ABSTRACT

At present, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has not been shown to be transmitted through food. Even so, the coronavirus disease 2019 (COVID-19) pandemic has changed how consumers view food and food safety. This study assessed consumer food safety practices during the COVID-19 pandemic using (i) surveys and (ii) online focus group discussions. From April to August 2020, five waves of surveys were distributed to an online U.S. consumer panel and screened to include only primary food preparers and grocery shoppers. The online focus groups were conducted via WebEx from May to July 2020. Focus group participants were recruited from the first wave of survey respondents. Both survey respondents and focus group participants reported higher levels of hand washing in response to the pandemic. However, survey participants' anticipated levels of hand washing after the pandemic decreased; some focus group participants noted that human nature “kicking in” could lead to lower levels of hand hygiene practice. For each of the 5 months, the surveys reported increased produce washing, both with water only and with water plus soap. Most focus group participants mentioned using water to wash their produce, but some reported using soap and even vinegar to “kill” the virus. Since consumers were worried that SARS-CoV-2 could survive on food, they started to mishandle food to address these concerns. However, this study also reported an increase in food thermometer use during the pandemic. Social determinants like gender, income, education, and age may have also influenced changes in levels of practice throughout the pandemic. The COVID-19 pandemic drove consumers to practice proper and improper food safety practices, which may or may not continue after the pandemic. This study's findings provide timely information to guide future food safety education and communication during health crises and pandemics.

HIGHLIGHTS
  • The COVID-19 pandemic has influenced changes in consumer food handling practices.

  • Consumers increased their frequency of proper food safety practices during the pandemic.

  • Many consumers washed fruits and vegetables with soap during the pandemic.

  • Social determinants like gender and income influenced some food handling practices.

The coronavirus disease 2019 (COVID-19) pandemic has affected how people think about food and food safety in the United States. According to the 2020 Food & Health Survey conducted by the International Food Information Council (IFIC) (35), COVID-19 was the top food safety issue for food handling and preparation in the United States. Almost half of Americans had concerns about food prepared outside the home, while 30% had concerns regarding meal preparation at home (35). Although severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has not been proven to be transmittable through food at the time of this article, concerns that the virus survives on raw foods of animal origin have persisted (57, 79).

During past pandemics, longitudinal survey studies assessed consumer risk perception and behavior (9, 20, 27). A previous study conducted during the 2009 H1N1 pandemic evaluated longitudinal trends in risk perceptions and vaccination intentions (27). Although many studies have evaluated consumer food safety knowledge and perceptions, few longitudinal studies have evaluated consumer food safety risk perceptions and practices during a pandemic. The available longitudinal studies evaluated food safety topics, including risk perceptions and behavioral changes during interventions (3, 45). Because of the lack of research related to consumer food handling practices during a pandemic, the present study utilized a longitudinal approach to assess consumer food handling practices that may have been impacted by the evolving COVID-19 pandemic.

While survey data indicate what is happening, focus group discussions can provide insight into why something is happening: researchers listen and collect qualitative data that include a range of opinions across several groups. Open-ended questions in a group setting allow participants to share their thoughts and feelings about an issue, product, or service (39). Previous studies on food safety have utilized focus groups as a method to collect consumer thoughts on food safety, food safety practices, and barriers to food safety (56, 67, 81). Longitudinal focus group discussions have also assessed changes in thoughts and practices over time (19, 29, 68). With technological advancements and the increased popularity of the Internet, online focus groups have become a popular research method (62, 76). Online focus groups overcome some of the challenges of face-to-face focus groups. Online focus group discussions allow participants to comfortably join the discussion from anywhere in the world, as long as they can access the Internet. This allows researchers to recruit a wider range of participants and reduce transportation costs (77). Research also suggests that the online environment provides participants with a subtle sense of anonymity since they are behind a screen, which allows them to discuss sensitive topics more openly (50, 82). Using online longitudinal focus groups is a novel approach in food safety research. The current study used online longitudinal focus group discussions to assess the changes in perceptions, attitudes, and practices of people in the United States in relation to food safety and the COVID-19 pandemic.

A mixed-method approach increases the validity of and confidence in the results, thereby addressing the shortcomings of using only quantitative or qualitative methods (33, 46). Published studies have used a mixed-method approach by combining survey data with data from interviews or focus group discussions to assess different consumer groups' food safety knowledge and risk perceptions (47, 56). The inclusion of both quantitative and qualitative methods can help researchers understand behaviors and perceptions, which can then assist in theory building or theory testing (63).

This study's objective was to assess food safety education needs and identify food handling behavior changes among consumers during a major pandemic. Researchers employed a longitudinal mixed-method approach using surveys and online focus group discussions to gain a comprehensive understanding of practices like hand hygiene, produce washing, and food thermometer use during the COVID-19 pandemic.

Research protocols were approved by the Institutional Review Board (IRB) before data collection began (IRB no. 2020-558).

Survey pilot study

The researchers developed survey items and distributed surveys using convenience sampling to pilot test face validity. A total of 26 pilot test surveys were completed. In order to test for internal consistency of the different scales, a Cronbach alpha test was conducted on the piloted survey items, and the alpha ranged from 0.65 to 0.91 (53). A few items were added and revised based on respondents' suggestions.

Survey longitudinal study

In order to assess the changes in risk perception and food safety behaviors, the survey was administered over 5 months. Each wave occurred once a month from April 2020 to August 2020. A longitudinal study is a research design that involves repeated observations of the same variables (e.g., people) over time. We were able to collect focus group discussion data among the same group of participants over 3 months. We were unable to collect survey data from the same exact people over time; however, we were able to make sure the participants were recruited from the same consumer panel through Qualtrics XM (Seattle, WA, and Provo, UT).

Survey respondents

For each of the 5 months, survey respondents were recruited from an online consumer panel of Qualtrics XM, an external online survey company (23, 65). The survey was sent to participants across the United States via e-mail invitation or through respondents' panel portals. Qualtrics ensured that a minimum of 700 respondents completed the survey each month (20). Although respondents were not the same people each month, Qualtrics guaranteed respondents were selected from the same pool of consumers. Qualtrics worked with researchers to ensure that each participant who completed the survey received a $5 incentive.

Survey items

Survey items were created based on previous studies related to past pandemics or food safety (2, 3, 20). The first survey in April 2020 had 46 items in total (three items were used to recruit participants for focus group discussions). The remaining four surveys were the same as the April 2020 survey but did not include the recruitment questions for the focus groups. Question topics included preventative practices (hand washing and sanitizing, produce washing, and thermometer usage) for COVID-19 and food safety. Current practices and changes in practices were assessed by asking if respondents practiced certain behaviors before the pandemic and/or during the pandemic and how much they anticipated practicing these behaviors after the pandemic. Participants were required to use a rating scale from 0 to 100, with 0 indicating “never” practice and 100 indicating “always” practice. The topics of these practice questions focused on personal hygiene, food handling, and kitchen cleanliness. All participants were asked about general food safety, including questions regarding their perceptions of food safety, their general concerns about food safety, and their confidence levels in their own food safety measures. All survey questions are included in supplemental Appendix SA.

