november 2007 - eprints.qut.edu.au · fever management information was learnt from numerous...

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Queensland University of Technology

School of Nursing

Faculty of Health

Institute of Health and Biomedical Innovation

Parents’ Management of Childhood Fever

Anne Majella Walsh

RN, EM, Dip App Sci, BA, Grad Dip HProm, MHSc

This thesis is submitted to fulfil the requirements for

degree of Doctor of Philosophy at the

Queensland University of Technology

November 2007

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KEY WORDS Childhood illness; child nursing; community care, decision making; evidence-based

practice; fever; focus groups; general paediatrics; health education; information

needs; instrument development; literature review; medications; medication

management; parental attitudes; parenting; public health nursing; subjective norms;

Theory of Planned Behavior.

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ABSTRACT

Despite decades of research about educational interventions to correct parents’

childhood fever management their knowledge remains poor and practices continue to

be based on beliefs about harmful outcomes. The purpose of this thesis was to 1)

identify Australian parents’ fever management knowledge, attitudes, practices and

methods of learning to manage fever and 2) undertake a theoretical exploration of the

determinants of parents’ intentions to reduce fever using the Theory of Planned

Behavior (TPB). Two studies were undertaken: a qualitative study with 15 parents;

and survey of 401 Queensland parents with a child aged between 6 months and 5

years.

Parents determine childhood fever through behavioural changes they have learnt to

associate with fever. Few were aware of the immunological beneficial effects

associated with fever and most believed fever harmful causing febrile convulsions

and brain damage. To prevent harm they monitored temperatures, used antipyretics,

dressed children in light clothing and sponged them with tepid, cool or cold water.

Despite believing antipyretics harmful most parents reduced temperatures of 38.3°C

± 0.6ºC with antipyretics, alternating two antipyretics when fever was not reduced or

returned. In addition to temperature reduction antipyretics were used to reduce

distress or general unwellness and pain or discomfort. Multiple factors were used to

determine antipyretic dosage including temperature, irritability and illness severity.

Over one-third of parents had overdosed their child with too frequent antipyretic

administration; more frequently with ibuprofen than paracetamol, 12:1.

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Fever management information was learnt from numerous sources. Doctors were the

most frequently reported followed by personal experience. With the variety of

information sources nearly half received conflicting information about how to

manage fever increasing concerns and creating uncertainty about how to best care for

their child. Despite this many believed they knew how to manage fever.

Some parents’ practices changed over time as a result of either positive or negative

experiences with fever indicating more positive or negative attitudes toward fever.

Positive experiences reduced antipyretic and medical service use; negative ones had

the adverse effect with increase in antipyretic use including alternating antipyretics

and double dosing with one antipyretic. Child medication behaviours also influenced

attitudes and practice intentions. Parents of children who readily took antipyretics

had more negative attitudes and intended to reduce their child’s next fever with

antipyretics. Negative attitudes were a significant determinant of fever management

intentions.

Parents’ practices were strongly influenced by their perception that doctors and

partners expected them to reduce fever. This expectation from partners is

understandable; from doctors it is not and indicates doctors’ propensity to

recommend reducing fever. There is an urgent need to identify doctors’ fever

management beliefs and rationales for practice recommendations. Parents also learn

to manage fever from nurses and pharmacists; their beliefs and management

rationales must also be determined and addressed.

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There is an urgent need to educate parents about evidence-based fever management

and reduce their unnecessary antipyretic use. They must be encouraged to delay

antipyretic administration using them to reduce pain rather than fever. Findings from

this thesis have identified the determinants of parents’ intentions to reduce fever;

negative attitudes and normative influences and positive child medication

behaviours. Future studies should examine the efficiency and cost effectiveness of

fever management educational programs for parents using different presentation

methods in multiple settings.

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TABLE OF CONTENTS

Key words iii

Abstract iv

Table of Contents vii

Table of Tables xii

Table of Figures xii

Declaration of Authorship xiii

Glossary of Acronyms and Terms xv

Publications Arising from the Research Program xvi

Conference Papers Arising from the Research Program xvii

Funding Attracted by the Research Program xviii

Examples of Media Interest Arising from the Research Program xix

Acknowledgements xx

CHAPTER 1 – INTRODUCTION AND SIGNIFICANCE OF THE STUDY 1

1.1 Introduction 1

1.2 Parents and Childhood Fever 1

1.2.1 Childhood Fever 2

1.2.2 Parents’ Fever Management 3

1.3 Health Professionals and Childhood Fever Management 6

1.4 Febrile Convulsions 7

1.5 Theoretical Framework 8

1.6 Thesis Outline 9

1.7 Purpose 10

1.8 Aims 11

1.9 Research Questions 11

1.10 Hypotheses 12

1.11 Summary 13

CHAPTER 2 – BACKGROUND 15

2.1 Introduction 15

2.2 Thermoregulation 15

2.2.1 Fever 16

2.2.2 Phases of Fever 21

2.2.3 Benefits of Fever 22

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2.3 Fever in Children 23

2.3.1 Febrile Convulsions 27

2.3.2 Antipyretics 35

2.3.3 Management of Childhood Fever 43

2.3.4 Health Professionals and Childhood Fever 46

2.4 Summary 47

CHAPTER 3 – PARENTS AND FEVER 49

3.1 Article – Management of Childhood Fever by Parents: Literature Review 50

3.1.1 Introduction 52

3.1.2 Search Method 53

3.1.3 Findings 54

3.1.4 Discussion 68

3.1.5 Conclusions 70

3.1.6 References 73

3.2 Summary of the Literature Review 79

3.3 Need for a Theoretical Framework 79

3.3.1 Determining a Theory 80

3.4 Theory of Planned Behavior 81

3.4.1 Applications of the Theory of Planned Behavior 85

3.5 Summary 87

CHAPTER 4 – METHODS 89

4.1 Introduction 89

4.2 Needs Assessment 90

4.3 Study Aims 92

4.4 Research Plan 93

4.4.1 Study1 – Focused Discussions 94

4.4.2 Study 2 – Survey 101

4.5 Summary 116

CHAPTER 5 – STUDY 1 117

5.1 Introduction 118

5.1.1 Literature Review 119

5.1.2 Aims 120

5.2 Method 121

5.2.1 Study Design 121

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5.2.2 Sample 121

5.2.3 Focused Questions 122

5.2.4 Recruitment and Procedure 122

5.2.5 Data Analysis 124

5.3 Findings 124

5.3.1 My Child has a Fever 124

5.3.2 Fever is Beneficial 125

5.3.3 High Fever is Harmful 126

5.3.4 Influencing Factors 127

5.3.5 Learning to Manage Fever 132

5.3.6 Managing Fever 133

5.3.7 Need for Timely, Consistent Information 134

5.4 Discussion 135

5.4.1 Influence of Beliefs 135

5.4.2 Influence of Parental Role 136

5.4.3 Influence of Experience 137

5.4.4 Influence of Knowledge 138

5.4.5 Implications for Health Professionals 138

5.4.6 Strengths and Limitations 139

5.5 Conclusions 139

5.6 Acknowledgments 139

5.7 Funding 140

5.8 References 140

CHAPTER 6 – STUDY 2 – DESCRIPTIVE FINDINGS 144

6.1 Article 1 – Underpinned by fear: a community study of parents’ fever management with young children

145


6.1.2 The Study 150

6.1.3 Results 155

6.1.4 Discussion 166

6.1.5 Conclusions and Recommendations 171

6.1.6 Acknowledgements 172

6.1.7 References 172

6.2 Article 2 – Over-the-counter medication use for childhood fever: a crossectional study of Australian parents

177


6.2.2 Methods 180

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6.2.3 Results 184

6.2.4 Discussion 189

6.2.5 Acknowledgements 193

6.2.6 References 194

6.3 Summary 196

CHAPTER 7 – DETERMINANTS OF PARENTS’ INTENTIONS TO REDUCE FEVER

198


7.1.1 Theoretical Framework 199

7.2 Hypotheses for the Fever Model 201

7.3 Hypotheses for the Medication Model 204

7.4 Approach to Analysis 206

7.5 Model Estimation 208

7.6 Assessing Model Fit 209

7.6.1 Chi-square Goodness-of-fit Statistic 209

7.6.2 Goodness-of-fit Index 210

7.6.3 Adjusted Goodness-of-fit Index 211

7.6.4 Comparative Fit Index 211

7.6.5 Root Mean Square Error Approximation 211

7.7 Preparation of Data for Analysis 212

7.7.1 Management of Missing Data 213

7.7.2 Univariate Normality Testing 213

7.7.3 Issues Due to Nonnormality 214

7.8 Results 216

7.8.1 Bivariate Exploration of Demographics 216

7.8.2 Demographics 216

7.8.3 Parents’ Intentions to reduce their Child’s next Fever 218

7.8.4 Parents’ Intentions to reduce their Child’s next Fever with Medications

238

7.8.5 Integration of Findings 254

7.8.6 Strengths and Limitations 257

7.8.7 Conclusions 258

CHAPTER 8 – INTEGRATION OF FINDINGS AND CONCLUSIONS 261


8.2 Integrating of Key Findings 262

8.3 Theoretical Implications 270

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8.4 Strengths and Limitations 273

8.5 Practice Implications 276

8.5.1 Parents 276

8.5.2 Doctors and Other Health Professionals 279

8.6 Implications for Future Studies 281

8.6 Overall Conclusions 284

Appendix 1 – Study 1 Documents 287

Appendix 2 – Study 2 Documents 295

Appendix 3 – Statements of author co-contributions to manuscripts 325

Appendix 4 – Conference abstracts 330

Appendix 5 – Media interest arising from the research program 337

References 385

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TABLE OF TABLES Table 4.1 Example of instrument items, sources and mode of data collection 111

Table 4.2 Distribution and return according to recruitment methods 114

Table 4.3 Parent Fever Management scale (PMF) 115

Table 5.1 Questions used in semi-structured discussions 123

Table 6.1 Example of instrument items, sources and mode of data collection 154

Table 6.2 Parent Fever Management scale (PMF) 157

Table 6.3 Participant demographics 158

Table 6.4 Parent reports of representative temperatures 159

Table 6.5 Differences in knowledge, beliefs, practices and receiving conflicting information

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Table 6.6 Parents’ perception of temperatures that can be harmful: the degree of harm and harmful events these temperatures could cause

162

Table 6.7 Distribution and return according to recruitment methods 181

Table 6.8 Instrument items and sources they were adapted from 183



Table 7.2 Participants demographics by recruitment method 220

Table 7.3 Items contributing to indicator variables for parents’ beliefs, norms and perceptions of control in the fever CFA model

221

Table 7.4 Correlations, descriptives and factor structure for the latent fever constructs

225

Table 7.5 Implied bivariate correlations for five TPB constructs in the fever model

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Table 7.6 Standardised and non-standardised effects of TPB constructs and demographic variables on parents’ intentions to reduce fever

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Table 7.7 Items contributing to indicator variables for parents’ beliefs, norms and perceptions of control of medication use in fever management for CFAs

241

Table 7.8 Standardised correlations for TPB constructs medication model 242

Table 7.9 Correlations, descriptives and factor structure for the latent medication constructs

244

Table 7.10 Standardised and non-standardised effects of TPB constructs and demographic variables on parents’ intentions to reduce fever with medications

251

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TABLE OF FIGURES Figure 2.1 Schematic representation of the classical concept of the sequential mechanisms in infections fever induction

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Figure 3.1 Parent Fever Management Education 72

Figure 3.2 Theory of Planned Behavior. 83

Figure 4.1 Diagrammatic representation of research methods 93

Figure 4.2 Questions used in semi-structured individual interviews and group discussions

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Figure 6.1 Temperature when parents administer medications to reduce fever 185

Figure 6.2 Temperature at which parents who had ‘alternated’ usually administered medications to reduce fever

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Figure 6.3 Temperature at which parents who believe medications harmful, administer medications

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Figure 7.1 Conceptual fever model of the hypothesised relationships predicting parents’ intentions to reduce their child’s next fever

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Figure 7.2 Conceptual medication model of the hypothesised relationships predicting parents’ intentions to reduce their child’s next fever with medications

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Figure 7.3 Respecified conceptual fever model of the hypothesised relationships predicting parents’ intentions to reduce their child’s next fever ‘fever model’

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Figure 7.4 Respecified conceptual fever model of the hypothesised relationships predicting parents’ intentions to reduce their child’s next fever with medications ‘medication model’

218

Figure 7.5 Confirmatory factor analysis model of TPB constructs 224

Figure 7.6 Structural model of the predictors of parents’ intentions to reduce their child’s next fever, determined through the Theory of Planned Behavior

229

Figure 7.7 CFA of predictors of intentions to reduce fevers with medications 243

Figure 7.8 Structural model of the predictors of parents’ intentions to reduce their child’s next fever with medications, determined through the Theory of Planned Behavior

250

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DECLARATION OF AUTHORSHIP The work contained in this thesis has not been previously submitted to meet

requirements for an award at this or any other higher education institution. To the

best of my knowledge and belief the thesis contains no material previously published

or written by another person except where due reference is made.

Signature ………………………………………… Date………………………………………………. Anne Walsh RN EM DipAppSci BA GradDipHProm MHSc

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GLOSSARY OF ACRONYMS AND TERMS TPB: Theory of Planned Behavior

PBC: Perceived Behavioural Control

PQ: Playgroup Queensland

CCC: Child Care Centre

ML: Maximum Likelihood

NC: Normed Chi-square-Square

GFI: Goodness-of-Fit Index

AGFI: Adjusted Goodness-of-Fit Index

AIC: Akaike Information Criterion

CFI: Comparative Fit Index

RSMEA: Root Mean Square Error of Approximation

CFA: Confirmatory Factor Analysis

SEM: Structural Equation Modelling

Health industry experience: people who had either education in a health profession

or had worked in a health setting

Antipyretics are medications with fever reduction properties, paracetamol and

ibuprofen

Medications are over-the-counter medications, antipyretics, used with childhood

fever, paracetamol and ibuprofen

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PUBLICATIONS ARISING FROM THE RESEARCH PROGRAM

Walsh, A. M., & Edwards, H. E. (2006). Management of childhood fever by parents:

literature review. Journal of Advanced Nursing, 54(2), 217-227. Impact Factor 1.342

(This manuscript can be found in Chapter 3)

Walsh, A. M., Edwards, H. E., & Fraser, J. A. (2007 online early). Influences on

parents' fever management: beliefs, experiences and information sources. Journal of

Clinical Nursing. Impact Factor 1.430


Walsh, A. M., Edwards, H., & Fraser, J. (under review). Underpinned by fear: a

community study of parents' fever management with young children. Journal of

Advanced Nursing. Impact Factor 1.342


Walsh, A. M., Edwards, H. E., & Fraser, J. (in press 14th April 2007). Over-the-

counter medication use for childhood fever: a crossectional study of Australian

parents. Journal of Paediatrics and Child Health. Impact Factor 0.931


Walsh, A. M., Edwards, H. E., & Fraser, J. (2006). Predictors of parents' intentions

to reduce childhood fevers. International Journal of Behavioural Medicine,

13(Supp), 124. (Copy in Appendix 4)

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CONFERENCE PAPERS ARISING FROM THE RESEARCH PROGRAM

Paper presented at the General Practice and Primary Health Care, Sydney, Australia, 2007:

Over-the-counter medication use for childhood fever: a crossectional study of Australian parents.

Paediatrics & Child Health Annual Meeting incorporated in the Royal Australian College of Physicians Annual Meeting, Melbourne, Australia, 2007:

Evidence-based management of uncomplicated pain and fever in children in the community setting. (Walsh third author)

23rd Quadrennial Congress of the International Council of Nurses, Taipei, Taiwan, 2005:

Febrile children: promoting evidence-based care by nurses and parents.

4th Annual Scientific Conference, Auckland, New Zealand, 2006:

Education based on the Theory of Planned Behavior promotes evidence-based fever management.

9th International Biennial Paediatric and Child Health Nurses Conference, Melbourne, Australia, 2006:

Parents' management of childhood fever - the need for evidence based education.

38th APACPH Conference 2006: Asia-Pacific Consortium for Public Health, Bangkok, Thailand, 2006:

Conflicting health information: Reducing fear and guilt for parents managing childhood fever.

9th International Congress of Behavioral Medicine, Bangkok, Thailand, 2006:

Predictors of parents' intentions to reduce childhood fevers. Poster presentation

23rd Quadrennial Congress of the International Council of Nurses, Taipei, Taiwan, 2005:

Febrile children: promoting evidence-based care by nurses and parents.

*The first author on seven of the eight conference papers was Walsh, A.M. (Abstracts in Appendix 4)

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FUNDING ATTRACTED BY THE RESEARCH PROGRAM

Queensland University of Technology Postgraduate Research Award for three years

Financial assistance for the sum of:

Financial support received in the years 2004 to 2007

Institute of Health and Biomedical Innovation Queensland University of Technology

awarded for 3 years


Confederation research funding was received for the purpose of data collection

Financial support received in the years 2005 to 2007

Australian Confederation of Paediatric and Child Health Nurses Margaret Sullivan

Scholarship



Financial support received in the year 2004

Royal College of Nursing Australia Joyce Wickham Scholarship




Grant in Aid


Funding was received for the purpose of presenting papers at an international

conference


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EXAMPLES OF MEDIA INTEREST ARISING FROM THE RESEARCH PROGRAM

Parents overdose young Adelaide Advertiser, 07/04/06, General News, Page 7 Parents are overdosing children on painkillers Canberra Times, 07/04/06, General News, Page 3 Parents misusing fever medications Daily Advertiser, 07/04/06, General News, Page 8 Overdose fears Launceston Examiner, 07/04/06, General News, Page 4 Parents overdosing kids Newcastle Herald, 07/04/06, General News, Parents feed kids too many drugs Queensland Times, 07/04/06, General News, Page 6 Parents overdose sick children West Australian, 07/04/06, General News, Page 5 Feverish kids can get too much of a good thing Sydney Morning Herald, 13/04/06, Health & Science, Page 3 Panicked parents unaware of medicine dangers Daily Telegraph, 10/04/06, General News, Page 13 ABC 720 Perth (Perth): Mornings - 06/04/06 09:24 Gillian O’Shaughnessy: Producer Ms Alicia Hanson 08 9220 2729 4BC (Brisbane): 08:30 News - 07/04/06 08:32 Newsreader: News Director Mr Steve Speziale 07 3908 8200 ABC 891 Adelaide (Adelaide): Drive - 07/04/06 04:18 Deb Tribe: Producer Mr Michael Ockerby 08 8343 4410 ABC 702 Sydney (Sydney): The World Today - 10/04/06 12:50 Eleanor Hall ABC North Coast NSW (Lismore): Afternoons - 12/04/06 02:51 Terry Sara: Station Phone 02 6627 2011

See Appendix 5 for more detail

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ACKNOWLEDGEMENTS

I wish to express my gratitude to Professor Helen Edwards for her guidance, support

and encouragement while undertaking and completing this thesis. I also wish to

express my gratitude to Doctor Jenny Fraser for her valuable input and

encouragement during the journey.

I would like to thank Doctor Helen Chapman and for her valuable assistance with

qualitative data analyses. I also thank Doctor Jan McDowell, Doctor Diana Battistuta

and Helen Skerman for their advice and statistical assistance during the journey.

Additionally, I would like to acknowledge the continued support and encouragement

from my fellow students and colleagues.

I thank all the parents who so generously gave of their time to participate in the

research. The Queensland University of Technology, Institute of Health and

Biomedical Innovation Australian Confederation of Paediatric Nursing and Royal

College of Nursing Australia and for their financial support in the form of

scholarships

Finally, I thank my family and friends for their support and encouragement. I

dedicate this thesis to my parents, Des and Peg Fitzgerald, and thank them for their

lifelong support and belief that I could achieve anything that I set out to.

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CHAPTER 1

INTRODUCTION AND SIGNIFICANCE OF THE STUDY

1.1 INTRODUCTION This chapter provides an overview of the key issues and rationale for the thesis and

outlines the thesis structure. The chapter begins by introducing the reader to

childhood fever and parents’ fever management beliefs and practices. Following this

is an introduction to health professionals’ beliefs and practices then the influence of

febrile convulsions on parents and health professionals are briefly addressed. Then

theoretical framework that forms the basis of this thesis is identified and briefly

described. The chapter then mentions the research questions, hypotheses to be tested

and outlines briefly the contents of the following chapters.

1.2 PARENTS AND CHILDHOOD FEVER Despite more than three decades of literature supporting the beneficial effects of mild

to moderate fever parents continue to perceive fever as maladaptive and harmful

(Atkins, 1982; Impicciatore, Nannini, Pandolfini, & Bonati, 1998; Kluger, 1979;

Kluger, Ringler, & Anver, 1975; Lorin, 1990, 1999; Sarrell, Cohen, & Kahan, 2002;

Schmitt, 1984; Taveras, Durousseau, & Flores, 2004). Little has changed in parents’

fundamental management of fever during this period, they continue to monitor

fever’s progress and use antipyretic medications to reduce fevers, to prevent harmful

outcomes, despite recommendations to reduce the use of antipyretics (e.g., Al-Eissa,

Al-Sanie et al., 2000; Blumenthal, 1998; Kinmonth, Fulton, & Campbell, 1992;

Kramer, Naimark, & Leduc, 1985; May & Bauchner, 1992; Sarrell et al., 2002;

Schmitt, 1980; Weiss & Herskowitz, 1983). It is not always necessary to normalise a

child’s temperature during a febrile illness, however, pain or discomfort associated

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with febrile illnesses should be reduced with analgesics (e.g., Knoebel, Narang, &

Ey, 2002; Lorin, 1999; Sadovsky, 2002; Sarrell et al., 2002). Unfortunately, the

common over-the-counter analgesics used for children, paracetamol and ibuprofen,

have antipyretic properties making this a complex issue for parents of febrile

children (eMIMS, 2007). To address this continuing problem it is imperative that

modifiable factors influencing parents’ negative beliefs about fever and inappropriate

practices are identified. Then programs can be developed to modify these factors and

promote the safe care for febrile children and over-the-counter medications use at

home. The overall aim of this research is to identify modifiable factors influencing

parents’ fever management.

1.2.1 Childhood Fever Fever is a common event during childhood and one of the most common reasons for

parents to seek medical advice with height of the fever generally the deciding factor

(Kelly, Morin, & Young, 1996; McErlean et al., 2001; Sarrell et al., 2002). During

the first two years of life children generally have between four and six febrile

episodes each year (McCarthy, 1999). These fevers are commonly a sign of self-

limiting viral infections although they signify serious illnesses in less than 10% of

cases and bacterial inflections in approximately 4% (Knoebel et al., 2002;

McCarthy). Parents (57%%) and health professionals, nurses (36%) and doctors

(14%), are concerned about fever with some parents (43%) perceiving the height of

fever an indicator of the severity of the illness (Lagerlov, Loeb, Slettevoll,

Lingjaerde, & Fetveit, 2006; Sarrell et al., 2002). However, in temperatures of 40°C

or less the temperature is more likely to be a sign of the body’s adaptive response to

the infectious process rather than the severity of illness (Blatteis, 2003;

VandenBosch, Lahaie, Rickelmann, & Gutridge, 1993). Fever does not always need

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to be treated. However, fever should be reduced in children who would be placed at

risk from the increased physiological demands of fever, such as children with pre-

existing cardiac, respiratory and neurological conditions (Blatteis, 2006). Allowing

fever can assist in the accurate diagnosis of an illness and demonstrate a response to

antibiotics (Connell, 1997). Despite this and numerous educational programs over

the past two decades parents continue to administer antipyretics to febrile children

and alarmingly continue to be advised to do so by health professionals (e.g.,

Mayoral, Marino, Rosenfeld, & Greensher, 2000; Poirier, Davis, Gonzalez-del Rey,

& Monroe, 2000; Sarrell et al., 2002).

1.2.2 Parents’ Fever Management Fever is a source of considerable anxiety for parents; they perceive it to be harmful

(Knoebel et al., 2002) and seek advice from health professionals for self-limiting

viral infections. Parents’ concern about and inappropriate treatment of childhood

fever, is well documented and probably multifactorial (e.g., Knoebel et al., 2002;

Kramer et al., 1985; Purssell, 2000; Schmitt, 1980). Attitudes and beliefs about fever

management are influenced positively or negatively by parents’ past personal

experiences with febrile children (Poirier et al., 2000). Additional factors include

anecdotal tragic outcomes of febrile children, cultural influences and information

provided by family, friends, health professionals and other sources such as written

materials and the Internet (Poirier et al., 2000). Parents’ concerns about fever relate

to their lack of information about fever management, moderate fever in their child,

inexperience with managing febrile children and low maternal educational levels

(Crocetti, Moghbeli, & Serwint, 2001; Impicciatore et al., 1998; Singhi, Padmini, &

Sood, 1991).

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Parents believe doctors are concerned about fever and that fevers are dangerous

(Crocetti et al., 2001). Beliefs that fever is harmful have risen since 1980 from 52%

(Schmitt, 1980) to 76% in 2001 (Crocetti et al., 2000). In 1980 parents were most

concerned about brain damage, febrile convulsions and delirium; in 2001 febrile

convulsions were the main concern followed by brain damage and death (Crocetti et

al., 2000; Schmitt, 1980). An indication of the strength of beliefs that fever is

harmful is the number of parents who would wake sleeping febrile children for an

antipyretic 79% to 93% (Crocetti et al., 2000; Schmitt, 1980). Studies exploring

parents’ definition of fever found parents define fever as temperatures ranging from

37.5ºC to 37.9ºC (Betz & Grunfeld, 2006; Karwowska, Nijssen-Jordan, Johnson, &

Davies, 2002); high fever as 38.9ºC to 39.1ºC (Karwowska et al.) and dangerous

fever 39.3ºC to 39.9ºC (Betz & Grunfeld, 2006; Karwowska et al., 2002). A number

of studies have sought to determine the prevalence of antipyretic administration and

temperature at which antipyretics are generally administered. Parents administer

antipyretics for temperatures as low as 37.8ºC to 38.2ºC (Betz & Grunfeld, 2006;

Crocetti et al., 2001; Karwowska et al., 2002; Sarrell et al., 2002) and base decisions

to reduce fever with antipyretics on temperature alone (Lagerlov et al., 2006). When

their child is febrile parents feel they need to do something, that they are not caring

appropriately for their child if they do not treat the fever (Impicciatore et al., 1998).

Aggressive antipyretic treatment of fever by parents remains common; incorrect

dosing and frequency of antipyretic administration is also common. For example, in

1993, 51% of parents administered paracetamol regularly throughout a 24-hour

period (Schnaiderman, Lahat, Sheefer, & Aladjem, 1993); 14% to 27% gave

paracetamol more frequently than fourth hourly and 33% to 50% gave ibuprofen at

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less than six hourly intervals (Betz & Grunfeld, 2006; Crocetti et al., 2001).

Paracetamol can be administered fourth hourly and Ibuprofen sixth hourly (eMIMS,

2007). Although paracetamol is generally considered a safe medication there are

genuine concerns about hepatotoxicity in children 5 weeks to 10 years of age (e.g.,

Kearns, Leeder, & Wasserman, 1998; Knoebel et al., 2002; Miles, Kamath, Dorney,

Gaskin, & O'Loughlin, 1999; Murphy, 1992). Of most concern is that paracetamol

overdose can cause hepatic toxicity (eMIMS, 2007; Mahadevan, McKiernan, Davies,

& Kelly, 2006). Physicians (50%) recommending parents alternate antipyretics,

paracetamol and ibuprofen (Mayoral et al., 2000; Wright & Liebelt, 2007), can be

confusing for parents as different dosages and frequencies are recommended

(Goldman, 2006; Saphyakhajon & Greene, 2006; Schmitt, 2006). The practice of

alternating antipyretics has been blamed for increasing the probability of exposing

children to toxic levels of antipyretics (Knoebel et al.). Aggressive antipyretic use is

often an attempt, by parents and health professionals, to prevent febrile convulsions

and is a contributing factor to negative attitudes toward fever (e.g., Poirier et al.,

2000, Sarrell, et al., 2002; Schmitt, 2006) .

Since 1980, studies exploring parents’ knowledge of, attitudes toward and

management of fever have been conducted in United States (Schmitt, 1980), Canada

(Kramer et al., 1985) and Saudi Arabia (Abdullah, Ashong, Al Habib, Karrar, & Al

Jishi, 1987). During the 1990s studies were conducted in India (Singhi et al., 1991),

the United Kingdom (Blumenthal, 1998) and Italy (Impicciatore et al., 1998). In the

last decade there are reports of parents’ knowledge and attitudes from Israel (Sarrell

et al., 2002), Canada (Karwowska et al., 2002) the United States (Taveras et al.,

2004) and the United Arab Emirates (Betz & Grunfeld, 2006). Although studies have

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been conducted in many countries there are some findings that differ. For example,

in Italy (Impicciatore et al.), the United States (Crocetti et al., 2001) and Canada

(Karwowska et al., 2002) more parents learn to manage fever from doctors than

family members. However in Saudi Arabia (Al-Eissa, Al-Zamil et al., 2000) parents

are equally likely to learn about fever from family, relatives, friends and doctors. No

published research identifies Australian parents’ fever management practices or their

sources of fever management information. In light of the continued concerns about

fever reported in the literature and the increase in antipyretic use with associated

incorrect dosing it is imperative that Australian parents’ fever management

knowledge, attitudes, practices and sources of information are identified. Then

educational programs can be developed to target specific modifiable factors such as

knowledge deficits; negative, inappropriate beliefs and unnecessary, unsafe practices.

1.3 HEALTH PROFESSIONALS AND CHILDHOOD FEVER MANAGEMENT There has been little change in health professionals’ negative attitudes toward fever

over the past decade (Sarrell et al., 2002; Walsh, Edwards, Courtney, Wilson, &

Monaghan, 2005). Health professionals continue to recommend fever reduction

strategies to prevent febrile convulsions and brain damage, reduce low grade fever

without other symptoms, waken sleeping febrile children for antipyretics and

administer a different antipyretic to children still febrile one hour following initial

antipyretic treatment (Abdullah et al., 1987, Poirier, et al., 2000; Sarrell, et al., 2002).

This is not surprising as the literature concerning the management of fever and

febrile convulsions is not consistent. For example, based on the evidence over the

past three decades many authors recommend supporting the role of fever in the

immunological response to an invading organism (e.g., Atkins, 1982; Duff, 1986;

7

Kluger, 1986; Lorin, 1990; 1994, 1999). Purssell (2000) advocates promoting

education, comfort and recovery rather than aggressive antipyretic therapy. On the

other hand, recommendations for nurses to advise parents to administration

paracetamol to feverish children and to continue this four to six hourly while fever is

present continue (e.g., Waterston, 2002). Parents learn to manage fever from health

professionals (Impicciatore et al., 1998; Karwowska et al., 2002) therefore health

professionals’ concerns and misconceptions about fever in addition to their overly

aggressive treatment of it contribute to parental fever phobia (e.g., May & Bauchner,

1992; Poirier et al.; Thomas et al., 1994; Weiss & Herskowitz, 1983).

1.4 FEBRILE CONVULSIONS Parents’ and health professionals’ concerns about febrile convulsions are well

documented (e.g., Huang, Liu, Huang, & Thomas, 2002; Miller, 1996; Rutter &

Metcalfe, 1978; Sarrell et al., 2002). Witnessing a febrile convulsion is a frightening

experience for parents, many of whom think their child is dying (e.g., Baumann,

2001; Purssell, 2000; Waterston, 2002). Some health professionals (11% to 22%)

report concerns about brain damage and death (6%) following a febrile convulsion

(Poirier et al., 2000; Thomas et al., 1994). Fears of the possibility of a febrile

convulsion have not only led to overaggressive treatment of fever by parents and

health professionals but have also increased parents’ anxiety and placed additional

strain on already limited community and acute health care resources through

unnecessary general practitioner and emergency department visits (Impicciatore et

al., 1998).

Traditionally antipyretics have been administered to prevent febrile convulsions,

however, there is no evidence to support that they prevent either initial or recurrent

8

febrile convulsions (van Stuijvenberg, Derksen-Lubsen, Steyerberg, Habbema, &

Moll, 1998). Febrile convulsions are benign, common events in 2% to 5% of children

aged 3 months to 5 years (D'Auria, 1997, Purssell, 2000). One-third of those who

have a febrile convulsion will have another (Offringa et al., 1994; Sadovsky, 2002).

A review of the literature in this area revealed that education about supportive care

by health professionals is more important than prophylactic treatment (Purssell,

2000). Purssell (2000) recommended health professionals focus on educating parents,

maintaining the child’s comfort and promoting recovery rather than aggressively

treating fever with antipyretics when a child is admitted to hospital following a

febrile convulsion. It is important that health professionals provide evidence-based

fever management education to parents to enable parents to safely care for their child

at home during subsequent febrile convulsions.

1.5 THEORETICAL FRAMEWORK People make decisions based on their knowledge about an action and the information

available to them. Knowledge influences beliefs, making them positive or negative

which in turn influence a person’s attitudes toward the consequences of acting in a

particular way, an evaluation of their beliefs (Ajzen, 1985). In fever management the

negative beliefs and attitudes of parents and health professionals are well known and

influence fever management. To enhance parents’ fever management practices it is

important to understand the factors behind their decision making, and the influences

on their management. The constructs of the Theory of Planned Behavior (Ajzen,

1985) identify the precursors of behaviour. This theory purports that a person’s

behaviour can be predicted from their intention to act in a certain manner.

Behavioural intention is predicted by the person’s attitudes toward, perceptions of

normative influences and control over the behaviour.

9

The Theory of Planned Behavior has been used to gain an understanding of many

health related behaviours, such as breast or testicular self-examination (McCaul,

Sandgren, O'Neil, & Hinsz, 1993), breast feeding (Janke, 1994), smoking cessation

following coronary artery bypass surgery (Bursey & Craig, 2000), fish consumption

in Belgium (Verbeke & Vackier, 2005), Jordanian married Muslim women’s

intentions to use contraceptives (Kridli & Newton, 2005) and Korean college

students’ intentions to engage in premarital sex (Cha, Doswell, Kim, Charron-

Prochownik, & Patrick, 2006). Educational programs based on this theory have

successfully changed nurses’ documentation and pain management behaviours

(Renfroe, O'Sullivan, & McGee, 1990), unsafe sexual behaviour (White, Terry, &

Hogg, 1994) and health protection behaviours (McCaul et al., 1993), surgical nurses’

post-operative opioid use (Edwards et al., 2001) and paediatric nurses’ fever

management practices (Edwards et al., in press).

The Theory of Planned Behavior is an appropriate theoretical framework to identify

the determinants of parents’ fever management practice intentions. Using this theory

the modifiable determinants of practice intentions, such as attitudes, normative

influences and perceptions of control can be targeted through educational programs.

This theoretical framework will be used to identify modifiable determinants in

parents’ intentions to reduce childhood fever and is explained in more detail in

Chapter 3.

1.6 THESIS OUTLINE This thesis consists of two studies. The first study is a qualitative study to identify

Queensland parents’ current knowledge, beliefs, practices and influences on practice.

Findings from this study assisted in the development of an instrument used in the

second study for a postal survey of Queensland parents exploring both descriptive

10

and theoretical aspects of fever management. The thesis is organised into eight

separate chapters. The overall chapter structure begins with an introduction and is

followed in Chapter 2 by more detailed background information about

thermoregulation, childhood fever and the role of antipyretics in fever management.

The next chapter, Chapter 3, is a manuscript reviewing the literature on parents’

management of childhood fever and then the need for a theoretical framework is

addressed. Manuscripts included in this thesis are presented in the format stipulated

by the journal to which they were submitted.

Chapter 4 is a detailed description of the methods used in both studies. Chapters 5 is

comprised of a manuscript reporting the findings from the first study, the qualitative

study exploring parents’ current knowledge, beliefs and practices. In Chapter 6 there

are two manuscripts describing different aspects of the descriptive data collected in

Study 2. The first manuscript addresses parents’ knowledge, beliefs and practices in

fever management; the second focuses on the use of antipyretics to reduce fever. In

Chapter 7 the methods used to prepare the theoretical data from the survey for

analysis, analytical methods and findings are presented and discussed in relation to

the literature. Chapter 8 is an integration of the key findings and their implications

for parents and health professionals. This is followed by directions for future studies

in this area then overall conclusions are drawn.

1.7 PURPOSE OF THE STUDY The purpose of this research was to investigate the current fever management

practices and influences on the practices of Queensland parents of well children aged

between 6 months and 5 years. Information gained was used to assist in the

development of an instrument to identify parents’ knowledge, beliefs, practices and

11

influences on practice determined through the Theory of Planned Behavior. Through

a crossectional community-based survey of Queensland parents’ knowledge, beliefs,

practices, antipyretic use, sources of information and determinants of intentions that

were identified. Findings identified practices were determined by poor knowledge

and negative beliefs and specific areas to target for education and future research.

1.8 AIMS The overall aim of this research was to identify parents’ knowledge, beliefs, practices

and influences on childhood fever management practices. The relationship between

parents’ attitudes, normative influences and perception of control when their child

has a fever on their fever management intentions was also investigated. The specific

aims were to:

1. Identify Queensland parents’ knowledge of fever, beliefs about fever, fever

management practices, antipyretic use, influences on practices and sources of

information about fever management. (Study 1 and 2)

2. Develop and trial a comprehensive instrument to explore parents’ childhood

fever management and the influences on fever management practices. (Study 2)

3. Identify the determinants of parents’ intentions to 1) reduce their child’s next

fever and 2) reduce their child’s next fever with medications through the Theory

of Planned Behavior. (Study 1 and 2)

1.9 RESEARCH QUESTIONS Based on the literature reviewed in the following chapters the following research

questions were proposed.

1. What do Queensland parents know about fever in young children?

2. What are Queensland parents’ beliefs about fever in young children?

3. How do Queensland parents manage fever in young children?

12

4. How do Queensland parents use antipyretic medications in fever management?

5. What influences Queensland parents’ medication use in fever management?

6. How do Queensland parents learn how to manage fever in young children?

7. What predicts Queensland parents’ intentions to reduce childhood fever?

8. What predicts Queensland parents’ intentions to reduce childhood fever with

medications?

1.10 HYPOTHESES

From the literature reviewed two theoretical models were explored. One model tested

parents’ intentions to reduce their child’s next fever, the fever model: hypotheses

tested were:

1. In accordance with the TPB, attitudes, subjective norms and perceived

behavioural control (fever management decision making and child medication

behaviour) will determine parents' intentions to reduce their child's next fever.

2. Perceived behavioural control related to child medication behaviour will

determine attitudes, subjective norms and perceived behavioural control in fever

management decision making.

3. Demographic factors, age, education, number of children and experience in the

health industry (education in a health profession or working in a health setting)

will determine parents’ attitudes, subjective norms and perceived behavioural

control (fever management decision making).

The second model explored parents’ intentions to reduce their child’s fever with

medications. Hypotheses tested in the medication model were:

13



behaviour) will determine parents' intentions to reduce their child's next fever

with medications.

2. Perceived behavioural control related to child medication behaviours will




health industry (education or working in a health setting) will determine parents’

attitudes, subjective norms and perceived behavioural control (fever management

decision making).

1.11 SUMMARY Fever is a common event in childhood causing significant concern for health

professionals and parents. This concern has resulted in the customary use of

antipyretic therapy to reduce fever and prevent febrile convulsions. Mild to moderate

fever does not always need to be reduced, only when it places an additional burden

on children already compromised by specific pre-existing conditions. Fever is

beneficial, febrile convulsions are benign. Fevers below 40°C are associated with

immunological benefits.

Based on the literature reviewed above this fever management research, consisting of

two studies, has been developed. This research reports the knowledge, attitudes,

normative influences on, perceived control over and practices in fever management

of Queensland parents. Study 1 was conducted to identify the current knowledge,

beliefs, norms, practices and influences on practice of Queensland parents fever

14

management. This was undertaken using focused interviews and focused group

discussions. Findings from Study 1 assisted in the development of the instrument

used in Study 2, a Queensland survey of parents of children aged 6 months to 5

years.

15

CHAPTER 2 – BACKGROUND

2.1 INTRODUCTION This chapter firstly introduces the concept of thermoregulation and the physiology,

phases and immunological benefits of fever. Following this, childhood fever, febrile

convulsions and parents’ perceptions of febrile convulsions are reviewed. The final

section addresses the use of antipyretics in fever management, evidence-based fever

management and health professionals’ perceptions of fever and fever management.

Parents’ perceptions of fever are addressed in the next chapter.

2.2 THERMOREGULATION Thermoregulation is considered an integrated complex physiological process

involving a continuum of neural structures and connections extending from the

hypothalamus and limbic system through the lower brain stem and reticular

formation to the spinal cord and spinal ganglia (Boulant, 2000; Mackowiak, 2000b).

The area generally referred to as the preoptic region, in and near the rostral

hypothalamus, is thought to be pivotal in thermoregulation and senses subtle

deviations in body temperature. In this role the preoptic region acts as the

coordinating centre for thermoregulation receiving afferent sensory input from

thermoreceptors throughout the body and strongly influencing lower effector areas

throughout the brain stem and spinal cord (Boulant, 2000).

Thermoregulation is believed to maintain the body at a constant core temperature, at

a set-point, through activation of warm and cold sensitive neurones throughout the

body and skin despite changes in ambient temperature and motor activity

(Zeisberger, 1999). In this manner thermoregulation is achieved through a balance in

16

the firing rate of cold-and warm-sensitive neurons to control the temperature set-

point (Ng, Lam, & Chow, 2002). Heat loss responses (e.g., panting and sweating) are

controlled by warm-sensitive neurones which increases proportionally with preoptic

temperature once a threshold or the set-point temperature has been reached. Cold-

sensitive neurones receive synaptic inhibition from nearby warm-sensitive neurones.

During preoptic cooling, the firing rates of warm-sensitive neurones decrease

reducing synaptic inhibition and allowing cold-sensitive neurones to increase firing

rates (Boulant, 2000; Ng et al., 2002).

The belief that all humans maintain the same temperature in normal conditions has

been challenged (Connell, 1997; Mackowiak, Wasserman, & Levine, 1992). In

healthy adults normal temperature has been found to vary from 35.6ºC to 38.2ºC with

a mean of 36.8ºC ± 0.4ºC; and it is thought that very few adults have a normal

temperature of 37.0ºC (Mackowiak et al. 1992). In 1997, following a review of the

literature, Connell (1997) determined normal body temperature’s set-point to range

from 36.5°C to 38.0°C. Additionally, body temperature is subject to diurnal circadian

rhythms associated with the sleep-wake cycle and varies up to 1°C daily with a

plateau at about 1400 to 2000 hours and a minimum about halfway through sleep,

between 0200 and 0400 hours (Anderson, 1988; Dershewitz, 1993; Samples, 1985;

Waterhouse et al., 2005).

2.2.1 Fever Fever is considered an intentional elevation of the body’s core temperature in

response to an invasion of an exogenous organism. During fever, core temperature

rise is the deliberate result of a regulated operation of active thermogenic effectors.

Hyperthermia, passive heat gain greater than the body’s capability to dissipate heat is

17

distinct from fever and the two should not be confused. Fever is believed to be a host

defence response to invasion from exogenous pyrogens including microbial

pathogens, such as bacteria, viruses, mycobacteria and fungi as well as non-microbial

antigens, such as inflammatory agents and drugs (Blatteis, 2006).

There has been a substantial increase in understanding the physiology of fever over

the past decade which was documented in a review by Blatteis (2006) who, himself,

has undertaken considerable work in this area (e.g., Blatteis, 2003, 2006; Blatteis,

Sehic, & Li, 1998). Blatteis (2006), Boulant (2000) and Mackowiak ( 2000b)

discovered that, when exogenous pyrogens enter the body through a break in the

skin, or through the respiratory, digestive or urinogenital systems, a concentration of

non-specific, local reactions occur to protect the host and preserve normal body

functioning. Initially, there is a local inflammatory response initiated by the release

by various cell types activated by the invading pathogens such as soluble, vasoactive

and chemoactive mediators. Among these are immunoglobulins which activate

mononuclear phagocytes to remove the microbes and release additional mediators

such as cytokines and other prostaglandins which enhance the inflammatory process.

These effects are further augmented by more compounds released by other local

sensitised cells; limited by counter-regulatory factors (e.g., interleukin [IL]-4, IL-6

and IL-10). Following this cellular debris, microbial products and mediators in the

inflamed area drain via the lymphatic vessels and are filtered by macrophages in the

lymph system. However, some of these materials stimulate local sensory nerves or

escape and are absorbed into the circulation. Local inflammatory effects now extend

throughout the body evoking a range of systemic reactions collectively called the

‘acute phase reaction’ mediated largely by the central nervous system.

18

The acute phase reaction has been found to be extensive and includes, for example,

increased pituitary hormone release (e.g., ACTH, GH), increased plasma iron levels,

reduced erythropoiesis, increased neutrophils, increased sympathetic nervous

activity, release of acute phase proteins (increased C-reactive proteins, reduced

albumin, increased haemoglobin), increased lipogenesis and increased pancreatic

insulin and glucagon. These responses, occurring as an organised integrated series of

regulated events, are an integral part of a highly coherent, interconnected

physiological phenomena that together constitute the primary, early non-specific host

defence response (Blatteis, 2006; Blatteis, Feleder, Perlik, & Li, 2004; Zeisberger,

1999). During the acute phase response a number of sickness behaviours or

alterations in physiological functions occur, such as fever, hyperalgesia, lethargy,

somnolence, hypophagia, weakness, malaise, reduced locomotor activity, and an

inability to concentrate which impact general host homeostasis (Blatteis, 2006;

Zeisberger, 1999).

The immuno-protective effects of fever are believed to occur during the subsequent

adaptive or later phase of fever. These effects protect the host from infection by the

same micro-organism. The immune benefits of fever activated during the late phase

include enhanced neutrophils and monocyte motility and emigration; enhanced

phagocytosis and pinocytosis; increased oxygen radical production by phagocytes;

increased interferon production; increased antiviral, antiproliferative and natural

killer cell-stimulating activities; increased antibody production and increased killing

of intracellular bacteria (Blatteis, 2003; Blatteis, 2006; Zeisberger, 1999).

19

The generally held view of the genesis of pathogen-induced fever, or the febrile

response, occurs in sequential steps, see Figure 2.1. Fever begins with the production

by peripheral mononuclear phagocytes, activated by the exogenous pyrogens, of

pyrogenic cytokines, principally tumour necrosis factor (TNF)-α, interleukin (IL)-1β,

and IL-6, interferons (IFN) and other cytokines and chemokines (Blatteis, 2006). The

release of these cytokines into the bloodstream and their transport to the preoptic-

anterior hypothalamic area (POA), the brain site of the primary thermoregulatory

controller; the ventromedial preoptic nucleus is thought to be the fever-producing

locus where they act (Boulant, 2000; Mackowiak, 2000b). Prostaglandin E2 (PGE2)

is considered to be the final fever mediator in the POA, induced by these cytokines.

In the laboratory setting febrile responses are promptly evoked when these cytokines

or PGE2 are microinjected into this site, and it is now generally accepted that

thermosensitive neurons contained in this region modulate the thermoregulatory

mechanisms that effect the development of fever (Boulant, 2000; Mackowiak,

2000b).

In humans and most mammals fever has an upper limit ranging from 41.0ºC to

42.0ºC (Mackowiak & Boulant, 1996). When humans are in a thermoneutral

environment febrile rises in body temperature tend to range from 0.5ºC to 3.0ºC with

most infections producing fevers between 38.5ºC and 40.5ºC with an average fever

of 39.5ºC. Mechanisms involved in temperature regulation may lie in the intrinsic

properties of the neurons in the rostral hypothalamus or the release of endogenous

antipyretic substances that antagonise the effects of the pyrogens on these neurones

(Mackowiak & Boulant, 1996).

20

Figure 2.1: Schematic representation of the classical concept of the sequential

mechanisms of infectious fever induction.

Modified from Blatteis, C. (2006) "Endotoxic fever: new concepts of its regulation suggest new approaches to its management." Pharmacology & Therapeutics 111: 194-223.

21

2.2.2 Phases of Fever Three phases of fever have been identified by a number of authors, a cold, hot and

defervescence phase (e.g., Bruce & Grove, 1992; Connell, 1997; Fruthaler, 1985;

Holtzclaw, 1992; McCarron, 1986). The cold phase begins when the set-point is reset

to a higher level. This phase lasts approximately 10 to 40 minutes during which all

heat-producing mechanisms are activated and there is a rapid steady rise in

temperature. Heat production increases oxygen demands by three to five times

normal resting levels contributing to a hypermetabolic state. In this state there are

associated increases in heart and respiratory rates and thirst. Vasoconstriction causes

the skin to look pale with cyanotic nail beds and to feel cool and dry.

During the hot phase the body has reached a new set-point and maintains the body

temperature at this new higher temperature. The length of this phase depends on the

time it takes to eradicate the pyrogenic cytokines responsible for the raised set-point.

Higher temperatures in this phase are maintained through a balance in heat

production and heat loss. Skin is flushed and warm and the individual feels hot.

Basal metabolic rate remains high so tachycardia and thirst continue. Other

symptoms associated with this phase include drowsiness, headache, photophobia,

reduced activity and appetite, feelings of weakness and/or restlessness and

sometimes convulsions. This phase ends when the underlying cause of fever has been

treated and/or eliminated by the body resulting in a decrease in set-point to normal.

The defervescence phase, the dramatic ‘breaking’ of the fever occurs when there is a

sudden decline in circulating pyrogenic cytokines and resetting of the hypothalamic

set-point back to normal. Heat loss mechanisms take over and heat production is

inhibited. The skin feels warm and is flushed due to vasodilation and sweating,

22

which can exacerbate existing dehydration. Finally the temperature returns to

normal.

2.2.3 Benefits of Fever Fever evolved long ago in phylogeny (evolutionary biology) and is widespread in the

animal kingdom in mammals, reptiles, amphibians and fish (Blatteis, 2006; Kluger,

1979; Mackowiak, 2000b). The widespread and continued prevalence of the febrile

response offers some of the strongest evidence that fever is an adaptive response

even though it places substantial demands on the body through increased metabolic

demands. This response would not have evolved and/or been so faithfully preserved

in the animal kingdom unless there was some net benefit to the host (Mackowiak,

2000b). Upon reviewing the thermophysiological and immunological literature,

Blatteis (2006), Mackowiak (2000b) and Zeisberger (1999) concluded fever to be

beneficial.

Evidence for fever’s beneficial role is found in the enhanced resistance of animals to

infection associated with increases in body temperature within a physiologically safe

range (Blatteis, 2006; Mackowiak, 2000b). Kluger and associates demonstrated not

only a direct correlation between body temperature and survival but that suppression

of the febrile response with sodium salicylate was associated with substantial

increases in mortality (Kluger, Kozak, Conn, Leon, & Soszynski, 1996; Kluger,

1979; Kluger, et al., 1975). In humans positive correlations have been found between

maximal temperature on the day bacteraemia was diagnosed and survival;

temperature greater than 38.0ºC associated with spontaneous bacterial peritonitis was

positively correlated with survival (Weinstein, Iannini, Stratton, & Eickhoff, 1978).

Reduced amount and length of viral shedding from rhinovirus have been reported

23

(Graham, Burrell, & Douglas, 1990; Stanley, Jackson, Panusarn, Rubenis, & Dirda,

1975). When this is considered in association with the phylogeny of the febrile

response there is strong evidence that fever is an adaptive response in most

circumstances (e.g., Blatteis, 2006;. Mackowiak, 2000b; Zeisberger, 1999).

As earlier stated, the mechanisms involved in the febrile response are believed to be

integral to the functioning of the febrile response, not an accidental biological effect.

Demonstrated benefits include the enhancement of phagocytosis, neutrophil

migration, T-cell proliferation and O2-radical production, the increased synthesis of

interferon and the augmented antiviral and antitumour activities of their cytokine and

the decreased growth rate and viability of iron-dependent bacteria (Blatteis, 2003;

Mackowiak, 1994, 2000b). Immunological enhancements occur at most elevated

temperatures and are present in low and moderate fevers but reduce to below

baseline levels as temperatures approach 40°C (Lorin, 1990). However, at

temperatures of 40°C certain bacterial and viral growth is impaired (Lorin, 1999).

Neurologically, slow-wave sleep patterns are produced when temperature is raised,

reducing the body’s energy requirements and conserving the energy needed to fight

infection (Blatteis, 2006).

2.3 FEVER IN CHILDREN

No definitive temperatures for normal fever or high fever are consistently reported in

the childhood fever literature although some have been suggested. In 1994, El-Radhi

and Carroll (1994) defined fever as “body temperature 1.0°C (1.8ºF) or greater above

the mean standard deviation at the site of recording”: that is, a rectal, oral or an

axillary temperature of 38.0ºC, 37.6ºC and 37.2°C respectively. Sarrell et al. (2002)

supported these definitions in 2002. Watts, Robertson and Thomas (2003) gave a

24

range of temperatures when undertaking a systematic review of literature in relation

to paediatric nursing care of childhood fever. They defined oral temperature of 37.6º

to 37.8ºC and rectal temperature from 38.0ºC to 38.3ºC as fever. Crocetti and

Serwint (2005) were the first to report tympanic temperatures, their definitions of

fever include a temperature of 37.8ºC orally, 38.0ºC for tympanic and rectal methods

and 37.2ºC when taken in the axilla.

Prior to these common definitions, a retrospective audit of 691 temperatures in

charts of well infants (less than 3 months) attending well-baby visits found infants’

normal temperature to be 37.5ºC ± 0.3ºC (Herzog & Coyne, 1993). These infants’

temperatures demonstrated a 0.3ºC seasonal variation between summer and winter

and a 0.1ºC per month increase from 1 month to 3 months of age. Herzog and Coyne

(1993) concluded 38.2ºC or greater would indicate fever in a 3 month infant.

However, infant’s body temperature can also be raised 1°C to 1.5°C by excessive

clothing, physical activity, hot weather, digestion including bottle or breast feeding,

hot baths, damage to body tissues and hyperpyrexia (Holtzclaw, 1992; McCarthy,

1999; Ng et al., 2002).

The range of body temperature in children has been found to be higher than adults

and decreases to adult levels from about one year onwards continuing through

puberty and stabilises at 13 to 14 years in girls and 17 to 18 years in boys (Lorin,

1999). This indicates that children also have higher temperatures when febrile than

adults due to higher metabolic rates and smaller body masses; children generate more

heat and have less body surface from which to lose it. Consequently the normal

processes of heat generation and heat removal can be more readily disrupted in

febrile children (Casey, 2000).

25

Childhood fever with infection seldom exceeds 40.0°C and poses negligible risk of

brain injury unless it exceeds 41.7ºC, harmful or dangerous fever; endogenous

antipyretics prevent this occurring (Mackowiak & Boulant, 1996). However,

although rare, temporary neuronal dysfunction may occur with high fever resulting in

delirium (Okumura, Uemura, Suzuki, Itomi, & Watanabe, 2004; Scheifele, 1994). A

Japanese study found 65% of children exhibiting febrile delirium had temperatures

greater than 39.0ºC (Onoe & Nisigaki, 2004). In this study an association between

febrile delirium in a current febrile illness and history of febrile convulsions, 20%, or

previous febrile delirium, 15%, was found. No serious brain dysfunction has been

found in children exhibiting febrile delirium. Febrile delirium usually occurs during

the first 3 days of illness, lasts for about 3 days, is a transient disturbance (10 minutes

or less) usually occurring at night and sometimes repeatedly within the same night

(Onoe & Nishigaki, 2004). Delirious behaviour associated with a febrile convulsion

is rare, 2%. It generally appears prior to febrile convulsions, usually short convulsion

less than 3 minutes in duration (Okumura et al., 2004).

It has been reported that many children tolerate low grade fevers, to 39.0°C, with

remarkable ease and there is consensus in the literature that temperatures of 40°C and

higher should be avoided (e.g., Connell, 1997; Holtzclaw, 1992; Lorin, 1999). This

combined with the beneficial effects of fever indicate that mild to moderate fever,

temperatures up to 40°C should not be routinely suppressed. High fevers in young

children, 40.5ºC or over, generally indicate a serious illness or bacteraemia (Schmitt,

1994), however, temperature is not the determining factor in illness severity. Active

children with temperatures of 40.0ºC do not require as close monitoring and urgent

medical advice as a lethargic, irritable, anorexic child with a temperature of 38.3ºC

26

(Bruhn, Lelyveld, & Ludwig, 1991). Seriously ill children behave differently to those

with a self-limiting viral infection, they are unusually quiet, drowsy or irritable and

cry differently, moaning or have an inconsolable loud cry (Van den Bruel et al.,

2005). However, serious illness from bacterial infections is becoming rare. It was

recently reported that only one in 200 children with acute fevers, 39.0ºC or higher

and white cell counts of 15,000/µL or more, had occult bacteraemia; Streptococcus

pneumoniae was the most common cause (Steele & Garrison, 2005).

Fever is beneficial in normal healthy children in the home setting, but seriously ill

children can become severely compromised by the additional physiological strain of

fever. For every 1°C above normal temperature there are associated physiological

changes. Metabolic, heart and respiratory rates increase 13%, 20 beats per minute

and four to five respirations per minute respectively. There is an associated increase

in oxygen consumption of 10% to 12% and an insensible fluid loss of 20%

(Goldberger, 1986). Increased fluid loss associated with reduced intake leads to

dehydration, the most common and dangerous side effect of fever (Holtzclaw, 1992).

During the cold stage blood pressure increases and glomerular filtration rates

decrease; this reverses during the hot phase (El-Radhi & Carrol, 1994; Gildea, 1992;

Holtzclaw, 1992). Increased urine output assists in the removal of the additional

metabolic wastes from the catabolic febrile state (Holtzclaw, 1992).

When fever is prolonged the risk of dehydration increases and anorexia, secondary to

generalised weakness and malaise, is common. Psychological effects include apathy,

confusion, delirium and withdrawal from people and activities (Bruce & Grove,

1992). These physiological and psychological effects of fever are important

27

considerations for parents caring for febrile children. Fever may trigger convulsions

in those with a seizure disorder or predisposition to febrile convulsions (Scheifele,

1994) and should be reduced in those for whom the additional physiological burden

places at risk (e.g., Holtzclaw, 1992, McCarthy, 1999). This includes children who

are seriously ill and children who have cardiorespiratory, neurological or metabolic

disorders are malnourished, dehydrated or have epileptic lesions who may not

tolerate the additional physiological demands during fever (Blatteis, 2006). It is

recommended fever in these children be reduced.

2.3.1 Febrile Convulsions Febrile convulsions are not a true epileptic disease but rather a special syndrome

characterised by a provoking factor (fever) and a typical range of 6 months to 6 years

(Nakayama & Arinami, 2006; Waruiru & Appleton, 2004). They were defined as ‘a

seizure in association with a febrile illness in the absence of any central nervous

system infection or acute electrolyte imbalance in children older than one month of

age with no prior afebrile seizures’ by the International League Against Epilepsy

(Commission on Classification and Terminology of the International League Against

Epilepsy, 1989). Approximately 30% to 40% of children who have one febrile

convulsion will have another (Berg et al., 1997).

Most febrile convulsions (75% to 85%) are simple lasting less than 10 minutes

(Annegers, Hauser, Shirts, & Kurland, 1987; Berg et al., 1997). Febrile convulsions

lasting longer than 15 minutes, complex febrile convulsions, occur in 9% of children

(Berg et al., 1997). Simple febrile convulsions are brief (<15 minutes), bilateral,

tonic-clonic seizures of short duration followed by a brief post-ictal period after

which the child readily returns to their pre-morbid baseline state (Baumann, 2001;

28

Kluger & Johnson, 1998). Complex febrile convulsions are focal, unilateral or

prolonged seizures lasting longer than 15 minutes or multiple convulsions within the

same illness ( Berg & Shinnar, 1996a; Shinnar & O'Dell, 2004). Febrile convulsions

longer than 30 minutes indicate febrile status epilepticus and occur in 5% of febrile

convulsions (Berg et al., 1997). Large epidemiological studies concluded simple

febrile convulsions to be benign, common events in children without a history of

afebrile convulsions or intracranial involvement (D'Auria, 1997) associated with

rectal temperatures above 38°C (Kudsen, Paerregaard, Andersen & Anderson, 1996).

In the United States of America and Europe febrile convulsions occur in 2% to 5% of

young children, aged 1 month to 5 years, and resolve before the age of 6 years

(D'Auria, 1997; Nelson & Ellenberg, 1978). Higher incidence rates have been

reported in Japan, 8.8%, India 5% to 10% and in Guam and the Marianna Islands 14

% of children have febrile convulsions (Kluger & Johnson, 1998). Interestingly,

lower incidence and recurrence rates were reported in a Chinese population, 0.4%

and 21% respectively, over a three year period. However, this study reported higher

rates of complex febrile convulsions, 16% (Chung, Wat, & Wong, 2006).

Febrile convulsions are precipitated by any febrile illness, for example, otitis media,

pneumonia, tonsillitis, influenza, or environmental factors that raise the body

temperature (Nelson & Ellenberg, 1983). Immunisations such as diphtheria–

pertussis–tetanus and measles are environmental precipitants of febrile convulsions.

In children who have an environmentally precipitated febrile convulsion 50% have a

genetic predisposition to febrile convulsions (Hirtz, Nelson, & Ellenberg, 1983).

