AN IMPACT EVALUATION: MEASURING KNOWLEDGE, ATTITUDES, AND

BEHAVIORS WITH FOOD THERMOMETER USE IN GROUND BEEF

PATTIES FOLLOWING A SOCIAL MARKETING CAMPAIGN IN

THE WOMEN, INFANTS, AND CHILDREN PROGRAM

By

JANA LEE CURRY

A thesis submitted in partial fulfillment of the requirements for the degree of

MASTER OF SCIENCE IN HUMAN NUTRITION

WASHINGTON STATE UNIVERSITY College of Pharmacy

AUGUST 2010

ii

To the Faculty of Washington State University: The members of the Committee appointed to examine the thesis of JANA LEE CURRY find it satisfactory and recommend that it be accepted. ____________________________________ Karen M. Killinger, Ph.D., Chair ____________________________________ Miriam E. Ballejos, Ph.D. ____________________________________ Jill Armstrong Shultz, Ph.D.

iii

ACKNOWLEDGMENT

I appreciated working with the thermometer team: Dr. Karen Killinger, Dr.

Miriam Ballejos, Dr. Sandra McCurdy, Zena Edwards, Amy Erickson, Tiffani Nalivka,

Courtney Staszak, and Katherine Warren.

I am grateful to the members of my committee for their guidance: Dr. Jill Shultz

and Dr. Miriam Ballejos.

Thanks to the staff at the University of Idaho’s SSRU for conducting our mixed-

mode survey and for taking a personal interest to make sure things ran smoothly.

Thank you to all my employers over the years. I worked full-time at the VA

Medical Center during the 5 years I attended Delta College completing a Pre-Dietetics

transfer degree. I then attended WSU full-time and worked 10-20 hours per week for the

entire 6 years of my undergraduate and graduate degree programs. It has been a long

journey.

And finally, a special huge thank you to JRA for going above and beyond; I could

not have gotten through this project without you. I am proceeding on.

iv

An Impact Evaluation: Measuring Knowledge, Attitudes, and

Behaviors with Food Thermometer Use in Ground Beef Patties following a

Social Marketing Campaign in the Women, Infants, and Children Program

Abstract

By Jana Lee Curry, MS Washington State University

August 2010

Chair: Karen Killinger

An internal endpoint temperature of 160°F is essential for safe cooking of ground

beef patties, since foodborne pathogens can be present throughout the meat. Consumers’

awareness of the risks associated with consuming undercooked ground beef and their role

in protecting themselves from foodborne illness through thermometer use is critical.

Therefore, food thermometer educational materials were developed and delivered using

an emotions-based social marketing approach for participants of the Special

Supplemental Nutrition Program for Women, Infants, and Children (WIC) in 17 counties

of Washington State. During the campaign, an impact evaluation was conducted using a

mixed-delivery mode survey. The evaluation tool, which was conducted post-

intervention, included a validated Stage of Change question to assess consumer intention

and behavior toward thermometer use. Additional questions about consumer

demographics, perception of the materials, knowledge, attitudes, and potential barriers to

thermometer use with ground beef patties were included. Results demonstrated that

v

participants acquired knowledge as a result of reading the packet of materials; nearly all

of the respondents (97%) agreed that they knew a safely cooked ground beef patty must

reach 160°F. Although about one-half of participants did not own a food thermometer,

44% had owned one for some time and 6% had recently purchased one since receiving

the materials. There was a statistically significant increase in thermometer use after

receiving the materials (Wilcoxon Signed Rank Test: p < 0.001). The highest percentage

of participants (39%) were in the Preparation Stage of Change indicating intent to begin

thermometer use with ground beef patties in the next month. However, two potential

barriers identified by most participants were 67% agreement that they don’t know of

anyone who uses a food thermometer with ground beef patties and 66% agreed that

thermometer use with ground beef patties is not part of their routine. In conclusion, the

educational materials assessed participant knowledge, and increased thermometer use

was reported with ground beef patties to improve food safety behaviors among women

with young children in Washington.

vi

TABLE OF CONTENTS

Page

ACKNOWLEDGMENT.................................................................................................... iii

ABSTRACT ....................................................................................................................... iv

LIST OF TABLES ........................................................................................................... viii

LIST OF FIGURES .............................................................................................................x

CHAPTER

1. LITERATURE REVIEW ..................................................................................1

Ground Beef Consumption ................................................................................1

Food Safety Related to Ground Beef .................................................................2

Thermometer Use for Food Safety of Ground Beef ..........................................8

The WIC Program ............................................................................................15

Barriers, Motivators, and Promotion of Thermometer Use .............................16

Use of Behavior Change Theory in Evaluation ...............................................26

Objectives ........................................................................................................33

References ........................................................................................................34

2. MANUSCRIPT ................................................................................................46

Introduction ................................................................................................46

Materials and Methods ...............................................................................50

Results and Discussion ..............................................................................63

Conclusion ...............................................................................................103

REFERENCES ................................................................................................................109

vii

TABLES AND FIGURES ...............................................................................................114

APPENDIX

A. Listing of Counties with Participating WIC Clinics ......................................139

B. WIC Thermometer Educational Materials .....................................................140

C. Written Survey ...............................................................................................143

D. Invitation to Survey Participation Card .........................................................159

E. Thank you Letter and Reminder Follow-up Card for Mail Survey ...............160

F. Training Material for SSRU Staff ..................................................................163

G. Web and Phone Survey Introduction .............................................................166

H. Question 1, “Other” Response .......................................................................168

I. Additional Participant Comments ..................................................................171

viii

LIST OF TABLES

1. Validated Survey Questions Regarding Intentions to Use a Food Thermometer

Based on the Transtheoretical Model (Stages of Change) ...................................114

2. Paired Questions Regarding Factors Influencing Important Attitudes, Perceived

Behavior Controls and Social Norms with Thermometer Use in Ground Beef

Patties Based on the Integrative Model of Behavior Change ..............................115

3. Subject Characteristics of WIC-Eligible Participating in the Impact Evaluation of

a Social Marketing Campaign for Thermometer Use with Ground Beef

Patties........... ........................................................................................................116

4. Thermometer Ownership Among Demographic Groups in the WIC Population

Participating in the Impact Evaluation .................................................................117

5. Perceived Barriers Among WIC Impact Evaluation Participants in Different

Thermometer Ownership Categories ...................................................................118

6. Participant Responses to Paired Questions Assessing Importance Attitudes,

Perceived Behavior Control and Social Norms based on the Integrative Model of

a Reasoned Action Approach ..............................................................................119

7. Frequency of WIC Participants Responses to Perceived Barriers to Thermometer

Use .......................................................................................................................122

8. WIC Participant Thermometer Ownership Among Stages of Change Categories.....

....................................................................................................................................122

ix

9. Participant Assessment of Knowledge as a Result of Receiving Campaign

Materials Regarding Thermometer Use with Ground Beef Patties Among

Different Stage of Change Categories .................................................................124

10. Participant Assessment of Barriers Regarding Thermometer use with Ground

Beef Patties Among Different Stages of Change Categories as a Result of

Receiving Campaign Materials ............................................................................125

11. Paired Question Assessment of Importance Attitudes, Perceived Behavior Control

and Social Norms Based on the Integrative Model of a Reasoned Action

Approach Regarding Thermometer Use with Ground Beef Patties Among

Different Stages of Change Categories ................................................................126

x

LIST OF FIGURES

1. Levels of Thermometer Use Reported by Web-based (1a) and Telephone and

Written (1b) Evaluation Participants Before and After Receiving the Campaign

Materials ..............................................................................................................130

2. Differences in Thermometer Use Categories Among Short-Term and Longer-

Term Thermometer Ownership for WIC Web-based (2a) and Telephone and

Written (2b) Evaluation Participants ...................................................................132

3. WIC Evaluation Participants Stratified by the Stages of Change ........................134

4. WIC Evaluation Participants Stratified by Level of Education in the Stages of

Change Classification ..........................................................................................135

5. WIC Evaluation Participants Stratified by Gender in the Stages of Change

Classification........................................................................................................136

6. WIC Evaluation Participants by Delivery Mode .................................................137

7. Survey Participants Stratified by Delivery Mode and Education Level ..............138

1

An Impact Evaluation: Measuring Knowledge, Attitudes, and Behaviors

with Food Thermometer Use in Ground Beef Patties following a Social

Marketing Campaign in the Women, Infants, and Children Program

Ground Beef Consumption

Beef dominates the retail meat market in terms of volume of sales and total dollar

amount; in 2007, consumers spent almost $75 billion dollars on beef (Cattlemen’s Beef

Promotion and Research Board, 2008). Ground beef, the most popular beef product in

the U.S., makes up approximately 42% of the total amount of beef sold either through

wholesale markets to food service establishments, or directly to consumers through retail

stores (Davis & Lin, 2005). On the average, Americans eat approximately 28 pounds of

ground beef per person per year. Approximately half of the total amount of all ground

beef is cooked and consumed in consumer homes (Davis & Lin, 2005).

The population group with the highest consumption of ground beef are those with

lower incomes. The Continuing Survey of Food Intake by Individuals report showed that

low-income (<130% of the poverty level) people ate more ground beef in pounds per

capita than those at other income levels (Davis & Lin, 2005). Ground beef remains a

good value for consumers on a limited food budget; retail prices of ground beef in the

U.S. averaged $3.065 per pound for January 2010, as compared to the price of a USDA

choice boneless sirloin steak at $5.312 per pound (U.S. Bureau of Labor Statistics, 2010).

2

Food Safety Related to Ground Beef

Food products of animal origin can be a source of pathogenic bacteria, such as

Salmonella spp., Clostridium perfringens, Staphyloccus aureus, and Escherichi coli (E.

coli) O157:H7 (Jay et al., 2005). Testing by the USDA Food Safety and Inspection

Service (FSIS) is conducted for both Salmonella and E. coli O157:H7 in ground beef as

part of the Public Health Risk-Based Inspection System for Processing and Slaughter;

there is a zero-tolerance policy for E. coli O157:H7 (USDA-FSIS, 2008a). E. coli

O157:H7 is a pathogen of concern in meat products including ground beef due to its

ability to cause hemorrhagic colitis and life-threatening sequelae in young children and

the elderly (Yoon & Hoyde, 2008).

The incidence of E. coli O157:H7 illnesses per 100,000 of the population is

relatively low at 1.12 compared to Salmonella at 16.20 (CDC, 2009a). It is estimated that

E. coli O157:H7 causes approximately 73,480 illnesses, 2,168 hospitalizations, and 61

deaths annually in the United States (Mead et al., 2000). For Salmonella, the annual

estimates are approximately 1,412,498 illnesses, 16,430 hospitalizations, and 582 deaths

annually (Mead et al., 2000). The outcomes of E. coli O157:H7 illnesses can be severe

and sometimes fatal. Approximately 53% of people 50 years and older who were

infected with E. coli O157:H7 were hospitalized, while only 40% of those infected with

Salmonella in that age group were hospitalized (CDC, 2009a). Also, the case fatality rate

for E. coli O157:H7 was highest in children 4 years old or less at 2.8%; while the case

fatality rate for Salmonella was highest in people 50 years old and older at 1.3% (CDC,

2009a).

3

Overview of E. coli O157:H7. The major reservoir of E. coli O157:H7 is in the

intestines of healthy cattle (Doyle & Beuchat, 2007; Jay, et al., 2005) and the most

common route of transmission to humans is through contaminated food, with ground beef

being the most common food vehicle (Rangel et al., 2005). The grinding of the beef

creates the opportunity for pathogen dispersion throughout the meat. A study examining

the prevalence of E. coli O157:H7 on cattle hides and carcasses at slaughter found that

approximately 47% of cattle hides and about 17% of pre-evisceration carcasses were

contaminated with the organism (Harhay et al., 2008). E. coli O157:H7 attributes of

concern include the organism’s ability to survive under stress conditions in foods.

Studies have shown E. coli O157:H7 to survive acidic conditions as low as pH 4.0

(Conner & Kotrola, 1995), in frozen ground beef patties stored at -20°C for over 9

months (Doyle & Schoeni, 1984), and with a minimum water activity of 0.95 (Schlundlt

et al., 2004). Ground beef patties pose a greater risk for bacterial contamination than

whole muscle cuts if not heated to a safe internal temperature, as ground beef provides

more surface area which allows for an increase in bacterial presence throughout the

product (Jay et al., 2005).

E. coli O157:H7 Prevalence. E. coli O157:H7 was first recognized as a

foodborne pathogen in 1982 following two outbreaks stemming from ground beef patties

consumed at a national chain of fast food restaurants in Oregon and Michigan; the

outbreaks affected at least 47 people (Riley et al., 1983). The organism was virtually

unknown prior to that time; the only prior identification of this serotype in the U.S. was

from a single case in California in 1975 (Riley et al., 1983). After the initial 1982

outbreak of E. coli O157:H7, many other small outbreaks followed (Rangel et al., 2005).

4

However, in 1993 a large outbreak occurred from the consumption of ground beef patties

at another fast food chain; this time over 700 people in 4 western states were associated

with the outbreak and 4 children died (Bell et al., 1994).

From 1982 to 2002 there were a total of 350 E. coli O157:H7 outbreaks resulting

in almost 8,600 cases (Rangel et al., 2005); however, outbreaks account for only a small

percentage of illnesses. In 2008, outbreaks of E. coli O157:H7 were linked to only 26%

of the total cases (CDC, 2009a); the majority of cases were sporadic. The number of

reported cases is probably not reflective of the true number of illnesses. Underreporting

of the illness is probably common, and can be partially attributed to milder cases with

less severe symptoms in which medical attention is not sought by the patient (Hui, et al.,

2001). Other causes of underreporting can be due to the lack of sample collection for

laboratory analysis, not testing specifically for the pathogen, or not reporting positive

results (Mead et al., 2000).

There has not been a significant improvement in the reduction of cases of E. coli

O157:H7 illness. Over the past three years, incidence of illness from E. coli O15:H7 has

remained constant (CDC, 2009a). To facilitate tracking of E. coli O157:H7 illnesses,

individual sporadic cases became reportable to the National Notifiable Diseases

Surveillance System in 1994 (CDC, 2009b) and in the year 2000 reporting became

mandatory in 48 states (Rangel et al., 2005).

E. coli O157:H7 Illness Characteristics. The pathogen E. coli O157:H7 has three

main virulence factors, including the production of shiga toxin(s), attaching and effacing

lesions, and the possession of a 60-mDA plasmid (Nataro & Kaper, 1998). These factors

are involved in producing the symptoms of hemorrhagic colitis. Hemorrhagic colitis is a

5

form of gastroenteritis which develops when certain strains of E. coli colonize the large

intestines and produce toxins; these toxins damage mucosa of the large intestine. If the

toxins enter the bloodstream, other organs may be harmed as well (Doyle & Beuchat,

2007). Although the infectious dose of E. coli O157:H7 is not known, it appears that 100

organisms or less can cause acute disease in humans (Doyle & Beuchat, 2007). After

ingestion of E. coli O157:H7, an incubation period follows, averaging approximately 3 to

5 days (Karmali, et al., 2009). The symptoms of an E. coli O157:H7 illness typically

includes hemorrhagic colitis that usually begins with painful abdominal cramps, followed

by a watery diarrhea (Riley et al., 1983). That usually progresses to a grossly bloody

diarrhea. Vomiting occurs in about half of the cases; fever is not usually present (Riley et

al., 1983). Hemorrhagic colitis can progress into hemolytic uremic syndrome (HUS).

HUS is defined by the development of microangiopathic hemolytic anemia,

thrombocytopenia, and renal failure (Doyle & Beuchat, 2007; Hui, et al., 2001). E. coli

O157:H7 that proceeds to HUS varies from 6-90% (reviewed in Hui et al., 2001).

The most at-risk populations for complications from foodborne illness are young

children, pregnant women, elderly people, and others with weakened immune systems

(Gerba et al., 1996). The incidence of E. coli O157:H7 infection varies by age; the

heaviest incidence burden of disease is among those 11 years of age and under (CDC,

2009a). Mortality seems to be highest in the very young and the elderly; a study which

examined 12 E. coli O157:H7 foodborne illness outbreaks found the ages of those with

fatal illnesses ranged from 1 – 4 years and 61 – 91 years of age (Rangel et al., 2005).

Meat Processing Regulatory Overview. With the identification of a new food

safety risk associated with meat products, strategies to address the risk during meat

6

processing were developed. The federal government provides regulatory oversight of

meat production (USDA-FSIS, 1996). The Federal Meat Inspection Act of 1906

mandated visual inspections of all livestock before and after slaughter. The USDA is

also sets sanitary standards for slaughterhouses and meat processing plants, and oversees

ongoing monitoring and inspection of all slaughter and meat product processing

operations involved in interstate commerce (USDA-FSIS, 1996).

The USDA provides 8,100 inspectors to approximately 6,200 meat and poultry

slaughter and processing plants throughout the U.S. More than 7 billion poultry and 130

million livestock are visually inspected before and after slaughter each year (USDA-

FSIS, 1996). There are 1,400 establishments producing raw ground beef which are

federally inspected to verify the effectiveness of the Hazard Analysis and Critical Control

Points (HACCP) systems (USDA-FSIS, 2009c). For meat products which do not cross

state lines, states can elect to use to use their own inspection system. Currently, 27 states

operate using this inspection system (USDA-FSIS, 2009a).

Bacterial Risk Reduction during Meat Processing. In 1994, 12 years after the

first major E. coli O157:H7 outbreaks in the U.S., the FSIS declared that raw ground beef

contaminated with E. coli O157:H7 was considered adulterated unless further processed

into ready-to-eat products. Therefore, a sampling and testing program for E. coli

O157:H7 in the finished ground beef was enacted (USDA-FSIS, 2002b). In 1996,

USDA-FSIS established the Pathogen Reduction/Hazard Analysis and Critical Control

Point (PR/HACCP) system for meat and poultry processes which requires each

processing plant that is federally inspected to devise a plan to take preventative and

corrective measures at each stage of the food production process where food safety

7

hazards might occur (USDA-FSIS, 2002b). Consequently, manufacturers were

responsible for hazard identification as well as prevention, reduction, or elimination of

biological, chemical, and physical hazards associated with raw meat, including

pathogenic bacteria. In 2002, the USDA-FSIS updated the requirements for

manufacturers of beef products to include E. coli O157:H7 in their HACCP plans

(USDA-FSIS, 2002c). In addition, beginning in 2007, the USDA-FSIS began microbial

testing of beef trim, a major component of ground beef, an effort to decrease the number

of positive raw ground beef samples (USDA-FSIS, 2009c).

Ground beef in the U.S. is also produced in local retail stores. Inspections of

retail establishments are not routinely conducted by the USDA-FSIS unless there are

extenuating circumstances such as when the retail store uses whole muscle and trimmings

from their own cutting/boning operations, or if proper records are not maintained

(USDA-FSIS, 2009c). Sampling and testing for E. coli O157:H7 from ground beef

produced in retail stores is performed less frequently; in 2008 the USDA-FSIS tested

only 115 raw ground beef samples from retail stores throughout the U.S. (USDA-FSIS,

2009c).

Consumer Perceptions and Current Status. The USDA provides regulatory

oversight of the meat industry to promote risk reduction and it is the legal obligation of

the industry to utilize preventative practices and interventions to reduce risk and to

evaluate the effectiveness of these practices (Dodd & Powell, 2009). These roles are not

always clearly communicated to consumers and retailers by the USDA in FSIS

documents, website pages, publications, and recall announcements (Dodd & Powell,

2009). Consumers may have unrealistic expectations that the USDA-FSIS inspection

8

program is intended to protect public health by ensuring that all ground beef is free of

harmful pathogens; therefore, consumer risk perception may be lower than the actual risk.

Consumers need to understand the importance of their role in controlling risk as related to

proper cooking.

Prevalence of E. coli O157:H7 in ground beef has increased. In meat processing

plants where ground beef is produced and packaged, federal sampling has shown an

increase in positive results over the past three years: 0.17% positive in 2006, 0.24% in

2007, and 0.47% in 2008 (USDA-FSIS, 2009b). Ground beef containing E. coli

O157:H7 has also been found in retail stores; one survey of Seattle, Washington retail

stores showed prevalence at 1.1% of E. coli O157:H7 in ground beef available for

consumer purchase (Samadpour et al., 2006).

If a ground beef product is released to the market and then identified as positive

for pathogen contamination afterwards, it may be voluntarily recalled by the

manufacturer. Most recalls of meat products occur after consumers become ill and seek

medical care (USDA-FSIS, 2008c). There were approximately 1,736,875 pounds of

ground beef and trimmings recalled in the U.S. for 2008 due to E. coli O157:H7

contamination in 2008 (USDA-FSIS, 2010).

Thermometer Use for Food Safety of Ground Beef Food safety consumer campaigns are designed to advocate safe food handling in

order to prevent foodborne illness in the home. Food safety practices focus on

recommendations to clean, separate, cook, and chill to ensure food safety. While three of

these can reduce the potential for microbial contamination and growth, only cooking to

recommended temperatures can destroy pathogens in food (Fightbac Partnership for Food

9

Safety Education, 2006; Be Food Safe, 2010). An internal temperature of 160°F for one

second is needed for the almost instantaneous destruction of E. coli O157:H7 in a ground

beef patty (Doyle & Schoeni, 1984).

Color as an Indicator of Ground Beef Doneness. Thermometers are not used as

the primary method of determining final endpoint cooking by consumers; instead, many

consumers rely on visual cues, such as interior color of the muscle or ground beef patty

(Cates, 1999; Kwon et al., 2008; McArthur et al., 2006). However, interior color of meat

does not always correlate with internal temperature in cooked meat (Lyon et al., 2000;

Killinger et al., 2000; Hague et al., 1994; Hunt et al., 1995). Certain factors may cause

the ground beef patty to turn a brown color prematurely (prior to 160°F) or to retain a

persistent pink color above160°F; therefore, color could mislead consumers who try to

judge when a safe cooking temperature has been reached by using visual appearance

alone (King & Whyte, 2006).

Muscle Chemistry; Premature Browning and Persistent Pink Color. Myoglobin

is the primary pigment in meat tissues, and many factors can influence myoglobin and

produce different meat colors. Myoglobin is a single-chain, iron-containing protein,

similar to a unit of hemoglobin, and is found in muscle tissue (Faustman et al., 1990). In

fresh meat, there are three possible forms of myoglobin. Deoxymyoglobin produces a

purplish-red color. When the ferrous iron forms a complex with oxygen, oxymyoglobin

is formed, which is bright red in color. When oxygmyoglobin is oxidized to ferric iron,

the formation of metmyglobin results in a brown color (Faustman et al., 1990). The

formation of metmyoglobin can be caused by a variety of factors. This includes pre- and

post-slaughter conditions of the animal, muscle type, bacterial levels, and storage

10

conditions (including time, temperature, lighting, and relative humidity) (Faustman et al.,

1990). Other considerations leading to premature browning include oxygenated

conditions, freezing and thawing methods, and added ingredients such as salts (King &

Whyte, 2006). Meat turns brown in color when cooking due to denaturation of the

pigment-containing proteins by heat (Brown, 2004). Premature browning can cause

ground beef patties which are undercooked, for example at150°F, to resemble those fully

cooked to 160°F (Hague et al., 1994).

Persistent pink is another phenomenon affecting the color of ground beef patties;

this phenomena occurs when the color of the meat remains pink above temperatures of

160°F. This can be caused by packaging conditions, higher pH, animal gender, rapid

thawing of frozen meat, or lower fat content (King & Whyte, 2006). A ground beef patty

with an interior persistent pink color might be overcooked before turning brown and thus

lead to a less-desirable meat product.

Current Recommendations and Consumer Thermometer Use. Prior to 1997, the

USDA advised consumers to cook ground beef patties until they were no longer pink

inside or until the juices were no longer red or pink. In 1997 the USDA changed

recommended cooking practices to heating ground beef patties to160°F and using a food

thermometer to ensure proper endpoint temperature (USDA-FSIS, 2003). The USDA-

FSIS recommends that consumers use a thermocouple or thermister thermometer with

thin meat products like ground beef patties (USDA-FSIS, 2008b). However,

thermocouples, while being fast and accurate, are more costly than other thermometers

and difficult to find in stores (USDA-FSIS, 2008b). Two types of instant-read

thermometers may be more practical for consumer use; both instant-read thermisters and

11

instant-read bimetallic coil dial thermometers are less expensive than thermocouples and

readily available in most areas. Although both types measure food temperature

accurately, the dial thermometer requires calibration, which may deter consumers

(McCurdy et al., 2004).

Even though thermometers are necessary for cooking ground beef patties and are

available to the consumer, many consumers do not own or use one. A large food safety

survey of over 1000 consumers evaluating home food safety practices showed that

although 26% believed that undercooking was a source of food poisoning, only 9% were

able to give the correct cooking temperature for ground beef patties (160°F) (Cody &

Hogue, 2003). Consumer attitudes about the importance of safe food practices and the

need to use a thermometer can be ambiguous. While 71% of consumers know that

packaged raw meat contains bacteria and 95% believe that inadequate cooking places a

person at a higher risk of a foodborne illness, 46% were undecided on the usefulness of a

thermometer when cooking meat (Redmond & Griffith, 2004a).

Consumer use of food thermometers with meat products is typically low. In four

consumer focus groups which were conducted regarding the use of food thermometers

with small cuts of meat (n=37), 54% did not use a food thermometer when cooking of

any type of meat product and 41% did so only when cooking roasts and turkeys; a mere

5% of participants stated that they used a food thermometer with thinner meat items such

as ground beef patties (McCurdy et al., 2005). Cody and Hogue (2003) reported data

from the Home Food Safety…It’s in Your Hands surveys (n=1006) and assessed

knowledge, attitudes, and food safety behaviors. It was found that among nine food

safety behaviors examined, the least frequent behavior reported by consumers was the

12

use of a food thermometer with meat. Another study found that undergraduates only

used a food thermometer with meat 25% of the time (McArthur et al., 2006). In another

study of young college-aged adults surveyed for food safety risks, only 7% of homes

contained a food thermometer (Byrd-Bredbenner et al., 2007). Although many

consumers seem to realize the importance of cooking foods thoroughly in order to

prevent foodborne illness, they are not knowledgeable about the endpoint temperature

needed, nor do many consumers own or use a thermometer.

