ABSTRACT

Consumers do not consider flour, a low-moisture food product, a high risk for microbial contamination. In the past 10 years, however, flour has been identified as a source of pathogenic bacteria, including Salmonella and Escherichia coli. Online surveys were conducted to study consumers' flour handling practices and knowledge about food safety risks related to flour. The survey also evaluated message impact on three food safety messages in communicating information and convincing consumers to adopt safe flour handling practices. Flour-using consumers (n = 1,045) from the United States reported they used flour to make cakes, cookies, and bread. Most consumers stored flour in sealed containers. Less than 1% kept a record of product identification numbers, such as lot numbers, and less than 11% kept brand and use-by date information. Many consumers (85%) were unaware of flour recalls, or outbreaks, and few (17%) believed they would be affected by flour recalls or outbreaks. If the recall affected the flour they bought, nearly half of the consumers (47%) would buy the same product from a different brand for a few months before they returned to the recalled brand. Among consumers who use flour to bake, 66% said they ate raw cookie dough or batter. Raw dough “eaters” were more difficult to convince to avoid eating and playing with raw flour than “noneaters.” Food safety messages were less impactful on those raw dough eaters than noneaters. Compared with the food safety message with only recommendations, those messages with recommendations and an explanation as to the benefits of the practice were more effective in convincing consumers to change their practices. These findings provide insight into effective consumer education about safe flour handling practices and could assist in the accurate development of risk assessment models related to flour handling.

HIGHLIGHTS
  • Most consumers were not aware that raw dough and batter may be a source of foodborne pathogens.

  • Most consumers were not aware of flour or flour product recalls.

  • More than half of flour-using consumers ate raw dough or batter.

  • Messages explaining why a practice was recommended were more effective than listing the practice.

  • Consumers preferred messages be placed at an obvious location, such as the middle of the package.

Flour has not been considered a source of pathogens historically, due to the inability of bacteria to grow in this product. However, pathogenic bacteria have been isolated from wheat flour samples and associated with flour and flour product foodborne outbreaks and recalls. Myoda et al. (57) surveyed U.S. wheat at harvest and found Salmonella and Escherichia coli in 1.23 and 0.44% of the samples, respectively. Six foodborne outbreaks were linked to wheat flour and flour products in the United States and Canada since 2009, sickening nearly 200 people with Salmonella and E. coli (44). The contaminated flour was in a wide range of products, including cookie dough, quick-bread mix, pizza dough, cake batter, frozen pot pies, and lasagna. Although the previous examples of recalled flour products were commercially prepared, similar homemade products could also be vehicles of foodborne pathogens, if using contaminated flour. As of 2019, multiple flour recalls from well-known flour brands occurred in the United States (7779). Consumers expect flour to be safe, and most are unaware of outbreaks or recalls associated with flour products (11). Consumers' improper flour handling practices, such as eating raw cookie dough and making homemade play dough, pose food safety risks. A national survey conducted almost 30 years ago reported 27% of consumers consumed cookie dough (47). More recent data reporting consumer flour handling and flour food safety knowledge has not been published.

The U.S. Food and Drug Administration (FDA) and Centers for Disease Control and Prevention published recommendations for consumers when handling flour, including not eating raw dough and batter, washing hands with soap after handling flour, and separating raw flour from ready-to-eat foods to prevent cross-contamination (26, 75). The flour industry has developed consumer educational materials, and several brands have started to include food safety messages and instructions on packages to inform consumers (5, 37, 58). The North American Millers' Association developed a voluntary food safety message for its members: “Raw flour is not ready-to-eat and must be thoroughly cooked before eating to prevent illness from bacteria in the flour. Do not eat or play with raw dough; wash hands, utensils, and surfaces after handling” (6). Food safety education effectiveness and message impact on general safe food handling practices were measured previously (15, 28, 35). At the time of this study, no evaluation data has been published to assess the message impact of flour safety communication on consumers' knowledge, attitudes, and behavior intention change.

To address this information gap, an online survey was conducted to understand consumers' flour handling practices and knowledge about food safety risks related to flour and to evaluate the message impact of three food safety messages in communicating information and convincing consumers to adopt safe flour handling practices. The research questions were the following: (i) What are consumers' flour handling practices? (ii) What is the consumer's knowledge about food safety risks related to flour? (iii) How do the current food safety messages, on flour product packages, impact consumers' flour handling behavior intent?

