Food needs and health behaviors in the COVID-19 situation: a case study of quarantined communities in densely populated areas of Bangkok, Thailand

Abstract

Background

The Thai government’s initial response to the novel coronavirus disease 2019 (COVID-19) led to confusion and food insecurity in quarantined low-income communities. Although free food programs were initiated, no official assessment of their impact exists. The objective of this study was to evaluate the effectiveness of these food programs by surveying the food requirements, food needs, and health behaviors of quarantined, densely populated communities in Bangkok.

Methods

A cross-sectional descriptive study was conducted with 410 urban dwellers from quarantined communities who received free food assistance. Data were collected via a questionnaire on food requirements, food hygiene, food needs, and health behaviors during the COVID-19 epidemic. The data were analyzed in terms of frequency, percentage, mean, and standard deviation. The associations between demographic characteristics, food needs, and health behaviors were analyzed using logistic regression.

Results

The participants demanded dried/canned food (54.9%) and three meals per day (64.9%), while the majority of the food provided consisted of rice and side dishes (96.2%) that were clean and qualified. In consideration of food needs, a high level of demand was observed in the first three levels: enough food, acceptable food, and reliability. Overall, dietary health behaviors were good. Logistic regression analysis revealed that being elderly (AOR = 3.67, 95% CI = 1.63–8.27) and having a moderate to high income level (AOR = 3.93, 95% CI = 2.23–6.94) were positively correlated with food needs. Similarly, good health behaviors were positively correlated with being female (AOR = 1.74, 95% CI = 1.12–2.69), being elderly (AOR = 3.73, 95% CI = 1.72–8.08), and having a moderate to high income level (AOR = 3.76, 95% CI = 2.38–5.93).

Conclusions

Preparing for future crises requires the consideration of demographic factors that influence food needs, personal choices, and dietary health behaviors. Future food assistance programs should focus on the provision of nonperishable and long-lasting food, which will ensure the consistent availability of three meals per day.

Introduction

The novel coronavirus disease 2019 (COVID-19) pandemic began in Wuhan, China in late 2019 and quickly impacted nearly every aspect of human life globally. Owing to the high infection rate and rising death tolls globally, the World Health Organization (WHO) declared a public health emergency of international concern to contain and eradicate the virus [1]. The spread of the virus has had a severe impact on socioeconomic and national stability, which has prompted many governments, including Thailand, to introduce emergency policies for post-pandemic recovery. In addition to immediate health-related actions, the Thai government also concentrated on social measures to mitigate the impact of the pandemic. For example, physical social distancing, lockdown, travel restrictions in infected communities and the quarantine of laborers at construction sites have been implemented. As these strict movement controls were enforced, food accessibility and security quickly became critical concerns, particularly for people living in quarantined communities in densely populated areas during the pandemic [2]. Food insecurity was further exacerbated by income reductions and job losses due to layoffs. In response, multiple emergency relief projects were established nationwide to aid those facing food shortages. According to Bangkok Biz News [3], a Thai news agency, five prominent organizations in the Bangkok area provided food and other commodities to affected communities during the COVID-19 lockdown. These organizations included the Mirror Foundation, the Agricultural Land Reform Office, the Bangkok Metropolitan Administration (BMA), Klong Toey local community authority, and other private charity organizations.

The term ‘food insecurity’ refers to the inability to access adequate amounts of food consistently [4]. The initial response to relieve food insecurity during this crisis involved coordinated efforts by government agencies, the private sector, and individuals to provide free daily food in affected areas. In Bangkok, many people were thrown into acute food insecurity because their ability to work and earn a stable income was curtailed. Low-income groups and average daily wage earners were particularly affected, with many unable to afford basic food items and essential supplies. Furthermore, those in densely populated urban communities have limited access to resources and facilities, intensifying the challenges of healthy food choice behaviors and ensuring personal hygiene.

