6
Communicating with Aging Populations

Food Forum member Edward Groth of Groth Consulting Services, Pelham, New York, opened this session by identifying two major challenges to communicating about food safety and nutrition with aging populations. First, having come from a background filled with “miscommunication about toxic chemicals and food safety,” he said that communication often fails because while the expert community assumes that all it has to do is “explain the wonderful science … and the public will fall in line,” this is not the case. Changing behavior is difficult, and it is important to know where the public is coming from. Kirkwood touched on this theme in his presentation during an earlier session, which is summarized in Chapter 5, as did several of the speakers in this session. Second, Groth cautioned that the number of newspapers regularly reporting science has decreased by more than two-thirds over the past 20 years or so, and magazines are “folding left and right.” He said that some people have described the current science communication environment as a “science communication crisis.”

He then introduced the first of four speakers for this session, Steven Bodhaine of The Futures Company, Chapel Hill, North Carolina. Bodhaine spoke about communication from a consumer perspective, emphasizing the importance of engaging consumers in a personal way. He described the results of a study aimed at understanding what motivates behavior change in older adult consumers. Caroline Smith DeWaal of the Center for Science in the Public Interest (CSPI), Washington, DC, discussed how consumers hear about and respond to food recall messages and outlined lessons learned



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6 Communicating with Aging Populations F ood Forum member Edward Groth of Groth Consulting Services, Pelham, New York, opened this session by identifying two major challenges to communicating about food safety and nutrition with aging populations. First, having come from a background filled with “mis- communication about toxic chemicals and food safety,” he said that com- munication often fails because while the expert community assumes that all it has to do is “explain the wonderful science . . . and the public will fall in line,” this is not the case. Changing behavior is difficult, and it is important to know where the public is coming from. Kirkwood touched on this theme in his presentation during an earlier session, which is sum- marized in Chapter 5, as did several of the speakers in this session. Second, Groth cautioned that the number of newspapers regularly reporting sci- ence has decreased by more than two-thirds over the past 20 years or so, and magazines are “folding left and right.” He said that some people have described the current science communication environment as a “science communication crisis.” He then introduced the first of four speakers for this session, Steven Bodhaine of The Futures Company, Chapel Hill, North Carolina. Bodhaine spoke about communication from a consumer perspective, emphasizing the importance of engaging consumers in a personal way. He described the re- sults of a study aimed at understanding what motivates behavior change in older adult consumers. Caroline Smith DeWaal of the Center for Science in the Public Interest (CSPI), Washington, DC, discussed how consumers hear about and respond to food recall messages and outlined lessons learned 0

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0 PRoVIdIng HEAltHy And SAFE FoodS AS WE AgE from recent food recalls. She emphasized the need to consider on-the-spot messaging as a way to reach older adults when urgent food safety infor- mation needs to be communicated. William Hallman of the Food Policy Institute (FPI) at Rutgers University, New Brunswick, New Jersey, discussed results of several FPI surveys aimed at understanding how people interpret and respond to food recalls. He echoed other calls to make food safety com- munication personal, and he also emphasized the importance of sending specific messages about what actions consumers should take. Finally, Ronni Chernoff of the Geriatric Research Education and Clinical Center, John L. McClellan Memorial Veterans Hospital, Little Rock, Arkansas, discussed health literacy in general and described key elements of effective written and oral health communication. She emphasized the importance of reinforcing key messages when communicating about food safety and nutrition. The session ended with a lengthy discussion with the audience. There were many questions about food recall compliance and how to improve food recall communication, the concept of opt-out strategizing (which Bod- haine had mentioned during his talk as a strategy for motivating behavioral change), the concept of “persuade by reason, motivate by emotion” (which Bodhaine had also introduced), the use of symbols to communicate food safety information, and the challenge of sending simple messages about complicated situations. CONSUMER DESIRES, NEEDS, AND MOTIVATIONS Presenter: Steven Bodhaine Bodhaine began by remarking that he hoped his talk would be some- what provocative and that the ideas and material he would be presenting were based on considerable consumer research: The Futures Company has been tracking consumer behavior for 40 years. He emphasized that health is not the center of most people’s lives, and health communication is “competing for attention in a very cluttered world.” In fact, he said, “I would submit that we are beyond clutter. We have actually entered an era of market resistance, where consumers are taking active measures to avoid our communication.” He argued further, “The era of mass marketing is over. It is dead. We can no longer expect to send a single message and hope that it will have resonance with our target audience.” The 2009 Health and Wellness Segmentation Study Bodhaine walked the workshop audience through some of what he and his colleagues have learned from their 2009 Health and Wellness Segmen- tation Study aimed at understanding what motivates behavior change in

