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[Table of Contents]
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June 2006
Qualitative Research with Transplant Recipients and Caregivers:
Food Safety Messages and Delivery Mechanisms
Final Report
Contract No. 53-3A94-03-12
Prepared for
Susan Conley
Barbara O'Brien
Janice
Adams-King
U.S. Department of Agriculture
Food Safety and
Inspection Service
Food Safety Education Staff
5601 Sunnyside
Avenue
Beltsville, MD 20705-5268
Prepared by
Katherine M. Kosa
Sheryl C. Cates
RTI
International
Health, Social, and Economics Research
Research Triangle
Park, NC 27709
RTI Project Number 0208893.017
*RTI International is a trade name of Research Triangle
Institute.
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Executive Summary
The U.S. Department of Agriculture's Food Safety and Inspection Service
(USDA, FSIS) developed a food safety booklet targeted to bone marrow and solid
organ transplant recipients and their caregivers. To determine the booklet's
effectiveness in educating transplant recipients and their caregivers on food
safety and to assess the best way to reach the target audience with food safety
messages, FSIS contracted with RTI International (RTI) to conduct qualitative
research with transplant recipients and caregivers. RTI conducted one focus
group discussion in Durham, North Carolina, on March 30, 2006, and 22 individual
telephone interviews from March 26 to April 2, 2006.
This report presents the findings from the focus group discussion and
telephone interviews with transplant recipients and caregivers. FSIS can use the
study findings to refine the booklet prior to dissemination and to identify
effective communication channels for reaching transplant recipients and
caregivers with food safety information.
ES.1 KEY FINDINGS
We list the key findings from the focus group discussion and telephone
interviews below.
Participants' Food Safety Concerns, Knowledge, and Practices
Many participants received food safety information as part
of their post-transplant education. Generally, this information was limited to
specific foods to avoid and proper hygiene practices.
Since receiving their transplants or providing care for a transplant
recipient, many participants received food safety information from a doctor or
another healthcare professional. The content and format of the information
varied by the institution that provided care, but many participants received
information that was generally limited to specific foods to avoid (e.g., raw
meat and sushi) and information on proper hygiene practices (e.g.,
handwashing).
Before receiving the booklet, most participants were somewhat concerned about
getting sick from food they prepare at home because they were aware of the
possible risks of foodborne illness, but were also confident in their abilities
to handle and prepare food safely at home. A few participants are less concerned
about getting sick than when they first received their transplants.
Although most participants say they are more cautious when preparing food at
home since their transplants, most participants can do more to handle and
prepare food safely. Most participants follow the recommended practices to keep
hands and surfaces clean and to prevent cross-contamination, but most
participants are not following the recommended practices to cook and chill food
safely. Most participants do not use a food thermometer and do not reheat deli
meats to steaming hot. Most participants do not own a refrigerator thermometer
and do not safely store large amounts of leftovers (e.g., soups and stews).
As recommended by a doctor or another healthcare professional, some
participants have stopped eating certain foods since receiving their
transplants. Most participants have not consumed or served sushi, ceviche, or
other raw fish, raw, unpasteurized milk, raw meat or poultry, cold hot dogs, raw
sprouts, unpasteurized fruit or vegetable juice, and refrigerated pâtés or meat
spreads. Since their transplants, some participants have consumed or served raw,
homemade cookie dough or cake batter and dishes that contain raw or undercooked
eggs (e.g., Caesar salad). Most participants have consumed or served cold deli
or luncheon meats and soft cheeses (e.g., feta).
A majority of participants were very concerned about getting sick from food
they ate outside their homes because "you have no control [outside your home]."
Because they have found restaurants they trust and frequent often, a few
participants are less concerned about getting sick from food they eat outside
their homes. A few participants are less concerned about getting sick than when
they first received their transplants.
Participants' Evaluation of the Booklet
Participants liked the booklet and thought it was well prepared, very
informative, comprehensive, concise, and easy to read. Most participants thought
the booklet contained relevant and useful information for transplant recipients
and their caregivers. Many participants shared the opinion of one participant
who said, "I really liked [the booklet]. It reinforced some things I already
knew, but I also picked up new information; like, I didn't know that I had to
worry about sprouts or bleu cheese." Most participants said they learned
something new after reading the booklet.
Participants liked the appearance of the booklet, particularly its colors,
pictures, and tables. Participants especially liked the charts and graphics
provided throughout the booklet. Many participants really liked the "Is It Done
Yet?" graphic and/or the "Cold Storage Chart" and thought they provided the most
valuable pieces of information in the booklet.
Participants' Knowledge and Behavior Changes
Each participant learned at least one new fact after reading the booklet, and
many participants plan to make at least one change in their food handling
practices based on what they learned.
After reading the booklet, many participants learned more about
- foodborne pathogens and foodborne illnesses,
- foods that pose a high risk for foodborne illness,
- safe ways to handle and prepare foods at home, and
- pasteurization.
Based on what they learned, many participants have made or plan to make the
following changes in their food handling practices:
- separate raw meat and poultry from other foods in the grocery
cart,
- follow recommendations in the "Cold Storage Chart" on page 11, and
- avoid eating sprouts.
Other participants have also made or plan to make other behavioral changes
based on what they learned (e.g., purchase a refrigerator thermometer and/or
food thermometer; divide large amounts of leftovers into shallow containers; and
stop eating soft-boiled eggs or eggs prepared over-easy).
Participants' Suggestions for Improving the Booklet
Participants were very forthcoming in offering their opinions and suggestions
for improving the booklet. Participants suggested changes for improving the
cover, pictures, and the text (e.g., removing the pictures of the woman in the
wheelchair and the pregnant woman) and adding other information to the booklet
(e.g., a discussion on whether organic foods are less or more risky for
transplant recipients). Participants also identified words and sentences they
found confusing (e.g., pasteurization).
Delivery Mechanisms
To reach transplant recipients and their caregivers with information on food
safety, almost every participant suggested distributing food safety information
to transplant coordinators at clinics and hospitals. Participants also suggested
many other venues for distributing food safety information to transplant
recipients and their caregivers (e.g., transplant and other healthcare
organizations, government agencies' Web sites, outreach programs and support
groups, doctors' offices, and pharmacies).
ES.2 RECOMMENDATIONS
The recommendations identify additional information FSIS
should consider including in the booklet and suggest refinements for improving
the booklet.
