A survey of poison center knowledge and utilization among urban and rural residents of Arizona.

BACKGROUND: Poison control centers (PCCs) hold great potential for saving health care resources particularly by preventing unnecessary medical evaluations. We developed a survey to better identify the needs and experiences of our service community. We hope to use these data to improve PCC outreach education and overall use of our services.
METHOD: A written questionnaire was developed in English and then translated into Spanish. Subjects agreeing to participate were then asked two verbal questions in English: are you at least 18 years of age? And; in what language would you like to complete the questionnaire; English or Spanish? All questionnaires completed by subjects ≥18 years of age were included. Questionnaires with missing responses, other than zip code, were included. Data collected include gender, age, zip code, primary language, ethnicity, education, health insurance status and experiences with the PCC. Subjects were not compensated for participation. Arizona zip codes were divided into "rural" or "urban" based on a census data website. Percentages and odds ratios were determined based on completed responses. Smaller subgroups, for some variables, were combined to increase sample sizes and improve statistical relevance.
RESULTS: Overall, women and subjects with children at home (regardless of ethnicity) were significantly more likely to have heard of the PCC although Blacks and Spanish-speakers were significantly less likely to have heard of the PCC. Similarly, respondents with children at home and those reporting a prior home poisoning (regardless of ethnicity) were significantly more likely to have called the PCC. Blacks were significantly less likely to have called the PCC. These findings were similar among people living in urban zip codes but not statistically significant among rural responders.
CONCLUSIONS: Based on a small survey, race and language spoken at home were variables identified as being associated with decreased awareness of poison centers. Focusing on these specific groups may assist in efforts to increase PCC penetrance, particularly among urban communities.

Background

In 2012, U.S. poison control centers (PCCs) handled over 3.3 million calls related to poisonings, drug information and environmental exposures (e.g. envenomations), including over 2.2 million human exposure [1]. Almost 94% of human exposures occurred at a residence, 80.1% were unintentional events and 69.2% were managed on site without referral to a health care facility. These numbers and percentages are similar to recent years [2].

Our PCC serves approximately four million residents of Maricopa County, Arizona. This area is dominated by the metropolitan area of Phoenix but also includes numerous rural areas and Native American communities. Our center routinely conducts quality assurance surveys to identify the needs of our community. We ask callers several questions related to our services including: caller satisfaction, insurance status and alternative plans if their PCC call went unanswered. This effort has identified potential barriers that may adversely affect awareness of our services. Previous work at another PCC suggested that increased self-referrals for evaluation of poison exposures among rural residents may be associated with decreased PCC awareness [3].

We therefore conducted a survey of the general public in our calling area to better identify barriers to PCC utilization. Our objective was to compare characteristics of urban and rural laypersons’ knowledge and experiences with a single regional PCC. We hope this data will assist with effective improvements in outreach efforts to our underserved areas and increase penetrance of other public health resources.

Method

A written questionnaire was developed (in English and Spanish) to evaluate the knowledge and use of a regional PCC by individuals living in urban and rural communities (Supplement figure). A trial of several test subjects was conducted to test the questionnaire. These test data did not affect the questionnaire or our interview method, and were not included in the final analysis.

Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.toxrep.2014.12.001.

Supplementary Fig. S1 The Questionnaire (English version).

A trained member of the study team recruited subjects in ten public venues (e.g. open markets, post offices, community gatherings) in both urban and rural areas within Maricopa County. Subjects were asked to participate in the study and were read a brief, scripted introduction. Those agreeing to participate were then asked two questions: “Are you at least 18 years of age?” and “In what language would you like to complete the questionnaire; English or Spanish?” Subjects not willing or able to answer these two questions in English were excluded.

A questionnaire in Spanish was translated from the English version by a certified (CyraCom®) translator. A study member handed out appropriate questionnaires and verbally clarified any specific questions in English. Data collected include gender, age, zip code, primary language, ethnicity, education, health insurance status and experiences with the PCC. Subjects were not compensated for participation. All forms completed by subjects ≥18 years of age were included. Questionnaires with missing responses, other than zip code, were included.

