Over the past 40 years, blood lead levels in the US population have declined dramatically. National Health and Nutrition Examination Survey (NHANES) blood lead data trends over several decades provide evidence of the effectiveness of policies that eliminated lead from gasoline, paints, and other consumer products.1 (Editor's Note: See the article by Dignam et al on page S13 in this issue.) A review of the 1976-1980 NHANES survey data indicate that, by today's standards, more than 99% of the US population had blood lead levels greater than the current Centers for Disease Control and Prevention (CDC) reference value.2
In 1988, Congress passed the Lead Contamination Control Act that created the CDC's Childhood Lead Poisoning Prevention Program (CLPPP) to support state and local programs to identify, monitor, and respond to cases of elevated blood lead levels in US children. (Editor's Note: See the article by Ettinger et al on page S5 in this issue.) State and local CLPPPs have used federal funding to develop prevention and surveillance programs to identify and monitor where children are most likely to be exposed to dangerous levels of lead, enforce safe renovation guidelines, and educate parents, the general public, and health care providers. Coupled with policies aimed at eliminating lead from environmental and other sources, the work of federal, state, and local CLPPPs has also contributed to the decline of child blood lead levels.
CDC's CLPPP develops “success stories” in partnership with state and local cooperative agreement recipients as one way to highlight lead poisoning prevention activities. Success stories showcase a public health program's progress toward achieving population health objectives and can be used to inform policy makers, stakeholders, and the general public.3 Effective success stories can be used to highlight the value of the work (Figure 1). This article describes how success stories can be used to identify, chronicle, and mobilize public health program achievements using the example of lead poisoning prevention.
Over time, the process for collecting and developing CLPPP “successes” has evolved. Early efforts to collect success stories from state and local CLPPPs resulted in broad or unfocused reports that did not effectively distinguish routine activity summaries from distinct notable successes to highlight program achievements. In annual reports, funded recipients often reported the completion of required activities as successes without linking them to anticipated outcomes or measures of effect. While the successful completion of these activities is as an important indicator for financial management and accountability, they did not truly define program progress toward national prevention goals or the impact of state and local work. There was no standardized process for documenting good examples of interim program achievements that demonstrated progress toward a key strategy, activity, or program area.
CDC's CLPPP revised the approach to success story development in order to better articulate the context, intervention or activity, and results related to programs' successes. Success stories should describe the “progress, achievements, impact, and future directions” of programs through the “documented achievement of milestones” in efforts to achieve program goals.4 Documented public health success stories should highlight important work that is facilitating improvements in population health. Key first steps are to identify the target audience, objective, focus, and content (Figure 2). Although success stories alone cannot be used to assess program effectiveness, they may serve as a valuable tool for program evaluation.5
In an effort to improve the quality of success stories, CLPPP developed a success story collection template (see Figure 3—Supplemental Digital Content Material, available at http://links.lww.com/JPHMP/A523) based on work by CDC's National Center for Chronic Disease Prevention and Health Promotion. The CLPPP template was adapted from CDC Division of Oral Health's “Impact and Value: Telling Your Program's Story” guide that illuminates best practices around success story collection and use.3 CLPPP tailored the template specifically for lead program cooperative agreement recipients so that the categories and examples used familiar language in line with program goals and objectives. The CLPPP template guides programs to organize and report information on 3 crucial features of the narrative (ie, challenge, response, and results) to more clearly and succinctly articulate their achievements in a standardized format. The template also allows for the collection of essential contextual information as well as qualitative and quantitative data to link success stories to short-, intermediate-, or long-term childhood lead poisoning prevention objectives.
A strong success story depicts a program identifying a particular challenge that hinders its program mission, describes how the program overcomes that obstacle, and demonstrates meaningful results. The data collection template was adapted to more accurately chronicle this narrative progression. In 2016, CDC published success stories from CLPPPs in Louisiana, Mississippi, New York City, Rhode Island, and Washington.6 Some of these success stories are used later to highlight an important feature of the success story narrative.
The “Specific Challenge” category requests that programs identify an obstacle faced in addressing childhood lead poisoning in their community. Information concerning the challenge including the time frame, impacted communities, and relevant data provides context. An example of a specific challenge is illustrated by Louisiana's success story in which it partnered with Women, Infants, and Children (WIC) clinics to test blood lead levels of hard-to-reach children:
Louisiana's data demonstrated that some children attending Women and Infants Special Nutrition Projects (WIC clinics) do not receive routine health prevention services and therefore are unlikely to receive blood lead testing at a medical clinic. The Louisiana Healthy Homes and Childhood Lead Poisoning Prevention Program partnered with a New Orleans area WIC clinic to pilot a blood lead testing program. The goals for the project were to increase lead testing rates of children in Louisiana and to determine the percentage of children tested during WIC clinic visit who had elevated blood lead levels.
