Fish contain key nutrients and are recommended as part of a healthy diet to support fetal neurodevelopment during pregnancy.1 However, fish consumption might result in fetal exposure to contaminants, including mercury, perfluoroalkyl and polyfluoroalkyl substances (PFAS), and polychlorinated biphenyls (PCBs).¹ The US Food and Drug Administration (FDA), Environmental Protection Agency (EPA),¹ and Wisconsin Department of Natural Resources (DNR)^2,3 have issued advisories to practice safe fish preparation methods and avoid consuming certain fish species. Several freshwater bodies near Milwaukee, Wisconsin, are designated as an Area of Concern because of contaminant levels and have additional consumption advisories.³

Asians individuals residing in the United States had higher reported fish consumption than other racial/ethnic groups⁴ and might be at higher risk for mercury, PFAS, or PCB contaminant exposure from fish.⁵ To better understand fish advisory awareness and consumption behaviors among Asian women of childbearing age (WCBA), we conducted a focus group and quantitative survey. Most focus group participants had not heard of specific advisories.⁶ Those who expressed greater self-efficacy (ie, the belief that they could make desired changes to their behavior) were more willing to follow advisories.⁶ Among survey respondents, only 40.5% had heard of any fish consumption advisories.⁷ These findings demonstrated a need for interventions to increase Asian WCBA’s awareness of fish advisories and willingness to follow them.

In this evaluation, we assessed whether educational messaging with or without a motivational self-affirmation component can increase perceived self-efficacy⁸ and lead to improved fish advisory awareness and safer fish consumption behaviors.

In total, 123 Asian women aged 20 to 50 years were survey participants. Thirty-eight participants were randomized to group 1, 43 to group 2, and 42 to group 3. Most participants were Hmong (n = 77, 63%), followed by Karen (n = 17, 14%), Chinese (n = 15, 12%), and Filipino (n = 14, 11%). Nearly all (n = 111, 90%) participants chose to complete the survey in English. Most participants had at least an associate degree (61%) (Table 1).

Most participants in the intervention groups reported intentions to follow educational messages. Immediately after the intervention, 77% of group 2 and 79% of group 3 reported they planned to “eat 1 to 2 servings (but not more) of fish every week.” Likewise, 91% to 93% said they planned to “choose to eat types (species) of fish that are lower in chemicals, like mercury” and “clean or cook fish using ways that may lower the amount of chemicals.” However, because group 1 did not answer these items, it is unclear whether the interventions improved participant intentions.

After 1 month, 77% of group 2 and 76% of group 3 reported they intended to follow the educational messages from the intervention (Table 2). Group 3 had higher odds than group 1 of reporting most behavior changes in the past 30 days, including “eating fewer fish meals” (OR 2.76; 95% CI, 1.12–7.03), “eating different types or species of fish” (OR 1.82; 95% CI, 0.75–4.47), and “avoided eating fish from some fishing locations” (OR 3.13; 95% CI, 1.25–8.22). Groups 2 and 3 reported eating the skin, head, guts, and belly fat of fish less often than group 1 (Table 2).

In this behavioral intervention of Asian WCBA in the Milwaukee area, we found motivational self-affirmation and educational messaging improved fish advisory awareness and safer fish consumption behaviors. Both groups 2 and 3 reported less frequent use of higher-contaminant fish preparation methods than group 1. These results are encouraging evidence that educational messaging might reduce these communities’ contaminant exposure from fish consumption. Group 3 was more likely than group 1 to report behavior changes to avoid contaminants from fish, indicating self-affirmation interventions are also beneficial. In keeping with our previous findings, intervention components designed to increase both fish advisory knowledge and self-efficacy increased safe fish consumption behaviors.

Maternal exposure to mercury, PFAS, and PCB contamination may lead to adverse birth outcomes and impact cognitive and reproductive health in infants.2 Our team’s prior studies found that a sample of mostly White, mostly male Milwaukee-area anglers had elevated contaminant levels, and in Wisconsin, Asian people have higher incidence of severe maternal morbidity and low birthweight than comparator groups.^11,12 Although these poor outcomes are likely multifactorial, limiting contaminant exposure from eating fish in Asian WCBA in the Milwaukee area may improve maternal and child health and reduce these health disparities. Clinicians and public health practitioners can use these combined educational and self-affirmation materials to reduce contaminant exposure from fish consumption in this community.

This behavioral intervention was associated with increased safe fish consumption behaviors among Asian WCBA in the Milwaukee area. Self-affirmation paired with educational messaging might be a valuable tool to reduce contaminant exposure from fish in this population.

Appendices: Available at www.wmjonline.org