Survey screening and demographics

The first two screening questions were, “Are you the primary food preparer in the household?” and “Are you the primary grocery shopper in the household?” These questions ensured that all survey participants were primary food preparers and primary grocery shoppers. The demographic screening questions helped match participants' characteristics to the general U.S. population (70). These questions included gender, age, ethnicity, state, income, and education. Other demographic questions included years of meal preparation experience, if there were people in the household who had health conditions, whether anyone in the household worked outside the home, and if anyone in the household had been tested for COVID-19. If anyone in the household had been tested for COVID-19, a follow-up question inquired if the test was positive.

Two questions contained answers like “if you are paying attention, please do not select this option” to detect participants' level of disengagement. We referred to these questions as “instructional manipulation checks” (IMCs); previous studies showed that some online survey respondents did not pay attention when answering questions (52). An IMC acted as an additional screener to improve the quality of the study.

Survey data analysis

Descriptive data, data within each month, and longitudinal data between successive months were analyzed using SPSS version 26 (IBM Corp., Armonk, NY). A paired-sample t test assesses significant differences between two means for the same participants or matched pairs of data (41, 80). This study used a paired-sample t test to assess the difference in means between the levels of practices (washing hands, washing fruits and vegetables, using hand sanitizer, etc.) before, during, and (anticipated) after COVID-19.

A delta (Δ), or difference, in levels of practice (before–during and after–during) assessed behavioral changes in practice based on social determinants that included gender, income, ethnicity, age, education, and whether there were any people in the household with health conditions. Negative deltas for before–during indicated that respondents increased their behavior in response to the pandemic. Similarly, negative deltas for after–during meant that respondents anticipated that they would decrease a behavior after the pandemic.

Further longitudinal analysis using two-way analysis of variance (ANOVA) was conducted to determine if these social determinants had any significant effect on the delta (behavioral change) from month to month (43). One-way ANOVA was also used for longitudinal assessment of significant differences between level-of-practice changes from month to month, without the effect of social determinants (42).

Focus group pilot study

The focus group script was pilot tested through six sessions, with an average of four participants per session. The purpose of the pilot study was to obtain feedback and make minor revisions to the script's questions. Questions were adjusted to allow the moderator to avoid stumbling over words and to provide clarity so participants could understand the questions. The pilot study also allowed researchers to create further probing questions or questions that would evoke further thoughts from participants on a certain topic (39).

Focus group script

The focus group script contained 11 questions related to COVID-19, separated into three sections: preventative measures, food safety concerns, and food safety information. The first section assessed current practices participants used to protect themselves from COVID-19 and whether they thought these practices protected them effectively. The second section addressed food safety concerns, food safety practices, food purchasing habits, and participants' plans to continue those preventative practices after the end of the pandemic. The third section obtained data regarding the quantity and quality of food safety information participants received during the pandemic, trusted sources of food safety information, and preferred delivery formats and topics of food safety communication during the pandemic. During the 3-month longitudinal study, similar questions were asked, with the addition of minor changes to assess the difference between the months. During the third month of the focus groups, an additional question was asked to assess whether participants had been aware or cautious of foodborne illness before the COVID-19 pandemic. This allowed researchers to obtain a baseline of attitudes toward foodborne illness before the pandemic.

Focus group participant recruitment

Focus group participants were recruited from the pool of respondents during the April 2020 wave of the survey. Those who volunteered for focus group sessions were split initially into three groups, low, medium, and high, based on the number of COVID-19 cases in the state in which they resided. This grouping helped assess any differences in perception and practices based on the number of cases in a state. Researchers compiled a list of all states plus Puerto Rico and the District of Columbia (52 “states” total) and the number of cases in each on 27 April 2020 (36). In order to maintain proportionality, any states with over 10,000 cases at the time were considered high, and the remainder were split in half and considered medium and low. This arrangement left 18 states in the high category, 17 in the medium, and 17 in the low (Supplemental Table S1).

After categorizing participants based on the number of cases in their state (low, medium, or high), a convenience sample of up to 12 participants was recruited for each group. Researchers initially planned to have at least three groups of individuals from each type of state to obtain a wide range of opinions across several groups (39). However, due to a low participation rate from low and medium states, researchers combined these groups to create low-medium groups. After recruitment, there were initially two low-medium (LM1 and LM2) groups and four high groups (H1 to H4). By the end of the study, there was one low-medium group and four high groups due to participants dropping out of the study or not showing up to the sessions.

Online longitudinal focus groups

Online longitudinal focus groups were used to assess changes in perception, attitudes, and practices of people in the United States in relation to food safety and the COVID-19 pandemic. Due to the COVID-19 pandemic and the participant locations, the focus group sessions were conducted online via a video-calling service known as WebEx 2020, version 40.2.14.19, from Cisco (San Jose, CA) (48, 59, 77). The sessions lasted a maximum of 90 min and were video and audio recorded for record-keeping and transcription purposes. A moderator and a co-moderator conducted the sessions: the moderator asked questions and directed conversational flow, while the co-moderator took notes. After each session, the moderator and co-moderator debriefed and discussed the highlights of the session. The sessions occurred once a month for three consecutive months, May, June, and July of 2020 (29, 68).

Focus group data analysis

Each session was transcribed word-for-word by one person and checked for accuracy by a different person. The transcriptions were uploaded into NVivo version 12 (QSR International, Burlington, MA) to be coded and analyzed. One researcher reviewed and coded all the transcriptions from the first-month sessions and developed an initial codebook using an inductive and deductive approach with different types of coding methods (5, 60, 64). The study employed a deductive approach by using the questions asked during the focus group sessions as a template and coding participant responses. The study used an inductive approach by coding noteworthy responses and allowing themes to emerge from the data directly (25). These coding methods included attribute, descriptive, emotion, and process coding (60). Attribute coding logs descriptive information about the participants, including gender and age. Descriptive coding refers to codes that summarize the topic of the data, while emotion coding logs the feelings of the participants. Lastly, process coding logs the actions that the participants describe (60). A separate researcher evaluated the codebook and independently coded two transcripts from the first month using the initial codebook. This step minimized bias in codebook development. The two researchers discussed any discrepancies and made changes to the codebook. Because this was a longitudinal study, additional codes apart from the first-month codes were expected. The codebook development occurred throughout the 3-month period to allow these additional codes to be included in the codebook. These additional codes were developed after focus group sessions when the moderator and co-moderator discussed the highlights of the discussion. Six codes in total were added after the initial codebook development. The final codebook (Table S2) was developed completely and finalized with the consensus of the two researchers. The codebook contained the codes, the definition of each code, the coding method, and an example directly from the transcriptions. After the final codebook was complete, the first researcher used the codebook to code the remainder of the sessions and the second researcher checked the transcriptions coded under each code for accuracy.

