Self-inflicted ingestion of harmful chemicals in adolescents and adults: Risk factors and characteristics

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A specific category of such injuries is those that are self-inflicted. Although intentionality for self-infliction may be difficult to determine, key explanatory risks and demographic factors may contribute towards a better understanding of self-inflicted and harmful chemical ingestion injuries. Methods: This study used secondary data that had been collected on burn injuries due to injection of harmful chemicals in a sample of South Africans from low-income communities close to major metropolitan centres. Logistic regression was used to determine how the risk for self-inflicted ingestion was differentiated from ingestion due to the actions of another person (other-inflicted ingestion) by sex and age cohort of the victim, and the presence of alcohol by examining paraffin ingestion versus that of other chemicals. Results: The current findings indicate that sex, age cohort, presence of alcohol, and chemicals other than paraffin are key explanatory factors for an increased risk for self-inflicted ingestion of harmful chemicals. Conclusions: The study empirically confirms the role of several key risk factors in what remains a largely unreported and understudied phenomenon. The findings contribute towards improved safety policies on availability and sale of chemical products and more focussed community interventions for at-risk individuals such as females and young people. It also flags the importance of assessing for alcohol use and alcohol use disorders at hospital admission of self-ingestion injuries. ingestion self-inflicted paraffin chemicals alcohol 1. Global Distribution, Demographics and Causality of Ingestion Mortality The exposure to harmful chemicals is common and may affect people through ingestion, inhalation, skin contact or via the umbilical cord to unborn children [1]. Chemicals such as pesticides, solvents, paints, detergents, kerosene or paraffin, carbon monoxide and drugs have been widely reported to lead to unintentional poisoning, with 61,523 deaths reported annually [2]. The intentional ingestion of chemicals is a further concern that accounts for 137 831 deaths reported each year, with pesticides the most common agent used, especially in Asia and central America ([3];[2];[1]). Globally, children and young adults are especially affected by unintentional poisoning [2]. Children are especially impacted by the acute and chronic effects of acute poisonings and exposure to air pollution, while older adults suffer chronic effects from air pollution and exposure to various carcinogens [1]. In the past three decades there has been an increasing research focus on unintentional poisonings and more recently on intentional self-poisoning, especially in low- and middle-income countries [4];[5]. The most prevalent agents of lethal poison ingestion vary by region and country. For example, in an Indian study on lethal poisoning between 1999 and 2018, pesticide mortality was most prominent with the most common agents including organophosphates (6387 deaths) and aluminum phosphide (5534 deaths) [6]. In 2016, Sri Lankan government hospitals recorded over 12 500 cases of organophosphate and carbamate pesticide poisoning [7], with the 17 to 49 years age cohort most affected, followed by those aged 50 to 69 years. In China, despite an observed decrease in poisoning mortality between 2006 and 2016, 87% of such deaths were due to pesticides and mostly suicide-related, with males, rural background, and older adults strongly associated with such intentional self-poisoning [8]. In parts of Africa, intentional poisoning mortality, especially attributed to organophosphates and pesticides, also pose a major public health problem [9]. In an Ethiopian study, 71.4% of such intentional self-poisoning cases were attributed to ingestion of bleach, with risk factors including being female and recent family disputes [10]. Higher frequencies of intentional ingestion of organophosphates (38%) were also found in Zambia, mostly attributed to suicidal attempts after family disputes [11]. In South Africa, accidental poisoning through ingestion of noxious substances contributed to 2.1% of all unintentional injury deaths in 2017 [12]. Paraffin had been implicated as an important agent to unintentional child poisonings, with 40 000 to 60 000 annual cases estimated [13]. Intentional self-poisoning has also been described as a significant burden in South Africa, with 863 suicides by poison ingestion in 2017 [14]. Emergency centers provide further illustration of these cases; e.g., in a Cape Town study over a six-month period, 192 patients were admitted for intentional self-poisoning [15]. The most common toxic agent was pharmaceuticals, specifically paracetamol, with females comprising two out of every three (68.8%) self-inflicted intentional poisoning admissions. Other South African hospital studies of acute poisoning, such as in Durban, reported that one quarter of all ingestion poisoning was due to the intake of tricyclic antidepressants [16]. This study also found that women were more likely to self-ingest with ethylene glycol (antifreeze), which was characterised with a 37.5% mortality rate. A Tshwane study reported that 50.2% of all poisonings were regarded as suicide related, with organophosphate poisoning indicated in 58% of males, and in 27.1% of females between 21–30 years [17]. Poisonings can be either self-inflicted or inflicted by others, and either intentional or unintentional. In self-inflicted instances, the poisoning incident could be either intentional or unintentional, the former arguably due to self-harm while the latter may occur through negligence or lack of knowledge. In instances of other-inflicted poisoning, incidents which are intentional would constitute an assault, while unintentional other-inflicted poisonings would not be regarded as an assault if there is no discernible identified intention to harm. However, the identification and confirmation of intentionality is complex, even in the instances of self-inflicted poisoning, as persons may intend to self-harm at the time of ingestion but later feel remorseful and thus report the ingestion as unintentional. Also, attempts to attract the attention of others by ingestion may be intentional, although the ingestion may not have been intended to achieve any self-harm of a significant nature. For these reasons, it is not always possible to conclusively confirm the intentionality of self-inflicted poison injuries without attendant information relating to the victim’s cognitive, psychological and affective state at the time of the injury. This study builds upon the emerging poison ingestion work in South Africa and describes the demographic and attendant key risk factors for self-inflicted ingestion cases. Due to limitations of data, the study does not distinguish between intentional and unintentional self-inflicted ingestion injuries, and compares all self-inflicted injuries against ingestion injuries attributable to or inflicted by the actions of others. The research explores how demographic factors identified in the literature – sex and age – as well as key attendant factors such as the presence or absence of alcohol and the use of paraffin versus other chemicals may differentiate the risk for self-inflicted from other-inflicted ingestion injuries. 2. Methods Primary data collection The primary data for this study was collected by the Paraffin Safety Association of Southern Africa (PASASA) (later renamed Household Energy Safety Association of Southern Africa - HESASA) as part of a larger study on household energy-related risks for mortality and morbidity in South Africa. The dataset for this analysis was derived from a sample of 19 hospitals servicing primarily low-income informal settlements situated nearby major metropolitan areas in eight of the country’s nine provinces. The hospitals are not representative of all hospitals in the country but all of them are located adjacent to and service impoverished communities characterised by informal homesteads. Participants for the study were interviewed at admission in their home language to obtain their informed consent and collect background information on demographics and injury circumstances. Due to low literacy levels amongst the participants, informed consent was obtained verbally. Following admission, participant records were populated by researchers with data obtained from hospital case records, providing detail on the clinical features of the burn injuries and treatment procedures and outcomes. The data was fully anonymised and all participant records were expunged of any form of personal identification information. The study was approved by the Health Research Ethics