Perceptions and Practices Related to the Consumption of Unpasteurized Milk

1. 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.

2. 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)

3. 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

4. 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

5. Listeriosis Rate by Ethnicity FoodNet Sites,1996–2003

6. Latino-Style Homemade CheeseHigh 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

7. 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

8. Futura Mamá Qualitative and Quantitative Study on Health Behaviors

9. 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

10. Qualitative StudyFocus 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)

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

12. 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

13. 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

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

15. 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

16. 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

17. 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

18. 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

19. Health Communication Channels

20. 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

21. 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

22. 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

23. 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

24. 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.