Influenza A is associated with prolonged post ictal impairment of consciousness

29

which may suggest influenza effects state of consciousness at the same time as it

induces the febrile convulsion (Hara et al., 2007). Sudden Infant Death Syndrome

(SIDS) was not associated with febrile convulsions in a large Danish epidemiological

study (Vestergaard, Basso, Henriksen, Ostergaard, & Olsen, 2002). The rate of SIDS

in children who had had a febrile convulsion was .002%; children with a first degree

relative who had a febrile convulsion had no overall increased risk of SIDS.

Febrile convulsions were thought to be associated with a rapidly rising temperature;

this has been disproved in both human and animal studies (Berg, 1993; Shinnar &

O'Dell, 2004). There is increasing evidence from human and animal studies that

Interlukin-1, a key cytokine in the production of the febrile response may be

implicated in the pathophysiology of febrile convulsions as it is also a proconvulsant

agent (Baram & Shinnar, 2002). Current treatment for febrile convulsions recognises

both simple and complex febrile convulsions are benign. No specific medical

treatment is recommended for simple febrile convulsions (Baumann, 2001). Parent

education is recommended for all parents of children who have a febrile convulsion

to reduce anxiety and enable parents to safely manage any recurrent febrile

convulsions. Sometimes the use of oral or rectal diazepam is recommended during

febrile episodes for children who have complex, prolonged or multiple febrile

convulsions that have a high risk of recurrence or live in remote geographical

locations (Shinnar & O'Dell, 2004).

In a review of the molecular genetics of febrile convulsions Nakayama and Arinami

(2006) concluded these convulsions have a significant genetic component. Six

susceptibility febrile convulsion loci have been identified on chromosomes 8q13–q21

30

(FEB1), 19p (FEB2), 2q23–q24 (FEB3), 5q14–q15 (FEB4), 6q22–q24 (FEB5), and

18p11 (FEB6). This genetically complex disorder is believed to be influenced by

variations in several of the susceptibility genes. Findings from recent studies report

varying results and no consistent or convincing febrile convulsion susceptibility

genes have emerged (Nakayama & Arinami, 2006).

2.3.1.1 Predictors of Febrile Convulsions Risk factors for initial and recurrent febrile convulsions have been identified in well-

designed studies (Shinnar & O'Dell, 2004). It is thought that febrile convulsions are

precipitated by a number of factors including a lower seizure threshold of the

developing cortex (normal seizure threshold is higher than 41.5°C (Kudsen et al.,

1996), susceptibility to infections, tendency to have high fevers and a genetic

component affecting the seizure threshold (Baumann, 2001; Freeman, 1992; Nelson

& Ellenberg, 1981). During the last decade febrile convulsion susceptibility genes

have been identified in regions of a number of chromosomes (Johnson et al., 1998;

Kluger & Johnson, 1998; Nakayama & Arinami, 2006; Thoman, Duffner, &

Shucard, 2004; Wallace, Berkovic, Howell, Sutherland, & Mulley, 1996).

Although strong correlations have been identified between the height of fever and the

occurrence of febrile convulsions in children who have 40.0°C to 41.1°C

temperatures, febrile convulsions also occur at lower temperatures, for example

38.0ºC (McCarthy, 1999). Febrile convulsions have been found more common in

boys, to peak between 10 and 20 months of age, and occur more frequently in

association with respiratory illnesses during winter and gastroenteritis in summer

(D'Auria, 1997). However, at least 50% of children who present following a febrile

31

convulsion have no identified risk factors for febrile convulsions (Waruiru &

Appleton, 2004).

There is consensus in the literature that the predictors of an initial febrile convulsion

are a febrile convulsion in a first or second degree relative, neonatal discharge at 30

days or later, very pre-term birth, parental report of slow development, more febrile

episodes per year or attending day care (Bethune, Gordon, Dooley, Camfield, &

Camfield, 1993; Herrgard et al., 2006; Huang et al., 1999; Mukherjee & Mukherjee,

2002). In children with a febrile illness additional factors include the peak

temperature during the illness and the underlying illness (Berg et al., 1995). For

example, gastroenteritis has a lower risk for febrile convulsions than otitis media or

other causes of fever (Berg et al., 1995). In children with two risk factors, 3% of the

population, the risk of an initial febrile convulsions is higher, approximately 28%

(Bethune et al., 1993).

Predictors of recurrent febrile convulsions include younger age at initial febrile

convulsion, history of febrile convulsions in a first degree relative, low peak

temperature during the fever, short duration of recognised fever and initial febrile

convulsions and the duration of the fever (Berg & Shinnar, 1996b; Berg et al., 1997;

Berg et al., 1992; Offringa et al., 1994). Recurrent febrile convulsions are more

likely to occur within the first 2 hours of fever onset in a subsequent febrile illness

and are more common in younger children (van Stuijvenberg, et al., 1998). The

length of fever prior to the initial febrile convulsion influences recurrence rates

within the following year. A prolonged febrile seizure is a risk factor for further

prolonged attacks (Berg et al., 1997). The risk of a recurrence for fevers lasting less

32

than one hour prior to the initial febrile convulsion is 44%, 23% for fevers between

one and 24 hours and there is a 13% risk of recurrence in the following year in fevers

which occurred 24 hours prior to the initial febrile convulsion (Berg et al., 1992).

Risks for recurrent febrile convulsions are cumulative as with initial febrile

convulsions. In a child younger than 1 year the cumulative risk is 25% and 30% in a

child younger than 2 years (Berg et al., 1992). A decreased risk of recurrence is

associated with a temperature of 39°C or higher at the time of the initial febrile

convulsion (Laditan, 1994).

More recent studies have examined circadian and genetic relationships with febrile

convulsions. In Italy first febrile convulsions occurred more frequently during the

winter months (December to February) peaking in January (Manfredini, Vergine,

Boari, Faggioli, & Borgna-Pignatti, 2004). They were more commonly associated

with upper respiratory tract infections and occurred most frequently between 1800

and 2400 hours peaking at 1831 hours. In males febrile convulsions peaked at 1755

hours and in females at 1932 hours. A study in the Netherlands found a positive

relationship between influenza and febrile convulsions (van Zeijl, Mullart, Borm, &

Galama, 2004). In a twin study of febrile convulsions, monozygotic twins were

significantly more likely to have a febrile convulsion if their pair did than dizygotic

twins supporting the genetic predisposition to febrile convulsions (Kjeldsen, Kyvik,

Friis, & Christensen, 2002).

2.3.1.2 Outcomes Following Febrile Convulsions No long-term effects have been identified in children aged 6 to 12 years following

febrile convulsions. Areas of health and intellect studied include attention, working

memory, scholastic ability and behaviour (Chang, Guo, Huang, Wang, & Tsai, 2000;

33

Chang, Guo, Wang, Huang, & Tsai, 2001); neurophysical and neurological

functioning (Kolfen, Pehle, & Konig, 1998) and health problems, speech, sleep,

overactivity and other behavioural concerns (Hutt, Trueman, & Hutt, 1999). Large

epidemiological studies report that measures to prevent additional febrile convulsions

are unlikely to alter the long-term outcome of most children who have a febrile

convulsion (e.g., Autret et al., 1990; Uhari, Rantala, Vainionpaa, & Kurttila, 1995).

A single febrile convulsion has not been found to increase the risk of epilepsy and no

causal relationship has been discovered between febrile convulsions and subsequent

epilepsy (Berg, 1992; Mukherjee & Mukherjee, 2002; Shinnar & O'Dell, 2004).

However, between 2% and 10% of children who have febrile convulsions

subsequently develop epilepsy; two to ten times the general population (Annegers et

al., 1987; Berg & Shinnar, 1996a,b). Risk factors for epilepsy following a febrile

convulsion are a complex or prolonged febrile convulsion, neurodevelopmental

abnormality, family history of epilepsy, three or more febrile convulsions and

duration of recognised fever less than one hour prior to febrile convulsion (Annegers

et al., 1987; Berg & Shinnar, 1996a; MacDonald, Johnson, Sander, & Shorvon, 1999;

Nelson & Ellenberg, 1983 ; Shinnar & O'Dell, 2004; Verity & Golding, 1991). A

family history of epilepsy and the presence of a neurodevelopmental abnormality are

recognised risk factors of epilepsy independent of febrile convulsions (Shinnar &

O'Dell, 2004).

2.3.1.3 Parents and Febrile Convulsions Parents may be very anxious when their child has a febrile convulsion. Actions

during febrile convulsions are often inappropriate and include sponging or

medicating the convulsing child to reduce fever; holding the child or lying the child

34

on their side, supine or prone; mouth to mouth resuscitation; hitting the child on the

back or shaking the child to arouse it, forcing an object, spoon or fingers, into their

child’s mouth to prevent them swallowing their tongue and some restrain the

convulsing child (Deng, Zulkifli, & Azizi, 1996; Flury, Aebi, & Donati, 2001;

Huang, et al., 2002; Ling, 2000). Some parents report believing febrile convulsions

to be harmful, causing death or damaging their child; they believe their child has

changed or looks damaged following a febrile convulsion (Flury et al., 2001; Huang

et al., 2002; Parmar, Shau, & Bavdekar, 2001; van Stuijvenberg et al., 1999). Parents

thought their child would or had died when they were convulsing, they also felt

helpless and panicked (Miller, 1996). Particular fears associated with febrile

convulsions include death, brain damage, paralysis, physical handicap later in life,

epilepsy, a recurrence and febrile convulsion in other children (Deng et al., 1996;

Parmar et al., 2001; van Stuijvenberg et al., 1999).

Most parents seek medical advice during or immediately following a febrile

convulsion (e.g., Deng et al., 1996; Ling, 2000; Miller, 1996; Parmar et al., 2001).

For parents, witnessing a febrile convulsion generates long lasting fears about

recurrences, they are very anxious with subsequent febrile episodes; monitor afebrile

children at night and report sleep disturbances including insomnia (Flury et al., 2001;

Miller, 1996). During subsequent febrile episodes parents frequently check their

child, sleep in the same bed or room as the child or leave the child’s door open (van

Stuijvenberg et al., 1999).

Although parents of children with recurrent febrile convulsion were more

knowledgeable about and had more positive attitudes toward febrile convulsions they

35

had similar concerns about febrile convulsions as parents of children following an

initial convulsion (Huang et al., 2002). Parents most frequently learn about febrile

convulsions from friends and relatives (Deng et al., 1996; Ling, 2000). Other sources

of information are health professionals, television, newspapers, magazines and radio

(Deng et al., 1996). Educational interventions have successfully improved parents’

poor knowledge, reduced negative attitudes, anxiety towards and inadequate first-aid

measures during febrile convulsions (Huang, 2001; Huang, Liu, & Huang, 1998;

Wassmer & Hanlon, 1999). Face to face educational programs are associated with

greater long term effectiveness than mailed information pamphlets (Huang, 2001).

2.3.2 Antipyretics In a historical review of antipyretics Duff (1986) wrote that when aspirin became

available in the late 19th century it was used by doctors to reduce the discomfort

associated with inflammation, at this time antipyresis was of secondary interest.

Following this the indiscriminate reduction of fever became a common medical

practice with the immediate symptomatic gains apparently outweighing any risks.

The use of antipyretics for fever reduction involves two critical assumptions; that

fever is at least in part harmful and suppressing fever will reduce if not eliminate

fever’s harmful effects. However, neither of these assumptions has been validated

experimentally (Mackowiak, 2000a). Fever is often perceived as a syndrome, or

illness in itself, that can initiate a dangerous, potentially life-threatening illness

(Blumenthal, 1998).

Other rationales for reducing fever with antipyretics include preventing febrile

convulsions, increasing comfort and reducing the metabolic costs of fever (e.g.,

Isaacs, Axelrod, & Lorber, 1990; Mackowiak, 2000a). Arguments for the use of

antipyretics in preventing febrile convulsions stem from beliefs that febrile

36

convulsions are caused by rapidly rising temperatures. In 1993, after reviewing the

evidence of the rate of rise of temperature and height of temperature and their roles

in febrile convulsions, Berg (1993) concluded that there was no evidence that the rate

of rise of temperature had any role in provoking febrile convulsions. Numerous

experimental studies exploring the effect of antipyretics in preventing an initial or

recurrent febrile convulsions conclude antipyretics ineffective in preventing febrile

convulsions (e.g., Baumann, 2001; Sagraves, 1999; Uhari et al., 1995; Van Esch et

al., 1995; van Stuijvenberg, et al., 1998). However, some reduction of risk of

recurrence may be achieved under optimal circumstances, namely that fever is

noticed at once and that antipyretics can be administered on time (van Esch et al.,

2000). Many initial and recurrent febrile convulsions occur within the first one to

two hours of a febrile illness making it difficult for parents to achieve this.

Carefully controlled experiments have not established the validity of the claim that

antipyretics improve comfort (Isaacs et al., 1990; Mackowiak, 2000a). Antipyretics

do reduce discomfort associated with hyperalgesia in the cold phase of fever to some

extent. Common antipyretics, paracetamol and ibuprofen have analgesic properties

(eMIMS, 2007). When a febrile child in pain is given an analgesic the medication

will reduce the child’s pain, making them more comfortable. This can cause parental

confusion or belief that the increase in comfort is associated with temperature

reduction rather than pain reduction (eMIMS, 2007). The improvement is not due to

reduced fever or reduction in circulating pathogens but to the analgesic properties of

most antipyretic medications. Nevertheless, it is important to remember that all

drugs, including antipyretics, have potentially noxious side effects. There was a

seven fold increase in the use of ibuprofen in an Australian metropolitan paediatric

37

hospital between 1999 and 2003 (Titchen, Cranswick, & Beggs, 2005). During this

period there were 10 adverse drug reactions from ibuprofen compared with 6 from

paracetamol. With the availability of ibuprofen and paracetamol in Australian

supermarkets there is an urgent need for parents to become aware of the need for

caution with the use of these drugs. Their use and advice about their use should be

directed by competent health professionals (Blatteis, 2006; Mackowiak, 2000b).

Fever reduction with antipyretics is recommended when the metabolic costs of fever

are greater than the physiological benefits. Although recommended, it is necessary to

be cautious, ensuring the symptomatic relief provided by the antipyretic does not

adversely affect the course of the febrile illness. Additionally, it is necessary to

ensure the toxicological costs (side effects) of an antipyretic regime are considerably

lower than fever’s beneficial efforts. When administering antipyretics parents and

health professionals must be careful not to induce shivering, shivering will further

increase both the temperature and metabolic rate (Mackowiak, 2000a). Although

antipyretics are recommended in certain situations the risk-benefit ratio of metabolic

cost and beneficial benefits from fever have not been determined (Blatteis, 2006;

Mackowiak, 2000a).

Paracetamol has been the standard treatment for fever since the discovery of an

association between aspirin and Reye’s syndrome (Starko, Ray, & Dominguez,

1980). It retains this status due to its effectiveness, low cost and minimal side effects

(McCarthy, 1999) although ibuprofen, a more expensive alternative, is increasing in

popularity (Knoebel et al., 2002). Ibuprofen is often used to treat fevers unresponsive

to paracetamol. Any additional benefit derived from ibuprofen in these situations is

38

probably small and must be weighed against ibuprofen’s potential toxicity, which

includes an antiplatelet effect, potential hypersensitivity, and gastrointestinal

irritation (eMIMS, 2007; Titchen et al., 2005).

Paracetamol and ibuprofen are believed to inhibit prostaglandin synthesis in the

thermoregulatory control area of the brain blocking the conversion of arachidonic

acid to prostaglandins such as PGE2 by inhibiting prostaglandin synthesis (Knoebel

et al., 2002; McCarthy, 1999; Vane & Botting, 1998). This effect is thought to be

critical in their antipyretic activity; the production of PGE2, at key sites in the

hypothalamus. PGE2 production is a widely regulated and critical step in

thermoregulation and for temperature increase and control when the febrile response

is activated (Blatteis & Sehic, 1997). Refer to Figure 2.1. Parents and health

professionals reducing childhood fever with antipyretics may unknowingly reducing

prostaglandin synthesis, altering the body’s intricate protective response to invading

pyrogens. There are studies demonstrating a negative effect of antipyretics on

recovery by prolonging illnesses. For example, viral shedding in rhinovirus (Stanley

et al., 1975) and crusting time of varicella lesions (Doran, De Angelis, Baumgardner,

& Mellits, 1989). They also inhibit the maturation of monocytes into macrophages

and interfere with lymphocyte activation and antibody production (Graham et al.,

1990).

2.3.2.1 Effectiveness of Antipyretics in Fever Reduction Antipyretics reduce temperature by 0.9°C to 1.3°C and when tepid sponging is

conducted 30 minutes following antipyretic administration temperature reduction

increases to between 1.3°C and 1.7°C (Friedman & Barton, 1990; Hunter, 1973;

Kinmonth et al., 1992; Sharber, 1997). Traditionally antipyretics were used to

39

prevent rises in temperature and by association febrile convulsions as febrile

convulsions were thought to be precipitated by the rapid rise in temperature

(Ouellette, 1993); this was unsubstantiated (Berg, 1993). It has been found that

controlling fever rarely, if ever, prevents an initial or a recurrent febrile convulsions

(e.g., Baumann, 1999, 2001; Rantala, Tarkka, & Uhari, 2000; Uhari et al., 1995; van

Esch et al., 2000; van Stuijvenberg, et al., 1998). However, temperature reduction is

recommended in some cases. For example, children with pre-existing cardiac,

respiratory, neurological, metabolic, renal or hepatic conditions are placed ‘at risk’

by the debilitating effects of an increased metabolic rate which include increased

pulse and respiratory rates, oxygen demand and insensible fluid loss (Holtzclaw,

1992; Reeves-Swift, 1990). Other children fever places at risk are those who are fluid

depleted, have low protein levels or an electrolyte imbalance (e.g., Betz et al., 1994;

D'Auria, 1997; McCullough, 1998; Stone, 1990).

Many studies have compared the efficiency of paracetamol compared with ibuprofen

in fever reduction. However, comparison of findings is difficult as in many of the

studies the inclusion criteria, definition of fever and the dosages of paracetamol and

ibuprofen compared differ. Limited research has been conducted using Australian

recommended dosage and administration frequencies for paracetamol and ibuprofen

(Beggs, Carroll, Walsh, & Palmer, under review). However, Walson et al. (1992) did

compared the Australian recommended doses 15mg/kg paracetamol and 10mg/kg

ibuprofen (eMIMS, 2007). They found no statistically significant difference in

temperature reduction between the two medications. A review by Goldman et al.

(2004) and Beggs et al. (under review) of single and multiple mono-therapy studies

comparing the efficacy and safety of paracetamol and ibuprofen concluded ibuprofen

40

significantly more effective after a single dose and after six hours. However, similar

efficacy and effectiveness were found when multiple mono-therapies of paracetamol

and ibuprofen in recommended doses were compared.

Reports of parents alternating antipyretics, paracetamol and ibuprofen, when fever is

not sufficiently reduced or returns are becoming more frequent, particularly over the

past decade. This is not a new practice, 53% of paediatric house officers’ alternated

aspirin and paracetamol in 1983 (Weiss & Herskowitz, 1983). In 2000 and 2001

reports indicated 7% to 27% of parents alternated (Crocetti, Moghbeli, & Serwint,

2001; Li, Lacher, & Crain, 2000)). This has increased significantly in the past year to

30% to 67% parents reporting they have alternated antipyretics (Nabulis et al., 2006;

Wright & Liebelt, 2007).

Until recently no experimental studies had explored the efficacy of alternating

antipyretics on fever reduction. In 2006 three studies were reported (Erlewyn-

Lajeunesse et al., 2006; Nabulis et al., 2006; Sarrell, Wielunsky, & Cohen, 2006).

Again, these studies used different alternating methods, dosages and frequencies of

medication administration. One study compared combined paracetamol and

ibuprofen with paracetamol or ibuprofen alone (Erlewyn-Lajeunesse et al., 2006).

Combined administration resulted in significantly greater temperature reduction than

paracetamol alone 0.35ºC but not the ibuprofen alone 0.25ºC. Another study

compared alternate-therapy with mono-therapy. An initial administration of

ibuprofen 10mg/kg was followed by either ibuprofen 10mg/kg (mono-therapy) or

paracetamol 15mg/kg (alternate-therapy) (Nabulis et al., 2006). Similar temperatures

were discovered four hours after the initial ibuprofen dose 37.5ºC in alternate-

41

therapy group and 37.7ºC in the mono-therapy group. Over an eight hour period

there was similar maximum temperature reduction of 2.2ºC ± 0.7ºC in the alternate-

therapy group and 2.1ºC ± 1.2ºC in the mono-therapy group. The third study,

conducted over a three day period, used loading doses followed by different

alternating doses and frequencies (Sarrell et al., 2006). In this study there was a 1.0ºC

additional reduction in temperature in the alternating medication group. Overall in

these studies the additional temperature reduction was between 0.3ºC and 1.0ºC

(Erlewyn-Lajeunesse et al., 2006; Nabulis et al., 2006; Sarrell et al., 2006).

2.3.2.2 Dangers of Antipyretics Although paracetamol is considered a safe medication liver failure is a well

recognised consequence of paracetamol overdose (Russell, Shann, Curtis, &

Mulholand, 2003) and there are genuine concerns about hepatotoxicity in children 5

weeks to 10 years of age (e.g., Kearns et al., 1998; Knoebel et al., 2002; Miles et al.,

1999; Murphy, 1992). Multiple doses of 60mg/kg/day from 1 to 8 days have been

associated with hepatic failure (Heubi, Barbacci, & Zimmerman, 1998). There are

reports of rare adverse reactions to paracetamol which have been neither confirmed

nor refuted: dyspepsia, nausea, allergic and haematological reactions. Caution must

be taken with paracetamol administration in children with hepatic or renal

dysfunction. Paracetamol overdose can result in severe liver damage and sometimes

acute renal tubular necrosis (eMIMS, 2007).

The most common reactions to ibuprofen are gastrointestinal disturbances such as

nausea, epigastric pain, heartburn, diarrhoea, abdominal distress, nausea and

vomiting, indigestion, constipation, abdominal cramps or pain and fullness of the

gastrointestinal tract (bloating and flatulence). Others include tinnitus, oedema, fluid

42

retention, dizziness, headaches, nervousness, maculopapular rashes and decreased

appetite. Caution should be taken in the administration of ibuprofen in children with

impaired renal or hepatic function or a history of gastrointestinal haemorrhage or

ulcer or inflammation of the lining of the stomach or bowel as in conditions such as

Crohn's disease or ulcerative colitis. Ibuprofen overdose causes depression of the

central nervous and the respiratory systems (eMIMS, 2007) .

Serious toxicity, from paracetamol has been reported in children with a febrile illness

who were unwell, anorexic, vomiting and/or dehydrated and who received fourth

hourly paracetamol 90mg/kg/day or greater for more than one day. Most at risk are

children under 2 years of age (Miles et al., 1999) and children who are both febrile

and acutely malnourished (Heubi et al., 1998). Analgesics/antipyretics are the most

frequently reported substances responsible for unintentional overdose in children

under the age of 12 years in the United States (Watson et al., 2004). Most, 76%,

paracetamol overdoses in children less than 19 years of age occur in children

younger than 6 years and all (100%) overdoses in children younger than 6 years were

unintentional (Angalakuditi, Coley, & Krenzelok, 2006). Although younger children

are likely to have a lower dose compared with older children and adolescents; the

impact is usually more severe and likely to be fatal (Angalakuditi et al., 2006).

Potential for dosing errors and overdosing increases with alternating antipyretics

(Mayoral et al., 2000). Toxicity and poison control centres receive many calls

regarding this practice and parental confusion is common (Knoebel et al., 2002).

Those particularly at risk are children younger than 1 year; the age where inaccurate

antipyretic dosing has been found to occur more frequently (Li et al., 2000).

43

McCullough (1998) recommends that the practice of alternating antipyretics be

confined to specialised units, under professional supervision, following careful

consideration of the risks and benefits of exposing the sick child to two drugs with

different half-lives.

There have been strong warnings about the dangers of alternating since the recent

publication of experiments in alternating antipyretics in febrile children (Goldman,

2006; Saphyakhajon & Greene, 2006; Schmitt, 2006). Alternating increases the risk

of incorrect dosing, more likely with ibuprofen than paracetamol, in both dosage and

frequency (Lagerlov, Helseth, & Holager, 2003; Li et al., 2000) and fever phobia.

This practice focuses on a need to ‘get fever under control’ and will increase parental

preoccupation with the height of the fever, their fear of fever and increase

unnecessary phone calls and medical service use (Schmitt, 2006).

2.3.3 Management of Childhood Fever Many papers have been published on the management of febrile children in the past

35 years. The risks and benefits of fever have been debated for more than two

decades along with the efficacy and necessity of reducing fevers with antipyretics.

Not all studies reach the same conclusion creating confusion as to the best practice in

caring for a febrile child. For the past two decades the normal value for human

temperature, 37.0°C, has had very little scientific support. A study of 148 adults

suggests that normal temperature in healthy subjects ranges from 35.6°C to 38.2°C

and only eight percent of those studied recording a temperature of 37.0°C

(Mackowiak et al., 1992).

44

Advice on the temperature at which fever should be treated varies. Cunha et al.

(1984) recommend treating fevers greater than 38.9°C, Thomas 38.3°C (1995) and

McCarthy 39.4°C (1999) while Lorin (1994; 1999) and Connell (1997) advocate

treating only fevers greater than 40°C when the physiological benefits of fever

diminish. Information relating to febrile convulsions and the use of antipyretics in

fever management also varies. A genetic predisposition toward febrile convulsions

was identified in the early 1990s (Freeman, 1992). Yet, in 1993 reducing fever with

antipyretics, tepid sponging and treating the underlying cause of the fever was

recommended to prevent febrile convulsions (Ouellette, 1993).

Since the early 1970s inconsistent results have been reported on the effectiveness of

antipyretics in combination with tepid sponging (e.g., Friedman & Barton, 1990;

Hunter, 1973; Mahar et al., 1994; Sharber, 1997) and any additional temperature

reduction is queried in relation to the discomfort caused, that is, crying, goose bumps

and shivering, which in themselves cause an increase in temperature (Connell, 1997;

Holtzclaw, 1992; McCarthy, 1999; Scheifele, 1994; Sharber, 1997). A recent

systematic review of the efficacy of tepid sponging in fever management determined

little benefit from tepid sponging (Watts, Robertson, Thomas, & Panel, 2001).

However, recommendations for tepid sponging in association with antipyretics still

occur in the literature (Bernath, Anderson, & Silagy, 2002; Chandra & Bhatnagar,

2002) along with advice to control the fever and reassure the family (McCarthy,

1999).

Current management of febrile convulsions depends heavily on studies from the

United States and United Kingdom where the latest practice in fever management is

45

the use of alternating antipyretics (Mayoral et al., 2000) even though strategies to

reduce fever to prevent febrile convulsions have been proven ineffective (Baumann,

2001; Camfield & Camfield, 1997). Fever, per se, does not always need to be treated,

although it should be treated in those it places at risk of further complications. The

latest scientific evidence supports the notion that fever has a role to play in

supporting the body’s defence against invading pyrogens and there is consensus that

temperatures above 40°C should be avoided, as there are reduced immunological

benefits at these temperatures (Connell, 1997).

Based on the literature above appropriate management of childhood fever includes

careful observation of the child’s response to fever, preventing dehydration,

supporting the febrile response and reducing distressing symptoms such as pain and

discomfort with recommended doses of analgesics (Connell, 1997). McCarthy (1999)

recommends determining the degree of illness from the child’s interactions with the

environment. This is achieved through observing the child’s alertness, playfulness or

irritability and consolability in addition to physical observations such as petechiae,

bulging fontanelle, nasal flaring and response to stimuli. Parents are anxious about

fever. If a child is shivering and vasoconstricted in a warm environment, it is safe to

assume their thermostatic set-point has been raised. If they become flushed and

perspire, cooling mechanisms are functioning.

The literature recommends avoiding temperatures above 40°C and temperature

reduction is mandatory above the upper limit of physiologic thermoregulation 41.1°C

(McCarthy, 1999). It is important for parents to be watchful when administering

antipyretics to dehydrated or severely malnourished children (Robertson, 2002) and

46

those with hepatic or renal impairment (eMIMS, 2007). In the more usual

temperature range, indicators for temperature control are less clear. In a febrile,

irritable, uncomfortable child, analgesia is warranted. Antipyresis is warranted in

children with underlying neurological or cardiopulmonary disease (McCarthy, 1999).

Parents learn to manage fever from health professionals, drawing on their knowledge

(Crocetti et al., 2001; Karwowska, et al., 2002). Therefore, health professionals’

current knowledge and attitudes toward fever contribute to parents’ knowledge of,

attitudes toward and management of fever. This makes it imperative that health

professionals have current fever management knowledge based on the latest

scientific evidence. They must challenge their negative beliefs and attitudes so that

they will be positioned to provide evidence-based fever management information to

parents of young children, allay parents’ inaccurate beliefs and reduce their fears of

harmful outcomes from childhood fever (Edwards et al., in press).

2.3.4 Health Professionals and Childhood Fever Parents report learning to manage fever from numerous sources with health

professionals being considered a reliable source of health information (e.g., Al-Eissa,

Al-Zamil et al., 2000; Barrett & Norton, 2000; Karwowska et al., 2002; McErlean et

al., 2001; Singhi et al., 1991). There are many reports about health professionals’

incorrect, phobic beliefs and practices, their knowledge, beliefs and fever

management practices are not always based on the latest scientific evidence.

Internationally, there are reports indicating health professionals, doctors and nurses,

believe fever to be harmful, causing febrile convulsions and brain damage

irrespective of country of research. For example, Canada (Ipp & Jaffe, 1993),

Switzerland (Gehri et al., 2005), Israel (Sarrell et al., 2002), Saudi Arabia (Al-Eissa

et al., 2001), Australia (Edwards, Courtney, Wilson, Monaghan, & Walsh, 2001b;

47

Walsh, et al., 2005) and the United States (Poirier, et al., 2000; Thomas et al., 1994).

Health professionals’ negative attitudes toward fever have remained unchanged over

the past 20 years (e.g., Abdullah, et al., 1987; Sarrell et al., 2002) despite strong

evidence for the beneficial effects of mild fever available for 30 years (e.g., Knoebel

et al., 2002; Lorin, 1999; Poirier et al., 2000; Sadovsky, 2001; Sarrell et al., 2002).

Health professionals as well as parents use the height of fever as a determinant of

illness severity (Sarrell et al., 2002; Walsh et al., 2005) and report that temperatures

as low as 38.3°C to 38.5°C require reduction to prevent febrile convulsions despite

evidence that febrile convulsions are benign events in young children which are not

prevented by antipyretics (D'Auria, 1997; Kudsen et al., 1996; May & Bauchner,

1992; Poirier et al., 2000; Sarrell et al., 2002; Van Esch et al., 1995). Health

professionals’ use of antipyretics to reduce low grade fever and recommendations to

parents to practice similarly continue (May & Bauchner, 1992; Mayoral et al., 2000;

Poirier et al., 2000; Sarrell et al., 2002; Sarrell & Kahan, 2003; Thomas et al., 1994;

Walsh et al., 2005; Waterston, 2002). Reports of health professionals alternating

antipyretics to reduce fever are widespread (Edwards, Courtney, Wilson, Monaghan,

& Walsh, 2003; May & Bauchner, 1992; Mayoral et al., 2000; Sarrell & Kahan,

2003). Health professionals and paediatricians also recommend parents alternate

antipyretics to reduce and maintain normal temperatures in children with a febrile

illness (Mayoral et al., 2000).

2.4 SUMMARY In humans, body temperature for each individual is maintained at a set temperature

‘set-point’ in the anterior hypothalamus through a highly orchestrated series of heat

production and conservation measures. When the set-point is raised by invading

48

micro-organisms the febrile response, a coordinated series of events to defend the

body against the organisms, is activated. Benefits of this response are evident in

children with temperatures up to 40°C and include enhancement of the

immunological system, reductions in serum iron and increases in phagocytic activity.

Associated with raised temperatures are incremental increases in heart, respiratory

and metabolic rates which place undue strain on some children. Fever should be

reduced in these children and in children with temperatures of 40°C or greater.

Benign convulsions associated with fever occur in 2% to 5% of children aged 3

months to 5 years. Aggressive antipyretic therapy has not been shown to prevent

these convulsions; it reinforces parents’ fever phobias and contributes to overdosing.

Parents are very concerned about the probability of febrile convulsions. They use

unsafe practices during febrile convulsions such as shaking, mouth to mouth

resuscitation, supine positioning and administering oral medications during a

convulsion. Health professionals, parents’ educators, hold negative attitudes toward

fever and recommend temperature reduction to prevent febrile convulsions. Health

professionals are responsible for educating parents about home fever management;

their negative attitudes might influence parents care of febrile children. It is

important for health professionals to educate parents about evidence-based fever

management, assessing and monitoring the child and treating the child, not the fever.

In the next chapter there is a published article exploring parents’ knowledge,

attitudes and practices in fever management, their sources of information and the

efficacy of educational interventions that have been trialled to improve parents’ fever

management practices. Following the article the need for a theoretical exploration of

the determinants of parents fever management is addressed.

49

CHAPTER 3 - PARENTS AND FEVER

This chapter begins with a published article reviewing the international literature

about parents’ management of childhood fever. The article reviews parents’

knowledge, attitudes and practices in fever management. Initially parents’ knowledge

of temperature and fever and antipyretics and the predictors of knowledge are

explored. Following this attitudes toward fever and predictors of attitudes are

discussed. Next parents’ practices in relation to fever management are reviewed.

These include temperature taking and fever management. The limitations of studies

exploring these areas are then discussed. Following this the information sources

parents use to learn to about fever management and antipyretics are explored. Finally

educational interventions developed and trialled to improve parents’ fever

management are discussed along with limitations of these studies.

The discussion following the article explores the lack of theoretically based research

into parents’ management of childhood fever as a reason for the continued reports of

parents’ concerns about harmful outcomes from fever despite successful educational

programs. An appropriate theory is chosen, the Theory of Planned Behavior, and its

assumptions and constructs discussed.

50

3.1 MANAGEMENT OF CHILDHOOD FEVER BY PARENTS: LITERATURE REVIEW Walsh, A., Edwards, H. (2006) Management of childhood fever by parents: literature

review. Journal of Advanced Nursing 54 (2), 217-227. Journal Impact Factor: 1.342

Abstract Aim. This paper reports a review which draws together findings from studies

targeting parents’ temperature-taking, antipyretic administration, attitudes, practices

and information-seeking behaviours.

Background. Parents’ concerns about the harmful effects of fever have been

reported for more than two decades. These concerns remain despite successful

educational interventions.

Method. Medline, CINAHL, PsycINFO, PsycARTICLES and Web of Science

databases were searched from 1980 to 2004 during November 2004. The search

terms were fever, child, parent, education, knowledge, belief, concern, temperature,

antipyretic and information, and combinations of these.

Findings. In the 1980s, studies were mainly descriptive of small single site samples

of parents with a febrile child seeking assistance from healthcare professionals. From

1990, sample sizes increased and multi-site studies were reported. Educational

interventions were designed to increase knowledge and reduce unnecessary use of

health services. One 2003 study targeted knowledge and attitudes. Parental

knowledge about normal body temperature and the temperature that indicates fever is

poor. Mild fever is misclassified by many as high, and parents actively reduce mild

fever with incorrect doses of antipyretics. Although some parents acknowledge the

benefits of mild fever, concerns about brain damage, febrile convulsions and death

from mild to moderate fever persist irrespective of parental education or socio-

51

economic status. Many base their fever management practices on inaccurate

temperature readings. Increased use of antipyretics to reduce fever and waking

sleeping febrile children for antipyretics or sponging reflects heightened concern

about harmful effects of fever. Educational interventions have reduced unnecessary

use of healthcare services, improved knowledge about fever and when to implement

management strategies, and reduced incorrect parental accuracy of antipyretic

dosing. Information-seeking behaviours in fever management differ according to

country of origin.

Conclusion. Despite successful educational interventions, little has changed in

parents’ fever management knowledge, attitudes and practices. There is a need for

interventions based on behaviour change theories to target the precursors of

behaviour, namely knowledge, attitudes, normative influences and parents’

perceptions of control.

Summary Statement What is already known about the topic

• Parents’ concerns about fever and its potential harm continue to be reported after

two decades of research and educational interventions.

• Parents’ decisions to seek medical assistance are frequently based on temperature

alone.

• Knowledge-based educational interventions have reduced parents’ inappropriate

use of healthcare services, increased knowledge and targeted inappropriate fever

management practices.

What this paper adds

• Parents are now more concerned about febrile convulsions than about brain damage

resulting from fever.

52

• Decisions to seek medical assistance are based on inaccurate temperature-taking

and use of low antipyretic doses.

• Educational programmes must be theoretically-based and target not only knowledge

but also the influences on parents’ and healthcare professionals’ attitudes,

normative influences and fever management practices.

3.1.1 Introduction

Parents are very concerned when they have a sick child, and often have difficulty

assessing the severity of the illness (Kai 1996a). Fever, a main indicator of illness, is

considered harmful by many parents (Crocetti et al. 2001) and a disease in itself

(Singhi et al. 1991). They often feel disempowered when their child is ill, and

believe they are not caring appropriately for their child if they do not treat the fever

(Kai 1996a). Papers describing parents' concern about and inappropriate management

of fever have been published in the healthcare literature over the past few decades,

and educational programmes developed to assist parents manage childhood fever

have proven effective (Casey et al. 1984, Crocetti et al. 2001, Sarrell & Kahan

2003). However, parents remain concerned about and mismanage fever, and seek

information and reassurance about their fever management practices from family,

friends, healthcare professionals, books, magazines and the Internet (e.g.

Impicciatore et al. 1998, Crocetti et al. 2001, Karwowska et al. 2002).

An article written in 1980 by Schmitt (1980) instigated interest in parents'

management of fever in the medical literature. Schmitt (1980) coined the phrase

'fever phobia' to describe parents' unrealistic fears about fever. This term has been

adopted to describe unrealistic fears about fever by both parents and healthcare

professionals (e.g. Abdullah et al. 1987, Sarrell et al. 2002). Since 1980, parents'

53

fever phobia, confirmed by their over-consultation of medical practitioners for minor

febrile illnesses, has been the impetus for most research in this area. Studies

conducted in the 1980s were descriptive and undertaken predominantly in the United

States of America (USA), with some in Canada and Saudi Arabia. During this

decade, only two controlled intervention studies were reported from the USA. The

1990s brought international interest in fever phobia, and descriptive studies were

published from the United Kingdom (UK), Italy, India and Israel and intervention

studies from the USA and UK. The quest to understand and enhance parental

management of fever continues into the 21st century as researchers try to understand

parents' concerns about fever and trial new methods to improve their fever

management. The aim of this paper is to review the literature reporting parents'

knowledge about fever, their attitudes towards it and their practices in the

management of childhood fever. Reports of educational interventions implemented

to assist parents' management of febrile children at home are also reviewed.

3.1.2 Search Method

During November 2004, Medline, CINAHL, PsycINFO, PsycARTICLES and Web

of Science databases were searched from January 1980 to October 2004. Papers were

included if they were from the developed world, written in English, explored fever in

common childhood illnesses (excluding, for example, meningitis and malaria) and, in

the case of quantitative studies, had sample sizes greater than 30. The search terms

were fever, child, parent, education, knowledge, belief, concern, temperature,

antipyretic and information, and combinations of these.

54

3.1.3 Findings

In this paper, we discuss the findings under the themes of parents' knowledge,

attitudes and practices in fever management, parents' sources of information about

fever management and educational interventions to improve parents' management of

childhood fever.

3.1.3.1 Parents’ Knowledge Temperature

Many people, healthcare professionals included, use body temperature to determine

state of health (e.g. Grossman et al. 1995, Blumenthal 2000, Edwards et al. 2001a,

Sarrell et al. 2002). Parents measure temperature by feeling body parts and/or using a

thermometer, but their knowledge of normal temperature and fever is poor. They

report that normal body temperature ranges from 35·0°C to 37·2°C (Singhi et al.

1991, Blumenthal 1998). Blumenthal (1998) found many parents in the UK did not

expect body temperature to rise on a hot summer day.

Although parents define temperatures between 37·0°C and 39·0°C as fever, 38·0°C

was the most commonly reported level they used for this (Kelly et al. 1996,

Blumenthal 1998, Impicciatore et al. 1998, Porter & Wenger 2000). High fever is

generally defined at temperatures around 39·0°C (Schmitt 1980, Singhi et al. 1991,

Karwowska et al. 2002); however, some parents recently reported high fever as

temperatures between 39·0°C and 40·0°C (Al-Eissa et al. 2000a, Crocetti et al.

2001). In the 1980s, 48% of parents reported that untreated temperatures could rise to

between 41·7°C and 43·3°C (Schmitt 1980, Kramer et al. 1985).

There has been limited exploration of the predictors of parental knowledge about

fever. In the 1980s, Kramer et al. (1985) discovered an inverse relationship between

55

the child's age and the minimum temperature considered as fever. Parents of younger

children considered higher temperatures to indicate fever than did parents of older

children. No differences were found in the temperature parents thought to indicate a

fever in a culturally-diverse population in the USA between Latinos, African

Americans and white Americans (Taveras et al. 2004). However, the height of fever

is commonly the deciding factor behind parents presenting at an emergency

department (McErlean et al. 2001).

Antipyretics

Parental knowledge about the effectiveness and appropriate dosing of antipyretics is

questionable. Knowledge about concentration differences between liquid

paracetamol and paracetamol drops is often incorrect (65%) (Barrett & Norton

2000), and some parents have reported that paracetamol and aspirin have

antihistamine, antiviral and decongestant properties (Ames et al. 1982) and that

paracetamol improves well-being (46%), prevents febrile convulsions (20%) or

prevents febrile convulsions and brain damage (28%) (Sarrell et al. 2002).

Although many parents are aware that an overdose of paracetamol could be

dangerous (62%) (Linder et al. 1999) or lethal (53%) (Kapasi et al. 1980), few are

aware of the possibility of liver toxicity (26%) (Linder et al. 1999). They (45%)

expect antipyretics to reduce temperatures to normal (Linder et al. 1999) and to

remain lowered for longer than the therapeutic time period (Kelly et al. 1996).

Knowledge about the effectiveness of antipyretics influences their decisions to seek

medical assistance. The failure of fever to respond to antipyretics is frequently the

reason parents attend emergency departments (Kelly et al. 1996, McErlean et al.

2001, Goldman & Scolnik 2004).

56

Many parents administer antipyretics in too low, too high or too frequent doses (Li

et al. 2000, Goldman & Scolnik 2004). Underdosing is more common in younger

and low weight children (Gribetz & Cronley 1987, Li et al. 2000), and incorrect

antipyretic dosing has been reported for nearly two decades. In 1987, 39% of parents

underdosed, 12% overdosed and only 32–35% correctly dosed febrile children with

paracetamol (Gribetz & Cronley 1987, Kilmon 1987). More recently, 47–49% of

febrile children presenting at emergency departments had received an appropriate

antipyretic doses prior to presentation (Li et al. 2000, McErlean et al. 2001, Goldman

& Scolnik 2004). Antipyretic doses administered by parents range between

6 mg/kg/dose (Gribetz & Cronley 1987) and 120 mg/kg/day (Linder et al. 1999).

Recently, the mean paracetamol dose administered by parents has been reported as

8·3 mg/kg/dose (Goldman & Scolnik 2004). Underdosing is associated with parents'

belief that a 5 mL teaspoon holds only 3 mL (Hyam et al. 1989, Linder et al. 1999),

not increasing dosages with the child's weight (Linder et al. 1999), incorrect beliefs

about the concentrations of children's paracetamol liquid and drops (Barrett &

Norton 2000) and determining the dose based on the child's age or temperature (Li

et al. 2000). Although there has been some improvement in correct antipyretic

dosing over the past two decades, overdosing has increased. In Linder et al.'s (1999)

study, 43% of parents correctly dosed their child, 24% underdosed and 33%

overdosed.

Alternating antipyretics is the latest reported parental method for controlling fever.

When parents do not perceive the antipyresis from one antipyretic (e.g. paracetamol)

to be satisfactory, they administer another (e.g. ibuprofen) 1–2 hours later. This

introduces another avenue for incorrect antipyretic usage (Crocetti et al. 2001).

Crocetti et al. (2001) found that 27% of parents alternate antipyretics. Li et al. (2000)

57

reported that parents incorrectly dosed children with one or both the antipyretics

paracetamol and/or ibuprofen, 7% of children (14 out of 200) received alternating

antipyretics, and only one child received correct doses of both. Overdosing was more

likely with ibuprofen than paracetamol both in dosage and frequency. Fever

legitimizes parents' use of antipyretics for fever-related problems such as helping the

child during illness, alleviating suffering, providing comfort, enabling the child to

sleep and giving parents a feeling of coping (Lagerlov et al. 2003).

Predictors of parental knowledge about antipyretics and correct dosing were

identified in the 1980s, education, income and age predicting antipyretic knowledge

(Ames et al. 1982). Less knowledge was associated with lower educational levels (7–

12 years of formal education), age between 15 and 30 years, lower income levels or

use of subsidized public health care. However, in the late 1990s it was reported that

younger mothers were more likely to read the instructions included with the bottle

and comply with recommended dosages (Linder et al. 1999). These differences have

not been found in the 21st century. More recent studies have focused on antipyretic

use rather than knowledge per se. Learning about antipyretics from doctors made no

difference to parents' antipyretic knowledge. Neither parent nor child variables have

been found to predict parental antipyretic knowledge (Barrett & Norton 2000) or

accurate antipyretic usage (McErlean et al. 2001).

Summary

In summary, parents' knowledge about normal body temperature and the temperature

that defines fever is poor. They classify mild fever as high and actively reduce

temperatures, sometimes normal temperatures, with incorrect doses of antipyretics.

When underdosed children's temperatures are not reduced to a level parents consider

58

satisfactory, they seek professional assistance, placing additional burdens on already

strained healthcare systems.

3.1.3.2 Attitudes

Parental fever phobia, concern about, and inappropriate treatment of, childhood fever

are well documented and possibly multifactorially caused (e.g. Schmitt 1980, Kramer

et al. 1985, Knoebel et al. 2002). This may be caused by past personal experience

with febrile children, anecdotal tragic outcomes of febrile children, cultural

influences and information from family, healthcare professionals and other sources

(Poirier et al. 2000). Over the 24 years of literature reviewed, many parents were

reported as believing fever to be harmful and being very worried about these

perceived harmful effects, despite numerous reports of the benefits of mild to

moderate fever in the medical and scientific literature (e.g. Kluger 1986, Lorin 1986,

1999, Zeisberger 1999, Mackowiak 2000, Blatteis 2003, Roth et al. 2004).

Parents' perceptions of the temperature at which fever is harmful have changed over

time. In the 1980s, although in the USA 94% of American parents of well children

(n = 100) believed fever to be harmful, only 4% believed temperatures in a normal

range, 37·8°C or lower, to be harmful; 48% believed temperatures below 40°C

(moderate fever) to be harmful (Schmitt 1980). In a recent Israeli study, 43%

(n = 1000) believed in the beneficial effects of low grade fever (37–38°C) during

infection; however, 57% believed that low grade fevers (38°C or lower) were

harmful (Sarrell et al. 2002).

Parental ratings of the harmful effects of fever have changed from 1980 to 2004,

although their main concerns continue to be brain damage, febrile convulsions and

death (e.g. Schmitt 1980, Kramer et al. 1985, Al-Eissa et al. 2000a, Crocetti et al.

59

2001, Karwowska et al. 2002). In the 1980s, they were more concerned about brain

damage (38–46%) than febrile convulsions (15–39%) (Schmitt 1980, Abdullah et al.

1987). More recently, although concerns about brain damage remain (21–53%),

concerns about febrile convulsions have increased dramatically (32–70%) (Al-Eissa

et al. 2000a, Crocetti et al. 2001, Karwowska et al. 2002). Reports of concerns that

fever is a sign of serious illness have reduced from 12–43% in the 1980s (Schmitt

1980, Abdullah et al. 1987) to 2–28% in the 2000s (Al-Eissa et al. 2000a, Crocetti

et al. 2001). Interestingly, an increase in parental concern about dehydration (80%)

and discomfort (75%) was recently reported by Canadian parents (Karwowska et al.

2002), compared with 4–8% in the 1980s (Schmitt 1980, Anderson 1988).

Although most research exploring parental attitudes and practices in fever

management has been quantitative, some qualitative studies during the past decade

have explored their perceptions of fever. Kai (1996b) found that these concerns were

influenced by the perceived threat of the illness and anxieties about fever, coughs

and the possibility of meningitis. These anxieties were heightened by the knowledge

that non-specific symptoms could precede a rapidly-progressing, serious illness. The

degree of parental concern about a symptom (e.g. fever or cough) was dependent on

the perception of the symptom hurting their child. Parents' personal control is

threatened by their child's illness, and attempts to maintain control include

monitoring symptoms and minimising discomfort. Lagerlov et al. (2003) has

reported that, although parents acknowledge that low to moderate fever reflects the

body's immunological response, they consider high or rapidly rising fever dangerous.

Predictors for parents' concerns about fever have been identified. Italian mothers'

concerns were positively associated with lack of information about fever

60

management, moderate fever in their child, inexperience with managing febrile

children and low maternal educational levels (Impicciatore et al. 1998). Other studies

corroborate these predictors, even among highly educated people and those in higher

socioeconomic classes (Kramer et al. 1985, Singhi et al. 1991). There has been little

change in these predictors over the last two decades (Crocetti et al. 2001).

Summary

In summary, although there is a move toward acknowledging the benefits of mild

fever, attitudes toward it remain negative. Beliefs about its harmful outcomes

identified in the 1980s (e.g. brain damage, febrile convulsions and death) persist,

irrespective of parental education or socio-economic status. Concerns about febrile

convulsions, dehydration and discomfort associated with fever have increased, and

attitudes toward fever seem to be similar irrespective of country of origin.

3.1.3.3 Practices Temperature-Taking

Although parents are concerned about the height of their child's temperature, not all

have a thermometer (38–44%) (Fischer et al. 1985). Owning a thermometer does not

predict ability to accurately take a temperature or read a thermometer. Several reports

state that few parents (30–46%) can accurately take a temperature and read a

thermometer (Fischer et al. 1985, Porter & Wenger 2000, Taveras et al. 2004).

Despite this, parents take febrile children's temperatures regularly, often hourly

(Crocetti et al. 2001), and initiate activities to reduce temperatures; sometimes this is

done with temperatures within a normal range (Schmitt 1980, Kilmon 1987,

Blumenthal 1998, Crocetti et al. 2001, Sarrell et al. 2002).

61

Correlations between inability to take a temperature accurately and parent variables

have been examined. Lower socioeconomic status and not owning a thermometer

predict an inability to read a thermometer accurately (Fischer et al. 1985). Fischer et

al. found no relationship between maternal age or the presence of other children in

the home and ability to read a thermometer. Banco and Jayasherkaramurthy (1990)

discovered that younger parents and those with higher socioeconomic backgrounds

and higher educational levels were more likely to own and accurately read a mercury

thermometer. This was corroborated by Porter and Wenger (2000), who found that

maternal age, educational level and socioeconomic status predicted accuracy of

temperature-talking.

3.1.3.4 Fever Management

Antipyretics have been and remain, for many parents, the preferred method for

reducing fevers (e.g. Kramer et al. 1985, Anderson 1988, Kelly et al. 1996,

Impicciatore et al. 1998, Linder et al. 1999, McErlean et al. 2001). They prefer to

treat fever with antipyretics rather than removing clothing or tepid sponging

(Kinmonth et al. 1992). Antipyretic use in fever management has increased from

67% of parents in 1980 (Schmitt 1980) to 95% in 2002 (Karwowska et al. 2002). In

the 1980s, parents administered antipyretics to children with normal temperatures

(67%) (Schmitt 1980) and temperatures below 38·3°C (71%) (Casey et al. 1984).

More recently, only 23% of parents reported treating fevers below 37·8°C with

antipyretics (Crocetti et al. 2001). Today, parents (46%) use antipyretics to promote

their child's well-being during a febrile episode (Sarrell et al. 2002), and this gives

them a feeling of mastery when their child is ill (Lagerlov et al. 2003).

62

Parents' practices have not changed. Waking sleeping febrile children for an

antipyretic was one of the early factors describing fever phobia (Schmitt 1980). In

1980, 48–53% of parents woke sleeping febrile children (Schmitt 1980, Kramer et al.

1985), and today this has increased to between 66% and 92% (Al-Eissa et al. 2000b,

Crocetti et al. 2001, Sarrell et al. 2002). Parents need reassurance that they are

managing their febrile child appropriately and often contact doctors about low fevers

or those of short duration (Kramer et al. 1985, Singhi et al. 1991, Kelly et al. 1996,

Impicciatore et al. 1998). Although this creates guilt in some parents, they feel that

they have little choice and need to share responsibility for their febrile child (Kai

1996b).

Other fever management practices in the 1980s included the use of tepid, cold or ice-

cold water and alcohol rubs (Schmitt 1980, Kramer et al. 1985, Abdullah et al. 1987,

Anderson 1988). Although tepid sponging has continued into the early 2000s (Al-

Eissa et al. 2000b, Crocetti et al. 2001, Karwowska et al. 2002), the use of cold or

ice-cold water and alcohol rubs has reduced considerably (Karwowska et al. 2002).

However, in Saudi Arabia, some parents continue to keep their febrile child warm by

controlling the ambient temperature or using additional clothing (Abdullah et al.

1987, Al-Eissa et al. 2000b), and continue to combine treatments such as tepid

sponging and antipyretic administration (Kramer et al. 1985, Blumenthal 1998, Al-

Eissa et al. 2000a). One fever management practice that has changed since the

documented association between Reye syndrome, aspirin and influenza is the use of

aspirin as an antipyretic; this has almost disappeared, along with a decline in the

incidence of Reye syndrome (Drwal-Klein & Phelps 1992, Cranswick 2000).

63

Summary

Although parents do not take accurate temperatures, they continue to base their fever

management practices on temperature. Today, fewer aim to reduce temperatures in

normal ranges, and some practices, such as the use of aspirin and cold or iced water

to reduce fever, have reduced. Other practices reflect an increased concern about

harmful effects of fever and the need for control during this frightening time. These

include increased use of antipyretics and waking sleeping febrile children for

antipyretics or sponging.

3.1.3.5 Limitations

The data above describe parents' knowledge, attitudes and practices in fever

management. Similar findings have been found in a number of different countries

and cultures; however, in most studies data were collected from concerned parents

seeking medical assistance for a concern such as fever or injury. Therefore the

findings might not be generalisable. Longitudinal studies have not been reported.

Parents' knowledge, attitudes and practices could change over time as the child ages

or with the birth of subsequent children.

Most studies in the 1980s exploring parents' management of fever were descriptive

cross-sectional studies using small single-site, convenience samples (36–249) from

hospitals or health clinics (e.g. Schmitt 1980, Ames et al. 1982, Kramer et al. 1985,

Abdullah et al. 1987). Instruments were researcher-developed (e.g. Schmitt 1980,

Casey et al. 1984, Kramer et al. 1985), sometimes the questions were reported (e.g.

Schmitt 1980, Kramer et al. 1985), and only one study compared findings with

earlier studies by using previously-developed questions (Anderson 1988). However,

64

instrument reliability, validity and data analysis were generally not reported (e.g.

Schmitt 1980, Kramer et al. 1985, Abdullah et al. 1987).

Larger samples (100–1237) were explored from 1990 onwards. Multi-site studies

were reported more frequently than single-site studies. Again, descriptive, cross-

sectional, comparative and multi-site studies compared the perceptions of

convenience samples of parents with febrile and afebrile children (e.g. Banco &

Jayasherkaramurthy 1990, Impicciatore et al. 1998, Linder et al. 1999). Community-

based studies were reported more frequently – three from 1990 to 2004 (Kai 1996b,

Impicciatore et al. 1998, Linder et al. 1999) – compared with one in the 1980s

(Anderson 1988). Instrument reliability and data analysis were reported more

frequently in the 1990s (e.g., Kai 1996b, Kelly et al. 1996, Impicciatore et al. 1998)

and in most studies from 2000 onwards.

3.1.3.6 Information Sources Fever

Parents learn to manage fever from different sources. In India, they were more likely

to learn from parents and relatives than doctors, friends or reading. However,

educated parents from higher socioeconomic backgrounds are more likely to learn

from reading and doctors (Singhi et al. 1991). Saudi Arabian parents are equally

likely to learn fever management from relatives and friends, doctors and reading (Al-

Eissa et al. 2000b). Italian mothers are more likely to learn to manage fever from

doctors during a febrile episode than during a visit when the child is well

(Impicciatore et al. 1998). More parents in the USA learn from doctors and nurses

than friends and relatives, experience, reading or television (Crocetti et al. 2001).

Canadian parents are most likely to learn from doctors (Karwowska et al. 2002),

65

while other regular sources are family, nurses, books, magazines, and some gather

information from the Internet and television.

Antipyretics

In the USA in the 1980s, parents learnt antipyretic dosing from doctors, previous

experience, friends, product advertising and medical reference books (Ames et al.

1982). In the 21st century, they are more likely to gather medication information

from doctors and packaging (Li et al. 2000). However, the source of antipyretic

information does not lead to a significant difference between correct and incorrect

doses in the USA (Li et al. 2000). Israeli parents learn from doctors,

mothers/grandmothers and instructions on containers (Linder et al. 1999).

3.1.3.7 Educational Interventions

Controlled educational interventions have effectively enhanced parents' knowledge

and fever management practices, reduced fever-related anxiety, fever-related clinic

visits and telephone calls to doctors. During the 1980s, experimental studies were

undertaken in health clinics to reduce inappropriate visits by educating parents about

fever management (Casey et al. 1984, Robinson et al. 1989). These studies

effectively increased the knowledge of parents from middle socioeconomic

background and reduced antipyretic use for temperatures below 38·3°C, dosing

errors and physician visits and telephone calls (Casey et al. 1984, Robinson et al.

1989). These positive changes were still evident 6 months after the intervention.

A randomized, controlled community-based study in the UK determined the effect

on general practice clinic visits of an educational booklet explaining the symptoms

and management of childhood illnesses such as fever, cough, sore throat and

diarrhoea (Usherwood 1991). Although it did not reduce clinic visits for fever, home

66

visits and out-of-hours calls for febrile children were statistically significantly

reduced. A paediatrician-administered intervention about the benefits of fever and

appropriate fever management practice was successful in Israel (Sarrell & Kahan

2003); parents' definitions of the different levels of fever (low, moderate and high)

were corrected, knowledge of when to initiate non-pharmacological rather than

pharmacological fever management reduction strategies was improved, and the

number of visits to paediatricians and emergency departments for febrile concerns

was reduced.

Nursing interventions have also been implemented. A comparative, pre- and post-test

study explored the effectiveness of educational interventions among minority groups

with lower socioeconomic backgrounds using an instruction sheet focused on aspects

of fever and its management (Kelly et al. 1996). Although unsuccessful in altering

knowledge of the temperature at which an antipyretic should be administered, the

intervention did improve accuracy of medication dosing. Quasi-experimental

interventions in emergency departments have successfully reduced parental anxiety,

improved caretakers' home management of fever and reduced emergency department

visits for fever (Murphy & Liebman 1995, O'Neill-Murphy et al. 2001).

Murphy and Liebman (1995) explored the efficacy of different teaching methods in

reducing parental anxiety, increasing ability to read a thermometer and managing

fever at home. Demonstration, discussion and written educational methods were

equally effective. O'Neill-Murphy et al. (2001) found a standard written fever

pamphlet and interactive educational intervention equally effective. A recent

American study by Broome et al. (2003) attempted a theoretically-based

intervention. Based on the attitudinal construct of the Theory of Planned Behavior

67

(Ajzen 1985), they explored influence of knowledge and attitudes on decision-

making. They claimed that increasing parents' knowledge about assessing childhood

fevers, communicating with healthcare professionals and implementing prescribed

fever management therapies would change parents' attitudes toward and knowledge

about fever management. Their experimental group had statistically significantly

more knowledge and an increase, though not statistically significant, in confidence in

fever management. However, changes in attitudes were not reported.

Summary

Educational interventions have successfully reduced parents' unnecessary use of

healthcare services for childhood fever. Additionally, they have improved knowledge

about fever, when to implement management strategies and accuracy of antipyretic

dosing through various mediums. Different educational media (e.g. discussion with

healthcare professionals, videos, pamphlets and booklets) and a combination of these

have not influenced outcomes. Only one intervention was theoretically-based and

addressed attitudes; all others targeted knowledge to change fever management

behaviours. There is a need for theoretically-based interventions to target not only

knowledge, but also attitudes, intentions and practices in fever management.