Consumer Risk Perceptions. Consumers may place a low level of risk on their

own food handling practices compared to that of others. In a review of questionnaires,

interview, focus groups, and observations to evaluate domestic food-handling practices

by Redmond and Griffith (2003), consumers considered meals prepared in the home the

least likely to cause foodborne illness and meals consumed in commercial eating

establishments the most likely to cause foodborne illness. However, consumer

perceptions were contrary to data which indicated that most cases of foodborne illness

actually stem from foods prepared in the home (Redmond & Griffith, 2003). Similarly,

people tended to believe they have less foodborne illness risk from home prepared food

than do other people or society in general, and that they had greater knowledge and

control of foodborne illness compared to that of other people or society (Frewer et al.,

1994). In the same study, partial correlations were examined between pairs of factors for

personal risk, control, and knowledge regarding foodborne illness from home prepared

foods. It was found that there was no relationship between perceived risk of foodborne

illness and its control. However, there was a negative relationship between perceived

risk and knowledge, and there was a positive relationship between perceived control and

13

knowledge (Frewer et al., 1994). The findings of Frewer et al. (1994) indicated that

consumers believed that their personal knowledge lowered their risk of foodborne illness,

and knowledge also gave them control over the risk. When it comes to sources of

acquired food safety knowledge, a review by Ralston et al. (2000) found that consumers

who stated using brochures as their source of food safety information, as opposed to other

sources such as magazines, cookbooks, television, and government agencies, felt less risk

from foodborne illness. Consumers who believed they possessed more specific food

safety knowledge than other people may perceive a decrease in their food safety risk; this

may be connected to a sense of being in control. Also, due to perceptions of having

more knowledge than others, they may feel that others are more in need of food safety

education.

Food safety risks from food preparation and consumption are an every day

occurrence. It is thought that people often use heuristics (or set rules used in specific

circumstances) to make decisions about performing certain actions. If the habitual action

brings positive results (no foodborne illness), then a feedback loop develops in which

accumulated positive results foster the formation of optimistic bias; thus it is deemed

unnecessary to seek new information (Fisher & Devries, 2008). Slovik (1987) developed

a diagram using two factors: “Dread Risk” and “Unknown Risk” with quadrants to

indicate their interactions. Dread Risk was highly characterized by a risk which included

uncontrollable factors, involves dread, global catastrophic events, fatal consequences,

inequitable among persons, high risk to future generations, not easily reduced, increasing

risk, and involuntary. Unknown Risk was highly characterized by a risk that was not

observable, unknown to those exposed, delayed effect, new risk, and risks which are

14

unknown to science. While bacterial contamination of ground beef is not visibly

observable, known to those exposed, and the risks are known to science. Also, eating

ground beef patties are a voluntary action, and so the risks may be perceived by

consumers as low, controllable and easily reduced. A study by Katapodi et al. (2005)

examined heuristic reasoning that influenced perceived breast cancer risk in individual

women. In that study, participants used past cancer experiences with family and friends

to estimate their risk of acquiring breast cancer and found related heuristics. The

experiences of cancer in friends and family members were easily recollected by the

participant, formulated into a model for a high-risk individual, and then this model was as

a basis of comparison to themeselves; affect and perceived control were also weighed

(Katapodi et al., 2005). Although each health risk behavior will have its own association

with particular heuristics, food safety may share several of those mentioned in the cancer

study, including perceived control based on hindsight bias of prior events. Positive

heuristic results may therefore lead to a continuation of prior habits and a promotion of

the perception of low risk. In the case of ground beef, because many people have had the

habit of using visual cues to determine doneness of ground beef patties with no ill

consequences, this may have led to the perception of a low level of risk.

In summary, since animal food products pose an inherent risk of pathogenic

contamination, it is important to cook to sufficient temperatures to eliminate any

pathogens. Previously recommended visual methods of determining doneness were

found to be unsound, and should be replaced by thermometer use. Consumers need to be

made aware of the risks of eating undercooked ground beef and to take measures to

15

protect themselves from foodborne illness by using a food thermometer when cooking

ground beef patties.

The WIC Program

The Special Supplemental Nutrition Program for Women, Infants, and Children

(WIC) currently provides some educational services regarding a variety of health topics

and therefore would be a suitable program for distribution of food safety materials to an

important target audience. WIC participants are a high-risk population for foodborne

illness complications. The WIC program serves over 8 million mothers, and their infants

or children per month (USDA-FNS, 2009a). WIC is a federal grant program which

provides vouchers for nutritious foods, some nutrition education, and referrals as needed

to other social service programs to women who meet the eligibility requirements for

income and nutritional risk (USDA-FNS, 2009a).

The WIC population is made up of lower-income females who are either

pregnant or who have infants or children under the age of 5. The majority (85%) of the

women are between the ages of 18 and 34 (USDA-FNS, 2009b). Approximately 70% of

the women have completed high school or have taken college courses; however about

30% do not have a high school degree. The ethnic makeup of the WIC population has

changed over time, with Hispanic enrollees steadily rising while Blacks and Caucasians

have decreased in numbers. In 2004, Hispanics made up 39%, Caucasians 35%, and

Blacks 20% (USDA-FNS, 2006).

WIC counselors have limited time to focus on nutritional education and

counseling for each WIC client; two brief nutrition educational sessions (Sigman-Grant et

al., 2008) must be offered to the client within a 6 month period; however, these may be

16

group sessions and attendance is voluntary (Besharov & Germanis, 2000). Furthermore,

the sessions are typically 4-17 minutes in duration (Sigman-Grant et al., 2008). Food

safety education in the WIC program is not a priority of the educational sessions, but is

given when a professional identifies a need (Schuele, 2004).

Food Safety Education among WIC Audiences. Studies indicated a need for

additional food safety education in the WIC program. When WIC clients were surveyed

about their food safety knowledge, 57% thought that the best way to check the doneness

of ground beef patties was to look at the color of the meat or the juice, and 14% thought

ground beef patties were done when left pink inside. Only 24% of WIC clients surveyed

knew that the internal temperature was the critical factor to ensure doneness (Kwon et al.,

2008). WIC directors and counselors agree that WIC clients need additional food safety

education. In a study by Schuele (2004), questionnaires were sent to directors and

counselors of 79 WIC clinics in a Midwestern state to gather information about the

challenges of food safety education in the WIC program. When asked to assess client

knowledge of good food safety practices, 90% of these health professionals rated their

clients’ knowledge as “fair” to “very poor.” About 27% of the WIC health professionals

indicated that food safety handout materials designed specifically for WIC clients would

be beneficial (Schuele, 2004). Written materials could enhance traditional counseling

sessions and provide additional health messages that would otherwise be omitted due to

time and financial constraints.

Barriers, Motivators, and Promotion of Thermometer Use Barriers to Thermometer Use. Six major factors that limit adopting

thermometer use have been identified among studies that have performed consumer focus

17

groups or surveys to examine attitudes and behaviors regarding food thermometers with

ground beef patties. Barriers associated with thermometer use include consumers’

perception of food thermometers as being unnecessary (Trepka et al., 2006; Athearn et

al., 2004; McCurdy et al., 2005), forgetting to use a thermometer when cooking

(Takeuchi et al., 2005; McCurdy et al., 2005; Trepka et al., 2006), as well as difficulty in

use with ground beef patties (McCurdy et al., 2005; Takeuchi et al., 2005). Other

identified barriers were a negative social connotation associated with thermometer use

(McCurdy et al., 2005; Takeuchi et al., 2005), the time and effort needed for use

(McCurdy et al., 2005; Takeuchi et al., 2005), as well as taste preference for undercooked

meat (Trepka et al., 2006; Athearn et al., 2004). Interestingly, cost was not identified as a

barrier to thermometer use by any of the studies reviewed. Although few studies have

examined this issue, one study specifically asked consumers about cost as a factor and it

was not found to be a barrier (Takeuchi et al., 2005).

Barrier: Importance of Thermometer Use. A major barrier identified was that

most consumers did not feel that food thermometer use with ground beef patties is

important or necessary. In a study by Redmond and Griffith (n=100), over 90% of

survey participants considered their risk of foodborne illness to be low after consuming

self-prepared food (Redmond & Griffith, 2004b). Likewise, in a study by Trepka et al.

(2006) among participants in five focus groups (n=32) of women in the WIC program,

none considered foodborne illness to be a major concern; they considered foodborne

illness a low risk as they did not associate any personal illness with improperly cooked

foods prepared in the home. In as study with pregnant and postpartum (<6 mos.)

participants in 11 focus groups, most (n=69) felt that their judgment and skill in

18

determining doneness was adequate (Athearn et al., 2004). Participants expressed a

disbelief in the validity of the recommendations when it did not fit with the reality of

their experiences, such as a woman from one Colorado focus group who stated “I haven’t

gotten sick yet, so I think my methods work” (Athearn et al., 2004). Another study using

four focus groups (n=37) examining the use of food thermometers with small cuts of

meat reported similar results; many participants stated that they had not been convinced

of the need to use a food thermometer (McCurdy et al., 2005).

Barrier: Remembering to Use a Thermometer. Even among consumers who are

aware of the need to use a food thermometer with thin cuts of meat, remembering to do

so was identified as the most frequent barrier by consumers. In a study by Takeuchi et al.

(2005), this was listed as the most frequent barrier to thermometer use with consumers

who did not use a thermometer. Similarly, consumers in focus groups said they were

“forgetful” of the thermometer when cooking (McCurdy et al., 2005). Many focus group

participants said that some food safety practices have not been part of their usual food

preparation routines. Many practices were developed during childhood, and were learned

from their mothers (Trepka et al., 2006). Therefore, long-time cooking practices that

have been firmly established from a trusted source may be difficult to change.

Additionally, many consumers believe that their current method is a positive habit,

demonstrated to them by the fact that they haven’t become ill (Athearn et al., 2004). One

reminder that can help consumers promote using a thermometer consistently is to have it

stored in a convenient, visible location. However, consumers stated that storage

considerations were a challenge (McCurdy et al., 2005). Tools which are not noticeable

or handy during food preparation can be forgotten and not used. Since ground beef

19

patties are often cooked both indoors and outdoors, a storage location accessible for both

locations may be needed.

Barrier: Confidence with Proper Thermometer Use. Self-efficacy (or perceived

behavior control) factors determine whether consumers possess the confidence that they

need for performing a behavior; these can include such things as uncertainty about the

mechanics of thermometer use with small cuts of meat, cooking within time constraints,

and cooking in various environments as well as cooking for other people. Consumers

identified lack of confidence in their skills when using a thermometer as a barrier to use

(McCurdy et al., 2005). For those participants who were already beginning to use a food

thermometer, difficulty in using a food thermometer with small cuts of meat was the

number one behavioral barrier, and it was also a major barrier to those who were

considering using one in the near future (Takeuchi et al., 2005). Since thermometer use

with thin cuts of meat has not been a common practice in most homes, consumers have

not often observed demonstrations of proper use. Takeuchi et al. (2005) examined

consumer confidence in using a thermometer in circumstances which might make using a

thermometer difficult, such as being busy or in a hurry, cooking ground beef patties for

multiple people or for just one person, and cooking outdoors; there was no significant

difference in pre-to-post-test self-efficacy after receiving an intervention through

educational materials (Takeuchi et al., 2005). Similar results were found in a study using

both focus groups and surveys to look at busy restaurant worker’s perceived control

beliefs (beliefs about the amount of control they possess over the behavior) regarding

food thermometer use; results based on the most frequently perceived control beliefs

suggested more thermometer training for employees in order to facilitate thermometer

20

use, as well as having a manager oversee the practice (York et al., 2009). Taken together,

study results indicated building self-efficacy should encompass both the skills and

abilities needed to perform the physical behavior, as well as the confidence to perform

the behavior when conditions are less than favorable. Therefore, training and information

on proper thermometer use may be important.

Barrier: The Amount of Time to Use a Thermometer. The amount of time to use

a thermometer when cooking thin cuts of meat has been noted as a barrier by some

consumers. In a survey, 27% of participants who were considering using a thermometer

within one month believed that it added time to the cooking process (Takeuchi et al.,

2005). Since the actual time to use a food thermometer is relatively short, consumers

who are unfamiliar with food thermometers may cite extra time as a barrier to use.

However, that barrier decreased with actual experience, as demonstrated by a low

percentage of consumers using a food thermometer who identified extra time as a barrier

(13% for those using a food thermometer for less than 6 months and 3% for those more

than 6 months) (Takeuchi et al., 2005).

Barrier: Inconvenience of Thermometer Use. Although thermometer use takes a

minimal time, it was perceived as inconvenient by some consumers, which acknowledges

the extra effort needed to perform the behavior. Most participants who use a

thermometer identified inconvenience as the second highest barrier to use by that group

(Takeuchi et al., 2005). In another study, focus group participants felt that it would be

time-consuming and inconvenient to continuously check several pieces of meat as they

cooked; these participants cited “laziness” about using a thermometer when cooking

(McCurdy et al., 2005).

21

Barrier: Not Knowing of Others Using a Food Thermometer. Another

challenging barrier identified with thermometer use was negative perceived social norms;

these are the behavioral expectations within a society and indicate the established and

approved ways of doing things. In several studies, consumers found that thermometer

use with ground beef patties was difficult to accept when they were not acquainted with

other people who used one. In a study by Takeuchi et al. (2005), not knowing others who

used a thermometer with thin cuts of meat was the second most cited barrier from

consumers who were not currently using a thermometer; however, there was a 24%

decrease in this perceived barrier following an intervention with educational materials.

Another potential social norm barrier is the influence of significant others. Because

thermometer use has not been widely accepted, focus group members anticipated

negative comments from family members and important others which would make it

difficult to continue the practiced behavior (McCurdy et al., 2005).

Barrier: Preference for Undercooked Meat. One factor that could pose an

unavoidable barrier to cooking ground beef patties to the recommended 160°F is that

some consumers have a taste or texture preference for undercooked meat. This was a

recurring theme in all five focus groups (n=32) by Trepka et al. (2006). Personal taste

preference for rare or medium-rare ground beef patties was also mentioned in the

majority of focus groups held by Athearn et al. (2004). A study reviewed by Ralston et

al. used a palatability motivation index to examine how strongly respondents prefer a

particular level of juiciness, taste, and tenderness of a rare or medium-rare ground beef

patty. Consumers that place importance on palatability characteristics of rare or medium-

rare ground beef patties were observed to have a 76% probability of cooking underdone

22

ground beef patties (Ralston et al., 2000). Due to preferences for undercooked meat, this

obstacle could be difficult to overcome as the food product may no longer be acceptable

to the consumer after increased heating to a safe temperature. However, Ralston also

showed that fewer Americans prefer undercooked ground beef patties; consumers serving

rare or medium-rare ground beef patties dropped from 24% in 1991 to 20% in 1996

(reviewed in Ralston et al., 2000).

Motivators for Thermometer Use. In addition to identifying how to reduce

barriers to thermometer use for consumers, there were several unique factors listed as

motivators by the studies reviewed. A key motivator that all the studies shared was that

thermometer use could prevent foodborne illness for certain high-risk groups such as

children, pregnant women, and the elderly (McCurdy et al, 2005; Takeuchi et al., 2005;

Trepka et al., 2006; Athearn et al., 2004). Consumers wanted the confidence that they

could personally protect susceptible people from becoming ill. Likewise, consumers who

were aware of the risks from bacteria in ground beef, wanted assurance that the meat

reached an internal temperature of 160°F. Only thermometer use provided this assurance.

In a study by Takeuchi et al. (2005) with consumers in the general population from

Washington and Idaho (n=295), the top motivator for participants was certainty of

knowing that the meat has reached a temperature adequate to kill bacteria.

Several focus groups (McCurdy et al., 2005) and a survey (reviewed by Ralston et

al., 2000) found that personal or family experience with foodborne illness was the

strongest motivator for thermometer use. Foodborne illness was found to be a strong

motivator in focus groups as well (Athearn et al., 2004). However, many people may not

23

acquire a foodborne illness or are not aware of experiencing one; therefore, educational

materials will need to help them relate to the experience.

Some participants believed that promotional materials should mention that

thermometer use could prevent overcooking of meat and lead to improved quality

(McCurdy et al., 2005; Takeuchi et al., 2005). For people interested in improving their

cooking skills, thermometer use can be promoted as a tool to produce a ground beef patty

with high-quality sensory characteristics.

Promotional Materials. Promotional materials need to be designed to counteract

barriers and emphasize motivators in order to encourage thermometer use. Consumer

input for material development is important. Focus group participants mentioned

repetition of the message was important (Trepka et al., 2006). Presenting the information

in a variety of ways would also appeal to different learning styles, preferences, and needs.

Another promotional approach suggested by focus group participants was to

provide strong scientific evidence and factual explanations to convince them of the need

to use a thermometer (Athearn et al., 2004). Research-supported facts, such as the

interior color of the ground beef patty is not a good indicator of doneness, was thought to

be important by focus groups (McCurdy et al., 2005). Specific information would help

the recommendations seem more credible for consumers (Athearn et al., 2004).

Information could include foodborne disease risk, incidence, and morbidity and

mortality. Furthermore, materials need to be designed for specific needs of a population

group (Athearn et al., 2004). These groups could include pregnant women, young

mothers, children learning to cook, or the elderly. Other demographic groups or those

with special conditions may have particular needs that could be targeted.

24

Delivery of Educational Materials. In addition to effective materials, campaign

delivery is also fundamental to success. Providing food safety information at appropriate

times and places when the audience is receptive is crucial, as well as through acceptable

sources. According to many focus group participants, before pregnancy or at the

beginning of pregnancy is a time to deliver health and food safety information to young

women (Athearn et al., 2004). Similarly, participants in focus groups agreed that

mothers, especially those having their first child, are more receptive to health information

(Trepka, 2006).

Since many people establish their food safety practices as children, the public

school system would be a good place to provide classes or information (Trepka et al.,

2006; McCurdy et al., 2005). These classes could be included within the regular

curriculum, or a special event held after school involving parents and other family

members.

Participants from 11 focus groups (n=69) who were either pregnant or less than

six months postpartum stated they wanted to receive food safety information through

trusted sources such as doctors’ offices and health clinics, and through the WIC program

(Athearn et al., 2004). Participants in five focus groups from a large WIC program in

Florida (n=32) agreed that WIC was a good place to have mandatory food safety training

for WIC clients, along with incentives (Trepka et al., 2006).

There are many formats for delivery of food safety messages. The written form is

very efficient way to reach many people, and it was the preferred method of delivery in

the majority of many focus groups with pregnant or postpartum women held by Athearn

et al. (2004). Written material formats include brief brochures and pamphlets to full-size

25

booklets (Athearn et al., 2004). Studies reviewed revealed that consumers sought quality

material that is colorful and appealing, and in a friendly format. Messages should use

minimal text and realistic photos (McCurdy et al., 2005; Trepka et al., 2006; Athearn et

al., 2004).

Physical demonstrations, food safety education classes, small discussion groups,

and television advertisements were suggested formats to provide promotional material

where consumers can hear verbal, procedural explanations and view the procedure as

well (McCurdy et al., 2005; Trepka et al., 2006; Athearn et al., 2004). Several studies

have recommended a website to provide additional information that could include video

demonstrations of thermometer use (Athearn et al., 2004; McCurdy et al., 2005). Visual

demonstrations may increase self-efficacy with inexperienced consumers and help them

overcome the barriers that thermometers are difficult to use and take too much time.

Trepka et al. (2008) found that there was a high level of satisfaction expressed by

WIC clients who had used an innovative interactive computer program to learn about

food safety, especially for those with a high school education or less. This learning

module provided a user-friendly format of audio, video, graphics, and text and was

designed specifically to appeal to the predominant ethnic group of that region.

Thermometer Promotion by Industry. Consumers identified several ways the

beef industry could provide motivation to use a thermometer. Thermometers designed

and marketed especially for ground beef patties and thin meats would be less confusing

for consumers to purchase and use (Athearn et al., 2004; McCurdy et al., 2005). Other

motivators to promote thermometer use included accuracy, ease of use, and simple

instructions. Consumers mentioned that if the thermometer could be stored visibly in the

26

kitchen, it would encourage use (McCurdy et al., 2005). Consumers also stated that it

would be helpful to have a written guide for the proper cooking temperatures of various

meats (Athearn et al., 2004), perhaps on a laminated card, on a magnet, or on a window

cling to affix to the kitchen window (McCurdy et al., 2005), and printed on recipes and in

cookbooks (Takeuchi et al., 2005; McCurdy et al.,2005).

Consumers also suggested food labeling that includes specific safe food handling

information on risky food products (Athearn et al., 2004). Since 1994, a safe handling

label is required by the Federal Government on all raw meat packages; this label gives

general instructions for keeping foods safe, such as “Cook thoroughly;” however, the

term “thoroughly” is not defined with endpoint temperatures (USDA-FSIS, 2007). A

conspicuous sticker placed on the outside of the meat package with the proper endpoint

temperature for that meat product would serve as a reminder to consumers to use a

thermometer as well as the correct temperature needed (McCurdy et al., 2005).

Use of Behavior Change Theories in Evaluation

Development of an intervention to increase thermometer use with ground beef

patties needs to address the barriers and motivators consumers identified as crucial for

them to adopt the behavior. Behavior change theories can help identify factors to

emphasize about a specific behavior change within a particular population. Additionally,

behavior change theories can form a framework not only for the design of an intervention

strategy for thermometer use, but also for the evaluation of program effectiveness.

Theory of Planned Behavior. The Theory of Planned Behavior (TPB) posits

that the constructs of attitudes, subjective norms, and perceived behavior control combine

in varying degrees to shape a person’s intention or readiness to initiate an action

27

(Montaño & Kasprzyk, 2002). Attitudes are derived from positive or negative beliefs

about a behavior and the evaluation of the behavioral outcome. Subjective norms are the

beliefs about whether most people important to the individual approve or disapprove of

the behavior. Subjective norms are founded upon the normative beliefs of specific

referents and the motivation to comply with those referents’ beliefs. Perceived behavior

control originates from the control beliefs regarding the perceived likelihood of barriers

and the power over performing the behavior during these challenging situations

(Montaño & Kasprzyk, 2002). Perceived behavior control directly affects intentions but

may also directly affect behavior (Armitage & Conner, 2001).

A meta-analysis of 185 independent studies found that the Theory of Planned

Behavior was able to account for 39% of the variance in intention to perform the

behavior in question, and 27% of the variance in the actual performed behavior

(Armitage & Conner, 2001). A recent study using the TPB to examine hygienic food

handling behaviors of college students added an additional variable to the TPB: past

behavior or habit (Mullan & Wong, 2009). In that study, TPB factors (attitudes,

perceived behavior control, social norms) alone predicted 66% variance regarding

forming intentions; the factors of perceived behavior control and subjective norms were

identified as significant, whereas attitudes were not. However, with the inclusion of habit

as a factor, the variance regarding intention increased to 69%; habit was identified as

significant as well. On the other hand, when it came to predicting behavior, intention was

a significant factor and together with perceived behavior control it predicted 21% of the

variance. However, when the factor of past behavior was included, with intention and

perceived behavior control, only past behavior was identified as a significant factor: habit

28

added an additional 18% to the variance above the 21% contributed by intention and

perceived behavior control (Mullan & Wong, 2009). Habit or past behavior was the

strongest predictor for the hygienic food handling behaviors of young students and may

also play a part in other food safety behaviors, such as thermometer use. Moreover, these

observations may be applicable to other populations as well.

Integrative Model. The Integrative Model of behavioral prediction (IM)

represents the latest formulation of the Reasoned Action Approach, which stemmed from

the Theory of Planned Behavior and the Theory of Reasoned Action (Fishbein, 2008).

According to Fishbein (2008), there are a multitude of factors which influence and lead to

the development of our beliefs. These background factors include demographics and

experienced culture, past behavior and habits acquired, as well as unique personalities

and individual differences. Stereotypical images and stigmas may be accepted as beliefs,

as well as media messages regarding the specific behavior (Fishbein, 2008).

As in the TPB, the IM proposes that attitudes, self-efficacy (perceived behavior

control) and social norms help form the intentions which precede behavior. Beliefs about

the behavior and its expected outcome lead to attitudes about the behavior. Also, beliefs

about power to control the particular behavior lead to perceived behavior control.

Finally, normative beliefs about what important others think we should do (injunctive

norms) and perceptions of what others think and do (descriptive norms) lead to

perceptions of social pressure. However, in this model, behavior can additionally be

modified by the person’s skills and abilities, or by environmental factors which act as

barriers; as in the TPB, self-efficacy affects intentions but can also modify behavior

directly (Fishbein, 2008).

29

The three factors of attitudes, norms, and perceived behavior control (self-

efficacy) will be weighted according to its importance in forming intentions depending on

the specific behavior and population (Fishbein, 2008). A study by Smith-McLallen and

Fishbein (2008) examined the roles of attitudes, social norms (normative pressure), and

perceived behavior control as predictors to perform six cancer-related behaviors: three

lifestyle behaviors (exercising, eating fruits and vegetables, weight-control diet) and three

cancer screening behaviors (mammogram, colonoscopy, prostate specific antigen). In

this study, the relative importance of attitudes, social norms, and perceived behavior

control in predicting behavior intentions varied by the behavior. Social norms were the

strongest predictors of two cancer screening tests, the colonoscopy and prostate specific

antigen, as well as in eating fruits and vegetables. On the other hand, perceived behavior

control had more influence on intentions to undergo a mammography and to exercise.

When it came to dieting, attitudes had the most influence on intention. Understanding the

influence and interaction of the factors among attitudes, norms, and perceived behavior

control can help interventions to specifically target factors that will promote behavior

change.

Utilizing components of the IM in educational materials and impact evaluation

may help to predict, understand, and change thermometer use behavior more effectively

than the TPB, by defining and separating the perceived behavior control elements into

self-efficacy, skills and abilities, and environmental barriers. Many of the thermometer

use studies that were reviewed identified both internal and external barriers to use, as

well as consumer concerns about the skills needed to properly use a thermometer in

ground beef patties.

30

Transtheoretical Model. Another prominent behavior change theory is the

Transtheoretical Model (TTM); it describes readiness for behavior change as moving

through a series of stages. These stages are designated Pre-contemplation,

Contemplation, Preparation, Action, Maintenance, and Termination (Prochaska, 2008).

In the Pre-contemplation stage, the individual does not intend to perform the behavior

change action; this can be influenced by a lack of knowledge or awareness of the

problem, or resignation associated with previous failed attempts. In Contemplation stage,

the action is intended within the next six months; however, there is still a great deal of

ambivalence regarding the positive and negative factors associated with the behavior. In

the Preparation stage, initial steps leading toward change have occurred, with plans to

take action within one month. The Action stage is defined by specific, observable

changes that are maintained for six months. When the behavior has been practiced

beyond six months, the Maintenance stage has been demonstrated and relapse prevention

is key. The termination stage is the ultimate goal; the behavior is achieved with extreme

confidence to continue and no temptation to relapse.

