Lead poisoning represents a major public health problem, particularly for children. Several studies have been conducted related to lead poisoning. Researchers analyzed how local lead law impacts property maintenance decisions, and fewer hazards which impacts lead poisoning rates in children (Korfmacher and Hanley). The researcher examined these laws in the broader context by evaluating case studies that represented a wide range of methodologies used to address the issue of lead poisoning (Korfmacher and Hanley). The study compiled a list of local lead laws that were passed or revised in a major way (Korfmacher and Hanley). Then the laws that were passed in the same environmental, legal, and technical situation faced by cities were the primary focus. The laws were created to address areas that the federal laws did not. There were several cities that had dated lead laws that were not being implemented and these areas were not reviewed in the study (Korfmacher and Hanley).
The laws were passed from the year 2000 and beyond. The majority of the laws that were reviewed focused on rental units (Korfmacher and Hanley). To evaluate the laws, the researchers identified structural features, contextual variables, and types, of implementation resources (Korfmacher and Hanley). All of the laws had similar structures including the type of housing to target, the elements that trigger an inspection, type of inspections that is required, and mitigating factors (Korfmacher and Hanley). The key resources identified that are needed to implement these local laws include inspection resources, enforcement tools, and evaluation systems (Korfmacher and Hanley). One of the case studies showed how Detroit law that all rental unit owners register their properties annually and prior to sale and that owners of properties build prior to 1978 must have authorized clearance (Korfmacher and Hanley). A lead inspection and lead assessment report must be provided (Korfmacher and Hanley). The law in Detroit is pretty robust. One of the weaknesses is the ability to enforce the law due to the administrative and personnel costs associated with the program (Korfmacher and Hanley). The comparison laid out in the case studies to other lead laws offers some pros and cons in fashioning legislative initiatives that address lead levels. Researchers suggest that lead laws address the physical environment, public awareness, health status and systems, economic housing market, state legal environment, political environment, implementation resources and case law (Korfmacher and Hanley). Each local community will address these components in a different way. The primary weakness of this study is that it cannot be generalized to all communities due to the differences in communities and how local environments approach lead poisoning.
The second study that will be reviewed is a spatial analysis conducted regarding the elevated blood levels of children in Flint, Michigan. This study evaluated the differences in pediatric blood level incidence before and after the water problems in Flint, Michigan (Hanna-Attisha, 2016). The blood levels of children under 5 years old was reviewed for the year 2013 and reviewed again in the year 2016 (Hanna-Attisha, 2016). The blood levels were evaluated during both time periods geographical locations through spatial analysis were analyzed during both time periods (Hanna-Attisha, 2016). The results showed that lead blood levels in children increased from 2.4 percent to 4.9 percent during this time period (Hanna-Attisha, 2016). This change was experienced after the water quality change and the most impacted neighborhoods experienced a 6.6 percent change (Hanna-Attisha, 2016). Geospatial analysis confirmed that disadvantaged neighborhoods were the ones that were most impacted by the water quality issues (Hanna-Attisha, 2016). And no significant shift in lead poisoning was seen outside the city (Hanna-Attisha, 2016). The study indicated that there was a significant statistical change in the blood lead levels in children under the age of 5. Further, a review of alternative lead poison sources revealed that the primary source of the lead poisoning was the water quality problems in Flint, Michigan (Hanna-Attisha, 2016). The study was limited in several ways including the study only included children under 5 who are at the greatest risk, lead screening is not completed for all children which can skew the numbers, there is considerable housing instability in Flint, and a large portion of the sample does not represent all lead screening conducted in Flint (Hanna-Attisha, 2016). The study identified the need for increased state and federal oversight particularly for areas of the country that have aging infrastructures, little water utility capacity, and arrogated city governance (Hanna-Attisha, 2016). The model proposed in this paper will aim to address some of the issues outlined in the two studies with an intervention that can aid in addressing BLLs in the broader audience of children.
