Improving Education Prevention To Help Reduce Lead Poisoning in the City of Philadelphia

Transcription

1 Improving Education Prevention To Help Reduce Lead Poisoning in the City of Philadelphia Environmental Public Health Leadership Institute Fellow: Jill Ann Coleman; BS Health Education and Training Specialist Supervisor Childhood Lead Poisoning Prevention Program Philadelphia Department of Public Health 2100 West Girard Avenue, Building #3, PNH Philadelphia, PA (215) Mentor: John Mcleod; R.S., MPH Director, Cuyahoga County Board of Health (Acknowledgements): Leslie M. Beitsch, MD, JD Associate Dean of Health Affairs, Florida State University, College of Medicine, Center for Medicine and Public Health Peter Palermo; BS, BA, MS Director, Childhood Lead Poisoning Prevention Program, Philadelphia Department of Public Health Fellow Project National Environmental Public Health Leadership Institute

2 EECUTIVE SUMMARY: In Philadelphia, Pennsylvania, Lead Poisoning disproportionately affects children of color, in lower socio-economic levels - especially those under 6 years of age. Prevention education must be provided for all population groups, but in particular, persons with low-income, living in older housing, and belonging to certain racial and ethnic groups. Access to prevention education information is not disseminated evenly. Studies linking race and socioeconomic status of certain communities show increased exposure to environmental health hazards and the lack of access to information. According to Healthy People 2010, Section 8, Environmental Hazards, regarding the proportions of African American, Hispanic and White populations living in air quality nonattainment areas in percent of Hispanics and 9.2 percent of Africa Americans were disproportionately exposed to lead pollutants, versus 6.0 of whites. 1 Although elevated blood lead levels (EBLL s) are at their lowest, historically, for the Philadelphia Department of Public Health (PDPH), Childhood Lead Poisoning Prevention Program (CLPPP), approximately half of all the babies born each year will live in neighborhoods with the highest reports of lead poisoning and some of the worst housing stock. Lead poisoning can take years to reveal damage, be misdiagnosed as a learning disability or behavioral problem, resemble flu-like symptoms or have no obvious signs at all. As adults, many may have a lifetime of under- or misdiagnosed and irreversible health, learning, and behavioral problems from their exposure to this environmental health hazard as a child. Eliminating all sources of lead poisoning completely proves difficult when 93% of Philadelphia s housing was built before residential lead paint was banned in 1978 (500,000+ homes). Other sources like soil, some water, toys, jewelry, crystal, home-remedies, make-up, matches, keys, ceramics, and many plastics, may contain lead. How does one successfully convey to disadvantaged families the basic message of what lead poisoning is, how do you become poisoned by it, and how do you prevent a child from ever being poisoned? A potential method would be to effectively educate and advocate at all levels of the public and private sectors to make screening and preventive education a number one priority. This would require reassessing current modes of health hazard education and outreach initiatives practiced by the Philadelphia Childhood Lead Poisoning Prevention Program (CLPPP), as well as assessing possible factors hindering the target audiences inability to incorporate simple, effective prevention techniques proven to successfully reduce lead in the home. To facilitate the task of lead hazard prevention in targeted communities, so that a poisoning never occurs, we will first need to succinctly define elimination and the specific contributing factors of hazard exposure that are found everywhere in the human environment. Secondly, we must tailor the prevention education information for the communities with the highest reported cases of lead poisoning collected by CLPPP 2, along with state and federal data. Poorly maintained housing in conjunction with construction, automobile and home repair work, can all be major contamination sources. Emphasis will be placed on communities who are often most vulnerable those with low income, high unemployment, and low literacy (many whose first language is not English). Advocacy for improved prevention education involves: updating training for CLPPP staff, building/housing officials, and city health care providers, on current lead and various other Fellow Project National Environmental Public Health Leadership Institute