MATERIALS AND METHODS

Pilot study

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).

Flour handling questions

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.

Message evaluation questions

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.

IMC and demographic questions

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.

Data analysis

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

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.

RESULTS

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.

TABLE 1

Demographic characteristics of survey participants (n = 1,045)

Demographic characteristics of survey participants (n = 1,045)
Demographic characteristics of survey participants (n = 1,045)

Flour usage and storage

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.

Food safety awareness

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%).

Awareness and practices during flour recalls

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).

TABLE 2

Consumers' report of flour recall practices and knowledge (n = 1,045)

Consumers' report of flour recall practices and knowledge (n = 1,045)
Consumers' report of flour recall practices and knowledge (n = 1,045)

Food safety message location and message impact

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.

TABLE 3

Eater and noneater perception of message effectiveness (n = 999)a

Eater and noneater perception of message effectiveness (n = 999)a
Eater and noneater perception of message effectiveness (n = 999)a

DISCUSSION

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).

Flour recalls

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 (2224). 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.

Communicating flour safety to consumers

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).

ACKNOWLEDGMENTS

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

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

REFERENCES

1.
Ajzen,
I.
1985
.
From intentions to actions: a theory of planned behavior
,
p.
11
39
.
In
Kuhl
J.
and
Beckmann
J.
(ed.),
Action control: from cognition to behavior
.
Springer
,
Berlin
.
2.
Allan,
P. D.,
Palmer
C.,
Chan
F.,
Lyons
R.,
Nicholson
O.,
Rose
M.,
Hales
S.,
and
Baker
M. G.
2018
.
Food safety labelling of chicken to prevent campylobacteriosis: consumer expectations and current practices
.
BMC Public Health
18
:
414
.
3.
Anduiza,
E.,
and
Galais
C.
2017
.
Answering without reading: IMCs and strong satisficing in online surveys
.
Int. J. Public Opin. Res
.
29
:
497
519
.
4.
Apaolaza,
V.,
Hartmann
P.,
Echebarria
C.,
and
Barrutia
J. M.
2017
.
Organic label's halo effect on sensory and hedonic experience of wine: a pilot study
.
J. Sens. Stud
.
32
:
e12243
.
5.
Ardent Mills
.
2019
.
Flour food safety
.
6.
Ardent Mills
.
2019
.
Flour food safety: 10 FAQs and answers
.
7.
Arnade,
C.,
Kuchler
F.,
and
Calvin
L.
2012
.
Consumers' response when regulators are uncertain about the source of foodborne illness
.
J. Consum. Policy
36
:
17
36
.
8.
Bakhtavoryan,
R.,
Capps,
O.
Jr
., and
Salin
V.
2012
.
Impact of food contamination on brands: a demand systems estimation of peanut butter
.
Agric. Res. Econ. Rev
.
41
:
327
339
.
9.
Barrett,
T.,
and
Feng
Y.
2020
.
Content analysis of food safety implications in online flour-handling recipes
.
Br. Food J
.
123:1024–1041.
10.
Becker,
M. W.,
Bello
N. M.,
Sundar
R. P.,
Peltier
C.,
and
Bix
L.
2015
.
