135: Poison Prevention and Education

Unintentional poisonings are a global health concern. According to the World Health Organization (WHO) Global Burden of Disease Project, in 2004 approximately 3,346,000 people died worldwide from unintentional poisoning.⁸⁰ Nearly 1 million people die each year as a result of suicide. Approximately 350,000 deaths result from the deliberate ingestion of pesticides. In addition, an estimated 5 million snakebites occur annually.⁸⁰ The WHO has undertaken initiatives in many countries, including the Bahamas, China, Ghana, Lebanon, Myanmar, Senegal, and Trinidad and Tobago to establish Poison Centers (PCs) and raise awareness about poison prevention. Worldwide, data on nonfatal poisoning rates are currently not available, although the increase in poison centers globally may result in improved research and surveillance programs.⁵⁴ This chapter focuses on programs in North America that aim to prevent unintentional poisonings and improve access to PC services.

Healthy People 2020 is a US federal program that outlines the health goals for the nation. These overarching goals are to attain high quality longer lives, achieve health equality and eliminate disparities, create social and physical environments that promote good health and promote quality of life, healthy development, and healthy behavior across all life stages. Two objectives in the Injury and Violence Prevention section relate to poison prevention. Objective IVP-9 is to reduce poisoning deaths and Objective IVP-10 is to reduce nonfatal poisonings.²⁵ Community based public education programs at PCs are designed to help meet these other public health objectives.

Since the first PC was established in 1953, a number of legislative efforts have improved poison prevention and awareness and reduced the number of unintentional poisonings in children. Public education programs at PCs have been influenced by these federal measures.⁷¹

National Poison Prevention Week

In 1961, President Kennedy signed Public Law 87–319, designating the third full week of March as National Poison Prevention Week (PPW) to raise awareness of the dangers of unintentional poisonings. Each year, ­during PPW, PCs and other organizations around the country organize events and activities to promote poison prevention.

Child-Resistant Packaging Act

In 1970, the Poison Prevention Packaging Act was passed. This law requires that the Consumer Product Safety Commission (CPSC) mandate the use of child-resistant containers for toxic household xenobiotics. In 1974, oral prescription medications were included in this requirement. A review of mortality data in children younger than 5 years of age shows a significant decrease in deaths after enforcement of the child-resistant packaging legislation.^61,71,75

Taste-Aversive Xenobiotics and Poison Prevention

Nontoxic taste-aversive xenobiotics are frequently added to products such as shampoo, cosmetics, cleaning products, automotive products, and rubbing alcohol to discourage ingestion.²⁴ This is done primarily to prevent poisoning in children except in the case of rubbing alcohol, where adults are also targeted. The most common taste-aversive xenobiotics are the denatonium salts, particularly denatonium benzoate (Bitrex, benzyldiethyl [(2,6-xylylcarbamoyl)methyl] ammonium benzoate), one of the most ­bitter-tasting xenobiotics known. The bitter taste of denatonium benzoate can be detected at 50 parts per billion (ppb). This aversive xenobiotic is used in concentrations of 6 to 50 parts per million (ppm), typically 6 ppm in cosmetic products and ethanol-containing household products and 30 to 50 ppm in methanol and ethylene glycol.^8,53 Only limited data are available on the usefulness of taste-aversive xenobiotics for prevention of poisoning. Studies using denatonium benzoate added to liquid detergent and orange juice demonstrate that it can decrease the amount ingested by children.^6,67 However, the degree of taste aversion is not universal. In one study, some children were noted to take more than one sip of denatonium benzoate-containing orange juice.⁶⁷ Taste aversion is partially a learned response. Frequently young children do not find a bitter taste as offensive as do adults.⁷ It seems unlikely that taste-aversive xenobiotics will eliminate unintentional ingestions in children, because ingestion is required for aversive effects to occur. Taste-aversive xenobiotics may be most beneficial in the prevention of poisoning by toxic and nonaversive xenobiotics, such as ethylene glycol, methanol, paraquat, certain pesticides, acetonitrile, and bromate-containing cosmetics, where more than one or two sips of the product must be ingested to cause significant toxicity. In 1995, Oregon became the first state to mandate the addition of an aversive xenobiotic to ethylene glycol- or methanol-containing car products in its 1995 Toxic Household Products statute. Analysis on the incidence and severity of ethylene glycol and methanol exposures before and after the mandate could not demonstrate any difference in children under 6 years of age.⁴⁹ Taste-aversive xenobiotics should therefore not be substitutes for other poison prevention modalities.