Committee (HREC) of the South African Medical Research Council. Sample The study dataset contains 12 079 cases comprising all types of energy-related injuries, in particular external and internal burns, for patients of all ages. Given the focus in this research on ingestion injuries in persons who are adolescents and older, a sub-sample selection was made using only cases for which ingestion was indicated as the cause of the injury and for which the patient age was reported as 13 years or older. This realised a final analysis sample of 1 718 cases. Analysis Descriptive statistics were used to illustrate key sample characteristics and binary logistic regression analysis modelling was undertaken to examine for differentiated risk for self-inflicted ingestion across a series of control and key explanatory factors. All analysis was performed using the IBM Statistical Package for Social Sciences (SPSS) version 27, using a p ≤ 0.05 significance level. Outcome and explanatory variables Outcome Variable - the outcome variable was a binary categorical variable differentiating between self-inflicted and other-inflicted ingestion of harmful substances. To sharpen the definition of the other-inflicted ingestion, all instances which were intentional, that is, which would be regarded as assault, were removed from the data. The other-inflicted category thus represents only cases of unintentional infliction of poison ingestion in the victim by other persons. For the category of self-inflicted, the data did not permit a clear resolution of intentionality. Accordingly, the category was not differentiated any further and is used throughout this study to reflect all instances of self-ingestion of harmful substances, whether intentional or unintentional. For the logistic regression modelling the reference category for the outcome variable was set as other-inflicted unintentional ingestion injury. Explanatory variables - the following explanatory variables were employed: Sex: Sex was recorded as either female or male (Reference Category) Age Cohort: Age was used as a categorical variable differentiated into four age cohorts as follows: adolescents: 13–17 years, youth or young adults: 18–39 years, mature adults: 30–44 years and older adults: 45 years and older (Reference Category). Presence of Alcohol: The presence or absence of alcohol was based on reporting at time of admission by patient and/or persons accompanying patient and/or observation by hospital staff, and was measured categorically as either Present or Not Present (Reference Category). The measure does not include information on prior history of use/abuse or related biomarker testing at admission or during hospitalisation. Paraffin and Other Chemicals: this variable was recorded at the time of observation from reporting by the patient or persons accompanying the patient and/or observation by hospital staff and was measured categorically as either Paraffin (Reference Category) or Other Chemical Substances. 3. Results 3.1. Descriptives The total number of participants used for analysis was 1718 (1584 - self-inflicted ingestion, 134 - other-inflicted ingestion). Table 1 demonstrates the variances between those who suffered ingestion of harmful substances through self-inflicted ingestion as compared to those who suffered such injury through other-inflicted ingestion. Table 1 Sample descriptive characteristics Self-Inflicted Ingestion 1584 (92.1%) Other-Inflicted Unintentional Ingestion 134 (7.8%) Total 1718 (100%) GENDER Female 81 (6.5%) 1168 (93.5%) 1249 (72.7%) Male 53 (11.3%) 416 (88.7%) 469 (27.3%) AGE COHORTS 13–17 Years 38 (9.5%) 362 (90.5%) 400 (23.3%) 18–29 Years 54 (6.1%) 833 (93.9%) 887 (51.6%) 30–44 Years 20 (6.2%) 304 (93.8%) 324 (18.8%) 45 Years and Older 22 (20.6%) 85 (79.4%) 107 (6.3%) ALCOHOL Alcohol Present 11 (5.4%) 191 (94.6%) 202 (11.8%) Alcohol Not Present 123 (8.1%) 1393 (91.9%) 1516 (88.2%) PARAFFIN vs OTHER CHEMICALS Not Paraffin 108 (6.9%) 1451 (93.1%) 1559 (90.8%) Paraffin 26 (16.4%) 133 (83.6%) 159 (9.2%) As seen in Table 1 , females constituted a much greater proportion of injuries due to ingestion of harmful substances (72.7%) than males (27.3%). Similarly, individuals from the younger age cohorts (13–17 and 18–29 years) comprised the greater proportion of ingestion injuries (74.9%), in contrast to older adults aged 45 years and older (6.3%). The overwhelming majority of ingestion injuries were not characterised by the presence of alcohol (88.2%), with alcohol only occurring in 11.8% of cases. Finally, in terms of the type of chemical substances causing the injuries, the larger proportion was due to the ingestion of chemicals other than paraffin (90.8%) rather than paraffin itself (9.2%). 3.2. Logistic regression analysis Binary logistic regression analysis was used to determine how the risk for self-inflicted ingestion was differentiated from the risk for other-inflicted ingestion by sex, age cohort, presence of alcohol, and ingestion of paraffin versus other harmful chemicals. To account for any potential model estimation problems due to small cell size, the logistic regression analysis was conducted using the bootstrapping method. The bootstrapping method is a procedure whereby the model and parameter estimation is undertaken on multiple different samples drawn from the same base sample. This analytic method returns more robust parameter estimates for each variable. The bootstrapping procedure used in this analysis entailed the drawing and testing of 1000 samples from the base sample. It was conducted by using the bias corrected and accelerated (BCa) intervals rather than the percentile intervals as these provide more robust estimation of the 95% confidence intervals. All Odds Ratio values reported are adjusted for all other variables in the model (see Table 2 ). Table 2 Logistic regression analysis assessing ingestion risk Self-Inflicted Ingestion Sig. Bias Corrected & accelerated Adjusted Odds Ratios (AOR) Bias Corrected & accelerated 95% Confidence Interval for AOR Lower Bound Upper Bound Female .001 1.961* 1.349 2.895 Male . . 13–17 years .001 2.730* 1.378 5.129 18–29 years .000 4.607* 2.529 8.180 30–44 years .000 4.436* 2.207 9.115 45 + years . . Alcohol Yes .047 1.918* 1.078 4.558 No Alcohol . . Other Chemicals .000 3.057* 1.834 4.697 Paraffin . . . . The − 2 Log Likelihood test returned a statistically significant result for the overall model (χ2 = 56.270, df = 6, p = .00), indicating that the model as comprised of all explanatory variables was a good fit to the data. The individual variable − 2 Log Likelihood tests further revealed statistically significant results for the explanatory variables in the model as follows: Sex (χ2 = 11.678, p = .00), Age cohort (χ2 = 27.634, p = .00), Presence of alcohol (χ2 = 4.352, p = .03) and Presence of Other Chemicals (other than paraffin) (χ2 = 17.749, p = .00). Inspection of the individual explanatory variables in the bootstrapped model revealed the following: Sex – Females were almost twice as likely than males to present at a hospital with self-inflicted ingestion as compared to ingestion inflicted by others (AOR = 1.961, BCa 95% CI: 1.349–2.895). Sex is thus a significant differentiator of the risk of self-inflicted ingestion. Age Cohort – When compared to adults aged 45 years or older, young adults aged 18–29 years were most at risk for self-inflicted ingestion, being more than four times more likely to present with self-inflicted injuries compared to the older cohort (AOR = 4.607, BCa 95% CI: 2.529–8.180), followed closely by mature adults aged 30 to 44 years (AOR = 4.436, BCa 95% CI: 2.207–9.115), with adolescents being twice as likely as older adults to suffer such ingestion (OR = 2.730, BCa 95% CI: 1.378–5.129). Overall, all three younger age cohorts are indicated to be at significantly higher risk for self-ingestion, whereas the oldest age cohort is at significantly higher risk for other-inflicted ingestion. Alcohol – Individuals for whom the presence of alcohol was recorded for the injury circumstances were twice as likely to suffer self-inflicted ingestion injuries relative to ingestion injuries inflicted by others (AOR = 1.918, BCa 95% CI: 1.078–4.558) Hence alcohol is a significant differentiator of the risk of self-inflicted ingestion from that of other-inflicted ingestion. Paraffin vs other chemicals – finally, self-inflicted injuries were about three times more likely in instances where chemicals other than paraffin were present (AOR = 3.057, BCa 95% CI: 1.834–4.697). This indicates that harmful chemical substances are three times more likely than paraffin to be the cause of injury when the injury is self-inflicted than when it is other-inflicted. 