Report 2019-105 Recommendation 6 Responses

Report 2019-105: Childhood Lead Levels: Millions of Children in Medi-Cal Have Not Received Required Testing for Lead Poisoning (Release Date: January 2020)

Recommendation #6 To: Public Health, Department of

To ensure that local prevention programs' outreach results in a reduced number of children with lead poisoning, CDPH should, by December 2020, require local prevention programs to demonstrate the effectiveness of their outreach in meeting this goal. If the local prevention programs are unable to demonstrate the effectiveness of their outreach in reducing the number of children with lead poisoning, CDPH should analyze the cost-effectiveness of other approaches, including proactive abatement, and require the local prevention programs to replace or augment outreach to the extent resources allow.

Annual Follow-Up Agency Response From November 2022

To evaluate the effectiveness of outreach activities in preventing lead exposure in California children, in 2020 the Childhood Lead Poisoning Prevention Branch (CLPPB) created an Evaluation Toolkit (attached) with survey tools for multiple target audiences and provided it to local Childhood Lead Poisoning Prevention Programs (CLPPPs) for this purpose. The toolkit was used by CLPPPs with available capacity to evaluate their outreach activities. CLPPB conducted an analysis of blood lead level (BLL) data to determine whether CLPPPs' outreach has been effective in preventing lead exposure in the local health jurisdictions (LHJs). CLPPB compared the BLLs in the LHJs that fulfilled outreach requirements (i.e., rigorous outreach) with those that did not (i.e., limited outreach)1, with the goal of understanding whether lead poisoning prevention outreach activities may be impacting BLLs in California children. Based on our analysis, we found that children who lived in LHJs with rigorous outreach efforts were statistically less likely to have an elevated BLL defined at or above either 4.5 µg/dL or 3.5 µg/dL2 when compared to children living in LHJs with limited outreach efforts. CLPPB's analysis, results, and next steps are further described in the attached CLPPP Outreach Evaluation Fact Sheet and policy document.

1Unfulfilled outreach requirements were due to COVID-19 pandemic impacts on CLPPP staffing.

2As of October 2021, the Centers for Disease Control and Prevention (CDC) defined the blood lead reference value (BLRV) of 3.5 µg/dL to identify children with BLLs that are higher than most children's levels; the previous CDC BLRV was 5 µg/dL (CDPH used 4.5 µg/dL).

California State Auditor's Assessment of Annual Follow-Up Status: Fully Implemented

CDPH performed an evaluation of the effectiveness of local programs' outreach in reducing the number of children with lead poisoning. It also implemented a policy to conduct that evaluation annually, and if it determines that a local program's outreach is ineffective in reducing lead levels, it will require the local program to increase other efforts to reduce lead levels, such as proactive abatement. CDPH's discussion of its toolkit is not relevant to this recommendation because the toolkit measures knowledge gains rather than reductions in the number of children with lead poisoning.

Annual Follow-Up Agency Response From October 2021

To determine the effectiveness of local prevention program outreach, CDPH will analyze the association between local health jurisdiction blood lead level trends and the quantitative results of outreach activities reported by local prevention programs in progress reports. Because the Scope of Work timeline for completion of outreach activities is annual, CDPH requires a full year of local prevention program progress reports to conduct the analysis. Progress reports covering outreach activities for the first full year of the contract were due July 30, 2021. Many local prevention programs were unable to comply with this deadline due to impacts from local states of COVID-19 and wildfires emergency and were granted extensions to mid-August. Once CDPH receives local prevention program progress reports for the first year of the contract, CDPH will begin conducting the analysis of local prevention program outreach activities with respect to blood lead levels. If outreach is determined to be ineffective, CDPH will explore corrective action measures and/or other approaches to prevention.

California State Auditor's Assessment of Annual Follow-Up Status: Pending

CDPH has described actions that could lead to implementation of this recommendation. It indicates that it has not yet completed its analysis, and it did not provide documentation, so it remains to be seen whether the data it uses for outreach activities and local lead levels is sufficient to demonstrate the effectiveness of that outreach.

