Consumer Knowledge and Behaviors Regarding Food Safety Risks Associated with Wheat Flour

Before data collection, the research protocol was approved by the institutional review board at Purdue University. The survey was reviewed by two food safety experts in consumer research for clarity, comprehensiveness, and establishing content validity. The survey was then distributed to 194 participants to pilot test the face validity and reliability. Twenty-five participants met all criteria and answered instructional manipulation checks (IMC) correctly. The criteria and IMC were presented in the following paragraphs. Cronbach's α was calculated for internal consistency. The flour handling questions Cronbach's α was between 0.89 and 0.92. The pilot study revealed some wording issues, including an overly complicated vocabulary. The researchers reworded the questions accordingly and lowered the readability level to grades 5 and 6 (on the basis of readabilityformulas.com).

The survey focused on four wheat flour types: all-purpose flour, whole wheat flour, bread flour, and quick-bread mix containing flour. “Quick-bread mix” was defined as cake, cookie, biscuit, pancake, muffin, or brownie mix. For each type of flour, questions addressed how the flour was obtained, stored, and consumed. Information on how consumers acquired and stored flour was accessed through multiple-choice questions. Consumers were asked if they had heard of flour-related foodborne recalls or outbreaks and if the information would affect the flour handling and/or purchase intent during and/or after the recalls or outbreaks were over. They were also asked questions to assess knowledge and risk perception of flour handling, including (i) what food products they believed to have a microbial food safety risk; (ii) what risk level they perceived for themselves to contract foodborne illnesses; and (iii) whether they would purchase flour associated with a recall or outbreak. Consumers were asked if they ate raw cookie dough or batter. Those who answered “never” were referred to as “noneaters” and those that answered “rarely,” “sometimes,” and “always,” were referred to “eaters.” The measurement domains, number of items, and the response format are not described in the “Materials and Methods” section because all instruments are presented in Supplemental Material.

A review of flour product packages (143 packages from 22 brands) for sale by a supermarket chain in West Lafayette, IN, in 2019, revealed the current food safety messages and placement on flour product packages. The current messages were categorized into two groups: containing only the recommendations and containing recommendations and why the recommendations should be followed. The most frequently used message was selected from each group and was evaluated in the survey. Therefore, two of three messages being evaluated were the current messages from flour packages. The third message was developed by the authors to include recommendations, reasons, and the benefits. In this study, only the message content was evaluated. The font size, contrast, and design of the food safety messages varied from brand to brand. Thus, when evaluating the messages, the images on flour packages were not used. Each participant evaluated all three messages, but the order of messages being evaluated were randomized. The randomization was to reduce the biases of the cumulative effect of the messages. After reading each message, participants were asked one question to evaluate the message's effectiveness of preventing consumers from eating or playing with flour, dough, or batter. Eaters were asked two more questions to evaluate the message impact: “due to this message, I will not eat raw dough or batter”; and “this message can remind me not to eat or play with flour, dough or batter.” All message impact qeustions were measured on a 7-point Likert scale, where 1 = extremely ineffective and 7 = extremely effective.

Preferred placement of safety and handling messages was also evaluated. The three placements of food safety messages were presented in figures: on the top of the package; in the middle of the package; and on the side of the package. Consumers were asked to select the figure that showed the preferred message location.

Two questions were developed to detect the participants' level of disengagement. In this article, we referred those questions to IMC. Previous studies showed some online survey respondents had disengaged behaviors and did not pay attention when filling out the questions (14, 60). IMC questions were inserted in the middle of the questions. For example, in a check-all-that-apply question about flour handling, one of the items was “if you are paying attention, check this item.” If the participants did not pay attention, their answers on the entire survey were not included in the final analysis. Thus, IMC questions were used as additional screeners to improve the quality of the study.

Demographic questions were asked at the end of the survey. Consumers were required to answer every question before moving to the next question. The survey contained 72 questions. The number of questions for each individual varied due to the logic flow of the survey. For example, if the participant only used “all-purpose flour,” then he or she would not see questions about whole wheat flour, bread flour, and quick-bread mix. On average, the survey took approximately 15 min to complete.

