Abstract
Lead exposure has been linked to neurological, reproductive, and developmental effects, and approximately 3.5% of Chicago children under the age of 3 years have elevated blood lead levels. The aim of this research was to provide outreach opportunities to address the issue of lead exposure in water and soil. A series of seven community-based health fairs were held with a combined approach of screening and education accomplished through partnerships with organizations established within underserved communities that leveraged resources. Community members attending the fairs brought in samples of soil from their yards and tap water for lead testing. Lead concentrations in the soil samples had a mean value of 305.7 parts per million, and 30% of the samples were above the Environmental Protection Agency’s action level for children’s play lots. The mean lead concentration in tap water was 8.3 parts per billion, with 6% of sample testing above the Environmental Protection Agency’s action level. There was no significant correlation between the lead levels in water and soil (p = .21), and there was no significant difference between the average lead concentrations in different areas of the city. A multifaceted approach was utilized to educate and engage and ultimately empower the communities affected by exposure to lead in urban settings.
Keywords
Low-level lead exposure has been linked to neurological, immunological, renal, reproductive, and developmental effects. There is sufficient evidence to demonstrate that adverse health effects occur at blood lead levels (BLL) as low as 5 micrograms per deciliter (µg/dl; U.S. Department of Health and Human Services, 2012). Lead can affect most organ systems, and perhaps most concerning, lead can affect cognitive development in children and can cause irreversible neurological effects (U.S. Department of Health and Human Services, 2012). Behaviorally, children with elevated BLL, defined as lead concentrations above 5 µg/dl, have shown poorer school attendance, and at moderate BLL between 10 and 20 µg/dl, children performed worse on standardized tests (Amato et al., 2012). Elevated BLL was associated with greater than 8 times increased odds of conduct disorder (Braun et al., 2008), and low-level exposure to lead during pregnancy can affect the development of the fetus and affect birth outcomes such as decreased birth weight and increased risk for preterm birth (Cheng et al., 2017; Xie et al., 2013).
Because of these impacts, the Centers for Disease Control and Prevention (CDC) have maintained that there is no safe level of lead exposure (CDC, 2012). In addition, the Healthy People 2020 campaign proposed by the Office of Disease Prevention and Health Promotion has set the goal of eliminating elevated BLL above 10 µg/dl (U.S. Department of Health and Human Services, 2018).
In the United States in 2014, of the over 2½ million children who were tested for lead, 4.25% had BLL equal to or greater than the Environmental Protection Agency’s (EPA) action level of 5 µg/dl, and Illinois was ranked the eighth highest state with 5.98% of children testing at elevated BLL (Shah et al., 2017). In Chicago, 3.5% of children under the age of 3 years who were tested had elevated BLL (Chicago Department of Public Health [CDPH], 2016). Although these levels have decreased over time, one study of 208 children younger than 6 years who were tested between 1995 and 2013 estimated the weighted mean BLL to be as high as 6.14 µg/dl. In some Chicago neighborhoods, the percentage of children with elevated BLL was as high as 4% (Winter & Sampson, 2017). This percentage exceeds the levels found in Flint, Michigan, after the water crisis where lead leaching from water pipes exposed residents to high lead concentrations. The aftermath of Flint has resulted in national outrage and criminal indictments of city and state officials, whereas little attention has been given to the health disparities associated with lead exposures in Chicago (Gomez et al., 2018).
The distribution of lead exposure in Chicago is not uniform, and there is an inequity in exposure to lead and its associated health effects. People living in poverty are exposed to lead at higher rates because they are typically living in older homes built before 1978 or living in housing in disrepair (Krieger & Higgins, 2002). Black and Hispanic children and children living in poverty were more likely to be exposed to lead (Amato et al., 2012). Black communities see the highest BLL compared with other racial communities (White, 2016). As previously mentioned, the overall mean BLL in Chicago for all children under the age of 6 years was estimated to be 6.14 µg/dl, whereas the estimated BLL for Black children was 7.48 µg/dl. Children living in predominately Black and Hispanic neighborhoods had higher average BLLs than children living in predominately White neighborhoods (Winter & Sampson, 2017). Children living in Chicago’s South, West, and Far South sides had significantly higher odds of elevated BLL, with odds ratios of 2.45, 3.29, and 2.12, respectively (Oyana & Margai, 2010).