Limitations

Many intervention studies have targeted knowledge only and used potentially biased

convenience samples of parents concerned about fever and those attending

paediatricians (Sarrell & Kahan 2003) and emergency departments (e.g. Murphy &

Liebman 1995, O'Neill-Murphy et al. 2001) for fever related concerns. Some studies

reported reduced inappropriate healthcare professional contact for childhood fevers

and increased parental knowledge (e.g. Casey et al. 1984, Robinson et al. 1989,

68

Broome et al. 2003), although not all did (Kelly et al. 1996). Samples in comparative

studies were small (52–156) (Kinmonth et al. 1992, Kelly et al. 1996). Quasi-

experimental studies had similarly-sized samples (87–130) (Casey et al. 1984,

Murphy & Liebman 1995, O'Neill-Murphy et al. 2001, Sarrell & Kahan 2003), and

samples in randomized controlled trials ranged from 216–497 (Robinson et al. 1989,

Usherwood 1991, Broome et al. 2003).

3.1.4 Discussion

There have been few changes in parents' knowledge, attitudes and practices over the

past two decades. They continue actively to reduce low grade fevers despite

persistent recommendations in the literature that only temperatures of 40°C or higher

be reduced; temperatures below 40°C support immunological activities associated

with fever (Lorin 1994, 1999, Connell 1997). Definitions of high fever, although

moving in the right direction, remain low at 40°C. Sarrell et al. (2002) defined

moderate fever as 40·0°C. Height of fever remains a common deciding factor in

seeking medical assistance and when, associated with antipyretic underdosing and

unrealistic expectations from antipyretics, overuse of medical services for febrile

children is understandable. The incidence of antipyretic overdosing has nearly

trebled in the last 20 years and concerns about overdosing, particularly in connection

with alternating antipyretics, are appropriate. An important issue for healthcare

professionals is the lack of association between parents' appropriate antipyretic use

and learning about antipyretics from healthcare professionals. This needs further

exploration.

Parental fever phobia, or unrealistic concerns about fever, persists. Increased

concerns about meningitis could result from the extensive media coverage of rare,

69

serious childhood illnesses, such as meningococcal meningitis. However, the reasons

for increased concerns need to be explored.

Educational interventions have improved parental knowledge and practices. Why,

then, are there no great changes in parents' knowledge, attitudes and practices over

the past two decades? Many educational programmes had specific goals, such as

reduction in parents' use of medical services for self-limiting viral infections. In order

to change behaviour, these interventions targeted knowledge and not attitudes or

environmental factors such as social influences and parental control when a child has

fever. Descriptive studies were often just that, rather than precursors of educational

interventions targeting parents' specific needs. There is a need to identify parental

knowledge, attitudes and practices and then to develop educational interventions

based on a behaviour change theory proven to be effective in situations where people

have an emotional involvement in a behaviour that is not always totally under their

control. The Theory of Planned Behavior (Ajzen 1985) has identified the predictors

of behaviours such as safe sex (McCamish et al. 1994) and nurses' management of

postoperative pain (Edwards et al. 2001a,b), and guided the development and

implementation of successful educational interventions. Predictors of other health

behaviours identified by this theory include smoking cessation following coronary

artery bypass surgery (Bursey & Craig 2000), breastfeeding (Janke 1994), breast or

testicular self-examination (McCaul et al. 1993), parents use of booster seats in cars

(Ferraro 2004) and pregnant adolescents' intentions to breastfeed (Wambach 1997,

Wambach & Koehn 2004).

The constancy of knowledge, attitudes and practices in countries where new parents

learn from their parents to manage fever is understandable. However, this is

70

unacceptable in countries where parents learn from healthcare professionals. An

exploration of the literature reporting healthcare professionals' knowledge, attitudes

and practices in this area sheds some light, and professional concerns about harmful

effects of fever (Abdullah et al. 1987, Thomas et al. 1994, Walsh et al. 2005) and

fever phobia (May & Bauchner 1992, Poirier et al. 2000, Sarrell et al. 2002) continue

to be reported. This could explain similarities in fever-related concerns between

parents who learn to manage fever from professionals and from previous generations.

Health education is a responsibility of all healthcare professionals. Fever education

must be based on the latest scientific evidence, and professionals' attitudes toward the

benefits of mild to moderate fever must be positive. To ensure that parents are

equipped to manage a febrile episode, health education should be included in clinic

visits when the child is well, preferably prior to a febrile episode. Parents must be

advised about accurate temperature-taking, how to care safely for a febrile child,

when to seek professional advice, the role of fever in the immunological process,

when to reduce fever with antipyretics, and how to administer antipyretics safely.

Reports in the literature highlight the need for parental and healthcare professional

education about fever and fever management to ensure that children are cared for

safely at home without seeking medical advice and reassurance for each febrile

episode.

3.1.5 Conclusion

Caring for a febrile child is emotionally challenging for parents, and limited

improvements in knowledge, attitudes and practices highlight the need for structured

research programmes. To develop such programmes, an assessment of parents'

knowledge, attitudes, practices and educational needs must precede the development

71

of theoretically-based interventions. Evidence-based health education by healthcare

professionals, and particularly by nurses delivering maternal-child health care,

should aim to precede a child's first febrile episode. Fever management education

must highlight the benefits of fever and equip parents with appropriate knowledge

and skills to manage mild to moderate fevers without unnecessary health professional

consultation. Figure 3.1 describes the components necessary for effective fever

management education.

72

ADVICE FOR PARENTS WHEN CARING FOR A SICK CHILD

• mild to moderate fever is beneficial and supports the immune system • observe the child, focus on the child’s well-being rather than temperature • make the child comfortable • dress in light clothing • encourage fluids – small, frequent drinks of clear liquid:

o e.g., water or diluted juice • reduce activity • light blanket for children who are cold or shivering • selectively reduce fevers with medications when fever is:

o greater than 39.0°C and associated with discomfort o 40°C or higher and o in all children who are irritable, miserable or appear to be in pain

• medication dosages for children up to 6 years: o paracetamol 15mg/kg every 4 hours up to 4 times a day, maximum

1g/day o ibuprofen, always administer with food or milk, check labelling as

dosage is age related until 2 years (not recommended in some countries to children younger than 2 years) then 10mg/kg 3 to 4 time a day, maximum of 1.2g/day.

o aspirin should be avoided • do not continue giving regular medication for > 48 hours without having the

child assessed by a doctor

SEEK MEDICAL ATTENTION IF THERE IS NO IMPROVEMENT IN 48 HOURS OR IF THE CHILD

• is febrile and under 6 months of age • looks ‘sick’, pale, lethargic or weak • suffers severe headache, neck stiffness or light hurts their eyes • has breathing difficulties • refuses to drink • persistently vomits • shows signs of drowsiness • suffers pain • has a rash of red-purple spots

Figure 3.1: Parental fever management education Adapted from: (Curtis & Starr, 2000; MIMS Australia Pty. Ltd., 1996-1999; Schmitt, 1984)

73

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3.2 SUMMARY OF LITERATURE REVIEW ARTICLE The article reviewed the literature about parents’ knowledge, attitudes and practices

in and sources of information about fever management. There have been few changes

over the past two decades with some practises, e.g., the use of antipyretics to reduce

fever and alternating antipyretics, increasing in prevalence. Concerns about harmful

outcomes from fever remain high with a shift in concern from brain damage to

febrile convulsions. Knowledge based educational interventions to assist parents

manage fever in an evidence-based manner have been reported as successful.

However, evidence of these changes is not apparent in baseline data from more

recent studies. Early interventions targeted parents’ knowledge to reduce

unnecessary health service utilisation. One study was loosely based on a behaviour

change theory targeting one of the theoretical constructs of the theory, attitudes, in

addition to knowledge.

3.3 NEED FOR A THEORETICAL BASE Parents continued fear of and perceived need to reduce fever highlight deficits in the

reportedly successful knowledge based education programs. Changes have been

neither sustainable over time nor from one generation to the next. The lack of

theoretically based educational interventions could be a contributing factor in parents

continued concern about fever and its perceived harmful effects. Kok (1993),

suggests the reason health educational interventions are ineffective is their lack of

theoretical base, adequate planning and evaluation. Whitehead (2004) has extended

this by including health educators’ poor understanding of the behaviour change

processes and the complexity of behaviour change and emphasises a need for careful

consideration of the theoretical and practical constructs underpinning health

education programs.

80

Parents’ fever management is determined during febrile episodes; it is an individual

behaviour. Therefore, theories focusing on the characteristics of the individual were

explored to determine fit for this research. The dominant individual behavioural

theories in the health education arena include the Health Belief Model (Rosenstock,

1974), Social Cognitive Theory (Bandura, 1977), Transtheoretical Model

(Prochaska, Johnson, & Lee, 1998) and the Theories of Reasoned Action (Fishbein &

Ajzen, 1975) and Planned Behavior (Ajzen, 1985). Newly emerging theories such as

the Information Motivation Behavioral Skills model (Fisher & Fisher, 2002) extend

earlier theories such as the Health Belief Model and Theories of Reasoned Action

and Planned Behavior. These dominant theories account for the majority of theory

based research and interventions in the health education literature.

3.3.1 Determining a Theory To determine an appropriate theoretical framework it is necessary to revisit the

currently identified predictors of parents’ fever management practices. Influences on

parents’ fever management are multifactorial and include knowledge, beliefs,

attitudes, sources of information and past experience with fever (e.g., Knoebel et al,

2002; Kramer et al., 1985; Schmitt, 1980). Additionally, childhood fever is not an

everyday occurrence. Febrile children make parents anxious (Betz & Grunfeld, 2006;

Goldman & Scolnik, 2004). Influences identified during a febrile episode could

differ according to the specific context and height of fever and be confounded by

parental anxiety related to these. It is therefore more appropriate to explore the

determinants of parents’ fever management when children are afebrile. To achieve

this it is necessary to explore behavioural intentions rather than behaviours,

behaviours that could be influenced by a specific febrile episode.

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Following a review of the fever management and health educational literature the

Theory of Planned Behavior was deemed the most appropriate theoretical basis for

the research as it identifies the determinants of behavioral intention. This theory

provides the constructs appropriate for identifying parents’ beliefs, attitudes, the

normative influences on them and their control over their fever management. An

earlier study conducted in the United States used one construct of the Theory of

Planned Behavior, attitudes, in an intervention to enhance parents’ management of

fever (Broome et al. 2003). This will be the first study to undertake a comprehensive

theoretical exploration of the determinants of parents’ fever management practices.

3.4 THEORY OF PLANNED BEHAVIOR The Theory of Planned Behavior (TPB) (Ajzen, 1985; 1991) is an extension of the

earlier Theory of Reasoned Action (TRA) (Fishbein & Ajzen, 1975). Both are

deliberative processing models and based on the assumption that when making

behavioural decisions, people rationally consider all information available and

implicitly or explicitly consider the implications of their actions. The TRA and TPB

postulate that a person’s intention to perform (or not perform) a behaviour is the

most important immediate determinant of that action (Ajzen, 2005). Within both

theories is the principal of compatibility which purports that each attitude and

behaviour has four elements: action, target, context and time. Attitudes and

behaviour are more likely to correspond when both are measured with the same

degree of specificity with respect to each element (Ajzen, 2005). Therefore fever

management behaviour consists of:

• an action or behaviour (using, or not using, medications to reduce fever)

• performed on or toward a target or object (febrile child, a child is a different

target each time they have a fever)

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• in a particular context (temperature 38.0ºC or greater)

• at a specified time or occasion (at home, going to child care, on vacation) (Ajzen,

2005).

The TRA was based on a compensatory, expectancy-value model of attitude which

proposed a person’s attitude towards an object was a function of their beliefs about

the object (characteristics, qualities and attributes) and evaluation of those beliefs.

The TRA purports the key predictor of performing behaviours under volitional

control are intentions to perform the behaviour. The underlying determinants of

intention are attitudes and subjective norms and the relative weighting given to each

of these varies according to the behaviour and population being studied (Fishbein &

Ajzen, 1975). The TPB extends the TRA to include situations under which a person

does not have complete volitional control over behaviour, this extension offers

insight into individuals’ situation specific behaviour (Ajzen, 1985, 1991, 2005).

According to the TPB there are three basic determinants to a person’s intention (and

behaviour) one personal in nature (attitudes), one reflecting social influence

(subjective norms) and a third dealing with issues of control (perceived behaviour

control). A person intends to perform a behaviour when they evaluate it positively,

experience social pressure to perform it and believe they have the means and

opportunity to do so. See Figure 3.1.

Attitudes toward a behaviour are determined by salient (accessible) beliefs about the

consequences of the behaviour – behavioural beliefs. Each behavioural belief is

linked to an attribute, such as the outcome or cost of performing the behaviour

(Ajzen, 2005; Conner & Sparks, 2005). For example a parent might believe it

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unlikely that not reducing fever would assist the body’s defences to fight infection,

but evaluate the outcome as good if fever did assist the body’s defences. Belief based

attitudes are favourable or unfavourable toward the behaviour.

Figure 3.2 Theory of Planned behaviour

Subjective norms are a function of normative beliefs. Normative beliefs reflect a

person’s expectation that specific individuals or groups would approve or disapprove

of their performing the behaviour, or might regularly perform the behaviour. People

who believe most referents with whom they are motivated to comply think they

should perform the behaviour will receive social pressure to perform the behaviour.

Referents in fever management include partners and doctors (Ajzen, 2005; Conner &

Sparks, 2005). For example, if a person believes their partner expects them to reduce

their child’s fever with medications and they are motivated to do what their partner

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wishes, then they are likely to reduce the fever with medications. Subjective norms

are supportive or unsupportive of the behaviour.

Perceived behavioural control is a function of beliefs about the presence or absence

of factors that facilitate or impede performance of a behaviour. Perceived

behavioural control beliefs may be based on past experience, experiences of others

and factors that reduce or increase their perceived difficulty of performing the

behaviour (Ajzen, 2005; Conner & Sparks, 2005). For example, parents would not

have high perceived behavioural control over administering paracetamol to their

febrile child if the parent believed fever should be managed with paracetamol but

their child regularly refused to take oral paracetamol when febrile.

Background factors can also influence behavioural, normative and control beliefs.

Many variables may be related to or influence the beliefs people hold such as age,

gender, marital status, ethnicity, socio-economic status, education, occupation,

religion, nationality and so on. In childhood fever management age, education and

inexperience in fever management have been identified as influencing knowledge

and concerns about fever (Ames et al. 1982; Crocetti et al. 2001; Impicciatore et al.,

1998; Kramer et al., 1985; Singhi et al., 1991). The potential influence of these

factors is recognised by the TPB, however, without a theoretical guide the specific

background factors influencing beliefs are unknown. Additional background factors

that could influence parents’ fever management include the number of children they

have, the age of their children, whether they have had employment in a health setting

and sources of fever management information.

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The TPB has been applied to a variety of behavioural domains over the past 20 years

and there is considerable support for the theory. Intentions to perform a behaviour

can be predicted from attitudes, subjective norms and perceptions of behavioural

control and behaviour can generally be predicted with considerable accuracy from

intentions and perceptions of perceived behavioural control (Ajzen, 2005). Meta-

analyses of the TPB literature provide good support for the TPB (e.g., Armitage &

Conner, 2001; Downs & Hausenblas, 2005; Godin & Kok, 1996; Rivis & Sheeran,

2003)

3.4.1 Applications of Theory of Planned Behavior The TPB has predicted intention to perform a variety of everyday behaviours. These

include, for example, pedestrians’ intentions to violate traffic regulations (Diaz,

2002), mobile phone use (Wang, Lin, & Luarn, 2006), young males’ intentions to

drink and drive (Marcil, Bergeron, & Audet, 2001) and blue collar workers’

intentions to exercise (Blue, Wilbur, & Marston-Scott, 2001). Health behaviours

predicted by the TPB include young adolescents’ fruit and vegetable consumption

(Lien, Lytle, & Komro, 2002), eating and activity behaviours (Wood Baker, Little, &

Brownell, 2003), breakfast eating behaviours (Gummeson, Jonsson, & Conner,

1997), fish consumption (Verbeke & Vackier, 2005), exercise intention (Rhodes &

Courneya, 2005; Rhodes, Courneya, & Jones, 2005) and purchasing foods enriched

with omega-3 fatty acids (Patch, Tapsell, & Williams, 2005).

However, few TPB studies have explored predictors of parent child rearing

behaviours. Studies have found parents’ attitudes toward booster seat use predict

booster seat use (Ferraro, 2004), adolescents’ attitudes, social norms and perceived

control influence pregnant adolescents’ intentions to breastfeed (Wambach & Koehn,

2004). Perceived control was found to influence breast feeding among new mothers

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in Hong Kong (Dodgson, Henly, Duckett, & Tarrant, 2003) and subjective norms

were the best predictors of Peruvian mothers’ intentions to seek medical help for

children with signs of pneumonia (Galvez, 2001). Identifying predictors of parents’

intentions allows for targeted interventions to be developed to improve parents’

practices. The dearth of research in this area exploring both the predictors of parents’

child health behaviours and interventions to improve parents’ child health behaviours

highlights the urgent need for theoretical research in this area.

Recommendations from the research on ‘Planned Behavior’ during the past two

decades (Ajzen & Madden, 1986; Anderson et al., 1998; Edwards, Nash et al., 2001;

Fishbein, 2000; Fishbein et al., 2001; Godin & Kok, 1996; McCaul et al., 1993;

Terry & O'Leary, 1995; White et al., 1994), assert the TPB contains variables

necessary to predict health behaviours and for the development of successful

interventions aimed at increasing intention to perform a particular health behaviour.

The TPB demonstrates that a person’s intention to perform a behaviour is the most

reliable predictor of behaviour. Therefore, research aimed at identifying the

predictors of intention and interventions aimed at changing behaviour must focus on

changing the specific behavioural antecedents influencing intention, namely

perceived control, attitudes and subjective norms in order to promote lasting

behavioural changes.

The TPB has been successfully used as a basis for educational interventions targeting

the predictors of behavioural intention. Positive results have been reported in

changing HIV/AIDS protection (McCamish, Timmins, Terry, & Gallois, 1993;

McCaul et al., 1993; White et al., 1994), use the bus instead of driving the car

(Bamberg, Ajzen, & Schmidt, 2003), wear bicycle safety helmets (Quine, Rutter, &

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Arnold, 2001), increase regular condom use (Fishbein et al., 2001) and change job-

seeking strategies (Van Ryn & Vinokur, 1992).

The TPB has also been used to identify predictors of intentions and behaviour and as

a guide for developing educational interventions. Successful applications of the TPB

to initially identify the predictors of intentions and then develop educational

interventions to change intentions are reported. For example, surgical nurses’

intentions to administer as required opioid analgesia to post-surgical patients with

pain (Edwards, Nash, Najman et al., 2001; Edwards, Nash et al., 2001) and paediatric

nurses’ intentions to reduce childhood fever with paracetamol (Edwards et al., in

press; Edwards et al., 2003; Walsh et al., 2005).

Prior to developing interventions to promote parents’ rational, consistent fever

management it is imperative that a comprehensive exploration of parents’ current

practices and the influences on those practices is undertaken. As factors influencing

parents’ fever management practices have been identified as multifactorial the TPB

provides an excellent theoretical basis upon which to explore the predictors of their

intentions. When predictors of intentions have been identified targeted educational

interventions can be developed and trialled to determine their effectiveness in

addressing identified needs.

3.5 SUMMARY Through this chapter the fever management and health educational literature were

examined to identify an appropriate theoretical framework to explore the

determinants of parents’ fever management practices. It was deemed appropriate to

examine the determinants of parents’ intentions as their practices could be situation

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specific. The Theory of Planned Behavior was deemed fitting as this theory purports

behaviour to be predicted by behavioural intention. This theory identifies the salient

(most accessible) beliefs and social influences and also considered perceptions of

control over the behaviour, which could be influenced by a number of factors.

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CHAPTER 4 – METHODS

4.1 INTRODUCTION This chapter describes the research designs, ethical considerations, samples,

instrument development and data collection methods for the two studies undertaken

for this thesis. Data preparation and methods of analysis are also discussed. The first

study, an elicitation study, was guided by Theory of Planned Behavior (TPB)

recommendations to identify the salient or accessible behavioural, normative and

control beliefs under study (Ajzen, 2006a; Francis et al., 2004). In addition to

gathering information about parents’ behavioural, normative and control beliefs in

fever management, data were also collected about parents’ fever management

knowledge, attitudes, practices and methods of searching for information about how

to manage childhood fever to inform survey item development.

The second study, a crossectional survey, was conducted to explore Queensland

parents’ fever management. The survey had three components. The first explored

parents’ knowledge about fever, fever management practices, beliefs about fever and

methods of learning to manage fever. The second targeted parents’ use of

medications in fever management. Finally parents’ intentions to reduce fever were

explored in the third section through the tenets of the TPB. Demographic information

was also collected. Queensland parents of children aged 6-months to 5-years were

targeted for this research because febrile convulsions have been identified in the

literature as parents’ major concern when children are febrile and febrile convulsions

generally occur in children aged between 6-months and 6-years (see Chapter 2). In

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these studies the term ‘medications’ was used to represent antipyretics, over-the-

counter medications that reduce fever.

As no Australian research has been conducted in this area two frameworks were used

to ensure comprehensive, complementary data were collected: a health promotion

needs assessment framework (Ewles & Simnett, 2003) and a theoretical framework

based on the Theory of Planned Behavior (Ajzen, 1985, 1991). A needs assessment

framework ensures comprehensive valid data are collected using multiple data

collection methods (Ewles & Simnett, 2003). The theoretical framework facilitated

the identification of specific predictors of parents’ behavioural intentions to reduce

fever and has been described in detail in Chapter 3. Research based on these

frameworks ensured the studies provided a comprehensive examination of parents’

knowledge, attitudes and fever management practices. When parents’ needs are

identified then educational programs can be developed to address these needs. Then

parents will be equipped to care of febrile children at home. Salient behavioural,

normative and perceived control beliefs in fever management were also identified.

4.2 NEEDS ASSESSMENT Ewles and Simnett’s (Ewles & Simnett, 2003) needs assessment framework drawn

from the work of Bradshaw (Bradshaw, 1972) targets four distinct types of needs:

normative, felt, expressed and comparative. Normative needs are the needs of most

parents in the area and are defined by professionals or experts. These were assessed

during the literature reviewed in Chapter 3. Felt needs are defined by the individuals

themselves. These will be determined through the focused interviews, group

discussions and survey. Parents’ felt fever management needs are shaped by their

circumstances, experiences, knowledge and understanding of fever. Expressed needs,

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those expressed by parents, will initially be identified through the focused interviews

and group discussions and then further explored through the survey. Finally,

comparative needs, comparing differences in needs by age, number of children,

educational attainment and experience in the health industry (education in a health

profession or having worked in a health setting) were explored through the survey

(Ewles & Simnett, 2003).

Based on the literature in Chapter 3 describing parents’ fever management practices

it was determined that a behavioural approach, focusing on the individual with data

collected from the target population, would be appropriate for the needs assessment

(Lawton, 1999). Collecting both qualitative and quantitative data ensures that the

phenomenon discovered by social scientists in relation to self-reported data, public

and private levels of responding, would not influence the findings (Lawton, 1999).

Public level data represents information parents think health professionals might

want to hear. This is often gathered through surveys. Private level data is information

parents would discuss with their family and friends. The inclusion of focused

individual interviews and group discussions ensured private level data were also

collected (Lawton, 1999). Examining both private and public accounts of parents’

beliefs and practices via focused interviews, group discussions and surveys provides

a more accurate and truer account of parents’ knowledge, attitudes, practices,

information gathering activities and fever management intentions. Additionally, an

initial qualitative study allows for exploration of the topic, is recommended by Ajzen

(2006a) to identify salient predictors of intention through the TPB, and ensures the

survey contains relevant, culturally appropriate items modified from previously

developed instruments and developed specifically for Study 2.

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4.3 STUDY AIMS The aims of Study 1 were to explore Queensland parents’ current knowledge of and

beliefs about fever, fever management practices; salient behavioural, normative and

perceived control beliefs; influences on fever management practices and sources of

fever management information. Findings from this study were used to develop

relevant, culturally appropriate questionnaire items and to modify items from

developed instruments for they survey conducted in Study 2.

Aims of Study 2 were to:

1. Identify Queensland parents’ knowledge of and beliefs about fever, fever

management practices and influences on practices.

2. Identify Queensland parents’ knowledge of appropriate medication dosage

and frequency, medication use in fever management and beliefs of harm from

medications used in fever management.

3. Discover where Queensland parents learnt about childhood fever

management and the impact of this on their practices.

4. Identify the predictors of Queensland parents’ intentions to reduce fever

according to the tenets of the TPB.

5. Develop and trial a comprehensive instrument to explore parents’

management of childhood fever and influences on fever management.

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4.4 RESEARCH PLAN The research plan is presented diagrammatically in Figure 4.1.

Figure 4.1: Diagrammatic representation of research methods

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4.4.1 Study 1 – Focused Discussions

4.4.1.1 Study Design Qualitative study using semi-structured focused interviews and group discussions.

4.4.1.2 Rationale The dearth of literature describing Australian parents’ management of childhood

fever and the need to elicit parents’ salient beliefs highlighted the need for an initial

exploratory study. Focused discussions were conducted, with parents of children

aged 6-months to 5-years at a time and place suitable to those indicating an interest

in participating. As all targeted parents had young children discussions therefore

were conducted at a time and in an environment suitable to those interested in

participating. This determined whether interested parents participated in a group

discussion or individual interview. Factors influencing participation in an interview

were a preference to be interviewed when their child was asleep, interviewed at

home so that children could play happily during the interview or at work during

lunch time. Discussions were conducted with natural groups such as a playgroup

meeting, child care centre and workplace. Discussions elicited parents’ salient

behavioural, normative and control beliefs and their knowledge about fever, fever

management practices and how parents learn to manage childhood fever.

4.4.1.3 Semi-Structured Focused Individual Interviews and Group Discussions Semi-structured focused interviews and semi-structured focused group discussions

were conducted using the same topic guide to direct discussions (Millward, 2006).

Both these methods involve participant participation and explanation of the specific

topic and provide insight into sources of complex behaviours and motivations. They

are appropriate to use in areas of limited research (Morgan, 2004) and have become

popular in health research as they produce rich, comprehensive, credible, valid

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information (Morrison-Beedy, Cote-Arsenault, & Fischeck Feinstein, 2001; Polit &

Beck, 2006). In psychological research these methods are commonly used to develop

or operationalise constructs, as a first step in questionnaire development and to test

the viability of a construct (Millward, 2006). A limitation of these methods is that

self-report data are collected. Self report data reflect what participants say not what

they do (Polit & Beck, 2006).

Focused Individual Interviews Focused interviews have been found to generate more data and better quality of data

per participant than group discussions. Interviews place a greater burden on the

participant to explain themselves to the researcher than group settings (Morgan,

2004). During interviews researchers have an opportunity to probe participant

experiences and beliefs in more depth. Additionally, participants may be more

willing to share their experiences in interviews than in a group setting, particularly

on sensitive topics such as their care of their children (Greenbaum, 2000; Morgan,

2004).

Focused Group Discussions During focused group discussions there is greater breadth of data collection (Morgan,

2004), participants are encouraged to query each other and to explain their thinking

(Morgan, 2004). The use of group processes during discussions encourages

participants to explore and clarify their views, ensuring comprehensive data are

collected (Morrison-Beedy et al., 2001). In this study natural groups of people who

knew each other were used. Natural groups are useful when the researcher wants to

understand how participants’ social knowledge about a subject, in this study

childhood fever management, was generated (Green & Thorogood, 2004).

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Two Data Collection Methods: Advantages and Disadvantages An advantage of using two methods to collect qualitative data is the quality

(interviews) and breadth (groups) of data generated (Morgan, 2004). Data collected

by interviews and groups were similar and data collection continued in both methods

until data saturation was achieved (Green & Thorogood, 2004). To confirm

saturation an additional group discussion was conducted. A disadvantage of using

two methods could be reflected in the data quality and breadth, although saturation

was achieved. However, group discussions offset some of the disadvantages of

individual interviews as the interviewer had access to interaction between

participants as well as between the interviewer and participant (Green & Thorogood,

2004).

4.4.1.4 Research Questions Research questions addressed by the focused interviews and group discussions were:

1. What do Queensland parents know about fever in young children?

2. What are Queensland parents’ beliefs about fever in young children?



Through the research questions behavioural, normative and perceived control beliefs

were identified.

4.4.1.5 Sample A convenient sample of Queensland parents of children aged between 6-months and

5-years was targeted to generate appropriate data (Green & Thorogood, 2004).

Parents of children enrolled at metropolitan child care centres and parents registered

with Playgroup Queensland were targeted. Eligibility criteria included being over 18

years of age, able to read and converse in English and being a parent/primary

caregiver for a child aged between 6-months and 5-years.

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4.4.1.6 Settings and Procedures Parents were recruited from two metropolitan child care centres and Playgroup

Queensland. At child care centres a letter of invitation to participate and an

information sheet about the study were given to parents of all children enrolled in the

child care centres. A copy of the Information sheet is available in Appendix 1.

Metropolitan members of Playgroup Queensland were recruited through an invitation

to participate in the Playgroup Queensland monthly online newsletter. A copy of the

invitation is in Appendix 1. Interested parents from child care centres and Playgroup

Queensland contacted the researcher by telephone or email. Parents’ contact details

and availability for group or individual discussion was discussed and arranged. Six

individual interviews and three group discussions were conducted. Both group and

individual discussions were conducted with parents recruited from child care centres

and Playgroup Queensland.

All discussions were audio taped and simultaneously recorded by a data recorder,

experienced in court data recording. A word document of the discussion was sent to

the researcher within two weeks following each discussion. Transcripts were sent to

participating parents through the child care centre director or posted directly to

parents for data checking to ensure transcript accurately reflected parents’

recollection of the discussion. All participants read the transcripts and reported they

represented their recollection of the discussion, beliefs and practices. No additional

information was contributed through this process.

4.4.1.7 Question Guide Semi-structured questions for the individual interviews and group discussions were

guided by an extensive review of the literature, the researcher’s past experience

educating paediatric nurses about evidence-based fever management (Edwards,

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Courtney et al., 2001b, 2003; Edwards, Walsh, et al., 2007, in press; Walsh &

Edwards, 2006; Walsh et a., 2005, 2006) and the constructs of the Theory of Planned

Behavior (Ajzen, 1985, 1991) (TPB). Four main areas were targeted through the

interviews and discussions: parents’ beliefs and concerns about fever, knowledge of

fever management, fever management practices and sources of information about

fever management. Figure 4.2 portrays the semi-structured questions and prompt

questions used for both interviews and group discussions.

4.4.1.6 Ethical Considerations Ethical approval was granted by the Queensland University of Technology Human

Research Ethics Committee prior to the commencement of participant recruitment

for this study. Parents were not pressured to participate as the researcher was an

outsider to the child care centres or Playgroup Queensland and was not in a position

for parents’ non-participation to impact children’s care. When participants contacted

the researcher to indicate interest they were informed about the study, that the

discussion would be audio taped and a data recorder would be attending the

discussion with the researcher. Prior to participating in a discussion, participant

confidentiality and anonymity were assured and written consent obtained. A copy of

the consent form is available in Appendix 1. Transcripts were returned to participants

for data checking to ensure the data accurately reported participants’ perception of

the discussion.

4.4.1.7 Data Analysis Wilkinson (2003) suggests there is no single or preferred method for analysing focus

group data and that data analysis is dependent on the data of interest, the content or

process. In this study the content was of interest. Content analysis, supplemented

with systematic quotations from the interviews to illustrate conclusions, was

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considered an appropriate method for analysing both interviews and group

discussions (Breakwell, 2006; Millward, 2006). As the emphasis of this research was

on the meaning of the content a classification system was initially generated from the

question guide used during data collection (Millward, 2006). Additional conceptual

codes arose during closer examination of the data.

Identifying that child is febrile

• How do you know when your child has a fever?

Beliefs about fever

• What are your thoughts when your child has a fever?

• Do you find you are concerned about the fever?

• Are you worried about the height of the fever?

• Has this changed as your child has grown older – or with successive children?

Managing fever

• How do you manage your child when they have a fever?

• How do you manage the fever?

• What influences your management of fever?

Fever management knowledge

• What do you know about fever?

• Do you think fever has any benefits?

• Do you think fever can be harmful?

Learning to manage fever

• Can you remember where you learnt how to look after a child with a fever?

• What information is needed by parents about fever management and when?

Figure 4.2: Questions used in semi-structured individual interviews and group discussions

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To ensure trustworthiness of the findings Burnard’s (1991) 14 stage content analysis

method was used. Using Burnard’s method transcripts were initially read and re-read

and the researcher became immersed in the data. Emergent headings or categories

were identified and linked to develop a category system. Following this the

researcher and an experienced qualitative researcher independently identified themes,

categories and sub-categories for two transcripts. These were checked and found

consistent. The remaining transcripts were then analysed by the researcher according

to identified themes and categories. Similar themes were collated into a WORD

document under the appropriate headings. It was not possible to involve participants

in checking the category system. They were however, involved in transcript

checking. In the final stages the findings are written up and examples linked together

and to the literature. See Chapter 5.

To ensure data trustworthiness and that comprehensive valid data were collected

multiple interviews and discussions were conducted until data saturation was

achieved and confirmed (Green & Thorogood, 2004; Morgan, 2004). A detailed

interview guide was used for all discussions, verbatim transcripts crosschecked with

the audiotape and transcripts returned to participants to determine data accuracy.

Data trustworthiness was assessed through credibility, dependability, confirmability

and transferability (Polit & Beck, 2006).

1. Data credibility was determined through triangulation and researcher

credibility. Triangulation was achieved by collecting data from multiple

participants and having two researchers independently develop categories and

themes from two transcripts and compare findings (Ploit & Beck, 2006).

Researcher credibility was assured as the researcher collecting and analysing

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the data was experienced in conducting and analysing focused interviews and

group discussions.

2. Dependability was determined through an inquiry audit with two researchers

scrutinising two transcripts as discussed under data credibility.

3. Confirmability was achieved through the development of an audit and

decision trail and inter-rater reliability by the independent coding of two

transcripts by two researchers (Polit & Beck, 2006).

4. Transferability was confirmed through data saturation (achieved after two

group and six interview discussions; a final group discussion confirmed

saturation) in both interviews and group discussions and the thorough

description of the research setting (Morgan, 2004; Polit & Beck, 2006).

4.4.2 Study 2 – Survey

4.4.2.1 Rationale The focused interviews and group discussions identified knowledge of and beliefs

about fever similar to parents internationally (see Chapter 5). However, some

practices and factors influencing practices, behavioural, normative and perceived

control beliefs had not been previously reported (see Chapter 5 and Chapter 7). To

identify the prevalence, distribution and interrelatedness of the interview and group

discussion findings a community based crossectional survey of Queensland parents

of well children was conducted.

Surveys are an appropriate method for gathering population data and are commonly

conducted when descriptive information about populations is unknown. Descriptive

information about a population’s specific knowledge, beliefs, opinions, attitudes,

practices and intentions of performing the specific practice as well as disease status

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and demographics is gathered through surveys (Minicheillo, Sullivan, Greenwood, &

Axford, 2004). Survey data provide a broader understanding of prevalence of a

health issues or factors influencing health behaviour (Minicheillo et al., 2004; Polit

& Beck, 2006). Surveys also assist in identifying the need for further research or

health education about specific health practices (Webster & Osborne, 2005).

Community based crossectional surveys are a quick and economical method of

collecting data from people not seeking health care (Minicheillo et al., 2004).

Through this crossectional survey a description of the knowledge, beliefs, practices

and influences on practices of Queensland parents of well children was gained.

Surveys are traditionally used in research based on the Theory of Planned Behavior

(Ajzen, 2006a) to identify attitudes, subjective norms perceived control and

behavioural intentions.

4.4.2.2 Research Design A postal, self administered, self report, crossectional survey was conducted.

4.4.2.3 Research Questions Research questions addressed by the survey were:

1. What do Queensland parents know about childhood fever?

2. What do Queensland parents believe about childhood fever?


4. How do Queensland parents use medications in fever management?

5. What influences Queensland parents’ medication use in fever management?


7. What predicts Queensland parents’ intentions to reduce childhood fever?

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8. What predicts Queensland parents’ intentions to reduce childhood fever with

medications?

4.4.2.4 Ethical Considerations Ethical approval was granted from the Queensland University of Technology Human

Research Ethics Committee to conduct the pilot and main survey. Parents self-

selected to participate and were free to withdraw at any time. The researcher had no

associated with the recruitment centres. Therefore parents’ participation or non-

participation in the research had no impact on the parents or the care of their

children. Participants were informed about the study through the recruitment

processes and an information sheet attached to the questionnaire. A copy of the

information sheet used in the pilot study is available in Appendix 2 and the main

study in Appendix 2. The information sheet explained that the participant’s

confidentiality and anonymity was assured and return of a completed questionnaire

would indicate consent to participate in the study. Prior to recruiting for the survey

the researcher obtained a Blue Card from the Employment Screening Services Unit

Commission for Children and Young People.

4.4.2.5 Instrument Development Initially an extensive search of the literature using CINAHL, Medline and

PsycArticles and PubMed databases was conducted. Only articles published, in

English, between the years 1980 and 2004 were examined. Databases were searched

for terms such as fever, child, seizure, convulsion, paracetamol, acetaminophen,

ibuprofen, parent, beliefs, temperature and health information and combinations of

these. A number of published articles had survey items included in the article (e.g.,

Abdullah, et al., 1987; Al-Eissa, Al-Sanie et al., 2000; Al-Eissa, Al-Zamil et al.,

2000; Birchley & Conroy, 2002; Blumenthal, 1998; Kapasi et al., 1980; Karwowska,

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et al., 2002; Li, et al., 2000; Sarrell, et al., 2002; Schmitt, 1980). Authors of other

developed instruments were contacted and instruments were obtained from Crocetti

(2001) and Kelly (1996). Items from developed instruments were adapted and other

items were developed from the information gained through Study 1 (Walsh,

Edwards, & Fraser, 2007a), to suit an Australian audience. Ajzen’s website was

explored for information about the development of items to address the tenets of the

Theory of Planned Behavior (TPB). Additional items were developed to target the

constructs of the TPB, namely parents’ beliefs about and attitudes toward fever, the

normative influences on and their perceptions of control over fever management and

fever management intentions. No developed scales targeting parents’ fever

management practices or beliefs were found during the literature search.

A pilot instrument was developed and had three sections. In the first section 14 items

explored parents’ fever management practices, four explored knowledge of fever,

five explored beliefs about fever, 12 recorded medication uses and four gathered

information about where parents learnt to manage fever. In the focused individual

interviews and group discussions parents used the terminology fever, high fever and

very high fever to describe mild, moderate and high fever. Therefore this

terminology was used in the instrument. This instrument is attached in Appendix 2.

In the second section 55 items targeted the tenets of the TPB and Section 3 recorded

demographic information on 21 items. Prior to piloting, the instrument was examined

for content and face validity and response bias by an expert panel consisting of two

clinical paediatric nurses, a paediatric nurse researcher, two nurse academics and a

nurse academic who was also a psychologist and familiar with the TPB (Polit &

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Beck, 2006). The panel confirmed the instrument was valid and items were placed in

a manner that would not cause response bias.

Pilot Test A test-retest study was conducted to determine the reliability of items in the survey

instrument (Polit & Beck, 2006).

Sample A convenient sample of parents was recruited. To be eligible for inclusion in the pilot

study parents were 18 years and older, able to read and write in English and had a

child aged between 6 months and 5 years of age.

Settings and Procedures Parents who participated in Study 1 indicated an interest in participating in the pilot

study. These parents were contacted by phone and if still interested in participating

were informed about the pilot study and their potential involvement. Additionally

paediatric nurses and nurse academics known to the researcher who met the

eligibility criteria were approached to determine interest in participating. Interested

parents were posted a survey package containing a letter describing the pilot study

and their potential involvement, a plain language statement about the research, a

questionnaire, a survey evaluation form and a reply paid envelope. These documents

are available in Appendix 2. The evaluation form was included to determine the

instrument’s readability, ease of completion and clarity of questions. Two weeks

following return of the first questionnaire a second identical questionnaire and reply

paid envelope were sent to participating parents. When questionnaires were not

returned within two weeks the researcher contacted the participant to enquire about

their interest in continued participation.

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Data Analysis Initially qualitative data were coded. All data were then entered into SPSS version 13

(SPSS, 2004) searched for outliers and irregularities and 25% of data rechecked for

data entry errors. No errors were detected. Item reliability on categorical items was

determined by Cohen’s Kappa and on continuous items by Bland Altman analysis.

Cohen’s Kappa is an appropriate measure of reliability or stability for nominal data,

the closer a score is to 1.0 the greater the item reliability and stability (Minicheillo et

al., 2004). Cohen’s Kappa takes into account the problem of chance responding, a

person responding in a particular manner by chance. Bland Altman analysis

compares two continuous measures (temperature in this study) by plotting the

differences between the two measures against the averages of the two measures

(Bland & Altman, 1986). Measures falling within limits of agreement (mean

difference ± 2SD) are considered reliable.

Results Nine parents participated in the test-retest study and included two clinical paediatric

nurses, a nurse academic and six parents from the semi-structured discussion study

(Walsh et al., 2007a). All participants were female. Their mean age was 34.4 years

(SD 11.1), most were in a partnered relationship (88.9%), had two children (66.7%),

an undergraduate or postgraduate degree (22.2% and 55.6% respectively), experience

in a health industry (66.7%, this includes education in a health profession or worked

in a health setting), were employed part-time (55.6%) and born in Australia (77.8%).

Feedback from participants indicated the instructions preceding each section were

clear, sufficient response space had been allocated to open-ended items and all but

one item was easily understood. In the final instrument the confusing item “How

harmful do you believe fever is” was preceded by a lead item “Can fever ever be

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harmful”. Additionally, an item was included to explore decision making in seeking

medical assistance and another reporting examples of the conflicting information

they had received, if they reported receiving conflicting information.

Test-retest (2-weeks) reliability of categorical data, determined by Kappa analysis,

ranged from 0.55 (on one item) to 1.00. Bland Altman analysis on continuous items

indicated responses for temperature representative of normal temperature, high, very

high and harmful fever temperatures when antipyretics were administered and items

targeting fever management practices were within the limits of agreement (mean

difference ± 2SD). One respondent’s responses on temperature for fever were outside

the limits of agreement (Bland & Altman, 1986). The questionnaire was deemed

suitable for use in the main study.

Final Instrument Following some minor adjustments to the pilot instrument the final instrument

consisted of 103 items in three sections. Section 1 included items targeting parents’:

o knowledge of temperature perceived to represent normal, fever, high and very

high fever (four items),

o beliefs about fever (six items) and beliefs about fever management

knowledge (one item),

o general fever management practices and practice changes over time (18

items),

o sources of fever management information (five items)

o medication administration (eight items),

o influences on medication administration (seven items) and

o beliefs about medication safety (two items).

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Section 2 targeted parents’:

o beliefs about fever being harmful (20 items) and outcome expectations of

those beliefs (20 items),

o normative beliefs about fever (eight items) and motivation to comply with

referents (four items),

o perceived behavioural control in fever management decision making (four

items), perceived behavioural control influenced by child medication

behaviour (whether febrile children were compliant or non-compliant with

medication administration) (four items) and

o intentions to reduce their child’s next fever (three items) and intentions to

reduce their child’s next fever with medications (three items).

In Section 3 22 items recorded demographic information about the participant, their

children, partner and sources of assistance in deciding on fever management. Table

4.1 presents an example of how constructs in Section 1 were developed to items. The

full instrument is available in Appendix 2.

As this was an exploratory study many items in Section 1 collected qualitative or

categorical data. Eight items exploring fever management practices were specifically

developed to create a parents’ fever management practice scale. Responses to these

items were recoded on Likert scales. This scale addressed a gap in the literature as no

developed scales had been found during the literature review to explore parents’

fever management knowledge, beliefs or practices.

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4.4.2.6 Survey Design A postal, self administered, self report crossectional study was conducted with

Queensland parents of children aged between 6-monhts and 5-years.

Sample A convenient sample of Queensland parents were targeted to participate in the

survey. Recruitment was conducted over a three-month period during February,

March and April 2005 and continued until the target of at least 384 participants had

been recruited. Parents were recruited through child care centres, kindergartens and

preschools, Playgroup Queensland online newsletter and quarterly magazine, Family

Day Care – Queensland and the monthly parenting magazines ‘Brisbane’s Child’ and

‘Mother and Child’ available freely to parents in the metropolitan and outer

metropolitan areas. To be eligible for inclusion in the study parents had to be 18

years and older, able to read and write in English and had a child aged between 6

months and 5 years of age.

Sample Size The sample size for the present survey was calculated by estimating the population

proportion with specified absolute precision (Lwanga & Lemeshow, 1991 p1,2,25).

Two key items used by Sarrell et al. (2002) in their sample size calculations a) the

temperature at which parents considered a child had a fever and b) the temperature at

which parents administered antipyretics were considered. A study conducted in Saudi

Arabia reported 46% of 560 parents believed fever to be a temperature between

37.0°C and 38.0°C (Al-Eissa, Al-Sanie et al. 2000). In a similar United Kingdom

study, Blumenthal (1998) reported 49% of 392 parents believed a temperature of

38.0°C to indicate fever. Eighty eight percent of the 392 parents studied by

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Blumenthal (1998) administered antipyretics for temperatures of 38.0°C or lower, as

did 78% of 650 parents in an Israeli study by Linder et al. (1999).

The following sample estimates were calculated using Lwanga and Lemeshow’s

estimating the population proportion with specified absolute precision (1991,

p1,2,25). If the true percentage of parents who consider temperatures of 38°C or less

to be fever is 50% with a relative precision of 45% at the 95% level of significance

and power of 90% a minimum number of 384 parents are needed. For a true

percentage of parents who administer antipyretics to children with temperatures of

38.0°C or lower of 90% with a relative precision of 85% at the 95% level of

significance and power of 90%, 138 parents are required to participate in the survey.

Therefore, a sample of 384 parents was the target sample size for the study.

Advertising Advertising was conducted through child care centres, kindergartens and preschools,

Playgroup Queensland, Family Day Care service and parenting magazines.

1) Contact was made with directors of privately owned child care centres and

kindergartens in the metropolitan and outer metropolitan area. Seven child care

centres or kindergartens and preschools agreed to advertise the study. Posters were

placed strategically around these centres and a letter describing the survey’s

rationale, parents’ potential involvement and researcher contacts was distributed to

all parents with children enrolled at the centre. One child care centre advertised the

survey in their weekly email newsletter and distributed the survey to all parents as an

attachment to a weekly newsletter. Interestingly this method had the lowest response

rate.

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Table 4.1: Example of instrument items, sources and mode of data collection

Construct Concept Items No. of Items Source Adapted Item Mode

Knowledge Temperature Fever, high fever, very

high fever

3 Crocetti 2001

Kramer et al. 1985

Schmitt 1980

Walsh et al. 2007

VASa

Beliefs Fever is harmful Fever is harmful 1 Kelly et al. 1996 Categorical

Temperature fever harmful 1 Kelly et al. 1996

Kramer et al. 1985

Interval scale

Degree of harm 1 Walsh et al. 2007 Likert scale

Medication Medication use Temperature Medications

used

2 Schmitt 1980

Abdullah et al 1987

Interval scale

Categorical

Dosage, frequency 2 Li et al. 2001 Categorical

Alternating

medications

Frequency of alternating 4 Crocetti et al. 2001

Walsh & Edwards 2007

Categorical

Open-ended a Visual analogue scale (VAS)

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2) Parents registered with Playgroup Queensland were informed of the survey

via the Playgroup Queensland online monthly newsletter during February, March and

April 2005 and the first quarterly magazine for 2005, distributed during February.

3) Advertisements were placed in ‘Brisbane’s Child’ during February, March

and April 2005 and ‘Woman and Child’ during March and April 2005 to alert parents

in the metropolitan and outer metropolitan area of the research.

4) Parents registered with Family Day Care Queensland were recruited through

the 80 Family Day Care centres throughout Queensland. Posters and informational

letters were sent to the centres who forwarded them to individual registered carers.

Carers then alerted parents to the study.

Interested parents, responding to advertising, contacted the researcher by phone

(49.6%) or email (50.4%). When contact was made the researcher, using a prepared

script, recorded contact details including telephone, email (if applicable) and postal

address. A survey package including a letter of introduction from the researcher,

plain language statement, survey and reply paid envelope were posted to each

interested parent. Examples of these are available in Appendix 2. Reminders letters

or emails were sent one month following the survey when a completed questionnaire

had not been returned (see Appendix 2).

Face-to-face Four child care centres or kindergartens and preschools agreed to participate in face-

to-face recruitment for the survey. Following negotiation with the director

recruitment dates were arranged, posters advertising the survey and recruitment days

were placed strategically in the centres. Additionally, a letter describing the survey

rationale, potential involvement and recruitment days was sent to the parents of each

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child enrolled in the centre. The researcher approached eligible parents at the agreed

times, introduced herself and the research and asked parents if they are interested in

participating. Interested parents were given a package containing a plain language

statement about the research; a questionnaire and an envelope (see Appendix 2).

Parents were asked to complete the questionnaire within a week and return it to a

sealed box in the director’s office. The researcher collected completed surveys for a

three week period following recruitment.

Snowball Methods Snowball recruitment was through researcher and participant contacts who recruited

parents within their social networks to the study. Survey packages were posted to and

distributed by the contacts and completed surveys returned to the researcher by mail.

Overall 401 parents were recruited through 1) advertising in parenting magazines

(92.4% returned); 2) face-to-face in childcare centres, kindergartens (60.0%

returned); and 3) snowball technique (57.3% returned). The overall response rate was

69%. See Table 4.2 for survey distribution and response rates.

Data Analysis – Sections 1 and 3 Prior to data entry responses to open-ended items were coded. Data were entered

twice into SPSS Version 13 (SPSS, 2004) and crosschecked for entry errors using

SPSS Data Entry Builder 4.0 software (SPSS, 1996-2003). Identified inconsistencies

were checked with raw data and corrected. Demographics were examined for

frequency and distribution. Categorical data were explored for frequency; the interval

scale for distribution, normality and outliers. Temperatures, recorded on six scales,

were checked for distribution normality and outliers. One extreme outlier, a report of

the temperature at which fever could be harmful (100ºC), was removed.

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Temperatures were normally distributed. Open-ended responses were collated using

the multiple response analysis in SPSS. Categorical and open-ended responses were

then explored for frequency and percentage of responses. Items developed to form a

scale were then psychometrically tested. Scale development of the TPB behavioural,

normative and perceived control beliefs is presented in Chapter 7 with the data

analysis method, results and discussion of findings from the TPB data.

Table 4.2: Survey distribution and return according to recruitment methods

Distributed N = 585 Returned N = 401 Recruitment method n % n %

Advertising 210 35.9 194 48.4

Childcare, Kindergarten,

Preschool 204 34.9 106 26.4

Snowball 171 29.2 98 24.4

Unknown 3 0.8

Parent Fever Management Scale (PFM) Development The eight items developed to evaluate parents’ fever management practices,

measured on 5-point Likert scales, were recoded prior to analysis to ensure a higher

score indicated a more frequent practice (1 = never, 3 = sometimes, 5 = always).

Factor analysis using principal component extraction was conducted. Subject to item

ratio was 1:50. Following examination of the scree plot, prior conceptual beliefs and

the underlying dimension of parents’ fever management practices (Green & Salkind,

2005) a one factor solution with an eigenvalue of 2.615 was selected. One item

“When my child has a fever I generally make sure they have plenty to drink” with

correlations less than 0.17 across all items and communality extraction of 0.52 was

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removed. The analysis was rerun and varimax rotation performed. A more

meaningful pattern was found in the non-rotated version (KMO=0.61, Bartlett’s

Specificity Approximate Chi Square 1162.642, df 28, p<0.01) which explained

36.9% of the variance. The scale, with a Cronbach’s Alpha of 0.70, was named

Parent Fever Management scale (PFM). Alpha levels of 0.70 are acceptable for a

new instrument (Nolan & Mock, 2000). Means, standard deviations and total PFM

scores, calculated by summation of each individual’s score for the set of items, were

explored. Table 4.3 reports the items included in the PFM scale. Test-retest reliability

by Bland Altman analysis confirmed scale items were reliable as scores were within

the limits of agreement (mean difference ± 2SD) (Bland & Altman, 1986).

Table 4.3: Parent Fever Management scale (PFM) a; N = 401; α = 0.70

When my child has a fever I generally Communalities Unrotated Principal

Component Meanb SD

Check on them during the night 0.224 0.473 4.56 0.73

Like to know what their temperature is 0.521 0.722 4.35 1.00

Take their temperature 0.505 0.710 4.34 1.05

Use over the counter medication to

reduce fever

0.294 0.542 4.16 0.97

Sleep in the same room as them 0.178 0.421 3.00 1.33

Take them to the doctor 0.368 0.607 3.15 0.87

Wake them up during the night for

medications to reduce fever

0.494 0.703 2.53 1.23

a PFM scale mean 15.89, SD 4.33, range 7 to 31, potential range 0 to 35 b 1 = never, 2 = rarely, 3 = sometimes, 4 = mostly, 5 = always Data Analysis – Section 2 Preparation of data for analysis according to the Theory of Planned Behavior is

addressed in Chapter 7 prior to discussion of the findings from this section of the

survey.

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4.5 SUMMARY This chapter has described the research plan, aims and research questions each study

addresses. Rationales for undertaking the two studies and study designs are discussed

along with the samples, settings and procedures and the development of questions

and instruments used to conduct the studies. Ethical considerations necessary before

conducting the studies and methods of analysing the data analyses were also

described. The next chapter contains an article describing the semi-structured

individual interviews and group discussions.

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CHAPTER 5 – STUDY 1

FOCUSED DISCUSSIONS

This chapter reports the findings from the qualitative study, undertaken in Study 1, to

determine Queensland parents’ current knowledge of and beliefs about fever, fever

management practices and methods of learning how to manage fever.

Influences on Parents' Fever Management: Beliefs, Experiences and Information Sources Walsh, A., Edwards, H. & Fraser, J. (2007). Influences on parents' fever

management: beliefs, experiences and information sources. Journal of Clinical

Nursing, doi: 10.1111/j.1365-2702.2006.01890.x. Journal Impact Factor: 1.430

Journal of Clinical Nursing 16(12): 2331-2340 (c)2007 Blackwell Publishing

Abstract Aims. Identify parents’ knowledge, beliefs, management and sources of information

about fever management.

Background. Despite numerous studies exploring parents’ management of

childhood fever, negative beliefs about fever and overuse of antipyretics and health

services for mild fevers and self-limiting viral illnesses continue to be reported.

Design. Qualitative design using semi-structured interviews and discussions.

Method. Fifteen metropolitan parents of children aged 6-months to 5-years self-

selected to participate in individual interviews or group discussions. Recruitment was

through Playgroup Queensland’s online newsletter and letters to all parents from two

childcare centres. Verbatim and audio data were collected by an experienced

moderator using a semi-structured interview guide.

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Data analysis: two transcripts were independently analysed by two researchers,

categories, sub-headings and codes were independently developed, crosschecked and

found comparable. Remaining transcripts were analysed using developed categories

and codes.

Findings. Fever, determined through behavioural changes, was perceived as ‘good’,

a warning something was wrong. High fever, reported as 38.0ºC to 39.1ºC, was

considered harmful; it must be prevented or reduced irrespective of concerns about

antipyretics. Positive febrile experiences reduced concern about fever. Negative

experiences such as febrile convulsions, media reports of harm, not receiving a

definitive diagnosis, inaccessibility to regular doctors and receiving conflicting

information about fever management increased concerns. Parents seek information

about fever from multiple sources such as doctors, books and other parents.

Conclusions. Parents’ experiences with and information sources about fever and

fever management influenced their knowledge, beliefs and practices. Positive

experiences reduce concerns, health service usage and sometimes antipyretic usage.

Negative experiences increase concerns, monitoring and antipyretic and health

service usage.

Relevance to clinical practice. Health professionals need to update their fever

management knowledge ensuring it is based on the latest scientific knowledge. They

must provide parents of young children with consistent, reliable information

preferably before their first child’s first febrile episode.

5.1 INTRODUCTION In 1980 Barton Schmitt (1980) coined the term ‘fever phobia’ to describe parents’

unrealistic concerns about childhood fever. Despite nearly three decades of education

and research parents’ concerns about and fever management practices remain

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virtually unchanged (Crocetti et al. 2001). Most studies focus on parents of febrile or

injured children; their knowledge, beliefs, practices and demographic predictors of

these (e.g. Ames et al. 1982, Impicciatore et al. 1998, McErlean et al, 2001). Reports

of factors influencing knowledge, beliefs and practices are scarce as is research on

parents of well children. For health professionals, particularly those working in well-

child clinics, this study provides a comprehensive assessment of fever management

practices useful for assisting parents make health related decisions for their children.

5.1.1 Literature review Numerous quantitative studies have described the knowledge, beliefs and practices

of parents with febrile or injured children seeking medical assistance from accident

and emergency departments, hospitals or community based clinics (e.g. Blumenthal

1998, Al-Eissa et al. 2000, Sarrell et al. 2002). Temperatures of 38.0ºC and below

continue to be considered representative of fever (e.g. Blumenthal et al., 1998,

Sarrell et al. 2002). Beliefs that fever is harmful causing febrile convulsions and

brain damage abound (e.g., Schmitt, 1980, Al-Eissa et al. 2000; Karwowska et al

.2002;). Antipyretic administration as the preferred method of reducing fever has

increased from 67% in 1980 (Schmitt 1980) to 95% in 2002 (Karwowska et al.

2002). Similarly, overdosing with antipyretics increased from 12% in 1987 (Kilmon

1987) to 33% in 1999 (Linder et al. 1999). Alternating antipyretics, a potentially

unsafe practice reported since 2000, increases the opportunity for overdosing with

either or both antipyretics (Mayoral et al. 2000, Carson 2003). However, the use of

cold/ice-cold sponging/bathing, alcohol rubs and Aspirin have reduced significantly

(Drwal-Klein & Phelps 1992, Cranswick & Coghlan 2000, Karwowska et al. 2002).

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Qualitative studies are few and report parental concerns, difficulties and practices

and factors influencing these (Kai, 1996a,b, Lagerlov et al. 2003). Kai (1996a,b)

concluded practices were influenced by the parenting role; to protect children from

suffering and harm. Childhood illnesses disempower parents. Monitoring

temperatures and reducing fevers with antipyretics gives a feeling of mastery and

medical assistance is sought for reassurance (Kai, 1996a,b, Lagerlov et al. 2003).

Fever legitimises the use of antipyretics; they calm the child allowing family

members to get some sleep (Lagerlov et al. 2003).

These studies provide a broad picture of parental fever management practices but

little insight into the reasons behind them. Data are needed to assist community-

based health professionals positively influence parents’ health decisions. Identifying

the knowledge, beliefs, practices of, and influencing factors on, parents of well

children’s practices enables health professionals target these parents’ education

toward reducing deficits and negative influences and reinforcing positive influences.

Learning to manage fever at a non-threatening time, when their child is well, would

assist the reduction of parents’ mismanagement of fever.

5.1.2 Aims The aim of the study was to investigate influences on fever management practices of

parents of well children aged between 6-months and 5-years. More specifically,

parents’ knowledge and beliefs about fever and fever management, methods of

managing fever, mode of learning to manage fever and the influences of these on

knowledge, beliefs and practices were explored.

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5.2 METHOD

5.2.1 Design A qualitative study using semi-structured discussions with individuals and groups

was undertaken to explore parents of well children’s fever management, gain an

understanding of their thinking and generate new knowledge (Minicheillo et al.

2004). Both methods involve participant explanation, provide insight into sources of

complex behaviours and motivations and are appropriate in areas of limited research

(Morgan 2004). Interview dynamics place a burden on interviewees to explain

themselves to the interviewer; in group discussions group members query each other

and explain themselves to each other (Morgan 2004).

Ethical approval was obtained from the university human research ethics committee.

Voluntary participation was by informed written consent with assurances of

confidentiality and anonymity.

5.2.2 Sample A purposive convenience sample of 15 metropolitan parents self selected to

participate. Eligibility criteria included aged 18 years or older, able to read and

converse in English and being a parent and primary caregiver for a child aged

between 6-months and 5-years. All participants were female, married (86.7%) and

aged between 29 and 42 years (mean 34.1, SD 3.63). Most were the primary

caregiver of two or more children (66.7%). They majority had either a university

degree (53.3%) or Technical And Further Education (TAFE) certificate (40%) and

were employed (93.3%) predominantly part-time (86.7%).

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5.2.3 Focused Questions Semi-structured questions were developed from an extensive review of the literature

and the author’s past experience in fever management research ( Edwards et al.

2001b, 2003; Walsh et al. 2005, 2006). Four areas were targeted: parents’ knowledge

and beliefs about fever, method of fever management and sources of information

about fever management. Questions are displayed in Table 1.

5.2.4 Recruitment and Procedure An advertisement in Playgroup Queensland’s monthly online newsletter and letters

distributed to parents of children enrolled at two Childcare centres resulted in

recruitment of five parents from each area. Interested parents contacted the

researcher and discussion mode (group or interview) was determined by parent’s

employment and parenting responsibilities. Six interviews and three group

discussions were conducted in naturalistic settings (home, office, childcare centre)

(Green & Thorogood 2004). Both interviews and discussions were conducted with

parents recruited from Playgroup Queensland or Childcare Centres.