Individuals must make decisions at every stage of the TTM as they weigh the pros

and cons of behavior change. According to Prochaska (2008) pros are advantages and

include things such as self-approval and or approval from others, as well as other benefits

for self or for others. Alternatively, the cons are disadvantages and may include self-

disapproval or disapproval from others, and result in a cost or forfeit of something for self

or for others. According to the model, to move from Pre-contemplation to the

Contemplation stage, the pros of the behavior need to be stressed. In Contemplation,

where pros and cons are equal, the cons need to be lowered so that there is a progression

31

into the Preparation and Action stages (Prochaska, 2008). The TTM has been effectively

used in many studies to identify intentions to perform a behavior, such as increasing fruit

and vegetable consumption in preschool-aged children (Hildebrand & Betts, 2009) and

dietary behaviors associated with smoking status (Delahanty, et al., 2008).

A study was designed using TTM to assess consumers’ readiness to use a food

thermometer with small cuts of meat; discriminate validity of a detailed stage-

classification question was established (Takeuchi et al., 2006). A survey question was

sent in two forms, a simple question format and a detailed question format, to 1000

randomly selected consumers and also to 231 employees and volunteers of Cooperative

Extension who were knowledgeable in food and nutrition education. Two stage-

classification questions (either using or owning a thermometer or not using or owning a

thermometer) were compared with a behavior question about thermometer ownership and

use for internal reliability. These were validated using Cronbach’s if-item-deleted option

for alpha which examines differences between questions. This showed that the detailed

classification question was more accurate in placing respondents in stages than the simple

format. Then a cross-tabulated chi-square test assessed concurrent validity by comparing

respondents’ stage classification based on the detailed formatted question. It was

determined that the two groups (consumers and employees) differed significantly in their

stages of change, verifying the discriminate validity (Takeuchi et al., 2006). A food

thermometer intervention was developed along with food thermometer use, employing

this detailed stage-classification question to evaluate the program (Takeuchi et al., 2005).

The stages of change classification showed that the percentage of consumers in

the Pre-contemplation stage significantly decreased after exposure to the educational

32

materials. Also, the percentages of participants in the more advanced stages of

Preparation, Action and Maintenance significantly increased after the intervention. There

was no change in numbers of respondents in the Contemplation stage (Takeuchi, et al.,

2005); this state of balance is probably due to the inward and outward flux of respondents

through this stage.

Since the TTM states that the advantages of a behavior change need emphasis to

those persons in the initial stages, after which the cons need to be minimized in order to

realize action, these are important elements to evaluate. When respondents were asked to

agree or disagree with statements regarding the advantages and disadvantages of using a

food thermometer, there were significant changes following the intervention. Agreement

with the pro statements increased and agreement with the con statements decreased

regarding using a food thermometer (Takeuchi et al., 2005). A relationship was

demonstrated between the decisional balance of advantages and disadvantages and the

stages of change. Prior to the intervention, only 4% of respondents reported the behavior

of food thermometer use regularly or most of the time with small cuts of meat. However,

following the intervention, there was a significant increase in behavior to 16% for those

who used a food thermometer regularly or most of the time (Takeuchi et al., 2005). As

predicted by the TTM, the post-intervention decisional balance showed that as

individuals moved through the stages of change progression, the advantages were more

favored than the disadvantages and moved participants to higher levels of the TTM

continuum (Takeuchi et al., 2005).

According to Prochaska (2008), the stages of the Transtheoretical Model can be

integrated with other behavior change models. The TTM pros and cons of benefits/costs

33

to self or others can combine with the Integrated Model core constructs of attitudes,

norms, and self-efficacy. While the IM can show which attitudes, perceived behavior

controls, and social norms are relevant to thermometer use within a population group, the

TTM can guide the timing of stage for promoting factors in order to evoke behavior

change. The TTM can also indicate the effectiveness of an intervention by identifying

how participants are staged with regard to their intentions and readiness to perform the

behavior.

Current Study Objectives

A promotional campaign for WIC women to advance their use of food

thermometers when cooking ground beef patties was designed based on an emotions-

based social marketing approach. Young children are at higher risk for foodborne illness,

so mothers of young children are a relevant target audience for education about

thermometer use. An impact evaluation of the campaign’s effectiveness was developed

and components utilized behavior change theories from the Transtheoretical Model

(Prochaska, 2008) and a Reasoned Action Approach (Fishbein, 2008).

The objectives of the impact evaluation were to:

1. Evaluate knowledge regarding food thermometer use with ground beef patties.

2. Assess food thermometer ownership and use with ground beef patties.

3. Examine the relationship between attitudes and intentions to use a food

thermometer with ground beef patties.

4. Assess possible barriers regarding food thermometer use with ground beef patties.

34

REFERENCES

Armitage, C.J. and M. Conner. 2001. Efficacy of the Theory of Planned Behaviour: a meta-

analytic review. British Journal of Social Psychology 40:471-499.

Athearn, P.N., P.A. Kendall, V. Hillers, M. Schroeder, V. Bergman, G. Chen, and L.C.

Medeiros. 2004. Awareness and acceptance of current food safety recommendations

during pregnancy. Maternal and Child Health Journal 8:149-162.

Be Food Safe. 2010. Introducing be food safe. Available at http://befoodsafe.org/ Accessed

May 7, 2010.

Bell, B.P., M. Goldoft, P.M. Griffin, M.A. Davis, D.C. Gordon, P.I. Tarr, C.A. Bartleson, J.H.

Lewis, T.J. Barrett, J.G. Wells, R. Baron, and J. Kobayashi. 1994. A multistate outbreak

of Escherichia coli O157:H7-associated bloody diarrhea and hemolytic uremic syndrome

from hamburgers; the Washington experience. JAMA 272:1349-53.

Besharov, D.J. and P. Germanis. 2000. Evaluating WIC. Evaluation Review 24:123-190.

Brown, A. (Ed.). 2004. Understanding food, principles and preparation. Second Edition.

Wadsworth, Belmont, California.

Byrd-Bredbenner, C., J. Mauer, V. Wheatley, E. Cottone, and M. Clancy. 2007. Food safety

hazards lurk in the kitchens of young adults. Journal of Food Protection 70:991-6.

Cates, S. 1999. Thermometer slogan focus group study. Final report prepared for USDA

Food Safety and Inspection Service. http://www.fsis.usda.gov/oa/research/rti_summ.pdf

Accessed 12/26/09.

Cattlemen’s Beef Promotion and Research Board – MyBeefCheckoff.com. 2008. Beef market

at a glance, statistics about America’s no. 1 selling protein. Available at

35

http://www.beefboard.org/news/files/factsheets/Beef-Market-at-a-Glance-April-2008.pdf

Accessed December 1, 2009.

Center for Disease Control and Prevention. April 10, 2009a. Preliminary FoodNet Data on the

Incidence of Infection with Pathogens Transmitted Commonly Through Food – 10 States,

2008. MMWR Weekly, 58(13), 1-94. Available at:

http://www.cdc.gov/mmwr/PDF/wk/mm5813.pdf Accessed August 1, 2009.

Center for Disease Control and Prevention. July 9, 2009b. Summary of Notifiable Diseases –

United States 2007, Shiga Toxin-Producing Escherichia coli (STEC). MMWR Weekly,

56(53), 1-94. Available at: http://www.cdc.gov/mmwr/PDF/wk/mm5653.pdf. Accessed

August 1, 2009.

Cody, M.M. and M.A. Hogue. 2003. Results of the home food safety—It’s in your hands

2002 survey: comparisons to the 1999 benchmark survey and healthy people 2010 food

safety behaviors objective. Journal of the American Dietetic Association 103:1115-25.

Conner, D.E. and J.S. Kotrola. 1995. Growth and survival of Escherichia coli O157:H7 under

acidic conditions. Applied and Environmental Microbiology 61:382-5.

Davis, C.G. and B-H Lin. 2005. Factors affecting U.S. beef consumption. United States

Department of Agriculture Economic Research Service. Available at:

http://www.ers.usda.gov/Publications/LDP/OCT05/ldpm13502/ Accessed March 2, 2009.

Delahanty, J.C., C.C. DiClemente, S. Havas, and P. Langenberg. 2008. Smoking status and

stages of change for dietary behaviors among WIC women. Am. J. Behav. 32:583-93.

36

Dodd, C. and D. Powell. 2009. Regulatory management and communication of risk associated

with Escherichia coli O157:H7 in ground beef. Foodborne Pathogens and Disease

6:743-7.

Doyle, M.P. and J.L. Schoeni. 1984. Survival and growth characteristics of Escherichia coli

associated with hemorrhagic colitis. Applied and Environmental Microbiology 48:855-6.

Doyle, M.P. and L.R. Beuchat (eds). 2007. Food microbiology: fundamentals and frontiers.

Third Edition. ASM Press, Washington, D.C.

Faustman, C. and R.G. Cassens. 1990. The biochemical basis for discoloration in fresh meat:

A review. Journal of Muscle Foods 1: 217-43.

Fightbac Partnership for Food Safety Education. 2006. Safe food handling; the core four

practices. Fightbac! Available at: http://www.fightbac.org/content/view/6/11/

Accessed December 23, 2009.

Fishbein, M. 2008. A Reasoned Action Approach to health promotion. Medical Decision

Making 28:834-844.

Fischer, A.R.H.,and P.W. DeVries. 2008. Everyday behaviour and everyday risk: An

approach to study people’s responses to frequently encountered food related health risks.

Health, Risk & Society 10:385-397.

Frewer, L.J., R. Sheperd, and P. Sparks. 1994. The interrelationship between perceived

knowledge, control, and risk associated with a range of food-related hazards targeted at

the individual, other people and society. Journal of Food Safety 14:19-40.

Gerba, C.P., J.B. Rose, and C.N. Haas. 1996. Sensitive populations: who is at the greatest

risk? International Journal of Food Microbiology 30:113-23.

37

Hague, M.A., K.E. Warren, M.C. Hunt, D.H. Kropf, C.L. Kastner, S.L. Stroda and D.E.

Johnson. 1994. Endpoint temperature, internal cooked color, and expressible juice color

relationships in ground beef patties. J. of Food Sci. 59:465-70.

Harhay, D.M., M.N. Guerini, T.M. Arthur, T.L. Wheeler and M. Koohmaraie. 2009.

Salmonella and Escherichia coli O157:H7 contamination on hides and carcasses of cull

cattle presented for slaughter in the United States: An evaluation of prevalence and

bacterial loads by immunomagnetic separation and direct plating methods. United States

Department of Agriculture Agricultural Research Service. Available at

http://www.ars.usda.gov/researach/publications/publications.htm?seq_no_115=224423

Accessed December 28, 2009.

Heldebrand, D.A. and N.M. Betts. 2009. Assessment of stage of change, decisional balance,

self-efficacy, and use of processes of change of low-income parents for increasing

servings of fruits and vegetables to preschool-aged children. Journal of Nutrition

Education and Behavior 41:110-19.

Hunt, M.C., K.E. Warren, M.A. Hague, D.H. Kropf, C.L. Waldner, S.L. Stroda and C.L.

Kastner. 1995. Cooked ground beef color is unreliable indicator of maximum internal

temperature. Agriculture and Food Chemistry Division Abstracts 209: 139.

Hui, Y.H., M.D. Pierson and J. R. Gorham (Ed.). 2001. Food disease handbook. Second

Edition. Marcel Dekker, Inc., New York, New York.

Jay, J.J., M.J. Loessner, D.A. Golden. 2005. Modern Food Microbiology. Seventh Edition.

Springer Science, New York, New York.

38

Karmali, M.A., V. Gannon, and J.M. Sargeant. 2010. Verocytotoxin-producing Escherichia

coli (VTEC). Vet. Microbiol. 140:360-70.

Katpodi, M.C., N.C. Facione, J.C. Humphreys, and M.J. Dodd. 2005. Perceived breast cancer

risk: heuristic reasoning and search for dominance structure. Social Science and

Medicine 60:421-32.

Killinger, K.M., M.C. Hunt, R.E. Campbell and D.H. Kropf. 2000. Factors affecting premature

browning during cooking of store-purchased ground beef. Journal of Food Science

65:585-587.

King, N.J. and R. Whyte. 2006. Does it look cooked? A review of factors that influence

cooked meat color. Journal of Food Science 71:R31-40.

Kwon, J., A.S. Wilson, C. Bednar, and L. Kennon. 2008. Food safety knowledge and

behaviors of Women, Infant, and Children (WIC) program participants in the United

States. Journal of Food Protection 71:1651-8.

Lyon, B.G., B.W. Berry, D. Soderberg, and N. Clinch. 2000. Visual color and doneness

indictors and the incidence of premature brown color in beef patties cooked to four end

point temperatures. Journal of Food Protection 63:1389-98.

McArthur, L.H., D. Holbert and W.A. Forsythe III. 2006. Compliance with food safety

recommendations among university undergraduates: Application of the Health Belief

model. Family and Consumer Sciences Research Journal 35:160-170.

McCurdy, S.M., E. Mayes, V. Hillers, D. Kang and M. Edlefsen. 2004. Availability, accuracy

and response time of instant-read food thermometers for consumer use. Food Protection

Trends 24:961-8.

39

McCurdy, S.M., V. Hillers, and S.E. Cann. 2005. Consumer reaction and interest in using

food thermometers when cooking small or thin meat items. Food Protection Trends

25:826-31.

Mead, P.S., L. Slutsker, V. Dietz, L.F. McCaig, J.S. Bresee, C. Shapiro, P.M. Griffin and R.V.

Tauxe. 2000. Food-related illness and death in the United States. Journal of

Environmental Health 62: 9-18.

Montaño, D.E. and D. Kasprzyk. (2002). The theory of reasoned action and the theory of

planned behavior. In K. Glanz, B.K. Rimer, F.M. Lewis (Eds.). Health behavior and

health education, theory, research and practice. (3rd ed., pp.67-95) Jossey-Bass, San

Francisco, CA.

Mullan, B.A. and C.L. Wong. 2009. Hygienic food handling behaviours. An application of the

Theory of Planned Behaviour. Appetite 52:757-761.

Nataro, J.P. and J.B. Kaper. 1998. Enterohemorrhgic E. coli. Clinical Microbiology Reviews

11:142-201.

Prochaska, J.O. 2008. Decision making in the Transtheoretical Model of behavior change.

Medical Decision Making 28:845-9.

Ralston, K., Y, Starke, P. Brent and T Riggins. 2000. Awareness of risks changing how

hamburgers are cooked. FoodReview 23:44-50.

Rangel, J.M., P.H. Sparling, C. Crowe, P.M. Griffin, and D.L. Swerdlow. 2005. Epidemiology

of Escherichia coli O157:H7 outbreaks, United States, 1982-2002. Emerging Infectious

Diseases 11:603-9.

40

Redmond, E.C. and C.J. Griffith. 2003. Consumer food handling in the home: A review of

food safety studies. Journal of Food Protection 66:130-61.

Redmond, E.C. and C.J. Griffith. 2004a. Consumer attitudes and perceptions towards

microbial food safety in the domestic kitchen. Journal of Food Safety 24:169-94.

Redmond, E.C. and C.J. Griffith. 2004b. Consumer perceptions of food safety risk, control

and responsibility. Appetite 43:309-313.

Riley, L.W., R.S. Remis, S.D. Helgerson, H.B. McGee, J.G. Wells, B.R. Davis, R.J. Herbert,

E.S. Olcott, L.M. Johnson, N.T. Hargrett, P.A. Blake and M.L. Cohen. 1983.

Hermorrhagic colitis associated with a rare Escherichia coli serotype. The New England

Journal of Medicine 308:681-5.

Samadpour, M., M.W. Barbour, T. Nguyen, T.M. Cao, F. Buck, G.A. Depavia, E. Mazengia, P.

Yang, D. Alfi, M. Lopes and J.D. Stopforth. 2006. Incidence of enterohemorrhagic

Escherichia coli, Escherichia coli O157:H7, Salmonella, and Listeria monocytogenes in

retail fresh ground beef, sprouts, and mushrooms. Journal of Food Protection 69:441-3.

Schlundt, J., H. Toyofuku, J. Jansen and S.A. Herbst. 2004. Emerging food-borne zoonoses.

Rev. Sci. Tech. Off. Int. Epiz. 23:513-33.

Schuele, B. 2004. Food safety education: Health professional’s knowledge and assessment of

WIC client needs. Journal of the American Dietetic Association 104:799-803.

Sigman-Grant, M., A. Rye, D. Loesch-Griffin and D. Mitchell. 2008. How to strengthen and

enhance WIC nutrition education. Journal of Nutrition Education and Behavior 40:317-

321.

Slovic, P. 1987. Perception of risk. Science 236:280-85.

41

Smith-McLallen, A. and M. Fishbein. 2008. Predictors of intentions to perform six cancer-

related behaviours: Roles for injunctive and descriptive norms. Psychology, Health and

Medicine 13:389-401.

Takeuchi, M.T., M. Edlefsen, S.M. McCurdy and V.N. Hillers. 2005. Educational intervention

enhances consumers’ readiness to adopt food thermometer use when cooking small cuts

of meat: An application of the Transtheoretical Model. Journal of Food Protection

68:1874-83.

Takeuchi, M.T., M. Edlefsen, S.M. McCurdy and V.N. Hillers. 2006. Development and

validation of Stages-of-Change questions to assess consumers’ readiness to use a food

thermometer when cooking small cuts of meat. Journal of the American Dietetic

Association 106:262-6.

Trepka, M.J., V. Murunga, S. Cherry, F.G. Huffman and Z. Dixon. 2006. Food safety beliefs

and barriers to safe food handling among WIC Program clients, Miami, Florida. J. Nutr.

Educ. Behav. 38:371-7.

Trepka, M.J., F.L. Newman, E.P. Davila, K.J. Matthew, Z. Dixon, T.G. Huffman. 2008.

Randomized Controlled Trial to Determine the Effectiveness of an Interactive

Multimedia Food Safety Education Program for the Clients of the Special Supplemental

Nutrition Program for Women, Infants, and Children. J. Am. Diet. Assoc. 108:978-84.

Tuttle, J., T. Gomez, M.P. Doyle, J.G. Wells, T. Zhao, R.V. Tauxe and P.M.Griffin. 1999.

Lessons from a large outbreak of Escherichia coli O157:H7 infections: Insights into the

infectious dose and method of widespread contamination of hamburger patties.

Epidemol. Infect. 122:185-192.

42

U.S. Bureau of Labor Statistics. April 2010. Average retail food and energy prices, U.S. city

average and midwest region. Accessed at http://data.bls.gov/ro3/apme.htm. Accessed

April15, 2010.

U.S. Department of Agriculture, Food and Nutrition Service. March 2006. WIC participant

and program characteristics 2004. WIC-04-PC. Available at:

http://www.fns.usda.gov/oane/MENU/Published/WIC/FILES/pc2004.pdf Accessed

September 7, 2009.

U.S. Department of Agriculture, Food and Nutrition Service. April 2009a. WIC, the Special

Supplemental Nutrition Program for Women, Infants and Children. Available at:

http://www.fns.usda.gov/wic/WIC-Fact-Sheet.pdf Accessed September 7, 2009.

U.S. Department of Agriculture, Food and Nutrition Service. May 2009b. 40 years: 1969-

2000, research, national survey of WIC participants: final report, executive summary.

Available at:

http://www.fns.usda.gov/oane/MENU/Published/WIC/FILES/WICSurvey.htm Accessed

September 7, 2009.

U.S. Department of Agriculture, Food Safety and Inspection Service. 1996. Food Safety and

Inspection Service. Available at: http://www.usda.gov/news/pubs/factbook/009a.pdf

Accessed June 24, 2009.

U.S. Department of Agriculture, Food Safety and Inspection Service. July 2002a. Meat

preparation, focus on ground beef. Available at:

http://www.fsis.usda.gov/Fact_Sheets/Ground_Beef_and_Food_Safety/index.asp

Accessed May 21, 2009.

43

U.S. Department of Agriculture, Food Safety and Inspection Service. September 2002b. New

measures to address E. coli O157:H7 contamination. Available at: http://origin-

www.fsis.usda.gov/OA/background/ec0902.pdf Accessed May 1, 2009.

U.S. Department of Agriculture, Food Safety and Inspection Service. October 2002c. E. Coli

O157:H7 contamination of beef products, 9 CFR Part 417. Available at

www.fsis.usda.gov/OPPDE/rdad/FRPubs/00-022N.pdf Accessed May 1, 2009.

U.S. Department of Agriculture, Food Safety and Inspection Service. April 2003. Meat

preparation, color of cooked ground beef as it relates to doneness. Available at:

http://www.fsis.usda.gov/Fact_Sheets/Color_of_Cooked_Ground_Beef/index.asp

Accessed June 30, 2009.

U.S. Department of Agriculture, Food Safety and Inspection Service. January 2007. FSIS

images, safe handling label text. Available at:

http://www.fsis.usda.gov/News_&_Events/Safe_Handling_Label_Text/index.asp

Accessed March 16, 2010.

U.S. Department of Agriculture, Food Safety and Inspection Service. April 2008a. Public health

risk-based inspection system for processing and slaughter, technical report. Available at:

http://www.fsis.usda.gov/OPPDE/NACMPI/Feb2008/Processing_Slaughter_Tech_Rpt_0

41808.pdf Accessed May 8, 2010.

U.S. Department of Agriculture, Food Safety and Inspection Service. May 2008b. Appliances

& thermometers, kitchen thermometers. Available at:

http://www.fsis.usda.gov/Fact_Sheets/Kitchen_Thermometes/index.asp Accessed August

18, 2009.

44

U.S. Department of Agriculture, Food Safety and Inspection Service. July 2008c. Final rule

makes retail lists available to consumers during recalls. Available at:

http://www.fsis.usda.gov/news_&_ events/Const_Update_071108/index.asp Accessed

May 27, 2009.

U.S. Department of Agriculture, Food Safety and Inspection Service. February 2009a. FSIS’

role in state inspection programs. Available at: http://origin-

www.fsis.usda.gov/PDF/Cons_Update_022009.pdf Accessed December 2009.

U.S. Department of Agriculture, Food Safety and Inspection Service. May 2009b.

Microbiological results of raw ground beef products analyzed for Escherichia coli

O157:H7, summarized by calendar year. Available at:

http://www.fsis.usda.gov/Science/Ecoli_O157_Summary_Tables/index.asp Accessed

July 20, 2009.

U.S. Department of Agriculture, Food Safety and Inspection Service. September 2009c.

Microbiological testing program for Escherichia coli O157:H7. Available at:

http://origin-www.fsis.usda.gov/Science/Ground_Beef_E.Coli_Testing_Results/index.asp

Accessed December 22, 2009.

U.S. Department of Agriculture, Food Safety and Inspection Service. April 2010. FSIS

recalls, recall case archive. Available at:

http://www.fsis.usda.gov/fsis_recalls/Recall_Case_Archive_2008/index.asp Accessed

May 7, 2010.

U.S. Food and Drug Administration, Department of Health and Human Service, Center for

Food Safety and Applied Nutrition. 2007. Escherichia coli O157:H7. Bad Bug Book,

45

Foodborne Pathogenic Microorganisms and Natural Toxins Handbook. Available at:

http://www.foodsafety.gov/~mow/chap15.html Accessed May 21, 2009.

Yoon, J.W. and C.J. Hoyde. 2008. All blood, no stool: Enterohemorrhagic Escherichia coli

O157:H7 infection. J. of Vet. Sci. 9:219-31.

York, V.K., L.A. Brannon, K.R. Roberts, C.W. Shanklin and A.D. Howells. 2009. Using the

Theory of Planned Behavior to elicit restaurant employee beliefs about food safety:

Using surveys versus focus groups. Journal of Foodservice Business Research 12:180-

97.

46

INTRODUCTION Food products of animal origin carry the inherent risk of pathogenic bacterial

contamination (Jay et al., 2005). Ground beef presents a higher risk meat product, due to

the grinding process which can incorporate surface bacteria throughout the meat.

Foodborne illness remains a concern in the U.S. It is estimated that Salmonella causes

approximately 1.4 million illnesses per year and E. coli O157:H7 approximately 73,480

illnesses (Mead et al., 2000). The most at-risk populations for complications from

foodborne illness are young children, elderly people, and others who are immuno-

compromised (Gerba et al., 1996). The heaviest incidence burden of disease from E. coli

O157:H7 are in young children under the age of 11 (CDC, 2009). E. coli O157:H7

colonizes the large intestines of humans, producing toxins which are involved in the

symptoms of hemorrhagic colitis (Doyle & Beuchat, 2007). Hemorrhagic colitis may

also progress into hemolytic uremic syndrome (HUS) (Hui et al., 2001). Consumers must

understand the risk of ingesting undercooked ground beef patties and to take proper

action through thermometer use.

For meat product safety, the USDA provides regulatory oversight and promotes

risk reduction and the meat industry is under legal obligation to perform risk-reduction

preventative practices and interventions, ultimately it is the consumer’s role to ensure that

ground beef patties are cooked properly to an internal endpoint temperature of 160°F to

prevent foodborne illness. In 1997, the USDA initiated recommendations of

thermometer use with ground beef patties; interior color of ground beef patties was

determined to be an inaccurate indicator that the meat had reached an adequate internal

temperature (USDA-FSIS, 2003). Thermometer use with ground beef patties remains

47

low; many consumers prefer to use visual cues of doneness instead (Athearn et al., 2004;

Cates, 1999; Kwon et al., 2008; McArthur et al., 2006). Risk perception may be low due

to perceived food safety knowledge by consumers which leads them to feel they have

more control over foodborne illness (Frewer et al., 1994). Also, heuristic reasoning states

that because consumption of ground beef patties is a voluntary action and bacterial

contamination is known, the risks may be perceived as low, controllable and easily

reduced (Slovik, 1987). Perceived control based on hindsight of prior events may lead to

a perception of less risk (Katapodi et al., 2005). Habitual actions which bring positive

results such as no foodborne illness, may develop into an optimistic bias, and new

information is deemed unnecessary (Fisher & Devries, 2008).