Front of pack labels enhance attention to nutrition information in novel and commercial brands
.
Food Policy
56
:
76
86
.
11.
Beecher,
C.
2019
.
Consumers need wake-up call about potential dangers of flour
.
Food Safety News
,
Seattle
.
12.
Belasco,
W.
2008
.
Food: the key concepts
.
Berg
,
Oxford
.
13.
Benedict,
J.
2013
.
Poisoned: the true story of the deadly E. coli outbreak that changed the way Americans eat
.
February Books
,
New York
.
14.
Berinsky,
A. J.,
Margolis
M. F.,
and
Sances
M. W.
2014
.
Separating the shirkers from the workers? Making sure respondents pay attention on self-administered surveys
.
Am. J. Polit. Sci
.
58
:
739
753
.
15.
Besson,
T.,
Lalot
F.,
Bochard
N.,
Flaudias
V.,
and
Zerhouni
O.
2019
.
The calories underestimation of “organic” food: exploring the impact of implicit evaluations
.
Appetite
137
:
134
144
.
16.
Bigouette,
J. P.,
Bethel
J. W.,
Bovbjerg
M. L.,
Waite-Cusic
J. G.,
Häse
C. C.,
and
Poulsen
K. P.
2018
.
Knowledge, attitudes and practices regarding raw milk consumption in the Pacific Northwest
.
Food Prot. Trends
38
:
104
110
.
17.
Bix,
L.,
Lockhart
H.,
Cardoso
F.,
and
Selke
S.
2003
.
The effect of color contrast on message legibility
.
J. Des. Commun
.
5
.
18.
Bix,
L.,
Lockhart
H.,
Selke
S.,
Cardoso
F.,
and
Olejnik
M.
2003
.
Is x-height a better indicator of legibility than type size for drug labels?
Packag. Technol. Sci
.
16
:
199
207
.
19.
Bix,
L.,
Sundar
R. P.,
Bello
N. M.,
Peltier
C.,
Weatherspoon
L. J.,
and
Becker
M. W.
2015
.
To see or not to see: do front of pack nutrition labels affect attention to overall nutrition information?
PLoS One
10
:
e0139732
.
20.
Bruhn,
C. M.
2014
.
Chicken preparation in the home: an observational study
.
Food Prot. Trends
34
:
318
330
.
21.
Buffer,
J.,
Kendall
P.,
Medeiros
L.,
Schroeder
M.,
and
Sofos
J.
2013
.
Nurses and dietitians differ in food safety information provided to highly susceptible clients
.
J. Nutr. Educ. Behav
.
45
:
102
108
.
22.
Centers for Disease Control and Prevention
.
2008
.
Multistate outbreak of Salmonella Saintpaul infections linked to raw produce
.
23.
Centers for Disease Control and Prevention
.
2009
.
Multistate outbreak of Salmonella Typhimurium infections linked to peanut butter, 2008–2009
.
24.
Centers for Disease Control and Prevention
.
2012
.
Multistate outbreak of listeriosis linked to whole cantaloupes from Jensen Farms, Colorado
.
25.
Centers for Disease Control and Prevention
.
2019
.
CDC food safety alert: E. coli O26 outbreak linked to flour
.
26.
Centers for Disease Control and Prevention
.
2019
.
Say no to raw dough!
Available at: https://www.cdc.gov/features/no-raw-dough/index.html. Accessed 28 October 2019.
27.
Channaiah,
L. H.,
Michael
M.,
Acuff
J. C.,
Phebus
R. K.,
Thippareddi
H.,
Olewnik
M.,
and
Milliken
G.
2017
.
Validation of the baking process as a kill-step for controlling Salmonella in muffins
.
Int. J. Food Microbiol
.
250
:
1
6
.
28.
Chapman,
B.,
Eversley
T.,
Fillion
K.,
MacLaurin
T.,
and
Powell
D.
2010
.
Assessment of food safety practices of food service food handlers (risk assessment data): testing a communication intervention (evaluation of tools)
.
J. Food Prot
.
73
:
1101
1107
.
29.
Chen,
H.,
Martinez
V.,
and
Feng
Y.
2020
.
Food safety education attitude and practice among health professionals in China, Peru, and the US
.
Food Control
109
:
106945
.
30.
Danyluk,
M. D.,
Jones
T. M.,
Abd
S. J.,
Frank
S.-D.,
Jacobs
M.,
and
Harris
L. J.
2007
.
Prevalence and amounts of Salmonella found on raw California almonds
.
J. Food Prot
.
70
