1. An Assessment of Mercury Risk, Fish Advisory Awareness, and Fish Consumption in a Latino Population in Wisconsin Jason Ricco MD/MPH Candidate UW School of Medicine and Public Health Jason Ricco MD/MPH Candidate UW School of Medicine and Public Health

2. Acknowledgements  This project would not have been possible without assistance and guidance from:  Preceptor: Laura Anderko, RN, PhD, University of Wisconsin-Milwaukee School of Nursing  Mentor: Henry A. Anderson, MD, Chief Medical Officer, Wisconsin Division of Public Health  Steve Ohly, RN, NP, Clinic Manager at Walker’s Point Community Clinic  The entire clinic staff and volunteers at Walker’s Point Community Clinic  MPH program for Milwaukee Scholars funding  This project would not have been possible without assistance and guidance from:  Preceptor: Laura Anderko, RN, PhD, University of Wisconsin-Milwaukee School of Nursing  Mentor: Henry A. Anderson, MD, Chief Medical Officer, Wisconsin Division of Public Health  Steve Ohly, RN, NP, Clinic Manager at Walker’s Point Community Clinic  The entire clinic staff and volunteers at Walker’s Point Community Clinic  MPH program for Milwaukee Scholars funding

3. Overview  Mercury Background  Fish Consumption  Fish Advisories  Study Design  Results  Recommendations  Conclusion  Mercury Background  Fish Consumption  Fish Advisories  Study Design  Results  Recommendations  Conclusion

4. Mercury Background  Highly neurotoxic heavy metal 1  Ubiquitous in environment- both natural and anthropogenic sources 1,2  2-to-5 fold increase in global atmospheric pool due to anthropogenic sources 1  Highly neurotoxic heavy metal 1  Ubiquitous in environment- both natural and anthropogenic sources 1,2  2-to-5 fold increase in global atmospheric pool due to anthropogenic sources 1

5. Mercury Background  Atmospheric inorganic mercury deposited into aquatic ecosystems 3  Converted to methyl mercury via bacterial methylation 3  MeHg bioconcentrated and bioaccummulated up the food chain 4  Levels in fish 10 6 times higher than levels in water 4  Atmospheric inorganic mercury deposited into aquatic ecosystems 3  Converted to methyl mercury via bacterial methylation 3  MeHg bioconcentrated and bioaccummulated up the food chain 4  Levels in fish 10 6 times higher than levels in water 4

7. Health Effects of Mercury  High-dose methyl mercury exposure can affect the central nervous system at any developmental stage 2,3,5  Fetus is highly sensitive to toxic doses of MeHg  Delayed developmental milestones, blindness, deafness, cerebral palsy in children born to unaffected mothers 2,3,5  High-dose methyl mercury exposure can affect the central nervous system at any developmental stage 2,3,5  Fetus is highly sensitive to toxic doses of MeHg  Delayed developmental milestones, blindness, deafness, cerebral palsy in children born to unaffected mothers 2,3,5

8. Minamata Bay, 1956

9. Health Effects of Mercury  Chronic, low-dose exposure to MeHg can lead to accumulation in nervous system, heart, liver, kidneys 3  Visual, speech, and hearing abnormalities  Ataxia and peripheral neuropathy  Increased risk of heart attack and coronary artery disease? 5,6  Chronic, low-dose exposure to MeHg can lead to accumulation in nervous system, heart, liver, kidneys 3  Visual, speech, and hearing abnormalities  Ataxia and peripheral neuropathy  Increased risk of heart attack and coronary artery disease? 5,6

10. Fish Consumption  Benefits  High protein  Low in Fat  Contains important nutrients  Affordability  Risks:  Most important source of methyl mercury exposure in humans 1  Source of other contaminants (PCBs, etc.)  Benefits  High protein  Low in Fat  Contains important nutrients  Affordability  Risks:  Most important source of methyl mercury exposure in humans 1  Source of other contaminants (PCBs, etc.)

11. Fish Advisories  As of 2002, 45 states have mercury advisories for sport-caught fish 1  U.S. EPA covers freshwater fish not under state advisories 1  U.S. FDA issues advisories for fish bought in stores and restaurants  2004- Joint EPA/FDA advisory issued 8  As of 2002, 45 states have mercury advisories for sport-caught fish 1  U.S. EPA covers freshwater fish not under state advisories 1  U.S. FDA issues advisories for fish bought in stores and restaurants  2004- Joint EPA/FDA advisory issued 8

12. Mercury Risk Disparities  Non-white populations in the U.S. have high fish consumption rates and high body burdens of mercury 1  Subsistence fishing more common in low-income, indigenous groups 9  Higher levels of blood MeHg in Mexican American and non-Hispanic black children than non-Hispanic white children 7  Non-white populations in the U.S. have high fish consumption rates and high body burdens of mercury 1  Subsistence fishing more common in low-income, indigenous groups 9  Higher levels of blood MeHg in Mexican American and non-Hispanic black children than non-Hispanic white children 7