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 CoMMUnICAtIng WItH AgIng PoPUlAtIonS consumers, particularly around health and wellness. The study was Wave 3 of the Yankelovich Health and Wellness Segmentation Study and included 6,000 U.S. respondents aged 18 and older. Participants were asked to fill out a 50-minute web-based questionnaire, and data were weighted by age, gender, income, education, and ethnicity. The study was based on the no- tion that people are taking different journeys through life, and understand- ing those journeys can aid in communicating more effectively and in a way that motivates behavior change. The study identified six types of journeys: • leading the Way (traditional, responsible, and proactive): 10 percent of study participants were identified as leading the Way. Health is a core value for these people, and most of them have normal body mass index (BMI), do not smoke, care about what they eat and drink, exercise regularly, and see a physician. Bodhaine described leading the Way people as having an internal locus of control and a future orientation, firmly believing that they can take charge and make a difference both now and in the future. Health communica- tions to leading the Way people work: they listen to messages such as “Be careful with what you eat in order to avoid future incidence of cancer.” • In It for Fun (sporty, wealth-oriented, driven): 17 percent of study participants were identified as In it for Fun. While In It for Fun people exercise, care about their weight, and watch what they eat, though their efforts have nothing to do with health. They value “looking good and feeling fine.” Exercise is part of their social fab- ric. They enjoy competition, and they want to be at the top of their game in order to reach their goals and meet their ambitions. In It for Fun people are not motivated by the same messages that lead- ing the Way people are, even though both types espouse healthful lifestyles. • Value Independence (ambitious, hardworking, leisure-less): 19 per- cent of study participants were identified as Value Independence. These are the “do-it-yourselfers,” people who have lost faith in sci- ence, organized medicine, and the voice of the expert. They are tired of confusing, conflicting, and contradictory messaging, and because they are savvy, they have concluded that they can “do it themselves.” They have access to information on the Internet, which they search diligently and judiciously. The challenge is that they are blinded by what they do not know. They have an attitude of profound cynicism. Many Value Independence people have a difficult time managing weight. They struggle to find “the solution” that ultimately works.

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 PRoVIdIng HEAltHy And SAFE FoodS AS WE AgE On average, they each have four chronic conditions. Because they have embraced the value of virtual health and place more confidence in the empathetic voice of a third party than they do in their physi- cian, Bodhaine said that communicating with them poses a “very interesting challenge.” • I need a Plan (traditional, home-oriented, and self-assured): 20 per- cent of study participants were identified as I need a Plan. Individu- als in this “undisciplined” group of people are exceedingly pleasant, Bodhaine said, “absolutely committed to dieting until chocolate cake is served.” Whereas leading the Way and Value Independence people possess extraordinary internal loci of control, I need a Plan people do not. They go on and off diets and, while willing, “cannot get there alone.” They embrace and applaud every bit of nutritional information but do not apply it. Reaching this group of people re- quires checklists, coaching, follow up, and accountability. People in this group have five chronic conditions each, on average, and obesity is one of their biggest health challenges. • not Right now (entertainment, downtime, family): 24 percent of study participants were identified as not Right now. People in this group tend to be younger and have somebody in their family who, for example, “is 93 years old and has been smoking since she was seven” and with whom they share the same genes. They are generally healthy. Their indifference makes them difficult to reach, and furthermore, they are also ultra-pressed for time, rac- ing about to maintain a professional agenda while also raising young children. They don’t feel any sense of urgency to change their behavior, and they view exercise and better nutrition as something that they will pursue when their kids are grown. They respond “more to the stick than to the carrot.” They will not change their behavior unless they are absolutely pushed through the door and forced to change. • get through the day (cautious, handy, and cash-strapped): 11 per- cent of study participants were identified as get through the day. Most people in this group have struggled with poor health for much of their lives. They average six chronic conditions each. They are very dependent on physicians and other health care professionals. They have tried and stopped many things in an effort to improve their health. Medically, they are an expensive group because of extensive physician interaction and pharmaceutical intervention. Although they want to be in control, they cannot succeed on their own.

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 CoMMUnICAtIng WItH AgIng PoPUlAtIonS Bodhaine reiterated that people are taking different journeys through life and that, when it comes to communication, “one size does not fit all.” Importantly, the goal of communication is not just to deliver information. Bodhaine said, “The last thing the consumer needs is more information.” Consumers already know that they need to eat better, lose weight, stop smoking, etc., in order to improve their health. In 2005, when the Healthy and Wellness Segmentation Study was first conducted, two-thirds of Ameri- cans were identified as overweight, and one-third as obese; statistics that persisted in 2009. This was true despite the fact that the messages to eat better, lose weight, stop smoking, etc. were communicated repeatedly in the intervening years. Why? Bodhaine said, “I would contend that one of the reasons that health is so hard is because life has become so easy. We have to learn how to apply certain tools to get people to move.” Persuade Through Reason, Motivate Through Emotion While the language of science is persuasive, rarely does the public act in response to scientific information. Bodhaine said, “We persuade by reason, but we motivate through emotion.” He used units of measure- ment on food labels as an example of the type of scientific information that is often meaningless to consumers. While including “serving size” information on labels is a step forward, most consumers do not have any visual cues to understand what the designated serving size actually is. The opt-out 100-calorie packs have also been helpful, as the word “calorie” on a food label means nothing to most consumers. Even if someone eats three or four 100-calorie packs of Oreos, that is better than eating a whole box. Similarly, “grams” means very little to many consumers, with many people not knowing whether a gram is greater or less than an ounce. As a final example, words like “riboflavin” have about as much meaning as words like “octane.” Most people know that 93 octane costs more than 87 octane, but beyond that, most consumers have no idea what octane is. Many consumers interpret nutrition information in the same way. They use it to compare (e.g., “This has more than that.”), without any real understanding of whether the nutrient or product in question is healthful. Often, communicating solely on a rational platform is viewed as ar- gumentative and rarely motivates behavior change. Even though there is power in the language of science, communicators often find they need to back away from the science if they want to reach consumers. Bodhaine emphasized that science communicators must link science to emotion. On the other hand, communicating solely on an emotive platform is viewed as communicating “fluff” and being manipulative. The challenge is to connect

