Parental Perceptions of Fever in Children A Qualitative Approach

Abstract

Fever remains one of the most common complaints in children seeking medical attention. It is a cause of great concern for caregivers, not infrequently out of proportion to the appearance of the child. In 1980, Barton Schmitt conducted a cross-sectional survey among parents and identified several misconceptions about fever that he termed “fever phobia”. This concept that was revisited in 2001 by Crocetti et al. who found that fever phobia still is very prevalent. Although questionnaire type studies are good at assessing what proportion of a population holds a certain, pre-defined opinion, they are not ideal to explore attitudes and beliefs or to draw out issues that may be unknown to the researcher. To investigate the perceptions of fever in children among caregivers in an inner city community we conducted three focus group interviews of 24 parents. We found that contrary to previously reported, parents did not perceive fever as an illness in itself but as a result of infection. Not knowing the cause or consequences of a fever was what worried parents the most when their children were febrile. Death, convulsions and dehydration were the most feared complications. Children were brought to medical attention with a high fever, a fever lasting for more than a few hours and with fever that did not respond to antipyretics.

Background

All pediatricians have at some point taken care of a febrile child and interacted with worried family members. Not infrequently, the degree of concern of the caregiver may seem inappropriate in relation to the child’s symptoms and appearance. To better understand the caregiver and to provide meaningful advice, it is important to know what the most common perceptions and misconceptions about fever are.  A focus group interview is an interactive process used to obtain information about a specific topic. ^{1 2}   It is a particularly useful method for investigating perceptions and feelings and to identify unknown beliefs. The hallmark of focus group interviews is its ability to exploit group interactions to produce insight and data that would be less accessible without the interaction of the group. ¹⁰   Several questionnaire type studies investigating parental perceptions (including misconceptions, often referred to as “fever phobia”) of fever have been done after a pioneering article by Schmitt in 1980 ³  The vast majority of these studies are based at least partly on this index article. They have consistently shown that that many parents believe that fever can cause brain damage and death, and that a sleeping child needs to be awakened for antipyretic administration. ^{4 5 6 7 8 9}   The strength of these studies is that the data of questionnaires is quantifiable and results can be reported as a percent of parents who hold certain belief. However, a weakness of questionnaires is that the data collected is limited to the answers that are available in the questionnaire. Perceptions that the researcher was not aware of and did not include in the questionnaire will be overlooked.

Few qualitative studies have been done on parental perceptions of fever. None have been done in the US. Walsh et al. studied attitudes towards fever in children among 15 Australian parents using individual as well as group discussions. They concluded that low “fever” (<38.0 C) was perceived as good and that high (38.0 – 39.1 C) fever was perceived as harmful and must be prevented. ¹¹   Kai conducted two individual and group interview studies in Newcastle upon Tyne, England, that focused not on fever but parental worries and their sources of information when their preschool children were acutely ill. Kai concluded that monitoring and reducing fevers was empowering to parents and that medical attention was sought for reassurance. ^{12 13}

The aim of this study was to investigate parental perceptions about the etiology, consequences and management of fever. Our hypothesis was that many parents have misconceptions about fever that are unknown to health care workers.

Methods

To test our hypothesis, a focus group methodology was employed. Participants were 24 parents recruited for 3 focus groups on a single day, April 24 2009. Participants were identified as “Hispanic”, “African-American” and “Indian” based on a self administered questionnaire. The subjects were recruited from participants of the Woman, Infants, and Children (WIC) program. One participant was not fluent in English for which the questions were translated by the moderator. Parents had an average of 1.7 children. The participants had household incomes between 100 and 185% of the Federal poverty income guidelines in order to qualify of WIC services. The interviews were recorded with a portable P3 Micro Cassette Recorder. Interviews were conducted until the questionnaires were saturated, that is when no new answers were obtained. This occurred at the third session where after no more interviews were done.

A single moderator employed a common series of questions (see table 1), which had been developed by the authors and then reviewed and revised by the Department of Pediatrics research committee.  Discussion among participants was encouraged. When the group reached a consensual answer, this was documented. When the group could not reach consensus, the opinion of the majority as well as all other answers were documented. Appropriate institutional review board approved the study.  To ensure inter rater reliability, a member of the research committee scored the questionnaires using the original recording with results not differing from that of the authors.

Results

Participants were identified as Hispanic, African-American and Indian based on a self administered questionnaire. 54% (n=13) were Hispanic, 42% (n=11) were African-American and 4% (n=1) were Indian. 4% (n=1) were male and 96% (n=23) female. Average number of children was 2.15. Group consensus was as follows; Fever was defined as a child being hot. Participants mentioned temperatures ranging from 100 to 101 degrees Fahrenheit being fever. The cause of a fever was thought to be an infection. Some participants mentioned specific infections such as ear and urinary tract infections. Some participants mentioned teething. None of the participants described fever as a disease in itself but always as a consequence of a separate process. Fever was considered to be causing harm in itself. What most worried parents when their child had a fever was the uncertainty of what caused the fever and what the consequences might be. Examples of phrases used to express this were “you don’t know what is going on” and “you don’t know what’s going to happen”. When asked what harmful effects fever can have, death, convulsions and dehydration were consistent answers. The child becoming comatose and suffering brain damage was also mentioned. Most parents would administer Tylenol or Motrin when their child had a fever. Some would seek medical attention immediately. A few would apply ice to the head of the child. When asked when a child would be taken to a doctor, consensus was that they should be seen when a fever was high, lasted more than a few hours or did not respond to antipyretics. The source of information about fever was primarily grandparents, the grandmother more than grandfather. Doctors were another common source of information.

Discussion

Counseling parents concerned about fever in their child is a daily task for many pediatricians. To deliver accurate and meaningful advice to caregivers, it is critical to understand parental perceptions of the etiology, consequences and management of fever.  Although several quantitative studies have addressed the issue, this is the first qualitative, focus group study on the subject. Contrary to previously reported, fever is thought of as a manifestation of infections and not as a disease in itself. When asked about how concerning fever was, correlating the fever with the appearance and activity of the child was strikingly absent. This suggests that educating parents to look less at the thermometer and more at the child is important anticipatory guidance. What worried caregivers most was uncertainty of the cause and complications of fever. Although a certain etiology of fever sometimes cannot be determined, informing the parent of the most likely cause and benign nature should be reassuring.

Conclusion

Fever is a cause for much parental concern and is thought of as a manifestation of an infection and not a disease in itself. Not knowing the cause and consequences of the fever is the most worrying aspect and death, convulsion and dehydration are the most feared complications. A high fever, a fever lasting more than a few hours and not responding to antipyretics prompted parents to seek medical attention. Qualitative studies in other demographic groups are needed to investigate into the generalizability of these findings in other populations.