13. Advisory Awareness Disparities  In general, non-white and low-income populations have low advisory awareness 1  1998-1999 12-state survey of women of childbearing age:  Whites more likely to be aware of state advisories (22%) compared to Latinos (12%) and African-Americans (11%) 1  In general, non-white and low-income populations have low advisory awareness 1  1998-1999 12-state survey of women of childbearing age:  Whites more likely to be aware of state advisories (22%) compared to Latinos (12%) and African-Americans (11%) 1

14. Mercury and Fish Advisories in WI  Considerable body of research in WI  Majority of studies focused on sport-fish consumption among anglers with fishing licenses  Ultimately, they focus on a predominantly non-Hispanic, white population  Considerable body of research in WI  Majority of studies focused on sport-fish consumption among anglers with fishing licenses  Ultimately, they focus on a predominantly non-Hispanic, white population

15. Mercury and Fish Advisories in WI  To date, no significant analysis of fish consumption, mercury and advisory awareness in a primarily Latino population in WI  Growing demographic in WI  Evidence of high risk status from other states  Significant language and cultural barriers present in this group  To date, no significant analysis of fish consumption, mercury and advisory awareness in a primarily Latino population in WI  Growing demographic in WI  Evidence of high risk status from other states  Significant language and cultural barriers present in this group

16. The Project  Descriptive analysis of mercury awareness, fish consumption patterns, and Advisory awareness in adult Latino patients in Milwaukee  Goal:  To lay the foundation for further research and funding for culturally competent interventions in mercury risk reduction in this population  Descriptive analysis of mercury awareness, fish consumption patterns, and Advisory awareness in adult Latino patients in Milwaukee  Goal:  To lay the foundation for further research and funding for culturally competent interventions in mercury risk reduction in this population

17. The Site  Aurora Walker’s Point Community Clinic  Serves a primarily Latino uninsured population in south Milwaukee  Aurora Walker’s Point Community Clinic  Serves a primarily Latino uninsured population in south Milwaukee

18. Study Design  Survey on mercury and fish advisory awareness, fish consumption patterns developed  Available in both Spanish and English  Patients in clinic waiting room asked to participate (84 agreed to participate)  Verbal consent obtained with assistance from interpreter  Hair samples obtained from consenting individuals  UW and UWM IRB approval obtained  Survey on mercury and fish advisory awareness, fish consumption patterns developed  Available in both Spanish and English  Patients in clinic waiting room asked to participate (84 agreed to participate)  Verbal consent obtained with assistance from interpreter  Hair samples obtained from consenting individuals  UW and UWM IRB approval obtained

19. Study Design  Additionally, a focus group was held with community members  Social Marketing Theory utilized to identify:  mercury risk perception  barriers to advisory adherence  input on culturally competent interventions that could succeed in the community  Additionally, a focus group was held with community members  Social Marketing Theory utilized to identify:  mercury risk perception  barriers to advisory adherence  input on culturally competent interventions that could succeed in the community

20. Survey Results

21. Results Summary  84% of respondents consumed fish in the past year  Average of 7 servings/month  Commercial fish most frequently consumed (78%)  Very low awareness of mercury health effects (8%) and fish advisories (7%)  84% of respondents consumed fish in the past year  Average of 7 servings/month  Commercial fish most frequently consumed (78%)  Very low awareness of mercury health effects (8%) and fish advisories (7%)

22. Focus Group Findings  Low awareness of mercury and fish advisories in the community  Language is an important barrier  Most fish consumed is store-bought  Advisories linked to licenses not effective in community  Should utilize local mass media (Spanish- language)  Low awareness of mercury and fish advisories in the community  Language is an important barrier  Most fish consumed is store-bought  Advisories linked to licenses not effective in community  Should utilize local mass media (Spanish- language)

23. Recommendations  Fish advisories must be culturally competent  Spanish-language  Acknowledge and address culturally-specific folk models of risk perception  Fish advisories must be culturally competent  Spanish-language  Acknowledge and address culturally-specific folk models of risk perception

24. Recommendations  Combine sport-fish and commercial fish advisory information into a single advisory  For both ease of dissemination and interpretation  Combine sport-fish and commercial fish advisory information into a single advisory  For both ease of dissemination and interpretation

25. Recommendations  Community members more receptive to mass media advisory information dissemination (television, radio, newspaper)  Previous efficacy with anti-tobacco campaigns 10  Community members more receptive to mass media advisory information dissemination (television, radio, newspaper)  Previous efficacy with anti-tobacco campaigns 10

26. Conclusions  Combination of significant fish consumption and very low mercury/advisory awareness makes this an at-risk population  Language and cultural barriers must be addressed  New methods of information dissemination are required to reach this and other subpopulations  Combination of significant fish consumption and very low mercury/advisory awareness makes this an at-risk population  Language and cultural barriers must be addressed  New methods of information dissemination are required to reach this and other subpopulations

27. Conclusions  98% of survey participants wanted more information on mercury and fish advisories  Potential for future intervention efficacy  Call for further research and grant funding for culturally competent intervention trials in this population  98% of survey participants wanted more information on mercury and fish advisories  Potential for future intervention efficacy  Call for further research and grant funding for culturally competent intervention trials in this population

28. Thank You

29. References