Challenging Dogma - Fall 2009

Thursday, December 17, 2009

A Critique and Redesign of the “Wipe Out Lead” Campaign of Greater Buffalo, New York- Whitney Cowell

I. Introduction
In 2006, almost 40,000 children residing in the United States were diagnosed with lead poisoning, a disease that often results in severe health consequences, such as developmental delays and neurobehavioral disorders (1,2). Of these children, data indicate that 93% are on Medicaid, a sign that their family likely has a low-income (3). Children can be tested for lead poisoning through a simple blood test that measures blood lead level; levels below 10 micrograms per deciliter of blood are considered permissible by the U.S. Centers for Disease Control and Prevention (1).
The disease has been a persistent problem throughout the U.S. since the advent of lead-based paint in the early 1930’s. Houses that were built before 1978 frequently contain lead paint, which can flake off in chunks or as particulate matter in dust. Children living in homes containing lead-based paint are at risk for exposure to lead through accidental ingestion of lead-laden dust and soil. Toddlers are especially vulnerable, as hand-to-mouth behavior is widespread among this age group, and because their small body size makes them more biologically sensitive to the hazard (4). To determine if lead is present in a home, a simple swab test can be conducted and sent to a laboratory for analysis. If results are positive, then abatement procedures should be carried out. This generally involves removal of the paint by professional hazard control workers; amateur removal of the paint can exacerbate the problem, as sanding and scraping without proper control measures creates ample amounts of lead-laden dust. As the result of the need for a professional and the time-consuming nature of the procedure, abatement can cost upwards of $10,000 per house; thus, for many families it is not an economically feasible option, unless monetary assistance is provided (5).
New York State, not including the city of New York, has the 10th highest blood lead levels in the country; among children tested in 2006, over 160,000 presented with elevated blood lead levels (6). Two-thirds of all lead poisoning cases that occur outside of New York City are found in the Greater Buffalo area of New York State; these statistics illustrate the seriousness of the lead poisoning crisis in this area (7). To reduce lead poisoning, the Community Foundation for Greater Buffalo has designed and implemented the “Wipe Out Lead” campaign. The primary purpose of the campaign is to help families avoid exposure to lead. Informational materials provide numerous suggestions for exposure reduction, including: testing homes and children for lead, learning how to safely conduct home repairs, feeding children a healthy diet, notifying landlords about peeling paint, routinely cleaning the household, and preventing children from chewing on windowsills. Further, the campaign provides a hotline number for parents and landlords to call if they have questions regarding lead exposure, or testing and abatement procedures (7).
This paper will present three critiques of the “Wipe Out Lead” campaign, followed by suggestions for the development of a more effective initiative.
II. A Critique of the “Wipe Out Lead” Campaign of the Greater Buffalo Area
This section of the paper presents three arguments, each of which highlights a major flaw of the “Wipe Out Lead” campaign. First, the campaign does not utilize marketing and advertising techniques to promote lead testing in children and homes. Second, the campaign does not adequately address environmental and societal factors that may influence the behavior of families that may lead to lead exposure and poisoning. Finally, the campaign does not account for Maslow’s Hierarchy of Needs in its recommendations for decreasing lead poisoning.
A. Marketing and Advertising Theory were not Applied During Campaign Development
The major promotional components of the “Wipe Out Lead” campaign include: an informational brochure, billboard ads, door hangers, posters, and a radio and television public service announcement. All of these materials use scare tactics to encourage parents to test their children and homes for lead. More specifically, the campaign materials suggest that homes with lead paint are unhealthy and that testing must be carried out to keep children safe and protect them from poisoning. These suggestions clearly indicate that the campaign appeals to the desire for health. However, it can be argued that the health-promoting characteristics of a house are not the most important factors that a family considers when moving in. Other more highly considered factors likely include: price, proximity to work and schools, and neighborhood characteristics. By not considering these elements, the campaign fails to identify and appeal to the core values of the community. If the campaign tapped into these core values, it would likely be more effective at changing the home testing and child screening behavior of the community.
The “Wipe Out Lead” campaign promises that exposure to lead will result in lead poisoning of children; this is supported by pictures of innocent babies and images of chipping paint. This promise is negative in nature and the support for it is weak. A stronger promise would be one that appeal to the core values of the community, such as control over one’s life, and would be supported by personal stories, captivating images, and metaphors (8). The lack of these basic marketing and advertising theories reduces the effectiveness of the “Wipe Out Lead” campaign.
