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Childhood fever in well-child clinics: a focus group study among doctors and nurses
© The Author(s). 2016
Received: 14 January 2016
Accepted: 21 June 2016
Published: 8 July 2016
Fever is common in children aged 0-4 years old and often leads to parental worries and in turn, high use of healthcare services. Educating parents may have beneficial effects on their sense of coping and fever management. Most parents receive information when their child is ill but it might be more desirable to educate parents in the setting of well-child clinics prior to their child becoming ill, in order to prepare parents for future illness management. This study aims to explore experiences of well-child clinic professionals when dealing with childhood fever and current practices of fever information provision to identify starting points for future interventions.
We held four focus group discussions based on naturalistic enquiry among 22 well-child clinic professionals. Data was analysed using the constant comparative technique.
Well-child clinic professionals regularly received questions from parents about childhood fever and felt that parental worries were the major driving factor behind these contacts. These worries were assumed to be driven by: (1) lack of knowledge (2) experiences with fever (3) educational level and size social network (4) inconsistencies in paracetamol administration advice among healthcare professionals. Well-child clinic professionals perceive current information provision as limited and stated a need for improvement. For example, information should be consistent, easy to find and understand.
Fever-related questions are common in well-child care and professionals perceive that most of the workload is driven by parental worries. The focus group discussions revealed a desire to optimise the current limited information provision for childhood fever. Future interventions aimed at improving information provision for fever in well-child clinics should consider parental level of knowledge, experience, educational level and social network and inconsistencies among healthcare providers. Future fever information provision should focus on improving fever management and practical skills.
Fever is common in children aged 0 to 4 years [1–3]. Parents’ misconceptions and unrealistic concerns make them easily worried when their child has a fever [4, 5]. They worry that fever might result in serious harm such as febrile seizures, brain damage or other adverse consequences [4, 6–9]. Subsequently, these worries drive healthcare-seeking behaviour. Schmitt introduced the term “fever phobia” in 1980 to describe these unrealistic fears in parents . Since then, multiple studies have shown that fever phobia is still present [4, 9–14]. Important drivers of fever phobia and consultations to the general practitioner (GP) are a lack of parental knowledge on coping with fever but also parents’ perceived sense of control in the face of the perceived threat of an illness [5, 9, 15, 16].
Qualitative research in primary care has shown that there is a need to educate parents about fever and to influence parental perceptions of the threat posed by fever. Educating parents may enhance their self-management and sense of control, reduce healthcare-seeking behaviour and lower antibiotic prescriptions [9, 16, 17]. Most parents receive information at the time their child is ill but it might be more desirable to educate parents prior to their child becoming ill, in order to prepare parents for future illness management. The setting of well-child clinics (WCC) might be a good place to achieve this [12, 16–18].
WCC professionals encounter young children regularly for check-ups and information provision is an important pillar of well-child consultations [18, 19]. In the Netherlands approximately 95 % of children aged 0 to 4 visit the WCC for regular check-ups . Parents tend to rely on WCC nurses for fever management advice and whether they should consult the GP or go to the hospital . To illustrate, about one-third of 80,000 referrals to the GP by WCC professionals is for childhood infections . Earlier studies have demonstrated that educating parents about childhood fever in the WCC setting may improve parental knowledge, attitude and use of healthcare services [23–32]. There are as yet no studies providing insight into the experiences and needs of WCC professionals in childhood fever consultations and WCC professionals’ current information provision practices.
The purpose of this study was to explore well-child care professionals’ experiences with childhood fever and current information provision practices when communicating with parents about fever management. By doing so, we hope to uncover barriers to and facilitators of information provision before a child’s new fever episode.
This descriptive qualitative study was based on naturalistic inquiry. Naturalistic inquiry studies real-world phenomena in natural settings and aims to inductively construct theories by means of a continuous interplay between data collection and analysis. Naturalistic inquiry includes special criteria for trustworthiness .
Dutch youth healthcare focuses on providing preventive care services to children aged 0 to 19 years old. Children are seen for regular check-ups and vaccination jabs by specially trained doctors and nurses. WCC professionals concentrate on children aged 0 to 4 years old and see the children about 12 times. WCC professionals monitor the child’s health status and development, screen for congenital disorders, provide vaccination jabs, provide parents with information and counselling and coordinate healthcare needs. In the Netherlands approximately 95 % of the children aged 0 to 4 years old visit the WCC for regular check-ups . Children are seen more frequently when there is need for extra care.
