title: Examining the Impact of a Public Health Message on Fish Consumption in Bermuda.
abstract: BACKGROUND
  In 2003 mean cord blood mercury concentrations in pregnant Bermudian women exceeded levels associated with adverse health outcomes in children. The principal mercury source was local fish species. Public health messages were developed suggesting pregnant women reduce consumption of fish species with higher mercury concentrations (e.g. swordfish), substituting species containing lower mercury concentrations, and elevated omega-3 fatty acids (e.g. anchovies). Recent evidence indicates mercury concentrations in Bermuda's pregnant women have fallen five- fold.
  
  
  OBJECTIVE
  Assess whether changes in women's fish eating patterns during pregnancy are consistent with the public health messaging. Determine who is making changes to their diet during pregnancy and why.
  
  
  METHODS
  Mixed methods study with a cross-sectional survey of 121 pregnant women, including 13 opened-ended interviews. Health system, social vulnerability, public health messaging, and socio-demographic variables were characterized and related to changes in fish consumption during pregnancy. Qualitative data were coded according to nutritional advice messages, comprehension of communication strategies, and sources of information.
  
  
  RESULTS
  95% of women surveyed encountered recommendations about fish consumption during pregnancy. 75% reported modifying fish eating behaviors because of recommendations. Principal sources of information about fish consumption in pregnancy were health care providers and the Internet. 71% of women reported reducing consumption of large fish species with greater mercury levels, but 60% reported reduced consumption of smaller, low mercury fish. No participant mentioned hearing about the benefits of fish consumption. More frequent exposure to public health messages during pregnancy was associated with lower reported consumption. Bermudian born women were less likely to reduce consumption of large fish species during pregnancy.
  
  
  CONCLUSIONS
  In Bermuda, public health messages advocating reduced consumption of larger, higher mercury-containing fish species appear effective, but masked the nutritional value message of small fish species, with low mercury concentration. Adjustment is needed to better balance the risk communication.
authors.affiliation: Office of Public Health Studies. University of Hawai'i at Mãnoa. Honolulu, Hawai'i, United States of America.
authors.forename: Catherine
authors.initials: C
authors.lastname: McLean Pirkle
authors.affiliation: Department of Health. Hamilton, Bermuda.
authors.forename: Cheryl
authors.initials: C
authors.lastname: Peek-Ball
authors.affiliation: King Edward VII Memorial Hospital, Hamilton, Bermuda.
authors.forename: Eugene
authors.initials: E
authors.lastname: Outerbridge
authors.affiliation: Department of Conservation Services. Hamilton Parish, Bermuda.
authors.forename: Philippe Max
authors.initials: PM
authors.lastname: Rouja
mesh_terms: D000328:Adult; D000818:Animals; D001605:Bermuda; D054626:Consumer Health Information / Q000592:standards*; D003430:Cross-Sectional Studies; D004435:Eating; D005247:Feeding Behavior; D005260:Female; D005399:Fishes; D005506:Food Contamination / Q000517:prevention & control*; D006801:Humans; D008297:Male; D011247:Pregnancy; D011634:Public Health; D036301:Qualitative Research; D017747:Seafood