Lead poison prevention: a comparative review of brochures.

Introduction

Lead poisoning is the most common environmental health problem affecting children in the United States (Bar-on & Russell, 1994; Biner, Matte, Kresnow, Houston & Sacks, 1996; Centers for Disease Control and Prevention [CDC], 1997; Goldman, 1994; Juberg, Kleiman, Kwon, & Simona, 1997). Scientists and scholars have long known that lead is toxic, and a number of studies have demonstrated that children are particularly vulnerable to lead toxicity (Bellinger, Stiles, & Needleman, 1992; Dietrick, Berger, & Succop, 1993; Needleman, Riess, Tobin, Biesecker, & Greenhouse, 1996; Rosen, 1992; Tong, Baghurst, McMichael, Sawyer, & Mudge, 1996). Needleman, one of the pioneers of lead toxicity research, used assessments of tooth lead levels as an indicator of lead toxicity and demonstrated that symptoms of lead toxicity in childhood persist throughout adolescence and into adulthood (Needleman, Schell, Bellinger, Leviton, & Allred, 1990). Elevated blood lead levels at an early age are associated with poor intellectual and academic performance (Bellinger et al.; Tong et al.), as well as poor motor-skill development (Dietrick et al.). Specifically, low-level exposure to lead during early childhood has been shown to be inversely associated with normal neurophysiological development through the first years of life (Baghurst et al., 1991; Wasserman, Staghezza-Jaramillo, Shrout, Popovac, & Graziano, 1998).

Infants, young children, pregnant women, and workers in lead-based industries are subject to the greatest level of risk. Children are especially susceptible to toxic effects from lead poisoning because of the impact on the developing central nervous system. Symptoms can be easily confused with other physical problems, resulting in many of the affected children being misdiagnosed and, therefore, not treated (Chao & Kilano, 1993; Yoder, Burright, & Donovick, 1993). Primary sources of lead poisoning are

[FIGURE 1 OMITTED]

* older and deteriorating lead-based paint, found mainly in older homes;

* lead-laden dust and soil found around older buildings and near highways;

* lead-based materials used in plumbing systems, which pollute domestic and public water supplies;

* food containers that contain lead; and

* cosmetics and traditional medicines (Juberg et al., 1997; Lynch, Malcoe, Skaggs, & Kegler, 2000; Olden, 1993; Pinkie et al. 1998).

There is no question that removing lead from the environment is the best method of preventing lead poisoning (Ryan, Levy, Pollack, & Walker, 1999). The only way to ensure that a child will not be poisoned is to remove or cover all sources of lead such as indoor lead paint and lead-contaminated soil. CDC recognizes, however, that it is not economically feasible in the short term to remove all lead from the environment. Devising low-cost, low-technology interventions for controlling lead hazards is important in helping reduce the risk of lead poisoning among children. Interim measures must be developed to immediately address the needs of the millions of children at risk. Health education in the home and in the community should be directed at factors that can be modified to reduce exposure (Murgueytio, Evans, Sterling, Serrano, & Roberts, 1998).

Health officials have developed comprehensive prevention programs to remove environmental lead and increase public awareness of problems affecting American children from exposure. One approach includes the development of a variety of educational materials aimed to reach those at risk (Dugbatey, Evans, Lienhop, & Stelzer, 1995; Kimbrough, LeVois, & Webb, 1994). Another approach is combining therapy with educational programs (Kassa, Bisesi, Khuder, & Park, 2000). Agencies have developed a variety of educational brochures and pamphlets discussing key issues concerning the hazards associated with lead poisoning and have provided recommendations on procedures to achieve prevention. The educational brochures and pamphlets describe specific hazards associated with lead poisoning and related actions that should be taken to minimize or eliminate the adverse effects of lead poisoning.

The study reported here evaluated lead poisoning prevention and intervention brochures that have been developed or adopted for use by state health agencies from a selected group of 11 states. The purpose was to determine reading levels of brochures and the most frequently addressed topics related to lead poison prevention. This report provides a consensus summary of the content and reading levels of the brochures. Health care professionals who are faced with writing a lead prevention brochure can use the information to decide which topic or topics to include in a new brochure and will be reminded of the importance of assessing readability.