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4 PRoVIdIng HEAltHy And SAFE FoodS AS WE AgE the science with something that is personally relevant to the consumer and then deliver the information in a way that is going to motivate action. Older Adults and the 2009 Health and Wellness Segmentation Study Older adults (defined in this case as the 50–64, 65–74, and ≥ 75 years age groups) comprised 62 percent of the I need a Plan segment identified in the 2009 Health and Wellness Segmentation Study. They need to be pro- vided with checklists and guidance, and they need to be held accountable so that they are more fully engaged. With respect to providing guidance, Bodhaine remarked that many consumers (in all segments, not just I need a Plan) turn to four or five sources of information before making decisions about health. Much of this information is on the Internet. Yet when people go online, they tend to be “absolutely confused” by what they read. Creat- ing harmony among these multiple sources of information is a challenge. Bodhaine stressed the importance of consolidating this information into something meaningful and credible. Fortunately, older adults comprise 54 percent of the leading the Way segment, but this segment comprises only 10 percent of the U.S. population. Nonetheless, people in this group can be evangelical in their ability to help others make changes. In general, older adults tend to be more serious about their health than younger adults and do everything they can to remain well. For example, ac- cording to 2009 Health and Wellness Segmentation Study data, 75 percent of adults age 65 and over reported having a physical within the past year, compared to 55 percent of the total study population. Also, 53 percent of adults age 65 and over agreed with the statement, “I am very focused on my long-term health and work hard to make decisions every day that will positively influence my future and health and wellness,” compared to 44 percent of the total study population. Many younger adults think that health is important but have other priorities. Also, many younger adults believe that they have the power to change their health behaviors but they do not have the attention span—they have higher priorities. Bodhaine said that as people get older and no longer have the pressure of work and other elements, they have time to focus more on health. Emotion plays a large part in how older consumers think about health. People with four or five chronic conditions often report that their health is good, and they consider themselves healthy because they have a positive outlook on life, wonderful family relationships, and a sense of purpose. The emotion of wellness can mask the physical reality of disease. Bodhaine stated that in order to motivate health behavior change in older adults, these other tenets of wellness must be embraced and couched within a broader, holistic view of health. For example, the need to be part of a

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 CoMMUnICAtIng WItH AgIng PoPUlAtIonS community and feel a sense of connection as well as the need to stay active mentally and socially are very important drivers of perceived well-being and, therefore, health. Health 3.0 Bodhaine repeated that single messages do not work and that com- munication must be personally relevant. He introduced the concepts of Health 1.0, Health 2.0, and Health 3.0. Health 1.0 is physician-centered (i.e., the “Marcus Welby, MD, doctor-knows-best environment”), Health 2.0 is consumer-centric health care, and Health 3.0 is the new era of ac- countability. Health 2.0 is not working because “consumers cannot get there alone.” Many consumers have neither the education nor experience to use BMI calculators and other tools. Now, with Health 3.0, individuals are held personally accountable for health behavior change, driven largely by workplace wellness initiatives. For example, North Carolina introduced a new program to begin in 2011 whereby overweight or obese individuals will pay a premium for their health insurance. Bodhaine concluded by stat- ing, “The age of accountability has come. How can we harness that in a positive, productive way to really motivate behavior change?” FOOD SAFETY MESSAgES: WHAT DO CONSUMERS HEAR? Presenter: Caroline Smith deWaal DeWaal began by remarking that the Center for Science in the Public Interest (CSPI) is a binational consumer advocacy organization founded in 1971 by Michael Jacobson. CSPI has been communicating with consum- ers for nearly four decades, with a focus on nutrition, health, and food safety. In addition to their nutrition Action Healthletter, CSPI maintains an outbreak database and publishes an annual outbreak Alert! Report. The center represents 950,000 subscribers/members in the United States and Canada. She said that her talk would address not just whether CSPI, but also government, is effectively communicating about food safety with the public. She identified two underlying themes of her talk: (1) Govern- ment itself needs communication education. Many government messages and tools “are not yet hitting the mark.” Government programs need to develop greater expertise in handling risk communication in a way that elicits the appropriate consumer response. (2) A key lesson learned from past outbreaks is that while people do not always take steps to protect themselves, they will take steps to protect people they care about. She said, “Sometimes if you aim for a different mark, you hit your target.” As such, targeting messages to families of elderly consumers is often helpful.

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 PRoVIdIng HEAltHy And SAFE FoodS AS WE AgE Risk Communication with Older Adults Risk communication with older adults is especially important because older adults are at greater risk for severe illness and death from unsafe food. FoodNet1 data from 2009 show that, among laboratory-isolated cases of illness from listeria and Shiga toxin-producing E. Coli (STEC) O157, the majority of hospitalizations occurred among adults age 50 and over (Vugia et. al., 2009) (see Table 6-1). A large percentage of hospitalizations for illnesses from other pathogens was also among adults 50 years and older. Further, the case fatality rate was highest in the 50 and over population for several pathogens (see Table 6-2). DeWaal noted several general observations about older adult consum- ers that should be kept in mind when considering how best to deliver urgent messages. TABLE 6-1 Percentage of Hospitalizations Composed of Adults Aged 50 or Over Pathogen Percent of Hospitalizations 86 listeria STEC O157 53 45 Vibrio 40 Salmonella 38 yersinia 28 Shigella 25 Cryptosporidium 21 Campylobacter SOURCE: Vugia et al., 2009. TABLE 6-2 Fatality Rate of Foodborne Illness in Adults Aged 50 or Over Pathogen Percent of Fatalities 20 listeria 7 Vibrio 1.3 Salmonella 0.4 Shigella 0.4 Campylobacter SOURCE: Vugia et al., 2009. 1 For additional discussion about CDC FoodNet data, see the summary of Steven Gendel’s presentation in Chapter 4.