Environmental exposures of lead can be found in the air, food, water, dust, and soil, and a major source of lead intake is from lead-contaminated house dust from chipping paint and soil from deteriorated housing built before 1978 (Lanphear et al., 1998; U.S. Department of Health and Human Services, 2012). In particular, children in Chicago are most at risk for exposure to lead through ingestion and inhalation of lead from paint dust generated in older homes. Children living in areas with relatively high percentages of pre-1950s housing have been found to have significantly higher odds of having elevated BLL (McClure et al., 2016). Furthermore, Hispanic and non-Hispanic Black homeowners were significantly more likely to live in “unhealthy” households defined in part as having exposure to environmental factors such as lead (Raymond & Brown, 2011).
Due to the ubiquitous nature of lead exposures, the severity of health effects, and the disparate impact on minority and poor communities, control measures should be focused on primary prevention efforts to stop exposure before it begins. The Academy of Pediatrics suggests that pediatricians work toward prevention by supplementing screening with education and outreach efforts (Newman et al., 2013). Educational interventions have resulted in a significant increase in knowledge in posttest evaluations and showed a significant decrease in lead dust on windowsills in homes and a decrease, although nonsignificant, in dust levels on floors after educational outreach was provided (Campbell et al., 2011). Furthermore, when screening for elevated BLL was followed by educational efforts, there was a significant reduction in the study population’s BLL (Prashant et al., 2008). A systematic review of interventions to reduce lead exposure showed that although there was little research about best practices to prevent exposures, interventions that combined environmental and educational interventions were more effective (Pfadenhauer et al., 2016).
The overall goal of this project was to mitigate the effects of lead exposure through community-based outreach efforts and to hold a series of health fairs with a combined approach of environmental screening and education. The specific objectives to achieve this goal were as follows: (1) to provide on-site testing of participants’ water and soil for lead contamination and (2) to provide educational materials and resources about lead, the associated health effects, and ways in which lead can be controlled. In addition, survey data were collected on health behaviors, knowledge about lead, and demographics to identify potential contributing factors to lead exposure for future intervention.
Method
Study Participants
Study participants were recruited through partnerships with not-for profit and community organizations. The pilot health fair was held in May 2017 at an organization focused on reducing violence in youth communities. Additional health fairs were then held at six Chicago locations in April 2018 through partnership with an organization that focuses on community building, youth development, and health and wellness. Health fairs were held in conjunction with events previously planned by community partners to leverage resources and recruitment efforts already in place, including monthly family nights and annual health fairs designed for children.
Seven Chicago communities were targeted for participation in the health fairs. These communities are served by the collaborating partners and represent distinct populations in terms of demographics, neighborhood factors, and indicators of lead exposure. Participation in the health fairs was open to the public, and study eligibility was not limited, with the exception of the survey, which was administered to participants 18 years of age or older. Participants in the health fairs were recruited through the traditional channels employed by the community partners, including email listservs, social media, and advertising in monthly newsletters. In addition, approximately 2 weeks prior to the health fairs, sampling kits composed of a 250-ml water bottle for collecting tap water samples, a quart-size ziplock bag for collecting soil samples, and instructions for sample collection in both English and Spanish were distributed at each community partner location.
Instructions on how to collect the soil samples followed the protocol set by the Agency for Toxic Substances and Disease Registry (ATSDR) for their Screening-Health-Outreach-Partnership (soilSHOP). The soilSHOP protocol is designed to “help people learn if their soil is contaminated with lead, and how to reduce exposures to contaminated soil and produce” (ATSDR, 2016). The specific instructions can be found in the Supplemental Appendix 1. Participants were instructed to collect soil at a depth of 2 inches for a play area and at a depth of 6 inches for a garden area and to collect samples from five locations, mix them together, and bring two cups of the mixture to the health fairs after it was allowed to dry in the sun.
