Public
Health Briefs Validation of a Poison Prevention Program BARBARA T. BRADEN
Abstract: The effectiveness of an empirically designed poison warning label and an educational program for three and four year old children was assessed in four groups of 39 such children, with one group serving as a control. The educational program appeared to improve intellectual (verbal) awareness of poisons, the label to improve visual discrimination, and the combination of the two to have the greatest overall impact. (Am J Public Health 69:942-944, 1979.)
Introduction Accidental poisonings in children under 5 years of age are a serious problem. In 1974, there were 135 deaths reported;' from 1974 to 1976, 10,077 hospitalizations occurred;2 in 1975, poison centers in 44 states reported 102,709 cases.3 Public health and medical authorities estimate that only one ingestion case in seven is recorded officially.4 A review of the literature failed to turn up any published poison prevention programs designed specifically for young children. Breault developed an extensive adult educational program in poison prevention through local organizations in a small town, over a ten-year period.5 The program met with limited success, however, with a 48 per cent increase in accidental poisonings in young children during the time of the study. The Poison Prevention Packaging Act of 1970 (Public Law 91-601), which requires potentially hazardous substances to use a "child resistant" cap or lid, represents another attempt to reduce accidental poisonings among young Address reprint requests to Barbara T. Braden, 409 Pocano Lane, El Paso, TX 79912. This paper, submitted to the Journal August 14, 1978, was revised and accepted for publication May 8, 1979. Editor's Note: See also editorial, page 852. 942
children. Unfortunately, not all potentially poisonous substances are covered by the law. As a result, many hazardous substance containers carry only written warnings which have no effect on children too young to read. Another approach to the problem has been the development of new poison logos used as warning labels, such as Mr. Yuk and Officer Ugg,* to replace the traditional skull and crossbones. Research has shown the skull and crossbones to have little meaning for children today.6 Studies are not available to determine the effectiveness of these symbols, but conclusions from a previous study examining characteristics of different logos suggest that both designs lack good discrimination qualities: "When both logos were given a simple test of being placed on bright bold labels of various household cleaner and medication containers, the two perspective images were rather difficult to spot ... (they) seemed to blend into the design of the containers."** An approach that seems promising has been developed by the Brokaw Hospital Poison Control Center in Normal, Illinois. This approach includes an educational program designed to help young children better understand the concept of poison and to increase their discrimination between harmful and nonharmful products. One of the basic elements of the program is an empirically researched logo (Siop)*** designed as a warning label to be placed on poisonous product containers to function as a deterrent. A study was designed to answer the following questions: *Mr. Yuk is a simple green circular face with frowning mouth and protruding tongue; Officer Ugg is a blue and green caricature of a policeman with his hands over his mouth. **Taradejna B: The Development of a Poison Logo for Brokaw Hospital, Illinois State University, unpublished Master's Thesis, 1975. ***When the educational program was being developed, children were taught to say "no! (stay away from) Siop!" The phrase "No Siop" is the word "poison" spelled backwards, and "Siop" was the name given to the snake-like creature intended to repel them. AJPH September 1979, Vol. 69, No. 9
PUBLIC HEALTH BRIEFS
FIGURE 1-Sliop, Brokaw Hospital, Poison Control Center, Normal, Illinois
* Do young children have difficulty discriminating poisonous from nonpoisonous products? * Is the educational program effective in improving discrimination of poisonous and nonpoisonous products? * Is the Siop warning label effective in improving discrimination of poisonous and nonpoisonous products? * What is the relative effectiveness of the educational program, the Siop warning label, and a combination of the two? * Do the two approaches differ in their effects on verbal and visual discrimination?
