Survey development and design

A cross-sectional study was conducted using an online questionnaire adapted from a previously published, peer-reviewed questionnaire [19]. The original questionnaire was modified by removing questions that were not relevant to Lebanese context (such as questions regarding the estimated percentage of the patient population covered by Medicare). The study questionnaire included 44 questions divided into four sections covering LDs’ demographic, educational and professional characteristics; telehealth experience before and during the pandemic; tools used; barriers, facilitators and benefits; and LDs’ perspectives on their telehealth experience. The questionnaire was pilot-tested, and feedback from the pilot was used to finalize its design. The inclusion criteria were: Lebanese dietitian, holding a bachelor’s degree in human nutrition and dietetics, licensed by the Lebanese Ministry of Public Health (MOPH), and practicing in Lebanon during COVID-19 pandemic.

Data collection

Due to the absence of complete list of LDs in Lebanon, and to maximize survey outreach and minimize the risk of undelivered emails, a link to the Google Forms survey was distributed via the Lebanese Order of Dietitians, social media platforms (WhatsApp, LinkedIn, and Facebook), as well as through nutrition faculties and alumni networks at Lebanese universities. To prevent overlapping and duplication in data collection, LDs who had already completed the questionnaire were asked not to participate. Data were collected using a self-administered, anonymous Google Forms questionnaire. The survey was designed to ensure participant confidentiality, with no personally identifiable information collected. Access to the responses was restricted to the research team. Participation was voluntary, and respondents provided informed consent at the beginning of the survey.

Ethical considerations

The study was reviewed and approved by the Lebanese American University Institutional Review Board (LAU IRB) under the reference LAU.SAS.RR1.29/Nov/2022. Informed consent was implied through voluntary completion of the questionnaire. Google Forms settings were configured to ensure that personal data, such as emails and IP addresses, were not collected. The participation in the study was anonymous, voluntary, and non-payable.

Statistical analysis

The survey data were managed and analyzed descriptively using Statistical Package for the Social Sciences (SPSS), Version 28. Means and standard deviations (SD and median (IQR) were reported for continuous variables, while counts and percentages were used for categorical variables.

Inclusivity in global research

Additional information regarding the ethical, cultural, and scientific considerations specific to inclusivity in global research is included in the Supporting Information (S3 File Inclusivity in Global Research Questionnaire).

Participants’ characteristics

In total, 94 LDs were included in this study. The sample consisted predominantly of females (98.9%) and young dietitians (mean (SD) age: 30.54 (6.41) years), with a master’s degree (58.5%), and a median (IQR) of 6.00 (3.00, 12.00) years of experience in dietetics practice. Most respondents (87.2%) identified clinical nutrition as their primary practice area, with a focus on weight management (84%), food and nutrition consultation (58.5%), and diabetes care (45.7%). S1 Table describes the socio-demographic characteristics of the participants.

Telehealth experience during COVID-19 pandemic

Although 48.4% (N = 45) of respondents reported using telehealth for nutrition care before the pandemic; this proportion increased significantly to 97.8% (N = 91) during COVID-19 pandemic. LDs who had prior experience with telehealth before the onset of the pandemic reported a mean (SD) of 1.43 (2.5) years of use. During the pandemic, and as illustrated in S1 Fig, the main tools used for delivering telehealth nutrition care were WhatsApp (90.3%), Zoom (72.0%), E-mails (41.9%), and telephone (39.8%). During telehealth sessions, LDs relied primarily on video calls (83.9%), followed by voice calls (67.7%) and voice messages (65.6%).

Most respondents (51.6%) spent more than 30 minutes in direct contact with individuals or groups to collect information on food and nutrition-related history (94.6%), patient history (89.2%), patient behavior (74.2%) and, knowledge, beliefs, and attitudes (72.0%). LDs reported spending an average of 6.4 hours per week of face-to-face counseling prior to the pandemic. While this may not reflect their total clinical workload, session lengths and patient volume vary by setting, where brief consultations were common during hospital rounds and longer sessions occurred in outpatient or private clinics settings. Moreover, some LDs worked part-time or saw patients based on availability, particularly in private practice. During the pandemic, the reported 30 minutes per telehealth session refers to the duration of individual remote consultations and reflects the additional time that LDs might need to collect comprehensive dietary histories and patient information in a virtual setting. The results of telehealth sessions were most frequently communicated to the referring medical providers through social media applications (40.9%), e-mail (21.5%), and electronic medical record (20.4%). The experience of LDs with telehealth for nutrition care before and during the pandemic is summarized in S2 Table.

