Factors related to Listeriosis Prevention in Pregnant Women: a Focus Group Study

Appendix II: Moderator’s Guide

• Prior to the focus group, the Informed Consent Form will be reviewed and signed. Participants will also complete a brief demographic questionnaire.

• Objectives: As you know, we are going to talk about food safety and pregnancy today. We’re going to look at some current health information for pregnant women and some new messages. I’m going to ask what you think about the information that I will present. Your opinion is important and will help us as we develop new health messages for pregnant women.

• Ground rules: Before we begin, I’d like to cover a few ground rules so that our group runs smoothly. First, it’s really important to speak one at a time and not to have side conversations. I’ll make sure that everyone has a chance to speak. Please treat everyone with respect. We do have a lot to cover today, so sometimes I may need to help move the group along. Also, there aren’t any right or wrong answers to the questions that I will ask—we are just looking for your opinion and your experiences. Finally, you don’t always have to agree. It’s very important for us to get a lot of different opinions. Are there any questions before we begin?

• Warm up: Let’s go around and introduce ourselves before we start the group.

• Tell us your first name, and maybe a little about your pregnancy, like what your due date is and whether you have any other children.

• Now, let’s talk about food: Has your pregnancy made you crave or stay away from any particular foods?

• Questions:

1. Have you ever heard that women should not eat certain foods while they’re pregnant? Which foods? Has anyone else heard to avoid that?

   1. Do you remember why you were told to avoid these foods?

   2. I’m going to ask if any of you have ever been told not to eat certain foods because of foodborne illness, but first, I just want to tell you what I mean by foodborne illness. When I say ‘foodborne illness’, I mean any sickness that you get from eating foods that have been contaminated with things like bacteria, viruses, or chemicals. You might also call it food poisoning.

      1. Since you’ve been pregnant, has anyone ever told you to stop eating some foods because they could cause a foodborne illness? Which foods?

2. How serious do you think foodborne illnesses are?

   1. Do you think that everyone has the same chance of getting a foodborne illness? Why or why not?

      1. [If anyone mentions that some people have a greater risk] Who is at greater risk? Why?

   2. How big a problem would it be for a pregnant woman to get a foodborne illness?

3. We’re going to focus on one specific foodborne illness today. I’d like you to look at some current information about it.

[Hand out Message A and read aloud to lower education groups (All messages are attached to the end of the guide.)]

1. How familiar is this information?

   1. What had you heard before?

   2. Where did you hear about Listeria?

   3. What was new to you?

2. Had you heard about this particular risk to pregnant women?

   1. How serious does listeriosis seem to you after reading this message?

3. How do you feel after reading this message?

4. There are two things to keep in mind. First, listeriosis is pretty rare. The second is that there are ways that pregnant women can lower their chance, or risk, of getting listeriosis. One way to lower your risk is to follow general food safety guidelines that are helpful for everyone, pregnant or not. We’ll give you a copy of these before you leave. There’s also advice just for pregnant women and that’s what we’re going to look at now. I’d like you to read through these guidelines. [Hand out Message B, read aloud to lower education groups]

1. How familiar are these guidelines?

   1. Which ones had you heard of before?

   2. Where had you heard about them?

   3. Were any of these guidelines new to you? Which ones?

2. Did you eat any of these foods before you were pregnant? [Probe for each food if it is not mentioned: hot dogs, lunch meats, soft cheeses, refrigerated pates or meat spreads, refrigerated smoked seafood, raw milk]

5. Thinking about all of the guidelines, how well have you personally followed them during your pregnancy? [Probe for food if it is not mentioned: hot dogs, lunch meats, soft cheeses, refrigerated pates or meat spreads, refrigerated smoked seafood, raw milk]

   1. For those who have not been following the guidelines: How confident are you that you could follow the guidelines if you decided you wanted to follow them?

   2. Is there anything hard about following this advice?

      1. Does this message provide you with enough information so that you could follow the advice? Why or why not?

   3. Is there anything that could make it easier for you to follow this advice?

6. Again, thinking about all of these guidelines: Do you think following these would reduce your risk of getting listeriosis? Why or why not?

7. We are trying to find ways to improve the information that pregnant women can use to learn about Listeria. I’m going to show you some information that might be added to the messages you’ve looked at earlier and ask your opinion about this additional information. [Message C]

   1. What is this message telling you?

   2. What do you think of this information?

      1. Does this information change your understanding of Listeria? How so?

      2. Would this information be useful to you personally? Why or why not?

8. Here is the next message that could be added to the information you looked at earlier. [Message D]

   1. What is this message telling you?

   2. What do you think of this information?

      1. Does this information change your understanding of Listeria? How so?

      2. Would this information be useful to you? Why or why not?

      3. Would this message make you change anything you were doing? How so?

9. Here is some information about the guidelines that’s a little different from what you’ve seen before. [Message E]

   1. What is this message telling you?

   2. How do you feel knowing that this advice could change?

   3. Would a message like this affect your decision to follow the guidelines? Why or why not?

      1. Would it affect your confidence in the guidelines? Why or why not?

   4. Would this information be useful to you? Why or why not?

10. Imagine that sometime in the future, a new food is added to the list of ‘Do Not Eat’ foods.

    1. How would you feel if a food you were currently enjoying during your pregnancy was added to the list? [Facilitator could pull in examples from the warm-up question]

    2. Let’s say that you’ve been eating this food and have not experienced any problems from it. What could a health expert tell you that would make you stop eating this food?