Method The sample consisted of 156 three and four year old children (70 male, 86 female) enrolled in eight midwestern day care centers and nursery schools. Subjects were randomly assigned to one of the following groups: Educational Program: Children were exposed to the educational program and posttested without Siop warning labels. Siop Warning Label: Children were not exposed to the educational program and posttested with Siop warning labels attached to all the poisonous product containers. Educational Program with Siop Warning Label: Children were exposed to the educational program and posttested with Siop warning labels attached to all the poisonous product containers. Control: Children were not exposed to the educational program and posttested without Siop warning labels. The educational program involved a three day presentation ranging from 15 to 30 minutes per day. Materials used during the program included: puppets, poisonous and nonpoisonous household product containers, a bulletin board illustrating household products, flash cards, activity books, antidote charts, and Siop warning labels. Parent-teacher guides were also available.t The Siop warning label was empirically designed to be round based on data showing a circle to be the geometric
tThe complete lesson plan for the program may be obtained from Brokaw Hospital Poison Control Center, Normal, IL 61761. AJPH September 1979, Vol. 69, No. 9
shape most easily recognized by young children.7 The background color selected was orange, the color found most attractive to young children, with the imposed character (Siop) a bright green, which tends to repel children.8 Particular shades of these colors were selected because they were among those colors least used by manufacturers in their product labels. The actual logo design, a representative of a serpent, was chosen because of the near universal avoidance of snakes. The label was attached to containers by an orange colored band. The pretest consisted of an 84-item three part questionnaire.** The first section probed the child's concepts of poison and danger. The second section explored the child's verbal discrimination of 20 poisonous and 20 nonpoisonous items randomly assigned to a list that was orally presented. The third section explored the child's visual discrimination of randomly selected product containers. The posttest44 was a re-administration of the pretest, with section three modified in two of the groups by having Siop warning labels attached to the poisonous product containers. Subjects in all four groups were tested individually. The educational program was administered three to seven days after the pretest. The two groups exposed to the educational program were then posttested two weeks after exposure. The posttests were administered three weeks after the pretest to the groups not receiving the educational program. The basic analysis was a one-way analysis of variance between and within treatment groups. The between groups sum of squares has been broken down into components corresponding to Factor A (Siop label), Factor B (Educational Program) and their interaction.
Results The data suggest that young children do have difficulty discriminating poisonous and nonpoisonous products as evidenced by the pretest scores where 30 to 40 per cent of the poisonous products were identified incorrectly (Table 1). ttAvailable
on request to
author. 943
PUBLIC HEALTH BRIEFS TABLE 1 -Per Cent of Poisonous Products Identified Correctly Across the Pretest and Posttest Conditions Verbal
Visual
Groups
Pretest
Posttest
Pretest
Posttest
Siop Label Educational Program Siop Label with Educational Program Control
70.8 64.1
73.0 80.0
70.2 66.4
79.8 75.0
62.7 72.7
83.4 75.5
59.5 64.6
86.2 65.5
sonous but may not improve the ability to differentiate them in actual practice. On the other hand, the Siop warning labels provide a more immediate means of identifying poisonous products. Although this study dealt specifically with preschool aged children, the use of the Siop warning labels might prove effective with other populations such as those with limited reading skills (the mentally retarded) or those not familiar with the language. The distinctiveness and visual qualities of the Siop warning label might also prove beneficial to those with limited or impaired vision.
ACKNOWLEDGMENTS
The combined educational program with the Siop warning label scored highest for both verbal and visual discrimination tasks, (Table 2). However, the educational program alone was relatively more effective in the verbal discrimination task than in the visual. The Siop warning label, on the other hand, did not substantially affect the intellectual awareness of avoiding poisons, but had a dramatic effect on visual discrimination of actual containers.
Discussion The data suggest that preschool children may not be aware that certain products are dangerous or harmful. About one-third of the poisonous items were not recognized as being potentially dangerous. Even if a child is aware that a product is harmful, he/she may not be able to recognize it as such when seeing it. In the visual discrimination task many poisonous products were mistakenly identified as acceptable products. The current approach to packaging and labeling products may not allow for easy recognition by the preschool child. The child's lack of awareness coupled with an inability to distinguish poisonous product containers contribute to the problem of accidental poisonings. Of the approaches employed in this study, it appears that the educational program may improve the child's knowledge or understanding of what substances are harmful or poi-
This research was conducted as Ms. Braden's Master's Degree thesis work at Illinois State University, Normal, IL. Upon submission of the pilot study to the Consumer Product Safety Commission, the author was appointed coordinator of a five-city grant (#CPSC-Q-78-076) from CPSC2 to introduce the Siop Program in the State of Illinois. The results of the grant work supported her original findings. Since her move to Texas, Ms. Braden serves as consultant to the ongoing grant work being conducted in Illinois.