Based on the findings from the focus group discussion and telephone
interviews with transplant recipients and caregivers, we offer the following
recommendations for improving the food safety booklet:
- define pasteurization and explain why it is important for transplant
recipients to choose food products (e.g., soft cheeses, eggs, fruit juices)
that have been pasteurized;
- explain why transplant recipients need to reheat hot dogs, deli meats, and
luncheon meats to steaming hot;
- instruct transplant recipients to contact their transplant coordinators
instead of their physicians or healthcare providers;
- expand the section "Being Smart: When Eating Out" (see Section 3.4.8,
page 3-23 for participants' suggestions);
- replace the word "you" with "transplant recipient" in the first section
titled "Food Safety: It's Especially Important for You" (page 2) and
throughout the text;
- remove the pictures of the pregnant woman and the woman in the wheelchair
from the front cover;
- improve the resolution of the picture of the woman using a meat
thermometer (page 6) and the picture of raw beef (page 8);
- enlarge the FightBAC!® logo (page 6);
- change the words printed in yellow (e.g., "separate" on page 9) to another
color (e.g., green) that is easier to read; and
- remove the "My Physicians: Quick Reference List" (page 16).
1. Introduction
RTI conducted a focus group discussion and 22 telephone
interviews with transplant recipients and caregivers to characterize their
food safety knowledge, attitudes, and practices and to obtain their feedback
on the food safety booklet developed by FSIS for transplant recipients and
their caregivers.
Bone marrow and solid organ transplant recipients (transplant recipients)
take immunosuppressive medications so their immune systems will not reject their
transplanted bone marrow or organs. Due to their weakened immune systems,
transplant recipients are at a higher risk of contracting a foodborne illness
that may result in a lengthier illness, hospitalization, or death. To better
understand associated foods and behaviors that have been linked
to foodborne illness, transplant recipients should be informed about
leading pathogens that cause foodborne illness in the United States.
Transplant recipients should also know and follow safe food handling practices
to prevent their exposure to pathogens known to cause foodborne illness.
The U.S. Department of Agriculture's Food Safety and Inspection Service
(USDA, FSIS) developed a food safety booklet targeted to transplant recipients
and their caregivers. Appendix A provides a copy of the booklet. To
determine the effectiveness of the booklet in educating transplant recipients
and their caregivers on food safety and to assess the best way to reach the
target audience with food safety messages, FSIS contracted with RTI
International (RTI) to conduct qualitative research with transplant recipients
and caregivers. RTI conducted one focus group discussion in Durham, North
Carolina, on March 30, 2006, and 22 individual telephone interviews from March
26 to April 2, 2006.
The objectives of the study were to
- characterize transplant recipients' and caregivers' concerns about
foodborne illness;
- assess transplant recipients' and caregivers' general food safety
knowledge and safe food handling practices;
- seek feedback from transplant recipients and caregivers on the booklet
regarding
- the look and feel of the booklet, including layout, comprehension level,
and overall design;
- the usefulness of the booklet's content; and
- suggestions for improving the booklet;
- seek feedback from transplant recipients and caregivers on the USDA
word-mark umbrella brand to determine receptivity, understanding, and overall
look and feel; and
- identify preferred communication channels and dissemination strategies for
the booklet.
FSIS can use the study findings to refine the booklet prior to dissemination
and to identify effective communication channels for reaching transplant
recipients and caregivers with food safety information.
This report describes the study design and presents the findings from the
focus group discussion and telephone interviews with transplant recipients and
caregivers. Section 2
describes the study design for the focus group and telephone interviews. Section 3
presents the results of the focus group and telephone interviews. Section 4
concludes the report with recommendations, based on the study findings, for
improving the booklet.
2. Study Design
In this section, we describe the procedures and materials used to conduct the
focus group and telephone interviews with transplant recipients and caregivers.
We originally planned to conduct two focus groups with transplant recipients and
one focus group with caregivers of transplant recipients. Because recruiting
transplant recipients and caregivers for the focus groups proved difficult, we
conducted instead a focus group discussion and telephone interviews to reach the
desired number of study participants.
2.1 STUDY PARTICIPANTS
RTI conducted one focus group discussion with four
transplant recipients and six caregivers and 22 telephone interviews with 15
transplant recipients and seven caregivers, for a total of 32 study
participants.
Appendix B provides the questionnaires used to screen for eligibility
and recruit participants for the study. To be eligible to participate in the
study, transplant recipients must have had a bone marrow transplant, a solid
organ transplant, or recurrent or chronic allograft rejection. Caregivers had to
be either a home healthcare aid (excluding licensed healthcare professionals) or
an individual who cares for a child, spouse, or parent who has received a bone
marrow or solid organ transplant. Participants had to also meet the following
eligibility criteria:
- be at least 18 years old;
- prepare meals that include meat and poultry at least three times per
week;
- have not participated in a focus group in the past 6 months; and
- have not been employed, nor have household members employed, by the
Federal government; cooperative extension service; the food service or food
industries; the healthcare industry; or a marketing research, advertising, or
public relations firm in the past 5 years.
2.2 STUDY MATERIALS
Working with FSIS, we prepared interview guides for conducting the focus
group and the telephone interviews. Appendix C contains two versions of the
interview guide: one for discussions with transplant recipients and the other
for discussions with caregivers. The interview guide addressed the following
topics:
- Food safety concerns, knowledge, and practices: Participants discussed
their concerns about foodborne illness and their knowledge and use of safe
food handling practices.
- Evaluation of the booklet: Participants offered their opinions about the
usefulness, attractiveness, ease of comprehension, relevancy, acceptability,
and persuasiveness of the booklet (Doak, Doak, and Root, 1985).
- Knowledge and behavior changes: Participants identified new information
that they learned about safe food handling practices and any changes they made
in how they handle and prepare food at home based on the booklet.
- Suggestions: Participants offered their suggestions for making the booklet
more understandable, informative, interesting, and attractive.
- Delivery mechanisms: Participants offered their suggestions on how and
where the booklet should be distributed to reach transplant recipients and
their caregivers.
We developed a prediscussion questionnaire to collect information on
participants' food handling practices and demographics. Most of the questions
were obtain from the FightBAC!® questionnaire that RTI developed for
FSIS. Appendix D contains two versions of the prediscussion questionnaire:
one for transplant recipients and the other for caregivers.
2.3 FOCUS GROUP WITH TRANSPLANT RECIPIENTS AND CAREGIVERS
RTI contracted with a local market research company in Durham, North
Carolina, to recruit participants and provide facilities for hosting the focus
group discussion. To recruit transplant recipients and caregivers, the local
market research company placed an advertisement in a local newspaper, the
News & Observer, and worked with 16 local pharmacies, six local
home healthcare providers, and the following 10 transplant support groups:
- Duke Lung Transplant Center,
- Duke Heart Transplant Center,
- Duke Liver Transplant Center,
- Duke Chapter of the Second Wind Lung Transplant Association,
- Eastern Carolina Chapter of the Transplant Recipients International
Organization (TRIO),
- Triangle Chapter of TRIO,
- University of North Carolina (UNC) Lung Transplant Support Group,
- UNC Chapter of the Second Wind Lung Transplant Association,
- Wake Forest University Baptist Medical Center Heart Transplant Support
Group, and
- Wake Forest University Baptist Medical Center Renal Transplant Support
Group.
