Communicating fish consumption advisories

Table of Contents:

1.  Purpose of communication manual 

2.  What is a fish consumption advisory and how are they currently communicated? 

3.  Current communications shortcomings 

4.  Best practices 

5.  Reaching hard-to-reach populations 

6.  References  

The purpose of this manual is to equip local health departments, fish and wildlife professionals, environmental educators, healthcare workers, conservation groups, and community members with tools to effectively communicate about fish consumption advisories. This manual is based around our work and experience in the Lower Cape Fear River Region of North Carolina, but can be applied statewide and, in some cases, beyond.

There is evidence that advisories often do not reach people who are catching and consuming fish from North Carolina lakes and rivers. Some of the most vulnerable populations, such as those who are food insecure, low-income, or non-English-speaking, also tend to be the most difficult to reach with important environmental health information.   

We hope that this manual can help you create and implement communication strategies for fish consumption advisories that are both effective and equitable. Collectively, we can work to protect communities while still supporting catching and eating fish in North Carolina.

Social science research provides several useful models for understanding the psychology of health behavior change and the design of risk communication messages. The theory of planned behavior and the health belief model focus on the complex process of changing one’s behavior when faced with a new health threat. Key elements of both models include accounting for perceived barriers (What stands in the way of adopting a new behavior?), attitudes toward a behavior (Do people view it positively or negatively?), subjective norms (Do other people they respect perform the behavior?), and self-efficacy (Do people believe they have the skills and ability to adopt a new behavior?).

When developing successful messages, communicators need to balance two elements: (a) bringing a health threat to the attention of those affected, and (b) providing guidance on what they can do to address the threat. Focusing too much on raising attention or not enough on guidance may cause a “fear control” response, where people focus only on managing their negative cognitions and feelings and not on addressing the threat itself. Messages must provide clear, achievable guidance on how affected individuals can protect themselves.

Some advisories are statewide, like for  methylmercury . Some advisories are specific to a body of water, like the advisory for Badin Lake, which specifically covers  PCBs in catfish .

Once DHHS sets an advisory, people like you - local health departments, fish and wildlife professionals, environmental educators, healthcare workers, and conservation groups - must communicate the advisories to the public. Advisories can be found on the  DHHS website , but more work is needed to effectively reach people. In North Carolina, county health departments are responsible for generating and posting physical signs based on existing advisories. Communicators should identify where existing signs are located in their communities, and determine if and where additional signs are needed.

Ideally, communication and education materials would be developed in collaboration with people most likely to be catching and eating fish. Acknowledging that that is not always possible, this toolkit uses documented best practices to help you design and implement effective messages about fish consumption advisories. These best practices are based on existing research and direct feedback we have received while working with communities and groups engaged in environmental health and education across the state.

Based on conversations with public health and environmental professionals, and reviews of the research literature, we know that many people are unaware of fish consumption advisories, their specific recommendations, or how to follow them (e.g., meal and portion sizes, preparation suggestions, alternative fish species). We also know that the limited resources, funding, and personnel in North Carolina can make it difficult for state and local health departments to disseminate advisory guidance to everyone on their own.

Much of the current communication about advisories relies on physical signage posted at rivers and lakes. Unfortunately, these signs are often ignored or missed altogether. Many signs are too text heavy, and deter people from taking the time needed to read them (Figure 3).  Some signs are posted where only a select subset of fishers will see them (e.g., boat ramps), and more strategic placement would likely reach more fishers. Additionally, there are many fishing locations where consumption advisory signs are not posted at all.

Evidence suggests that people respond best to visual communications that use relatable images (such as families and children), bright colors, variation in text size and style, and that contain a fair amount of white space (C. Klein, personal communication, February 2021). Current advisory signs tend not to consistently follow this design guidance.

Research shows that many fishers prefer reading signs along the shoreline as a means of learning about advisories, but physical signs alone at these locations are not sufficient for reaching all people who may be catching and/or consuming fish. The following pages will show examples of best practices for conveying specific messages related to FCAs.

The following best practices have been summarized from existing research, and from our own experiences and observations when sharing fish consumption advisory information in communities.

When conveying information, try to focus on one or two simple messages instead of combining multiple ideas in one place. Once you’ve decided on your message(s), then you can work on making sure they are clear and easy to follow.

Use clear, concrete categories, such as “high, medium, low” risk fish species, or “people who are or may become pregnant” instead of “women of childbearing age.” This makes it easier for people to interpret and make decisions.

