The European Journal of Public Health Advance Access originally published online on July 19, 2005
The European Journal of Public Health 2005 15(5):523-527; doi:10.1093/eurpub/cki016
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Miscellaneous |
Public understanding of food risks in four European countries: a qualitative study
Judith M. Green1, Alizon K. Draper2, Elizabeth A. Dowler3, Giolo Fele4, Vera Hagenhoff5, Maria Rusanen6 and Timo Rusanen6
1 HSRU, London School of Hygiene & Tropical Medicine, Keppel Street, London, UK
2 School of Integrated Health, University of Westminster, London, UK
3 Department of Sociology, University of Warwick, Coventry, UK
4 Facoltà di Sociologia, University of Trento, Trento, Italy
5 Institut für Agrarökonomie, Lehrstuhl für Agrarmarketing der Universität Kiel, Kiel, Germany
6 Department of Applied Biotechnology, University of Kuopio, Kuopio, Finland
Correspondence: Judith M. Green, HSRU, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, UK, tel: +44 20 7927 2024, fax: +44 20 7580 8183; e-mail: Judith.green{at}lshtm.ac.uk
Received January 9, 2004, accepted May 4, 2004
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Background: In the wake of the ‘bovine spongiform encephalopathy (BSE) crisis’ there was renewed interest in how those responsible for public health could take account of public views, both to ‘democratize’ policy making and to increase the likelihood of information about health risks resonating with public concerns. This study explored how members of the public in four European countries (Finland, Germany, Italy and the UK) understood food risks in general, and risks arising from BSE in particular. The aims were to identify the sources of knowledge used and trusted by the public and to explore how public views could be accessed for public health information policy. Methods: Thirty-six focus group interviews were held using a common protocol across the four countries, including people from four lifecycle stages. Results: The study demonstrated the utility of using focus groups as a relatively efficient method for accessing public views, and the feasibility of cross-national qualitative research on public views. We found that public views of food risks are neither irrational nor naïve, but that they do need to be interpreted in the context of everyday food purchasing decisions, in which particular food risks are unlikely to have the same salience as they do for experts. Conclusions: Focus groups are a feasible method for accessing public knowledge on public health risks to inform information strategies.
Keywords: BSE, focus groups, food risk, information policy, public knowledge
The first case of bovine spongiform encephalopathy (BSE) was identified in 1986 in the UK. Since then BSE has been a recurring item of public concern across much of Europe, in particular the issue of cross-species transfer and the consequent risk to humans posed by beef consumption. In March 1996 the announcement by the UK Minister of Health in the House of Commons that 10 cases of a new variant of Creutzfeldt–Jacob disease (CJD) had been diagnosed provoked a crisis of public confidence in British beef, not only in the UK,1 but throughout Europe. Sales fell dramatically and the European Union (EU) imposed a Europe-wide ban on sales until appropriate repair measures had been taken. The identification of domestic cases in Germany in 2000 and in Italy in 2001 had a further impact on consumer confidence in beef in other European countries, when it became clear that the problem was not solely one of controlling British imports. The emergence of BSE highlighted both the internationalization of health risks and the need to take public views into account at various points in the policy-making process, especially that of disseminating information about risks. Following the announcement that BSE was a possible cause of cases of CJD, counter to earlier reassurances that there was no risk to human health in eating beef, there was a marked loss of faith in government information about health in general,2 as well as on the threat of BSE specifically.3 The Phillips Inquiry4 into how the UK government had handled the affair identified the overly paternalistic attitude of the government as a factor in generating this mistrust of risk information. Risk communication strategies that assume a naïve, irrational public that will ‘overreact’ to uncertainties in scientific knowledge may be counter-productive, in that they risk generating widespread scepticism about all public health information. However, devising ways of communicating risks effectively is a challenge for public health. It requires sophisticated knowledge about the ways in which members of the public understand risk and the relative importance of specific risks in their decision making. To address these concerns in the context of food risks in Europe, this study was commissioned as part of a larger project on public perceptions of BSE and CJD risk. The aims were to compare public views of food risks in four countries, to identify what sources of information were trusted and to identify how policy makers could utilize such information for public health information.
