Evaluation of Knowledge, Attitudes and Practices of Parents Presenting to a Hospital Emergency Department with a Complaint of Fever in a Child

1. Introduction

Fever is one of the most common complaints of childhood that constitutes an important part of emergency applications [1, 2, 3]. However, it is a clinical condition that is frequently misinterpreted by families and is often not approached properly [4]. Sometimes even normal body temperature can be considered as fever by families leading to implementation of inappropriate practice patterns [5, 6, 7, 8]. Informing parents about the definition, appropriate measurement and treatment of fever is considered to relieve anxiety among parents and to reduce unnecessary applications to the emergency room [9].

Mothers usually take care of the febrile child and intervene with fever in the first place [10]. However, low maternal educational level, high number of children in the family, disadvantageous conditions of household environment, insufficient knowledge of mothers about approaching to a febrile child and lack of reliable fever measurement method at home have been considered amongst the main factors related to poor management of a febrile child [11, 12, 13].

In addition to implementation of planned and systematic health trainings, nurses and doctors have important roles in raising awareness among families and encouraging the right health behavior in approaching the febrile child with use of appropriate measurement methods and accurate interpretation [14]. Accordingly, determining the current knowledge and practices of the families about their approach to a febrile child seems to play a key role in identifying needs and planning health education for them.

This study was therefore designed to evaluate the fever-related knowledge, attitude and practices among parents presenting to a hospital emergency department with a complaint of fever in a child.

2. Materials and methods

3. Results

Overall, 277 of 504 (55.0%) pediatric patients were female and the mean age was 5.4 $\pm$ 4.2 years (ranged 0 to 12 years), while the majority (82.4%) of children had at least one sibling. The hospital admissions were made by the mother in 44.6% of cases and by both parents in 33.5% of cases. The mean $\pm$ SD maternal and paternal age was 31.2 $\pm$ 7.2 years and 36.1 $\pm$ 8.1 years, respectively (Table 1).

Overall, 37.1% of the mothers were primary school graduates and 81.5% were housewives, while 37.9% of the fathers were secondary school graduates and 34.9% of them were workers (Table 1).

Overall, 283 (56.2%) parents reported that they have noticed the fever by touching, while 11.7% reported to use thermometer-based measurement with and 244 (48.4%) stated that they repeat the measurement at 30-min intervals. The time to hospital admission was within the first 6 hours after noticing fever in 64.3% of cases. The most frightening situation related to fever was reported to be the risk of seizure by 432 (85.7%) parents, while 398 (78.9%) parents reported that they first take of the child’s clothes and 371 (73.6%) parents reported that they use antipyretics (paracetamol-based drugs in 60.3%) after realization of the high fever (Table 2, Table 3).

Mothers with higher educational level as compared to those with lower educational level were more likely to use thermometer in understanding that the child had a fever (p = 0.046), use a 30-min interval between subsequent measurements (p = 0.041), and use antipyretic drugs (p = 0.045) rather than warm shower (p = 0.027) for the management of fever (Table 4).

Fathers with higher educational level as compared to those with lower educational level were more likely to accompany their wife in hospital admission (p = 0.008), to use thermometer in understanding that the child had a fever (p = 0.045), use a 30-min interval between subsequent measurements (p = 0.002), and use antipyretic drugs (p $<$ 0.001) rather than warm shower (p = 0.003) or direct hospital admission (p = 0.003) (Table 5).

4. Discussion

Fever is very common in infancy and childhood, especially in the first three years, and high fever may cause undesirable conditions in the child during this period [15, 16, 17].

Our findings related to sociodemographic characteristics of mothers indicate majority of them to be housewives along with their lower educational attainment, supporting the data from past studies in mothers of febrile children with hospital admission in Turkey [12, 18]. These findings are consistent with the fact that mothers are usually the primary caretakers of children in Turkey [19] and emphasize the likelihood of unemployed mothers to take more responsibility than fathers in child care in routine daily care as well as in case of illness. However, given that lower educational attainment was associated with risk of poor practice in approaching to the febrile child, such as recognition of fever by touching rather than by objective measurement methods, our findings emphasize a need for education of parents regarding correct approach to febrile child. In fact, past studies also reported that mothers mostly used ineffective methods for measuring fever such as by touching (ranged, 65.9 to 82.2%) rather than using thermometers (ranged 16.1 to 20.1%9) [8, 20]. This seems notable given that the correct follow-up of the fever guides the physicians’ treatment decision and planning in accordance with the course of the disease.