3 Healthy Homes hazardous materials 3 ; developing strategic partnerships with community agencies and neighborhood programs, child advocacy groups, parenting & childcare programs, and bilingual & immigrant organizations with translation and interpretive services. INTRODUCTION/BACKGROUND: Environmental health hazards often disproportionately and adversely affect children of color, in lower socio-economic levels, as young as nine months. The foremost cause of lead poisoning in children in the United States is deteriorating lead-based paint and paint-contaminated dust and soil in and around older homes. Because lead was not banned from residential paint until 1978, many older homes and apartments contain at least some lead-based paint. Despite those efforts, privately owned, unsubsidized housing which accounts for about 90 percent of the houses classified as hazardous continue to pose a danger because the federal government does not effectively regulate the lead-based-paint hazards in this housing stock. Primary prevention efforts at this level were left to the cities and states. Unfortunately, many of the professionals and policy makers who play a major role in fashioning state and local lead-poisoning-prevention strategies are not up-to-date on the many policy issues related to lead poisoning. Even though public health intervention measures are activated at an EBLL of 10 ug/dl, recent CDC statistics and many studies indicate that lead harms at levels below 5 ug/dl. Eliminating lead completely would require eliminating every possible source a seemingly insurmountable task since new sources such as artificial turf on athletic fields and endless toy and food recalls due to lead contamination, are constantly reported. It is my charge to conceptualize and incorporate the best low literacy training tool (often modified for underserved, or English-as-asecond-language populations throughout Philadelphia) to accomplish each of our five modules; education, screening, medical management, hazard identification, and reduction. Problem Statement: Why, despite numerous education and outreach efforts, have we not been able to develop effective prevention education for families after they receive their first screening notification - as mandated by the City- for children ages nine months to six years, with an EBLL higher than nine (>9) 4? In addition, the CDC defines the blood lead level of 10 ug/dl as the point where public health measures should be activated. This does not mean that a child with a lower lead level is safe the CDC states that no level of lead in a child is safe. Many studies have indicated that lead harms the child at levels below 5 ug/dl. The CLPPP receives blood lead test results on 40,000 of the 100,000 children under age 6 that reside in Philadelphia every year. Even after multiple education initiatives, CLPPP has been unsuccessful in effectively communicating a public health message to this target audience that lead poisoning is one hundred percent preventable. Some contributing factors could be language and other barriers to understanding, as well as the fact that other hardships in lower socioeconomic levels, which often take precedence over maintaining annual blood screenings and in-home prevention methods Fellow Project National Environmental Public Health Leadership Institute

4 Prevention & Education Interventions Behavior Over Time Graph: Blood Lead Screenings F I Housing Code Enforcement F I Community Partnerships F I Financial Status F I (EBLLs) # Children w/ Elevated Blood Lead Levels As temporary fixes - or prevention education initiatives - are introduced to the target community, EBLL s decrease, creating temporary results. However, these short-lived, limitedly-funded programs often end due to budget cuts. Overtime peaks and valleys, or a zigzag effect is created.

5 Causal Loop Diagrams and applicable Archetypes:

6 10 Essential Environmental Health Services 5 : This project will incorporate 8 of the10 Essential Environmental Health Services 1. Monitor health status to identify community problems: Lead continues to be one of leading environmental health hazards in the nation. Deteriorating lead-based paint and paintcontaminated dust and soil in and around older homes has been identified as the foremost cause of lead poisoning in children (especially ages 9 months to 6 years.) 2. Diagnose and investigate health problems and health hazards in the community. Because lead was not banned from residential paint until 1978, many older homes and apartments contain at least some lead-based paint. Despite those efforts, privately owned, unsubsidized housing which accounts for about 90 percent of the houses classified as hazardous continue to pose a danger. 3 Inform, educate and empower people about health issues: This project seeks to increase and improve access to low literacy education materials and prevention methods for populations most at risk. 4. Mobilize community partnerships and action to identify and solve health problems. By collaborating with local community-based organizations targeting Asian, Spanish and Englishas-a-second- language populations, as well as immigrant and refugee groups. 5. Develop policies and plans that support individual and community health efforts: Local child advocacy organizations and independent watchdogs will work to promote health hazard policies and make recommendations for increased state and federal funding to local and state officials. 7. Link people to needed personal health services and assure the provision of health care when otherwise unavailable: The project will partner with local agencies, community liaisons and advocates to help child caregivers find a medical home base, as well as all applicable divisions under PDPH especially public health care providers in the Division of Ambulatory Health Services (AHS), which oversees the City s nine District Health Care Centers and provides free services to all residents including undocumented populations. 8. Assure a competent public health and personal health care workforce: This initiative will reinforce to CLPPP staff and other PDPH units the importance of continued blood screenings and the need to increases public health prevention awareness of environmental health hazards such as lead. 10. Research for new insights and innovate solutions to health problems: A culturallysensitive prevention education tool on home health hazard prevention will be marketed to lower literacy levels and targeted populations most at-risk via existing partnerships with students and faculty at local Public Health institutions such as Temple, Drexel, and the University of Pennsylvania, who will help determine current thinking and best practices.