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Methods |
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Four countries (Finland, Italy, Germany and the UK) were chosen to reflect different trends in meat consumption5 (see table 1). Within each country, we selected groups of the public to reflect four key stages in the lifecycle that were theoretically related to different food purchasing and preparation responsibilities and experiences of food safety. These were: adolescents (aged 14–16 years), with few or no responsibilities for food purchasing decisions; young singles (aged 20–25 years with no dependants), with responsibilities for choosing food for themselves; family food purchasers (with young children), with responsibility for choosing foods for a family; and older citizens (aged over 55 years), who were likely to have experienced changes in food availability over their lifetimes. Within each country, the research team identified other variables theoretically likely to affect attitudes to food risk, such as social class, geographical location and rural or urban residence. A sampling grid was constructed, and groups were purposively sampled across this to include a range within each country (see table 2). Thus the aim was not to include a statistically representative sample of participants, but rather to include a range of groups to reflect the likely sources of difference in attitudes to food risk to facilitate cross and within country comparisons. We recruited pre-existing groups wherever possible, to maximize interaction between participants.6 This is an effective method of accessing not only the content of public accounts, but also evidence of the social processes by which these accounts are formed.
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A standardized protocol for use across the four countries was agreed. Participants were invited to discuss the topic ‘choosing safe foods’, and were offered an incentive (
25 store voucher). The group discussion began with two tasks to generate discussion (ranking a number of foodstuffs in order of their potential risks, and ranking potential sources of BSE) and a number of prompts were used, designed to explore the participants' views of food safety in general, sources of knowledge about food risk, faith in those sources of knowledge and their concerns about BSE. The discussion was transcribed and analysed qualitatively. Analysis was carried out initially within country, by identifying recurring themes within each data set. These initial lists of themes were then discussed, and an agreed common set of concepts developed for coding and analysis across the four countries (see Draper et al.7 for details). Fieldwork for this study was carried out during 1999–2000. This was some years after concerns about BSE had peaked in the UK, but before the other participating countries had identified their first ‘domestic’ cases of BSE. It is, then, a snapshot of public views when there was not a noticeable ‘crisis’.
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Results |
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Thirty-six groups were held in total. In this paper, we focus on three findings that are of particular relevance for those responsible for public health information: the relative importance of ‘risk’ in public accounts of food choices; the evidence used by the public to assess food risks; and the issue of trust in information sources.
The relative importance of ‘risk’
First, participants in focus groups in all countries saw ‘food safety’ as a complex, multidimensional concept that was not primarily about the kinds of risk to health posed by BSE:
"Are we going to define safe in terms of genetically safe or bacterially safe or cholesterol safe or are we going to come to any definition?" (older citizen, Midlands).
At a point when concern about BSE had declined in the UK, and was marginal to those in other countries, whose citizens largely saw it as a question of avoiding British imports, participants across all countries and lifecycle stages reported that other issues of food ‘quality’ or ‘risk’ were of relatively more salience than BSE. The specific issues focused on varied across the Europe. In Finland, participants were concerned about the issue of additives in foods. In Germany, little concern was expressed in general about the issue of food safety, although additives were mentioned in response to closed questions on concerns:
"I also do not trust German foodstuffs. Why do they contain so much additives? If it is clean you do not need these additives. They are alarming." (older citizen, Kiel)
"I am critical towards convenience food. There is added this and that, I oppose them although I also use them." (single, Kuopio)
Italian participants were more concerned with naturalness and taste, and in some locations had concerns about the ‘industrialization’ of food production or specific issues of food adulteration:
"At the industrial level I think that all food stuffs are the same ... I trust locally made bread, which unfortunately I can't get, so I have to buy industrial bread." (single, Bologna)
In general, participants in all groups across the four countries, with the exception of family food purchasers, were careful to present themselves as not unduly worried about the health risks of food. A ‘sensible pragmatism’ characterized the responses of many to choosing ‘safe’ foodstuffs:
"rarely you stop and think about [the safety of] those pastries really." (family food purchaser, Kuopio)
A "If you like, you eat it"
B "You can find something unhealthy in everything you eat. You can't think about it too much." (adolescent, Trento)
"But there is nobody at your elbow when you go shopping is there, saying buy this, buy that, I just go and if I like it I buy it, I don't think about a radio report or a newspaper report to buy it, I just buy it if I like it." (older citizen, Midlands)
There were two major reasons why ‘food safety’ was not reported as a primary concern. One was that other aspects of food, especially cost, had more salience for many participants. Cost was recognized as to some extent opposed to safety, at the level of both domestic food purchasing decisions and national food policies. At the domestic level, several participants in all countries noted that they would prefer organic foodstuffs, for instance, on the grounds of quality, but that cost prohibited this. Others noted that they made decisions (such as buying cheaper cuts of meat) that consciously traded-off safety (or at least quality) against cost. To some extent there was a recognition that issues such as the BSE crisis were the result of similar trade-offs at the level of national policy: that the need for more efficient food production for a population entailed some risk of compromising safety:
"I think about prices, not about poisons." (single, Bologna)
"But organic meat is far too expensive! We can't afford that." (older citizen, Kiel)
"Of course the consumer is partly responsible [for BSE]! ... We all want cheap food, we all buy at Aldi [discount supermarket]—that's a viscous circle—one the one hand we want to eat healthily, on the other hand cheaply. And both are possible—but there are exceptions." (single, Kiel)
The other reason for the relative lack of prominence given in the group discussions to risk and safety was that many participants were more comfortable with other frameworks, such as nutrition or pleasure, for discussing food choice.