Moreover, past studies from Turkey indicated regional differences in availability of a thermometer at home as well as knowledge on reading a thermometer, which are considered to affect the choice of appropriate fever recognition method in addition to the educational factors [12, 21, 22]. In studies from Western Turkey, authors noted higher rate of fever measurement with thermometer at home by mothers in relation to their higher education level [12, 18], while in a study from Southeastern Turkey, only half of mothers admitted to hospital with a febrile child reported presence of thermometer at home [21]. The current study was conducted in Sanliurfa province which is located in Southeastern Turkey and considered to be an undeveloped region of the country with 63.6% of the population living in shantytowns in the city outskirts and in poor socio-economic and environmental conditions [23]. Hence, the socioeconomic background of parents recruited in the current study seems to be the major factor underlying their poor practice (i.e. thermometer use only by 11.7%, subsequent measurements with $<$ 30 min interval) regarding approach to a febrile child.

Fever in a child can become an important cause of anxiety for caregivers, and unnecessary fears can cause erroneous practices [24, 25, 26]. Various studies have shown that anxiety is reflected in mothers’ attitudes and behaviors during fever [25, 27, 28, 29, 30]. In a study, mothers of a febrile children was reported to measure their children’s body temperature very frequently, to stay awake all night to monitor the body temperature, and to wake their children frequently to measure their body temperature or give them antipyretic drugs [12]. In a past study on attitudes of parents with a febrile child in an emergency setting, it was reported that home treatment of fever can be worrisome, with too-frequent dosing and inappropriate topical treatments, while presence of both parents in the emergency department was reported to be associated with lower levels of worry [6]. Accordingly, only one third of presentations to our hospital emergency department with a complaint of fever in a child were performed by both parents, and father with higher educational attainment were more likely to accompany their wives in hospital admission.

The incidence of febrile seizures in children is approximately 4-5% and it has a good prognosis with no permanent damage, whereas it is considered important in terms of associated risk of recurrence and development of afebrile seizures [31, 32]. Parents with a child experiencing a febrile seizure for the first time are considered to experience considerable fear and anxiety due to their lack of comprehension about the event and how to act during the seizure [8, 33]. Notably, the risk of seizure was considered as the most frightening situation related to fever by majority of the parents in the current study, similarly in high and low educational level groups, supporting that fever phobia remains a common condition among caregivers, regardless of the educational attainment [19].

Bathing with warm water, applying warm compresses and using antipyretic drugs have been reported as the most frequent measures to reduce fever in children [24, 34, 35]. Peripheral cooling was consistently reported to be the most common method used by parents to reduce fever in a febrile child as followed by the use of antipyretic agents in our country [10, 12, 20, 25, 36]. Nonetheless, it should be noted that while warm water has been used by most of mothers as an antipyretic method, the high prevalence of wrong practices has also been emphasized such as applying compresses with alcohol and cold water, and frequent use of high dose antipyretic drugs [34].

Certain limitations to this study should be considered. First, due to single-center study design, the study findings cannot be generalized and thus may not reflect the attitudes and practices of the general population. Second, the questionnaire is developed by the researchers and not a standardized validated questionnaire. Third, lack of data on psychometric assessments such as State-Trait Anxiety Inventory is another limitation which otherwise would extend the knowledge achieved on concerns of families about the fever in the current study.

5. Conclusion

In conclusion, our findings indicate a need for improved practice among caregivers regarding the approach to febrile child in terms of objective measurement and better management of high fever. In addition, our findings also emphasize high prevalence of fear phobia among parents that may adversely affect their approach towards the febrile child, leading to unnecessary emergency admission or inappropriate use of antipyretics. Given the direct association of educational attainment with caregivers’ approach to febrile child, healthcare professionals should be able to carry out more effective training activities to improve the approach of parents to a febrile child to prevent inappropriate practices by reducing the unnecessary fear and to ensure better practice regarding identification, interpretation and management of fever in a child.

Acknowledgments

The authors are very grateful to Mustafa Soyak who is the secretary of Halfeti State Hospital’s Department of Pediatrics for helping with processing of data into the system and storage of patient questionnary forms.

Conflict of interest

Authors declare no financial or commercial conflict of interest.

Ethical Statement

Written informed consent was obtained from each participant who agreed to participate in the study The study was approved by the Ethics Committee of Harran University Faculty of Medicine (Date of approval: 18/11/2019, Protocol No: 19/05/01).