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 CoMMUnICAtIng WItH AgIng PoPUlAtIonS Older consumers • Listen to radio and TV regularly. In fact, most consumers of all ages get food recall information from radio or TV. • Are willing to follow label directions (e.g., “For safety, freeze or discard after January 14.”). • May not be technologically “savvy.” DeWaal said that the elderly may be the fastest-growing segment of Internet users (as Bodhaine had remarked), and future elderly populations may rely on the Internet for information, but it is highly unlikely that the Internet will become a major source of information for the current elderly population. • May not be current with newspapers. • May be less willing to throw away food. Case Examples of Communication Challenges DeWaal discussed several case examples illustrating the communication challenges of food safety recalls: • the Peanut Corporation of America (PCA) recall: The 2009 PCA Salmonella typhimurium outbreak sickened hundreds of people and killed nine. It was a very serious outbreak that demanded urgent risk communication. The government implemented three novel com- munication technologies as part of its recall strategy, none of which were very effective: (1) The Food and Drug Administration’s (FDA’s) Peanut Product Recall Widget, which was useful to some people but too technological for the elderly and other vulnerable groups. (2) FDA on Twitter, which is out of the realm of experience of many elderly and other vulnerable groups. (3) An online spreadsheet with line listings of recalled products, which was very difficult for con- sumers to use. • Honduran cantaloupes recall: In response to the 2008 cantaloupe Salmonella outbreak, FDA put out a press release stating, “The cantaloupes were distributed for sale . . . in cardboard cartons with the brand ‘Dole’ and ‘PRODUCT OF HONDURAS’ printed on each of the side panels of the carton.” The problem with this, DeWaal said, is that consumers, especially older consumers, do not buy can- taloupes by the carton. It was impossible for consumers to know whether the single cantaloupe they had just purchased was part of the recall. Now, there is a country-of-origin label requirement, but it is unclear how far this label will go and if, for example, half, sliced, or cut-up cantaloupes will be required to have the label.

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 PRoVIdIng HEAltHy And SAFE FoodS AS WE AgE • Hallmark/Westland Meat Packing Co. beef recall: The recall notice from the U.S. Department of Agriculture (USDA) for the 2008 beef recall read, “Hallmark/Westland Meat Packing Co . . . is voluntarily recalling approximately 143,383,823 pounds of raw and frozen beef products that FSIS (Food Safety and Inspection Service) has deter- mined to be unfit for human food because the cattle did not receive complete and proper inspection.” The problem here was that most consumers do not know what a “voluntary” recall is. While it is technically accurate that all food recalls other than infant formula recalls are voluntary, most consumers interpret use of the word “voluntary” to mean that the recall is not serious. Otherwise, the recall would be mandatory. DeWaal stated that use of the word “vol- untary” is counterproductive and paradoxical; how can something that the government has deemed unfit for human consumption be only voluntarily recalled? Since this press release was issued, USDA has changed its policy. DeWaal said that, in general, much of the recall information posted online by FDA and USDA is not useful to the public. For example, nei- ther agency has a searchable database (i.e., consumers cannot search by commodity, data, pathogen, brand name, etc.). DeWaal mentioned the combined FDA/USDA information site, www.foodsafety.gov, and said she expects that it will be an improvement. In comparison, several nongovern- mental organizations have stepped in to provide needed information. CSPI has an Outbreak Alert webpage (http://www.cspinet.org/foodsafety) where consumers can search for recall information and a database that allows consumers to review historical outbreak information by food, pathogen, or state. Safe Tables Our Priority also sends daily e-mail alerts notifying the public of pending outbreaks and recalls. Direct-to-Consumer Notification DeWaal identified direct-to-consumer notification as a potentially good strategy for reaching older consumers with urgent food safety messages. In particular CSPI is recommending the following: • Retailers should use loyalty programs to notify consumers of Class I recalls (the most serious category of recalls, involving a potential for serious injury or death). For example, Costco did this during the PCA outbreak, notifying more than 1.5 million consumers by phone and many more by mail that they had purchased a product that was the subject of a Class I recall. This was a very important and effec- tive way of reaching their customers.

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 CoMMUnICAtIng WItH AgIng PoPUlAtIonS • Recall notifications should be posted at retail stores and on shelves where recalled products were sold. DeWaal emphasized that this type of on-the-spot communicating does not mean posting a notice on a bulletin board near the entrance to the store, where consum- ers rarely stop, but rather right on the shelf near the product being sold. Shoppers tend to be “creatures of habit,” going back to the same aisles and shelves to retrieve the same product they bought last week. This type of on-the-spot information would be very effective in terms of alerting customers to problems in products they have already purchased. Food Safety in Restaurants While the food industry often claims that food safety problems are the responsibility of consumers, data indicate that between 1999 and 2006, 41 percent of 5,778 outbreaks in the United States were sourced to foods prepared in restaurants or food establishments (Figure 6-1). Targeting res- taurant food safety is a very important but often overlooked need. FIgURE 6-1 Outbreaks of food safety problems by location, 1999–2006 (n = 5,778). SOURCE: CSPI, Outbreak Alert! Database, 2008. Figure 6-1, fixed

