The population, concept, and context (PCC) framework (Table 1) was used to formulate the research question (RQ) of this scoping review (Peters et al., 2015).

RQ: How does socioeconomic status affect the rate for foodborne illness among the general population in the MENA region?

The available literature on the impact of socioeconomic status (SES) on the burden of foodborne illnesses in the MENA region is scattered, underexplored, and fragmented. Moreover, the topic cuts through different methodologies used to examine this interrelationship. Therefore, among the different types of reviews, the scoping review (ScR) was selected. A ScR aims to answer broad research questions (Peters et al., 2015; Rodger et al., 2024; Verdejo et al., 2021; Colquhoun et al., 2014), condense research findings, identify research gaps (Tricco et al., 2018; Munn et al., 2022), and inform proposals for future systematic reviews (Mitton et al., 2009; Mak and Thomas, 2022). The proposed ScR was conducted in accordance with the JBI methodology for scoping reviews (JBI, 2024) and the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) statement (Tricco et al., 2018).

The inclusion and exclusion criteria were determined based on the PCC framework of this scoping review (ScR) and are presented in Table 2. This ScR considered all study designs, peer-reviewed studies, and gray literature. However, systematic reviews that met the inclusion criteria were excluded since they are considered secondary studies, but the papers cited in systematic reviews were eligible. Moreover, all studies published in English within the last 10 years were considered for inclusion. A 10-year cutoff was adopted to ensure that the review focuses on the most recent evidence, as societal conditions can change dramatically over a decade. When it comes to exclusion criteria, studies involving participants under the age of five, studies on foodborne illnesses caused by Helicobacter pylori, and viruses were excluded. Moreover, studies conducted in Turkey were excluded, as the classification of this country as part of the MENA region can vary depending on its geographical, cultural, political, or historical contexts.

The search strategy aimed to identify the published studies and gray literature. In this scoping review, identifying relevant search terms was crucial to ensure the comprehensiveness and relevance of the collected data (Kabir et al., 2024). Therefore, to explore the association between SES and foodborne illnesses in countries of the MENA region, key concepts were considered as follows: “socioeconomic status,” “income,” “food poisoning,” “foodborne pathogens,” “MENA countries,” “Saudi Arabia,” “Jordan”; additional countries in the MENA region; and synonyms and related terms were also included (Table 3). Moreover, Boolean operators (AND, OR, and NOT) were used to refine the search strategy. The Boolean logic narrowed the search by using AND and broadened it by using OR.

A three-step search strategy was adopted for selecting sources of evidence. In the first step, the search was conducted in Medline and Scopus databases, since they provide comprehensive coverage of relevant literature and support a thorough exploration of research gaps. The initial search was broad, identifying words and phrases found in the titles, abstracts, and indexes of papers that were used in the final search strategy. Then, further search was performed using terms identified in the initial search to find additional databases and gray literature sites. The list from references of the initial and further search papers was screened to retrieve additional studies. This last step, known as “snowballing,” was time-consuming; however, it was a crucial step to ensure that as many relevant papers as possible were retrieved. Accordingly, the selected databases in this ScR (Medline [PubMed], Web of Science, and Embase) were accessed to develop a complete search strategy using all possible MeSH terms, keywords, and Emtree combinations for each database (Table 4). Additional articles and gray literature were retrieved from Google Scholar and Google search to be included in the PRISMA-ScR flow chart (Tricco et al., 2018). After completing the search, all identified relevant citations were exported and uploaded into Zotero 6.0.37, followed by the removal of duplicates. Then, titles and abstracts of the identified articles were screened to select articles aligned with the inclusion criteria of the scoping review. The full text of relevant sources was retrieved and further assessed to check in detail whether they align with the review’s inclusion criteria to end up with the eligible articles to be considered in this scoping review. Moreover, the reasons for excluding sources of evidence at each stage were reported and presented in a PRISMA-ScR flow diagram.