To ensure data comparability, data collection was conducted by one moderator,

experienced in group discussions and interviewing. All discussions were facilitated

by the use a semi-structured interview guide finalised following an initial exploratory

interview (Morgan 2004). See Table 1. Predetermined prompt questions stimulated

discussion when necessary. Data saturation was reached after two group and six

interview discussions. A final group discussion with five parents confirmed

saturation. The moderator ensured equality in group participant’s involvement.

Group discussions were between 50 and 90 minutes, interviews 20 to 30 minutes.

Natural groups were used with participants acquainted through work or childcare

connections (Green & Thorogood 2004). Data reliability was ensured through

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verbatim and audio recording by a data reporter, used previously by the moderator.

Transcripts were checked with audio recordings and minimal errors, mainly medical

terms, corrected. Transcripts were forwarded to participants for content checking.

Ten participants returned transcripts and were satisfied it reflected the discussion.

Table 5.1: Questions used in semi-structured discussions

Identifying that child is febrile

• How do you know when your child has a fever?

Beliefs about fever

• What are your thoughts when your child has a fever?

• Do you find you are concerned about the fever?

• Are you worried about the height of the fever?

• Has this changed as your child has grown older – or with successive children?

Managing fever

• How do you manage your child when they have a fever?

• How do you manage the fever?

• What influences your management of fever?

Fever management knowledge

• What do you know about fever?

• Do you think fever has any benefits?

• Do you think fever can be harmful?

Learning to manage fever

• Can you remember where you learnt how to look after a child with a fever?

• What information is needed by parents about fever management and when?

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5.2.5 Data Analysis To ensure data trustworthiness and that comprehensive valid data were

collected multiple discussions were conducted until data saturation was

achieved and confirmed (Morgan 2004). Data were analysed thematically in

accordance with Burnard’s (1991) 14 stage method. Emergent themes were

then linked to develop a category system. The first author and an experienced

qualitative researcher independently identified themes, categories and sub-

categories for two transcripts. These were checked and deemed to be

consistent. Remaining transcripts were analysed by the first author according

to identified themes and categories.

5.3 FINDINGS Findings will be discussed according to the six themes: my child has a fever; fever is

beneficial, high fever is harmful, influencing factors, managing fever and learning to

manage fever.

5.3.1 My Child has a Fever Parents associate specific changes in their child’s normal behaviour with fever.

These include lethargy, agitation or restlessness, irritability, listlessness, withdrawal,

wanting to be comforted or stay close to a parent, refusing food, babbling in a

feverish manner or becoming very quiet verbally. Not sleeping well, pulling at the

ears or flushed cheeks were also reported as signs of fever. Children able to

communicate verbally tell parents they feel unwell. These behaviours cause parents

to touch their child to see if they are ‘hot’, indicating a fever.

P9. With my kids it is that they don't have the energy, usually that's the first sign.

They get a bit whiny. They won't eat and you go to give them breakfast or something

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to eat and they won't eat. They just are clingy, my daughter is ‘Velcro’…hanging off

your body.

5.3.2 Fever is Beneficial Fever was considered a warning signal, alerting parents that something was wrong

with their child’s body. This was considered to be ‘good’. Some thought fever was

part of the body’s defence mechanism for combating invading organisms. Most were

unaware of immunological benefits associated with fever; those who were had learnt

from health professionals. Knowledge of temperature representative of fever was

poor, ranging from 37.5ºC to 39.1ºC (mean 38.1ºC, SD 0.5). Parents believed

temperatures would continue to rise if they were not actively reduced; there was no

ceiling for temperatures resulting from infection. The discussion below highlights

that although fever is beneficial there is concern about the height of the fever.

P12. My doctor has told me that fever is good. He said "Don't panic about fever;

that is your body is trying to fight whatever is going on in there." Even though it is

bad, it is good. It is trying to get it (the infection) out of the system.

P15. I think it is good. It is the natural way of trying to confront or work over the

virus.

P14. If it is natural and I am only asking a question here - if it is natural, how come

we give Panadol (paracetamol) to take it down then? Do you see what I am saying?

P15. Yes.

P13. I might be able to answer that one. From where I stand, the reason I give

them the Nurofen (ibuprofen), Panadol or whatever when they have their

temperature is because the temperature gets to the level that I don't feel comfortable

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with. I start thinking of potential fitting or the fact that you know their head is going

to explode or ---

P14. They could end up with brain damage.

P13. And so to that extreme, that's why, because the temperature and all the rest is

good, I ignore it and that's just my way of doing things. That's not to say they are not

scary. Temperatures are scary. Temperatures can be very scary.

5.3.3 High Fever is Harmful Harm from high fever included febrile convulsions, death, dehydration, a stroke and

cardiac problems. Most parents indicated high fever, ranging from 38.0ºC to 39.1ºC

was harmful. All believed temperatures of 40.0ºC and over harmful. To prevent harm

high fever must be prevented, controlled and reduced. Children were monitored

closely and antipyretics administered when temperatures did not reduce or continued

to rise. Medical assistance was sought for temperatures unable to be reduced,

recurrent and high fevers. In an attempt to prevent harm advice was sought from the

family general practitioner (GP) prior to a weekend or public holiday, if a child

remained febrile for more than one day, became listless or lethargic or there was a

probability of dehydration.

P7. 39 something, 40… I would be concerned if I couldn't get that fever down, that

whole seizure thing, whether that would cause some sort of brain damage, something

with the brain.

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5.3.4 Influencing Factors Factors reducing and increasing concerns about fever were reported.

5.3.4.1 Positive Factors Reduce Concern Most parents reported their concerns reduced over time as they learnt to identify

illness behaviours and differentiate between serious and minor self-limiting illness.

High temperatures unrelated to illness behaviours were not as worrying.

P1. It’s quite different now from the first new baby I think. It really does change

after you have had the second one, I think. Now I don’t worry so much. If you had

spoken to me in the first six months of my first child, my responses would have been

quite different.

Behaviours associated with specific illnesses (e.g., tonsillitis and otitis media) were

learned through consultations with health professionals. Receiving definitive

diagnoses and consistent medical advice increases parents’ confidence in their GP.

Parents receiving reassurance of their ability to judge illness severity, use appropriate

fever management practices and determine when medical assistance is necessary feel

confident in their own abilities to manage childhood fevers appropriately.

P6. But because they were so young I went to the GP more for reassurance more

than anything, more to see what I was planning on doing, for reassurance. So I

received that reassurance.

Parnets believed that immunised children were unlikely to contract serious illnesses

and that older children are stronger and less likely to convulse. Parents can

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communicate with verbal children. Learning appropriate antipyretic dosage and

frequency and that antipyretics can be alternated increases perceptions of control

over fever, reducing concerns. Medication information was gathered from

medication labels, health professionals and pharmacists.

P2. The real beauty was you can give Panadol and Nurofen. Because they are two

different types of medication they won't overdose. You can only give Panadol four or

six hourly, he would be all right for two hours, then – up again, whereas if you gave

him Nurofen you could manage it pretty much the whole time without him spiking.

That was really useful information and I didn't know that to start with.

5.3.4.2 Negative Factors Increase Concern High Temperatures The first childhood fever, fever in babies, the firstborn and very young children were

reported as very worrying. Temperatures that rose rapidly or were not reduced by

antipyretics and fevers persisting for two or more days increased concerns for all

parents. In addition to temperature, rashes, high fevers associated with lethargy or

listlessness, potential serious illnesses and febrile convulsions added to parental

concern.

P7. …if they got really sort of quiet, listless kind of, couldn't rouse them or they

seemed a bit strange. If they were like that and they have high fever then I would be

worried.

Fear of Serious Illness External influences such as media reports, conflicting perceptions of illness severity

between GP and parent and when GPs do not give a definitive diagnosis increase

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parents’ concerns. Media reports reinforce beliefs that fever is harmful and indicates

a serious illness. Reports of children seriously ill with meningococcal disease, rapid

deterioration of a febrile child with dire consequences and negative outcomes

following misdiagnosis increase concerns.

P7. Meningococcal, like every other mother, because you see all these things on

Today Tonight and A Current Affair (national current affair shows) like that because

I suppose, right or wrong, they have kind of honed in that message, that you

probably don't always have a lot of time.

When a definitive diagnosis is not found, parents are told ‘ít’s a virus´, or parental

concern and belief in illness severity is not reflected by the GP then parents become

increasingly concerned and their confidence in the GP reduces. Dissatisfied parents

sometimes sought a second or even third opinion from another GP or paediatric

emergency department. Receiving a different diagnosis or recommended treatment

from another GP can reduce parents’ confidence in GPs and increase their use of

emergency departments.

P9. "It's just a virus." I think how can you just look at them and say "It's just a

virus." How do you know it's not meningitis?

P14. I took him to the doctor and I expressed my concern and they said everything

was all right and I walked out, knowing he wasn't all right, and he ended up in

hospital that night for a week and a half so I just don't have a lot of faith in doctors.

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Inaccessible family GPs on weekends or public holidays increase concerns about

their child deteriorating; this causes some to seek medical advice earlier than usual.

Others wait until their GP is available and worry about their child in the interim.

Some seek advice from an emergency department.

P5. If it is coming up to a weekend, I won't let her go for the, say if it is Friday I

won't let it go for the weekend. I will get it checked in case its something like a sore

throat, ears or coming down with a virus. It is reassurance for yourself.

Inconsistent Information Conflicting information about how to manage fever increased concerns, especially

when the information came from sources considered reliable and trustworthy, e.g., a

child health help-line, pharmacist, GP or emergency department. Conflicting GP

information included definitions of fever (38.0°C to 40.0°C), fever is beneficial – not

harmful versus administer antipyretics every four hours febrile children.

Misinformation from other parents included febrile convulsions at 38.0ºC;

temperatures of 39.0ºC – 40.0°C cause febrile convulsions with resulting brain

damage. When this occurs worried, anxious parents still need to decide how to

manage the fever; where to go for information, who to trust.

P3 … one doctor will tell you something different to the nurse or tell you something

different to the chemist. That sort of does make it a bit hard sometimes.

Parental Protective Role - Protecting from Harm All parents believed fever could precipitate a febrile convulsion. They had incorrect

knowledge of risk factors for febrile convulsions learnt from, e.g., mothers groups,

child health books. Parents reported a strong need to control and reduce fever to

protect children from the harm associated with fever.

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P5. My immediate thought is basically to control the fever so they don't end up

having febrile convulsions or something like that.

Although antipyretics were used to reduce fever and thereby protect from harm some

had concerns about antipyretics. Concerns were expressed about medication dosages,

the possibility of overdosing and the safe length of time to use antipyretics, e.g., five

days for a young child. Conflicting beliefs make fever management difficult; beliefs

that fever must be controlled and reduced conflict with beliefs that antipyretics have

harmful side effects. However, beliefs about the harmfulness of fever were stronger

and antipyretics were used to reduce fevers. Media reports of accidental paracetamol

overdosing contributed to this dilemma. However, by alternating antipyretics parents

were able to reduce high fevers reducing this concern. Alternating antipyretics was

considered a safe practice; fever was reduced and overdosing with one antipyretic

prevented.

P2. I worry about what effect the drugs have on them. I do try not to use them but

you have to. The flipside of that is that I worry about whether it gets too high. If that

is going to happen there are those two concerns, kind of balancing each other out.

Negative events associated with fever increase perceptions of harm causing parental

guilt. Parents assumed responsibility for delaying seeking medical assistance for

illnesses believed inconsequential, e.g., tonsillitis diagnosed as glandular fever, and

precipitating a febrile convulsion by tepid bathing a febrile child (40°C). Children of

three parents (20%) had a febrile convulsion increasing antipyretic use and the belief

fever is harmful. One parent introduced a safe guard mechanism to prevent continued

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accidental overdosing with antipyretics by recording medication administration

during febrile episodes.

P9. We write it on the notice board now because there were two times when I had

given it to her and half an hour later he had.

Antipyretics are believed to reduce temperatures and therefore prevent febrile

convulsions. Following a febrile convulsion, parents administered antipyretics as

soon as they were aware a child was febrile. Only one parent, when the child did not

have a recurrent febrile convulsion, returned to pre-febrile convulsion management

using non-pharmacological methods first. Others continued to reduce all fevers with

antipyretics.

P9. Antipyretics at 38 and a half probably! I don't let it go too high. My daughter

had a fit once from a high temperature and I was quite frightened by that so I don't

usually let it hang around for too long.

5.3.5 Learning to Manage Fever Parents reported learning about fever and its management from child health books,

doctors, child health nurses and help lines, hospitals, emergency departments,

professional education, biology or physiology lectures at school or university, other

mothers, own mother, sisters, friends with children and pharmacists. Information

from health professionals was most trusted. The Internet was not generally a source

of child health information. The accuracy of information and reliable sites was

questioned. Books or a phone call are easier information sources, than the Internet,

with a child is febrile.

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P3 We had phone calls to Mum, we had phone calls to the child health people, visits

to the chemist, to see what they thought down at the chemist. We were at the doctor's

once. The doctor said "It will be gone in 24 hours." Finally, the second doctor's was

after the hospital visit.

5.3.6 Managing Fever Fever management includes identifying the cause for the fever and symptoms

necessitating medical intervention. They are controlled or reduced by both non-

pharmacological and pharmacological methods. Children able to communicate

verbally were asked how they felt. Most parents used non-pharmacological methods

initially. These included removing additional clothing, monitoring to ensure the child

did not get chilled, cold drinks or ice blocks and cool/tepid cloths or baths. During

hot tropical summers environmental cooling included opening windows, using fans

and air-conditioners. Most offered fluids although some report febrile children were

reluctant to drink. Comforting the child, monitoring behaviour and encouraging rest

were reported by some.

Antipyretics were the first line of treatment for some irrespective of temperature.

Others used them when non-pharmacological methods were ineffective. Additional

methods are incorporated when temperatures were not reduced sufficiently within 30

minutes to two hours following an antipyretic. These included additional non-

pharmacological methods or an alternate antipyretic was administered. Some

preferred a specific antipyretic, for example ibuprofen; others avoided ibuprofen

because of side effects, gastrointestinal bleeding and triggering asthma. Antipyretic

administration ranged from one dose, regular doses of the same antipyretic and

alternating antipyretics. Antipyretics were administered for temperatures ranging

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from 37.0°C to 40.0°C (mean 38.3°C, SD 0.78°C) and for pain. All parents had used

antipyretic to reduced temperatures of 39.0°C.

P6. Generally check their forehead then take temperature, ask them how long they

have felt this way, try to think of a probably cause, temperature of 38 would probably

keep a closer eye on them, 37.5 doesn’t worry me. Lie them down, keep them

comfortable, remove extra clothing, make sure they don’t get chilled, monitor, if

distressed/crying/complaining of a headache give paracetamol, otherwise offer lots

of fluids, cuddle them, sit down next to them and pat them, keep them calm, just keep

an eye on the temperature, take temperature every couple of hours, use a wet flannel,

cool/lukewarm bath, prior to medications. Do keep an eye on them because one had

a febrile convulsion.

Decisions to seek medical advice were influenced by distance to and availability of

preferred GP. Weekends and close physical proximity increased GP use for advice

and reassurance. Others living a distance, e.g. 30 minute drive, from their GP delay

seeking assistance until it is ‘really’ necessary. Parents not confident in local GPs

seek advice and reassurance from emergency departments.

5.3.7 Need for Timely, Consistent Information Parents considered it important for all parents, particularly new parents, to have

accurate information about fever, common childhood illnesses, signs and symptoms

of illness and managing a febrile child. Perceptions of the ideal time to receive

information were mixed. Some recommended during antenatal classes, ‘you are very

busy with the baby postnatally’. A 2-week old firstborn had a febrile illness. Others

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recommended post-delivery, before the first febrile illness, from a doctor or child

health nurse at a well-baby visit or with the first immunisation.

5.4 DISCUSSION Parents’ fever management practices were influenced by their knowledge, beliefs and

information sources about fever management. They had limited knowledge of the

physiological changes and associated immunological benefits of fever. Fever was

believed to be harmful, requiring active reduction. Some parents dressed febrile

children in light clothing, encouraged fluids and monitored them prior to

antipyretics; others used antipyretics as a first line of treatment. Negative experiences

during febrile episodes influenced management increasing antipyretic use and

concern. Initially fever management was learnt from a variety of sources. Conflicting

information made management decisions difficult causing parents to seek further

advice, often medical. For most, concerns about fever reduced over time or

uneventful febrile illnesses.

5.4.1 Influence of Beliefs Parents believed fever needed to be controlled, treated quickly to prevent it rising

any higher or harming their child. The range of temperatures considered fever varied

1.6ºC (37.5ºC to 39.1ºC). Although some believed mild fever beneficial, they were

reluctant to allow fever to get too high. Parents reported concern about and actively

reduced temperatures of 38.0ºC to 39.0ºC (mild fever) with antipyretics, all reduced

temperatures of 40ºC (moderate fever). Beliefs of potential harm from fever have

been reported previously, febrile convulsions, dehydration, brain damage and death

(e.g. Crocetti et al. 2001, Karwowska et al. 2002, Sarrell i2002). Additional harmful

beliefs of stroke and cardiac problems were reported indicating transference of harm

to other major organs highlights parental fears; fears that are increasing rather than

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decreasing fever phobia. Fever is not harmful, has a natural upper limit and

convulsions resulting from fever are benign (e.g. Chang et al. 2000, Chang et al.

2001, Kolfen et al. 1998, Lorin 1986).

Beliefs that fever indicates a serious illness were reinforced by media reports of

meningitis and meningococcal disease and occasions where misdiagnosis resulted in

a life-threatening event. Kai (1996b) reported this in 1996. Media influences may be

greater now than ten years ago. Increased media coverage and easy access to

information via the Internet could be responsible for maintaining and possibly

strengthening these beliefs. Interestingly beliefs about serious illnesses was tempered

with perceptions that older children, three years or older, were stronger and therefore

more resistant to serious illness than younger children. Although appropriate

immunisations were believed to protect children from serious illnesses, parents were

still concerned about meningitis in general and meningococcal meningitis

specifically.

5.4.2 Influence of Parental Role Parental protective role creates conflict. Parents believe fever is harmful and must be

reduced but are worried about side effects from, or overdosing their child with,

antipyretics. Despite this, beliefs about the potential harm of fever make antipyretic

use essential. Most parents alternated antipyretics. This practice increased control

over fever, reduced fever, maintained fevers at a temperature considered safe.

Concerns about overdosing with one antipyretic and side effects of each antipyretic

are also reduced by alternating antipyretics. Similarly to parents studied by Lagerlov

et al. (2003) antipyretics gave parents a feeling of control, they helped parents

believe they were preventing harm.

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5.4.3 Influence of Experience Similar to earlier work by Kai (1996a) behaviours associated with fever were learnt

through experience with fevers. Identification of a cause for fever, fever management

strategies and illness severity were sought from books, friends and health

professionals. Parents perceived their need for reassurance from health professionals

with early febrile episodes as a learning experience enabling them to differentiate

between minor and serious illnesses and illnesses requiring medical intervention,

e.g., otitis media, tonsillitis. Positive influences of experience were evident in

comparisons between earlier negative beliefs, with the first baby, and current more

positive beliefs. For example, febrile convulsions and brain damage are not

associated with temperatures of 38.0ºC and high temperatures (39.0ºC) unrelated to

illness behaviours are not harmful and do not require antipyretics.

Negative experiences during a febrile episode were associated with increased

monitoring and antipyretic use. Feelings of guilt were associated with perceived

inappropriate home management, precipitating a febrile convulsion and delays in

seeking medical assistance for a fever requiring medial intervention, e.g., antibiotics,

reflecting a strong sense of responsibility to be competent parents (Kai, 1996a).

Experiences with missed or unsatisfactory diagnosis or being told ‘it’s a virus’

continue to cause confusion and anxiety (Kai, 1996a). Parents reporting these

experiences frequently sought a second opinion. When beliefs the child was ill and/or

required treatment were confirmed, trust in general practitioners reduced and

paediatric emergency departments became the preferred source for medical advice

influencing both private and public health service use.

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5.4.4 Influences of Knowledge and Information Sources Influences of parents’ limited knowledge about benefits of fever are evident in their

beliefs and fever reduction practices. Knowledge of fever’s benefits, although

limited, was learnt from doctors. The endless search for information from a variety of

sources created additional problems. Information from family, friends, books and

health professionals was often contradictory. Conflicting information increases

concerns about management promoting feelings of insecurity. Parents either seek

additional information from health professionals and literature or base management

decisions on past experiences, not necessarily positive experiences.

5.4.5 Implications for Health Professionals Conflicting information about fever management from health professionals is

unacceptable. Evidence about the benefits of mild to moderate fever and

recommendations for antipyretic use based on the child’s well-being have been

reported in health literature for more than two decades (e.g. Schmitt 1984, Kluger,

1986, Lorin, 1986, 1999, Zeisberger 1999, Mackowiak 2000, Blatteis 2003, Roth et

al. 2004). Health professional encouragement of unnecessary fever reduction

reinforces negative beliefs and can prolong illnesses (Graham et al. 1990).

Unnecessary antipyretic administration and alternating antipyretics increase the

probability of overdosing with potentially serious consequences (Kearns et al. 1998).

It is necessary to raise health professionals’ awareness of these issues. Health

professionals must update their knowledge and encourage parents to practice in a

manner based on the latest scientific evidence. Education must target individual

parent’s knowledge deficits, beliefs and practices. Current myths and misconceptions

must be addressed to enable parents to respond with evidence-based information

when confronted. Evidence-based guidelines for the use of antipyretics in mild to

moderate fever are necessary.

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5.4.6 Strengths and Limitations This study detailed the fever management practices of parents of well children; the

aim was achieved and important influences identified. However, qualitative research

is not generalisable and parents who participated had tertiary education and were

from metropolitan areas. Therefore findings need to be interpreted with caution.

Future studies with larger and more representative samples are needed to confirm the

findings of this study.

5.5 CONCLUSIONS Mixed experiences with and information sources about childhood fevers influenced

parental knowledge, beliefs and practices. For most, beliefs and concerns about and

negative consequences of fever reduced over time through experiences with

uneventful febrile episodes, learning to identify differences between minor self-

limiting viral infections and serious illnesses, beliefs that serious illnesses were

unlikely in immunised children and perceptions of increased knowledge. For some,

reduced antipyretic use was associated with reduced concerns. Negative experiences

during a febrile episode, such as a febrile convulsion, delayed medical intervention,

being told ‘it’s a virus’, receiving conflicting advice and media reports of serious

illnesses reinforced negative beliefs. Negative beliefs encouraged increased

antipyretic administration, monitoring and health service usage. Health professionals

must ensure fever management information provided to parents is consistent, based

on the latest scientific evidence and made available to parents before their first

experience with a childhood fever.

5.6 ACKNOWLEDGEMENTS The authors would like to thank Dr Helen Chapman from the School of Nursing,

Queensland University of Technology for expert assistance with data analysis and

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the Australian Confederation of Paediatric and Child Health Nurses for their support

through the Margaret Sullivan Scholarship which assisted in data collection. We

would also like to thank the parents who gave their valuable time to participate.

5.7 FUNDING Margaret Sullivan Scholarship from the Australian Confederation of Paediatric and

Child Health Nursing Queensland Inc.

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CHAPTER 6 – STUDY 2

DESCRIPTIVE FINDINGS

This chapter presents two articles reporting the descriptive findings from Section 1 of

Study 2, the survey of Queensland parents. The instrument developed for use in

Study 2 was based on the literature and findings from Study 1, the qualitative study

reported in the previous chapter. In the first article parents’ fever management

knowledge, beliefs, practices and sources of fever management information are

reported. Specific areas included in the first article, developed from findings from

Study 1, explored changes in fever management practices over time and the

influences on these, temperatures considered harmful and the harm these

temperatures could cause, specific concerns when a child is febrile, influences on

alternating antipyretics and receiving conflicting information.

The second article focuses on the use of over-the-counter medications in childhood

fever management. Specific areas included in article 2 developed from the findings

from Study 1 are difficulties in medication administration, temperatures at which

parents alternate antipyretics and reasons for alternating, whether medications were

perceived as harmful and the harm these medications could cause. Items targeting the

type of medications used to reduce fever identified paracetamol and ibuprofen and

included space for parents to include additional over-the-counter preparations such as

homeopathic, herbal and additional analgesic/antipyretics.

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6.1 ARTICLE 1 Underpinned by fear: a community study of parents' fever management with young children Walsh, A. M., Edwards, H., & Fraser, J. (under review). Underpinned by fear: a

community study of parents' fever management with young children. Journal of

Advanced Nursing. Journal Impact Factor: 1.342

Abstract Aims. Explore Australian parents’ knowledge, beliefs, practices and information

sources about fever management and develop a scale to measure parents’ fever

management practices.

Background. Internationally, parental fever phobia and overuse of antipyretics to

reduce fever continues. No developed scales are available. Australian parents’ beliefs

and practices are unknown.

Method. A community-based, postal survey of 401 Australian parents of well-

children aged 6-months to 5-years during 2005 were recruited through advertising

(48.4%), face-to-face (26.4%) and snowball (24.4%) methods. A 33 item instrument

was developed; construct and content validity determined by an expert panel and

item reliability by test-retest with nine parents.

Results. Most respondents were female, had university education and lived in a

major city. Moderate fever (40.0ºC ± 1.0ºC) was reported harmful (88%), causing

febrile convulsions (77.7%). Usual practices targeted temperature reduction,

antipyretic administration (87.8%), temperature monitoring (52.5%) and 51.8% had

alternated antipyretics. Fewer evidence-based practices such as encouraging fluids

(49.0%) and light clothing (43.8%) were reported. Positive changes over time

(36.4%) included less concern; delayed or reduced antipyretic use. Negative practice

146

changes (22.7%) included greater concern and increased antipyretic use. Medical

advice was sought for illness symptoms (48.7%), high (37.4%) or persistent (41.5%)

fevers. Fever management was learnt from doctors, family and friends and

experience; receiving conflicting information (41.9%) increased concerns and

created uncertainty about best practice.

Conclusions. Australian parents’ practices are influenced by concerns about fever

indicated by preferences for antipyretic use and the percentage who had alternated

antipyretics. Conflicting information increases concerns identifying a need for

consistent evidence-based information from health professionals.

What is already known about this topic:

o Internationally, parents are overly concerned about harmful outcomes from

childhood fever.

o Antipyretic use, as parents’ preferred method of reducing fever, has

increased.

o Parents often incorrectly dose febrile children with antipyretics.

o No known tools to measure the physical burden of care on parents during

childhood fever.

What this paper adds: o Australian parents have similar concerns about harmful outcomes from

childhood fever as their international counterparts.

o More than half the parents surveyed had alternated antipyretics.

o Parents receive conflicting information about how to manage fever causing

confusion and increasing concerns and best practice in fever management.

o Development of a scale to measure parents’ fever management practices.

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6.1.1 Introduction Internationally, little has changed in parents’ concerns about childhood fever since

Schmitt (1980) coined the term ‘fever phobia’ describing parents’ irrational concerns

about fever. Parents continue to reduce fever to prevent febrile convulsions and brain

damage and more recently to prevent discomfort and improve general well-being

(Crocetti et al. 2001, Karwowska et al. 2002). Childhood fever has a socioeconomic,

physical and emotional influence on parents who take time off work, seek medical

advice, purchase pharmaceuticals and need more assistance at home (Principi et al.,

2004). Fever phobia increases the physical and emotional burden through constant

temperature taking, worry and sleepless nights and could influence parents’ practices

(Impicciatore et al. 1997, Lagerlov et al. 2003). Internationally, although many

studies are reported, studies replicating earlier studies allowing comparisons are

scarce (Crocetti et al. 2001, Taveras et al. 2004) and scales appropriate for fever

management research unavailable. This paper begins to address this deficit and the

dearth of literature reporting Australian parents’ knowledge, beliefs, practices and

methods of learning to manage fever.

6.1.1.1 Background Fever No definitive temperatures considered to be normal, fever or high fever are

consistently reported in the literature. Normal temperature in infants ranges from

37.5ºC ± 0.3ºC with 0.3ºC seasonal variation between summer and winter and a

0.1ºC per month increase from 1-month to 3-months of age (Herzog & Coyne, 1993).

Hertzog and Coyne (1993) concluded 38.2ºC or greater would indicate fever in a 3-

month infant. Others report 38.0ºC, indicates childhood fever (Chamberlain et al.

1995, Schmitt 1984). More recently Sarrell et al. (2002), agreeing with El-Radhi and

Carroll (1994), defined fever as 38.0°C rectally or an axillary temperature of 37.2°C.

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Moderate fevers, up to 40.0ºC are associated with immunological benefits (Connell

1997, Holtzclaw 1992, Lorin 1999). High fevers, 40.5ºC or over, generally indicate

bacterial infection (Schmitt 1984). Brain damage is unlikely unless fever exceeds

41.7ºC, harmful or dangerous fever; exogenous antipyretics prevent this occurring in

infectious fever (Mackowiak & Boulant 1996).

Parents and Fever Parents seeking medical assistance in an emergency department in the United Arab

Emirates recently reported 37.5ºC to indicate fever (Betz & Grunfeld 2006).

Canadian parents of febrile children reported fever to be 37.9ºC (SD 0.7ºC), high

fever 39.2ºC (SD 0.7ºC) and dangerous fever 39.9ºC (SD 0.8ºC) (Karwowska et al.,

2002). Other studies reported parent definitions of fever between 37.0°C and 39.0°C

with 38.0°C most common (Blumenthal 1998, Impicciatore et al. 1998, Porter &

Wenger 2000) and high fever between 39.0°C and 40.0°C (Al-Eissa et al. 2000a,

Crocetti et al. 2001).

Parents reduce mild low grade fevers, 38.2ºC to 38.9ºC, to prevent harmful outcomes

(Al-Eissa et al. 2000b, Crocetti et al. 2001, Karwowska et al. 2002). Antipyretic use,

the preferred fever reduction method, has increased from 67% (Schmitt 1980) to 95%

(Karwowska et al. 2002). In the last decade the practice of alternating antipyretics

when temperature reduction is insufficient or fever returns has become more popular

(Crocetti et al. 2001, Li et al. 2000); recently 67% of parents in Alabama, United

States, alternated (Wright & Liebelt 2007). This is disturbing in relation to continued

reports of parents’ incorrect antipyretic dosing (Goldman & Scolnik 2004, Kilmon

1987). Recently, less than half, 47% to 49%, the children presenting at emergency

departments had received the correct antipyretic dose (Goldman & Scolnik 2004,

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McErlean et al, 2001). Underdosing with antipyretics increases health service usage

as parents perceive fever not sufficiently reduced or returning too soon (Li et al.

2000, McErlean et al. 2001). Overdosing has trebled from 12% (Kilmon 1987) to

33% (Linder et al. 1999). Younger children, under two years, are at greater risk of

unintentional overdosing (Alander et al. 2000, Kozer et al. 2002). Paracetamol is

among the most common over-the-counter medications associated with unintentional

overdose in Australian children younger than five years (Chien et al. 2003).

Fever is Beneficial There is overwhelming evidence that fever is an adaptive response in all vertebrates

(Kluger 1979). Mild to moderate fevers during febrile illnesses are associated with

enhanced immunological responses (Blatteis et al. 1998, Kluger 1986, Lorin 1999,

Mackowiak 1998). Fever plays a pivotal role in the anti-inflammatory response;

antipyretics may interfere with this response and should be avoided unless overriding

conditions exist (Blatteis 2003, Klein & Cunha 1996, Mackowiak 1998). Reducing

fever to prevent febrile convulsions is ineffective and unwarranted (Chang et al.

2001, Hutt et al. 1999). Large epidemiological studies concluded febrile convulsions

are benign events occurring in 5% of children aged three months to five years

(Chang et al. 2001, Kolfen et al. 1998).

Most recent research targeted parents of febrile children and parents seeking advice

at health clinics (Karwowska et al. 2002, Sarrell et al. 2002). Having an ill child or

being in a health environment could influence parents’ perceptions or responses. In

light of the dearth of Australian literature and community-based studies it was timely

for a comprehensive community-based investigation of Australian parents’ fever

150

management. This study builds on findings from a qualitative study to identify

Australian parents’ current knowledge, beliefs and practices (Walsh et al. 2007a).

6.1.2 The Study

6.1.2.1 Aims The aims of this study were to identify the knowledge, beliefs, practices and methods

of managing fever in a crossectional community-based sample of Australian parents

of young children and develop a scale to explore parents’ fever management

practices. Parents’ antipyretic use is discussed in detail elsewhere (Walsh et al.

2007b).

6.1.2.2 Design A self-report, self-administered, crossectional survey was undertaken in 2005.

6.1.2.3 Sample A convenient sample of parents of children aged between 6-months and 5-years

living in Queensland, Australia was recruited. Recruitment was through a range of

strategies: 1) advertising in parenting magazines (210 distributed, 194 returned;

92.4%); 2) face-to-face in child care centres, kindergartens and preschools (204

distributed, 104 returned; 60.0%); and 3) snowball technique (171 distributed, 98

returned; 57.3%). Nearly half were recruited through advertising (48.4%) and similar

percentages through childcare centres (26.4%) and snowball (24.4%). Three (0.8%)

returned completed questionnaires with the identifying number removed.

6.1.2.4 Data Collection In an attempt to recruit a representative sample three recruitment methods were

employed; 1) advertising, 2) face-to-face and 3) snowball.

1) Over a 3-month period advertisements were placed in parenting magazines

accessible freely to parents in metropolitan and outer metropolitan areas.

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Playgroup Queensland members were targeted through the monthly online

newsletter and quarterly magazine. Queensland parents using Family Day

Care were targeted through care providers. Interested parents contacted the

researcher by phone (49.6%) or email (50.4%). Survey packages, containing

a letter of introduction, information sheet, survey and reply paid envelope,

were posted to interested parents.

2) Parents from metropolitan and outer metropolitan childcare centres,

kindergartens and preschools were informed of the study through posters and

individual letters. Interested parents received a survey package following

face-to-face recruitment and returned completed surveys to a sealed box in

the centre.

3) Queensland wide snowball recruitment was conducted through respondents

and researcher networks. Completed surveys were returned by mail or

collected by the initial contact and returned to the researcher.

6.1.2.5 Instrument An extensive search of the literature was conducted through Medline, CINAHL,

PsycINFO, PsycARTICLES and Web of Science databases from 1980 to 2004 for

articles from the developed world published in English. Instrument items were

developed from published and unpublished instruments and information gained

through semi-structured discussions with Australian parents of young children

(Walsh et al. 2007a). The instrument was piloted and the final instrument consisted

of 33 items. It explored parents’ knowledge (five items), beliefs about fever (six

items), general fever management practices (18 items) and sources of fever

management information (four items). See Table 6.1 for examples of constructs to

item development.

152

Appropriate terminology was determined through an earlier study (Walsh et al.

2007a); ‘medication’ was used for antipyretics and other over-the-counter

medications used to reduce fever; ‘fever’ for mild fever, ‘high fever’ for moderate

fever and ‘very high fever’ for high fever. To begin to address the deficit of

psychometrically tested scales for use in fever management research eight of the 18

fever management practices targeted parents’ physical burden of care during

childhood fever. Twenty-two demographic items were included.

6.1.2.6 Validity and Reliability Sample size was calculated by estimating the population proportion with specified

absolute precision (Lwanga & Lemeshow 1991). Calculations were based on

findings from other studies. Forty-six to 49% of parents believed a temperature of

38.0ºC represented fever (Al-Eissa et al. 2000a, Blumenthal 1988) and 78% to 80%

administered antipyretics for temperatures of 38.0ºC (Blumenthal 1998, Linder et al.

1999). For relative precision of the results at the 95% significance level and power of

90% a minimum sample of 384 parents were required.

Instrument content and face validity were confirmed by an expert panel consisting of

two clinical paediatric nurses, a paediatric nurse researcher and two nurse academics

(Polit & Hungler 1999). Item reliability was determined by test-retest (2-weeks) with

nine parents of children aged 6-months to 5-years. Kappa on categorical items ranged

from 0.55 (on one item) to 1.00. Bland Altman analysis (Bland & Altman 1986) on

all continuous items indicated responses were within the limits of agreement (mean

difference ± 2SD). One respondent’s responses on temperature for fever were outside

the limits of agreement. Following minor adjustments the instrument was deemed

suitable.

153

6.1.2.7 Ethical Considerations Ethical approval was obtained from the Queensland University of Technology

human research ethics committee. Voluntary participation in the study was by

informed consent with assurances of confidentiality and anonymity for all

participants. The return of a completed survey was considered consent to participate

in the study.

6.1.2.8 Data Analysis Responses to open-ended questions were coded and entered into SPSS Version 13

(SPSS 2004). Entry errors were checked and corrected using SPSS Data Entry

Builder 4.0 (SPSS 1996-2003). Demographic variables were examined for frequency

and distribution. Items measuring perceptions of temperatures representative of

fever, recorded on six scales, were checked for distribution normality and outliers.

An extreme outlier, fever is harmful at 100ºC, was removed (Tabachnick & Fidell

2007). Open-ended responses were collated using the multiple response analysis in

SPSS. Categorical and open-ended responses were then explored for frequency and

percentage of responses. Demographic influences of recruitment method, age,

number of children, educational attainment and experience in the health industry

were explored using ANOVA and Tukey post hoc tests, t-test and chi-square tests as

appropriate. Interestingly no correlations between age and dependent variables were

discovered.

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Table 6.1: Example of instrument items, sources and mode of data collection

Construct Concept Items No. of

Items Source Adapted Item Mode

Knowledge Temperature Normal 1 Blumenthal 1998; Crocetti 2001 VASa

Fever 1 Crocetti 2001; Kramer et al. 1985 VAS

High fever 1 Crocetti 2001;Schmitt 1980 VAS

Very high fever 1 Walsh et al. in press VAS

Fever

management

Know how to best manage

fever

1 Walsh et al. in press Categorical

Beliefs Fever is harmful Fever is harmful 1 Kelly et al. 1996 Categorical

Temperature fever harmful 1 Kelly et al. 1996; Kramer et al. 1985 Interval scale

Degree of harm 1 Walsh et al. in press Likert scale

Harm rank ordered 1 Kramer et al. 1985; Abdullah et al.

1987

Open-ended

Most worried during febrile

episode

1 Walsh et al. in press Open-ended

Other worries 1 Walsh et al. in press Open-ended a Visual analogue scale (VAS) 35.0ºC to 43.0ºC

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Parent Fever Management Scale Development (PFM) The eight items developed to evaluate parents’ fever management, measured on 5-

point Likert scales, were recoded prior to analysis to ensure a higher score indicated

a more frequent practice (1 = never, 3 = sometimes, 5 = always). Factor analysis

using principal component extraction was conducted. Subject to item ratio was 1:50.

Following examination of the scree plot, prior conceptual beliefs and the underlying

dimension of parents’ fever management practices (Green & Salkind, 2005) a one

factor solution with an eigenvalue of 2.615 was selected. One item “When my child

has a fever I generally make sure they have plenty to drink” with correlations less

than 0.17 across all items and communality extraction of 0.52 was removed. The

analysis was rerun and varimax rotation performed. A more meaningful pattern was

found in the non-rotated version (KMO=0.61, Bartlett’s Specificity Approximate Chi

Square 1162.642, df 28, p<0.01) which explained 36.9% of the variance. The scale,

with a Cronbach’s Alpha of 0.70, was named Parent Fever Management scale

(PFM). Alpha levels of 0.70 are acceptable for a new instrument (Nolan & Mock

2000). Means, standard deviations and total PFM scores, calculated by summation of

each individual’s score for the set of items, were explored. Table 6.2 reports the

items included in the PFM scale. Test-retest reliability by Bland Altman analysis

confirmed scale items were reliable as scores were within the limits of agreement

(mean difference ± 2SD). See Table 6.2 for items in the PFM scale.

6.1.3 Results Respondents were aged between 20 and 52 years (mean 34.58, SD 4.83), female

(97.5%), in a married or defacto relationship (93.5%) and a child who had had at

least one fever (99.7%). Forty-one (10.2%) had a child who had had a febrile

convulsion; nine a child with epilepsy (2.2%). Most had a university education; two

or more children, were born in Australia and lived in a major city. See Table 6.3 for

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additional demographic information. There were no significant differences between

recruitment methods in age, educational achievement or employment status. Those

recruited through advertising were less likely to come from a major city

(χ2[396]=44.97,p<0.01) and had fewer children (F[2,395]=4.380,p=0.01).

6.1.3.1 Knowledge Temperatures reported to represent normal temperature ranged from 35.2ºC to

38.7ºC (mean 36.8ºC, SD 0.5ºC) with 96.4% of the sample reporting between 36.0ºC

and 38.0ºC as normal. Temperatures representing ‘fever’ ranged from 36.7ºC to

40.5ºC (mean 38.2ºC, SD 0.6ºC). One third (33.3%) reported between 38.1ºC and

39.0ºC indicated fever and 56.3% reported 38.0ºC or lower. Reports of ‘high fever’

ranged from 37.5ºC to 42.6ºC (mean 39.4ºC, SD 0.8ºC); 38.4% reported between

39.1ºC and 40.0ºC and 47% identified 39.0ºC or lower. ‘Very high fever’ was

reported to range from 38.0ºC to 43.0ºC (mean 40.3ºC, SD 1.0ºC); 43.4% of the

sample reported 40.1ºC and above. See Table 6.4 for more detail.

Educational attainment and experience in the health industry influenced knowledge.

Specifically, educational attainment made significant differences to reports of high

(F[3,393]=3.243, p=.02) and very high fever (F[3,394]=4.062, p=.01). Parents with a

degree or higher degree reported lower temperatures for high (p=.06 and p=.02

respectively) and very high fever (p=.03 and p=.01 respectively) than those with

secondary education. Parents with health industry experience reported lower

temperatures representing fever (t(389)=3.260, p=.01) high (t(391)=2.233, p=.03) and

very high fever (t(392) = 2.496, p = .01) than parents without this experience. See

Table 6.5.

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Table 6.2: Parent Fever Management scale (PFM)a

When my child has a fever I generally CommunalitiesUnrotated Principal

Component Meanb SD

Check on them during the night1 0.224 0.473 4.56 0.73

Like to know what their temperature is2 0.521 0.722 4.35 1.00

Take their temperature2 0.505 0.710 4.34 1.05

Use over the counter medication to

reduce fever3,4

0.294 0.542 4.16 0.97

Sleep in the same room as them1 0.178 0.421 3.00 1.33

Take them to the doctor5-7 0.368 0.607 3.15 0.87

Wake them up during the night for

medications to reduce fever2,4,5,8,9

0.494 0.703 2.53 1.23

a PFM scale mean 15.89, SD 4.33, range 7 to 31, potential range 0 to 35; scale α=0.70, N=401 b 1 = never, 2 = rarely, 3 = sometimes, 4 = mostly, 5 = always Items were adapted from 1 Lagerlov et al. 2003, 2Crocetti et al. 2001, 3Karwowska et al. 2002, 4Sarrell et al. 2002, 5Kramer et al. 1985, 6Kelly et al. 1996, 7Impicciatore et al. 1998, 8Schmitt 1980 and 9Al-Eissa et al. 2000.

6.1.3.2 Beliefs Most parents (71.1%) reported knowing how to best manage childhood fever and

some were unsure (19.5%). There were significant differences in beliefs about

knowledge of fever management dependent on the number of children parents had

(χ2[2,399] = 14.193, p = .01) and health industry experience (χ2[1,394] = 10.236, p =

.01). Parents with three or more children (84.6%) and those with health industry

experience (81.9%) perceived themselves more knowledge about fever management

than those with one child (60.2%) or no health industry experience (66.3%).

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Table 6.3: Participant demographics N = 401

N % Highest Educational Achievement N = 400

Some/completed secondary school TAFEa certificate/diploma Undergraduate degree Postgraduate degree

68 74 162 96

17.0 18.5 40.5 24.0

Employment Status N = 401

Not at present/on leave Full-time work/student Part-time work/student Casual work

164 61 128 48

40.9 15.2 31.9 12.0

Number of Children N = 401 1 2 3 to 6

119 204 78

29.7 50.9 19.5

Country of Birth N = 401 Australia United Kingdom New Zealand Other

325 28 23 25

81.0 7.0 5.8 6.2

Partner’s Country of Birth N = 401 Australia United Kingdom New Zealand Other

288 39 18 56

71.8 9.7 4.5 14.0

Geographical Location N = 390 Major city (ARIAb 0 ≤ 0.2) Inner regional area (ARIA > 0.2 ≤ 2.4) Outer regional area (ARIA > 2.4 ≤ 5.9)

292 80 18

74.9 20.5 4.6

a TAFE Technical And Further Education bAccessibility/Remoteness Index of Australia

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Table 6.4: Parent reports of representative temperatures

Normal

Temperature Fever High Fever Very High Fever Harmful Fever

Antipyretics

Administered Degrees Celsius % % % % % %

≤ 36.0 10.0 * * * * *

36.1 – 36.5 26.3 * * * 0.3 *

36.6 – 37.0 38.0 1.5 * * 0.0 2.5

37.1 – 37.5 21.0 18.2 0.3 * 0.6 11.2

37.6 – 38.0 43.0 36.6 3.8 0.8 2.8 42.7

38.1 – 38.5 0.5 25.0 14.1 1.0 2.5 17.0

38.6 – 39.0 0.3 8.3 28.9 9.3 14.3 21.4

39.1 – 39.5 * 6.8 18.8 14.8 6.2 1.6

39.6 – 40.0 * 2.8 19.6 29.8 51.3 3.6

40.1 – 40.5 * 0.8 8.3 16.5 2.0 *

40.6 – 41.0 * * 2.3 11.3 12.0 *

> 41.0 * * 4.0 16.5 8.1 *

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Table 6.5: Differences in knowledge, beliefs, practices and receiving conflicting information N = 401

Fever ºC High Fever ºC

Very High Fever ºC

Harmful Fever ºC FMP Scale

Fever Management Knowledge

Received Conflicting Information

Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) % Yes % Yes

Number of Children

1 child

2 children

3-6 children

38.2 (0.66)

38.2 (0.65)

38.0 (0.55)

39.4 (0.89)

39.4 (0.81)

39.2 (0.66)

40.3 (1.07)

40.3 (1.00)

40.2 (0.76)

40.1 (1.10)

39.9 (0.80)

40.1 (1.06)

15.47 (4.30)

15.99 (4.35)

16.24 (4.34)

60.2

72.9

84.6

50.8

40.9

30.8

Educational Attainment

Secondary

TAFE

Degree

Higher degree

38.3 (0.74)

38.2 (0.57)

38.2 (0.61)

38.1 (0.64)

39.6 (0.98)

39.4 (0.79)

39.3 (0.73)

39.2 (0.79)

40.6 (1.08)

40.2 (1.05)

40.3 (0.90)

40.1 (0.93)

40.3 (1.17)

39.7 (0.84)

40.0 (0.92)

40.1 (0.86)

14.37 (4.12)

14.43 (4.19)

16.98 (3.99)

16.24 (4.60)

60.3

73.0

77.2

66.7

33.8

31.5

44.4

50.5

Experience in the Health Industry

Yes

No

38.0 (0.52)

38.2 (0.66)

39.2 (0.76)

39.4 (0.81)

40.1 (0.88)

40.3 (1.00)

40.0 (0.89)

40.0 (0.99)

16.45 (4.45)

15.62 (4.25)

81.9

66.3

47.7

38.7

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Parents were asked if fever could be harmful, at what temperature, how harmful

these fevers could be and the harm that fevers at this temperature could cause. Most

parents (88.8%) believed fever could be harmful, few believed it was not harmful

(2.5%). Educational attainment influenced perceptions of the temperature that could

cause harm (F[3,352] = 5.266, p = .01). Parents with secondary education reported a

higher temperature than those TAFE (p = .01) or a degree (p = .05). See Table 6.5.

Temperatures considered harmful ranged from 36.5ºC to 43.0ºC (mean 40.0ºC, SD

1.0ºC). This was explored to determine how harmful this temperature could be and

the outcomes that could occur at the harmful temperature. Of the 87.6% who

reported a temperature that could be harmful 59.2% reported this very or reasonably

harmful. It is important to note that 14.4% of parents believed temperatures of 39.0ºC

and lower could be harmful to very harmful; 50.3% reported this for temperatures of

40.0ºC or lower. See Table 6.6 for reports of harmful fevers. Specific harmful

outcomes at the identified harmful temperature were reported in rank order (1-3; 1 =

the most harm) by 91.8%. Febrile convulsions, brain damage, and dehydration, an

indication of serious/fatal illnesses and loss of consciousness were most frequently

reported. Table 6.6 presents parents’ reports the degree of harm from harmful

temperatures and harmful events that could occur at the temperature considered

harmful.

During febrile episodes parents (N=394) were most concerned about febrile

convulsions (35.0%) and the underlying cause of the fever (20.1%). In addition to

their main concern parents (N=705, multiple responses) were also concerned about

the cause of the fever (29.7%), serious/fatal illnesses (23.2%), their child’s well-

162

being (22.3%), specific illness related concerns, e.g., cough, vomiting, pain (20.6%),

dehydration (16.9%), parent/family problems because of the illness, e.g., unable to

go to work, lack of sleep, the illness being contagious (16.1%) and febrile

convulsions (11.6%).

Table 6.6: Parents’ perception of temperatures that can be harmful; the degree of harm and harmful events these temperatures could cause (N = 348)

≤ 39.0°C n=70

39.1°C - 40.0°C n=200

40.1°C - 41.0°C n=49

≥ 41.1°C n=29 Total Degree of Harm

% % % % % Very harmful 12.9 20.5 20.4 41.4 20.7

Reasonably harmful 45.7 40.5 24.5 31.0 38.5

Harmful 27.1 26.5 42.9 20.7 28.4

A little harmful 12.9 12.5 8.2 6.9 11.5

Not very harmful 1.4 0.0 4.0 0.0 0.9

Harmful events from temperatures that could cause harm

≤ 39.0°C n=140

39.1°C - 40.0°C n=394

40.1°C - 41.0°C n=96

≥ 41.1°C n=57 Total

Harmful Events

%a %a %a %a %a

Febrile convulsions 81.4 78.8 76.0 64.3 77.7

Brain damage 24.3 24.7 40.0 42.9 28.3

Dehydration 27.1 25.3 20.0 28.6 25.1

Indicative of serious illness

14.3 17.7 18.0 7.2 16.2

Loss of consciousness 14.1 12.1 8.0 25.0 12.4

Organ damage 8.6 13.1 8.0 7.1 11.0 a Percent of responses

Forty-one parents had a child who had had a febrile convulsion. Concerns during

febrile convulsions were brain damage (22.2%) and the child being hurt (22.2%),

unable to breathe (16.7%), remaining unconscious (11.1%) or dying (11.1%).

Concerns during subsequent febrile episodes were febrile convulsions (70.0%),

163

temperature reduction (25.0%), the underlying cause (25.0%) and brain damage

(10.0%).

6.1.3.3 Practices Fever management practices were explored qualitatively to explore the most salient

practices, and were reported by 400 parents. Most frequent practices reported were

administering antipyretics (87.8%), temperature monitoring (52.5%), offering fluids

(49.0%) and dressing the child in light clothing (43.8%). Some comforted distressed

children (38.8%), ensured the child was comfortable, for example, lying on a sofa

(27.3%), used tepid (23.8%) or cool sponging/bathing (14.0%). Only 14% sought

medical advice. When fever was considered ‘very high’ additional practices were

reported by 46.9%. These included seeking medical advice (63.7%), using

antipyretics (35.2%), tepid or cool sponging/bathing (15.0% and 8.8% respectively).

Ninety-two percent of parents (N=365) reported ‘usually’ using antipyretics to

reduce fevers ranging from 37.0ºC to 40.0ºC (mean 38.3ºC, SD 0.6). Of these 57.3%

used antipyretics for temperatures below 38.5ºC and 17.1% below 38.0ºC. More than

half 51.8% had alternated antipyretics. Of these 39.8% sometimes, 11.7% mostly and

0.5% always alternated antipyretics. Influences on alternating antipyretics were

advice from a doctor or at a hospital (49.5%), child febrile post-antipyretic (41.7%)

and therapeutic qualities of the different antipyretics (21.6%). Medication use and

influences on use are reported in detail elsewhere (Walsh et al. 2007b).

The literature reports parents’ overuse of medical services for febrile children.

Parents’ (N=398) decisions to seek medical advice were influenced by specific

illness symptoms such as pain or a cough (49.7%), persistent fever (41.5%), high

164

fever (37.4%) and general unwellness, deterioration or lethargy (34.7%). Other

influences were an inability to reduce the fever or fever recurring post antipyretic

(29.4%), a need for advice or reassurance (20.4%).

Our earlier study identified practices do change over time and with subsequent

children (Walsh & Edwards 2007). In this study one third (39.4%) of parents

reported practice changes over time, some changes were positive or evidence-based,

others negative or phobic. Positive changes reflected reduced concern about fever

(36.4%), delaying or rarely using medications (34.4%) and delaying seeking medical

advice (19.5%). Of concern is that 22.7% reported increased antipyretic use which

included alternating antipyretics and a double dose of antipyretics.

6.1.3.4 Parent Fever Management Scale (PFM) Responses to items on the PFM scale confirm parents’ qualitative reports above

(refer to Table 6.2). Parents usually take the child’s temperature, use antipyretics to

reduce fever and sometimes take febrile children to the doctor. These include usually

checking on febrile children at night, sometimes sleeping in the same room and

waking febrile children for an antipyretic during the night. Total scale scores ranged

from 7 to 31 (potential range 7 – 35); mean 15.89 (SD 4.33). Mean score above the

median indicates a febrile child places a moderate burden on parents. Those with a

university education reported greater burden (F[3,399]=172.449, p ≤.001) than those

with secondary (degree, p ≤ 0.001; higher degree p = .03) or TAFE education (degree

p ≤ 0.001; higher degree p = .03 (see Table 65). There is scope for this scale to be

further developed as a useful tool to determine the burden of childhood fever places

on parents.

165

6.1.3.5 How Parents Learnt to Manage Fever Parents learnt to manage fever from multiple sources. Most frequently reported were

doctors (60.9%), personal experience or trial and error learning (39.1%), childcare

books and magazines (26.0%), peers, other mothers and friends (24.0%) and their

own mothers (22.5%). Fever management was also learnt from nurses (19.2%),

personal professional knowledge (12.1%) and other family members (12.9%). Some

actively researched fever management (12.1%); others learnt from pharmacists

(7.3%) and a few learnt about fever from alternative therapists (2.3%) and medical

help lines (1.3%).

Nearly half the parents (41.9%) had received conflicting information about managing

fever. For example, always reduce fever versus fever is good for the body, regular

antipyretics versus as required and do not alternate antipyretics versus alternate

antipyretics. Some received different advice from general practitioners and paediatric

emergency departments. Receiving conflicting information created feelings of

uncertainty and confusion (77.1%), anger and frustration (16.6%) and concern about

best management (14.6%). Some parents continued to make their own decisions

(17.8%) or sought further information from an expert such as a paediatrician,

pharmacist or general practitioner (7.6%). A number of demographic variables were

associated with receiving conflicting information; recruitment method

(χ2[2,N=396]=7.104, p=.03), number of children (χ2[2,399]=7.938, p=.02) and

educational attainment (χ[3,398]=8.401, p=.04). Parents recruited face-to-face were

least likely to report receiving conflicting information (32.1%) compared with

advertising (47.9%) and snowball methods (40.8%). Those with one child; TAFE or

degree education were more likely to report receiving conflicting information. See

Table 6.5.

166

6.1.4 Discussion This study identified Australian parents’ knowledge, beliefs and practices in

childhood fever management. Parents, perceiving they are knowledgeable, reported

normal temperatures indicated fever, believed moderate fever harmful causing febrile

convulsions and usually reduced normal temperatures and mild fevers with

antipyretics. Usual fever management practices, checking and medicating febrile

children throughout the night, place an additional burden on parents. Fever

management was learnt from numerous sources including doctors as well as trial and

error, peers and own mothers; receiving conflicting information from these varied

sources is not surprising. Caring for a febrile child is worrying; the additional

disruptions to parents’ life during this time and attempting to determine best practice

contribute to making this an even more daunting experience. Health professionals

have a responsibility to ensure parents not only know how to best care for febrile

children but also receive the necessary and timely support and reassurance.

6.1.4.1 Knowledge In this community-based study parents identified a wide range of temperatures

representative of normal, fever, high and very high fever. Interestingly the mean

temperature for fever, 38.2ºC and high fever, 39.4ºC reported were higher than those

reported by parents in other studies recruited from health care facilities or schools,

37.6ºC to 38.0ºC and 37.8ºC to 39.2ºC respectively (Betz & Grunfeld 2006,

Karwowska et al. 2002, Soon et al. 2003). Are Australian parents more

knowledgeable or do these findings reflect differences in perceptions when children

are well. If the latter, then educating parents when perceptions are more positive

could increase evidence-based practice. More research is needed to explore this

phenomenon.

167

6.1.4.2 Beliefs Parents in this study, similar to their international counterparts, believed fever

harmful causing febrile convulsions, brain damage and dehydration (Al-Eissa et al.

2000a, Betz & Grunfeld 2006, Crocetti et al. 2001, Karwowska et al. 2002) with

febrile convulsions their main concern. Parents of today are more concerned about

febrile convulsions than previously reported (Crocetti et al. 2001, Karwowska et al.

2002). These convulsions are rare occurring in less than 5% of children under the age

of five years (Kira et al. 2005, Vestergaard et al. 2002). Parent education has been

found effective in reducing concerns in parents of children who have had a febrile

convulsion (Huang et al. 2001, Wassmer & Hanlon 1999). Education about the

prevalence and predictors of febrile convulsions and safely caring for a child during a

febrile convulsion is necessary and may contribute to reducing fever phobia and

unnecessary fever reduction.

6.1.4.3 Practices The most common practices reported, antipyretics and temperature monitoring,

indicate parents’ focus on the need to reduce fever. Less than half the parents

reported practices supported by the literature, encouraging fluids, dressing in light

clothing and reducing activity (Connell 1997, Schmitt 1994, Watts et al. 2003).

Decisions to seek medical assistance were equally influenced by a need to reduce

temperature and specific illness related factors. These findings reflect a stronger

focus on the child’s temperature than on the child’s general well-being, indicating the

care of febrile children was motivated by fever phobia. Reports of very high and

harmful fever were similar and corroborate earlier studies reporting parents’

perception of harmful fevers, between 39.3ºC and 40.0ºC (Betz & Grunfeld 2006,

Sarrell et al. 2002). This is concerning, parents perceive moderate fever, fever with

immunological benefits to be harmful.

168

Importantly, practices did change over time for some parents. This is an important

finding specifically as positive changes indicated reduced concerns about fever and

negative changes more concern. Our pilot work found a negative experience with

childhood fever, febrile convulsion, increased concerns and antipyretic use (Walsh et

al. 2007a). Negative practice changes indicate a need for parents who have had

negative experiences to receive advice and reassurance from health professionals

following these negative experiences.

Reducing fever with antipyretics was common and consistent with recent studies

(Sarrell et al, 2002). However, the number of parents who had alternated antipyretics

is disturbing; more than half had alternated, a significant increase from rates reported

in the last few years, 7% to 27% (Crocetti et al. 2001, Li et al. 2000). Is this

becoming a common practice? Warnings about the dangers of alternating, increasing

fever phobia and antipyretic overdosing, abound (Goldman 2006, Saphyakhajon &

Greene 2006, Schmitt 2006). Alternating increases the risk of incorrect dosing, more

likely with ibuprofen than paracetamol, in both dosage and frequency (Lagerlov et

al. 2003, Li et al. 2000). Recent experimental studies comparing mono and

alternating therapies report an increased reduction of approximately 1.0ºC, over a 24

hour period, with alternating therapies (Erlewyn-Lajeunesse et al. 2006, Nabulis et

al. 2006, Sarrell et al. 2006). Is the risk of increasing parents’ focus on temperature

and antipyretic overdosing warranted for a 1.0ºC temperature reduction?

6.1.4.4 Parent Fever Management Scale The development of this scale assisted in determining parents’ usual practices and

reflects their concerns. Parents wanted to know their child’s temperature, checked

them during the night, gave antipyretics during the night and sometimes slept in the

169

same room. These practices indicate phobic beliefs and place additional demands on

parents causing tiredness and risking physical exhaustion during febrile episodes.

Australian parents use paracetamol to promote children’s sleep thereby allowing

parents to sleep (Allotey et al. 2004). Fear of negative outcomes influences

antipyretic use. Understanding parents’ concerns and the impact childhood fever has

on parents is important to assist health professionals target education and provide

appropriate reassurance.

6.1.4.5 Demographic Influences Interestingly, parents’ demography had little influence on their knowledge, beliefs

and practices. Our findings related to higher educational attainment conflict with

previous reports. However, that more than half of the sample had university

education must be considered; a more heterogeneous sample could have resulted in

different findings and needs further investigation. Nevertheless, some studies do

report lower educational levels associated with increased concerns about febrile

children (Impicciatore et al. 1998) and some report no educational influence (Kramer

et al. 1985, Singhi et al. 1991). The negative influence of a higher educational level

has not been reported. That more than half the parents had a university education

could explain our findings, however, this requires further exploration.

Health industry experience, not previously explored, had the greatest negative

influence on beliefs and practices. Most parents with either health education or

experience working in a health setting reported knowing how to manage fever.