Categories and themes were developed and analyzed using inductive and deductive approaches as well (Table 1). Both methods allow research questions to be addressed and emergent themes to be discovered. This method ensures a comprehensive review and exploration of all data (81).

TABLE 1

Focus group codes and categories and the themes generated

Focus group codes and categories and the themes generated
Focus group codes and categories and the themes generated

Survey respondents and focus group participants

A total of 3,584 respondents completed the online survey and passed the IMC, with over 700 respondents per month for each of the 5 months from April to August 2020 (Table 2). Slightly more than half were female, approximately 20% were aged 65 years and older, and a majority were white (non-Hispanic). Because the survey was designed to match the U.S. population, the demographic results (gender, age, ethnicity, income, and education) were consistent throughout the 5 months. Most respondents had over 5 years of experience in preparing meals, and at least 37% in each month reported having someone in the household with one health condition listed (Table 2). Most households reported a total of one or two people.

TABLE 2

Overview of survey demographics from April to August

Overview of survey demographics from April to August
Overview of survey demographics from April to August

After the final recruitment of focus group participants, the first session contained two low-medium (LM1 and LM2) groups and four high groups (H1 to H4). The turnout rates, or the percentage of participants who showed up for the first focus group session, were 70, 40, 67, 83, 75, and 50% for LM1, LM2, H1, H2, H3, and H4, respectively. After the first focus group session, LM1 and LM2 were combined due to the low turnout rate of only three people in LM2 (40%), as focus groups usually consist of at least five members (39). The second session's turnout rate was 100% for all groups except LM and H2 (90%). Finally, the last session's turnout was 100% for all groups except LM (78%) and H3 (89%). In total, 38 of 43 people completed the study, with 7 people in the one low-medium group and 31 people in the high groups (8 in H1, 9 in H2, 8 in H3, and 6 in H4). Overall, there was no apparent difference in responses from high groups versus low groups. This may be due to a varied number of cases in different cities within the same state or due to the type of people who volunteered for these discussions. The demographic characteristics of focus group participants are shown in Table 3. A little over half (56%) were female, and the focus groups members included a wide range of ages, with 26% being 45 to 54 years old. Most (81%) identified as white (non-Hispanic). The demographics for the survey were similar to these findings.

TABLE 3

Overview of demographics for all focus group members

Overview of demographics for all focus group members
Overview of demographics for all focus group members

The survey respondents answered questions about safe food handling practices during the COVID-19 pandemic, and focus group participants elaborated on and discussed why they were doing certain practices. This mixed-method approach provided researchers with more in-depth insights on why people might be engaging in certain practices during this major health event. In the sections below, “survey respondents” are those who contributed to survey results, while “focus group participants” are those who contributed to focus group results.

Hand hygiene

Hand cleanliness cannot only reduce the spread of COVID-19 but is also a vital food safety practice that can decrease the risk of foodborne illness. Although survey respondents reported high levels of hand washing with soap during the pandemic, they anticipated a significant decrease after COVID-19 within all months surveyed (Fig. S1). In contrast, while there were low levels of hand washing with just water during the pandemic, survey respondents anticipated significantly higher levels of washing their hands after the pandemic with water only as opposed to using both soap and water.

Many focus group participants mentioned hand washing as a practice to avoid contracting COVID-19 from people and food. Although most focus group participants did not mention if they used soap while washing, one participant admitted to previously using only water at times: “So when I was at work, I have this peer pressure. You're around people, and in a public restroom you must do the full hand wash . . . I was just pretty much a water-and-go person here in the house, and now I'm doing the whole happy birthday song with soap” (female, 45 to 54, H1, May). When asked if they would continue the practice of washing hands after the pandemic, almost all the focus group participants said they would continue. However, their reasons varied as to why they would continue after the pandemic: (i) increased awareness of diseases or risk, (ii) newly formed habits during the pandemic, and (iii) increased awareness of personal hygiene practice. However, some focus group participants also agreed that human nature would “kick in,” and the level of practice might decrease over time.

Hand sanitizer use is not a recommended safe food handling practice but was recommended during the pandemic for the prevention of SARS-CoV-2 transmission (14, 69). Hand sanitizing was considered a practice that would be reduced after the pandemic. Figure S1 shows the decline of anticipated hand sanitizer use after the pandemic in all months during the survey study, which was similar to the focus groups. When assessing longitudinal differences for practices during COVID-19, the levels of hand sanitizer use were significantly lower in April than in July and August 2020. Throughout the 3-month-long focus group study, many participants anticipated stopping the use of hand sanitizers after the pandemic or even during the pandemic for these reasons: it is an additional step, it irritates the skin, perceptions that it may be toxic to the body, and that it could kill “regular” germs on the skin. Some people also noted that they did not use it often before the pandemic, so they anticipated that this practice would simply fade after the pandemic. Similar to hand hygiene, consumers reported changes in the method and levels of produce washing during the COVID-19 pandemic, as we discuss in the following section.

When analyzing the effect of social determinants on the behavioral change for hand washing, gender and income had a significant impact on the behavioral changes in response to the pandemic and anticipated change after the pandemic in most months. Meanwhile, education and age only had an impact in 1 or 2 months (Table S3A to S3E). When examining the behavioral change in response to the pandemic, males had a greater change than females in washing hands with soap in response to the pandemic. Similarly, respondents with higher incomes (>$50,000 annually), education levels (≥bachelor's degree), and ages (>55 years old) showed greater changes in washing hands with soap in response to the pandemic. When examining the anticipated behavioral change after the pandemic, males, respondents with higher income (>$50,000 annually), and older adults (>55 years old) anticipated themselves as significantly more likely to maintain their behavior of washing hands with soap after the pandemic.

Produce washing

The survey also assessed fruit- and vegetable-washing levels, both with water only and water plus soap (Fig. S1). In each month, there was a significant increase in produce washing with water only and with water plus soap during the pandemic compared with (what they remembered doing) before the pandemic. Although respondents' anticipated levels of produce washing (after the pandemic) with just water remained the same in April, May, and June, there was a significant decline in July and August. The anticipated levels after the pandemic for water plus soap stayed nearly the same for all months until August, when there was a significant decline (Fig. S1).

