Background: In the global effort to enhance the provision of high-quality healthcare in paediatric settings, healthcare providers (HCPs) have developed a range of strategies. One approach that has been employed is the utilisation of shared decision-making (SDM), which places a strong emphasis on children actively participating in their healthcare, particularly during the decision-making process. Despite the abundance of evidence supporting the positive effects of SDM on children, its implementation in paediatric settings remains underrated. In Malaysia, research regarding SDM in paediatric settings is still lacking. This study aims to explore children’s participation in the shared decision-making process related to healthcare in paediatric hospital settings in Malaysia. Methods: This study used a generic qualitative approach. Data was obtained through a combination of participant observation and semi-structured interviews. Participant observation was carried out with 100 participants (26 hospitalised children ranging in age from 7 to 12 years old, their parents, and 48 HCPs from three university hospitals in Malaysia). Semi-structured interviews were conducted with 35 participants (nine children, 12 parents, and 14 HCPs). Data was analysed using framework analysis. Results: Children were seen to participate to varying degrees. Five themes emerged from the children’s participation in the SDM process during their hospitalisation: i) children being ignored, ii) children being informed, iii) children being listened to, iv) children being recognised, and v) children serving as decision-makers. Children occupied one of two roles in the SDM process, being either passive or active participants. The roles of children fluctuated throughout their hospitalisation depending on the circumstances they encountered during the communication and decision-making process. The involvement of parents and HCPs appeared to be the most significant factor influencing the degree of children's participation in the SDM process. The roles of the adults either facilitated or hindered the children’s participation in this process. Conclusion: The children’s preferences and levels of participation consistently exhibited variability. To effectively address the needs and well-being of children, it is imperative for adults to comprehend their thoughts. By doing so, adults can establish meaningful communication with children, optimising their overall health outcomes. HCPs have an especially critical role in facilitating children’s participation by providing information and simultaneously empowering the children’s active involvement. The findings of this study are of vital importance for the field of paediatric healthcare, particularly in relation to enhancing the treatment quality and improving the delivery of healthcare services for children within hospital settings. Keywords: shared decision-making, participation, involvement, children, healthcare, Malaysia

Household insecticide has become a necessity among the urban community in Malaysia including Kuantan City, Pahang as a control vector for tropical diseases such as dengue and malaria, which are highly influenced by the humid climate and urbanisation. The insecticide is made of type 1 pyrethroid chemicals that recognised to be safe. However, the incidence of insecticide intoxication suggested insufficient studies on its usage and exposure effects. Thus, it high lightened the importance of toxicology study as part of forensic nursing elements in understanding the toxicity aspect of insecticide that appeared on the patient. The study aimed to assess the knowledge, attitude, and practice (KAP) level on household insecticide toxicity and its associated factors among the community in Kuantan and gather biological data through animal toxicological test. The information obtained was used to design a presentation slide containing information regarding household insecticide exposure risk and safe handling and disseminate it to the public. This study was a multi-methods study comprising of three phases. The first phase was a cross-sectional survey involving 199 respondents conducted through a selfadministered questionnaire, that contained sociodemographic and KAP's data. The second phase comprised a chemicals assessment which conducted using the zebrafish model to evaluate the potential insecticide (cl-trans allethrin and d-phenothrin) exposure toxicity effects at different concentrations (0.20, 0.40, , 0.80, 1.60, 3.20 and 0.13, 0.25, 0.51, 1.00, 2.0 μg/L, respectively) for 96 hours. The gill morphology and gene expression of the zebrafish were analysed. During the third phase of the study, data collected previously were used to develop educational materials on toxic insecticide information and validated process by four content experts and a feasibility study involving 128 target audiences. The first phase of the study showed that respondents had adequate KAP scores. The marital status affected knowledge of singles and married person. There were significant associations between females with knowledge and attitude levels (p < 0.05). Strong positive correlations between knowledge and attitude (r + 0.80,p 0.01), between knowledge and practice (r + 0.76,p 0.01), and a good positive correlation between attitude and practice (r = + 0. 74, p 0.01 ). The second phase of the study indicated that the adult Maximum Tolerated Dose ford-trans allethrin and d-phenothrin was 0.18 and 0.12 μg/day, respectively, which is lower than the normal levels detected in a household environment. The insecticide also caused gills injuries such as hypertrophy, lamellar fusion, lamellar lifting and necrosis to the zebrafish, which alter the gill's morphology and structure. The insecticide also altered baxa, c-myca, gadd45b and p53 gene function. Overall, the experimental studies explained that insecticide poses an exposure risk to human in a form of harmful effects on the respiratory system. For the third phase of the study, the content expert and target audience highly validated the developed educational material, with the overall Content Validity Index of0.85 and 0.91. In conclusion, phase one indicated that community had adequate insecticide KAP level. The phase two reveals the effects of acute insecticide exposure on the respiratory systems. In phase three, the study concludes with the establishment of education material. Since the usage of insecticide in the community in the study was only at observational level, hence, it requires further investigation to evaluate actual practices at individual household level. The education material developed in this study can be used as a tool for risk assessment in forensic nursing field in relation to insecticide usage in broader community.