Parental Perceptions of Barriers to Blood Lead Testing
Introduction: This study identified barriers to blood lead testing from the perspective of parents of young children eligible for Medicaid.
Method: Data were gathered from three focus groups. Participants were asked if they were familiar with the dangers of high blood lead levels, rationale for not having a child tested for blood lead, what would facilitate having blood lead testing, and how they wanted to learn about blood lead poisoning.
Results: Most parents (n = 30) were unfamiliar with the causes and effects of lead poisoning. While many reported their child had been tested for lead, others were unsure because they were not told the Purpose of blood draws. Participants suggested that having all services in one facility would decrease travel and thus facilitate blood lead testing; others wanted the discomfort associated with phlebotomy minimized. Participants preferred to learn about lead poisoning from low-literacy brochures, videos, and television ads.
Discussion: Nurses should institute measures in their practice sites to improve blood lead poisoning prevention education and blood lead testing rates and to reduce the pain and anxiety associated with this procedure.

Lead poisoning remains the major environmental health problem for young children, with approximately 6% of children 1 to 2 years old and 3.5% of children between 3 to 5 years old having elevated blood lead levels (EBL) (≥ 10 mg/dL). Prevalence rates are higher for children who are poor, of non-Hispanic Black race, or living in older housing (Center for Disease Control and Prevention [CDC], 2000; Manton, Angle, Stanek, Reese, & Kuehnemann, 2000; Meyer, Dignam, Homa, Schoonover, & Brody, 2003; Vivier et al., 2001). Lead poisoning at levels 10 µg/dL or greater has been associated with learning disabilities, behavioral changes, hyperactivity, impaired growth, mental retardation, coma, seizures, and death (Burns, Baghurst, Sawyer, McMichael, & Tong, 1999; Needleman, Riess, Tobin, Biesecker, & Greenhouse, 1996). More recently, adverse effects such as decreased academic performance have been associated with blood lead levels (BLL) below 10 µg/dL (Lanphear, Dietrich, Auinger, & Cox, 2000; Schwartz, 1994; Tong, Baghurst, Sawyer, Burns, & McMichael, 1998). Approximately 26% of non-Hispanic Black children, 28% of Mexican-American children, and 19% of non-Hispanic White children ages 1 to 5 years have a BLL of ≥ 5 µg/dL (Bernard & McGeehin, 2003). For children with very high EBLs requiring chelation (BLL 45 µg/dL or higher), there is no evidence of reduction or reversal of cognitive injury (Bellinger, 2004; Rogan et al., 2001). Blood lead testing has been identified as a critical strategy in the elimination of elevated BLLs in children, a Healthy People 2010 objective (President's Task Force, 2000; Tinker & Keiser, 1997; US Department of Health and Human Services, 2000).

The Centers for Medicaid and Medicare Services' (CMS) policies require that all children enrolled in Medicaid undergo blood lead testing at ages 12 and 24 months. Children between 36 and 72 months should be tested if they had not previously been tested. Vivier et al. (2001) found that 85% (n = 690) of children between 1 and 2 years of age enrolled in a Rhode Island Medicaid managed care plan affiliated with one teaching hospital had a BLL. Of these, 27.5% (n = 190) had a BLL above 10 µg/dL. The U.S. General Accounting Office (GAO) (1998) estimates that 535,000 children (9%) receiving Medicaid had an EBL and that the majority of children with EBL are Medicaid eligible. In contrast to the findings of Vivier et al., the GAO found that 81% of the children enrolled in Medicaid had not had a BLL. The GAO concluded that CMS's mandatory testing policy has not adequately identified children with EBL (CDC, 2000; U.S. GAO). In Ohio, where this study occurred, 4700 children had BLLs at or above 10 µg/dL in 2003. A data-harmonizing project using the Ohio Department of Health (ODH) lead surveillance data and the Ohio Department of Job and Family Services (ODJFS) Medicaid claims data revealed that only 32% of children enrolled in Medicaid were tested for lead (ODH, 2004). Little is known regarding barriers to BLL testing for children who are eligible for Medicaid.

Although parental refusal or parents not requesting a blood lead test for their child have been identified as barriers by health care professionals, and anticipatory guidance protocols generally include lead poisoning prevention education of parents/guardians of young children, most parents do not recall receiving such guidance (Goldman, Demissie, DiStefano, McNally, & Rhoads, 1998; Mahon, 1997). Mahon found that only 11% of the 80 Philadelphia parents/caregivers interviewed identified lead poisoning as a major health concern. More than half of the respondents incorrectly identified Philadelphia as a city at low risk for lead poisoning. Of the 32 participants who recalled someone talking to them about lead poisoning, more than 70% reported that the information was from a physician or other health care provider. Approximately 40% of the respondents recalled having read some information on lead poisoning prevention. Similarly, Mehta and Binns (1998) reported that 34% of the 2225 Chicago area parents responding to a survey on lead knowledge recalled receiving information on lead poisoning prevention from a health care provider. In contrast, 63% of 271 respondents attending a Wisconsin lead testing clinic had prior information on lead risks (Porter, 1997). In the only published study that addressed barriers to blood lead testing, Kegler, Stern, Whitecrow-Ollis, and Malcoe (2003) explored the topic in an American Indian community. Identified barriers to lead testing for the 332 respondents included parents/caregivers not wanting to see their child hurt (10.5%), lack of transportation or money for the test (5.1%), lack of time (4.8%), forgetting about the need for a blood lead test (3.0%), and not knowing where to get the test (1.5%). Multivariate analysis revealed the odds of a child having an annual blood lead test were 1.5 times greater if the parent/caregiver was self-confident in their ability to obtain the testing. The objectives of this study are to further explore barriers to blood lead testing and current levels of awareness of the dangers of lead poisoning from the perspective of parents and caregivers of young children eligible for Medicaid. Findings presented here are from a larger study in which barriers to blood lead testing were explored from the perspectives of parents/caregivers as well as Medicaid health care providers.