The division of Arizona zip codes into “rural” or “urban” classification was completed, a priori, using the State of Missouri Census Data Center's zip code tabulation area [4].

Primary data used to separate subjects were the reported zip codes. Secondary data included age, gender, education, primary language, health insurance status, history of PCC-related illness or injury, PCC utilization and awareness of the toll free PCC number. A preliminary review of answers to several questions identified limitations which prevented their inclusion in formal analysis; see below.

After dividing subjects into urban or rural zip code groups, the predictors for two questions (“Have you heard of the PCC?” and “Have you ever called the PCC?”) were analyzed using the following variables: gender, age, primary language, ethnicity, education, health insurance status, children at home, distance from an ED and history of a previous household poisoning.

Descriptive statistics (percentages) were used to report subgroups and responses. Odds ratios (ORs) were determined for variables related to PCC knowledge and utilization. These ORs were reported for rural and urban respondents. The study protocol and both versions of the questionnaire were approved by our local institutional review board.

Results

A total of 330 subjects were enrolled and completed the questionnaire. Of these, 307 (93%) surveys were completed in English. Respondents were primarily from urban zip codes (n = 253; 76.6%) and women (n = 204; 61.8%). Subject demographics are shown in Table 1. No questionnaires were excluded for any reason.

Table 1

Respondents’ demographics (n = 330).

Variable	Combined	Urban	Rural
	(n = 330; total %)	(n = 253; group %)	(n = 77; group %)
Gender	Male = 125 (37.9)	Male = 92 (36.4)	Male = 33 (42.9)
	Female = 204 (61.8)	Female = 160 (63.2)	Female = 44 (57.1)
	No answer = 1 (0.3)	No answer = 1 (0.4)
Age (years)	18–24 = 58 (17.6)	18–24 = 44 (17.4)	18–24 = 14 (18.2)
	25–30 = 31 (9.4)	25–30 = 30 (11.9)	25–30 = 1 (1.3)
	31–40 = 58 (17.5)	31–40 = 53 (20.9)	31–40 = 5 (6.5)
	41–50 = 55 (16.7)	41–50 = 42 (16.6)	41–50 = 13 (16.8)
	51–60 = 39 (11.8)	51–60 = 20 (7.9)	51–60 = 19 (24.7)
	>60 = 89 (27.0)	>60 = 64 (25.2)	>60 = 25 (32.5)
Primary language spoken at home	English = 265* (80.3)	English = 196 (77.5)	English = 69 (89.6)
	Spanish = 31 (9.4)	Spanish = 29 (11.5)	Spanish = 2 (2.6)
	Eng/Span = 31** (9.4)	Eng/Span = 25 (9.9)	Eng/Span = 6 (7.8)
	No answer = 3 (0.9)	No answer = 3 (1.1)
Ethnicity	AI/AN = 6 (1.8)	AI/AN = 4 (1.6)	AI/AN = 2 (2.6)
	Asian = 9 ()	Asian = 8 (3.1)	Asian = 1 (1.3)
AI = American Indian	Black/AA = 36 (10.9)	Black/AA = 35 (13.8)	Black/AA = 1 (1.3)
AN = Alaskan Native	Hispanic = 68 (20.6)	Hispanic = 60 (23.7)	Hispanic = 8 (10.4)
AA = African American	NH/PI = 2 (0.6)	NH/PI = 1 (0.4)	NH/PI = 1 (1.3)
NH = Native Hawaiian	White = 190 (57.6)	White = 132 (52.2)	White = 58 (75.3)
PI = Pacific Islander	2+ races = 16 (4.8)	2+ races = 10 (3.9)	2+ races = 6 (7.8)
	No answer = 3 (0.9)	No answer = 3 (1.2)
Level of education	Some HS = 19 (5.8)	Some HS = 14 (5.5)	Some HS = 5 (6.5)
	HS = 73 (22.1)	HS = 53 (20.9)	HS = 20 (26.0)
HS = High school	TS = 23 (6.9)	TS =16 (6.3)	TS = 7 (9.0)
TS = Trade school	College = 92 (27.8)	College = 73 (28.9)	College = 19 (24.7)
CG = College graduate	CG = 81 (24.5)	CG = 61 (24.1)	CG = 20 (26)
	Grad School = 42 (12.7)	Graduate = 36 (14.2)	Graduate = 6 (7.8)
Kids <18 YO at home	No = 205 (62.1)	No = 149 (58.9)	No = 56 (72.7)
	Yes = 119 (36.1)	Yes = 98 (37.5)	Yes = 21 (27.3)
	No answer = 6 (1.8)	No answer = 6 (2.4)
Distance to nearest hospital (miles)	<1 = 40 (12.1)	<1 = 36 (14.2)	<1 = 4 (5.2)
	1 to 5 = 150 (45.5)	1 to 5 = 133 (52.5)	1 to 5 = 17 (22.1)
	5 to 10 = 75 (22.7)	5 to 10 = 62 (24.5)	5 to 10 = 13 (16.9)
	>10 = 52 (15.8)	>10 = 13 (5.1)	>10 = 39 (50.6)
	Unknown = 11 (3.3)	Unknown = 7 (2.8)	Unknown = 4 (5.2)
	No answer = 2 (0.6)	No answer = 2 (0.8)