7 National Goals Supported CDC Health Protection Goals 6 By focusing on the optimal development of infants, toddlers and children up to age 6 the age group most at risk for being effected by lead poisoning, three of the four goals to reduce health disparities and achieve improvements in people s lives will be met. The goal to provide simple prevention education tools to be adopted in various public healthcare settings by providers, and adapted for home use, will help to encourage better health hazard behavior and healthier homes in the most vulnerable populations. Healthy People 2010 Objectives 7 : This project incorporates the focus in Chapter 8, Environmental Health that focuses on promoting broad environmental health prevention efforts to increase the public s awareness of health hazards, such as lead, at all levels. It will provide public access to understandable and useful information on the sources and health effects of lead, and as act as a catalyst to provide resources to nongovernmental groups via community collaborations. Additionally, it will continue the trend of providing programs based on evidenced-based materials and professional and public education campaigns to select populations, thus supporting the CDC s goal of health for all through a healthy environment. National Strategy to Revitalize Environmental Public Health Services 8 This initiative seeks to protect against environmental health hazards and promote and encourage healthy behaviors via a variety of goals. One goal ensures the quality and accessibility of health services as well as the capacity to build, improve and support them at local levels. Effective approaches will be defined to address the existing and emerging needs of the target audience and their encouraged involvement in innovative environmental public health practices that emphasize prevention and strategic intervention. By enhancing services and developing strong working relationships among stakeholders, the project seeks to communicate and market improved communication and information sharing among public health agencies, communities and policy makers, to improve understanding and sharing effective promotion and dissemination education models to engage communities and policy makers. Environmental Health Competency Project: Recommendation for Core Competencies for Local Environmental Health Practitioners 9 The project will aid in information gathering, identifying, and locating the use of appropriate reference material and analyzed data and test results, and help present the results in an appropriate way to different types of audiences in low literacy and translated formats.

8 Project Logic Model:

9 PROJECT OBJECTIVES/DESCRIPTION/DELIVERABLES: Program Goal: Develop an effective education tool to reduce Elevated Blood Lead Levels (EBLL s) - in children ages 9 months 6 years with an initial screening test >9. Health Problem: Lead Poisoning adversely affects child development causing irreversible brain damage, behavioral disabilities, pregnancy problems or even death Outcome Objective: By September 2010, implement an approved, effective prevention education tool for Philadelphia County Determinant: Reduce EBLL s after first screening by at least 20% (~100 children) Impact Objective: In-home, low literacy prevention education tool Contributing Factors: 1. Lack of public awareness on environmental hazard education and prevention information 2. Lack of focus on EBLL s as a child health care priority 3. Lack of support and follow through from Health Care Providers to screen for EBLL s 4. Poor housing stock (93% Philadelphia homes with lead paint) 5. Incomplete medical records/tracking of children with reported EBLL s 6. Transient target audience 7. Rapid rental/tenant turnover 8. Lower socioeconomic level (disproportionately effected); Most urban households face high costs for nonfood essentials including rent, water, and sanitation, transportation health care and medicines 9. Diverse/multilingual community 10. Limited access to English-as-a-Second-Language (ESL) translated services & materials 11. Lack of support/follow through from various sources of power and authority among different levels of government; unresponsiveness to accountability and quality engagement with targeted communities most effected by lead hazards Process Objectives: 1. By February 2010 collect/review City s initial blood screening tests data (>9) 2. By March 2010 identify and secure community based/multicultural partners, school contacts and academic resources 3. By June 2010, design and test first draft of home, prevention education tool: complete 1-on-1 and community focus groups, meetings and collect feedback/recommendations from PDPH and community-based affiliates 5. By September 2010 implement and test low literacy, community-friendly prevention education tool

10 METHODOLOGY: Events: Design data research query Review and discuss questionnaire results Draft education tool with recommendations Test for readability levels Enlist translation services Train staff Design /distribute questionnaire/timeline for responses Collect/compile/update results Coordinate and conduct focus groups in target community for feedback Activities: Collect current data from CLPPP (local and national) Collect/compare/contrast national statistics Enlist CLPPP, PDPH, academic staff support Meet with key contacts/staff for support and input Identify community based & multicultural venues Test market education tool Collect results/implement improvements Implement citywide NET STEPS/INTENDED RESULTS: Develop/improve a lead hazard prevention education tool for home training Develop a training protocol to be used by for health care providers, and community health and lead hazard reduction staff Community by-in and implementation & promotion Incorporate interpretation and translation services Utilization and implementation throughout Philadelphia County CONCLUSIONS AND EPECTED OUTCOMES: The decline in childhood lead poisoning across the United States represents a public health success. However, the public health arena must continue to be a voice for vulnerable populations housing rights to safe environments and basic social services - especially in the area of effective environmental health education and prevention. We must continue to focus on the link between adequate living conditions for children, which are essential to their cognitive, physical, cultural and emotional and social development - particularly children who are disproportionately vulnerable to the negative effects of hazardous living conditions. 10. Accountability and partnerships with governments and authorities at the state and local level are critical to insuring that health hazard initiatives, such as lead poisoning

