by Eric Frohmberg

Maine’s Fish Consumption Advisories
Development, Distribution and Evaluation
Eric Frohmberg
Maine Environmental and Occupational Health Program
Maine DHHS Public Health • Environmental and Occupational Health Program

Outline
Problem Analysis
Audience Needs
Assessment
Formative
Evaluation
Communication
Strategy Design
Communication Strategy
Implementation
Process
Evaluation
Summative
Evaluation

Fish and Mercury Basics
ALL FISH have some
mercury in them.
Dominant concern for mercury is the developing baby.
Fish is also good for you – communicating a conflicting message

What do we know?
• Current exposures are significant
Women 16-49
(1999-2000 NHANES)
Blood Hg (ug/L) n=1709
75 th
25 th 90 th
0.4 0.9 2.0 4.9 7.1
95 th
50 th EPA RfD=3.4
• Only 31% Maine women of childbearing age aware
of mercury advisories (WI/ME 12-State RDD Survey, 2000)

Audience Identification
Who do we want to Reach?
• Pregnant women
• Women who may get pregnant
• Women who are nursing
• Children under 8
Techniques to Reach Them
• Birth Registry Database ∩
Sport Fishing License
Database
• 40% of Pregnancies in
WIC
• OB/GYN, Family Practice,
and Pediatricians
A lot more to Audience Identification

Audience Identification
• Approximately 50% of U.S. adults read at or
below 8 th grade level.
• Reading level decreases with increasing poverty,
age, illness, and stress.
• In 1994, 80% of health care materials distributed are written
at a level that only 3% of adults can easily read.
Source: National Adult Literacy Survey of 1993
Riffenburgh and Associates 1994

Technique: Writing “Plain Language”
• Grade Level - Use readability analysis.
• Content -Tell them what the need to know, not nice
to know. Remove jargon. Conversational tone. Active
voice.
• Layout – effective use of graphics, plenty of white space,
appropriate typeface (limit sans serif and ALL CAPS).

How People Scan Text
People scan the top ½ of the line
For that reason it is harder to read
sans serif
AND HARDER TO READ ALL CAPS

Evaluate: Focus/Key Informant Group Testing
Hints
• Find existing groups to use.
• ~6-8 People. Recommend a moderator and a note taker.
• Plan your questioning route – start broad, then focus.
• Reimburse participants for their time – gift certificates,
payments, gifts.

Example: What did we learn?
Before
After

Writing to Different Audiences

Tables versus Charts

Distribution
Develop New “Easy to Read”
Brochure
Targeted Delivery
Target Mailings
• Linkage of Fishing License Database
& Birth Certificate Registry
WIC Clinics
• In Maine, WIC sees ~40
of all pregnancies
Health Care Providers
• OB/GYN Doctors
• FPs and GPs who perform OB
• Nurse Midwife

Evaluation: 4 myths
Evaluation is too complicated, no one here knows how to do it.
Evaluation takes too long.
It is too risky. What if it shows our funding source that we
haven’t succeeded?
We affected only 30% of our intended audience – our program is
a failure.
Source: NCI 2002. Making Health Communication Programs Work.

Evaluation – What is your baseline?
Baseline Survey: 1999 – to assess existing knowledge of
advisories
Evaluation Survey 2000 – to assess impact of brochure
Percent
50
40
30
20
10
32
41
35
Are 26you aware your state has
advice for consuming fish?
0
Maine
Wisconsin
1999 2000

New Moms Survey: Design/Methods
• 24 pages, 75 questions
• Pre-tested
•Mail survey
• Sample drawn from Birth
Certificate Registry
• ~60% response rate (n=768)
• Asked for hair sample

Survey: Helpful Hints
• Data analysis plan
• Identify data sources for key comparisons
• Think about evaluation during design of materials
• Identify goals – what is a “success”?

Comparison of Studies
1998/9 Pre-Survey
2000 Post Survey
2004 Moms
Target Pop
Women of
Childbearing Age
Women of
Childbearing Age
Moms
Sample Size
535
493
768
Mean Age
34 ± 7.5
34 ± 8.6
27 ± 5.7
Race
95% white
96% white
96% white
Fishing Lics
39%
40%
44%
Aware State
Has Advice
32%
41%
60%

How do you measure success?
Awareness that the state has advice up to 60%
31% of the total sample reported getting our brochure
Of the total sample only 6.5% ate any “forbidden fish” in last 3
months of pregnancy
Of those who got brochure, 93% reported reading it.
Of those who got brochure, 64% had a HCP talk to them about
the information in it.

Measuring Success, Cont’d
Ate fish and got
brochure
Ate fish and didn’t
get brochure
p value
Ate White Tuna
54% (48-60)
64% (59-68)
0.02
Ate Light Tuna
39% (33-46)
30% (25-35) 0.02

What can we say about distribution?
31% of the total sample reported getting our brochure
Of the total surveyed population
•4% in mail
•24% from Doc/CNM
• 9% got it from WIC
41% of the sample were on WIC
• 29% of those in WIC remember getting it from WIC

Distribution: Cont’d
Education

What can we say about the population?
1999 Women
OCB
2000 Women
OCB
2004 Moms
Before Pregnant
2004 Moms
Last trimester
Ate any
sportfish
21%
21%
14%
5%
Of those who ate fish in last trimester, only 13% ate more than 2
meals per week.

This is an iterative process: New Draft Brochure

Cost?
• ~$13,000 for first brochure
• ~$6,000 for distribution
• ~ $15,000 for evaluation
• ~ $15,000 for redesign

For more information:
• Low Literacy Communication Skills for Health Professionals:
Biddeford, ME; Albuquerque, NM:
http://www.healthliteracyinstitute.net/
• Focus Group Interviewing Workshop, Minneapolis, MN: email
Richard Krueger at: rkrueger@tc.umn.edu
• Krueger, R.A. and M.A. Casey. 2000. Focus Groups: A Practical
Guide for Applied Research. 3 rd Ed., Sage Publ.
• NCI. 2002. Making Health Communication Programs Work. NIH
Publication No. 02-5145. FREE at 1-800-4-Cancer
http://www.cancer.gov/pinkbook
• CDCynergy 3.0 Your Guide to Effective Health Communication.
http://www.cdc.gov/communication/cdcynergy.htm