When downloading data, Qualtrics XM (Provo, UT) converted the response to numerical values for data analysis. Data were analyzed by using Excel 2016 (Microsoft Corporation, Redmond, WA) for descriptive analysis and SPSS, version 9.4 (Chicago, IL) for Student's t test and one-way analysis of variance (ANOVA). Statistical significance was determined at P < 0.05. Logistic regression was used between different groups in some demographic categories to see the strength in association of attention to flour packages and responding practices to flour recalls. The output of the logistic regression included a change in the odds ratio (OR) or the exponential function of the regression coefficient (⁠\(\def\upalpha{\unicode[Times]{x3B1}}\)\(\def\upbeta{\unicode[Times]{x3B2}}\)\(\def\upgamma{\unicode[Times]{x3B3}}\)\(\def\updelta{\unicode[Times]{x3B4}}\)\(\def\upvarepsilon{\unicode[Times]{x3B5}}\)\(\def\upzeta{\unicode[Times]{x3B6}}\)\(\def\upeta{\unicode[Times]{x3B7}}\)\(\def\uptheta{\unicode[Times]{x3B8}}\)\(\def\upiota{\unicode[Times]{x3B9}}\)\(\def\upkappa{\unicode[Times]{x3BA}}\)\(\def\uplambda{\unicode[Times]{x3BB}}\)\(\def\upmu{\unicode[Times]{x3BC}}\)\(\def\upnu{\unicode[Times]{x3BD}}\)\(\def\upxi{\unicode[Times]{x3BE}}\)\(\def\upomicron{\unicode[Times]{x3BF}}\)\(\def\uppi{\unicode[Times]{x3C0}}\)\(\def\uprho{\unicode[Times]{x3C1}}\)\(\def\upsigma{\unicode[Times]{x3C3}}\)\(\def\uptau{\unicode[Times]{x3C4}}\)\(\def\upupsilon{\unicode[Times]{x3C5}}\)\(\def\upphi{\unicode[Times]{x3C6}}\)\(\def\upchi{\unicode[Times]{x3C7}}\)\(\def\uppsy{\unicode[Times]{x3C8}}\)\(\def\upomega{\unicode[Times]{x3C9}}\)\(\def\bialpha{\boldsymbol{\alpha}}\)\(\def\bibeta{\boldsymbol{\beta}}\)\(\def\bigamma{\boldsymbol{\gamma}}\)\(\def\bidelta{\boldsymbol{\delta}}\)\(\def\bivarepsilon{\boldsymbol{\varepsilon}}\)\(\def\bizeta{\boldsymbol{\zeta}}\)\(\def\bieta{\boldsymbol{\eta}}\)\(\def\bitheta{\boldsymbol{\theta}}\)\(\def\biiota{\\boldsymbol{\iota}}\)\(\def\bikappa{\boldsymbol{\kappa}}\)\(\def\bilambda{\boldsymbol{\lambda}}\)\(\def\\bimu{\boldsymbol{\mu}}\)\(\def\binu{\boldsymbol{\nu}}\)\(\def\bixi{\boldsymbol{\xi}}\)\(\def\biomicron{\boldsymbol{\micron}}\)\(\def\bipi{\boldsymbol{\pi}}\)\(\def\birho{\boldsymbol{\rho}}\)\(\def\bisigma{\boldsymbol{\sigma}}\)\(\def\bitau{\boldsymbol{\\tau}}\)\(\def\biupsilon{\boldsymbol{\upsilon}}\)\(\def\biphi{\boldsymbol{\phi}}\)\(\def\bichi{\boldsymbol{\chi}}\)\(\def\bipsy{\boldsymbol{\psy}}\)\(\def\biomega{\boldsymbol{\omega}}\)\(\def\bupalpha{\bf{\alpha}}\)\(\def\bupbeta{\bf{\beta}}\)\(\def\bupgamma{\bf{\gamma}}\)\(\def\bupdelta{\bf{\delta}}\)\(\def\bupvarepsilon{\bf{\varepsilon}}\)\(\def\bupzeta{\bf{\zeta}}\)\(\def\bupeta{\bf{\eta}}\)\(\def\buptheta{\bf{\theta}}\)\(\def\bupiota{\bf{\iota}}\)\(\def\bupkappa{\bf{\kappa}}\)\(\def\\buplambda{\bf{\lambda}}\)\(\def\bupmu{\bf{\mu}}\)\(\def\bupnu{\bf{\nu}}\)\(\def\bupxi{\bf{\xi}}\)\(\def\bupomicron{\bf{\micron}}\)\(\def\buppi{\bf{\pi}}\)\(\def\buprho{\bf{\rho}}\)\(\def\bupsigma{\bf{\sigma}}\)\(\def\buptau{\bf{\tau}}\)\(\def\bupupsilon{\bf{\upsilon}}\)\(\def\bupphi{\bf{\phi}}\)\(\def\bupchi{\bf{\chi}}\)\(\def\buppsy{\bf{\psy}}\)\(\def\bupomega{\bf{\omega}}\)\(\def\bGamma{\bf{\Gamma}}\)\(\def\bDelta{\bf{\Delta}}\)\(\def\bTheta{\bf{\Theta}}\)\(\def\bLambda{\bf{\Lambda}}\)\(\def\bXi{\bf{\Xi}}\)\(\def\bPi{\bf{\Pi}}\)\(\def\bSigma{\bf{\Sigma}}\)\(\def\bPhi{\bf{\Phi}}\)\(\def\bPsi{\bf{\Psi}}\)\(\def\bOmega{\bf{\Omega}}\)\({e^b}\)⁠) for each demographic category. This change was the OR associated with 1 unit increase of the exposure. The OR was the odds that an outcome will occur, given a particular exposure, compared with the outcome occurring without the exposure. In this study, the outcome was whether consumers had a specific practice, and the exposure was the group in each demographic category. If the OR was less than 1, then one group was less likely to have the practice. If the OR was 1, then the exposure did not affect the odds. If OR was greater than 1, then one group was more likely to practice the behavior than the other group was.

