Overcoming barriers and improving public health nursing practice.

Public health nurses (PHN) are critical to ensuring the health of communities. Absent the most basic information on the PHN workforce in our state, we conducted interviews with 21 PHN and school health nurse (SHN) leaders and an online survey of PHNs and SHNs practicing in Maryland (N = 491). Our study identified an older, very experienced, and well-educated workforce. Both the interviews and survey identified similar barriers: low salaries, recruitment and hiring challenges, limited funding for public health programs, and no opportunities for education or career advancement. Survey participants also identified barriers of inadequate leadership, recognition, and communication including PHNs not being represented at decision-making tables or at the state leadership level. Strategies to promote public health nursing from leaders and survey participants were similar: increasing awareness about what public health and PHNs do and their value; improving advocacy and stakeholder engagement; improving access and availability of services; improving PHN leadership representation at the state level; a improving PHN salaries and benefits including tuition reimbursement. Although results were similar to national studies, comprehensive, granular workforce data is critical to ensure the public health workforce can meet current and emerging public health needs and that public health infrastructure and services are appropriately funded.

Elevated blood lead levels and reading readiness at the start of kindergarten.

OBJECTIVE: To evaluate the relationship between blood lead levels (BLLs) and reading readiness at kindergarten entry, an early marker of school performance, in a diverse urban school population. METHODS: Kindergarten reading readiness test scores for children attending public kindergarten in Providence, Rhode Island, were linked to state health department records of blood lead testing by using individual identifiers. The study population (N = 3406) was 59% Hispanic. For each child, the geometric mean BLL was estimated by using all previously reported BLLs. Analyses were adjusted for gender, age, year enrolled, race, child language, and free/reduced lunch status as a measure of socioeconomic status. RESULTS: The median geometric mean BLL was 4.2 µg/dL; 20% of children had at least 1 venous BLL ≥10 µg/dL. Compared with children with BLLs <5 µg/dL, the adjusted prevalence ratios (95% confidence interval [CI]) for failing to achieve the national benchmark for reading readiness were 1.21 (1.19 to 1.23) and 1.56 (1.51 to 1.60) for children with BLLs of 5 to 9 and ≥10 µg/dL, respectively. On average, reading readiness scores decreased by 4.5 (95% CI: -2.9 to -6.2) and 10.0 (95% CI: -7.0 to -13.3) points for children with BLLs of 5 to 9 and ≥10 µg/dL, respectively, compared with BLLs <5 µg/dL. CONCLUSIONS: BLLs well below 10 µg/dL were associated with lower reading readiness at kindergarten entry. The high prevalence of elevated BLLs warrants additional investigation in other high-risk US populations. Results suggest benefits from additional collaboration between public health, public education, and community data providers.

Effects of HUD-supported lead hazard control interventions in housing on children's blood lead.

The Evaluation of the US Department of Housing and Urban Development Lead-Based Paint Hazard Control Grant Program studied the effectiveness of the housing intervention performed in reducing the blood lead of children at four post-intervention times (6-months, 1-year, 2-years, and 3-years). A repeat measures analysis showed that blood lead levels declined up to three-years post-intervention. The results at each successive collection time were significantly lower than at the previous post-intervention time except for the difference between the levels at two and three years. At two-years post-intervention, geometric mean blood lead levels were approximately 37% lower than at pre-intervention. Children with pre-intervention blood lead levels as low as 10 µg/dL experienced substantial declines in blood lead levels. Previous studies have found substantial improvements only if a child's pre-intervention blood lead level was above 20 µg/dL. Individual interior lead hazard control treatments as grouped by Interior Strategy were not a significant predictor of post-intervention blood lead levels. However, children living in dwellings where exterior lead hazard control interventions were done had lower blood lead levels at one-year post-intervention than those living in dwellings without the exterior interventions (all other factors being equal), but those differences were only significant when the mean exterior paint lead loading at pre-intervention was about the 90th percentile (7.0mg/cm(2)). This observation suggests that exterior lead hazard control can be an important component of a lead hazard control plan. Children who were six to eleven months of age at pre-intervention had a significant increase in blood lead at one-year post-intervention, probably due to other exposures.

A coordinated relocation strategy for enhancing case management of lead poisoned children: outcomes and costs.