4. Discussion The objectives of this study were to assess all ingestion injuries by three identifying factors, namely (i) the proportion of those that are due to self-ingestion; (ii) the sex and age cohorts most affected; and (iii) the roles of alcohol and other substances. The current findings indicate that sex, age, the presence of alcohol and the ingestion of chemicals other than paraffin were all key explanatory factors with regards to the risk for injuries due to self-inflicted ingestion as compared to ingestion due to the actions of others. The current findings on the greater risk for self-ingestion of harmful chemicals in females, and thus the likely higher rates of self-harm, align with South African, African and global research and trends on the manner in which high levels of social adversity for women may translate into the higher risk for self-harm behaviour ([18];[19]). The impact of patriarchal social systems, through social inequality norms, discrimination in essential services such as education and reproductive health, restricted economic opportunities, and constrained gender-based social roles, highlight the greater socio-cultural, occupational and personal challenges for women. In South Africa, high rates of gender-based violence are reported to enforce gender hierarchies, with 25 to 40% of South African women reporting sexual and/or physical violence at some point in their lives [20]. The pervasive challenges faced by girls and women in South and elsewhere are therefore unsurprisingly associated with higher rates of personal distress, hopelessness and powerlessness, and consequently, greater likelihood of self-harm [21]. This study also highlighted age as an important indicator for the greater risk of self-inflicted ingestion, with the highest incidence observed in young adults aged 18 to 29 years, followed by youth aged between 13 and 17, and then mature adults aged between 30 and 44. The result for youth reflects public health concerns for this and equivalent cohorts in other settings, e.g. in the United States of America, where youth suicide is a significant concern specifically explained through the difficulties placed by increasing social demands and economic hardship on psychosocial development [22]. This period in life is characterised, although not necessarily universally, by significant physical, cognitive-emotional, and relational changes [23]. The increased socio-cultural demands that are encountered during this period may be highly stressful and accompanied by feelings of helplessness, insecurity, and a loss of control ([24];[23]), which may be exacerbated by alcohol and substance use. This study confirmed the role of alcohol in differentiating the risk of self-inflicted ingestion from that of other-inflicted ingestion, doubling the risk for self-inflicted injuries. This result is consistent with other research reporting on the association between alcohol and self-ingestion behaviour with a harmful substance ([25];[26]; [27]). In South Africa, alcohol availability and usage is widespread with binge drinking common amongst young people [28]. The excessive use of alcohol affects judgement, inhibitory control and risk-taking behaviour [29] and often impairs both relationships and especially individual coping [22]. In the current study, mature adults aged 30 to 44 were found to be more than four times more vulnerable than adults aged 45 years and older for self-inflicted ingestion. This cohort is also considered an intensive life period, with significant life demands and events related to adulthood, with employment or unemployment, marriage and family demands, and lifestyle pressures, all of which can impact wellbeing and ultimately suicidal behaviour ([23];[30]). In South Africa, the unemployment rate has been reported at all-time highs in the past decade [31] with profound socio-economic challenges for both younger and more mature age cohorts, straining the emotional and social capacities of individuals. The struggle to find employment or the loss of employment and income and the impact of this on South African families has been extremely stressful, with individuals who typically carry the responsibility of family care burdened by increased rates of family instability, alcohol use and dependence, interpersonal conflict and violence, and psychological illness [23]. In South Africa, there are furthermore specific health challenges for this age group; in particular HIV prevalence peaks between 30 and 39 years, with the highest rates reported amongst females, with consequent impacts on social stigma and personal coping [23]. Finally, the study highlighted that the use of chemicals other than paraffin was more likely during instances of self-inflicted poisoning. The use of other chemicals over paraffin could reflect perceptions of the potency or impact of such chemicals (e.g. pesticides or paracetamols), as well as their accessibility [17], arguably facilitated by the global rise of a DIY culture which has promoted the availability of highly corrosive and harmful substances despite concerns of the latter’s safety [32]. 5. Strengths and limitations This study highlights the phenomenon of self-inflicted ingestion injury, specifically within South Africa. This study had access to large sample data, which is generally rare in resource limited contexts such as lower to middle income countries where such data collection and distribution is minimal. Nevertheless, the data used in this study reflect collection from the year 2011 at the very latest, and hence may have a very limited usage life beyond the current period due to changing societal and household conditions. Additionally, while the data enabled the differentiation of self-inflicted from other inflicted injury, it did not permit an examination of intentionality within the category of self-inflicted injury. Accordingly, it is not possible to know the proportion of self-inflicted injury with is attributable to volition and that which is due to negligence or carelessness. This constrains the application of the results to the wider research and literature on self-harm ingestion. 6. Conclusions This study contributes towards a largely unreported phenomenon around self-ingestion. This has been identified as a knowledge gap in the field, and this study thus sheds light on this complex issue by contributing towards a more nuanced understanding of this phenomenon. Achieving a fuller understanding around self-inflicted ingestion may serve to inform future safety policies on the manner of how chemical products are sold, and the ways in which future prevention and psychosocial interventions can target this area of intentional self-inflicted ingestion injuries. It also provides some recommendations for the triage process at hospitals during admissions, whereby self-ingestion can be noted as a marker for potential underlying or co-occurring mental health issues and the need for relevant psychotherapeutic or psychiatric treatment interventions. Declarations Availability of data and materials The data was obtained from the Household Energy Safety Association of Southern Africa (HESASA), a public benefit organisation located in Cape Town, South Africa. Access to the HESASA data is available via direct request to the organisation. Funding The authors wish to acknowledge the University of South Africa and the South African Medical Research Council and for the funding and institutional support provided. Author information Rajen Govender, Wayne van Tonder and Ashley van Niekerk contributed equally to this work. Authors and Affiliations Institute for Social and Health Sciences, University of South Africa Rajen Govender, Wayne van Tonder, Ashley van Niekerk Masculinity and Health Research Unit, University of South Africa and South African Medical Research Council Rajen Govender, Wayne van Tonder, Ashley van Niekerk Contributions RG, WvT and AvN wrote and revised the article; RG collected and analysed the data. All authors approved the final version. Corresponding author Correspondence to Ashley van Niekerk Ethics declarations Ethics approval and consent to participate The study (EC021-11/2017) was approved by the Health Research Ethics Committee (HREC) of the South African Medical Research Council. Consent for publication Not applicable Competing interests The authors declare no competing interests. References World Health Organisation: Global Health Observatory (GHO) http://www.who.int/gho/en/ (2016). Accessed on 19 Sep 2023. World Health Organization: Accidental poisoning by and exposure to noxious substances. In International statistical classification of diseases and related health problems (11th ed.) https://icd.who.int/ (2019). Accessed on 19 Dec 2023. World Health Organization. Poisoning Prevention and Management [Internet]. World Health Organization. 2021. Available from: https://www.who.int/ipcs/poisons/en/ Accessed on 19 Dec 2023. Eddleston M. Patterns and problems of deliberate self‐poisoning in the developing world. 