Focus Groups of US Adults KAP of Foodborne Disease Outbreaks and Illness Prevention

Form Approved

OMB Control No.: 0920-1154

Expiration date: 01/31/2020

Attachment E: CDC Foodborne Outbreak Knowledge and Practices

Focus Group Approach - Focus Group Moderator Guide [100 minutes]

1. TOPICS AND QUESTIONS FOR DISCUSSION

Topic 1 – Defining Foodborne Disease Outbreak

1. Let’s start with a very general topic, and we will get more specific as we go. What initially comes to mind when I say the words foodborne disease outbreak?

Probe:

1. What, if any, other words or phrases would you use to define, describe, etc., foodborne illnesses?

Provide definition after discussion if needed: A foodborne disease outbreak is defined as an incident in which two or more persons experience a similar illness resulting from the ingestion of a common food.* CDC coordinates the investigation into the outbreak when multiple states are involved.

Topic 2 – Foodborne Outbreak Messaging

Now we are going to talk about foodborne disease outbreak messaging, communications, etc.,

2. Thinking back over the past 3-4 years, approximately how often have you heard or read about a foodborne disease outbreak? (If necessary: that could be per year, per month, etc.)

3. Thinking again about the past few years, where or from whom have you heard about foodborne disease outbreaks?

Probe: (No detail needed on each of the following sources, these serve as reminders to the moderator only)

1. 

   Public reporting burden of this collection of information is estimated to average 100 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB Control Number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-1154

   A government agency? >>> Federal? State? City or County? >>> Health Department? Consumer Affairs Department? Public Safety Department? School or school staff?

2. Private individual, company, or organization? >>> Doctor? Other health care provider? Family member or friend? Grocery, restaurant, or other food seller? Consumer advocate or social services organization?

3. News media? >>> Newspaper? Television? Radio?

4. Social media? >>> Facebook, Twitter, Official sites (e.g. CDC) vs. friends and family, etc.

5. Websites? Specific sites or via search like Google?

6. {Outdoor advertising such as billboards, bus or train ads, etc.?}

7. When you read or hear a message about a foodborne illness outbreak, in general how do you evaluate how serious a problem it could be for you or a relative or friend?

Probe:

1. How dangerous are foodborne disease outbreaks? >>> Death? Serious illness requiring hospitalization? Illness, discomfort, inconvenience while at home, work, or other places?

2. What kinds of words or phrases make a message about a foodborne illness outbreak seem more serious or dangerous?

3. Conversely, what kinds of words or phrases might make a message seem important but not as serious or dangerous versus other messages?

4. To what extent, and how, does the tone or feel of a message about foodborne illness outbreak affect how serious or dangerous you think the problem is? >>> Examples?

5. To what extent does the specific bacteria or pathogen mentioned in the message affect how serious or dangerous you think the problem is? (If necessary: it could be things like E. Coli, Salmonella, Listeria, etc.)

4. When you read or hear a message about a foodborne illness outbreak, how do you know if it applies to you? When you read or hear a message about a foodborne illness outbreak, in general how do you know if it applies to you or a relative or friend, especially the likelihood of getting the infection mentioned?

Probe: (As appropriate, refer to comments from Q6.)

1. What makes someone think they are either highly susceptible or unlikely to get the infection mentioned in the message about a foodborne disease outbreak?

2. To what extent does the specific bacteria or pathogen mentioned in the message make you believe or feel that you are more or less likely to become infected if you eat the food mentioned? (If necessary: it could be things like E. Coli, Salmonella, Listeria, etc.)

3. What else, if anything, seems likely to make you believe or feel that you are more, or less, likely to acquire the infection mentioned if you eat the food mentioned?

Topic 3 – High Risk Foods

5. In general, what foods are more likely to carry germs that can make you sick?

Probe:

1. To what extent do you eat {foods mentioned} and what does it depend on?

2. What do you think of when you think of soft cheeses? Is there anything about those types of cheeses that make them riskier for germ contamination?

(If necessary, after some discussion, define soft cheese as cheeses that are high in moisture content, such as fresh, surface-ripened or aged cheeses. Soft cheeses have a moist, creamy, or crumbly texture and are often spread on bread or crackers. Examples of soft cheeses include Brie, bleu cheese, gorgonzola and queso fresco.)