Explanation of why the proposed program is unique
This proposed program is draws from the Massachusetts model of lead prevention in children which includes prevention, diagnosis, treatment, and researches the sources of lead poisoning such as epidemiologic, educational, and clinical actions as required. However, the proposed model is unique in that it adds a component of monitoring water quality to ensure that water is not a source of lead poison. This program plans to address the major issues that have occurred in Flint, Michigan by observing water quality to identify any potential problems that may occur with lead poisoning through this source. Further, decisions will be made by state officials to cut-off water supply or redirect audiences that are impacted by areas where water quality is compromised by lead to other resources such as bottled water. This will be recommended until the problem with lead in the water is rectified. This approach will be suggested moving forward to prevent issues with lead poisoning through the water supply. Further, many of the children audiences that are studied are those under the age of 5. This intervention will study a different audience, children and adolescents ages 5-18 which is unique.
Logic model
The logic model provides information about how a Lead Poisoning Prevention Program will be implemented. The model includes inputs that are designed to lay the groundwork for the lead poisoning prevention program. The activities including requesting information that can underpin the program and the primary activities such as creating a website, marketing and educational materials, requesting data from key organizations that can also help to provide this information, and creating frameworks for reports that can support the suggested outcomes for the intervention. The outcomes include fostering public awareness through the website, creating a data collection framework, and testing the intervention to determine if lead poisoning levels are reduced in target audience in Flint, MI. These activities are important to create the initial foundation, the activities to move the intervention forward, and outcomes measures that can evaluate the efficacy of the intervention.
Population and sample
The population that will be primarily monitored and targeted with this intervention will be children and adolescents under the age of 18 who are in the public school system. The primary geographic locations that will be targeted are the zip codes in Flint, Michigan. Overall, the population in Flint is close to 102,000 and about 27.3 percent of this population are children and adolescents under the age of 18 (The United States Census Bureau). Therefore, the primary number of children and adolescents that will be included in the intervention is about 27,846.
Outcome evaluation design and tools
The outcome evaluation tools include statistical collection of data from the website to determine what pages are being accessed, how frequently they are accessed and how long users engage with the pages on the website. Further, information about BLL levels will be collected for the key target audience, children and adolescents between the ages of 5-18. And community surveys that test the levels of awareness about signs, symptoms and of lead poisoning will be conducted. Finally, information about shifts in BLL levels will be evaluated using a retrospective study design targeting the 3 largest hospital laboratories that processed lead poisoning patients. This information then will be evaluated six months after the intervention is introduced in the community for the audience that the intervention is targeting which is adolescents age 5-18.
Process evaluation design and tools
The program director will be completing the evaluation design and tools for this program with the help of the program assistant. This includes pulling information from the website to determine traction or engagement on the site. This also includes creating a research study to determine usually multiple logistic regression the influence of a number of variables including, age, geographic location, gender, and whether or not the child is in a two-parent or single-parent home. This will isolate whether or not the specific interventions had an impact on the target audience.
Further, the surveys that will be conducted to determine awareness in the target audiences. These surveys will be conducted using Likert scale tools that ask about signs and symptoms associated with lead poisoning. The purpose of these tools is to create benchmarks that can underpin future study of this particular subject. An example from the survey is as follows:
Lead poisoning causes behavioral and learning problems in children.
Strongly agree / agree / don’t know / disagree / strongly disagree
Other questions will be similarly worded using the parameters of lower IQ and hyperactivity, stunted growth, premature birth, hearing problems, anemia diminished growth of the fetus, premature birth, cardiovascular problems such as increased blood pressure and frequency of hypertension diminished kidney function, and problems in reproductive health.
Ethical considerations
Whenever research or programs are introduced there are several ethical considerations that must be addressed. Because the audience that will be monitored is primarily children the program must be reviewed by appropriate authorities such as institutional review boards, to maintain adherence to ethical standards. Further, the child’s identity will be protected as a part of this program. Data will be de-identified and used for monitoring purposes based on the geographic area where the programs are instituted. Any research that is conducted related to the program will outline ethical considerations and how data will be protected.
Figure 1. Logic model, including implementation and outcome objectives
Process evaluation tools
The process evaluation tools that will be used to better understand what is occurring include focus groups, surveys of key audiences including parents, children, and key community stakeholders. Further, children in particular, with the permission of parents will be engaged in focus groups to determine their level of knowledge about lead poisoning signs, symptoms, and risk factors.