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Cite Share Download PDF Status: Published Journal Publication published 20 Jun, 2024 Read the published version in BMC Public Health → Version 1 posted Editorial decision: Revision requested 20 Nov, 2023 Reviews received at journal 16 Nov, 2023 Reviewers agreed at journal 07 Nov, 2023 Reviewers agreed at journal 01 Nov, 2023 Reviewers invited by journal 01 Nov, 2023 Editor assigned by journal 01 Nov, 2023 Editor invited by journal 03 Oct, 2023 Submission checks completed at journal 03 Oct, 2023 First submitted to journal 23 Sep, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3380255","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":237512259,"identity":"e1130b38-1c7d-4d72-b39c-4976d59b94ff","order_by":0,"name":"Rajen Govender","email":"","orcid":"","institution":"University of South Africa","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Rajen","middleName":"","lastName":"Govender","suffix":""},{"id":237512260,"identity":"1984f303-1cdd-4ce7-9fbb-ddea7183d307","order_by":1,"name":"Wayne van Tonder","email":"","orcid":"","institution":"University of South Africa","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Wayne","middleName":"van","lastName":"Tonder","suffix":""},{"id":237512261,"identity":"c3980389-7bb4-49f8-a2a5-3770b0993608","order_by":2,"name":"Ashley van Niekerk","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3ElEQVRIiWNgGAWjYFACxgbGBgY2ORCDJC18xqRoAauVSyRevcHt5saHM2rM0jfcbm7+8IPBTp6B//AD/FruHGw23HAsLXfDnYNtkj0MyYYNDMcM8GqRnJHYJvmA7VjuhhuJbQw8DMwJQHcS1NL+88G//+kGNxKbP/5hqE9gYGb/gFcLv0RiG+PGNrYEoJYGaR6GwwkMbDz4bQFqaZac2cdmOBPoMGkZg+OGbTw8BXi1sEmkP/zY841Nnu9G+uOPbyqq5fn5j2/AqwUNAJ3ERor6UTAKRsEoGAXYAQAcLUWSJW+CdgAAAABJRU5ErkJggg==","orcid":"","institution":"University of South Africa","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Ashley","middleName":"van","lastName":"Niekerk","suffix":""}],"badges":[],"createdAt":"2023-09-23 18:44:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3380255/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3380255/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12889-024-18971-3","type":"published","date":"2024-06-20T16:03:04+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":58823921,"identity":"41573e2c-ad35-4eec-960d-2ddc16702eff","added_by":"auto","created_at":"2024-06-21 17:10:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":506421,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3380255/v1/ef3931a7-0479-4f5a-b3c4-157ed369b31f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Self-inflicted ingestion of harmful chemicals in adolescents and adults: Risk factors and characteristics","fulltext":[{"header":"1. Global Distribution, Demographics and Causality of Ingestion Mortality","content":"\u003cp\u003eThe exposure to harmful chemicals is common and may affect people through ingestion, inhalation, skin contact or via the umbilical cord to unborn children [1]. Chemicals such as pesticides, solvents, paints, detergents, kerosene or paraffin, carbon monoxide and drugs have been widely reported to lead to unintentional poisoning, with 61,523 deaths reported annually [2]. The intentional ingestion of chemicals is a further concern that accounts for 137 831 deaths reported each year, with pesticides the most common agent used, especially in Asia and central America ([3];[2];[1]). Globally, children and young adults are especially affected by unintentional poisoning [2]. Children are especially impacted by the acute and chronic effects of acute poisonings and exposure to air pollution, while older adults suffer chronic effects from air pollution and exposure to various carcinogens [1].\u003c/p\u003e \u003cp\u003eIn the past three decades there has been an increasing research focus on unintentional poisonings and more recently on intentional self-poisoning, especially in low- and middle-income countries [4];[5]. The most prevalent agents of lethal poison ingestion vary by region and country. For example, in an Indian study on lethal poisoning between 1999 and 2018, pesticide mortality was most prominent with the most common agents including organophosphates (6387 deaths) and aluminum phosphide (5534 deaths) [6]. In 2016, Sri Lankan government hospitals recorded over 12 500 cases of organophosphate and carbamate pesticide poisoning [7], with the 17 to 49 years age cohort most affected, followed by those aged 50 to 69 years. In China, despite an observed decrease in poisoning mortality between 2006 and 2016, 87% of such deaths were due to pesticides and mostly suicide-related, with males, rural background, and older adults strongly associated with such intentional self-poisoning [8]. In parts of Africa, intentional poisoning mortality, especially attributed to organophosphates and pesticides, also pose a major public health problem [9]. In an Ethiopian study, 71.4% of such intentional self-poisoning cases were attributed to ingestion of bleach, with risk factors including being female and recent family disputes [10]. Higher frequencies of intentional ingestion of organophosphates (38%) were also found in Zambia, mostly attributed to suicidal attempts after family disputes [11].\u003c/p\u003e \u003cp\u003eIn South Africa, accidental poisoning through ingestion of noxious substances contributed to 2.1% of all unintentional injury deaths in 2017 [12]. Paraffin had been implicated as an important agent to unintentional child poisonings, with 40 000 to 60 000 annual cases estimated [13]. Intentional self-poisoning has also been described as a significant burden in South Africa, with 863 suicides by poison ingestion in 2017 [14]. Emergency centers provide further illustration of these cases; e.g., in a Cape Town study over a six-month period, 192 patients were admitted for intentional self-poisoning [15]. The most common toxic agent was pharmaceuticals, specifically paracetamol, with females comprising two out of every three (68.8%) self-inflicted intentional poisoning admissions. Other South African hospital studies of acute poisoning, such as in Durban, reported that one quarter of all ingestion poisoning was due to the intake of tricyclic antidepressants [16]. This study also found that women were more likely to self-ingest with ethylene glycol (antifreeze), which was characterised with a 37.5% mortality rate. A Tshwane study reported that 50.2% of all poisonings were regarded as suicide related, with organophosphate poisoning indicated in 58% of males, and in 27.1% of females between 21\u0026ndash;30 years [17].\u003c/p\u003e \u003cp\u003ePoisonings can be either self-inflicted or inflicted by others, and either intentional or unintentional. In self-inflicted instances, the poisoning incident could be either intentional or unintentional, the former arguably due to self-harm while the latter may occur through negligence or lack of knowledge. In instances of other-inflicted poisoning, incidents which are intentional would constitute an assault, while unintentional other-inflicted poisonings would not be regarded as an assault if there is no discernible identified intention to harm. However, the identification and confirmation of intentionality is complex, even in the instances of self-inflicted poisoning, as persons may intend to self-harm at the time of ingestion but later feel remorseful and thus report the ingestion as unintentional. Also, attempts to attract the attention of others by ingestion may be intentional, although the ingestion may not have been intended to achieve any self-harm of a significant nature. For these reasons, it is not always possible to conclusively confirm the intentionality of self-inflicted poison injuries without attendant information relating to the victim\u0026rsquo;s cognitive, psychological and affective state at the time of the injury.\u003c/p\u003e \u003cp\u003eThis study builds upon the emerging poison ingestion work in South Africa and describes the demographic and attendant key risk factors for self-inflicted ingestion cases. Due to limitations of data, the study does not distinguish between intentional and unintentional self-inflicted ingestion injuries, and compares all self-inflicted injuries against ingestion injuries attributable to or inflicted by the actions of others. The research explores how demographic factors identified in the literature \u0026ndash; sex and age \u0026ndash; as well as key attendant factors such as the presence or absence of alcohol and the use of paraffin versus other chemicals may differentiate the risk for self-inflicted from other-inflicted ingestion injuries.