Use logical colors and graphics to help people interpret the guidance. Think about a traffic light; people tend to associate green with good or go, yellow with caution, and red with stop. Similarly, people recognize a meter or gauge, and tend to interpret high to mean “danger” or “stop,” and low to be “safe,” which can be an effective low-literacy tool for conveying relative risks from different fish, and drawing attention to the least contaminated fish.

Use images of the fish. Some people might not know the species name, but will recognize an image of the species in the advisory. When possible, use high-resolution, detailed images of the fish you are identifying. ⁴  

Many FCAs provide guidance that varies for different groups of people. Children, pregnant people, people who may become pregnant, and the elderly are often more vulnerable to the contaminants addressed by advisories. For instance, in High Rock Lake, the advisory says that pregnant people, nursing people, and children under age 15 should not eat any catfish from the lake due to the presence of PCBs, while other groups can eat it once a week.

Prioritize language focusing on the most sensitive populations, with the most restrictive advisories. Trying to address varying guidance or provide advice for multiple populations on a single sign can cause confusion. However, language can be too restrictive and can unintentionally imply that advisories do not apply to the general population, as in the case in the graphic below.

While less sensitive groups are likely able to eat more than the guidance provided for the most vulnerable populations, using only the most protective recommendations on a sign allows messaging to be streamlined, and ensures  that we are addressing the most vulnerable groups. When attempting to  include recommendations for other groups on a given graphic, it can get cluttered and may cause confusion (e.g., the same species of fish would show up in different colors or categories). Oftentimes, the best way to avoid confusion is to create separate handouts for vulnerable and general populations.

When possible, clearly and concretely define the populations your message is targeting.

“Children 17 and under” is a more accurate category than “children 1 to 17,” as it answers the question of “what about infants?”  Instead of “women of childbearing age,” “women between 15 and 45” is a more concrete category. Ultimately, those who are most susceptible to the contaminants in fish and those most likely to consume fish should be able to understand and act on the guidance you publish. ⁵ 

a. Risks and benefits of eating fish

When conveying risks of fish consumption, we do not want to deter people from eating fish altogether. Fish can be a healthy, low-cost source of protein and nutrition for many people. In fact, fish are one of the largest food sources of “good fats” that promote heart and brain health, reduce the risk of some cancers, and can decrease the prevalence of allergies in children.

Still, consuming fish with elevated levels of contaminants can be harmful to people’s health, especially fetuses, children, and adults with some chronic diseases, so it is important that messages clearly balance the benefits and risks.

b. Portion sizes

Advisories provide guidance on meal limits and serving sizes to help people determine how much of a certain fish species they can eat in a given time period. But FCAs often make recommendations based on one “meal” or “serving.”  How much fish is in one meal? How large is one serving?

When we order food at a restaurant or cook food in our kitchens, we don’t often weigh or measure our portion sizes, so when we present FCA information, we need to help people understand the serving recommendations.

One way to do this is to use graphics that give people a general idea of serving size recommendations. Studies show that people widely understand the recommendation when using an image like the one above, which shows the recommended serving sizes using an adult hand for scale. The image below shows a checkbook and deck of cards to compare serving size recommendations.

You can also provide information based on how people usually eat the fish. For instance, make clear if the guidance is for raw or cooked fish, because the amount of fish can change through cooking. Present the portion sizes that most people usually eat for a meal of fish (~6-8 ounces), and then suggest limits to frequency (e.g., one meal per week) instead of quantity of fish (e.g., ounces per week). ⁶  Subsistence fishermen represent a population for whom fish may be a significant part of their diets, and if they are unaware of consumption advisories, they may be eating more fish than is recommended to protect health.

c. Preparation and cooking techniques

There are certain preparation and cooking techniques that may help reduce exposure to contaminants, such as fileting and grilling/baking as opposed to frying. In suggesting these preparation techniques, you present people with an alternative to avoiding fish altogether.

In addition to providing alternative preparation techniques, it is obviously important that folks know which species might be safer to eat than others from the waterway they are fishing; ⁷ 

And while fish consumption advisories do this inherently, it is worth providing general guidance on safer vs less safe species. For instance, smaller fish tend to have lower levels of contaminants (may not be true for all chemicals, like PFAS), and can be a helpful rule of thumb in communication materials (Figure 20).

c. Address misconceptions

Sometimes, people will have beliefs about catching, cooking, and eating fish that do not align with scientific consensus. It may be necessary to address some of these misconceptions in your messaging.

Common Misconception 1: Fish that are contaminated with harmful chemicals will look, smell, or taste different than other fish. We know that “healthy looking” fish are not necessarily free from contaminants.