One population of special concern are clients of the Special Supplemental

Nutrition Program for Women, Infants, and Children (WIC). WIC serves over 8 million

mothers and their infants or children per month (USDA-FNS, 2009a). Studies indicated a

need for additional food safety education in this population; a survey of WIC health

professionals by Schuele (2004) indicated that food safety handout materials designed

specifically for WIC clients would be beneficial. Educational materials must address not

only promotion of thermometer use, but also perceived barriers. Six major factors

identified by consumers that limit adopting thermometer use included the perception of

thermometers as unnecessary (Trepka et al., 2006; Athearn et al., 2004; McCurdy et al.,

2005), forgetting to use one (McCurdy et al., 2005; Takeuchi et al., 2005, Trepka et al.,

2006), difficulty with use in ground beef patties (McCurdy et al., 2005; Takeuchi et al.,

2005), a negative social connotation (McCurdy et al., 2005; Takeuchi et al., 2005), the

amount of time to use one (McCurdy et al., 2005; Takeuchi et al., 2005), and a taste

48

preference for undercooked meat (Trepka et al., 2006; Athearn et al., 2004). The WIC

population includes children, a group at high risk for foodborne illness. There is a need

for food safety materials to promote thermometer use in this higher-risk population, and

addressing potential barriers is critical for consumers to considering thermometer use

with ground beef patties.

Behavior change theories can be effectively used to design an intervention as well

as evaluate the impact. The Integrative Model of the Reasoned Action Approach

behavioral prediction posits that the constructs of attitudes, social norms, and perceived

behavior control combine in varying degrees to shape intentions or readiness to initiate an

action; furthermore, skills and abilities, and barriers play an additional role (Fishbein,

2008). Another prominent behavior change theory is the Transtheoretical Model; it

describes readiness for behavior change as moving through a series of stages (Prochaska,

2008). The Transtheoretical Model can be utilized to indicate the effectiveness of an

intervention by identifying participant intentions and readiness to perform a behavior.

Together, these two behavior change theories can be used to assess attitudes, social

norms, and perceived behavior control of participants in various stages of readiness to use

a thermometer. Perceived barriers could also be identified with associations to stages of

change. This information could help target future campaign materials more effectively to

specific attitudes and barriers based on the readiness to begin thermometer use.

A promotional campaign for WIC clients to advance the use of food thermometers

when cooking ground beef patties was designed based on an emotions-based social

marketing approach. An impact evaluation for the campaign utilizing aspects based on

the Integrative Model and the Transtheoretical Model behavior change theories was

49

developed. The objectives of the impact evaluation were to evaluate increases in

knowledge regarding food thermometer use with ground beef patties and to assess food

thermometer ownership and use with ground beef patties. Finally, the relationship

between attitudes and intentions to use a food thermometer with ground beef patties, as

well as to assess possible barriers regarding food thermometer use with ground beef

patties were examined.

50

MATERIALS AND METHODS

Overall Project Overview

The described thesis project was a component of a larger project entitled

“Advancing Accurate Consumer Use of Instant-Read Food Thermometers through

Grocery Stores and Women, Infants, and Children (WIC) Program.” The purpose of the

project was to increase knowledge and accurate use of food thermometers with ground

beef patties in the general population as well as in underserved, hard-to-reach

populations. The campaign slogan was “160°F for your Family” and focused on

thermometer use with ground beef patties. This was a continuation of a previous project,

“Reducing Risk with Food Thermometers: Strategies for Behavior Change” with the

slogan “Now you’re Cooking…Using a Food Thermometer,” which promoted

thermometer use with thin cuts of meat. The “160°F for your Family” campaign included

five major components.

Consumer Practices with Ground Beef Patties. The first component of the

campaign was to determine common consumer purchasing, storage, preparation, and

cooking practices with ground beef patties. A telephone survey of 800 adult consumers

who prepared and cooked ground beef patties was conducted in households in the states

of Washington and Idaho. This information was used in two ways: to assess the

accuracy of dial and digital thermometers using common consumer preparation and

cooking practices and to develop an educational campaign to promote the use of

thermometers with ground beef patties.

51

Assessment of Dial and Digital Thermometer Accuracy. The second

component of this project was the assessment of accuracy for commonly available

models of instant-read dial and digital thermometers in different price ranges to measure

endpoint temperature in ground beef patties. Both standard laboratory methods and

common consumer cooking practices were used to assess accuracy in order to clarify

appropriate recommendations on thermometer use to consumers.

Thermometer Use Campaign Development. The third component involved

developing motivational thermometer-use campaigns based on social marketing

techniques for two separate audiences, general consumers and mothers with young

children. The campaigns were designed to employ an emotions-based social marketing

approach by connecting a desired behavior with an important value held by the audience.

A grocery store campaign was conducted with shoppers at the meat counters of

Associated Food Stores (AFS) in Idaho and a campaign for mothers with young children

was delivered through the Special Supplemental Nutrition Program for Women, Infants,

and Children (WIC) clinics in 17 counties in Washington (Appendix A). Needs

assessments were conducted initially and resulted in the design of a brochure and three

recipe cards for the AFS audience. For WIC clients, several focus groups were

conducted to aid in identifying “pulse-point” messages, or the underlying emotional

triggers that influence behaviors, that would resonate with the audience to promote food

safety and thermometer use.

WIC Campaign Material Development. Pulse-points, such as mothers’ desires

for security for themselves and their children, as well as happiness and a good life, were

identified. Photographs for campaign materials were selected to be personally relevant to

52

mothers. The slogan “160°F for your Family” was developed to emphasize the endpoint

temperature for safely cooked ground beef patties. The logo included 160°F in a

digitalized-font with the slogan inside a heart-shaped red ribbon with the words

“Tradition, Celebration, Security” printed on the ends of the ribbon; these words were

chosen to represent the positive feelings associated with thermometer use. Repetition of

the 160°F message was placed throughout the materials. Three 4” x 9” brochures for the

WIC audience along with small posters (8.5” x 11” and 11” x 17”) were subsequently

developed (Appendix B) that would appeal to emotional pulse points to promote

thermometer use. A website (www.uidaho.edu/thermometers) was also designed for the

general public to provide more detailed information about thermometers.

Campaign Impact Evaluation. The fourth component of the project was

development and delivery of impact evaluation tools to evaluate the effectiveness of the

AFS educational materials and the WIC educational materials. The two evaluation tools

were similar, although the AFS survey contained several questions regarding the recipe

cards which were developed specifically for that campaign, while the WIC survey

contained a question regarding the WIC materials. The WIC survey also contained

additional questions regarding the consumption of ground beef patties in the household,

as well as potential barriers to thermometer use. The development and outcomes of the

WIC evaluation tool will be addressed in this thesis. The evaluation tool for the WIC

campaign is provided in Appendix C.

WIC Campaign Delivery and Impact Evaluation

Delivering the WIC Campaign and Evaluation Announcement. An emotions-

based social marketing campaign was developed for WIC clients, and the materials were

53

delivered to WIC clinics in 17 counties in the state of Washington (Appendix A); the

campaign and impact evaluation data collection took place during an 8-week period from

August through September 2009 to coincide with the grilling season.

Small display stands holding an 8.5” x 11” poster featuring one of the campaign

designs were placed in the WIC offices and waiting rooms. The poster of a sick child

with a medical thermometer was chosen to capture interest in the display due to the

positive feedback from participants in the preceding focus groups. The display stands

contained packets of educational materials consisting of three brochures regarding food

thermometer use with ground beef patties. In order to evaluate the effectiveness of the

campaign, clients were recruited for participation in the impact evaluation via

announcement cards within the packets; these announcements highlighted that

participants completing the evaluation would receive a Wal-mart or Safeway gift card

incentive; a $10 value (Appendix D).

WIC Campaign Evaluation Instrument.

Introduction and Campaign Materials Assessment. As an introduction to the

survey, the evaluation began by clarifying the types of thermometers that would be

discussed, as well pictures of the materials and display as a reminder. Question 1

addressed the display, and what compelled clients to approach it. Campaign attributes

emphasized photos, colors, educational messages, and a logo. Identifying the attributes

that attracted participants to the materials was important as well as what components

were most useful. Question 2 asked if they picked up the materials; some participants

may have just read the poster display. In Question 3, participants were also asked what

54

they did with the materials since receiving them. Furthermore, participants were asked if

the materials made them feel thermometer use was important (Question 4).

WIC Household Ground Beef Patty Consumption. Two questions (Questions 6

and 7) addressed the frequency ground beef patties were cooked at home and household

members who commonly consumed them. These questions examined how often WIC

families cook ground beef patties and if children specifically consume them, in order to

evaluate the food safety risk within the target audience.

Thermometer Ownership and Use. Participants were asked about thermometer

ownership with ground beef patties (Question 8). Furthermore, frequency of

thermometer use before and after receiving the materials was assessed using a

retrospective pre-post question (Question 9a and 9b). This 2-part question asked how

often a food thermometer was used when cooking ground beef patties before picking up

the packet of material, and then how often it was used after picking up the packet of

material. The 5-point response scale ranged from almost always to never. This question

was used as a means of evaluating change in frequency of thermometer use as indicator

of the effectiveness of the materials; it was the only question utilizing a comparison of

thermometer use behavior before and after the campaign.

Campaign Website. A campaign website provided more information about

thermometers, and the website address was printed on the materials. The website also

provided a link to the online evaluation of the educational materials; the evaluation was

also offered through written and telephone formats. Two questions focused on the

website. Respondents were asked whether they visited the website (Question 10) and if

55

so, whether they felt the website provided useful information about food thermometers

when cooking ground beef patties (Question 11).

Main Reason to Use a Thermometer. Question 13 asked what the main reason

was for thermometer use when cooking hamburger patties. The first response choice was

that they do not use a food thermometer; two other responses choices were to cook

hamburgers the way my family likes them, and to make hamburgers safe for my family.

There was also an option to provide an “other” response.

Campaign Contribution to Participant Knowledge. Three knowledge questions

assessed consumer understanding of proper cooking temperatures and thermometer use as

a result of reading the campaign material. Question 14 addressed consumer knowledge

that the only way to safely cook a ground beef patty involved using a food thermometer.

Question 15 addressed knowledge that 160°F is the adequate temperature needed to kill

bacteria in a ground beef patty. Question 16 assessed knowledge and confidence in

ability to accurately measure the temperature of a ground beef patty; this information was

mainly provided through the use of photos in the materials.

Stage of Change and Attitudes toward Thermometer Use. To facilitate the

development of the impact evaluation, behavior change theories were identified to

develop appropriate questions for aspects of the evaluation. It was decided that two

models, the Transtheoretical Model (Prochaska, 2008; Prochaska, 2002) and a Reasoned

Action Approach (Fishbein, 2008) were appropriate. Important concepts from these

theories formed the basis of intention and attitudinal statements in the impact evaluation.

A question based on the Transtheoretical Model was validated in a previous

study (Takeuchi, 2006) and was utilized in the current evaluation to determine

56

participants’ intentions toward thermometer use (Table 1). In addition, seven paired

questions (Table 2) were developed based on the constructs of importance attitudes,

perceived behavior control, and social norms (Fishbein’s Reasoned Action Approach)

were used to assess attitude contributions that may lead to intentions for thermometer use

(Fishbein, 2008). The use of the two models in combination assists with connecting

important attitudes with intentions for thermometer use at each stage of behavior change.

The Stage of Change question (Question 12) provided client response choices for

the statement that best describes participant ownership and use of a food thermometer

when cooking ground beef patties. The first three response choices corresponded to lack

of ownership of a food thermometer with degree of intention to purchase one for use with

ground beef patties, while the last five response choices corresponded to current

ownership of a food thermometer with degree of intention about use with ground beef

patties. The first and fourth response choices indicated no intention of buying or using a

food thermometer for use with ground beef patties at the time of the evaluation (Pre-

contemplation stage). At the Pre-contemplation stage, there is no awareness of the need

to begin using a thermometer, or desire to perform the behavior. The second and fifth

response choices were consideration of buying or using a thermometer with ground beef

patties within the next six months (Contemplation stage). In Contemplation, the pros and

cons of the behavior are weighed. The third and sixth response choices involved

planning to buy or use a thermometer within the next month (Preparation stage). In the

Preparation stage, there are some small steps taken towards initiating the behavior.

The final two responses were selections for those who already owned and used a

food thermometer currently with ground beef patties. The seventh response choice was

57

for thermometer owners who have used a thermometer with ground beef patties for less

than six months (Action stage); in this stage overt actions have occurred. In the eighth

response choice, thermometer owners have been using a thermometer with ground beef

patties regularly for over six months (Maintenance stage). The Maintenance stage has

been achieved when the behavior has been performed for over six months and has been

routinely established.

The next section (Questions 17-30) consisted of 14 statements describing

attitudes about importance of thermometer use, perceived behavior control (self-efficacy)

and social norm opinions. These are based on concepts from the theory of a Reasoned

Action Approach, which posits that these three constructs combine in varying degrees for

a particular behavior to shape a person’s intentions to change or adopt a behavior

(Fishbein, 2008). Because intentions immediately precede behavior, it is important to

identify the factors which contribute to forming intentions in order to provide a

successful intervention.

The 14 attitudinal statements were developed as 7 paired questions, with a

positive statement and a similar, but negatively-worded counterpart statement, in order to

provide a measure of internal reliability (Table 2). Four paired questions were utilized to

determine importance attitudes about thermometer practices with ground beef patties.

The questions included topics about methods to check doneness which will ensure a safe

ground beef patty, importance in cooking the meat to 160°F, food thermometer use as a

priority in the home, and importance in producing a quality ground beef patty. Two

paired questions investigated perceived behavior control: one pair regarding time as a

factor in thermometer use, and one pair on ease of thermometer use with ground beef

58

patties. A final pair examined a social norm, the influence by comments or actions of

others regarding food safety and thermometer use. The 14 attitudinal statements were

ordered randomly in the evaluation to reduce the likelihood participants would notice

similarities between positively- and negatively-worded pairs.

Barriers to Thermometer Use. The next section (Questions 31 – 37) was designed

to identify factors that might prevent clients from behavior change with thermometer use.

The barrier statements were also used in the previous study evaluation (Takeuchi et al.,

2005). Identification of barriers among the WIC audience specifically would be useful.

Demographics. Demographic information (Questions 38 – 45) was collected and

included location of the WIC clinic where materials were encountered, gender, year of

birth, and number of adults and children in the household, level of education completed,

household income, and racial-ethnic background. At the end of the survey, a box was

provided for additional comments.

The evaluation tool was reviewed by experts for content validity and pilot tested

by the general public for face validity in order to verify the clarity of wording and

appropriateness of item format. Minor refining was performed based on validity testing.

The final instrument contained 45 questions (Appendix C).

Data Collection. In order to accommodate a variety of consumer preferences, the

evaluation was offered in three different delivery modes: internet, telephone, and a

written version. Delivery of the evaluations to participants was facilitated by the

University of Idaho’s Social Science Research Unit. The internet and written evaluations

used colored photos of the materials as visual reminders of the campaign materials, and

photos of instant-read thermometers to clarify the types of instant-read thermometers.

59

For these delivery modes, a thank you letter and follow-up reminder card were sent to

mail survey participants (Appendix E). For the telephone evaluation, staff of the Social

Sciences Research Center (SSRU) at the University of Idaho, who administered the

evaluation, verbally reminded respondents of the materials, answered questions, and

described the thermometers in detail (Appendix F). There was also a listing of

Frequently Asked Questions available for reference (Appendix F). The web and phone

survey introductions are provided in Appendix G.

A notable difference in delivery mode format occurred in the web-based survey as

opposed to the telephone or written surveys. In the web survey programming,

participants in Question 8 who indicated they did not own either a digital or dial food

thermometer were directed to Question 10 and did not answer Questions 9a and 9b, the

retrospective pre-test post-test question. Telephone or written survey participants

answered question 9a and 9b regardless of their response to Question 8. The difference

described in the web format was not an intentional design request, but was inserted

during formatting of the web-based survey.

This evaluation was voluntary for WIC participants, and the study was approved

by the University of Idaho’s Institutional Review Board. Criteria for participation in the

evaluation were to be 18 years old or older, cook ground beef patties, and to have read

the packet of materials. Although the campaign was intended for delivery to WIC clients,

it was not limited to that group; the materials were openly available to anyone in the

clinic waiting areas and also were expected to be shared with friends and relatives.

However, the focus of the educational campaign was the WIC population; respondents

who were WIC-ineligible based on income and household size were removed from the

60

data set. The Food and Nutrition Service of the USDA publishes the WIC Income

Eligibility Guidelines online (USDA-FNS, 2009b) that specify the number of persons in

the household with the corresponding maximum annual income allowed to be eligible to

receive WIC services. Any evaluation with fewer household members appropriate for the

amount of income claimed was eliminated. One incomplete survey was eliminated as

well. The respondent sample originally consisted of 487 adults but after excluding WIC-

ineligible participants the analysis included 433 WIC or WIC-eligible participants.

Data Analysis. Statistical analysis was performed using Minitab (Minitab, Inc.,

Version 15.0). Demographic characteristics were stratified so that Chi-square

assumptions were satisfied and assessed for significance against other variables of

interest. Stratification was conducted as follows: racial-ethnic background categories

were collapsed into Caucasian/White, Hispanic/Latino/a, and Other (which included the

following original categories: Black/African American, American Indian/Native

American, Asian or Pacific Islander, Aleut or Eskimo, and other mixed race).

Educational group categories were collapsed into four categories: 12th grade or less with

no diploma; high school graduate or GED; Technical, Vocational, or Associates Degree;

and Bachelor, Graduate, or professional degree. Income had the two highest levels

collapsed into one category resulting in five total categories: less than $10,000, $10,000-

$19,000, $20,000-$29,999, $30,000-$39,000, and $40,000 and over. Number of adults in

the household were collapsed into three categories: one adult, two adults, and three or

more adults. Number of children in the household were collapsed into five categories:

no children, one child, two children, three children, and four or more children.

61

Responses to open-ended questions were categorized to highlight major trends.

Frequencies and percentages were utilized to describe nominal and ordinal data.

For the retrospective pre-test post-test (Question 9a and 9b), the Wilcoxon Signed

Rank Test evaluated statistical significance in frequency of thermometer use between

before and after receiving the educational materials. Responses from the web-based

format were analyzed separately from the telephone and written formats due to

differences in evaluation administration described previously, where web participants

who did not own a thermometer did not respond to Questions 9a and 9b. To evaluate

differences in frequency of thermometer use between longer-term thermometer owners

and those who recently purchased a thermometer, differences for participant thermometer

use responses on the 5-point Likert scale between the pre-test question and post-test

question were calculated and examined using the Kruskal-Wallis Test for web-based

survey participants and telephone and written survey participants.

For Question 3, responses were coded separately as “yes” or “no” for each

response, as multiple responses could be selected. To examine responses collectively, the

most frequent responses, that the participant read or kept the materials, were coded as

individual responses in the same category. Responses were coded to capture the

information that the participant neither read nor kept the materials or they both read and

kept the materials.

Statistical associations between paired questions (Questions 17-30) which were ranked by

using the 5-point Likert-type scale were identified using Tests of Concordance and

Spearmans rho for correlations. This was conducted to provide a measure of internal

reliability for the survey. For statistical analysis, the scale of one question was reversed

62

for examination of consistency of responses. Spearman’s rho provides a correlation

coefficient ranging from -1 to 1. Values closer to -1 or 1 indicate a stronger relationship

between the variables. Positive values indicate a linear relationship where low and high

values on both scales are associated with each other. Negative values indicate an inverse

relationship where low values on one scale tend to correspond with high values on the

other. For statistical analysis, the scale of one question was reversed for examination of

consistency of responses.

The 5-point Likert-type scales, used for knowledge questions (Questions 14-16),

importance of the materials (Question 4), and paired attitude questions (Questions 17-30)

consisted of Strongly Agree, Somewhat Agree, Neither Agree nor Disagree, Somewhat

Disagree and Strongly Disagree. For examination of the following questions and

relationships with other factors, this scale was collapsed into three categories: Strongly

and Somewhat Agree were combined into Agree, Neither Agree nor Disagree were

designated as Neutral, and Somewhat Disagree and Strongly Disagree were combined

into Disagree.

The Stages of Change question (Question 12) responses were collapsed into 5

categories as described previously (reference) based on the stages of Pre-contemplation,

Contemplation, Preparation, Action, and Maintenance. Pearson’s Chi-square was

performed on this question with other variables of interest. Spearman’s rho and Tests of

Concordance were utilized for the stages of change with attitude questions, to assess

direction and strength of agreement between the stages of change and each statement

regarding importance attitudes, perceived behavior control, and social norms.

63

RESULTS AND DISCUSSION

Respondents’ Profile. Among the WIC offices of 17 Washington counties who

agreed to participate during the 8-week campaign, 13 counties had respondents who

completed surveys, with a total of 433 respondents (Appendix A). Demographic

characteristics of the survey participants are presented in stratified formats utilized for

statistical analysis in Table 3. The majority of respondents were female (94%) with 6%

males. Respondents were stratified as 18-24 years old (30%), 25-29 years old (28%), 30-

34 years old (19%), and those 35 and older (23%). This age range is typical for the WIC

population, who are primarily of childbearing age; the majority (85%) of WIC clients

nationwide are 18 – 34 years of age (USDA-FNS, 2006). Most participants identified

themselves as Caucasian/White (70%), while Hispanic/Latino/a (15%), American

Indian/Native American (5%), Other/Mixed Race (5%), Black/African American (2%),

and Asian/Pacific Islander (2%) comprised the remainder of the total sample. The

observed population in this study included a much higher percentage of Caucasians with

lower percentages of other ethnic groups reported when compared overall to WIC

demographics in the U.S. In contrast, the three highest-ranked ethnic groups represented

in WIC nationally were: Hispanics (39%), followed closely by Caucasians/Whites

(35%), and African Americans/Blacks (20%) (USDA-FNS, 2006).

The most frequent education level reported by respondents was completion of

high school or GED at 30%, while 28% had taken some college courses but had not

completed a degree. The most common total household income levels for the previous

year reported were < $10,000 (27%), $10,000-19,999 (23%), and $20,000-29,999 (26%),

$30,000-39,999 (14%). Households predominately contained two adults (61%); less

64

common responses were with three adults (15%), and one adult (14%). Households with

up to six adults were reported. Households with one or two children were the most

frequently reported (29% and 34% respectively); the remainder ranged from no children

(first-time pregnancy) up to 7 children.

Cooking Frequency and Consumption. Almost half (49%) of the respondents

indicated ground beef patties were cooked at home about once per month (49%), while

39% cooked ground beef patties weekly, 11% less than once a month, and 1% never

cooked ground beef patties. The vast majority of respondents reported that both adults

(95%) and children (80%) consume ground beef patties in their household. It was

reported that a lower percentage of teens (35%) consumed ground beef patties; however,

fewer teens eating ground beef patties in the household may be attributed to the WIC

population surveyed in this study. WIC-eligible families must include children 5 years

old or younger, so there is a tendency to have families with predominantly young

children in WIC; it is less common to have teens in a WIC household. With almost 90%

of WIC clients preparing ground beef patties in their homes 1-4 times per month and the

majority of households having both adults and children consuming ground beef patties, it

is vitally important to ensure that clients receive effective food safety materials regarding

proper cooking of ground beef patties.

Display and Materials. In order to ascertain specific elements of the display

that attracted respondents, components of the materials were addressed. The most

frequent factors attracting respondents to the display were the message (24%) and the

photos (23%); however the logo did not capture the respondents’ attention (8%), nor did

the colors (6%). Some respondents (7%) stated they were unable to remember the

65

display. Interestingly, the most frequent response for Question 1 was “Other” (33%).

When “Other” responses were examined, 69% of respondents indicated “materials were

handed to them.” Similarly, 9% of respondents commented that they were “directed to

the materials.” Some respondents (11%) indicated “earning the $10 incentive” caused

them to approach the display (Appendix H).

Although the food safety educational campaign was based on social marketing

principles, and materials were designed to appeal to WIC clients, only about a half of the

respondents indicated aspects of the materials (message or photos) caused them to

approach the display. Many respondents were directed to the materials by the WIC staff,

who either mentioned them or handed them out. This observation of the successful

delivery of materials by WIC staff may direct further exploration of the most efficient

delivery routes for educational materials to clients.

Participants were asked what they had done with the materials since collecting

them, and to choose all responses that applied. Most (74%) respondents read the packet

of information. Furthermore, 32% of respondents kept the materials for future reference,

while 7% gave the materials to someone else. Finally, 2% of respondents threw the

materials out and less than 1% provided an alternative response under the “Other”

category.

Almost three-fourths of the respondents read the materials, and one-third kept

them for future reference, which provided an indication that respondents valued the

materials. Moreover, most participants (93%) indicated the materials helped emphasize

thermometer use as important. The materials contained several types of information,

including grilling tips, a mom’s testimony about her child becoming ill from an

66

undercooked ground beef patty, a cooking activity to make heart-shaped hamburgers, and

a cartoon strip discussing thermometer use. Participants were asked which type of

information was the most useful. Participants almost equally favored the grilling tips

(39%) and the Mom’s testimony (37%); while the cooking activity (18%) and the cartoon

strip (8%) were perceived as less useful. From these results, it appears that factual

information such as grilling tips and an emotion-based message such as the mom’s

testimony were both relevant to include in thermometer use educational materials.

Website. A website was developed to provide more information on food

thermometer use with ground beef patties and provided a link to access the web-based

survey. The majority of participants (57%) stated that they visited the website, while

43% did not. However, 68% of participants utilized the website to access the web-based

survey. The discrepancy could be due to participants who visited the website primarily to

participate in the web-based survey; some of these participants may have indicated they

did not visit the website to investigate educational content. When participants were asked

about the usefulness of the website (total number of respondents, 362), 60% of the

respondents felt that website provided useful information to help use a food thermometer

when cooking ground beef patties. Though no respondents disagreed about the website’s

usefulness, 9% were neutral and an additional 31% stated they did not visit the website.

Between the two questions focusing on the website, 43% and 31% of participants

indicated that they did not visit the website; the observed difference was in part affected

by approximately 68 participants who used the web-based survey but did not answer the

question about the website’s usefulness.

67

A majority of participants found the website useful which could warrant further

impact evaluation to examine the current website for additional educational effectiveness.

Trepka et al. (2008) conducted a randomized, controlled trial in the WIC population to

determine the effectiveness of an interactive multimedia food safety education program

on a computer kiosk at a WIC clinic. The multimedia program incorporated audio, video,

and graphics in addition to text; but reading skills were not required for the program; the

control group received educational pamphlets. Results of that study showed a

significantly high level of satisfaction among the interactive-media group, particularly

among those with only a high school education or less. Compared to those with more

advanced formal education, participants with less education were more likely to state that

they enjoyed using the interactive multimedia program (p = 0.002), preferred that method

of learning over reading of pamphlets (p = 0.01) and wanted to use it for other health and

nutrition topics (p = 0.04). Among participants in this study, approximately 43%

possessed a high school education or less, this group may represent an appropriate

audience to receive thermometer food safety education via computer-based formats. In

this study, the most frequently used survey format was the web-based, online format

(68%). Demonstrating that not only did Washington WIC participants have access to the

internet, but many also showed a preference for using the computer over other means for

taking surveys. Taken together, many WIC clients seemed to have access, interest, and

skills for computer-based activities and educational tools. It may be feasible to offer

future food safety education (as well as other health and nutrition education) through

websites to interested clients; utilizing this format would also greatly increase

dissemination of the materials to a broad audience in a cost-effective manner.