However, they reported lower temperatures for fever, high and very high fever, a

greater physical burden of care and were more likely to have received conflicting

information indicating greater concern about fever than parents without health

170

industry experience. Health professionals’ fever phobia continues to be reported

(Karwowska et al. 2002, Sarrell et al. 2002, Walsh et al. 2005) despite evidence of

the beneficial role of fever and lack of support for antipyretic use to prevent febrile

convulsions (Chang et al. 2001, Hutt et al. 1999, Lorin 1999). Do health

professionals’ negative beliefs and practices influence others in the health industry,

irrespective of position?

6.1.4.6 Practice Implications Parents concerns about managing their febrile child were evident by their quest for

information. Inaccurate information from friends and relatives is understandable and

multifactorial (Purssell 2000, Schmitt 1980). Information from health professionals is

expected to be accurate and reliable (Walsh et al. 2007a). That this is not so is

evident in reports from parents with health industry experience. Reports of some

health professionals’ concern about harmful outcomes from fever, febrile

convulsions, persist (Karwowska et al, 2002, Sarrell et al. 2002, Walsh et al. 2005).

Information from phobic health professionals and those practicing in line with the

latest scientific evidence will be incongruent, increasing parental concern.

Additionally, more parents in this study reported learning to manage fever by

experience than previously, 39% versus 14% (Crocetti et al. 2001).

Health professionals must update their knowledge and recommend practices in

accordance with the latest scientific evidence. It is imperative all health professionals

provide evidence-based information not only to parents but also to peers and

colleagues. Childhood fever, a frightening experience for parents, is inevitable.

Health professionals have a responsibility to assist parents care safely for febrile

children without undue demands on parents’ own health. The development and use

171

of guidelines for evidence-based fever management and dissemination through

reliable sources is essential. Scientifically based advice, for parents, on how to care

for a febrile child and when to seek medical advice has been available since 1984

(Schmitt 1984, El-Radhi & Carroll 1994) and must be distributed by health

professionals to parents.

6.1.4.7 Strengths and Limitations This large, comprehensive, community-based study of parents’ fever management

highlights the need for evidence-based education of not only parents but also the

health professionals from whom parents reported learning to manage fever (80%).

Care must be taken in generalisation of these findings as the sample was self-

selected, most had university education and lived in major cities and data were

collected by self-report. Findings were not influenced by recruitment method but

were by educational attainment.

6.1.5 Conclusions and Recommendations Fever management remains a challenging time for parents of young children. Their

knowledge is inaccurate and incorrect beliefs about fever being harmful strongly

influence practices with alternating antipyretics to reduce fever becoming a common

practice. Parents with higher education or health industry experience reported greater

concern. There is an urgent need to ensure health professionals’ knowledge is in line

with the latest scientific evidence; parents receiving inconsistent information from

health professionals is unacceptable. Additionally, the development of fever

management guidelines and evidence-based education programs and literature and

consistent use of these tools with all parents of young children is recommended.

172

Further research is needed to determine whether parents’ perceptions about fever

differ when their child is well and febrile, the influences on practice change over

time, the influence of education about febrile convulsions prevalence, predictors and

management of febrile convulsions and the development of fever management

guidelines and their influence on parents’ practices,

6.1.6 Acknowledgements The authors would like to thank the expert panel and parents who gave their valuable

time to participate. This study was supported in part by the Joyce Wickham

Scholarship awarded by the Royal College of Nursing Australia.

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6.2 ARTICLE 2

Over-the-counter medication use for childhood fever: a crossectional study of Australian parents. Walsh, A., Edwards, H., & Fraser, J. (2007). Over-the-counter medication use for

childhood fever: A cross-sectional study of Australian parents. Journal of

Paediatrics and Child Health, doi:10.1111/j.1440-1754.2007.01161.x.

Journal of Paediatrics and Child Health 43(9): 601-606 (c) 2007 Blackwell Publishing

ABSTRACT

Aim: To report Australian parents’ medication (paracetamol, ibuprofen and

homeopathic) use in childhood fever management.

Methods: A cross-sectional survey of 401 Queensland parents of children aged

between 6 months and 5 years recruited through advertising (48.4%), face-to-face

(26.4%) and snowball (24.4%) methods was conducted. A 17-item instrument was

developed; construct and content validity were determined by an expert panel, and

item reliability by test–retest with nine parents. Areas targeted were medication use,

influences on, and barriers to medication use.

Results: Most participants were female, had tertiary education and lived in a major

city (mean age 34.6 years). Reducing children’s fever with over-the-counter

medications was common (91%): 94% of parents reported using paracetamol and

77% reported using ibuprofen. A few (3.7%) used homeopathic remedies. Dosage

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was determined by weight (86.3%), age (84.3%), temperature (32.4%), illness

severity (31.4%) and lethargy (20.9%). Frequency was determined by instructions on

the medication label (55.3%), temperature (40.6%) and well-being (27.7%).

Ibuprofen was administered too frequently by 31.5% (four hourly by 22.8%), and

paracetamol by 3.8%. Fifty-two per cent had alternated medications, 65.8% of these

for temperatures below 38.5°C. Decisions to alternate were influenced by

information from doctors/hospitals (49.5%) and children remaining febrile post-

antipyretic (41.7%). Most parents reported over-the-counter medications as

potentially harmful (73.2%), citing liver (38.2%), stomach (26.4%) and kidney

(18.6%) damage and overdose (35.7%) as concerns. When medications were refused

or spat out (44.0%), parents used force (62.4%), different methods (29.5%) or

suppositories (20.8%).

Conclusions: Most parents used over-the-counter medications to reduce fever,

often below 38.5°C. The belief that these medications were harmful was overridden

by fears of harmful outcomes from fever.

Key Points o Parents believe over-the-counter medications may harm children but still use

them to reduce low grade fevers.

o Influences on alternating medications include recommendations from and

observing heath professionals’ practices and children remaining febrile post-

medication.

o Ibuprofen administration four hourly indicates confusion with paracetamol

administration.

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6.2.1 Introduction Despite more than two decades of literature reporting fever as beneficial.1,2 parents

continue to reduce mild fever, below 38.5ºC, with medications to prevent febrile

convulsions, brain damage and dehydration.3-6 Incorrect antipyretic dosing and

frequency is common, reports of parents overdosing febrile children increased 21%

from 1987 to 1999.7-10 Although literature reporting parents’ beliefs about fever and

medication use abounds literature reporting Australian parents’ fever management

practices is scarce. This paper addresses this deficit by reporting findings from a

crossectional survey of a community based sample of Queensland parents of young

children. Findings will assist Australian health professionals develop and target

education to ensure correct antipyretic use by parents and address parental concerns

about fever.

Antipyretics as parents’ preferred method of managing fever has increased

significantly from 67% in 198011 to 95% in 2002.5 Over the past decade alternating

antipyretics has becoming an accepted practice in controlling fever.4,12 This is

disturbing13,14 as reports of parents’ administration of antipyretics at too low, high, or

frequent doses is common.7,12,15 Recent reports indicated that 45% to 53% of parents

of febrile children had administered incorrect doses of antipyretics prior to seeking

medical assistance.7,12

In addition to reducing temperatures with antipyretics parents also use them to

promote their child’s wellbeing during a febrile episode.3 Using antipyretics

increases parents’ control when their child is ill.16 Temperature reduction is not

always necessary. Many children tolerate low grade fevers to 39.0°C with

remarkable ease.1,17 There is consensus in the literature to reduce temperatures as

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they approach 40°C (moderate fever) as the immunological benefits of fever are

reduced at 40.0ºC.1,17 There is little indication for medication administration below

38.3ºC, excepting to relieve pain.18

In Australia, paracetamol is one of the most common over-the-counter medications

associated with unintentional overdose in children younger than five years of age.19

When Australian parents use paracetamol to calm upset children, lift children’s mood

and to sedate children so that parents can get some sleep, this is not surprising.20

Paracetamol has been attributed with magical qualities and is perceived as a safe

drug; it increases parents’ control and time management during childhood

illnesses.16,20 The increase in antipyretic use internationally4,5 and reports of

Australian parents misuse of paracetamol20 highlight the importance of identifying

Australian parents’ antipyretic use in fever management and the factors influencing

antipyretic use.

This paper describes Australian parents’ medication usage and influences on

medication use for childhood fever management in a community based sample of

Australian parents with children aged between 6-months and 5-years. It reports part

of a larger study exploring parents’ knowledge, beliefs, practices, influences on

practices and medication use, information sources about fever management, reported

elsewhere,21 and predictors of intentions to reduce fever with medications.

6.2.2 Methods

6.2.2.1 Design A self report crossectional survey was conducted.

181

6.2.2.2 Ethical Considerations Approval was obtained from the Queensland University of Technology Human

Research Ethics Committee. Voluntary participation was by informed consent with

assurances of confidentiality and anonymity. Return of a completed survey was taken

as consent to participate. Project conforms to the provisions of the Declaration of

Helsinki.22

6.2.2.3 Sample A purposive convenience sample of parents of a child aged between 6-months and 5-

years, aged 18 years or older, able to read and write in English and living in

Queensland, Australia was targeted. Four hundred and one parents were recruited

through 1) advertisements in parenting magazines (48.4%), 2) childcare centres,

kindergartens and preschools (26.4%) and 3) snowball techniques (24.4%). Three

respondents (0.8%) returned completed questionnaires with the identifying

recruitment number removed. Overall response rate was 36.9%. See Table 6.7 for

targeted and recruited samples.

Table 6.7: Distribution and return according to recruitment methods

Distributed n = 585 Returneda n = 401 Recruitment method

N % N %

Advertising 210 35.9 194 48.4

Childcare, kindergarten, preschool

204 34.9 106 26.4

Snowball 171 29.2 98 24.4

Unknown 3 0.8 a overall response rate 69%

182

6.2.2.4 Procedures In an attempt to recruit a representative sample three recruitment methods were

employed; 1) advertising, 2) face-to-face and 3) snowball.

1. Over a 3-month period advertisements were placed in parenting magazines

accessible free of charge to parents in metropolitan and outer metropolitan areas.

Playgroup Queensland members were targeted through the monthly online

newsletter and quarterly magazine. Queensland parents using Family Day Care

were targeted through care providers. Interested parents contacted the researcher

by phone (49.6%) or email (50.4%). Survey packages, containing a letter of

introduction, information sheet, survey and reply paid envelope, were posted to

interested parents.

2. Parents from metropolitan and outer metropolitan childcare centres,

kindergartens and preschools were informed of the study through posters and

individual letters. Interested parents received a survey package following face-to-

face recruitment and returned completed surveys to a sealed box in the centre.

3. Queensland wide snowball recruitment was conducted through respondents and

researcher networks. Completed surveys were returned by mail or collected by

the initial contact and returned to the researcher.

6.2.2.5 Instrument A self-report questionnaire was developed from the international literature and

discussions with Queensland parents.23 See Table 6.8 for sources. The developed

instrument addressed parents’ medication use, influences on medication use and

perceptions of the safety of medications used for fever management on 17 items. The

term medication was used to indicate over-the-counter medications (e.g.,

paracetamol and ibuprofen) and include homeopathic or non-traditional medications.

183

Content and face validity were determined by an expert panel of paediatric nurses,

nurse academics and paediatric nurse researchers.28

Table 6.8: Instrument items and the sources they were adapted from

Concept Area Items Source Mode

Medication use

Temperature medications used

2 Schmitt 198011

Abdullah et al 198724

Interval scale

Categorical

Dosage 1 Li et al. 200112 Categorical

Frequency 1 Mason et al. 200325 Open-ended

Alternating medications

Frequency of alternating

4 Crocetti et al. 20014

walsh et al. 200723

Categorical

Open-ended

Influences on medication use

Influences on medication administration

4 Sarrell et al. 20023

Kapasi et al. 198026

Li et al. 200012

Walsh et al. 200723

Categorical

Open-ended

Difficulties and how overcome

3

Walsh et al. 200723 Categorical

Open-ended

Beliefs Medication safety

2 Birchley & conroy 200227

Categorical

Open-ended Test-retest (N=9) was undertaken with parents of children aged 6-months to 5-years

and included a paediatric nurse, nurse academics and participants from a semi-

structured discussion study.23 Item reliability for categorical items determined by

Kappa analysis was 1.00. Bland Altman analysis on continuous items indicated

responses for temperature when medications were usually administered was within

184

the limits of agreement (mean difference ± 2SD).29 Instructions and items were clear

and easily understood.

The final instrument explored parents’ medication administration (eight items),

influences on medication administration (seven items) and beliefs about medication

safety (two items). Demographic information was also collected. This was an

exploratory study and categorical items (e.g., yes, no, unsure) often preceded open-

ended items. Table 6.8 provides the items and source.

6.2.2.6 Data Management and Aanalysis Data were entered into SPSS Version 13 (SPSS Inc., Chicago,IL, USA).30 Responses

to open-ended questions were coded prior to entry. Data entry accuracy was ensured

by SPSS Data Entry Builder 4.0 (SPSS Inc., Chicago,IL, USA).31 Demographics

were examined for frequency and distribution. Open-ended items were examined for

frequency of response. Categorical data were explored for frequency; the interval

scale for distribution, normality and outliers. ANOVA and chi-square analyses were

conducted to explore for demographic differences in alternating medications and

frequency of medication administration.

6.2.3 Results Participants (N=401) were aged between 20 and 52 years (mean 34.58, SD 4.83),

female (N=401, 97.5%) and most in a married or defacto relationship (N=375,

93.5%). Some parents (N=401, 11.2%) reported having a child with a chronic illness,

identified as asthma by 77.3% (N=44) of cases. Experience in a health industry

(education in health care or worked in a health setting) was reported by 32.3%

(N=401). Most respondents had tertiary education; more than one child, were born in

Australia and lived in a major city. See Table 6.9 for additional demographic

185

information. Geographical location was determined through residential postcode

initially classified using Delivery Office as per the Australia Post website,32 then the

Accessibility/Remoteness Index of Australia (ARIA) and finally the Remoteness

Area.33

Before presenting the results it should be noted that parents in this sample reported

the temperature they considered to be fever to range from 36.7ºC to 40.5ºC (M

38.2ºC, SD 0.6ºC), high fever ranged from 37.5ºC to 42.6ºC (M 39.4ºC, SD0.8ºC)

and very high fever ranged from 38.0ºC to 43.0ºC (M 40.3ºC, SD 1.0ºC).21

6.2.3.1 Medication Use Parents (N=401, 91%) reduced temperatures ranging from 37.0°C to 40.0°C (M

38.3°C, SD 0.63) with medications. Most used medications to reduce fevers

perceived as high (N=365, 92.0%) and very high fever (97.0%). Disturbingly, nearly

half (43.4%) reduced fever perceived as mild with medications and 57.3% regularly

used medications to reduce temperatures below 38.5ºC. See Figure 6.1 for more

detail.

Figure 6.1: Temperature when parents administer medications to reduce fever N =

368

0

10

20

30

40

50

≤37.9C 38.0C - 38.4C 38.5C - 38.9C ≥39.0C

%

186


N Percent

Highest educational achievement n = 400

Some/completed secondary school

Tafea certificate/diploma

Undergraduate degree

Postgraduate degree

68

74

162

96

17.0

18.5

40.5

24.0

Employment status n = 401

Full-time work/student

Part-time work/student

Casual work

Not at present/on leave

61

128

48

164

15.2

31.9

12.0

40.9

Number of children n = 401

1

2

3 to 6

119

204

78

29.7

50.9

19.5

Country of birth n = 401

Australia

United kingdom

New zealand

Other

325

28

23

25

81.0

7.0

5.8

6.2

Partner’s country of birth n = 401

Australia

United kingdom

New zealand

Other

288

39

18

56

71.8

9.7

4.5

14.0

Geographical location n = 390

Major city (ariab 0 ≤ 0.2)

Inner regional area (aria > 0.2 ≤ 2.4)

Outer regional area (aria > 2.4 ≤ 5.9)

292

80

18

74.9

20.5

4.6 a TAFE Technical And Further Education bAccessibility/Remoteness Index of Australia

187

A small number of parents (N=401, 3.7%) reported using homeopathic preparations

to reduce fever; paracetamol was used by 94% and ibuprofen by 77.1%. Although

decisions to use medications were primarily influenced by temperature many

reported additional factors (N=401, 67.9%). These included the child’s altered

behaviour and/or general wellbeing (57.6%), the presence of pain or discomfort

(32.0%), illness symptoms (22.6%) (e.g., vomiting, cough, cold, rhinitis), sleeping

problems (15.8%) and not eating or drinking (4.1%). Medications were also used

when children had a history of febrile convulsions (3.7%) and non-pharmacological

or homeopathic methods were ineffective (3.3%).

In response to our question regarding frequency of medication administration parents

reported administering paracetamol at one to eight hourly intervals (N=368).

Although most (73.9%) reported four hourly intervals, 3.8% reported more frequent

intervals. Ibuprofen was administered at three to eight hourly intervals (N=260); one-

third (38.6%) reported six hourly administration. Alarmingly, 31.5% reported more

frequent intervals three to five hourly; 22.8% administered ibuprofen four hourly.

Parents with one child (43.3%) reported incorrect ibuprofen administration more

frequently than those with three or more children (15.1%) (F[2,257]=4.114,p=0.02).

A tendency toward incorrect ibuprofen administration was found in parents recruited

through advertising (33.3%) and face-to-face (32.4%) compared with those recruited

by snowball methods (18.9%) (F[2,256]=2.512,p=.08).

Factors influencing medication dosage (N=401) included the child’s weight (86.3%),

age (84.3%), temperature (32.4%), illness severity (31.4%), presence of

lethargy/listlessness (20.9%) and irritability (18.0%). Frequency of administration

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(N=401) was influenced by instructions on the medication label (55.3%), child’s

temperature (40.6%), wellbeing (27.7%), doctor’s advice (10.7%) and time of day

(4.3%) (e.g., at bedtime to assist sleep).

6.2.3.2 Alternating Medications The practice of alternating medications, paracetamol and ibuprofen, was common

(N=401, 51.8%). Parents alternated to reduce mild (5.8%), high (55.6%) and very

high fever (91.8%) (see Figure 6.2). Frequency of alternating ranged from once

(N=207, 19.9%), to rarely (28.2%), sometimes (39.8%), mostly (11.7%) and always

(0.5%). Disturbingly 65.8% of parents who alternated did so to reduce mild fever,

temperatures below 38.5ºC. Decisions to alternate were influenced by advice from a

doctor or at a hospital (49.5%), a child febrile post-medication (41.7%), different

therapeutic qualities of the medications (21.6%) and advice from others (8.8%).

Medications were also alternated to increase comfort (7.8%), for children with a

history of febrile convulsions (2.0%) and to encourage fluid intake (1.5%). Again

parents recruited through advertising (66.7%) reported alternating medications more

frequently than those recruited through face-to-face (58.2%) or snowball (48.1%)

methods (χ2[2, N=397]=7.331,p=.03). Parents who had exposure to the health

industry (61.7%) were more likely (χ2[1,N=396]=7.884,p=.01) to alternate

medications than those with no exposure (46.6%).

6.2.3.3 Medications are Harmful Most parents believed medications used to reduce fever were harmful (N=401,

73.2%). Some were unsure of this (16.3%) and 10.5% believed them not to be

harmful. Parents reported harmful outcomes from these medications to be liver

damage (38.2%), overdose (35.7%), stomach (26.4%) or kidney damage (18.6%),

reduced immunity (7.9%) and allergic reactions (7.5%). Figure 6.3 presents the

189

temperatures at which parents believing medications can cause harm administer

medications.

Febrile children are not always compliant with medication administration; nearly half

the parents (N=401, 44.0%) had experienced difficulties. These included children

refusing to swallow the medication/spitting it out (80.6%), being too distressed by

the illness/fever (45.3%) or too sleepy (2.9%) to take the medication. To ensure

febrile children received medications parents used force (62.4%), a different

administration method such as a cup or spoon (29.5%) or coaxed and encouraged

their child (27.2%). Some used paracetamol suppositories (20.8%), a different

medication (11.6%), non-pharmacological (4.8%) and homeopathic methods (2.3%)

or sought medical advice (2.3%).

6.2.4 Discussion Fever challenges parents’ protective role, making them very anxious. The prevalence

of Queensland parents’ use of medication to reduce fever is high despite believing

these medications harmful. When temperatures were not reduced sufficiently many

parents administered an alternate medication and when children refused medications

force was used to ensure the medication was taken. Ibuprofen use was high with

associated administration at too frequent intervals. In addition to temperature,

parents’ decisions relating to medication dosage and frequency were influenced by

many factors; child’s behaviour, pain/discomfort, medication label, child’s age and

weight. Clearly, fever phobia outweighs parents’ concerns about the safety of

medication use for their children.

190

Figure 6.2: Temperature at which parents who had ‘alternated’ usually administered medications to reduce fever N = 207

Figure 6.3: Temperatures at which parents who believe medications harmful, administer medications N = 265

0

10

20

30

40

50

≤ 37.9C 38.0C - 38.4C 35.5C - 38.9C ≥ 39.0C

%

0

10

20

30

40

50

≤ 37.9C 38.0C - 38.4C 38.5C - 38.9C ≥ 39.0C

%

191

6.2.4.1 Medication Use We found parents medicated to reduce mean temperatures of 38.3ºC, a temperature

similar to their definition of fever 38.2ºC.21 Similar findings have been reported.

American34 parents define fever as 38.0ºC and medicate at 38.1ºC and Canadian5

parents define fever as 37.9ºC and medicate 38.2ºC. Parents reducing temperatures

defined as fever highlight their concerns about fever. More than half the parents in

this study medicated temperatures below 38.5ºC, mild fever, and alternated

medications at temperatures below 39.5ºC, moderate fever.

Although paracetamol was the most frequently used medication, most parents also

used ibuprofen. Internationally, other studies report much lower rates of ibuprofen

use.3,8 This is disturbing as more parents indicated administering ibuprofen at too

frequent intervals with four hourly most common implying there may be confusion

when parents use multiple medications. However, these findings do align with those

from other studies, too frequent administration is more likely with ibuprofen.4,15

The use of antipyretics for behaviour control, improving well-being and sleeping

have been previously reported.3-5, 8,20 Queensland parents’ reports were similar

indicating an urgent need for health professionals to educate parents about

antipyretics’ actions. The attribution of magical qualities to antipyretics encourages

their use, increasing fever phobia and the probability of overdosing. Providing

parents with appropriate fever management strategies such as encouraging fluids and

rest, keeping febrile children comfortable and guidelines of when to use medications

and seek medical advice is needed to reduce phobias and overdosing.

192

6.2.4.2 Alternating Medications – Clinical Implications The rate of alternating medications is increasing and influenced by information from

doctors and hospitals, temperatures not reduced sufficiently after an initial

medication, medication properties and advice from others. Observing health

professionals alternate medications and receiving advice to alternate from doctors

significantly influenced parents’ practices.13,23,35 Alternating has been reported since

the 1980s when aspirin and paracetamol were alternated.36 The influence of the

health profession in alternating is evidenced by the higher percentage of parents with

exposure to this industry alternating. This is possibly understandable when

considered in association of continued reports of health professionals’ concerns

about fever and recommendations to alternate antipyretics.3,5,13 Recent experimental

studies exploring the efficacy of alternating antipyretics in febrile children35,37,38

found minimal additional temperature reduction, that is from 0.3ºC to 1.0ºC as a

result of a combined dose38 from alternating medications over a 24-h period.37

Caution is recommended in advising parents to alternate emphasising the risk of

parental confusion and dosage errors.14,39 Additionally, identifying a need to alternate

to ‘get fever under control’ will increase parental preoccupation with and fear of

fever increasing unnecessary phone calls and medical service use.14 Increased

medication use could produce an associated increase in accidental overdosing. Over-

the-counter medications are readily available; marketing includes recommendations

from celebrity and health professional mothers. Health professionals, especially

doctors and nurses, have a responsibility in child advocacy to make parents more

competent in the use of such easily available and potentially harmful drugs.

193

6.2.4.3 Strengths and Limitations This large, comprehensive study highlights the need for evidence-based education for

parents and the health professionals from whom parents’ information is sourced.

However, care must be taken in generalisation of these findings as the sample was

self-selected and most had tertiary education and lived in major cities and data were

collected by self-report. That those recruited through advertising were more likely to

overdose and alternate medications indicates the sample could be biased toward

medication use. It was not within the scope of this study to collect data relating to

the medication dosages parents administered.

6.2.4.4 Conclusions Health professionals have a vital role in ensuring parents appropriately medicate their

children. The inappropriate and overuse of antipyretics by Queensland parents

highlights the need for parental education about medication dosage and actions.

Fever phobia, implied by Queensland parents’ rate of alternating antipyretics and use

of medications believed harmful to reduce fever, must be addressed. Education based

on the latest scientific evidence is needed for all parents of young children. Ideally all

parents should learn how to manage fever prior to their first child’s first febrile

episode. Findings from this study may not be confined to Queensland. Therefore,

replication of this study in other Australian states is recommended to determine the

extent of parental fever phobia and medication misuse in Australia.

6.2.5 Acknowledgements The authors would like to acknowledge the support of the Royal College of Nursing,

Australia for the Joyce Wickham Memorial Scholarship which assisted in the

undertaking of this study. We would also like to thank those involved in the expert

panel and all the parents who so generously gave of their time to complete the pilot

and main study.

194

6.2.6 References 1 Lorin M. Pathogenesis of fever and its treatment. In: McMillan JB, DeAngelis C,

Feigin RD, Warshaw JB, eds. Oski’s Pediatrics: Principles and Practices, 3rd ed. Philadelphia, PA: Lippincott, Williams & Wilkins, 1999; 848–50.

2 Lorin M. Is fever a friend or a foe? Contemp. Pediatr. 1986; 3: 35–46. 3 Sarrell M, Cohen H, Kahan E. Physicians’, nurses’, and parents’ attitudes to and

knowledge about fever in early childhood. Patient Educ. Coun. 2002; 46: 61–5.

4 Crocetti M, Moghbeli N, Serwint J. Fever phobia revisited: have parental

misconceptions about fever changed in 20 years? Pediatrics 2001; 107: 1241–6.

5 Karwowska A, Nijssen-Jordan C, Johnson D, Davies H. Parental and health care

provider understanding of childhood fever: a Canadian perspective. Can. J. Emerg. Med. 2002; 4: 394–400.

6 van Stuijvenberg M, de Vos S, Tjiang G, Steyerberg E, Derksen-Lubsen G, Moll

H. Parents’ fear regarding fever and febrile seizures. Acta Paediatr. 1999; 88: 618–22.

7 Goldman R, Scolnik D. Underdosing of acetaminophen by parents and emergency

utilization. Pediatr. Emerg. Care 2004; 20: 89–93. 8 Betz C, Grunfeld A. Fever phobia in the emergency department: a survey of

children’s caregivers. Eur. J. Emerg. Med. 2006; 13: 129–33. 9 Kilmon C. Parents’ knowledge and practices related to fever management. J.

Pediatr. Health Care 1987; 1: 173–9. 10 Linder N, Sirota L, Snapir A et al. Parental knowledge of the treatment of fever

in children. IMAJ 1999; 1: 158–60. 11 Schmitt B. Fever phobia: misconceptions of parents about fevers. Am. J. Dis.

Child. 1980; 134: 176–81. 12 Li S, Lacher B, Crain E. Acetaminophen and ibuprofen dosing by parents.

Pediatr. Emerg. Car. 2000; 16: 394–7. 13 Mayoral C, Marino R, Rosenfeld W, Greensher J. Alternating antipyretics: is this

an alternative. Pediatrics 2000; 105: 1009–12. 14 Schmitt B. Concerns over alternating acetaminophen and ibuprofen for fever.

Arch. Pediatr. Adolesc. Med. 2006; 160: 757. 15 Bilenko N, Tessler H, Okbe R, Press J, Gorodischer R. Determinants of

antipyretic misuse in children up to 5 years of age: a cross-sectional study. Clin. Ther. 2006; 28: 783–93.

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16 Lagerlov P, Helseth S, Holager T. Childhood illnesses and the use of paracetamol (acetaminophen): a qualitative study of parents’ management of common childhood illnesses. Fam. Pract. 2003; 20: 717–23.

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knowledge about antipyretic drugs. J. Pediatr. 1980; 97: 1035–7. 27 Birchley N, Conroy S. Parental management of over-the-counter medicines.

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6.3 SUMMARY Parents have negative beliefs about fever and reduce fever to prevent harmful

outcomes, principally febrile convulsions. Temperature reducing strategies were

dependent on the height of fever as was seeking medical advice. Doctors were the

most frequently reported source for learning to manage fever followed by past

experience. Experience influenced practice change. Positive experiences reduced

antipyretic and medical service use, negative experiences increased antipyretic and

medical service use. Antipyretics were the preferred method of fever reduction for

197

mean temperatures of 38.3ºC. Half the parents had alternated antipyretics on the

recommendation of doctors and hospitals.

198

CHAPTER 7

DETERMINANTS OF PARENTS’ INTENTIONS TO REDUCE FEVER

7.1 INTRODUCTION This chapter describes the methods, results and discussion of findings from the

second section of the survey, the theoretical data. The survey used in Study 2 was

completed by 401 parents and is available for perusal in Appendix 2. Two conceptual

models were examined to identify the influence of demographic factors and

theoretical constructs to the Theory of Planned Behavior (TPB) on parents’ fever

management intentions.

The chapter begins by identifying the hypotheses to be tested for each model and the

conceptual frameworks for each model are depicted. Next the approach to analysis,

structural equation modelling, and its appropriateness is discussed. Following this the

method of model estimation and statistical methods for assessing model fit are

described. Preparation of data for analysis including the management of missing

values, normality testing and issues due to nonnormality are then addressed.

Following this bivariate correlations of the demographic variables are described then

the theoretical models tested. The fever model, results and discussion are addressed

first. The medication model is similarly reported. Finally there is a discussion of the

overall findings and comparisons between the models. Implications of the findings

and recommendations for future research are addressed in Chapter 8.

199

7.1.1 Theoretical framework The Theory of Planned Behavior (TPB) (Ajzen, 1985) described in Chapter 3 forms

the theoretical framework used to determine the predictors of parents’ fever

management intentions. Two specific intentions were explored: 1) parents’ intention

to reduce their child’s next fever (fever model) and 2) parents’ intention to reduce

their child’s next fever with over-the-counter medications (medication model).

Central to the TPB is the premise that an individual’s overt behaviour is related to

their intention to perform the behaviour. Behavioural intention is determined by the

person’s attitudes toward the behaviour (an individual’s positive or negative

evaluation of the behaviour), subjective norms (individual’s perception of social

pressure from significant referents) and perceived behavioural control (perceived

potential constraints, both internal and external, on the individual performing the

behaviour) (Ajzen, 2006a,b). In accordance with the TPB, parents’ fever

management intentions were determined by their attitudes toward the benefits or

harmful outcomes from fever, perceived expectations of significant others about

fever reduction, perceptions of control over fever management decision making (self-

efficacy; internal or direct control) and of child medication behaviour

(controllability; external or indirect control) on managing fever. Background

influences contributing to parents’ intentions explored in this study through the TPB

were age, educational level, number of children and experience in the health

industry.

This section of the instrument has a strong theoretical basis. Directions for

developing items to address theoretical constructs of the TPB are well established

and were used to develop the instrument items (Ajzen, 2006a; Francis et al., 2004).

Ajzen (2006a) advises the development of TPB instruments be guided by an

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elicitation study. This was undertaken through a qualitative, elicitation study, Study 1

which is reported in Chapter 5, to determine salient beliefs about fever and fever

management, principal referents in fever management and perceptions of control and

perceived barriers to control when managing fever (Ajzen, 2006a). Findings from the

elicitation study and the fever management literature from 1980 to 2004 directed

item development for use in this section of the instrument.

Parents’ fever management behavioural intentions have not been previously explored

either theoretically or through the TPB. Therefore, theoretical constructs of the TPB,

in relation to parents’ fever management intentions have not been previously

developed. To ensure high reliability of survey items (indicator variables) and correct

estimations of the associations between the theoretical constructs, Ajzen (2006a)

advises the use of indirect measures of the TPB’s constructs. Therefore, the

development of items exploring the theoretical constructs was guided by Ajzen’s

recommendations of the necessary conceptual and methodological considerations

when constructing a TPB instrument (Ajzen, 2006a). Items targeting attitudes

included behavioural beliefs, beliefs about the likely outcome of the behaviour and

the evaluations of these outcomes. Those exploring subjective norms included

normative beliefs, beliefs about the normative expectations of others and motivation

to comply with these expectations. Both internal and external dimensions of

perceived behavioural control (PBC) were explored (Ajzen, 2006a; Frances et al.,

2004). The internal dimensions (direct control) explored were parents’ self-efficacy

in relation to controlling fever management decision making. External dimensions

(indirect control) explored whether child medication behaviour, if a child took

medications easily, made managing fever easier. Several direct items were used to

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measure intention and measured whether parents intended, planned or would try to

reduce the next fever and reduce their child’s next fever with medications (Ajzen,

2006a).

TPB instrument validity and reliability were determined both theoretically and

statistically. When using the TPB construct validity is determined through the

theoretically determined constructs (Ajzen, 2006a). Face and content validity of

instrument items were determined by an expert panel including a psychologist

familiar with TPB research, a paediatric nurse researcher, clinical paediatric nurses

and nurse academics. Analytical methods using confirmatory factor analysis

explored convergent and discriminant validity through the extent to which items

converge on a construct or share a high proportion of variance in common and

construct reliability (Hair, Black, Babin, Anderson & Tatham, 2006). The use of

indirect measures rather than direct measures has been shown to increase TPB

construct reliability (Ajzen, 2006a). Construct and discriminant validity and

construct reliability are discussed later in the chapter in sections addressing each

model.

7.2 HYPOTHESES FOR THE FEVER MODEL Parents’ intentions to reduce their child’s next fever were explored through their:

• Attitudes toward reducing fever to prevent harmful outcomes from fever (fever

beliefs – six items). See attitudes fever in Figure 7.1,

• Normative influences from partner, mother, friends and doctor to reduce fever

(normative beliefs – eight items). See norms fever in Figure 7.1,

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• Perceived behavioural control in decision making related to fever management

(perceived control beliefs, direct control – four items). See PBC decision making

in Figure 7.1,

• Perceived behavioural control related to child medication behaviour (child

behaviours beliefs, indirect control– four items). See PBC child medication

behaviour in Figure 7.1,

• Intentions to reduce their child’s next fever (intentions – three items). See

intentions to reduce fever in Figure 7.1 and

• Demographic factors: age (one item), educational level (one item), number of

children (one item) and experience in the health industry (one item). See Figure

7.1 for age, education, number of children and health industry.

The hypotheses tested in the fever model were:

5 In accordance with the TPB, attitudes, subjective norms and perceived


behaviour) will determine parents' intentions to reduce their child's next fever.

6 Perceived behavioural control related to child medication behaviour will



7 Demographic factors, age, education, number of children and experience in the

health industry (education in a health profession or working in a health setting)

will determine parents’ attitudes, subjective norms and perceived behavioural

control (fever management decision making).

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Demographic variables were not hypothesised to influence parents’ indirect control

over managing fever (perceived behavioural control child medication behaviours).

Figure 7.1 shows a diagrammatic representation of hypothesised relationships

between demographic variables and the theoretical constructs of the TPB with

intention. In accordance with the TPB, attitudes, norms and perceived behavioural

control were assumed to be correlated (Ajzen, 1991). Attitudes, norms, perceived

behaviour control in decision making and child medication behaviour were

hypothesised to determine parents’ intention to reduce fever.

Figure 7.1: Conceptual fever model of the hypothesised relationships determining parents’ intentions to reduce their child’s next fever.

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7.3 HYPOTHESES FOR THE MEDICATION MODEL Parents’ intentions to reduce their child’s next fever with medications were explored

through their:

• Attitudes toward reducing fever with medications to prevent harmful outcomes

from fever (beliefs about reducing fever with medications – eight items). See

attitudes medications in Figure 7.2,

• Normative influences from partner, mother, friends and doctor to reduce fever

with medications (normative beliefs about reducing fever with medications –

eight items). See norms medications in Figure 7.2,

• Perception of control in decision making related to fever management (perceived

control beliefs – four items). See PBC decision making in Figure 7.2,

• Perceived behavioural control related to child medication behaviours (child

behaviours – four items). See PBC child medication behaviour in Figure 7.2,

• Intentions to reduce their child’s next fever with medications (intentions – three

items). See intentions to reduce fever with medications in Figure 7.2 and,

• Demographic factors: age (one item), educational level (one item), number of

children (one item) and experience in the health industry (one item). See Figure

7.2 for age, education, number of children and health industry.

The hypotheses tested in the medication model were:



behaviour) will determine parents' intentions to reduce their child's next fever

with medications.

205

5. Perceived behavioural control related to child medication behaviours will




health industry (education or working in a health setting) will determine parents’

attitudes, subjective norms and perceived behavioural control (fever management

decision making).

Again demographic variables were not hypothesised to influence perceived

behavioural control influenced by child medication behaviour. Perceptions of control

explored were the same in both models. Figure 7.2 shows a diagrammatic

representation of the hypothesised relationships between demographic variables and

the theoretical constructs of the TPB with parents’ intention to reduce fever with

medications.

Figure 7.2: Conceptual medication model of the hypothesised relationships predicting parents’ intentions to reduce their child’s next fever with medications.

206

7.4 APPROACH TO ANALYSIS When using the TPB, Hankins, French and Horne (2000) recommend the use of

multiple regression or structural equation modelling to determine the relative

contributions of attitudes, norms and perceived control in the prediction of intention.

Regression and structural equation modelling are used for different levels of model

complexity. Regression, with its modelling of direct relationships, is a subset of the

complex models with which structural equation modelling can cope (Tabachinck &

Fidell, 2007). With the development of user-friendly computer programs structural

equation modelling has become more popular and is particularly relevant where

constructs that can not be directly measured, such as personality traits and attitudes,

are inferred from test or questionnaire items (Fife-Shaw, 2006). The TPB infers a

person’s attitudes, subjective norms, perceived control and intentions from cross-

products of questionnaire items. Structural equation modelling (SEM) is an

appropriate analytical method for correlational and experimental studies, however

crossectional designs are reported more frequently (Hair et al., 2006).

SEM approaches use two types of models (measurement and structural) to determine

a priori relationships between questionnaire items that define latent constructs

(measurement) and relationships between independent and dependent variables

(structural). In this way the models represent confirmatory modelling of a theory

rather than exploratory modelling using factor analysis and multiple regression

analyses. The measurement model, confirmatory factor analysis (CFA), models the

relationships between observed items and unobserved, or latent variables; confirms

item inclusion in a factor (scale); and whether the items and factor have a predefined

unidimensional or multidimensional relationship. The second model, the structural

model, models the relationships between the unobserved latent variables, developed

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through CFA as well as their relationship to any additional observed variables.

Cross-sectional studies exploring latent variable or measurement models are common

in TPB literature (MacCallum & Austin, 2000).

CFA and exploratory factor analysis answer different research questions. CFA is

used when confirming an established model while exploratory factor analysis is used

to establish a likely model. In accordance with the TPB a full latent variable CFA

model specifies the relationships of the indicator variables to the latent variables and

relationships between latent variables (MacCallum & Austin, 2000).

Both SEM and multiple regression are general linear models valid only if specific

assumptions are met and the hypothesised causal relationships have been determined

by sound underlying theory and research design (Weston & Gore, 2006). Similarly to

regression, SEM allows for the identification of linear relationships between

independent and dependent constructs or directly observed variables. The

assumptions of SEM are:

o interval data are assumed,

o multivariate normality of the indicators – violation leads to large differences

in the chi-square test (χ2) undermining its utility,

o linear relationships between indicator and latent variables,

o theoretically under-identified or just-identified models are inappropriate (the

number of free parameters must be less than or equal to the number of

observations)

o sample size is dependent on the number of parameters and should be greater

than 200 (complex models require larger samples) and

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o single factors should have at least three indicators for a model to be identified

(Kline, 2005).

An exception to the last assumption is when models have more than one factor there

can be a minimum of two indicator variables per factor (Bollen, 1989) in samples

greater than 150 (Marsh & Hau, 1999).

In summary, the analytical capabilities of CFA and SEM make it a more appropriate

method for confirming relationships between questionnaire items and constructs

(CFA) and between both independent and dependent constructs (SEM) in TPB

research when assumptions are met.

7.5 MODEL ESTIMATION The most commonly used estimation method in SEM is maximum likelihood

estimation. It is the statistical principle underlying the derivation of parameter

estimates: the estimates maximising the likelihood (the continuous generalisation)

that the data (the observed covariances) are drawn from a population assumed to be

the same as that reflected in the coefficient estimates. Maximum likelihood

estimation selects estimates with the greatest chance of reproducing the observed

data (Kline, 2005). It is a ‘normal theory’ method and assumes the population

distribution for the errors associated with the indicator variables are multivariate

normal. Generally, if these distributions are severely nonnormal corrections should

be made (Kline, 2005).

In large samples with severely nonnormal distributions on continuous variables the

maximum likelihood parameter estimates are generally accurate. However, estimated

standard errors can be too low (negatively biased) by as much as 25-50% (depending

on data and model) resulting in inappropriate rejection of the null hypothesis and

209

hence an inflated Type I error rate. Additionally, in the presence of nonnormality, the

rate of Type II error may be up to 50% compared to an expected 5% when normal

distributions are assumed, again depending upon the data and model (Chou &

Bentler, 1995; Curran, West & Finch, 1997).

Despite this, parameter estimates generated by maximum likelihood estimations have

been found to be relatively robust against violations of normality assumptions (Hair

et al., 2006; Kline, 2005). Maximum likelihood estimations on nonnormal data have

been compared with generalised least squares and weighted least squares to explore

the effects on fit indices and parameter bias in different sample sizes. Reliable results

have been produced under many circumstances (Olsson, Foss, & Breivik, 2004;

Olsson, Foss, Troye, & Howell, 2000).

7.6 ASSESSING MODEL FIT There are many statistical methods available to determine how well a structural

equation model fits the observed data; these generally assess model goodness-of-fit

(model saturation) and badness-of-fit (model parsimony). Generally both goodness

and badness-of-fit statistics are reported (Hair et al., 2006). Fit statistics used in the

following analyses are discussed below along with the rationale for choosing each

statistic. Goodness-of-fit statistics to be reported are the chi-square goodness-of-fit

statistic, normed chi-square goodness-of-fit index, adjusted goodness-of-fit index and

comparative fit index. The badness-of-fit statistic reported is the root mean square

error approximation.

7.6.1 Chi-Square Goodness-of-Fit Statistic (χ2 GOF)

The most common goodness-of-fit index is the χ2 GOF which assumes multivariate

normality and tests difference in estimated and actual observed covariance matrices.

210

A significant χ2 suggests the model does not fit the sample data, alternatively a

nonsignificant χ2 indicates the model fits the data well. However, finding an exact fit

is rare and as with most statistics large sample sizes increase power resulting in

significance of negligible effect sizes (Weston & Gore, 2006). In SEM χ2 values

increase as sample sizes (degrees of freedom) increase influencing the model χ2 GOF

(Hair et al., 2006; Kline, 2005). To reduce the sensitivity of χ2 to sample size and

model complexity it has been suggested the χ2 value be divided by the degrees of

freedom (df) resulting in a normed chi-square (NC), a lower value. Although there

are no clear guidelines for minimally acceptable NC values, Bollen (1989)

recommended NC ratios of 2:1, 3:1 or even as high as 5:1 as indicating reasonable

fit. More recently Hair et al. (2006) suggested a χ2/df ratio of 3:1 or less to be

associated with better fitting models. However, SEM models reflect an a priori

theory; χ2 GOF might not be important as a measure of model fit (Hair et al., 2006).

Therefore, in the following analyses if χ2 GOF is significant then NC with a ratio

less than 3:1 was used to determine model goodness-of-fit.

7.6.2 Goodness-of-Fit Index (GFI) The GFI is similar to R2 used in regression to summarise the variance explained in a

dependent variable by the independent variables. In SEM it explains the variance

accounted for in the entire model (Weston & Gore, 2006). It is an absolute fit index

and is less sensitive to sample size or χ2. Possible ranges of GFI values are 0 to 1

with higher values indicating better fit. Generally GFI values of .90 have been

accepted as good, others argue for .95 (Hair et al., 2006). In this study, values greater

than .90 are accepted as indicating good fit of model to data.

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7.6.3 Adjusted Goodness of Fit Index (AGFI) The AGFI accounts for model complexity by adjusting the GFI by a ratio of the

degrees of freedom used in the model and the degrees of freedom available. The

AGFI penalises complex models in favour of models with the minimum number of

free paths (fewer degrees of freedom). AGFI values from 0 to 1 are generally lower

than GFI in proportion to model complexity, again greater than .90 is accepted as a

good fit of model to data and was used in this study (Hair et al., 2006).

7.6.4 Comparative Fit Index (CFI) CFI, an incremental fit statistic, is relatively insensitive to model complexity and is a

widely used index (Hair et al., 2006; Weston & Gore, 2006). It assesses the relative

improvement in fit of the model compared with the baseline model (independence

model or null model which assumes zero population covariances among observed

variables). The CFI is normed so that values range from 0 to 1 with higher values

indicating a better fit; values less than .90 are not usually associated with well fitting

models (Hair et al., 2006; Hu and Bentler 1999; Weston & Gore, 2006). Although

values greater than .90 are considered a reasonably good fit of the researcher’s model

to reduce the probability of Type II error with acceptable rates of Type I error CFI

values of .95 and above are used in this study (Hu & Bentler 1999).

7.6.5 Root Mean Square Error Approximation (RMSEA) RMSEA is a parsimony-adjusted index in that its formula includes a measure that

attempts to correct for model complexity and approximates a noncentral χ2

distribution. An added parameter, the non-centrality parameter, measures the degree

of inconsistency of the data with the null hypothesis (Hair et al., 2006; Kline, 2005).

The fit of the researcher’s model is not assumed to be perfect (Hair et al., 2006;

Kline, 2005). In contrast to the preceding, RMSEA is a badness-of-fit index

212

measuring model parsimony. Generally values of .10 or less are acceptable, however,

Hu and Bentler (1999) found RSMEA values of .06 and lower resulted in lower and

acceptable rates of Type II error in simple and complex misspecified models under

both robustness and nonrobustness conditions.

Precision of the RSMEA is assessed by confidence intervals (90%) which provide

additional assistance in evaluation of model fit. A narrow confidence interval

indicates good fit of the RSMEA value in reflecting model fit to the population. If

the lower boundary is less than .05 the model has a close approximate fit; 90%

confidence intervals have a maximum boundary of .10 (Hair et al., 2006). For this

study RMSEA values of .06 and confidence intervals of below .05 to .10 are

accepted as representing close fitting models.

7.7 PREPARATION OF DATA FOR ANALYSIS Prior to analysis, TPB data were recoded to ensure a higher score indicated a

positive, favourable or supportive response representing evidence-based fever

management. Items forming beliefs, norms and perceived control were prepared in

accordance with the TPB (Ajzen, 1991; Ajzen & Fishbein, 1980). Belief indicator

items were created by multiplying the individual’s expectancy and value beliefs,

creating new variables. Subjective norm indicator items were created similarly by

cross-multiplying each individual’s perceived likelihood of a particular individual or

group approving of the behaviour and their motivation to comply with this individual

or group. Perceived behavioural control in fever management decision making (PBC

decision making) indicator items were developed by multiplying each respondent’s

decision making beliefs with their perceptions of the power that making fever

management decision had on managing fever. Perceived behavioural control related

213

to child medication behaviours (PBC child medication behaviour) were created by

multiplying the child’s medication behaviour with its influence on fever

management. As CFA and SEM analyses were to be conducted, belief, norm,

decision making, perceived control child factors and intention items were not

summed.

7.7.1 Management of Missing Data Cases with more than 10% of data missing (10 cases) were excluded from this

analysis leaving a sample of N = 391. The remaining surveys had less than .002% of

data missing completely at random and were included in the analysis (Hair et al.,

2006). On the 14 belief items missing data were replaced with a midpoint response,

indicating a neutral belief. No subjective norm or perceived behavioural control

responses were missing. When participants had indicated a normative response was

not applicable (e.g., they did not have a partner as a referent) this response was

replaced with a median response indicating a theoretically appropriate neutral

normative effect. Two cases had missing data on an intention item; these data were

replaced with the case mean from the other two intention items. Missing

demographic items were replaced prior to SEM analysis. This included replacing

eight age responses with the mean (34), one educational attainment responses with

the median (a degree) and one in experience in the health industry was replaced with

a negative response.

7.7.2 Univariate Normality Testing All variables for inclusion in the analysis were checked for univariate normality

using skewness and kurtosis. Data were not normally distributed on the indicator

items for either independent or dependent latent variables. On 15 of the 19 indicator

items for independent variables, standard deviations were not half the mean and three

214

variables demonstrated positive skewness (greater than + 3.0). Nine items

demonstrated leptokurtic kurtosis (greater than ± 3) (Hair et al., 2006a) with kurtosis

greater than 10 indicating a potential problem on three of these nine items (Kline,

2005). All six outcome indicator variables had standard deviations greater than half

the mean and two demonstrated leptokurtic kurtosis greater than ± 3 (Hair et al.,

2006a). Items with potentially problematic kurtosis were checked for response

congruence and found representative of people who had positive beliefs and practices

in fever management. They did not think fever harmful, administered antipyretics at

39.0ºC to 40.0ºC or did not have a specific temperature at which they administered

antipyretics. These cases represented logical, valid responses from the sample

population and were not removed (Weston & Gore, 2006).

In an attempt to improve univariate normality, square root transformations were

calculated. This is an appropriate method to correct positive skewness (Tabachnick

& Fidell, 2007). Following transformation three belief indicator items retained

minimal leptokurtic kurtosis 3.0, 4.0 and 4.1. As the transformed data did not

demonstrate skewness or extreme kurtosis the transformed data were used in the

following modelling.

7.7.3 Issues Due to Nonnormality There is conflicting information about the effect on nonnormal data in SEM. Hair et

al. (2006) report that in large samples, 250 or greater, violations of univariate

normality have little impact and acceptance of a misspecified model is less likely

when CFI is .95 or higher and standardised root mean residual (SMRS) greater than

.06. SMRS is a badness-of-fit statistic measuring the differences between the

standardised sample variances and covariances with model estimated variances and

215

covariances (Hair, et al., 2006). Although SMRS was not available in the statistical

package used for the analysis, AMOS 6 (Arbuckle, 2005), a similar badness of fit

index, RSMEA was available and was defined earlier. A complex analysis of

conventional and new GOF indices by Hu and Bentler (1999) found that when

RSMEA was less than .05 (or .06) and SRMR less than .06 (.07, .08, .09, .10 or .11)

reasonable proportions (94% to 100%) of misspecified models were rejected.

Additionally, combinations of RSMEA less than .06 and SMRS less than .09 (or .10)

resulted in the least number of Type I and Type II error rates. Bentler (1990) reported

large χ2 and underestimated CFIs to be problems with nonnormally distributed data

in SEM. However, modifying hypothesised models to gain a better χ2 fit of the model

to the data is not recommended as SEM tests predetermined, a priori models.

Modifying theoretical hypotheses could lead to inappropriate non-replicable

modifications in otherwise theoretically adequate models (Byrne, 2001). Models

tested in this study were theoretically sound therefore CFI of .95 or greater, RMSEA

of .06 or less were used to determine model fit.

Another method of accommodating nonnormality is bootstrapping (Yung & Bentler,

1996). Bootstrapping creates multiple sub-samples from an original database and

compares the parametric values over repeated samples drawn with replacement from

the original sample. Bootstrapping allows for the estimation of parameters, standard

errors, and model test statistics to be tested in empirical sampling distributions from

large numbers of generated samples (Kline, 2005; Yung & Bentler, 1996). Bootstrap

estimates are less biased than maximum likelihood estimates when underlying

distributions are nonnormal (Byrne, 2001). In the following analysis 1000 bootstrap

samples automatically generated in AMOS 6 were drawn to determine model fit.

216

In summary, with consideration of the normality issues and complexity of the models

the analyses were conducted using maximum likelihood estimation with

bootstrapping (1000). Model fit to data will be estimated using NC less than 3:1

ratio, GFI greater than .90, AGFI greater than .90, CFI greater than .95 and RMSEA

of .06 or less. Although χ2GOF will be reported in the findings it will not be used as

the method of determining statistical fit of the models to the data.

7.8 RESULTS

7.8.1 Bivariate Exploration of Demographics Initially relationships between demographic variables of those included in the

theoretical analysis (N = 391) were explored through bivariate correlations using

Pearson’s r. Age was significantly correlated with educational attainment (r = .29, p

< .01), number of children (r = .24, p < .01) and experience in the health industry (r

= .19, p < .01). Educational attainment was significantly correlated with experience

in the health industry (r = .16, p < .01). As age was significantly related to all other

demographics being explored it was removed from the conceptual frameworks.

Demographic variables included in the final conceptual models were educational

attainment, number of children and health industry experience. Theoretical variables

were attitudes, subjective norms, PBC decision making and PBC child medication

behaviour. The re-specified conceptual models are presented in Figures 7.3 and 7.4.

7.8.2 Demographics Respondents (N = 391) were aged between 20 and 52 years (mean 34.5, SD 4.7),

female (97.4%) and in a married or defacto relationship (93.3%). Forty-one (10.5%)

had a child who had experienced a febrile convulsion and nine a child with epilepsy

(2.3%). Nearly one third, 32%, had experience in a health setting (either health

education or worked in a health environment). Most had a university education; two

217

or more children, were born in Australia and lived in a major city. See Table 7.1 for

additional demographic information.

Figure 7.3: Re-specified conceptual model of the hypothesised relationships predicting parents’ intentions to reduce their child’s next fever, ‘fever model’

There were no statically significant differences between participants based on their

age, educational achievement or employment status. Parents recruited through

advertising were significantly more likely to come from an inner regional area than

those recruited through face-to-face and snowball (p < 0.01 and < 0.01 respectively)

and less likely to come from a major city (p < 0.01) than those recruited through

face-to-face (F[2,383] = 10.642, p < .01). Recruitment method also influenced

number of children with those recruited through advertising significantly more likely

to have fewer children (p < 0.01) than those recruited through face-to-face (F[2,385]

= 6.208, p < .01). Table 7.2 displays additional recruitment information.

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Figure 7.4: Re-specified conceptual model of the hypothesised relationships predicting parents’ intentions to reduce their child’s next fever with medications, ‘medication model’

7.8.3 Parents’ Intentions to Reduce Their Child’s Next Fever

7.8.3.1 Confirmatory Factor Analysis – Fever Model As all items were developed theoretically, a priori, a four-factor independent cluster

congeneric measurement model was tested. The model was comprised of four latent

variables:

1. Attitude toward reducing fever to prevent harm,

2. Subjective norms about reducing fever,

3. Perceived behavioural control in decision making in fever management and

4. Perceived behavioural control related to child medication behaviour factors.

In accordance with the TPB, items were expected to load uniquely on their respective

latent constructs. Questionnaire items whose cross-products contributed to the

indicator variables in this CFA are presented in Table 7.3. Due to nonnormal

distributions on the indicator items, square root transformed data were used for

modelling.

219


Demographic N %a

Highest Educational Achievement N = 390 Some/completed secondary school TAFE certificate/diploma Undergraduate degree Postgraduate degree

67 74 157 93

17.2 18.9 40.2 23.8

Employment Status N = Not at present/on leave Full-time work/student Part-time work/student Casual work

160 60 123 48

40.9 15.3 31.5 12.3

Number of Children N = 391 1 2 3 to 6

113 202 76

28.9 51.7 19.4

Country of Birth N = 388 Australia United Kingdom New Zealand Other

316 28 22 22

81.4 7.2 5.7 5.7

Partner’s Country of Birth N = 369

Australia United Kingdom New Zealand Other

280 38 18 33

75.9 10.3 4.9 8.9

Geographical Location N = 388 Major city (ARIAb 0 – 0.20) Inner regional area (ARIA 0.21 - 2.40) Outer regional area (ARIA 2.41 to 5.90)

Remote area (ARIA 9.21 to 10.53) Very remote (ARIA 10.54 and over)

287 76 17 7 1

74.0 19.6 4.4 1.8 0.3

a Rounding to 100% bARIA is the Accessibility and Remoteness Index of Australia. Geographical location was determined using respondents’ postcode which was initially classified using Delivery Office as per the Australia Post website (2005), then the Accessibility/Remoteness Index of Australia (ARIA) and finally the Remoteness Area (Trewin, 2005).

220

Table 7.2: Participant demographics by recruitment method N = 388

Advertising (n=207)

Face-to-face (n=104)

Snowball (n=77)

N % N % N % Number of children

1

2

3 to 6

74

99

34

35.7

47.8

16.4

15

64

25

14.4

61.5

24.0

24

37

16

31.2

48.1

20.8

Geographical Location

Major city

Inner regional area

Outer regional area

Remote area

Very remote

Missing

140

55

11

0

1

0

67.6

26.6

5.3

0.0

0.5

0.0

94

10

0

0

0

0

90.4

9.6

0.0

0.0

0.0

0.0

52

10

6

7

0

2

67.5

13.0

7.8

9.1

0.0

2.6

Maximum likelihood estimations were conducted to determine factorial validity of

indicator items with latent factors using AMOS 6.0 (Arbuckle, 2005). Both pattern

and structure coefficients were considered in evaluation of the measurement structure

and multiple criteria used to assess goodness-of-fit. The correlations between

constructs were freely estimated. Pattern coefficients represent the standardised

factor loadings derived from AMOS (Byrne, 2001). Structure coefficients represent

the influence of each factor on items not hypothesised to comprise that factor (Byrne,

2001). Modification indices were examined to enhance model fit to data. These

indices identify systematic error, rather than random measurement error, in item

responses. This error may be derived from characteristics specific to the item,

characteristics specific to the respondents (bias), social desirability or a high degree

of overlap in item content (Byrne, 2001).

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Table 7.3: Items contributing to indicator variables for parents’ beliefs, norms and perception of control in the fever CFA model CODE QUESTIONNAIRE ITEMS

Behavioural Belief Expectation BF1 Reducing my child’s fever will prevent my child

from being harmed by the fever (extremely likely to extremely unlikely)

Reducing my child’s fever to protect them from harm is (extremely good to extremely bad)

BF2 Reducing my child’s fever will reduce any discomfort caused by the fever

Reducing my child’s fever to relieve discomfort is

BF3 Reducing my child’s fever will prevent my child having a febrile convulsion

Reducing my child’s fever to prevent febrile convulsions is

Normative Belief Motivation To Comply NF1 When my child has a fever my husband/partner

thinks I should reduce the fever (extremely likely to extremely unlikely)

When caring for your child with a fever how much do you do what your husband/partner thinks you should do (not at all to very much)

NF2 When my child has a fever my mother thinks I should reduce the fever

When caring for your child with a fever how much do you do what your mother thinks you should do

NF3 When my child has a fever my friends think I should reduce the fever

When caring for your child with a fever how much do you do what your friends think you should do

NF4 When my child has a fever my doctor thinks I should reduce the fever

When caring for your child with a fever how much do you do what your doctor thinks you should do

PBC Decision Making Belief (Direct PBC) Confidence in Performing the Behaviour PC_D1 When my child has a fever I decide how to

manage it For me to decide by myself how to manage my child’s fever makes it (much easier to manage fever to more difficult to manage fever)

PC_D2 Deciding whether or not to use medications to reduce my child’s fever is completely up to me

For me, to decide by myself whether I manage my child’s fever with medications is

PBC Child Medication Behaviour Belief (Indirect PBC) Power of Child Medication Behaviour CF_1 My child takes medications easily when they

have a fever (strongly agree to strongly disagree) When my child has a fever he/she usually takes medications to reduce fever easily, this makes it (much easier to manage fever to more difficult to manage fever)

CF_2 I am confident I will be able to reduce my child’s next fever with medications

For me, using medications to reduce my child’s fever makes it

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In reviewing the modification indices output it was evident that the only

measurement error of any substantial note appeared in the covariances portion of the

output. The largest modification index of 28.88 represented error covariance between

normative influences from mother and friends. Normative means (ranges 1-7)

indicated an unsupportive normative influence; however the means for mother (3.18,

SD 1.24) and friend (3.44, SD 1.17) were more supportive than partner (2.61, SD

1.12) and doctor (2.17, SD 0.99). In this instance there may be a high degree of

overlap in item content or a similar normative influence from these sources, mothers

and friends (Byrne, 2001). If the model was re-estimated with this parameter

specified as free, the overall χ2 would be expected to reduce by 29 and the value of

the estimate itself to reduce by 0.25 (Byrne, 2001). Therefore, the model was

respecified with the error terms for mother and friends allowed to covary.

The resultant model was a good fit to the data in both statistical and practical terms.

GOF indices were χ2(37, N = 391) = 70.26, p = .001, NC 1.90; GFI .97, AGFI .95,

CFI .97 and RMSEA .05 (.03 to .07; 90% CI). The factor structure coefficients for

the estimated parameters are presented in Table 7.4. All indicator variables

demonstrated unidimensional loading onto their respective factors. Loadings ranged

from .48 to .91 and were statistically significant at the .001 level, indicating

discriminant validity. Factor construct reliability was determined by Cronbach’s

Alpha. Reliability of the attitudes toward fever construct was .80, subjective norm in

reducing fever .74, perceived behavioural control (PBC) decision making .78 and

PBC child medication behaviour .65 on the transformed data. See Figure 7.5 for the

CFA fever model. This model demonstrates the relationships between indicator

variables and TPB latent constructs, standardised parameters are reported.