Participants were recruited in May 2019 from an online consumer panel of Qualtrics XM, an external online survey company. Qualtrics XM sent invitations to participants across the United States either via e-mail or to the respondents' panel portal. The researchers paid Qualtrics XM for access to a sample that was aligned to specific demographics. Qualtrics XM partnered with sample providers and had access to a pool of 90 million participants who could respond to the survey. All participants agreed to be contacted by sample providers to respond to the survey. The support team ensured that participants received an incentive to complete the entire survey. Qualtrics XM worked with Rybbon Inc. (McLean, VA), a partner that simplifies the process of incentives management. We did not inquire what the incentives were, but they were adequate for the participants to volunteer.

Participant selection criteria included the following: (i) the primary food handler of the household; (ii) the primary grocery shopper of the household; and (iii) use of wheat flour or quick-bread mix containing wheat flour at least once a month. In addition, quotas for demographic characteristics were set by the researchers to mirror the U.S. population. Due to challenges in recruiting participants, we loosened the criteria of gender. However, the other characteristics, including age, ethnicity groups, and state residents were considered to be representative.

Although 6,837 consumers completed the survey, only 4,399 (64%) met all three inclusion criteria, and 1,045 of these passed both IMC attention questions. This article only reports results from these participants (n = 1,045) who completed the survey, met all inclusion criteria, and passed both IMC questions. Most (63%) were female, one-third (37%) were ages 35 to 54, 60% were white, non-Hispanic, and 28% reported the household included children ages 5 years or younger (Table 1). Participants' geographic locations covered 48 states, with no participants from Alaska and Wyoming.

Most consumers used flour recipes from cookbooks, but some, especially young adults (18 to 24 years old), relied on YouTube and blogs. More than half (64%) of the young adults used YouTube videos, and 31% used blogs (data not presented in tables). Almost all participants (89%) used all-purpose flour, and more than half (62%) used quick-bread mix (Table S1). Whole wheat flour and bread flour were used by 28 and 21% of participants, respectively. Almost all consumers purchased flour in the grocery store, usually buying two boxes of quick-bread mix (42%), and 1 to 2 lb (0.45 to 0.91 kg) of flour (all-purpose, bread, and whole wheat; >30%). The length of time flour remained in the household varied by type of flour: 2 weeks to 1 month for quick and bread flour and 1 to 6 months for all-purpose flour. Most participants reported using flour to make cakes, muffins, cookies, and bread. A small number (n = 46; 5%) did not use flour to make dough or batter, so those participants were not asked if they ate raw dough or batter.

Most participants stored flour in sealed containers at room temperature, while one-fifth stored flour in its original package (Table S2). More than 68% stored flour at room temperature, regardless of whether they put the flour into a container. Among those who used sealed containers, less than 1% kept product lot identification numbers, and less than 11% kept brand and use-by date information. This group said they washed sealed containers before and after use.

