PEDIATRICS Vol. 111 No. 1 January 2003, pp. 21-26
Effects of a Videotape to Increase Use of Poison Control Centers by Low-Income and Spanish-Speaking Families: A Randomized, Controlled Trial
* Division of General Pediatrics, Department of Pediatrics
Children’s Health Council
Center for Research in Disease Prevention, Department of Medicine, Stanford University School of Medicine, Stanford, California
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONDESIGN AND METHODSRESULTSDISCUSSIONCONCLUSIONREFERENCES |
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Background. Poison control centers (PCCs) reduce health care costs for childhood poisonings by providing telephone advice for home management of most cases. Past research suggests that PCCs are underutilized by low-income minority and Spanish-speaking parents because of lack of knowledge and misconceptions about the PCC. A videotape intervention was designed to address these barriers to PCC use.
Objective. To evaluate the effectiveness of a videotape intervention (videotape, PCC pamphlet, and PCC stickers) in improving knowledge, attitudes, behaviors, and behavioral intention regarding use of the PCC in a low-income and predominantly Spanish-speaking population in Northern California.
Methods. Two hundred eighty-nine parents of children <6 years of age, attending educational classes at 2 Women, Infant, and Children (WIC) clinics participated in a randomized, controlled trial. WIC classes were randomized to receive the video intervention (video group) or to attend the regularly scheduled WIC class (control group). Participants completed a baseline questionnaire and 2 to 4 weeks later, a follow-up telephone interview. Changes from baseline to posttest were compared in the treatment and control groups using analysis of variance.
Results. Compared with the control group, the video group showed an increase in knowledge about the PCC’s function, its hours of operation, and staff qualifications; was more likely to feel confident in speaking with and carrying out recommendations made by the PCC; was less likely to believe the PCC would report a mother for neglect; was more likely to have the correct PCC phone number posted in their homes; and when presented with several hypothetical emergency scenarios, was more likely to correctly answer that calling the PCC was the best action to take in a poisoning situation.
Conclusions. This videotape intervention was highly effective in changing knowledge, attitudes, behaviors, and behavioral intentions concerning the PCC within this population. As a result, use of this video may help increase use of the PCC by low-income and Spanish-speaking families.
Key Words: poison control centers • poison prevention • videotape
Abbreviations: PCC, Poison Control Center • WIC, Women, Infant, and Children • CI, confidence interval
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONDESIGN AND METHODSRESULTSDISCUSSIONCONCLUSIONREFERENCES |
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Each year more than 1 million cases of unintentional poisoning exposures involving children are reported in the United States.1 Poison control centers (PCCs) provide immediate telephone advice about optimal management of any type of poisoning exposure. Because the majority of poisonings involving children can be safely managed at home, PCCs reduce health care costs for childhood poisonings by preventing unnecessary health care facility visits.2–4 They also reduce morbidity by expediting referral to a health care facility when necessary.5 There are 65 PCCs in the United States and of these, 52 are certified by the American Association of Poison Control Centers.6 To be certified by the American Association of Poison Control Centers, a center must meet specified standards, including accessibility to callers 24 hours every day and multiple language capabilities.
Unfortunately, many parents do not utilize PCCs for unintentional poisoning incidents involving children. Previous studies by Kelly et al7,8 revealed that in an urban Texas community, PCCs were underutilized by low-income minority and Spanish-speaking parents. This underutilization was not simply attributable to lack of knowledge about the PCC but to certain misconceptions about it. Parents were unsure of staff qualifications, unclear of the realm of products for which the PCC could offer advice, and, in general, believed that speaking to a physician was preferable. Parents were concerned about the possibility of being reported for neglecting their children. Spanish-speaking parents feared a language barrier. Many parents suggested that they did not feel confident that they could carry out the recommendations of the PCC in a stressful situation and would prefer to call 911 or go to the emergency department.
To address the barriers identified in previous research,7,8 we created a brief videotape intervention, targeted to low-income minority and Spanish-speaking mothers, designed to improve their knowledge, attitudes, and behaviors concerning the PCC. Our video intervention was tested in a culturally diverse, low-income, predominantly Spanish-speaking population in Northern California.