9 subjects reported English and: Ibo (3); Tagalog (3): Filipino (1); Vietnamese (1); Ukrainian (1).

3 subjects reported a 3rd language: Tagalog (1); Navajo (1).

The distributions of responses to each question (variable) are reported in Table 2 (combined data for all zip codes) and Table 3 (separated into urban and rural subgroups). Responses to study questions were not provided on 37 (0.86%) out of 4290 included data points. Overall, 78% had heard of the PCC and 17% had called the PCC.

Table 2

Combined responses to analyzed questions.

Variable (n = responses with data)	Number (percentage) [Comments]
Zip codes (n = 330)	Urban: 253 (76.7)
	Rural: 77 (23.3)
Have you heard of the PCC (n = 328)	No: 72 (22)
	Yes: 256 (78)
Have you called the PCC (n = 326)	No: 272 (83.4)
	Yes: 54 (16.6)
Ethnicity (n = 327)	AI/AN/Asian/NH/PI/2+: 33 (10.4)Black: 36 (10.9)Hispanic/Latino: 70 (20.7)*White: 188 (57.9)*
Highest level of education (n = 330)	Some high school: 19 (5.8)High school Graduate or trade school: 96 (29.0)College (with or without graduating): 173 (52.4)Graduate School: 42 (12.7)
Do you have health insurance (n = 325)	No: 76 (23.4)
	Yes: 249 (76.6)
Children < 18 YO at home (n = 324)	No: 205 (63.3)
	Yes: 119 (36.7)
	111 of the “yes” responses reported ages: <6 YO = 27 (24.3)
	6–18 YO = 84 (75.7)
Distance to nearest hospital (in miles; n = 317)	<1: 40 (12.6)
	1–5: 150 (47.3)
	5–10: 75 (23.7)
	>10: 52 (16.4)
Have you or a household member been poisoned (n = 329)	No: 264 (80.2)
	Yes: 65 (19.8)

Subjects reporting 2+ ethnicities were assigned to either White or Hispanic.

Table 3

Urban compared to rural responders for other reported variables.