68

Knowledge. Three impact questions were designed to evaluate knowledge

regarding food thermometer use as a result of reading the materials. Although the

campaign was developed using emotions-based messages, there were a number of factual

elements in the materials. The results revealed that 87% of respondents agreed that they

understand that using a food thermometer is the only way to safely cook a ground beef

patty. As a result of reading the packet of materials, nearly all of the respondents (97%)

stated that they knew a safely cooked ground beef patty must reach 160°F. The

campaign logo consisted of a heart-shaped “160°F for Your Family” which was located

on the front of each brochure, with another reminder of “160°F” prominently displayed in

a circle on the back. The use of 160°F on both sides of the materials reinforced the

proper temperature for safely cooked ground beef patties. These two messages regarding

the use of a food thermometer as the only accurate method to determine doneness in a

ground beef patty, and the proper endpoint temperature which must be reached, seemed

to be accepted by the majority of participants with an enhancement in knowledge.

Finally, a photo of an instant-read food thermometer correctly inserted into the

side of a ground beef patty was placed on the front of each brochure; this depiction was

utilized to demonstrate how a thermometer should be used with a thin meat cut like a

ground beef patty. Participants (88%) agreed they felt more confident in their ability to

accurately measure the temperature of a ground beef patty. The results demonstrated that

participants in this study acquired knowledge about the use of thermometers with ground

beef patties through campaign materials. Taken together with the high level of agreement

that materials emphasized the importance of thermometer use, the results demonstrated

that the materials were effective in delivering the intended messages.

69

Providing factual information to increase knowledge and awareness about a

specific behavior is an important component for an educational campaign. Increasing

awareness to acknowledge that behavior needs to be changed and create a shift in

intentions is particularly critical for consumers in the early Stages of Change. According

to Prochaska (2008), increasing knowledge and awareness is a critical factor, especially

among consumers who are in the Pre-Contemplation and Contemplation stages, where

there is no awareness of the need for the behavior or pros and cons of the behavior are

being considered. Takeuchi et al. (2005) observed that 80% of participants (n=295) from

the general population were classified in the Pre-Contemplation stage regarding

thermometer use with thin cuts of meat prior to receiving educational materials in an

intervention; in this stage individuals are unaware or in denial of potential risks from

undercooked meat. The observed high percentage of consumers in that study classified in

pre-contemplation was likely a true representation of the larger population since food

thermometer use with ground beef patties is typically very low (Cody et al, 2003;

McCurdy et al., 2005).

Ownership of a Food Thermometer. To determine food thermometer

ownership, both the web and written formats asked about owning a thermometer and

provided dial and digital instant-read thermometer photos for reference. The trained staff

for the telephone survey provided a verbal description of dial and digital instant-read

thermometers to the respondent (Appendix F). There were no significant differences in

responses by survey format. Overall, more than one-half of the participants (51%) did

not own an instant-read thermometer, however, 44% had owned one for some time, and

6% indicated they bought one after selecting the packet of materials. The 6% increase in

70

food thermometer ownership in the present study is similar to the study by Takeuchi

(2005), who observed an 8% increase in ownership after an educational intervention.

Interestingly, Takeuchi (2005) found that 34% of participants (n = 295) in the general

population in 2003 owned an instant-read food thermometer for use with small cuts of

meat prior to the educational intervention, whereas this study observed 44% of the WIC

population owned a thermometer.

Statistically significant differences were noted between thermometer ownership

and racial-ethnic background, income, educational level, age, and perceived barriers. The

relationships identified helped define populations that own and don’t own thermometers

among WIC participants. Thermometer ownership differed significantly (p = 0.03) by

racial-ethnic background (Table 4). There were more Hispanics (68%) who did not own

a thermometer in comparison to other races and Caucasians that did not own a

thermometer (55% and 46% respectively). For those who recently bought thermometers

since viewing the materials, observed values were similar to those expected by Chi-

square analysis among racial-ethnic background categories.

Thermometer ownership also varied significantly (p < 0.001) by income level

(Table 4). Significantly more respondents (77%) with an income level > $40,000 per

year had owned a thermometer for some time, compared to participants in lower income

levels (35-48%). Additionally, differences (p = 0.06) among participants were also

observed between level of education and thermometer ownership (Table 4). Fewer

respondents with a high school degree or those with less than a high school degree were

longer-term thermometer owners (36% and 32% respectively), compared to those with

some college (48%) or a bachelor’s degree and higher (53%). Respondent age was

71

another factor which was significant (p < 0.001) with regard to thermometer ownership

(Table 4). More respondents (64%) in the youngest age group of 18-24 years old did not

own a food thermometer; in contrast, fewer (34%) of the highest age group of 35 years

old and older did not own a thermometer. In fact, more respondents (59%) in the highest

age group had owned one for some time, while fewer in the youngest age group (30%)

were longer-term owners. These results helped characterize thermometer owners and

provided insight on populations where thermometer ownership could be promoted and

populations that own a thermometer where use needs to be emphasized.

Significant differences were also found in potential barrier statements with

thermometer ownership. Four barrier statements were found to differ significantly by

thermometer ownership using Chi-square analysis (Table 5). Regarding difficulty of

thermometer use with a ground beef patty (p = 0.04), more respondents (11%) that owned

a thermometer for some time agreed that thermometers are difficult to use in ground beef

patties, compared to those who recently purchased one (8%) or do not own a

thermometer (5%). Additionally, more participants who do not own a thermometer

(78%) agreed that they did not know of anyone who uses a thermometer with ground beef

patties compared to those respondents who owned a thermometer for some time or had

recently purchased one (56% and 52% respectively). The cost of purchasing a

thermometer as a potential barrier differed significantly (p < 0.001) by thermometer

ownership. A higher percentage of respondents who did not own a thermometer (33%)

agreed that buying one is expensive; this compares to respondents who either recently

bought one (13%) or had owned one for some time (6%). Finally, for participants who

did not own a thermometer, 82% agreed that using a food thermometer is not part of their

72

routine, which is consistent with their lack of ownership. However, 48% of participants

who recently purchased a thermometer as well as those who have owned a thermometer

for some time (49%) also agreed that it is not part of their routine.

Of the small percentage (6%) of participants who recently purchased a food

thermometer after reviewing the materials, there were no strong associations with

demographics to help characterize this group. The percentage of those who recently

purchased a thermometer may be low due to a short time period between receiving the

materials and electing to take the survey, which was noted by some participants in the

comments section. All participant comments are summarized and categorized in

Appendix I.

Altogether, the findings from this study provided characterization of thermometer

ownership among the Washington WIC population. Owners of food thermometers are

generally older and have higher education and income levels. Among participants who

had owned a thermometer for some time, potential barriers included difficulty in

thermometer use with ground beef patties and not being part of their routine.

Alternatively, participants that did not own food thermometers were younger, less

educated, and included more Hispanics. Barriers with higher levels of agreement by

participants that did not own thermometers were that they were too expensive, and

participants didn’t know other people using thermometers with ground beef patties.

Use Before and After the Materials. In order to address the effect of the

materials on thermometer use, a retrospective pre-test question assessed frequency of

thermometer use before and after picking up the materials (n = 286). The lower response

rate for this question was due to the web survey format, which included a skip of this

73

question for participants who stated they did not own a thermometer. Therefore,

statistical analysis was performed on data provided through the web-based survey

separately from that of the telephone and written surveys.

The retrospective pre-test question addressed frequency of thermometer use with

ground beef patties before obtaining the materials, while the post-test question assessed

frequency of use after receiving the materials. This was the only question in the survey

to ascertain an actual change in food thermometer use with ground beef patties as a result

of receiving the materials. Statistical analysis was performed using the Wilcoxon Signed

Rank Test, and results indicated a statistically significant increase in thermometer use

after receiving the materials for both the web-based survey (p < 0.001, Wilcoxon Test

Statistic = 5341.0) and the combined written and telephone surveys (p < 0.001, Wilcoxon

Test Statistic = 1195.0).

For the web-based survey, only thermometer owners had the opportunity to

respond to Question 9a and 9b. For the pre-test question, most participants of the web-

based survey (52%) reported never using a thermometer with ground beef patties prior to

receiving the materials (Figure1a ). Two thermometer use categories increased after

participants received the materials: almost always (26% increase) and most of the time

(20% increase), while two categories decreased: sometimes (2% decrease) and never

(45% decrease).

In both the written and telephone surveys, all participants had the opportunity to

respond to Questions 9a and 9b, however, similar results were observed. Most

participants (68%) in the pre-test reported never using a thermometer with ground beef

patties (Figure1b) prior to receiving the materials. Three thermometer use categories

74

increased after participants received the materials: almost always (17% increase), most

of the time (6% increase), and half the time (1% increase). Responses for two categories

decreased after receiving the materials: sometimes (5% decrease) and never (19%

decrease). The results indicated that the materials were effective in increasing

participant thermometer use.

The increased thermometer use observed for both the web-based group and the

telephone and written survey group for most of the time to almost always was greater the

results reported in a similar study by Takeuchi (2005). In that study, thermometer use

following the educational materials intervention showed an increase of 12% for those

who used a thermometer 76% to 100% of the time when cooking thin cuts of meat

(Takeuchi, 2005). The present study used a retrospective pre-test while Takeuchi’s study

design was a traditional pre-test and post-test; biases may have occurred based upon

participants’ recollections of past behavior in this present study.

Thermometer Use among Thermometer Owners. Differences in frequency of

use before and after receiving the materials were examined among participants who either

owned a thermometer for some time or had recently purchased one. Results were

examined separately for participants who completed the survey by web and those who

completed the survey by telephone and written forms.

Thermometer Use among Thermometer Owners: Web-based Survey Participants.

Before the educational campaign, 51% of those who owned a thermometer for some time

never used it with ground beef patties; only 15% of that group almost always used one.

Among those who recently purchased a thermometer since receiving the materials, 57%

never used a thermometer before receiving the materials, and none always used it with

75

ground beef patties at that time. However, after receiving the material there was a

reversal in the trend for both groups. For those who had owned for some time, 7% stated

they never used a thermometer with ground beef patties; 39% almost always used one.

Likewise, for those who recently owned, a large increase in use was demonstrated, with

50% reporting thermometer use with ground beef patties almost always and only 7%

stating they never used one. The increase in thermometer use after receiving campaign

materials was similar (p = 0.147) among longer-term thermometer owners and those who

purchased a thermometer after receiving materials, as evidenced by the Kruskal-Wallis

test examining differences in participant responses before and after receiving the

materials (Figure 2a).

Thermometer Use among Thermometer Owners: Combined Telephone and

Written Survey Participants. Before the educational campaign, 32% of those who owned

a thermometer for some time never used it with ground beef patties; 26% of that group

almost always used one. Among those who recently purchased a thermometer since

receiving the materials, 55% never used a thermometer before receiving the materials,

and only 9% almost always used it with ground beef patties at that time. However, after

receiving the material there was a reversal in the trend for both groups. For those who

had owned for some time, 15% stated they never used a thermometer with ground beef

patties; 48% always used one. Likewise, for those who recently owned, an increase in

use was demonstrated, with 45% reporting thermometer use with ground beef patties

almost always and 27% stated they never used one. The increase in thermometer use

after receiving campaign materials was similar (p = 0.695) among longer-term

thermometer owners and those who purchased a thermometer after receiving materials, as

76

evidenced by the Kruskal-Wallis test examining differences in participant responses

before and after receiving the materials (Figure2b).

It appears that both the web-survey participants and the telephone and written

survey participants shared similar results. Participants who had owned a thermometer for

some time and those who recently bought one seemed equally motivated by the materials

and an increase in thermometer use was seen for both groups.

Main Reason for Thermometer Use. The highest percentage of respondents

(48%) indicated the main reason for using a food thermometer when cooking ground beef

patties was to make ground beef safe for their family. Only 5% of participants indicated

the main reason for thermometer use was to cook ground beef patties the way their family

likes them (juicier, tastier), and 3% provided other responses. Additionally, 44% of

participants indicated that they don’t use a thermometer with ground beef patties. For

participants who use a thermometer, preventing foodborne illness was the primary

motivating factor. Therefore, food safety is a topic that educational materials need to

highlight in order to promote thermometer use. Similarly, other studies have found that

two key motivators for using a food thermometer were the assurance that the temperature

needed to kill pathogens has been reached (Takeuchi et al., 2005) and that thermometer

use could prevent foodborne illness in high-risk groups (McCurdy et al., 2005; Takeuchi,

et al., 2005; Trepka et al., 2006; Athearn et al., 2004). All together, these findings

demonstrated that food safety promotion should be stressed in educational materials.

Specifically, points of emphasis should include temperature is the only true indication of

a safely cooked ground beef patty, and that the behavior is necessary in order to prevent

foodborne illness in children and others at increased risk.

77

Discrepancies in Reported Thermometer Ownership and Use. Discrepancies

in responses for thermometer ownership and use were noted. Participants were asked if

they owned a dial or digital instant-read thermometer (Question 8) and results showed

that 51% did not own one, 6% bought one since collecting campaign materials, and 44%

has owned one for some time (n = 433). These values corresponded well with the Stages

of Change question (n = 430) (Question 12) in which 50% of participants indicated they

do not own a thermometer. The question addressing frequency of thermometer use

before and after receiving the materials utilized a 5-pt scale of “never” to “nearly

always.” Only 26% of respondents reported never using a thermometer with ground beef

patties after reviewing the materials. However, about half of the respondents do not own

a thermometer so a higher percentage of those reporting they do not use a thermometer

would have been expected. This discrepancy was clarified by the survey format

structure. A lower response rate (n = 286) was observed due to a skip of this question in

the web-based survey if participants had previously responded they did not own a dial or

digital instant-read thermometer. Since the majority of respondents used the web

delivery mode (68%), the questions about thermometer use before and after (Questions

9a and 9b) contained a smaller percentage of individuals who do not own a thermometer

(26% or 76 individuals) from the telephone and written surveys.

Another area of participant response discrepancies addressed the main reason for

using a food thermometer when cooking hamburger patties (Question 13) (n = 430),

included a response choice “I don’t use a food thermometer when cooking hamburger

patties,” as well as response choices for safety reasons or to make a better quality

hamburger patty. Approximately 44% reported they didn’t use a thermometer with

78

hamburger patties. Again, a higher percentage would be expected given 50% of

respondents did not own a thermometer. Further analysis of this question by

thermometer ownership showed that out of the 218 respondents who stated they do not

own a thermometer, 146 stated that they do not use a thermometer for this question.

However, out of the remainder of respondents who did not own a thermometer (72 total),

59 respondents indicated thermometer use for safety reasons and 5 respondents stated

thermometer use to make hamburgers the way their family likes them. It is possible that

individuals who did not own a thermometer answered on the assumption that if they were

to use a thermometer, it would be for the selected responses that indicated thermometer

use.

Importance Attitudes, Perceived Behavior Controls, and Social Norms.

Participant attitudes, specifically importance attitudes, perceived behavior controls, and

social norms toward thermometer use (Questions 17-30) were addressed in the impact

evaluation as these were stressed factors that influence behavior in the Integrated Model

of the Reasoned Approach model of behavior change (Fishbein, 2008). Fourteen

statements (Table 2) examined factors contributing to thermometer use behaviors;

participants indicated agreement or disagreement on a 5-point Likert scale. Questions

were written as pairs with a positively-worded statement along with a similar but

oppositely worded negative statement to provide a measure of internal reliability for

consistency of participant responses the study. For statistical analysis, the scale of one

question was reversed for examination of consistency of responses. For all seven pairs,

results of Spearman’s rho showed a positive correlation within each pair and Tests of

Concordance showed statistically significant relationships as well (Table 6).

79

Importance Attitudes. Four paired questions examined importance attitudes. In

Pair 1 (Questions 17 and 24) (Spearman’s rho = 0.26), most participants (85%) agreed

with the positive statement that checking the temperature is the only way to ensure a safe

ground beef patty; however, 35% agreed that there are many ways to check the safety of

ground beef patties besides a thermometer. Regarding Pair 2 (Questions 19 and 28),

almost all participants (96%) agreed with the statement that ground beef patties need to

be cooked to 160°F in order to avoid foodborne illness; and 6% agreed that serving

undercooked ground beef patties were safe for their families; (Spearmans rho = 0.26).

For Pair 3 (Questions 20 and 29), just over half (54%) of participants indicated that

thermometer use with ground beef patties was a priority in their home while 40% of

participants agreed that they never think about using a thermometer with ground beef

patties; Spearmans rho = (0.31). With Pair 4 (Questions 21 and 30) (Spearman’s rho =

0.14), 53% of the participants agreed that using a thermometer enhances the juiciness of a

ground beef patty. In the negatively-worded statement, 55% agreed that it is safer to

overcook hamburgers, even if it means the meat is less juicy.

Review of responses for the importance attitudes revealed interesting findings for

each pair. In Pair 1, (Spearman’s rho = 0.26) although there is a statistical correlation

demonstrating agreement between the positively and negatively worded statements, some

participants seemed ambiguous regarding the need to use a thermometer versus other

means to determine safety and doneness of ground beef patties, with 35% of participants

agreeing that other means could ensure ground beef patty safety. It is possible that

although the materials conveyed to participants that thermometer use ensures the safety

of ground beef patties, that they were reluctant to relinquish previously used practices

80

that they perceived to ensure ground beef patty safety and still question the need for

thermometers. Positive heuristics may influence this observation, in which previous

routines and habits have led to positive outcomes with no identified foodborne illness,

and so an optimistic bias develops reinforcing this behavior (Fisher & Devries, 2008). In

this way, there is no need to rethink the behavior each time, the pattern continues and

strengthens the belief. Hence, consumers are not convinced thermometer use is necessary

based on previous, positively-enforced experiences.

The correlation in Pair 2 (Spearman’s rho = 0.26) demonstrates consistency that

participants agreed that proper cooking of ground beef patties will prevent foodborne

illness and undercooked patties are not safe to serve their families. Alternatively, for Pair

3, a slightly larger positive correlation (Spearman’s rho = 0.31) was observed (the highest

correlation among the importance attitudes paired questions). However, two consistent

populations were identified from this question. One group agreed that thermometer use

was a priority and disagreed that they never think about it. In contrast, another

population demonstrated consistency with disagreement that thermometer use was a

priority and agreement that they never think about using one, strengthening the statistical

correlation. While some participants appeared committed to thermometer use, another

group was apparently not convinced of the need for thermometer use by the materials.

For Pair 4, the lowest correlation among importance attitudes was observed

(Spearman’s rho = 0.17). Participants were not consistent in their agreement with using a

thermometer to enhance juiciness and the preference to overcook meat to ensure safety.

The materials discussed that thermometer use would enhance eating quality for ground

beef patties. Some participants may have agreed with the concept in the positive

81

statement regarding enhanced quality through personal experience or knowledge gained

through the materials. However, the majority of participants agreed that relying on

overcooking to ensure safety was preferred to ensuring eating quality. It appeared that the

issue of proper cooking to produce a higher quality ground beef patty and the need to

overcook in order to feel secure about the safety of the ground beef patty were two

separate issues for participants.

Overcooking appears to be another approach used by participants to ensure the

safety of a ground beef patty when thermometers are not used. The results from Pair 4

appear consistent with the question in the survey addressing the primary reason for

thermometer use with ground beef patties, with 47.9% indicating safety reasons and 5.4%

indicating eating quality characteristics, demonstrating that meat quality was not an

influential factor. Combining observations from Pairs 3 and 4, it is possible that some

consumers would rather overcook to ensure safety rather than adopt thermometer use as a

priority in their home.

Perceived Behavior Control. The two sets of paired questions assessed perceived

behavior control regarding thermometer use. For Pair 1 (Questions 18 and 27)

(Spearman’s rho = 0.27); most participants agreed (92%) that it only takes a short time to

use a thermometer, and some participants agreed (14%) that they do not have enough

time to perform the activity.

Among all of the attitudes examined, Pair 2 (Questions 23 and 26) in the

perceived behavior control category had the highest Spearman’s rho (0.34). Participants

(87%) agreed that it is easy to use a thermometer with ground beef patties, and 7% agreed

that it seemed complicated to use a thermometer with ground beef patties.

82

Summarizing the perceived behavior control findings, Pair 1 showed that

although most participants acknowledged a short amount of time is actually needed to use

a thermometer, there are some who agreed that they don’t have enough time to use a

thermometer with ground beef patties. For Pair 2, most participants perceived

thermometer use as a fairly simple and straightforward procedure.

Social Norms. The final set of paired questions examined social norms. The two

questions for the pair (Questions 22 and 25) were slightly different in meaning, which

may have contributed to a lower correlation between the questions; (Spearman’s rho =

0.12). The first question was written as a norm addressing the participant’s commitment

to protecting themselves and their family from foodborne illness in spite of the thoughts

and feelings of others. The second question was written as a norm about the increased

likelihood of thermometer use with ground beef patties if others performed the behavior.

Participants (91%) agreed that they would do whatever is needed in order to protect their

families from foodborne illness, regardless of others. In the second question, 21% agreed

that they would be more apt to use a thermometer if they knew that other people did as

well. For some individuals, thermometer use may be perceived as something that others

do not deem as important. As more awareness is created regarding the importance of

thermometer use in preventing foodborne illness, thermometer use may become a more

socially-accepted practice.

Summary of Paired Statements. According to the Reasoned Action Approach

(Fishbein, 2008) not all three of the factors of attitudes, perceived behavior control, and

social norms will be influential in every behavior. Participants appeared consistent on the

importance attitude that hamburgers must be properly cooked for safe consumption as

83

well as the perceived behavior control that thermometers are easy to use with ground beef

patties. Certain factors that warrant emphasis in thermometer educational materials based

on participant responses include the importance attitudes that methods other than

thermometer use cannot ensure ground beef patty safety and being conscious of

thermometer use when cooking ground beef patties. Social norms and ensuring a juicy

product did not seem to be factors that would influence thermometer use with the WIC

audience.

Possible Barriers to Thermometer Use. A set of questions was utilized to

examine factors that might make food thermometer use difficult when cooking ground

beef patties (Table 7). These barrier statements were utilized in a previous study by

Takeuchi et al. (2005) in which perception of barriers with thermometer use in thin cuts

of meat was examined both before and after an intervention with educational materials.

In the current study, two factors were identified by the majority of participants as

barriers: 67% agreed they don’t know of anyone who uses a food thermometer for

cooking ground beef patties and 66% agreed that using a food thermometer when

cooking ground beef patties is not part of their routine. It is possible, however, that

survey participants may have interpreted these questions as a statement of fact about their

current situation, and not so much as something that would prevent them from using a

food thermometer. Takeuchi (2005) observed similar barriers after an intervention with

educational materials; 48% of respondents did not know of anyone else who used a food

thermometer with ground beef patties and 44% agreed that thermometer use was not part

of their lifestyle.

84

Most participants disagreed with the barrier statements in the current study.

Participants disagreed that using a food thermometer was inconvenient and a hassle

(88%), and that it is difficult to use a food thermometer in a patty (92%). Also,

participants disagreed using a food thermometer adds extra time to cooking (81%), and

that buying a food thermometer is too expensive (79%). Additionally, participants

disagreed that it is hard to remember to use a food thermometer when cooking ground

beef patties (63%), which corresponds well with the negatively-worded importance

attitude question where 40% disagreed they never think of using a thermometer with

ground beef patties.

Results of the study by Takeuchi et al. (2005) showed significant changes

regarding barriers from pre- to post-intervention with educational materials. Following

the educational intervention, 91% of respondents disagreed that that buying a

thermometer was too expensive. Other perceived barriers with significant changes from

pre- to post-intervention were participant disagreement with never thinking of using a

thermometer (50%) and that thermometers are difficult to use with thin cuts of meat

(53%). Additionally, a non-significant change from pre- to post-intervention statement

identified that 85% of respondents disagreed that using a thermometer adds extra time to

cooking.

Among the WIC audience surveyed in this study, the highest percentage of

participants agreed they did not know of anyone who uses a food thermometer for

cooking ground beef patties and using a food thermometer when cooking ground beef

patties as not part of their routine as potential barriers. Interestingly, these barriers

ranked lowest of the barriers presented to the general population post-intervention in the

85

study by Takeuchi (2005). Both studies shared the same third and fourth highest-ranking

barriers: that it was hard to remember to use a thermometer or that respondents never

thought about using a food thermometer with ground beef patties. From these results, it

seems that not having thermometer use as part of the routine or lifestyle and not

remembering to use a thermometer when cooking ground beef patties are important in

participant perceptions of barriers. Further investigation will need to be done to examine

the possible barrier of not knowing of anyone who uses a food thermometer with ground

beef patties.

The Stages of Change. To assess participants’ readiness to use a food

thermometer with ground beef patties, a previously-validated Stages of Change question

was utilized (See Table 1 for the complete question). When classified into the Stages of

Change, 22% of respondents were in Pre-contemplation, 22% Contemplation, 39%

Preparation, 8% Action, and 10% Maintenance (Figure 3). Overall, the highest number

of participants were classified in the Preparation stage (166 participants of 426). In

comparison, a study by Takeuchi (n = 295) which used an educational materials

intervention, examined intentions to use a food thermometer with thin cuts of meat

utilizing the same validated Stages of Change question. The post-intervention results

indicated that the highest percentage of participants (46%) were staged in Pre-

contemplation, and with 12% in Contemplation, 7% in Preparation, 18% in Action, and

16% in the Maintenance stage (Takeuchi, 2005). The current study observed fewer of

participants in Pre-contemplation (22%) after an educational intervention with the WIC

audience. However, Takeuchi observed higher levels of participants in Action (18%) and

Maintenance (16%) in the post-test compared with the current study (8% and 10%

86

respectively) following the intervention. Although the current study did not measure

participants’ intentions prior to the intervention, the educational materials may have

effectively moved participants into Preparation, where the highest frequency was

observed.

There were several factors which showed significant associations with the Stages

of Change Model; significant demographic groups included gender, delivery mode, and

educational level. Gender and delivery mode will be discussed in later sections. Other

factors assessed by the Stages of Change were thermometer ownership, barriers, as well

as attitudes, perceived behavior control, and social norms.