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DESIGN AND METHODS |
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TOPABSTRACTINTRODUCTIONDESIGN AND METHODSRESULTSDISCUSSIONCONCLUSIONREFERENCES |
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We conducted a randomized, controlled trial over a 4-month period at 2 Women, Infant, and Children (WIC) clinics, both located in San Mateo County in Northern California. Participants were parents of young children (age range: 15 months to 6 years), who were scheduled to attend an educational class at 1 of the 2 WIC clinics. Forty-three classes were randomized to either a treatment group or a control group using a random numbers table. This study was approved by the Institutional Review Board of Stanford University and by the San Mateo County Health Services Agency.
At the beginning of each class session, a bilingual research assistant invited all eligible parents or relatives to participate in the study. To be eligible, a participant was required to live in the same home with a WIC-enrolled child <6 years of age, and to be able to speak the language in which the class was to be conducted (English or Spanish). Parents were asked to complete a preintervention questionnaire, to attend the entire class session, and to complete a follow-up telephone interview within approximately 1 month. An incentive of $10 was offered for completion of the first questionnaire and class session, and an additional $10 was offered after the completion of the follow-up telephone interview. After written consent was obtained, all participants completed a 5-page multiple choice and fill-in-the-blank baseline questionnaire. Because of the low literacy level of many of the parents, the questionnaire was read aloud to the class so parents could follow along. The research assistant and WIC staff assisted illiterate parents by transcribing their answers onto questionnaires.
After completion of the baseline questionnaire, groups were managed as follows: Participants in the treatment groups viewed the educational video and were given a PCC pamphlet and 2 stickers with the PCC phone number (see description of intervention). There was no discussion after the video, and all questions were deferred until after the follow-up telephone interview. Participants assigned to the control groups attended the regularly scheduled educational classes prepared by WIC. During the study period, control classes were presented on immunizations and healthy snacks.
Approximately 2 to 4 weeks later (postintervention), each participant was contacted by telephone and asked to respond verbally to the same questions included in the baseline questionnaire. A bilingual research assistant conducted all follow-up interviews and was blinded as to whether a participant was in the treatment group or control group.
Intervention
The intervention included an educational videotape, a PCC pamphlet, and PCC stickers. The videotape "Making the Right Call: The Poison Control Center" was created by the first author (N.R.K.) and colleagues.9 It is 9 minutes in duration and is available in English and Spanish versions. It includes general information about the function of the PCC, its hours of operation, and the qualifications of the staff. Testimonials from a culturally diverse group of physicians, PCC staff members, and mothers are included. The Spanish video was filmed with Spanish dialogue and minimal "voice-over" for the English-speakers.
In addition to the testimonials, 2 poisoning scenarios are dramatically reenacted. In the first poisoning scenario, a Hispanic mother finds her child wet and crying after knocking over a bucket of household bleach and fears she has swallowed some bleach. She calls the PCC and is guided through a short series of questions, advised of appropriate home management, and reassured that the child does not need to go to the emergency department. In the second poisoning scenario, an African American mother discovers that her child has taken one of his grandmother’s anti-hypertensive pills. She calls the PCC and is appropriately advised to take her child immediately to the emergency department for evaluation. Using this format, mothers model the desired behavior of calling the PCC and the staff demonstrate, in a helpful and caring manner, their expertise in handling poisoning situations. The use of bilingual Hispanic video participants was included to enhance the effects of the modeling for Hispanic viewers.
The pamphlet used in the intervention was designed by the California Poison Control System and is available in English and Spanish versions. It includes basic information about the PCC and poison prevention, and it lists potentially poisonous products found in most households. It briefly discusses poisonous plants and the use of syrup of ipecac to induce vomiting when appropriate.
The PCC stickers display the toll-free telephone number and are to be placed on or near the home telephone for easy accessibility. At the time of this study, the stickers displayed the statewide toll-free number for callers in California. However, as of January 2002, there is a national toll-free telephone number (1–800-222–1222), which can be accessed from anywhere in the United States.
