The role of primary caregivers’ knowledge, attitudes, and practices in paediatric medication safety

Abstract

Objective

To assess primary caregivers’ knowledge, attitudes, and practices (KAP) regarding the prevention of unintentional drug poisoning in children.

Results

Most primary caregivers (96.9%) were aware of drug overdose risks, and 85.5% understood variations in syrup strengths. However, only 44.9% knew the legal consequences of repeated poisonings. Unsafe practices were prevalent, with 37.7% administering medications without clinician consultation and 25.5% attempting to induce vomiting following poisoning. Among parent caregivers, the median knowledge score was 7 (IQR 6–8), and the median practice score was 13 (IQR 12–14). Higher parental knowledge significantly correlated with safer practices (p = 0.001) and positive attitudes (p = 0.02). However, attitudes (p = 0.880) and practices (p = 0.229) did not differ significantly between caregivers with and without prior poisoning experience. Despite high knowledge levels, unsafe practices remain common, highlighting the need for targeted interventions to improve practical skills and reduce childhood poisoning rates.

Introduction

Childhood poisoning remains a significant global public health issue, with a particularly high burden in low- and middle-income countries (LMICs) [1]. Data suggest that the incidence of unintentional poisoning in these regions is up to four times higher than in high-income countries [2]. Over-the-counter medications such as paracetamol, antihistamines, iron supplements, and cough remedies, along with prescription drugs including analgesics and antidepressants, are among the most frequent causes of accidental poisoning [3]. Despite the known risks, parental awareness of drug safety and poisoning prevention remains limited, particularly in the absence of community-based educational initiatives designed to promote safer practices [4].

In Sri Lanka, factors such as insufficient knowledge about the risks of drug poisoning and the lack of urgency in seeking medical care following ingestion often result in delayed presentations at emergency departments [5]. These delays can increase the severity of poisoning outcomes, further burdening the healthcare system [6]. While unintentional drug poisoning is preventable, it is often overlooked in public health efforts, and there is a clear need for focused interventions [7].

This study seeks to assess primary caregivers’ knowledge, attitudes, and practices (KAP) regarding the prevention of unintentional drug poisonings in children. Understanding these factors is essential for designing targeted educational programs and interventions to address existing gaps in parental awareness and practices [8]. By examining parental behaviours and beliefs, the study aimed to inform the development of effective, culturally relevant strategies to reduce the incidence of childhood poisoning and improve outcomes. This is a crucial step toward creating safer environments for children and enhancing public health efforts in resource-limited settings including Sri Lanka.

Methods

A cross-sectional, descriptive study was conducted at Colombo North Teaching Hospital, Sri Lanka, from February to August 2024. 523 caregivers were approached for the study, of which 385 primary caregivers consented to complete a 42-item self-administered questionnaire. Primary caregiver was defined for the study as the caregiver who administered medications to the child at home. This questionnaire assessed participants' knowledge (08 items), attitudes (18 items), and practices (16 items) concerning the prevention of childhood accidental pharmaceutical poisonings. Inclusion criteria for the study included parents or other primary caregivers of children attending Colombo North Teaching Hospital during the study period who provided informed written consent and were able to complete the questionnaire. Exclusion criteria included caregivers who were not the primary caregivers of children, declined consent, or had incomplete questionnaire responses.

The sample size was determined using the Cochrane formula, leading to a total of 385 participants. Eligibility of the primary caregivers was determined through a two-step screening process. First, the caregivers were approached by trained research assistants in waiting areas or wards and provided with a brief explanation of the study’s purpose. Interested individuals were then screened for inclusion criteria. Once eligibility was confirmed, the consenting primary caregivers were provided with the questionnaire and research assistants were available to clarify any questions without influencing responses. Efforts were made to recruit participants across different times of the day and week to capture a diverse sample representative of the hospital’s patient population.