3. What do you think of when you think of leafy greens? Is there anything about those types of greens that make them riskier for germ contamination? (If necessary, after some discussion, define leafy greens as plant leaves eaten as a vegetable, which include lettuce, spinach, arugula, red leaf lettuce, kale, and cabbage. They can be sold loose as heads or individual leaves, in bags of just one type of leafy green or a mixture, or in plastic “clamshell” containers of one type of leafy green or a mixture.)

4. Does the risk of contamination change depending on where the food was produced? To what extent? >>> Country? State? Farm, manufacturer, producer, etc.? Hander, transporter, seller, etc.? Grocer, restaurant, or other seller?

6. Thinking about everything we have talked about thus far, how do you compare foodborne disease outbreak messages related to specific products versus more general items? For example, what are the similarities or differences between an advisory for Honey Smacks Cereal and an advisory for uncooked vegetables and meats?

7. Getting technical here, what do you think is the difference between a food recall and a foodborne disease outbreak? (If necessary: a recall is when the U.S. Department of Agriculture, the U.S. Food and Drug Administration, or a food producer tells consumers they should return a food item to where they bought it, and get a refund. A recalled food item is illegal to sell.)

Probe:

1. To what extent, if at all, are you familiar with {CDC} Food Safety Alerts, and Investigation Notices? >>> What is the purpose of each? What is the difference between them?

2. Where have you seen Food Safety Alerts? Where have you seen Investigation Notices? >>> Have you seen these on the CDC website, and if so, what do you think about them?

8. Every year, there are roughly 800 foodborne disease outbreaks reported in the United States. Some of these affect a couple people while others affect more, some are found within a single state while others include more than one state, some are particularly risk for certain groups, like pregnant women, and others present a risk for everyone. What types of outbreaks do you want to hear about?

Probe:

1. How do you respond to seeing multiple messages on foodborne illnesses in a short period of time? Do you have any experience related to this that you can describe?

2. How often is too often for messages about foodborne disease outbreak?

3. What are your reactions to seeing information about foodborne illnesses frequently? (if needed, probe further on whether they become more or less likely to react to the messaging)

4. Based on your experiences, when do you think would be the best time to reach and inform people? Are you more likely to look or see these messages on one day versus another?

Topic 4 – Personal Behavior During and After Outbreaks

9. When you hear or read a message about foodborne disease outbreak what is your first reaction?

Probe:

1. To what extent, if at all, does that depend on the source(s) of the message? Message language and tone?

10. What action, if any, do you take upon hearing or reading a message about foodborne disease outbreak, and what does it depend on?

Probe:

1. Do you share it with your family and friends? How do you share this information?

2. What might impact your decision to share this information with others?

3. How well the message helped you understand the situation and your choices and their possible outcomes?

4. Switch to a similar type of food, brand, etc.?

5. Throw away the food mentioned? Eat it but perhaps in a different way than usual such as with extra cooking or other precautions? Eat it with no changes?

6. Try to return it to where you bought it?

11. How do you know when an outbreak is over, or no longer something to consider or worry about, and how does that affect what you do?

Probe:

7. In general for how long do you avoid, or handle differently than usual, a food item or product that was involved in a disease outbreak? >>> What does that depend on?

8. To what extent, if at all, does that depend on the source(s) of the message? Message language and tone?

12. What types of people are more likely to have severe health outcomes from eating contaminated food?

Probe:

1. To what extent, or how, do you fit with (what was mentioned)?

2. What, if anything, can you do to reduce your (your relative’s/friend’s) risk of foodborne illness and its potential for serious consequences?

Topic 5 – Recall Messaging [Time Permitting]

13. We are almost done now. Earlier we talked about food recalls versus outbreaks. Now I want to spend the last few minutes talking a little more about recalls. First, in the past few years how often have you heard about food recalls?

14. Who, if anyone, have you heard from about a food recall?

15. What language, tone, etc., about a food recall message makes it seem you will be more, or less, harmed if you eat the food mentioned?

