| How to safely prepare food at home | 212 (48.5) | 114 (51.6) | 98 (45.4) |
| How to properly store food at home | 191 (43.7) | 132 (59.7) | 137 (63.4) |
Data are expressed as n (percentage of group) of yes. Percentage will not equal 100% because categories are not mutually exclusive. Bold values represent significant differences between the food insecure and food secure groups (P < 0.05).
DISCUSSION
This study investigated consumer food handling concerns and practices during the COVID-19 pandemic in Chicago, IL, and whether these differed by food insecurity status. Participants had some concerns about COVID-19 transmission through groceries and food packaging, especially with unprocessed foods items (e.g., fresh produce, meat, fish and seafood). Many participants engaged in unsafe based food handling practices in an attempt to prevent COVID-19 transmission through food. These practices included washing produce and meat with cleaning agents, which ran counter to established government guidelines ( 3 , 45 ). Additional analyses revealed that participants with food insecurity were significantly more concerned about foodborne COVID-19 transmission and more engaged in unsafe food handling practices than food secure individuals.
The uncertainty surrounding modes of COVID-19 transmission early in the pandemic may have contributed to a greater perceived risk of disease among U.S. consumers ( 17 ). This phenomenon was reflected in the results presented here, confirming that participants were concerned about foodborne COVID-19 transmission. These results were also consistent with previous surveys that found U.S. consumers felt there was some risk of contracting COVID-19 from food, although to a lesser degree than human-to-human transmission ( 40 , 46 ). The type of food appeared to impact participants' perceived risk of COVID-19 contraction. Overall, participants reported lower concern scores with processed foods than unprocessed foods in the present study. A possible explanation might be that processed food items are often packaged items and can be sanitized without damaging the food, so the perceived risk of transmission is lowered. This hypothesis is supported by our finding that a large percentage of participants (34%) wiped food packages with cleaning agents.
Associations between greater risk perception of disease and more frequent safe food handling practices have been established primarily through cross-sectional design studies ( 49 ). Findings from the present study support this association; several studies, including ours, have reported changes in food handling procedures due to the pandemic ( 10 , 12 , 16 , 21 , 41 ). However, not all changes followed government recommendations. Similar to findings from previous studies, several participants in this study reported using cleaning agents (i.e., soap, hydrogen peroxide, bleach, vinegar, alcohol) to clean their food ( 10 , 12 , 16 , 21 , 41 ). Up to 22% of participants in this study used at least one cleaning agent to wash meat prior to consumption. The use of bleach, soap, and other agents to directly clean food is countermand to existing safe food handling guidance due to chemical risks. Participants also reported leaving meat and other perishable goods outside for over an hour to prevent COVID-19 transmission; such practices may increase microbial food safety risks (e.g., by allowing for pathogen growth on the food items). These shifts toward higher risk practices were consistent with data gathered by the Centers for Disease Control and Prevention and American Association of Poison Control Centers, which reported a 20 and 16% increase in exposure calls related to cleaners from January to March 2020 compared with the same 3 months during 2018 and 2019, respectively ( 6 ). Fear and anxiety might be two of several factors that can account for this increase in unsafe food handling practices ( 10 ). Given the novelty of COVID-19 and attention in the media, there can be strong motivation for consumers to alleviate perceived risk concerns through modified actions and behaviors ( 13 , 15 , 29 , 49 ). Engagement with higher risk food handling practices may serve as a means to reduce one's perceived risk about contracting COVID-19 or to work within the resource constraints imposed by the pandemic (e.g., loss of wages, higher cost of goods, and price spikes) ( 24 , 37 ).
To our knowledge, this study is one of the first to investigate whether COVID-19–driven shifts in food handling concerns and practices differed by food security status. Participants with food insecurity had significantly greater concerns about COVID-19 transmission through food and engaged in more unsafe food handling practices in attempts to prevent transmission. These findings are consistent with results from a previous study that found greater food security was associated with less engagement with food safety practices prior to the pandemic ( 9 ). Most COVID-19–related food safety studies examined sociodemographic factors associated with food handling practices ( 41 ). The totality of evidence suggests that those with greater resources (i.e., income, general education) were more likely to perform government-recommended food handling practices ( 41 ). Yet, those with food insecurity in the present study had greater engagement in nongovernment-recommended food handling practices to prevent COVID-19 transmission. These differences in food handling practices between food insecure and secure groups may partly stem from access to government-recommended safe food handling knowledge. Studies outside of COVID-19 have found individuals with lower income were unaware of government-recommended practices known to reduce risk of foodborne illnesses ( 23 , 47 ).
Other factors may also drive the lower engagement of safe food handling practices among individuals with food insecurity. Preliminary evidence noted that the lack of resources (e.g., thermometers, cutting boards) and culturally sensitive information may drive the greater use of high-risk practices among food insecure populations ( 23 , 32 ). Despite the barriers facing food insecure respondents in the present study, a majority expressed a desire to learn more about good consumer food handling practices, indicating a need for additional guidance and messaging targeting food insecure groups. Although income and education primarily focus on the economic barrier to safe food handling practices, food insecurity also focuses on the physical access to foods. The investigation of food insecurity during the COVID-19 pandemic, rather than solely focusing on income and/or education, is particularly appropriate, as the Centers for Disease Control and Prevention has encouraged the general population to find alternative approaches to public transportation, thus limiting physical access to purchase foods ( 5 ). Further investigation of the unique challenges among individuals with food insecurity is needed to mitigate barriers to safe food handling practices for this population.