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Parents’ attitudes toward fever were unfavourable; they believed fever should be

reduced to prevent harm, febrile convulsions and discomfort. Beliefs about reducing

fever to prevent discomfort and febrile convulsions were more unfavourable than

those related to reducing fever to prevent harm, although these were still

unfavourable. Parents perceived the strongest normative influence from doctors, an

unsupportive normative influence; they perceive doctors expected fever to be

reduced and were willing to reduce fever based on this perception. Normative

influences from partners were also unsupportive, though not as extreme as doctors.

Interestingly normative influences in reducing fever from their own mother and

friends were ambivalent, more supportive of evidence-based fever management than

that from doctors and partners. Reports of behavioural control over fever

management were positive. Parents believed making fever management decisions

made fever management easier (direct PBC). When children took medications easily

parents found it easier to manage fever (indirect PBC). See Table 7.4 for the factor

structure of the latent constructs and correlations and descriptives for the indicator

variables in the CFA fever model.

7.8.3.2 Structural Equation Model – Fever Model In accordance with the TPB a five-factor cluster measurement model incorporating

parents’ intentions to reduce the next fever and the four constructs (attitudes, norms,

PBC decision making and PBC child medication behaviours) was tested to explore

relationships between the constructs and intention. Following this a structural model

of parents’ intentions to reduce their child’s next fever was tested. The main purpose

of this analysis was to ensure that the constructs under consideration determined

discriminant validity when intention items were included in the model. The latent

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AttitudeFever

.48

BF3e1

.69

.47

BF2e2.69

.82

BF1e3.91

NormFever

.44

NF4e4

.23

NF3e5

.26

NF2e6

.44

NF1e7

.67

.48

.51

.66

PBC ChildMedicationBehaviour

.68

PC_C2e8

.36

PC_C1e9

.83

.60

PBC DecisionMaking.72

PC_D2e10

.56

PC_D1e11

.85

.75

.67

-.54

-.24

-.43

-.08

.34

.48

Figure 7.5: Confirmatory factor analysis model of TPB constructs attitude toward fever being harmful, subjective norms about reducing fever, PBC decision making and PBC child medication behaviour. Note all effects are standardised.

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Table 7.4: Correlations, descriptives and factor structure for the latent fever constructs in the full sample N=391 Intentions Attitude

Fever Norm Fever

PBC Decision

PBC Child

Mean (SD) Minimum Maximum Skewness Kurtosis

Attitude Fever .734

Norm Fever .696 .669

PBC Decision -.198 -.239 -.076

PBC Child -.414 -.535 -.430 .339

Intend .733* .538 .510 -.145 -.304 1.184 (0.333) 1.00 2.65 1.811 2.636

Plan .857 .628 .596 -.170 -.355 1.283 (0.387) 1.00 2.65 1.299 1.003

Try .857 .628 .596 -.170 -.355 1.278 (0.387) 1.00 2.65 1.264 0.748

BF1 .650 .906 .607 -.217 -.485 2.159 (1.039) 1.00 5.92 .953 .468

BF2 .520 .689 .461 -.165 -.369 1.799 (.753) 1.00 4.90 .964 .759

BF3 .509 .693 .464 -.166 -.371 1.806 (.953) 1.00 7.00 1.763 4.119

NF1 .486 .443 .662 -.050 -.284 2.615 (1.115) 1.00 7.00 .820 .497

NF2 .363 .342 .510 -.039 -.219 3.184 (1.239) 1.00 7.00 .322 -.557

NF3 .328 .332 .481 -.037 -.207 3.435 (1.170) 1.00 7.00 .206 -.539

NF4 .435 .445 .665 -.050 -.286 2.175 (.985) 1.00 5.92 .732 -.043

PC_D1 -.152 -.179 -.057 .750 .254 5.869 (1.000) 1.41 7.00 .989 .858

PC_D2 -.165 -.202 -.064 .846 .286 5.860 (1.065) 1.73 7.00 -1.175 1.313

CF_1 -.249 -.321 -.258 .203 .600 5.517 (1.325) 1.00 7.00 -1.076 .617

CF_2 -.341 -.442 -.355 .279 .825 5.541 (1.079) 1.00 7.00 -1.093 1.463

* Factor pattern in bold font. Lower indicator variable scores indicate an unfavourable belief, unsupportive norm, perception of control of fever management through decision making and influence of child medication behaviour on fever management, range 1-7

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variable for intention to reduce the next fever (α .85) was represented by three

indicator items with a stem ‘The next time my child has a fever’ and items ‘I will try

to reduce my child’s fever,’ ‘I intend to reduce my child’s fever’ and I plan to reduce

my child’s fever’. See Table 7.4 for intention indicator item correlations and

descriptives. All indicator items loaded significantly on their construct (p ≤ .001) and

all constructs loaded significantly on each other excepting fever norms and PBC

decision making (p = .28). The model was found to fit the data well χ2(66, N = 391)

= 107.20, p = .001, NC 1.62; GFI .96, AGFI .94, CFI .98 and RMSEA .04 (.03 to

.05; 90% CI). See Table 7.5 for correlations of all variables included in the final CFA

fever model.

Table 7.5: Standardised bivariate correlations for TPB constructs – fever model

Attitudes Norms PBC Decision PBC Child

Norms .68

PBC decision -.24 -.08

PBC child -.55 -.42 .34

Intention to reduce fever

.73 .70 -.20 -.41

Consistent with the TPB a structural model hypothesising relationships between

intentions and attitudes, subjective norms and perceived behavioural control was

tested. The model was also explored for demographic influences of educational

attainment, number of children and experience in the health industry on parents’

attitudes, subjective norms and PBC decision making. The model fitted the data well:

χ2 (102, N = 391) = 180.11, df 102, p ≤.000, NC 1.77, GFI .95, AGFI .93, CFI .96,

RMSEA .04 (.03 to .06; 90% CI). The structural model is presented in Figure 7.6.

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For interpretation of the model, standardised beta weights of .10 and above will be

deemed of practical significance as this area has not been previously explored. Weak

relationships are defined as a standardised beta weight ranging from .10 to .29;

moderate relationships from .30 to .49 and strong relationships from .50 and greater

for this study. With the exception of the pathways from PBC decision making to

intention (β -.07, p = 0.16), attitudes to PBC decision making (β -.18, p = 0.10),

subjective norms to PBC decision making (β .17, p = 0.12) and PBC child factors to

intention (β .03, p = 0.69) all TPB pathways were significant at the 0.05 level.

However, although not statistically significant, attitudes and subjective norms made a

substantive practical contribution to PBC decisions making.

There were some significant, though weak, pathways from demographic variables to

TPB variables (Cohen, 1992). Educational attainment had a significant pathway to

subjective norms (β .12, p = 0.05), attitudes (β .11, p = 0.02) and PBC decision

making (β -.18, p = 0.01). The pathways from experience in the health industry to

subjective norms (β .12, p = 0.05) and number of children to PBC decision making

(β .17, p = 0.01) were also significant. All other pathways from demographic

variables to TPB variables were neither statically nor practically significant. See the

structural model in Figure 7.6 for a clearer presentation of the SEM findings.

The significant statistical and practical contributions discussed here are the

standardised parameters (see Table 7.6). Attitudes had a direct effect on PBC

decision making -.18 (p < 0.001) and parents’ intention to reduce their child’s next

fever .47 (p < 0.001); attitudes total effect on intentions was .40. Subjective norms

had the strongest direct effect on attitudes .53 (p < 0.001) and intention .38 (p <

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0.001) and a total effect on intention of .62. PBC child medication behaviour factors

had a total indirect effect on intention of -.42, mediated through attitudes (indirect -

.21). Although the direct effect of PBC child medication behaviour factors on

intention was not significant, .03, their total effect on intention was -.41. Educational

attainment had a total effect on intention of .14 mediated through attitudes (indirect

.06, non-significant; direct .11, p < 0.05), subjective norms (direct .12, p < 0.05) and

PBC decision making (direct -.18, p < 0.01). However the total effects of educational

attainment were weak: attitude.17; subjective norms .12; PBC decision making -.19

and intention .14. This model explains 60% of the variance in parents’ intentions to

reduce their child’s next fever. The complete record of the standardised and

nonstandardised effects in the fever SEM is available in the Table 7.6.

Hypothesis 1 postulated that in accordance with the TPB, attitudes, subjective norms

and perceived behavioural control would determine parents' intentions to reduce their

child's next fever and was supported, though some of the influence was indirect.

Hypothesis 2 postulated that PBC child medication behaviours would determine

attitudes, subjective norms and BPC decision making and was supported.

Hypothesis 3 postulated that demographic factors would determine attitudes,

subjective norms and PBC decision making. The postulated hypothesis relating to

educational attainment was supported; educational attainment determined attitudes,

subjective norms and PBC decision making. Hypotheses relating to the number of

children and experience in the health industry were unsupported.

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Figure 7.6: Structural model of the predictors of parents’ intentions to reduce their child’s next fever, determined through the Theory of Planned Behavior. Note all effects are standardised; block lines indicate a pathway significant at the 0.05 level, dotted lines indicate pathways of practical substantive influence and dashed lines indicate non-significant pathways with limited practical significance. The variation in attitudes, norms, PBC decision making and intentions are included.

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Table 7.6: Standardised and non-standardised effects of TPB constructs and demographic variables on parents’ intentions to reduce fever

Attitude Norm PBC Decision PBC Child Education No. Children Health

Industry Sta Nstb St Nst St Nst St Nst St Nst St Nst St Nst

Total effects

Attitude * * .53 .55 * * -.52 -.42 .17 .11 .00 .00 .11 .16

Subjective norms * * * * * * -.41 -.31 .12 .07 .07 .06 .12 .15

PBC decision -.18 -.22 .08 .10 * * .29 .30 -.19 -.14 .17 .20 .09 .16

Intention .40 .18 .62 .24 -.07 -.02 -.40 -.12 .14 .03 .02 .01 .09 .05

Direct effects

Attitude * * .53 .55 * * -.31 -.25 .11 .07 -.04 -.03 .05 .07


PBC decision -.18 -.22 .17 .23 * * .27 .27 -.18 -.14 .16 .19 .09 .16

Intention .47 .17 .38 .15 -.07 -.02 .03 .01 .00 .00 .00 .00 .00 .00

Indirect effects

Attitude * * * * * * -.21 -.17 .06 .04 .04 .04 .06 .08

Subjective norms * * * * * * .00 .00 .00 .00 .00 .00 .00 .00

PBC decision * * -.09 -.12 * * .02 .02 -.01 -.01 .01 .01 .00 .00

Intention .01 .01 .24 .09 * * -.42 -.13 .14 .03 .02 .01 .09 .05 a standardised effects; b non-standardised effects * no pathway between the two variables

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7.8.3.3 Interpretation and Discussion of the Results In accordance with the TPB, intentions to reduce fever were directly determined by

attitudes and normative influences and indirectly by PBC child medication

behaviours, mediated through attitudes and subjective norms (Ajzen, 2005). Sixty

percent of the variance in parents’ intentions to reduce their child’s next fever was

explained by unfavourable attitudes, unsupportive subjective norms, positive PBC

child medication behaviours, lower educational level and having experience in the

health industry. Figure 7.6 and Table 7.6 explain these effects in more detail. Neither

PBC decision making nor the number of children parents have made a statistical or

practical significance contribution to intentions to reduce fever. Parents who 1)

believed fever should be reduced to prevent harm and that 2) others expected them to

reduce fever or 3) had children compliant with medications, making it easier for

parents to manage fever, were more likely to intend to reduce their child’s next fever.

Additionally, those with lower education levels (secondary and TAFE) or health

industry experience were more likely to intend to reduce their child’s next fever.

Attitudes Queensland parents, similarly to their international counterparts, reported negative

attitudes toward fever and reduced fever to prevent febrile convulsions, discomfort

and harm (e.g., Al-Eissa, Al-Sanie et al., 2000; Crocetti et al., 2001; Sarrell et al.,

2002; Schmitt, 1980). See Table 7.4. Beliefs related to febrile convulsions and

discomfort were more negative than those toward harm indicating specific reasons

for reducing fever. Fever phobia and undue concerns about negative outcomes from

fever have been reported for decades (e.g., Crocetti et al., 2001; Sarrell et al., 2002;

Schmitt, 1980). Concerns about febrile convulsions have increased over the past 25

years and are now parents’ main concern during febrile episodes (Al-Eissa, Al-Sanie

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et al., 2000; Al-Eissa, Al-Zamil et al., 2000; Crocetti et al., 2001; Karwowska et al.,

2002). Interestingly parents were similarly concerned about preventing discomfort

indicating a strong desire to protect their child from harm, however, fever does not

cause discomfort (Kramer, Naimark, Roberts-Brauer, McDougall, & Leduc, 1991).

Similar influences from febrile convulsions and discomfort is worrying and parents

reporting these beliefs reported stronger intentions to reduce fever. Concern about

discomfort could reflect parents’ protective role, protecting their child from harm, to

reduce the burden of childhood illness on the family (Lagerlov et al., 2003) or a

lifestyle choice, preventing interference in family life (Allotey et al., 2004). This

requires further exploration to identify parents’ rationales for reducing fever to

prevent discomfort.

Fifty-four percent of the variance in parents’ attitude was explained by subjective

norms, PBC child medication behaviours, educational level and health industry

experience. The overall influence of subjective norms and PBC child medication

behaviours on attitudes was strong. PBC child medication behaviours both directly

and indirectly influenced attitudes, mediated through subjective norms. Background

factors of educational level and health industry experience had statistically

significant, though weak influences on attitudes. Parents, believing others expected

them to reduce fever, with children compliant with medications, lower educational

levels and health industry experience were more likely to believe fever should be

reduced to prevent harmful outcomes (unfavourable attitudes). Results from some

studies indicate lower educational levels make attitudes toward fever less favourable

(Impicciatore et al., 1998), conversely others studies found no difference in attitudes

when educational level was explored (Crocetti et al., 2001; Kramer et al., 1985;

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Singhi et al., 1991). The majority of parents in this study had a university education;

this could cause a positive bias making attitudes toward fever more favourable

reducing the influence of education on attitudes.

The negative influence of health industry experience on attitudes has not been

reported. Conceptually, this experience should have a positive influence on attitudes;

these parents should have been exposed to evidence-based information and practices.

The negative influence from health industry experience, found in this model,

indicates the need for further exploration of this phenomenon. Findings confirm

literature reports of health professionals’ negative or unfavourable attitudes toward

fever (e.g., Karwowska, et al., 2002; Poirier, et al., 2000; Walsh, et al., 2004, Wright

& Liebelt, 2007). The strength of the influence of health professionals’ unfavourable

attitudes on those working in a health setting needs exploring.

Interestingly, when PBC child medication behaviours were negative, children were

non-compliant with medications or medication administration did not make it easier

to manage fever, attitudes toward fever were more favourable. This suggests that as

parents have positive experiences with fevers, when fever is not reduced by

medications because their child refused the medication, unfavourable beliefs about

fever, that it is harmful, reduce. The influence of PBC child medication behaviours

on attitudes is understandable. When medication administration does not make it

easier to manage fever and there are no negative outcomes from fever, then parents’

negative beliefs are challenged. With repeated similar experiences and challenges

attitudes become more favourable; parents are less likely to believe that fever must

be reduced. A comment from a parent in Study 1 (Chapter 5) highlights the influence

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of experience on beliefs. Beliefs that temperatures of 38.0ºC cause febrile

convulsions changed after the child had a temperature of 40.0ºC and did not convulse

(Walsh et al., 2007a). This implies a change in accessible beliefs and/or evaluation of

beliefs leading to attitude change.

The role of knowledge as an antecedent of attitudes has been recognised for many

years (Fishbein, 1963). As parents acquire new information, children refusing

medications were unharmed by fever, their subjective evaluation of the attributes of

fever changes subsequently altering attitudes toward fever (Fishbein & Ajzen, 1972).

Therefore, if parents can be encouraged to appropriately defer medication

administration, their attitudes toward fever being harmful may change, becoming

more favourable. The role of education, health professional support and reassurance

to alter the unfavourable beliefs held by parents about fever is evident. Additionally,

as doctors were a significant referent for parents’ fever management decisions,

support for medication delay from doctors should have a positive influence on both

attitudes and subjective norms, making them more supportive of evidence-based

fever management.

Subjective Norms Subjective norms were unsupportive of fever being beneficial (see Table 7.4).

Parents perceived a normative influence from their main referents to reduce fever.

Interestingly, normative influences from their partner and doctors were more

unsupportive than those from their own mothers and friends. Although the influences

from referents had a moderate direct effect on intentions they made the strongest

overall effect on intentions mediated through attitudes and PBC decision making.

Those who perceived a normative influence from referents to reduce fever and were

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motivated to comply with this perceived influence were more likely to intend to

reduce their child’s next fever.

Twenty percent of the variance in subjective norms was explained by moderate

influences from PBC child medication behaviours and weak influences from

educational attainment, experience in the health industry and PBC decision making.

Parents who reported positive PBC child medication behaviours reported greater

influence from unsupportive norms. Conversely when PBC child medication

behaviours were negative (non-compliance or medications did not made it easier to

manage fever) parents reported more supportive normative influences on intentions.

Those with lower educational levels or who had experience in the health industry

reported greater influence from unsupportive norms to reduce fever.

Childhood fever management is an emotional issue motivated by fear of harmful

outcomes (e.g., Crocetti et al., 2001; Sarrell et al., 2002). Parents perceived doctors,

partners, mothers and friends expected fever to be reduced, with greater influence

from doctors and partners. Fever is a common symptom for which parents seek

medical advice (Goldman et al., 2004; McErlean et al., 2001). Most fevers are not

serious; serious illness occurs in less than 10 percent of cases (Knoebel et al., 2002;

McCarthy, 1999). Reducing fever reduces concerns about harmful outcomes from

fever; this in turn reduces inappropriate health service usage (Impicciatore et al.,

1998; Robbins, Hundley, & Osman, 2003). The negative influence from experience

in the health industry confirms this to some degree; doctors were a significant

referent, an unsupportive referent. In health settings children are often unwell and the

association between febrile illnesses and febrile convulsions is much higher than the

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general population (19% versus 5%) (Edwards et al., 2003). The combination of

these explains, to some extent, the unsupportive normative influence of this

experience. A normative influence from partners is understandable. Partners share

the concerns and protective role of the parent who responded to the survey. Other

contributing factors to the strong normative influence from referents possibly include

media reports of dire outcomes from missed diagnoses of febrile illnesses, higher

parental awareness of, and concern about, febrile convulsions and learning to manage

fever from these referents (e.g., Crocetti et al., 2001; Karwowska et al., 2002; Walsh

et al., 2007a; Wright & Liebelt, 2007).

Generally, attitudes or perceived behavioural control, not subjective norms, are the

strongest predictors on intention (Ajzen, 2005). The strong normative influence

found in this study is important, particularly when health professional

recommendations and use of antipyretics for fever management is considered (e.g.,

Edwards et al., 2001; May & Bauchner, 1992; Mayoral et al., 2000; Waterston,

2002). There is an urgent need for further exploration to identify specific normative

influences parents working in health settings receive and then steps can be taken to

correct the situation. In this study, the strength of normative influences on intention

could explain the lack of influence from PBC decision making.

PBC Decision Making PBC decision making was positive. Parents believed deciding how to manage fever

made managing fever easier (see Table 7.4). Conceptually, controlling fever

management decision making would influence fever management intentions ‘If I

decide how to manage fever I will either intend or not intend to reduce fever based

on my attitudes and normative influences’. However, PBC decision making made

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neither a statistical nor practical contribution to intentions. Contributions to PBC

decision making from other variables were weak. Variance in PBC decision making

(18%) was explained by attitudes, subjective norms, PBC child medication

behaviours, educational attainment and number of children. PBC child medication

behaviours made the greatest, though weak, contribution.

Although weak, the influence from multiple variables on parents’ fever management

decision making indicates this to be a complex issue. Parents who held more

favourable attitudes, perceived others to expect fever to be reduced and had a child

compliant with medication administration reported stronger beliefs that making fever

management decisions makes it easier to manage fever. Those who have lower

education levels or more than one child also reported believing that having control

over fever management decisions made it easier to manage fever.

PBC Child Medication Behaviours PBC child medication behaviours were positive (see Table 7.4). Febrile children’s

compliance with medication administration made it easier to manage fever. Although

this had no direct influence on intentions it had a moderate overall effect on

intentions mediated through attitudes and subjective norms. PBC child medication

behaviours had an overall strong effect on attitudes mediated through subjective

norms. They made a moderate contribution to subjective norms and had a weak

effect on PBC decision making. See Figure 7.6 and Table 7.6 for more detail. Parents

reporting positive PBC child medication behaviours reported less favourable

attitudes, fewer supportive normative influences and higher perceptions that

controlling fever management decision making makes it easier to manage fever.

Alternatively, when children either did not take medications or although taking

238

medications, it did not make it easier to manage fever, reported more favourable

attitudes toward fever and more supportive normative influences.

This model identified the significant influence of indirect controlling factors, child

medication behaviour, on attitudes and subjective norms and intentions. When

children take medications easily parents intend to reduce fever. This association has

been discussed previously. The influence of experience on fever management beliefs

and intentions requires further exploration. There were similar influences from both

indicator variables in PBC child medication behaviours, which need further

exploring, possibly as individual direct items; child compliance with medications and

using medications makes it easier to manage fever.

7.8.3.4 Summary Parents’ intentions to reduce their child’s next fever were greater when they reported

unfavourable attitudes, unsupportive normative influences and child compliance with

medications making it easier to manage fever. Parents with higher educational levels

and/or experience in the health industry intended to reduce fever. In this model an

unsupportive normative influence from partners, doctors, mothers and friends had the

greatest overall influence on intentions. Child medication behaviour directly

influenced attitudes and subjective norms and had an indirect influence on intentions.

PBC decision making made little contribution to intention.

7.8.4 Parents’ Intentions to Reduce Fever with Medications

7.8.4.1 Confirmatory Factor Analysis – Medications Model An a priori, four-factor independent cluster congeneric measurement model was

tested. The model was comprised of four latent variables:

1. Attitude toward reducing fever with medications to prevent harm,

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2. Subjective norms about reducing fever with medications,

3. Perceived behavioural control in decision making in fever management and

4. Perceived behavioural control child medication behaviours related to

medication compliance.

In accordance with the TPB, items were expected to load uniquely on their respective

latent constructs. Questionnaire items whose cross-products contributed to the

indicator variables in this CFA are presented in Table 7.7. Due to nonnormal

distributions on the indicator items, square root transformed data were used for

modelling.

In reviewing the modification indices output there was a suggestion that items ‘my

child usually takes medication easily when they have a fever’ and normative

influences from the respondent’s mother cross load. This was not conceptually

probable therefore the covariances were examined. The largest modification index

covariance of 112.05, parameter change .73, indicated a problem with the

measurement error of the above items that might be derived from characteristics

specific to the items, respondents or influenced by social desirability (Aish &

Joreskob 1990). Respecification of the model with these parameters free would

reduce the overall χ2 by 112 and the estimate itself to reduce by .73 (Byrne, 2001).

The model was respecified with these error terms allowed to covary.

When the respecified model was tested the largest modification index of 27.15,

parameter change .25, indicated measurement error covariance between normative

influence from mother and friends. Again differences were present in the normative

means indicating an unsupportive normative influence from partner and doctors and

a neutral to supportive influence from mother and friends (see Table 7.8). In this

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instance there may be a high degree of overlap in item content or a similar influence

from mother and friends. When the model was respecified and retested with these

error terms allowed to covary no further measurement errors were indicated. The

model was a good fit to the data χ2(46, N = 391) = 116.85, p ≤ .001, NC 2.54, GFI

.95, AGFI .92, CFI .96, RMSEA .06 (.05 to .08; 90% CI). Table 7.8 presents the

factor structure of the latent constructs and correlations and descriptives for the

indicator variables in the CFA medication model and Figure 7.7 a diagrammatic

presentation of the CFA medications model.

Parents’ attitudes toward reducing fever with medications were unfavourable when

considered against the latest scientific evidence. They believed fever should be

reduced with medications to prevent harm, febrile convulsions, discomfort and

listlessness. Again the strongest unfavourable beliefs relate to discomfort and febrile

convulsions. Strong unsupportive normative influences from doctors were again

evident with those from partners, mothers and friends similar to those in the fever

model. Parents’ perceived referents expected fever to be reduced with medications.

The same PBC constructs are used in both models. As expected, correlations

between standardised constructs differed according to the model. In the medication

model there was a weaker relationship between subjective norms and attitudes than

in the fever model (.68 versus .59 respectively) and stronger relations between PBC

child medication behaviour and attitudes in the medication model (-.77 versus -.55).

See Figure 7.7 and Table 7.9 for further information about the medication CFA

model. A comparison between CFA models can be achieved by comparing Figures

7.5 and 7.7 and Tables 7.4 and 7.9.

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Table 7.7: Items contributing to indicator variables for parents’ beliefs, norms and perception of control in medication use in fever management for CFAs CODE QUESTIONNAIRE ITEMS

Behavioural Belief Expectation BM1 Reducing my child’s fever with medications will

prevent my child from being harmed by the fever (extremely likely to extremely unlikely)

Reducing my child’s fever with medications to protect them from harm is (extremely good to extremely bad)

BM2 Reducing my child’s fever with medications will reduce any discomfort caused by the fever

Reducing my child’s fever with medications to relieve discomfort is

BM3 Reducing my child’s fever with medications will reduce listlessness (e.g., tiredness preventing normal activities) caused by fever

Reducing my child’s fever to relieve listlessness (e.g., tiredness preventing normal activities) associated with fever is

BM4 Reducing my child’s fever with medications will prevent my child having a febrile convulsion

Reducing my child’s fever with medications to prevent febrile convulsions is

Normative Belief Motivation To Comply NM1 When my child has a fever my husband/partner

thinks I should reduce the fever with medications (extremely likely to extremely unlikely)

When caring for your child with a fever how much do you do what your husband/partner thinks you should do

NM2 When my child has a fever my mother thinks I should reduce the fever with medications

When caring for your child with a fever how much do you do what your mother thinks you should do

NM3 When my child has a fever my friends think I should reduce the fever with medications

When caring for your child with a fever how much do you do what your friends think you should do

NM4 When my child has a fever my doctor thinks I should reduce the fever with medications

When caring for your child with a fever how much do you do what your doctor thinks you should do

PBC Decision Making Belief (Direct PBC) Confidence in Performing the Behaviour PC_D1 When my child has a fever I decide how to manage

it For me to decide by myself how to manage my child’s fever makes it (much easier to manage fever to more difficult to manage fever)

PC_D2 Deciding whether or not to use medications to reduce my child’s fever is completely up to me

For me, to decide by myself whether I manage my child’s fever with medications is

PBC Child Medication Behaviour Belief (Indirect PBC) Power of Child Medication Behaviours PC_C1 My child takes medications easily when they have a

fever (strongly agree to strongly disagree) When my child has a fever he/she usually takes medications to reduce fever easily, this makes it (much easier to manage fever to more difficult to manage fever)

PC_C2 I am confident I will be able to reduce my child’s next fever with medications

For me, using medications to reduce my child’s fever makes it

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7.8.4.2 Structural Equation Model – Medication Model Prior to testing the structural model a five-factor cluster measurement model of all

constructs was evaluated to ensure constructs under consideration demonstrated

discriminant validity. The latent factor for intentions to reduce fever with

medications (α = .93) was represented by a cluster of three indicator variables with a

stem “The next time my child has a fever” and items ‘I will try to reduce my child’s

fever with medications’, ‘I intend to reduce my child’s fever with medications’ and ‘I

plan to reduce my child’s fever with medications’. All indicator variables loaded

significantly on to their construct indicating construct validity. The model was a

good fit to the data χ2(78, N = 391) = 170.35, p ≤ 0.001, NC 2.18, GFI .95, AGFI .92,

CFI .97, RMSEA .06 (.04 to .07; 90% CI). Correlations for all TPB constructs

included in the final medication CFA model are presented in Table 7.8.

Table 7.8: Standardised bivariate correlations for TPB constructs medication model Attitudes Norms PBC

Decision PBC Child

Norms .59

PBC decision -.18 -.10

PBC child -.77 -.49 .36

Intention to reduce fever with medications

.74 .70 -.19 -.70

Again a TPB structural model hypothesising the relationships between intentions and

attitudes, subjective norms, PBC decision making and PBC child medication

behaviours, educational attainment, number of children and experience in the health

industry was tested. The model was a reasonable statistical fit to the data and a good

practical fit with a χ2 (117, N = 391) = 253.185, p ≤ .001, NC 2.16, GFI .93, AGFI

.90, CFI .96, RMSEA .06 (.05 to .06; 90% CI). The model was interpreted using the

243

.99

AttitudeMedications

BM3

1.15

e1.79

1

BM2

.28

e2 .771

BM1

.29

e31.00

1

.47

NormMedications

NM4

.43

e4

NM3

1.01

e5

NM2

1.44

e6

NM1

.75

e7

1.00

1

.881

.741

1.09

1

.44

PBC ChildMedicationBehaviourPC_C2

.41

e8

PC_C11.21

e9

1.311

1.001

.51

PBC DecisionMaking

PC_D2.23

e10

PC_D1.49

e11

1.331

1.001

.41

-.51

-.13

-.23

-.04

.17

BM4

.66

e12

.71

1

.77

.35

Figure 7.7: CFA of predictors of intentions to reduce fevers with medications. Note all effects are standardised.

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Table 7.9: Correlations, descriptives and factor structure for the latent medication constructs for the full sample N=391 Intention Attitude

Fever Norm Fever

PBC Decision

PBC Child

Mean (SD) Minimum Maximum Skewness Kurtosis

Attitude .650

Norm Fever .612 .594

PBC Decision -.169 -.177 -.090

PBC Child -.612 -.779 -.496 .360

Intend .878 .650 .612 -.169 -.612 1.495 (0.453) 1.00 2.65 0.505 -.569

Plan .934 .692 .651 -.180 -.651 1.519 (0.454) 1.00 2.65 0.448 -.678

Try .914 .678 .637 -.176 -.637 1.526 (0.470) 1.00 2.65 0.478 -.717

BM1 .663 .880 .522 -.155 -.686 2.684 (1.133) 1.00 7.00 .824 .844

BM2 .606 .824 .489 -.146 -.642 2.125 (.931) 1.00 7.00 1.462 4.027

BM3 .425 .590 .350 -.104 -.460 3.116 (1.332) 1.00 7.00 .486 -.177

BM4 .486 .659 .391 -.116 -.513 2.046 (1.078) 1.00 7.00 1.508 3.027

NM1 .482 .389 .656 -.059 -.325 2.787 (1.148) 1.00 7.00 .603 -.020

NM2 .272 .230 .388 -.035 -.193 3.721 (1.288) 1.00 7.00 .096 -.725

NM3 .356 .308 .518 -.047 -.257 3.518 (1.174) 1.00 7.00 .080 -.610

NM4 .481 .429 .722 -.065 -.358 2.177 (.953) 1.00 5.29 .715 -.109

PC_D1 -.138 -.126 -.064 .713 .257 5.869 (1.000) 1.41 7.00 -.989 .858

PC_D2 -.171 -.157 -.080 .890 .321 5.860 (1.065) 1.73 7.00 -1.175 1.313

PC_C1 -.352 -.402 -.256 .186 .516 5.517 (1.325) 1.00 7.00 -1.076 .617

PC_C2 -.568 -.626 -.398 .289 .803 5.541 (1.079) 1.00 7.00 -1.093 1.463

* Factor pattern in bold font. A lower score on the indicator variables indicates a negative belief, norm, and perception of control and influence of child factor, range 1-7

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same criteria as the fever model: standardised beta weights of .10 and above were

deemed of practical significance; weak relationships were defined as a standardised

beta weight ranging from .10 to .29; moderate relationships from .30 to .49 and

strong relationships from .50 and greater. In the medication model there was

practical significance and a trend toward statistical significance between attitudes

and PBC decision making (β .26, p = .07). All other pathways were statistically

significant at the .01 level with the exception of the pathways from subjective norms

to PBC decision making (β .01, p = .91) and intention (β -.01, p = .92).

Again some significant, though weak direct, pathways from demographic variables

to TPB constructs were identified. There was a significant pathway from educational

attainment to attitudes (β .09, p = .03) and PBC decision making (β -.21, p ≤ .01).

The pathways from experience in the health industry to subjective norms (β .15, p =

.01) and number of children to PBC decision making (β .17, p = .01) were also

significant. All other pathways from demographic variables to TPB variables were

neither statistically nor practically significant. See Figure 7.8 for a clearer

presentation of the SEM findings.

The effects of TPB constructs on intention reported here are the standardised effects.

Subjective norms had a moderate total effect on intention .46, directly .38 and

indirectly through attitudes (.28). Attitudes had a moderate direct and total effect on

intention (.30) mediated by PBC decision making (.26). However, PBC decision

making has neither a total or direct effect on intentions (-.01). In this model PBC

child medication behaviours had the strongest total effect (-.70) on parents’

intentions to reduce fever with medications (indirect -.42, direct -.28). These factors

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were mediated through attitudes (direct -.62) and subjective norms (direct -.49). PBC

child medication behaviours had a strong overall effect on attitudes of -.76, directly -

.62 and indirectly -.14, mediated through subjective norms (direct -.49). Interestingly

few demographic variables had an effect on the constructs of the TPB or parents’

intentions. Educational attainment and experience in a health environment had direct

(-.21 and .17 respectively) and total effect (-.18 and .17 respectively) on PBC

decision making. See Table 7.10 for the standardised and unstandardised effects.

Hypothesis 1 postulated that in accordance with the TPB, attitudes, subjective norms

and perceived behavioural control would determine parents' intentions to reduce their

child's next fever with medications and was supported.

Hypothesis 2 postulated that PBC child medication behaviours would determine

attitudes, subjective norms and BPC decision making and was supported.

Hypothesis 3 postulated that educational attainment, number of children and

experience in the health industry would determine attitudes, subjective norms and

PBC decision making and was unsupported.

7.8.4.3 Interpretation and Discussion of the Results Again predictive constructs of the TPB, attitudes, subjective norms and PBC child

medication behaviour (indirect PBC) predicted parents’ intentions to reduce fever

with medications (Ajzen, 2005). Sixty-eight percent of the variance in intentions to

was determined by unfavourable attitudes, unsupportive subjective norms, positive

PBC child medication behaviours and PBC decision making, having experience in

the health industry, lower educational level and more children.

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In this model PBC decision making and background factors, educational level,

number of children and health industry experience did not contribute significantly to

parents’ intentions to reduce fever with medications. Figure 7.8 and Table 7.10

explain these effects in more detail. Parents with a child compliant with medication

administration making fever management easier, believed others expected them to

reduce fever with medications and that fever should be reduced with medications to

prevent harm intend to reduce their child’s next fever with medication.

Attitudes Again, attitudes were negative with similar beliefs about reducing fever in relation to

febrile convulsions and discomfort as in the fever model (see Tables 7.4 and 7.8).

Interestingly beliefs about reducing fever with medications to reduce listlessness

were neutral; overall, parents were ambivalent about the effect medications have on

listlessness related to fever. Attitudes toward reducing fever with medications have a

moderate influence on intentions. Parents with unfavourable attitudes who believe

fever should be reduced with medications report greater intentions to reduce their

child’s next fever with medications than those with more favourable attitudes.

The use of medications to reduce fever has increased and is now the preferred

method for most parents with as many as 95% having been reported (Karwowska et

al., 2002). In this study 91% of parents regularly used medications to reduce

temperatures of 38.3ºC ± 0.6ºC, mild fever (Walsh et al., 2007b). Over-the-counter

medication use in childhood is becoming commonplace (Allotey et al., 2004).

Australian parents report using antipyretics not only to reduce pain and fever but to

promote sleep, for mood alteration, babysitting and sending children to school

indicating their use for parental lifestyle factors (Allotey et al., 2004). The reported

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rates of incorrect antipyretic dosing, 47% to 49%, both under and overdosing

(Goldman & Scolnik, 2004; Li et al. 2000), highlight the need for education about

not only appropriate use but also the correct dosage and frequency. In young children

the dosage is determined by weight; weight can change significantly between febrile

episodes, therefore, the correct dose during the last febrile episode is not necessarily

correct for future febrile illnesses.

Sixty-four percent of the variance in parents’ attitudes was explained by subjective

norms, PBC child factors, level of education, number of children and health industry

experience. Parents who believed others expected them to reduce fever with

medications and had a child who took medications easily, making fever management

easier, or lower educational attainment reported fewer favourable attitudes and

greater intentions to reduce their child’s next fever with medications. As in the fever

model, parents of children who did not take medications easily when febrile, reported

more evidence-based attitudes toward fever and fewer unsupportive normative

influences in fever management; fever does not need to be reduced with medications.

In this model PBC child medication behaviour had a strong influence over attitudes;

the influence of subjective norms on attitudes was moderate.

Subjective norms In the medication model subjective norms were unsupportive of evidence-based

fever management (see Table 7.8). Again, the least supportive normative influences

were from doctors. Parents who reported negative normative influence from doctors

(fever should be reduced with medications) intended to reduce their child’s next

fever with medications more frequently than those reporting more supportive norms

from doctors. Twenty-seven percent of the variance in subjective norms was

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explained by PBC child medication behaviours, health industry experience, number

of children and educational level. The overall influence on intentions from referents

was stronger than that from attitudes (.46 versus .30). In this model PBC child

medication behaviours were again the strongest influence on subjective norms.

Health industry experience was the only background factor significantly influencing

intentions.

The literature abounds with reports of doctors advising parents to reduce fever with

medications and alternate medications to maintain fever reduction (Del Vecchio &

Sundel, 2001; May & Bauchner, 1992; Mayoral et al., 2000; Wright & Liebelt,

2007). It is therefore not surprising parents believe doctors expect fever to be

reduced with medications. Parents participating in the qualitative study, Study 1,

sought reassurance from doctors that their fever management practices were correct

and considered them a reliable source of fever management information (Walsh et

al., 2007a). Parents, receiving incorrect information, will intend to reduce fever with

medications in accordance with the advice received from their doctor.

PBC Decision Making Although parents believed making fever management decisions made fever

management easier this again had no significant or practical influence on their fever

management intentions (see Table 7.9). Eighteen percent of the variance in parents’

PBC decision making was explained by their attitudes, subjective norms, PBC child

medication behaviours, educational attainment, number of children and health

industry experience. PBC child medication behaviours, educational attainment and

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Figure 7.8: Structural model of the predictors of parents’ intentions to reduce fever with medications, determined through the Theory of Planned Behavior. Note all effects are standardised; block lines indicate a pathway significant at the 0.05 level, dotted lines a non-significant pathway. The variation in attitudes, norms, perceived behavioural control decision making and intentions are included.

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Table 7.10: Standardised and non-standardised effects of TPB constructs and demographic variables on parents’ intentions to reduce fever with medications

Attitude Norm PBC Decision PBC Child Education No. Children Health

Industry Sta Nstb St Nst St Nst St Nst St Nst St Nst St Nst

Total effects

Attitude * * .28 .32 * * -.76 -.88 .10 .07 .01 .01 .04 .06


PBC decision .26 .27 .08 .10 * * .32 .39 -.18 -.14 .17 .19 .08 .14

Intention .30 .16 .46 .28 -.01 .00 -.70 -.42 .05 .02 .03 .02 .07 .06

Direct effects

Attitude * * .28 .32 * * -.62 -.72 .09 .07 -.01 -.02 -.01 -.01


PBC decision .26 .27 .01 .01 * * .52 .64 -.21 -.16 .17 .19 .07 .12

Intention .30 .16 .38 .23 -.01 .00 -.28 -.17 * * * * * *

Indirect effects

Attitude * * * * * * -.14 -.16 .01 .01 .02 .02 .04 .07

Subjective norms * * * * * * .00 .00 .00 .00 .00 .00 00 00

PBC decision * * .07 .09 * * -.20 -.25 .03 .02 .00 .00 .01 .02

Intention .00 .00 .08 .05 * * -.42 -.25 .05 .02 .03 .02 .07 .06 a standardised effects; b non-standardised effects * no pathway between the two variables

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number of children make a significant contribution to PBC decision making. Parents

reporting unfavourable attitudes reported more frequently that making fever

management decisions makes it easier to manage fever. Parents of children

compliant with medication administration who had lower education levels and more

than one child reported controlling fever management decisions made managing

fever easier.

PBC Child Medication Behaviours Again, PBC child medication behaviours were positive (see Table 7.8); when

children were compliant with medication administration it was easier to manage

fever. In this model PBC child medication behaviours had a direct negative influence

on intentions and very strong overall effect on intentions. When febrile children took

medications easily parents intended to reduce their child’s next fever with

medications more frequently than parents of children who do not take medications

easily. PBC child medication behaviours had a very strong overall influence on

attitudes, mediated through subjective norms, and a strong overall influence on

subjective norms. The moderate influence of PBC child medication behaviours on

PBC decision making was mediated through attitudes and subjective norms. See

Figure 7.8 and Table 7.10.

The strong negative influence of PBC child medication behaviours on attitudes and

subjective norms suggests experience has a significant role in not only attitude

formation (Ajzen, 2005), but also in the influence of subjective norms. When child

non-compliance with medications does not harm the child, have a negative impact on

the child, or make fever management more difficult, then parents’ attitudes toward

fever were more favourable and they report more supportive norms. Parents’

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perception that others expect them to reduce fever with medications was also weaker.

Additionally, when a child is complaint with medications and this does not make

managing fever easier, then attitudes toward the need to reduce fever with

medications and normative influences become more supportive. The combination of

these factors contributed to fewer reports of intentions to reduce fever with

medications, these parents’ fever management practice was more evidence-based.

The strength of these associations has significant implications for parent education

which will be discussed further in the concluding section of this chapter.

Additionally, the considerable influence of child medication behaviour on attitudes,

norms and intentions is important. This has not been reported elsewhere and is

significant not only in fever management but in the general care of children; it

requires further exploration.

7.8.4.4 Summary Parents intended to reduce their child’s next fever with medications when they

reported unfavourable attitudes, fever must be reduced with medications to prevent

harmful outcomes, perceived unsupportive normative influences from doctors,

partners, mothers and friends, and their child was complaint with medications. Lower

levels of education had a negative influence on attitudes making them less favourable

and a positive influence on PBC decision making. The number of children a parent

has positively influenced PBC decision making. Experience in the health industry

again had an adverse influence on subjective norms making them less supportive. In

this model PBC child medication behaviours made the greatest contribution to

intentions.

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7.8.5 Integration of Findings This exploratory study, conceptually based on the Theory of Planned Behavior, was

undertaken to identify predictors of parents’ intentions to 1) reduce childhood fever

and 2) reduce childhood fever with medications. TPB constructs were significant

predictors of intentions in both models predicting 60% of the variance in parents’

intentions in the fever model and 68% in the medication model. Model specific

attitudes toward reducing fever to prevent harm and normative influences to reduce

fever predicted intentions in both models highlighting differences in practice

determinants. The greatest contribution to intention also differed by model.

Unsupportive norms about reducing fever were the most significant predictor of

parents’ intentions to reduce fever with more unsupportive norms from partners and

doctors than mothers and friends. In the medication model positive PBC child

medication behaviours (indirect controlling factors) made the greatest contribution.

Both these constructs were mediated through unfavourable attitudes. Both supportive

norms and negative PBC child medication behaviours made attitudes more

favourable and intentions more evidence-based.

The greatest contribution to intentions from subjective norms, in the fever model, is

unusual (Ajzen, 2005). It highlights the important role referents play in determining a

parent’s fever management intentions. Social pressure to conform was strong.

Reliance on others for advice is understandable when parents’ concerns about fever

and fears of harmful outcomes from fever were considered. Unsupportive normative

influences were greatest from doctors and partners. The attitudes of partners could

either concur or conflict with the participant. However, the unfavourable attitudes

and unsupportive norms reported in the study indicate partners possibly have similar

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attitudes to those who participated. Considering the significant influence from

partners on intentions partners must be included in any educational programs

targeting parents’ evidence-based fever management.

The negative influence from doctors and need for them to update their knowledge

and recommendations in accordance with the latest scientific evidence has been

addressed earlier in this thesis. Queensland doctors’ attitudes and practices have not

been reported though recommendations to reduce fever with medications have

(Pearce & Curtis, 2005). Parents’ perception that doctors expect fever to be reduced

and reduced with medications is understandable and highlights the urgent necessity

for doctors to update their knowledge and recommendations.

Attempts to address parents’ poor knowledge and negative attitudes have been

undertaken over the past few decades and were reported in Chapter 3 (Walsh &

Edwards, 2006). Most education programs reported target knowledge rather than

attitudes or specific practices to reduce unnecessary use of medical services. Despite

this fever continues to be reported as the most frequent reason for seeking medical

advice (Kelly et al., 1996; McErlean et al., 2001). When this is considered in

conjunction with the strength of the unsupportive normative influences from

partners, doctors, mothers and friends to reduce fever it suggests general concerns

about fever not only in health professions but also in the community. The need for

both health professional and community based education is evident when these

findings are considered in relation to other studies.

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The influence of PBC child medication behaviours on intentions to reduce fever with

medications is of particular importance. It is interesting to note that PBC child

medication behaviours have no direct influence on intentions in the fever model and

only a moderate direct influence on intention in the medication model. On the

perceived behavioural control continuum, PBC child medication behaviours have a

stronger influence on intention in the medication model than the fever model (Ajzen,

2005). This construct was mediated through attitudes and subjective norms in both

models implying parents’ past experiences with fever play a role in their subjective

norms and attitudes. Parents are aware that it can be difficult to manage fever.

Therefore, despite intending to manage fever they are cognisant they may not be

successful irrespective of whether they make fever management decisions and, or,

their child was amenable to taking medications. This could help to explain the non-

significant influence of PBC decision making on intention. Although parents report

making fever management decisions makes it easier to manage fever making these

decisions had no influence on their intentions in either model. This is an important

finding and should be considered when developing educational programs to improve

parents’ fever management.

Perceptions of control explored in this study highlight the incomplete control parents

have on fever reduction. Further exploration of these constructs will assist in

determining the exact influence perceived behavioural control has on fever

management intentions. Do positive experiences with fever irrespective of child

medication behaviour influence attitudes, subjective norms and intentions? How does

being the decision maker influence fever management decisions and intentions?

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The literature reporting parents’ fever management knowledge, attitudes and

practices and effective educational programs targeting specific knowledge, beliefs

and practices is extensive (see Chapter 3). With the exception of increased

antipyretic use and alternating antipyretics, unnecessary practices that place children

at risk of overdose, little has changed in these during the past three decades (e.g.,

Abdullah et al., 1987; Anderson, 1988; Karwowska et al., 2002; Kramer et al., 1985;

Schmitt, 1980). Specific determinants of parents’ fever management practices or

intentions have not been reported. This study makes a significant contribution to

childhood fever management and the fever management literature through the

identification of the determinants of parents’ intentions. These findings can

effectively direct educational programs targeting not only parents of young children

and their partners but also health professionals and the general public in the benefits

of fever and evidence-based fever management.

7.8.6 Strengths and Limitations This study adds to the literature reporting parents’ fever management as no

theoretically based analysis or predictors of fever management intentions have been

previously reported. A large sample of Queensland parents (N = 391) was recruited

through three recruitment methods to improve generalisability of the findings. The

questionnaire was grounded in data from preliminary findings in the qualitative

study, Study 1, (Walsh et al., 2007a). Additionally, items were specific to the target,

action, context and time elements of the population of interest (Ajzen, 1991; Ajzen &

Fishbein, 1980) increasing content validity and ensuring appropriateness for the

specific population (Blue, 1995). Construct and discriminant validity and reliability

were confirmed through the CFA. There were minimal missing data and the sample

size was fitting for complex structural equation modelling and to minimise the

258

effects from violations of normality (see SEM assumptions and model estimation)

(Kline, 2005).

On the other hand, findings and generalisations should be considered with the

following in mind. The sample was self-selected, mostly females who had a

university education and lived in a major city. Data were self-reported. Raw data

were not normally distributed and some kurtosis remained following square root

transformation. On the other hand, a sample size calculation was conducted prior to

data collection and the sample was larger than required. In addition, all efforts were

made to reduce influence on the analysis from non-Normality (see Assessing Model

Fit and Issues due to non-Normality). Multiple measures of goodness-of-fit statistics

were used to determine model fit to data and good fit was found.

7.8.7 Conclusions The TPB predicted the determinants of parents’ intentions to reduce fever and reduce

fever with medications. Interestingly, the strongest direct predictor of intentions was

not the strongest overall predictor in either model. This is important and highlights

the need for complex analyses of complex behaviours, behaviours which include an

emotional component. Different constructs make the greatest contribution to

intention in the models, subjective norms in the fever model and PBC child

medication behaviours in the medication model. PBC decision making made no

significant contribution to intention in either model. Both perceived behavioural

control constructs require further exploration to determine the specific influences

perceptions of control have over not only intentions but also attitudes and subjective

norms. Caring for a febrile child is a highly emotive experience for parents as is

attempting to medicate a sick child who refuses medications. Parents’ need to protect

their child may influence both perceived behavioural constructs explored in this

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study. Further studies should explore parents’ emotional involvement during a febrile

illness as well as their behavioural intentions and behaviours. Exploration of moral

and descriptive norms may give more insight into the strong influence of subjective

norms in the fever model.

Parents intended to reduce fever and reduce fever with medications. Intentions were

determined by unfavourable attitudes, unsupportive subjective norms and positive

PBC child medication behaviours. Similar percentages of the variation in intention

were predicted in both models. The significant contribution of subjective norms to

attitudes and intention in both models highlight the strength of parents’ perceived

normative influence to reduce fever and the strength of this influence. Believing

doctors expect fever to be reduced identifies the need for health professionals to

upgrade their knowledge. PBC child medication behaviours contribution to intention

in the medication model was much greater than in the fever model. This requires

further exploration as medications are parents’ preferred method of fever

management. Although demographic factors have some influence on attitudes,

subjective norms and PBC decision making they have a weak overall influence on

intention in the fever model only. However, this may be influenced by sample

homogeneity.

Parents’ intentions and the determinants of intentions in both models highlight the

need for education of both parents and health professionals to reduce the strong

unsupportive normative influences which in turn influence decision making and

intentions. It is imperative health professionals consistently provide evidence-based

information about fever management, not only to parents of young children but to

260

the community as a whole. Identification of an influence on intentions of non-

compliance with antipyretics highlights an unexpected need for parents; the skill to

medicate children when necessary. Doctors order medications for children; they and

other health professionals have an important role in ensuring parents can safely

administer these medications when necessary.

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CHAPTER 8

INTEGRATION OF FINDINGS AND CONCLUSIONS

8.1 INTRODUCTION The overall aims of this thesis were to identify parents’ knowledge, beliefs, practices

and influences on childhood fever management practices. Specific aims were to:

1. Identify Queensland parents’ knowledge of fever, beliefs about fever, fever

management practices, antipyretic use, influences on practices and sources of

information about fever management. (Study 1 & 2)

2. Develop and trial a comprehensive instrument to explore parents’ childhood

fever management and the influences on fever management practices. (Study

1 & 2)

3. Identify the determinants of parents’ intentions to 1) reduce their child’s next

fever and 2) reduce their child’s next fever with antipyretics through the

Theory of Planned Behavior. (Study 2)

The research is unique in that it provides not only a comprehensive understanding of

parents’ fever management and the underlying factors influencing their practices but

also the determinants of their behavioural intentions though the Theory of Planned

Behavior. This chapter synthesises the key findings and examines their practical

implications for parents and health professionals. Findings from each study have

been discussed in earlier chapters. This final chapter begins with an integration of the

key findings from the two studies and a discussion of the related literature. Following

this the strengths and limitations of the research are presented then the implications

262

of the findings for parents and health professionals are discussed. Finally,

recommendations for future research are made and general conclusions presented.

8.2 INTEGRATION OF KEY FINDINGS Fever was perceived as a negative event by parents in these studies and they also

believe significant others have similar perceptions. Parents believed fever was

harmful, causing febrile convulsions, brain damage, cardiac events or a stroke and

intended to reduce fever to prevent harm. Negative beliefs about fever produced

unfavourable attitudes toward fever and were a significant determinant in parents’

intentions to reduce fever.

Parents’ knowledge about fever and appropriate antipyretic administration was

limited and confounded by negative beliefs. Beliefs about the immunological

benefits of fever were vague in Study 1 and beliefs about harmful outcomes from

fever were prevalent in both studies. Confusion about beneficial effects of fever has

been previously reported. Although considering low grade fevers beneficial parents

reported it necessary to reduce low grade fevers without other symptoms (Sarrell, et

al., 2002). Beliefs about the need to reduce fever to prevent febrile convulsions and

brain damage are common (eg., Crocetti, 2001; Karwowska et al., 2002; Sarrell et

al., 2002) and were reported by participants in both studies. Correct beliefs about

fever causing dehydration (eg., Holtzclaw, 1992; Lorin 1999; Reeves-Swift, 1990;

Schmitt, 1994) were reported in Study 2 and have been reported lately indicating

parents have some evidence-based knowledge about fever (Karwowska et al., 2002).

However, parents in both studies reported that fever indicated a serious illness,

highlighting their beliefs that fever is harmful. The impact of knowledge and beliefs

on practices was evident in parents’ intentions to reduce fever. Unfavourable

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attitudes toward fever were a significant determinant of parents’ intention to reduce

fever in both models tested in Study 2.

Fears about harmful outcomes from fever overrode parents’ beliefs that antipyretics

could be harmful. Despite believing antipyretics were harmful, the majority of

parents in both studies regularly used them to reduce fever. In Study 2 parents used

antipyretics for a mean temperature of 38.3ºC. Reducing low grade fevers with

antipyretics is not uncommon in the literature and reports of parents’ reliance on

antipyretics to control fever are increasing (Crocetti, 2001; Karwowska et al., 2002).

In 1980 in the United States only 11% of parents reported reducing low grade fevers,

37.8ºC (Schmitt, 1980), however, this increased to 25% in 2001 (Crocetti et al.,

2001). In the mid 2000s, 70% of Greek mothers reported reducing temperatures

between 37.5ºC to 38.5ºC with antipyretics (Matziou et al., in press). Antipyretics as

the preferred method of managing fever increased from 67% in 1980 to 95% in 2002

(Karwowska et al., 2002; Schmitt, 1980); 91% of parents reported this in Study 2.

Practices confirmed negative beliefs and unfavourable attitudes with more than half

those in Study 2 regularly reducing mild fevers and sometimes normal temperatures

with antipyretics.

Although parents reported reducing low grade fevers with antipyretics, the range of

temperatures reduced varied considerably, from 37.0ºC to 40.0ºC, indicating

different levels of knowledge of and beliefs about fever and some appropriate use of

antipyretics. Despite this, parents’ overall attitudes in Study 2 were strong and

unfavourable. Ajzen (2005) considers strong attitudes to be relatively stable over

time and strengthened by experience with the attitude object, in this case childhood

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fever, and information about the issue. Factors influencing parents’ beliefs are

multifactorial (Poirier et al., 2000). Parents in both studies had experience with

childhood fever and sought information about how to manage fever from multiple

sources. Positive and negative experiences influencing practice changes were

reported in Study 1 and practice changes over time were reported in Study 2. In

Australia, catastrophic outcomes from serious febrile illnesses are newsworthy and

receive significant media attention. This can cause parents to reflect on their

attitudes. Those with unfavourable attitudes toward fever could incorporate this

information reinforcing their attitudes and intentions to reduce fever (Ajzen, 2005).

Unfavourable attitudes toward fever significantly determined intentions to reduce

fever in both models.

Parents reported learning to manage fever from doctors, past experience, family and

friends. Other studies report parents gathering fever management information from

similar sources (eg., Al-Eissa, Al-Zamil, et al., 2000; Crocetti, 2001; Karwowska et

al., 2002). In Study 2 parents’ intentions to reduce fever and reduce fever with

medications were strongly influenced by beliefs that others expected them to reduce

fever, indicating unsupportive norms. They perceived strong social pressure from

partners and doctors to reduce fever, stronger than that from their own mothers and

friends. In the fever model unsupportive norms were the strongest determinant of

intention both directly and mediated through attitudes. Different strengths in

perceived expectations highlight the conflict parents experience with childhood fever

management.

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The impact of parents’ perceived expectations of others on their fever management

practices has not been reported previously. Unsupportive normative influences could

reflect a moral or ethical component as well as parents’ emotional involvement in

caring for a febrile child; particularly as the strongest normative influences were

from doctors in both models. Caring for a febrile child is emotionally taxing (Kai,

1996; Lagerlov et al., 2003). Concerns about their child elicit parents’ protective role

and their duty of care for their child (Kai, 1996). Mothers report preferring to stay

close to febrile children; not wanting to delegate care and postponing other duties

and social activities (Lagerlov et al., 2003). The strong influence from partners to

reduce fever indicates they possibly have similar concerns to the parents who

participated in Study 2. However, it was not within the scope of the thesis to explore

this. Stronger normative influences from partners in parenting intentions, compared

with mothers and friends, were found in a study determining the predictors of

parents’ intentions to attend parenting classes (Wellington, White & Liossis, 2006).

The need for support from partners in parenting practices may have a strong

normative influence on parenting intentions and needs further examination. The

strong unsupportive normative influence from partners indicates parents’ need for

approval from their partner when caring for a febrile child.

Doctors are presumed knowledgeable about health issues. Parents in Study 1

reported doctors as their most reliable source of fever management information

(Walsh & Edwards, 2007). In Study 2 doctors were the most frequent source of fever

management information with nurses being reported less frequently. Practices and

intentions based on beliefs of doctors’ expectations of practice should reflect the

latest scientific evidence. This was not so. Parents, believing doctors expected them

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to, reduced fever with antipyretics; alternated antipyretics when fever was not

sufficiently reduced or returned, and intended to reduce fever with antipyretics.

Recommendations from doctors to reduce fever and alternate antipyretics to

normalise temperature during febrile illnesses continue to be reported, supporting

parents’ normative beliefs (May & Bauchner, 1992; Mayoral et al., 2000; Wright &

Leibelt, 2007). The role of health professionals was substantiated in Study 2 by the

impact that having health industry experience had on unsupportive norms. These

parents reported stronger normative influences to reduce fever and reduce fever with

antipyretics than those without this experience.

Fortunately not all authors or health professionals advise parents to reduce fever.

Some recommend evidence-based fever management and the use of antipyretics for

pain relief during febrile illnesses, not fever reduction (eg., Lorin, 1999; Mayoral et

al., 2000; Schmitt, 2006; Walsh et al., 2005; Watts et al., 2003). On the other hand,

Australian general practitioners have been advised to recommend parents normalise

fever with antipyretics despite scientific evidence recommending not reducing fever

(Pearce & Curtis, 2005). The rationale for this advice was the general practitioners’

relationship with their patients (parents in this case), which was considered to be

more important, and a stronger determinant of practice recommendations, than

scientific evidence. Although believing doctors a credible, reliable source of

information, parents in both studies received conflicting information about fever

management from doctors. Receiving conflicting information, not receiving a

definitive diagnosis and incongruence in perception of illness severity was reported

to harm the doctor-parent relationship. When unsatisfied with medical advice,

parents sought advice elsewhere: from another general practitioner or an emergency

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department increasing health service usage. Receiving conflicting advice challenges

parents’ protective roles and to overcome this they seek further information to ensure

they are correctly caring for their child.

Although parents want to protect their child from harm their children are not always

compliant with their wishes. In Study 2, parents reported febrile children were not

always compliant with medication administration. This is an important finding

indicating a need for health professionals to ensure parents are able to medicate their

children when necessary. Some children need regular medications; others may need a

course of, for example, antibiotics or an analgesic for pain relief. When medications

are needed, it is important children receive correct doses at appropriate intervals.

Health professionals have an important role in teaching parents to medicate their

children correctly ensuring the prescribed dose is administered.

Another important finding from Study 2 was the effect child medication behaviours

have on attitudes and subjective norms. When children did not take medications

easily parents reported more favourable attitudes, supportive norms and intentions

indicative of evidence-based fever management. This indicates parents had more

positive beliefs about fever being beneficial or that fever was not harmful and that

they were less likely to believe others expected fever should be reduced with

antipyretics. Further exploration of the specific effect of child medication behaviours

on parental beliefs is necessary.

The influence of child medication behaviour has not been previously reported in

relation to childhood fever management. This finding has implications for parent

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education indicating the positive role experience can play in fever management.

When children refusing antipyretics were unharmed during febrile episodes parents

received new information about fever and fever management which supports Ajzen’s

theory on attitude change (Ajzen, 2005). Parents’ direct personal experiences, in this

case no negative outcome from fever, produced more favourable attitudes. The

unfavourable attitudes of the parents, whose febrile children who were reluctant to

take medications, were regularly challenged.