16. What language, tone, etc., about a food recall message makes it seem more, or less, likely that you will be susceptible to the problems mentioned as associated with the food item or product?

Close Out – [5 minutes]

I am going to quickly ask my colleagues if there is anything else we need to cover. I will be back in one minute or less, but please feel free to continue talking among yourselves.

That is all the material we needed to cover, but is there anything else that any of you would like to add, or are there any questions that I should have asked but did not?

Thank you for your participation and insights. It was a great focus group that will help improve future communication and messaging about foodborne illness.

Moderator thanks respondents for their time and participation and dismisses them.

Hybrid Approach - Focus Group Moderator Guide [45 minutes]

2. TOPICS AND QUESTIONS FOR DISCUSSION

Topic 1 – Foodborne Outbreak Messaging

Now we are going to talk about foodborne disease outbreak messaging, communications, etc.,

1. Thinking back over the past few years, approximately how often have you heard or read about a foodborne disease outbreak? (If necessary: that could be per year, per month, etc.)

2. Thinking again about the past few years, where or from whom have you heard about foodborne disease outbreaks?

Probe: (No detail needed on each of the following sources, these serve as reminders to the moderator only)

8. A government agency? >>> Federal? State? City or County? >>> Health Department? Consumer Affairs Department? Public Safety Department? School or school staff?

9. Private individual, company, or organization? >>> Doctor? Other health care provider? Family member or friend? Grocery, restaurant, or other food seller? Consumer advocate or social services organization?

10. News media? >>> Newspaper? Television? Radio?

11. Social media? >>> Facebook, Twitter, Government sites (e.g. CDC) vs. family/friends, etc.

12. Websites? Specific sites or via search like Google?

13. {Outdoor advertising such as billboards, bus or train ads, etc.?}

3. The individual interviews you just did here covered this next question in more detail, and perhaps was more personal, than we need to be here, but please share some of your thoughts about the types of foodborne disease messages you have heard or read, and what they typically mean to you?

Probe:

1. What are your impressions of the messages you’ve seen about foodborne illness?

2. In general, how clear and understandable are the messages? (If necessary, do they tend to be too technical, full of jargon, etc.?)

3. When you read or hear a message about a foodborne illness outbreak, in general how do you know if it applies to you, especially your likelihood of getting the infection mentioned? (If necessary, how do the specific words, or the tone, of a message make it seem more, or less, relevant to you?) {Ask for examples}

4. When you read or hear a message about a foodborne illness outbreak, in general how do you evaluate how serious a problem it could be for you? (If necessary, how do the specific words, or the tone, of a message make it seem more, or less, dangerous?) {Ask for examples}

Thinking about everything we have talked about thus far, how do you compare foodborne disease outbreak messages related to specific products versus more general items? For example, what are the similarities or differences between an advisory for Honey Smacks Cereal and an advisory for uncooked vegetables and meats?

4. What action, if any, do you take upon hearing or reading a message about foodborne disease outbreak, and what does it depend on?

Probe – Action:

1. Share it with family and friends, and if so, how?

2. Switch to a similar type of food, brand, etc.?

3. Throw away the food mentioned?

4. Eat the food mentioned but perhaps in a different way than usual such as with extra cooking or other precautions?

5. Eat the food with no changes in how you prepare and eat it?

6. Try to return it to place of purchase?

Probe – What action depends on:

7. What might impact your decision to share the information with others? (If necessary, specific language, tone, source, relevance, relationship.)

8. How well the message helped you understand the situation and your choices and their possible outcomes?

Topic 2 – High Risk Foods

5. In general, what are high-risk foods in terms of possible foodborne disease and illness? In other words, what foods are more likely to result in foodborne disease?

Probe:

1. What do you know about the risk factors associated with soft cheeses? What do you consider as soft cheese? Could you provide some examples?

(If necessary, after some discussion, define soft cheese as cheeses that are high in moisture content, such as fresh, surface-ripened or aged cheeses. Soft cheeses have a moist, creamy, or crumbly texture and are often spread on bread or crackers. Examples of soft cheeses include Brie, bleu cheese, gorgonzola and queso fresco.)