1-Year Agency Response

Local prevention programs are in the process of implementing their new Scope of Work requirement to evaluate the effectiveness of program outreach activities. CDPH has developed the attached outreach evaluation toolkit and held training sessions in July 2020 to assist local programs with this requirement and is working with them to evaluate the effectiveness of outreach activities in reducing the number of children with lead poisoning. The new evaluation toolkit provides outreach evaluation guidance and survey tools that local programs can use to assess changes in target population knowledge and behavior resulting from outreach activities. In February 2021, CDPH will receive the results of local program outreach activities in progress reports covering the first six months of the new contract cycle (July-December 2020). Upon receipt of the progress reports, CDPH will review the quantitative results of local program outreach activities, provide feedback to local programs, and begin assessing the effectiveness of outreach activities in reducing the number of children with lead poisoning. To help examine the impact of outreach activities on reducing blood lead levels in children, CDPH is in the process of analyzing blood lead level changes resulting from the lead education packets that CDPH has been mailing since July 2016 to the families of children with blood lead levels of 4.5-9.4 mcg/dL in California health jurisdictions that do not contract with CDPH. Because the Scope of Work timeline for completion of outreach activities is annual, CDPH will perform a complete assessment of outreach effectiveness after the end of the first contract year (June 30, 2021). If outreach is determined to be ineffective, CDPH will explore corrective action measures and/or other approaches to prevention.

California State Auditor's Assessment of 1-Year Status: No Action Taken

CDPH's description of the steps taken to address this recommendation do not differ significantly from the condition we reviewed during the course of our audit. The toolkit it describes addresses whether outreach resulted in an increase in participants' knowledge, but does not address whether the outreach resulted in a reduced number of children with lead poisoning, as we recommended. CDPH states that it will begin assessing the effectiveness of outreach activities in reducing the number of children with lead poisoning as it receives progress reports, and that it has begun analyzing blood lead level changes resulting from the lead education packets that it has mailed since July 2016; however, this does not address our our recommendation. Specifically, our recommendation pertains to local programs demonstrating the effectiveness of their outreach in reducing the number of children with lead poisoning.

6-Month Agency Response

From December 2019-April 2020, CDPH completed its review of all 49 local health jurisdiction scopes of work received for the new contract cycle (FY 2020-21 through FY 2022-23), which included the new outreach evaluation requirements. Local program implementation will begin July 1, 2020. CDPH is currently updating the progress report template to link reporting requirements to the new scope of work. CDPH will communicate reporting expectations and offer training opportunities for local programs at the beginning of the new contract cycle.

In February 2021, CDPH will receive local program outreach evaluation results in progress reports covering the first six months of the new contract cycle (July-December 2020). At that time, CDPH will review reports for evaluation progress, continue to provide technical assistance as needed, and begin assessing the effectiveness of outreach activities in reducing the number of children with lead poisoning. Because the scope of work timeline for completion of outreach activities is annual, CDPH will perform a complete assessment after the end of the first contract year (June 30, 2021). CDPH will explore other approaches to prevention if outreach is determined to be ineffective.

California State Auditor's Assessment of 6-Month Status: No Action Taken

CDPH provided updated contracts with local prevention programs that include scopes of work requiring them to demonstrate the effectiveness of their outreach. However, these contracts do not require the local programs to assess whether their outreach has reduced the number of children with elevated lead tests, as we recommended. Further, CDPH has not yet begun the process it describes of assessing local programs' progress in reducing the number of children with lead poisoning. We will review CDPH's progress after it has implemented this process.

60-Day Agency Response

CDPH has updated local prevention programs' scope of work requirements beginning in FY 2020-21 through FY 2022-23 to include the evaluation of outreach for purposes of demonstrating its effectiveness. The scope of work template with the new evaluation requirement was disseminated to local prevention programs in November 2019, and completed scopes of work are currently undergoing review by CDPH CLPPB. CDPH will provide technical assistance to local programs on outreach evaluation and check on evaluation progress every six months. CDPH will receive for review local programs' evaluation results to assess whether outreach activities are effective in reducing the number of children with lead poisoning. CDPH will explore other approaches to prevention if outreach is determined to be ineffective.

California State Auditor's Assessment of 60-Day Status: Pending

We will review CDPH's new scope of work requirements, CDPH's analysis of the effectiveness of local programs' outreach, and any corresponding evaluation of other approaches once CDPH has implemented this recommendation.

All Recommendations in 2019-105

Agency responses received are posted verbatim.