A report on the development of a community-oriented education program
Childhood lead poisoning is one of the most common preventable pediatric problems in the United States today. The knowledge that currently exists in the scientific community about the sources and pathways of lead exposure and about possible ways of preventing the ensuing poisoning is sufficient to facilitate the development of programs that should permanently eradicate this disease (1). Measures aimed at addressing this problem in a comprehensive manner include community-wide, environmental interventions as well as educational and nutritional campaigns. Educational programs should have the elimination of lead hazards as their primary goal.
This paper discusses some key factors that aided the planning and development of a community-based intervention to prevent childhood lead poisoning. It presents an overview of a process of seeking, networking, and building coalitions or partnerships to combat a classic environmental health problem that confronts a target population. The central message is how a broad cross-section of organizations can be brought together in the design of a program and thereby enhance the prospects of its routinization. As the program is designated, "Mr. Lead Spot" approaches education on childhood lead poisoning from the standpoint that the child is the primary beneficiary of whatever information that is necessary for behavior modification. It, therefore, directs the message specifically to children and treats the range of caregivers (parents, teachers, and healthcare providers) as support agents.
The second contribution that this article makes is to introduce this innovative child-friendly program, a program with a design that shows a clear departure from the traditional ways of addressing childhood lead poisoning. To facilitate a fuller appreciation of this process, the nature and scope of the intervention, the theoretical basis for, and a description of the community education program are presented.
Mr. Lead Spot
The program in its entirety is a package with specific messages tailored for the various classes of audience. The key component, "Mr. Lead Spot," however, is the intervention for preschoolers themselves. It is an interactive program that utilizes storytelling, puppetry, and music to teach children, aged 2 to 5 years, behaviors that should help them protect themselves against lead poisoning. In the presentation, "Mr. Lead Spot" represents the unfriendly and sick lead poison that can hide in paint chips/flakes on walls and window wells, in the dust that settles on window sills and on carpets or hard floors, and that can get into toys. Specially designed artistic props that serve as visual aids for the children are used to highlight these common sources and pathways of lead poisoning. A puppeteer plays the combined role of "Mr. Lead Spot" and "Yackle De Doo."
"Yackle De Doo" is the innocent 2-year old boy who plays around the house like any child his age and who could become poisoned through the hand-to-mouth actions in which he engages. At the beginning of a presentation, a moderator first sets the scene by asking the children about what they might know about lead poisoning and then "fills in the blanks," stating the basic facts about lead-based paint in homes. After introducing the participants, the moderator tells the story about the boy, "Yackle De Doo," and invites members of the audience (two or three at a time) to come forward and to help teach him about lead poisoning. At all times, the youngsters are encouraged to actively participate in the dialogue with "Yackle De Doo." In the process, the messages "wash your hands after play, wash your hands and face before going to bed, and wash your hands after using the rest room; put only food in your mouth and do not chew on paint; ask Mom to clean your toys" are reinforced.
Familiar nursery rhymes provide the tunes for sing-song sessions that reiterate the handwashing message. Parents and teachers have other messages aimed at helping them maintain lead-free environments. That is, adult handlers of children require some anticipatory guidance. Their messages address activities that help them play their role as custodians of the children's environment. For instance, parents can keep home dust levels to the minimum, cover peeling paint areas, grow vegetation in the yard to keep children away from lead-based paint flakes, and help keep toys clean.
All the other segments of the audience (parents, teachers, school nurses, health department workers) involved in the lead problem are invited to view this presentation as it is delivered to the preschool groups. They are encouraged to see it on several occasions, to the point that they would be able to conduct or supervise further presentations. Through slides, videos, and discussions in seminar format, supplementary information on prevention practices that are relevant to the specific target group as reinforcers, will be marketed to the members of this secondary and/or tertiary audience.
No lasting behavior modification could be achieved in the short term. Therefore, the efficacy of the intervention as a whole would depend on iteration of the central messages over a long period of time. With this in mind, parent groups, teachers, older children such as those in the middle and high school levels, special talent students such as those in the performing arts schools, voluntary organizations such as 4-H, and healthcare providers within the community would be recruited and trained to help implement the program, using the strategy of training-the-trainer. That is, the health specialist would help train the community groups who would in turn help train selected students (fifth to eighth graders) so that these students could finally take charge of the program. The program, therefore, requires full cooperation from health departments and community-based organizations that have been dealing with the lead problem to date.
Furthermore, because the sources and pathways of childhood lead poisoning are notably attributable to a complexity of community and individual behaviors and activities, a well-coordinated and multi-sectoral program planning is imperative. Such a planning model is necessary if the program is to be sustained over time. Another requirement is that the program should be based on an appreciation of the valuable roles that existing community resources, human and otherwise, could play. That is, resources, in the form of the various grassroots, private, and public sector institutions have been identified and engaged in providing various inputs to the program.
