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One-third of children globally have blood lead levels (BLLs) exceeding the (former) US CDC reference value of 5 μg/dL; this value may be as high as one-half for children in low- and middle-income countries (LMICs). Lead exposure occurs through a variety of routes (e.g., water, dust, air), and in LMICs specifically, informal economies (e.g., battery recycling) can drive lead exposures due, in part, to absent regulation. Previous work by our team identified a ubiquitous source of lead (Pb), in the form of Pb-containing components used in manually operated pumps, in Toamasina, Madagascar. Characterization of BLLs of children exposed to this drinking water, and identification of additional exposure routes were needed. BLLs were measured for 362 children (aged 6 months to 6 years) in parallel with surveying to assess 14 risk factors related to demographics/socioeconomics, diet, use of pitcher pumps, and parental occupations. BLL data were also compared against a recent meta-review of BLLs for LMICs. Median childhood BLL (7.1 μg/dL) was consistent with those of other Sub-Saharan African LMICs (6.8 μg/dL) and generally higher than LMICs in other continents. Risk factors significantly associated (p < 0.05, univariate logistic regression) with elevated BLL (at ≥ 5 μg/dL) included male gender, living near a railway or major roadway (owing potentially to legacy lead pollution), having lower-cost flooring, daily consumption of foods (beans, vegetables, rice) commonly cooked in recycled aluminum pots (a previously identified lead source for this community), and a maternal occupation (laundry-person) associated with lower socioeconomic status (SES). Findings were similar at the ≥ 10 μg/dL BLL status. Our methods and findings may be appropriate in identifying and reducing lead exposures for children in other urbanizing cities, particularly in Sub-Saharan Africa, where lead exposure routes are complex and varied owing to informal economics and substantial legacy pollution.more » « less
Background and Situation Analysis
The importance of Water Sanitation and Hygiene (WASH) projects for the protection of health is embedded in the sustainable development goals. However, within the development and humanitarian fields sustainability of WASH projects is still a challenge with 30–50% of projects failing within two to five years of implementation. Though failure is not linked to any one source, a common theme speaks to a greater need for community engagement and integration of the wants and needs of the end-user in the design process. Social marketing, with its focus on the consumer and use of commercial marketing strategies to achieve behavior change is a promising approach that can be integrated into ongoing WASH initiatives to meet program outcomes and to achieve long-term sustainability.
Primary audience includes technicians who manufacture and repair pitcher pumps. Secondary audience includes community members in Toamasina, Madagascar, who will experience a decrease in exposure to lead through their water supply.
Decrease exposure to lead (Pb) introduced through the use of a decentralized, self-supply water system, the pitcher pump. Specifically, decrease use of leaded components in the manufacturing and repair of pitcher-pumps
Development of the intervention followed the social marketing process including conducting a situational analysis, identification and selection of a behavioral focus and priority population, formative research, development of an integrated marketing strategy, pretesting the strategy, followed by campaign implementation, and monitoring and evaluation. An intervention focused on building a sense of community and introducing the element of professionalism for the pump manufacturers was developed, consisting of personalized one-on-one outreach to raise awareness of the health topic, followed by skill building trainings on how to make the switch to non-leaded components. This was coupled with tangible products that created a new professional network, documentation of work, and backing of work by trusted government entities.
Evaluation Methods and Results
Using the theory of planned behavior, a pre/post-test summative evaluation was developed. Preliminary results indicate that pump technicians no longer use lead in pumps unless specifically requested by the pump owners. These results indicate a positive shift towards the use of lead-free components with project follow-up and analysis ongoing.
Recommendations for Social Marketing Practice
Use of social marketing within the WASH sector is lacking. This paper demonstrates the integration of social marketing in an ongoing WASH project. Through a description of each step of the process, our experiences in implementing it and the lessons learned, we hope to guide future integration. Additionally, this paper demonstrates the convergence of engineers and social marketers working collaboratively on an interdisciplinary team and how this served to enhance project understanding, aid in building local partnerships and help with long-term sustainability.
Lead (Pb) exposure through water contamination is an important issue at the intersection of public health and water, sanitation, and hygiene (WASH). Behavior-change programs designed to address this pressing problem rarely take a behavioral-science-informed approach, nor do they consider the role of intermediate players who often influence and support behavior change. Social marketing segments the population and focuses on the consumer/user throughout program development and implementation. To illustrate the social marketing process, this cross-sectional, qualitative design study investigates the use of Pb in the construction and maintenance of household pitcher pumps for potable water in Madagascar. A sample of 18 technicians were interviewed on their current practices, motivators, barriers, and communication channels for knowledge exchange. The results reveal the importance of peers, those considered experts or “market mavens”, and the need for information on the dangers of Pb as an outdated practice for any future intervention. This study advances the notion of a design shift within engineering WASH projects, whereby social/behavioral approaches are used to consider the needs, concerns, and current behaviors of the consumer. We also advocate for engaging intermediate players who often influence behavior change in the rollout of an engineering innovation.more » « less