Highlighting the importance of child medication behaviours on antipyretic

administration was the finding that these behaviours had no direct influence on

intentions in the fever model but had both a direct and the strongest overall influence

in the medication model. Medication use was parents’ preferred method of reducing

fever in these and other studies (eg., Crocetti, 2001; Karwowska et al., 2002;

Matziou et al., in press; Mc Erlean et al., 2001). In light of the rapid increase in the

practice of alternating antipyretics (Crocetti, 2001; Li et al., 2000; Wright & Leibelt,

2007; Matziou et al., in press) the influence of negative child medication behaviours

on parents’ intentions to use antipyretics is a key finding from this research.

Most parents regularly used medications, with half alternating antipyretics, and

parents intended to reduce their child’s next fever with medications. This is

worrying as many parents incorrectly determined medication dose and frequency.

They reported using the height or recurrence of fever, illness severity and the child’s

general wellbeing. Height of fever is reported to be a common determining factor in

parents’ antipyretic administration (eg., Crocetti, 2001; Karwowska et al., 2002). As

in other studies, overdosing with ibuprofen was more common (Bilenko, Tessler,

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Okbe, Press, & Gorodischer, 2006; Li, Lacher, & Crain, 2000). In Study 2, three

quarters of the parents used both antipyretics. Confusion from using two antipyretics

was indicated through the number of parents who administered ibuprofen at four

hourly intervals (22%). There are recommendations in the literature for paracetamol

as the preferred medication for pain and fever in children as fewer adverse drug

reactions are associated with paracetamol compared with ibuprofen (Titchen,

Cranswick & Beggs, 2005).

Rationales for antipyretic use were also erroneous. Parents in Study 2 used

antipyretics: to reduce illness symptoms such as coughs, colds, rhinitis, vomiting

and pain; for sleeping problems; and to improve the child’s general wellbeing. This

reflects parents’ beliefs in the 1980s when antipyretics were believed to have

antihistamine, antiviral and decongestant properties (Ames et al., 1982). Australian

parents use paracetamol to calm upset children, improve children’s mood and

promote sleep (Allotey et al., 2004). Of concern is parents’ preference for

antipyretics to control fever and the proportion of parents who alternate antipyretics.

This indicates a normalising of medication use and the use of analgesics/antipyretics

in a preventative rather than curative role despite believing that

analgesics/antipyretics can be harmful.

Fortunately, not all parents relied on antipyretics. In both studies some parents

reported a reduction in antipyretic use over time. With experience and as their child

aged they became more confident in caring for febrile children and delayed

antipyretic use. Alternatively, some increased antipyretic use over time indicating

less favourable attitudes and unsupportive normative influences on their fever

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management intentions. Experiences with febrile children influenced decisions about

antipyretic use in Study 1. Further exploration of specific experiences and their

influence is needed and could assist in the development of scenarios for use with

parents to promote evidence-based fever management.

However, although influenced by unfavourable attitudes and positive child

medication behaviours, making fever management decisions did not influence

parents’ intentions to reduce fever in either of the models tested in Study 2. This,

when considered with the high reported rate of antipyretic use, indicates parents

encounter difficulties when attempting to control or normalise fever. Parents’ use of

antipyretics and inability to normalise temperature prior to seeking medical advice

confirms this (Betz & Grunfield, 2006; Karwowska et al., 2002; Mason, Thorp &

Burke, 2003). Parents intended to reduce fever irrespective of their role in making

fever management decisions. The lack of influence of decision making on fever

management intentions is an important finding and of significant value when

developing education programs. Targeting parents’ decision making will not alter

their intentions or behaviour. Areas for educational programs to target, identified

through this research, are unfavourable attitudes and unsupportive normative

influences and providing parents with positive experiences with childhood fevers that

have not been reduced by antipyretics.

8.3 THEORETICAL IMPLICATIONS This thesis has a strong theoretical base through employment of the TPB, a theory

acknowledged for its ability to identify attitude-behaviour relationships and

determinants of behavioural intention in situations where people do not have

complete control (Ajzen, 1985, 1991, 2005; Armitage and Conner, 2001). Parents’

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management of childhood fever is guided by many factors: fear of harmful

outcomes; a need to protect their child; inaccurate and/or conflicting information

about best practice; and that it is not under their volitional control. This cognitive

theory predicts the cognitive determinants of behavioural intentions in people not

necessarily motivated to or interested in changing behaviour. The predictive ability

of the TPB in health-related behaviours has been repeatedly demonstrated through a

number of reviews including meta-analyses (eg., Albarracin, Johnson, Fishbein &

Muellerleile, 2001; Armitage & Connor, 2001; Godin & Kok, 1996). Generally the

TPB explains around 40% of the variance in people’s intentions and 34% of the

variance in their health related behaviour (Armitage & Conner, 2001; Godin & Kok,

1996; Rivis & Sheeran, 2003).

Despite the volume of literature reporting TPB studies there is a dearth of literature

reporting the determinants of parents’ intentions when caring for their child’s health.

In those published, while some report the determinants of parenting intentions not all

report the predicted variance in intention. A high correlation was found between

maternal attitudes toward infant feeding methods and intentions, .67, and intentions

with behaviour, .82 (Manstead, Proffitt & Smart, 1983). Maternal attitudes toward

restricting infants’ sugar intake correlated with their intentions, .64 (Beale &

Manstead, 1991). Parental attitudes toward the use of child car restraints were

correlated with intention, .77, and predicted 67% of the variance in parents’

intentions (Ferraro, 2004). In the above studies attitudes and perceived behavioural

control predicted intentions, however, subjective norms made no significant

contribution to intentions. More recently, subjective norms were found to make a

significant contribution to parents’ intentions to attend group parenting education (β

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.33); 37% of variance in parents’ intention was predicted in this study (Wellington &

White, 2006). Interestingly, in this study perceptions of control did not significantly

contribute to intentions and attitudes were the strongest predictor, stronger than

subjective norms.

The findings explain a significant amount of variance in factors influencing parents’

fever management intentions. In this thesis the TPB explained 60% and 68% of the

variance in parents’ fever management intentions. Parents’ attitudes toward reducing

fever to prevent harm and reducing fever with medications to prevent harm were

highly correlated, .73 and .74 respectively. Subjective norms had a high correlation,

.70, with intention in both models. Perceived control over decision making was

weakly correlated with intention, -.20 in the fever model and -.19 in the medication

model. Perceptions of control due to child medication behaviour were moderately

correlated with intention in the fever model, -.41, and highly correlated in the

medication model. -.70. Associations between behavioural intention and behaviour

were not within the scope of this thesis and need exploring in future studies.

However, this thesis makes a significant contribution to parenting and TPB literature

through the amount of variance explained in the behavioural intentions of parents in

a parenting behaviour; a behaviour that involves consideration of numerous factors

and is highly emotional.

Through the TPB this thesis has identified the difficulties parents have in caring for

an ill child. The finding of strong unsupportive normative influences implies parents

of ill children need to be perceived as caring appropriately for their child, particularly

by their partner and doctor. Are parents similarly concerned about other parenting

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behaviours, such as, infant feeding methods, introducing solids, healthy food choices,

toilet training or immunisation? The TPB is acknowledged as an excellent theory for

identifying health related problems yet there is little research identifying

determinants of parenting styles and decision making (eg., Armitage & Conner,

2001; Albarracin et al., 2001; Ajzen 2005; Godin & Kok, 1996). Further exploration

of these areas is needed. Methods used in this thesis are appropriate for exploring the

determinants of other parenting behavioural intentions.

8.4 STRENGTHS AND LIMITATIONS The findings from this thesis are important. Australian parents’ fever management

practices and influences on their practice have not previously been reported. Decades

of research have identified parents’ knowledge, attitudes and practices but not the

determinants of these practices (see Chapter 3). No theoretical exploration of

parents’ fever management intentions has been reported. Identification of predictors

of intentions and the complex decision making involved in parents’ fever

management intentions, through a major attitude-behaviour theory, provides

important information for health professionals educating parents about childhood

fever management.

In accordance with the TPB an elicitation study was conducted to identify the current

salient beliefs, practices and referents (Ajzen, 2006). This qualitative study informed

the development of the instrument guided by advice from Ajzen (2006b) and Francis

et al. (2004) and was further refined following the piloting with nine parents. To

ensure construct reliability of indirect variables, multiple measures of subjective

norms and both direct and indirect measures of perceived behavioural control were

used (Ajzen, 2006b). Face and content validity were confirmed by an expert panel

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and a pilot study (Polit & Beck 2006), construct and discriminant validity and

construct reliability were confirmed through confirmatory factor analysis (Hair et al.,

2006). The comprehensive instrument developed in this thesis contributes to fever

management literature, provides an instrument to enable comparison studies to be

undertaken and is suitable for evaluating educational interventions.

The thesis provides a comprehensive report of Queensland parents’ fever

management. It provides health professionals with essential information about

parents’ fever management and the influence that health professionals’ negative

beliefs and practices have on parents’ practices. This thesis adds to the literature in

two distinct ways. There is no literature reporting the determinants of parents’ fever

management and no report of Australian parents’ fever management. The variation

of intentions determined by the theoretical models was high, 60% and 68%, and

explains a considerable amount of parents’ decision making when managing a febrile

child. Many studies identify a mean of 30% of the variance in intentions (Armitage

& Conner, 2001). Additionally, there is limited literature exploring determinants of

intentions in parenting or child health behavioural intentions or practices. This thesis

contributes significantly to this area.

The major limitations of the thesis relate to the sample in Study 2. The sample was

self-selected and mostly females who had a university education and lived in major

cities. Data in this study were collected by self-report, however, data lent itself to

self-report and enabled a more diverse sample to be studied (Polit & Beck, 2006).

Participants were recruited through three distinct recruitment methods in an attempt

to reduce selection bias (Minicheillo et al., 2004; Polit & Beck, 2006) and improve

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generalisability of the findings. Despite this, parents recruited through advertising

(half the sample) were less likely to come from a major city and more likely to have

fewer children. These parents received conflicting information about how to manage

fever and reported having alternated antipyretics more frequently than those recruited

through other methods. These experiences may have influenced the responses from

those recruited through advertising therefore caution is needed in interpreting the

findings.

Most participants were female although females were not specifically targeted. It is

possible the gender imbalance influenced the results. However, the females who did

respond reported a strong normative influence from their partners, implying their

partners had similar beliefs and practices. Most participants lived in a major city and

would therefore have ready access to medical assistance through general

practitioners and hospitals. The need to travel further distances for medical advice

may influence the fever management practices of parents living in rural and remote

areas therefore findings must be considered carefully. Limited access to health

assistance could promote the more frequent use of antipyretics in parents believing

fever harmful.

Additionally, more than half the parents had a university degree. Parents with lower

educational attainment reported different beliefs about temperatures representative of

high, very high and harmful fever; managed fever differently and were less likely to

have received conflicting information about fever management. Findings, therefore,

may be more applicable to parents with university education. The influence of

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education on fever management intentions needs further exploration with a more

heterogeneous sample.

Although data related to the TPB were nonnormal all efforts were made to reduce

any influence on the analyses and transformed data were used for the analysis (Hu &

Bentler, 1999; Yung & Bentler, 1996). Multiple measures of goodness-of-fit

statistics were used to determine model fit to data and models were explored for both

good and bad fit. Sample bias could have influenced the impact of background

factors on intentions. A study with a heterogeneous sample, including more rural and

remote parents, those with lower educational levels and fewer with health industry

experience may have different findings. A more educationally heterogeneous sample

may report even less favourable attitudes toward fever and more influence from

unsupportive normative influences and increased intentions to reduce fever. Parents

living in rural and remote areas may have additional factors influencing their fever

management intentions due to the appropriateness of the health service available,

distances necessary to travel for medical advice and transport availability. The

findings reported in this thesis should be considered with the above in mind.

8.5 PRACTICE IMPLICATIONS

8.5.1 Parents This large study of Queensland parents identified their poor knowledge of fever,

fever’s benefits and evidence-based fever management. Although correctly seeking

fever management information from doctors and perceiving them as reliable, credible

sources of health information, parents received conflicting information which made

fever management unnecessarily taxing and complex. Parents have a right to know

the findings of the latest scientific evidence and evidence-based recommendations

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for caring for their febrile child. Currently, many Queensland parents, while

attempting to protect their children from harmful outcomes from fever, are placing

children at risk from unnecessary antipyretic overuse and overdose.

The strong normative influence in reducing fever to prevent harm indicates the need

for broad community based education. To reduce unfavourable normative influence

from partners, education programs need to target both parents simultaneously. In

Study 1, a group of parents discussing the benefits and harm of childhood fever

began to challenge their use of antipyretics to reduce fever (see Chapter 5).

Education in groups would enable parents to discuss their fears and experiences, both

positive and negative, and learn about evidence-based fever management.

Parents’ unfavourable attitudes toward fever and intentions to reduce fever, with or

without medications, signify the need for change. The rate of antipyretic use,

alternating antipyretics and overdosing indicate the urgent need for parent education

about evidence-based fever management, appropriate antipyretic use and when to

seek medical assistance. Most parents used paracetamol but many also used

ibuprofen which is of concern particularly in relation to the proportion who

overdosed their child with ibuprofen and the harm associated with administering

ibuprofen to children who are dehydrated or have asthma (eMIMS, 2007). The rate

of Queensland parents’ ibuprofen use confirms its increasing use in Australia. A

seven-fold increase in ibuprofen use was found from 1999 to 2003 in an Australian

metropolitan paediatric hospital with associated higher rates of adverse drug

reactions compared with paracetamol (10:6) (Titchen et al., 2005). It could be

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hypothesised that the fictitious properties attributed by Australian parents to

paracetamol (Allotey et al., 2004) are also attributed to ibuprofen.

Parents should be encouraged to delay antipyretic administration for fever reduction

and only use analgesics to relieve pain associated with febrile illnesses. Antipyretics

are unnecessary for temperatures below 39.0ºC unless associated with pain (Curtis &

Starr, 2000; Schmitt, 1994). Alternating antipyretics is unnecessary and focuses

parents’ attention to the temperature rather than child’s well-being and it must be

discouraged, particularly for mild to moderate fever (Goldman, 2006; Saphyakhajon

& Greene, 2006; Schmitt, 2006). Nearly a decade ago it was recommended

antipyretics only be alternated in specialised units under professional supervision due

to the potential risks associated with administering two drugs to an ill child

(McCullough, 1998). This recommendation needs to be taken seriously by parents

and those advising them on the care of a febrile child.

Parents’ desire to appropriately care for children with febrile illnesses is evidenced

by their search for knowledge. The impact of experience on attitudes and practice

indicates the need for parents to learn to care for a febrile child before having a

negative experience, preferably before the first febrile episode. Ideally parents will

learn to manage fever before the first immunisations are due. This will not only

prepare parents for caring for their child following immunisation it will ensure most

parents are educated before their child’s first febrile episode.

Another important outcome from this thesis is evidence that parents have difficulty

medicating their children. At times children need to take medications; parents need to

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be taught how to administer medications to their child and advised on alternate

methods for use when children are distressed or reluctant. This responsibility lies not

only with parents and those prescribing and dispensing medications but also with

paediatric, child health and practice nurses who are ideally placed to demonstrate and

advise parents about childhood medication administration, dosage and frequency.

8.5.2 Doctors and Other Health Professionals Parents reported strong unsupportive normative influences from doctors and

alternated antipyretics on recommendations from doctors and hospitals. Fever does

not necessarily need to be reduced (Lorin, 1999; Schmitt 1994). Parents of febrile

children seek medical advice to access the doctors’ clinical skill and their ability to

discuss what is wrong with their child and how to manage them at home; they are not

seeking a prescription for antibiotics or antipyretics (Bhrolchain, 2004; Kallestrup &

Bro, 2003; Stivers, Mangione-Smith, Elliott, McDonald, & Heritage, 2003). Doctors

must respect parents’ integrity without fearing evidence-based information will harm

their therapeutic relationship. Receiving conflicting information did appear to harm

this relationship causing parents seek advice elsewhere.

The influence of experience on parents’ attitudes and fever management intentions

highlight additional areas for doctors to assist parents. When parents have, or hear of,

a negative fever experience from friends or the media, doctors have an important role

in talking with the parents, explaining the circumstances and the likelihood or

unlikelihood of the event recurring. Positive fever management and advice seeking

need to be referred to when a negative event occurs to support parents in their role as

protector of their child. Alternatively, when parents seek timely medical advice they

need to be encouraged. Additionally, when doctors prescribe medications for

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children they should ensure parents can correctly administer the medication, provide

them with alternative methods to use should a child refuse the medication and alert

them to the consequences of a missed dose.

Parents reported they learnt to manage fever from nurses less frequently than from

doctors. Health education is an important aspect of the nurses’ role. They are ideally

placed to educate parents in hospitals, general practices where they are employed as

practice nurses, child health clinics and pharmacies where well baby clinics are

conducted. Nurses need to focus on the antecedents of parents’ intentions to reduce

fever, their unfavourable attitudes toward fever and perceptions that others expect

fever be reduced. To facilitate this education nurses should ensure their knowledge is

based on the latest scientific evidence to prevent parents receiving conflicting

information. Parents’ interest in fever management is evident from their quest for

information, from many sources.

Parents’ fears cause them to overuse and overdose children with antipyretics to

normalise mild fever and sometimes normal temperatures. Health professionals, as a

group, need to address this issue, assist parents to realise the benefits of fever and

that it is best to focus on the child’s well-being rather than the temperature and allow

the body’s immune processes to function ((National Collaborating Centre for

Women's and Children's Health [NCCWCH], 2007; Schmitt, 2000). Febrile children

should rest and allow their body to destroy the invading organism and produce

antibodies to prevent re-infection with the same organism (Blatteis, 2003, 2006;

Zeisberger, 1999).

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Health professionals need to encourage parents to delay antipyretic administration in

children who do not exhibit pain or discomfort and have no pre-existing medical

conditions. Through experience, parents may incorporate the positive benefits of

fever into their belief system. Care of a febrile child should focus on: the child’s

well-being rather than temperature; using analgesics to relieve pain associated with

febrile illnesses; and not reducing fevers under 39.0ºC unless associated with

discomfort or pain (Schmitt, 1994; NCCWCH, 2007) .

8.6 IMPLICATIONS FOR FUTURE STUDIES The identification of determinants of intentions to reduce fever provides an excellent

basis for the development, implementation and evaluation of educational

interventions. The strongest predictors of intentions were unfavourable attitudes and

unsupportive norms. A number of different methods can be used to correct these

beliefs and create new evidence-based beliefs. Ajzen (2006b) recommends using

persuasive communications in, for example, newspapers, flyers, television, face-to-

face discussions or observational modelling. Other methods commonly used to

change incorrect beliefs are information, increasing skills, goal setting, rehearsal of

skills, modelling, planning and implementation, and social encouragement and

support (Hardeman, Johnston & Jounston et al., 2002). Ajzen (2006) also

recommends the development of implementation intentions. These are a specific plan

identifying how the next fever will be managed, when antipyretics will be

administered and how the febrile child will be managed (Gollwitzer, 1999).

Most studies reporting TPB educational interventions involve information giving

about the risks of the behaviour and the connections of behaviour and outcomes

(Hardeman et al., 2002). TPB based interventions to change health professional

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behaviour have used information, identification of current beliefs and referents, and

the influence of these, peer group discussions, skill rehearsal (scenario) and peer

support (Edwards et al. 2001; Edwards et al., 2007, in press).

Educational programs could be developed and trialled with parents representative of

those who participated in this study. Interventions should target the identified

incorrect beliefs with scientifically determined information, such as: fever is

beneficial and does not always need to be reduced; and febrile convulsions are

benign and occur in less than 5% of children. New favourable beliefs about the use

of antipyretics for pain rather than fever need to be introduced. Other new beliefs to

introduce include when fever should be reduced and when it is necessary to seek

medical attention both urgently and within the next 24 hours. Parents with favourable

beliefs about fever who are knowledgeable about when to seek medical advice will

be more confident in their management of childhood fevers. Parents in the study

identified knowledge and experience as sources of reassurance about their fever

management practices, reducing their concerns.

Randomised controlled educational interventions need to be developed, implemented

and evaluated in paediatric hospitals and units, child health clinics and maternity

hospitals as well as child care centres and kindergartens and preschools. It is

important to include partners in these programs as partners are a significant a source

of unsupportive norms which make attitudes less favourable. Controlled trials can be

conducted by paediatric and emergency nurses modelling evidence-based fever

management and providing clear explanations of their rationales for either

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administering an antipyretic or not administering an antipyretic to a child with a

febrile illness.

At a community level a series of brief articles could be produced targeting the

incorrect beliefs described earlier. Sources used to recruit participants for this thesis

would enable distribution of such articles throughout Queensland. These include

freely available parenting magazines, Playgroup Queensland, child care centres,

kindergartens and preschools and the Family Day Care Service. Recruitment,

baseline data collection and randomisation of parents, prior to the community project

with follow-up data collection will enable the effectiveness of community based

programs to be evaluated.

Programs should be trialled through different settings and with varied presentation

methods. Comparisons between parents’ interest in learning in the specific setting,

perceived credibility and reliability of the information, use of and ease of

understanding the information, and time and cost effectiveness of the programs need

to be examined. Varied presentation methods should reflect the parents’ lifestyle and

include interactive computer based programs in waiting rooms, pharmacies and

libraries. Other presentation methods include compact discs, booklets and take home

pamphlets to reinforce and remind parents of best practice. Anecdotally, these can be

useful when evidence-based information is challenged by others not aware of the

latest scientific evidence.

Although parents reported doctors as their main source of information, nurses and

pharmacists were also mentioned. Therefore, future studies need to identify the

284

knowledge, beliefs, and fever management recommendations of all health

professionals caring for febrile children or advising parents on the care of a febrile

child. This includes general practitioners, paediatricians, child health nurses,

paediatric, emergency and general nurses, pharmacists and pharmacy assistants, and

child care workers. Deficits identified through these studies could then be targeted

through education and evidence-based guidelines and policies for childhood fever

management developed and implemented.

8.7 OVERALL CONCLUSIONS Queensland parents have poor knowledge of evidence-based childhood fever

management. This contributes to negative beliefs about harmful outcomes from fever

and unfavourable attitudes toward fever which influence their practice and practice

intentions. The unsupportive normative influence from partners is understandable,

but from doctors it is unacceptable and should be urgently addressed. Child

medication behaviours have not been previously explored and findings indicate their

importance in parents’ fever management intentions. The strong influence of child

medication behaviour on intentions is a novel finding, not previously reported and

can be used by health professionals as a method of encouraging parents to delay

antipyretic administration.

The thesis contributes significantly to childhood fever management, paediatric care,

parenting decision making and the body of literature reporting childhood fever

management. There is an urgent need for parents to be consistently educated about

evidence-based fever management by non-phobic health professionals.

Recommendations for care must be consistently based on the latest scientific

285

evidence. Parents unnecessary overuse of, and overdose with, over-the-counter

medications for mild fever must cease.

287

Appendix 1

Study 1 Documents

288

FEVER IN YOUNG CHILDREN

INFORMATION FOR PARENTS ABOUT THE FOCUS GROUP DISCUSSION This research is being undertaken as part of a Doctor of Philosophy degree and will be conducted under the guidance of experienced researchers from the School of Nursing at the Queensland University of Technology (QUT)

Researcher: Anne Walsh, School of Nursing, (QUT), 3864 3856 Principal Supervisor: Professor Helen Edwards, Head, School of Nursing, (QUT), 3864 3844

Raising a young child is not easy and when your child becomes ill this is even more difficult. Many parents are worried about their child’s fever when they are ill. They seek advice on how best to care for their child. There is a lot of the advice available. However, advice can vary, making it hard for parents to know what the best thing to do is. This can make parents even more worried about how to care for their sick child. As you have a child aged between 6 months and 5 years you will have had to look after a child with a fever. Not much is known about how Australian parents look after their children when they have a fever. Also, little is known about how Australian parents learn how to manage fever. As this is something every parent will have to do it is important to find this out. Then nurses and doctors can help parents during this worrying time. I would like to invite you to join in a group discussion about children’s fever. The other parents in the group have children at the same child care centre as you. The discussion will be at the child care centre at a time that suits interested parents. It will take about 30 minutes. The discussion will be recorded by a person who types in shorthand, it will also be audio taped. When the discussion has been typed I will send a copy to you to make sure it is accurate. I plan to use the information from the discussions to develop a survey. This survey will be sent to parents of children aged 6 months to 5 years. By joining in a group discussion you might learn more about childhood fever. What is learnt from the discussions will be used to help Australian parents in the future when their child has a fever. I do not wish anyone to be identified through the information I collect. To make sure your records are confidential, names will not be kept on any record. To ensure the privacy of those in the discussion please do not use peoples’ names. Audio tapes will be destroyed when the information has been examined. All the information I collect will be kept secure in a locked filing cabinet. Only I and my supervisors will have access to this information. No information about the study will be published in any form that would allow you or your child care centre to be recognised. Participating in a discussion is voluntary. You are free to leave at any time without comment or penalty. Being involved in a discussion should not pose any risk to you. The only inconvenience you should experience is the use of your time. If you have any questions about this research please contact me, Anne Walsh, on 3864 3856 or my supervisor, Prof. Helen Edwards on 3864 3844. You may also contact the Queensland University of Technology’s Research Ethics Officer on 3864 2340 if you have any concerns about the ethical conduct of this research.

289


FOCUS GROUP MEMBER CONSENT FORM

Researcher: Anne Walsh, School of Nursing, (QUT), 3864 3856

Principal Supervisor: Professor Helen Edwards, Head, School of Nursing, (QUT), 3864 3844 I _________________________________________ (please print your full name) have read the

information sheet about “Fever in Young Children” and had any questions or queries

answered to my satisfaction by Anne Walsh.

I have read and understood the Information Statement and had any questions or queries

explained to me by Anne Walsh. I understand that:

♦ If I have any further questions I can contact the researchers at any time;

♦ My participation is voluntary and I may withdraw from this focus group discussion at

any time without comment or penalty;

♦ All information that I give during the focus group discussion will be kept in the strictest

confidence and no information will be released in any way that I could be identified.

I hereby consent to be involved in this study.

______________________________________ _________________ Signed (focus group member) Date ______________________________________ __________________ Witnessed by (please print) Date ______________________________________ Witness signature

If you have any questions about the ethical conduct of this research please contact the Queensland University of Technology Research Ethics Officer on 3864 2340.

290


INFORMATION FOR PARENTS ABOUT THE FOCUSED INTERVIEW

This research is being undertaken as part of a Doctor of Philosophy degree and will be conducted under the guidance of experienced researchers from the School of Nursing at the Queensland University of Technology (QUT)


Raising a young child is not easy and when your child becomes ill this is even more difficult. Many parents are worried about their child’s fever when they are ill. They seek advice on how best to care for their child. There is a lot of the advice available. However, advice can vary, making it hard for parents to know what the best thing to do is. This can make parents even more worried about how to care for their sick child. As you have a child aged between 6 months and 5 years you will have had to look after a child with a fever. Not much is known about how Australian parents look after their children when they have a fever. Also, little is known about how Australian parents learn how to manage fever. As this is something every parent will have to do it is important to find this out. Then nurses and doctors can help parents during this worrying time. I would like to have the opportunity to discus children’s fever with you. The discussion can take place at a venue and time that suits you. It will take about 30 minutes. The discussion will be recorded by a person who types in shorthand, it will also be audio taped. When the discussion has been typed I will send a copy to you to make sure it is accurate. I plan to use the information from the discussions to develop a survey. This survey will be sent to parents of children aged 6 months to 5 years. What is learnt from the discussions will be used to help Australian parents in the future when their child has a fever. I do not wish anyone to be identified through the information I collect. To make sure your records are confidential, names will not be kept on any record. Audio tapes will be destroyed when the information has been examined. All the information I collect will be kept secure in a locked filing cabinet. Only I and my supervisors will have access to this information. No information about the study will be published in any form that would allow you or your playgroup to be recognised. Participating in a discussion is voluntary. You are free to leave at any time without comment or penalty. Being involved in a discussion should not pose any risk to you. The only inconvenience you should experience is the use of your time. If you have any questions about this research please contact me, Anne Walsh, on 3864 3856 or my supervisor, Prof. Helen Edwards on 3864 3844. You may also contact the Queensland University of Technology’s Research Ethics Officer on 3864 2340 if you have any concerns about the ethical conduct of this research.

291


FOCUSSED INTERVIEW CONSENT FORM


I _________________________________________ (please print your full name) have read the

information sheet about “Fever in Young Children” and had any questions or queries

answered to my satisfaction by Anne Walsh.

I have read and understood the Information Statement and had any questions or queries

explained to me by Anne Walsh. I understand that:

♦ If I have any further questions I can contact the researchers at any time;

♦ My participation is voluntary and I may withdraw from this focus group discussion at

any time without comment or penalty;

♦ All information that I give during the focused interview will be kept in the strictest

confidence and no information will be released in any way that I could be identified.

I hereby consent to be involved in this study.

______________________________________ _________________ Signed (participant) Date ______________________________________ __________________ Witnessed by (please print) Date ______________________________________ Witness signature

If you have any questions about the ethical conduct of this research please contact the Queensland University of Technology’s Research Ethics Officer on 3864 2340.

FOCUS GROUP QUESTIONS FOR FACILITATOR

292

How do you know when your child has a fever?

Focus 1 – Concerns about fever

What are your thoughts when your child has a fever?

Do you find you are concerned about the fever?

Are you worried about the height of the fever?

Has this changed as your child has grown older – or with successive children?

How has this changed?

What influenced these changes?

Focus 2 – Managing fever

How do you manage your child when they have a fever?

How do you manage the fever? What else do you do?

What influences your management of fever?

Has this changed as your child has grown older – or with successive children?

How has this changed? What influenced these changes?

Focus 3 – Fever management knowledge

What do you know about fever?

Do you think fever has any benefits? Do you think fever can be harmful?

What do you know about how to manage a fever?

Focus 4 – Information gathering and reliability of information

Can you remember where you learnt how to look after a child with a fever?

Has anyone influenced how you manage fever?

Has any particular information you have influenced how you manage fever?

How accurate do you think this information is?

When do you think is the right time for parents to learn about fever?

Where would be the best place to have fever management information available?

Who from?

What type of information – a talk, leaflet, other?

Have you used the Internet or leaflets from, eg., pharmacies to assist in your management of

fever?

Do you use these sources for other medical information?

What have the most important elements of this discussion been for you?

293

FOCUS FOR CHILDHOOD FEVER RESEARCH

Participant copy

How do you know when your child has a fever?

Concerns about fever

Managing fever

How you learn to manage fever

Information sources and reliability of this information

Best place and time to learn about fever management

294

FOCUS GROUP DEMOGRAPHIC INFORMATION

Please complete the following questions about yourself

1. Your age at your last birthday Please insert the number of years

………….…..years

2. Your gender

Female Male

3. Your marital status

Single (never married) Married Defacto Divorced/Separated Widowed

4. The number of children you have Please circle the number 5. The number of children you have who are under 5 years of age Please circle the number

1 2 1 2 3 4 5 1 2 3 4 5 6 7

1 2 3 4 5

6. Your highest level of education

Please circle highest level of education completed

Completed Primary School Secondary Schooling Completed Secondary School Completed a TAFE course Completed a University Degree Completed Postgraduate Degree

Currently studying (Please specify)

……..……………………… 7. Are you currently working outside the home? No Yes If YES, is this

Full-time Part-time

8. Do you have any assistance with caring for your child or children? Yes No If YES, does this person influence your child care practices? Yes No

1 2 3 4 5 6 7 1 2 1 2 1 2 1 2

STIMULUS QUESTIONS

9. The temperature at which I consider my child has a fever is (Please specify) …..………..°C or circle Do not know

10. I generally give medication to my child when their temperature is greater than (Please specify) ………….°C or circle Do not know

295

Appendix 2

Study 2 Documents

296

Pilot Study

Documents

297

RE: PILOTING OF THE CHILDHOOD FEVER MANAGEMENT SURVEY Dear, This package has been sent to you following our discussion about the development of a questionnaire to explore parents’ management of fever in young children. I have now finalised the development of the questionnaire and would be grateful if you would complete the questionnaire and send it back to me with your feedback in the enclosed stamped envelope. I particular I am interested in whether:

all instructions are easy to read and understand, the questions are easy to read, it is easy to understand what the questions were are asking you, the questions are easy to answer, and if you think I should be asking parents about any other issues you

have experienced or feel are important in relation to managing fever in young children.

If you find an instruction or question difficult to understand or answer could you please identify it on the questionnaire. If you have a suggestion that would make it easier to understand the instruction or question or make the question easier to answer could you please write that on the questionnaire. If you would like to discuss anything about the questionnaire with me please do not hesitate to contact me during work hours on 07 3864 3856, anytime on 041 256 0182 or by email at [email protected] The number on the questionnaire is so that I will know when you return the questionnaires. I will then post you the second questionnaire when I receive this one back. Thank you for your very valuable assistance in this research and in ensuring the questionnaire will provide useful information about how parents manage fever in young children. Yours sincerely. Anne Walsh PhD Candidate School of Nursing Queensland University of Technology Victoria Park Road Kelvin Grove 4059

298

RE: PILOTING OF THE CHILDHOOD FEVER MANAGEMENT SURVEY Dear , Thank you for your feedback on the questionnaire. As we discussed

on the telephone it is necessary to determine the reliability of the

questions, that is, whether people interpreted them the same way, or

similarly, on separate occasions. If the questions are deemed reliable

by this method it can then be assumed that others will interpret

them similarly. If the questions are interpreted differently on separate

occasions then the data collected with these questions would not be a

valid representation of parents fever management. This is why I am

asking you to please complete the questionnaire again.

After returning this questionnaire would you like to receive a copy of

some best practice guidelines from the United States? These

guidelines are similar to those I will be using when I develop an

educational intervention for parents about managing fever in young

children, the final stage of this research program, which I plan to

undertake next year.

I do understand that this is very time consuming and I appreciate

and thank you for your contribution to this research. I have enclosed

for you a small token of my appreciation. Again, if you would like to

discuss anything about the questionnaire with me please do not

hesitate to contact me during work hours on 07 3864 3856, anytime

on 041 256 0182 or by email at [email protected]

Yours sincerely. Anne Walsh PhD Candidate School of Nursing Queensland University of Technology Victoria Park Road Kelvin Grove 4059

299

CHILDHOOD FEVER

MANAGEMENT

- - - INSTRUCTIONS - - -

1. The questionnaire asks for your general opinions about fever and

managing fever in children aged between 6 months and 6 years. 2. It might be an idea to do this survey when the children are asleep

and you are less likely to be interrupted. 3. Please answer every question by marking your answer with a pen as

indicated. 4. In some instances certain questions may look alike but each one is

different. 5. There are no right or wrong answers. If you are unsure how to answer a

question please give the best answer you can. 6. In this questionnaire MEDICATION only refers to over the counter

medication, eg., Panadol and Nurofen, NOT to antibiotics. 7. After you have completed the questionnaire please place it in the reply

paid envelope supplied and return it at your earliest convenience to the Queensland University of Technology.

Thank you for offering to participate in this research.

300

Section 1 The following questions relate to the times when your child has a fever.

1 What things do you usually do when your child has a fever?

(Please specify)

____________________________________________________________________ __________________________________

2 What is the very first thing you do when you discover your child has a fever? (Please specify)

__________________________________

3 If you think the fever is very high do you do these same things? (Please circle)

1. Yes Please go to Q5 2. No 3. Unsure Please go to Q5

4 If NO what other things would you do if you think the fever is very high? (Please specify)

____________________________________________________________________ __________________________________

5 Has your management of fever changed as your child has grown older OR with the birth of other children? (Please circle)

1. Yes 2. No Please go to Q7 3. Unsure Please go to Q7

6 If YES – how has your fever management changed? (Please specify)

____________________________________________________________________ __________________________________

7 Please mark with an X on the line the temperature you would consider to be NORMAL for your child.

I_____ı_____I_____ı_____I______ı_____I_____ı_____I_____ı_____I_____ı_____I_____ı_____I_____ı_____I 35.0°C 36.0°C 37.0°C 38.0°C 39.0°C 40.0°C 41.0°C 42.0°C 43.0°C

8

Please mark with an X on the line the temperature you would consider to be a FEVER for your child.


9

Please mark with an X on the line the temperature you would consider to be a HIGH FEVER for your child.


10

Please mark with an X on the line the temperature you would consider to be a VERY HIGH FEVER for your child.


301

The following questions relate to fever in general

11

How harmful do you believe fever is? (Please circle one)

1. Very harmful 2. Reasonably harmful 3. Harmful 4. A little harmful 5. Not very harmful 6. Not harmful Please go to Q14

12 At what temperature is fever harmful? (Please specify)

_____________°C

13 In your opinion what harm can high fever cause to a child? (Please rank these in decreasing order of concern to you)

1. ______________________________ 2. ______________________________ 3. ______________________________

14 What are you MOST worried about when your child has a fever? (Please specify)

__________________________________

15 What other things do you worry about when your child has a fever? (Please specify)

____________________________________________________________________ __________________________________

The following questions ask what you GENERALLY do when your child has a fever.

Please circle the ONE number that best describes what you generally do.

When my child has a fever I generally Always Mostly Sometimes Rarely Never

16 Take their temperature 1 2 3 4 5 17 Like to know what their temperature is 1 2 3 4 5 18 Make sure they have plenty to drink 1 2 3 4 5 19 Use medication to reduce the fever 1 2 3 4 5 20 Check on them during the night 1 2 3 4 5 21 Sleep in the same room as them 1 2 3 4 5 22 Wake them up during the night for medication to

reduce their fever 1 2 3 4 5

23 Take them to the doctor 1 2 3 4 5

The following questions ask about your use of OVER THE COUNTER MEDICATIONS

(not antibiotics) to reduce fever. There are no right or wrong answers we are

interested in how you GENERALLY use this medication to reduce fever.

24 At what temperature do you USUALLY give your child medication to reduce fever? (Please specify)

____________°C

25 Do any other things influence your decision to give your child

medication to reduce fever? (Please circle)


302

26 If YES, what other things influence your decision to give medication to your child when they have a fever? (Please specify)

______________________________________________________________________________________________________

Yes No Paracetamol (Panadol) 1 2 Ibuprofen (Nurofen) 1 2

27 What medications do you use? (Please circle ALL that apply)

Other medication (Please specify)_____________

28 When do you use medication to reduce fever? (Please circle ALL that apply)

1. With every fever 2. With most fevers 3. With mild fevers 4. With high fevers 5. With very high fevers 6. Never

29 Have you ever alternated the use of paracetamol (eg., Panadol) and ibuprofen (eg., Nurofen) when your child has a fever? For example, paracetamol at 10am, ibuprofen at 12md, paracetamol at 2pm (Please circle)

1. Yes 2. No Please go to Q32

30 If YES – what influenced your decision to use alternating medications to reduce fever? (Please specify)

____________________________________________________________________

31 How often have you used alternating medications to reduce your child’s fever? (Please circle)

1. With every fever 2. With most fevers 3. With mild fevers 4. With high fevers 5. With very high fevers 6. Other (Please specify)_____________

32 What things about your child do you consider when you work out how much medication to give them to reduce their fever? (Please circle all that apply)

1. Age 2. Sex 3. Height 4. Weight 5. Height of fever 6. Severity of illness 7. Irritability 8. Listlessness (eg., too tired for normal activities) 9. Other (Please specify) ____________

33 What is the most frequent interval (how many hours between doses) that you can give a child with a fever medication to reduce the fever? (Please specify for each medication you use to reduce your child’s fever)

1. Paracetamol _______________ 2. Ibuprofen _______________ 3. Other medication (Please specify) _______________

34 Can medication used to reduce fever be harmful to children? (Please circle)


35 If YES – what harm do you think these medications can cause? (Please specify)

____________________________________________________________________

303

The following questions relate to how YOU learnt to manage fever.

36

Do you feel you know the best way to manage fever in your children? (Please circle)

1. Yes 2. No 3. Unsure

37 How did you learn to manage fever? (Please specify)

____________________________________________________________________ __________________________________ __________________________________

38 Have you ever received conflicting information about how to manage your child’s fever

1. Yes 2. No

39 If YES, how did this make you feel about managing your child’s

fever

__________________________________ __________________________________ __________________________________ __________________________________

Please turn over to Section 2

The next section, Section 2 may take a while, please

take your time.

Some of the questions might seem to be the

same, but they are different.

304

Section 2

We acknowledge that decisions about how to manage your child’s fever are

often complex. However, in the questions below we are interested in your

GENERAL OPINIONS about managing your child’s fever.

These questions use a rating scale with 7 places; please circle the number that best describes your opinion. For example if you were asked to rate the statement “I decide the

types of food my child is given to eat” the 7 places should be interpreted as follows

I decide the types of food my child is given to eat

1 2 3 4 5 6 7 TRUE

Definitely True

True Somewhat True

Neither Somewhat Untrue

Untrue Definitely Untrue

UNTRUE

In this section MEDICATION only refers to over the counter medication

(eg., Panadol or Nurofen, NOT to antibiotics) and

FEBRILE CONVULSION refers to a fit or seizure that is associated with fever.

Please circle the ONE number that corresponds with your best answer

Generally speaking, how much do you agree or disagree with the following

Strongly Agree

Strongly Disagree

1 When my child has a fever I decide how to manage it 1 2 3 4 5 6 7 2 My child takes medication easily when they have a fever 1 2 3 4 5 6 7 3 I am confident I will be able to reduce my child’s next fever with

medication 1 2 3 4 5 6 7

4 Deciding whether or not to use medication to reduce my child’s fever is completely up to me

1 2 3 4 5 6 7

When your child next has a fever how true or untrue will each of the following be?

Definitely

True Definitely

Untrue 5 I will try to reduce my child’s next fever 1 2 3 4 5 6 7 6 I will try to reduce my child’s next fever with medication 1 2 3 4 5 6 7 7 I will try to reduce my child’s next fever below 38.0°C with medication 1 2 3 4 5 6 7

305

When your child has a fever how likely or unlikely is each of the following?

Extremely

Likely Extremely

Unlikely 8 Reducing my child’s fever will prevent my child from being harmed by

the fever 1 2 3 4 5 6 7

9 Reducing my child’s fever will reduce any discomfort caused by the fever

1 2 3 4 5 6 7

10 Reducing my child’s fever will prevent my child from having a febrile convulsion

1 2 3 4 5 6 7

11 Reducing my child’s fever with medication will prevent my child being harmed by the fever

1 2 3 4 5 6 7

12 Reducing my child’s fever with medication will reduce discomfort caused by the fever

1 2 3 4 5 6 7

13 Reducing my child’s fever with medication will reduce the listlessness (eg., tiredness preventing normal activities) caused by fever

1 2 3 4 5 6 7

14 Reducing my child’s fever with medication will prevent my child having a febrile convulsion

1 2 3 4 5 6 7

15 Fevers of 38.0°C and below can harm my child 1 2 3 4 5 6 7 16 Taking my child’s temperature regularly informs me of my child’s

condition 1 2 3 4 5 6 7

17 Monitoring my child’s well-being informs me about how they are feeling

1 2 3 4 5 6 7

18 Not reducing my child’s fever will assist their body’s defences fight the infection

1 2 3 4 5 6 7

19 Knowing the cause of my child’s fever reduces my concerns about the fever

1 2 3 4 5 6 7

20 My doctor generally knows the cause of my child’s fever 1 2 3 4 5 6 7

Generally speaking when you are caring for your child with a fever

For these questions please circle NA if the question is not applicable to you

Not At All

Very Much

21 How much do you do what your husband/partner thinks you should do? NA 1 2 3 4 5 6 7 22 How much do you do what your mother thinks you should do? NA 1 2 3 4 5 6 7 23 How much do you do what your friends think you should do? NA 1 2 3 4 5 6 7 24 How much do you do what your doctor thinks you should do? NA 1 2 3 4 5 6 7

306

When your child next has a fever how likely or unlikely is each of the following?

Extremely

Likely Extremely

Unlikely 25 The next time my child has a fever I intend to reduce my child’s fever 1 2 3 4 5 6 7

26 The next time my child has a fever I intend to reduce the fever with medication

1 2 3 4 5 6 7

27 The next time my child has a fever of 38.0°C or below I intend to reduce the fever with medication

1 2 3 4 5 6 7

What do you generally BELIEVE about each of the following

Extremely Bad

Extremely Good

28 Reducing my child’s fever to protect them from harm is 1 2 3 4 5 6 7 29 Reducing my child’s fever to relieve discomfort is 1 2 3 4 5 6 7 30 Reducing my child’s fever to prevent febrile convulsions is 1 2 3 4 5 6 7 31 Reducing my child’s fever with medication is 1 2 3 4 5 6 7 32 Reducing my child’s fever with medication to relieve discomfort is 1 2 3 4 5 6 7 33 Reducing my child’s fever with medication to relieve the listlessness

(tiredness) associated with fever is 1 2 3 4 5 6 7

34 Reducing my child’s fever with medication to prevent febrile convulsions is

1 2 3 4 5 6 7

35 Reducing my child’s fevers of 38.0°C or below is 1 2 3 4 5 6 7 36 Taking my child’s temperature regularly to monitor their condition is 1 2 3 4 5 6 7 37 Observing my child’s well-being to monitor their condition is 1 2 3 4 5 6 7 38 Allowing my child’s body’s natural defences to assist in fighting the

illness is 1 2 3 4 5 6 7

39 Not being as concerned about the fever due to knowing its cause is 1 2 3 4 5 6 7 40 Knowing the cause of the fever from a doctor is 1 2 3 4 5 6 7

Do the following make it easier or more difficult for you to manage your child’s fever

Much Easier to Manage Fever

More Difficult to Manage Fever

41 For me, deciding how to manage my child’s fever makes it 1 2 3 4 5 6 7 42 When my child has a fever he/she usually takes medication to reduce

fever easily, this makes it 1 2 3 4 5 6 7

43 For me, using medication to reduce my child’s fever makes it 1 2 3 4 5 6 7

44 For me, to decide by myself whether I manage my child’s fever with medications is

1 2 3 4 5 6 7

307

In general, when your child has a fever how likely or unlikely is each of the

following?


Extremely Likely

Extremely Unlikely

45 When my child has a fever my husband/partner thinks I should reduce the fever

NA 1 2 3 4 5 6 7

46 When my child has a fever my mother thinks I should reduce the fever NA 1 2 3 4 5 6 7 47 When my child has a fever my friends think I should reduce the fever NA 1 2 3 4 5 6 7

48 When my child has a fever my doctor thinks I should reduce the fever NA 1 2 3 4 5 6 7

49 When my child has a fever my husband/partner thinks I should reduce the fever with medication

NA 1 2 3 4 5 6 7

50 When my child has a fever my mother thinks I should reduce the fever with medication

NA 1 2 3 4 5 6 7

51 When my child has a fever my friends think I should reduce the fever with medication

NA 1 2 3 4 5 6 7

52 When my child has a fever my doctor thinks I should reduce the fever with medication

NA 1 2 3 4 5 6 7

Generally speaking, how much do you agree or disagree with each of the following

Strongly Agree

Strongly Disagree

53 I plan to reduce my child’s next fever 1 2 3 4 5 6 7 54 I plan to reduce my child’s next fever with medication 1 2 3 4 5 6 7 55 I plan to reduce my child’s next fever below 38.0°C with medication 1 2 3 4 5 6 7

Please turn over to Section 3,

the final section.

308

Section 3

This section asks for some information about you and your children 1

Do you have a child with a chronic illness (eg., asthma, diabetes). (Please circle)

1. Yes (Please specify) _____________________________ 2. No

2 Do you have a child who is an epileptic – or has had a fit that was not associated with a fever? (Please circle)

1. Yes 2. No

3 Do you have a child who has had a febrile convulsion or fit associated with fever? (Please circle)


4 Is there any family history of febrile convulsions, eg., mother, sibling, uncle? (Please circle)

1. Yes (Please specify) _____________________________ 2. No

5 What were you MOST worried about when your child had a febrile convulsion? (Please specify)

________________________________________________________________________

6 Do you worry that your child will have another febrile convulsion? (Please circle)

1. Yes 2. No

7 What do you worry about NOW when your child has a fever? (Please specify)

________________________________________________________________________ ____________________________________

8 How many febrile convulsions or fits associated with fever has your child had? (Please specify the number of febrile convulsions your child has had)

___________________________________

9 Please indicate your age at your last birthday? (Please insert the number of years)

_____________________ years

10 Please indicate your gender. (Please circle) 1. Female 2. Male

11 Please indicate your marital status. (Please circle)

1. Single (never married) 2. Married 3. Defacto 4. Divorced/Separated 5. Widowed

12 Please write the birth date of each of your children in the spaces provided.

_________________________ _________________________ _________________________ _________________________ _________________________ _________________________

309

13 Please indicate your HIGHEST level of education (Please circle the highest level of education you have completed)

1. Completed Primary School 2. Undertook some Secondary Schooling 3. Competed Secondary School 4. Completed a TAFE course 5. Completed a University Degree 6. Completed a Postgraduate Degree

14 Have you had any education in a health profession or worked

in health care?

1. Yes (Please specify) ____________________________________ 2. No

15 Please write in the space provided the country where you were born.

____________________________________

16 Please write in the space provided the country where your husband/partner was born.

____________________________________

17 Are you currently employed? (Please circle) 1. Full-time 2. Part-time 3. Casually 4. Not at present

18 Could you please DESCRIBE your current or most recent occupation (eg., secretary, dietician, fast food worker, nurse, cleaner, accountant, etc.) in the space provided.

____________________________________ ____________________________________

19 Do you have a child who has had at least one fever? (Please circle)

1. Yes 2. No

20 Are you the parent who provides the MOST care for your child when they have a fever? (Please circle)

1. Yes 2. No

21 Which of the following people help you decide how to care for your child when they are ill? (Please circle ALL that apply)

1. Husband/Partner 2. Mother 3. Father 4. Mother-in-law 5. Father-in-law 6. Friends with similarly aged children 7. Friends with older children 8. Friends without children 9. Friends with a medical background 10. Work friends 11. Others (Please specify)-

__________________

22 Please write the postcode or your home address in the space provided.

Postcode _____________________

How long did it take you to complete the survey this time? (Please circle the time)

15

minutes

20

minutes

25

minutes

30

minutes

35

minutes

310

Main Study Documents

311


INFORMATION FOR PARENTS ABOUT THE SURVEY



Raising a young child is not easy and when your child becomes ill this is even more difficult. Many parents are worried about their child’s fever when they are ill. They seek advice on how best to care for their child. There is a lot of the advice available. However, advice can vary, making it hard for parents to know what is the best thing to do. This can make parents even more worried about how to care for their sick child. As you have a child aged between 6 months and 5 years you will have had to look after a child with a fever. Not much is known about how Australian parents look after their children when they have a fever. Also, little is known about how Australian parents learn how to manage fever. As this is something every parent will have to do it is important to find this out. Then nurses and doctors can help parents during this worrying time. I would like to invite you to participate in a survey about children’s fever. The survey asks questions about how you know your child has a fever, how you manage fever in your children, what you know about fever and how you learnt to manage fever. There area also few questions asking for some personal information about you. It will take about 20 minutes to answer the questionnaire. Once you have answered the questions, or those you can, please place the questionnaire in the stamped, addressed envelope included in this package and return it to the researcher. What is learnt from the survey will be used to help Australian parents in the future when their child has a fever. I do not wish anyone to be identified through the information I collect. To make sure your records are confidential please do not write your name or address on the questionnaire. All the information I collect through the survey will be kept secure in a locked filing cabinet. Only I and my supervisors will have access to this information. No information about the study will be published in any form that would allow you to be recognised. Participating in the survey is voluntary. Answering the questionnaire should not pose any risk to you. The only inconvenience you should experience is the use of your time. If you have any questions about this research please contact me, Anne Walsh, on 3864 3856 or my supervisor, Prof. Helen Edwards on 3864 3844. You may also contact the Queensland University of Technology’s Research Ethics Officer on 3864 2340 if you have any concerns about the ethical conduct of this research.

312


INFORMATION FOR PARENTS ABOUT THE SURVEY



Raising a young child is not easy and when your child becomes ill this is even more difficult. Many parents are worried about their child’s fever when they are ill. They seek advice on how best to care for their child. There is a lot of the advice available. However, advice can vary, making it hard for parents to know what is the best thing to do. This can make parents even more worried about how to care for their sick child. As you have a child aged between 6 months and 5 years you will have had to look after a child with a fever. Not much is known about how Australian parents look after their children when they have a fever. Also, little is known about how Australian parents learn how to manage fever. As this is something every parent will have to do it is important to find this out. Then nurses and doctors can help parents during this worrying time. I would like to invite you to participate in a survey about children’s fever. The survey asks questions about how you know your child has a fever, how you manage fever in your children, what you know about fever and how you learnt to manage fever. There are also a few questions asking for some personal information about you. It will take about 20 minutes to answer the questionnaire. Once you have answered the questions, or those you can, please place the questionnaire in the envelope included in this package and return it to the researcher at the child care centre this afternoon. If you prefer to take a few days to complete the questionnaire it can be returned in the enclosed envelope to the child care centre and placed in the sealed box in the director’s office. What is learnt from the survey will be used to help Australian parents in the future when their child has a fever. I do not wish anyone to be identified through the information I collect. To make sure your records are confidential please do not write your name or address on the questionnaire. All the information I collect through the survey will be kept secure in a locked filing cabinet. Only I and my supervisors will have access to this information. No information about the study will be published in any form that would allow you or your child care centre to be recognised. Participating in the survey is voluntary. Answering the questionnaire should not pose any risk to you. The only inconvenience you should experience is the use of your time. If you have any questions about this research please contact me, Anne Walsh, on 3864 3856 or my supervisor, Prof. Helen Edwards on 3864 3844. You may also contact the Queensland University of Technology’s Research Ethics Officer on 3864 2340 if you have any concerns about the ethical conduct of this research.

313

CHILDHOOD FEVER

MANAGEMENT

- - - INSTRUCTIONS - - -

1. The questionnaire asks for your general opinions about fever and managing fever in children aged between 6 months and 6 years.

2. It might be an idea to do this survey when the children are asleep and you

are less likely to be interrupted, it will take about 20 minutes to complete.

3. Please answer every question by marking your answer with a pen as

indicated. 4. In some instances certain questions may look alike but each one is

different. 5. There are no right or wrong answers. If you are unsure how to answer a

question please give the best answer you can. 6. In this questionnaire MEDICATION only refers to over the counter

medication, eg., Panadol and Nurofen, NOT to antibiotics. 7. After you have completed the questionnaire please place it in the box

provided in the Director’s office or return it at your earliest convenience to the Queensland University of Technology in the reply paid envelope supplied.

Thank you for offering to participate in this research.

314

Section 1 The following questions relate to the times when your child has a fever.

1 What things do you usually do when your child has a fever?

(Please list)

____________________________________________________________________ __________________________________ __________________________________ __________________________________

2 What is the very first thing you do when you know your child has a fever? (Please write the very first thing you do)

__________________________________

3 If you think the fever is very high do you do these same things? (Please circle)

1. Yes Please go to Q5 2. No 3. Unsure Please go to Q5

4 If NO what other things would you do if you think the fever is very high? (Please list)

____________________________________________________________________ __________________________________ __________________________________ __________________________________

5 Has your management of fever changed as your child has grown older OR with the birth of other children? (Please circle)


6 If YES – how has your fever management changed? (Please list)

____________________________________________________________________ __________________________________ __________________________________ __________________________________

7 Please mark with an X on the line the temperature you would consider to be NORMAL for your child.


8

Please mark with an X on the line the temperature you would consider to be a FEVER for your child.


9

Please mark with an X on the line the temperature you would consider to be a HIGH FEVER for your child.


315

10 Please mark with an X on the line the temperature you would consider to be a VERY HIGH FEVER for your child.


The following questions relate to fever in general

11

Can fever ever be harmful? (Please circle)

1. Yes 2. No Please go to Q15 3. Sometimes

12

At what temperature is fever harmful? (Please specify)

_____________°C

13

How harmful is fever at the temperature you have identified in Question 12? (Please circle one)

1. Very harmful 2. Reasonably harmful 3. Harmful 4. A little harmful 5. Not very harmful

14 In your opinion what harm can fevers at the temperature identified in Question 12 cause a child? (Please rank these in decreasing order of concern to you with the most harmful first)

1. ______________________________ 2. ______________________________ 3. ______________________________

15 What are you MOST worried about when your child has a fever? (Please specify)

__________________________________

16 What other things do you worry about when your child has a fever? (Please list)

____________________________________________________________________ __________________________________ __________________________________ __________________________________

The following questions ask what you GENERALLY do when your child has a fever.

Please circle the ONE number that best describes what you generally do.

When my child has a fever I generally Always Mostly Sometimes Rarely Never

17 Take their temperature 1 2 3 4 5 18 Like to know what their temperature is 1 2 3 4 5 19 Make sure they have plenty to drink 1 2 3 4 5 20 Use over the counter medication to reduce the fever 1 2 3 4 5 21 Check on them during the night 1 2 3 4 5 22 Sleep in the same room as them 1 2 3 4 5 23 Wake them up during the night for medication to

reduce their fever 1 2 3 4 5

24 Take them to the doctor 1 2 3 4 5

316

25 When your child has a fever what influences your decision to take them to a doctor? (Please list)

_____________________________________________________________________________________________________________________________________________________________________

The following questions ask about your use of OVER THE COUNTER MEDICATIONS

(not antibiotics) to reduce fever. There are no right or wrong answers we are

interested in how you GENERALLY use this medication to reduce fever.

26

Do you ever have difficulty giving your child medications to reduce fever? (Please circle)

1. Yes 2. No Please go to Q 29

27 Please list the difficulties you have had when giving your child

medications to reduce fever. __________________________________________________________________________________________________________________________________________________________________________

28 Please list how do you have dealt with these difficulties?

__________________________________________________________________________________________________________________________________________________________________________

29 At what temperature do you USUALLY give your child medication to reduce fever? (Please specify)

____________°C

30 Do any other things influence your decision to give your child

medication to reduce fever? (Please circle)


31 If YES, what other things influence your decision to give medication to your child when they have a fever? (Please list)

______________________________________________________________________________________________________ ____________________________________________________________________

Yes No Paracetamol (eg., Panadol) 1 2 Ibuprofen (eg., Nurofen) 1 2

32 What medications do you use? (Please circle ALL that apply)

Other medication (Please specify)_____________

33 When do you use medication to reduce fever? (Please circle ALL that apply)

1. With mild fevers 2. With high fevers 3. With very high fevers 4. Other (Please list)_______________

______________________________

317

34 Have you ever alternated the use of paracetamol (eg., Panadol) and ibuprofen (eg., Nurofen) when your child has a fever? For example, paracetamol at 10am, ibuprofen at 12md, paracetamol at 2pm (Please circle)


35 If YES – what influenced your decision to use alternating medications to reduce fever? (Please list)

____________________________________________________________________ ____________________________________________________________________

36 How often have you used alternating medications to reduce your child’s fever? (Please circle)

1. Always – with every fever 2. Mostly – with most fevers 3. Sometimes – with some fevers 4. Rarely 5. Only once 6. Other (Please list)________________

37 What types of fever do you alternate medications to reduce your child’s fever? (Please circle ALL that apply)

1. Mild fevers 2. High fevers 3. Very high fevers 4. Other (Please list)________________

38 What things about your child do you consider when you work out how much medication to give them to reduce their fever? (Please circle ALL that apply)

1. Age 2. Sex 3. Height 4. Weight 5. Height of fever 6. Severity of illness 7. Irritability 8. Listlessness (eg., too tired for normal activities) 9. Other (Please list)___ ____________

39 What is the most frequent interval (how many hours between doses) that you can give a child with a fever medication to reduce the fever? (Please write the interval for each medication you use to reduce your child’s fever)

1. Paracetamol _______________ 2. Ibuprofen _______________ 3. Other medication (Please list) ____________________

40 How do you usually determine how frequently to give your child medication to reduce their fever? (Please list)

________________________________________________________________________________________________________________________________________

41 Can medication used to reduce fever be harmful to children? (Please circle)


42 If YES – what harm do you think these medications can cause? (Please list)

____________________________________________________________________ ____________________________________________________________________

318

The following questions relate to how YOU learnt to manage fever.

43

Do you feel you know the best way to manage fever in your children? (Please circle)

1. Yes 2. No 3. Unsure

44 How did you learn to manage fever? (Please list)

____________________________________________________________________ __________________________________ __________________________________ ______________________________________________________________________________________________________

45 Have you ever received conflicting information about how to manage your child’s fever? (Please circle)


46 If YES, please give examples of the conflicting information you

have received. (Please list)

____________________________________________________________________________________________________________________________________________________________________________________________________________

47 When you received conflicting information about managing fever how did it make you feel about managing your child’s fever? (Please list)

__________________________________ __________________________________ __________________________________ ____________________________________________________________________

48 Is there anything else you would like to comment on about managing your child’s fever? (Please comment in the space provided below)

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

319

Section 2

Decisions about how to manage your child’s fever are often complex.

However, in the questions below we are interested in your

GENERAL OPINIONS about managing your child’s fever.

These questions use a rating scale with 7 places; please circle the number that best describes your opinion. For example if you were asked to rate the statement “I decide the

types of food my child is given to eat” the 7 places should be interpreted as follows

I decide the types of food my child is given to eat

1 2 3 4 5 6 7 TRUE

Definitely True

True Somewhat True

Neither Somewhat Untrue

Untrue Definitely Untrue

UNTRUE

In this section MEDICATION only refers to over the counter medication

(eg., Panadol or Nurofen, NOT to antibiotics) and

FEBRILE CONVULSION refers to a fit or seizure that is associated with fever. Please circle the ONE number that corresponds with your best answer

GENERALLY speaking, how much do you agree or disagree with the following?