Educational Level and the Stages of Change. Educational level was significantly

different (p = 0.012) (Figure 4) among the Stages of Change categories. Higher

percentages of participants with some college were observed in Pre-contemplation and

Contemplation (25% and 27% respectively). Additionally, the educational level with the

highest level of participants in Pre-contemplation was Bachelor’s degree or higher (29%).

The Preparation stage contained higher numbers of participants than expected with a high

school degree or with less than a high school degree (48% and 50%, respectively). Fewer

participants than expected with some college or a bachelor’s degree or higher were in

Preparation (31% and 34%, respectively) For the Action stage, there were more

participants (16%) with less than a high school degree in this stage; this compared to

those with a high school degree (8%), some college (6%), and bachelor’s degree or

higher (5%). The Maintenance stage appeared to have a more balanced representation

from the different education levels based on expected values: less than high school and

87

high school degree (7% and 9% respectively), some college and bachelor’s degree or

higher (each 11%)

Participants with a high school degree or less tended to be at higher stages of

change (Preparation and Action) compared to those with some college or a Bachelor’s

degree or higher (Pre-contemplation to Preparation). The current educational materials

may have been more effective in motivating participants with lower education levels to

use thermometers with ground beef patties. It is possible that emotions-based messages

were more effective with lower educational levels, whereas logic-based materials may be

more effective with WIC participants of higher educational levels. Observations of the

most useful components of the materials among different educational level support this

inference. Chi-square analysis showed that 51% of those with less than a high school

education felt that the emotions-based mom’s testimony was most useful compared to

36% who found grilling tips useful. On the other hand, 52% of those with a Bachelor’s

degree or higher felt that the more factual grilling tips were the most useful; only 33%

found the mom’ testimony to be the most useful: χ2 (DF=9) 15.662 (p = 0.074)

Participants with a bachelor’s degree or higher had higher than expected numbers

staged in Pre-contemplation (29%), indicating a lack of interest to use a food

thermometer with ground beef patties. It is interesting that individuals with a Bachelor’s

degree or higher tended to be in Pre-contemplation, given that this group included higher

numbers of thermometer owners (61%). Examination of demographic categories of

participants that kept the educational materials for future reference revealed there were

fewer than expected of those with a bachelor’s degree or higher who kept the materials:

χ2 (DF=3) 8.546 (p = 0.036), and more than expected threw them away: χ2 (DF=3) 13.684

88

(p = 0.003). Food thermometer use may already be familiar to this group of higher

educated participants, and the materials may not be perceived as needed or valuable.

Participant Action with Materials and the Stages of Change. Participants varied

significantly with what they did with the materials after picking them up, based on the

Stages of Change (χ2 (DF=12) 20.386 (p=0.060)). There were 59 participants (out of 416

total) who did not read or keep the materials; 86% of those were in the pre-action stages.

Alternatively, there were 225 participants who stated they read the materials. In addition,

82 participants both read and kept the materials; 45% were in Preparation. This

demonstrates that the majority of participants read the materials, and many who were

preparing for thermometer use found the materials valuable and kept them.

Thermometer Ownership and the Stages of Change. Classification of respondents

in the Stages of Change differed significantly (χ2 (DF=8) 148.655 (p < 0.001)) with

thermometer ownership (Table 8). Interestingly, there were more respondents than

expected who owned a thermometer for some time (longer-term owners) who were in

Pre-contemplation (32%), compared to those who did not own a thermometer (12%).

Among participants who owned thermometers longer, 25% were in Preparation and 9%

in Contemplation. Greater than expected numbers of thermometer owners were observed

in the stages of Maintenance (20%) and Action (14%) in the Chi-square analysis. These

results demonstrated that while some thermometer owners have adopted thermometer use

with ground beef patties, almost one-third of owners (60/187) did not demonstrate

intention to adopt the practice. Further investigation is needed to clarify factors that

would motivate this group to use thermometers with ground beef patties.

89

Knowledge and the Stages of Change. Three knowledge questions were

examined against the Stages of Change to determine significant associations with

particular stages (Table 9). The question regarding the use of a food thermometer as the

only way to safely cook a hamburger patty showed statistical significance (p <0.001) with

the Stages of Change categories. As respondents advanced through the stages, the

percentage of those who agreed that using a food thermometer is the only way to safely

cook a hamburger patty steadily increased; from 71% in Pre-contemplation to 100% in

Maintenance.

For the other two knowledge questions, Chi-square p-values for association

between knowledge and the Stages of Change were not determined due to invalid Chi-

square approximations due to cells with expected counts less than 1. However,

interesting trends were noted. The question examining knowledge that a safely cooked

hamburger patty must reach 160°F showed a consistently high percentage of agreement

throughout all Stages of Change (92% - 100%). The knowledge question regarding

confidence in the ability to measure the temperature of a hamburger patty showed a lower

percentage of agreement in the early stages of Pre-contemplation and Contemplation

(79% each) and higher percentages of neutral responses as well (18% and 20%

respectively). However, the remainder of the stages from Preparation through

Maintenance had higher levels of agreement (95% - 97%).

Most participants across all stages of change agreed that ground beef patties need

to reach 160°F for safety indicating factual information was accepted by participants at

all stages almost equally. Alternatively, regarding thermometer use as the only safe way

to cook a ground beef patty, higher levels of agreement were observed in Preparation to

90

Maintenance; so as agreement increased, so did intention and adoption of thermometer

use with ground beef patties. Fewer participants in the early stages indicated confidence

about measuring the temperature of a ground beef patty; however those who are

preparing to use or using a thermometer in Preparation to Maintenance had higher levels

of agreement regarding confidence about proper use.

Barriers and the Stages of Change. Potential barriers examined within the Stages

of Change were assessed using Chi-square analysis (Table 10), and each had significant

associations. The perceived barrier that using a food thermometer is inconvenient and a

hassle was examined within the Stages of Change framework (p < 0.001). Compared to

the other stages, more participants (24%) in Pre-contemplation agreed thermometer use

was a hassle compared to those in other stages. For the barrier that it is difficult to use a

food thermometer in a hamburger patty, the highest levels of agreement with that

statement were among participants in Pre-contemplation (15%) and Contemplation

(11%). The barrier that it is hard to remember to use a food thermometer when cooking

ground beef patties had the highest level of agreement by participants in the Pre-

contemplation (48%) and Contemplation stages (55%). While the highest amount of

agreement with the statement that participants did not know of anyone who uses a food

thermometer for cooking hamburger patties (79%) was from participants in the

Contemplation stage followed by Pre-contemplation (74%) and Preparation (72%). The

results from the barrier that using a food thermometer with hamburger patties is not part

of their routine had the largest percentage of those who agreed (85%) with the statement

in Pre-contemplation (85%) and Contemplation (83%). The highest number who agreed

that using a food thermometer adds extra time to cooking were in the Contemplation

91

stage (29%), although there was also more agreement in Pre-contemplation than expected

(27%) from Chi-square analysis. Finally, the highest percentage of participants who

agreed that buying a food thermometer is too expensive were in the Contemplation stage

(42%). In comparison with the study by Takeuchi et al. (2005) in which potential

barriers about using food thermometers with thin cuts of meat were assessed against the

Stages of Change; two of the same top 3 barriers were identified among participants in

Pre-contemplation to Preparation, agreement with they never think about using a

thermometer and I don’t know of anyone who uses a thermometer with ground beef

patties.

Altogether, it appears that the more participants in the early stages of Pre-

contemplation, Contemplation, and Preparation) agreed with the barrier statements

compared to participants in Action or Maintenance. However, the two barriers with the

largest number of participants who agreed from the pre-action stages were that using a

food thermometer with hamburger patties is not part of their routine (n =268) and they

don’t know of anyone who uses a food thermometer for cooking hamburger patties (n =

261). The third highest barrier reported by participants in pre-action stages was that it is

hard to remember to use a food thermometer when cooking ground beef patties (n = 145).

These barriers may be related in that thermometer use is hard to remember and has not

been incorporated into cooking practices. Furthermore, these participants do not know of

others performing the behavior, which may affect motivation to adopt it. These barriers

may reflect past habits rather than a barrier but may need to be targeted in future

campaigns to aid participants in setting new behavior patterns for thermometer use with

ground beef patties.

92

It is important to address potential barriers in promotional materials to encourage

adoption of the desired behavior. Focus groups have identified two factors useful to

promote thermometer use: repetition of the message (Trepka et al., 2006) and use of a

variety of material formats (Athearn et al., 2004; McCurdy et al., 2005; Trepka et al.,

2006). Development of promotional materials to counteract the barriers identified in this

study may help motivate consumers. Together, using repetition of the message in various

formats may demonstrate that thermometer use with ground beef patties is an acceptable

and widespread practice in society. To help counteract the barrier that food thermometer

use is not part of the participant’s routine, the practice may need to be introduced to

women before pregnancy or at the start of pregnancy (Athearn et al., 2004); many focus

group participants felt WIC clinics were a trusted source to receive such information

(Athearn et al., 2004; Trepka et al., 2006). Using WIC clinics to promote thermometer

use would also help ensure that the children in the household would be familiar with the

practice and may be more willing to use one as they develop cooking habits.

Attitudes, Perceived Behavior Control and Social Norms with the Stages of

Change. Attitudes about importance, perceived behavior control, and social norms were

assessed for associations with the Stage of Change categories using Spearman’s rho,

Tests of Concordance, and Chi-square analysis (Table 11). The 14 attitudinal statements

were developed into 7 paired questions, with a positive statement and a similar, but

negatively-worded counterpart statement, in order to provide a measure of internal

reliability. Data for all statements are provided in Table 11, results for eight statements

will be highlighted in the text for discussion.

93

Attitudes Regarding the Importance of Thermometer Use. In pair 1 (Questions 17

and 24) the positive statement (Question 24) in the set stated that checking the

temperature of a hamburger patty is the only way to know harmful bacteria have been

killed. Agreement with this statement steadily increased from Pre-contemplation (73%)

to Maintenance (98%) (Spearman’s rho = - 0.187). The negative Spearman’s rho

indicated that participants at higher Stages of Change tended to agree with the statement

while those at lower Stages of Change expressed more disagreement. The negatively-

worded counterpart (Question 17) was that there are many ways to check the safety of a

hamburger patty without using a food thermometer (Spearman’s rho = 0.213). The Stage

of Change category with the highest agreement with that statement was Pre-

contemplation (48%) and the lowest level of agreement was observed in Maintenance

(22%). The positive Spearman’s rho indicated that individuals at lower Stages of Change

tended to agree with the statement while those at higher Stages of Change tended to

disagree. Neutral responses ranged from 12-23% for this statement.

Given the lower levels of agreement and higher levels of neutral responses for the

negatively-worded statement that there are many ways to check the safety of hamburger

patties besides using a food thermometer, compared to the positively-worded statement

this attitude about the importance of thermometer use may be a point of emphasis for

educational materials. Most participants agreed checking the temperature is the only way

to know harmful bacteria have been killed; however emphasis that it is the only way to

ensure safety and other methods are not reliable appears to be a message that is needed,

especially with individuals at lower Stages of Change.

94

In Pair 3, the positive statement (Question 20) conveyed that using a food

thermometer when cooking hamburger patties was a priority in the home. The

participants in Maintenance stage showed the highest percentage of agreement (93%)

while the lowest percentage of agreement was 33% in Contemplation (Spearman’s rho =

- 0.400). The second statement (Question 29) was negatively-worded about never

thinking of using a thermometer with hamburger patties. Approximately 66% of those in

Pre-contemplation agreed with that statement compared to 7% in Maintenance

(Spearman’s rho = 0.427). The statements in this pair showed the strongest correlation

values observed among the Integrative Model of the Reasoned Action Approach

statements. As participants moved toward Maintenance in the Stages of Change, there

was increased agreement that thermometer use was a priority in their homes, and at lower

Stages of Change, there was increased agreement that participants never think about

using a food thermometer with ground beef patties.

Perceived Behavior Control. Two sets of paired questions evaluated Perceived

Behavior Control among the Stages of Change. In one pair, the positive statement

(Question 27) it only takes a short time to use a food thermometer, the Spearman’s rho

correlation (-0.101) indicated that agreement was not strongly correlated with Stages of

Change category, as observed by agreement ranging from 88% to 100% among the

Stages of Change categories. Alternatively, in the negatively-worded statement, higher

correlation among the Stages of Change was observed (Question 18). The largest

percentage of participants who agreed that the participant just doesn’t have enough time

to use a food thermometer with hamburger patties were in Pre-contemplation stage (28%)

with 2% agreement among those in Maintenance (Spearman’s rho = 0.326).

95

In the second statement, responses were correlated with the Stages of Change.

The positive statement (Question 26) conveyed it is easy to use a food thermometer with

ground beef patties. Agreement ranged from 75% at Pre-contemplation to 98% in

Maintenance stage; (Spearman’s rho = - 0.209). The negatively-worded statement

(Question 23) was thermometer use seemed really complicated. Participant disagreement

ranged from 95% in Maintenance to 72% in Contemplation; (Spearman’s rho = 0.178).

For the Perceived Behavior Control statements, Stages of Change appeared to be

most influenced in participant response regarding just not having enough time to use a

thermometer with ground beef patties. Therefore, emphasizing thermometer use as a

quick and easy food safety technique may be important for those in lower Stage of

Change categories.

Discussion of Barriers and Attitudes with the Stages of Change. Understanding

barriers and influential attitudes, perceived behavior control and social norm factors

within population at different Stages of Change is important to develop appropriate

materials to promote thermometer use. Significant more factors observed in the early

Stages of Change (Pre-contemplation and Contemplation) included higher levels of the

following:

• Agreed that there are many ways to check the safety of a ground beef patty

other than thermometers (Question 17)

• Agreed that they do not have time to use a thermometer (Question 18)

• Agreed that thermometer use was not a priority (Question 20)

• Agreed they would prefer to overcook hamburgers to make them safe,

even if the meat is less juicy (Question 21)

96

• Agreed thermometer use complicated (Question 23)

• Agreed they do not think about it with ground beef patties (Question 29)

• Agreed thermometer use is a hassle (Question 31)

• Agreed that thermometers are expensive (Question 37)

Participants throughout the Stages of Change agreed with the importance attitude

that that checking the temperature is needed to know that bacteria have been killed.

From these results, it appears that participants in the early stages of Pre-

contemplation and Contemplation need to have attitudes factors and perceived behavior

control factors stressed to them in educational materials in order to move to higher stages.

Educational materials should promote the pros of thermometer use, such as making

thermometer use a priority, temperature as the only way to know harmful bacteria are

killed, and the ease of thermometer use; stressing the pros will help advance participants

from the Pre-contemplation stage to the Contemplation stage (Prochaska, 2008).

Reducing the cons, such as the amount of time needed for thermometer use,

thermometers as a hassle and being difficult to use, as well as expense of purchasing one,

will promote a movement from the Contemplation stage into the Preparation stage

(Prochaska, 2008).

Male Respondents. Over 60% of respondents in this survey reported their

households contained two adults, but it is not known how many WIC households contain

adult males. In a preceding survey of common consumer cooking practices of ground

beef patties in the general population, grilling was the most popular outdoor method of

cooking ground beef patties, with males cooking outdoors 65% of the time (unpublished

data). Because males in this survey comprised only a small fraction (6%, n=25) of the

97

total sample, any significant results may need to be examined further with a larger sample

size; however, there were a number of interesting findings in this survey by gender that

might warrant further exploration.

Differences were observed between gender and components of the materials that

attracted them to the display. A higher percentage of males (24%) were attracted to the

display due to the logo compared to females (7%). Additionally, more (20%) of males

stated they couldn’t remember the display; this compared to only 6% of females: χ2

(DF=5) 21.002 (p -value = 0.001). Regarding the most useful aspects of the materials,

fewer males (9%) stated the Mom’s Testimony was useful compared to females (39%).

Alternatively, the majority of males (68%) found the grilling tips useful compared to

females (37%): χ2 (DF=3)10.866 (p = 0.012). Given that males tend to perform outdoor

cooking of ground beef patties, this observation is consistent with findings from the

ground beef survey. These findings may indicate that other types of materials may be

more effective with males.

Barriers to thermometer use with ground beef patties also differed by gender. A

higher number of males (24%) agreed that thermometer use with ground beef patties is

difficult than did females (7%): χ2 (DF=1) 9.859 (p = 0.002). Also, a higher percentage

of males (20%) agreed that using a thermometer with ground beef patties seemed

complicated compared to females (7%): χ2 (DF=2) 6.622 (p = 0.036). Males (40%)

identified thermometer use takes extra time, while only 18% of females agreed with this

barrier: χ2 (DF=1) 7.796 (p = 0.005). Additionally, more males (28%) agreed that they

don’t have enough time to use a thermometer when cooking ground beef patties; only

13% of females agreed with that statement: χ2 (DF=2) 4.480 (p = 0.106).

98

Among importance attitudes, 50% of females disagreed that there are many ways

to check the safety of ground beef patties; while 28% of males disagreed with that

statement: χ2 (DF=2) 4.443 (p = 0.108). This may indicate that the majority of males

may believe that there are many ways to check the safety of ground beef patties and are

not convinced for the need for thermometers. Similarly, more males (12%) than females

(4%) disagreed with the knowledge question that using a food thermometer is the only

way to know that a ground beef patty has been cooked safely: χ2 (DF=2) 4.661 (p =

0.097). Finally, more males (20%) compared to females (7%) were neutral regarding

whether you need to check the temperature of a ground beef patty to know if harmful

bacteria have been killed: χ2 (DF=2) 9.068 (p = 0.011).

When the Stage of Change question was examined (Figure 5), fewer males (12%)

than expected were in the Preparation stage; in contrast, the largest numbers of females

(41%) were in the Preparation stage: χ2 (DF=4) 9.575 (p = 0.048). The largest numbers

of males (32%) were in the Contemplation stage, compared to 22% of females. Both

males and females were close to expected values in the Pre-contemplation stage (24%

and 21% respectively). Also, 12% of males were in the Action stage and 7% of females

were in that stage; this was also close to the expected values. Interestingly, 20% of males

were in the Maintenance stage (5 individuals compared to the expected count of 2), with

only 9% of females (37 individuals compared to the expected count of 40) found in that

stage.

The results of this study showed that although males noticed the campaign logo (a

heart-shaped ribbon with a digital “read-out” of 160°F), they did not seem to be as

affected by the emotional messages, photos, or the mom’s testimony. Also, males

99

identified barriers to thermometer use more frequently including that thermometer use

was difficult, complicated, and takes extra time. Males agreed that there are other means

to determine the safety of a ground beef patty besides using a thermometer. According to

the Transtheoretical Model (Prochaska et al., 2008), the Contemplation stage involves a

decisional balance where the pros and cons of engaging in the behavior are still being

weighed. If the cons are lessened at this point, it may propel the individual into the

Preparation stage, in which they are beginning to make plans to take action in the next 30

days. Results indicated that more females were staged in Preparation and may have been

more affected by the materials, while males were mainly staged in Pre-contemplation and

not considering thermometer use or in the Contemplation stage in which they were still

debating the decision to begin thermometer use. Although further research will need to

be conducted to examine what would motivate males to consider using a thermometer

with ground beef patties, the identified cons are that thermometer use may be difficult,

complicated, and takes extra time, as well as the attitude that there are many ways to

check the safety without the use of thermometers, will need to be overcome.

A study with over 2,300 survey respondents looked at high-risk food consumption

and food safety practices (Nesbitt et al., 2009) and found that males were significantly

less likely than females to have heard about the risks of foodborne illness from ground

beef and that males were significantly more likely to have unsafe food handling practices

than women. Another survey study of over 700 people (Roseman & Kurzynske, 2006)

showed that males were significantly more confident in the safety of the nations’ food

supply, did not think the occurrence of foodborne illness was very common, and were

more likely to consume undercooked ground beef patties. These studies indicate that

100

males are unaware or unconvinced of the risks of foodborne illness; this perception may

lead to unsafe food handling practices. Another study by Meer and Misner (2000)

showed that women had significantly higher scores on food safety knowledge and

practices than men (n=268). From the limited results in this present study, future

research may be needed about other approaches with educational materials which may be

more effective with males. Males may need to be presented with more knowledge-based

information and specific facts about the risks of pathogen contamination in ground beef,

foodborne illness associated with these pathogens, and temperature (160°F) as the only

sure consumer method of destroying pathogens.

Campaign Delivery Modes. Participants preferred to take the survey by various

delivery modes; 68% used the web-based survey (administered through a link on the

informational website), 19% by telephone, and 12% through a written survey (Figure 6).

Demographic factors which were not significant with delivery mode included: gender,

age, number of children or adults in the household, income, or race.

However, there was a significant difference (χ2 (DF=6) 19.764 (p = 0.003) in

delivery mode preference by level of education (Figure 7). Fewer (7%) people in the

highest education group (Bachelor’s degree or higher) used the telephone survey; this

compares with those participants with less than a high school degree (23%), high school

degree (25%), and some college who used the telephone survey (18%). There were more

participants (20%) with less than a high school degree who used the mail survey,

compared to other participants with a high school degree (16%), bachelor’s or higher

(10%), and with some college education (8%). The web survey was used more

infrequently by those with less education (below a high school degree and those with a

101

high school degree, 57% and 58% respectively) compared to those with higher education

(some college and a bachelor’s degree or higher; 74% and 82% respectively):

Participant classification in the stages of change differed by delivery mode (p =

0.092). There were more participants (17%) of the Maintenance stage that selected the

telephone delivery mode, as compared to the other formats, web (8%) or mail (6%): χ2

(DF=8) 13.641 (p = 0.092). It is interesting and unexpected to observe differences in

thermometer use behaviors and preferences for survey delivery format. The telephone

delivery mode appears to have attracted more people who had already been using a

thermometer prior to seeing the campaign materials. However, it was important to

collect their opinions about the effectiveness of the materials since reinforcement is

valuable in maintaining the current behavior.

The present study used a mixed mode of survey administration which was

carefully designed to reduce any measurable differences by keeping the three survey

formats as nearly identical as possible. Offering three modes as a way of administering

the survey was utilized in order to increase the number of responses. This may also help

to increase sample representation and reduce bias by including portions of the population

who may not participate in the survey if it were offered in an unsuitable format for their

personal needs and preferences. There can be a variation in survey participation by

delivery mode based on a variety of factors, including demographics, attitudes, or

behaviors. In this study, it was valuable to have included more survey options, since

results demonstrated that almost half of the WIC clients with lower education levels

utilized phone and mail surveys and that the telephone survey captured more responses

from individuals who were in the Maintenance stage in the Stages of Change. Future

102

research is needed to identify ways that different survey modes attract users with

particular characteristics and traits.

103

CONCLUSIONS

The evaluation of the emotions-based social marketing campaign in the

Washington WIC population documented campaign impacts and revealed defining

characteristics regarding thermometer use. Almost 90% of the participants prepared

ground beef patties in their homes 1- 4 times per month; 80% stated that children

consumed the ground beef patties. However, over half of respondents (51%) reported a

lack of thermometer ownership for a dial or digital instant-read thermometer, although

44% had owned one for some time and 6% indicated purchasing one since this campaign.

There were more participants from the Hispanic population represented in this study who

did not own a thermometer compared to Caucasians or other ethnic-racial backgrounds.

Participants who owned a thermometer for some time tended to be older (35 years old or

older), had higher educational levels, and higher income.

The majority of respondents agreed that the packet of materials helped them to

feel that using a food thermometer when cooking ground beef patties is important.

Knowledge was assessed about thermometer use; the majority agreed they understood

that a safely cooked ground beef patty must reach 160°F and that using a food

thermometer is the only way to safely cook a ground beef patty. Additionally,

participants agreed that they were more confident in their ability to accurately measure

the temperature of a ground beef patty. The materials were effective in communicating

intended messages to the target audience.

Thermometer use increased significantly (p < 0.001) following this campaign.

Participants stated that before reading the materials, the majority did not use a

thermometer when cooking ground beef patties, however, following the campaign, the

104

majority were using a thermometer almost always to always. Participants who recently

purchased a thermometer and those who had owned for some time showed no significant

difference in thermometer use frequencies; the materials were equally effective for both

groups.

Participant attitudes about importance, perceived behavior control, and social

norms were identified. The questions assessing importance attitudes found that an

overwhelming majority of respondents agreed that under-cooked ground beef patties

were not safe to serve their family and that ground beef patties need to be cooked to

160°F in order to prevent people from becoming ill. However, some participants were

ambiguous about the methods needed to determine the safety of a ground beef patty; the

majority agreed that checking the temperature is the only way to know that harmful

bacteria have been killed, but over half of respondents either agreed or were neutral there

are many ways to check the safety of a ground beef patty. Although half the respondents

stated that thermometer use with ground beef patties is a priority in their home, over 40%

agreed that they never think about using one with ground beef patties. Also, just over

half the respondents agreed that using a food thermometer enhances the juiciness of the

meat because it is cooked just right, approximately that same number also agreed it is

safer to overcook the ground beef patties even though the meat is less juicy. These

results were supported by the observation that the majority of participants indicated the

main reason people used a food thermometer was to make ground beef patties safe for

their families, not to make ground beef patties tastier and juicier.

Overall, perceived behavior control was positive about thermometer use. Most

participants agreed it was easy to do and not complicated. Most respondents felt it only

105

took a short time to use a food thermometer, although some indicated they personally did

not have enough time to use a thermometer with ground beef patties, so this needs to be

stressed in the materials. Social norms were also not an issue for the majority of

respondents; they agreed they would do whatever was needed in order to protect their

families, no matter what others might say or do. However, some respondents agreed they

would be more apt to use a thermometer with ground beef patties if they knew of others

who did as well.

The most frequent barriers identified by the majority of participants were that

they don’t know of anyone who uses a food thermometer when cooking ground beef

patties (67%) and it is not part of their routine (66%). Other factors such as

inconvenience and hassle, difficulty in use, remembering, extra cook time, and expense

were not identified as barriers by the majority.

When it came to intentions of using a thermometer, the Stages of Change question

found the largest percentage of respondents to be in the Preparation stage (39%).

Additionally, this question classified a combined 18% of participants into the Action or

Maintenance stages. However, a combined 44% of respondents were in Pre-

contemplation or Contemplation stages, in which the respondents were not motivated to

change behavior, or the decision was still being weighed. It appears that in the early

stages of Pre-contemplation and contemplation, importance attitudes about thermometer

use as a priority and that temperature is the only way to know harmful bacterial have

been killed were major factors, as are the perceived behavior control factors of the ease of

thermometer use and the amount of time needed to use a thermometer.