Toll-Free Access to Poison Centers

In 2000, the Poison Control Center Enhancement and Awareness Act (PL 106-174) was enacted with a goal of nationwide access to PCs. A toll-free number (1-800-222-1222) was established in 2001 for all US PCs.⁷⁸­Callers are connected to a regional PC based on the area code and telephone number exchange. Figure 135–1 displays the national logo incorporated into educational efforts.

Poison Center educators encompass a range of educational backgrounds including nurses, pharmacists, health educators, and teachers. The role of the public educator is based on social marketing concepts and encompasses two objectives: health promotion to change behavior, and marketing of the PC.⁶⁹ Public education programs at PCs teach poison prevention techniques (primary prevention) and raise awareness about available services should a poisoning occur (secondary prevention). Education programs may utilize primary or secondary teaching or a combination of both.^5,27,32,39 Public educators at PCs provide a range of community based programs ranging from workshops and health fairs to producing print materials, videos and or DVDs, and awareness campaigns through public service advertising using radio, television, print, and mass transit venues. Social media in health promotion offers an opportunity to further expand the dissemination of health information to diverse audiences through enhanced communication.⁴⁷ Since underserved groups use mobile handheld devices frequently to access information,cell phones, mobile technology, and online resources provide new ways that educators can disseminate health messages to those in need.

Educators also participate in community health coalitions, working in conjunction with other injury prevention groups such as National Safe Kids, and collaborate with a wide range of community health agencies. Caregivers of children younger than age 6 have often been the most important group to reach with education programs. Educators often work with national programs for families including Women, Infant and Children (WIC), Head Start, and the Red Cross.

By contrast, older adults (individuals older than 65 years of age) have not been a priority population for PC education resources. However, this group represents a large number of fatalities reported nationally to PCs, primarily due to medication errors.^10,27 Programs for older adults offer an educational opportunity to reach this high risk population. Collaborative programs with the American Association of Retired Persons (AARP), senior centers, and Departments for the Aging offer an opportunity to provide collaborations focusing on poison prevention and medicine safety programs through educational interventions conducted in senior centers, community agencies, and other groups that serve independently living older adults.

The membership of the American Association of Poison Control ­Center’s Public Education Committee (PEC) includes the educators from PCs across the United States and Canada. The mission of the PEC is to provide poison prevention awareness programs in an effort to reduce ­morbidity and mortality associated with poisoning. Each year, the PEC provides educational sessions at the North American Congress of Clinical Toxicology. PEC workshops focus on program development, evaluation, grant writing, strategic planning, and other topics of interest to PC educators.²⁷

To develop successful poison education programs, educators must first analyze demographic data, call volume rates, cultural and language issues, and barriers to calling a PC. Geographic information systems (GIS) software offers a way for PCs to map demographic data. The use of this type of software is increasing in public health and can be applied to PC efforts. The coordination of data retrieval from various data entry programs and the use of GIS software by PC staff provides access to call rates by zip codes, counties, census tracts, or congressional districts to be used for planning programs. Health and social services for the targeted community may also be presented using GIS maps. Using GIS for population based programs is recommended for developing social marketing campaigns, health education programs, outreach efforts, and coalition building.⁶⁰ The study of geographic areas with low call rates enhances the potential for targeted and focused educational programs.