To ensure sufficient and effective emergency food aid for those affected by crises (such as pandemics or natural disasters) food handling practices must prioritize hygiene and nutrition. Food providers should follow the “Hierarchy of Food Needs” model, developed by Setter [5], adapted from Marslow’s Hierarchy of Needs, to manage food aid programs. The model, which is structured as a pyramid, prioritizes food needs as follows (from base to apex): (1) enough food, is at the foundation of the pyramid; (2) acceptable food; (3) reliable, ongoing access to food; (4) good-tasting food; (5) novel food; and at the apex (6) instrumental food (Fig. 1).

Fig. 1

Satter’s Hierarchy of food needs

To increase preparedness for future crises, including pandemics and natural disasters, data collected during the COVID-19 pandemic were analyzed to assess the adequacy and effectiveness of free food programs. In particular, limited information has been available regarding food insecurity during the COVID-19 crisis, such as restrictions on access to nutritious food, as well as food needs among quarantined groups and dietary health behaviors, which impacts the wider community spread of the virus and has long-term effects on health issues. The objective of this study was to evaluate the adequacy of these food programs by surveying food requirements, food needs, and dietary health behaviors in quarantined, densely populated communities in Bangkok.

Methodology

Study design, participants and setting

This cross-sectional descriptive study was conducted in a district area of Bangkok, and focused on people receiving free food distribution during the COVID-19 pandemic in densely populated communities. Using Cochrane’s method, the necessary sample size was calculated with a confidence level of 95%, an acceptable margin of error of 5% (d = 0.05), and an estimated proportion of 0.5:

$${\rm{n = }}\frac{{{{\rm{z}}^{\rm{2}}}{\rm{p}}\left( {{\rm{1 - p}}} \right)}}{{{{\rm{d}}^{\rm{2}}}}}$$

Therefore, the sample size was approximately 385.

All the participants were individuals who were distributed food during the COVID-19 pandemic and who resided in communities that had previously been quarantined in Dusit district, Bangkok. Data were collected from January to March 2022. The inclusion criteria were (a) free food recipients who lived in an urban community affected by the COVID-19 pandemic and (b) aged 18–70 years who were able to communicate properly. The participants were drawn from three community types within the Dusit district: urban communities, densely populated communities, and housing communities. Stratified sampling was employed to select the community, followed by simple random sampling using house numbers to obtain the required sample size proportional to each community. Consequently, the sample sizes for individuals from urban, densely populated, and housing communities were 194, 145, and 71 respectively, totaling 410 participants.

Questionnaire

The questionnaire was composed of four parts:1) general information (13 items); 2) food requirements and food hygiene (17 items); 3) food needs; and 4) dietary health behaviors during the pandemic (15 items). The food hygiene aspects were presented mainly in terms of questions about food distribution. The content validity of the questionnaire was verified by three experts in the field of food and nutrition from different institutions. The assessment focused on ensuring comprehensive and clear content validity across food requirements, food hygiene, and food needs, yielding a content validity index of 0.8. Additionally, the construct validity of food needs was analyzed on the basis of Ellyn Satter’s hierarchy of food needs framework [5]. The questionnaire on food requirements and food hygiene consisted of 17 items. It was developed on the basis of the research objectives and literature review. Ten items related to daily food requirements included the number of meals required and the type of food desired. Seven items related to food hygiene included exploring factors such as the characteristics of the food and rice, as well as freshness and cleanliness.

The questionnaire on food needs was weighted according to the six-level hierarchy: (i) enough food (3 items); (ii) acceptable food (3 items); (iii) reliable, ongoing access to food (5 items); (iv) good-tasting food (2 items); (v) novel food (1 item); and (vi) instrumental food (1 item). The answers were rated as high, moderate, or low with corresponding scores of 3, 2 and 1, respectively. The average mean scores of 1-1.49, 1.50–2.49 and greater than 2.50 represented a low, moderate and high need for food, respectively.