Though participants perceived raw chicken, ground beef, and eggs as likely to pose a microbiological food safety risk (64 to 76%), raw dough (bread and cookie) and batters were at a slightly lower percentage (39 to 56%), and raw noodles were seen as a risk by only 26% of participants. Only 15% of consumers recognized all these foods (including raw nuts and raw produce) could pose microbiological contamination risks (Table S2).

Consumers considered themselves as knowledgeable about food safety (83%) and were confident of flour handling practices (85%). Half agreed the risk of contracting a foodborne illness was low compared with an average person of their sex and age. Although most reported they followed recommended safe flour handling practices, including washing hands, less than half of those who cleaned counters had a sanitizing step (46%), and only a quarter said they used soap (28%). Cleaning and sanitizing countertops after flour handling is one of the safe flour handling practices.

Regarding raw cookie dough or batter, over 70% of consumers recognized people could contract a foodborne illness from eating raw cookie dough and that harmful bacteria could travel on flour from different surfaces to foods. Among consumers who lived with young children, nearly one-fifth allowed their children to play with (17%) or taste (18%) the raw dough or batter. Of those who used flour to make dough or batter (n = 999), one-third said they never ate or played with the raw product. We categorized those respondents in the noneaters group (n = 336; 34%) and the rest in the eaters group (n = 663; 66%).

Overall consumer awareness of flour recalls was low: most (85%) had never heard of a food recall related to flour or quick-bread mix; less than one-third (29%) believed a recalled product could be sold in the grocery stores in which they shop; and only 15% thought the flour products they used had the possibility of being recalled. Despite the general lack of awareness about flour recalls, most (70%) said they would check the brand and lot number if they heard about a recall. One-fifth (22%) would throw away the flour, no matter if it was related to the recall, and 16% would advise friends and family to stay away from all flour. Only 3% of consumers said they did not care about the recalls and would continue using the flour. If they discovered the flour was part of a food recall, most consumers would throw it away, and one-third would return it to the store. Less than a third would clean and sanitize the kitchen surfaces that came into contact with the flour.

Consumers' behavioral intentions about product and brand loyalty revealed that nearly half (47%) would buy the same product manufactured by a different brand for a few months before returning to the recalled brand. Some (13%) said they would never buy the same product from this brand, while a few (9%) said they would never even buy other products from this brand. Those who would never buy the same product from this brand were more common among men, participants with a higher educational level, younger than age 65 years, participants living with children, and eaters (Table S4). Even if the recall did not involve the brand or type of the flour they bought, consumers would still react to the recall. Some would stop buying the product for a few months even after the recall was over, and a few would quit buying the product altogether (Table 2).

Only 22% of consumers said they paid attention to food safety messages on flour packages. Older adults (65 years old and older) and participants who do not consume raw dough, noneaters, were more likely to pay attention to those messages (Table 3). When asked where they wanted to see caution notices about food safety messages, consumers wanted the messages to be displayed at an obvious place on flour packages, The “middle of the package” was selected by half of the respondents, followed by “top of the package” (34%) and “on the side of the package” (14%). When asked who was responsible to communicate to consumers that raw flour may contain bacteria that can make people sick, most respondents answered the flour company (71%) and government (42%), followed by health professionals (26%; Table S2).

Consumers who used flour to make dough or batter were asked to assess the message impact of the three food safety messages (Table 3). Consumers believed that the message that included the recommendations, explanations of the practices, and the benefits of practicing these recommendations, as the most effective in preventing people from eating or playing with raw flour products. Noneaters perceived all messages to be significantly more effective than eaters (Student's t test, P < 0.05). The most effective message for all participants also convinced eaters to quit eating raw dough or batter, with a mean score of 5.05 on a 7-point scale (ANOVA, P < 0.05). The mean scores were compared among other demographic groups, but no statistical significance was found.