:
820
827
.
31.
Danyluk,
M. D.,
Uesugi
A. R.,
and
Harris
L. J.
2005
.
Survival of Salmonella Enteritidis PT 30 on inoculated almonds after commercial fumigation with propylene oxide
.
J. Food Prot
.
68
:
1613
1622
.
32.
Du,
W.-X.,
Danyluk
M. D.,
and
Harris
L. J.
2010
.
Efficacy of aqueous and alcohol-based quaternary ammonium sanitizers for reducing Salmonella in dusts generated in almond hulling and shelling facilities
.
J. Food Sci
.
75
:
M7
M13
.
33.
Feng,
Y.,
and
Bruhn
C.
2019
.
Motivators and barriers to cooking and refrigerator thermometer use among consumers and food workers: a review
.
J. Food Prot
.
82
:
128
150
.
34.
Feng,
Y.,
Bruhn
C.,
and
Health Management and Education
.
2016
.
Food safety education for people with diabetes and pregnant women: a positive deviance approach
.
Food Control
66
:
107
115
.
35.
Feng,
Y.,
Bruhn
C.,
and
Marx
D.
2016
.
Evaluation of the effectiveness of food irradiation messages
.
Food Prot. Trends
36
:
272
283
.
36.
Feng,
Y.,
Bruhn
C. M.,
Elder
G.,
and
Boyden
D.
2019
.
Assessment of knowledge and behavior change of a high school positive deviance food safety curriculum
.
J. Food Sci. Educ
.
18
:
45
51
.
37.
Food Safety Strategies
.
2019
.
Flour food safety: FAQs and answers
.
Available at: https://www.foodsafetystrategies.com/articles/606-flour-food safety-faqs-and-answers. Accessed 25 October 2019.
38.
Forghani,
F.,
den Bakker
M.,
Liao
J.-Y.,
Payton
A. S.,
Futral
A. N.,
and
Diez-Gonzalez
F.
2019
.
Salmonella and enterohemorrhagic Escherichia coli serogroups O45, O121, O145 in wheat flour: effects of long-term storage and thermal treatments
.
Front. Microbiol
.
10
:
323
.
39.
Frelka,
J. C.,
and
Harris
L. J.
2015
.
Evaluation of microbial loads and the effects of antimicrobial sprays in postharvest handling of California walnuts
.
Food Microbiol
.
48
:
133
142
.
40.
Goodall,
C.,
and
Appiah
O.
2008
.
Adolescents' perceptions of Canadian cigarette package warning labels: investigating the effects of message framing
.
J. Health Commun
.
23
:
117
127
.
41.
Grasso,
E. M.,
Grove
S. F.,
Halik
L. A.,
Arritt
F.,
and
Keller
S. E.
2015
.
Cleaning and sanitation of Salmonella-contaminated peanut butter processing equipment
.
Food Microbiol
.
46
:
100
106
.
42.
Hallman,
W. K.,
Cuite
C. L.,
and
Hooker
N. H.
2009
.
Consumer responses to food recalls: 2008 national survey report. RR-0109-018
.
Food Policy Institute
,
Rutgers, The State University of New Jersey, New Brunswick
.
43.
Harris,
L. J.,
Uesugi
A. R.,
Abd
S. J.,
and
McCarthy
K. L.
2012
.
Survival of Salmonella Enteritidis PT 30 on inoculated almond kernels in hot water treatments
.
Food Res. Int
.
45
:
1093
1098
.
44.
Harris,
L. J.,
and
Yada
S.
2019
.
Flour and cereal grains-outbreaks and recalls: foodborne illness outbreaks and product recalls
.
45.
International Food Information Council Foundation
.
2018
.
Food & health survey: consumer attitudes towards food safety, nutrition & health
.
Available at: https://www.foodinsight.org/2018-food-and-health-survey. Accessed 15 March 2019.
46.
Jacob,
C.,
Mathiasen
L.,
and
Powell
D. A.
2010
.
Designing effective messages for microbial food safety hazards
.
Food Control
21
:
1
6
.
47.
Klontz,
K. C.,
Timbo
B.,
Fein
S.,
and
Levy
A.
1995
.
Prevalence of selected food consumption and preparation behaviors associated with incrased risks of foodborne disease
.
J. Food Prot
.
58
:
927
930
.
48.
Kuchler,
F.
2015
.
How much does it matter how sick you get? Consumers' responses to foodborne disease outbreaks of different severities