Once the study inclusion was confirmed, the key data points were identified for extraction from the eligible studies and then charted. The abstraction tool included the authors’ names, year of publication, region, aim of the study, study design, sampling techniques, sample size, key findings, type of pathogens, and limitations. Article selection, screening, data extraction, and charting were completed by 24 August 2024.

The synthesis in this study was qualitative due to the broad nature of ScR. A descriptive narrative synthesis was adopted in this review, and the abstracted information was grouped by income, level of education, and employment of study participants. No critical appraisal or formal assessment of study quality was conducted as per ScR guidelines (Tricco et al., 2018; JBI, 2024).

In this scoping review, four studies did not explore the impact of participants’ monthly income on the rate of developing intestinal infections (Kiani et al., 2016; Motazedian et al., 2015; Dafalla et al., 2017; Balarak et al., 2016). Al-jawabreh et al. showed a significant difference among participants in terms of monthly income, where participants with low income were at higher risk of developing intestinal parasitic infections (IPIs; Al-Jawabreh et al., 2019). Moreover, Salama and his colleagues declared that 92.9% of hospitalized participants with Salmonella spp. infection was associated with a low socioeconomic level (Salama et al., 2019). Surprisingly, the average income was significantly associated with a higher rate of infectious intestinal disease among study participants compared to those with either a higher or lower income (Al Alkeem et al., 2019). When it comes to studies recruiting school children, Atwa et al. showed that the rate of infection with intestinal parasites increases significantly when monthly family income decreases (Atwa and Thabet, 2016). Moreover, another study reported that living in a rural area with low SES was significantly associated with a higher rate of parasitic infection, where 67.7% of study participants reported infection with Cryptosporidium spp. (Shalaby and Shalaby, 2015). Boughattas et al. declared that among 29 participants, no one showed parasitic infection; thus, the top-earning category in his study showed significantly lower rate of infections (Boughattas et al., 2019). However, the two studies conducted in Saudi Arabia and Lebanon showed findings that conflicted with those mentioned previously, since the difference between children with and without IPIs was not significant in terms of the monthly income of the Saudi family (Bakarman et al., 2019). Although the rate of parasitic infection was higher among Lebanese school children with low SES than those with higher SES (Osman et al., 2016), the difference was not statistically significant except for G. duodenalis, where the rate of infection was 36.6% compared to those with high SES 15% (CI 3.2 [1.6–6.1]).

Out of 12 studies, three studies did not assess the association between the level of education and the prevalence of intestinal infection among the study participants (Osman et al., 2016; Dafalla et al., 2017; Shalaby and Shalaby, 2015). Similarly, Al-jawabreh et al. and Al Alkeem et al. reported that the level of education of participants was not significantly associated with the rate of intestinal infection either among the study participants (Al Alkeem et al., 2019) or their children (Al-Jawabreh et al., 2019). These findings are similar to those reported by the studies conducted in Egypt (Atwa and Thabet, 2016) and Saudi Arabia (Bakarman et al., 2019). Moreover, the rate of Salmonella spp. infection was not correlated with the education level of the hospitalized patients in the study conducted by Salama and his colleagues (Salama et al., 2019). When it comes to the two studies that assessed the prevalence of IPIs among food-handlers in Iran, the level of education was not associated with the rate of parasitic infections among all participants (Motazedian et al., 2015; Balarak et al., 2016). However, Kiani et al. proved that the participants with a low level of education were at a higher risk of developing IPIs, which act as a key driver of gastrointestinal disorders such as diarrhea, dysentery, and abdominal pain (Kiani et al., 2016). Most importantly, a study conducted in Qatar to explore the sociodemographic risk factors for developing IPIs among immigrants found that the level of IPIs was heterogeneous across the five levels of education, with the rate of infection significantly higher in those with the elementary school level and lower in those with higher levels (Boughattas et al., 2019).