    3. Let’s take a look at our last message [Message F]. This is an example of a message you could see if a new food was added to the list. It’s using hot dogs as an example.

       1. Before you mentioned that if a new food was added, you would feel [fill in emotions described in 10a]. How would a message like this affect your feelings if a new food were added to the list?

       2. How would a message like this affect what you would do if a new food were added to the list?

11. I’d like you to work together to decide which of the messages about Listeria you think should definitely be included in any kind of information for pregnant women, like in a brochure or on a webpage. You can specify entire pages or just sections.

    1. What pieces of information are most important? Why do you think so?

12. We’ve covered a lot of information today. Will anything you heard have an impact on what you’re currently doing? Why or why not?

    1. How will your behavior change?

• Debriefing: Before we end, I would like to give you a handout that you can take home. It contains the general food safety information that I talked about earlier and information on food safety specifically for pregnant women.

• I would like to give you the opportunity to ask any questions you might have about what we covered today. Also remember that if you have questions after the study, you have contact information on the informed consent form that you have a copy of. If there are no more questions, I would like to thank you for coming today.

Message A

What is Listeria?

Listeria is a kind of harmful bacteria that can contaminate many kinds of foods.

• It is different from other bacteria because it can grow at refrigerator temperatures.

If you eat a food that has been contaminated with Listeria, you could get an infection called listeriosis.

• Pregnant women are 20 times more likely to get listeriosis than other healthy adults.

Pregnant women might not even feel sick from listeriosis, but they can pass the infection to their babies.

• This infection can cause miscarriage or stillbirth.

• In newborns, it can cause serious problems like blood infections or meningitis (an infection around the brain and spinal cord).

Message B

Don't eat:

Hot dogs and luncheon meats unless they're reheated until steaming hot

Soft cheeses unless they're made with pasteurized milk

• Make sure the label says, "Made with pasteurized milk."

• What are soft cheeses? Feta, Brie, and Camembert, blue-veined cheeses, queso blanco, queso fresco, or Panela

Refrigerated pâtés or meat spreads

Refrigerated smoked seafood unless it's in a cooked dish, such as a casserole.

• Refrigerated smoked seafood, such as salmon, trout, whitefish, cod, tuna, or mackerel is most often labeled as "nova-style," "lox," "kippered," "smoked," or "jerky."

• These types of fish are found in the refrigerator section or sold at deli counters of grocery stores and delicatessens.

Raw (unpasteurized) milk or foods that contain unpasteurized milk.

Message C

Listeriosis is rare, but pregnancy increases your risk

• Here’s why: Your immune system is weaker when you are pregnant. This is normal—It helps you and your baby get along with each other. This weakness makes it harder for your body to fight off harmful bacteria, like Listeria.

• You could get listeriosis at any time in your pregnancy, but it is most common in the third trimester.

“If I had known about the risks of consuming deli meat while I was pregnant, I might have been able to prevent my miscarriage.”

– Silvia

“For those of you who think it cannot happen, YOU’RE WRONG! My perfectly healthy baby was stillborn at 35 weeks from what my doctors believe to be a listeriosis infection.”

– Michelle

Message D

If you think it’s hard to follow these guidelines, remember that your pregnancy won’t last forever.

Keep in mind that following these guidelines can help you prevent a miscarriage, stillbirth, or a life-threatening infection to your newborn.

Here’s what other pregnant women have said about preventing listeriosis:

“Even a slim chance of miscarriage is still a chance. If there’s a way to avoid listeriosis, why not do it?”

—Shenice

"I am really not a worry-wart when it comes to being pregnant... But if heating my lunch meat eliminates a risk, I’ll do it." —Jen

“I love queso blanco. So I just check the label when I buy it to make sure it’s made from pasteurized milk.”

• Zaira

Message E

In the 1980’s, scientists learned that people could get listeriosis from eating contaminated foods. They keep studying Listeria so they can identify foods that are easily contaminated as well as new ways to control Listeria.

• Here’s an example of how research has affected the guidelines:

• Before 2003, pregnant women were told not to eat soft cheeses at all. Then, new studies showed that it is fine to eat soft cheeses when they are made from pasteurized milk.

• The guidelines could change as we learn more ways to keep you and your baby healthy.

• If you get pregnant again, make sure you have the most up-to-date information. Remember, this advice could change as we learn more about Listeria.

Message F

New Findings about Listeria

Scientists have found that hot dogs are easily contaminated with Listeria. They are now telling pregnant women NOT to eat hot dogs unless they have been reheated until steaming hot.

• If you have eaten hot dogs and feel fine, don’t worry. Remember, listeriosis is very rare.

• Now that you know about the risk from hot dogs, you can make sure to eat them only if they’re steaming hot—it’s another way to keep you and your baby healthy.