REFERENCES 1. U.S. Dept. of Health, Education, and Welfare. Mortality statistics-Special Reports, Accident Fatalities; Division of Vital Statistics, National Center for Health Statistics, 1975. Public Health Service, Food and Drug Administration, Bethesda, MD. 2. U.S. Dept. of Health, Education, and Welfare. National Clearinghouse for Poison Control Centers Bulletin, February 1978. Public Health Service, Food and Drug Administration, Bethesda, MD. 3. U.S. Dept. of Health, Education, and Welfare. National Clearinghouse for Poison Control Centers Bulletin, February 1977. Public Health Service, Food and Drug Administration, Bethesda, MD. 4. Illinois Dept. of Public Health. Poison Control Program Report1974. Released by the State of Illinois, July 1975. 5. Breault H: Five years with five million child-resistant containers. Clin Toxicology 7:91-95, 1974. 6. National Poison Center Network. How Mr. Yuk was developed. University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, 1971. 7. Gibson E: Principles of Perceptual Learning and Development. New York: Cornell University, 1969. 8. Sharpe D: The Psychology of Color and Design. Chicago, Nelson-Hall, Publisher, 1974.
TABLE 2-Summary of Analysis of Variance of Verbal and Visual Discrimination Scores Verbal
Source
Siop Label Educational Program Siop Label X Educational Program Within
Visual
MS
F
MS
F
1 1
76.15 114.54
5.15* 7.74**
336.16
43.04*** 31.20***
1
14.14
0.95
152
14.78
df
243.74 4.05
0.51
7.81
*p .05
**p .01 ***p.001
944
AJPH September 1979, Vol. 69, No. 9
Health Briefs Validation of a Poison Prevention Program BARBARA T. BRADEN
Abstract: The effectiveness of an empirically designed poison warning label and an educational program for three and four year old children was assessed in four groups of 39 such children, with one group serving as a control. The educational program appeared to improve intellectual (verbal) awareness of poisons, the label to improve visual discrimination, and the combination of the two to have the greatest overall impact. (Am J Public Health 69:942-944, 1979.)
Introduction Accidental poisonings in children under 5 years of age are a serious problem. In 1974, there were 135 deaths reported;' from 1974 to 1976, 10,077 hospitalizations occurred;2 in 1975, poison centers in 44 states reported 102,709 cases.3 Public health and medical authorities estimate that only one ingestion case in seven is recorded officially.4 A review of the literature failed to turn up any published poison prevention programs designed specifically for young children. Breault developed an extensive adult educational program in poison prevention through local organizations in a small town, over a ten-year period.5 The program met with limited success, however, with a 48 per cent increase in accidental poisonings in young children during the time of the study. The Poison Prevention Packaging Act of 1970 (Public Law 91-601), which requires potentially hazardous substances to use a "child resistant" cap or lid, represents another attempt to reduce accidental poisonings among young Address reprint requests to Barbara T. Braden, 409 Pocano Lane, El Paso, TX 79912. This paper, submitted to the Journal August 14, 1978, was revised and accepted for publication May 8, 1979. Editor's Note: See also editorial, page 852. 942
children. Unfortunately, not all potentially poisonous substances are covered by the law. As a result, many hazardous substance containers carry only written warnings which have no effect on children too young to read. Another approach to the problem has been the development of new poison logos used as warning labels, such as Mr. Yuk and Officer Ugg,* to replace the traditional skull and crossbones. Research has shown the skull and crossbones to have little meaning for children today.6 Studies are not available to determine the effectiveness of these symbols, but conclusions from a previous study examining characteristics of different logos suggest that both designs lack good discrimination qualities: "When both logos were given a simple test of being placed on bright bold labels of various household cleaner and medication containers, the two perspective images were rather difficult to spot ... (they) seemed to blend into the design of the containers."