Methods

Since an aim of the study was to collect data to design a brochure for Illinois, brochures were requested from 13 states either entirely or partially located within a 300-mile radius of Springfield, Illinois. Phone contact with each agency identified key personnel. The person identified as responsible for program operation was mailed a packet containing a cover letter, a brief questionnaire, and a return-mail envelope with a request for one or more samples of brochures on prevention of childhood lead poisoning. Several of the agencies chose to submit two brochures. Identification of the origin of each questionnaire and brochure was protected upon receipt by removal of identifying information from all materials and random assignment of an alphabetic code.

After initial agency contact, the questionnaires and brochures were returned over a four-month period. A total of 20 brochures were studied. The measurement criteria were, first, the establishment of a standard readability level based on average population norms and, second, the selection of key topics. Each brochure was evaluated according to the Fry Graph Reading Level Index (Fry, 1968) since the authors had previous experience with this index. In comparison with other readability formulas--the SMOG Readability Formula (McLaughlin, 1969), for instance, and the Gunning Fog Index (Gunning, 1968)--the Fry Graph Reading Level Index offers the advantage of calculating the grade level as well as allowing the reviewer to plot readability on a graph (Figure 1). (Word-processing software such as Microsoft World may include the Flesch-Kincaid formula to determine readability and could have been used except that the brochures were provided in printed format and were not transferred into a word-processing program.) One point was awarded for readability that fell within 4th- to 6th- grade levels, the levels thought to be appropriate for targeted materials (Brizius & Foster, 1987; Shield & Mullen, 1994). If readability tested at any other level, no point was awarded.

Data from CDC guidelines (CDC, 1991, 1997) and a literature review were used to define six broad key topics: nutrition, hygiene, cleaning, water, work-hobby, and soil. Individual areas of measurement for each key topic were established by dividing the six key topics into 14 subtopics. One point was awarded for each subtopic discussed in the sample brochures. Table 1 gives the subtopics. The maximum achievable score was 15 points: one point for readability and 14 for subtopic content.

Many of the brochures targeted prevention and intervention issues. Other agencies chose to divide subtopic material into two brochures, concentrating the message content of each brochure on specific issues. Brochures that were developed for different perspectives still addressed key issues through the discussion of similar subtopics. The assessment included data from all 20 brochures received from the agencies. Responses were received from 92.3 percent of the agencies originally contacted (12 of 13), and 84 percent (11 of 13) returned brochures. Sixty-nine percent (nine of 13) returned two brochures each; two of the agencies returned one brochure, and two did not return any brochures.

Results

Readability

The average readability level for the sample brochures was estimated to be slightly above the sixth-grade level (at 6.15). Reading levels ranged from third grade through ninth grade (Figure 1). A fourth-through-sixth-grade level was achieved in 40 percent of the brochures (eight of 20). Ten percent (two of 20) were written at a third-grade level, while 50 percent (10 of 20) were written at seventh- through ninth-grade levels. Eight agencies had one or more brochures written within the targeted fourth-through-sixth-grade level. Five percent (one of 20) were written at fourth-grade level, 20 percent (four of 20) were written at a fifth-grade level, and 15 percent (three of 20) were written at a sixth-grade level.

In this 11-state study, 40 percent of the brochures (eight of 20) achieved the targeted fourth-through-sixth-grade readability range. A subgroup of eight brochures that targeted a readability level of seventh to eighth grade was analyzed separately. This subgroup was obtained from a review of questionnaire responses indicating that brochures from this group of agencies were designed to have a seventh-to-eighth-grade readability level. Only 37.5 percent of these brochures (three of eight) actually matched that target. Twenty five percent (two of eight) had a sixth-grade readability level, 12.5 percent (one of eight) had a fourth-grade level, and 25 percent (two of eight) had a third-grade level.

Subtopics

The scores for subtopic inclusion in the brochures ranged from a low of two subtopics to a high of 11 subtopics out of the possible 14. The mean was about seven (6.95) subtopics per brochure. This mean divided the brochures into two equal groups, with 10 brochures having fewer than seven subtopics and 10 brochures having more than seven subtopics.

The three topics most frequently covered were as follows (the figures in parentheses indicate the percentage of brochures that covered each topic):

* wash hands and face frequently (90 percent);

* provide foods that contain good sources of protein, iron, calcium, and vitamins A and C daily (85 percent); and

* use damp cleaning methods when dusting and mopping (65 percent).

