B1 Irizarry De La Cruz

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Perceptions and Practices Related to the Consumption of Unpasteurized Milk Products, Listeriosis and Pregnancy Complications: Voices from a Hispanic/Latino Community Margie Irizarry-De La Cruz, MPH Mirna Perez-Rodriguez, MSW Consuelo Beck-Sague, MD Jeremy Sobel, MD, MPH Office of the Director, Division of Reproductive Health, NCCD Foodborne & Diarrheal Disease Branch, NCID Centers for Disease Control and Prevention The findings and conclusions in this presentation have not been formally disseminated by the Centers for Disease Control and Prevention and should not be construed to represent any agency determination or policy.

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Overview Background Hispanic-Latinos and Reproductive Health Listeriosis and High Risk Foods Listeriosis and Pregnancy Qualitative Study – focus groups Quantitative Study – community survey Discussion and Conclusions Recommendations HL (Hispanic/Latino)

Hispanic-Latinos & Reproductive Health: 

Hispanic-Latinos & Reproductive Health HL fastest growing U.S. minority group 14.2% of U.S. population 47% immigrants Pregnancy outcome rates, 1998–2002 93.30/yr Live births 100.30/yr Fetal loss 10.05/yr PTD 5.61/yr LBW Limited research on HL’s health behaviors Listeriosis and pregnancy complications

Listeria monocytogenes: 

Listeria monocytogenes Gram-positive bacterium Foodborne pathogen Food safety challenge Commonly found in the environment Can persist for months & years Can grow at refrigeration temperatures 1– 45°C Incidence higher in HL Infants Women of childbearing age

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Listeriosis Rate by Ethnicity FoodNet Sites,1996–2003

Latino-Style Homemade CheeseHigh risk of Listeriosis: 

Latino-Style Homemade Cheese High risk of Listeriosis Traditional, widely consumed HL food Often prepared from unpasteurized milk Often home-prepared in unsanitary places Buckets Bathtubs Sink Outbreaks linked to unpasteurized HL cheese Los Angeles, CA 1985 81 HL, 20 stillbirths,10 neonates North Carolina, 2000 12 HL, 5 stillbirths,3 PTB,2 neonates

Listeriosis and Pregnancy: 

Listeriosis and Pregnancy Transmission Ingestion of contaminated food Transplacental Clinical features 2–6 weeks incubation period for invasive disease Asymptomatic infections can occur Mild flu-like illness to sepsis, meningitis Infection during pregnancy can cause: Stillbirths/spontaneous miscarriages Preterm labor or systemic infection Early/late-onset sepsis and meningitis in newborn

Futura Mamá: 

Futura Mamá Qualitative and Quantitative Study on Health Behaviors

Objectives: 

Objectives Understand participants’ knowledge, attitude and risk perceptions Unpasteurized milk Pregnancy health issues Characterize participants’ Preferences seeking/receiving educational material and health education strategies Literacy level to develop culturally and linguistically appropriate educational material Barriers faced in accessing accurate information

Qualitative StudyFocus Groups : 

Qualitative Study Focus Groups Conducted 8 focus groups in Hall County, GA 8/23-8/28 2003 7 Hispanic women's groups 1 Hispanic men's group Participants recruited at two sites Hall County Health Department, Gainesville Serves 25% of the county’s HL population Catholic Church in Gainesville, GA. Membership of 16,000 HL Participants enrolled by age group and gender 7 Women’s groups (18–25, 26–32, 33–40, >41 years) 1 Men’s group (>18 years)

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76 participants (6–16 participants per group) 70 born in Mexico 53 women childbearing age (range 18–40 years) 5 pregnant women Focus Group Participants

Perceptions of Focus Groups Participants (N=76): 

Perceptions of Focus Groups Participants (N=76) Majority believe unpasteurized products are “healthier” Most can distinguish home-made from commercially-made cheese by taste Most can not distinguish between unpasteurized and pasteurized milk or cheese More than half regularly consume home-made cheese None have heard of listeriosis or associated pregnancy complications All believe in usefulness of prenatal care

