Community Outreach: Dartmouth-Manchester Partnership for Health

Because of our program’s expertise in toxic metals, our regional constituents reached out to us to partner with them to address childhood lead poisoning in New Hampshire, focusing on the city of Manchester. Housing in Manchester largely pre-dates bans on lead-based paint, and the distressed housing in the central city is analogous to thousands of point-sources of lead exposure. Manchester, New Hampshire’s largest city, has the highest childhood lead poisoning rate in the state.

Lead-hazard reduction efforts are strongly affected by the context in which they operate [1]. According to a 1998 review by the National Center for Healthy Housing, "The existence or lack of state and local laws regarding lead hazard control, the supply of trained and certified lead industry professionals, the attitude of the housing industry and the state of public awareness all contribute to the effectiveness of these programs” [2]. Our community outreach addresses several of these context factors.

Public Policy: Supporting Legislative Changes to Prevent Lead Poisoning

In 2004, we partnered with Vermont Law School to research and write an analysis of outstanding state lead laws at the request of one of our community collaborators, the Greater Manchester (NH) Partners Against Lead Poisoning. The report examines legal language in detail and includes the “back-story” on the processes that led to legislation and anecdotes about the effectiveness of the resulting law. Far outliving its original purpose, this report is still being requested by New Hampshire and Vermont legislators, lawyers, health care professionals, people in the housing and building industries and others. The report (State Legislation Addressing Prevention of Childhood Lead Poisoning: A Policy Report for the Greater Manchester (NH) Partners Against Lead Poisoning) is still being requested by New Hampshire and Vermont legislators, lawyers, health care professionals, people in the housing and building industries and others. Lead poisoning prevention advocates in other regions of the US have also requested copies. Largely because of this work, Nancy Serrell and Bethany Fleishman were asked to participate in statewide task force convened in 2006 by the Vermont Attorney General to re-examine lead poisoning policy in Vermont. The task force is now preparing recommendations for the Vermont Legislature. This fall, Nancy Serrell was appointed by NH Governor John Lynch to the Governor’s Task Force on Lead, which is drafting recommendations for legislative change in New Hampshire.

In fall 2006 our Outreach Core submitted a proposal to make lead poisoning prevention an “Action Step” priority for the New Hampshire Children’s Advocacy Network, a coalition of nearly 200 state organizations committed to children’s issues. Members voted to adopt our Action Step, advocating for state policies that proactively protect children from lead hazards, as a priority for the 2007 legislative session. As part of this process, our Outreach team was trained by the FrameWorks Institute in effectively using linguistic framing to influence public discourse.

Community Capacity: Facilitating New Partnerships

Lead poisoning is connected with a host of social, political and economic issues [3]. With our community partners at the Manchester Health Department and The Way Home, a local housing agency, we organized a multi-stakeholder community meeting in December 2005. The goal was to bring together health care professionals, housing and building departments, property owners, school administrators, local businesses and private foundations into new partnerships focusing on lead poisoning prevention. Following the meeting, several New Hampshire foundations decided to join forces in taking an active role in lead poisoning prevention. This summer, the three foundations convened an information-gathering meeting of stakeholders statewide to discuss the state’s lead policies and to explore the feasibility of forming an action coalition to coordinate efforts at policy change. Another foundation has also provided seed money for a window replacement revolving fund for property owners in Manchester.

Education: Manchester Screening Initiative

Illustration by Bethany Fleishman

Though raising awareness of lead poisoning is important for reducing the hazard, campaigns that simply raise awareness do not protect children, and strategies that focus on changing diet, hygiene and housekeeping practices of families have been shown to produce limited benefit and may even inadvertently shift the burden of responsibility to parents.1 To be effective in protecting children, education efforts need to be focused on those with the power to implement change.

Our Screening Initiative focuses on physicians. Because of the prevalence of pre-1950 housing in Manchester, the city is designated one of the highest risk regions of the state, with the recommendation from the U.S. Centers for Disease Control and Prevention (CDC) that all one- and two-year old children be tested for lead exposure. This goal is far from met. Through a pilot project funded by EPA in 2004 we began working with the Manchester Health Department to explore barriers to lead screening in five pediatric practices in the city. The project included:

• informal lunchtime conversations about screening (using a scripted survey) with practice teams, led by Dartmouth and Health Department staff;

• chart reviews by the Health Department to determine screening rates.

We have continued this work as an Outreach project. We analyzed our pilot survey and completed the chart audits, and our results suggest that barriers in Manchester are consistent with those described in the literature on clinician noncompliance with practice guidelines, including screening guidelines. Our lunchtime discussions suggest that “clinical office systems” are a barrier that is amenable to change. Evidence in the literature suggests that quality improvement coaching can lead to improvements in screening children for lead.

In the intervention phase of this project we returned to each practice to share individual screening rate data (compared to other city groups). We are now working with a quality improvement expert at Dartmouth-Hitchcock Medical Center to produce an online tutorial targeted at Manchester pediatric practice teams. This tutorial will include lectures, a tool to streamline the chart audit process, and quality improvement coaching. The original practices from our pilot study now serve as advisors and the director of one clinic, a pediatrician, gave one of the tutorial lectures.

References Cited:

1. Alliance for Healthy Homes. 2003. Making lead-safe housing the central focus of strategic plans to eliminate childhood lead poisoning. Washington, DC: Alliance for Healthy Homes.

2. National Center for Healthy Housing. 1998. Designing and managing LHC programs: lessons learned to date. Columbia, MD: National Center for Healthy Housing.

3. G Kingsley. 2003. Housing, health and the neighborhood context. American Journal of Preventive Medicine 24(3S):7