Focus groups, surveys, and interviews provide useful qualitative methods for PC educators to identify the perceptions of parents and caregivers about calling the PC. Barriers regarding PC utilization include not knowing the PC number, preference for calling 9-1-1 rather than the PC, fear of being reported to child welfare agencies, concerns with regard to confidentiality, language difficulties, lack of in person contact with health care providers, low self-efficacy, and concerns regarding the cost of the call.^{1,4,9,28,29,65,73} Each of these barriers must be considered and creatively addressed when planning new programs for reaching caregivers of young children. In one study, 51% of caregivers interviewed in a low income urban pediatric clinic said that they would immediately take their children to the emergency department (ED) after a possible poisoning exposure.⁶³ In a separate study, focus group participants stated they would not call the PC in the case of a poison emergency. Their responses ranking was (1) call the pediatrician, (2) go to the ED, (3) read the label, and (4) call a friend after a poisoning exposure.²⁸ A focus group with parents provided information to refine a telephone survey concentrating on hazardous household materials and health risks. Feedback from caregivers resulted in a more concise instrument with more targeted questions. In addition, perceptions of the PC and suggestions for future educational interventions were also gathered from participants.²⁸ Involving the target audience in the development and testing of information is demonstrated to have improved outcomes when disseminating information.⁷²

Follow-up surveys provide a way to analyze factors related to PC access. English- and Spanish-speaking caregivers in Texas were contacted after an ED visit related to a poisoning exposure in a child. Findings showed that more than half had spoken to PC staff prior to the hospital visit. Of those who did not call the PC, 68% claimed prior knowledge of the PC, yet failed to use it. Significant demographic variables associated with a failure to call the PC were Hispanic (schooled in Mexico) and African American ethnicities.³¹ Findings from an ethnographic study of 50 Mexican-American mothers with children younger than 5 years of age demonstrated that none had the PC number in their home.⁴⁶

In person interviews were conducted with parents in the pediatric clinic about poison prevention strategies and awareness of the poison center.^16,20 A pilot study to determine predictors of storage included accultur­ation, age, gender, and education among parents found that less acculturated parents were more likely to store medicines and cleaning products unsafely in the home.¹⁶ Another study conducted with 216 parents and ­caregivers reported that 80% were aware of the poison center services. However, none knew the 800 number specifically, although many stated they had the number in their home. Of the 42 participants (20% of the sample) unaware of the PC services, 57% were non-English speakers.²⁰

In order for educators to plan effective programs with older adults a needs assessment of the perceived barriers and benefits for this target group related to accessing the PC is required. Focus groups conducted with older adults show that most do not perceive the PC as an appropriate service for their concerns, but rather as a service for children and parents. Additionally, the participants expressed a very narrow view of what was considered a poison such as bleach and household products. Similar to caregivers of children, older adults repeatedly state that they would call 9-1-1 in an emergency.¹¹

Over half of the 2 million annual calls to PCs nationally involve children younger than 6 years of age.¹⁰ As a result, programs to teach caregivers about primary and secondary prevention techniques have been the major aim of education efforts. Typically, these programs focus on teaching poison prevention (Table 135–1) and raising awareness of PC services. Poison education programs designed to address barriers to accessing the PC through community interventions are reported in the literature. In one study, parents at two WIC centers reported an increased comfort level with calling the PC after a video based intervention.³⁰ Interventions have demonstrated an increase in knowledge about PC messages and poison prevention in the study groups.^30,38

Interventions Targeting Health Behavior

Unintentional poisonings frequently happen when children are left unattended for a brief period of time (< 5 minutes) and a toxic product in use or recently purchased is left within reach of the unattended child.⁵¹ A qualitative study conducted of 65 parents, some whose children had experienced an unintentional poisoning, showed that poison prevention strategies were not consistently implemented in the home. Recommendations included ongoing parent education to reemphasize that “child resistant” is not “childproof,” and reinforce safe storage of potentially toxic products, particularly those that are often used.²² When knowledge and behavior were measured through telephone surveys conducted 3 months after a poison prevention packet was mailed to families of young children who had experienced a poisoning, caregivers were more likely to have the PC number posted in the home.^30,79