We selected WCC professionals providing care to children aged 0 to 4 years in the Maastricht region of the Netherlands. By doing so, we covered neighbourhoods with varying socioeconomic statuses and educational levels. A staff physician of the WCC organization emailed all 30 WCC doctors and nurses to inform them about the study and invite them to participate. Both doctors and nurses were purposefully sampled to participate in focus group discussions. We aimed to mix doctors and nurses as they work in teams at the WCC and we wanted to facilitate and foster discussion among participants by including different viewpoints and experiences. We aimed to include 4–6 participants per focus group.
Focus groups (FG) were organised in November 2014 in Maastricht. The meetings lasted for 60 min each. The topic list was based on sensitizing concepts derived from scientific literature and expert discussions . The topic list incorporated two main themes: (1) current experiences with childhood fever information provision to parents, and (2) exploration of starting points to improve future fever information provision (see Additional file 1). An independent and experienced moderator with a background as medical doctor led the focus group discussions. The moderator was accompanied by two observers (JS, LP) who are also MD, and the main researcher (KP) with a background in health sciences. The observers and main researcher made field notes during data collection. The focus group discussions were audio recorded and recorded on camera. We reached data saturation after three focus group discussions and performed one additional focus group to confirm the findings. JS and LP transcribed the focus group discussions verbatim and double-checked the transcripts.
Data collection and analysis was performed simultaneously according to constant comparative technique . Categories emerged inductively from the focus group data by performing open and axial coding, and deductively through constant comparison. The topic list was discussed and adjusted among the wider research team after every focus group discussion. The data was coded by three researchers (JS, LP, KP) with NVivo version 9. We discussed the codes, main categories and subcategories extensively in the research team and inconsistencies were resolved by consensus.
Trustworthiness of data
To achieve methodological triangulation we combined focus group discussions and field notes. Next, to accomplish data source triangulation we incorporated experiences of WCC professionals who worked at different WCC locations within different neighbourhoods with a variety of socioeconomic statuses and educational levels. Furthermore, we assembled doctors and nurses together in focus group discussions to foster discussion from different professional viewpoints. Investigator triangulation was accomplished by incorporating researchers from different backgrounds in the research team, i.e. a health scientist, two medical doctors and a general practitioner. These were all actively involved in all stages of the research process. Peer debriefing meetings were held regularly among the research team. We performed a member check of the transcript among all participants [36, 37].
A total of 22 well-child clinic professionals (seven doctors, 15 nurses) participated in four focus group discussions. The average age of participants was 45 years old and 21 were female. Average work experience at the WCC was 16.4 years, ranging from 0 to 36 years.
Main category and subcategories
The coding process yielded one main category and four subcategories. Parental worries about childhood fever emerged as the main category from the data and was seen as the major driving factor behind most fever-related contacts with the WCC. We identified 4 subcategories which are all closely related to and possible drivers of parental worries: (1) level of knowledge of parents, (2) level of experience of parents, (3) influence of educational level and social network of parents and, (4) perceived degree of inconsistency in received advice. Together with the participants we explored starting points to improve current fever information provision.
“In particular when the temperature keeps on rising and reaches 40.2 °C, then parents start panicking, [saying] ‘Help, what should I do?’” (Nurse 3, FG3).
They just want to be heard. Or want to hear the opinion of a professional (Nurse 3, FG2).(…) Yes, they say they feel more reassured afterwards (Nurse 1, FG2). Because they know what steps to take (Nurse 4, FG2).
Parents’ worries often start as soon as the child’s temperature hits 37.8 °C and they’re like, “Oooohh” (Doctor 2, FG4).
(…)They fear febrile seizures (Nurse 1, FG3).(…) Dehydration, meningitis (Nurse 2, FG3). And spots as well (Doctor 1, FG3).
Their GP has said so many times there is nothing wrong with their child. And then they call us (Doctor 2, FG1).
Level of knowledge
Parents call and ask: “His temperature is slightly elevated, what to do? How long do we have to wait, should we give medication, is this normal? (…) My child has 37.6 degrees Celsius; is that a fever?” (Nurse 5, FG2).
They talk about fever but often parents already call us when the temperature is 37.8 °C or 37.9 °C because they start to worry (Nurse 4,FG1).
The only thing they think of is, “Fever? Oh I have to give paracetamol!” (…) But not everyone knows you have to go through this and it will pass. And also that if you do nothing, it will pass (Nurse 1, FG2).
Although I say to them every time not to provide paracetamol. They do it every time. The information just doesn’t stick (Nurse 1, FG1).
Level of experience
You have to get to know your baby. So it is more to deal with the worries of the parents than with seeing the child (Nurse 1, FG1).
The first time is fierce, and the second time too but they don’t call us that quickly anymore when it happens for the third or fourth time (Nurse 3, FG3).
Gaining experience was also felt to be closely related to gaining more knowledge on how to cope with fever episodes. The WCC professionals believe that this is why they receive fewer questions from parents with multiple children.