The data collection tool was a self-administered, pre-tested questionnaire designed to gather information on socio-demographic characteristics, knowledge, attitudes, and practices (KAP) related to preventing unintentional drug poisoning in children. The questionnaire was developed based on an extensive review of existing literature on paediatric medication safety and expert input from paediatricians and public health specialists. Items were selected to comprehensively cover domains of knowledge (e.g., awareness of overdose risks and drug interactions), attitudes (e.g., perceptions of safe storage and supervision), and practices (e.g., medication administration and first-aid measures). To ensure clarity and reliability, the questionnaire underwent pre-testing with a sample of twenty parents before distribution. Feedback from the pre-testing process was used to refine item wording and structure, ensuring the tool’s reliability and cultural appropriateness for the Sri Lankan context. Responses indicating positive KAP consistent with good medical practice were assigned a score of “1,” while negative responses received a score of “0.” Random sampling was employed to mitigate selection bias.

Data were analysed using SPSS 25.0. Categorical variables were summarized as frequencies and percentages, while continuous variables were presented as medians and interquartile ranges (IQR). Normal distribution was assessed using skewness (− 1 to + 1) and kurtosis (− 1.5 to + 1.5) values. Independent sample t-tests compared means between groups, and Kruskal–Wallis tests were applied for non-parametric data. Correlations between variables were evaluated using Pearson’s correlation coefficient, with statistical significance set at p < 0.05. Informed written consent was obtained from all participants. Ethical approval was obtained from the Ethics Review Committee of the Postgraduate Institute of Medicine, University of Colombo.

Results

A total of 385 primary caregivers participated in the study, with 320 parents (either mother or father) accounting for 83.1% of the total. Sixty-five primary caregivers (16.9%) were non-parents. The group of participants categorized as “non-parent” primary caregivers consisted of grandmothers (34), grandfathers (16), aunts (7), uncles (4), and occasionally elder brothers (2) and sisters (2). Among the participants, 80.6% of mothers and 80.0% of fathers had completed at least their secondary education (Table 1).

Table 1 Education level of parents

Only ten incidents of previous drug poisonings were reported, yielding an incidence rate of 2.6 per 100 participants. Demographic data of children are described in Table 2.

Table 2 Demographic characteristics of the participant children

Primary caregivers’ knowledge regarding pharmaceutical poisonings

The results indicated a high level of awareness among primary caregivers concerning the risks associated with medication overdoses; 96.9% (N = 373) acknowledged that drugs could be overdosed. Furthermore, 75.3% (N = 290) recognized the severe symptoms associated with allergic reactions. Additionally, 77.1% (N = 297) were informed that certain medications should not be co-administered due to the potential for adverse drug interactions. A noteworthy 85.5% (N = 329) understood that the same volume of different syrup formulations could vary significantly in strength. Conversely, 44.9% (N = 173) were unaware of the legal implications in cases of recurrent accidental ingestion, while 17.1% (N = 66) mistakenly believed that the pediatric dose of a medication equated to half the adult dose.

Primary caregivers’ attitudes towards pharmaceutical poisonings

Regarding the attitudes of primary caregivers, 19.0% (N = 73) justified leaving their children unsupervised, citing busy schedules as the primary reason. In contrast, an overwhelming majority (91.7%, N = 353) considered informational leaflets and advertisements as valuable resources for understanding drug poisoning. When inquired about the precautions they would take to prevent their children from ingesting harmful medications (Table 3), an impressive 96.1% (N = 370) of primary caregivers reported that they would store drugs in locations inaccessible to children.

Table 3 Primary caregivers’ attitudes towards prevention of ingestion of potentially harmful medicines

In the event of drug poisoning, the predominant action proposed by primary caregivers was to immediately transport the child to a hospital (97.7%), while 27.5% indicated they would attempt to induce vomiting by inserting a finger (Table 4).

Table 4 Action proposed by primary caregivers

A significant 94.0% (N = 362) expressed a willingness to receive information regarding the side effects and precautions associated with medications. Moreover, 58.2% (N = 224) believed they would have acted differently in previous incidents had they received adequate information. A substantial 95.8% (N = 369) indicated their commitment to educating their children about toxic products to promote self-protective behaviours. Additionally, 93.0% (N = 358) acknowledged the importance of receiving educational materials, such as descriptive leaflets, alongside medications.