The ED presents an opportunity for poison education programs to work with families to prevent further poisoning exposures.¹⁷ An injury prevention program provided to caregivers of young children after a home injury was effective, particularly regarding retention of poison prevention information and the use of safety devices.⁵⁶ The use of a computer kiosk in an ED to provide personalized child safety information including specific advice of poison storage for parents showed increased knowledge scores on follow-up telephone surveys.²³

The effectiveness of poison prevention education for families who called the PC following a potential exposure in a young child was also studied. Poison prevention instructions, telephone stickers, and a cabinet lock were sent to the family one week after the initial call. Follow-up telephone interviews showed that intervention group recipients reported a higher use of the cabinet lock (59%) and were significantly more likely to post the telephone number for the PC (78%) than those in the control group who did not receive any poison prevention materials within 2 weeks of the incident.⁷⁹

Poison education programs developed to address caregiver barriers have also been evaluated. An educational video targeting low income and Spanish speaking mothers was developed and evaluated. Results showed increased knowledge about the services, staff, and appropriate use of the PC compared with a control group that attended the regularly scheduled WIC class.³⁰

Instructor training programs have been designed by a number of PCs to reach leaders or educators of community based organizations to incorporate poison education into their roles for the general population. An evaluation of the “Be Poison Smart” program showed an increase in knowledge and behavior change among service providers after a standardized training session. These reported changes included having the PC number visibly posted and keeping hazardous products out of reach.⁵⁵ Working with community based services such as WIC presents an opportunity to reach the target population. Pretests and posttests administered to WIC staff and public health nurses showed increased understanding about poison prevention and increased awareness of PC services.⁵⁷ Community health workers (promotoras) are involved in health promotion particularly in hard to reach communities. A train-the-trainer model evaluation demonstrated increased knowledge and behavior for teaching healthy homes promotion in the community setting.⁴⁰

Focus group participants identified pediatricians as a trusted source of health information for parents.^28,65 The AAP includes a poison prevention counseling recommendation as part of The Injury Prevention Program (TIPP). TIPP is a safety education program for parents of children newborn through 12 years of age. The TIPP age related safety sheets include poison prevention advice for parents of children aged 6 to 12 month, 1 to 2 years, and 2 to 4 years.² Each safety sheet encourages parents to call the toll-free number for PCs if the child ingests a potentially poisonous product. It is important that the AAP continues its support for efforts by PCs to prevent childhood poisonings.³⁹ In another study, family practitioners and pediatricians were surveyed with respect to poison prevention counseling for parents. Although more than 80% of both groups reported that this was an important topic, family practitioners were less likely than pediatricians to provide poison information during a visit.²¹

Education programs are designed for school-age curricula. The effectiveness of MORE HEALTH, a program to teach kindergarten and third-grade students about poison prevention, was studied.³⁸ Posttests administered 1 to 2 weeks after the intervention showed increased knowledge in the intervention group of children. Parents of children in the intervention group also self reported that their homes were more likely to be “poison-proofed.”

