Food Protection Trends - November/December 2021 - 548

outbreaks is one important component of the Centers for
Disease Control and Prevention's (CDC) overall effort. Risk
communication to the public has proven, in many areas of
public health, an effective tool to raise awareness, increase
knowledge, and change behaviors (2).
Although most foodborne outbreaks are local, multistate
foodborne outbreaks cause a disproportionate number of
illnesses, hospitalizations, and deaths. From 2010 to 2014, a
common foodborne source was identified in 120 multistate
foodborne outbreaks, and in 55 of these outbreaks, a food
product recall occurred. Even though these outbreaks
accounted for 3% of all reported foodborne outbreaks, they
were responsible for 11% of illnesses, 34% of hospitalizations,
and 56% of deaths (7). Given the disproportionate impact
of multistate outbreaks and given that consumers can often
take actions to reduce their risk of illness, it is especially
important to assess the attitudes, perceptions, behaviors, and
how people receive information around multistate outbreaks.
Public notification is an essential part of the public
health response effort, providing timely access to reliable
information and encouraging the public to make informed
choices to prevent additional illnesses. During the multistate
outbreak investigations that CDC coordinates, a variety
of communication avenues are used, including the CDC
website, Facebook, Twitter, Instagram, partner social media
accounts, and news media, to notify the public about
ongoing multistate foodborne outbreaks and what people can
do to protect themselves from becoming ill. Each outbreak
investigation can require unique public health messages,
making timely and accurate public communication essential
to relay advice to consumers. Public communication during
outbreaks serves several functions, including notifying
consumers of an outbreak, sharing information about
the results of an investigation, and providing advice and
enumerating actions consumers and retailers can take to
protect themselves and their customers. Such actions can
include avoiding eating or selling certain foods for a specific
time, returning or discarding foods, following routine
food safety recommendations, and seeking health care.
CDC uses two Web-based communication tools to deliver
information about foodborne outbreaks to the public during
outbreaks. These tools are referred to as food safety alerts or
investigation notices (5). A food safety alert provides urgent,
specific advice to consumers, restaurants, and retailers about
foods to avoid eating or selling. This advice may include
information about a recall or other warnings. An investigation
notice provides information about an outbreak not yet linked
to a food source, or an outbreak linked to a general type or
category of food, rather than a specific food.
Since 2006, CDC has provided communication on
over 150 multistate foodborne outbreaks on the website.
However, the message content and format have never been
evaluated with the target audiences, and to our knowledge,
there has been limited work exploring the attitudes and
548 Food Protection Trends November/December
perceptions of consumers toward multistate foodborne
outbreaks. To better inform the communication strategy
for foodborne illness, we conducted a series of focus groups
of adults in the Washington, D.C., metropolitan area to
understand attitudes, perceptions, behaviors, and how people
receive information around foodborne disease outbreaks.
MATERIALS AND METHODS
The project used qualitative methods of cognitive interviews
and focus groups, which are a representation of the attitudes
and beliefs of the participants and should not be generalized to
a larger population. The project consisted of four focus groups
(25 participants) designed to assess the attitudes, perceptions,
behaviors, and how people receive information around
foodborne disease outbreaks. Two groups were traditional
100-min focus group sessions (18 total participants), while
the remaining two were hybrid groups (7 total participants)
that consisted of a one-on-one 40-min cognitive interview
session, followed by a 45-min traditional focus group in which
the individuals separately interviewed came back together.
Despite a relatively small sample size of 25 participants,
the hybrid methodology of mixing both focus groups and
individual interviews allowed for more comprehensive findings
by expanding the depth of responses (11). Ultimately, we felt
that the depth of responses would provide more actionable
results to inform risk communication strategy compared with
additional focus groups to increase the total sample size of
participants (16). The cognitive interviewing method (20) is
a technique in which respondents are asked to report directly
on cognitive or mental processes as they are being interviewed.
The question response process model (21) evaluates the four
stages an individual goes through to respond to a survey item:
comprehension, retrieval, judgement, and response. Cognitive
interviewing has become a technique commonly employed
to evaluate and assess warning label effectiveness (22) as a
test of comprehension of communication and messaging
materials, because it helps determine how well respondents
understand messaging. The open-ended format used in the
cognitive interviewing method offers insight on respondents'
understanding of messaging, reactions to the message, and
existing knowledge on the content and is generally considered
free from interviewer-imposed bias. One of the hybrid groups
was limited to adults aged 65 and older because they are at
a higher risk for serious health complications as a result of
foodborne illness (3), and we felt it useful to identify the
attitudes and perceptions of participants within this specific
age group to consider any implications for risk communication
strategy. Potential differences in attitudes, perceptions,
behaviors, and how people receive information from the general
public were also identified to inform future risk communication
strategy among this high-risk group. All sessions were
segmented by education level to create homogenous groups
to avoid potential bias that might arise from varied levels of
understanding, behavioral impacts, or perceptions.
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