** An approach that seems promising has been developed by the Brokaw Hospital Poison Control Center in Normal, Illinois. This approach includes an educational program designed to help young children better understand the concept of poison and to increase their discrimination between harmful and nonharmful products. One of the basic elements of the program is an empirically researched logo (Siop)*** designed as a warning label to be placed on poisonous product containers to function as a deterrent. A study was designed to answer the following questions: *Mr. Yuk is a simple green circular face with frowning mouth and protruding tongue; Officer Ugg is a blue and green caricature of a policeman with his hands over his mouth. **Taradejna B: The Development of a Poison Logo for Brokaw Hospital, Illinois State University, unpublished Master's Thesis, 1975. ***When the educational program was being developed, children were taught to say "no! (stay away from) Siop!" The phrase "No Siop" is the word "poison" spelled backwards, and "Siop" was the name given to the snake-like creature intended to repel them. AJPH September 1979, Vol. 69, No. 9
PUBLIC HEALTH BRIEFS
FIGURE 1-Sliop, Brokaw Hospital, Poison Control Center, Normal, Illinois
* Do young children have difficulty discriminating poisonous from nonpoisonous products? * Is the educational program effective in improving discrimination of poisonous and nonpoisonous products? * Is the Siop warning label effective in improving discrimination of poisonous and nonpoisonous products? * What is the relative effectiveness of the educational program, the Siop warning label, and a combination of the two? * Do the two approaches differ in their effects on verbal and visual discrimination?
Method The sample consisted of 156 three and four year old children (70 male, 86 female) enrolled in eight midwestern day care centers and nursery schools. Subjects were randomly assigned to one of the following groups: Educational Program: Children were exposed to the educational program and posttested without Siop warning labels. Siop Warning Label: Children were not exposed to the educational program and posttested with Siop warning labels attached to all the poisonous product containers. Educational Program with Siop Warning Label: Children were exposed to the educational program and posttested with Siop warning labels attached to all the poisonous product containers. Control: Children were not exposed to the educational program and posttested without Siop warning labels. The educational program involved a three day presentation ranging from 15 to 30 minutes per day. Materials used during the program included: puppets, poisonous and nonpoisonous household product containers, a bulletin board illustrating household products, flash cards, activity books, antidote charts, and Siop warning labels. Parent-teacher guides were also available.t The Siop warning label was empirically designed to be round based on data showing a circle to be the geometric
tThe complete lesson plan for the program may be obtained from Brokaw Hospital Poison Control Center, Normal, IL 61761. AJPH September 1979, Vol. 69, No. 9
shape most easily recognized by young children.7 The background color selected was orange, the color found most attractive to young children, with the imposed character (Siop) a bright green, which tends to repel children.8 Particular shades of these colors were selected because they were among those colors least used by manufacturers in their product labels. The actual logo design, a representative of a serpent, was chosen because of the near universal avoidance of snakes. The label was attached to containers by an orange colored band. The pretest consisted of an 84-item three part questionnaire.** The first section probed the child's concepts of poison and danger. The second section explored the child's verbal discrimination of 20 poisonous and 20 nonpoisonous items randomly assigned to a list that was orally presented. The third section explored the child's visual discrimination of randomly selected product containers. The posttest44 was a re-administration of the pretest, with section three modified in two of the groups by having Siop warning labels attached to the poisonous product containers. Subjects in all four groups were tested individually. The educational program was administered three to seven days after the pretest. The two groups exposed to the educational program were then posttested two weeks after exposure. The posttests were administered three weeks after the pretest to the groups not receiving the educational program. The basic analysis was a one-way analysis of variance between and within treatment groups. The between groups sum of squares has been broken down into components corresponding to Factor A (Siop label), Factor B (Educational Program) and their interaction.