Questionnaire
A 30-item questionnaire was developed for this study. It assessed demographic information, knowledge, attitudes, behaviors, and behavioral intentions regarding the PCC.
Knowledge questions such as "What are the hours the Poison Control Center is open?" were asked in a yes/no or multiple-choice format. Attitude questions such as "How likely is it that a mother will be reported for neglecting her child if she calls the Poison Control Center?" were asked using 5-point Likert-type scale format. Behavior questions were in a yes/no format, such as "Do you have the Poison Control Center number posted in your home?" Finally, to assess behavioral intent, parents were presented with 8 emergency scenarios and asked to identify what a parent should do first in each situation. For each scenario, parents were given the following choices: 1) go to the emergency department, 2) call 911, 3) call the PCC, 4) wait to see if anything happens to the child, 5) call the doctor, or 6) "other," with space to write their own response. Four poisoning scenarios involved children who were exposed to or ingested specific substances: household bleach, an anti-hypertensive medication, a household plant, and over-the-counter cough syrup. A general poisoning scenario was included in which participants were asked what a parent should do if he/she thinks a child has eaten "something poisonous." To assess whether participants knew that the PCC can communicate to the public in multiple languages, they also were asked what a parent should do if he/she thinks a child has eaten "something poisonous" and this parent only speaks Spanish. Two nonpoisoning emergency scenarios also were included—a child who was cut by a rock and is bleeding and a child who is choking on a piece of candy.
Data Analysis
Multiple choice and yes/no questions were coded as "0" if incorrect and "1" if correct. Attitude questions were coded on a 5-point Likert-type scale from -2 (least desirable response) to + 2 (most favorable response). Treatment and control groups were assessed for baseline differences by comparing mean scores using the Student t test for continuous variables and 
2 tests for categorical variables. Mean scores were calculated for the categories of knowledge, attitudes, behaviors, and behavioral intent by summing the scores of all questions in each category for each participant. We then calculated the differences in scores from baseline to posttest (change scores) for each category of questions and compared the mean changes between treatment and control groups using analysis of variance. Effect sizes are reported as mean treatment-control differences and their 95% confidence intervals. To reduce the risk of type 1 error from multiple testing, statistical tests of differences between the treatment and control groups were only performed on the summed category index scores.
The primary analyses were conducted with individual as the unit of analysis. Although participants were randomized in groups (classes) and the intervention was delivered in a group setting, this was done to facilitate implementation in the real world WIC setting, to maximize the generalizability of the results. The intervention included no group discussion during or after the video. Any questions about the videotape were deferred until after the follow-up interview was completed. Therefore, we performed these analyses under the assumption of no within-group correlation of responses (people within the same group are no more likely to respond the same as people in different groups). To check the validity of this assumption, we also repeated the same outcome analyses with class as the unit of analysis.
As a secondary analysis, adjusting for demographic variables that differed between groups at baseline, we repeated the individual-level outcome analysis including these variables as covariates. All analyses were performed according to intention-to-treat principles. All randomized participants were included in the analysis according to the treatment group they were originally assigned, irrespective of dropout or any other intercurrent events. Participants with some missing data at follow-up were conservatively assumed to have an incorrect answer, or, for Likert scale questions, a neutral score of zero. Alpha = 0.05 was the criterion for statistical significance for all analyses.
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RESULTS |
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TOPABSTRACTINTRODUCTIONDESIGN AND METHODSRESULTSDISCUSSIONCONCLUSIONREFERENCES |
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Approximately 91% of eligible parents agreed to participate. Of the 323 participants at baseline, 289 (89%) also were assessed at follow-up. Of the 34 not assessed at follow-up, 7 had no phone and 27 were unable to be reached (not at home, moved, or otherwise lost to follow-up). There were no significant demographic differences between participants who were followed-up and those who were not followed-up. There were 43 class sessions conducted and of these, 23 were randomized to control and 20 were randomized to treatment classes. Most classes were held in the morning and the mean ± standard deviation class size was 6.7 ± 3.4. There were no differences between treatment and control groups in terms of class size or time of day class was held.
