Knowledge, attitudes and practices of Iranian people about food safety and hygiene during covid-19 pandemic

Coronaviruses are a wide group of viruses that often cause mild to severe respiratory tract infections like the common cold [1]. Over the last two decades, three novel coronaviruses have evolved from animal reservoirs, causing significant and widespread illness and death [2]. There are hundreds of coronaviruses, the majority of which are found in animals such as pigs, camels, bats, and cats. 229E NL63 OC43 HKU1 SARS-CoV MERS-CoV and SARS-CoV-2 are the seven varieties of known coronaviruses that cause illness in humans [3]. In December 2019, SARS-CoV-2 appeared from Wuhan, China, causing COVID-19 illness. On March 11, 2020, the World Health Organization (WHO) labeled this disease a worldwide pandemic. Approximately two-thirds of the primary cases of patients were found to be linked to the Huanan seafood market in Wuhan, where in addition to aquatic animals, other animals such as civets and raccoon dogs were also sold live [4]. Although, reputable international organizations, including the WHO, food and drug Administration (FDA) and the center for disease control (CDC), have not reported any evidence of covid-19 transmission by food, many people are concerned about covid-19 transmission through water and food due to reports of primary cases of the disease from the seafood market [5].

According to the literature, SARS-CoV-2 is a respiratory virus that spreads directly through infected people's respiratory droplets when they sneeze or cough [6]. The modes of transmission of this virus differ from those of food-borne viruses such as noroviruses and hepatitis viruses. However, it is possible to transmit it indirectly through an infected person working in food establishments. In other words, if an infected person touches the food, sneezes or coughs on it, and then another person comes into contact with the same food and touches his/her nose, eyes, or consumes it, there is a potential of transmission [7]. Furthermore, because studies have shown that the SARS-CoV-2 can survive in cold and refrigerated environments, there is a chance that the virus will be present in refrigerated and cold foods [8].

Despite the start of worldwide vaccination and the proportion of good coverage in communities, the morbidity and mortality rate remain high. As a result, in order to control and eliminate this disease, people must continue to follow health and safety protocols (physical and social distance, masks, etc.) in addition to vaccination [9].

The way people behave in society has a direct impact on the control and prevention of Covid 19 disease, and the process of transmission of this disease is affected by public health behaviors. The existence of preventive health behaviors in times of epidemic in society requires a high level of health knowledge and attitude. The knowledge and attitudes of people about health concerns and issues can lead to the prediction of a health behavior [10]. According to studies, increasing people's knowledge about health issues has a highly favorable effect on improving health status and leading to healthier attitudes and practices. For instance, Jahed Khaniki et al. (2012) conducted a research at Tehran University of Medical Sciences to assess students' knowledge and attitudes on health and food safety. They found that students who have completed food-related courses had a very high level of knowledge and attitude towards other students, as well as significantly better health practices [11].

Given the importance of people's knowledge and attitude regarding food safety during Covid pandemic and absence of related studies among Iranian people, the aim of this study was to determine the level of knowledge, attitude and practice of Iranian peoples (More than 16 years old) about food safety and hygiene during the Covid-19 disease pandemic using an electronic questionnaire.

In this study, we developed a valid and reliable questionnaire to assess the knowledge (K), attitude (A) and practice (P) of Iranian peoples regarding food safety during covid-19 pandemics. Because of multidimensional nature of human activity during pandemics developing comprehensive questionnaires, which contain the important aspect of individual’s relationship and activity, is an urgent need [20]. The developed questionnaire by our team included the essential items to evaluate the personal, interpersonal and the functional activity of individual in society during pandemics.

We evaluate the knowledge of individuals about covid-19 pandemic based on difficulty index. The difficulty index also was satisfactory. Based on our results from KMO test in EFA analysis the sample size of our study was sufficient. During the EFA analysis 20 question were included in the two main groups of our questionnaire. Different item indicators were used to evaluate the dimension of the designed questionnaire. The GFI was in the acceptable range [21]. Different research articles showed that GFI could be influenced by different factors such as degree of freedom and sample size [22, 23]. Our results showed that χ2/df of our model were also within the range of recommended value. The Parsimony-Adjusted Measures Index (PNFI) was in the acceptable range of model fit. One of most preferred measures of model fit is RMSEA. The value exhibits that the developed model was acceptable. According to the results of the CFA analysis, the items were fit for the expected scale. The mentioned CFA indices also confirmed our developed model. Based on the results of descriptive statistics the KR-20 of knowledge and Cronbachs’ alpha of attitude and practice were sufficient.

A Specific covid-19 K-A-P questionnaire was designed by park in 2021. This questionnaire was developed based on international and domestic information. Ten experts evaluated the items and determined the content validity. The Kaiser–Meyer–Olkin value of 0.735 of this questionnaire indicated a highly acceptable score. The Cronbach's α of 0.75 showed an acceptable level of reliability of their tool [24]. Our designed tool is in agreement with her work. The Cronbach's Alpha for attitude and practice of our tool were 0.74 and 0.80 respectively. KR-20 results also indicated a 0.82 score for knowledge aspect of our questionnaire. These results indicate that K-A-P measurement instrument is a valid tool to assess the knowledge, attitudes and practices about covid-19.