106

Barriers among Stage of Change categories were also examined. For Pre-

contemplation, there were more respondents in this stage who agreed that thermometer

use is a hassle compared to the other stages and that thermometers are difficult to use; it

is also not part of their routine. For the Contemplation stage, the results of barrier

statements show that more respondents in this stage than in the other stages agree that

thermometers are too expensive, thermometer use is hard to remember, thermometer use

takes extra time, and they don’t know of anyone who uses a food thermometer with

ground beef patties. However, those in higher stages saw much less agreement with these

barriers, demonstrating that these are the issues that need to be addressed in order to

progress to thermometer use.

This evaluation of the emotions-based social marketing campaign showed it to be

effective with the WIC population of Washington state.

Limitations

There were some limitations of this study due to the overall design. There was

only one question on thermometer use which was a pre-test post-test question; no other

pre-test was given. Also, several respondents mentioned that it had been a very short

period of time between when they received the materials and when they took the survey,

in which there would not have been sufficient time to adopt any behavior change.

Because the survey was offered in three modes; internet, telephone, and mail, there are

apt to be some differences. One example is that the web survey had a skip in questions

about owning and using a thermometer; the other two modes did not. Also, although this

study was designed using an emotions-based social marketing approach, the effectiveness

107

of specific elements in the poster display stand at attracting participants was reduced

because many respondents received the materials directly from WIC staff.

Future Research

Although our sample size of males was too small to make any general

conclusions, results point to the need for further examination of this particular group for

effective food safety educational materials. Males may be driven by different motivators

than females which would be needed to help move them through the Stages of Change.

There were fewer males in the Preparation Stage of Change; instead, more were in Pre-

contemplation or Contemplation. This demonstrates that this campaign and its materials

may not be as effective with males, and a needs assessment may discover more effective

messages and graphics specific to the needs of males.

Hispanics are another group that may be targeted for a needs assessment. One of

the participating counties in particular contained a large Hispanic WIC population, and

yet there was only a 15% participation of the survey. The materials may need to be

written for Spanish-speaking people, as the survey staff at SSRU stated they received

requests for the survey in Spanish. Many Hispanics do not own thermometer compared

to other ethnic-racial backgrounds, so that is a concern when cooking ground beef patties.

Since there were more participants with higher levels of education, as well as

those who had owned a thermometer for some time in Pre-contemplation and

Contemplation, it appears that this group either had tried using thermometers in the past

and found them to be difficult to use, or was not motivated by the materials. This

illustrates the need to emphasize ease of thermometer use to individuals in the early

Stages of Change.

108

Also, the top three barriers that may reflect past cooking habits (they don’t know

of anyone who uses a food thermometer with ground beef patties, its not part of their

routine, its hard to remember to use one); these may need to be targeted in order to aid

participants to develop new behavior patterns that include routine thermometer use.

109

REFERENCES

Athearn, P.N., P.A. Kendall, V. Hillers, M. Schroeder, V. Bergman, G. Chen, and L.C.

Medeiros. 2004. Awareness and acceptance of current food safety recommendations

during pregnancy. Maternal and Child Health Journal 8:149-162.

Cates, S. 1999. Thermometer slogan focus group study. Final report prepared for USDA Food

Safety and Inspection Service. http://www.fsis.usda.gov/oa/research/rti_summ.pdf

Accessed 12/26/09.

Center for Disease Control and Prevention. April 10, 2009. Preliminary FoodNet Data on the

Incidence of Infection with Pathogens Transmitted Commonly Through Food – 10 States,

2008. MMWR Weekly, 58(13), 1-94. Available at:

http://www.cdc.gov/mmwr/PDF/wk/mm5813.pdf Accessed August 1, 2009.

Cody, M.M. and M.A. Hogue. 2003. Results of the home food safety—It’s in your hands 2002

survey: comparisons to the 1999 benchmark survey and healthy people 2010 food safety

behaviors objective. Journal of the American Dietetic Association 103:1115-25.

Doyle, M.P. and L.R. Beuchat (eds). 2007. Food microbiology: fundamentals and frontiers.

Third Edition. ASM Press, Washington, D.C.

Fischer, A.R.H.,and P.W. DeVries. 2008. Everyday behaviour and everyday risk: An approach

to study people’s responses to frequently encountered food related health risks. Health,

Risk & Society 10:385-397.

Fishbein, M. 2008. A Reasoned Action Approach to health promotion. Medical Decision

Making 28:834-844.

110

Frewer, L.J., R. Sheperd, and P. Sparks. 1994. The interrelationship between perceived

knowledge, control, and risk associated with a range of food-related hazards targeted at

the individual, other people and society. Journal of Food Safety 14:19-40.

Gerba, C.P., J.B. Rose, and C.N. Haas. 1996. Sensitive populations: who is at the greatest

risk? International Journal of Food Microbiology 30:113-23.

Hui, Y.H., M.D. Pierson and J. R. Gorham (Ed.). 2001. Food disease handbook. Second

Edition. Marcel Dekker, Inc., New York, New York.

Jay, J.J., M.J. Loessner, D.A. Golden. 2005. Modern Food Microbiology. Seventh Edition.

Springer Science, New York, New York.

Katpodi, M.C., N.C. Facione, J.C. Humphreys, and M.J. Dodd. 2005. Perceived breast cancer

risk: heuristic reasoning and search for dominance structure. Social Science and

Medicine 60:421-32.

Kwon, J., A.S. Wilson, C. Bednar, and L. Kennon. 2008. Food safety knowledge and behaviors

of Women, Infant, and Children (WIC) program participants in the United States.

Journal of Food Protection 71:1651-8.

McArthur, L.H., D. Holbert and W.A. Forsythe III. 2006. Compliance with food safety

recommendations among university undergraduates: Application of the Health Belief

model. Family and Consumer Sciences Research Journal 35:160-170.

McCurdy, S.M., V. Hillers, and S.E. Cann. 2005. Consumer reaction and interest in using food

thermometers when cooking small or thin meat items. Food Protection Trends 25:826-

31.

111

Mead, P.S., L. Slutsker, V. Dietz, L.F. McCaig, J.S. Bresee, C. Shapiro, P.M. Griffin and R.V.

Tauxe. 2000. Food-related illness and death in the United States. Journal of

Environmental Health 62: 9-18

Meer, R.R. and S.L. Misner. Food safety knowledge and behavior of expanded food and

nutrition education program participants in Arizona. Journal of Food Protection.

63:1725-31.

Nesbitt, A., S. Majowicz, R. Finley, B. Marshall, F. Pollari, J. Sargeant, C. Ribble, J. Wilson,

and N. Sittler. 2009. High-risk food consumption and food safety practices in a

Canadian community. Journal of Food Protection 72:2575-86.

Prochaska, J.O., C.A. Redding and K.E. Evers. 2002. The Transtheoretical Model and the

stages of change. In K. Glanz, B.K. Rimer, F.M. Lewis (Eds.). Health behavior and

health education, theory, research and practice. (3rd ed., pp.67-95) Jossey-Bass, San

Francisco, CA.

Prochaska, J.O. 2008. Decision making in the Transtheoretical Model of behavior change.

Medical Decision Making 28:845-9.

Roseman, M. and J. Kurznynske. 2006. Food safety perceptions and behaviors of Kentucky

consumers. Journal of Food Protection 69: 1412-21.

Schuele, B. 2004. Food safety education: Health professional’s knowledge and assessment of

WIC client needs. Journal of the American Dietetic Association 104:799-803.

Slovic, P. 1987. Perception of risk. Science 236:280-85.

Takeuchi, M.T., M. Edlefsen, S.M. McCurdy and V.N. Hillers. 2005. Educational intervention

enhances consumers’ readiness to adopt food thermometer use when cooking small cuts

112

of meat: An application of the Transtheoretical Model. Journal of Food Protection

68:1874-83.

Takeuchi, M.T., M. Edlefsen, S.M. McCurdy and V.N. Hillers. 2006. Development and

validation of Stages-of-Change questions to assess consumers’ readiness to use a food

thermometer when cooking small cuts of meat. Journal of the American Dietetic

Association 106:262-6.

Trepka, M.J., V. Murunga, S. Cherry, F.G. Huffman and Z. Dixon. 2006. Food safety beliefs

and barriers to safe food handling among WIC Program clients, Miami, Florida. J. Nutr.

Educ. Behav. 38:371-7.

Trepka, M.J., F.L. Newman, E.P. Davila, K.J. Matthew, Z. Dixon, T.G. Huffman. 2008.

Randomized Controlled Trial to Determine the Effectiveness of an Interactive

Multimedia Food Safety Education Program for the Clients of the Special Supplemental

Nutrition Program for Women, Infants, and Children. J. Am. Diet. Assoc. 108:978-84.

U.S. Department of Agriculture, Food and Nutrition Service. March 2006. WIC participant and

program characteristics 2004. WIC-04-PC. Available at:

http://www.fns.usda.gov/oane/MENU/Published/WIC/FILES/pc2004.pdf Accessed

September 7, 2009.

U.S. Department of Agriculture, Food and Nutrition Service. April 2009a. WIC, the Special

Supplemental Nutrition Program for Women, Infants and Children. Available at:

http://www.fns.usda.gov/wic/WIC-Fact-Sheet.pdf Accessed September 7, 2009.

U.S. Department of Agriculture, Food and Nutrition Service. June 2009b. WIC income

eligibility guidelines 2009-2010. Available at:

http://www.fns.usda.gov/wic/howtoapply/incomeguidelines.htm Accessed May 31, 2010.

113

U.S. Department of Agriculture, Food Safety and Inspection Service. April 2003. Meat

preparation, color of cooked ground beef as it relates to doneness. Available at:

http://www.fsis.usda.gov/Fact_Sheets/Color_of_Cooked_Ground_Beef/index.asp

Accessed June 30, 2009.

114

TABLE 1 VALIDATED SURVEY QUESTION REGARDING INTENTIONS TO USE A FOOD THERMOMETER

BASED ON THE TRANSTHEORETICAL MODEL (STAGES OF CHANGE) I DO NOT own a food thermometer...

(Pre-contemplation) ___...and I do not have any intention of buying one for cooking hamburger patties at this time. (Contemplation) ___...but I have thought about buying one in the next six months for use with hamburger patties. (Preparation) ___...but I plan to buy one in the next month for use with hamburger patties. I DO own a food thermometer... (Pre-contemplation) ___...but I have never thought seriously about using it to cook hamburger patties. (Contemplation) ___and I have thought about starting to use it for cooking hamburger patties within the next six months. (Preparation) ___...and I plan to start using it for cooking hamburger patties within the next month. (Action) ___...and I have used it regularly for cooking hamburger patties for less than six months. (Maintenance) ___...and I have used it regularly for cooking hamburger patties for more than six months. ________________________________________________________________________

115

TABLE 2 PAIRED QUESTIONS REGARDING FACTORS INFLUENCING IMPORTANCE ATTITUDES, PERCEIVED BEHAVIOR CONTROL, AND SOCIAL NORMS WITH THERMOMETER USE IN

GROUND BEEF PATTIES BASED ON THE INTEGRATIVE MODEL OF BEHAVIOR CHANGE*+ Importance Attitudes Pair 1 (+) “Checking the temperature of a hamburger patty is the only way to know harmful bacteria have been killed” (-) “There are many ways to check the safety of the hamburger patties besides using a food thermometer” Pair 2 (+) “In order to prevent people from becoming ill, hamburger patties should be cooked to 160°F” (-) “Under-cooked hamburger patties are safe to serve my family” Pair 3 (+) “Using a food thermometer when cooking hamburger patties is a priority in my home” (-) “I never think about using a food thermometer with hamburger patties” Pair 4 (+) “Using a food thermometer with hamburger patties enhances the juiciness of the meat because it is cooked just right” (-) “I prefer to overcook hamburger patties to make them safe, even if it means the meat is less juicy” Perceived Behavior Control Pair 1 (+) “It only takes a short time to use a food thermometer” (-) “I just don’t have enough time to use a food thermometer with hamburger patties” Pair 2 (+) “It is easy to use a food thermometer with hamburger patties” (-) “Using a food thermometer with a hamburger patty seems really complicated” Social Norms Pair 1 (+) “I do whatever I can to protect myself, my family, and my friends from food borne illness, no matter what others might think or do” (-) “I would be more likely to use a food thermometer with hamburger patties if I knew that other people did as well” *Respondents were asked to respond to the statements using a 5-point Likert scale. The 5-point Likert-type scales consisted of Strongly Agree, Somewhat Agree, Neither Agree nor Disagree, Somewhat Disagree and Strongly Disagree. +The Likert scale was collapsed to satisfy chi-square assumptions for analysis. This scale was collapsed into three categories: Strongly and Somewhat Agree were combined into Agree, Neither Agree nor Disagree were designated as Neutral, and Somewhat Disagree and Strongly Disagree were combined into Disagree.

116

TABLE 3 SUBJECT CHARACTERISTICS OF WIC-ELIGIBLE PARTICIPANTS IN THE IMPACT EVAUATION

OF A SOCIAL MARKETING CAMPAIGN FOR THERMOMETER USE WITH GROUND BEEF PATTIES

Characteristic n (%) Gender: Male 25 (6) Female 403 (94) Age*: 18 – 24 128 (30) 25 – 29 119 (28) 30 – 34 82 (19) 35+ 95 (23) Number of Household Members+: Adults 1 58 (14) 2 262 (61) 3+ 107 (25) Children 0 28 (7) 1 125 (30) 2 146 (34) 3 66 (16) 4+ 62 (15) Level of Education Completed+: Less than high school, no diploma 56(13) High School graduate, GED 130 (30) Technical/vocational degree/certificate or 185 (43) some college courses or Associate’s degree Bachelor’s degree/Graduate or professional degree 57 (14) Income+: <$10,000 112 (27) $10,000-19,9999 6 (23) $20,000-$29,999 110 (26) $30,000-$39,999 58 (14) ≥$40,000 44 (10) Ethnicity/Race+: Caucasian or White 299 (70) Hispanic/Latino/a 63 (15) Other or mixed race 65 (14) + Categories were collapsed for statistical analysis *Age was stratified into age ranges

117

TABLE 4 THERMOMETER OWNERSHIP AMONG DEMOGRAPHIC GROUPS IN THE WIC POPULATION

PARTICIPATING IN THE IMPACT EVALUATION* Characteristic Chi-Square

___________________________________________ (p-value) Don’t Own Recently Own Owned Longer DF n(% of column) Ethnicity/Race: 10.723 (0.030) DF = 4 Caucasian or White 139 (46) 18 (6) 142 (47) Hispanic/Latino/a 43 (68) 3 (5) 17 (27) Other 36 (55) 4 (6) 25 (38) Income: 30.711 (< 0.001) DF = 8 < $10,000 65 (58) 8 (7) 39 (35) $10,000-19,9999 54 (56) 3 (3) 39 (41) $20,000-$29,999 62 (56) 6 (5) 42 (38) $30,000-$39,999 25 (43) 5 (9) 28 (48) ≥ $40,000 7 (16) 3 (7) 34 (77) Level of Education Completed: 11.903 (0.064) DF = 6 < High School degree 34 (61) 4 (7) 18 (32) High School degree 77 (59) 6 (5) 47 (36) Some college 86 (46) 10 (5) 89 (48) ≥ Bachelor’s degree 22 (39) 5 (9) 30 (53) Age: 26.624 (< 0.001) DF = 6 18 – 24 y.o. 82 (64) 8 (6) 38 (30) 25 – 29 y.o. 68 (57) 7 (6) 44 (37) 30 – 34 y.o. 35 (43) 3 (4) 44 (54) ≥ 35 y.o. 34 (34) 7 (7) 58 (59) *Factors with statistical significance were included in the table.

118

TABLE 5 PERCEIVED BARRIERS AMONG WIC IMPACT EVALUATION PARTICIPANTS IN DIFFERENT

THERMOMETER OWNERSHIP CATEGORIES Perceived Chi-Square Barrier ____________________________________________________ (p-value) Don’t Own Recently Own Owned Longer n(% of Column) DF = 2 Using a food thermometer is inconvenient and a hassle. 0.102 (0.950) NS* Agree 26 (12) 3 (12) 24 (13) Disagree 193 (88) 22 (88) 162 (87) It is difficult to use a food thermometer in a hamburger patty. 6.438 (0.040) Agree 10 (5) 2 (8) 21 (11) Disagree 208 (95) 23 (92) 164 (89) It is hard to remember to use a food thermometer when cooking hamburger patties. 2.240 (0.326) NS* Agree 85 (39) 6 (24) 68 (37) Disagree 132 (61) 19 (76) 117 (63) I don’t know of anyone who uses a food thermometer for cooking hamburger patties. 23.123 (< 0.001) Agree 169 (78) 13 (52) 104 (56) Disagree 49 (22) 12 (48) 81 (44) Using a food thermometer with hamburger patties is not part of my routine. 52.340 (< 0.001) Agree 178 (82) 12 (48) 91 (49) Disagree 39 (18) 13 (52) 95 (51) Using a food thermometer adds extra time to cooking. 0.556 (0.757)* Agree 39 (18) 6 (24) 36 (19) Disagree 177 (82) 19 (76) 149 (81) Buying a food thermometer is too expensive. 43.309 (< 0.001) Agree 69 (33) 3 (13) 12 (6) Disagree 142 (67) 20 (87) 174 (94) *NS = non-significant

119

TABLE 6 PARTICIPANT RESPONSES TO PAIRED QUESTIONS ASSESSING IMPORTANCE ATTITUDES,

PERCEIVED BEHAVIOR CONTROLS AND SOCIAL NORMS BASED ON THE INTEGRATIVE MODEL OF A REASONED ACTION APPROACH*

Response Spearman’s Test of ___________________________________ Rho Concordance Agree Neutral Disagree (p-value) n(%) n(%) n(%) Importance Attitudes: Pair 1 (Questions 24 & 17): 0.26 < 0.001 (+) “Checking the temperature of a hamburger patty is the only way to know harmful bacteria have been killed” 362 (85) 32 (7) 34 (8) (-) “There are many ways to check the safety of the hamburger patties besides using a food thermometer” 150 (35) 70 (16) 208 (49) Pair 2 (Questions 28 & 19): 0.26 < 0.001 (+) “In order to prevent people from becoming ill, hamburger patties should be cooked to 160°F” 411 (96) 12 (3) 6 (1) (-) “Under-cooked hamburger patties are safe to serve my family” 24 (6) 13 (3) 392 (91) Pair 3 (Questions 20 & 29): 0.31 <0.001 (+) “Using a food thermometer when cooking hamburger patties is a priority in my home” 229 (54) 121 (28) 75 (18) (-) “I never think about using a food thermometer with hamburger patties” 172 (40) 84 (20) 169 (40)

120

(Continued From Previous Page) Response Spearman’s Test of ___________________________________ Rho Concordance Agree Neutral Disagree (p-value) n(%) n(%) n(%) Pair 4 (Questions 21 & 30): 0.14 0.001 (+) “Using a food thermometer with hamburger patties enhances the juiciness of the meat because it is cooked just right” 228 (53) 142 (33) 57 (13) (-) “I prefer to overcook hamburger patties to make them safe, even if it means the meat is less juicy” 236 (55) 69 (16) 122 (29) Perceived Behavior Control: Pair 1 (Questions 27 & 18): 0.27 < 0.001 (+) “It only takes a short time to use a food thermometer” 392 (92) 28 (7) 7 (2) (-) “I just don’t have enough time to use a food thermometer with hamburger patties” 60 (14) 86 (20) 281 (66) Pair Two (Questions 26 & 23): 0.34 < 0.001 (+) “It is easy to use a food thermometer with hamburger patties” 368 (87) 46 (11) 10 (2) (-) “Using a food thermometer with a hamburger patty seems really complicated” 31 (7) 42 (10) 351 (83)

121

(Continued From Previous Page) Response Spearman’s Test of ___________________________________ Rho Concordance Agree Neutral Disagree (p-value) n(%) n(%) n(%) Social Norms: Pair One (Questions 22 & 25): 0.12 0.007 (+) “I do whatever I can to protect myself, my family, and my friends from food borne illness, no matter what others might think or do” 390 (91) 30 (7) 7 (2) (-) “I would be more likely to use a food thermometer with hamburger patties if I knew that other people did as well” 91 (21) 107 (25) 229 (54) *(Fishbein, 2008)

122

TABLE 7 FREQUENCY OF WIC PARTICIPANT RESPONSES TO PERCEIVED BARRIERS TO

THERMOMETER USE Response Agree Disagree __________________________

n(%) Using a food thermometer is inconvenient and a hassle. 53 (12) 377 (88) It is difficult to use a food thermometer in a hamburger patty. 33 (8) 394 (92) It is hard to remember to use a food thermometer when cooking hamburger patties. 159 (37) 268 (63) I don’t know of anyone who uses a food thermometer for cooking hamburger patties. 286 (67) 142 (33) Using a food thermometer with hamburger patties is not part of my routine. 281 (66) 147 (34) Using a food thermometer adds extra time to cooking. 81 (19) 344 (81) Buying a food thermometer is too expensive. 84 (20) 334 (79)

123

TABLE 8 WIC PARTICIPANT THERMOMETER OWNERSHIP AMONG STAGES OF CHANGE CATEGORIES Response Stages Chi-Square ________________________________________________ (p-value) PC C P A M n(% of Column) DF = 8 148.665 (< 0.001) Do Not Own a Thermometer 26 (12) 78 (36) 112 (51) 0 (0) 2 (1) Recently Own a Thermometer 7 (28) 1 (4) 8 (32) 6 (24) 3 (12) Owned a Thermometer For Some Time 60 (32) 16 (9) 47 (25) 27 (14) 37 (20) PC=Pre-contemplation, C=Contemplation, P=Preparation, A=Action, M=Maintenance

124

TABLE 9 PARTICIPANT ASSESSMENT OF KNOWLEDGE AS A RESULT OF RECEIVING CAMPAIGN MATERIALS REGARDING THERMOMETER USE WITH GROUND BEEF PATTIES AMONG

DIFFERENT STAGES OF CHANGE CATEGORIES Response Stages Chi-Square ________________________________________________ PC C P A M n(% of Column) DF = 8 Using a food thermometer is the only way to safely cook a hamburger patty. 44.83, p < 0.001 Agree 65 (71) 77 (81) 158 (95) 32 (97) 42 (100) Neutral 17 (18) 11 (12) 8 (5) 1 (3) 0 (0) Disagree 10 (11) 7 (7) 1 (1) 0 (0) 0 (0) A safely cooked hamburger patty must reach 160°F. 19.29* Agree 85 (92) 89 (97) 166 (100) 32 (97)) 42 (100) Neutral 4 (4)) 3 (3) 0 (0) 1 (3) 0 (0) Disagree 3 (3) 0 (0) 0 (0) 0 (0) 0 (0) I am more confident in my ability to measure the temperature of a hamburger patty. 27.38* Agree 73 (79) 75 (79) 158 (95) 32 (97) 40 (95) Neutral 17 (18) 19 (20) 7 (4) 1 (3) 2 (5) Disagree 2 (2) 1 (1) 2 (1) 0 (0) 0 (0) PC=Pre-contemplation, C=Contemplation, P=Preparation, A=Action, M=Maintenance *P-value was not computed because Chi-Square approximation was probably invalid due to cells with expected counts less than 1.