The types of nutrition assessment and monitoring conducted via telehealth during the pandemic are illustrated in S3 Fig.

During the COVID-19 pandemic, the most reported activities among LDs included the collection of food and nutrition-related history (94.6%) followed by patient history (89.2%), assessment of physical activity, behavior, beliefs and attitudes, as well as evaluation of biochemical data, anthropometrics, medication use, food access barriers, and nutrient administration. S3 Fig displays the types of nutrition assessments and monitoring, or evaluation activities conducted remotely by Lebanese Licensed Dietitians (LDs).

Barriers, facilitators, benefits and perspectives related to telehealth use

The reported barriers, facilitators and benefits of telehealth use during COVID-19 pandemic are figured in S3 Table. The most frequently reported barriers to providing telehealth nutrition care were bad connections (74.2%) followed by patients preferring face-to-face consultation (61.3%), and patients lacking technical literacy (33.3%). Among the benefits, LDs cited scheduling flexibility (83.9%), reduced practice-related costs (77.4%), the promotion of technology acceptance and penetration (69.9%), and compliance with COVID-19 social distancing measures (53.8%). At this point, it is worth noting that the reported 6.4 hours per week reflects specifically the one-on-one counseling, whereas the 10.7 hours indicated in S3 Table represents the total weekly time dedicated to face-to-face nutrition care, including counseling, inpatient visits, group sessions, and educational activities. Unfortunately, and as shown in S2 Fig, during the pandemic, most respondents did not receive any training on how to properly conduct telehealth (93.5%) and did not consult any specific guidance (94.6%). Moreover, participants rated their overall experience with telehealth during the pandemic at a mean (SD) of 6.62 on a scale from 1 to 10. A majority agreed that telehealth is needed in Lebanon (78.5%), 64.6% believed it is applicable in the Lebanese context, and a 81.7% expressed their willingness to continue using telehealth after the pandemic. Additionally, 78.5% indicated interest in receiving future telehealth training for nutrition care, and 74.2% reported the need for specific TPG to ensure proper delivery of remote services (74.2%).

This study is the first to investigate telehealth use among LDs prior and during COVID-19 pandemic in the absence of national Telehealth practice guidelines (TPG), standards and best practices to ensure ethical and safe practices. It identifies telehealth tools used, as well as the perceived benefits and barriers, and offers insights into the applicability, effectiveness, and future sustainability of telehealth in the Lebanese context. Amid COVID-19 pandemic, this study reports an increase in telehealth use among LDs, reflecting trends observed among other healthcare professionals in Lebanon, and dietitians in other countries [6–20]. Remarkably, most LDs (97.8%) reported using telehealth for nutrition care amid COVID-19 pandemic. In time of pandemic, telehealth has been perceived as a viable tool able to overpass lockdown measures, ensure patient safety, maintain the cycle of life, and support mental health and quality of life [12, 14-19]. Interestingly, we note a high use of telehealth practices among LDs before COVID-19 pandemic (48.4%), compared to only 15% of dietitians in Italy and 37% of dietitians in the US who performed telehealth activities prior the pandemic [12]. This early adoption could be related to the fact that some telehealth activities were initiated in the country before the pandemic onset as alternative practices to encompass the impact of the socioeconomic crisis, notably the scarcity of resources, lack of job opportunities, and limitation of transportation [6–21].