The pharmacies, home healthcare providers, and the transplant support groups
posted fliers and talked with transplant recipients and their caregivers about
the study.
On March 30, 2006, RTI conducted one focus group discussion with four
transplant recipients and six caregivers, for a total of 10 participants. Table 2-1
provides information on participants' demographics.
RTI mailed participants the food safety booklet and instructed them to read
the booklet prior to the focus group discussion. After arriving at the focus
group facility, participants completed the prediscussion questionnaire. Two
trained moderators conducted the focus group discussion, which lasted
approximately 90 minutes. Focus group participants received a free gift (a
refrigerator thermometer) and a monetary incentive of $75.
Table 2-1. Participants'
Demographics
| Characteristic |
Transplant Recipients
(n = 18) |
Caregivers
(n = 13) |
| Gender |
|
|
| Male |
8 |
1 |
| Female |
10 |
12 |
| Age |
|
|
| 18-29 |
0 |
0 |
| 30-44 |
2 |
2 |
| 45-59 |
7 |
7 |
| Over 60 |
9 |
4 |
| Hispanic or Spanish origin |
1 |
0 |
| Race |
|
|
| White/Caucasian |
16 |
11 |
| Black/African American |
1 |
1 |
| Native American or Alaskan Native |
0 |
1 |
| Another race or multiracial |
1 |
0 |
| Education |
|
|
| High school graduate or GED |
2 |
1 |
| Some college |
8 |
6 |
| College graduate |
3 |
4 |
| Postgraduate |
5 |
2 |
| Income |
|
|
| Less than $25,000 |
1 |
3 |
| $25,000 - $49,999 |
4 |
1 |
| $50,000 - $74, 999 |
3 |
4 |
| $75,000 - $100,000 |
6 |
3 |
| More than $100,000 |
3 |
2 |
| No response |
1 |
0 |
| Source: Prediscussion
Questionnaire (n = 31). Because a probability-based sample was not used,
these results should not be generalized to the population of U.S.
transplant recipients and caregivers in any statistical
sense. |
2.4 TELEPHONE INTERVIEWS WITH TRANSPLANT RECIPIENTS AND CAREGIVERS
We contacted the Executive Director of Transplant Foundation, Inc.1 to
help recruit participants for the telephone interviews. The organization sent an
e-mail about the study to its membership, and within 2 days, over 100 members
expressed interest in participating in the study. RTI conducted telephone
interviews with 15 transplant recipients and seven caregivers, for a total of 22
participants. Table 2-1
provides information on participants' demographics.
Prior to the telephone interviews, RTI mailed each participant the food
safety booklet and the prediscussion questionnaire. Participants were instructed
to complete the questionnaire and return it to RTI in a postage-paid envelope.
Each interview lasted approximately 45 minutes, and participants received a
monetary incentive of $75 for their participation.
2.5 ANALYSIS
The focus group discussion was professionally videotaped, audio recorded, and
transcribed. Appendix E provides the transcript of the focus group
discussion. The moderators reviewed the videotape and the transcription to
prepare a detailed summary of the focus group.
The interviewers took extensive notes during the telephone interviews and
reviewed the notes to prepare detailed summaries of two to five individual
participants' interviews.
The detailed summaries of the focus group and telephone interviews were
systematically analyzed to identify common themes and any exceptions to these
themes. We did not analyze the qualitative results by type of participant
(transplant recipient vs. caregiver) because of the small number of
participants.
We entered the responses to the prediscussion questionnaire
(n = 31)2 into a Microsoft Excel spreadsheet and
calculated proportions for each question. Because a probability-based sample was
not used, the results of the prediscussion questionnaire should not be
generalized to the population of U.S. transplant recipients and their caregivers
in any statistical sense.
3. Results
In this section, we describe the results of the focus group discussion and
the telephone interviews with transplant recipients and caregivers and present
the findings from the pre-discussion questionnaire.
3.1 FOOD SAFETY CONCERNS, KNOWLEDGE, AND PRACTICES
Many participants received food safety information as part
of their post-transplant education. Generally, this information was limited to
specific foods to avoid and proper hygiene practices.
Since receiving their transplants or providing care for a transplant
recipient, many participants received food safety information from a doctor or
another healthcare professional (e.g., nutritionist, dietitian, transplant
coordinator). The content and format of the information, however, varied by the
institution that provided care. Because of food safety concerns, most
participants were given a list of foods to avoid (e.g., raw or rare meat,
uncooked or undercooked fish, unwashed fruits and vegetables) after receiving
their transplants. Most participants were also instructed to avoid certain foods
(e.g., grapefruit, grapefruit juice) that may interfere with their
immuno-suppressive medications. Some participants were told to avoid certain
foods for the rest of their lives, but others were not given a specific
timeframe. Some participants were instructed to avoid salad bars and buffets
when eating out. A few participants received information on safe food handling;
but, for the most part, it was limited to proper hygiene (e.g., washing hands
before and after handling food). Most participants did not receive information
on how to recognize foodborne illness or what to do if they suspected they had
contracted foodborne illness.
After receiving their transplants, a few participants received notebooks on
post-transplant care that contained sections on food safety. These participants
said the food safety information was similar but not as detailed as that
provided in the booklet. One participant who received food safety information
also had to take a 1-hour food safety course and pass a food safety quiz before
she was discharged from her transplantation program.
Most participants have not searched for additional information on food safety
since receiving their transplants. A few participants, however, have learned
about food safety from the following sources:
- cooking shows,
- family members,
- Food and Drug Administration's (FDA's) Web site,
- the Internet,
- newsletters of transplant organizations,
- newspaper articles,
- product packaging, and
- television news programs.
Before receiving the booklet, most participants were somewhat concerned about
getting sick from food they prepare at home because they were aware of the
possible risks of foodborne illness from taking immuno-suppressive medications.
Most participants, however, are also confident in their abilities to handle,
prepare, cook, and store food safely at home. A few participants are less
concerned than when they first received their transplants.
Most participants are more cautious about handling food since receiving their
transplants. Most participants wash their hands more frequently. Many
participants overcook meat and poultry to ensure doneness. Several participants
use paper towels instead of dish towels. A few participants wash fruits and
vegetables and pay more attention to cold storage times and product dating.