Strongly Agree

Strongly Disagree

1 When my child has a fever I decide how to manage it 1 2 3 4 5 6 7 2 My child takes medication easily when they have a fever 1 2 3 4 5 6 7 3 I am confident I will be able to reduce my child’s next fever with


4 Deciding whether or not to use medication to reduce my child’s fever is completely up to me

1 2 3 4 5 6 7

When your child next has a fever how true or untrue will each of the following

GENERALLY be?

Definitely True

Definitely Untrue

5 I will try to reduce my child’s next fever 1 2 3 4 5 6 7 6 I will try to reduce my child’s next fever with medication 1 2 3 4 5 6 7 7 I will try to reduce my child’s next fever of 38.0°C or below with


320

In GENERAL, when your child has a fever how likely or unlikely is each of the

following?

Extremely Likely

Extremely Unlikely

8 Reducing my child’s fever will prevent my child from being harmed by the fever

1 2 3 4 5 6 7

9 Reducing my child’s fever will reduce any discomfort caused by the fever

1 2 3 4 5 6 7

10 Reducing my child’s fever will prevent my child from having a febrile convulsion

1 2 3 4 5 6 7

11 Reducing my child’s fever with medication will prevent my child being harmed by the fever

1 2 3 4 5 6 7

12 Reducing my child’s fever with medication will reduce discomfort caused by the fever

1 2 3 4 5 6 7

13 Reducing my child’s fever with medication will reduce the listlessness (eg., tiredness preventing normal activities) caused by fever

1 2 3 4 5 6 7

14 Reducing my child’s fever with medication will prevent my child having a febrile convulsion

1 2 3 4 5 6 7

15 Fevers of 38.0°C and below can harm my child 1 2 3 4 5 6 7 16 Taking my child’s temperature regularly informs me of my child’s

condition 1 2 3 4 5 6 7

17 Monitoring my child’s well-being informs me about how they are feeling

1 2 3 4 5 6 7

18 Not reducing my child’s fever will assist their body’s defences fight the infection

1 2 3 4 5 6 7

19 Knowing the cause of my child’s fever reduces my concerns about the fever

1 2 3 4 5 6 7

20 My doctor generally knows the cause of my child’s fever 1 2 3 4 5 6 7

GENERALLY speaking when you are caring for your child with a fever


Not At All

Very Much

21 How much do you do what your husband/partner thinks you should do? NA 1 2 3 4 5 6 7 22 How much do you do what your mother thinks you should do? NA 1 2 3 4 5 6 7 23 How much do you do what your friends think you should do? NA 1 2 3 4 5 6 7 24 How much do you do what your doctor thinks you should do? NA 1 2 3 4 5 6 7

321

In GENERAL, when your child next has a fever how likely or unlikely is each of the

following?

Extremely Likely

Extremely Unlikely

25 The next time my child has a fever I intend to reduce my child’s fever 1 2 3 4 5 6 7

26 The next time my child has a fever I intend to reduce the fever with medication

1 2 3 4 5 6 7

27 The next time my child has a fever of 38.0°C or below I intend to reduce the fever with medication

1 2 3 4 5 6 7

What do you GENERALLY BELIEVE about each of the following in relation to fever?

Extremely Bad

Extremely Good

28 Reducing my child’s fever to protect them from harm is 1 2 3 4 5 6 7 29 Reducing my child’s fever to relieve discomfort is 1 2 3 4 5 6 7 30 Reducing my child’s fever to prevent febrile convulsions is 1 2 3 4 5 6 7 31 Reducing my child’s fever with medication is 1 2 3 4 5 6 7 32 Reducing my child’s fever with medication to relieve discomfort is 1 2 3 4 5 6 7 33 Reducing my child’s fever with medication to relieve the listlessness

(eg., tiredness preventing normal activities) associated with fever is 1 2 3 4 5 6 7

34 Reducing my child’s fever with medication to prevent febrile convulsions is

1 2 3 4 5 6 7

35 Reducing my child’s fevers of 38.0°C or below is 1 2 3 4 5 6 7 36 Taking my child’s temperature regularly to monitor their condition is 1 2 3 4 5 6 7 37 Observing my child’s well-being to monitor their condition is 1 2 3 4 5 6 7 38 Allowing my child’s body’s natural defences to assist in fighting the

illness is 1 2 3 4 5 6 7

39 Not being as concerned about the fever due to knowing its cause is 1 2 3 4 5 6 7 40 Knowing the cause of the fever from a doctor is 1 2 3 4 5 6 7

In GENERAL, do the following make it easier or more difficult for you to manage

your child’s fever?

Much Easier to Manage Fever

More Difficult to Manage Fever

41 For me, to decide by myself how to manage my child’s fever makes it 1 2 3 4 5 6 7 42 When my child has a fever he/she usually takes medication to reduce

fever easily, this makes it 1 2 3 4 5 6 7

43 For me, using medication to reduce my child’s fever makes it 1 2 3 4 5 6 7

44 For me, to decide by myself whether I manage my child’s fever with medications is

1 2 3 4 5 6 7

322

In GENERAL, when your child has a fever how likely or unlikely is each of the

following?


Extremely Likely

Extremely Unlikely

45 When my child has a fever my husband/partner thinks I should reduce the fever

NA 1 2 3 4 5 6 7

46 When my child has a fever my mother thinks I should reduce the fever NA 1 2 3 4 5 6 7 47 When my child has a fever my friends think I should reduce the fever NA 1 2 3 4 5 6 7

48 When my child has a fever my doctor thinks I should reduce the fever NA 1 2 3 4 5 6 7

49 When my child has a fever my husband/partner thinks I should reduce the fever with medication

NA 1 2 3 4 5 6 7

50 When my child has a fever my mother thinks I should reduce the fever with medication

NA 1 2 3 4 5 6 7

51 When my child has a fever my friends think I should reduce the fever with medication

NA 1 2 3 4 5 6 7

52 When my child has a fever my doctor thinks I should reduce the fever with medication

NA 1 2 3 4 5 6 7

GENERALLY speaking, in relation to managing your child’s fever, how much do you

agree or disagree with each of the following

Strongly Agree

Strongly Disagree

53 I plan to reduce my child’s next fever 1 2 3 4 5 6 7 54 I plan to reduce my child’s next fever with medication 1 2 3 4 5 6 7 55 I plan to reduce my child’s next fever of 38.0°C or below with


323

Section 3

This section asks for some information about you and your children 1

Do you have a child with a chronic illness (eg., asthma, diabetes). (Please circle)

1. No 2. Yes (Please list) ___________________

2 Do you have a child who is an epileptic – or has had a fit that was not associated with a fever? (Please circle)

1. No 2. Yes

3 Do you have a child who has had a febrile convulsion or fit associated with fever? (Please circle)

1. No Please go to Q9 2. Yes

4 Is there any family history of febrile convulsions, eg., mother, sibling, uncle? (Please circle)


5 What were you MOST worried about when your child had a febrile convulsion? (Please list)

________________________________________________________________________

6 Do you worry that your child will have another febrile convulsion? (Please circle)

1. No 2. Yes

7 What do you worry about NOW when your child has a fever? (Please list)

________________________________________________________________________ ____________________________________ ____________________________________

8 How many febrile convulsions or fits associated with fever has your child had? (Please specify the number of febrile convulsions your child has had)

___________________________________

9 Please indicate your age at your last birthday? (Please insert the number of years)

_____________________ years

10 Please indicate your gender. (Please circle) 1. Female 2. Male

11 Please indicate your marital status. (Please circle)

1. Single (never married) 2. Married 3. Defacto 4. Divorced/Separated 5. Widowed

12 Please write the birth date of each of your children in the spaces provided.

_________________________ _________________________ _________________________ _________________________ _________________________ _________________________

324

13 Please indicate your HIGHEST level of education (Please circle the highest level of education you have completed)

1. Completed Primary School 2. Undertook some Secondary Schooling 3. Competed Secondary School 4. Completed a TAFE course 5. Completed a University Degree 6. Completed a Postgraduate Degree

14 Have you had any education in a health profession or worked

in health care?


_________________________________

15 Please write in the space provided the country where you were born.

____________________________________

16 Please write in the space provided the country where your husband/partner was born.

____________________________________

17 Are you currently employed? (Please circle)

1. Full-time 2. Part-time 3. Casually 4. Not at present 5. Full-time student 6. Part-time student 7. On leave (eg., maternity)

18 Could you please DESCRIBE your current or most recent occupation (eg., secretary, dietician, fast food worker, nurse, cleaner, accountant, etc.) in the space provided.

____________________________________ ____________________________________ ____________________________________

19 Do you have a child who has had at least one fever? (Please circle)

1. Yes 2. No

20 Are you the parent who provides the MOST care for your child when they have a fever? (Please circle)

1. Yes 2. No

21 Which of the following people help you decide how to care for your child when they are ill? (Please circle ALL that apply)

1. Husband/Partner 2. Mother 3. Father 4. Mother-in-law 5. Father-in-law 6. Friends with similarly aged children 7. Friends with older children 8. Friends without children 9. Friends with a medical background 10. Work friends 11. Doctor 12. Nurse 13. Others (Please list)__________________

22 Please write the postcode or your home address in the space provided.

Postcode _____________________

Thank you for your valuable assistance with this research

325

Appendix 3

Statements of Author Co-Contributions to

Manuscripts

326

Walsh, A. M., & Edwards, H. E. (2006). Management of childhood fever by

parents: literature review. Journal of Advanced Nursing, 54(2), 217-227.

In the case of this article in Chapter 3

Statement of Contribution of Co-Authors for Thesis by Published Paper The authors listed below have certified* that: 1. they meet the criteria for authorship in that they have participated in the conception, execution, or

interpretation, of at least that part of the publication in their field of expertise; 2. they take public responsibility for their part of the publication, except for the responsible author

who accepts overall responsibility for the publication; 3. there are no other authors of the publication according to these criteria; 4. potential conflicts of interest have been disclosed to (a) granting bodies, (b) the editor or publisher

of journals or other publications, and (c) the head of the responsible academic unit, and 5. they agree to the use of the publication in the student’s thesis and its publication on the

Australasian Digital Thesis database consistent with any limitations set by publisher requirements.

Contributor Statement of contribution*

Anne Walsh

5th August 2004

Study design, recruited participants, collected and analysed data, wrote the manuscript.

Prof. Helen Edwards

Study design and critical revision of the manuscript for important intellectual content, supervised the study.

Principal Supervisor Confirmation I have sighted email or other correspondence from all Co-authors confirming their certifying authorship and. _______________________ ____________________ ______________________ Name Signature Date

327

Walsh, A. M., Edwards, H. E., & Fraser, J. A. (2007 Online Early). Influences on parents' fever management: beliefs, experiences and information sources. Journal of Clinical Nursing, doi: 10.1111/j.1365-2702.2006.01890.x.

In the case of this article in Chapter 5:

Statement of Contribution of Co-Authors for Thesis by Published Paper

The authors listed below have certified* that: 6. they meet the criteria for authorship in that they have participated in the conception, execution, or






Anne Walsh

5th August 2004


Prof. Helen Edwards


Dr. Jenny Fraser

Assisted in study design, study supervision and manuscript revision.


328

Walsh, A. M., Edwards, H., & Fraser, J. (Under Review). Underpinned by fear: a

community study of parents' fever management with young children. Journal of Advanced Nursing.


Statement of Contribution of Co-Authors for Thesis by Published Paper

The authors listed below have certified* that: 11. they meet the criteria for authorship in that they have participated in the conception, execution, or






Anne Walsh

5th August 2004


Prof. Helen Edwards


Dr. Jenny Fraser



329

Walsh, A., Edwards, H., & Fraser, J. (2007 Online Early). Over-the-counter

medication use for childhood fever: A cross-sectional study of Australian parents. Journal of Paediatrics and Child Health, doi:10.1111/j.1440-1754.2007.01161.x.


Statement of Contribution of Co-Authors for Thesis by Published Paper The authors listed below have certified* that: 16. they meet the criteria for authorship in that they have participated in the conception, execution, or






Anne Walsh

5th August 2004


Prof. Helen Edwards


Dr. Jenny Fraser



330

Appendix 4

Conference Abstracts

331

AUSTRALASIAN SOCIETY OF BEHAVIOURAL HEALTH AND MEDICINE (ASBHM)

4th Annual Scientific Conference Spencer on Byron, Takapuna

Auckland, New Zealand 9-11 February 2006

EDUCATION BASED ON THE THEORY OF PLANNED BEHAVIOR

PROMOTES EVIDENCE-BASED FEVER MANAGEMENT

Authors: 1Walsh, A., 1Edwards, H., 1Courtney, M., 2Wilson, J., 2Monaghan, S. & 2Young, J. 1 Queensland University of Technology, Australia 2 Royal Children's Hospital, Brisbane, Australia

Introduction: Reports of concerns about fever, inconsistent fever management practices and health professionals’ escalating inappropriate use of antipyretics continue despite evidence of benefits of mild to moderate fever. Current practices of alternating antipyretics to reduce fever and maintain ‘normal’ temperature highlights concerns. This controlled experiment explored the effectiveness of a peer education program (PEP) based on the Theory of Planned Behavior in changing paediatric nurses’ intentions to administer antipyretics to febrile children. Methods: The eight week program consisted of four one-hour sessions repeated regularly over two-weeks. The program promoted peer education and support and targeted peer groups. All nurses employed in paediatric medical wards of two metropolitan paediatric hospitals in Australia during the eight month research period were eligible to participate in the surveys. Hospitals were allocated to experimental and control conditions. The PEP was delivered to nurses at the experimental hospital only. Data were collected one month pre-PEP, one month post-PEP and four months post-PEP (latency data) by survey and chart audit. Charts of all eligible children admitted during data collection periods were audited. Results: The PEP significantly reduced nurses’ intentions to administer antipyretics to the next febrile child (p=0.01). Practice changes were demonstrated by chart audits. Mean temperatures when antipyretics were administered were higher one month post-PEP than pre-PEP (38.5°C vs 38.1°C), however, this was not maintained in latency data (38.2°C). Normative influences over intentions (p=0.01) and nurses’ perception of personal control reduced significantly (p=0.01) highlighting increased awareness of external influences over antipyretic administration. Following the program nurses were significantly less likely to believe their colleagues (p=0.00) or medical officers (p=0.03) expected them to administer antipyretics. Additionally they were less likely to comply with colleagues’ (p=0.01) or medical officers’ (p=0.05) expectations for antipyretic administration post PEP. Conclusions: The program successfully promoted evidence-based intentions and practices by reducing normative influences and incorrect perceptions of control over antipyretic administration.

332

AUSTRALIAN CONFEDERATION OF PAEDIATRIC AND CHILD HEALTH NURSES (ACPCHN)

9th International Biennial Paediatric and Child Health Nurses Conference,

17-19 May, 2006, Melbourne, Australia

PARENTS’ MANAGEMENT OF CHILDHOOD FEVER – THE NEED FOR EVIDENCE BASED EDUCATION

Authors: Anne Walsh, Helen Edwards, Jenny Fraser. School of Nursing, Queensland University of Technology Background Fevers are common events in the lives of young children. International studies continue to report parents’ concerns about childhood fevers. Parents find fevers frightening and base care on inaccurate information from other parents, friends, health professionals, parenting books and more recently the media and Internet rather than the latest scientific evidence. This research explores previously unknown fever management practices, concerns and information sources of Australian parents. Method Four hundred and one Queensland parents completed a self-report survey using an instrument developed from the literature and focused discussions with 15 parents. The survey identified parents’ definitions of fever, fever management practices, concerns and influences on their practices. Findings Parents define fever as 36.7°C to 41.2°C (mode 38.0°C). Most parents (91%) actively reduce fever with antipyretics for temperatures ranging from 37.0°C to 40.0°C (mode 38.0°C). Antipyretics administration is influenced by discomfort, distress or general unwellness (87%) and pain (32%). Parents are most concerned about febrile convulsions (45%), the cause of fever (26%), brain damage (23%) and serious illness (28%). They seek medical assistance for fevers considered ‘very high’ (38.0°C to 43.0°C, mode 40.0°C) (65%), symptoms of febrile illnesses such as cough, increased respirations and pain (44%), length of time child has been febrile (42%) and general unwellness (21%). Fever management is learnt from medical practitioners (61%), child health books (27%), mothers/mothers-in-law (23%) and nurses (16%) and through past experience (39%). Nearly half the parents (42%) had received conflicting information about fever management which made them feel confused (29%), concerned (18%), unsure about fever management (40%) or angry/frustrated (16%). Conclusions and Recommendations Parents’ fever management is not based on the latest scientific evidence. Paediatric and child health nurses are ideally placed to reduce parents’ concerns, increase their confidence and reduce the unnecessary use of health resources related to childhood fever. Key words: fever, parents’ concerns, parents’ management

333

INTERNATIONAL SOCIETY OF BEHAVIORAL MEDICINE

9th International Congress of Behavioral Medicine 29th November – 2nd December, 2006, Sofitel Central Plaza Hotel,

Bangkok, Thailand

PREDICTORS OF PARENTS’ INTENTIONS TO REDUCE CHILDHOOD FEVERS

Authors: Walsh, A.M.(*), Edwards, H.E., Fraser, J.A. Background Parents concerns about and immunological benefits of mild to moderate fevers have been reported for 25 years. Recent reports indicate practices of alternating antipyretics when fever has not reduced sufficiently. Purpose The purpose of this study was to explore the predictors of Australian parents’ intentions to reduce childhood fevers by non-pharmacological and pharmacological methods. Method A crossectional survey of 397 parents of children aged between 6-months and 5-years was undertaken. An instrument was developed from focused discussions with 15 parents, existing instruments and literature. Instrument face, content and construct validity were determined by an expert panel and readability by 10 parents. Predictors of intention to reduce fever, reduce fevers with antipyretics and reduce fevers of 38.0°C or below were determined through the Theory of Planned Behavior. Predictors explored were parents’ beliefs about benefits of reducing fever, normative influences on reducing fever and reducing fever with antipyretics and perceived control over fever management. Results Simultaneous regressions were conducted. Beliefs (42%) and norms relating to fever reduction (16%) were strongest predictors of intentions to reduce fever R2=.27. Norms about reducing fevers with antipyretics (47%) and beliefs (37%) positively influenced intentions to reduce fevers with antipyretics R2=.34 and norms about fever reduction had a negative influence (20%). Predictors of intentions to reduce fevers of 38.0°C or below were weaker R2=.14, however, beliefs (24%) and norms about reducing fevers with antipyretics (29%) predicted this practice. Conclusions Negative beliefs about fever and fever management and normative influences were the strongest predictors of parents’ fever management intentions. These findings highlight the need to target all parents’ beliefs about fever and its benefits and correct norms relating to reducing fever and the dangers of unnecessary and/or overuse of antipyretics in children with a febrile illness.

334

ASIA-PACIFIC ACADEMIC CONSORTIUM FOR PUBLIC HEALTH (APCPH)

38th APACPH Annual Conference – Partnership for Human Security and Health

Bangkok, Thailand December 3-6, 2006

Authors: Walsh, A. Edwards, H., Fraser, J.

INFLUENCE OF INACCURATE, CONFLICTING HEALTH INFORMATION ON

PARENTS’ MANAGEMENT OF CHILDHOOD FEVER Background Internationally, studies continue to report parents’ concerns about childhood fevers. Parents find fevers frightening and base care on inaccurate, often conflicting health information gathered from multiple sources. Purpose Identify impact of inaccurate and conflicting health information on fever management practices of parents of young children. Methods Four-hundred Queensland parents of children aged 6-months to 5-years completed a self-report survey developed from the literature and focused discussions with 15 parents. The survey identified parents’ definitions of fever, fever management practices, concerns and influences on their practices. Summary of results Inaccurate beliefs that fever is harmful (88%) causing brain damage and febrile convulsions influenced practices, eg., 24 hour monitoring, unnecessary initiation of fever reduction strategies and medication administration for temperatures considered fever 38.2ºC±0.7 (43%) and high fever 39.4ºC±0.8 (75%). Medical advice was sought for fever (15%) and high fever (64%). Despite believing fever reducing medications harmful (73%) parents routinely use them to reduce temperatures of 38.3ºC±0.6. Many (65%) used multiple medication combinations, eg., paracetamol, ibuprofen, homeopathic preparations; 52% had alternated medications and 35% administered medications at too frequent intervals, overdosing their child. Most parents (71%) believed they knew how to manage fever. Parents learnt about fever management from health professionals (80%), past experience (39%), literature (26%), peers (24%) and mothers (23%). Nearly half (42%) received conflicting information causing confusion and increased concerns (66%) and frustration (16%). Conclusions and Reflections Inaccurate, conflicting information influenced parents’ beliefs and practices. Low grade fevers precipitated unnecessary fever reduction strategies; health services utilisation and medication administration (some overdosing) although medications were believed harmful. Health professionals, responsible for health education, must ensure all parents of young children are provided with accurate, evidence-based, consistent fever management information, preferably before the firstborn has a fever.

335

GENERAL PRACTITIONER AND PRIMARY HEALTH CARE

2007 GP & PHC Research Conference

Sydney, Australia 23 to 25 May 2007

Authors: Walsh, A. Edwards, H., Fraser, J.

OVER-THE-COUNTER MEDICATION USE IN CHILDHOOD FEVER MANAGEMENT: HEALTH PROFESSIONALS WORKING WITH

PARENTS Background Internationally parents are overly concerned about and unnecessarily reduce childhood fever, often overdoing children with antipyretics. Objectives Identify Australian parents’ beliefs and practices in childhood fever management. Methods Crossectional survey of 401 Queensland parents recruited through advertising (48.4%), face-to-face (26.4%) and snowball (24.4%) methods. An instrument was developed, construct and content validity determined by an expert panel and item reliability by test-retest with nine parents. Areas targeted were beliefs about fever, medication use, influences on and barriers to medication use. Principal findings Parents, believing fever harmful, usually used antipyretics to reduce temperatures from 37.0°C to 40.0°C (38.3°C±0.6). Medical advice was sought for specific illness symptoms, length of illness, height of fever, inability to reduce fever or recurrent fever and children generally unwell. Antipyretic use was influenced by temperature, distress or general unwellness and pain or discomfort. Nearly all used paracetamol (94%) and most used ibuprofen (77%). Overdosing by too frequent administration was common with ibuprofen (31.8%), 4th hourly by 22%, and infrequent with paracetamol 3.8%. Alternating antipyretics was common (51.8%) and this practice was influenced by health professional recommendations and children remaining febrile post-antipyretic. Beliefs that antipyretics were harmful (73.2%) did not preclude administration. Medication refusals (44.0%) were overcome by using force, different administration methods including suppositories. Discussion Parents’ fears about negative outcomes from fever are highlighted by their use of over-the-counter medications to reduce low-grade fevers, despite believing these medications harmful. Errors in medication administration frequency indicate confusion from multiple medication use and alternating antipyretics. Implications Practice implications for health professionals will be to provide evidence-based information to parents targeting the benefits of fever, when and how to safely use medications and when to seek medical assistance. Parents need advice and reassurance on how to manage fever, a common, frightening event in childhood.

336

PAEDIATRICS & CHILD HEALTH ANNUAL MEETING INCORPORATED IN THE ROYAL AUSTRALIAN COLLEGE OF PHYSICIANS ANNUAL MEETING

6th - 10th May, 2007, Melbourne, Australia

EVIDENCE-BASED MANAGEMENT OF UNCOMPLICATED PAIN AND FEVER IN CHILDREN IN THE COMMUNITY SETTING Authors: Beggs S1, Carroll P2, Walsh A3, Nissen M4, Bennett S5, Yeo G-T6 1Royal Children’s Hospital, Parkville, VIC; 2University of NSW, Sydney, NSW; 3Queensland University of Technology, Kelvin Grove, QLD; 4Royal Children’s Hospital, Brisbane, QLD; 5Bennett, S. Pharmacy, Balmain, NSW; 6Berowra Family Medical Practice, Sydney, NSW. Introduction: Childhood fever is the most common reason for parents to seek medical attention.1 Despite successful educational interventions fever phobia persists.2 Healthcare professionals can play a pivotal role in educating parents on how best to manage such conditions. We provide practical, yet evidence-based, guidance on the management of children (aged 0-12 years) presenting in the community setting with pain and/or fever in association with common childhood ailments. Method Design: Electronic database searching (1966-August 2006) was conducted to identify articles relating to the management of pain and or fever in children aged 0-12 years. Additional articles were found through archives and the reference lists of identified articles. Recommendations: (1) Fever alone does not need to be treated. (2) Parents should watch for signs of development of potential serious problems (vomiting, irritability, lethargy, apathy) and seek further medical advice if a fever persists for more than 48 hours or if the child's condition deteriorates. (3) Paracetamol (15mg/kg) and ibuprofen (10mg/kg) are equally effective analgesics and antipyretics. (4) Both drugs are generally well tolerated, but the potential exists for more iatrogenic risks with ibuprofen use. (5) Alternating therapy is not recommended. Conclusions: While both paracetamol and ibuprofen may be appropriate for use in children, we need to encourage the quality use of all medicines. This means discouraging their use simply to lower temperature and primarily considering them for pain or fever with associated discomfort. Given that there is no obvious efficacy advantage to using ibuprofen, there appears no reason to change from continuing to use paracetamol as the first-line treatment of choice in paediatric patients. References: (1) Dixon G, et al. Clinical and consumer guidelines related to the management of childhood fever. A literature review. Journal of Research in Nursing 2006;11(3):263-278. (2) Walsh A, Edwards H. Management of childhood fever by parents: literature review. J Adv Nurs 2006;54(2):217-227.

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Appendix 5

Media Interest Arising from the Research

Program

338

2006

Anne Walsh - "Fever" Media Coverage 6/4-13/4

Press

Feverish kids can get too much of a good thingSydney Morning Herald, 13/04/06, Health & Science, Page 3By: AAP Almost a third of parents overdose children with over-the-counter fevermedications, making youngsters susceptible to liver damage and stomachbleeding, a study has found. A Queensland University of Technologyreview of 24 years of global research found more than 30 per cent ofparents overdose their children on drugs such as paracetamol andibuprofen. Keywords: of Technology (1), University (2)

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Parents take cautious approach to medicineNorthern Daily Leader, 11/04/06, General News, Page 2By: None Almost a third of parents are overdosing children with over the counterfever medications a study has found, but a Tamworth pharmacist said mostparents were only too willing to seek his advice. A Queensland University ofTechnology (QUT) review of 24 years of international research found morethan 30 per cent of parents overdose their children on drugs such asparacetamol and ibuprofen. Keywords: Biomedical Innovation (1), Institute of Health (1), of Technology(1), QUT (3), University (1)


Panicked parents unaware of medicine dangersDaily Telegraph, 10/04/06, General News, Page 13By: Clare Masters More than half of parents are inadvertently overdosing their children withoff-the-shelf medications such as paracetamol, potentially causing themlong-term health problems. A "pill-popping culture" is encouraging mumsand dads to over-medicate children and panicked parents are also mixingmedication, Australian research found. Keywords: of Technology (1), University (1)


Subscribers should refer to the original article before making any financial decisions or forming anyopinions. This information is for the use of Media Monitors' subscribers only and may not beprovided to any third party for any purpose whatsoever without the express written permission ofMedia Monitors Australia Pty Ltd.

Parents overdose youngAdelaide Advertiser, 07/04/06, General News, Page 7By: None Almost a third of parents overdose children with over the counter fevermedications, making youngsters susceptible to liver damage and stomachbleeding, a study has found. A review of 24 years of international researchby the Queensland University of Technology found more than 30 per centof parents overdosed their children on such drugs as paracetamol andibuprofen. Keywords: of Technology (1), QUT (1), University (1)


Over counter overdosesBallarat Courier, 07/04/06, General News, Page 3By: None Almost a third of parents are overdosing children with over the counterfever medications, making youngsters susceptible to liver damage andstomach bleeding, a study has found. A Queensland University ofTechnology review of 24 years of international research found more than30 per cent of parents overdose their children on drugs such asparacetamol and ibuprofen. Keywords: of Technology (1), University (1)


Parents overdosing children: studyBarrier Daily Truth, 07/04/06, General News, Page 8By: AAP Almost a third of parents are overdosing children with over the counterfever medication, making youngsters susceptible to liver damage andstomach bleeding, a study has found. A Queensland University ofTechnology (QUT) review of 24 years of international research found morethan 30 per cent of parents overdose their children on drugs such asparacetamol and ibuprofen. Keywords: of Technology (1), QUT (1), University (1)


Overdosed childrenBorder Mail, 07/04/06, General News, Page 4By: None Almost a third of parents are overdosing children with over the counterfever medicine, making youngsters susceptible to liver damage andstomach bleeding, a study has found. A Queensland University ofTechnology review of 24 years of International research found more than30 per cent of parents overdose their children on drugs such asparacetamol and Ibuprofen, with some suffering severe liver damage. Keywords: of Technology (1), University (1)



Parents overdosing children on medicationBurnie Advocate, 07/04/06, General News, Page 10By: None Almost a third of parents are overdosing children with over-the-counterfever medications, making youngsters susceptible to liver damage andstomach bleeding, a study has found. A Queensland University ofTechnology review of 24 years of international research found more than30 per cent of parents overdose their children on drugs such asparacetamol and ibuprofen. Keywords: Biomedical Innovation (1), Institute of Health (1), of Technology(1), QUT (2), University (1)


Parents OD kids on fever medicineCairns Post, 07/04/06, General News, Page 16By: None Almost a third of parents are overdosing children with over the counterfever medications, making youngsters susceptible to liver damage andstomach bleeding, a study has found. A Queensland University ofTechnology review of 24 years of international research found more than30 per cent of parents overdose their children on drugs such asparacetamol and ibuprofen. Keywords: of Technology (1), QUT (1), University (1)


Parents are overdo sing children on painkillersCanberra Times, 07/04/06, General News, Page 3By: None Almost a third of parents are overdosing children with over-the-counterfever medications, making youngsters susceptible to liver damage andstomach bleeding, a study has found. A Queensland University ofTechnology review of 24 years of international research found more than30 per cent of parents overdosed their children on drugs such asparacetamol and ibuprofen. Keywords: Biomedical Innovation (1), Institute of Health (1), of Technology(1), University (3)


Parents misusing fever medicationsDaily Advertiser, 07/04/06, General News, Page 8By: None Almost a third of parents are overdosing children with over the counterfever medications, making youngsters susceptible to liver damage andstomach bleeding, a study has found. A Queensland University ofTechnology (QUT) review of 24 years of international research found morethan 30 per cent of parents overdose their children on drugs such - asparacetamol and ibuprofen. Keywords: Biomedical Innovation (1), Institute of Health (1), of Technology(2), QUT (3), University (2)



Parents overdosing children on fever medications: StudyDaily Mercury, 07/04/06, General News, Page 11By: Roberta Mancuso Almost a third of parents are overdosing children with over the counterfever medications, making youngsters susceptible to liver damage andstomach bleeding, a study has found. A Queensland University ofTechnology review of 24 years of international research found more than30 per cent of parents overdose their children on drugs such asparacetamol and ibuprofen. Keywords: Biomedical Innovation (1), Institute of Health (1), of Technology(1), QUT (2), University (1)


Overdosing fever kidsGold Coast Bulletin, 07/04/06, General News, Page 12By: None Almost a third of parents are overdosing children with over-the-counterfever medications, making youngsters susceptible to liver damage andstomach bleeding, says a study. A Queensland University of Technologyreview of 24 years of research found more than 30 per cent of parentsoverdose children on drugs such as paracetamol and ibuprofen. Keywords: of Technology (1), University (1)


Parents can't get dose rightHerald Sun, 07/04/06, General News, Page 20By: Michelle Pountney Almost a third of parents overdose their children with medicines such asparacetamol and ibuprofen when they have a fever, increasing their child'srisk of liver damage and internal bleeding. An Australian review of 24 yearsof international research found mismanagement of fever was a universaltrend. Keywords: of Technology (1), University (1)


Overdose fearsLaunceston Examiner, 07/04/06, General News, Page 4By: None Almost a third of parents are overdosing children with over-the counterfever medications, making youngsters susceptible to liver damage andstomach bleeding, a study has found. The findings came from aQueensland University of Technology review of 24 years of internationalresearch.



Parents overdosing kidsNewcastle Herald, 07/04/06, General News, Page 19By: AAP Almost a third of parents are overdosing children with over-the-counterfever medications, making youngsters susceptible to liver damage andstomach bleeding, a study has found. A Queensland University ofTechnology (QUID review of 24 years of international research found morethan 30 per cent of parents overdose their children on drugs such asparacetamol and ibuprofen. Keywords: Biomedical Innovation (1), Institute of Health (1), of Technology(1), QUT (2), University (1)


Parents overdosing children on fever medications: studyNews Mail, 07/04/06, General News, Page 10By: Roberta Mancuso Almost a third of parents are overdosing children with over the counterfever medications, making youngsters susceptible to liver damage andstomach bleeding, a study has found. A Queensland University ofTechnology review of 24 years of international research found more than30 per cent of parents overdose their children on drugs such asparacetamol and ibuprofen. Keywords: Biomedical Innovation (1), Institute of Health (1), of Technology(1), QUT (2), University (1)


Parents feed kids too many drugsQueensland Times, 07/04/06, General News, Page 6By: AAP Almost one third of parents overdose their children with over-the-counterfever medications, making youngsters susceptible to liver damage andstomach bleeding, a study has found. A Queensland University ofTechnology (QUT) review of 24 years of international research found morethan 30% of parents overdosed their children on drugs such asparacetamol and ibuprofen. Keywords: of Technology (1), QUT (2), University (1)


Overdose fears for fever medicineSunshine Coast Daily, 07/04/06, General News, Page 7By: AAP Almost a third of parents are overdosing children with over-the-counterfever medications, making youngsters susceptible to liver damage andstomach bleeding, a study has found. A Queensland University ofTechnology (QUT) review of 24 years of international research found morethan 30% of parents overdose their children on drugs such as paracetamoland ibuprofen. Keywords: Biomedical Innovation (1), Institute of Health (1), of Technology(1), QUT (3), University (1)



Children overdosed by parentsTownsville Bulletin, 07/04/06, General News, Page 4By: None Almost a third of parents are overdosing children with over the counterfever medications, making youngsters susceptible to liver damage andstomach bleeding, a study has found. A Queensland University ofTechnology (QUT) review of 24 years of international research found morethan 30 per cent of parents overdose their children on drugs such asparacetamol and ibuprofen. Keywords: Biomedical Innovation (1), Institute of Health (1), of Technology(1), QUT (3), University (1)


Parents overdose sick childrenWest Australian, 07/04/06, General News, Page 5By: Cathy O'Leary An alarming one-third of Australian parents are accidentally overdosingtheir children by doubling up on common over-the-counter pain-killers suchas Panadol and Nurofen. As a result many children are being put at risk ofinternal bleeding and even liver damage. Keywords: of Technology (1), University (1)


Fed: Parents overdosing children on fever medications: studyAAP Newswire, 06/04/06, National, Page 0By: AAP A study's found almost a third of parents are overdosing children with over-the-counter fever medications. And that's making them susceptible to liverdamage and stomach bleeding. Keywords: of Technology (1), University (1)

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Radio & TV

ABC North Coast NSW (Lismore)Afternoons - 12/04/06 02:51Terry SaraStation Phone 02 6627 2011 Anne Walsh from the Queensland University of Technology says there hasbeen an increase over the last 20 years internationally of parents whoprefer to use a medication to handle their children's fever. The mostcommon ones used are paracetamol and ibuprofin. Parents are better offlooking at their child and their wellbeing. Ms Walsh is currently looking atAustralian parents and how they handle fever. Interviewees: Anne Walsh, Queensland University of Technology NurseResearcher.Duration: 5.00Summary ID: 200021585263© Media Monitors

Demographics

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ABC 702 Sydney (Sydney)The World Today - 10/04/06 12:50Eleanor Hall A survey undertaken at the QLD Uni of Technology has shown that up tohalf of all Australian parents give their children the wrong dose ofmedication. Nursing researcher, Anne Walsh says 33% of parents try toreduce their childrens' fever by increased dosages and this shows a greaterreliance on medication. She explains that common medications bought insupermarkets could potentially cause much damage to children andparents should monitor them more carefully. Interviewees: Anne Walsh, Nursing Researcher, Qld Uni of TechnologyMentions: IbuprofenDuration: 3.34Summary ID: S00021551722© Media Monitors

Demographics

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2700024300176002950051200

ABC 891 Adelaide (Adelaide)Drive - 07/04/06 04:18Deb TribeProducer Mr Michael Ockerby 08 8343 4410 Medical issues continued: Tribe says research by the Qld Uni ofTechnology has found 30% of parents overdose their children with over thecounter medications like Paracetamol and Ibuprofen. Grummet says anoverdose of Paracetamol can cause kidney problems. He says Ibuprofencauses kidney and gut problems. He says figures from the Royal Children'sHospital in Melbourne showed there were horrifying numbers of overdosedchildren. Interviewees: Phil Grummet, spokesman, Pharmacy Guild of AustraliaDuration: 2.45Summary ID: A00021533696© Media Monitors

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4BC (Brisbane)08:30 News - 07/04/06 08:32NewsreaderNews Director Mr Steve Speziale 07 3908 8200 QUT Nursing researcher Ann Walsh says half of all parents incorrectlydose their children with over the counter medication for fever. Interviewees: Ann Walsh, nursing researcher, QUTDuration: 0.34Summary ID: B00021524453© Media Monitors

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ABC 720 Perth (Perth)Mornings - 06/04/06 09:24Gillian O’ShaughnessyProducer Ms Alicia Hanson 08 9220 2729 Almost half of all parents incorrectly dose their children with over-the-counter medications to manager temperatures which may not actually dealwith the symptoms. Qld Uni of Technology nursing researcher Anne Walshsays international studies show many parents overdose or underdoseyoungsters. Walsh says Paracetamol and Ibuprofen are the most usedmedications. She explains some of the mistakes parents can make and thepossible ramifications. Interviewees: Anne Walsh, Nursing Researcher, Qld Uni of TechnologyDuration: 8.03Summary ID: P00021512020© Media Monitors

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1700016000

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2007

COPYRIGHT This report and its contents are for the use of Media Monitors' subscribers only and may not be provided to any third party for anypurpose whatsoever without the express written permission of Media Monitors Australia Pty Ltd.

DISCLAIMER The material contained in this report is for general information purposes only. Any figures in this report are an estimation andshould not be taken as definitive statistics. Subscribers should refer to the original article before making any financial decisions or forming anyopinions. Media Monitors makes no representations and, to the extent permitted by law, excludes all warranties in relation to the informationcontained in the report and is not liable to you or to any third party for any losses, costs or expenses, resulting from any use or misuse of thereport.

Anne Walsh PhD results media coverage

13/09/2007

Study finds parents dose fevered kids too heavilyQueensland Times, 13/09/07, General News, Page 11By: None

QUEENSLAND parents need proper education in managing fever in youngchildren as many give medication incorrectly and often unnecessarily, saysQueensland University of Technology (QUT) nursing researcher AnneWalsh. In a study of more than 400 Queensland parents, Ms Walsh hasfound 32 per cent of parents administer ibuprofen too often, with four percent for paracetamol.

Keywords: of Technology(1), QUEENSLAND(3), QUT(1), University(1)

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12/09/2007

Channel 9 (Brisbane)Brisbane Extra - 12/09/2007 5:37 PMLisa Wilkinson

According to new research, one in three parents are dosing their children tooheavily with medication when they are ill. Reporter Lisa Honeywillinvestigates safe dispensation of medications to children. Mother JodyMittelheuser says she regularly reaches for medication when her childrenhave a fever and says she follows directions closely. QUT Researcher AnneWalsh says parents are overusing medications. Walsh says she surveyed400m parents across Qld to see how they managed fever and says aboutone third were overmedicating their children. Paediatrician Dr Johanna Holtsays fever alone is not a reason to medicate children

Interviewees: Anne Walsh, QUT; Dr Johanna Holt, Paediatrician; JodyMittelheuser, MotherMentions: Nurofen; Panadol.Vision: Milo; PanadolDuration: 3.57Summary ID: B00027890491© Media Monitors

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10/09/2007

ABC Far North (Cairns)Mornings - 10/09/2007 9:25 AMPat Morrish

Morrish talks about the topic of ill children being given incorrect dosages ofparacetamol for fever treatment. Morrish then speaks with Anne Walsh(*),Senior Research Fellow, Queensland University of Technology (QUT), abouther study into how Australians manage their children’s fever and her warningof misuse of over-the-counter medicine for children’s health can harm theirhealth. Walsh explains differences in fever medicine including differingdosage rates and response times including for paracetamol and ibuprofen.Walsh mentions that she is pleased that drug maker, Glaxo Smith Kleine ispaying attention to her research.

Interviewees: Anne Walsh(*), Senior Research Fellow, QueenslandUniversity of Technology (QUT).Duration: 5.00Summary ID: 400027853912© Media Monitors

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07/09/2007

ABC New England North West (Tamworth)Inland Afternoons - 7/09/2007 3:13 PMAlison Buchanan

According to a study of 400 parents by the Queensland University ofTechnology, a percentage of parents are administering paracetamol andibuprofen incorrectly. Tim Logan from the Pharmacy Guild of Australia says itis not always smart to stop a fever. Giving too much paracetamol can causeliver damage, warns Logan, who explains says too much ibuprofen cancause digestive problems. Too many people believe that at larger dose willremedy people at a quicker pace, which is incorrect. People need to usemedicines wisely stresses Logan.

Interviewees: Tim Logan, Pharmacy Guild of AustraliaDuration: 7.30Summary ID: 200027835318This program or part thereof is syndicated to the following 3 station(s):-ABC Central West NSW (Orange), ABC Riverina (Wagga Wagga), ABCWestern Plains NSW (Dubbo)© Media Monitors

Demographics

Demographics are notavailable as the mediaoutlet has notcommissioned audienceresearch into this timeslot.



3AW (Melbourne)Afternoons - 7/09/2007 2:44 PMDenis Walter

Walter claims a newspaper article claims parents are giving children toomuch medicine or cannot manage fever. Anne Walsh, senior research fellow,Qld University of Technology explains her study on Qld parents and how theymanage mild fever in children and claims they are over medicating and overdosing children with ibuprofen by using it like it is paracetamol. Walsh warnsagainst over dosing with ibuprofen on dehydrated children as it causesgastro problems, headaches and asthma. Walsh explains how fever isbeneficial.

Interviewees: Anne Walsh, senior research fellow, Qld University ofTechnologyDuration: 4.59Summary ID: M00027834979© Media Monitors

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ABC 666 Canberra (Canberra)Morning - 7/09/2007 9:45 AMAlex Sloan

Interview with Anne Walsh, Senior Research Fellow Queensland Universityof Technology to discuss a study conducted on the over dosing of children oncommon medications such as Ibuprofen and Paracetamol. Walsh says itseems using two different medications at the same time parents arebecoming confused at which to give at and at what rate. Walsh discusseshow parents were selected for the study and advises of the the resultsdisclosed during the study with note that parents seem to be overworied by achilds fever. Walsh advises that health professionals may need to look at thelatest literature and suggests parents be educated in the benefits fevers havefor a child.

Interviewees: Anne Walsh, Senior Research Fellow Queensland Universityof TechnologyMentions: Dr Michael Fascher, Royal College of General PractitionersDuration: 9.24Summary ID: C00027831328© Media Monitors

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5AA (Adelaide)Pilkington & Conlon - 7/09/2007 8:08 AMChris Dittmar & Jane Doyle

Doyle says an interesting report from QUT has emerged that says parentsare not that good at treating their kids at home for high fevers. She says thereport says 33% of parents don't know how to manage fever in their childrenand often give excessive doses of over the counter medicines. Ford says attime there is some confusion about how to treat a child's fever. He says oftenparents think they should be able to stop a fever immediately which is notrealistic. He says a fever can be an indicator of white bloods cells trying toget rid of an infection. He says parents can give their kids a small does ofparacetamol to minimise the symptoms. Doyle says some doctors haverecommended parents alternate between different medications likeparacetamol and ibuprofen. Ford says doctors generally recommend parentsuse paracetamol because there are some complications with usingibuprofen. He says parents don't need to give their kids more than four dosesin a day. Dittmar asks if parents resort to medication to quickly. Ford saysthat might be a bit true. Dittmar says drinking a lot of water helps to reduce afever and sickness. He says fluid intake is so important.

Interviewees: Dr Peter Ford, SA President, AMADuration: 8.28Summary ID: A00027828283© Media Monitors

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ABC 702 Sydney (Sydney)05:30 News - 7/09/2007 5:31 AMNewsreader

New Queensland University of Technology research has found parents relytoo much on over the counter medications when their child has a fever.

Interviewees: Anne Walsh, Senior ResearcherDuration: 0.45Summary ID: S00027824735This program or part thereof is syndicated to the following 11 station(s):-ABC Central Coast (Gosford), ABC Central West NSW (Orange), ABC FarWest NSW (Broken Hill), ABC Illawarra (Wollongong), ABC Mid North CoastNSW (Port Macquarie), ABC New England North West (Tamworth), ABCNorth Coast NSW (Lismore), ABC Riverina (Wagga Wagga), ABC SouthEast NSW (Bega), ABC Upper Hunter (Muswellbrook), ABC Western PlainsNSW (Dubbo)© Media Monitors

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Parents dosing kids too heavilyHobart Mercury, 07/09/07, General News, Page 10By: AAP

A survey of parents has revealed that one third dose their children up ondrugs more heavily than necessary to treat fever. The Queensland studyshowed that the pain reliever ibuprofen was administered too frequently by32 per cent of more than 400 parents surveyed.

Keywords: of Technology(1), Queensland(2), University(1)

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Parents quick to medicate childrenSunshine Coast Daily, 07/09/07, General News, Page 11By: TAMARA MCLEAN OF AAP

Ibuprofen is overused A SURVEY of parents has revealed that one thirddose their children up on drugs more heavily than necessary to treat fever.


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Overzealous parents warned against overdosing a feverCourier Mail, 07/09/07, General News, Page 23By: Tamara McLean

ONE in three parents dose their children up on drugs more heavily thannecessary to treat a fever. A Queensland study released yesterday showedthat the pain reliever ibuprofen was administered too frequently by 32 percent of more than 400 parents surveyed.


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Parents giving kids too much medicineAustralian, 07/09/07, General News, Page 3By: Clara Pirani

MedicaL reporter ONE-THIRD of parents don’t know how to manage fever intheir children and often give excessive doses of medicine. A survey of 400parents found 32 per cent gave their children incorrect amounts of ibuprofenand 4 per cent gave high levels of paracetamol.


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Parents overdose childrenWest Australian, 07/09/07, General News, Page 15By: None

One third of parents dose their children up on drugs more heavily thannecessary to treat fever, a survey shows. The Queensland study showed thatthe pain reliever ibuprofen was administered too frequently by 32 per cent ofmore than 400 parents surveyed.


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Children dosed up on painkillersMaitland Mercury, 07/09/07, General News, Page 7By: None

SYDNEY - A survey of parents has revealed that one third dose their childrenup on drugs more heavily than necessary to treat fever. The Queenslandstudy showed that the pain reliever ibuprofen was administered toofrequently by 32 per cent of more than 400 parents surveyed.


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1 in 3 parents misuse painkillers Kids are all dosed upBorder Mail, 07/09/07, General News, Page 11By: None

A SURVEY of parents has revealed that one third dose their children up ondrugs more heavily than necessary to treat fever. The Queensland studyshowed that the pain reliever ibuprofen was administered too frequently by32 per cent of more than 400 parents surveyed.


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Painkillers given to kids too often: studyBurnie Advocate, 07/09/07, General News, Page 16By: None

SYDNEY A survey of parents has revealed that one third dose their childrenup on drugs more heavily than necessary to treat fever. The Queenslandstudy showed that the pain reliever ibuprofen was administered toofrequently by 32 per cent of more than 400 parents surveyed. Most of thesewere giving the medication every four hours instead of the recommendedsix-to-eight hourly intervals.


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06/09/2007

Fed: One in three parents giving painkillers too regularlyAAP Newswire, 06/09/07, National, Page 0By: AAP

By Tamara McLean, Medical Writer SYDNEY, Sept 6 AAP - A survey ofparents has revealed that one third dose their children up on drugs moreheavily than necessary to treat fever.


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Study findsparents dosefevered kidstoo heavilyQUEENSLAND parents needproper education in managingfever in young children as manygive medication incorrectly andoften unnecessarily, saysQueensland University ofTechnology (QUT) nursingresearcher Anne Walsh.

In a study of more than 400Queensland parents, Ms Walshhas found 32 per cent of parentsadminister ibuprofen too often,with four per cent forparacetamol.

She said the most disturbingfinding was that 23 per cent ofparents gave their childrenibuprofen every four hoursinstead of the recommended sixto eight hourly intervals.

"All parents should learn howto manage fever before theirchild's first febrile episode," MsWalsh said.

She said incorrect use ofmedications could cause liverdamage and stomach upsets.

"In many cases it would bebetter if parents first managefever by giving their childrenmore fluids and rest, and keepingthem comfortable," Ms Walshsaid.

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Queensland Times13/09/2007Page: 11General NewsRegion: Ipswich QLD Circulation: 10947Type: RegionalSize: 70.26 sq.cmsMTWTFS-

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ParentsdosingkidstooheavilyA SURVEY of parents hasrevealed that one thirddose their children up ondrugs more heavily thannecessary to treat fever.

The Queensland studyshowed that the pain re-liever ibuprofen was ad-ministered too frequentlyby 32 per cent of morethan 400 parents sur-veyed.

Most of these were giv-ing the medication everyfour hours instead of therecommended six-to-eighthourly intervals.

Lead researcher AnneWalsh, from the Queens-land University of Tech-nology. said the resultswere concerning, particu-larly as parents shouldnot be giving medicationto treat mild fever in thefirst place.

"The fact that they weregiving medication too fre-quently is a real worry,"Ms Walsh said.

"But what they don'tseem to understand is thata low-grade fever under 40degrees on its own doesnot need to be treated.

"The body has purpose-

ly set its temperaturehigher to try to stop bac-teria from multiplying:it's an immune response."

The standard painkillerparacetamol, branded asPanadol, and ibuprofen, anon-steroidal anti-inflammatory drug(NSAID) under brandslike Nurofen, are widelyused to treat pain andfever.

Too many parents werealternating between thetwo medications, makingtiming confusing.

"Given that such a highpercentage of parents aregiving ibuprofen too fre-quently, it may be thatthey are assuming it is thesame as paracetamolwhich can be given fourhourly," Ms Walsh said.

Many were administer-ing both at once, a poten-tially dangerous practicethat was not recom-mended.

Over administeringcould lead to liver damageand stomach upset, espe-cially if the child is dehy-drated by the fever.

AAP

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Hobart Mercury07/09/2007Page: 10General NewsRegion: Hobart Circulation: 47947Type: Capital City DailySize: 101.44 sq.cmsMTWTFS-

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Parentsquick tomedicatechildrenIbuprofen is overusedBy TAMARA MCLEAN of AAPA SURVEY of parents has re-vealed that one third dosetheir children up on drugsmore heavily than necessaryto treat fever.

The Queensland studyshowed that the pain relieveribuprofen was administeredtoo frequently by 32% ofmore than 400 parents sur-veyed.

Most of these were givingthe medication every fourhours instead of the recom-mended six-to-eight hourlyintervals.

Lead researcher AnneWalsh, from the QueenslandUniversity of Technology,said the results were con-cerning, particularly as pa-rents should not be giving

medication to treat mild fev-er in the first place.

"The fact that they weregiving medication too fre-quently is a real worry," MsWalsh said.

"But what they don't seemto understand is that a low-grade fever under 40 degreeson its own does not need tobe treated.

"The body has purposelyset its temperature higher totry to stop bacteria frommultiplying; it's an immuneresponse."

The standard painkillerparacetamol, branded as Pa-nadol, and ibuprofen, a non-steroidal anti-inflammatorydrug (NSAID) under brandslike Nurofen, are widely usedto treat pain and fever.

Too many parents were al-ternating between the twomedications, making timingconfusing.

"Given that such a highpercentage of parents aregiving ibuprofen too fre-quently, it may be that theyare assuming it is the sameas paracetamol which can begiven four-hourly," MsWalsh said.

Many were administeringboth at once, a potentiallydangerous practice that wasnot recommended.

Over administering couldlead to liver damage and sto-mach upset, especially if thechild is dehydrated by thefever.

She said it was not pa-rents' fault they were mis-

managing fever, as they werejust following accepted prac-tice and trying to maintainsome control over their chil-dren's wellbeing.

However, there was an ur-gent need for evidence-basededucation for parents andthe health professionals whogive them information.

"In many cases it would bebetter if parents first managefever by giving their childrenmore fluids and rest, andkeeping them comfortable."

Unwell children should beclosely monitored and pa-rents should seek medicaladvice if they display severesymptoms, or show no im-provement within 48 hours.

-AAP

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Sunshine Coast Daily07/09/2007Page: 11General NewsRegion: Maroochydore QLD Circulation: 22743Type: RegionalSize: 210.93 sq.cmsMTWTFS-

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Overzealous parents warnedagainst overdosing a feverTamara McLean

ONE in three parents dosetheir children up on drugsmore heavily than necess-ary to treat a fever.

A Queensland study re-leased yesterday showedthat the pain reliever ibu-profen was administeredtoo frequently by 32 percent of more than 400parents surveyed.

Most of these were giv-ing the medication everyfour hours instead of therecommended six-to-eighthourly intervals.

Lead researcher AnneWalsh, from the Queens-land University of Techno-

logy, said the results wereconcerning, particularly asparents should not be giv-ing medication to treatmild fever in the first place.

"What they (parents)don't seem to understandis that a low-grade feverunder 40 degrees on itsown does not need to betreated," Ms Walsh said.

"The body has pur-posely set its temperaturehigher to try to stop bac-teria from multiplying; it'san immune response."

The standard painkillerparacetamol, branded asPanadol, and ibuprofen, anon-steroidal anti-inflammatory drug under

brands such as Nurofen,were widely used to treatpain and fever.

She said many parentswere giving ibuprofen toofrequently and assuming itwas the same as para-cetamol which could begiven every four hours.

Over administeringcould lead to liver damageand stomach upset, es-pecially if the child wasdehydrated by the fever.

Unwell children shouldbe closely monitored andparents should seek medi-cal advice if they displaysevere symptoms, or showno improvement within48 hours.

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Courier Mail07/09/2007Page: 23General NewsRegion: Brisbane Circulation: 214451Type: Capital City DailySize: 89.10 sq.cmsMTWTFS-

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Parents giving kids too much medicineClara PiraniMedical reporter

ONE-THIRD of parents don'tknow how to manage fever intheir children and often giveexcessive doses of medicine.

A survey of 400 parents found32 per cent gave their childrenincorrect amounts of ibuprofenand 4 per cent gave high levels ofparacetamol.

The finding that almost 25 percent gave their children ibupro-fen every four hours, instead ofthe recommended six- to eight-hourly intervals, was disturbing,said Queensland University ofTechnology senior research fel-low Anne Walsh, who conductedthe study.

"About 60 per cent of the

parents were university-educated, so I think if we did alarger version of this study, itwould be more widespread," MsWalsh said.

"If you give children too muchparacetamol, they can developliver damage. And if they take toomuch ibuprofen, it can causegastro and stomach upsets, andcan bring on asthma."

The survey found parents wereconfused about the advice theyreceived from doctors.

"A lot of parents involved inthe survey reported that theylearned about how to treat feverfrom their doctor, and many werereceiving conflicting advice andthey don't know what to do.

"Some doctors have recom-mended that parents alternate

medication, so they are givingmedications every few hours andare getting confused about thedosage and frequency."

More than 50 per cent ofparents were unnecessarily givingmedication to treat mild fevers,Ms Walsh said.

We urgently need evidence-based education for parents andthe health professionals who givethem information. There is dec-ades of research that proves amild fever is beneficial in fightinginfection, and there is little needto give medication for a fever lessthan 39 degrees."

Sydney GP and Royal Austral-ian College of General Practi-tioners spokesman MichaelFasher agreed that many parents

were overly-concerned aboutfever in children.

"In our culture, fever phobia isendemic. Fever phobia is a focuson fever in an unwell child that isunhelpful," Dr Fasher said.

"It's reasonable to use eitherparacetamol or Nurofen to im-prove the wellbeing of a childwho is miserable with a virileillness," he said. "But I agreethere is no evidence of the safetyof alternating drugs.

"The single most importantsign for parents to look for duringthe febrile period of these ill-nesses is if the child is becomingprogressively more drowsy andlethargic."

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Australian07/09/2007Page: 3General NewsRegion: National Circulation: 129000Type: NationalSize: 138.95 sq.cmsMTWTF

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ParentsoverdosechildrenER1SE

One third of parentsdose their children upon drugs more heavilythan necessary totreat fever, a surveyshows.

The Queenslandstudy showed that thepain reliever ibuprofenwas administered toofrequently by 32 percent of more than 400parents surveyed.

Most of them gavethe medication everyfour hours instead of therecommendedsix-to-eight hourlyintervals.

Lead researcher AnneWalsh, fromQueensland Universityof Technology, said theresults were a concern,particularly as parentsshould not be givingmedication to treat mildfever in the firstplace.

"The fact that theywere giving medicationtoo frequently is a realworry," Ms Walsh said.

She said many parentsgot confused with thefour-hourly dosage rateof paracetamol.

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West Australian07/09/2007Page: 15General NewsRegion: Perth Circulation: 206025Type: Capital City DailySize: 50.34 sq.cmsMTWTFS-

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Children dosedup on painkillers

SYDNEY - A survey ofparents has revealed thatone third dose their chil-dren up on drugs moreheavily than necessary totreat fever.

The Queensland studyshowed that the pain reliev-er ibuprofen was adminis-tered too frequently by 32per cent of more than 400parents surveyed.

Most of these weregiving the medicationevery four hours instead ofthe recommended six-to-eight hourly intervals.

Lead researcher AnneWalsh, from theQueensland University ofTechnology, said theresults were concerning,particularly as parentsshould not be giving med-ication to treat mild fever inthe first place.

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Maitland Mercury07/09/2007Page: 7General NewsRegion: Maitland NSW Circulation: 4418Type: RegionalSize: 33.95 sq.cmsMTWTF--

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1 in 3 parents misuse painkillers

Kids are all dosed upA SURVEY of parents has revealedthat one third dose their children upon drugs more heavily than necessaryto treat fever.

The Queensland study showed thatthe pain reliever ibuprofen was admin-istered too frequently by 32 per cent ofmore than 400 parents surveyed.

Most of these were giving the medi-cation every four hours instead, of therecommended six-to-eight hourly in-tervals.

Lead researcher Anne Walsh, fromthe Queensland University of Technol-ogy, said the results were concerning,particularly as parents should not begiving medication to treat mild feverin the first place.

"The fact that they were giving med-ication too frequently is a real worry,"Ms Walsh said.

`But what they don't seem to under-

stand is that a low-grade fever under40 degrees on its own does not need tobe treated.

"The body has purposely set its tem-perature higher to try to stop bacteriafrom multiplying, it's an immune re-sponse."

The standard painkiller paraceta-mol, branded as Panadol, and ibupro-fen. a non-steroidal anti-inflammatorydrug (NSAID) under brands like Nuro-fen, are widely used to treat pain andfever.

Too many parents were alternatingbetween the two medications, makingtiming confusing.

"Given that such a high percentageof parents are giving ibuprofen toofrequently, it may be that they are as-suming it is the same as paracetamolwhich can be given four hourly," Ms

Many were administering both atonce, a potentially dangerous practicethat was not recommended.

Over administering could lead toliver damage and stomach upset, es-pecially if the child is dehydrated bythe fever.

She said it was not parents' faultthey were mismanaging fever, as theywere just following accepted practiceand trying to maintain some controlover their children's wellbeing.

However, there was an urgent needfor evidence-based education for par-ents and the health professionals whogive them information.

"In many cases it would be better ifparents first manage fever by givingtheir children more fluids and rest,and keeping them comfortable."

Walsh said.

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Border Mail07/09/2007Page: 11General NewsRegion: Albury-Wodonga VIC Circulation: 26617Type: RegionalSize: 172.73 sq.cmsMTWTFS-

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Painkillers given tokids too often: study

SYDNEY - A survey of parents hasrevealed that one third dose their childrenup on drugs more heavily than necessary totreat fever. The Queensland study showedthat the pain reliever ibuprofen wasadministered too frequently by 32 per centof more than 400 parents surveyed.

Most of these were giving the medicationevery four hours instead of therecommended six-to-eight hourly intervals.

Lead researcher Anne Walsh, from theQueensland University of Technology, saidthe results were concerning, particularly asparents should not be giving medication totreat mild fever in the first place.

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Burnie Advocate07/09/2007Page: 16General NewsRegion: Burnie TAS Circulation: 24811Type: RegionalSize: 42.34 sq.cmsMTWTFS-

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Content Supplied by Australian Associated Press© AAP, All Rights Reserved. See disclaimer at http://aap.com.au/disclaimer.asp

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