Wheat flour is a raw and minimally processed product that can be contaminated with pathogens if it is not subject to further treatment. Previous research demonstrated that although low-moisture foods do not support the growth of most pathogenic microorganisms, such as Salmonella and E. coli, a pathogen can survive sufficient time and in sufficient numbers to cause illness (30, 38). Forghani et al. (38) found that pathogenic E. coli and Salmonella in flour could be enumerated for 12 and 16 weeks, respectively, at room temperature, which was the condition that most consumers reported storing flour in this study. Myoda et al. (57) surveyed U.S. wheat at harvest and found Salmonella and E. coli in 1.23 and 0.44% of the samples, respectively. Once these pathogens are present, they are difficult to eliminate due to increased persistence (27, 31, 50, 51, 72), significantly enhanced thermal resistance (43, 66, 67, 70), and limitations of existing sanitation solutions (32, 39, 41). Despite these dangers, many consumers in this study did not consider flour to be a food product that poses a food safety risk.

This phenomenon was also reported in other consumer survey studies. Less than a quarter of pet owners considered dry pet foods as a potential source of foodborne pathogens (69). In another study, only one-tenth of consumers believed people could contract foodborne illness from eating sesame seed products (49).

Two factors contributed to consumers' low-risk perception of low-moisture foods. First, foodborne outbreaks associated with low-moisture foods were not widely reported until recently. Many consumers started to be cautious of ground beef after the 1993 Jack in the Box outbreak, which was widely reported and used as a case study in many food safety books and publications (13, 62, 64). Second, the “halo effect” of certain foods could lead consumers to overlook food safety risks. Consumers tend to link flour with baking goods, which is often associated with positive feelings. The perceived halo of flour made consumers less worried about its food safety risks. Previously, the halo effect of organic foods was reported to mislead consumers on the perceived sensory experiences and calorie estimations (4, 15, 54). Similarly, raw milk consumers favored potential health and taste benefits over potential food safety risks (16, 53).

In addition to the lack of awareness of flour's food safety risks, consumers were also unaware of flour recalls. The current study reported that 85% of participants had never heard of flour recalls or outbreaks, which confirmed the results from a prior consumer survey, where only 15 and 4% of consumers had heard of outbreaks of salmonellosis associated with peanut butter and sesame seed products, respectively (49). Although this study was conducted in 2019, there have been several recalls and outbreaks associated with flour products contaminated by E. coli O121 and Salmonella since 2017 (44).

Government agencies and the media reported food recalls and outbreaks via multiple media channels (25, 71), but the information still was not retained by consumers. Among those who had heard of the flour recalls, most received the information from televison news, social media, and government agencies' Web sites. More participants said they learned of the recalls through social media (e.g., Facebook) rather than government agencies' official Web sites. This finding contradicted a previous study, which investigated consumers' online media preference for food safety information, and reported that despite the great potential of social media, Web sites were generally the preferred platform to receive information (52). The discrepancies can be explained by differences in survey question design. The current study's only social media example was Facebook, while the FDA's official Web site was the only example of a government agency Web site. The Ma et al. study (52), however, used broader definitions of social media and Web sites.

Consumers responded to food recalls or outbreaks by reducing the purchase of the product, regardless of whether the issue affected the products they had purchased. Consumers reported they would slowly return to purchasing the recalled product after the recall was over. These findings were confirmed by consumers' responses to previous outbreaks: a 2008 tomato outbreak, a 2009 peanut butter outbreak, and a 2011 cantaloupe outbreak (22–24). In response to those incidents, consumers reduced purchases of tomatoes, peanut butter, and cantaloupes temporarily. Wittenberger and Dohlman's (84) study of a 2009 peanut butter outbreak reported that consumer purchases slowed as the scope of the recalls spread.

Over time, retail sales recovered slowly (7, 8, 48). However, consumers' responses to food recalls and outbreaks may also be affected by consumers' perceived vulnerability and media coverage. An empirical study found that in the 2011 Listeria cantaloupe recall, consumers purchased significantly fewer cantaloupes than a similar recall associated with Salmonella in the following year (48). The study's researchers suggested consumers considered Listeria to be a higher risk of contracting than Salmonella, which contributed to the different consumer response.

Beyond these challenges, consumers' storage practices make it challenging for them to identify whether the flour in home kitchens is part of a recall. In a food recall, consumers were advised to check the products they purchased by brands, lot numbers, and dates (76). This study showed that most consumers stored flour in sealed containers and discarded the packages with information used to trace products. The findings supported a previous consumer survey that found that very few consumers had ever located a recalled food product, even if many had searched for it (42).