Demographics
Of the 289 participants who were assessed at follow-up, there were 144 in the control group and 145 in the treatment (video) group. Because of occasional missing data, baseline analysis samples ranged from 282 to 289. Group characteristics are reported in Table 1. There were no significant differences between treatment and control groups for most demographic variables. However, control group participants were more likely to be English speakers or bilingual (>80% of bilinguals spoke English and Spanish) and reported completing more school, and although the vast majority of participants in both groups were mothers, there were 8 fathers in the control group and none in the treatment group.
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Baseline Comparisons
There were no significant differences between control and treatment groups at baseline for knowledge, attitudes, or behaviors scores (Table 2). There was a small, but statistically significant difference between control and treatment groups for the behavioral intent score.
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Change Comparisons
Changes in Knowledge
Changes from baseline to posttest in the treatment and control groups are shown in Table 2, including analysis of variance results for individuals as the unit of analysis and for class as the unit of analysis. The treatment group showed greater improvement for all 4 knowledge questions regarding the PCC. There was only a slight increase in the number of participants in either group who answered the ipecac question correctly at posttest. Changes in knowledge scores were significantly greater in the treatment group than the control group.
Changes in Attitudes
The treatment group also demonstrated significantly improved attitudes regarding the PCC in response to the intervention. Video viewers tended to report an increased comfort level for talking with the PCC staff and carrying out their recommendations after watching the video. In addition, they were less likely to believe the PCC would report a mother for neglecting her child.
Changes in Behaviors
After the intervention, treatment group participants increased their mean behavior score significantly more than the control group. There seemed to be little change for either group for having ipecac at home. However, there was a marked increase in the number of participants in the treatment group who stated that they had the PCC phone number posted at home. To verify that parents did indeed have the PCC number at their home, they were asked to read the phone number back to the interviewer at the time of the posttest. Sixty-three percent of treatment group participants were able to give the correct phone number to the interviewer at posttest, compared with only 19% of control group participants (P < .001).
Changes in Behavioral Intent
For the 8 emergency scenarios, the treatment group significantly increased their correct responses by 
2 answers more than the control group. For all the poisoning scenarios (except the situation in which a mother believes her child has eaten "something poisonous"), at least twice as many treatment group participants answered correctly at posttest compared with baseline.
To check the validity of our assumption of no nonzero correlation of responses within groups, we repeated the same outcome analyses with class as the unit of analysis (treatment, N = 20; control, N = 23). The effect size estimates (differences between groups) were similar with slightly wider confidence intervals (CIs), as would be expected for the smaller sample size, but all treatment versus control differences remained statistically significant at P < .001 (Table 2). Therefore, our assumption proved correct and the conclusions are the same for both analyses.
Secondary Analyses
Analyses were repeated including demographic variables as covariates, to adjust for potential differences between groups. The results did not change when gender, education, language in which class was conducted, and language spoken at home were included as covariates. For knowledge, the mean change score was 1.03 (95% CI: 0.73- 1.33). The mean change score for attitudes was 1.59 (95% CI: 1.05–2.13). For behaviors, the mean change score was 0.57 (95% CI: 0.44–0.70), and for behavioral intent scenarios, the mean change score was 2.13 (95% CI: 1.72–2.54). These differences all remained statistically significant at P < .001.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONDESIGN AND METHODSRESULTSDISCUSSIONCONCLUSIONREFERENCES |
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This study demonstrates that a brief videotape-based intervention can improve knowledge, attitudes, behaviors, and behavioral intentions regarding use of the PCC among low-income and Spanish-speaking parents. Previous studies indicated that low-income and Spanish-speaking parents in an urban Texas community may have been underusing the poison center for unintentional poisoning incidents involving children because of lack of knowledge of the PCC, misperceptions about the qualifications of the staff and accessibility for those not speaking English, fear of perceived neglect, and insecurity in carrying out the PCC’s recommendations.7,8 Baseline data obtained from the current study showed low-income parents in Northern California also have little knowledge about the center. At baseline, less than half of participants in both groups stated that they knew about the PCC and only about one-third stated that they had the phone number at their home. However, after receiving the intervention, significant increases were found in parents’ knowledge, attitudes, behaviors, and behavioral intentions concerning the PCC when compared with the control group. Having basic knowledge about the existence of the center and its functions obviously is essential to making a decision to use it. There tended to be only minimal improvement for the question concerning the use of syrup of ipecac. Syrup of ipecac was not discussed in the video, but was described in the pamphlet that was given to video viewers only. This question was intended to help us determine whether watching the video motivated parents to read the pamphlet that was given to them. Our findings suggest that parents may not have read the pamphlet, or that the pamphlet was less effective for improving knowledge. Because of the low literacy level of our participants, we believe the more likely explanation is the parents did not or could not read the pamphlet. This was one of the reasons we chose the video medium for our intervention.