Results The data suggest that young children do have difficulty discriminating poisonous and nonpoisonous products as evidenced by the pretest scores where 30 to 40 per cent of the poisonous products were identified incorrectly (Table 1). ttAvailable
on request to
author. 943
PUBLIC HEALTH BRIEFS TABLE 1 -Per Cent of Poisonous Products Identified Correctly Across the Pretest and Posttest Conditions Verbal
Visual
Groups
Pretest
Posttest
Pretest
Posttest
Siop Label Educational Program Siop Label with Educational Program Control
70.8 64.1
73.0 80.0
70.2 66.4
79.8 75.0
62.7 72.7
83.4 75.5
59.5 64.6
86.2 65.5
sonous but may not improve the ability to differentiate them in actual practice. On the other hand, the Siop warning labels provide a more immediate means of identifying poisonous products. Although this study dealt specifically with preschool aged children, the use of the Siop warning labels might prove effective with other populations such as those with limited reading skills (the mentally retarded) or those not familiar with the language. The distinctiveness and visual qualities of the Siop warning label might also prove beneficial to those with limited or impaired vision.
ACKNOWLEDGMENTS
The combined educational program with the Siop warning label scored highest for both verbal and visual discrimination tasks, (Table 2). However, the educational program alone was relatively more effective in the verbal discrimination task than in the visual. The Siop warning label, on the other hand, did not substantially affect the intellectual awareness of avoiding poisons, but had a dramatic effect on visual discrimination of actual containers.
Discussion The data suggest that preschool children may not be aware that certain products are dangerous or harmful. About one-third of the poisonous items were not recognized as being potentially dangerous. Even if a child is aware that a product is harmful, he/she may not be able to recognize it as such when seeing it. In the visual discrimination task many poisonous products were mistakenly identified as acceptable products. The current approach to packaging and labeling products may not allow for easy recognition by the preschool child. The child's lack of awareness coupled with an inability to distinguish poisonous product containers contribute to the problem of accidental poisonings. Of the approaches employed in this study, it appears that the educational program may improve the child's knowledge or understanding of what substances are harmful or poi-
This research was conducted as Ms. Braden's Master's Degree thesis work at Illinois State University, Normal, IL. Upon submission of the pilot study to the Consumer Product Safety Commission, the author was appointed coordinator of a five-city grant (#CPSC-Q-78-076) from CPSC2 to introduce the Siop Program in the State of Illinois. The results of the grant work supported her original findings. Since her move to Texas, Ms. Braden serves as consultant to the ongoing grant work being conducted in Illinois.
REFERENCES 1. U.S. Dept. of Health, Education, and Welfare. Mortality statistics-Special Reports, Accident Fatalities; Division of Vital Statistics, National Center for Health Statistics, 1975. Public Health Service, Food and Drug Administration, Bethesda, MD. 2. U.S. Dept. of Health, Education, and Welfare. National Clearinghouse for Poison Control Centers Bulletin, February 1978. Public Health Service, Food and Drug Administration, Bethesda, MD. 3. U.S. Dept. of Health, Education, and Welfare. National Clearinghouse for Poison Control Centers Bulletin, February 1977. Public Health Service, Food and Drug Administration, Bethesda, MD. 4. Illinois Dept. of Public Health. Poison Control Program Report1974. Released by the State of Illinois, July 1975. 5. Breault H: Five years with five million child-resistant containers. Clin Toxicology 7:91-95, 1974. 6. National Poison Center Network. How Mr. Yuk was developed. University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, 1971. 7. Gibson E: Principles of Perceptual Learning and Development. New York: Cornell University, 1969. 8. Sharpe D: The Psychology of Color and Design. Chicago, Nelson-Hall, Publisher, 1974.
TABLE 2-Summary of Analysis of Variance of Verbal and Visual Discrimination Scores Verbal
Source
Siop Label Educational Program Siop Label X Educational Program Within
Visual
MS
F
MS
F
1 1
76.15 114.54
5.15* 7.74**
336.16
43.04*** 31.20***
1
14.14
0.95
152
14.78
df
243.74 4.05
0.51
7.81
*p .05
**p .01 ***p.001
944
AJPH September 1979, Vol. 69, No. 9