The following subtopics appeared in 50 to 55 percent of the brochures:

* do not use hot tap water to drink, cook with, or mix baby formula (55 percent);

* run tap water after non-use for two minutes to clear pipes of pollutants (55 percent);

* limit high-fat and greasy foods in the daily diet (for children more than two years of age) (50 percent);

* do not store open foods in cans, ceramic dishes with lead glaze, pewter, or crystal (50 percent); and

* reduce exposure to lead-contaminated bare-soil areas, such as those located in high-traffic areas, and to buildings with peeling or chipping paint (50 percent).

The following subtopics appeared in 40 to 45 percent of the brochures:

* allow only food items in mouth (45 percent);

* use soap products that contain trisodium phosphate (TSP) for damp cleaning (45 percent);

* change clothes at work to reduce family exposure (45 percent); and

* wash work-hobby clothes separately from family wash (40 percent).

The following two subtopics were included infrequently:

* provide meals on regular schedules to help children maintain a full stomach (20 percent);

* do not smoke, chew gum, eat, or drink while working in a hazardous lead environment (five percent).

Discussion

Childhood lead poisoning has become one of the most common environmental health problems in the United States today. This study evaluated lead poison prevention brochures for readability and topic content. The review revealed that the brochures were generally targeted at providing the parent or caregiver with basic information about prevention or intervention measures associated with childhood lead poisoning. Analysis of brochure readability levels found that 50 percent of the sample brochures were written at seventh- to ninth-grade reading levels, 40 percent at fourth- to sixth-grade levels, and 10 percent at the third-grade level. The average reading level for the United States is reportedly fifth through 10th grade (Ferrell-Miller & Gentry, 1989). Studies have shown, however, that the segments of the population most at risk for lead toxicity tend to be of lower socioeconomic status and to have lower literacy levels than the general population (McCabe, 1989; Shield & Mullen, 1994), probably fourth- through sixth-grade levels (Shield & Mullen, 1994).

Often, written materials are inadvertently developed at a reading level that exceeds the average reading skills of the targeted population. In the sample examined for this study, the majority of the brochures were written at or above the seventh-grade reading level, which was perhaps higher than would be recommended. Written educational materials should have readability levels that meet the anticipated reading abilities of the targeted population segment. Therefore, to help ensure that lead-poisoning-prevention materials reach the broadest spectrum of the targeted group, readability levels should be at fourth- through sixth-grade reading levels (Shield & Mullen, 1994).

None of the sample brochures included all 14 subtopics. Inclusion of that many subtopics might make a brochure too complicated or complex (Boyd, 1987). An overload of information could intimidate or overwhelm the average reader of a lead-poisoning-prevention brochure and result in the suggestions not being understood or followed. According to the data, brochures probably should be limited to seven topics or fewer.

The subtopics that were identified in 50 percent or more of the brochures analyzed in the study could constitute the recommended brochure content. As indicated in the Results section above, the following subtopics were identified in at least 65 percent of the brochures:

* wash hands and faces frequently;

* provide foods that contain good sources of protein, iron, calcium, and vitamins A and C daily; and

* use damp cleaning methods when dusting and mopping.

Several recent studies indicate that there is an inverse relationship between blood lead and ascorbate levels, and that inclusion of foods rich in vitamin C should be emphasized (Cheng et al., 1998; Dawson, Evans, Harris, Teter & McGanity, 1999; Simon & Hudes, 1999).

Additional subtopics were addressed by at least 50 percent of the agencies studied here and could be considered for inclusion:

* do not use hot tap water to drink, cook with, or mix baby formula;

* run tap water after non-use for two minutes to clear pipes of pollutants;

* limit high-fat and greasy foods in daily diet (for children over two years of age);

* do not store open foods in cans, ceramic dishes with lead glaze, pewter, or crystal; and

* reduce exposure to lead-contaminated bare-soil areas, such as those located in high-traffic areas, and to buildings with peeling or chipping paint.

The other subtopics, those included in less than 50 percent of the brochures, may be important to some agencies but may not be essential. The additional material may in fact be too much information to provide in one brochure.

All of the subtopics included in the 11-state study constitute information that some parents and care providers should receive, depending on the needs of the population. According to the key health priorities and major concerns in each area within the 11-state region, the subtopics may be rated differently. Thus as local priorities dictate, the ideal brochure may include subtopics other than those most frequently addressed in this study. All of the subtopics listed here are important to childhood lead poisoning prevention because each addresses behaviors or practices that greatly influence the availability of lead in a young child's environment.