Although many focus group participants reported using only water to wash fruits and vegetables in May and June, some used soap, or even vinegar, to “kill the virus.” By July, many participants had started washing their produce with just water instead of using soap and water. One reason participants identified for washing their produce was their fear of people “breathing” on the food or touching it at the grocery store. One participant expressed her concern in this way: “I just have nightmares of people going into stores touching everything and leaving it behind for someone else. . . . making sure that I take care of any fruit or vegetables. Even my bananas before I eat them” (female, 65+, H1, May). Although many focus group participants reported feeling more comfortable about not contracting COVID-19 from food by the third session, some still used water plus soap or vinegar.

When analyzing the effect of social determinants on the behavioral change for produce washing with water only, age had an impact in one of the months where older adults (>55 years old) anticipated themselves as significantly more likely to maintain their behavioral change of produce washing with water only after the pandemic (Table S3A to S3E). However, gender, age, and education had an impact in 1 of the 5 months for produce washing with soap. When examining the behavioral change in response to the pandemic, females and those with higher education levels (≥bachelor's degree) had significantly changed their behavior and washed produce with soap more in response to the pandemic. When examining the anticipated behavioral change after the pandemic, older adults (>55 years old) anticipated themselves as significantly more likely to quit their behavioral change of produce washing with soap after the pandemic.

When comparing overall behavioral change in response to the pandemic from month to month, respondents were more likely to change their behavior in produce washing with soap in response to the pandemic in April than in later months (June and July). When examining the impact of social determinants on behavioral change from month to month, in April, those with higher education levels (≥bachelor's degree) had a significantly increased level of produce washing with soap, while in June and July, the behavioral changes were similar for both levels of education (data not presented in the tables).

Thermometer use

The use of food thermometers and refrigerator thermometers was reported during the survey study (Fig. S1). Most consumers claimed they used food thermometers at least “sometimes” during the pandemic. Compared with before the pandemic, there was a significant increase in food thermometer use during the pandemic. The increase was significant in each survey for each of the 5 months. However, when assessing longitudinal differences for food thermometer use during COVID-19, significantly more survey respondents said they used food thermometers in July than in May.

In contrast to the survey results, only a few focus group participants mentioned using food thermometers to check the doneness of foods: “Chicken is supposed to be 155 or 165. I have a marker in there, and so I just keep my food thermometer, and I just measure everything” (female, 45 to 54, LM, June). Some focus group participants mentioned cooking food as a practice to kill the virus. One participant purchased a food thermometer in response to the pandemic: “I just bought a food thermometer, and I know that I probably should have had one before” (male, 35 to 44, LM, July). Among the focus group participants who did not use food thermometers, only one provided the rationale that he had a “good grip” on meat doneness.

When analyzing the effect of social determinants on the behavioral change in response to the pandemic for thermometer use, age had an impact in 2 of the 5 months, while income and education had an impact in 1 of the 5 months (Table S3A to S3E). Gender did not have an impact on the behavioral change of thermometer use in any of the months. When examining the behavioral change in response to the pandemic, younger adults (<55 years old), those with a higher income (>$50,000 annually), and those with a higher education level (≥bachelor's degree) had a greater change in their behavior for using food thermometers in response to the pandemic.

Decline in postpandemic hand hygiene

Hand hygiene and proper hand washing was the earliest and most important recommendation that experts gave to consumers when the COVID-19 pandemic hit the United States (15, 78). In the present study, the survey data and focus groups confirmed an increase in hand washing during the pandemic compared with before the pandemic. This finding is similar to recent studies focused on hand hygiene and the COVID-19 pandemic and previous studies about the H1N1 pandemics (30, 55). The increase in hand washing during these health events may be due to the emphasis on this practice as a preventative measure for diseases in general (17). However, survey and focus group results showed a significant reduction in anticipated hand washing with soap and hand sanitizer use after the pandemic.

This decrease in proper hand hygiene throughout the pandemic and as anticipated after the pandemic may be attributed to people becoming less responsive to risks involved in decreased hand hygiene, or as focus group participants mentioned, human nature “kick[ing] in.” This phenomenon, coined “caution fatigue,” describes people reducing their vigilance in taking precautionary measures (38, 51). This lack of vigilance not only increases the risk of spreading SARS-CoV-2 but can cause the spread of other diseases as well. When assessing hand sanitizer use separately, some focus group participants were concerned it was harmful; this may be due to reports of harmful ingredients. In June 2020, the U.S. Food and Drug Administration warned against using certain alcohol-based hand sanitizers because they may contain ingredients like methanol, which may be toxic and cause adverse effects if used or ingested (73). Another reason for less hand sanitizer use might be the low availability of hand sanitizer during the pandemic (58).

Because a large percentage of foodborne disease outbreaks are caused by lack of hand hygiene, a decline in hand washing and hand sanitizing may cause an increase in consumers' risk of contracting a foodborne illness (10). Hand hygiene is an important component of food safety messages to ensure consumer safe food handling practices. Consumers should also be educated on the importance of hand hygiene not only for the pandemic but to prevent cross-contamination and foodborne diseases.

Increased caution in food preparation during COVID-19

The COVID-19 pandemic has caused consumers to change their food handling practices. The survey and focus group results in the current study showed increased fruit and vegetable washing and food thermometer use by consumers during the pandemic. This is an indication that consumers are becoming more cautious when preparing foods during the pandemic. Although there is no evidence yet to prove that COVID-19 can be spread through food, consumers may worry about people touching their food, which can cause the food to be a fomite, or an inanimate object that can spread pathogens and infect humans (28). A previous study on the spread of norovirus on a houseboat found that fomites played a potential role in the contamination and outbreak of norovirus (37). The fear of food itself may also play a role in consumer food handling changes during the pandemic. A recent study noted a possible connection between frozen foods and the spread of SARS-CoV-2 (54). Although food handling was not explored thoroughly during past pandemics, consumer behavioral change and increased preventative measures were observed in response to these previous pandemics and health events (7, 20, 55). Because food safety was a major concern during COVID-19, consumers may be seeking more information and learning about food handling practices (34). A more recent study in China of the COVID-19 pandemic's impact on food safety knowledge in residents found that the pandemic may have also improved consumers' food safety knowledge and behavior (61).

Consumers implemented fruit and vegetable washing practices as a preventative measure against COVID-19. There may be a connection between produce washing and new COVID-19 cases in the United States. The present study reported that anticipated levels of produce washing after the pandemic with water only and water plus soap declined in August. This may be due to the declining case numbers by August 2020 (13, 18). Consumers might have been less afraid of contracting SARS-CoV-2 from their food because of the declining number of cases. Although water was the primary method used to wash produce, some focus group participants in this study reported using other techniques, like soap or vinegar, to clean their fruits and vegetables. A recent content analysis of food safety information in YouTube videos during the COVID-19 pandemic (June 2020) found that some people, including health care professionals, suggested that people should wash their fruits and vegetables with soap (66). The content analysis study also found that some people suggested this practice because it was the same as the recommended practice for proper hand washing. This dissemination of misinformation may be one reason consumers in the United States wash their produce with water plus soap instead of water only. Another recent study found an increase in calls to poison control centers about exposure to cleaners and disinfectants, which may be due to consumers using these products on food (26). Many experts warn against washing fruits and vegetables with anything but water only since detergents may not rinse off the produce, which can make consumers ill when the produce is ingested (71, 72).