Zhong and his colleagues designed another K-A-P measurement tools. Their instrument consisted of two parts including demographic information and KAP. Their questionnaire had 12 question including four clinical presentations (K1-K4), three transmission routes (K5-K7), and five prevention and control (K8-K12) of COVID-19. The Cronbach's alpha coefficient of the knowledge questionnaire was 0.71 in their sample, indicating acceptable internal consistency [25]. Their tool internal consistency is less than our knowledge questionnaire, which is 0.82 and a higher reliability of our instrument.

Results of current study showed that Iranian people had a high level of knowledge, attitude and practice regarding food safety in Covid-19. In this study, 88.2% of the participants had a college or university degree. These findings demonstrate the importance of level of education in enhancing knowledge and attitudes, which leads to successful hygienic practice performance. According to statistical analysis, more than 95% of participants gathered information regarding food safety through various media. These findings indicate that people has felt the need to learn more information during the corona outbreak, and getting this information naturally has led to increased knowledge, attitude, and, as a result, better hygienic practice performance. The most important reason is related to the measures taken by Iran ministry of health and medical education, including sensitization, virtual training, advertising and installation of educational banners in public view, encouraging people to use packaged food and etc.

Several researches have been conducted to evaluate the knowledge, attitudes, and practices of working people in food industry worldwide during covid-19. Jubayer and his colleuges designed a questionnaire to assess the knowledge, attitude, and practices of food industry workers in Bangladesh and their results were promising. The correct response rate of their model were for knowledge 89.7%, attitude 93%, practices 88.2% and they concluded that the respondent showed a satisfactory level of KAP during covid-19 pandemics [26]. Another article performed in Egypt by Abdelrassoul and colleagues. They assessed the knowledge, attitude, and performance of home service providers (motor couriers) of fast food restaurants in Egypt. Six hundred paper questionnaires were distributed among food delivery providers. Their findings showed that people have good knowledge and awareness. However, the level of performance in these persons was low and they were not able to use their knowledge to serve the customers during the covid-19 pandemic. They showed that in order to increase and improve the functional behavior of service providers, continuous training, monitoring and supervision should be done and the existence of a control team for coronary heart disease in restaurants is necessary [27].

Li et al. (2020) in their online questionnaire study assessed and evaluated the knowledge, attitude and practice of more than 123,000 workers in various factories about the new coronavirus in China. In this cross-sectional study, questionnaires were collected online. There were 20 questions about knowledge, six questions about attitude and six questions about performance of workers. The mean scores of knowledge, attitude and practice were 16.3, 4.5 and 5.8, respectively. In this study, about 68.8% of workers positively evaluated gargling with salt water to protect against Covid-19 disease. The study also found that, on average, older and less educated people had low knowledge and practice about Covid-19 disease [28]. Shi and Zhang performed another research in china about the subject. They examined the effects and consequences of Covid disease on the knowledge and practice of food consumers about food safety in their study, data were collected from 1373 participants in the form of an electronic questionnaire. Their findings show that during the Covid-19 epidemic, people paid more attention to health protocols [29].

Luo performed a survey to investigate the knowledge, attitudes and practices (K-A-P) of Chinese people about food safety during covid-19 pandemics. Their designed questionnaire included socio-demographic information, the attention towards COVID-19, K-A-P about food safety and nutrition. Total number of 2272 participant was included in this study. The results of this article indicated that K-A-P of Chinese individuals should be more improved during covid-19 pandemic due to health emergency. They also suggested that other measures such as improving educational materials about covid-19 should be implemented in order to avoid biased or misleading information [30]. With the emergence of the Covid-19 epidemic, the Iranian Ministry of Health and medical education required all citizens to follow health guidelines in order to control and prevent the irreversible repercussions of Covid-19 disease. As a result of these initiatives, people became more aware of the protocols. Undoubtedly, the Covid-19 pandemic influenced people's knowledge and behavior towards food safety. Our findings in this study showed that the Iranian people in the context of the Covid-19 epidemic had a high level of knowledge, attitude and behavior about food hygiene and safety. In other words, it is possible to claim that knowledge, attitudes and practices of people have improved during the covid-19 pandemic due to health emergency conditions.

Our study introduced a specific KAP regarding food safety in covid-19 questionnaire consisted of 27 item multidimensional scale with strong psychometric features. This designed tool is a valid and reliable questionnaire, which allows the researcher to evaluate the knowledge, attitudes and practices of the participants regarding food safety during covid-19 pandemics. This instrument has some advantage compare to other developed questionnaire mentioned above due to culturally adoption and could be potent asset to provide better understanding of knowledge, attitudes and practices during covid-19 pandemics. Moreover, our findings showed a satisfactory level of KAP during covid-19 pandemics. As the study was an online survey, people who have able to fill the online questionnaire participated in this study. Due to the changing situation of Covid pandemic we need to gather data in a limited period.