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 PRoVIdIng HEAltHy And SAFE FoodS AS WE AgE He also emphasized there is no single “public” and that there are multiple audiences with varying knowledge, experiences, and attitudes. Market segmentation and tailored recall messages are an important means of communicating in a way that motivates consumers to respond appropriately. Making Specific Calls to Action Hallman also emphasized the importance of specific calls to action. After judging that they are at risk, consumers want to know how to reduce that risk. For example, should they throw out the product, or can they wash and cook it? Some people, however, do not follow advice. For example, during the Salmonella Saintpaul outbreak, 93 percent of survey respondents said that they had heard about the warning not to eat tomatoes (Cuite et al., 2008). Of those 93 percent, 80 percent said they had eaten tomatoes before the warning. Of those 80 percent, 64 percent said they had eaten tomatoes during the warning. Of those, 36 percent ate tomatoes that were included in the warning. Of those, 89 percent were aware of the warning at the moment they ate the tomatoes. When asked why they ate tomatoes that were considered not safe (Table 6-4), 41 percent said “I thought they wouldn’t hurt me”; 13 percent said “I distrust the government and/or me- dia”; 13 percent said “It must be safe if it’s being sold”; and 12 percent said “I made it safe (e.g., washed it, cooked it).” Thus some people know- ingly eat recalled foods. Overall, according to FPI data, about 12 percent of Americans have eaten a food that they thought had been recalled. Hall- man expressed concern that the lack of apparent consequences is likely to weaken confidence in future warnings. TABLE 6-4 Survey Respondents’ Reasons for Eating Recalled Tomatoes Statement Percentage Citing I thought they wouldn’t hurt me 41 I distrust the government and/or 13 media It must be safe if it is being sold 13 I made it safe (e.g., washed it, 12 cooked it) Other 20 NOTE: n = 124; statements were responses to the question, “Why did you eat the tomatoes that were considered safe not to eat?” SOURCE: Food Policy Institute, 2008 (Cuite et al., 2008).

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 CoMMUnICAtIng WItH AgIng PoPUlAtIonS Unlike many other health-related messages about food, recalls are generally limited in scope and time. But even “all-clear” messages (i.e., that the food is safe to eat again) are not getting through. A week and a half after lifting the tomato advisory, only 46 percent of respondents aware of the advisory “strongly agreed” that authorities considered it okay to eat tomatoes again (Cuite et al., 2008). Six weeks after the end of the 2006 spinach recall, only 55 percent of respondents who were aware of the recall thought it was “definitely true” that authorities said that spinach available in supermarkets was safe to eat (Cuite et al., 2007). Hallman emphasized the importance of reassuring consumers that the problem that led to the recall has been fixed and that it is safe to eat the product again. Both industry and government need to work on messages that reinforce this. Conclusion In conclusion, Hallman restated what he had said at the beginning of his talk: improvements in foodborne illness outbreak surveillance and the ability to identify outbreak strains of pathogens are likely to lead to more warnings, advisories, market withdrawals, and recalls in the future. There- fore, getting the communication right is essential. COMMUNICATINg NUTRITION MESSAgES TO OLDER PERSONS Presenter: Ronni Chernoff Chernoff began by noting that the Arkansas Geriatric Education Center addresses health literacy but does not deal directly with consumers, rather it deals with the people who deal with consumers. She listed a number of key findings from the National Assessment of Adult Literacy, which measures American adults’ literacy skills.3 • Adults age 65 and over have lower health literacy scores than any other age group. In general, older adults tend to be less educated than the rest of the population. • Women have higher literacy scores than men. Chernoff explained that this is probably because women tend to pay more attention to health messages, because they are the primary caregivers for their children as well as for their older parents. 3 National Center for Education Statistics, 2003.

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0 PRoVIdIng HEAltHy And SAFE FoodS AS WE AgE • Adults with low literacy are more likely to get health information from radio and television than from written sources. • Adults with higher literacy receive their health information from newspapers, magazines, books, brochures, or the Internet. Chernoff mentioned how difficult it has been to conduct online courses and reach a point where even health professionals in rural areas are tak- ing part, making the idea of getting consumers to use the Internet for accessing health information seem even more challenging. For the remainder of her presentation, Chernoff discussed the elements of effective written and oral communication. She stressed the importance of reinforcing key messages, for example by giving consumers something to take home after the interaction. Often, most of what has been said is forgotten by the time people walk out the door. Giving them something to take home reinforces key messages. The Elements of Effective Written Communication First, she listed and described elements of effective written communication: • develop easy-to-read forms. Health professionals often feel the need to communicate so much information that they develop compli- cated forms that people with low literacy levels may have difficulty understanding. • Use plain language. Health professionals often feel the need to im- press people by using “big words,” which may be self-gratifying but not helpful. • Provide relevant examples. Reiterating comments from previous speakers, Chernoff emphasized the importance of making communi- cation personal and providing examples of how information is likely to affect the consumer. • Be specific. Talking in global terms does not help people understand how information might potentially affect them. • get client to give feedback by asking questions. Asking the client to reflect what they heard increases the likelihood that the message is understood. • Provide forms in many languages. America is a country of increas- ingly diverse languages. • train staff to provide assistance. It is important that all staff be able to assist people in interpreting the information that has been provided. • limit messages to a few key points. Providing a large amount of information can easily overwhelm. By “keeping it simple,” messages are more likely to be internalized.