Recommendations have been made to develop programs targeting older adults, particularly about potential problems with medication use and storage.^27,36,68 Efforts to teach nursing home staff about potential poisoning exposures are also recommended.³⁶ There has been a shift in the priority of poison education programs to address this target population. An ED study of older adults showed that seniors had poor knowledge of their current medications. In addition, patients taking more medications were less likely to know the proper dose, name, and purpose of the medications.^14,76

Community-Wide Interventions

A review of pediatric literature focusing on community based poisoning prevention programs showed that only four studies could be found using poisoning rates as the outcome measure. Additional creative studies to measure community based poison prevention efforts will be essential to determine the importance of these efforts.⁵⁰

In general, mass mailing of poison information is generally not an effective means to increase call volume for poison exposure or information requests nor is it cost effective.^19,34 Similarly, a distribution of textbook covers with the national logo and PC information to elementary and secondary schools in low PC utilization counties was not an effective method for increasing PC calls.⁸² A hospital mailing that combined primary (poison prevention tips) and secondary (telephone stickers) messages were included in an established family health promotion magazine distributed widely in the PC regional area. This effort resulted in an increased call volume in areas where at least 5% of the residents received the information.³² In addition, another study result in that overall call volume increased by 11.2% after more than 1 million pieces of literature containing the toll-free number were distributed at sites including emergency departments, doctor offices, schools, and pharmacies.³³

An increased number of information calls to the PC was attributed to a campaign developed to raise community awareness.⁷⁰ Media provide a venue for conducting educational activities. Direct mail, radio, television, newspapers, and magazines were incorporated into a media campaign developed to raise awareness in a particular Latino community. A telephone survey conducted pre- and post-media campaign showed an increase in awareness about the PC.¹ Although developing this type of program is often costly compared with other education efforts, the potential audiences are vast. Mass media campaigns are powerful tools used in health promotion and disease prevention efforts.⁵⁸ Research shows that a multilevel approach of media campaigns combined with community-based interventions and health education materials influence health behaviors and raise awareness. Additional factors that contribute to ­successful mass media campaigns include influencing the information environment to maximize exposure, using social marketing strategies, creating a supportive environment for the target audience to make health changes, and theory based process analyses to permit changes ­mid-campaign and assess outcomes and subsequent strategies in an iterative manner.⁵⁸ Radio and television news stations often provide a way to broadcast poison prevention messages during PPW and during periods associated with perceived increased risks to a community. Social media is viewed as a communications tool rather than a factor in behavior change. Therefore, a process evaluation strategy is appropriate for ­measuring reach, context, delivery, and fidelity of application.⁴⁷

Multilingual Populations

Language and culture must be addressed when planning community-based programs. Quantitative and qualitative research examining Latino communities and calls to the PC have been conducted. The findings from interviews with 206 Latino parents at a WIC site showed that 62% had not heard of the local PC and 77% did not know the PC services were free and offered in Spanish.⁷⁴ Two other studies examined the call rates in communities with significant Latino populations. These areas had lower call rates than comparable areas based on demographic and socioeconomic factors.^15,73 Furthermore, a number of studies demonstrate that Spanish speaking caregivers are less likely to call the PC because of concerns including confidentiality and language barriers.^1,4,15,29,46 In a study conducted with 100 Mexican-American mothers of children younger than 5 years of age, 32% reported that a doctor or nurse would be the initial contact for health advice.⁴³ Other sources include friends and family (29%), mother, grandmother, mother-in-law (21%), and spouses (17%). Most of the mothers (81%) acknowledged the use of home remedies to treat their childrens’ illnesses.⁴³ New immigrant families from Mexico and Latin America are at high risk for poisoning exposures. PC education programs should target populations in communities where the impact has the potential to be consequential.⁶⁶ Caution should be used when planning programs based on census data for demographic information as this data may not reflect the specific population or characteristic under study in community based programs. When ethnicity information is not collected from callers who contact the PC, there are severe limitations to the value of the data.¹⁵

Qualitative research can help to identify cultural issues when planning targeted education efforts. Monolingual Spanish speaking mothers were more likely to report poor storage of household products and lack of protective placement of plants.¹ Mexican-born mothers of children younger than 5 years of age were interviewed in their homes about poison prevention techniques. Safe storage was clearly a problem in these homes with 64% of homes having bleach stored within reach of children. The presence of multiple families living in the same home further impedes safe storage practices. In this study, families stored all personal products including medications and household cleansing agents with them in their bedrooms rather than in common areas such as the bathroom.⁴⁶

