BMC Public Health BioMed Central Research article

Background Undernutrition is a leading cause of child mortality in developing countries, especially in sub-Saharan Africa. We examine the household and community level socioeconomic and environmental factors associated with child nutritional status in Cameroon, and changes in the effects of these factors during the 1990s economic crisis. We further consider age-specific effects of household economic status on child nutrition. Methods Child nutritional status was measured by weight-for-age (WAZ) and height-for-age (HAZ) z-scores. Data were from Demographic and Health Surveys conducted in 1991 and 1998. We used analysis of variance to assess the bivariate association between the explanatory factors and nutritional status. Multivariate, multilevel analyses were undertaken to estimate the net effects of both household and community factors. Results Average WAZ and HAZ declined respectively from -0.70 standard deviations (SD), i.e. 0.70 SD below the reference median, to -0.83 SD (p = 0.006) and from -1.03 SD to -1.14 SD (p = 0.026) between 1991 and 1998. These declines occurred mostly among boys, children over 12 months of age, and those of low socioeconomic status. Maternal education and maternal health seeking behavior were associated with better child nutrition. Household economic status had an overall positive effect that increased during the crisis, but it had little effect in children under 6 months of age. Improved household (water, sanitation and cooking fuel) and community environment had positive effects. Children living in the driest regions of the country were consistently worst off, and those in the largest cities were best off. Conclusion Both household and community factors have significant impact on child health in Cameroon. Understanding these relationships can facilitate design of age- and community-specific intervention programs.


Background
Lead is a ubiquitous and poisonous heavy metal. It is widely distributed in the environment (air, soil, sediment, surface and ground water, food, dust, paint) and in biological systems [1]. It occurs both naturally and as a result of human activities [2]. One of the most common sources of human exposure to lead is through exhaust from use of leaded petrol. However this practice is being discontinued worldwide [3] leaving the domestic environment (through house paint, potable water and dust) as the main continuing source of lead exposure in many communities around the world. While both adults and children can suffer from chronic low-dose lead exposure, the effect is more marked in children [2,[4][5][6].
In Nigeria, like most developing countries, very little attention is currently paid to environmental health problems including chronic lead exposure [7]. Yet these factors are responsible for more morbidity, disability-adjusted quality of life loss and mortality than in developed countries [7][8][9]. It was recently estimated that a reduction of the blood lead levels of children in the United States from 17.1 µg/dL to 2.0 µg/dL, in the period 1976 to 1999, resulted in public health benefits of $319 billion [10]. The proportional impact of reducing childhood lead exposure in developing countries, where children's blood lead levels are likely to be higher, would be much greater. While many developing countries are currently making efforts to reduce exposure to lead by using lead-free petrol, very little is being done to address the more ubiquitous sources of exposure in the domestic environment [9]. In this study, we conducted several focus group discussions with adult residents of Ibadan, a large metropolis in South Western Nigeria to evaluate their knowledge, attitudes and practices with respect to chronic low-dose domestic lead exposure and its effect on health.