If parents have seen how a child ended up in a hospital or experienced a serious condition, it plays a role when their own child starts to get ill (Doctor 1, FG3).
Influence of educational level and social network
In my opinion the group of higher-educated parents has a lot of questions. They do not act on their intuition but want to know all the ins and outs, and are unable to let it go (Doctor 3, FG4).
We have to see this more from a practical point of view: if a child doesn’t get a fever, it can go to child daycare; otherwise you have to stay home from work (Doctor 2, FG1).
(..)If you have grandparents who support those parents....but if you have a small network like higher-educated parents, I think they are. [Nurse 2,FG 3]: they are very worried (Doctor 1, FG3).
Participants explained that a substantial social network may provide support by transferring knowledge and sharing experiences regarding fever. However, WCC professionals also acknowledge that the social network may boost parental worries by sharing horror stories on severe underlying illness and/or adverse events and cause more worries among parents.
Inconsistent information provision
WCC professionals stated that parental worries and the urge to ask questions may also arise from inconsistent information provision among different healthcare providers or from information sources such as the Internet.
And then they go to the chemist or GP and hear “No, that’s (paracetamol dosage) really not allowed”. “You gave us the wrong advice!” While it was according to our (WCC) guidelines. (Nurse 6, FG2).
WCC professionals find this difficult and try to comfort parents by explaining the differences.
Parents use Google a lot these days and: “Well the GP told me this but I started searching on the Internet and I read something completely different!” (Nurse 3, FG3).
Suggestions for improvement
Most important is that parents know where they can find the information whenever they need it. Whether they call us, whether it is described in a booklet, whether they can look it up on the Internet. If they just know where to find the most recent information (Doctor 2, FG1).
The WCC check-up at 4 weeks is a good moment. Just after the final visit of the midwife, when she (midwife) has already started talking about fever, what of course, she is going to do from now on (Doctor 2, FG4)
Discussion and Conclusion
According to WCC professionals parental worries about childhood fever are the major driving factor behind most fever-related contacts with the WCC. Four subcategories were identified as possible drivers of parental worries: level of knowledge, level of experience, influence of educational level and social network, and perceived inconsistency in paracetamol administration advice among healthcare professionals. In addition, WCC professionals believe that current information provision on fever is limited and focuses mainly on fever as a side-effect of vaccination jabs. WCC professionals subsequently expressed the need to improve current information provision and provided starting points in terms of its findability, language, lay-out, content and timing. It was especially mentioned that the content of information provided should become more consistent among different healthcare providers to avoid worries caused by uncertainty. The timing of information provision was under debate but leaned towards the first two months of a child’s life.
According to WCC professional parents often seem to overestimate the significance of body temperature and perceive that the degree of fever indicates the severity of the underlying illness. This finding is in accordance with previous research that parental worries may arise because of the belief that fever is a disease and not just a symptom of illness. Subsequently, when parents view fever as a disease on its own, this will ultimately lead to misconceptions about its role in illness [4, 5]. It is also demonstrated that parental worries lead to the increased use of healthcare services [1, 2, 38].
Corresponding with earlier research, WCC professionals perceived they received most questions from first-time parents, with younger children causing more worries, because those parents lack own experience of coping with fever. As a consequence, parents consult a GP more often for a firstborn child than for a second or subsequent child [39, 40]. Our study also confirms that parents feel uncertain about their actions during fever episodes and consult WCC professionals regularly for advice [4, 10, 21, 40–44].
In line with previous research WCC professionals stated that the social network is an important source of information for parents [10, 40, 45]. WCC professionals experienced that higher-educated parents worry more quickly and tend to rely more on advice of healthcare providers and the Internet than lower-educated parents. It is known from the literature that healthcare professionals and the Internet are an important source of information for parents [4, 10, 40, 43, 45]. Previous research also showed that the Internet is mostly used as information source by younger parents and children . WCC professionals explained the difference between higher and lower educated parents in relying on healthcare professionals by the observation that higher-educated parents seem to have a smaller social network in close proximity to rely on for advice. This observation is in accordance with previous research which demonstrated that parents who did not graduate from high school were less likely to consult a healthcare professional and depended more on nonmedical individuals for advice. However, a lower educational level was also associated with practices that could delay care [15, 46, 47]. Differences among lower and higher educated parents in relying on the social network and healthcare professionals as important information sources should be considered when developing information provision about childhood fever.