11 prevention, remain central. We must continue to fight for equity and social inclusion, and insure that healthy children and their families are at the center of agendas for development and implementation of environmental health initiatives. The leadership and commitment of City officials remains key in the development and promotion of plans that guide policy decisions and budgetary allocations; identify concrete goals and attainable, realistic targets; as well as consistent reporting and monitoring practices. Improvements continue in studying, bio-monitoring and identifying scientific evidence on the acute and long term effects of heavy metals such as lead, as well as tracking the importation of many lead-tainted products manufactured outside of the United States. However, disparities exist in the environmental exposures certain populations face and in the health status of these populations. Lastly, in order to combat the numerous health risks associated with poor quality housing construction and materials, it is imperative that we continue to advocate for legislation, adherence and governance on building code enforcement and environmental regulation. This goal requires a substantial, long-term commitment to improve household environments and upgrade programs to give low-income communities a greater capacity to access quality housing and healthy environmental neighborhood-based initiatives. LEADERSHIP DEVELOPMENT OPPORTUNITIES: Jill Ann Coleman The benefits of working with EPHLI have been innumerable. I consider it a privilege and honor to have been chosen as a participant. The Cohort V was the impetus I needed to take it to the next level, complete my next degree and further my knowledge in the field of Public Health Education. I feel my skills as a Training Specialist have been greatly improved by incorporating the latest Public Health trends, ideas, techniques, and thinking systems I learned through this program. The wealth of knowledge and new insight on ways to approach and implement initiatives are already in motion. I would like to thank my mentor, Ohio John - John Mcleod, and my Team Mcleod members: Rebecca Love, Boston John - John McVeigh, and Bob Hasenyager, for their patience and support, idea-sharing, and encouragement. Overall, it was a very valuable experience. I also owe much appreciation to my EPHLI Coach, Les Beitsch. Lastly, I would like to thank all the instructors and staff who gave of their time and energy. ABOUT THE EPHLI FELLOW(s) Jill Ann Coleman has worked for the City of Philadelphia for more than seventeen years and is currently a Health Education and Training Specialist Supervisor for the Philadelphia Department of Public Health, Childhood Lead Poisoning Prevention

12 Program. Having worked as a certified Childbirth Educator and Parenting Instructor for the Division of Maternal, Child & Family Health, under the State s Healthy Start Initiative, Jill designed and implemented a myriad of health education projects and campaigns on such topics as prenatal care, postpartum depression, second-hand smoke, testicular cancer, osteoporosis, HIV/AIDS, teen sexual health, domestic violence, abstinence and nutrition. With a background in Microbiology, she initially began her health education training as a researcher at the Howard University School of Medicine and Dentistry, as well as the George Washington University Medical Center, and went on to develop education programs for the District of Columbia Department of Human Services, Commission of Public Health, and District of Columbia Public Schools. She also spearheaded a collaborative with the Philadelphia Mural Arts Program (MAP) to design a public health mural entitled Lead Harms, in the City s North Philadelphia section (the area with the highest reports of Child Lead Poisoning). Her most recent research project included the position of Project Leader for a four-year, community-based Telemedicine weight loss study on African American Churches, for the Temple University Center for Obesity Research and Education. Jill is currently wrapping up a one year exhibit on the History of Lead, entitled The Devouring Element: Lead s Impact on Health, she helped coordinate with the College of Physicians of Philadelphia, Mutter Museum.

13 REFERENCES 1. CDC Healthy People 2010: National Center for Health Statistics: Healthy People 2010 Objectives: 2. Policies and Procedures. (2009) Philadelphia Department of Public Health, Childhood Lead Poisoning Prevention Program HUD: Philadelphia Childhood Lead Poisoning Elimination Plan (2009) Philadelphia Department of Public Health, Childhood Lead Poisoning Prevention Program. Carl Osaki, RS, MSPH, Northwest Center for Public Health Practice, 10 Essential Environmental Health Services 6. CDC Health Protection Goals 7. Healthy People 2010 Objectives: 8. National Strategy to Revitalize Environmental Public Health Services 9. Environmental Health Competency Project: Recommendation for Core Competencies for Local Environmental Health Practitioners petencies.htm 10. Poverty and Exclusion Among Urban Children