Methods
This study was conducted in Ibadan, South Western Nigeria in 2004, as part of the Reducing Exposure of Children to Lead Study (RECLES) of the University of Ibadan. Nigeria has a population of about 136 million people, at least 40 million of whom live in the South Western part of the country. Most, 60%, of the population live below poverty line and the estimated GDP per capita in 2004 was $1,000. Ibadan is one of the major urban centers in Nigeria; the largest indigenous city in West Africa with a population of about 2 million people. The population is largely engaged in small scale farming, trading and service occupations. Ibadan hosts several institutions of higher learning, of which the University of Ibadan, established in 1948, is the oldest. Along with its affiliated medical institution, the University College Hospital; the two institutions formed the base for this study. About 80% of the adult population of Ibadan is literate. There are several small and medium scale industries in Ibadan and during the 1990s, there was a car battery manufacturing company, but it closed down about 8 years ago.
In order to ensure representation of the population of the entire city, we randomly selected 40 healthy individuals by personal contact and mail, from the 5 administrative units of the city, taking care to ensure balance of religious affiliation, occupation, gender and social economic status. The individuals were invited to meet for a discussion on a pertinent health problem and were not told before hand that the topic of the discussion would be lead exposure. Recruitment continued until there was a group of ten people for each of the four groups. After arrival, participants were informed about study objective and told that each interview will last about 11/2 hours. Trained facilitators conducted the sessions and written consent was obtained from all focus groups participants. Individuals younger than 18 years of age, those unable to communicate in English or Yoruba (the indigenous language of Ibadan) or those unable to give consent were excluded from the study. Participants were given gifts worth $7:00 to cover transport and other expenses incurred in order to participate in the study.
The discussion guide for the focus group discussions was developed by EOA and CAA based on the literature and knowledge of the local environment. Facilitators occasionally interjected in the discussions using a non-directive approach to focus participants on the topic of interest and move discussions along. Following introduction, participants were encouraged to freely discuss along the themes in the discussion guide shown in Table 1. The discussions were audio-taped and transcribed by a secretary who was not part of the study team. The transcripts were then reviewed by the authors in a two step process. First, major themes were identified and these were aggregated into lists. Phrases and quotations that highlighted these themes were identified. Sub-themes within the major themes were also identified and aggregated into lists. The major themes and sub-themes from each reviewer were then compared and the lists merged. Where there were disagreements between the raters, a third person was asked to review the pertinent sections of the transcript and a consensus reached on the substance. Coding began by identifying broad conceptual themes like; knowledge of lead and lead exposure, attitudes to lead exposure, health implications and practices regarding lead exposure. Specific attention was given to the knowledge about lead, lead level testing in the home, lead poisoning and the health impact of lead exposure. Ethical approval for this study was obtained from the Oyo State Ministry of Health Ethics Committee.

Knowledge
What is lead and where can it be found? Most participants believed that lead is a metal which is used in soldering materials and it can be found in cooking pots, domestic and automobile batteries, pencils, cosmetics, fuel, local herbs and medications. Discussants thought that lead is poisonous. It can cause asthma, cancer, eye and chest diseases and can shorten lifespan. Many participants mentioned some of the commonly used canned foods and condiments in Nigerian markets, such as canned tomato puree, canned fish, tinned milk, cutlery and cooking utensils as potential sources of lead. Participant: (Children) tend to be dull if they are exposed to lead.
Participant: It affects intelligence.

Where can we get information about lead and additional comments?
Discussants felt that they can obtain information about lead exposure from welders, automobile battery repairers and manufacturers. There was general agreement on the need for the government to do more to increase awareness of lead exposure while putting effective remediation measures in place (Table 2).

Attitudes
What do you think of when you hear "lead poisoning"?
The use of the term poison engaged the attention of the discussants, though they did not know specifically about lead poisoning. They were sure that the metal is poisonous. Overall, they felt that apart from specialists in the field, most people do not know what "lead poisoning" is about.
How do you think we are exposed to lead and how can we reduce it? Most of the discussants believed that one can be exposed to lead through petrol, pipe-borne water and pencils. Less commonly, they also mentioned soil, cooking utensils, soap and industrial pollution as sources of lead exposure. There was general agreement that there is a need to increase awareness of lead exposure and increase the role of regulatory agencies in ensuring that products sold on the market do not contain lead. Some participants suggested that people should return to the use of earthenware pots for cooking, out of concern that modern cooking utensils may be associated with lead exposure, though they acknowledged that such a move is not likely to be popular. Other participants thought that recent govern- Some participants think that since lead is used for welding, pencils, paints, etc, it is needed and beneficial. (Table  3)