Given the limited financial resources, LDs might have resorted to remote modalities for delivering nutrition care. However, despite some pre-pandemic telehealth activities, the majority still focused on face-to-face consultations in clinics (82%) and hospitals, suggesting that pre-pandemic telehealth practices were primarily used for follow-up with existing patients and/or for continuous education. Similar pre-pandemic patterns were noted among Lebanese physicians who, with limited financial resources caused by the economic crisis, were unable to travel to attend international conference and relied mainly on telehealth for continuing medical education. [6] Additionally, the use of videoconferencing for telehealth consultations was reported to be low among Lebanese physicians before the pandemic [6]. In contrast, the COVID-19 pandemic imposed a rapid shift toward audiovisuals tools and videoconferencing. LDs embraced telehealth, with their uptake being centered in private practices and among newly graduated LDs. In Lebanon, private practice is a common but self-managed form of employment, often represented under “clinics” in our data. This swift telehealth uptake observed in the country could be explained by the fact that LDs population was relatively young (mean (SD) age: 30.54 (6.41) years), already familiar with new technologies and accustomed to using smart applications, which came in similar to a study conducted on Italian dietitians.²⁰ Comparable findings were also observed in the MENA region [14]. Thus, LDs initiated telehealth amid COVID-19 pandemic by relying on WhatsApp (90.3%) as a main tool, followed by Zoom (72.0%), Emails (41.9%) and phone calls (39.8%). Similarly, Lebanese physicians reported using WhatsApp (79%), phone calls (77%) and email (63%), along with platforms such as Zoom and social media (e.g., Facebook, YouTube and Instagram) [6]. Remarkably, during the pandemic, the use of mobile applications/software as telehealth tools was highly observed in low-to-middle income countries, with a strong preference for audio-visuals tools such as WhatsApp, Zoom, Facebook Messenger and Skype [22]. This was reflected in our study, which showed that LDs were able to select telehealth tools suited to the country’s economic status, despite the absence of official guidance. These tools offered LDs an atmosphere similar to in-clinic consultations, enabling direct interactions with patients (both within and outside Lebanon), as well as data collection, feedback, and evaluation. In contrast, the use of Zoom for healthcare and electronic medical record was minimal (around 3%) and exclusively reported among LDs working in hospitals. In fact, Electronic Healthcare Records were incorporated in some major private hospitals before the pandemic, but their use was limited to the context of some practices [6]. Moreover, telehealth platforms available in Lebanon (such as TrakMD, SohatiDoc, Doctori, and Drapp) were not authorized by MOPH and the Lebanese Order of Physicians [23]. Due to these facts, both Lebanese physicians and patients reported a preference for using WhatsApp instead of telehealth platforms as it allowed for spontaneous, informal and free of charge communication [23]. The findings of this study reflect limited integration of telehealth into the Lebanese nutrition care system prior to the pandemic. which hindered LDs’ ability to leverage existing infrastructure and deliver remote services effectively. As a result, LDs were not professionally equipped to initiate remote consultations, and both their profession and resilience were challenged by the pandemic. This may explain their reliance on mobile and social media applications (such as WhatsApp, Facebook Messenger…) (40.9%) and direct emails (21.5%) to communicate with referring medical providers. Social media applications thus emerged as alternative telehealth tools, enabling direct communication with patients, medical providers and colleagues, as well as indirect communication with virtual profiles via its platforms. In contrast to other scientific-based applications and business communication platforms, social media provided a user-friendly environment that enabled LDs to create and disseminate dietetic content using graphics, videos and interactive tools which allowed broader engagement and interdisciplinary integration. As a result, dietitians were able to go beyond counselling and nutrition care to address concerns, social trends, and common interests experienced in times of pandemic [14]. In the same directions, Rozga et al. (2021) found that dietitians preferred social media due to its accessibility and ease of interaction compared to rigid institutional platforms [19]. Similarly, Bookari et al. (2023) reported that Arab dietitians relied on social media to connect with diverse audiences and found it effective in addressing public concerns and social trends during the pandemic [15]. Furthermore, Alboraie et al. (2022) pointed out the regulatory, technical and infrastructural challenges of formal telemedicine platforms, making social media a more feasible and accessible communication tool [24].