Evidence used to assess food risks
Although participants did not necessarily prioritize safety explicitly as an important quality of food, it was clear from discussions about choosing food that there were a number of strategies used to ensure that food purchased or consumed was as safe as possible. In these discussions, formal or ‘scientific’ sources of evidence were rarely cited to justify decisions about or assessments of food risks. This is not because participants were ‘irrational’ about potential risks, simply that, in making complex choices in an arena with considerable ‘expert’ information available, pragmatic decision aids are needed. These decision aids are rooted in cultural frameworks that lay down broad ways of assessing the quality of food (such as those that divide potentially edible from non-edible foodstuffs and those that order the preferences of food), together with a number of learnt ‘craft skills’, in assessing particular foods. These craft skills are expressed in general terms as ‘common sense’, often reflected in aesthetic judgements that utilize smell, taste or visual appearance, or assessments of the cleanliness of retailers:
"The fatty person behind the meat counter who always has her handkerchief in the sleeves. It makes me sick. Then I think she touches my cold meat. Then I prefer to take the pre-packed meat from Aldi [supermarket]." (single, Germany)
"The best way is direct sales by farms ... so you can see ... if they are clean or dirty, when they milk the cows." (family food purchaser, Eckernförde)
"Yes there is nothing worse than going to a grubby old shop and buying something"
"Especially if it's not in a packet"
"It's all grubby and dirty you wouldn't want to buy it"
"And the person as well that is serving you they look a bit"
"That is true"
"If you go to a butcher and he has got stuff under his nails" (adolescents, Midlands)
"The pastures of Trentino ... go and drink the milk they produce and smell the fragrance!" (older citizen, Trento)
A key element of the cultural frameworks in all countries was the issue of provenance of food. In all groups, participants expressed highest faith in food that came from known origins, which explained why foods identified as ‘safest’ were those that were home grown or from local producers. Perhaps the most eloquent on the virtues of local produce were the participants from Trento in Italy (see quote above), who cited a range of products from their locality as safer, more nutritious and healthier than those of other regions and countries, but the increasing faith in produce that came from known, local origins was notable across both countries and lifecycle stages:
"We eat only berries we have been picking up by ourselves. Fruits and berries I think they contain awful lot of preservatives." (family food purchaser, Kuopio)
"We probably all agree then that if we grew the vegetables ourselves ... one would assume that if we grew it ourselves, I would assume, that I knew that I hadn't put any chemicals on it, so I would assume that my runner beans and my tomatoes and my friend's reared in her greenhouse and she then gives them to me and then I go on with the process, I would assume that they were safe to eat." (older citizen, London & environs)
"I think beef from Schleswig-Holstein is somewhat safer, I think." (adolescent, Kiel)
"I never worry about eggs personally, I get eggs locally, I just think they are quite fresh, I never worry about eggs." (family food purchaser, London & environs)
In practice, however, few consumers relied primarily on home or local produce. In a market where food production is largely commercialized, with provenance very difficult to identify, responsibility for ensuring quality and safety has to some extent be delegated to others, such as retailers and surveillance systems.