Instructions on how to collect the water samples followed the protocol set by the EPA in the “Water Testing Recommendations for Chicago Residents” (EPA, 2019). Residents were asked to collect the sample after a 6-hour period when water in the house was not used and to draw the sample first thing in the morning before any water was used. They were asked to fill the water bottle provided to them to approximately half an inch from the top and to not run the water from the tap before collecting the sample.
Health Promotion
The health fairs were designed to supplement larger public health initiatives with elements of health promotion and community participation, which is recommended for environmental health interventions in urban settings with health inequity such as Chicago (Kjellstrom et al., 2007). Furthermore, targeted community-level interventions were employed as recommended by the EPA’s “3Ts” approach for reducing exposure to lead. The recommendations include “training” to raise awareness, “testing” to determine the lead levels, and “telling” to inform the community about the potential health risk and what actions they can take to control their exposures (EPA, 2006).
Each health fair had between two and four student volunteers who were educated about lead, including common exposure pathways, associated health outcomes, and strategies to minimize and mitigate exposure to lead. At least one volunteer was bilingual in Spanish and English at each of the health fairs, and the health information materials and survey were also available in Spanish. Training of the health educators was accomplished through a train-the-trainer model, which was used as an effective method to help health educators deliver information to the community (Edmondson & Williamson, 1998). When the results of the water and soil analysis were released during the health fair, the student volunteers communicated this information directly to the participant through one-on-one counseling sessions and also shared information about lead published by ATSDR (2016) and the Wisconsin Department of Health Services (2008). When the analysis of the samples was not completed during the health fairs, the results and health information were sent directly by mail or email to the participants. The communication included a summary of the results, an explanation of what the results meant, and suggestions of next steps and control strategies if necessary.
Data Collection
Lead concentration in water was measured using a LeadTrak II test kit and portable colorimeter (Hach Company, Loveland, Colorado) with a detection limit of 1 part per billion (ppb). Lead concentration in soil was measured using a pXRF, a spectrometer from Thermo Scientific Portable Analytical Instruments (Tewksbury, Massachusetts), with a detection limit of approximately 20 parts per million (ppm). Information on health knowledge and behavior was collected using a 31-question optional survey, which was self-administered by the participant. The survey was composed of 10 scaled questions addressing knowledge of lead, lead exposure, the associated health effects, and how to minimize adverse health outcomes; five questions about children occupying the home; 11 questions about the participant’s home and health behaviors that may contribute to or reduce lead exposure in the home; and five demographic questions. Researchers developed the survey by combining newly written questions with a selection of prompts from the validated Behavioral Health Risk Factor Surveillance System questionnaire (CDC, 2013). A copy of the survey can be found in Supplemental Appendix 2.
Data Analysis
Statistical analysis was conducted using SPSS Statistics software (IBM Analytics, Armonk, New York). Analysis of variance was used to determine if there was a statistical difference between lead levels in the different areas of the city. Due to the small sample size and uneven distribution across the sample area, lead concentration data could not be correlated across city areas or controlled for additional area-specific variables. Geographic Information Systems technology (Esri, Redlands, California) was used to map the distribution of lead levels and identify areas of high lead concentrations.
Results
Testing Results
The health fairs were held during preplanned events, including a monthly family night to gather community members together for games and food and an annual health fair to prepare families for having a safe summer. Many community members attended these events, but only a fraction of the total people in attendance participated in our outreach efforts. It was not possible to estimate the overall participation in the events or the number of people who interacted with our volunteers and took health information but did not participate.
A total of 288 water and soil samples brought by 193 participants were tested. Approximately 40% of participants brought in both soil and water samples, whereas 5% of participants brought in only a soil sample and 54% of participants brought in only a water sample. Of the participants who brought in multiple samples, 11 participants brought in two soil samples, one participant brought in three soil samples, 10 participants brought in two water samples, and one participant brought in four water samples. These samples were from the same home but from different locations such as the front and backyard or filtered and nonfiltered water sources. Approximately 65.3% (n = 126) of the participants completed the survey.