Parents’ self-reported attitudes also were changed by the intervention. Those who viewed the video were more likely to feel comfortable talking with someone at the PCC and following their recommendations, and were less likely to believe the center would report a mother for neglect compared with parents who did not view the video. In a previous study, these were specific issues raised by parents as contributing to under-utilization of the PCC.8 According to the Theory of Reasoned Action, the strength of a person’s intent to perform a health behavior is related in part to his/her attitudes toward that health behavior.10 In addition, the Health Belief Model proposes that to effect a behavior change, one must believe the benefits of the behavior change outweigh any barriers.11 Thus, if a parent has a positive attitude concerning a potential interaction with the PCC, the likelihood of that parent calling the center for help may be increased.
In terms of actual behavior change, we found the treatment group had a remarkable improvement in the number of parents who reported to have the PCC number posted at home compared with the video group (82% vs 33%) after the intervention. We were able to verify this by asking the parent to read the phone number back to the interviewer. A significantly greater number of parents in the treatment group gave the correct phone number compared with the control group (63% vs 19%, P < .001). This finding shows that the intervention was successful in eliciting true behavior change. Parents in the treatment group were given a PCC sticker displaying the toll-free number at the end of the class session. Thus, parents who were able to correctly provide the interviewer with the number had most likely placed the sticker somewhere convenient to the telephone as they were instructed. This is potentially a very important behavior, because the likelihood that a parent will call the PCC in the event of a poisoning emergency should be increased if the phone number is readily available.
There was no increase in the number of parents having syrup of ipecac in the home after the intervention. Syrup of ipecac was not given to parents at the end of the class session. Thus, a parent would have had to learn about syrup of ipecac by reading the pamphlet, and also would have had to purchase it. Cost and insufficient time to obtain syrup of ipecac may have been barriers for this low-income group of parents.
In evaluating responses to the poisoning scenarios, we found a dramatic difference between groups after the intervention. Video viewers increased their number of correct responses an average of >2 of 8 total, compared with the control group participants. For 4 of 6 poisoning scenarios, there were twice as many participants in the treatment group who answered correctly to "Call the Poison Control Center" at posttest compared with the control group. At baseline, just over half of both groups reported that one should call the PCC for "something poisonous," and thus, there was relatively less room for improvement for this question. It seems the video also successfully clarifies that the PCC can effectively communicate with persons speaking languages other than English, as illustrated by the increase in correct answers for the scenario involving "something poisonous" and the mother only speaks Spanish. In addition, parents were able to generalize the information presented in the video scenarios (involving bleach and an anti-hypertensive medication) to other potential poisoning situations (household plant and over-the-counter cough syrup).
As measures of behavioral intent, results from the hypothetical scenario questions are expected to predict whether or not a parent will actually use the PCC in the event of a poisoning emergency.10 However, a much larger sample size and much longer study would be required to assess actual PCC use.