Variable	Urban (n = 253)	Rural (n = 77)
Do you have health insurance	No = 63 (24.8)	No = 13 (17.1)
	Yes = 187 (73.6)	Yes = 62 (81.6)
	No answer = 4 (1.6)	No answer = 1 (1.3)
Yes: children <18 YO at home	Yes = 98 (38.7)	Yes = 18 (23.3)
Children <6 YO	55 (21.7)	5 (6.5)
Children 6–18 YO	40 (15.8)	13 (16.9)
No answer	3 (1.2)	–
History of household poisoning	No = 205 (81.0)	No = 61 (79.2)
	Yes = 48 (19.0)	Yes = 16 (20.8)
Have you heard of the PCC	No = 59 (23.3)	No = 13 (16.9)
	Yes = 192 (75.9)	Yes = 64 (83.1)
	No answer = 2 (0.8)
Have you ever called the PCC	No = 209 (82.6)	No = 63 (81.8)
	Yes = 40 (15.8)	Yes = 14 (18.2)
	No answer = 4 (1.6)
Knew the PCC phone number	17 (6.7)	3 (3.9)

As shown in Table 4a, overall, women and respondents with children at home were significantly more likely to have heard of the PCC (OR = 2.18, 95% CI: 1.12–4.22 and OR = 2.90, 95% CI: 1.27–6.59 respectively). However, Blacks and Spanish-speakers were significantly less likely to have heard of the PCC (OR = 0.28, 95% CI: 0.09–0.81 and OR = 0.06, 95% CI: 0.01–0.32; respectively). In fact, Blacks were 72% less likely to have heard of the PCC compared to Whites, and Spanish-speakers were 94% less likely to have heard of the PCC compared to English-speakers. Similarly, as shown in Table 4b, Blacks were significantly less likely to have called the PCC (OR = 0.14, 95% CI: 0.02–0.71). Respondents with children at home and those reporting a prior poisoning at home were significantly more likely to have called the PCC (OR = 5.50, 95% CI: 2.38–12.69 and OR = 8.48, 95% CI: 3.76–19.10; respectively). As shown in Tables 4c and 4d, these findings were similar among people living in urban zip codes. For example, Spanish-speakers and Blacks were significantly less likely to have heard of the PCC, while women and respondents with children at home were significantly more likely to have heard of the PCC (Table 4c).

Table 4

Odds rations for knowledge and use of the poison center.

Variable	Odds ratio	95% confidence interval
(a) Overall (combine data): have you heard of the poison control center
Rural zip code	1.02	0.41–2.52
Female gender*	2.18	1.12–4.22
Age > 24 years	0.82	0.66–1.00
Primary language
Spanish	0.06	0.01–0.32
English and Spanish	0.27	0.057–1.25
Ethnicity
Native/Asian/Islander	0.86	0.23–3.07
Black	0.28	0.09–0.81
Hispanic	0.47	0.10–2.10
High school graduate or beyond	0.98	0.61–1.55
Have health insurance	1.76	0.76–4.04
Kids < 18 at home	2.90	1.27–6.59
More than 1 mile to nearest hospital	0.92	0.61–1.37
Prior poisoning at home	2.38	0.92–6.13
(b) Overall (combined data): have you called the poison control center
Rural zip code	1.00	0.40–2.47
Female gender	1.99	0.92–4.24
Age > 24 years	1.17	0.92–1.47
Primary language
Spanish	0.17	0.011–2.52
English and Spanish	1.13	0.15–8.03
Ethnicity
Native/Asian/Islander	0.40	0.12–1.32
Black	0.14	0.02–0.71
Hispanic	0.46	0.09–2.32
High school graduate or beyond	1.14	0.69–1.87
Have health insurance	0.87	0.33–2.28
Kids < 18 at home	5.50	2.38–12.69
More than 1 miles to nearest hospital	0.95	0.61–1.49
Prior poisoning at home	8.48	3.76–19.10
(c) Urban zip codes: have you heard of the poison control center
Female gender	2.25	1.05–4.79
Age > 24 years	0.88	0.70–1.10
Primary language
Spanish	0.06	0.00–0.36
English and Spanish	0.43	0.08–2.19
Ethnicity
Native/Asian/Islander	0.77	0.16–3.50
Black	0.30	0.10–0.86
Hispanic	0.42	0.08–2.12
High school graduation or beyond	1.09	0.64–1.84
Have health insurance	1.61	0.64–4.00
Kids < 18 at home	2.93	1.19–7.19
More than 1 mile from nearest hospital	0.88	0.53–1.43
Prior poisoning at home	1.96	0.66–5.76
(d) Urban zip codes: have you called the poison control center
Female gender	2.28	0.90–5.76
Age > 24 years	1.15	0.88–1.49
Primary language
Spanish	1.10	0.03–34.19
English and Spanish	7.56	0.46–122.77
Ethnicity
Native/Asian/Islander	0.12	0.01–0.72
Black	0.14	0.02–0.68
Hispanic	0.07	0.00–1.08
High school graduation or beyond	1.48	0.81–2.66
Have health insurance	0.71	0.21–2.36
Kids < 18 at home	5.02	1.93–13.00
More than 1 mile from nearest hospital	0.85	0.47–1.53
Prior poisoning at home	5.56	−14.73
(e) Rural zip codes: have you heard of the poison control center
Female gender	2.68	0.45–15.92
Age > 24 years	0.34	0.10–1.05
Primary language
Spanish#	N/A	–
English and Spanish	N/A	–
Ethnicity
Native/Asian/Islander	0.84	0.06–10.65
Black	N/A
Hispanic	N/A	–
High school graduation or beyond	1.07	0.25–4.51
Have health insurance	9.39	0.35–249.49
Kids < 18 at home	7.52	0.24–228.49
More than 1 mile from nearest hospital	0.56	0.18–1.68
Prior poisoning at home	9.53	0.48–185.87
(f) Rural zip codes: have you called the poison control center
Female gender	3.59	.53–23.96026
Age > 24 years	2.30	.98–5.393063
Primary language
Spanish	N/A
English and Spanish	N/A
Ethnicity
Native/Asian/Islander	0.93	.09–9.310166
Black	N/A	–
Hispanic	15.08	.3159136–720.0969
High school graduation or beyond	0.38	.0834443–1.766269
Have health insurance	3.74	.3612698–38.79639
Kids < 18 at home	N/A	–
More than 1 mile from nearest hospital	1.37	.39–4.78
Prior poisoning at home	ID	–