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003e \u003cb\u003ePrimary data collection\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe primary data for this study was collected by the Paraffin Safety Association of Southern Africa (PASASA) (later renamed Household Energy Safety Association of Southern Africa - HESASA) as part of a larger study on household energy-related risks for mortality and morbidity in South Africa. The dataset for this analysis was derived from a sample of 19 hospitals servicing primarily low-income informal settlements situated nearby major metropolitan areas in eight of the country\u0026rsquo;s nine provinces. The hospitals are not representative of all hospitals in the country but all of them are located adjacent to and service impoverished communities characterised by informal homesteads. Participants for the study were interviewed at admission in their home language to obtain their informed consent and collect background information on demographics and injury circumstances. Due to low literacy levels amongst the participants, informed consent was obtained verbally. Following admission, participant records were populated by researchers with data obtained from hospital case records, providing detail on the clinical features of the burn injuries and treatment procedures and outcomes. The data was fully anonymised and all participant records were expunged of any form of personal identification information. The study was approved by the Health Research Ethics Committee (HREC) of the South African Medical Research Council.\u003c/p\u003e \u003cp\u003e \u003cb\u003eSample\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe study dataset contains 12 079 cases comprising all types of energy-related injuries, in particular external and internal burns, for patients of all ages. Given the focus in this research on ingestion injuries in persons who are adolescents and older, a sub-sample selection was made using only cases for which ingestion was indicated as the cause of the injury and for which the patient age was reported as 13 years or older. This realised a final analysis sample of 1 718 cases.\u003c/p\u003e \u003cp\u003e \u003cb\u003eAnalysis\u003c/b\u003e \u003c/p\u003e \u003cp\u003eDescriptive statistics were used to illustrate key sample characteristics and binary logistic regression analysis modelling was undertaken to examine for differentiated risk for self-inflicted ingestion across a series of control and key explanatory factors. All analysis was performed using the IBM Statistical Package for Social Sciences (SPSS) version 27, using a p\u0026thinsp;\u0026le;\u0026thinsp;0.05 significance level.\u003c/p\u003e \u003cp\u003e \u003cb\u003eOutcome and explanatory variables\u003c/b\u003e \u003c/p\u003e \u003cp\u003eOutcome Variable - the outcome variable was a binary categorical variable differentiating between self-inflicted and other-inflicted ingestion of harmful substances. To sharpen the definition of the other-inflicted ingestion, all instances which were intentional, that is, which would be regarded as assault, were removed from the data. The other-inflicted category thus represents only cases of unintentional infliction of poison ingestion in the victim by other persons. For the category of self-inflicted, the data did not permit a clear resolution of intentionality. Accordingly, the category was not differentiated any further and is used throughout this study to reflect all instances of self-ingestion of harmful substances, whether intentional or unintentional. For the logistic regression modelling the reference category for the outcome variable was set as other-inflicted unintentional ingestion injury.\u003c/p\u003e \u003cp\u003eExplanatory variables - the following explanatory variables were employed:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eSex: Sex was recorded as either female or male (Reference Category)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAge Cohort: Age was used as a categorical variable differentiated into four age cohorts as follows: adolescents: 13\u0026ndash;17 years, youth or young adults: 18\u0026ndash;39 years, mature adults: 30\u0026ndash;44 years and older adults: 45 years and older (Reference Category).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePresence of Alcohol: The presence or absence of alcohol was based on reporting at time of admission by patient and/or persons accompanying patient and/or observation by hospital staff, and was measured categorically as either Present or Not Present (Reference Category). The measure does not include information on prior history of use/abuse or related biomarker testing at admission or during hospitalisation.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eParaffin and Other Chemicals: this variable was recorded at the time of observation from reporting by the patient or persons accompanying the patient and/or observation by hospital staff and was measured categorically as either Paraffin (Reference Category) or Other Chemical Substances.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e3.1. Descriptives\u003c/h2\u003e \u003cp\u003eThe total number of participants used for analysis was 1718 (1584 - self-inflicted ingestion, 134 - other-inflicted ingestion). Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e demonstrates the variances between those who suffered ingestion of harmful substances through self-inflicted ingestion as compared to those who suffered such injury through other-inflicted ingestion.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSample descriptive characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSelf-Inflicted Ingestion\u003c/p\u003e \u003cp\u003e1584 (92.1%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOther-Inflicted Unintentional Ingestion\u003c/p\u003e \u003cp\u003e134 (7.8%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003e1718 (100%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGENDER\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e81 (6.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1168 (93.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1249 (72.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e53 (11.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e416 (88.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e469 (27.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAGE COHORTS\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13\u0026ndash;17 Years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e38 (9.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e362 (90.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e400 (23.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18\u0026ndash;29 Years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e54 (6.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e833 (93.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e887 (51.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30\u0026ndash;44 Years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20 (6.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e304 (93.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e324 (18.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e45 Years and Older\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22 (20.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e85 (79.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e107 (6.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eALCOHOL\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlcohol Present\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11 (5.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e191 (94.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e202 (11.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlcohol Not Present\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e123 (8.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1393 (91.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1516 (88.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePARAFFIN vs OTHER CHEMICALS\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot Paraffin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e108 (6.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1451 (93.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1559 (90.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParaffin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26 (16.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e133 (83.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e159 (9.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAs seen in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, females constituted a much greater proportion of injuries due to ingestion of harmful substances (72.7%) than males (27.3%). Similarly, individuals from the younger age cohorts (13\u0026ndash;17 and 18\u0026ndash;29 years) comprised the greater proportion of ingestion injuries (74.9%), in contrast to older adults aged 45 years and older (6.3%). The overwhelming majority of ingestion injuries were not characterised by the presence of alcohol (88.2%), with alcohol only occurring in 11.8% of cases. Finally, in terms of the type of chemical substances causing the injuries, the larger proportion was due to the ingestion of chemicals other than paraffin (90.8%) rather than paraffin itself (9.2%).