# Presentation: 474986

##   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.

**Notes:**
Good Afternoon, Today I’ll be discussing Perceptions and Practices Related to the Consumption of Unpasteurized Milk Products, Listeriosis and Pregnancy Complications. I’d like to thank my colleagues Mirna, Consuelo and Jeremy. 

## 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)

**Notes:**
Before I launch into details about this study, I’ll give a background on: 
 Hispanic/Latinos and Reproductive Health
 Listeriosis & associated high risk foods
 Listeriosis and pregnancy
Then, I’ll discuss the qualitative and quantitative studies we conducted and provide some discussion, conclusion and recommendations. 
I’ll be using HL throughout my presentation referring to Hispanic/Latino.

## 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

**Notes:**
Hispanic-Latinos constitute the fastest growing and largest U.S. minority group
Over 14% of the U.S. population of whom 47% are immigrants    
Looking at yearly rates of pregnancy outcomes for Hispanic/Latinos nationwide, there are over 93 live births, over 100 fetal losses, 10 preterm deliveries and approximately 6 low birth weight newborns.
Limited research has been conducted on Hispanic/Latino’s health behaviors, particularly those related to Listeriosis and associated pregnancy complications. 

## 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

**Notes:**
L. monocytogenes is a gram-positive food borne pathogen transmitted when a person eats contaminated food. It represents a food safety challenge since it is commonly found in the environment and can persist for months or years for as long as there are micronutrients for the bacteria to grow and multiply. 
Unlike most foodborne pathogens, listeria can grow in temperatures ranging from 1-45 degrees Celsius. 
Hispanics/Latinos bear a disproportionate higher incidence of listeriosis when compared to other racial/ethnic groups; especially among infants and women of childbearing age 

## Listeriosis Rate by Ethnicity

-  FoodNet Sites,1996**–**2003

**Notes:**
FoodNet, an active laboratory and population based surveillance network in 10 states including Georgia, has conducted active surveillance for listeriosis since 1996. 
This graph shows a far higher incidence of Listeriosis in Hispanic than non-Hispanics from 1996 until 2001. There was a decline in 2002, but we’ve seen an increase again in 2003. 

## 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

**Notes:**
Latino home-made cheese is a traditional food widely consumed by HL and often prepared at home from unpasteurized milk in unsanitary places including buckets, bathtubs and sinks.
Several outbreaks underscore the high potential for epidemic transmission of Listeriosis among HL. 
To name a few, in 1985, an outbreak in Los Angeles County associated with commercially-made Latino cheese involved 81 HL and resulted in 20 stillbirths and 10 infected newborns. 
In 2000, an outbreak in North Carolina associated with Home-made cheese involved 12 HL including 10 pregnant women whose pregnancies ended in 5 stillbirths, 3 premature births and 2 infected newborns.

## 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

**Notes:**
Since Listeria monocytogenes can cross the placenta, it can also be transmitted vertically from the mother to her fetus.
It can take from 2-6 weeks for invasive disease and most people are asymptomatic. Transplacental 
transmission can occur with both symptomatic and asymptomatic bacterimia. The clinical syndrome
for pregnant women typically ranges from a mild, flu-like illness to sepsis and meningitis.
Maternal infection can result in stillbirths, preterm labor or systemic listeria infection in the newborn.
Infected newborns exhibit early- and late-onset of sepsis and meningitis.

## Futura Mamá

- Qualitative and Quantitative
-  Study on Health Behaviors

**Notes:**
A qualitative and quantitative study was conducted in Georgia as part of a two phase educational intervention, Futura Mamá or Expecting mother. This program aims to study health behaviors and educate Hispanic-Latino communities about the risk related to consumption of unpasteurized milk-containing food and pregnancy complications. 

## 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

**Notes:**
The objectives of this study were to understand participant’s knowledge, attitude and risk perceptions, regarding unpasteurized milk products and pregnancy health issues, 
Characterizes participants’ preferences towards seeking/receiving educational material and health education strategies,
Assess literacy to guide the development of culturally and linguistically appropriate educational material and,
Identify barriers faced by the Hispanic/Latino community for accessing accurate health information.

## 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)

**Notes:**
Eight focus groups consisting of Hispanic/Latino participants were conducted in Gainesville, GA between august 23 and 28 of 2003.
To ensure representativeness, participants were recruited at two sites:
The Hall County Health Department which serves 25% of the county’s Hispano/Latino population and a local Catholic Church with an active membership of 16,000 Catholic Hispano/Latinos.

## 76 participants (6–16 participants per group)

70 born in Mexico

53 women childbearing age 
         (range 18–40 years)

5 pregnant women

- 70 born in Mexico
- 53 women childbearing age
-          (range 18–40 years)
- 5 pregnant women

- Focus Group Participants

**Notes:**
A total of 76 HL participated in the focus groups. 70 were born in Mexico
Other origins included Colombia, Costa Rica, Guatemala, El Salvador, and Puerto Rico;
53 were women of childbearing age ranging from 18 to 40 years of whom 5 were pregnant. 