Among the three key components of socioeconomic factors, occupation was the least assessed factor in the eligible records, since only 6 out of 12 studies explored the association between occupation categories and intestinal infections. Moreover, only one study found that the rate of intestinal infections was significantly associated with the category of occupation, where food handlers showed the highest rate of infection at 52% followed by a rate that decreased to 16.4% (Dafalla et al., 2017). In contrast, profession type had no association with the rate of IPIs among hospitalized patients or food handlers in Iran (Kiani et al., 2016; Balarak et al., 2016). The rate of infections varied between different occupations in a study conducted by Motazedian et al. The highest rate was recorded among participants working as herbal sellers (16%), while the lowest rate was recorded among those working as office servers; howevre, this difference was not statistically significant in terms of occupational groups (Motazedian et al., 2015). Identical results were reported after exploring the rate of intestinal infections among immigrant workers in Qatar (Boughattas et al., 2019). In addition, the study recruiting school children found that the difference between children with and without IPIs was not significant in terms of parental occupation (paternal or maternal; Bakarman et al., 2019).

The predominant pathogens explored in the eligible studies were classified as follows: one study conducted in the United Arab Emirates, which reported a prevalence of intestinal infectious diseases (IIDs) of 4.2%, but did not report the causative pathogens (Al Alkeem et al., 2019). On the other hand, out of 12 records, only one study was related to bacterial foodborne diseases. This study was conducted in Egypt, and the findings showed that the proportion of Salmonella-infected subjects was 33.9% among H. pylori-negative patients (Salama et al., 2019). Two studies exclusively explored the prevalence of protozoan Cryptosporidium spp. among participants, with results recorded in prevalence rates of 13.5 (Shalaby and Shalaby, 2015) and 4.5% (Boughattas et al., 2019) among school children and immigrant workers, respectively. Regarding the other studies, the prevalence of parasitic pathogens was heterogeneous. After fecal examination of the collected samples from participants, the prevalence ranged between 5 and 85% (26–32, 35), and the infections included single, double or multi-parasitic infectious intestinal disease. Moreover, G. lamblia, E. histolytica and E. coli were found to be the predominant intestinal parasites in the studies conducted in the UAE, Iran, Palestine, and Egypt (Al-Jawabreh et al., 2019; Motazedian et al., 2015; Dafalla et al., 2017; Balarak et al., 2016; Atwa and Thabet, 2016). However, Osman et al., Kiani et al., and Bakarman et al. reported that the predominant isolated protozoan was Blastocystis sp., followed by E. coli, G. lamblia, and Cryptosporidium spp. (Bakarman et al., 2019; Kiani et al., 2016; Osman et al., 2016). Helminth infections were less frequent and included A. lumbricoides, Hookworm Trichuris trichiura, Taenia spp., with very few cases caused by H. nana. (Al-Jawabreh et al., 2019; Dafalla et al., 2017; Atwa and Thabet, 2016). Although the prevalence and causative agents varied significantly between studies, similar findings were reported in terms of symptoms such as abdominal pain, diarrhea, and vomiting among study participants (Bakarman et al., 2019; Kiani et al., 2016; Osman et al., 2016).

In this review, the similarities lie in the most common types of pathogens (Figure 3), sampling techniques (Figure 4), socioeconomic status, and limitations (Table 6). In contrast, the most important differences are presented in Table 7.