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e3.2. Logistic regression analysis\u003c/h2\u003e \u003cp\u003eBinary logistic regression analysis was used to determine how the risk for self-inflicted ingestion was differentiated from the risk for other-inflicted ingestion by sex, age cohort, presence of alcohol, and ingestion of paraffin versus other harmful chemicals. To account for any potential model estimation problems due to small cell size, the logistic regression analysis was conducted using the bootstrapping method. The bootstrapping method is a procedure whereby the model and parameter estimation is undertaken on multiple different samples drawn from the same base sample. This analytic method returns more robust parameter estimates for each variable. The bootstrapping procedure used in this analysis entailed the drawing and testing of 1000 samples from the base sample. It was conducted by using the bias corrected and accelerated (BCa) intervals rather than the percentile intervals as these provide more robust estimation of the 95% confidence intervals. All Odds Ratio values reported are adjusted for all other variables in the model (see Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLogistic regression analysis assessing ingestion risk\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSelf-Inflicted Ingestion\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSig.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eBias Corrected \u0026amp; accelerated Adjusted Odds Ratios (AOR)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eBias Corrected \u0026amp; accelerated 95% Confidence Interval for AOR\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLower Bound\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUpper Bound\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.961*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.349\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.895\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13\u0026ndash;17 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.730*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.378\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.129\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18\u0026ndash;29 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.607*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.529\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8.180\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30\u0026ndash;44 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.436*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.207\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e9.115\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e45\u0026thinsp;+\u0026thinsp;years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlcohol Yes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.047\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.918*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.078\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.558\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo Alcohol\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther Chemicals\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.057*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.834\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.697\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParaffin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe \u0026minus;\u0026thinsp;2 Log Likelihood test returned a statistically significant result for the overall model (χ2\u0026thinsp;=\u0026thinsp;56.270, df\u0026thinsp;=\u0026thinsp;6, p\u0026thinsp;=\u0026thinsp;.00), indicating that the model as comprised of all explanatory variables was a good fit to the data. The individual variable \u0026minus;\u0026thinsp;2 Log Likelihood tests further revealed statistically significant results for the explanatory variables in the model as follows: Sex (χ2\u0026thinsp;=\u0026thinsp;11.678, p\u0026thinsp;=\u0026thinsp;.00), Age cohort (χ2\u0026thinsp;=\u0026thinsp;27.634, p\u0026thinsp;=\u0026thinsp;.00), Presence of alcohol (χ2\u0026thinsp;=\u0026thinsp;4.352, p\u0026thinsp;=\u0026thinsp;.03) and Presence of Other Chemicals (other than paraffin) (χ2\u0026thinsp;=\u0026thinsp;17.749, p\u0026thinsp;=\u0026thinsp;.00).\u003c/p\u003e \u003cp\u003eInspection of the individual explanatory variables in the bootstrapped model revealed the following:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eSex \u0026ndash; Females were almost twice as likely than males to present at a hospital with self-inflicted ingestion as compared to ingestion inflicted by others (AOR\u0026thinsp;=\u0026thinsp;1.961, BCa 95% CI: 1.349\u0026ndash;2.895). Sex is thus a significant differentiator of the risk of self-inflicted ingestion.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAge Cohort \u0026ndash; When compared to adults aged 45 years or older, young adults aged 18\u0026ndash;29 years were most at risk for self-inflicted ingestion, being more than four times more likely to present with self-inflicted injuries compared to the older cohort (AOR\u0026thinsp;=\u0026thinsp;4.607, BCa 95% CI: 2.529\u0026ndash;8.180), followed closely by mature adults aged 30 to 44 years (AOR\u0026thinsp;=\u0026thinsp;4.436, BCa 95% CI: 2.207\u0026ndash;9.115), with adolescents being twice as likely as older adults to suffer such ingestion (OR\u0026thinsp;=\u0026thinsp;2.730, BCa 95% CI: 1.378\u0026ndash;5.129). Overall, all three younger age cohorts are indicated to be at significantly higher risk for self-ingestion, whereas the oldest age cohort is at significantly higher risk for other-inflicted ingestion.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAlcohol \u0026ndash; Individuals for whom the presence of alcohol was recorded for the injury circumstances were twice as likely to suffer self-inflicted ingestion injuries relative to ingestion injuries inflicted by others (AOR\u0026thinsp;=\u0026thinsp;1.918, BCa 95% CI: 1.078\u0026ndash;4.558) Hence alcohol is a significant differentiator of the risk of self-inflicted ingestion from that of other-inflicted ingestion.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eParaffin vs other chemicals \u0026ndash; finally, self-inflicted injuries were about three times more likely in instances where chemicals other than paraffin were present (AOR\u0026thinsp;=\u0026thinsp;3.057, BCa 95% CI: 1.834\u0026ndash;4.697). This indicates that harmful chemical substances are three times more likely than paraffin to be the cause of injury when the injury is self-inflicted than when it is other-inflicted.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThe objectives of this study were to assess all ingestion injuries by three identifying factors, namely (i) the proportion of those that are due to self-ingestion; (ii) the sex and age cohorts most affected; and (iii) the roles of alcohol and other substances. The current findings indicate that sex, age, the presence of alcohol and the ingestion of chemicals other than paraffin were all key explanatory factors with regards to the risk for injuries due to self-inflicted ingestion as compared to ingestion due to the actions of others.\u003c/p\u003e \u003cp\u003eThe current findings on the greater risk for self-ingestion of harmful chemicals in females, and thus the likely higher rates of self-harm, align with South African, African and global research and trends on the manner in which high levels of social adversity for women may translate into the higher risk for self-harm behaviour ([18];[19]). The impact of patriarchal social systems, through social inequality norms, discrimination in essential services such as education and reproductive health, restricted economic opportunities, and constrained gender-based social roles, highlight the greater socio-cultural, occupational and personal challenges for women. In South Africa, high rates of gender-based violence are reported to enforce gender hierarchies, with 25 to 40% of South African women reporting sexual and/or physical violence at some point in their lives [20]. The pervasive challenges faced by girls and women in South and elsewhere are therefore unsurprisingly associated with higher rates of personal distress, hopelessness and powerlessness, and consequently, greater likelihood of self-harm [21].