2. What do you know about the risk factors associated with leafy greens? What would you consider as leafy greens? Could you provide some examples? (If necessary, after some discussion, define leafy greens as plant leaves eaten as a vegetable, which include lettuce, spinach, arugula, red leaf lettuce, kale, and cabbage. They can be sold loose as heads or individual leaves, in bags of just one type of leafy green or a mixture, or in plastic “clamshell” containers of one type of leafy green or a mixture.)

Topic 3 – CDC Webpage Investigation Notice

6. Look again at the Investigation notice. During the interviews we discussed whether the information on this webpage was easy to understand, what your reactions are to the message and what aspects are helpful to you. Now we will discuss together what you like and/or dislike about the webpage.

Probe:

1. What is the main message of this notice?

2. What do you like and/or dislike about the Investigation Notice? For reasons why/why not?

3. What do you like and/or dislike about the text in the Investigation Notice? For reasons why/why not

4. What are your thoughts on the icons used?

5. What are your thoughts on the information available to you?

7. Now, I would like to get your suggestions for improvement

1. What would you change to make:

• The information on the Investigation Notice easier to understand?

• People realize the importance of the information on the Investigation Notice?

• People realize the risk of the food discussed in the Investigation Notice?

2. How would you improve the way information is presented on this page?

3. How would you improve the text on this page?

4. Working as a team, think about the format and the information displayed in the notice. What are the most important changes that need to be made to make this an effective notice?

Topic 4 – CDC Webpage Food Safety Alert

8. Look again at the Food Safety Alert. During the interviews we discussed whether the information on this webpage was easy to understand, what your reactions are to the message and what aspects are helpful to you. Now we will discuss together what you like and/or dislike about the webpage.

Probe:

1. What is the main message of this notice?

2. What do you like and/or dislike about the food safety alert? For reasons why/why not?

3. What do you like and/or dislike about the text in the food safety alert? For reasons why/why not?

4. What are your thoughts on the icons used?

5. What are your thoughts on the information available to you?

9. Now, I would like to get your suggestions for improvement

1. What would you change to make:

• The information on the food safety alert easier to understand?

• People realize the importance of the information on the food safety alert?

• People realize the risk of the food discussed in the food safety alert?

2. How would you improve the way information is presented on this page?

3. How would you improve the text on this page?

4. Working as a team, think about the format and the information displayed in the notice. What are the most important changes that need to be made to make this an effective notice?

Close Out

I am going to quickly ask my associates if there is anything else we need to cover. I will be back in one minute or less, but please feel free to continue talking among yourselves.

That is all the material we needed to cover, but is there anything else that any of you would like to add, or are there any questions that I should have asked but did not?

Thank you for your participation and insights in this focus group and the individual interviews before this. Your participation will help improve future communication and messaging about foodborne illness.

Hybrid Approach – Cognitive Interview Protocol [40 minutes]

Topic 1 – Defining Foodborne Disease Outbreak

1. Let’s start with a very general topic, and we will get more specific as we go. What initially comes to mind when I say the words foodborne disease outbreak?

Probe:

2. What, if any, other words or phrases would you use to define, describe, etc., foodborne illnesses?

Topic 2 – Foodborne Illness Messages and Personal/Family/Friend Risk

2. What types of people are more likely to be at even higher risk of serious problems associated with foodborne illness?

Probe:

1. To what extent, or how, do you fit with (what was mentioned)?

2. How do your family members or friends fit with that?

3. What, if anything, can you do to reduce your, or your relative’s or friend’s risk of foodborne illness and its potential for serious consequences? {Ask for examples}

4. To what extent have you done (mentioned in c), and what happened?

3. When you read or hear a message about a foodborne illness outbreak, in general how do you know if it applies to you or a relative or friend, especially the likelihood of getting the infection mentioned?

Probe:

1. Remember there are no wrong answers or judgement in this interview, so let me ask, how well do you understand messages about foodborne illness, and what does it depend on? Can you mention examples of such messages or pieces of messages that were clear and understandable, and some that were not?

2. To what extent or not are messages about foodborne illness too technical, full of jargon, etc.? If you see or hear a message like that, what do you do? (If necessary, ignore it; go over it multiple times to try to understand; seek explanation from somewhere or someone?)