Trust in information
To facilitate choices in such complex food markets, trust is an essential element, which was explicitly mentioned by many participants. Trust was discussed first in general terms, as an expression of the alternative to having to make endless individual decisions. In this sense, participants said, for instance, that one ‘had to just trust that food is safe’. More specifically, there were particular information sources and organizations that were actively trusted to either provide safe food or to provide trustworthy information about that food. There were also agencies explicitly not trusted. In all countries except Finland (where participants expressed a high degree of trust in both government and its systems), participants made routine comments about the lack of trustworthiness of politicians, who were seen as acting in terms of vested interests that were unlikely to be those of the consumer:
"Politicians are always ambiguous. They waffle their way around a subject. Therefore they are not to be trusted." (single, Kiel)
"I think anything said by any politician you take with a pinch of salt, don't you?" (family food purchaser, London)
"If you discover that an entire country concealed a serious problem, and if that country was England, where you believed the rules were obeyed, it's clear that it's difficult to have faith in anyone." (family food purchaser, Naples)
As the last comment suggests, the BSE crisis was seen as a key contributor to this lack of faith. To some extent, ‘experts’ such as scientists were similarly mistrusted. Some reported frustration with the uncertainties of expert advice on food, but others were sceptical of the neutrality of experts:
"Scientists work for themselves and want to be the best, want to publish, they want to maintain their status." (family food purchaser, Kiel)
"Experts are all very well, but I'd trust one who wasn't in the economic loop, who acts not in his own interests but in the interests of the consumer." (adolescent, Trento)
"... if a foreign scientist said something, I'd believe him. Why foreign? Because he's impartial" (single, Naples)
Trusted information sources were of two kinds. First were those embedded in personal networks, in which particular individuals were seen as reliable sources of both information and safe food. The archetypal embodiment of this kind of trust in was the ‘local butcher’, who was suggested across all countries as someone who could be relied upon to provide good quality, safe food and to know the provenance of that food on behalf of the consumer:
"The seller in the shop told me that all the beef, which is sold in Finland, is Finnish, on the other hand they don't know everything and they are also dependent on (the fact that people want to by only Finnish beef) but I trust their frankness." (family food purchaser, Kuopio)
"I think it's a matter of trust. I have a butcher. He is a very good butcher and I trust the meat I buy off of him and all his beef is definitely from BSE-free herds and therefore I am very happy to eat his beef. I would not be so happy buying beef at a supermarket ... and I think again it comes back to trust." (older citizen, Midlands)
Following on from a concern with vested interests, the second mechanism by which trust was constructed was through distance, specifically distance from what were seen as political interests. In Finland, participants had a high degree of faith in their national regulatory systems, in part because these were seen (in principle, if not always in practice) to be acting the public interest. In Germany, there was more faith in their own national systems than in international ones, and in both Germany and Finland participants expressed concern that international regulations (such as those entailed by membership of the EU) would weaken national systems.
"I fear that within Europe more and more laws and their implementation are being scrapped because we have to arrange ourselves that little bit too much with others." (older citizen, Eckernförde)
"It is very negative thing that we must try to get everything to be in a so large scale in agriculture [due to the EU membership in 1995], agriculture products are cultivated with accelerating manner or with such a feed that makes calves to grow faster so that I think is negative." (family food purchaser, Kuopio)
In contrast, in both the UK and Italy, participants in many groups (particularly the younger ones) expressed more faith in potential European regulatory systems than in existing national ones, because the EU was perceived as more distant from, for instance, national producers' interests:
"The EU will make a stop to things, I think it will make things safer because they are going to stop dodgy things going on, I mean if they are passing laws and stuff, then they are going to be stopping a lot of things." (adolescent, Midlands)
"You can trust the European Union, because they work to the advantage of several countries, not just one, and there are lots of checks and they are organized." (adolescent, Trento)
"I absolutely do not feel protected by current Italian legislation, and I hope that with Europe, I don't know, perhaps something will change ... in the sense that there will be stricter rules." (family food purchaser, Trento)
The one set of vested interests that was trusted was that of consumers, either in the form of consumer organizations (which were cited as a trustworthy source of information) or in the form of organizations whose interests were served by presenting themselves as one the side of the consumer. Many saw large retailers as, although driven by profit, to be concerned about their reputation such that they could be trusted not to endanger this by selling risky food. Large supermarket chains and baby food manufacturers were singled out in several groups as agencies that could be trusted to provide safe food for this reason:
" ‘Hipp’ [baby food manufacturer]—they are so trustworthy." (family food purchaser, Kiel)
"they [supermarkets] don't want to lose their profits, so they have to keep certain standards." (adolescent, Midlands)
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Discussion |
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This study utilized focus groups to access public views of food safety across four European countries. Few qualitative studies have addressed cross-national issues, as the need for culturally sensitive methods of data collection often militates against the use of standardized protocols for comparative purposes. By developing a sampling frame and protocol that could be adapted for different settings, we have demonstrated the possibilities of collecting qualitative comparative data. The sampling strategy allowed comparisons both within and across different countries and lifecycle stages.
