The United States Centers for Disease Control (CDC, 1991) has identified lead poisoning as "... one of the most common and preventable pediatric health problems today." In 1990, CDC lowered the clinical level of blood poisoning from 25/dL to 10/dL in response to findings indicating children can exhibit symptoms of lead poisoning at the lower level (Davis & Svendsgaard, 1987). Researchers have known lead poisoning to cause fatigue, hearing loss, anemia, decreased cognitive development, kidney failure, unhealthy pregnancies, comas and death (Needleman, Schell, Bellinger, Biesecker & Greenhouse, 1990). Children are most vulnerable up to age six, during central nervous system development. Recent research has also linked high bone lead levels to antisocial and delinquent behavior (Needleman, Riess, Tobin, Biesecker & Greenhouse, 1996)

Lead poisoning is not often identified as the source of health problems in children because the symptoms are common to other childhood diseases (Rabin, 1989). Other diseases are ruled out once the child has been tested and found to have a high lead burden. Traditionally, testing for blood lead levels has been sporadic or deemed unnecessary by the health community as common wisdom dictated that damage occurred only with a high lead burden (Agency for Toxic Substances and Disease Registry, 1990).

Results of extensive and persuasive research in the past two decades validate the serious health impact with low blood lead levels (CDC, 1991). Response by the health community to set new lead poisoning management standards have varied throughout the U.S. The northeastern states stepped forward to initiate the first lead awareness campaigns (Rabin, 1989), while the West Coast lagged behind.

Like all states, California has it share of environmental lead contaminants, but the public was unaware of the associated health problems. It took a lawsuit by a parent and a community organization to mandate a change in health screenings for young children (Matthews and People United for a Better Oakland v. Coye, 1991). As of 1991, the California Department of Health Services (CDHS), Child Health and Disability Prevention (CHDP) Program issued a directive to physicians to screen all children under the age of six when they undergo health assessments (West's Annotated California Codes, 1990). In particular, reports show Latino children screened to date have high lead levels that demonstrate the need for preventative efforts at three levels: primary (exposure source), secondary (early identification and intervention), and tertiary (diagnosis and treatment to avoid sequelae) (Garza, 1995).

As screening increased, a higher detection rate of lead poisoning was reported. There was an unmet need for lead poisoning education targeted to at-risk families. To address the educational void, the University of California Cooperative Extension advisors in nutrition, family and consumer sciences (NF&CS) and an Extension Toxicologist, University of California, Davis, developed multicultural educational materials necessary for California's population. Since many cultural practices are related to lead-based products, this project required culturally sensitive outreach efforts to Latinos. Though paint is the number one source of lead poisoning, the Extension curriculum included a focus on folk medicines and testing tableware, especially imported ceramic pottery used by Mexican and Mexican-American populations.

The purpose of this project was to assess the effectiveness of training community extenders to promote primary prevention of lead poisoning in Latino communities by employing culturally appropriate methodologies. Building on Extension's historical past of solving community problems through education, advisors acting as the principal investigators, initiated a project of collaboration and training with public health and family support agencies serving 11,792,400 million southern California residents (California Department of Finance, 1996). The California Public Health Foundation funded the five-county project.

The need for partnerships in nutrition education has accelerated because of continuing budget decreases and limited staff. Present economic pressures make it necessary that agencies move from independent to closely coordinated efforts targeted to meet the needs of specific demographic groups (Lopez & Romero-Gwynn, 1997). In California, Cooperative Extension NF&CS advisors have diversified and expanded their role in the last decade. Their work has extended from direct teaching of consumers to include project development and funding acquisition, and providing in-service educational programs for professionals and local agency staff. While these activities agree with Extension's mission, using partnerships allow NF&CS advisors to serve wider and more diverse audiences.

Extension advisors determined the need for lead poisoning awareness at the county level. Pilot projects in several counties prompted the development of multicultural educational materials and visual aids. From these projects, it was determined that the Latino population was at great risk. Two advisors, serving as principal investigators, proposed and received grant funds for educational programs targeting Latinos, specifically those of Mexican ancestry, in five counties. Funding allowed for a research project with an evaluation component for the cultural appropriateness of the curriculum and teaching aids, knowledge gained, and data collection on ceramic ware usage.

The role of cooperating county advisors' was to develop strategic alliances built on mutual trust while maximizing community resources. Health and family support staff were recruited to attend extender training, commonly called "train the trainer" workshops. The participants were provided with the curriculum, visual aids, ceramic testing supplies, and data collection instruments. Project management included determining effectiveness of extender training followed by guidance and support in outreach efforts. The evaluation component assessed program effectiveness and required the submission of clientele and ceramic ware testing data for project compilation.

Five counties were selected based on high Latino populations and the interest of the advisor. The participating advisors' tenure in Extension varied from more than 20 years to less than one year. Each county advisor embarked on the project with the intent to follow the grant requirements while building partnerships within their counties. The initial partner-building effort was left to the discretion of the advisors and their ability to identify good team players.