Common Misconception 2:  A lake or river that appears clean does not have contaminated fish in it. If you are communicating about advisories in general, you may want to note that water that appears clean, or is used for swimming and recreation, may still have contaminated fish.

Common Misconception 3: Frying, grilling, or soaking your fish will remove any harmful contaminants. While certain preparation methods may help reduce some contaminants (see Figure 17), the process of cooking does not inherently make a fish free of contaminants.

Common Misconception 4: Bottom-dwelling fish (e.g. catfish) are the only species that have elevated levels of contaminants. Due to bioaccumulation, some smaller fish species have lower levels of contaminants relative to larger fish species (Figure 23), but where in the water column a fish lives does not inherently make it more or less contaminated.

Tan and colleagues (2011) found other beliefs and misconceptions that fishermen in California had about fish consumption (Figure 22). Some of these may be important to address when creating your messages.

e. Use existing, trusted channels of communication

Instead of trying to start from scratch, make use of the channels through which communities already get their information, helping to generate buy-in and build trust. Knowing which people and organizations are a community’s trusted outlets for communication can take a lot of time and effort. Examples of these trusted channels may include churches, community centers, health clinics, and radio stations. ⁸ 

Disseminating messages in different forms (signs, brochures, social media posts, conversations) in various locations (fishing piers, bait and tackle shops, restaurants) can help us reach more people and not rely solely on online information. Having FCA information in other locations can help ensure that no one medium becomes too text heavy, and it also enables us to reach more people with the information. For instance, the Wildlife Resources Commission and other agencies that issue subsistence fishing waivers could provide advisory information, or have supplementary information on their websites.

If possible, we recommend conducting a brief survey or key actor interviews to find out where the people you are trying to reach with advisory information would be most likely to access and trust it. Local researchers or universities may be able to help with this; the graph below shows the results from a survey of bankside fishers along the lower Cape Fear River basin, conducted by Duke University researchers. In order to effectively target communication and outreach efforts, people were asked, “where have you heard information about fish that are safe or not safe to eat?”

General suggestions include sharing information at regular intervals (like the start of peak fishing seasons) and making use of social media, websites, and traditional media (newspapers, radio). When possible, share information with people who have purchased fishing licenses. Tabling at fishing-related events can be valuable not only for communicating information but for building community and forming new relationships. It is helpful, also, to work with existing products you or other groups may already have to include advisory information. Examples include visitor brochures, informational pamphlets about fishing, and health-related publications.

Despite all of the above guidance, there remain populations that are considered “hard-to-reach.” Factors like educational background, access  to information sources, and language barriers may make reaching some demographic groups more difficult than others. Socioeconomic status, which is often related to low literacy levels, can also make certain communities  harder to reach since people in these groups may have fewer financial resources to respond to health problems that arise. ⁹ 

To effectively reach these groups, it is important to consider 1) the above factors and why they might make folks hard to reach and 2) how this population receives and interprets communication from health organizations. It is important to note, as well, that the descriptor “hard to reach” does not describe a monolithic group - in other words, all hard-to-reach subpopulations might be hard to reach in different ways and therefore require diversified approaches.

Overall, there are several best practices for reaching hard-to-reach populations. They are:

1. Provide all materials/outreach in translation if you are addressing non-native English speakers
2. Use culturally relevant names for species, objects, places etc.
3. Disseminate information through trusted channels of communication for hard-to-reach subgroups
4. Understand your audience - what do they care about? What do they need?

In one study about how to get family planning services to hard-to-reach populations, researchers found that designing special programs and outreach activities to target certain groups was helpful; for instance, a health department in Oregon offered programs targeted to non-English speaking women in the Hispanic community which included access to counseling and medical services. Other suggestions ranged from offering services on a timetable that would accommodate different schedules, such as those of migrant workers, to applying for grants from local foundations to account for the additional expenses that catering to hard-to-reach populations are likely to incur. ¹⁰ 

Researchers in a separate study found that when traditionally hard-to-reach groups, such as the Latinx population are connected to an “integrated storytelling network,” like a system of targeted messages and tailored communication strategies, they are more likely to find critical health-related resources, whether or not they have health insurance or regular access to healthcare. ¹¹  This assessment demonstrates how the themes of community, mutual understanding, and meeting people where they are stand out as helpful ways to bridge divides and reach characteristically hard-to-reach populations with health communication messages.

Much of the above can be summed up by the idea of knowing your audience. As Wilkin and Ball-Rokeach caution, “unless we develop more effective ways to distinguish the ‘best’ communication options to reach a target audience in our current communication environment, it will not be long before everyone is considered hard-to-reach.

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