\u003c/p\u003e \u003cp\u003eThis study also highlighted age as an important indicator for the greater risk of self-inflicted ingestion, with the highest incidence observed in young adults aged 18 to 29 years, followed by youth aged between 13 and 17, and then mature adults aged between 30 and 44. The result for youth reflects public health concerns for this and equivalent cohorts in other settings, e.g. in the United States of America, where youth suicide is a significant concern specifically explained through the difficulties placed by increasing social demands and economic hardship on psychosocial development [22]. This period in life is characterised, although not necessarily universally, by significant physical, cognitive-emotional, and relational changes [23]. The increased socio-cultural demands that are encountered during this period may be highly stressful and accompanied by feelings of helplessness, insecurity, and a loss of control ([24];[23]), which may be exacerbated by alcohol and substance use. This study confirmed the role of alcohol in differentiating the risk of self-inflicted ingestion from that of other-inflicted ingestion, doubling the risk for self-inflicted injuries. This result is consistent with other research reporting on the association between alcohol and self-ingestion behaviour with a harmful substance ([25];[26]; [27]). In South Africa, alcohol availability and usage is widespread with binge drinking common amongst young people [28]. The excessive use of alcohol affects judgement, inhibitory control and risk-taking behaviour [29] and often impairs both relationships and especially individual coping [22].\u003c/p\u003e \u003cp\u003eIn the current study, mature adults aged 30 to 44 were found to be more than four times more vulnerable than adults aged 45 years and older for self-inflicted ingestion. This cohort is also considered an intensive life period, with significant life demands and events related to adulthood, with employment or unemployment, marriage and family demands, and lifestyle pressures, all of which can impact wellbeing and ultimately suicidal behaviour ([23];[30]). In South Africa, the unemployment rate has been reported at all-time highs in the past decade [31] with profound socio-economic challenges for both younger and more mature age cohorts, straining the emotional and social capacities of individuals. The struggle to find employment or the loss of employment and income and the impact of this on South African families has been extremely stressful, with individuals who typically carry the responsibility of family care burdened by increased rates of family instability, alcohol use and dependence, interpersonal conflict and violence, and psychological illness [23]. In South Africa, there are furthermore specific health challenges for this age group; in particular HIV prevalence peaks between 30 and 39 years, with the highest rates reported amongst females, with consequent impacts on social stigma and personal coping [23].\u003c/p\u003e \u003cp\u003eFinally, the study highlighted that the use of chemicals other than paraffin was more likely during instances of self-inflicted poisoning. The use of other chemicals over paraffin could reflect perceptions of the potency or impact of such chemicals (e.g. pesticides or paracetamols), as well as their accessibility [17], arguably facilitated by the global rise of a DIY culture which has promoted the availability of highly corrosive and harmful substances despite concerns of the latter\u0026rsquo;s safety [32].\u003c/p\u003e"},{"header":"5. Strengths and limitations","content":"\u003cp\u003eThis study highlights the phenomenon of self-inflicted ingestion injury, specifically within South Africa. This study had access to large sample data, which is generally rare in resource limited contexts such as lower to middle income countries where such data collection and distribution is minimal. Nevertheless, the data used in this study reflect collection from the year 2011 at the very latest, and hence may have a very limited usage life beyond the current period due to changing societal and household conditions. Additionally, while the data enabled the differentiation of self-inflicted from other inflicted injury, it did not permit an examination of intentionality within the category of self-inflicted injury. Accordingly, it is not possible to know the proportion of self-inflicted injury with is attributable to volition and that which is due to negligence or carelessness. This constrains the application of the results to the wider research and literature on self-harm ingestion.\u003c/p\u003e"},{"header":"6. Conclusions","content":"\u003cp\u003eThis study contributes towards a largely unreported phenomenon around self-ingestion. This has been identified as a knowledge gap in the field, and this study thus sheds light on this complex issue by contributing towards a more nuanced understanding of this phenomenon. Achieving a fuller understanding around self-inflicted ingestion may serve to inform future safety policies on the manner of how chemical products are sold, and the ways in which future prevention and psychosocial interventions can target this area of intentional self-inflicted ingestion injuries. It also provides some recommendations for the triage process at hospitals during admissions, whereby self-ingestion can be noted as a marker for potential underlying or co-occurring mental health issues and the need for relevant psychotherapeutic or psychiatric treatment interventions.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data was obtained from the \u003cem\u003eHousehold Energy Safety Association\u003c/em\u003e\u0026nbsp;of\u0026nbsp;\u003cem\u003eSouthern Africa (HESASA), a public benefit organisation located in Cape Town, South Africa. \u003c/em\u003e\u0026nbsp;Access to the HESASA data is available via direct request to the organisation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors wish to acknowledge the University of South Africa and the South African Medical\u003c/p\u003e\n\u003cp\u003eResearch Council and for the funding and institutional support provided.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRajen Govender, Wayne van Tonder and Ashley van Niekerk contributed equally to this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors and Affiliations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInstitute for Social and Health Sciences, University of South Africa\u003c/p\u003e\n\u003cp\u003eRajen Govender, Wayne van Tonder, Ashley van Niekerk\u003c/p\u003e\n\u003cp\u003eMasculinity and Health Research Unit, University of South Africa and South African Medical Research Council\u003c/p\u003e\n\u003cp\u003eRajen Govender, Wayne van Tonder, Ashley van Niekerk\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRG, WvT and AvN wrote and revised the article; RG collected and analysed the data. All authors approved the final version.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCorresponding author\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCorrespondence to Ashley van Niekerk\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics declarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study (EC021-11/2017) was approved by the Health Research Ethics Committee (HREC) of the South African Medical Research Council.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWorld Health Organisation: Global Health Observatory (GHO) http://www.who.int/gho/en/ (2016). 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BMC Public Health. 2020;20(1875):1-19. doi:10.1186/s12889-020-09939-0\u003c/li\u003e\n\u003cli\u003eKarunarathne A, Bhalla A, Sethi A, Perera U, Eddleston M. Importance of pesticides for lethal poisoning in India during 1999 to 2018: a systematic review. BMC Public Health. 2021;21(1441). https://doi.org/10.1186/s12889-021-11156-2\u003c/li\u003e\n\u003cli\u003eRathnayake S, Rathnayake S, WMNKL W. Prevalence of Agro-chemical Poisoning; with special reference to Organophosphates and Carbamate Insecticide Poisoning among Hospital Admissions of Nuwaraeliya District General Hospital, Sri Lanka from 2014 to 2018. Int.\u0026nbsp;j.\u0026nbsp;sci.\u0026nbsp;Res.. 2019;9(7):120-124.\u003c/li\u003e\n\u003cli\u003eWang L, Yin P, Cheng P, Liu Y, Schwebel D, Qi J, et al. Poisoning deaths in China, 2006\u0026ndash;2016. Bull.\u0026nbsp;World Health Organ.. 2018;96(5):314-326A. doi:10.2471/BLT.17.203943\u003c/li\u003e\n\u003cli\u003eLoha K, Lamoree M, Weiss J, de Boer J. Import, disposal, and health impacts of pesticides in the East Africa Rift (EAR) zone: A review on management and policy analysis. Crop Prot.. 2018;112:322-331. doi:10.1016/j.cropro.2018.06.014\u003c/li\u003e\n\u003cli\u003e Adinew G, Wordekal A, DeVos E, Birru E, Abdulwahib M. Poisoning cases and their management in emergency centres of government hospitals in northwest Ethiopia. Afr J Emerg Med.. 2017;7(2):74-78. doi:10.1016/j.afjem.2017.04.005\u003c/li\u003e\n\u003cli\u003e Mwanza B, Kanyimba S. Acute poisoning in the community and its associated mortality at the University Teaching Hospital, Lusaka, Zambia. Med J Zambia.. 