Implications for Research and Practice

The data from this study can be used throughout the development of lead hazard prevention brochures. Writers of educational materials are advised to follow four steps basic to the development of topics for educational materials (Ferrell-Miller & Gentry, 1989). The steps are

1. assess the targeted population group through definition of the information needed,

2. define the subtopic or subtopics to be presented,

3. write the educational message, and

4. review and evaluate the message.

The evaluation should include a review not only of the message or subtopic content, but also of the readability level, to help ensure that the anticipated target audience can read, understand, and act on the message (Ferrell-Miller & Gentry, 1989; McCabe, 1989).

The importance of readable writing by scientists and researchers has been discussed (Goldbort, 2001), and educational materials also should be evaluated for read-ability. The Fry method is one way to assess readability (Fry, 1968). More than 50 read-ability formulas have been published, however (Allensworth & Luther, 1986; Chall & Dale, 1995; Klare, 1974-5). A readability formula is an equation, usually developed through study of the relationship between text features (i.e., syllables, words, sentences) and text difficulty (as measured by reading comprehension, reading rates, and expert judgement of difficulty). The concept of readability is, however, broader than any readability formula or procedure developed to measure it. Formulas are best viewed as tests of comprehension difficulty. Also important to a comprehensive estimate of readability are the physical features of text, such as size of print, number of words in a paragraph and on a page, and the number of pictures and how they relate to the text. These factors are not addressed in the widely used readability formulas. The SMOG Readability Formula (McLaughlin, 1969) and the Gunning Fog Index (Gunning, 1968) are other tools used for evaluation of printed materials. The Flesch-Kincaid Grade Level Index and Flesch Reading Ease are examples of computer programs that can automatically calculate readability and may be of use in the development of materials on the computer. After the "spelling and grammar" option has been exercised in Microsoft Word, the reading levels are displayed. Other software packages are available. The authors encourage anyone writing material for the public to evaluate alternative methods.

A concern not addressed by this study is the availability of the lead prevention brochures to their targeted audience or their effect on blood lead levels. Simply printing a brochure does not mean that it reaches the intended audience. At least one study, however, has shown a significant decrease in blood lead levels when parent peers, using lead prevention materials, educate parents whose children have high blood lead levels (Kimbrough et al., 1994).

Brochures should contain only essential information and should not overwhelm or confuse a reader by including too many subtopics. Many of the brochures examined for this study covered six to 10 subtopics, and only subtopics that are considered primary issues for the targeted region should be included. This study provided a consensus summary using the reading levels and topics from brochures in use today. Following these basic guidelines could assist in the development of an easy-to-read brochure that is useful, understandable, and of value to the targeted audience.

TABLE 1 Six Major Lead Prevention Topics with 14 Subtopics

Key Topics  Subtopics

Nutrition    1. Provide foods that contain good sources of protein,
                iron, calcium, and vitamins A & C daily.
             2. Provide meals on regular schedules to help children
                maintain a full stomach.
             3. Limit high-fat and greasy foods in a daily diet (for
                children over 2 years of age).
             4. Do not store food in open lead-containing cans, ceramic
                dishes with lead glaze, pewter, or crystal.
Hygiene      5. Wash hands and face frequently.
             6. Only allow food items in mouth.
Cleaning     7. Use damp cleaning methods when dusting and mopping.
             8. Use soap products that contain TSP for damp cleaning.
Water        9. Do not use hot tap water to drink, cook with, or mix
                baby formula.
            10. Run tap water after non-use for two minutes to clear
                pipes of pollutants.
Work-hobby  11. Wash work/hobby clothes separately from family wash.
            12. Change clothes at work to reduce family exposure.
            13. Do not smoke, chew gum, eat, or drink while working in a
                hazardous lead environment.
Soil        14. Reduce exposure to contaminated bare-soil areas such as
                those located in high-traffic areas, and to buildings
                with peeling or chipping paint.

(Adapted from Roper, Houk, & Binder, 1991).

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Jeannette Endres, M.P.H., Ph.D., R.D.

Joe Montgomery, M.S., R.D.

Patricia Welch, Ph.D., R.D., L.D.

Corresponding Author: Jeannette Endres, Department of Animal Science, Food and Nutrition, Mail Code: 4317, Southern Illinois University, Carbondale, IL 62901. E-mail: <[e-mail]>.