B. The “Wipe Out Lead” Campaign Does Not Account for Environmental & Societal Influences on Behavior
By failing to fully consider all environmental and societal factors that may influence the testing and abatement seeking behavior of community members, the “Wipe Out Lead” campaign falls victim to the fundamental attribution error (9). The campaign assumes that families fail to protect their children from lead exposure primarily because they are uninformed about the dangers and pervasive nature of the hazard. However, in reality, numerous environmental and societal factors likely influence the behavior of families to seek out testing and abatement.
A central recommendation of the “Wipe Out Lead” campaign encourages families to have their children tested for lead poisoning by taking them to their doctor. The campaign recognizes that not everyone has a primary care physician, and thus provides a phone number in the informational brochure and on the website that families can call if they are in this situation. However, the campaign does not address barriers families may face such as a lack of reliable transportation. Further, certain sub-populations may physically have trouble taking their children to a screening exam. For example, busy single moms or immobile pregnant women may not have the time or ability to set-up and follow through with an appointment.
Another central recommendation of the campaign suggests that parents should feed their children healthy food because children with a “good diet” absorb less lead. This recommendation fails to consider multiple barriers to obtaining, preparing, and feeding children a balanced meal. First, it assumes that parents know what a “good diet” consists of. The campaign website provides some basic nutritional information in addition to three examples each of a healthy breakfast, lunch, and dinner. However, this information is not included in the campaign materials that are distributed such as flyers and door hangers, and is not mentioned in the T.V. advertisements or radio commercials. Further, the education material on the components of a healthy diet is not comprehensive, and widespread distribution of this information is lacking. Similarly, the campaign assumes that parents can afford to buy healthy food and have time to prepare home-cooked meals. However, as revealed earlier, the majority of children afflicted by lead poisoning are from low-income families. These families may not be able to afford to shop at health food stores or buy high-quality produce, dairy, and meat products. This is notable as it has been well established that junk foods are generally cheaper than fruits and vegetables; this point is illustrated by a recent study which suggests that energy-dense junk food costs $1.76 per 1000 calories, compared to $18.16 per 1000 calories for nutritious, low-energy options (10). Furthermore, parents of low-income families are more likely to be single and to be working long hours or more than one job; these factors contribute to the difficulty these parents may face when trying to find time to dedicate to preparing meals. This time restraint may further lead to an increased consumption of fast food, which is frequently low in nutritional value (11).
Finally, the campaign recommends that families notify their landlords if they are renting a property that they believe may contain lead paint (7). However, the campaign fails to consider that lead abatement may not be economically feasible for the landlord, and alternative lead-free housing options that are affordable for the family may be limited or difficult to find. In these situations, a family may be aware of the dangers of the house, but due to economic circumstances may not have the means to make changes. The campaign does little to target landlords and provide options for lead abatement; the only two aspects of the campaign targeted towards landlords include distribution of information that informs landlords that the law requires they notify tenants of lead hazards on the property, and provision of a hotline number landlords can call if they believe they may qualify for undisclosed free-services. Thus, by under-valuing these situational explanations for why families may not follow recommendations and do not carry out testing, the campaign fails to adequately address the barriers to lead poisoning prevention families face.
C. The “Wipe Out Lead” Campaign Does Not Account for the Hierarchy of Needs
The “Wipe Out Lead” campaign assumes that if a child or house tests positive for lead, then the family will move out or carry-out abatement procedures to ensure that their children do not develop lead poisoning (7). However, the campaign fails to consider that these options are not possible for some families. This is problematic as a family’s need for shelter is likely more fundamental than their desire to protect their children from the potential for developing lead poisoning and the health consequences that are associated with it. This illustrates that the campaign does not account for the Hierarchy of Needs, developed by A. H. Maslow in the 1940’s as a component of his Theory of Human Motivation. The Hierarchy of Needs posits that certain human needs must be satisfied before others can be fulfilled; the most prepotent of needs are physiological, followed by safety, love, esteem, and lastly self-actualization. The motivation to have shelter has been considered by social scientists as a component of the most basic physiological needs (12). The need to protect against adverse health outcomes has most often been considered a component of the need for safety; however, it has been argued that the need to prevent against long-term health effects can be characterized by the desire for self-actualization. For example, a mother’s desire to protect her children from the development of disease can be characterized as a self-actualization goal. The placement of the need for shelter below the need for prevention of long-term health consequences has implications for the success of the “Wipe Out Lead” campaign. If families follow-through with testing, and subsequently discover that their homes are ridden with lead and that their children have elevated blood lead levels, the campaign suggests that they choose between moving out or carrying-out lead abatement procedures. However, both of these options are associated with substantial economic costs, thus in many cases, especially among low-income households, families may be forced to choose between a home that has potential dangerous health consequences, or no shelter at all (5). Applying the Hierarchy of Needs to this situation, it is likely that families will choose to continue living in their homes, regardless of the presence of lead contamination. As a result, in these scenarios the campaign is effectively useless, providing no reasonable alternatives for families that cannot afford to remove themselves from their lead-laden homes.