Focus Group Findings: 

Focus Group Findings Compared to older women, women aged <32 (n=35) were more willing to accept: Possibility of health risks related to consumption of unpasteurized milk products Advice offered by healthcare providers Men less willing than women to trust physician Women prefer discussing health concerns with mothers or other relatives rather than healthcare provider

Quantitative StudyCommunity Survey, Hall County, GA19.6% HL: 

Quantitative Study Community Survey, Hall County, GA 19.6% HL

Recruitment of Participants: 

Recruitment of Participants Enrolled by age group and gender Women aged ≥ 18 to 44 years Women aged ≥ 45 years Men aged ≥ 18 years Methodology Predominantly Hispanic residential areas 14 residential areas met criteria Door to door survey in target HL communities 1 eligible participant per household Spanish questionnaire In person interviews Administered by trained interviewers

Study Population: 

Study Population 485 Hispanics invited to participate July 19 - 29 2005 400 (82.0%) accepted 228 (57.0%) female 26 (11.4%) pregnant 183 (80.2%) reproductive age (18-44 years) Approximately half completed elementary or middle school Most participants were Mexican origin Language proficiency 352 (88.0%) read Spanish well 43 (10.8%) read English

Unpasteurized Milk Products : 

Unpasteurized Milk Products 206 (51.5%) believed unpasteurized products may be hazardous to health 210 (55.2%) believed gastrointestinal illness could be caused by food that taste and smell good 158 (50.2%) preferred cheese from unpasteurized milk 265 (66.3%) did not realize eating unpasteurized cheeses during pregnancy increases risk miscarriage 279 (69.8%) believed unpasteurized products “healthier” choice during pregnancy

Pregnancy-related Health Issues: 

Pregnancy-related Health Issues 375 (93.8%) believed in usefulness of prenatal care 347 (86.8%) believed asymptomatic illness during pregnancy can cause infant illness or death 42 (10.5%) had heard of listeriosis or associated pregnancy complications

Health Communication Channels: 

Health Communication Channels

Analysis restricted to women : 

Analysis restricted to women 214 (93.9%) believe birth defects and congenital illness are preventable with prenatal vaccines, vitamins, blood test 147 (64.5%) believe unpasteurized cheeses may cause gastrointestinal illness in mother or infant 150 (65.7%) believe unpasteurized (“raw”) milk have more vitamins, and is “healthier” during pregnancy 113 (49.5%) knew that some foods should not be eaten during pregnancy 201(88.2%) discuss health concerns with physicians or health professionals

Conclusions: 

Conclusions Limited awareness of risks related to unpasteurized milk products among members of HL community High value placed on “healthful” aspects of food and on prenatal care Strong preference for specific types of health education

Limitations: 

Limitations Accuracy of demographic information Immigration issues Mistrust of U.S. government More than one person per household could have participated in focus groups (qualitative study) Difficult settings for recruitment (quantitative study) Not all Hispanics Work multiple jobs

Recommendations: 

Recommendations Develop an educational intervention approach to promote behavioral changes by means of: Using broadcast to deliver health education messages Telenovelas Radionovelas Fotonovelas Develop an interpersonal reinforcement at the community level “Health Promotoras” Evaluate effectiveness of intervention Adapt the pilot educational intervention in other HL communities

Acknowledgments : 

Acknowledgments Office of Minority and Women’s Health, NCID, CDC Marian McDonald, PhD Georgia State DOH Susan Lance-Parker,D.V.M., PhD Melissa D’Angelo Foodborne & Diarrheal Disease Branch, NCID,CCID,CDC Division of Reproductive Health/NCCDPHP,CCHP,CDC The findings and conclusions in this presentation have not been formally disseminated by the Centers for Disease Control and Prevention and should not be construed to represent any agency determination or policy.