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Summary of Program
ATSDR Great Lakes Research Program
Current Gaps in the Effectiveness of Fish Advisories
Michigan Fish Advisory Pilot Program
Program Budget and Implementation
Program Year I
Program Year II
Program Year III
Senate Report 107-43 directs ATSDR report by December 31, 2001, on the feasibility of a proposal to establish a pilot program in Michigan for fish consumption advisories, including funding requirements for such a pilot program. This report responds to the directive by demonstrating how ATSDR and its Great Lakes partners can build upon 10 years of successful research efforts in the basin to establish a new program that specifically addresses this emerging public health priority. Key parameters for the program are identified.Summary of Program
ATSDR could undertake a 3-year pilot program aimed at increasing awareness and observance of fish advisory guidelines among vulnerable populations in the Upper Peninsula of Michigan, such as men and women of reproductive age, sport and subsistence anglers and their families, and American Indian communities. However, within existing resources, ATSDR is only able to fund the programs that are currently underway and described later (see ATSDR Great Lakes Research Program). This new program could provide these residents with outreach education helping them to make decisions that could, in turn, minimize their exposure to contaminants in the sport-caught fish. The pilot program could provide technical and financial support to partners in Michigan to identify the barriers to following fish advisories faced by vulnerable populations and identifying more effective communication channels to help people stay healthy by following the fish advisories' guidelines about fish consumption. The program could include community members and community organizations as partners in all phases of the study. The estimated cost of this intervention and evaluation program would be $1.5 million over a 3-year period.Background
Partially surrounded by four of the Great Lakes, Michigan has more coastline than any state except Alaska. Michigan has numerous waterways, including 11,000 lakes and 36,000 miles of rivers and streams, as well as parts of Lakes Huron, Michigan, Superior, and Erie. Recreational or sport fishing attracts 2 million Michigan residents and 334,000 nonresidents annually.
In recent times, the quality of the Great Lakes ecosystem has been significantly compromised with toxic substances in the water, eutrophication, over fishing, and invasive species arising from various activities associated with the Great Lakes. Over the years, the same chemical contaminants found in the waterways of the Great Lakes were also detected in the native fish and wildlife. Polychlorinated biphenyls (PCBs) and mercury are among the contaminants detected.
From 1993 through 1995, Michigan had 132 fish consumption health advisories for its waterways. Although the state has some outreach efforts to educate the public about health advisories, less populated areas, such as Michigan's Upper Peninsula area, have been more difficult for these programs to reach because of their remote location and low population density. Fifteen counties are located in Michigan's Upper Peninsula. The population for these counties is 317,616, representing only 3.2% of the total state population.
The Upper Peninsula area has a specific need for health education about fish advisories. Many residents fall in the vulnerable groups of reproductive-age men and women, sport and subsistence anglers and their families, and minorities including American Indians. In addition, many of the residents depend heavily on sport fish as a subsistence food. Because the population is spread out over a large and often remote area, the process of educating people there is more difficult.ATSDR Great Lakes Research Program
The Agency for Toxic Substances and Disease Registry (ATSDR) conducts a congressionally-mandated Great Lakes Human Health Effects Research Program in the eight Great Lakes states. This research program is designed to characterize exposure to persistent toxic substances (PTSs) from fish consumption and investigate the potential for citizens of the Great Lakes states to have adverse health effects. These PTSs include PCBs, dichlorodiphenyl trichloroethane (DDT), dieldrin, toxaphene, mirex, methylmercury, benzo[a]pyrene, hexachlorobenzene (HCB), furans, dioxins, and alkylated lead.
The goals of this program are pursued in a broader context that is built on the five traditional elements of disease prevention: identification, evaluation, control, dissemination, and infrastructure. This program has directed its research efforts on the most vulnerable populations, including subsistence anglers, American Indians, Asian Americans, pregnant women, fetuses, nursing infants whose mothers consume contaminated Great Lakes sport fish, young children, the elderly, and the urban poor. This research program is conducted through grants to Great Lakes state health departments, academic institutions, and federally recognized tribal governments. Various state, federal, private, and environmental organizations are also program partners.
ATSDR has conducted research in the Great Lakes basin for 10 years and has three research grants ongoing in the state of Michigan as part of this effort -- two grants at Michigan State University and one at the Michigan Department of Community Health. These grants are investigating the potential for adverse reproductive outcomes in couples who are Great Lakes sport fish consumers. In addition, ATSDR has worked closely with several tribal governments and tribal organizations in the Upper Peninsula of Michigan, including L'Anse Reservation, Bay Mills Chippewa Reservation, Sault Ste. Marie Chippewa Reservation, and the Great Lakes Indian Fish and Wildlife Commission.