Although most participants say they are more cautious when preparing food at
home, most participants can do more to handle and prepare food safely. Table 3-1
presents the percentage of participants who reported using specific safe
handling practices the last time they handled food. Most participants follow the
recommended practices for cleanliness (78 percent to 92 percent) and practices
to avoid cross-contamination (72 percent to 100 percent). Only 67 percent of
transplant recipients and 38 percent of caregivers own a food thermometer. Most
participants do not use a food thermometer to check whether roasts, whole
turkeys, chicken parts, and hamburgers reach a safe internal temperature. Most
participants reheat hot dogs to steaming hot but do not reheat deli meats prior
to consumption. Less than one-third of participants have a refrigerator
thermometer. All participants store unopened packages of deli or luncheon meats
for the recommended time of 14 days or less, and many participants (63 percent
to 70 percent) store opened packages of deli or luncheon meats for the
recommended time of 3 to 5 days. Few participants (25 percent to 44 percent)
safely store large amounts of leftovers (e.g., soups and stews).
Table 3-1. Percentage of Participants Who
Reported Using Specific Safe Handling Practices the Last Time They Handled
Food
| Practice |
Transplant Recipients
(n = 18) |
Caregivers
(n = 13) |
| Clean: Wash hands and surfaces often |
|
|
| Always wash hands with soap before preparing food |
89 |
92 |
| Washed hands with soap after handling raw
meat/poultry/seafood/eggs/seafood/eggs |
78 |
85 |
| Separate: Don't cross-contaminate |
|
|
Properly cleaned cutting boards or other surfaces after
cutting raw
meat/poultry/seafood/eggs and before using them to prepare
other foodsa |
88 |
85 |
Properly cleaned dishes or utensils after preparing
raw
meat/poultry/seafood/eggs and before using them to prepare other
foodsa |
89 |
85 |
When grilling, used clean or different dish for raw and
cooked
meat/poultry |
94 |
100 |
Properly cleaned cutting boards or other surfaces after
cutting fresh fruits
or vegetables and before using them to prepare
other foodsa |
78 |
85 |
Properly cleaned dishes or utensils after preparing fresh
fruits or
vegetables and before using them to prepare other
foodsa |
72 |
85 |
| Cook: Cook to proper temperatures |
|
|
| Own a food thermometer |
67 |
38 |
| Used a food thermometer when cooking whole chicken or
turkey |
44 |
25 |
| Used a food thermometer when cooking roasts or large pieces
of meat |
47 |
23 |
| Used a food thermometer when cooking chicken parts, such as
breasts or thighs |
0 |
0 |
| Used a food thermometer when cooking hamburgers |
0 |
8 |
| Used a food thermometer when reheating leftovers containing
meat/poultry |
0 |
0 |
| Safely prepared deli or luncheon meatb |
6 |
0 |
| Safely prepared hot dogsb |
86 |
100 |
| Chill: Refrigerate promptly |
|
|
| Refrigerator has built-in thermometer |
22 |
15 |
| Own a refrigerator thermometerc |
28 |
31 |
| Know the temperature inside refrigerator |
17 |
15 |
| Safely stored an unopened package of deli or luncheon meat
in the refrigerator |
100 |
100 |
| Safely stored an opened package of deli or luncheon meat in
the refrigerator |
63 |
70 |
| Safely stored large amounts of leftovers in the
refrigeratord |
44 |
25 |
aWashed with soap
and/or bleach or used a different item.
bHeated until
steaming hot.
cIncludes built-in
thermometers.
dRefrigerated leftovers within 2 hours after
cooking and stored in one or more shallow containers.
Source:
Prediscussion Questionnaire (n = 31). Because a probability-based sample
was not used, these results should not be generalized to the population of
U.S. transplant recipients and caregivers in any statistical
sense. |
As recommended by a doctor or another healthcare professional, some
participants have stopped eating certain foods since receiving their
transplants. Table 3-2
presents the number of participants who reported eating or serving high risk
foods after transplantation. Most participants have not consumed or served
sushi, ceviche, or other raw fish; raw, unpasteurized milk; raw meat or poultry
(e.g., steak tartar); cold hot dogs; raw sprouts; unpasteurized fruit or
vegetable juice; and refrigerated pâtés or meat spreads. Since receiving their
transplants, about one-third of participants have consumed or served raw,
homemade cookie dough or cake batter, and dishes that contain raw or undercooked
eggs (e.g., Caesar salad or homemade eggnog). Most participants (67 percent to
89 percent) have consumed or served cold deli or luncheon meats and soft cheeses
(e.g., Brie, feta, Camembert, blue, queso fresco).
Table 3-2. Percentage of Participants Who
Reported Eating or Serving High-Risk Foods After Receiving
Transplant
| High-Risk Food |
Transplant Recipients
(n = 18) |
Caregivers
(n = 13) |
| Cold deli or luncheon meats |
89 |
77 |
| Soft cheese, such as Brie, feta, Camembert, blue, queso
fresco |
67 |
8 |
| Dishes that contain raw or undercooked eggs (e.g., Caesar
salad or homemade eggnog) |
33 |
8 |
| Raw, homemade cookie dough or cake batter |
6 |
31 |
| Refrigerated smoked seafood, such as salmon, trout,
mackerel, cod |
22 |
15 |
| Refrigerated pâtés or meat spreads |
17 |
0 |
| Raw sprouts |
11 |
8 |
| Unpasteurized fruit or vegetable juice or cider |
11 |
0 |
| Steak tartar (raw ground or chopped beef) or other raw meat
or poultry |
6 |
8 |
| Sushi, ceviche, or other raw fish |
0 |
0 |
| Raw, unpasteurized milk |
0 |
0 |
| Cold hot dogs |
0 |
0 |
| Source: Prediscussion
Questionnaire (n = 31). Because a probability-based sample was not used,
these results should not be generalized to the population of U.S.
transplant recipients and their caregivers in any statistical
sense. |
The majority of participants were very concerned about getting sick from food
they ate outside their homes because "you have no control [outside your home]."
One participant said she is now very concerned because she and about 20 other
transplant recipients contracted foodborne illness at a holiday party. Another
participant was very concerned because her husband contracted listeriosis in
January 2006 and had to be hospitalized for a few weeks. Because they have found
restaurants they trust and frequent often, a few participants are less concerned
about getting sick from food they eat outside their homes. A few participants
are less concerned about getting sick than when they first received their
transplants.
3.2 PARTICIPANTS' EVALUATION OF THE BOOKLET
We present participants' impressions of the booklet below.
3.2.1 Overall Impressions
Participants liked the booklet and thought it was well prepared, very
informative, comprehensive, and attractive. Most participants thought the
booklet contained relevant and useful information. Many participants shared the
opinion of one participant who said, "I really liked [the booklet]. It
reinforced some things I already knew, but I also picked up new information;
like, I didn't know that I had to worry about sprouts or bleu cheese." Most
participants said they learned something new after reading the booklet.
Participants especially liked the charts and graphics provided throughout the
booklet. Many participants really liked the "Is It Done Yet?" graphic and/or the
"Cold Storage Chart" and thought they provided the most valuable pieces of
information in the booklet. Several participants liked the chart "Major
Pathogens that Cause Foodborne Illness," because they were not aware of the
different types of pathogens that can cause foodborne illness.