The difficulties of communicating risk information, and assessing public understanding of risk information, have been well documented.8–10 On issues such as food safety, public health professionals and policy makers face a difficult challenge in disseminating information about the level of risk and how to manage it in such a way as to both resonate with public concerns and provide accurate information that will be understood by the public. The widespread scepticism about risk information in the wake of the overly paternalistic attitude of early government information on BSE in the UK illustrates the dangers of misjudging public information needs. This study has three implications for the management of risk information. First, ‘crisis’ reactions to risk information appear to be short-lived, but the negative effects of feeling misled may be longer lasting. Consumers in these four European countries were, in general, unconcerned by 1999 about the particular risks from BSE and beef products, although (except in Finland) they did express general cynicism about sources of information such as government spokespeople and health experts. This implies that an information strategy that is open about risk uncertainties may be, in the long term, more effective than one that attempts to simplify messages to reduce ‘irrational’ reactions. There are parallels perhaps with the coverage of risk uncertainties around the MMR vaccination programme in the UK. Official guidance that simply discounts evidence of risk has perhaps had a more damaging effect on the vaccination programme than one that might have been more transparent and honest about risk uncertainty. Public understanding of risk is complex and sophisticated, and information with overly simplistic messages may be read as ‘covering up’ or being ill-informed.11
The second implication is that information needs to be targeted rather differently at different population groups. The adolescents, young singles, family food purchasers and older citizens in this study had very different frameworks for prioritizing and using risk information. Adolescents and older citizens were in general unconcerned about risk and safety: adolescents because they had few opportunities to make food purchasing decisions, and older citizens because they saw themselves as ‘risk hardy’ survivors who had no need to concern themselves with risks such as BSE, which were unlikely to have short-term effects. The main groups concerned about food risks in all four countries were, not surprisingly, the family food purchasers, who were responsible for the safety of food provided to their children. However, they were, in general, more comfortable with frameworks of ‘nutrition’ or ‘health’ than risk and safety for discussing food choice.
Thirdly, consumers in all countries except Finland were sceptical of many ‘official’ sources of information, considering them tainted by vested interests other than that of the consumer. Organizations such as the UK's Food Standards Agency face the difficult task of demonstrating their independence of producers' interests if they are to be a credible source of information on food risk in the future. In many European countries, public health professionals are, perhaps, also more likely to be trusted as credible information sources if they can frame their communication with the public as independent of government departments, in the interests of consumers and as sophisticated in its understanding of the uncertainties of scientific evidence.
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Public health professionals are increasingly responsible for communicating risk information to the public. Risk communication strategies are likely to be most effective if they resonate with public concerns and reflect the sophistication of public knowledge about the complexities of risk and safety. In the arena of food safety, we have shown how focus group interviews can generate information about how the public frame their knowledge of risks and what sources of information are trusted. To be credible, sources of information on food risks, public health professionals must endeavour to be open about scientific uncertainty.
Key points
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Acknowledgments |
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We are grateful to Dr Carlos Dora, project colleagues, Francesca Gleria (for research assistance on the Italian fieldwork) and all those in the four countries who participated in the focus groups. This study was funded by the EU (European TSE Project grant PL 987028), and led by the WHO Regional Office for Europe.
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7 Draper A, Green J, Dowler E, et al. Final report for Task 1: Inter-country results and comparison. (European TSE Project PL 987028). Copenhagen: WHO Regional Office for Europe, 2002.
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11 Sellerberg AM. In food we trust? Vitally necessary confidence — and unfamiliar ways of attaining it. In: Fürst E, Prättälä R, Ekström M, et al., editors. Palatable worlds: socio-cultural food studies. Oslo: Solum Forlag, 1991:193–201.
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