Lead concentrations in the soil samples ranged from 0 to 1,978 ppm, with a mean value of 305.7 ppm, 95% CI [243.0, 368.4]. Forty-one soil samples (45%) were above the threshold of 100 ppm. Lead levels above 100 ppm in soil could pose a potential health risk and warrant the use of safe gardening techniques and were considered above a level of concern (EPA, 2014). Twenty-seven samples (30%) were above 400 ppm, which is the EPA action level for soil lead in child-occupied play lots (EPA, 2014). Lead concentrations in the water samples ranged from 0 to 150 ppb, with a mean value of 8.3 ppb, 95% CI [2.8, 13.8]. Twenty-one water samples (11%) were above 5 ppb, the Food and Drug Administration’s allowable level in bottled water, and 12 (6%) were above 15 ppb, the EPA’s action level for potable water (EPA, 2014). There was no significant correlation between the lead levels in the water and soil (p = .21).
Overall, there was no apparent association between where the sample was taken and the lead level. Spatial patterns of soil and water lead concentrations were mapped across the city of Chicago (Figures 1 and 2). The figures show the city of Chicago divided by community areas as the numbered quadrants. Both maps show that the North, Northwest, and Far Northwest sides were more heavily represented because the health fairs in those areas were more highly attended. When the data were aggregated into areas of the city, analysis of variance showed that there was no significant difference between the mean lead concentration in soil (F4,83 = 0.5, p = .73) or in water (F4,186 = 0.8, p = .54) in the different areas (Table 1).
Lead concentration in soil samples collected during health fairs.
Lead concentration in water samples collected during health fairs.
Aggregate Lead Level Values Grouped by Chicago Districts.
Health Promotion
Health educators explained the results of the lead testing to participants who brought in samples and were available to answer questions from all attendees, including individuals who did not bring in samples. Participants with elevated lead levels were given information about how to minimize and mitigate their exposure to lead in their environment, including an explanation of safe gardening techniques, water filtration systems, and practices to minimize tracking dust and soil into the home.
Survey Data
The health behavior and demographic survey results are outlined in Table 2. Our sample population was approximately 60% White, whereas the Chicago population is approximately 50% White, meaning that our racial distribution was slightly different from that of the city of Chicago (U.S. Census Bureau, 2019). In addition, the number of college graduates was twice than that reported for Chicago residents in the 2010 census, and the annual household income was skewed toward the higher income brackets (U.S. Census Bureau, 2019). Subsequently, the housing type had a slightly higher representation of single-family homes, which were only 50% of the housing stock in Chicago between 2009 and 2013 (Chicago Metropolitan Agency for Planning, 2015), and a lower percentage of houses built prior to 1978, which were 81% of the housing stock in 2015 (Fokum et al., 2016).
Health Behavior and Demographic Information Collected by Questionnaire During Health Fairs.
Note. Percentage represents the portion of participants answering the questions.
Questions related to health knowledge revealed that although 76% (n = 96) of participants who completed the survey reported to know “what lead is” and 65% (n = 82) reported “knowledge of the health effects of lead,” only 23% (n = 29) knew of the methods to reduce the health risks associated with lead exposure. Seventy-six percent (n = 96) of the respondents reported use of a water filtering system, the most common of which were pitchers or carafes, with 46% (n = 58) of respondents reporting their use, followed by refrigerator-based filtering systems, with 33% (n = 42) reporting their use. Seventeen percent of the respondents (n = 21) answered that they never wear shoes in the home, which is a recommended way to prevent outdoor dust with lead contamination into the house and thus a way to reduce lead exposure to indoor lead-contaminated dust (ATSDR, 2007).
Discussion
In summary, a series of health fairs was conducted to promote environmental health with regard to lead in drinking water and soil. This was accomplished through community partnerships that leveraged resources and avenues for community engagement and by developing and piloting a model for health promotion, education, and testing.
Water and soil testing revealed that there were elevated concentrations of lead across the city, with elevated concentrations in areas with and without excess rates of elevated BLLs. As seen in Figure 3, areas with high rates of lead poisoning are concentrated on the West, South, and Far South sides of Chicago (CDPH, 2011). These areas of elevated BLL are consistent with previous findings that showed higher risk for lead poisoning in the West, South, and Far South sides of Chicago (Oyana & Margai, 2010). However, as seen in our data, the distribution of lead in water and soil does not follow that same pattern, with high levels found across the city. The apparent discrepancy between exposure and health outcome may be a result of exposures beyond outdoor soil and drinking water. Lead-contaminated dust in the home is an important, if not the primary, source of lead exposure to children in an urban setting (Lanphear & Roghmann, 1996). Lead-contaminated dust in the home is a product of lead-based paint found in older homes (ATSDR, 2007). As 75% of our respondents reported living in homes built prior to 1978, it is expected that lead contamination in house dust would be a common exposure in Chicago and should be evaluated in the future.