Outcome evaluation tools
The surveys and studies that will be used to evaluate the outcomes for this program include a descriptive analysis of the website statistics, qualitative analysis using focus groups with students age 5-18, a Likert-type survey that will determine levels of awareness, and a multiple logistic regression that will help to study the variables related to decreases in BLLs that determine whether or not someone has been poisoned with lead. The website study will start with a zero baseline and analyze statistics 6 months after the interventions are introduced. In addition, the Likert-type survey will be conducted at the beginning of the program and six months after the intervention is introduced. Finally, the logistic regression will be performed six months after the intervention is implemented as well.
Budget form, cost per subject, cost-effectiveness ratio
Personnel Costs
Program Director compensation $__75,000___
Program assistant(s) $__45,000___
Total Personnel Costs: $120,000
Non-Personnel Costs (please itemize)
Supplies
Brochures & Marketing materials $50,000
Educational Materials $20,000
Website $20,000
Office supplies $5,000
Subtotal: Supplies $95,000
Equipment
Two laptops $5,000
Software licenses $2,500
Subtotal: Equipment $7,500
Travel and Subsistence:
Mileage $2,500
Meetings & Food $4,000
Subtotal: Travel and Subsistence $6,500
Other (books, photocopying, focus group recording transcription etc.)
Focus groups and research $10,500
Photocopies $8,500
$
Subtotal: Other $19,000
Total Non-Personnel Costs: $128,000
Total Project Cost Requested: $248,000
Cost per subject:
$248,000 ÷ 27,846 = $8.90 per subject
Cost effectiveness ratio: (show the calculation)
C1 and E1 represent the cost and effect in the intervention group and C0 and E0 represent the cost and effect in the control care group.
C1 – C0
C1 = $248,000
Co = $0
E1 – E0
E1 = 10
Eo = 0
ICER = 24,800
Budget justification
The budget for this project is necessary to complete the tasks needed to implement the program. Two staff members to cover the entire program is very lean. These individuals will be creating the program infrastructure and will provide support to ongoing programmatic operations. The primary function of the program director is to establish the framework to monitor the water quality for the children and adolescents who live in Flint, Michigan. The program director will fashion a program that addresses one of the more recent risk factors in lead poisoning, water quality. The program assistant will be the primary individual charged with gathering data from both the water quality monitoring functions within the city and the BLLs of children under the age of 18 in Flint, Michigan. In order to sustain operations, the program requires materials, marketing, education, equipment and other miscellaneous items to execute the program. In comparison to other programs, the budget for this program is quite lean. In fact, the office space where the program is donated and the research costs for the program are relatively low.
Further, lead poisoning can cause ill health effects including “appetite [loss], constipation, abdominal colic, decreased IQ, behavioral problems (inattentive, hyperactive, or disorganized behaviors), hearing and balance problems, encephalopathy, anemia, growth retardation, delayed sexual maturation, dental caries, cardiovascular disease, renal disease, convulsions, coma, and death” (Bennett, Lowry & Newman, 2015, p. 15). The costs of these issues is certainly worth the budget as outlined in this program. And the cost per subject is relatively low which means the intervention can have an impact on this particular target audience.
Works Cited
Bennett, Kent, Jennifer Lowry, and Nicholas Newman. "Lead Poisoning: What's New About An Old Problem?." Contemporary Pediatrics 32.4 (2015): 14-22 9p. CINAHL Complete. Web. 12 Mar. 2016.
Hanna-Attisha, Mona, et al. "Elevated Blood Lead Levels In Children Associated With The Flint Drinking Water Crisis: A Spatial Analysis Of Risk And Public Health Response." American Journal of Public Health 106.2 (2016): 283-290 8p. CINAHL Complete. Web. 12 Mar. 2016.
Korfmacher, Katrina S., and Michael L. Hanley. "Are Local Laws The Key To Ending Childhood Lead Poisoning?." Journal Of Health Politics, Policy & Law 38.4 (2013): 757-813 57p. CINAHL Complete. Web. 12 Mar. 2016.
The United States Census Bureau. "Flint City Michigan QuickFacts from the US Census Bureau">." Census.gov. N.p., 2015. Web. 13 Mar. 2016.