The ATSDR research program has found that vulnerable populations in the Great Lakes area are still being exposed to PTSs, and there are health consequences associated with these exposures. Their body burden levels of PTSs are two to four times higher than in the general U.S. population. Among these vulnerable populations, neurodevelopmental deficits in newborns and cognitive deficits in children and adults have been found. Disturbances in reproductive parameters (i.e., increased infertility) have been demonstrated in adults.
In response to these findings, researchers in the ATSDR Great Lakes program created a Consortium of Great Lakes state health departments that developed outreach educational material about fish consumption health advisories. These materials are used extensively in Michigan and most other Great Lakes states. The outreach materials are also translated into languages other than English to educate non-English speaking fish consumers, and provided in novel print forms as well. These materials may be adapted further to meet the needs of the people living in the Upper Peninsula of Michigan.Current Gaps in the Effectiveness of Fish Advisories
ATSDR-funded research indicates that the populations who are most vulnerable are the least knowledgeable about health advisories for fish consumption. These advisories alert the public about contaminants in fish and what species of fish need to be avoided. Although fish consumption advisories are somewhat successful in reaching white male recreational anglers, they are less successful in reaching others who are at the greatest risk (Tilden, 1997).
Currently, the Michigan fish consumption advisory is written in English and distributed to anglers when individuals apply for a fishing license. It is also available over the Internet and distributed at some local and county health departments, doctors' offices, grocery stores, special interest environmental organizations, and offices for U.S. Department of Agriculture's Women, Infants and Children (WIC) program.
About 50% of anglers are not licensed to fish, and, therefore, may never receive the advisory (Tilden, 1997). Moreover, it is unclear if individuals most in need of complying with the fish advisory (e.g., women who may prepare and eat Great Lakes sport fish but do not fish) receive copies from the anglers or other sources.
The Michigan fish advisory is written at or above the 10th grade reading level. However, a minority of the population reads English at this level. In the Upper Peninsula of Michigan, persons with no high school diploma by age 25 make up 18% of the population. Thus, many individuals may not be able to read the current Michigan fish advisory effectively. Equally problematic, the fish consumption advisory is produced only in English. Individuals for whom English is a second language may have difficulty following the advice.
A 1995 Michigan Environmental Science Board (MESB) report provides suggestions for improving the health education and risk communication effectiveness of fish consumption advisories. MESB recommended that populations at greatest risk receive tailored messages through the most effective communication channels possible. In addition, MESB recommended a clarification and simplification of fish consumption messages.Michigan Fish Advisory Pilot Program
Building upon a long history of successful collaboration with state and local partners, tribal governments, and educational institutions in Michigan, ATSDR could design and implement a pilot program for increasing the reach and effectiveness of fish consumption advisories in Michigan. The pilot program would focus on the geographical area of the Upper Peninsula of Michigan. The Upper Peninsula region was chosen for this pilot study because a significant percentage of the population in this region relies on sport fish as a regular component of their diet, the region's population has lower socio-economic status than the rest of the state, and three of the Great Lakes surround the region.Program Objectives
The objectives of the proposed pilot program would be to:
Each of these goals would address the needs of specific vulnerable subpopulations, including unlicensed anglers, men and women of reproductive age, and Asian and American Indian communities, the poor, and older adults. The pilot program could develop tailored, culturally relevant, and specific health education and risk communication recommendations for each population subgroup. At the completion of the pilot program, general design and implementation methods applicable across all vulnerable target audiences would be disseminated.
The pilot program could be implemented in a select number of demographically diverse counties in the Upper Peninsula. We would identify counties whose populations contain the greatest number of vulnerable individuals. Specific criteria for county selection would include the following: percentage of racial/ethnic minorities, percentage of women of childbearing age, presence of American Indian Reservations, socioeconomic status, and access to primary health care.
Active and sustained participation from community members in counties in the Upper Peninsula of Michigan would also be critical to the success of the study. Specifically, this study would: (1) build on strengths and resources within the Upper Peninsula; (2) include community members and participating institutions/organizations as partners in all phases of the study; and (3) facilitate co-learning among all parties involved (adapted from Israel et al., 1998).
Actively engaging community members would help to ensure:
The application of health education and risk communication theories in this pilot program would be essential. Health education and risk communication theories offer a general framework within which to design interventions (Hochbaum, Sorenson, & Lorig, 1992). Ultimately, the application of health education and risk communication theory to this pilot program holds tremendous advantages in terms of understanding and evaluating fish consumption behaviors. As noted earlier, institutional and community/tribal partners would be critical to the success of the program. Potential institutional partners include state and local health departments, universities, tribal colleges and tribes that are strategically situated to address the needs of Upper Peninsula residents.Program Budget and Implementation
The proposed pilot program could be completed during a 3-year project period. Proposed program activities follow.Program Year I