III. A Redesign of the “Wipe Out Lead” Campaign
This section proposes the development of a new, more effective campaign that encourages lead screening and abatement behavior among community members of the Greater Buffalo area, taking into consideration the previously identified flaws in the current “Wipe Out Lead” campaign.
A. The Proposal
I propose the development of a multifaceted lead poisoning prevention campaign and initiative. The program will take an environmental approach to: increasing awareness and education, screening children for poisoning, testing homes for the presence of lead, and providing options for safe and realistic abatement or relocation.
1. The Campaign Will Employ Advertising & Marketing Theory Techniques
Campaign education and awareness materials will be developed by applying marketing and advertising theories and approaches. Formative research will be conducted to determine the core values of the target population, namely low-income families living in the Greater Buffalo area. The results of this research will be used to develop a promise that appeals to one or two of the identified values. For example, if an identified core value is control, the promise could emphasize how having your home and child tested for lead gives an individual more control over their home environment. To support the promise the advertisements will use realistic and relatable images, metaphors, and true stories told by families who have faced lead poisoning. These messages will be disseminated via billboards, door hangers, and television and radio public service announcements. Campaign materials will be distributed at physicians’ offices, day care centers, school PTA meetings, WIC offices, churches and other locales that parents are likely to visit. The campaign will not revolve around the desire for health, as research suggests that appealing to health is not an effective method for changing an individuals’ behavior, as health is generally not regarded by most as a core value. For example, the “Truth” campaign, designed by the American Legacy Foundation, employed commercial marketing strategies, such as research and branding, to decrease smoking rates among teenagers. After the inception of the campaign, the number of Florida middle school students who smoked cigarettes between 1998 and 2000 decreased by almost 10% and the number of high school smokers declined by 6.5% (13). Thus, by redefining lead screening and abatement to be in the communities’ self-interest, the campaign will be more likely to influence the behavior of the target population.
2. The Initiative Will Address Environmental Barriers to Lead Poisoning Prevention
The initiative will address environmental barriers families may encounter when trying to prevent the occurrence of lead poisoning. The campaign will recommend that all families with children under 6-years of age have them tested for lead annually; this requires a simple blood test involving a finger prick. However, compliance with this requirement may be an issue for many families if they do not have a primary care physician or do not have reliable transportation to access their physician. To overcome these barriers to screening, this initiative proposes the development and use of a mobile lead screening unit. The unit will bring the testing site to community members; drives will be located at elementary schools, large day care centers, churches, and other locales frequented by community members. Care will be taken to have the mobile screening unit available at times other than those of a 9-5 workday, thereby allowing parents who work a full time job to attend. The screening will be offered to children under 6 years of age free of charge; to cover costs, the initiative will apply for grant money from the U.S. Department of Housing and Urban Development which currently funds similar initiatives.
Second, the lead poisoning prevention initiative will develop a home visitation program in which trained volunteers will perform visits to the households of pregnant women and single mothers. These women are key sub-groups of the target population who deserve extra care as they are often: under large amounts of stress, busy caring for children while also possibly working, less mobile if near the end of a pregnancy, and possibly less knowledgeable regarding the issues of lead compared to other parents if they are pregnant with their first child. Further, the fetus is vulnerable to lead poisoning while in the womb as the contaminant can cross through the placenta (4). Therefore, home visitation should be an effective method for reaching these sensitive populations and educating them on the health consequences of lead poisoning and the importance of testing.
A third recommendation of the proposed campaign will encourage parents to feed their children a nutritious diet, as healthy diets have been associated with decreased blood uptake by the body (4). To support this recommendation and address potential barriers, the initiative will not only provide educational material containing information on the components of a healthy diet, but will also organize cooking and shopping classes. The classes will teach families the basics of healthy eating, how to affordably purchase healthy foods, and how to cook a balanced meal in a reasonable amount of time. Classes will take place at community centers, such as local churches and town halls.
The campaign and initiative will also design materials and tactics for targeting landlords. Currently, the majority of low-income families living in the Greater Buffalo area rent homes, thus landlords are a key target population as they have control over the quality and safety of their properties. Landlords will be reached through the development of campaign materials that appeal the core values of this population. Also, meetings will be organized with the purpose of educating landlords on the importance of testing their properties for lead and providing them with resources to carry out lead abatement procedures.