In terms of food consumption behavior during the COVID-19 pandemic, the questionnaire was adapted from the Ministry of Public Health of Thailand. The consumption behaviors were analyzed from the perspective of the frequency of their expressed behaviors. There were three choices (each with an assigned score) for the participants to choose in response to the questions: routine (2), sometimes (1) and not practice at all (0). A mean average score of 0-1.29 is interpreted as poor dietary health behaviors, and a mean average score of 1.30–1.59 indicates moderate dietary health behaviors, whereas a mean average score of 1.60-2.00 indicates good dietary health behaviors.

Before the survey of the food recipients, a pilot test of questionnaire reliability was performed with 30 people who met the criteria as the participants. The reliability of the questionnaire was evaluated using Cronbach’s alpha, with a value of 0.75. This Cronbach’s alpha factor indicated that the questionnaire had a high level of reliability. Thus, the questionnaire received no further modifications and was employed to collect data.

To initiate the data collection process, community leaders were contacted to request access to potential participants. Data were collected via interview questionnaires. The questions were read to the participants by the researcher, and the participants responded verbally. This study was approved by the Research Ethics Committee of the Institutional Review Board of Navamindradhiraj University (COA 013/2564), Bangkok, Thailand. The IRB thoroughly reviewed and assessed the study’s ethical aspects, ensuring participant rights, confidentiality, and adherence to ethical standards. Informed consent was obtained from all participants, and the study design followed the guidelines outlined by the approved IRB protocol. For confidentiality, the data were anonymized and only the pooled/total outcomes are presented.

Data analysis

The demographic characteristics of the food recipients, food requirements and food hygiene were calculated including frequencies and percentages. The analysis of food needs was categorized into three levels: low, moderate, and high, using frequencies and percentages. Additionally, the overall mean score and standard deviation (SD) were calculated. For dietary health behaviors during the COVID-19 pandemic, the data were divided into three levels, namely, poor, moderate, and good, with the overall mean score and SD calculated. Factors influencing food needs and health behaviors were analyzed using logistic regression. Owing to the low number of individuals in the low category, participants with low and moderate levels were combined into a category identified as “low to moderate level” and “poor to moderate level”. The data were analyzed by SPSS, version 28.0 (IBM SPSS Statistics for Windows, version 28.0. Armonk, NY: IBM Corp). This study used the STROBE cross-sectional checklist when writing the report [6].

Results

Background characteristics

All of the 410 participants in this study were from communities in the Dusit district of Bangkok, Thailand. The majority of them live in urban communities (47.3%), whereas 35.4% and 17.3% live in densely populated communities and housing communities, respectively. The majority of the sample group was women (59.0%), and most were in the late working-age to elderly age group. Households with 1–3 members were the most common (53.2%). Most participants had completed primary education or less, with 68.0% employed. A large portion, 55.9%, had a monthly income not exceeding 8,300 baht, and the majority consumed three meals a day (Table 1).

Table 1 Demographic characteristics of the food recipients

Food requirements and food hygiene

Table 2 presented detailed information on the needs at the food distribution centers as expressed by the recipients. More than half of the recipients wanted dried/canned food and 3 meals per day. However, 62.8% of them received 1 meal per day and 48.8% of the participants had to wait between 10 and 20 min to receive food (Table 2). Every time food was available for distribution, 68.7% of the participants lined up for food and the frequencies of food distributions of 1–2, 3–5, and 6–7 times per week were 44.6%, 36.6% and 18.8%, respectively (Table 2). Food provided by the distribution programs was usually purchased from local restaurants and markets (75.9%) and 61.3% of recipients received food between 9.00 and 11.00 am (Table 2).

Table 2 Food requirements and food hygiene

In terms of food hygiene, overall ready-to-eat food was newly cooked and packed in clean boxes. Two participants in the free food program (0.5%) received bad, smelly rice and 28 recipients (6.8%) received abnormal, damaged canned food that was discarded. Twenty-two participants (5.4%) experienced stomach discomfort after consuming food provided by the food program; nonetheless, 93.2% of the food recipients were satisfied with the free food provided by the programs (Table 2).