Food-related behaviors may be the result of complex interactions among three competing considerations: the consumer's “identity,” matters of “convenience,” and a sense of “responsibility” (12). Consumers' storage practices could be explained by the three components proposed by Belasco (12). The identity component of this interaction was the perceived risk level associated with flour. In an earlier interview study, Terpstra et al. (68) revealed that consumers were more likely to practice hygienic storage when handling perceived higher-risk food, such as meat or dairy. Convenience referred to the habit of flour storage, learned from peers and family, and practiced for years. Responsibility, as explained by Belasco, was “an awareness of the consequences of what they eat” (12). In the context of flour storage, responsibility meant consumers' awareness of potential recalls associated with flour and awareness of the consequences of such a foodborne illness.

Three factors that could influence consumer handling of flour were examined: the content (what to present), the location (where to present), and the format (how to present). First, regarding content, this study found that messages with recommendations and an explanation of the benefits of practicing those recommendations were more likely to lead consumers to change their practices, compared with simply listing the recommendation. Previous studies reported that the rationale for recommendations is a significant feature of effective food safety communication. Feng et al. discovered that when communicating about food irradiation, the most effective message contained information about the benefits of choosing the technology (35). Chapman et al. (28) also suggested that messages regarding why safe handling is important could lead to safer food handling behaviors.

Although no extant studies have evaluated safe handling messages about flour, evaluation studies of cigarette and alcohol warning messages have been widely reported. Messages that were loss framed or associated with fear arousal were more effective in persuading consumers to avoid a behavior (40, 83). The three messages evaluated in this study were modified by using actual flour packages from the supermarket. They were all gain-framed messages, which means the messages focused on the positive aspects of abstaining from consuming or playing with raw flour. Unlike studies of cigarette or alcohol, flour safety warning messages were focused on guiding consumers to practice safe food handling, rather than asking consumers to abstain from purchasing flour products. Loss-framed messages being applied in flour safety communication, however, must be very carefully focused to maintain market demand and encourage recommended practices.

Regardless of whether the message was gain or loss framed, when developing communication content, it was always important to customize messages for the target audiences. This study found that consumers who never ate raw cookie dough were likely to continue that behavior after reading the messages than those who ate raw cookie dough. In this case, the food safety message reinforced the consumers' current practices. Convincing eaters to become noneaters is more challenging.

This study found that more noneaters compared with eaters believed recalled products could be sold at the stores at which they shopped often. Different beliefs and food handling practices segmented consumers into different groups with various levels of intervention resistance. Jacob et al reported that targeting a segment of the population and understanding the knowledge, attitudes, and perceptions of the individuals included in that segment can lead to more effective food safety education (46). A previous study also found that pregnant women and people with diabetes perceived food safety risks differently, and the effectiveness of the same education varied between the two groups (34), suggesting that additional research could examine the content of flour safety messages to address target audiences' intervention resistance.

The second aspect of flour safety communication being studied is the location of messages on packaging. Consumers reported they preferred food safety messages to be placed in the middle of the front or back of the flour packages. None of the packages reviewed had food safety messages placed on the front. Instead, the messages were placed in the back, on the side, or on top of the packages. Previous studies of nutrition labels found that information on the front of the package increased consumers' attention (10, 19).

This study did not evaluate the message impact in the context of other information on flour packages, such as brand and design. Previous studies suggested that health messages on packages had a limited impact on consumers' food decision making when being presented in the context of other information. Consumer eye-tracking studies reported that when there was abundant information on food packages, health information was less retained by consumers than brands and product names (59, 80). In the few seconds in which consumers made a product selection, they were less likely to retain all information available on packages (55). Therefore, a subset of the information was usually selected for further processing, whereas the remainder was not processed, and consumers were not aware of its presence on the label (81). Future research should be conducted to understand the impact of flour safety information in relation to other information offered on flour packages.

The third aspect of flour safety communication studied was message formatting on packages. The authors' review of packages in the supermarket revealed that contrast and font size rendered some food safety messages difficult to read. Font size and color were not evaluated in this study; however, others have reported poor display quality of poultry food safety information on packaging (2). Drug-labeling evaluation studies showed that the type, size, and color contrast of the labels affected readability (17, 18). A review paper of warning label effectiveness noted that “vividness-enhancing characteristics,” including contrast and font size, were significant factors contributing to the effectiveness of messages influencing consumers' decision making (65). To regulate the readability of over-the-counter drug fact labels and nutrition panel labels, the FDA published rules (73, 74). Future flour safety communications can benefit from lessons learned from other health information and labeling best practices.

