Main findings
Parents generally cautiously wait and see before contacting GP out-of-hours care when their child has a fever. Not one specific symptom, but a combination of fever with other symptoms, makes them anxious and drives care seeking. Because parents work during the day and fever typically rises during the early evening, the decision to seek care was often made during out-of-hours care. When contacting a GP out-of-hours service, parents did not expect antibiotics but sought reassurance from a professional, which parents felt could be achieved by a thorough physical examination. Finally, they believed that there is a lack of reliable consistent information on (self-management strategies for) childhood fever before, during and after a consultation.
Comparison with existing literature
The degree of fever alone has previously shown to have a low predictive value for the severity of an illness in children [
1]. Interestingly parents mentioned a higher temperature would indicate a more severe illness, sometimes even mentioning a specific limit. This belief is in accordance with previous research, indicating that parents still believe high fever is harmful [
2,
23,
24]. There are studies that show that by increasing parental knowledge this misconception can be reduced [
25]. However, some parents were able to describe that their fears were not based on their rational knowledge but mostly on their emotions. This means there were also parents who acknowledged they rationally knew that a higher temperature did not indicate a more severe illness, but emotionally their anxiety increased when the body temperature increased. Some secondary care studies describe that despite increasing knowledge, anxiety remains [
26]. However, to our understanding this is the first study in which parents actually described this discrepancy between rational and emotions themselves. Education and information about fever might therefore only reduce anxiety to a certain extent. This is something to take into account when developing interventions to reduce anxiety among parents of febrile children.
The need for reassurance from an expert was expressed by all parents and is in accordance with other literature [
3,
27,
28]. This reassurance can, at least partly, be obtained by a physical examination. Previous research already showed a physical examination is valued as an important component of a GP consultation and parents feel reassured when they know what’s going on with their child [
3,
9,
27,
28]. Parents rely on a GP for their expertise, as reported in a Scandinavian study which was aimed at studying when parents with an ill child consult a physician [
9,
27].
In accordance with existing literature, we found that parents’ expectations of a GP’s consultation were not specific and parents generally do not expect antibiotics [
3]. However, in agreement with a recent study our data suggests that parents consult because of a perceived threat to their child’s health, which then in turn prompts clinicians to prescribe antibiotics [
29,
30]. In contrast, only a small percentage of children presenting with a fever actually requires treatment based on the incidence of serious bacterial infections [
31]. However, recent Dutch studies show that one in three to four children with fever who visit the GP out-of-hours service receive antibiotics [
10,
11], suggesting that antibiotic prescribing is still higher than warranted. As in adults with acute cough, one explanation could be that GPs assume patients or in this case parents expect antibiotics [
32]. This study underlines the fact that parents indeed do not expect antibiotics.
Parents actively search for information before contacting a GP [
27]. As suggested previously, we found that this information did not always reassure parents, but even raised anxiety in some cases [
2]. A relatively new finding of this study in comparison to previous research is the usage of the internet as a main source of information for parents. One of the challenges in the usage of internet as an information source is the fact that parents expressed that there is a lack of reliable consistent information on the internet [
33].
Another important aspect of information provided to parents of febrile children that is suggested in previous studies is the fact that reliable, consistent information can potentially provide parents with better knowledge [
34] and with a safety net [
7]. By providing parents information on what to do and when to consult when their child has fever in accordance with the NICE 2013 traffic light system [
1], their self-management can be increased without leading to complications for their children [
7]. As suggested earlier, this may very well be even more effective if the same information that is provided at the point-of-care during a consultation, is also provided to parents in the general public before their children get sick [
2].
Strengths and limitations
This is the first qualitative describing study enrolled in a GP out-of-hours setting that gives in-depth insight into the motivations, expectations and experiences of parents when they visit a GP out-of-hours with their febrile child. This setting is important because most consultations are handled by GPs without referral to secondary care and many consultations take place during out-of-hours care [
10].
Despite efforts to make parents feel comfortable and safe by letting them choose the location of the interview, parents may have given socially acceptable answers, thereby holding back valuable information. Because interviews were not executed immediately after the consultation there was some risk of recall bias. We did however perform the interviews within 2 weeks and feel this was the most ethical and pragmatic approach since it is undesirable to execute an interview with parents’ their sick child being present. Although we attempted to describe the motivation, expectations and experiences of parents, there may be potential underlying and influencing factors, which were not discovered during this study.
The different perspectives, member check, peer debriefings and investigator and data triangulation helped to increase trustworthiness. However, all researchers had a medical background with an interest in general practice and infections which might have influenced their views and interpretation of the data. As only parents who visited the out-of-hours service were included, we are missing data from parents who stayed at home with their febrile child. It is possible these parents have different expectations and experiences considering fever. Additionally, since health care systems and illness experience are culturally different, we do not know to what extent these results are generalizable to other countries. Nevertheless, we believe that these results are at least to some extent generalizable to Western countries with similar health care systems. In addition, we provided information about the methodology and background information of parents to help others decide whether the results of this study are transferable to their context.
Implications for practice
Lacking self-management strategies seem to influence parental consultations which do then in turn potentially thrive antibiotic prescriptions [
29,
30]. It is previously shown that an information exchange tool is effective in reducing the number of antibiotic prescriptions and intention to re-consult in children with upper respiratory tract infections and that such a tool can increase parental and clinician confidence in managing these illnesses [
21,
35]. We believe that this strategy could also be used in children presenting with a fever. Therefore, future research should focus on improving information on childhood fever provided in the consulting room in a consistent, tailored, written way. However, this might be challenging during out-of-hours care where there is no pre-existing relationship between GPs and parents and where time is limited [
30]. Therefore, we believe that future studies should also focus on providing consistent parental education to parents in the general public, thereby improving parental confidence and self-management when their child has a fever.