Survey participants increased their food thermometer use in response to the pandemic, and focus group participants also mentioned using heat while cooking food to kill the virus. The increase in thermometer use during the pandemic may indicate that consumers have become more aware of food safety measures during the pandemic by connecting the safe food handling to killing the virus on food. The current survey also reported a significant increase in the use of thermometers in July compared with May. There are two potential factors that may contribute to this longitudinal change. There were higher numbers of new COVID-19 cases in the United States in July than in May, which may have influenced consumers to take extra precautions in July (16). Another possible reason may be connected to the outbreak of COVID-19 in Beijing, which was reported to be associated with imported salmon (4). The increasing number of people becoming ill from May to July and the raw-food–related outbreak news may have influenced consumers to take extra steps to make sure the virus is eliminated. Because the current study concluded there was an increase in food thermometer use, it is important to spread information on proper food thermometer techniques and correct endpoint temperatures (24). A previous study found that although most food workers understood the importance of using a food thermometer when cooking meat and poultry products, very few knew the endpoint temperature needed to ensure product safety (8).

Food safety experts and educators should be aware of heightened food safety concerns during major health events so that evidence-based, proper cleaning methods can be disseminated to consumers earlier during the pandemic so as to avoid consumers harming themselves with improper techniques like using soap to wash produce. Increased awareness of food safety practices is also beneficial to consumers and food safety educators, who should use this time during the pandemic and other similar health events to provide consumers with correct information while food safety attention levels have increased.

Social determinants of health affecting food handling changes during COVID-19

Many demographic characteristics are social determinants of health, conditions that affect a wide range of health, functioning, and quality-of-life outcomes and risks (11). Exploring the impact of social determinants for consumer food handling practices can aid food safety and health experts to develop audience-targeted educational materials. Social determinants, including gender, income, education level, and age, were reported in the 5-month survey results.

Male respondents significantly changed their behavior in hand washing with soap compared with females (Table S3A to S3E). The difference between genders could be caused by the fact that males tended to have a lower compliance rate of hand washing with soap before the pandemic. The gender difference in hand washing was also reported in other studies. A recent Centers for Disease Control and Prevention study reported that men were less likely to remember to wash their hands than women during the COVID-19 pandemic (12). Previous studies also found that gender played a role in health engagement (22, 74). Ek's (22) study on the effect of gender on health information behavior found that being female was a strong predictor of being more involved and proactive in health-related issues compared with males. The lack of male involvement around health issues may be a reason for lower levels of hand washing before the pandemic. However, the pandemic resulted in males having a significantly greater change in washing hands with soap than females, which may indicate that the fear-inducing nature of the COVID-19 pandemic may have influenced males to make greater changes.

In most months, the responses indicated that those with over $50,000 in annual income had higher levels of hand washing with soap than those with incomes lower than this annual figure. In some months, the responses also displayed that those in this higher-income category were more likely to use a food thermometer more during the pandemic than those in the lower-income category. Previous studies have assessed food safety knowledge and practices of low-income groups (40, 75). A study by Wenrich et al. (75) found that many low-income adults in Pennsylvania had risky food practices and beliefs. These included being unaware of correct refrigeration temperatures, cross-contamination, and a lack of disinfection practices. Low-income individuals may have multiple barriers preventing safe food handling practices or the acquisition of food safety knowledge. These individuals may not have access to proper food safety courses due to distance, Internet availability, or insufficient funds to pay for such courses. An observational study also found that families making less than $1,000 per month were less likely to use cutting boards, paper towels, and soap (21, 67). Therefore, it is important to consider how some consumers may not have opportunities or access to information and resources due to their financial situation. A higher income can also allow consumers to have more food safety resources, such as thermometers and disinfectants, which are necessary to perform certain safe food handling practices. It has been shown that the pandemic had a major economic impact on the United States (31). With the decline in employment and earnings during the pandemic, those with lower income may be even less inclinced to practice safe food behaviors due to the barriers; they may be more focused on providing the essentials for themselves and their families.

Much like income, those with a bachelor's degree or higher had greater levels of hand washing with soap and thermometer use during the pandemic than those with lower education levels. Similar results were seen in a previous study where researchers assessed the food safety practices and risk perceptions of Mexican-Americans and found that those with a college degree or higher acknowledged that food thermometer use is important and hand washing was a method to reduce the risk of food poisoning (56). Another more recent study (32) on consumer perceptions of food safety found that those with higher education levels were more likely to own a food thermometer. People with higher educational degrees may be more likely to seek information and put preventative measures into practice.

Education also had an effect when assessed longitudinally. Those with higher education levels practiced washing produce with soap more in April, but the changes started to even out between education levels in June and July. This may be explained by the dissemination of false information earlier on during the pandemic and how those with higher education levels may have heard about it first. However, as more information about proper practices emerged, the levels of washing produce with soap declined as well. Food safety educators should find ways to reach people from all educational backgrounds during major health events like the COVID-19 pandemic and under normal circumstances.

Age played some role in consumers' preventative measures during the pandemic. The current survey results showed that, in some areas, older adults tended to be more careful with hand hygiene in response to the pandemic. These findings are similar to a previous health study where older adults (45 to 64 years old) were more engaged in diabetes risk reduction activities (1). However, this study also found that younger adults (<55 years old) had a significant increase in using thermometers in response to the pandemic. This contradicts previous studies where younger participants (<34 years old) had a lower usage of food thermometers and less knowledge on how to use one (6, 24, 49). This shift in behavior during the COVID-19 pandemic may be due to the increased awareness of food safety during this time. It also needs to be noted that the previous studies reported the age group of the participants as younger than 34 years old, while in the current survey, the younger participants referred to those who were younger than 55 years old. The differences could also be attributed to the age group differences between the studies.

Although this study was carefully planned and executed, there were some limitations. Respondents and participants may not accurately represent all consumers in the United States due to the online nature of the recruitment process. Some consumers may not have had access to the Internet, and those recruited may have had similar mindsets, as they came from the same panel. Because focus group participants volunteered to be a part of this study, they may have had stronger views on this topic as well. Dropping out or not showing up to focus group sessions are limitations that have been noted in previous longitudinal focus group studies (29, 44). Possible reasons for not joining or completing all three discussion sessions can be scheduling conflicts, emergencies, loss of interest, forgetting the appointment, or even connectivity issues with the online platform. Because the present study's participants lived in different time zones, there might have also been confusion about session appointment times.