Greater engagement with high-risk food handling practices might also be partly attributed to miscommunication or limited communication about recommended food handling practices. A Morbidity and Mortality Weekly Report article by the Centers for Disease Control and Prevention presented a case study about a consumer who heard on the news about the importance of cleaning groceries and then proceeded to soak her produce with bleach, eventually ending in the emergency department from chemical inhalation ( 6 ). In the current study, the highest proportion of participants, particularly those with food insecurity, received food handling information from social media rather than from safe sources, such as health care professionals. The survey data are consistent with prior studies that found social media has been one of the preferred modes of acquiring information about COVID-19 transmission ( 18 , 38 ). However, COVID-19 content on social media about food and about COVID-19 prevention is also rife with misinformation ( 22 , 39 ). One recent study determined that 28% of YouTube videos about food handling practices encouraged washing produce with cleaning agents ( 39 ). Other themes of food handling information also emerged: some videos claimed that the government had no recommendations about food handling and that it was appropriate to leave groceries on the garage or porch for 3 days ( 39 ). The conflicting public food handling information can result in limited clarity as to the appropriate action, especially as outdated information is still circulating among the public and contradicting the new information ( 48 ). Collectively, ours and others' findings highlight the importance of clear safe guidance on food handling practices during crises. This need for clearer risk messaging has been echoed by other studies that examined changes in consumer information-seeking behavior and practices during the COVID-19 pandemic ( 12 , 16 , 26 ).
A strength of this study was the use of previously published items from studies or national surveys to measure food handling concerns and practices, allowing for some comparison with research in this area ( 8 , 27 , 35 , 42 , 43 ). Although other studies investigated sociodemographic factors, this study was the first, to our knowledge, to investigate whether food-related resources are associated with different types of food handling concerns and practices. The study also investigated how concerns and practices may differ between food items. Survey items did not ask “why” certain behaviors were done for the purpose of restricting data to binary, quantitative values for easier statistical analysis; however, this limits our ability to draw conclusions about the rationale behind the survey behaviors. Limitations include the cross-sectional nature of this study, which prevents us from drawing any cause-and-effect relationships between variables. More than half of participants graduated college (53%), which may have influenced true estimates, as higher education was previously associated with greater familiarity with food handling concepts, such as pasteurization ( 1 ). The study results have limited generalizability to those who are food insecure with less educational attainment and who are not English speaking. The survey also relied on participant self-reporting, which could impact the accuracy of capturing actual food handling behavior. There was a high enrollment of individuals with food insecurity in our sample (51%), which could potentially be due to using MTurk as a means for recruitment, as they have a participant pool of individuals seeking employment. Finally, there are confounding variables that this study did not adjust for, such as a previous COVID-19 diagnosis. Despite these limitations, this study identified avenues of research on which future studies can develop food safety-related interventions, particularly for those with food insecurity.
Although this study focused on the impact of the COVID-19 pandemic on consumer food handling concerns and practices, our study provides fundamental knowledge by characterizing the COVID-19–related concerns and behaviors for consumers who experience food insecurity. Participants with food insecurity were more concerned about COVID-19 transmission and often engaged in more unsafe food handling behaviors than food secure individuals. This result suggests a connection between food security status, risk perception, and health behavior changes in light of mixed health messaging. The Centers for Disease Control and Prevention emphasizes that public messages should continue to stress safe food handling practices to prevent COVID-19 transmission in households, but the medical community faces several competing concerns that can hamper food handling communication to consumers ( 16 , 36 ). A majority of respondents used noncurated resources (e.g., social media, YouTube) to gather information on food handling practices to prevent COVID-19; reliance on these noncurated resources could expose respondents to outdated guidance. Dissemination of proper food handling information through social media, YouTube, and similar sources may be a potential medium to help halt misinformation regarding food-related COVID-19 transmission, especially for those with food insecurity. Future studies should use mixed method approaches to understand why participants choose to engage with unsafe food handling procedures and establish collaborations with the public on how to develop effective messages about food safety practices.
ACKNOWLEDGMENTS
This work was supported by National Institutes of Health National Cancer Institute training grants (T32CA193193 and T32ES007271) at the time of this study. The content is solely the responsibility of the authors and does not represent the official views of the National Institutes of Health, the USDA, or any other federal agency. The authors are grateful to the participants of this study for contributions to this research. We also thank Lucia Ontiveros and Steven W. Hays from Northwestern University for administrative support. Thank you to the JFP editors, reviewers, and the copy editor for their efforts in helping us improve this manuscript.
SUPPLEMENTAL MATERIAL
Supplemental material associated with this article can be found online at: https://doi.org/10.4315/JFP-21-216.s1
Supplementary Material
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