Food needs

Food needs were classified into six levels, with the majority showing moderate to high levels of food needs across all six. When the overall mean scores for the first three levels, i.e., enough food, acceptable food, and reliable, ongoing access to food, were analyzed, the average scores were high at 2.55 (SD = 0.46), 2.65 (SD = 0.37), and 2.66 (SD = 0.32), respectively. Moreover, good-tasting food, novel food, and instrumental food were found to have moderate needs as shown by the mean average scores of 2.34 (SD = 0.52), 2.45 (SD = 0.56) and 2.10 (SD = 0.76), respectively, for food needs levels 4, 5 and 6 (Table 3).

Table 3 Ellyen Satter’s food needs

Dietary health behaviors during the COVID-19 pandemic

Overall, the health behaviors related to eating habits among food recipients were rated at a good level, with an average score of 1.61 (SD = 0.19). When analyzed by individual items, dietary health behaviors were categorized as poor, moderate, or good. The behaviors with poor ratings included “Always reheat received food, either from the program or food delivery service” (mean = 1.03, SD = 0.73) and “Eat out” (mean = 1.16, SD = 0.61). Health behaviors rated at a moderate level were “Always reheat food before eating leftover food,” (mean = 1.52, SD = 0.62) “Not sharing a drinking cup/glass with others,” (mean = 1.55, SD = 0.75) and “Eating food with others” (mean = 1.26, SD = 0.65). All other health behaviors were rated at a good level, with 10 out of 15 items, or 66.7%, falling under the good category as presented in Table 4.

Table 4 Food recipients’ dietary health behaviors during the COVID-19 pandemic

Associations between demographic characteristics, food needs, and dietary health behaviors

The associations between demographic characteristics and food needs revealed that age and income significantly affected the level of food needs. In terms of age, individuals aged 45–59 years and 60–70 years had a significantly greater level of food needs than those aged 18–29 years (reference group), with p-value of 0.038 (AOR = 2.31, 95% CI = 1.05–5.11) and 0.002 (AOR = 3.67, 95% CI = 1.63–8.27), respectively. With respect to income, those with a monthly income over 8,300 baht had a significantly greater level of food needs than those with a lower income did, p-value < 0.001 (AOR = 3.93, 95% CI = 2.23–6.94) as presented in Table 5.

Table 5 Association between demographic characteristics and food needs

When demographic characteristics and dietary health behavior data, were reviewed, sex, age and income level were associated with healthy behaviors. Compared with males, females had significantly better dietary health behavior levels, with a p-value of 0.013 (AOR = 1.74, 95% CI = 1.12–2.69). In the 60–70 years age group, healthy behavior levels were significantly better than those in the 18–29 years age group (reference group), with a p-value of 0.001 (AOR = 3.73, 95% CI = 1.05–5.11). When reviewing income, individuals earning more than 8,300 baht per month had significantly better healthy behavior standards than those with lower income did, with a p-value < 0.001 (AOR = 3.76, 95% CI = 2.38–5.93) (Table 6).

Table 6 Association between demographic characteristics and dietary health behaviors

Discussion

Food insecurity was a key issue during the COVID-19 pandemic, which resulted in significant restrictions on access to food, particularly within quarantined communities. This situation has led to an increase in food assistance programs in Thailand. In the past, food assistance programs in Thailand generally lacked formal establishment by the government, except during emergency crises. For example, food distribution occurred during major floods, notably in central Thailand in 2011 [7, 8]. Similarly, food assistance during the COVID-19 pandemic emerged as a response to the emergency situation. This approach contrasts with practices in other countries, where food assistance programs have been established in advance. For example, the Supplemental Nutrition Assistance Program (SNAP), developed by the United States Department of Agriculture (USDA), is the largest food assistance program in the United States. It was created to address food security and improve nutrition among children from low-income families [9]. Food Bank initiatives have also emerged in several countries including Canada, Australia, and Germany [10, 11, 12], as a response to food insecurity among low-income populations.