Relevancy
All participants believed the booklet contained information they need to
know, and many participants appreciated that USDA had prepared a booklet
targeted to transplant recipients and their caregivers. One participant said,
"[The booklet] has a lot of good information that all transplant recipients
should know." Another participant said, "[Food safety] education is part of a
transplant recipient's lifestyle. The more we know, the better chance we'll
avoid [organ] rejection."
Usefulness
Many participants shared the opinion of one participant who said, "[The
booklet] is an extremely good reference on food safety," and several
participants said they would refer back to the booklet for food safety
information.
Pictures
Most participants liked the pictures in the booklet and thought they were
used appropriately. One participant said, "[The booklet] is visually appealing."
Several participants, however, thought the resolution of some of the pictures
(e.g., pages 6 and 8) could be improved. Also, several participants liked the
FightBAC!® logo (page 6) but thought it should be enlarged to
increase readability.
Colors
Participants really liked the colors used in the booklet. A few participants
particularly liked the color blue used throughout the booklet. One participant
said, "The colors make [the booklet] pleasing to the eye." Some participants,
however, found the words printed in yellow (e.g., "separate" on page 9) hard to
read.
Length
Most participants thought the length of the booklet was just right—neither
too long nor too short. Most participants thought the booklet sufficiently
covered key food safety topics for transplant recipients.
Font
Participants liked the appearance of the booklet,
especially its colors, pictures, and tables. Participants thought the booklet
was concise and easy to read.
All participants found the font size easy to read. One participant commented
that he could read it without his glasses.
Acceptability
Only a few participants found aspects of the booklet annoying or offensive.
Several participants did not like the picture of the woman in the wheelchair on
the front cover because she looked "out of place," "sad," and "disgusted."
Although these participants realize some transplant recipients require
wheelchairs, they did not think that the woman in the picture represented
transplant recipients because transplant recipients like to be seen as everyone
else and are happy to be alive.
One participant thought the section, "Food Safety: It's Especially Important
for You," was condescending because she believes all transplant recipients and
caregivers already know and understand this information. Many participants said
they already knew the information on page 2, but none of these participants
shared her concern.
One participant described the first bullet on page 3, "The food supply in the
United States is safe—but it can still be a source of infection for all persons"
as "an oxymoron, and [I] would prefer [USDA] to tell me like it is." A few
participants also suggested that "it's better to be tough about it [when
providing information to transplant recipients]."
Comprehension
Participants thought the booklet was well organized, concise, and easy to
read. One participant said, "[The booklet] was easy and straight to the
point."
Although participants thought the booklet was easy to understand, some
participants admitted they did not know about pasteurization and that some food
products (e.g., eggs) can be pasteurized to reduce the risk of foodborne
illness. Other participants had misperceptions about pasteurization; for
example, some participants thought all eggs and soft cheeses are
pasteurized.
A few participants thought the chart, "Major Pathogens that Cause Foodborne
Illness," on pages 4 and 5 may be too technical for some people to understand,
but they believed it was important information to include in the booklet.
A few participants who believe they know a great deal about food safety
thought the booklet was a little redundant but also agreed "you can't explain
[food safety] enough to people who don't know about it."
Participants suggested changes for items in the booklet they found confusing
or hard to understand. These suggestions are offered in Section 3.4.
3.2.2 Evaluation of Booklet by Section
We present participants' impressions of each section of the booklet
below.
Cover
Most participants liked the cover of the booklet but
suggested removing the pictures of the pregnant woman and the woman in the
wheelchair.
Most participants liked the cover and said it represented a good
cross-section of people who could be transplant recipients. At least one
participant, however, did not associate the people on the front cover with
transplant recipients and suggested adding a picture of a doctor or a hospital
to the cover.
Some participants were surprised to see the pictures of the woman in the
wheelchair and the pregnant woman on the front cover. One participant said,
"It's realistic [to see a transplant patient in a wheelchair], but most
transplant patients want to be seen like everyone else." One participant said,
"Normally, transplant patients do not get pregnant. Pregnancy is not a part of
our lives." Another participant said, "It's sort of risky to become pregnant
after a transplant." In addition, a few participants thought the picture of the
woman in the wheelchair looked "superimposed," and one participant thought the
inclusion of the pregnant woman suggested the booklet was targeted to the
general public instead of transplant recipients.
A few participants would rather see food or graphics of different organs
instead of pictures of people on the cover. No matter what type of pictures is
used on the cover, some participants said the title alone would encourage
transplant recipients to pick up the booklet.
Word-Mark Umbrella Brand
Some participants said the word-mark umbrella brand logo, "Be Food Safe from
USDA," grabbed their attention because of its contrasting colors. A few
participants described the logo as "attractive" and "eye-catching."
Participants said the logo conveyed the following ideas:
- "cleanliness,"
- "be careful when eating food,"
- "cook safely and purchase foods that are safe to eat," and
- "the things you've done all your life are not necessarily the best ways
[to handle food safely]."
Other participants did not pay much attention to the logo until the
moderator/interviewer asked them about it. One participant said, "[The logo]
doesn't stand out." Most of these participants said the logo would not encourage
them to pick up the booklet.
Whether participants liked or disliked the logo, some participants thought
"from USDA" was hard to read in yellow print.
Food Safety: It's Especially Important for You
Most participants believed this section included important information but
also said they already knew transplant recipients are immuno-compromised because
of the medications they take. Several participants liked the foodborne illness
statistics on page 3 and were surprised the numbers are so high. One participant
said, "The numbers back up the seriousness [of foodborne illness]."
Major Pathogens that Cause Foodborne Illness
Most participants thought this section was very useful and informative
because they were not aware of some of the pathogens that can cause foodborne
illness. One participant said, "[This section] scares the heck out of you," and
another participant said, "[This section] was shock-therapy. I better be careful
[when handling food]." Some participants liked that the symptoms of foodborne
illness were listed. Several participants thought the section was easy to read;
however, a few participants said the information was too technical. One
participant did not like this section. This participant thought the pathogens
and the symptoms were hard to differentiate; however, he did believe this
section provided important information that should be kept in the booklet.
Eating at Home: Making Wise Food Choices and Common Foods: The Low-Risk
Options
Most participants liked this section and found it useful and informative.
Many participants learned the most from this section because they were not aware
of some of the foods that pose a high risk of contracting foodborne illness
(e.g., cold luncheon meat, soft cheeses). Some participants mentioned they liked
the FightBAC!® logo but found it too small to read. A few
participants were indifferent to this section; although they thought this
section provided important information, they believed it was information they
already knew. A few participants thought this section was redundant; they
thought the information was already covered in the booklet.