Due to the limited number of questions allowed on the survey, questions about meal delivery and how consumers decided at which grocery stores to shop were not included in the survey. The questions in the survey were pilot tested for face validity; however, other validities were not examined. Furthermore, this study is based on self-reported behavior, not actual observation. Previous studies reported discrepancies between self-reported and actual food handling behaviors (8, 24). Future studies can evaluate consumers' safe food handling behavioral change via observation or other similar methods.

This study concludes that the COVID-19 pandemic has impacted consumer food safety handling practices in the United States. While some safe food handling practices increased, such as hand hygiene, washing produce with water, and food thermometer use, some potential mishandling practices identified may be due to the spread of misinformation, like washing produce with soap. It is critical to engage the public in learning about safe food handling practices earlier on during major health incidents, like the COVID-19 pandemic. More research needs to explore social determinants' impacts on behavioral change during a pandemic. This study's findings provide timely information to guide future food safety education and communication during health crises and pandemics.

We thank the following individuals for their expertise and assistance: Han Chen, Tressie Barrett, Juan Archila-Godínez, Ziyue Zhang, Cai Chen, Ishani Roychowdhury, Audra Brewer, and Rose Ernst.

Supplemental material associated with this article can be found online at: https://doi.org/10.4315/JFP-21-006.s1; https://doi.org/10.4315/JFP-21-006.s2