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 CoMMUnICAtIng WItH AgIng PoPUlAtIonS • Present concrete examples. Providing concrete examples gives people an “anchor” that helps them hold onto the information. • Repeat and reinforce the most important points. • Provide culturally appropriate and age appropriate content. People must be able to fit information into what they know based on their life experiences. Chernoff mentioned that some of the geriatric edu- cation centers in Oklahoma, for example, deal with many Native Americans and therefore must communicate information in a way that fits into an experience that is very different than that of other Americans. • Ensure the reading level is no higher than th grade, or rd grade for limited literacy groups. This is challenging for professionals who are accustomed to writing for and speaking to professional audiences, but it is the only way to reach many consumers. Chernoff mentioned how easy it is for consumers to confuse listeria with Wisteria, for example, or to think that listeria has something to do with Lister- ine. Many consumers have no framework for the word “listeria”; they don’t know what it is or how to process the information. • Add simple drawings to explain what you are talking about. • Avoid too much detail and complex diagrams. Diagrams with too many lines and colors end up having very little meaning for most people. • Provide visual step-by-step diagrams or pictures. For example, to illustrate how to give an insulin injection or how to take pills. • Use large type font (at least  point). Many older adults cannot read small print, even with glasses or after surgery. • limit number of fonts. Fancy or varying fonts can be visually ex- hausting, particularly for older adults. • Avoid all capital letters. ALL CAPS tend to run together, making them difficult to read. • Use headings and bullets. Headings and bullets can be helpful in organizing information in a logical, rational way. • Avoid long sentences. Again, try to maintain a 5th grade reading level. • leave white space. Too much information on a page and small mar- gins can turn readers away. • Use strong contrast colors. Chernoff remarked that initially, she and her colleagues assumed that older adults would want information presented in pastel colors (e.g., light yellows, pinks, and blues). But they discovered that older adults prefer strong colors because of the contrast, which makes reading easier. • Use captions to highlight information. Highlighting information is a way to reinforce key messages.

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 PRoVIdIng HEAltHy And SAFE FoodS AS WE AgE The Elements of Effective Oral Communication Chernoff then listed and described elements of effective oral c ommunication: • listen. Chernoff called listening “perhaps the single most important thing in oral communication.” • Speak slowly. When speaking with older adults or to somebody for whom English is not the primary language, it is important not to yell but rather to speak slowly. • Sit during the meeting. Being face-to-face and not looking down on someone is less intimidating for them. • Have the individal respond to what you have said. Getting feed- back is the only way to know whether somebody understands the information. • Encourage questions. Ask, “What questions do you have?” and not “Do you have any questions?” When asked the latter, most people will respond “no.” Encouraging clients to ask specific questions is more effective. • Use plain language. • Create an opportunity for dialogue or conversation. • Create orienting statements (e.g., “First let’s talk about your favorite food . . .”). For example, asking somebody to talk about a favorite food is a better way to initiate conversation than asking if they eat vegetables. • limit information at each meeting. • Stress the most important point (e.g., “Your blood sugar is too high and we need to discuss what you can do to control it.”). • Review the most important point. • draw or use pictures to illustrate a point. • Use verbal and written explanation together, not just one or the other. • Verify understanding of material. • Summarize the meeting and conclude by telling the individual what to expect next. • Keep sessions brief and focus on one point. Chernoff said that, based on her experience, it is unlikely that people who have been eating a certain way for 75 years are going to change their entire diet. Focus- ing on one thing rather than their overall diet stands a better chance of motivating change. • Relate new information to past experience. Use stories or personal examples.

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 CoMMUnICAtIng WItH AgIng PoPUlAtIonS • Present information one step at a time and omit unnecessary information. • Create a supportive environment. Have an attitude of helpfulness; create a quiet place; have straight-backed chairs; use large and easy- to-follow signs; and assist with follow-up scheduling. • Use engaging methods (e.g., video examples or take-home materials with telephone numbers). QUESTIONS AND DISCUSSION The four presentations prompted many questions from the audience about recalls, the concept of opt-out strategizing, the concept of persuading by reason but motivating through emotion, the use of symbols to convey food safety information, and the challenge of sending simple messages about complicated situations. Food Recalls Several questions on food recalls initiated a discussion that compared food recalls to recalls of other consumer goods and the possibilities for enhancing food recall communication. Compliance with Food Recalls Hallman was asked how compliance with food recalls compares with recalls for other types of products. Hallman said that he did not know but that part of the problem with food recalls is that often by the time the food is recalled, it is either past its shelf life or the majority has already been consumed. Often it is difficult to find a recalled food item in the home. It is easier to find recalled tires, for example, and therefore compliance with a recall of that type of non-food item might be higher. Improving Food Recall Communication All of the presenters were asked to provide their opinions on what could be done to improve food recall communication. DeWaal emphasized the importance of reminding consumers that something they had pur- chased was being recalled. Retail notification would be a very direct way to send this reminder. Additionally, information should be posted on stores shelves where the product is located, notifying shoppers of the recall and requesting that they please return the product. She also mentioned that most government food recall communications are targeted at retailers, not the consuming public, even though they are published for the public. For