It is important to consider employment of bilingual staff as public educators when attempting to expand public awareness. The benefits of a bilingual educator include the ability to provide programs directly to an audience and eliminate the need for a translator. A lack of bilingual providers was the most significant barrier identified for Spanish speaking women interviewed about injury prevention techniques.²⁶­Recommendations for more effective outreach to Latino populations include television advertisements and distribution of written information at schools, churches, and doctor offices.⁷⁴ Health education programs including mass media campaigns, designed to accurately reflect the cultural identity—language, beliefs, roles—of the targeted population are more likely to be accepted. Storytelling has also been a recommended strategy for health education among many cultures.⁴⁴ When asked to provide suggestions for poison prevention education, responses included Spanish radio and video programs as well as brochures that incorporate culturally appropriate values. Including messages into widely recognized media such as telenovelas should also be considered when developing information dissemination channels. Most parents reported interest in learning from PC staff, doctor, or a teacher.¹⁶

Field testing concepts and materials are important for the development and distribution of appropriate information for multicultural populations. Further work is needed to examine cultural beliefs related to poison prevention use of and access to the PC. It is important to address cultural beliefs related to use of herbal and other complementary medicines.³⁰ New education programs are needed to reach multilingual and multicultural targeted populations communities across the country. Programs may be more successful if individuals trust and view a source as credible, particularly when cultural attitudes and beliefs closely resemble their own.^16,35,44 In addition, promotoras or community health workers should be considered to deliver primary prevention information in the Hispanic community for building relationships with parents and overcoming cultural barriers.^16,40

Health Literacy/Numeracy

Health literacy is defined as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”⁷² Health literacy encompasses the ability to read, understand, and discuss medical information. Research from the US Department of Education shows that only 12% of US English speaking adults have proficient health literacy skills.⁷² Older adults, Hispanic adults, immigrants, those with less than a high school degree or GED, and low income individuals are at highest risk for low health literacy.³⁷ People with low functional health literacy abilities are less likely to understand written and verbal health information, medicine labels, and appointment information.³⁷ This type of health information is often ­written at reading levels of at least tenth grade or higher.¹⁸ The recommended ­reading level for written information is sixth grade. Most Americans are able to understand medical information at this level.⁷² In addition to ­reading level, use of graphics, font style, color, type size, and layout are important components when developing print material.^18,72 Recommendations for nonprint methods for communicating health information include visuals (posters, fotonovelas, pictographs), action-oriented activities (role-play, theater, storytelling), audiovisuals (videos, DVDs), and improving patient–provider communication.^16,18,52,72

Warning and medication labels are often difficult to understand. The inability to read these warning labels in English presents a barrier for safe storage and safe use of medication and products.⁴⁶ Identification of products often includes brand recognition.⁴⁵ Instructions for proper use and warnings may not be understood from the label independent of language.

In order to address medication safety issues, particularly with medication labels, a number of studies have evaluated ways to simplify the information provided. New recommendations for standardized prescription medicine labels incorporate four specific time periods (morning, noon, evening, and bedtime) and plain language techniques on the container.^76,77 Similarly, recommendations for nonprescription medicine labels have been developed.⁸¹

The effects of health numeracy as a distinct component of health literacy are presented in the literature.^48,64 Numeracy is an element of health literacy and involves the ability to use numeric information to make effective health decisions in daily life.³ This also includes concepts of risk, probability, and the communication of scientific evidence.^48,62,64 Health-related tasks including measuring medications, scheduling appointments, and refilling prescriptions rely on applied numeracy skills.^62,64 Patients managing multiple prescription and nonprescription regimens will lead to potential medication errors.⁷⁶ Educators need to understand the importance of interventions that accurately assess numeracy levels and appropriately address health outcomes. Recommendations for techniques to improve understanding of numeric information include simplifying concepts, using plain language strategies, and utilizing “teach-back” patient understanding strategies.^3,72

Applying Health Education Principles to Poison Education Programs

Health education involves planning, implementing, and evaluating programs based on theories and models. These models offer direction for educators with health promotion planning.⁴² There is a need to increase the number of poison educational programs incorporating health education principles. This includes educational efforts designed to reach individuals through community based programs and media campaigns.