Distribution of elevated blood lead levels across Chicago.
The strength of this study was in the educational outreach that filled a perceived need within Chicago. Due to the high-profile water contamination in Flint, Michigan, and recent articles pointing to elevated lead levels in Chicago’s drinking water, there has been increased anxiety and fear related to lead exposure and the associated health effects (Hanna-Attisha et al., 2016; Milman, 2016). Immediately prior to our outreach efforts, the Chicago Tribune reported that tap water lead concentrations were above 5 ppb in almost 70% of tested homes (Hawthorne & Reyes, 2018). The ramifications of these reports can lead to mental health issues within the community including fear, anxiety, and depression as well as outrage and a sense of inequity (Cutherbertson et al., 2016; Ekenga et al., 2018). Health promotion and educational efforts can reduce stress and anxiety through establishing a sense of control and self-efficacy (Glanz et al., 2015). In particular, health promotion efforts that address environmental health issues with established health inequities, such as lead, are more effective when they incorporate access to resources, which in turn reduces the inequities in environmental exposures and health effects (Schulz & Northridge, 2004). Thus, the inclusion of health promotion into our health fairs was consistent with the effective best practices in environmental health outreach.
There were additional strengths within the model that serve as lessons for future implementation. First, to maximize outreach efforts, it was important to partner with a reliable community partner who can assist with community outreach. Our community partners are long-standing organizations in the city of Chicago with strong administrative infrastructure that allowed for more efficient advertisement of the health fairs to their members. This lesson is consistent with the recommendations for building health equity in underserved communities. The literature points to the importance of building partnerships that can access community resources and support organizing efforts (American Public Health Association, 2016; National Academies of Sciences, Engineering, and Medicine, 2017).
Second, this model was successful in giving our students the opportunity to participate in community-based participatory research and experiential training and learning. Having these opportunities not only develops student communication and improves their self-confidence but also serves as a way to improve learning of the enduring skills of public health application (Mobley-Smith et al., 2004). The students participated in direct outreach with community members and were able to apply their academic training to address an ongoing environmental health issue. The students also gained experience in community-based participatory research efforts through collaboration with our community partners as well as communication with the organizations’ members. These opportunities for experiential learning were an important asset to the model as it provided for enhanced learning for our students (Kolb & Kolb, 2017).
Finally, the community organizations and their members were able to observe on-site testing and public health leaders in action. This was integral to our outreach efforts as a way to engage community members and ultimately to increase their self-efficacy in addressing environmental hazards. Engaging the community in this way has been shown to increase environmental health literacy and enable the participants to make decisions that protect their health (Gray, 2018). Having direct contact with the scientists and disseminating results within the community have also been shown to lead to more powerful and meaningful connections with the partnering organizations and the academic and scientific communities in general (MacDavitt et al., 2016).
Although there were positive outcomes, there were aspects of the model that need revision. First, the testing equipment used was cost prohibitive and the data collection methodology was not standardized. We were able to secure the equipment through a loan and at reduced rates by leveraging our connections with the equipment providers. This may not be feasible and is not sustainable in the long term. It is recommended that partnerships with laboratories be brokered such that analysis can be conducted off-site at a lower cost. This should be supplemented with a follow-up session that gives the community an opportunity to interface with the researchers in order to discuss results. Furthermore, community members collected soil and water without oversight. Community members were instructed about the proper data collection methods; however, without verification, the results were considered screening and not regulatory, and the participants were instructed to conduct more rigorous follow-up testing when appropriate.