The literature showed high discrepancies regarding the impact of income/social class on the occurrence of intestinal diseases. In this scoping review, Dafalla et al. Motazedia et al., Balarak et al., and Kiani et al. did not study the association between income/social class and the occurrence of intestinal infections. However, it has been proven that a higher rate of intestinal infections is significantly associated with low monthly income and/or living in rural areas (Salama et al., 2019; Al-Jawabreh et al., 2019; Shalaby and Shalaby, 2015; Boughattas et al., 2019). These findings were in accordance with other studies showing that low-income families may consume food from traditional sources, drink improperly treated water, and have poor access to healthcare services, which puts them at higher risk of developing infectious diseases (Quandt et al., 2004; Gulliford, 2002; Goh et al., 2004). Moreover, Atwa et al. declared that family size was a crucial predictor of parasitic infection, since a large number of persons per household with low income negatively impacts their health in terms of intestinal infection rates (Atwa and Thabet, 2016). These findings were in accordance with other studies that showed a direct impact of poverty on Cryptosporidium spp. infection rate, since these studies suggested more immediate links between household food insecurity and the risk of developing parasitic intestinal infections (Katona and Katona-Apte, 2008). Food inadequacy reduces the nutritional status of the host and their immune response, which in turn increases their susceptibility to parasitic infection (Katona and Katona-Apte, 2008; Weigel et al., 2007). On the other hand, households with inadequate access to food due to low income are more likely to consume food products from traditional sources where food safety and sanitation regulations could be violated (Quandt et al., 2004). Moreover, populations with low income have poor access to healthcare, which makes them at higher risk of developing infectious diseases (Gulliford, 2002). According to Goh et al., the source of drinking water is an additional risk factor for low-income households in developing countries, which sometimes lack an efficient treatment system (Goh et al., 2004). On the other hand, two studies in this scoping review proved no correlation between income and the rate of intestinal infection (Bakarman et al., 2019; Osman et al., 2016), these findings were in accordance with the study by Becker et al., who found a difference in the odds of seropositivity between individuals in households close to the poverty threshold and those in households with an income three times above the poverty line; however, this association was not significant (Becker et al., 2015). Conversely, other studies showed that in some high-income countries, populations with high living standards are at higher risk of developing intestinal parasitic infections (Lake et al., 2007). Some studies link this greater risk to the fact that individuals living with high living standards engage in recreational activities such as traveling (McLaughlin et al., 2000), using swimming pools, walking in the countryside with animals (Kavanagh et al., 2005) in addition to consuming fresh vegetables and fruits (Hunter et al., 2004).

Out of the 12 eligible studies, 3 studies did not assess the association between the level of education of participants and the occurrence of intestinal diseases (Osman et al., 2016; Dafalla et al., 2017; Shalaby and Shalaby, 2015). Seven studies have proven that the rate of parasitic (Al Alkeem et al., 2019; Al-Jawabreh et al., 2019; Bakarman et al., 2019; Motazedian et al., 2015; Balarak et al., 2016; Atwa and Thabet, 2016) and bacterial (Salama et al., 2019) intestinal infections is significantly higher in those with low-level of education. These findings were in accordance with other studies that have shown that parasitic infection is more prevalent in uneducated people (Becker et al., 2015; Schmidt et al., 2009; Ali et al., 2014). According to these studies, individuals lack adequate access to media and educational resources related to hand hygiene (Schmidt et al., 2009; Ali et al., 2014). Moreover, Sarkari et al. and Moragaa et al. declared that educated individuals showed better knowledge, attitudes, and practices toward parasitic infection transmission (Sarkari et al., 2016; Moragaa et al., 2024). Therefore, health education enhances good personal hygiene and sanitary practices, as well as improves the implementation of prevention and control measures for parasitic diseases (Choy et al., 2014). Conversely, the eligible studies conducted in Iran and Qatar showed no significant association between intestinal infections and level of education (Kiani et al., 2016; Boughattas et al., 2019). This finding aligns with Alqarni et al. who demonstrated that the intestinal parasite infections were detected among food handlers with a high level of education (Alqarni et al., 2023). This may bring up a suggestion that the two socioeconomic factors education and occupation may interfere, and the type of occupation may pose the individual at higher risk of parasitic infection regardless of the education level, this hypothesis was proved by Dafalla et al., who reported that food handlers had the highest rate of infection compared to all other occupational groups studied (Dafalla et al., 2017). This finding was in accordance with other studies, which shows that farmers (Fuhrimann et al., 2016) and agricultural workers (Lengerich et al., 1993) are more likely to be infected by hookworms and are highly exposed to parasites such as Cryptosporidium spp. when compared to other groups. This could be explained by the fact that these workers are in direct contact with soil and water contaminated with livestock excrement (Becker et al., 2015).