2017;44(1):26-33.\u003c/li\u003e\n\u003cli\u003e Statistics South Africa. Mortality and causes of death in South Africa: findings from death notification. Pretoria: Department of Statistics of South Africa; 2017.\u003c/li\u003e\n\u003cli\u003e Matzopoulos R, Carolissen G. Estimating the incidence of paraffin ingestion. Afr.\u0026nbsp;Saf.\u0026nbsp;Promot.. 2006;4(3):4-14.\u003c/li\u003e\n\u003cli\u003e Prinsloo M, Mhlongo S, Dekel B, Gwebushe N, Martin L, Saayman G, et al. The 2nd Injury Mortality Survey: A national study of injury mortality levels and causes in South Africa in 2017. Cape Town: South African Medical Research Council. 2021.\u003c/li\u003e\n\u003cli\u003e van Hoving D, Hunter L, Gerber R, lategan H, Marks C. The burden of intentional self-poisoning on a district-level public Hospital in Cape Town, South Africa. Afr J Emerg Med.. 2018;8(3):79-83. doi:10.1016/j.afjem.2018.03.002\u003c/li\u003e\n\u003cli\u003e Goga R, de Vasconcellos K, Singh D. Acute poisonings presenting to King Edward VIII hospital intensive care unit in Durban, South Africa. South. Afr. j. crit. care.. 2021;37(1):10-15. doi:10.7196/SAJCC.2021.v37i1.408\u003c/li\u003e\n\u003cli\u003e Razwiedani LL, Rautenbach PG. Epidemiology of organophosphate poisoning in the Tshwane District of South Africa. Environmental health insights. 2017 Feb 24;11: doi:10.1177/1178630217694149\u003c/li\u003e\n\u003cli\u003e De Wet N. Gendered risk factors associated with self-harm mortality among youth in South Africa, 2006 \u0026ndash; 2014, S. Afr. med. j..2017;107(12): 1132-1136\u003c/li\u003e\n\u003cli\u003e Quarshie ENB, Waterman MG, House AO. Self-harm with suicidal and non-suicidal intent in young people in sub-Saharan Africa: a systematic review. BMC Psychiatry. 2020;20. https://doi.org/10.1186/s12888-020-02587-z\u003c/li\u003e\n\u003cli\u003e Seedat M, Van Niekerk A, Jewkes R, Suffla S, Ratele K. Violence and injuries in South Africa: Prioritising an agenda for prevention. Lancet. 2009;374:68-79.\u003c/li\u003e\n\u003cli\u003e Devries KM, Mak JY, Bacchus LJ, et al. Intimate partner violence and incident depressive symptoms and suicide attempts: a systematic review of longitudinal studies. PLoS Med. 2013;10:e1001439. UNFPA. State of the world population 2013: motherhood in childhood. Facing the challenge of adolescent pregnancy. New York, NY: United Nations Population Fund; 2013.\u003c/li\u003e\n\u003cli\u003e Spiller HA, Ackerman JP, Spiller NE, Casavant MJ. Sex- and age-specific increases in suicide attempts by self-poisoning in the United States among youth and young adults from 2000 to 2018. J. Pediatr.. 2019;210:201-208. https://doi.org/10.1016/j.jpeds.2019.02.045\u003c/li\u003e\n\u003cli\u003e Shefer T, Duncan N, van Niekerk A. Adolescence, Adulthood and Ageing. In: Swartz L, de la Rey C, Duncan N, Townsend L, O\u0026rsquo;Neill V, Makhubela M, editors. Psychology: An Introduction, 5th Edition. Cape Town: Oxford University Press; 2021. p. 91-125.\u003c/li\u003e\n\u003cli\u003e Bilsen J. Suicide and Youth: Risk Factors. Front.\u0026nbsp;Psychiatry.. 2018;9.\u0026nbsp;https://doi.org/10.3389/fpsyt.2018.00540\u003c/li\u003e\n\u003cli\u003e Lee V, Connolly M, Calello D. Paediatric poisoning by ingestion: developmental overview and synopsis of national trends. Pediatr.\u0026nbsp;Ann.. 2017;46(12):e443-e448.\u003c/li\u003e\n\u003cli\u003e Eddleston M, Buckley N, Eyer P, Dawson A. Management of acute organophosphorus pesticide poisoning. Lancet. 2008;371(9612):597-607. doi:10.1016/S01406736(07)61202-1\u003c/li\u003e\n\u003cli\u003e van der Hoek W, Konradsen F. Risk factors for acute pesticide poisoning in Sri Lanka. Trop. Med. Int. Health.. 2005;10(6):589-596. doi:10.1111/j.13653156.2005.01416.x\u003c/li\u003e\n\u003cli\u003e Vellios NG, van Walbeek CP. Self-reported alcohol use and binge drinking in South Africa: evidence from the National Income Dynamics Study, 2014 - 2015. S. Afr. Med. J.. 2018;108(1):33\u0026ndash;39.\u003c/li\u003e\n\u003cli\u003e Haller M, Chassin L. Risk pathways among traumatic stress, posttraumatic stress disorder symptoms, and alcohol and drug problems: a test of four hypotheses. Psychol Addict Behav.. 2014;28(3):841\u0026ndash;51.\u003c/li\u003e\n\u003cli\u003e Schreiber J, Culpepper L. Suicidal ideation and behavior in adults. In: Peter P Roy-Byrne \u0026amp; David Solomon (Eds.), UpToDate. Retrieved November 29, 2021, from\u0026nbsp;https://www.uptodate.com/contents/suicidal-ideation-and-behavior-in-adults#H5.\u003c/li\u003e\n\u003cli\u003e Statistics South Africa. Quarterly Labour Force Survey (QLFS) Q2:2021.\u0026nbsp;http://www.statssa.gov.za/publications/P0211/Presentation%20QLFS%20Q2_2021.pdf\u003c/li\u003e\n\u003cli\u003e Hardwicke J, Hunter T, Staruch R, Moiemen N. Chemical burns \u0026ndash; An historical comparison and review of the literature. Burns. 2012;38(3):3837.\u0026nbsp;https://doi.org/10.1016/j.burns.2011.09.014\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"ingestion, self-inflicted, paraffin, chemicals, alcohol","lastPublishedDoi":"10.21203/rs.3.rs-3380255/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3380255/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eInjury due to ingestion of harmful chemicals has become an area of concern globally. A specific category of such injuries is those that are self-inflicted. Although intentionality for self-infliction may be difficult to determine, key explanatory risks and demographic factors may contribute towards a better understanding of self-inflicted and harmful chemical ingestion injuries.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e This study used secondary data that had been collected on burn injuries due to injection of harmful chemicals in a sample of South Africans from low-income communities close to major metropolitan centres. Logistic regression was used to determine how the risk for self-inflicted ingestion was differentiated from ingestion due to the actions of another person (other-inflicted ingestion) by sex and age cohort of the victim, and the presence of alcohol by examining paraffin ingestion versus that of other chemicals.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003eThe current findings indicate that sex, age cohort, presence of alcohol, and chemicals other than paraffin are key explanatory factors for an increased risk for self-inflicted ingestion of harmful chemicals.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e The study empirically confirms the role of several key risk factors in what remains a largely unreported and understudied phenomenon. The findings contribute towards improved safety policies on availability and sale of chemical products and more focussed community interventions for at-risk individuals such as females and young people. It also flags the importance of assessing for alcohol use and alcohol use disorders at hospital admission of self-ingestion injuries.\u003c/p\u003e","manuscriptTitle":"Self-inflicted ingestion of harmful chemicals in adolescents and adults: Risk factors and characteristics","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-10-09 11:03:02","doi":"10.21203/rs.3.rs-3380255/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2023-11-21T03:11:12+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-11-16T06:09:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"5218c5e7-b84e-4deb-a094-96cc1cd8ab70","date":"2023-11-07T20:06:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"bff566b0-a379-4914-bf6c-f0a8ab39c32c","date":"2023-11-01T22:53:03+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2023-11-01T11:31:50+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-11-01T10:36:39+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2023-10-03T17:21:18+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2023-10-03T06:29:20+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2023-09-23T18:29:48+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cfb477f6-041b-4cee-9fef-33fe6b2b739a","owner":[],"postedDate":"October 9th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-06-21T16:03:04+00:00","versionOfRecord":{"articleIdentity":"rs-3380255","link":"https://doi.org/10.1186/s12889-024-18971-3","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2024-06-20 16:03:04","publishedOnDateReadable":"June 20th, 2024"},"versionCreatedAt":"2023-10-09 11:03:02","video":"","vorDoi":"10.1186/s12889-024-18971-3","vorDoiUrl":"https://doi.org/10.1186/s12889-024-18971-3","workflowStages":[]},"version":"v1","identity":"rs-3380255","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3380255","identity":"rs-3380255","version":["v1"]},"buildId":"WrCJVZZCHTDjtuVLN7oU0","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}