The “Program Response” category requests that programs detail the intervention or activity that was initiated to address the specific challenge. Information such as actions performed by the program, communities targeted, collaborating organizations, or agencies and the timeline of operations all contribute to a clear understanding of the program's intervention. Washington's success story illustrates how the program collaborated with state partners to update and implement clinical screening guidelines leading to the identification of a new high-risk group:
The Washington State Health Officer convened an expert panel to develop risk-based childhood lead screening recommendations for use by clinicians in the state. The Washington State Lead Poisoning Prevention Program partnered with the Refugee Health Program to screen all refugee children between 6 months and 16 years of age as part of the refugee resettlement program. Over a 3-year period from 2013 to 2016, they screened 3275 children. Fourteen percent of the refugee children screened had elevated blood lead levels and 3% with blood lead levels greater than 10 μg/dL. These children were then able to be linked to appropriate follow-up services.
The “Measurable Results” category requests that programs identify qualitative or quantitative data as an indicator of the activity or intervention's effectiveness. A demonstrated change from the beginning of the activity or intervention to its conclusion helps demonstrate the overall community benefit from the implemented activity or applied intervention. Rhode Island's success story describes quantifiable changes over time that are tied to an intervention:
In 2011, 4 core cities in Rhode Island reported having 3 times the number of children with blood lead levels of 10 μg/dL or more compared with other Rhode Island cities and towns. An estimated 80% of Rhode Island homes were built before 1978 and likely contain lead-based paint hazards that can create lead dust hazards during renovations to these homes. Rhode Island implemented the US EPA's 2010 Lead-Based Paint Renovation, Repair and Painting (RRP) Rule that requires workers to be certified and trained in the use of lead-safe work practices and requires renovation, repair, and painting firms to be licensed by the Department of Health. Following the first full year of the program, 180 cases of RRP violations were prosecuted by the Providence City Solicitor's Office for failure to obtain lead-safe certificates for rental units and there were 128 fewer cases of children with elevated blood lead levels in Providence (one of the 4 core cities).
Implications for Policy & Practice
- Success stories can be used to clarify program objectives, foster collaboration, communicate best practices, and demonstrate effective use of resources.
- Well-written success stories that describe a clear challenge, response, and results can help stakeholders understand the impacts of public health programs.
- Success stories support implementation of prevention strategies that sustain progress toward national objectives.
Success stories from CLPPPs showcase best practices in childhood lead poisoning prevention as measured by progress toward or achievement of national and local prevention objectives. These stories highlight important work that may be of interest to policy makers, program partners and stakeholders (including CDC), and those affected by the work of these agencies (eg, health care providers, families at-risk for lead exposure). CLPPPs often seek ways to improve their programs and in many instances look to their colleagues for information. Each success story showcases tangible results of prevention and surveillance activities conducted by state and local health agencies. As success stories are shared, both funded and unfunded state and local health agencies may be motivated to pursue similar strategies and activities. In addition, information shared through success stories provides examples of what is working well in other jurisdictions or what adjustments had to be made that help other programs identify best practices and lessons learned. Success stories allow programs to increase mission awareness, build stakeholder support, generate community interest, and collectively demonstrate progress toward meeting national program objectives. In addition, success stories may inform the development of future prevention strategies, as partners and other stakeholders uncover what works for the prevention and surveillance of childhood lead poisoning.
CDC's CLPPP recently reexamined criteria for success stories to improve the process for identifying and documenting CLPPP successes in improving child health. Although annual reports provided valuable information on activities accomplished as a result of CDC support, CDC's CLPPP was often unable to distinguish between routine activity summaries and distinct notable successes. The new approach for identifying and chronicling success stories resulted in stronger products that allow both CDC and program recipients to demonstrate achievement of key program objectives.
Success stories allow programs to highlight their efforts toward meeting population health objectives. CDC staff guide programs in crafting success stories that are concise, direct, and related to CDC's program strategies and national prevention goals. Success stories developed with the CLPPP template will serve to highlight important lead prevention work that programs can use to share their accomplishments with policy makers, health care providers, and the general public seeking information on childhood lead poisoning prevention activities in their communities.
1. Brown MJ, Margolis S. Lead in drinking water and human blood lead levels in the United States. MMWR Suppl. 2012;61(4):1–9.
2. Annest JL, Pirkle JL, Makuc D, Neese JW, Bayse DD, Kovar MG. Chronological trend in blood lead levels between 1976 and 1980. N Engl J Med. 1983;308(23):1373–1377.
4. O'Toole T, Gates S, Scoville J. Success Stories
Made Easy: Growing, Finding, and Using Strong Stories. Atlanta, GA: National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) DNPAO 1305 & 1422 Grantee Meeting; 2016. http://livingwell.utah.gov/docs/ndpp/Success_Stories.pdf
. Accessed January 7, 2017.
5. Lavinghouze R, Price A, Smith K. The program success story: a valuable tool for program evaluation. Health Promot Pract. 2007;8(4):323–331.
6. Centers for Disease Control and Prevention. State programs: read about what state programs are doing. https://www.cdc.gov/nceh/lead/programs
. Published April 2016. Accessed June 10, 2018.