125

TABLE 10 PARTICIPANT ASSESSMENT OF BARRIERS REGARDING THERMOMETER USE WITH

GROUND BEEF PATTIES AMONG DIFFERENT STAGES OF CHANGE CATEGORIES AS A RESULT OF RECEIVING CAMPAIGN MATERIALS

Response Stages Chi-Square ________________________________________________ PC C P A M n(% of Column) DF = 4 Using a food thermometer is inconvenient and a hassle. 21.04, p < 0.001 Agree 22 (24) 15 (16) 12 (7) 3 (9) 1 (2) Disagree 69 (76) 80 (84) 155 (93) 30 (91) 41 (98) It is difficult to use a food thermometer in a hamburger patty. 15.51, p = 0.004 Agree 14 (15) 10 (11) 5 (3) 3 (9) 1 (2) Disagree 77 (85) 84 (89) 161 (97) 30 (91) 41 (98) It is hard to remember to use a food thermometer when cooking hamburger patties. 41.17, p < 0.001 Agree 44 (48) 52 (55) 49 (30) 11 (33) 2 (5) Disagree 47 (52) 42 (45) 116 (70) 22 (67) 40 (95) I don’t know of anyone who uses a food thermometer for cooking hamburger patties. 58.19, p < 0.001 Agree 67 (74) 75 (79) 119 (72) 14 (42) 9 (21) Disagree 23 (26) 20 (21) 47 (28) 19 (58) 33 (79) Using a food thermometer with hamburger patties is not part of my routine. 112.89, p < 0.001 Agree 77 (85) 78 (83) 113 (68) 9 (27) 3 (7) Disagree 14 (15) 16 (17) 53 (32) 24 (73) 39 (93) Using a food thermometer adds extra time to cooking. 19.65, p = 0.001 Agree 25 (27) 26 (29) 18 (11) 7 (21) 4 (10) Disagree 66 (73) 65 (71) 149 (89) 26 (79) 38 (90) Buying a food thermometer is too expensive. 43.86, p < 0.001 Agree 17 (19) 39 (42) 24 (15) 1 (3) 2 (5) Disagree 72 (81) 53 (58) 138 (85) 32 (97) 40 (95) PC=Pre-contemplation, C=Contemplation, P=Preparation, A=Action, M=Maintenance

126

TABLE 11 PAIRED QUESTIONS ASSESSING IMPORTANCE ATTITUDES, PERCEIVED BEHAVIOR

CONTROLS AND SOCIAL NORMS BASED ON THE INTEGRATIVE MODEL OF A REASONED ACTION APPROACH REGARDING THERMOMETER USE WITH GROUND BEEF PATTIES

AMONG DIFFERENT STAGES OF CHANGE CATEGORIES+

Response rs* Test of Chi-Square Concord. (p-value) Stages (p-value) PC C P A M ___________________________________ n(% of Column) DF = 4 Importance Attitudes: Pair 1: (+) “Checking the temperature of a hamburger patty is the only way to know harmful bacteria have been killed” - 0.19 (0.999) 20.50 (0.009) Agree 66 (73) 78 (82) 148 (89) 28 (85) 41 (98) Neutral 13 (14) 10 (11) 7 (4) 2 (6) 0 (0) Disagree 12 (13) 7 (7) 11 (7) 3 (9) 1 (2) (-) “There are many ways to check the safety of the hamburger patties besides using a food thermometer” 0.21 (<0.001) 25.80 (0.001) Agree 44 (48) 40 (42) 47 (28) 10 (30) 9 (22) Neutral 13 (14) 22 (23) 24 (14) 5 (15) 5 (12) Disagree 34 (37) 33 (35) 96 (57) 18 (55) 27 (66) Pair 2: (+) “In order to prevent people from becoming ill, hamburger patties should be cooked to 160°F” -0.06 (0.904) 13.94** Agree 84 (92) 92 (97) 164 (98) 29 (88) 42 (100) Neutral 4 (4) 2 (2) 2 (1) 3 (9) 0 (0) Disagree 3 (3) 1 (1) 1 (1) 1 (3) 0 (0) (-) “Under-cooked hamburger patties are safe to serve my family” 0.12 (0.006) 16.56** Agree 11 (12) 6 (6) 3 (2) 1 (3) 3 (7) Neutral 4 (4) 3 (3) 2 (1) 2 (6) 1 (2) Disagree 76 (84) 86 (91) 161 (97) 30 (92) 38 (90)

127

(Continued from Previous Page)

Response rs* Test of Chi-Square Concord. (p-value) Stages (p-value) PC C P A M ___________________________________ n(% of Column) DF = 4 Pair 3: (+) “Using a food thermometer when cooking hamburger patties is a priority in my home” -0.40 (1.0) 80.99 (< 0.001) Agree 33 (37) 31 (33) 101 (61) 26 (79) 39 (93) Neutral 25 (28) 36 (38) 49 (30) 7 (21) 3 (7) Disagree 31 (35) 27 (29) 16 (10) 0 (0) 0 (0) (-) “I never think about using a food thermometer with hamburger patties” 0.43 (<0.001) 92.03 (< 0.001) Agree 59 (66) 47 (50) 58 (35) 7 (21) 3 (7) Neutral 18 (20) 23 (24) 37 (22) 3 (9) 2 (5) Disagree 13 (14) 24 (26) 72 (43) 23 (70) 37 (88) Pair 4: (+) “Using a food thermometer with hamburger patties enhances the juiciness of the meat because it is cooked just right” -0.16 (0.999) 18.64 (0.017) Agree 37 (41) 44 (46) 99 (60) 18 (55) 30 (71) Neutral 38 (42) 39 (41) 46 (28) 12 (36) 6 (14) Disagree 15 (17) 12 (13) 21 (13) 3 (9) 6 (14) (-) “I prefer to overcook hamburger patties to make them safe, even if it means the meat is less juicy” 0.13 (0.004) 18.28 (0.019) Agree 49 (54) 64 (69) 93 (56) 14 (42) 16 (38) Neutral 19 (21) 12 (13) 24 (14) 7 (21) 6 (14) Disagree 23 (25) 18 (19) 50 (30) 12 (36) 20 (48)

128

(Continued from Previous Page)

Response rs* Test of Chi-Square Concord. (p-value) Stages (p-value) PC C P A M ___________________________________ n(% of Column) DF = 4 Perceived Behavior Control: Pair 1: (+) “It only takes a short time to use a food thermometer” -0.10 (0.981) 12.91** Agree 80 (89) 85 (90) 157 (95) 29 (88) 42 (100) Neutral 6 (7) 8 (8) 9 (5) 3 (9) 0 (0) Disagree 4 (4) 2 (2) 0 (0) 1 (3) 0 (0) (-) “I just don’t have enough time to use a food thermometer with hamburger patties” 0.33 (<0.001) 52.03 (0.001) Agree 25 (28) 16 (17) 13 (8) 5 (15) 1 (2) Neutral 27 (30) 25 (26) 26 (16) 4 (12) 2 (5) Disagree 38 (42) 54 (57) 128 (77) 24 (73) 39 (93) Pair Two: (+) “It is easy to use a food thermometer with hamburger patties” -0.21 (0.999) 23.01** Agree 68 (75) 80 (85) 150 (90) 31 (94) 41 (98) Neutral 17 (19) 13 (14) 13 (8) 2 (6) 1 (2) Disagree 6 (7) 1 (1) 3 (2) 0 (0) 0 (0) (-) “Using a food thermometer with a hamburger patty seems really complicated” 0.18 (<0.001) 21.04 (0.007) Agree 9 (10) 13 (14) 7 (4) 1 (3) 1 (2) Neutral 12 (13) 14 (15) 11 (7) 4 (13) 1 (2) Disagree 70 (77) 68 (72) 146 (89) 27 (84) 39 (95)

129

(Continued from Previous Page)

Response rs* Test of Chi-Square Concord. (p-value) Stages (p-value) PC C P A M ___________________________________ n(% of Column) DF = 4 Social Norms: Pair One: (+) “I do whatever I can to protect myself, my family, and my friends from food borne illness, no matter what others might think or do” -0.10 (0.976) 10.66** Agree 78 (87) 85 (90) 156 (94) 29 (88) 41 (98) Neutral 10 (11) 8 (9) 6 (4) 4 (12) 1 (2) Disagree 2 (2) 1 (1) 4 (2) 0 (0) 0 (0) (-) “I would be more likely to use a food thermometer with hamburger patties if I knew that other people did as well” 0.04 (0.190) 9.62 (0.247)*** Agree 17 (19) 27 (29) 37 (22) 7 (21) 4 (10) Neutral 28 (31) 17 (18) 40 (24) 9 (27) 13 (31) Disagree 46 (51) 51 (54) 90 (54) 17 (52) 25 (60) +Integrative Model of a Reasoned Action Approach (Fishbein, 2008) and Stages of Change (Prochaska, 2008) PC=Pre-contemplation, C=Contemplation, P=Preparation, A=Action, M=Maintenance. *rs = Spearman’s rho. ** P-value was not computed because Chi-Square approximation was probably invalid due to cells with expected counts less than 1. * ** non-significant

130

Figure 1a. Levels of Thermometer Use Reported by Web-based Evaluation Participants Before and After Receiving the Campaign Materials*

147 7

21

52

40

27

7

19

7

0102030405060708090

100

Almost Always Most of theTime

Half of theTime

Sometimes Never

Frequency

Perc

enta

ge o

f Par

ticip

ants

BeforeAfter

*Wilcoxon Signed Rank Test Statistic 5341.0 (p < 0.001) N=151

131

Figure 1b. Levels of Thermometer Use Reported by Telephone and Written Evaluation Participants Before and After Receiving the Campaign Materials

115 4

12

68

28

115 7

49

0102030405060708090

100

Almost Always Most of theTime

Half of theTime

Sometimes Never

Frequency

Perc

enta

ge o

f Par

ticip

ants

BeforeAfter

*Wilcoxon Signed Rank Test Statistic 1195.0 (p < 0.001) N=132

132

Figure 2a. Differences in Thermometer Use Categories among Short-term and Longer-term Thermometer Owners for WIC Web-based Evaluation Participants

72

-1 -1-7

33 29

1

-3

-60

-80

-60

-40

-20

0

20

40

Frequency of Thermometer Use

Diff

eren

ce in

Num

ber

of O

bser

ved

Recently OwnedOwned for Some Time

Kruskal-Wallis Test (p = 0.147) non-significant

Alm

ost Alw

ays

Most of the Tim

e

Half the Tim

e

Sometim

e

Never

133

Figure 2b. Differences in Thermometer Use Categories among Short-term and Longer-term Thermometer Owners for WIC Telephone and Written Evaluation Participants

4

1

-1 -1-3

108

0

-11-9

-15

-10

-5

0

5

10

15

Frequency of Thermometer Use

Diff

ernc

e in

Num

ber

of O

bser

ved

Recently OwnedOwned for Some Time

Kruskal-Wallis Test (p = 0.695) non-significant

Alm

ost Alw

ays

Most of the Tim

e

Half the Tim

e

Sometim

es

Never

134

Figure 3. Participants Stratified by the Stages of Change

05

1015202530354045

Pre-co

ntempla

tion

Contem

platio

n

Prepara

tion

Action

Mainten

ance

Stages

Perc

enta

gePre-contemplationContemplationPreparationActionMaintenance

135

Figure 4. WIC Evaluation Participants Stratified by Level of Education and Stages of Change Classification*

0

10

20

30

40

50

60

Pre-Con

templa

tion

Contem

platio

n

Prepara

tion

Action

Mainten

ance

Stages

Perc

enta

ge o

f Par

ticip

ants

<High School DegreeHigh School DegreeSome College≥Bachelor's Degree

*Stages of Change (Prochaska, 2008) χ2 (DF=12) 25.587 (p = 0.012).

136

Figure 5. WIC Evaluation Participants Stratified by Gender in the Stages of Change Model*

0

10

20

30

40

50Pre-

Contem

platio

n

Contem

platio

n

Prepara

tion

Action

Mainten

ance

Stages

Perc

enta

ge o

f Par

ticip

ants

Male Female

*Stages of Change (Prochaska, 2008) χ2 (DF=4) 9.575 (p = 0.048)

137

Figure 6. WIC Evaluation Participation by Delivery Mode

Mail12%

Web69%

Phone19%

MailWebPhone

138

Figure 7. WIC Evaluation Participants Stratified by Delivery Mode and Education Level

0102030405060708090

Mail Phone Web

Mode

Perc

enta

ge o

f Par

ticip

ants

<High School DegreeHigh School DegreeSome College≥Bachelor's Degree

χ2 (DF=6) 19.764 (p = 0.003)

139

APPENDIX A—Participating Counties

Listing of counties in Washington State with WIC offices participating in the “160°F for your Family” campaign and evaluation

1. Adams

2. Benton

3. Clallam

4. Cowlitz

5. Grant

6. Island

7. Jefferson

8. Klickitat

9. Lewis

10. Lincoln

11. Okanogan

12. Pierce

13. Spokane

14. Wallla Walla

15. Whatcom

16. Whitman

17. Yakima

140

APPENDIX B – WIC Thermometer Educational Materials

141

APPENDIX B--WIC Thermometer Educational Material

142

APPENDIX B--WIC Thermometer Educational Material

143

APPENDIX C – Written Format of Evaluation tool for WIC Participants

144

APPENDIX C – Written Format of Evaluation tool for WIC Participants

145

APPENDIX C – Written Format of Evaluation tool for WIC Participants

146

APPENDIX C – Written Format of Evaluation tool for WIC Participants

147

APPENDIX C – Written Format of Evaluation tool for WIC Participants

148

APPENDIX C – Written Format of Evaluation tool for WIC Participants

149

APPENDIX C – Written Format of Evaluation tool for WIC Participants

150

APPENDIX C – Written Format of Evaluation tool for WIC Participants

151

APPENDIX C – Written Format of Evaluation tool for WIC Participants

152

APPENDIX C – Written Format of Evaluation tool for WIC Participants

153

APPENDIX C – Written Format of Evaluation tool for WIC Participants

154

APPENDIX C – Written Format of Evaluation tool for WIC Participants

155

APPENDIX C – Written Format of Evaluation tool for WIC Participants

156

APPENDIX C – Written Format of Evaluation tool for WIC Participants

157

APPENDIX C – Written Format of Evaluation tool for WIC Participants

158

APPENDIX C – Written Format of Evaluation tool for WIC Participants

159

APPENDIX D – Survey announcement card distributed with packet of educational materials to the WIC audience

160

APPENDIX E – Thank you letter and reminder follow-up card for mail survey

DATE Mary A. WIC 100 Main Street Twin Falls, ID 00000 Dear Mary A. WIC, The University of Idaho’s Social Science Research Unit, in conjunction with the School of Family and Consumer Sciences at the University of Idaho and the Departments of Nutrition and Exercise Metabolism and Food Science at Washington State University, is conducting a study about the effectiveness of a food thermometer educational campaign. You have been included in this study because you contacted the University of Idaho to receive a written survey regarding the food thermometer campaign. In order for the results to truly represent ground beef consumers in Washington, it is important that the survey be completed to the best of your ability. You must be at least 18 years of age or older AND cook ground beef patties in your home. Results from the survey will be used to evaluate the effectiveness of our educational materials developed and to see if a behavior change has occurred in regards to food thermometer use. If successful, the materials designed for this campaign will be made available for consumers and the promotion of food thermometer use will continue through the University of Idaho and Washington State University. The information you provide will be completely confidential; neither your name nor any identifying information will be connected to the data you provide. This study has been approved by the Internal Review Board at the University of Idaho. The survey will take about 10 minutes to complete and you may omit any questions if you wish. Because we value your feedback, we are including a $10 gift card to Wal-Mart or Safeway. Once the study is complete, the final report will be available on both the SSRU website (http://agls.uidaho.edu/ssru) and the “160°F For Your Family” website (/). If you have any questions about the survey, you may call the Social Science Research Unit toll-free at 1-877-542-3019. Thank you for your help! Your participation is greatly appreciated!

161

Sincerely, Jana Curry Graduate Student, Research Assistant Exercise Science and Metabolism, College of Pharmacy Washington State University

162

Appendix E-- Thank you and reminder card

Thank you and reminder card-WIC Date Last week a written survey was mailed to you seeking your thoughts and opinions about a food thermometer educational campaign. You were mailed this survey because you requested one from the University of Idaho’s Social Science Research Unit. If you have already completed and returned the survey, we thank you and truly appreciate your help! If you haven’t completed this survey, please do so today. We would appreciate your feedback because this is the only way we can really see if the food thermometer campaign was effective and enjoyed by people like yourself. This is how we can make changes to the educational materials about using a food thermometer so that more people will be receptive to them. If you did not receive the survey, or if you need a new survey, please don’t hesitate to call us toll free at 1-877-542-3019. We will get one in the mail to you today. Thank you, Jana Curry Graduate Student, Research Assistant Exercise Science and Metabolism, College of Pharmacy Washington State University

163

APPENDIX F – Training material for SSRU staff delivery of the telephone format 160 °F For You Family: Food Thermometer Survey - Two types of thermometers that we are asking about in this survey:

Dial and Digital Instant Read Food Thermometers (excludes oven safe roast, oven, and candy thermometers)

OUR FOCUS Not Discussing

Dial Digital

- Pointer Display - Bimetallic Coil Sensor - 2 to 2.5 inch sensing area at the tip of the probe

- Digital display front - Thermistor Sensor - ½ inch sensing area at the tip of the probe

OVEN SAFE - ROAST: roast thermometers usually have larger display heads and may be oven safe.

OVEN: These thermometers are safe to be used in the oven while product is cooking.

CANDY: Used for making candies and jams.

164

Appendix F-- Frequently Asked Questions about Thermometer Use

“160 for your family” Thermometer Surveys (AFS and WIC versions) FAQ

Q. When will I receive my incentive (gift card)? A. Your gift card will be sent to you within 4 weeks of taking the survey. Q. AFS: Can I use my gift card at any Associated Food Store? OR How do I know which stores I can use this gift card? A: Your gift card can be used at a number of stores that carry the Western Family brand of groceries (see list of gift card stores). If the store you picked up your recipe card(s) and/or brochure at does not accept Western Family Gift Cards, then we will give you a gift certificate for the store you shopped at. Q. WIC: Where can I use my gift card? A. You can use your gift card at any Wal-Mart or Safeway (Carrs, Dominick’s, Genuardi’s, Pavilions, Randalls, Tom Thumb, and Vons). Q. Do I have to participate in the follow-up survey? (Associated Food Stores only!) A. You do not have to participate in the follow-up survey. However, we would greatly appreciate your help and will provide an incentive for completing this survey as well. By completing the follow-up survey, you are giving us an opportunity to compare results over a three month time period to see if any behavior changes have been maintained over time. Q. When will I be contacted again for the follow-up survey? (Associated Food Stores only!) A. If you agree to participate in the follow-up survey and would like to receive another gift card, the University of Idaho will contact you in about three months from today’s date. Q. What will you use this information for? A. We will be using the data we gather from this survey to evaluate the effectiveness of the food thermometer campaign and will also be assessing whether or not there was any behavior change in regards to thermometer use. This information will also help us to better develop educational materials about using a food thermometer when cooking hamburger patties. Q. Will you sell my contact information? A. We will not sell or use your contact information for any other purpose besides this survey. All your personal information will be kept confidential and stored safely and securely. Q. How long will this survey take? A. This survey should take approximately 10 minutes of your time.

165

Q. What kind of questions will you ask? A. This survey will be asking you questions about the food thermometer campaign that was in Associated Food Stores throughout Idaho or in Women, Infants, Children (WIC) or Public Health Offices in Washington State this summer. Questions will ask about the educational materials on the display, your use of a food thermometer, your thoughts and feelings towards thermometer use, and will finish with some general demographic questions. Q. Where can I buy a thermometer? A. You can buy a dial or digital food thermometer at most grocery stores, kitchen specialty stores, hardware stores, department stores, and Drug/Variety Stores.

166

APPENDIX G – Web delivery mode survey introduction

“160°F For Your Family” Food Thermometer Survey WEB Introduction

Women, Infants, Children (WIC) Version Did you pick up the educational materials from a grocery store or a Women, Infants, and Children (WIC) office? then link to appropriate survey introduction. Hello and thank you for visiting our website to complete this survey. To help us gather the most accurate information you must be 18 years of age or older AND cook hamburger patties in your home.

This survey includes questions about a food thermometer educational campaign that was in your local Women, Infants, and Children (WIC) office or public health office this summer. This survey has been approved by the Internal Review Board at the University of Idaho. It is voluntary and if you come to any question you would prefer not to answer, just skip over the question and proceed to the next. We’d like to assure you that your responses will be kept confidential. Because we value your feedback, you will receive a $10 gift card to Wal-Mart or Safeway for your participation in this study. ____________________________________________________________________________

ASK AT END OF SURVEY

Where would you like to receive your gift card from? _____Wal-Mart _____Safeway

167

Appendix G—Telephone delivery mode survey introduction

“160°F For Your Family” Food Thermometer Survey PHONE Introduction

Women, Infants, Children (WIC) Version Note instructions in italics are for interviewers and are not read. When person calls in ask:

• Did you pick up the educational materials from a grocery store or a Women, Infants, and Children (WIC) office? then branch into appropriate introduction

-_________________________________________________________________________ Hello, my name is _______________ and I’m calling from the Social Science Research Unit at the University of Idaho. We are calling about a food thermometer educational campaign that was in your local Women, Infants, and Children (WIC) office or public health office this summer. I would like to speak to someone in your household who is 18 years of age or older AND cooks hamburger patties in your home. Would this happen to be you?

Yes, proceed with survey No, ask to speak to an adult who cooks hamburger patties or thank them

for their time and terminate call

This interview takes about 10 minutes on average. The survey includes questions about the packet of materials regarding use of food thermometers when cooking hamburger patties that you recently picked up. Because we value your feedback, you will receive a $10 gift card to Wal-Mart or Safeway for participating in this study. This interview is voluntary and has been approved by the Internal Review Board at the University of Idaho. If we come to any question you would prefer not to answer, just let me know and I’ll skip over it. I’d like to assure you that your responses will be kept strictly confidential. Do you have any questions before we begin? ____________________________________________________________________________

. ASK AT END OF SURVEY

Where would you like to receive your gift card from? _____Wal-Mart _____Safeway

168

APPENDIX H – Survey Question 1, “Other” Responses (Categorized by Type) Materials were handed to them: Handed to them WIC worker handed it to them Handed to them Women handed it to them at WIC Given to them at WIC Given Someone handed it to me Someone handed it to me It was right on the counter Handed to them Handed to them Handed to them Someone gave it to her Handed to them Given materials Handed to them Handed to them Handed the materials Handed to them Handed to them Handed to them Handed to them Given to her Handed to her WIC person gave it to them Handed materials Handed materials Handed materials Handed packet Gave it to her Handed to them Handed to them Handed to them Handed to them Handed to them Handed to them Handed information Handed to them Handed to them Given Materials Was given materials Women gave her the materials Handed to them The receptionist handed to them Handed to them by the WIC staff The materials were given to me by my WIC nurse it was given to me by a worker i got it from the lady at wic It was given to me by WIC office personnel. WIC employee handed it to me I was given the materiels from a WIC employee WIC staff gave it to me

169

WIC representative It was handed to me The WIC lady gave me the brochure WIC Office a woman at WIC gave it to me I mentioned making the kids hamburgers and she handed me them from her desk. Wic receptionist gave it to me I was given the brochure from the W.I.C. Provider Given to me by employee I didn't see a display my case worker handed me the handouts given pamphlet by WIC someone handed for pamphlet to me I was given the information by my wic worker they gave me the paperwork WIC staff gave me the information. I got the papers from wic. the brochures were given to me Was given to me at WIC appointment I got it from my WIC office I was given them by the wic provider. it was handed to me This was in a packet handed out. the lady gave them to me It was given to me. My WIC rep handed it to me wic handed it tome The pamphlets were handed to me. a nurse gave me the packet IT WAS GIVEN TO ME BY THE LADIES IN THE OFFICE WHEN I RECIEVED MY CHECKS someone handed to me the lady at the front desk gave me one the wic lady handed it to me They handed it to me given the info from the wic employee WAS GIVEN SOME HANDOUTS it was handed to me at wic they handed it to me The receptionist I was given the information by WIC Staff. was presented to me by a wic certifier it was just handed to me Directed to the materials: Recommended by WIC personel nurse at the office pointed it out display was shown to me Staff suggestion The WIC lady showed me it The Nurse Pointed It Out. WIC employee pointed it out wic counselor pointed it out The nurse asked me if i had seen this wic office brought it to my attention the lady at the wic office told me about it Was asked to take the survey Was asked if she wanted to take the survey

170

I did not approach it They reccomended me to take the survey Earning $10: Earning 10$ 10$ Coupon For the 10$ Gift card 10 dollars 10 dollars 10 dollars 10 dollars 10$ gift certificate Sign would you like to earn $10 The $10 gift card 10$ gift card The $10.00 gift card a sign that said "ask me how you can earn a $10 card to safeway or walmart" Note on WIC sign in computer saying "ask us how you can get a $10.00 gift card 'Would you like to earn $10?' Noticed the materials: Read and thought it looked interesting Was the first thing I saw when I came in (it was on a table) Card found in magazine Saw it and picked it up curiosity Thinking of my childs safety as I seen the thermometer Obtained the materials outside of WIC: Friend gave it to her Daughter left materials at his house, handed it to her a friend friend told me about the survey Someone that visits WIC gave them to me. Photograph: Baby on pamphlet the sleeping baby Message: And the message "You already use one of these..." Everything on the display: All of it All

171

APPENDIX I – Additional participant comments* provided in the comment box at the end of the survey or conveyed to the SSRU staff over the telephone (Categorized by type) Mechanics with the materials: I had trouble reading the cartoon on the brochure, it was too small and hard to read. Did not get the entire packet. I received this packet from someone that goes to WIC. I am not associated with WIC. Ownership and Use of thermometer: Use to own a food thermometer. I will use it in all my meat. I will bye me a food thermometer so I can start testing my food. I am going to buy a thermometer with the certificate. Some of the questions in this survey were hard to answer. Before I read the information I never used the thermometer but have used it once or twice since reading the information. So I don’t know if... Some of the questions were sort of difficult to answer, because I just received the packet today. I have never used a thermometer to check hamb., but think I will now when it’s convenient, 4wise I’ll... I never had used a food thermometer for cooking hamburgers before, they always ended up kinda over-cooked. I am definitely using one now, to make sure my family is safe, and that the burgers are still... I never used a mea thermometer for hamburger patties befour< i will and do now everytime!! It’s hard to remember to use a thermometer when cooking unless its pork i always remember. I have been using a thermometer in most of my cooking for years. It is the only sure-fire way to ensure hambergers, fish, chicken, and pork products are properly cooked. Thank you for this info it was helpful and actually made me go and buy a theremometer. Thank you i now know how to really use a thermometer with patties just from lookng at your website, thank. i have told my famile and friends im sure their going to start using one too. I am a nurse working closely with WIC Staff. I appreciate this information and think it will help us to be safer when cooking meats. I will definitely buy a thermometer and use it. I’ve read about the use of themeter when cooking and have always wanted to buy one. Importance: After I read the info you sent, I realize how really important having one is. I have a meat thermometer and a candy one too. I think its important to use them for any meat you cook.

172

That this information on the packets is really helpfull and hopefully it will get more familys to use a thermometer when cooking hamburger patties, as i do now. I think that if even one child or adult doesn’t lose their health due to e-coli, it is money well spent. WIC privides alot of useful information on imporatnt things we need to know. Technical: Tell people how to use a thermometer....take the patty off direct heat first...or not..etc. I found the information on the handouts helpful, especially the picture of how to insert the thermometer into the hamburger very helpful. Since burgers at 160 are too done for me, you could talk about if you like them rarer, after cooking let the burger rest (like a steak) to continue cooking until it reaches 160. The website explained the proper way to use a food thermometer to check hamburger patties, but the packet did not. The packet was great in communicating the importance of using a thermometer, but people... Accurately using thermometers can be difficult. I like the photo of the thermometer and tongs because it shows how to insert the thermometer into the meat. The photo with the hand blocks the view of... It can be trickier when using a dial metal stem thermometer. Encourage digitals because they are so much easier and more accurate with thin foods. A quick bit on cross contamination might be beneficial... It easy to check the hamburger and 4 meat with the thermomter. I rather be safe then get sick with E coli and the burgers were not burned! Knowledge: Q37 – doesn’t know. Use to think it was 150 degrees for hamburger before she got the materials. The materials were informative. I had no idea that meat needed to be cooked to a specific temperature to be safe. I appreciate the pamplet as I did not even think about using a thermometer to check the temp...and I didn’t know the temp that a hamburger should be cooked to. Appreciation: Thank you for sharing this wonderful helpful survey and gift card. Thank you. Thank you for providing open brochures availible to read and keep my family safe from undercooked patties! It was interesting knowing thermometer use for hamburger, no idea of it, thank you. The gift card will help me afford a food thermometer. Thank you! Thanks for making aware of the dangers. Thank you for making my family and I aware of the importance to check our hamburger patties with a thermometer, we never have before, but will start with our next BBQ. Thank you for keeping my friend... Thank you for the thermometer info and making food safe.

173

Thank you for the information...I always use a thermometer 4 meat; I appreciate the reminder to use it for hamburgers as well. Thanks for the info. Thank you for this opportunity. Your info was really helpfull thanks. This information is helpful and new to me I enjoyed learning something new that will prevent my family from becoming ill thanks a million! Good info, keep up the good work. Other: The Gov’t should focus more on making sure the plants where meat is butchered and cut are sanitary, and educate people on storing meat also. I know where my meat is butchered and cut and wrapped...

174