Each county received funding for project staffing and supplies. The initial calls for involvement stated the following project requirements per county:

Test 200 pots, dishes or other ceramic ware.

Prepare media coverage of lead hazard education and ceramic ware testing.

Train extenders/educators who will conduct at least five educational programs reaching a total of 175 clients per county from the targeted audience.

Compile trainer and curriculum evaluations.

Collect data that include some basic clientele demographics, risk assessment, ceramic testing results, and pre-/post-tests of knowledge gained.

Key collaborators were local public health departments in the five counties who were assessing children for lead poisoning during well-baby examinations. Other community partners selected had a history of reaching parents of at-risk children, had successfully served limited resource families, and gained clientele trust. Cooperators included Head Start; Migrant Education; Healthy Start; Women, Infant and Children's Program; Adult Education; and community housing programs in Imperial, Los Angeles, Madera/Merced, Riverside, and Ventura counties. The participating agencies all needed culturally inclusive materials and training aids to use at their clinic sites or outreach efforts, which they could gain from their involvement.

In this project, partners were aware of lead poisoning in their communities but were without resource materials to deliver the necessary education. A memorandum of understanding was signed outlining their rights and responsibilities.

Their rights as a participating agency in the Lead Poisoning Awareness Project were to be provided with:

• A training session and methodologies on lead poisoning education.
• Cultural awareness of environmental lead contaminants.
• An English/Spanish video - "Lead - The Silent Epidemic."
• A teaching outline and consumer camera-ready masters.
• Ceramic ware lead testing supplies and corresponding data forms.
• Two evaluation tools; 1) Risk assessment - "Childhood Lead Poisoning Evaluation Questionnaire", and 2) Pre/post test for assessing clientele knowledge gained

Participating agency responsibilities included:

Coordinating lead poisoning educational efforts within Latino communities.

Advertising the lead education program and testing of ceramic as a public service in coordination with UC Cooperative Extension.

Conducting educational programs to reach a minimum of 35 adults.

Test ceramic ware equivalent to the test kits provided by project.

Submission of testing data and evaluation tools to a county advisor by established deadlines.

The five participating counties trained a total of 208 extenders. Evaluations of the trainers were completed by 161 of the trained extenders. The evaluation results (see Table 1) showed that the information was well-received, well-presented, and intended to be used by most of the participants.

The variety of methods for clientele outreach included flyer announcements, meeting notices in newsletters, radio and television interviews, newspaper articles, and posters. Each county exceeded the recommended expectations for media coverage and most specifically the targeted Spanish-speaking communities.

This project reached a total of 1,695 individuals with training and ceramic testing. Of these clients, 1,339 provided demographic information. Although the project targeted Latinos, the workshops were advertised as a public service; therefore a diversity of ethnicities was represented in the total contacts as shown in Table 2.

A total of 552 post-tests was returned from the five project counties. A project requirement was that 75% of the respondents would correctly identify paint and ceramic ware as lead sources. Respondents correctly identifying sources of lead numbered 469 (85%), while 70 (13%) knew one of the two correct answers, and 13 (2%) answered incorrectly.

Extension educational programs are determined by assessed needs or current events. Advisors are often regarded as the local unbiased, scientific resource in their community. In food safety and nutrition, the public and media turn to Extension to address concerns such as outbreaks of E. Coli in hamburgers or cyclosporiasis in raspberries. In this project, advisors were not reactive to a public health outbreak but proactive in primary and secondary prevention to lower a health risk. They detected the need for educational information from pilot studies, recent scientific studies, and the CDC lowering of lead poisoning action standards.

Some collaborators, such as public health agencies, were informed of the existing lead contaminants but had not developed an outreach or educational strategy. Likewise, family support programs had heard of lead poisoning and wanted to reduce the risk but did not plan to develop a lead poisoning awareness program. This collaborative effort informed all participants with scientific information on the status of lead poisoning and blood testing.

Extension's decision to test ceramic ware was a service that helped families with one aspect of lead testing. Collaborators felt the testing was within their programmatic protocol and abilities of staff. Testing ceramic ware is an outstanding hands-on opportunity to validate the presence of lead. Many agencies have continued to offer lead education well after the project ended and they were no longer provided with test kits. Some agencies decided to purchase additional test kits for use with their clientele.

County advisors who had not previously been involved in lead education were attracted by project incentives to establish a program in their communities. Three of the participating counties had staff trained in lead education but had not yet established an Extension program. Additionally, the "train-the-trainer" approach encouraged community agencies to introduce lead education into their programming. With culturally appropriate English/Spanish curriculum and teaching aids, extenders were empowered to reach the targeted clientele. Beyond the free training and curriculum provided, some agencies were part of the research effort to learn if collaboration is of mutual benefit to them and their clients.

A surprising result of this project was recognition and publicity within Cooperative Extension for a model program of affirmative action programming. State Extension administrators cite the lead education project as proactive and a successful combination of local community collaboration. This educational effort reached a traditionally under-served and hard-to-reach population. Because of successful collaboration, one principal investigator was able to acquire additional funding to develop a bilingual lead education video. The substantiation of established partnerships and a preview of findings supported the video funding request.