Taking Care: Handling and Preparing Food Safely
Most participants liked this section, especially the "Is It Done Yet?"
graphic and the "Cold Storage Chart." Most participants found this section
useful and informative. Although many participants were familiar with and follow
most of the recommended practices in this section, most participants learned at
least one new fact.
In the Know: Becoming a Better Shopper
Some participants thought the information in this section was important and
useful although they were already familiar with most of the information. Some
participants appreciated the information on product dating because it helped
clarify the difference between the different types of dates. Some participants
were indifferent to this section because it included information with which they
were already familiar.
Being Smart: When Eating Out
Some participants thought this section provided useful and important
information. Because they already follow these recommendations when eating out,
some participants appreciated the information but thought this section provided
"nothing new." A few participants found this section redundant; they thought the
information was already covered in other sections of the booklet. A few
participants believe this section has the potential to encourage transplant
recipients to speak up and ask more questions when eating at restaurants.
Foodborne Illness: Know the Symptoms and Foodborne Illness Action
Plan
Most participants thought these sections provided useful information, and
many participants said they would likely follow the action plan if they
suspected they had contracted foodborne illness. Many participants did not think
the "My Physicians: Quick Reference List" was necessary because transplant
recipients already have this information readily available.
For More Information on Food Safety
Some participants said they would likely call the Meat and Poultry Hotline or
visit the Web sites listed in this section if they had a food safety concern or
question.
3.3 KNOWLEDGE AND BEHAVIOR CHANGES
Each participant learned at least one new fact after reading the booklet, and
many participants plan to make at least one change based on what they
learned.
3.3.1 Knowledge Learned
After reading the booklet, participants' awareness of foodborne pathogens and
foodborne illness increased. Participants learned the following new
information:
- Many participants were not aware of the different foodborne pathogens and
their associated symptoms listed in the chart "Major Pathogens that Cause
Foodborne Illness" (pages 4 and 5).
- Several participants were surprised to learn about the foodborne illness
statistics on page 3; they had "no idea the numbers were so high."
- A few participants were surprised that there are over 2,300 types of
Salmonella.
After reading the booklet, many participants learned that some foods pose a
higher risk for foodborne illness. Participants learned the following new
information:
- From the chart "Common Foods: The Low Risk Options," (page 7), many
participants were surprised to learn that luncheon meats, precooked seafood
(e.g., shrimp, crab), sprouts, soft cheeses, and foods that contain uncooked
eggs (e.g., Caesar dressing) are considered high-risk foods.
- Several participants were also surprised to learn they should avoid
soft-boiled eggs or eggs prepared over-easy (i.e., yolks are not fully cooked)
from the chart "Smart Menu Choices" (page 15).
- A few participants also learned that they should avoid buffets and salad
bars because they may contain undercooked foods or foods that have been at
room temperature too long (page 14).
After reading the booklet, many participants learned more
about
- foodborne pathogens and foodborne illnesses,
- foods that pose a high risk for foodborne illness,
- ways to safely handle and prepare foods at home, and
- pasteurization.
Many participants learned how to handle and prepare foods more safely at home
from "Taking Care: Handling and Preparing Food Safely" (pages 8-11).
Participants learned the following new information:
- Many participants learned the recommended internal temperatures of several
types of food from the "Is It Done Yet?" graphic on page 9.
- Many participants learned the recommended storage times for bacon,
luncheon meat, hot dogs, and leftovers from the "Cold Storage Chart" on page
11.
- Some participants learned raw meat and poultry should be separated from
other foods in the grocery cart (page 9).
- Several participants learned the differences between sell-by, use-by, and
best-if-used-by dates (page 13).
- Several participants learned the color of food is not a reliable indicator
of doneness (page 9).
- A few participants learned leftovers should be reheated to a specific
temperature and egg dishes should be cooked to a specific internal temperature
(pages 9 and 10).
- A few participants learned the temperature of their refrigerators should
be 40˚F or below (page 10).
- A few participants learned that large amounts of leftovers should be
divided into shallow containers and that foods should never be defrosted at
room temperature (page 10).
- A few participants learned that separate cutting boards should be used for
fresh produce and raw meat and poultry (page 9).
Many participants learned about pasteurization after reading the booklet.
Participants learned the following new information:
- Many participants learned that soft cheeses, like bleu cheese and feta,
can be made from unpasteurized milk.
- Some participants learned that some foods (e.g., eggs and fruit juices)
can be pasteurized.
- After reading the booklet, however, some participants had misperceptions
about pasteurization; for example, some participants thought all eggs and soft
cheeses are pasteurized.
3.3.2 Behavior Changes
Based on what they learned, participants made or plan to make changes in
their food handling practices. Many participants did or plan to make at least
one of the following changes in their food handling practices:
- separate raw meat and poultry from other foods in the grocery
cart,
- follow recommendations in the "Cold Storage Chart" on page 11, and
- avoid sprouts.
Based on what they learned, some participants made or plan to make at least
one of the following changes in their food handling practices:
- read labels more carefully to identify foods that have been
pasteurized,
- cut out and use the "Is It Done Yet?" graphic, and
- avoid buffets and salad bars.
A few participants made or plan to make at least one of the following changes
in their food handling practices:
- purchase a refrigerator thermometer;
- clean the inside of the refrigerator;
- use product dating;
- divide large amounts of leftovers into shallow containers;
- store eggs in the original carton;
- defrost foods in the refrigerator, cold water, or microwave;
- use separate cutting boards for raw meat and produce;
- purchase a food thermometer;
- use a food thermometer to check the doneness of chicken, egg dishes, and
leftovers;
- stop eating soft-boiled eggs or eggs prepared over-easy;
- avoid or reheat luncheon meat;
- do not purchase precooked seafood; and
- ask for help when ordering at restaurants.
3.4 SUGGESTIONS FOR IMPROVING THE BOOKLET
Participants were very forthcoming in offering their opinions and suggestions
for improving the booklet. Participants suggested printing the booklet on higher
quality paper and providing a large print version for people who are visually
impaired. Participants suggested adding a glossary to define words that may be
unfamiliar to some readers (e.g., cross-contamination, pasteurization, ceviche,
and alfalfa).
Participants suggested adding the following information to the booklet:
- discuss whether bleach is a recommended cleaning agent for transplant
recipients,
- discuss whether kitchen sponges are a recommended cleaning tool for
transplant recipients,
- identify foods (e.g., grapefruit, kiwis) that interfere with
immuno-suppressive medications,
- discuss whether organic foods are less or more risky for transplant
recipients,
- discuss whether prepared and/or packaged foods (e.g., chicken salad or
frozen entrees) are less or more risky for transplant recipients,
- discuss whether soft-serve ice cream is safe for transplant recipients to
eat,
- discuss whether transplant recipients should be concerned about salad
bars, and
- discuss whether transplant recipients should be concerned about
pesticides.