With funding from the Environmental Protection Agency (EPA) through the Missouri Department of Health (MODOH), Saint Louis University School of Public Health (SLUSPH) has developed and implemented a lead education program aimed at "community groups, not-for-profit groups, neighborhood associations, church groups, school organizations, public service groups, and other organizations that provide settings accessing parents." This is part of an effort by the state of Missouri to address all aspects of lead poisoning as a public health problem.
Community-lead education efforts have traditionally been directed primarily at parents or other caregivers on behalf of children, while interventions with direct focus on the child have received less attention. The program presented here sidesteps this common approach and starts from the premise that the child should be a true beneficiary of lead education, and that the caregiver is in a supportive role. The preschool child is capable of learning, given the right kind of experience and incentive.
The mandate for this contract requires the program to cover the entire St. Louis metropolitan area. To adequately fulfill this requirement, ways have to be found to maximize the community participation.
The Networking Process
The networking process started with a listing of identifiable groups of individuals and organizations within the geographic areas to be served. This included major academic institutions and lower level educational facilities; religious organizations (through the umbrella of the Interfaith Partnership); and local, district, and state health and social welfare as well as education departments. Initially, any of these groups that came to mind was listed. That is, there was no order in grouping or categorizing names. No consideration of possible benefits or information to be obtained from any particular person or organization came into the planning at this stage. All valuable information such as name of contact person, address, and telephone and fax numbers were entered, and the list was regularly updated and augmented as new or more information became available.
After compiling the initial list, establishing telephone contacts was the next step. The purpose was to introduce the program as well as the program director while updating the available database in the process. Where possible, appointments for site visits were negotiated concurrently. In making such appointments, the caller made every effort not to appear to be imposing in any way. For instance, the caller always offered to visit rather than suggest or imply that the person being contacted visit the university. The central message being conveyed, in this regard, was that the program planner needs the community or the individual and not vice versa. As another example, the conversation went along the following lines, "Hello Mr. Jones, I am Kwesi Dugbatey from St. Louis University School of Public Health. We are currently developing a lead education program for the prevention of childhood lead poisoning, and I am calling to see if I could visit with and brief you on the program. We believe we could learn a few things from you since you have been in the field for some time now. It is also possible we might be able to work together in some ways;" or, "We've learned that you have an ongoing program that deals with childhood lead poisoning, and we would be very grateful if we could explore with you areas in which we could support one another."
With the introduction presented in this way, the response has always been very positive and informative. People talked freely about whatever it was that they do and provided further information that led to more helpful contacts until a good network of resourceful persons and organizations evolved.
This network has become the basis for planning with regard to identifying individuals, groups or organizations, and settings that are most likely to be receptive or helpful in implementing the program. The actual development of "Mr. Lead Spot" became possible as a result 'of this networking: the artists who drew the first illustrations of the sources of lead poisoning; the volunteers who created the puppets; and the many individuals who shared ideas which were very helpful at one stage or the other.
Some Benefits of Networking and Community Participation
The first significant outcome of this method of networking is the knowledge one gains on what programs the health departments or non-governmental organizations (NGOs) have in place and how these programs operate. In this instance, a brief evaluation of existing programs emerged from the process and the findings were then fed into the design of the current program. For instance, spending time with the technicians in the various clinics run by the city of St. Louis, particularly observing their work in the mobile lead clinics in the projects and in daycare centers, brought home to the observer some important behavior patterns and attitudes of children and their parents. It became clear at first-hand how children and parents receive behavior modifying information and how they handle that information. Gaining access to these clinics and being welcomed as a partner, rather than a mere observer, has also been very helpful. Useful channels of communication opened up in such circumstances.
Perceptions about the university as a corporate citizen, remote and positioned higher in the scheme of things in society, became apparent and need to be changed. This active effort at cultivating cooperative community relations for the development and implementation of this lead education program will play a significant role in bringing about the required change. Traditionally, St. Louis University has not been perceived at the grassroots level as having a social agenda of particular relevance to the needs of the community, particularly in the most economically depressed sections of metropolitan St. Louis. It has, therefore, been very rewarding to see the pleasant change in attitudes of various people and organizations who were very happy to learn that St. Louis University, through its School of Public Health has been willing to "come down" to seek and to work in cooperative ventures with them.
In many instances, local health departments that are confronted with similar problems choose to work in isolation rather than forge common strategies. This program can claim a measure of improved cooperation among personnel working on the issue of lead poisoning. They embraced the new approach as a viable method, and personnel from various health departments freely offered suggestions. They have also demonstrated an unusual readiness to see the program through. This experience of bringing various health departments together for a course has highlighted a fundamental fact; that is, every individual health department has areas in the management of public health problems in which they excel and areas in which they are less effective. On the other hand, the problems are not unique to any local health department and could best be handled through joint efforts.