N/A: insufficient data for analysis.

bold: statistically significant results.

In addition, among people living in urban zip codes, Native Americans/Asians and Blacks were less likely to have called the PCC (Table 4d). Subjects with children at home and those reporting previous home poisonings were significantly more likely to have called the PCC (OR = 5.02, 95% CI: 1.93–13.00 and OR = 5.56, 95% CI: 2.09–14.73; respectively).

These findings were similar among rural zip code respondents but given the small sample size were not statistically significant (Tables 4e and 4f).

Discussion

Previous research has shown that PCCs save health care resources by preventing unnecessary emergency department (ED) visits and decreasing lengths of hospital stay [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16]. Other work has demonstrated that targeted outreach activities increase PCC utilization [17]. Data suggest that the introduction of a national toll-free telephone number (800-222-1222) for access to PCC services resulted in increased calls, particularly from rural areas [18]. Increasing the knowledge and use of US regional PCCs will inevitably save health care resources.

These results identified several demographic variables (race and language spoken at home) that were associated with decreased knowledge about, and use of, our poison center. The variables identifying current non-users of our services were further differentiated by rural or urban zip code assignment. Using this information should help develop targeted interventions to increase PCC utilization by the identified segments of our service area with low penetrance. Our next steps are to study the effects of structured outreach education on specific focus groups, and to develop interventions that improve penetrance.

There are several limitations of this study including small sample size (particularly among the rural group) and no standardization for subject recruitment (manner or place). The survey was conducted in a single metropolitan area with three groups of residents (English-speaking whites, English speaking Hispanics and non-English speaking Hispanics) that limit external validity. Lastly, several open-ended questions (e.g. “What do you consider poison-related injuries?”) produced varied answers and were not analyzed as independent variables.

Conclusions

Based on a small survey of Arizona residents, several variables were identified as being associated with either increased or limited awareness of our regional poison control center. Focusing interventions toward specific ethnic groups and Spanish-speakers may assist with increasing the penetrance of our poison center among rural and urban communities.

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