The five county project, while successful, had several limitations that the principal investigators wish to acknowledge. The inception of the project began with Cooperative Extension taking the lead to find funding and provide curriculum materials. It is apparent by the number of extenders that many agencies were interested in receiving the lead education curriculum materials and visual aids. The problem existed in following through with the expected outreach process. The advisors had expectations of a research project model that was foreign to most of the collaborators. Many agencies held workshops but did not fulfill all the requirements of data collection. These tasks were seen as burdensome since agencies have fewer needs for documentation and, for most, a sign-in sheet sufficed.

Additionally, some collaborators had a sense of uneven ownership of the project. While training was provided to teach lead education, more detailed guidelines should be prepared for insuring quality control of the teaching and evaluation. In a few instances, Extension advisors were asked to reinforce extender training. These extenders were uncomfortable with their lead knowledge base as they had waited weeks since the initial training to offer clientele programs.

Overall, the program objectives were achieved. The project met Cooperative Extension's goal for lead education and prevention while providing a potential opportunity to improve the health status of families at-risk. The implementation of the extender concept was feasible and effective in adding to the knowledge base of participating families. A long term effect of the project was that after completion, several agencies have adopted and integrated the curriculum materials as part of their regular program. As a result, cooperating agencies have turned to the Extension advisors for lead education, updates and in-service training.

The project provided the opportunity for participating agencies to use a standardized lead education curriculum targeting a specific cultural group. This is an important factor that can contribute to preventing the inconsistencies that are often found among different health education programs due to the use of materials prepared by different sources. Furthermore, staff from participating agencies became knowledgeable of the health and traditions of Latinos of Mexican descent.

People are usually more willing to commit themselves to expending time and energy on an activity if they clearly understand what they are doing and why they are doing it (Young & Mills, 1993). Applying this concept could address the sense of uneven project ownership among some collaborators as they were not approached until after curriculum development and acquisition of funds. While training was provided to teach lead education, detailed guidelines could be prepared cooperatively to insure quality control of the clientele teaching, testing, evaluation, and data collection. Therefore, it is recommended that collaborators have a role in initial project development and design.

As the project ends for Extension and agencies continue using the educational materials, deciding long term program effectiveness is important. Behavior change in the clientele, continued appropriateness of curriculum, and program delivery need to be monitored. As new lead information and warnings are learned, staff will need to be updated. Ideally the best situation allows for partnership to continue to address lead poisoning prevention until the problem is reduced. The roles may change for leadership allowing collaborators to take the lead and determine program direction.

Once a program shows progress and achievement as did the lead pilot projects, advisors could build on the success and seek funding support. Finding funding support has been a difficult task for Extension N,F&CS advisors given the paucity of money available to help with applied research and the development of educational programs and materials. Lead education programming in California has allowed Extension NF&CS advisors to acquire much needed funds.

In conclusion, the collaborative project was feasible and effective in the delivery of lead awareness education. Engaging in a joint project allowed for accomplishments far greater than one agency alone could produce. Inclusion and exposure to collaborative work also united the partners for continued and future community work.

Agency for Toxic Substances and Disease Registry. (1990, June). Case studies in environmental medicine: lead toxicity. Atlanta: Author.

California Department of Finance (1996, February). California County Profiles. Sacramento, CA: Economic Research.

Centers for Disease Control. (1991). Preventing lead poisoning in young children: a statement by the Centers for Disease Control. Atlanta: Author.

Davis, J. M. and Svendsgaard, D. J. (1987). Lead and child development. Nature, 329, 297-300.

Garza, A. (1995). Childhood plumbism in California: Implications for Latinos. Latino Health Review, Vol. II(1), 12-18.

Lopez, M. L., & Romero-Gwynn, E. (1997, Summer). Building educational partnerships to serve Latinos in central California. Journal of Family and Consumer Sciences, Vol. 89(2), 16-19, 24)

Matthews and People United for a Better Oakland v. Coye. United States District Court, N. D. California. No. C 90 3620 EFL, 1991.

Needleman, H. L., Riess, J. A., Tobin, M. J., Biesecker, G. E., & Greenhouse, J. B. (1996). Bone lead levels and delinquent behavior. Journal of the American Medical Association, 275(5), 363-369.

Needleman, H. L., Schell A., Bellinger D., Leviton A., & Allred E. N. (1990). The long term effects of exposure to low doses of lead in childhood: An 11-year follow-up report. New England Journal of Medicine, 322, 83-8.

Rabin, R. (1989). Warnings unheeded: A history of child lead poisoning. American Journal of Public Health, 79(12), 1668-1674.

West's Annotated California Codes (1990). Health and Safety Codes: Sections 309.7 - 309.77 (pp. 192-196). St. Paul, MN: West Publishing Co.

Young, R. C. and Mills, N. (1993). Health Reform: Team building among government agencies. Manhattan, KS: Cooperative Extension Service, Kansas State University, 8-93.

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