Both the Health Belief Model (HBM) and Social Cognitive Theory (SCT) incorporate the concept of “self-efficacy” and are applicable when designing poison prevention interventions and mass media campaigns. Self-efficacy is the individual’s belief that he or she will be able to accomplish the task requested.^13,18,41,58 Many health educators believe that self-efficacy is necessary to enable behavior change. The SCT suggests that individuals, the environment, and behavior are intimately and inextricably interrelated.⁴¹ The HBM suggests that individuals are more likely to make health behavior changes based on perceived risk susceptibility, severity, potential barriers, and self-efficacy. These decisions are made when actions are seen as potentially more beneficial to the individual than the perceived risks associated with surmounting the current barriers.¹³

In one study, the HBM approach was used as a framework for poison prevention and for the assessment of barriers to PC use. Questions for focus group participants were developed based on the principles of HBM—that is, perceived susceptibility, severity, benefits, barriers, and self-efficacy related to the health action requested. Most of the mothers viewed poisoning as an emergency and felt it was a health concern for their children. Cues to action are also a component of the model and involve discussions about poison prevention or related information. Participants recommended using community based venues and culturally appropriate information to expand awareness about poison prevention and the poison center.⁹

The HBM and SCT approaches were used to develop the questions for focus groups in both English and Spanish. These questions addressed issues related to poison prevention (severity and susceptibility), the services of the PC (including barriers), and suggestions for education. Focus group participants suggested the use of modeling to reinforce real life scenarios in which a mother handles the poisoning emergency with the staff at the PC with a positive outcome.²⁹ As a result, a video was developed addressing these ideas. Two poisoning situations in which a mother calls the center are depicted. One involves home management (ingestion of bleach) and the second involves taking the child to the emergency department (swallowing grandmother’s antihypertensive pill). The video and correlated teaching guides are available in English and Spanish.³⁰

It is important to develop questionnaires that will be accepted and understood by the target population. A Spanish language instrument that addresses home safety beliefs using the HBM framework was developed and tested. Low income, monolingual, Spanish speaking mothers of children younger than 4 years of age were interviewed about perceived susceptibility, severity, barriers, and self-efficacy factors affecting unintentional home injuries including poison prevention measures. Barriers identified include literacy skills and access to bilingual health information.²⁶

The HBM supports the idea that a “teachable moment” may be the ideal opportunity to present poison prevention interventions.^23,56 People may be more open to health information after experiencing a traumatic experience.¹² Events such as an unintentional poisoning exposure may motivate individuals to behavioral change. Applying HBM principles suggests that individuals will make changes in terms of poison prevention when or if they view the severity and susceptibility of a poisoning to be high in the home. Many languages are enriched by cultural variations that must be incorporated into poison education programs and best practices for outreach. Our goal as educators is to provide efforts using models that have been tested and evaluated for addressing focused community efforts in each population served by the PC.

• Poison center public education efforts must encompass needs assessments, program development, implementation, and evaluation.

• Focus groups with caregivers of young children conducted across the country have consistently identified barriers to calling poison centers. These include calling 9-1-1, fear of being reported to child welfare agencies, and lack of confidence in handling poisoning emergencies.

• Using health education theories and models, programs should be developed that address these barriers and encourage caregivers to use the services of the PC appropriately.

• Education programs focusing on the needs of older adults and promoting using the poison center as a resource for medicine safety should be designed.

• Cultural, health literacy, health numeracy, and language needs of target populations are important considerations when planning poison education programs.

References