.
ERR-193. Economic Research Service
,
U.S. Department of Agriculture
,
Washington, DC
.
49.
Lee,
L.,
Metz
D.,
Giovanni
M.,
and
Bruhn
C.
2011
.
Consumer knowledge and handling of tree nuts: food safety implications
.
Food Prot. Trends
31
:
18
-
27
.
50.
Limcharoenchat,
P.,
James
M. K.,
and
Marks
B. P.
2019
.
Survival and thermal resistance of Salmonella Enteritidis PT 30 on almonds after long-term storage
.
J. Food Prot
.
82
:
194
199
.
51.
Liu,
S.,
Tang
J.,
Tadapaneni
R. K.,
Yang
R.,
and
Zhu
M.-J.
2018
.
Exponentially increased thermal resistance of Salmonella spp. and Enterococcus faecium at reduced water activity
.
Appl. Environ. Microbiol
.
84
:
e02742-17.
52.
Ma,
J.,
Almanza
B.,
Ghiselli
R.,
Vorvoreanu
M.,
and
Sydnor
S.
2017
.
Food safety information on the Internet: consumer media preferences
.
Food Prot. Trends
37
:
247
255
.
53.
Markham,
L.,
Auld
G.,
Bunning
M.,
and
Thilmany
D.
2014
.
Attitudes and beliefs of raw milk consumers in northern Colorado
.
J. Hunger Environ. Nutr
.
9
:
546
564
.
54.
Mditshwa,
A.,
Magwaza
L. S.,
Tesfay
S. Z.,
and
Mbili
N.
2017
.
Postharvest quality and composition of organically and conventionally produced fruits: a review
.
Sci. Hortic
.
216
:
148
159
.
55.
Milosavljevic,
M.,
and
Cerf
M.
2015
.
First attention then intention
.
Int. J. Advert
.
27
:
381
398
.
56.
Morrison,
E.,
and
Young
I.
2019
.
The missing ingredient: food safety messages on popular recipe blogs
.
Food Prot. Trends
39
:
28
39
.
57.
Myoda,
S. P.,
Gilbreth
S.,
Akins-Lewenthal
D.,
Davidson
S. K.,
and
Samadpour
M.
2019
.
Occurrence and levels of Salmonella, enterohemorrhagic Escherichia coli, and Listeria in raw wheat
.
J. Food Prot
.
82
:
1022
1027
.
58.
North American Millers' Association
.
2017
.
Grain milling industry releases new consumer educational food safety video for wheat flour: proper handling and baking of flour eliminates food safety risk
.
59.
Oliveira,
D.,
Machín
L.,
Deliza
R.,
Rosenthal
A.,
Walter
E. H.,
Giménez
A.,
and
Ares
G.
2016
.
Consumers' attention to functional food labels: insights from eye-tracking and change detection in a case study with probiotic milk
.
LWT - Food Sci. Technol
.
68
:
160
167
.
60.
Oppenheimer,
D. M.,
Meyvis
T.,
and
Davidenko
N.
2009
.
Instructional manipulation checks: detecting satisficing to increase statistical power
.
J. Exp. Soc. Psychol
.
45
:
867
872
.
61.
The Partnership for Food Safety Education
.
n.d.
Safe recipe styleguide
.
Available at: https://www.saferecipeguide.org/why/. Accessed
28
October
2019
.
62.
Seo,
S.,
Jang
S.,
Almanza
B.,
Miao
L.,
and
Behnke
C.
2014
.
The negative spillover effect of food crises on restaurant firms: did Jack in the Box really recover from an E. coli scare?
Int. J. Hosp. Manag
.
39
:
107
121
.
63.
Shamon,
H.,
and
Berning
C. C.
2020
.
Attention check items and instructions in online surveys with incentivized and non-incentivized samples: boon or bane for data quality?
Surv. Res. Methods
14
:
55
77
.
64.
Simon,
M.
2011
.
Jack in the box surprise: how E. coli became a household word
.
65.
Spink,
J.,
Singh
J.,
and
Singh
S. P.
2011
.
Review of package warning labels and their effect on consumer behaviour with insights to future anticounterfeit strategy of label and communication systems
.
Packag. Technol. Sci
.
24
:
469
484
.
66.
Syamaladevi,
R. M.,
Tang
J.,
Villa-Rojas
R.,
Sablani
S.,
Carter
B.,
and
Campbell
G.
2016
.
Influence of water activity on thermal resistance of microorganisms in low-moisture foods: a review