Despite randomization, there were some minor demographic differences between the treatment and control groups. The control group included more participants who were male, bilingual, or English-speaking, and had a higher mean educational level than the treatment group. We addressed this potential imbalance by performing a secondary analysis, including these variables as covariates. The results did not change when adjusting for these baseline differences in demographic variables. Baseline behavioral intent scores were also significantly different between control and treatment groups. Interestingly, the control group had a slightly higher mean baseline score than the treatment group. However, the large improvements in the treatment group dwarfed these baseline differences, and argue against regression to the mean, scaling, and other potential alternative explanations of our findings.
One of the important strengths of our study is its potential generalizability. We wanted to test our intervention just as it would be used in the community. We selected WIC as the setting because it serves predominantly a low-income and lower-literate population and clients are required to periodically attend educational classes. Our intervention was substituted into WIC’s existing educational curriculum during the study period with minimal disruption to the clinic. The randomized, clinical trial design and the conservative intention-to-treat analysis provide strong internal validity for the study, and thus, the ability to confidently attribute the observed changes to the intervention.
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CONCLUSION |
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TOPABSTRACTINTRODUCTIONDESIGN AND METHODSRESULTSDISCUSSIONCONCLUSIONREFERENCES |
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This brief and relatively low-cost video intervention was highly effective in changing knowledge, attitudes, actual behaviors, and behavioral intentions concerning the PCC within this low-income and predominantly Spanish-speaking population. These results suggest that this intervention approach may be effective if used nationwide in WIC, Head Start, and other programs and/or agencies that have contact with parents and caregivers of young children. We believe these are important steps toward the ultimate goal of increasing appropriate use of the PCC and decreasing unnecessary medical facility visits for minor poisoning incidents.
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ACKNOWLEDGMENTS |
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This study was supported by the Child Health Research Fund at Stanford University School of Medicine and by a gift from the California Poison Control System, San Francisco Division.
We thank the following organizations who funded the production of the videotape, "Making the Right Call: The Poison Control Center": Southeast Texas Poison Center, Texas Advisory Commission on State Emergency Communications, Texas Department of Health and Baylor College of Medicine. This video may be purchased by contacting the first author at the following address: Nancy R. Kelly, MD, MPH, Texas Children’s Hospital, 6621 Fannin St, Suite 1540, Mail Code 1540.00, Houston, TX 77030.
We also thank Jennifer R. Najera, MA, and Elise Stone, MS, CHES, for their significant contributions to this project. We greatly appreciate the Redwood City and San Mateo WIC clinics’ staff and clients for making this study possible.
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FOOTNOTES |
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Received for publication Feb 7, 2002; Accepted Jun 6, 2002.
Address correspondence to Nancy R. Kelly, MD, MPH, Texas Children’s Hospital, 6621 Fannin St, Suite 1540, Mail Code: 1540.00, Houston, TX 77030. E-mail: nkelly{at}bcm.tmc.edu
Dr Kelly is currently at Baylor College of Medicine, Houston, Texas.
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REFERENCES |
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TOPABSTRACTINTRODUCTIONDESIGN AND METHODSRESULTSDISCUSSIONCONCLUSIONREFERENCES |
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- Litovitz TL, Klein-Schwartz W, White S, et al. 2000 annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med.2001; 5 :337 –395
- King WD, Palmisano PA. Poison control centers: can their value be measured? South Med J.1991; 84 :722 –726[Web of Science][Medline]
- Chafee-Bahomon C, Lovejoy FH. Effectiveness of a regional poison center in reducing excess emergency room visits for children’s poisonings.
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[Abstract/Free Full Text] - Yamamoto JG, Wiebe RA, Matthews WJ. Toxic exposures and ingestions in Honolulu: I. A prospective pediatric ED cohort; II. A prospective poison center cohort. Pediatr Emerg Care.1991; 7 :141 –148[Medline]
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- American Association of Poison Control Centers. Criteria for certification of poison centers and poison center systems. September 1998. Available at: http://www.aapcc.org/certcrit_new.htm. Accessed May 21, 2002
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PEDIATRICS (ISSN 1098-4275). ©2003 by the American Academy of Pediatrics
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