Building on these observations, this study acknowledges that in the absence of authorized telehealth systems and a legal framework, and with the presence of underdeveloped infrastructure, a socio-economic crisis and limited resources, resorting to social media during the pandemic supported the resilience of LDs and provided them with business opportunities and marketing experience for professional growth. In the same direction, the use of social media as a telehealth tool was widely reported in other Arab countries (such as the UAE, KSA and Jordan), and appeared to be an effective telehealth tool during COVID-19 pandemic, despite ongoing concerns about privacy and data misuse [14]. Recent studies conducted in these countries, including Lebanon, revealed a significant shift toward telehealth during the COVID-19 pandemic. More than 63% of dietitians reported high reliance on social and mass media platforms, with Instagram emerging as the most commonly tool used (51.7%) [15]. Key benefits of these platforms included broader outreach and quick information sharing, despite challenges related to time constraints and effective communication [15]. During remote nutrition care, LDs identified several barriers centered around bad connections (74.2%), patients preferring face-to-face consultation (61.3%) and patients lacking technical literacy (33.3%). They expressed discomfort during telehealth sessions and faced challenges specific to the dietetic profession, such as difficulties in collecting physical data and conducting comprehensive nutrition assessments (32.3%). In addition, cultural barriers related to privacy concerns were identified in our study, including patient discomfort with discussing personal health information in the virtual settings. These findings are consistent with reports from the United States and several Arab countries. For example, Bookari et al. (2022) highlighted how sociocultural norms in Arab countries, particularly those related to gender roles and concerns about confidentiality, affect telehealth communication, especially in shared household spaces [14]. [14–24]. Similarly, Egyptian healthcare providers observed patient resistance to telehealth consultations due to cultural expectations around trust, confidentiality, privacy and the absence of secure communication systems [24]. In the US, Rozga et al. (2021) also reported that dietitian encountered patient reluctance to engage in telehealth sessions due to lack of privacy in home settings [19]. The use of commercially available platforms such as WhatsApp and Zoom for telehealth raises significant concerns regarding patient privacy and data security. In Lebanon, the absence of enforceable data protection laws and telehealth-specific regulations aggravated these risks and underscores the need for legal frameworks and TPG to govern digital practices and protect patient confidentiality [7].

One of the notable findings in this study is that 50.5% of LDs reported delivering nutrition care to patients located outside Lebanon. Under normal circumstances, and due to professional licensing restriction, such cross-border practices could have legal implications. However, this became possible during the pandemic due to the temporary relaxation of telehealth regulations, including regulatory adjustments such as waived licensure requirements to enable broader telehealth services [19]. It is worth noting that these international consultations were provided independently by LDs on a private basis and, in the absence of formal regulations governing cross-border telehealth practices, were neither affiliated with nor reimbursed by any national health system. In similar, Lebanese physicians practiced telehealth during the COVID-19 pandemic in an unregulated environment and expressed the need for regulatory frameworks to guide and protect their remote activities [6]. This highlights a systemic gap in telehealth governance in Lebanon and a lack of knowledge regarding the legal and ethical aspects of telehealth use across countries and health professions, underscoring the need for official TPG and professional training. Similarly, only a minority of physicians in KSA reported being aware of existent regulations governing the proper delivery of telehealth via smart devices, further emphasizing the need for clear regulatory guidance [25]. Nevertheless, LDs recognized several telehealth benefits, including scheduling flexibility (83.9%), decrease in practice-related costs (77.4%), and improved compliance with social distancing measures (53.8%). The mean (SD) rating of their overall experience scored 6.62, on a scale from 1 to 10. LDs found telehealth to be effective and applicable in Lebanon and expressed a strong need for the development of TPG and related trainings. They were also aware of the absence of a legal framework and professional support to ensure protection of professional practice, confidentiality, security, and privacy (S3 Table). Similar needs were reported by dietitians in Italy and in the UAE [12,14].

In conclusion, the study findings align with those reported among dietitians in other countries and among medical professionals in Lebanon. The Lebanese telehealth experience closely mirrors that of the MENA region during COVID-19 pandemic [26]. Yet, we demonstrate that telehealth is effective, applicable and necessary in the Lebanese context, serving as a resilient alternative for delivering care in time of pandemic, disasters, and severe crisis, with strong willingness among LDs to continue its use beyond COVID-19 pandemic.