Controlling residential lead hazards is critical for case management of lead poisoned children. To attain this goal, permanent relocation of the family is sometimes necessary or advisable for many reasons, including poor housing conditions; extensive lead hazards; lack of abatement resources, landlord compliance and local enforcement capacity; and family eviction. During 1996-1998, the Kennedy Krieger Institute implemented a unique capitated program for case management of Baltimore City children with blood lead concentrations (PbB) >19 microg/dL. The Program provided financial, housing, and social work assistance to facilitate relocation as a means of providing safer housing. Nearly half of the Program families relocated with direct assistance, and 28% relocated on their own. The Program evaluation examined the costs and benefits of relocation. Average relocation cost per child was relatively inexpensive (<1,500 dollars). Average relocation time of 5 months (range <2 months to >12 months) was less than the 8-month average time to complete lead hazard control work in 14 city and state programs funded by U.S. HUD. Relocation was associated with (1) a statistically significant decrease in dust lead loadings on floors, windowsills and window troughs that persisted for one year, and (2) statistically significantly greater decreases in children's PbB compared to children who did not relocate from untreated homes. Children relocated to housing that met current Federal residential dust lead standards had statistically significant decreases in blood lead levels. Visual inspection did not consistently identify relocation houses with dust lead levels below current Federal standards, indicating that dust testing should be an essential component of future programs. This will require additional resources for dust testing and possibly cleaning and repairs but is expected to yield additional benefits for children. The findings support recent U.S. CDC case management recommendations suggesting that permanent relocation to safer housing is a viable means to reduce children's lead exposure. The benefits of relocation notwithstanding, 40% of families moved at least twice. Research is needed to better understand how to expedite relocation and encourage families to remain in safe housing. Relocation does not negate owners' and health authorities' responsibilities to address lead hazards in the child's original house in order to protect future occupants.

The effectiveness of low-cost soil treatments to reduce soil and dust lead hazards: The Boston lead safe yards low cost lead in soil treatment, demonstration and evaluation.

The Boston lead safe yards low cost lead in soil treatment, demonstration, and evaluation was developed to explore the viability and effectiveness of low-cost soil interventions to reduce exposure to soil lead hazards. Buildings that had been abated for lead to Massachusetts's deleading standards in the previous 5 yrs and met other program requirements were recruited for the evaluation. Following individual property assessments, yards were treated with application of ground coverings and ground barriers in 2000-2001 and followed up at 1 yr. The treatment cost ranged from 1095 dollars to 5643 dollars with an average of 2798 dollars. Soil lead levels at the building dripline, measured with a field-portable X-ray fluorescence analyzer (Niton Model 702 Spectrum Analyzer), dropped from 2021 PPM at baseline to 206 PPM at 1-yr follow-up. Most of the barrier treatments continued to block access to the lead-contaminated soil at 1yr. At the follow-up, few properties with grass treatment had areas that were completely bare, but 28% had more than a small amount of treated areas bare. Treatments were effective in reducing entryway dust lead in the rear of the building if the residents reported they had maintained the yard treatments. Each additional yard work activity reported was predicted to lower 1-yr floor dust lead loading at the rear common/main and dwelling unit entries by about 20%. Each additional 100 ft2 of yard treated was predicted to lower 1-yr floor dust loading at the rear dwelling unit entry by 19%. Treatments did not show a dust lead effect at 1 yr in the front entryway of the building, but the investigators believe that this may be due to the effect of resident cleaning overshadowing the treatment effect.

A randomized, community-based trial of home visiting to reduce blood lead levels in children.

OBJECTIVE: The objective of this study was to measure the effectiveness of intensive case management to reduce blood lead levels (BLLs) in children. Lead poisoning remains a common, preventable pediatric condition despite advances in reducing children's BLLs in the United States. Substantial evidence implicates lead paint-contaminated house dust as the most common high-dose source of lead in children's environments. Housekeeping and parental supervision also may contribute to risk for lead exposure. METHODS: We conducted a community-based, randomized trial of comprehensive education and home visiting for families of children with BLLs 15 to 19 microg/dL. BLLs after 1 year of follow-up were compared for intervention group children, whose families received individualized education that was designed to address specific risks factors in a child's environment, and comparison group children, whose families received customary care, usually 1 or 2 educational visits. Environmental samples were collected at baseline and after 1 year of follow-up for intervention group children and compared with those of comparison group children, collected only at the end of study. RESULTS: During the follow-up period, parents of intervention group children (n = 92) successfully decreased dust lead levels and significantly improved parent-child interaction and family housekeeping practices compared with comparison group children (n = 83). Overall geometric mean BLLs declined by 47%, and the difference in BLL by group was not significant (9 vs 8.3 microg/dL for intervention versus comparison group children, respectively.) After 1 year, nearly half of enrolled children had BLLs > or = 10 microg/dL. CONCLUSIONS: Until a reservoir of lead-safe housing is created, programs that educate families to reduce environmental exposure are needed. Although providing families with quantitative information regarding lead contamination may have a role in short-term efforts to prevent lead exposure, these null findings suggest that it has little benefit once BLLs are elevated.