During the COVID-19 outbreak in Thailand, food distribution efforts focused primarily on ready-to-eat meal boxes and nonperishable dry food. This approach was consistent with food assistance programs in many countries that distributed both fresh and dry food items. However, survey findings revealed that recipients expressed the highest demand for dry food, likely because these items have a longer shelf life than does fresh food. Concerns about food security led people to worry and feel anxious about not having enough food for the following days, resulting in them stockpiling food. Additionally, they desired three meals per day, as this is a fundamental food requirement for daily living. This finding aligns with those of previous studies, particularly among low-income groups, who prioritize the quantity and consistency of food over variety, nutritional value or health-oriented food because of the food insecurity they face [13]. Having enough food that is readily accessible is the standard of security most needed by this demographic. Thus, obtaining sufficient food takes precedence over other concerns. This instinct is evident in the survey results concerning food needs within COVID-19-affected communities (Tables 1, 2, and 3). People in these communities are primarily concerned about having enough food for each meal, showing less concern about the specific types of food. This concern is reflected in the observation that recipients attend every food distribution event at the centers (Table 2). The distributed food must be acceptable to them, meaning it should appear appetizing, clean, and freshly prepared. With respect to food needs, nutritional content was not a significant concern for the low- income group which showed little interest in flavorful, exotic or high-nutritional-value food, with their average needs across all categories being moderate (Table 3). An analysis of demographic data revealed that most community members were working-age to elderly individuals, predominantly from low-income backgrounds [earning less than 8,300 baht (US$ 242) per month]. To define low income, we followed the Thai government’ income threshold criteria, which offer welfare benefits for individuals earning less than 100,000 baht (US$ 2,921) per year to increase living costs.

An analysis of the factors influencing food needs indicated that older working-age individuals and elderly individuals have significantly greater food needs than do the 18–29 age group (the reference group), with increases of 2.31 and 3.67 times, respectively. This increased food needs among older working-age and elderly individuals is likely the result of these groups prioritizing food quality, nutritional value, and healthy choices over quantity. This preference can be attributed to several factors, including reduced physical requirements due to metabolic changes, the need for high-quality nutrition to mitigate health risks and issues such as bone deterioration. Consequently, they have a greater need for nutrient-rich foods, such as those high in protein, calcium, and vitamin D [14, 15]. Another variable impacting food needs is income level. Individuals with moderate to high incomes (over 8,300 baht per month) have significantly greater food needs than low-income individuals do (p < 0.001). This finding is unsurprising, as income level influences access to nutritious food and provides greater food choice. Low-income individuals typically prioritize food that provides satiety over nutritional value, selecting food in sufficient quantity to satisfy their hunger, and aligning with the base level of the food needs pyramid. Some studies have also reported that low-income individuals often worry about inadequate food supplies, leading them to rely on food banks [16].

In terms of health behavior, most individuals demonstrated good health practices, partly due to widespread public announcements and media communication on self-care practices across various platforms in Thailand. However, the participants did not excel in all areas. Table 4 reveals that reheating distributed food and avoiding eating outside scored lower in terms of dietary health behavior levels. One reason for this is the ease of access to street food in Thailand, especially in urban areas [17], along with a general preference among Thais not to cook at home. This differs from practices in some countries, such as China, where home cooking is more common [18]. An analysis of factors influencing dietary health behavior revealed a positive correlation with female sex, older age, and income level. Specifically, women tend to be more health-conscious than men are and are generally more concerned about preventive measures against infection, leading to stricter adherence to health guidelines. This finding aligns with those of previous studies [19, 20] showing that women are more attentive to and consistent in following COVID-19 preventive measures than men are. Carli’s research [21] further highlights that women often assume caregiving roles within families and communities, requiring them to stay informed about health matters to protect those around them. Consequently, women tend to follow public health recommendations more consistently. Additionally, women are more receptive to information about COVID-19 prevention, leading to greater knowledge and more appropriate health practices [22].