A primary healthcare framework
Experience from a number of developing countries such as Costa Rica, Botswana, and Zimbabwe testify to the fact that where community participation is sufficiently encouraged and practiced, a more efficient resource utilization follows (2). In turn, the impact of programs on disease prevention or health promotion is more tangible. This is the essence of primary healthcare as set forth in the 1978 Alma-Ata Declaration (3). In the planning and design of the community lead education program in the greater metropolitan area of St. Louis, this system of organizing and delivering primary care readily serves as a vehicle for implementation. Specifically, a concerted effort has been made to seek out relevant community organizations and institutions through which and with whom durable partnerships could be formed. Not-for-profit organizations such as church groups, neighborhood associations, school organizations, public service groups, and others provide the appropriate settings for accessing parents and the children.
Traditionally, program planning entails three levels of activities: a definition of the problem at hand, formulation of program objectives, and the devision of the means or series of activities for accomplishing these objectives. For this program, the problem had been implicitly defined in the contractual agreement, namely, that lead poisoning is one of the most common and preventable pediatric health problems in the metropolitan St. Louis area. It is also a given that primary prevention efforts (that is, elimination of lead hazards before children are poisoned) is the key objective (1).
The program is designed to reduce the prevalence of lead poisoning in children, aged six months to six years, through community education, the central piece of the intervention being specifically directed towards the child. However, the educational element is only part of a comprehensive and community-wide environmental intervention program that includes information on how to manage the environment as well as on the role of appropriate nutrition. With the child as the primary target audience, therefore, the key challenge becomes the identification and cultivation of ideal settings for meeting these children. Co-opting the parents, teachers, and other guardians also becomes crucial.
The role of social marketing
Within the primary healthcare framework, effective ways for reaching target populations and audiences have been extensively explored in third-world countries. Lessons from the field in promoting public health ideas, such as oral rehydration (ORT) and immunizations, particularly pertaining to the role of social marketing and the use of participatory learning, are available and have been heavily tapped into this design (4). The key lesson here is that, in seeking to influence the health of people at risk, it is most important to understand the clients' perspective and to understand how individuals and communities can be empowered to promote their health or save their lives.
To effectively apply this social marketing orientation to the problem at hand, that is, lead poisoning among children, it is important to adequately segment the target audience and strive for optimal audience participation. In this case, the primary target audience is the child and parents while all other caregivers are regarded operationally as reinforcers of what is communicated to the child. Care providers such as parents-as-teachers, daycare and nursery teachers, and lead clinic workers are considered a secondary audience in as much as they can and do influence the children in their personal hygiene and nutritional needs. Furthermore, communication channels are studied and properly adapted to the needs and requirements of the specific clients (5).
Experience from the field also shows that learning arises primarily from the participants' experience in the training sessions rather than their assimilation of given materials (6). Therefore, the guiding principle here is participatory learning. That is, materials have been designed for interactive, hands-on work among clients and facilitators. Child-friendly products, principally puppets, storytelling, music, and rhyme have been designed so as to facilitate this interactive learning process.
This paper has reviewed the process of development and introduction of a non-traditional educational program for the prevention of childhood lead poisoning, including a brief description of the program itself. Community participation has been very vital in the development and implementation of the program. The coming together of pertinent personnel from all the designated health departments and the School of Public Health lead to a positive cross-fertilization of ideas that helped shape the ultimate product for the target audiences. Talents were pooled for the presentation of the program to the various groups. As a concrete example, a dedicated team of health educators, nurses, industrial hygienists, and other technical personnel at the St. Louis County Department of Health were instrumental in giving life to the main ideas embodied. Some of them actually created the artwork (first wings) that were later perfected by professionals. They recruited volunteers who made the puppets, and spent time searching for the artists and graphic specialists responsible for the final product currently in use. The net product of this networking process is the creation of a durable and effective team to finalize the development and implementation of a community-based program to deal with childhood lead poisoning in the metropolitan St. Louis area.
The development of this program would not have been possible without the generous assistance of professionals from some health agencies and other organizations in the St. Louis metropolitan area and in the state of Missouri at large, including St. Louis County Health Department, City of St. Louis Department of Health & Hospitals, East St. Louis Health Department, Missouri Department of Health, Interfaith Partnership, St. Louis Metropolitan Schools, and Bureau of Environmental Epidemiology.
The authors express their sincere thanks to Valda Croskey for providing the stimulus and the environment for the valuable partnership that developed between the lead program team at St. Louis University School of Public Health and the St. Louis County Department of Health. Sincere thanks to Muriel Scarbrough and St. Louis Department of Health volunteers, Virginia Watts, Delores Merrick, Nadine Meyer, Polley Hetz, and Cathy Amjad who produced the puppets. Numerous others such as Brenda Quarles and James Miller of the City of St. Louis Health Department and Keith Bromley of East St. Louis Health Department, have also been very forthcoming with suggestions on the development of the program as well as providing more contacts for the formation of durable networks.
Funds for this lead education program were provided by Region VII of the Environmental Protection Agency and the Missouri Department of Health.
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Kwesi Dugbatey, M.D., Ph.D., M.P.H., Asst. Professor, Division of Environmental and Occupational Health, Dept. of Community Health, School of Public Health, St. Louis University, 3663 Lindell Blvd., St. Louis, MO 63108.…