National evaluation of the US Department of Housing and Urban Development Lead-Based Paint Hazard Control Grant Program: study methods.

The US Department of Housing and Urban Development (HUD) undertook an evaluation of its Lead Hazard Control Grant Program between 1994 and 1999. The Evaluation is the largest study ever done on the effectiveness of lead hazard controls implemented in residential dwellings. The Evaluation had several major objectives: determining the effectiveness of various lead hazard controls in reducing residential dust lead levels and children's blood lead levels, establishing the costs of doing lead hazard control work and factors that influence those costs, determining the rate of clearance testing failures and their causes, and identifying possible negative effects of lead hazard control work on children's blood lead levels. This paper reports the overall research design and data collection methods of the Evaluation. The large number of dwelling units enrolled in the Evaluation was possible only by the innovative partnership among HUD, the Evaluators, and the grantees. HUD and the Evaluators relied on the grantees for essentially all of the data collection. The 14 participating HUD Lead Hazard Control Grantees were responsible for implementing the lead hazard control programs in their communities and collecting the study data. This paper describes the methods for recruiting and enrolling dwellings and families, collecting environmental and housing data, interviewing participating families, and collecting data on lead hazard control work performed and its costs. The paper also describes the basic quality control and quality assurance procedures used. The principal outcome measures were lead in dust collected using wipes from floors, window sills, and window troughs and lead in blood collected from children who were 6 years old or younger at enrollment. Data collection was conducted before intervention, immediately postintervention, and 6 and 12 months postintervention. For a subset of dwellings undergoing an extended follow-up data were also collected at 24 and 36 months postintervention. This paper provides the context for subsequent reports that will describe such findings as the influence of lead hazard control work on serial dust lead levels, the influence of lead hazard control work on serial blood lead levels in children, the nature and costs of the lead hazard control work done at the dwellings, and the experience of the grantees in meeting clearance testing requirements.

Occurrence and determinants of increases in blood lead levels in children shortly after lead hazard control activities.

This study is an examination of the effect of lead hazard control strategies on children's blood lead levels immediately after an intervention was conducted as part of the US Department of Housing and Urban Development's Lead-Based Paint Hazard Control Grant Program. Fourteen state and local government grantees participated in the evaluation. The findings indicated an overall average reduction in the blood lead levels of 869 children soon after the implementation of lead hazard controls. However, 9.3% of these children (n = 81) had blood lead increases of 5 microg/dL or more. Data routinely collected as part of the evaluation, as well as additional information supplied by the individual programs, were used to determine potential reasons for these observed increases in blood lead. A logistic regression analysis indicated that three principal factors were associated with the blood lead increases: the number of exterior deteriorations present in the child's home (prior to intervention), the educational level of the female parent or guardian of the child, and the child's age. The statistical analysis did not find evidence that children living in households that either did not relocate or relocated for less than the full work period were significantly more likely to have a blood lead increase equal to or greater than 5 microg/dL than children living in households that fully relocated. Statistical analyses also did not reveal any single interior strategy to be more or less likely than others to be associated with a blood lead increase of 5 microg/dL or more.

Prevalence and location of teeth marks observed on painted surfaces in an evaluation of the HUD lead hazard control grant program.

Data from an evaluation of the HUD Lead Hazard Control Grant Program were used to evaluate the prevalence and location of teeth marks on painted surfaces in residential housing. The results of these analyses will be useful in the development of more effective pediatric lead poisoning prevention programs. These programs have historically placed considerable emphasis on surfaces accessible to children for mouthing activities. This study analyzes the largest set of data ever assembled on the prevalence of teeth marks in housing. Data from 308,851 observations in 3,454 housing units were analyzed to determine the prevalence of teeth mark observations per surface, dwelling unit, and building component, and by housing age, inspector, and grantee. An average of 4.0 teeth marks per 10,000 surfaces with paint-lead greater than or equal to 1.0 mg/cm2 were observed. For surfaces with less than 1.0 mg/cm2 lead the rate was 1.5 teeth marks/10,000 surfaces. The number of teeth marks per 10,000 surfaces increased with age of housing for surfaces with 1.0 mg/cm2 or higher lead but not for surfaces with less than 1.0 mg/cm2 lead. Teeth mark observation rates were 36 times higher for windowsills than for other components and ranged up to 11 per 10,000 surfaces and 9 dwellings per 100 dwelling units for 2 grantees with the highest rates. Blood lead levels in children exhibiting moderate to high mouthing behavior were higher than in children without such behavior, especially in housing where teeth marks were observed. Special priority should be given to windowsills when making decisions on lead hazard control for "accessible," "chewable," or "mouthable" surfaces.