1.
Ali,
M. K.,
Bullard
K. M.,
Imperatore
G.,
Benoit
S. R.,
Rolka
D. B.,
Albright
A. L.,
and
Gregg
E. W.
2019
.
Reach and use of diabetes prevention services in the United States, 2016-2017
.
JAMA Netw. Open
2
:
e193160
.
2.
Bangerter,
A.,
Krings
F.,
Mouton
A.,
Gilles
I.,
Green
E. G.,
and
Clémence
A.
2012
.
Longitudinal investigation of public trust in institutions relative to the 2009 H1N1 pandemic in Switzerland
.
PLoS One
7
:
e49806
.
3.
Barrett,
T.,
and
Feng
Y.
2021
.
Evaluation of food safety curriculum effectiveness: a longitudinal study of high-school-aged youths' knowledge retention, risk-perception, and perceived behavioral control
.
Food Control
121
:
107587
.
4.
BBC News.
18 June
2020
.
Coronavirus Beijing: why an outbreak sparked a salmon panic in China
.
Available at: https://www.bbc.com/news/world-asia-china-53089137. Accessed 17 December 2020.
5.
Braun,
V.,
and
Clarke
V.
2006
.
Using thematic analysis in psychology
.
Qual. Res. Psychol
.
3
:
77
101
.
6.
Brennan,
M.,
McCarthy
M.,
and
Ritson
C.
2007
.
Why do consumers deviate from best microbiological food safety advice? An examination of ‘high-risk'consumers on the island of Ireland
.
Appetite
49
:
405
418
.
7.
Brug,
J.,
Aro
A. R.,
Oenema
A.,
De Zwart
O.,
Richardus
J. H.,
and
Bishop
G. D.
2004
.
SARS risk perception, knowledge, precautions, and information sources, the Netherlands
.
Emerg. Infect. Dis
.
10
:
1486
1489
.
8.
Bruhn,
C. M.
2014
.
Chicken preparation in the home: an observational study
.
Food Prot. Trends
34
:
318
330
.
9.
Bults,
M.,
Beaujean
D. J.,
de Zwart
O.,
Kok
G.,
van Empelen
P.,
van Steenbergen
J. E.,
Richardus
J. H.,
and
Voeten
H. A.
2011
.
Perceived risk, anxiety, and behavioural responses of the general public during the early phase of the influenza A (H1N1) pandemic in the Netherlands: results of three consecutive online surveys
.
BMC Public Health
11
:
2
.
10.
Centers for Disease Control and Prevention.
2016
.
Hygiene fast facts. Information on water-related hygiene.
Available at: https://www.cdc.gov/healthywater/hygiene/fast_facts.html. Accessed 8 December 2020.
11.
Centers for Disease Control and Prevention.
2019
.
Social determinants of health: know what affects health
.
Available at: https://www.cdc.gov/socialdeterminants/faqs/index.htm#faq7. Accessed 17 December 2020.
12.
Centers for Disease Control and Prevention.
2020
.
Characteristics associated with adults remembering to wash hands in multiple situations before and during the COVID-19 pandemic—United States, October 2019 and June 2020
.
Available at: https://www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6940a2-H.pdf. Accessed 6 December 2020.
13.
Centers for Disease Control and Prevention.
2020
.
COVIDView summary ending on August 22, 2020
.
14.
Centers for Disease Control and Prevention.
2020
.
Handwashing: clean hands save lives. When and how to wash your hands.
Available at: https://www.cdc.gov/handwashing/when-how-handwashing.html. Accessed 14 October 2020.
15.
Centers for Disease Control and Prevention.
2020
.
COVID-19. How to protect yourself & others.
16.
Centers for Disease Control and Prevention.
2020
.
Previous U.S. COVID-19 case data.
17.
Centers for Disease Control and Prevention.
2020
.
Handwashing: clean hands save lives. Show me the science—why wash your hands?
Available at: https://www.cdc.gov/handwashing/why-handwashing.html. Accessed 8 December 2020.
18.
Health
CNN
22 October
2020
.
Daily coronavirus case numbers in the US are at levels not seen since the summer, and 14 states recently have set hospitalization records
.
19.
Derrett,
S.,
and
Colhoun
S.
2011
.
Being a quantitative interviewer: qualitatively exploring interviewers' experiences in a longitudinal cohort study
.
BMC Med. Res. Methodol
.
11
:
1
10
.
20.
de Zwart,
O.,
Veldhuijzen
I. K.,
Richardus
J. H.,
and
Brug
J.
2010
.
Monitoring of risk perceptions and correlates of precautionary behaviour related to human avian influenza during 2006–2007 in the Netherlands: results of seven consecutive surveys
.
BMC Infect. Dis
.
10
:
114
.
21.
Dharod,
J. M.,
Perez-Escamilla
R.,
Paciello
S.,
Venkitanarayanan
K.,
Bermudez-Millan
A.,
and
Damio
G.
2007
.
Critical control points for home prepared ‘chicken and salad' in Puerto Rican households
.
Food Prot. Trends
27
:
544
552
.
22.
Ek,
S.
2015
.
Gender differences in health information behaviour: a Finnish population-based survey
.
Health Promot. Int
.
30
:
736
745
.
23.
Feng,
Y.,
and
Archila
J.
2020
.
Consumer knowledge and behaviors regarding food safety risks associated with wheat flour
.
24.
Feng,
Y.,
and
Bruhn
C. M.
2019
.
Motivators and barriers to cooking and refrigerator thermometer use among consumers and food workers: a review
.
J. Food Prot
.
82
:
128
150
.
25.
Fereday,
J.,
and
Muir-Cochrane
E.
2006
.
Demonstrating rigor using thematic analysis: a hybrid approach of inductive and deductive coding and theme development
.
Int. J. Qual. Methods
5
:
80
92
.
26.
Gharpure,
R.,
Hunter
C. M.,
Schnall
A. H.,
Barrett
C. E.,
Kirby
A. E.,
Kunz
J.,
Berling
K.,
Mercante
J. W.,
Murphy
J. L.,
and
Garcia-Williams
A. G.
2020
.
Knowledge and practices regarding safe household cleaning and disinfection for COVID-19 prevention—United States, May 2020
.
Am. J. Transplant
.
20
:
2946
2950
.
27.
Gidengil,
C. A.,
Parker
A. M.,
and
Zikmund-Fisher
B. J.
2012
.
Trends in risk perceptions and vaccination intentions: a longitudinal study of the first year of the H1N1 pandemic
.
Am. J. Public Health
102
:
672
679
.
28.
Goldman,
E.
2020
.
Exaggerated risk of transmission of COVID-19 by fomites
.
Lancet Infect. Dis
.
20
:
892
893
.
29.
Grey,
C. N.,
Schmieder-Gaite
T.,
Jiang
S.,
Nascimento
C.,
and
Poortinga
W.
2017
.
Cold homes, fuel poverty and energy efficiency improvements: a longitudinal focus group approach
.
Indoor Built Environ
.
26
:
902
913
.
30.
Haas,
R.,
Sekercioglu
F.,
Meldrum
R.,
and
Young
I.
2020
.
“I walk around like my hands are covered in mud”: food safety and hand hygiene behaviours of Canadians during the COVID-19 pandemic
.
31.
Han,
J.,
Meyer
B. D.,
and
Sullivan
J. X.
2020
.
Income and poverty in the COVID-19 pandemic
.
National Bureau of Economic Research
,
Cambridge, MA
.
http://www.nber.org/papers/w27729. Accessed 20 November 2020.
32.
Her,
E.,
Almanza
B. A.,
Ma
J.,
Ge
L.,
Liu
Y.,
Lando
A.,
Wu
F.,
and
Verrill
L.
2020
.
Microbial awareness and risk perceptions are key to thermometer ownership and use
.
Food Control
115
:
107268
.
33.
Hurmerinta-Peltomäki,
L.,
and
Nummela
N.
2006
.
Mixed methods in international business research: a value-added perspective
.
Manag. Int. Rev
.
46
:
439
459
.
35.
International Food Infomation Council.
2020
.
COVID-19 pandemic transforms the way we shop, eat and think about food, according to IFIC's 2020 Food & Health Survey
.
36.
Johns Hopkins Coronovirus Resource Center.
2020
.
COVID-19 dashboard
.
Center for Systems Science and Engineering (CSSE)
,
Johns Hopkins University, Baltimore, Maryland
.
Available at: https://coronavirus.jhu.edu/map.html. Accessed 27 April 2020.
37.
Jones,
E. L.,
Kramer
A.,
Gaither
M.,
and
Gerba
C. P.
2007
.
Role of fomite contamination during an outbreak of norovirus on houseboats
.
Int. J. Environ. Health Res
.
17
:
123
131
.
38.
Kossakovski,
F.
29
July
2020
.
Why people are taking more coronavirus risks as the pandemic drags on
.
39.
Krueger,
R. A.
2014
.
Focus groups: a practical guide for applied research
.
Sage Publications
,
Los Angeles
.
40.
Kwon,
J.,
Wilson
A. N.,
Bednar
C.,
and
Kennon
L.
2008
.
Food safety knowledge and behaviors of Women, Infant, and Children (WIC) program participants in the United States
.
J. Food Prot
.
71
