Australian Health Promotion Association

Michael Rosenberg, Lisa Wood, Melita Leeds and Sue Wicks

Introduction: The prevention of childhood poisoning is recognised as a major public health priority that lies within the remit of injury control in Australia.1 Internationally, studies in countries as diverse as the US,2 Thailand,3 Sweden,4 and Iran5 mirror similar concerns6 about both the prevalence of childhood poisoning and the importance of preventive measures.

Although fatal childhood poisonings have declined significantly over recent decades, the ingestion of poisons among children remains a major cause of injury, as evidenced in both hospital attendance figures and calls to poison ‘help lines’.7,8 Between 1995 and 2000, 2,531 children were hospitalised as a result of unintentional poisoning in WA.9 Such statistics fail to represent the full magnitude of the problem, as some cases are seen by a General Practitioner or do not require hospitalisation or medical care.10 The WA Poisons Information Centre 2002 Annual Report recorded a total of 19,613 calls about children and poisons, with 12,805 of these related to toddlers (1-4 years) and a further 873 calls relating to children less than 12 months of age.

Recent Australian studies show that the majority of hospital admissions for the ingestion of potentially poisonous products among children under five are attributed to medicines.8,11,12 Prescription medications, over-the-counter medicines11 and herbal remedies are also culpable.13 The practice of making children’s medicines ‘nice tasting’ to ease administration means that there is not the natural deterrent of an unpleasant taste that may occur with some other poisons.3 In some countries, parents go so far as to try to entice children to take their medicine by likening medicine to ‘candy’,3 compounded by the sale of lollies in simulated pilldispensing packaging in some places (see Figure 1).

As many parents and child development studies testify, it is ‘natural’ for young children to explore their surrounds, put things into their mouths3 and experience new taste sensations. Preventing such childhood explorations is not necessarily desirable or realistic. Therefore, interventions need to target environmental factors and the behaviour of caregivers as factors that are (theoretically) more amenable to change.

The most common location for poisoning to occur is in the home,8,12 often in the living/dining, kitchen or bedrooms.8 The majority of ingestions are of products used by someone else in the household in the preceding 4 hours.14 Accessibility to potentially harmful substances is a major issue,2 and the absence of supervision and children playing alone increases the risk of poisoning.3

Although the role of the home environment in contributing to childhood poisoning is well documented, the focus to date is primarily on the presence or absence of preventive measures. There is limited data relating to perceptions and attitudes of parents that may affect whether preventive measures are actually put in place. Chien argues, for example, that unless parents and carers are aware of the toxicity of over-the-counter medicines, they may be less vigilant in storing them appropriately.11 However, awareness of toxicity alone may not be sufficient to compel preventive action, or may be outweighed by the practical issues of, say, conveniently accessing paracetamol when a headache descends on a parent or care-giver.15

As articulated in a number of behavioural theories, people’s attitudes and beliefs about an issue are not synonymous with factual knowledge and, as noted above, knowledge alone may not adequately explain parental responses to childhood poisoning prevention. In the literature to date, injury prevention appears to be under-represented in the application of health behaviour theories, compared with the theory-based interventions or evaluations that can be found pertaining to issues such as smoking cessation, physical activity, cancer screening and safe sex. The relatively sparse application of behavioural theory to injury prevention has been argued as potentially to the detriment of more effective interventions.16,17 Across public health more broadly, it has also been lamented that “too many interventions are not guided by a theoretical framework that specifies how they are supposed to elicit health behaviour change”.18

Health-related behaviours do not occur in a vacuum.19 As captured by socio-ecological and systems models of health, behaviour occurs within a sphere of influence that includes the environments and settings in which people live, work and play.20 As such, it is increasingly recognised that single measures will have limited effectiveness in preventing childhood poisonings. Safe packaging, for example, is by no means adequate as an isolated measure and cannot compensate for unsafe home storage or dispensing practices.7 As with many other childhood injury issues, poisoning prevention requires a multistrategy approach including better child-resistant closures, clearer labelling on products, and educating parents on the importance of supervision, safe storage and use of potentially poisonous products.7 Yet, as in many areas of public health, there remains a wide void
between what is recommended and what is acted upon in the community, and evidence of effective multifaceted interventions in the literature to date is rare.7

This paper seeks to probe behind aspects of this void by examining parental perceptions and knowledge within a Health Belief Model (HBM) framework21 as depicted in Figure 2.

As noted by Rothman,18 calls for greater use of theory are often broad, but there is a need to also investigate the unique value of a particular theory to an issue or intervention. While the HBM is often touted in health promotion textbooks, there is a relative paucity of published literature demonstrating applications of this theory to interventions in real world settings. Exceptions include the application of the HBM to the use of bicycle helmets,22 infection-control practices23 and osteoporosis.24 To our knowledge, this paper represents the first published application of the HBM as a lens and framework through which to consider factors that potentially influence childhood poisoning prevention.

Issue addressed: Preventing childhood poisoning is an important injury-control priority, requiring a multi-strategy approach. However, there remains a wide void between what is recommended by prevention programs and the evidence, and what is acted upon in the day-to-day family environment. This paper seeks to probe behind aspects of this void by examining parental perceptions in relation to childhood poisoning within a Health Belief Model framework.
Methods: Data were collected through telephone interviews from 200 randomly selected Western Australian parents/guardians of children aged 0-4 years.
Results: The uptake of poisoning prevention strategies was associated with the perceived susceptibility and seriousness of poisoning from different common household products. In particular, those products considered most fatally poisonous (workshop/garden chemicals) and a common cause of childhood poisoning were the most likely to be locked up and kept out of reach of children. Conversely, over-the-counter medicines were not considered by the majority of parents as fatally poisonous or as a common cause of poisoning, and were less likely to be locked up and placed out of reach. However, such medicines are the most common cause of unintentional childhood poisoning.
Conclusion: The results suggest that perceptions of susceptibility and seriousness need to be targeted as part of efforts to encourage parents to reduce household risks of childhood poisoning. This is particularly warranted in relation to those common household products (e.g. medicines) where there is a misperception of lower likelihood of serious poisoning occurring.
So what? Despite various childhood poisoning prevention initiatives in Australia, incidents remain high. Through the lens of the Health Belief Model, it may be that differences in parental perceptions of susceptibility and seriousness could explain variability in preventive measures taken for different potentially poisonous household products. This warrants further research and has implications for the way in which health promotion intervention strategies and messages for parents and carers are framed.

Health Promotion Journal of Australia 2011; 22: 217-22