In moving beyond packaging, consumers expected flour companies, the government, and health professionals to communicate that raw flour may contain foodborne pathogens. Consumers regarded health professionals (physicians, pharmacists, dietitians, or nurses) to be the most trustworthy sources of food safety information (45). However, health professionals do not always deliver food safety information to patients (29), and many are not confident about their own food safety knowledge (85). Even when patients initiated the topic of food safety themselves, only around 40% of registered dietitians and registered nurses provided food safety education (21). This suggests that although health professionals are a trusted source of information, they do not appear to be actively engaging in food safety education.

Most consumers perceived themselves to be knowledgeable and were confident of their safe food handling practices, though there have been few observational studies to validate consumers' self-reported flour handling. Previous observation studies of other safe food handling practices suggested consumers' actions did not always reflect their knowledge, and they often overrated the practices in self-reported surveys (20, 33, 36). Some researchers termed this phenomenon “optimism bias” (82). They suggested that when developing food safety education materials, behavioral change models should be used to address consumers' attitudes and perceived behavior controls, especially for consumers who believed they knew how to handle food safely (1).

Despite a careful design process, this study still has some limitations. Consumers volunteering for this study were recruited online to obtain a representative sample of the U.S. population. Although it is assumed the respondents represent flour-using consumers, in general, there may be differences in lifestyle and flour handling practices between this sample and the general population. Moreover, specific subgroups could also have differing views about foodborne illness, risk perception of food items, and food safety messages in contrast to those expressed by the study sample. For example, although respondents were asked about risk perception of food items, the consumption of those foods was not collected. Future research can focus on understanding the determinants of consumers' risk perception of food. Further, this study is based on self-reported behavior, not actual observation. Unfortunately, a large percentage of participants did not pass the quality check questions (IMC). Many factors may be related to the passing rate of IMC, such as the length and the context of the survey (3, 63). Future research is needed to understand more about the quality of online survey responses. Finally, as this study only evaluated the impact of message content, there are situations that were not considered in the assessment. For example, if the message is on the top of the package, the message effectiveness will be affected, after the package is opened from the top. Future studies will consider evaluating the effectiveness of flour messages on real packages.

In summary, this study found that many consumers were not aware of flour recalls or outbreaks and had eaten raw cookie dough or batter. Food safety messages explaining why to practice and the benefits of practicing flour handling recommendations were more effective than the recommendation-only message in convincing consumers to change practices and in communicating the information. Consumers preferred the message be placed at an obvious location on the package. These findings provide insight into effective consumer education about safe flour handling practices and could assist in the accurate development of risk assessment models. On the basis of these findings, the authors recommend the following.

A critical need exists to develop more flour food safety education and communication programs for consumers. Consumers do not perceive flour and flour products as posing food safety risks. The flour handling practices may increase the risk of foodborne illness due to raw dough eating and improper sanitation. Food safety education programs for consumers should include information about flour-related risks and proper handling during a recall.

Message impact, accessibility, and readability of food safety messages on flour packages should be considered by both flour manufacturers and policy makers. Consumers want those messages printed in a more obvious location on the packages, and the content of those messages matters. Messages should be developed to include the recommended practice, explanation of why the practice is important, and the benefits of practicing the recommendations.

Flour food safety information should be adopted in recipes and cooking shows. To achieve a behavior change, consumers need reminders of recommended practices. Previous studies (9, 56) showed that popular recipes often lack food safety messages. Guidelines for social media influencers and cooking show hosts can be developed, such as the “Safe Recipe Styleguide” by The Partnership for Food Safety Education (61).

We thank the following individuals for expertise and assistance: Dr. Christine Bruhn, a retired extension specialist from the University of California, Davis; and Han Chen and Tressie Barrett, graduate student researchers at Purdue University. This material is partially supported by the National Institute of Food and Agriculture, U.S. Department of Agriculture, Hatch projects (1016049, 2020-68012-31822, and 2017-67012-26119).

Supplemental material associated with this article can be found online at: https://doi.org/10.4315/JFP-19-562.s1; https://doi.org/10.4315/JFP-19-562.s2