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4 PRoVIdIng HEAltHy And SAFE FoodS AS WE AgE example, during the 2008 Honduran cantaloupe recall, while it was impor- tant to communicate with retailers, it would also have been very helpful for consumers to know whether the single cantaloupe they had purchased was part of the recall. Groth suggested placing coupon dispensers with information about food recalls in aisles, instead of or in addition to information on the shelves. That way, people could take coupons containing all of the necessary infor- mation about the recalled product (e.g., brand, lot number) and see if they actually have any recalled product in their home. Bodhaine said that it is important to repeatedly deliver an accurate message through a credible channel. He said that consumers usually have to hear a message seven times before they realize that it pertains to them. He said that a local voice is more credible to consumers than a distant voice. For example, local stores may be more credible than Congress. Also, given that consumers are turning to multiple sources of information “in search of the truth,” it is important that the same message be delivered across all platforms (e.g., physicians, WebMD, and MayoClinic.com4). Bodhaine also emphasized the importance of telling consumers not just what to do but why they should be doing it. Chernoff stated that sending the same message through multiple media is very important, because people do not necessarily receive messages from the same sources. She emphasized the importance of “keeping it simple,” “keeping it repetitive,” and “having it accessible in multiple ways.” Hallman emphasized the importance of reinforcing the message that older consumers really need to pay attention to the issue at hand. Through such reinforcement, even if the older consumers themselves do not hear the message, their children and friends may. For example, one reason influenza vaccinations in older adults have a fairly high compliance rate is because many children nudge their parents to “go do this.” Hallman also empha- sized the need for a searchable database where food recall information can be easily accessed, for example some kind of tool that allows consumers to scan a food bar code to see if that particular food product has been recalled. He mentioned the 2009 PCA recall and the large number of consumers that refused to buy any peanut butter products, even those not affected by the recall, because they were afraid. Having some sort of application, for example on smart phones, whereby consumers could simply scan the bar- code and see whether in fact the product in hand was on a recall list would alleviate some of this fear. 4 Available online at webmd.com and www.mayoclinic.com/health/DiseasesIndex/Diseases Index.

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 CoMMUnICAtIng WItH AgIng PoPUlAtIonS Opt-Out Strategizing Bodhaine was asked to elaborate on opt-out health solutions. Bodhaine used 401(k) plans as an example. 401(k) retirement plans used to be opt-in, whereby employees had to choose to participate and make a conscientious decision to part with a portion of their income. As a result, enrollments were relatively low and disappointing; so employers began experimenting with the notion of automatically enrolling employees in their 401(k) plans and forcing employees to make a conscientious decision to not participate. As a result, enrollments levels increased significantly. In health care, most actions require that consumers make conscientious decisions “to do the right thing in a world that craves convenience.” As Bodhaine mentioned during his presentation, “one of the reasons that health is so hard is because life has become so extraordinarily easy.” Opt-out health solutions make it easy for consumers to “make the right decision.” An example of an opt-out health solution is putting larger labels on fruits and vegetables than on other food items in cafeterias and changing the placement of foods at the check- out counter (e.g. moving salty and sweet foods to the back of the cafeteria and placing fruit up front near checkout). It has been demonstrated at the Mayo Clinic that both of these actions increase consumption of fruits and vegetables. Another opt-out health solution is the 100-calorie snack pack, which makes the decision-making process very simple for the consumer by eliminating the need to calculate calories or estimate serving size. Groth commented on the likelihood that some people will object to opt-out solutions. Groth agreed with Bodhaine that it makes sense to build incentives into the system to make it easier for people to “do the right thing,” but he said that some people might consider opt-out solutions to be coercive. For example, he was once a member of a record club where each member received the monthly record unless he or she mailed a card back to the company requesting that the record not be sent. Many consumers have grown up thinking that opt-out programs, like the old record clubs, are coercive. Bodhaine replied that consumers respond better to nudges than they do mandates, and he encouraged Groth (and others) to read the book nudge (Thaler and Sunstein, 2004). Persuade by Reason, Motivate Through Emotion An audience member commented on Bodhaine’s “persuade by reason, motivate through emotion” phrase and asked Bodhaine to provide some examples of how communicators could link science and emotion. Bodhaine said that he did not want to undervalue the power of science and that sci- entific facts provide the “substantive platform” and “reason to believe.” However, most consumers rarely understand the science or how to apply it