.
Compr. Rev. Food Sci. Saf
.
15
:
353
370
.
67.
Taylor,
M. H.,
Tsai
H.-C.,
Rasco
B.,
Tang
J.,
and
Zhu
M.-J.
2018
.
Stability of Listeria monocytogenes in wheat flour during extended storage and isothermal treatment
.
Food Control
91
:
434
439
.
68.
Terpstra,
M. J.,
Steenbekkers
L. P. A.,
de Maertelaere
N. C. M.,
and
Nijhuis
S.
2005
.
Food storage and disposal: consumer practices and knowledge
.
Br. Food J
.
107
:
526
533
.
69.
Thomas,
M.,
and
Feng
Y.
2020
.
Risk of foodborne illness from pet food: assessing pet owners' knowledge, behavior, and risk perception
.
J. Food Prot
.
83
:
1998
2007
.
70.
Tsai,
H.-C.,
Taylor
M. H.,
Song
X.,
Sheng
L.,
Tang
J.,
and
Zhu
M.-J.
2019
.
Thermal resistance of Listeria monocytogenes in natural unsweetened cocoa powder under different water activity
.
Food Control
102
:
22
28
.
71.
Tyko,
K.
2019
.
E. coli outbreak linked to Aldi flour after 17 ill; flour recalled in 11 states
.
72.
Uesugi,
A. R.,
Danyluk
M. D.,
Mandrell
R. E.,
and
Harris
L. J.
2007
.
Isolation of Salmonella Enteritidis phage type 30 from a single almond orchard over a 5-year period
.
J. Food Prot
.
70
:
1784
1789
.
73.
U.S. Food and Drug Administration
.
1977
.
Food for human consumption; food labeling; final rule
.
Fed. Regist
.
42
:
14308
14315
.
74.
U.S. Food and Drug Administration
.
1999
.
Over-the-counter human drugs; labeling requirements; final rule
.
Fed. Regist
.
64
:
13254
13303
.
75.
U.S. Food and Drug Administration
.
2017
.
Raw dough's a raw deal and could make you sick
.
76.
U.S. Food and Drug Administration
.
2018
.
Identifynig recalled products
.
77.
U.S. Food and Drug Administration
.
2019
.
General Mills recalls five pound bags of gold medal unbleached all purpose flour
.
78.
U.S. Food and Drug Administration
.
2019
.
Hometown Food company recalls two production LOT codes of Pillsbury® unbleached all-purpose 5lb flour due to possible health risk
.
79.
U.S. Food and Drug Administration
.
2019
.
In cooperation with ADM Milling Co., Hometown Food company issues voluntary recall of specific lot codes Pillsbury® best bread flour due to possible health risk
.
80.
Varela,
P.,
Antúnez
L.,
Cadena
R. S.,
Giménez
A.,
and
Ares
G.
2014
.
Attentional capture and importance of package attributes for consumers' perceived similarities and differences among products: a case study with breakfast cereal packages
.
Food Res. Int
.
64
:
701
710
.
81.
Wedel,
M.,
and
Pieters
R.
2008
.
A review of eye-tracking research in marketing
,
p.
123
147
.
In
Malhotra
N. K.
(ed.),
Review of marketing research, 4th ed
.
Emerald Group Publishing
,
Bingley, UK
.
82.
Weinstein,
N. D.
1989
.
Optimistic biases about personal risks
.
Science
246
:
1232
1234
.
83.
Wigg,
S.,
and
Stafford
L. D.
2016
.
Health warnings on alcoholic beverages: perception of the health risks and intentions towards alcohol consumption
.
PLoS One
11
:
e0153027
.
84.
Wittenberger,
K.,
and
Dohlman
E.
2010
.
Impacts of the 2008-09 foodborne illness outbreak linked to Salmonella in peanuts. OCS-10a-01
.
Economic Research Service
,
U.S. Department of Agriculture,
Washington, DC
.
85.
Wong,
S.,
Marcus
R.,
Hawkins
M.,
Shallow
S.,
McCombs
K. G.,
Swanson
E.,
Anderson
B.,
Shiferaw
B.,
Garman
R.,
Noonan
K.,
and
Van Gilder
T.
2004
.
Physicians as food safety educators: a practices and perceptions survey
.
Clin. Infect. Dis
.
38
:
212
218
.
This is an open access article under the CC BY-NC-ND license (https://creativecommons.org/licenses/by-nc-nd/4.0/)

Supplementary data