Another consideration in revising the model was difference in turnout between the health fairs. This issue could be addressed by working with community health workers who are embedded in the targeted areas or by creating a community advisory board (CAB) made up of people from the target communities. The use of CABs has proven to enhance participation, success, and quality of various types of community-based participatory research projects (Adams et al., 2014; Isler et al., 2015). These methods can provide researchers with ideas for more specialized avenues for outreach, how to tailor materials and advertising plans, and how to mobilize participation through existing community networks. Furthermore, benefits of integrating CABs and community health workers into community-based participatory research projects serve as being mutually beneficial for the research team and the target community in that they support ownership of resources and promote long-term project sustainability (Wallerstein & Duran, 2010).
There were also limitations to our research methodology. One limitation was the differential response to the health fairs. Although all efforts were made to have uniform participation, the areas of Chicago with some of the highest reported lead poisoning rates had very low turnout. These areas of the city are typically underserved by the public health system and therefore have higher rates of adverse health outcomes (CDPH, 2016). Interventions in typically underserved communities such as these have better recruitment and retention when researchers partner with, train, and utilize collaborating staff who are culturally matched with the community stakeholders and when the collaborating partner staff is involved in the research process from the design phase (Carroll et al., 2011; Pinto, 2009). It is recommended that future efforts of this kind incorporate collaborating partner staff throughout the research and recruitment efforts.
Furthermore, the demographic makeup of the participants was not representative of the target population as it was over 60% White in a city that is only 50% White (U.S. Census Bureau, 2019). This is a significant limitation as the intervention was designed to meet the needs of minority populations that are disproportionately affected by the adverse health outcomes associated with lead. This uneven response may have been due to a general lack of awareness and understanding about lead, and therefore, future efforts to reach underserved communities should implement a systematic approach that makes participation default such as embedding the process within an educational or work setting.
Another limitation was the lack of assurance and follow through with the participants. The health fairs were originally intended to be an inclusive event with participants receiving their results and all of the necessary health information during the event. Thus, we did not intend to collect their contact information nor conduct any follow-up post health fairs. Due to the high turnout and, thus, a limited time spent with each of the participants, we were unable to complete all of the analysis and revised our methods accordingly to send the results to the participants directly. This adjustment created an opportunity for connecting with participants post health fairs to assess their change in knowledge and behavior and evaluate if the suggested controls and practices were implemented. However, there was no infrastructure to do so, and we are limited in assessing the effectiveness of our intervention or determining if lead exposures were reduced due to our efforts.
The issue of lead exposure demands continued attention in a systematic manner that engages underserved communities who bear the burden of the negative health outcomes associated with lead exposure. When approaching environmental health issues, a multifaceted approach was shown effective. Efforts should be made to include health promotion and educational components in environmental interventions to ensure that efforts to minimize exposures are made in an effective manner.
Supplemental Material
Appendix_1-Self_Administered_Questionnaire – Supplemental material for Lead Health Fairs: A Community-Based Approach to Addressing Lead Exposure in Chicago
Supplemental material, Appendix_1-Self_Administered_Questionnaire for Lead Health Fairs: A Community-Based Approach to Addressing Lead Exposure in Chicago by Julia Lippert, James Montgomery and Camille DeMarco in Health Education & Behavior
Supplemental Material
Appendix_2-Soil_Sampling_Instructions – Supplemental material for Lead Health Fairs: A Community-Based Approach to Addressing Lead Exposure in Chicago
Supplemental material, Appendix_2-Soil_Sampling_Instructions for Lead Health Fairs: A Community-Based Approach to Addressing Lead Exposure in Chicago by Julia Lippert, James Montgomery and Camille DeMarco in Health Education & Behavior
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding for the rental cost for each of the health fairs, promotional materials, filtering water pitchers, and raffle prizes to encourage participation was provided by DePaul University’s Vincentian Endowment fund and the Academic Incentives Pool. Collection and analysis of soil samples followed the protocols set by the Agency for Toxic Substances and Disease Registry (ATSDR) for their Screening-Health-Outreach-Partnership (soilSHOP). Equipment to test lead in the soil was donated by Alpha Solutions, Inc., a representative of Thermo Scientific and Analytics Lounge, a community lab that provides low-cost analytical equipment to community members. Silver Lake Research Corporation donated free home test kits.
References
Supplementary Material
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