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 PRoVIdIng HEAltHy And SAFE FoodS AS WE AgE to themselves, or they become bored with the facts. He used car purchas- ing as an example. Telling a potential buyer what antilock brakes are or how they work does not necessarily motivate a car purchase. The func- tional benefit of those antilock brakes must somehow be linked to what is important to the consumer (e.g., “my loving concern for my family”). On the other hand, telling a person to buy a car because they love their family is construed as “fluff.” He said that the old Michelin ads, with images of children and the tag line “because so much is riding on your tires,” were a “brilliant way to demonstrate the added value of creating an emotional link to a tire.” He suggested that emotion is often best communicated through cue and symbol rather than word. DeWaal added that emotion is a natural component of the issue of food safety. Media stories that focus on individuals who have fallen ill from eating contaminated food products naturally lend themselves to providing “a level of emotion and a level of connection.” Severe foodborne illnesses are random events. They can happen to anyone, and they cross all socio- economic and partisan lines. Also, victims are rarely silent or hidden. She mentioned how victims rallied after the Jack-in-the-Box E. coli O157:H7 outbreak in 1993 and organized Safe Tables Our Priority (S.T.O.P.). So there is a natural connection between the science and emotion with out- break data, with victims themselves providing the motivation. Hallman stated that the challenge for FDA and industry when putting together press releases is to lead with emotion, so that the story is picked up by the media, but then follow up with the critical scientific information so that readers (and consumers) know who is at risk, what those at risk can do to minimize their risk, and what the symptoms of illness are. Using Symbols to Communicate Food Safety Information An audience member described North Carolina’s restaurant inspec- tion scoring system and how the news media has picked up on it (every week, the local new media list restaurants that have received the highest and lowest scores) and then asked whether any of the presenters had any anecdotal- or study-based thoughts on whether this type of “simple mes- saging” has proven effective for aging consumers. In addition it was asked whether front-of-package nutrition symbols seem to be of help to older adults. DeWaal replied that food safety messaging does not usually rely on things like front-of-package labeling or other glance messages that are being used for nutrition communication because food recall situations are usually urgent and demand action steps. Convincing consumers not to eat a food product because it is potentially contaminated is a terrific challenge, because many people believe that all food is safe. Even when they know something has been recalled, they eat it. Bodhaine agreed that overcoming

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 CoMMUnICAtIng WItH AgIng PoPUlAtIonS consumers’ cavalier attitudes about food is a major challenge. There is a belief that “because we do it every day, it must be okay for us.” Bodhaine expressed concern about the way that so many different man- ufacturers and retailers are launching their own independent food labeling and safety information systems. He said that by introducing a multitude of different symbols and signals to the consumer, “We have taught them once again to ignore us.” He said that delivering information in a meaningful way is challenging. A question was asked about how consumers would differentiate be- tween icons/symbols used for different purposes (e.g., one set of symbols for added sugars, fats, etc.; another set for overall healthfulness; another set for recalls or other safety information). DeWaal stated that CSPI does not recommend rating foods for safety by using symbols or icons on pack- aging. However, there may be packages with limited shelf lives and with risks linked to the amount of time already shelved (e.g., the risk of listeria contamination in processed meat products). These packages could have a red dot, for instance, indicating that the product is “out of date” or a yel- low dot indicating “freeze now and use later,” and so on. She mentioned that food scientists are researching this type of application. Chernoff commented on the need to place expiration dates in places that are more readily accessible. She mentioned that expiration dates on the striated caps of peanut butter jars are unreadable. Placing expiration dates on the label instead of on the striation, as well as in large, highlighted font, would be a simple improvement that would make a big difference. Hallman commented on the gray market for food products and how dollar stores and the like have erased lot numbers or copied over expiration dates. Many older Americans, particularly those who are food insecure, shop at these establishments. Bodhaine remarked that the author of the symbol is almost as impor- tant as the symbol itself. He said that over the past several years, businesses have knowingly delivered a growing number of bad products and services, and consumers have become increasingly skeptical. He said that govern- ment and manufacturers are not always the trusted voices and that col- laborative efforts are needed to establish a new trusted voice. Groth agreed and stated that neither is the academic voice the answer, because it speaks in jargon. Bodhaine suggested that the commercial and academic sectors work together to build a platform for moving forward and motivating consumers to change their behaviors. While on the topic of symbols, Hallman highlighted the challenge of using package symbols to communicate microwave instructions, given that different microwaves have different wattages and that microwave times dif- fer dramatically. He mentioned that some retailers are beginning to match symbols on their food packages with symbols on microwaves indicating

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 PRoVIdIng HEAltHy And SAFE FoodS AS WE AgE which microwave button to push in order to thoroughly heat the package in question, but the issue needs to be addressed more fully. Groth pointed to Consumer Reports’ iconic five-point quality symbol system (excellent, very good, good, fair, poor) as an example of successfully quantifying in an understandable way a very complicated phenomenon. That system can be used to characterize products based on ratings of 20 or more different properties. He suggested that a similar system might be worth considering for conveying information about food safety. Sending Simple Messages About Complicated Situations Groth mentioned that several speakers had emphasized the need to keep messages simple so that they can be understood. However, the situ- ation at hand is often very complicated. For example, FDA’s list of foods that older adults should not eat (which Sundlof had described during his presentation in an earlier session) includes raw fish. Groth said that he loves raw fish and eats it several times a week, and that he is more concerned with his long-term cardiovascular health than he is the risk of becoming ill from eating contaminated raw fish. “So I am making risk-risk tradeoffs. In fact, a lot of the world is,” he said. “If we oversimplify the message too much, we will steer people into bad behavior. So how do we deal with that?” DeWaal mentioned that outbreak data indicate that sushi is not implicated very of- ten. Groth said that he is worried about the “generic problem,” not sushi in particular. DeWaal replied that the generic problem could be with FDA’s message. She said, “It is absolutely true that any high-risk consumer should avoid certain raw seafood. . . . It is vital that that message get out. . . . If they are saying avoid all raw seafood, that may be overstating a problem that really is more isolated.” Bodhaine said that he is less concerned with simplicity than with rel- evance. No matter how simple a message is, he said, “When we fail to couch our message in a framework that is personally relevant to the target audience, it has little prayer of ever penetrating to the point of changing behavior.” He reiterated the need to understand who the target audience is and how to craft messages in a way that will be personally relevant to that audience. While public health professionals often want to communicate with everybody, which he called noble and virtuous, he said that using a single message to communicate with everybody is flawed from the outset.