Discussion
In this study, we found some awareness of lead exposure among our participants. Many of them were aware of the presence of lead in petrol but had little knowledge of domestic sources of lead exposure such as paint, water and soil. Many of the participants confused the popular appellation for pencils, which is "lead pencil", to imply that the writing element in pencils were made of lead. Sev- eral of our FGD participants were aware of lead exposure arising from car battery manufacture and repairs. There used to be a motor car battery manufacturing plant in Ibadan and many residents were aware of the environmental degradation associated with its operations. Participants were also aware of the presence of lead in some alternative medicines and in association with occupations such as welding. Some of our participants were aware of the health implications of lead exposure in children, suggesting that it may be responsible for "abnormal behavior" and "dullness". Nevertheless, none of the participants has ever tested their environments for lead.
At least one participant who works with the government department in charge of civil engineering was aware that facilities for testing lead level in the environment exists but added that this was usually done by large organizations and not individuals. Participants believed that there is need to increase awareness of lead exposure in the community. Many however agreed when another participant suggested that people are likely to be pragmatic in their response to any campaign to reduce exposure to lead, suggesting that alternative sources of income should be found for those whose occupation is likely to be affected by lead remediation activities, otherwise such campaigns will fail. Furthermore, it was suggested that alternatives should be provided for lead contaminated products. While some of the participants were hopeful that research results will lead to government intervention, others were not as optimistic, suggesting that previous experience does not support any expectation that the government will respond positively to such research. Most of the participants felt that they can obtain information about lead from those who are occupationally exposed to it.
There is increasing awareness of the risks posed by domestic exposure to lead, particularly to children. Children can be exposed to lead through dust inhalation and ingestion [10,11]. In a survey of households in the United Kingdom, the total estimated lead intake of young children was 36 µg/day, of which 1 µg/day was by inhalation and the rest by ingestion [12]. Recent prevalence studies show that over 90% of children in urban and rural communities of Cape Province, South Africa have blood lead levels ≥ 10 mg/dl. Studies in other countries likewise suggest that childhood lead poisoning is a widespread urban health problem throughout the continent of Africa [13,14]. Reduction of childhood lead exposure will result in substantial economic gains, possibly to a greater degree than has been reported from developed countries [10,15].
This study has outlined the current knowledge, attitudes and practices of a cross section of Ibadan residents about lead exposure. To our knowledge, there is no previous report on the use of FGD to ascertain knowledge of health hazard posed by lead exposure in Nigeria or any other parts of Africa. Our participants were similar to the general Nigerian population in terms of age, sex and occupation [16]; however the presence of a battery manufacturing company in Ibadan in the recent past may have increased the baseline knowledge of residents in this city to lead exposure compared to other parts of Nigeria. There is little or no enforcement of minimum standard for lead content of domestic environment in Nigeria. This is partly because of low awareness of the health implications of these exposures and competing attention from infectious diseases like HIV/AIDS and malaria. There has never been domestic lead abatement in Nigeria and none is planned.
Focus group discussions provide an opportunity to interview a group of individuals in a directed conversation about a specific topic and it can be used to generate new insights about attitudes and beliefs [17,18]. The interaction among participants leads to the promotion of rich discussion and opportunity to present contrary opinions that are not limited by the constraints imposed by the limited choices in a quantitative study [17,19]. In situations where little previous documentation exists, such as this topic, focus group discussions help to generate new ideas and hypothesis for further research. They can also be used in conjunction with other methodological techniques for triangulation purposes thus helping to validate research findings [20]. However like other qualitative research methods, their results and conclusions must be treated with caution [21].
We conducted four focus group discussions and it may be considered that bigger groups or more groups would lead to more valid conclusions. This is however not necessarily so [22,23]. In addition, it is possible that having such a heterogeneous group may dilute the information obtained and may be unrepresentative of the population's knowledge and attitudes to lead exposure. The facilitators' prompts and interventions may also be misunderstood and in the few instances where the participants spoke in Yoruba, the sense of the contribution may have been lost in the translation.

Conclusion
In conclusion, this study shows that there was limited knowledge and awareness of domestic sources of lead exposure and its health effect in Nigeria. The origins of popular misconceptions about lead exposure and effective means of correcting them need to be explored. The most popular of these was about pencils, a ubiquitous writing implement made of graphite that carries no known health risk. Our findings suggest that more studies are needed to fully understand the knowledge, attitudes and practices of this population to lead exposure in order to develop appropriate health education intervention.