## 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

**Notes:**
We got a pretty good idea of the participant’s perception regarding their traditional food and health. The majority believe that unpasteurized-milk products are “healthier” have “more vitamins” and “nutrients” 
Most claimed they can distinguish home-made from commercially-made cheese by taste, but  can not distinguish between unpasteurized and pasteurized milk or cheese.
More than half reported regular consumption of home-made cheese including pregnant participants.
None had heard of listeriosis or associated pregnancy complications.
Surprisingly, all believe in the usefulness of prenatal care.

## 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

**Notes:**
Our findings show that compare to older women, younger Hispanic women less than 32 years were more likely to accept the possibility of health risks related to consumption of unpasteurized milk products. 
They expressed a somewhat greater willingness to accept advice offered by healthcare providers.
Men expressed less willingness than women to trust physicians. Overall, women prefer discussing health concerns with mothers or other relatives rather than healthcare providers.

Next, I’m going to present findings from our quantitative study. 

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

**Notes:**
We then conducted a community survey in Hall County which has one of the largest Hispanic/Latino populations in Georgia, constituting about 20% of the county’s population.  
Participants were recruited at 14 residential sites which included mobile homes, apartment complexes and Private and rental single homes.  

## 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

**Notes:**
The study population consisted of three HL groups:  women of childbearing age 18 to 44 years old; women 45 years and over; and men 18 years and over. 
Predominantly Hispanic residential areas were identified in collaboration with Hall county health officials and community leaders. We  conducted a door to door survey in  target HL communities; only one eligible person per household was invited to participate in the survey. A Spanish questionnaire was administered in-person by a trained interviewer. 

## 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

**Notes:**
Four hundred KAP surveys were conducted in Gainesville, GA., between July 19 - 29 2005; 57% of the participants were female of whom over 11% reported to be pregnant. Over 80% were of reproductive age. About half had completed elementary or middle school and most participants were of Mexican origin. The majority stated they read Spanish well; however, only about 11% said they could read English. 

## 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

**Notes:**
Findings from our quantitative study indicate that:
Over half of participants believed that Unpasteurized milk may be hazardous to health
And that gastrointestinal illness could be caused by food that taste and smell good
However, over half prefer cheese made from unpasteurized milk.
Over 66% did not realize that eating unpasteurized cheeses during pregnancy increases the risk of miscarriage, most believe that raw milk have more vitamins, and therefore, it is a “healthier” choice during pregnancy. 

## 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

**Notes:**
The overwhelming majority of participants believed that prenatal care is beneficial, and that asymptomatic illnesses during pregnancy can cause infant illness or death.
Only about 11% had heard about listeriosis and its association with spontaneous miscarriage. 

## Health Communication Channels

**Notes:**
All participants reported they preferred getting and receiving medical information about listeriosis and pregnancy-related infections by Pamphlets, TV/Radio and In-person learning formats such as Workshops. Videos were not among the preferred media.

## 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

**Notes:**
In my analysis restricted to women, the overwhelming majority stated that some birth defects and congenital illnesses are preventable with prenatal vaccines, vitamins or blood tests
Most women also believe that eating unpasteurized cheeses during pregnancy may cause gastrointestinal
illness in mother or infant. However, most women believe that unpasteurized milk have more vitamins, and is “healthier” during pregnancy. 
Less than half knew that some foods should not be eaten during pregnancy 
Most women stated that they discuss their health concerns with physicians or other health professional

## 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

**Notes:**
In conclusion, this study showed that little awareness of risks related to unpasteurized milk products exists among members of the HL community
We found that High value is placed on “healthful” aspects of food and on prenatal care
And we found a strong preference for specific modes of delivery for health information. 

## 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

**Notes:**
Some of the limitations we found during the study were that:
Demographic information might not be 100% accurate because of the immigration status of many of the participants and the mistrust toward government agencies. 
More than one person per household could have participated in focus groups since we did not collect demographic information and it was conducted anonymously. 
Also, because recruitment areas were not arranged in a identifiable pattern,
residents were not all Hispanics and 
sampling population is employed in multiple jobs, it was difficult to find qualified participants.  

## 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

**Notes:**
Based on our study findings, we recommend  to develop an educational intervention approach to promote behavioral changes by means of:
Using broadcast as the medium to deliver health education messages such as Telenovelas, Radionovelas and Fotonovelas
Develop an interpersonal reinforcement at the community level as the well known approach of "Health Promotoras”
Evaluate effectiveness of the intervention and explore the possibility of adapting the pilot educational
intervention in other HL communities.

## 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.

**Notes:**
I will like to thank all the people involved in the development of the Futura Mama program.
Thank you!