3. The Initiative Will Provide Abatement and Relocation Resources to Landlords and Families
Finally, the campaign will provide families and landlords with reasonable options for carrying out lead abatement, and will provide families with resources that will help them find a lead-safe home if abatement is not possible and they feel it is in their best interest to relocate. Property owners faced with the need to carryout abatement will be able to apply for money to fully or partially subsidize the cost of the procedure. To be eligible for the grants, the families or landlords must prove that they have had their home tested for lead and that unsafe lead levels were found, and they must be low to moderate income according to the U.S. Department of Housing and Urban Development. Money will be raised in a variety of manners including: grants from the U.S. Department of Housing and Urban Development, donations from private foundations, contributions from the corporate community of the Greater Buffalo area, and fundraising projects such as a reception or auction.
Secondly, the initiative will create and publish a housing registry that will list lead-free and lead-safe rental and for-sale properties, this list will be available online and distributed in print along with the other campaign materials.
Provision of these resources and options is critical, as many families that are facing lead contamination would otherwise not have the ability to change their situation. Without these resources, some families would be forced to choose between living in an unsafe house or living on the streets. Taking into consideration Maslow’s Hierarchy of Needs, it is likely that in these situations, most parents would choose the safety and security of a home, even if it did contain hazardous levels of lead.
IV. Conclusion
In conclusion, the “Wipe Out Lead” campaign centered in Greater Buffalo, New York would be more successful if it employed advertising and marketing theory to promote lead poisoning screening and abatement procedures, if it accounted for environmental barriers to screening and abatement, and if it considered the importance of the Hierarchy of Needs in the decision making of families who experience elevated blood lead levels. The advertising campaign should be reformulated to include formative research and should appeal to the communities’ core values rather than health. Secondly, the initiative should employ a mobile clinic and a home visitation service to make testing more accessible for all community members. Thirdly, adequate dietary information should be provided, in addition to classes on shopping and cooking on a monetary and time budget. Finally, the initiative should provide abatement resources to both landlords and families. Collectively, it is likely that the implementation of these changes will aid in the reduction of lead poisoning in the Greater Buffalo area.
REFERENCES:
1. Centers for Disease Control and Prevention. Childhood Lead Poisoning Data,
Statistics, and Surveillance. Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/nceh/lead/data/index.htm.
2. Environmental Protection Agency Integrated Risk Information System. Lead and
Compounds. Atlanta, GA: Environmental Protection Agency. http://www.epa.gov/iris/subst/0277.htm.
3. Kaufmann, et al. Elevated Blood Lead Levels and Blood Lead Screening Among US
Children Aged One to Five Years: 1988-1994. Pediatrics Vol.106 No.6 December 2000.
4. Agency for Toxic Substances and Disease Registry. Lead. Atlanta, GA: Centers for
Disease Control and Prevention. http://www.atsdr.cdc.gov/substances/toxsubstance.asp?toxid=22.
5. Environmental Protection Agency. Lead in Paint, Dust, and Soil. Atlanta, GA:
Environmental Protection Agency. http://www.epa.gov/lead/.
6. Centers for Disease Control and Protection. Lead: New York Data, Statistics,
Surveillance. Atlanta, GA: Centers for Disease Control and Protection. http://www.cdc.gov/nceh/lead/data/state/nydata.htm.
7. Community Foundation for Greater Buffalo. Wipe Out Lead. Buffalo, NY:
Community Foundation. http://wipeoutlead.com/.
8. Siegel M. Marketing social change: An opportunity for the public health practitioner
(Chapter 3). In Siegel M, Doner L. Marketing Public Health: Strategies to Promote Social Change (2nd edition). Sudbury, MA: Jones and Barlett Publishers, 2007, pp. 45-71.
9. Leal, Linda. The Essentials of Psychology. Picataway, NJ: Research and Education
Association, 1994.
10. Monsivals P, Drewnowski A. “The rising cost of low-energy-density foods.” Journal
of the American Dietics Association 2007; 107(12):2071-2076.
11. Paeratakul S, Ferdinand D, Champagne C, and Ryan D, et al. “Fast food consumption
among US adults and children: dietary and nutrient intake profile.” Journal of the American Dietic Association 2003;103(10):1332-1338.
12. Maslow A. “A theory of human motivation” Psychological Review 1943; 50:376-396.
13. Hicks JJ. The strategy behind Florida’s “truth” campaign. Tobacco Control 2001;
10:3-5.

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