Other explanations of why higher educated parents tend to rely more on healthcare providers may lie within the fact that education enhances parents’ knowledge of fever, healthcare facilities and may improve their capability to communicate with healthcare providers . Also, it may be possible that parents with a low income may tend to wait longer to avoid medical expenditures . It was perceived that inconsistency in received advice, due to the use of different guidelines by WCC professionals, GPs, GPs, medical specialists, and chemists, led to confusion, more uncertainty and worries during fever episodes. Previous research already indicated that practice variations exist in treating febrile infants among pediatric emergency physicians . Different studies also showed that providing conflicting information on fever management increases worries among participants, especially when the information comes from sources considered reliable and trustworthy, such as a healthcare professional . Like recent qualitative research among parents presenting to GP out-of-hours services with a febrile child, WCC professionals recommended providing consistent information among different healthcare providers .
WCC professionals perceive that the information currently available on fever is very limited, differs across healthcare providers and does not focus on fever as a separate topic but mainly on fever as a possible side-effect of vaccination jabs. In addition, they stated that current information provision on fever needs improvement. Previous research indicates that educational interventions seem to be most effective when they are provided in personal discussions to tailor information to needs, beliefs, experience, and skills, of end-users. In addition, information resources should be accurate, consistent, written, simple to use, and contain simple symbols, [9, 41, 52, 53]. According to Cabral et al  interventions may be more effective if they focus on reducing uncertainty in situations when a consultation or antibiotic prescription is needed by increasing knowledge among parents and clinicians about which symptoms need medical attention.
This is the first qualitative study to explore the experiences of WCC professionals towards childhood fever and current information provision, to inform future interventions aimed at educating parents prior to their child’s first fever episode. A strength of our study is the inclusion of WCC professionals working at different WCC locations in the region of Maastricht (the Netherlands), thereby including neighbourhoods with a variety of socioeconomic statuses. We achieved methodological and investigator triangulation, held peer debriefings with the wider research team and a member check.
Dutch WCC has specially trained doctors and nurses in preventive youth healthcare, while GPs have a gatekeeping role and mostly focus on curative youth healthcare. The tasks of Dutch WCCs do resemble the tasks of other preventive healthcare services worldwide We believe that our findings regarding information provision about childhood fever may be transferable to other countries as well.
We purposefully sampled WCC professionals from a small and deprived region in the Netherlands with a limited diversity in ethnicities. It is therefore possible that the views and experiences may differ from WCC professionals in other regions. It is important to keep in mind that the WCC professionals expressed their thoughts about possible drivers of fever-related contacts in parents and we did not investigate the experiences of parents themselves.
Fever-related questions are common in well-child care and professionals perceive that most of the workload is driven by parental worries. Four categories were identified as possible drivers of parental worries: lack of knowledge, lack of experience or having had negative experiences with fever in the past, educational level and size of social network and inconsistencies in paracetamol administration advice. This study demonstrates that current information provision on fever is limited and current information provision need to be optimised and should acknowledge patients’ characteristics and inconsistencies among healthcare providers.
Based on these results we can state that future interventions should aim to lower worries among parents. It is important not only to educate parents on an ad hoc basis when children are ill but also prior to a child’s first fever episode to prepare parents for future illness. This can be achieved by tailoring interventions to the needs of parents and accounting for their level of knowledge, experience, educational level and availability of a social network. To clarify, future fever information provision should focus on improving fever management and practical skills since parents seem to lack knowledge of fever pathophysiology and self-management strategies. Particular attention should be paid to first-time parents who lack experience with childhood fever episodes and to higher-educated parents with a small social network. It is also essential that paracetamol administration advice is consistent among different healthcare professionals. Furthermore, information should be easy to find, easy to understand and verbal information provision needs to be supported by hard copy visual information and web-based applications. The timing of information provision on fever is still under debate but the tendency is to provide it within the first two months of a child’s life.
FG, Focus group discussion; GP, general practitioner; WCC, well-child clinics
The authors would like to thank the WCC professionals for participating in our study.
Jochen Cals is supported by a Veni-grant (91614078) of the Netherlands Organisation for Health Research and Development (ZonMw).
Availability of data and materials
The transcribed focus group discussions supporting the conclusions of this article can be made available on request of individuals.
KP conceptualized, designed and coordinated the study, supervised the focus group sessions and participated in the analysis, revised the initial manuscript into the final manuscript. LP and JS co-operated in preparing the focus group discussions, participated in the analysis, have written a draft of the manuscript. NH and GJD critically reviewed the manuscript. JC supervised the design and carrying out of the study, critically reviewed the manuscript. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
Consent for publication
Participants provided consent to use the focus group data anonymously for research and publication.
Ethics approval and consent to participate
Informed consent was obtained before the start of the focus group discussions. Data was used anonymously. Participants received 30 euros worth of gift vouchers. The study was approved by the Medical Ethics Committee of Maastricht University Medical Centre (METC 13-4-060.4).
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
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