:
1651
1658
.
41.
Laerd Statistics.
2015
.
Paired-samples t-test using SPSS statistics
.
42.
Laerd Statistics.
2017
.
One-way ANOVA using SPSS Statistics
.
Available at: https://statistics.laerd.com/. Accessed 25 February 2020.
43.
Laerd Statistics.
2017
.
Two-way ANOVA using SPSS Statistics
.
Available at: https://statistics.laerd.com/. Accessed 20 November 2020.
44.
Lam,
W.,
Fielding
R.,
Johnston
J.,
Tin
K.,
and
Leung
G.
2004
.
Identifying barriers to the adoption of evidence-based medicine practice in clinical clerks: a longitudinal focus group study
.
Med. Educ
.
38
:
987
997
.
45.
Majowicz,
S. E.,
Hammond
D.,
Dubin
J. A.,
Diplock
K. J.,
Jones-Bitton
A.,
Rebellato
S.,
and
Leatherdale
S. T.
2017
.
A longitudinal evaluation of food safety knowledge and attitudes among Ontario high school students following a food handler training program
.
Food Control
76
:
108
116
.
46.
McKim,
C. A.
2017
.
The value of mixed methods research: a mixed methods study
.
J. Mix. Methods Res
.
11
:
202
222
.
47.
Meysenburg,
R.,
Albrecht
J. A.,
Litchfield
R.,
and
Ritter-Gooder
P. K.
2014
.
Food safety knowledge, practices and beliefs of primary food preparers in families with young children. A mixed methods study
.
Appetite
73
:
121
131
.
48.
Morrison,
D.,
Lichtenwald
K.,
and
Tang
R.
2020
.
Extending the online focus group method using web-based conferencing to explore older adults online learning
.
Int. J. Res. Method Educ
.
43
:
78
92
.
49.
Murray,
R.,
Glass-Kaastra
S.,
Gardhouse
C.,
Marshall
B.,
Ciampa
N.,
Franklin
K.,
Hurst
M.,
Thomas
M. K.,
and
Nesbitt
A.
2017
.
Canadian consumer food safety practices and knowledge: foodbook study
.
J. Food Prot
.
80
:
1711
1718
.
50.
Nicholas,
D. B.,
Lach
L.,
King
G.,
Scott
M.,
Boydell
K.,
Sawatzky
B. J.,
Reisman
J.,
Schippel
E.,
and
Young
N. L.
2010
.
Contrasting internet and face-to-face focus groups for children with chronic health conditions: outcomes and participant experiences
.
Int. J. Qual. Methods
9
:
105
121
.
51.
Northwestern Medicine.
2020
.
Do you have COVID-19 caution fatigue?
52.
Oppenheimer,
D. M.,
Meyvis
T.,
and
Davidenko
N.
2009
.
Instructional manipulation checks: detecting satisficing to increase statistical power
.
J. Exp. Soc. Psychol
.
45
:
867
872
.
53.
Pallant,
J.
2010
.
SPSS survival manual : a step by step guide to data analysis using SPSS
.
McGraw Hill
,
Maidenhead, England
.
54.
Pang,
X.,
Ren
L.,
Wu
S.,
Ma
W.,
Yang
J.,
Di
L.,
Li
J.,
Xiao
Y.,
Kang
L.,
and
Du
S.
2020
.
Cold-chain food contamination as the possible origin of covid-19 resurgence in Beijing
.
Natl. Sci. Rev
.
12
:
1861
1864
.
55.
Park,
J.-H.,
Cheong
H.-K.,
Son
D.-Y.,
Kim
S.-U.,
and
Ha
C.-M.
2010
.
Perceptions and behaviors related to hand hygiene for the prevention of H1N1 influenza transmission among Korean university students during the peak pandemic period
.
BMC Infect. Dis
.
10
:
222
.
56.
Parra,
P. A.,
Kim
H.,
Shapiro
M. A.,
Gravani
R. B.,
and
Bradley
S. D.
2014
.
Home food safety knowledge, risk perception, and practices among Mexican-Americans
.
Food Control
37
:
115
125
.
57.
Pressman,
P.,
Naidu
A. S.,
and
Clemens
R.
2020
.
COVID-19 and food safety: risk management and future considerations
.
Nutr. Today
55
:
125
128
.
58.
Rebmann,
T.,
Vassallo
A.,
and
Holdsworth
J. E.
2020
.
Availability of personal protective equipment and infection prevention supplies during the first month of the COVID-19 pandemic: a national study by the APIC COVID-19 task force
.
59.
Richard,
B.,
Sivo
S.,
Orlowski
M.,
Ford
R.,
Murphy
J.,
Boote
D.,
and
Witta
E.
2018
.
Online focus groups: a valuable alternative for hospitality research?
Int. J. Contemp. Hosp. Manag
.
30
:
3175
3191
.
60.
Saldaña,
J.
2015
.
The coding manual for qualitative researchers
.
Sage Publications
,
Los Angeles
.
61.
Shi,
M.,
Xiang
C.,
and
Zhang
X.-H.
2020
.
Impacts of the COVID-19 pandemic on consumers' food safety knowledge and behavior in China
.
J. Integr. Agric
.
19
:
2926
2936
.
62.
Synnot,
A.,
Hill
S.,
Summers
M.,
and
Taylor
M.
2014
.
Comparing face-to-face and online qualitative research with people with multiple sclerosis
.
Qual. Health Res
.
24
:
431
438
.
63.
Taylor,
J. Z.,
and
Rostron
K. I.
2018
.
The development of a safety and quality culture assessment tool from a longitudinal, mixed-method research journey
.
Worldw. Hosp. Tour. Themes
10
:
313
329
.
64.
Thomas,
D. R.
2006
.
A general inductive approach for analyzing qualitative evaluation data
.
Am. J. Eval
.
27
:
237
246
.
65.
Thomas,
M.,
and
Feng
Y.
2020
.
Risk of foodborne illness from pet food: assessing pet owners' knowledge, behavior, and risk perception
.
J. Food Prot
.
83
:
1998
2007
.
66.
Thomas,
M.,
Haynes
P.,
Archila-Godínez
J. C.,
Nguyen
M.,
Xu
W.,
and
Feng
Y.
2021
.
Exploring food safety messages in an era of COVID-19: analysis of YouTube video content
.
J. Food Prot
.
84
:
1000
1008
.
67.
Trepka,
M. J.,
Murunga
V.,
Cherry
S.,
Huffman
F. G.,
and
Dixon
Z.
2006
.
Food safety beliefs and barriers to safe food handling among WIC program clients, Miami, Florida
.
J. Nutr. Educ. Behav
.
38
:
371
377
.
68.
Ungar,
M.,
Duque
L. F.,
and
Hernandez
D.
2011
.
Can focus groups be used for longitudinal evaluation? Findings from the Medellin early prevention of aggression program
.
Int. J. Mult. Res. Approaches
5
:
40
51
.
69.
University of Minnesota Extension.
2018
.
Hand sanitizers not a replacement for handwashing in food service settings
.
70.
U.S. Census Bureau.
2010
.
Decennial census datasets
.
71.
U.S. Department of Agriculture.
2011
.
Washing food: does it promote food safety?
72.
U.S. Food and Drug Administration.
2018
.
Selecting and serving produce safely
.
73.
U.S. Food and Drug Administration. 27 July
2020
.
Coronavirus (COVID-19) update: FDA reiterates warning about dangerous alcohol-based hand sanitizers containing methanol, takes additional action to address concerning products
.
74.
Wellstead,
P.
2011
.
Information behaviour of Australian men experiencing stressful life events: the role of social networks and confidants
.
Inf. Res.
16
:
paper 474.
75.
Wenrich,
T.,
Cason
K.,
Lv
N.,
and
Kassab
C.
2003
.
Food safety knowledge and practices of low income adults in Pennsylvania
.
Food Prot. Trends
23
:
326
335
.
76.
Wilkerson,
J. M.,
Iantaffi
A.,
Grey
J. A.,
Bockting
W. O.,
and
Rosser
B. S.
2014
.
Recommendations for internet-based qualitative health research with hard-to-reach populations
.
Qual. Health Res
.
24
:
561
574
.
77.
Woodyatt,
C. R.,
Finneran
C. A.,
and
Stephenson
R.
2016
.
In-person versus online focus group discussions: a comparative analysis of data quality
.
Qual. Health Res
.
26
:
741
749
.
78.
World Health Organization.
2020
.
Basic protective measures against the new coronavirus
.
79.
World Health Organization.
2020
.
Coronavirus disease 2019 (COVID-19) situation report–32
.
80.
Xu,
M.,
Fralick
D.,
Zheng
J. Z.,
Wang
B.,
Tu
X. M.,
and
Feng
C.
2017
.
The differences and similarities between two-sample t-test and paired t-test
.
Shanghai Arch. Psychiatry
29
:
184
188
.
81.
Yang,
L. L.,
Khalid
M. L.,
Duong
M. D.,
Kessinger
J. N. B.,
Ong
B. N.,
Drape
T. A.,
Williams
R. C.,
Archibald
T.,
Chapman
B. J.,
and
Boyer
R. R.
2019
.
Consumer response to mechanically tenderized beef (MTB) and MTB labels: an exploratory focus group study
.
J. Food Prot
.
82
:
1484
1495
.
82.
Ybarra,
M. L.,
DuBois
L. Z.,
Parsons
J. T.,
Prescott
T. L.,
and
Mustanski
B.
2014
.
Online focus groups as an HIV prevention program for gay, bisexual, and queer adolescent males
.
AIDS Educ. Prev
.
26
:
554
564
.
This is an open access article under the CC BY-NC-ND license (https://creativecommons.org/licenses/cc-by-nc-nd/4.0/)

Supplementary data