The following pages provide participants' suggestions for improving each
section of the booklet.
For improving the cover, participants offered the following suggestions:
- increase the font size of the phase "Food Safety for,"
- remove the word "solid" from the subtitle,
- remove the picture of the woman in the wheelchair,
- remove the picture of the pregnant woman,
- include pictures of food,
- replace pictures of people with pictures of food or graphics of different
organs, and
- add a hospital or doctor's office to the background.
3.4.2 Food Safety: It's Especially Important for You!
For improving this section, participants offered the following
suggestions:
- add Dr. Samuel James' credentials;
- replace the word "you" with "transplant recipient" in the title and
throughout the text;
- bold the subsection title "Foodborne Illness in the United
States";
- use "food poisoning" rather than "foodborne illness";
- explain how foodborne illness can be fatal because "people do not
understand how food can kill them";
- add to the text that "transplant recipients will always be
immuno-comprised despite what is mentioned in the media about how certain
foods and/or vitamins can improve your immune system";
- include a statement about contacting a doctor to learn what foods he/she
recommends the reader should avoid to prevent foodborne illness and/or drug
interactions;
- stress to the reader that even if he thinks he only has stomach ache, he
should contact his doctor immediately because it may be something more
serious, like foodborne illness;
- emphasize that caregivers, family members, and transplant recipients are a
team and that information in the booklet is important for everyone;
- provide the publication date;
- unbold "what's inside"; and
- change the sidebar "Make safe food handling a lifelong commitment to
minimize your risk of foodborne illness," to "you need to change your [food
handling] habits to avoid foodborne illness."
3.4.3 Major Pathogens that Cause Foodborne Illness
For improving this section, participants offered the following
suggestions:
- add the phonetic spelling of the pathogens;
- include other foodborne illnesses, like botulism and trichinosis;
- define pasteurized, unpasteurized, and raw milk;
- explain how water, fruit, and vegetables can become contaminated;
- instruct readers to contact their physician even if they are not sure they
have foodborne illness;
- list more foods associated with each pathogen;
- explain how foodborne illnesses are diagnosed (e.g., blood tests);
- use the term "unpasteurized milk" instead of "raw milk";
- format the table as a tear-out sheet;
- explain whether "contaminated water" refers to drinking water or water
from a lake or river;
- explain what "person-to-person" means; and
- clarify the first bullet under Associated Foods/Sources for
"Toxoplasma gondii."
3.4.4 Eating at Home: Making Wise Food Choices and Common Foods: The
Low-Risk Options
For improving this section, participants offered the following
suggestions:
- explain why hot dogs, deli meats, and luncheon meats need to be
reheated;
- change "alfalfa, bean, or any other" to "alfalfa, bean, or any other
sprout";
- enlarge FightBAC!® logo;
- change "Uncooked fresh fruits and vegetables" to "Fresh fruits and raw
vegetables";
- add "bagged salads" to "Uncooked fresh fruits and vegetables";
- list only the "higher risk" foods;
- explain why certain foods (e.g., smoked fish, eggs, sprouts, cheeses) pose
a higher risk to transplant recipients;
- add a sidebar that directs readers to consult their transplant
coordinators if they have concerns about food choices;
- instruct readers to consult their doctors before trying food supplements
or vitamins that can affect the immune system;
- explain whether organic foods are more or less risky; and
- add a statement that stresses to readers to discard food they have
concerns about.
3.4.5 Taking Care: Handling and Preparing Food Safely (pages 8 and 9)
For improving these two pages of this section, participants offered the
following suggestions:
- instruct readers to avoid vegetable washes because they contain the acid
found in grapefruits;
- address not reusing bottles of water without first washing them;
- add "with soap and warm water" to the third bullet under "Separate";
and
- delete the phrase "packaged at the plant" in the third bullet under
"Cook."
3.4.6 Taking Care: Handling and Preparing Food Safely (pages 10 and 11)
For improving the last two pages of this section, participants offered the
following suggestions:
- change "does not freeze well" to "do not freeze" in reference to "egg,
chicken, ham, tuna, and macaroni salad";
- include a mailing address or phone number to obtain a hard copy of the
"Cold Storage Chart"; and
- list the "Four Basic Steps to Food Safety" on one page.
3.4.7 In the Know: Becoming a Better Shopper
For improving this section, participants offered the following
suggestions:
- explain why USDA recommends storing shell eggs in their original
cartons;
- add information about wiping the tops of cans before opening;
- add information about examining product packaging for tears, dents, or
other defects before purchasing;
- explain what constitutes "unsafe or unclean conditions" in the last bullet
on page 12;
- move the word "other" under the third bullet on page 12 to the next
line;
- include information about sanitation wipes now available at local grocery
stores to clean the handles of their carts; and
- add more pictures of food labels so readers will know where to look for
product dates on different types of food products (i.e., cans, eggs).
3.4.8 Being Smart: When Eating Out
For improving this section, participants offered the following
suggestions:
- instruct readers to be aware of their surroundings when eating out and to
examine restaurants closely, including their sanitation scores;
- instruct readers to examine restaurants and feel free to leave if it does
not meet his expectations;
- encourage readers to feel comfortable to explain their situation to a
waiter or waitress, which would also be an excellent opportunity to educate a
food worker about weakened immune systems and foodborne illness;
- encourage readers to ask for substitutions at restaurants;
- encourage readers to make another food selection when in doubt;
- encourage readers to follow up after food is brought to the table and
verify that it was prepared as ordered;
- include information about choosing bottled water and avoiding tap water
outside the home;
- instruct readers to head straight home from a restaurant so they can store
leftovers within 2 hours;
- add recommended storage times for "doggie bags";
- provide more information about traveling to foreign countries and taking
cruises; and
- advise transplant recipients to bring antibiotics with them when
traveling.
3.4.9 Foodborne Illness: Know the Symptoms and Foodborne Illness Action
Plan
For improving this section, participants offered the following
suggestions:
- provide a Web address that includes links to local health
departments;
- change the first bullet on page 17 to "Consult your transplant
coordinator…immediately";
- emphasize the importance of "not waiting 24 hours" and "contacting your
transplant coordinator immediately" under the first bullet on page 17;
- instruct readers not to take any over-the-counter medicines to relieve
symptoms without contacting their transplant coordinator first;
- instruct readers not to ignore possible symptoms of foodborne
illness;
- explain how to identify whether a food was a source of foodborne
illness;
- explain that some people who have foodborne illness may be
asymptomatic;
- add the
symbol to the "My Physicians: Quick Reference List"; and
- capitalize the "R" in "… Quick reference List."