Primary caregivers’ practices towards drug poisoning prevention

Regarding practical applications, 37.7% (N = 145) of primary caregivers were using medicines at home without prior clinician prescription or recommendation. However, most of these medications were over-the-counter medications such as paracetamol (48.1%), chlorpheniramine (6.2%) and vitamin C (2.3%) (Table 5). Notably, despite paracetamol’s prevalence, 11.2% (N = 43) of parents were unaware of the appropriate pediatric dosage.

Table 5 Most commonly used medicines by primary caregivers at home

An overwhelming 98.0% (N = 379) of primary caregivers reported that they were capable of adhering to prescribed dosages for their children. In terms of emergency responses, 93.0% (N = 358) indicated they would not wait for symptoms to appear following a medication overdose or self-ingestion.

In terms of preventive measures, 89.4% (N = 344) of primary caregivers reported storing drugs in locations inaccessible to children. Additionally, 50.9% (N = 196) secured medications in locked areas. A remarkable 98.2% (N = 378) double-checked drug names and dosages before administration. Moreover, 97.1% (N = 374) checked expiration dates prior to giving medications to their children, and 87.0% (N = 335) disposed of expired medications in inaccessible areas for children. Notably, 95.8% (N = 369) refrained from storing medications alongside food or other commonly used items, although 8.1% (N = 31) admitted to mixing medications with food or drinks. A concerning 42.1% (N = 162) reported breaking tablets to achieve the desired dose, while 10.9% (N = 42) used kitchen spoons for measuring liquid medications. Furthermore, 6.2% (N = 24) shared their own medications with children at lower doses during illness. Encouragingly, 70.6% (N = 272) explained to their children that medications should not be ingested solely because they appeared appealing.

The median knowledge score regarding drug poisoning among parents (n = 320) was 7 (IQR = 6–8), while the median attitude score was 15 (IQR = 13–16). The median practice score concerning drug poisoning prevention was 13 (IQR = 12–14), culminating in a median total score of 34 (IQR = 32–36) (Table 6).

Table 6 Parental knowledge, attitudes, and practices regarding drug poisoning

Comparative analysis between parents with prior experience of drug poisoning incidents and those without revealed no significant differences in attitudes or practices (p = 0.880 and p = 0.229, respectively). However, a significant difference was noted in the knowledge domain (p = 0.013), with parents whose children had experienced previous drug poisonings exhibiting lower knowledge scores (median = 5, IQR 5–8) compared to those with no prior incidents (median = 7, IQR 6–8).

The educational level of each parent significantly influenced their knowledge regarding drug poisoning; however, attitudes and practices were not significantly affected (Tables 7 and 8).

Table 7 Maternal level of education in relation with the attitudes and practices

Table 8 Paternal level of education in relation with the attitudes and practices

Interestingly, parental knowledge did not correlate significantly with attitudes (p = 0.394, Spearman’s rho 0.044). However, parental practices regarding drug poisoning prevention were significantly influenced by both knowledge (p = 0.001, Spearman’s rho 0.255) and attitudes (p = 0.02, Spearman’s rho 0.118), eliciting weakly positive correlations.

Discussion

This study aimed to assess the knowledge, attitudes, and practices (KAP) of primary caregivers regarding the prevention of unintentional drug poisoning in children. The findings reveal a concerning dichotomy between the relatively high levels of awareness regarding drug overdose risks and the prevalence of unsafe practices among parents. A significant majority of primary caregivers (96.9%) acknowledged the risks of drug overdose, and a substantial percentage understood the varying strengths of different syrup formulations (85.5%).

The median knowledge score of 7 reflects a generally adequate level of awareness among parent primary caregivers, with most demonstrating familiarity with key issues such as allergic reactions and drug interactions. However, some gaps remain, including a lack of understanding regarding the legal implications of recurrent poisoning, which could benefit from targeted educational initiatives to ensure comprehensive awareness. Most caregivers prioritize the well-being of their child above all else. For the vast majority, concerns about their child’s safety and care are the primary drivers of their actions, rather than fear of legal consequences.