With respect to age, older adults exhibited better health behaviors in preventing COVID-19 than did those in the 18–29 age group. This may be because older adults are more aware of their health risks and are more motivated to protect themselves from COVID-19 as many may already have underlying health conditions, particularly non-communicable diseases such as diabetes, hypertension, and heart disease. These conditions increase their incentive to follow preventive measures strictly, as infection significantly elevates mortality risk. This motivation for rigorous adherence to prevention aligns with the findings of a previous study [23]. Furthermore, family support also plays a crucial role, as older adults often receive encouragement and assistance from family members to adhere to preventive measures strictly. This familial support is likely a contributing factor to why older adults tend to practice better health behaviors than other age groups do [24]. However, a previous study presented conflicting information, suggesting that younger individuals may be more adaptable in following health guidelines during the COVID-19 pandemic. This adaptability is attributed to their greater access to information and higher proficiency in using technology [25].

Income levels also affect individual compliance with preventive behaviors. Compared with low-income groups, middle- to high-income groups showed better adherence to health practices. This disparity arises because individuals with higher incomes have better access to supportive resources and information, as well as greater purchasing power and decision-making capabilities than those with lower incomes. Financial status plays a crucial role in promoting health, as evidenced by a study indicating that digital finance has a positive impact on health, particularly among populations with lower socio-economic status. The research also highlights that digital finance helps enhance health-related behaviors, increases spending on healthcare services, and facilitates access to better healthcare [26]. Furthermore, financial status and income levels are linked to COVID-19 prevention behaviors and correspondingly influence individuals’ risk of contracting the disease [27, 28]. Economic inequality poses limitations for low-income individuals in the context of preventive measures. During the COVID-19 pandemic, those with financial means often stockpiled certain long-lasting, nutritious foods, causing prices to rise. This price increase further affected low-income individuals who struggled to afford food, a trend especially pronounced in developing countries [29].

Strengths and limitations

This study surveyed individuals affected by the COVID-19 pandemic who received free food, a time when both the public and private sectors in Thailand were heavily involved in food distribution efforts. However, assessments of actual food requirements and needs are lacking, particularly within densely populated urban communities. In this research, we examined the relationship between factors influencing food needs and health behaviors, which will be beneficial for future preparedness planning.

A significant limitation of this study was its scope as a case study within a single community in the Dusit District of Bangkok. The sample was drawn from only specific areas in Bangkok, which may not represent the entire population impacted during the COVID-19 pandemic. Therefore, limitations restrict the generalizability of the findings to broader populations. Nonetheless, efforts have been made to select samples representing community types and to consider proportions within the community. Second, data collection relied solely on interviews, which may not have provided sufficient depth of information. The interview-based approach used to gather responses for the survey may have limitations, as interviewer guidance could influence respondents’ answers. Third, this study had a limited data collection timeframe, which may not have captured the long-term implications or dynamics of the situation. Finally, this study focused on individuals aged 18–70 years, thus not covering all age groups impacted by the COVID-19 situation.

Conclusion

Valuable insights were gained in the effectiveness and efficiency of food assistance programs for those who were affected by the COVID-19 pandemic. The findings of this study indicate that preparing for future crises requires the consideration of demographic factors influencing food needs and health behaviors. In particular, future food assistance programs should focus on the provision of nonperishable and long-lasting food, ensuring the consistent availability of three meals per day. Additionally, food support should target specific nutritional needs, especially for vulnerable groups such as elderly individuals, who have greater food needs than other groups do. Strengthening food security and supporting dietary health behaviors across all age groups should be an ongoing effort. Such support should be formalized as a policy to ensure readiness for potential future outbreaks.