3. In what situations, if any, have you found yourself mistaken in what you understood a message to be or mean, and what happened?

4. How do the specific words, or the tone, of a message make it seem more, or less, relevant to you or family and friends? {Ask for examples}

5. How do you incorporate or balance messages about foodborne illness with your lifestyle and choices? (If necessary, what and where you eat, where you buy food, how you prepare food?)

6. Only in as much detail as you are comfortable with, please share your experience, or those of family members or friends, with foodborne illness, and how messages or warnings about it could have or actually did help.

4. When you read or hear a message about a foodborne illness outbreak, in general how do you evaluate how serious a problem it could be for you or a relative or friend?

Probe:

1. How do the specific words, or the tone, of a message make it seem more, or less, of a serious problem for you or family and friends? {Ask for examples}

2. How do you incorporate or balance messages about foodborne illness with other health or safety concerns that you or family or friends face? (If necessary, chronic disease or conditions, medications or supplements, dietary restrictions or requirements, past experience with foodborne illness)

3. How, if at all, have messages about foodborne illness made the situation seem more, or less, serious for you or a relative or friend than it actually was? What happened? (If necessary, serious illness and hospitalization, or worse; out of action at home and missing work and other important activities)

Topic 3 – Consumer Behavior Related to Foodborne Illness Messages

5. What action, if any, do you take upon hearing or reading a message about foodborne disease outbreak, and what does it depend on?

Probe – Action:

1. Share with family and friends, and if so, how?

2. Switch to a similar type of food, brand, etc.?

3. Throw away the food mentioned?

4. Eat the food mentioned but perhaps in a different way than usual such as with extra cooking or other precautions?

5. Eat the food with no changes in how you prepare and eat it?

6. Try to return it to place of purchase?

Probe – What action depends on:

7. What might impact your decision to share the information with others? (If necessary, specific language, tone, source, relevance, type and status of relationship.)

8. How well the message helped you understand the situation and your choices and their possible outcomes?

6. How do you know when an outbreak is over, or no longer something to consider or worry about, and how does that affect what you do?

Probe:

1. In general for how long do you avoid, or handle differently than usual, a food item or product that was involved in a disease outbreak? What does that depend on?

2. To what extent, if at all, does that depend on the source(s) of the message? Message language and tone?

Topic 4 – CDC Webpage Investigation Notice

7. Please take a look at this {Present Investigation Notice Page to Participant}. I would like you to take some time to read and explore the information provided here and please think out loud as you do so.

Probe:

1. Have you seen an investigation notice like this in the past?

2. What is your first impression? What is your first thought when you look at the webpage?

3. Does the page catch your attention? What in particular catches your attention? Or what about it is not attention catching?

4. Can you tell me in your own words, what information is this webpage providing?

5. What message is this investigation notice trying to get across?

6. What do you think is the main purpose of the investigation notice?

7. What, if any, part of this notice is confusing to you?

8. Are there words or descriptions that you found hard to understand? If so, point them out to me.

Topic 5 – Food Safety Alert

1. Please take a look at this {Present Investigation Notice Page to Participant}. I would like you to take some time to read and explore the information provided here and please think out loud as you do so.

Probe:

1. Have you seen an investigation notice like this in the past?

2. What is your first impression? What is your first thought when you look at the webpage?

3. Does the page catch your attention? What in particular catches your attention? Or what about it is not attention catching?

4. Can you tell me in your own words, what information is this webpage providing?

5. What message is this investigation notice trying to get across?

6. What do you think is the main purpose of the investigation notice?

7. What, if any, part of this notice is confusing to you?

8. Are there words or descriptions that you found hard to understand? If so, point them out to me.

Close Out

That is all the material we needed to cover in this portion of today’s event, but is there anything else that you would like to add, or are there any questions that I should have asked but did not?

It was a great interview and I enjoyed working with you in this format. It is time for a 15-minute break and then the 45-minute focus group about similar topics. Thank you for your participation and insights that will help improve future communication and messaging about foodborne illness.

CDC Foodborne Outbreak Data Collection Protocols – Knowledge and Practice – EurekaFacts – 3/14/19 – Page 13 of 13