3.4.10 For More Information on Food Safety and the Back Cover
For improving the last page and the inside back cover, participants offered
the following suggestions:
- add a Web address that specifically addresses recalls;
- underline or highlight the Web addresses for easy reference;
- print cut-outs on stock card and place in the middle of the booklet on a
tear-off sheet;
- enlarge font on the cut-out "Ordering 'Smart' When Eating Out";
and
- add "The Four Basic Steps to Food Safety."
 
3.5 DELIVERY MECHANISMS
To reach transplant recipients and their caregivers
with information on food safety, almost every participant suggested
distributing food safety information to transplant coordinators at clinics and
hospitals.
Most participants said that transplant recipients and their caregivers rely
more on their transplant coordinators than they do on their doctors to provide
them with information they need to know. To reach transplant recipients and
their caregivers with information on food safety, almost every participant
suggested distributing food safety information to transplant coordinators at
clinics and hospitals. A few participants suggested that transplant coordinators
distribute the food safety booklet to transplant patients and their caregivers
at both pre- and post-transplant.
Many participants also suggested distributing food safety information to
transplant recipients and their caregivers via the following venues:
- transplant organizations, such as the Transplant Foundation, TRIO, the
United Network of Organ Sharing (UNOS), Second Wind Lung Transplant
Association, and the Blood and Marrow Transplant Clinical Trials
Network;
- other health organizations, such as the American Liver Association, the
American Diabetics Association, the American Cancer Society, the National
Kidney Foundation, and the Diabetes Research Institute;
- Web sites of government agencies, such as USDA, FDA, and local health
departments;
- outreach programs, such as the National Kidney Foundation's Transplant
Games and Camp Sunshine, an organization that supports children with
life-threatening illnesses and their families;
- support groups for transplant recipients and their caregivers, including
online support groups, such as www.classkids.org, www.tigerfund.org,
www.giftsfromheaven.info, and www.organdonor.gov;
- state organ donor services, such as Carolina Donor Services and Donor
Network of Arizona;
- doctors' offices;
- laboratories where blood work is conducted;
- health fairs;
- pharmaceutical companies;
- pharmacies;
- conferences/seminars; and
- grocery stores.
Most participants said they trust USDA to provide transplant recipients with
information on food safety. They also trust their transplant coordinators and
transplant organizations (e.g., TRIO and UNOS) to provide them with information
on food safety.
With regard to food safety information targeted to transplant recipients,
most participants would prefer to be called "transplant recipients," "transplant
patients," "immuno-suppressed," or "immuno-compromised."
4. Recommendations
In this section, we present our recommendations based on the findings from
the focus group discussion and the telephone interviews with transplant
recipients and caregivers. These recommendations identify additional information
that FSIS should consider including in the booklet and address suggested
refinements for improving the booklet. Based on the study findings, we recommend
that FSIS consider the following:
FSIS can use the study findings to refine the booklet prior
to dissemination and to identify effective communication channels for reaching
transplant recipients and their caregivers with food safety
information.
- Defining pasteurization and explaining why it is important for
transplant recipients to choose food products that have been
pasteurized. Some participants admitted they did not know about
pasteurization and that some food products (e.g., soft cheeses, eggs, fruit
juices) can be pasteurized to reduce the risk of foodborne illness. Other
participants had misperceptions about pasteurization; for example, some
participants believe all eggs and soft cheeses are pasteurized.
- Explaining why transplant recipients need to reheat hot dogs, deli
meats, and luncheon meats to steaming hot. Most participants thought
this recommendation was "silly," "ridiculous," and "an inconvenience." Some
participants wondered why USDA recommends reheating hot dogs, deli meats, and
luncheon meats to steaming hot. Without more information, most participants
said they are unlikely to adopt the recommendation.
- Instructing transplant recipients to contact their transplant
coordinators instead of their physicians or healthcare providers.
Most participants said they rely more on their transplant coordinators than on
their doctors to provide them with information on post-transplant care.
Several participants said that they would call their transplant coordinators,
not their doctors, if they suspected they had contracted foodborne illness.
Also, a few participants said their transplant coordinators know more about
their medical histories and have faster access to their medical
records.
- Expanding the section "Being Smart: When Eating Out."
Some participants thought this section provided "nothing new" and would be
more useful if it was expanded. Participants believe this section, if
expanded, has the potential to encourage transplant recipients to speak up and
ask more questions when eating at restaurants. Participants offered several
suggestions for improving this section of the booklet (see Section 3.4.8,
page 3-23).
- Replacing the word "you" with "transplant recipient" throughout
the text to make the message more personalized. A few participants
suggested replacing the word "you" with "transplant recipients" in the first
section titled "Food Safety: It's Especially Important for You" (page 2). A
few participants also thought the sidebars throughout the booklet could be
more compelling if the words "transplant recipients" were used; for example,
changing the sidebar on page 3 from "Make safe food handling a lifelong
commitment to minimize your risk of foodborne illness" to "Transplant
recipients need to make safe food handling a lifelong commitment to minimize
their risk of foodborne illness."
- Removing the pictures of the pregnant woman and the woman in the
wheelchair from the front cover. Participants thought the pictures of
the pregnant woman and the woman in the wheelchair were inappropriate to
include on the cover of a booklet targeted to transplant recipients. Although
transplant recipients could be in a wheelchair, they prefer not to be
portrayed as disabled. Also, it is unlikely for a transplant recipient to be
pregnant.
- Improving the resolution of the picture of the woman using a meat
thermometer (page 6) and the picture of raw beef (page 8). Most
participants liked the pictures in the booklet and thought they were used
appropriately throughout the booklet. Some participants, however, thought the
resolution of these two pictures could be improved.
- Enlarging the FightBAC!® logo (page 6). Some
participants mentioned they liked the FightBAC!® logo but found it
too small to read. Because the "The Four Basic Steps to Food Safety"—clean,
separate, cook, and chill—are listed on three different pages (pages 8-10), a
few participants suggested listing the four steps on one page or presenting
the information as a cut-out on the inside back cover of the booklet.
- Changing the words printed in yellow to another color that is
easier to read. Some participants found the words "separate" on page
9 and "from USDA" of the word-mark umbrella brand logo "Be Food Safe from
USDA" hard to read. Participants suggested using the color green instead of
yellow.
- Removing the "My Physicians: Quick Reference List" (page
16). Many participants did not think the "My Physicians: Quick
Reference List" was necessary because transplant recipients already have this
information readily available (e.g., on their refrigerators, in their wallets,
or programmed in their telephones).
5. References
Doak, C.C., Doak, L.G., & Root, J. (1985). Teaching Patients with Low
Literacy Skills. Philadelphia, PA: Lippincott.
Endnotes
Transplant Foundation, Inc. (www.transplantfoundation.org) is a nonprofit
organization located in Miami, Florida, that provides services for transplant
recipients, community education on organ donation, and funding for transplant
research.
2 One
transplant recipient did not complete the prediscussion questionnaire.
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