Moreover, although primary caregivers reported a strong commitment to preventative practices such as storing medications out of children’s reach (96.1%), unsafe practices were also reported. For instance, 37.7% admitted to administering medications without prior consultation with a healthcare professional. Notably, salbutamol, domperidone and antibiotics were among these medications. This behaviour may be concerning when it involves a family with lower educational background, as it may increase the risk of accidental poisoning. Research has shown that parental decision-making in medication administration often lacks sufficient knowledge, leading to potentially harmful outcomes [9, 10].

The study also found that 25.5% of primary caregivers attempted to induce vomiting following a poisoning incident, a practice that is not recommended by medical professionals due to potential complications. This mismanagement reflects a critical area for intervention, as inadequate understanding of first-aid responses to poisoning can exacerbate health outcomes [11]. Furthermore, the lack of correlation between prior experience of poisoning incidents and subsequent knowledge or attitudes suggests a disconnect between personal experience and learning, which may limit the effectiveness of experiential learning in promoting safer practices.

Interestingly, the educational level of parent primary caregivers emerged as a significant factor influencing their knowledge of drug poisoning, with higher educational attainment correlating with greater knowledge. This finding aligns with previous studies, suggesting that educational interventions should be tailored to address varying educational backgrounds to enhance understanding and application of safe practices [12]. Despite this, attitudes and practices did not significantly differ based on educational levels, indicating that knowledge alone is insufficient to drive behavioural change. Primary caregivers with prior poisoning experience often had higher knowledge but no significant improvements in attitudes or practices, highlighting the gap between awareness and behaviour. This suggests that knowledge alone is insufficient to drive safe practices, as cultural norms and lack of practical skills may persist. Educational programs post-poisoning should focus on transforming attitudes and teaching actionable skills through methods such as role-playing and practical demonstrations. Studies show that knowledge retention is often better than sustained behaviour change, emphasizing the need for hands-on training and community reinforcement [13]. Long-term research on retained knowledge and practices post-intervention can guide the development of effective, sustainable programs.

Limitations

This study has several limitations that warrant consideration. Firstly, its cross-sectional design limits the ability to establish causal relationships between parental knowledge, attitudes, and practices regarding pediatric medication safety. Secondly, data collection via a self-administered questionnaire introduces the possibility of social desirability bias, where participants may have over-reported safe practices or under-reported unsafe behaviors. Thirdly, the study was conducted in a single tertiary care hospital, which may restrict the generalizability of the findings to other settings, such as rural areas or different healthcare institutions. Additionally, despite pre-testing the questionnaire, the reliance on self-reported data poses a risk of recall bias, particularly for questions about past poisoning incidents. The study focused exclusively on parents (320 respondents) and excluded 65 non-parent caregivers to maintain consistency in analysing the relationship between educational level and knowledge, attitudes, and practices. While this approach ensured uniformity in the analysis, it may limit the applicability of the findings to all primary caregivers. Finally, the absence of qualitative methods constrained the exploration of underlying reasons for unsafe practices and contextual barriers to improving pediatric medication safety. Future research should address these limitations by employing longitudinal designs, expanding the scope to multiple settings, and incorporating qualitative methodologies to provide a more comprehensive understanding of the issue.

Conclusion

While this study highlights a commendable level of primary caregivers’ awareness regarding drug poisoning risks, it underscores the need for a more targeted approach to education. Our findings reveal that knowledge alone does not consistently translate into safer attitudes or practices, suggesting that the knowledge base being assessed and potentially taught may not align optimally with the practical skills and behavioural changes required for effective poisoning prevention. This misalignment emphasizes the need to reevaluate the content and delivery of educational interventions, ensuring that they address critical gaps and are directly applicable to real-life scenarios. Future efforts should focus on designing comprehensive educational programs that integrate practical training, behaviour modification strategies, and tailored messaging to align knowledge with actionable practices. Public health initiatives should also consider the broader contextual factors influencing parental behaviours, such as accessibility of healthcare resources and cultural norms. By ensuring that education directly supports safer practices, more effective interventions can be developed and implemented to reduce the incidence of unintentional drug poisoning in children and enhance overall pediatric medication safety.