Randomised controlled trial of an intervention to improve parental knowledge and management practices of fever

We know that parents require resources which can assist them to improve fever knowledge and management practices, and this is supported in the literature [1‐6]. Fever is one of the most common childhood symptoms [3, 5, 7‐11] and is defined as a temperature of greater than 38 °C [12, 13]. Fever is usually a self-limiting symptom with very low rates of associated serious illness [14‐17].

Despite the benign nature of fever, parents often become alarmed and very concerned [4, 18‐27]. Previous literature has demonstrated that this often leads to; aggressive treatment strategies; unnecessary and incorrect use of antipyretics [28‐34]; and parents seeking medical advice [13, 19, 32, 35‐38]. Consequently, fever is one of the most common reasons for consultations with healthcare professionals (HCPs) [5, 7, 39‐45]. Many of these consultation could be avoided if there was clarity on fever definition and fever management practices.

The management of fever by antipyretics is acceptable, when there is associated signs of distress [8]. In medical practice alternating antipyretics is deemed necessary when fever occurs with other symptoms (e.g. otitis media, pain), however, guidelines suggest that antipyretics should not be alternated to manage fever in the absence of distress [8, 46‐48]. The inherent problem with alternating antipyretics is that sometimes, a concerned parent may become confused as to what antipyretic they last administered and this may lead to dosing errors. Dosing regimens with antipyretics can lead to confusion as although similar, maximum numbers of administrations per day differ. For example, in Ireland, for a child aged 7–9 years, Calpol (Paracetamol) is administered up to 4 times per day while Neurofen (Ibuprofen) is administered up to three times per day. This can lead to possible safety issues when alternating antipyretics. HCPs, especially general practitioners (GPs) are giving appropriate information when they suggest alternating in specific cases (e.g. fever accompanied with distress despite monotherapy) [8, 49]. However, our previous research has shown that parents alternate between antipyretics both with and without the presence of distress [6]. Manufacturers have attempted to address the dangers associated with overdosing children with antipyretics by adjusting dosing schedules to include narrower age bands and including doses calculated based on weight. This serves to underpin the problems with unintentional overdose with antipyretics. However, this does not address the use of antipyretics when there is no need. The purpose of our study was thus to address this need. Our prior research has shown that parents have requested accessible, consistent and reliable information resources to be made available to them [1, 2, 6, 50], with a particular desire for paper-based information resources [1, 6]. We know that educational interventions increase parental knowledge and decrease clinic visits and consultations for fever and other minor illnesses [51‐59]. thus potentially easing the burden on HCPs and providing a cost saving for the health service as well as the family seeking medical help [60].

The findings from our RCT of an educational intervention showed that an information leaflet for parents increases correct definition of fever temperature and decreases incorrect management practices. The increase in knowledge was sustained, and further improved, up to 2 weeks after administration of the leaflet. Parents who received a copy of the leaflet before completion of the questionnaire were more likely to select the correct temperature definition for fever, less likely to believe that using antipyretic medication together is more effective, and more likely to think that alternating antipyretics is effective only if the child is still distressed. These parents were also less likely to use medication unless their child had a temperature and was simultaneously distressed, and less likely to use tepid sponging. We found that satisfaction with the leaflet was high.

Parents have repeatedly highlighted a need for information resources [1, 2]. The current research suggests that this information leaflet can empower parents so that they can take an informed approach to the care of their children when they have a fever or febrile illness, similar to previous research [64]. We know that increasing parents’ health knowledge and health literacy is important as health literacy and good health outcomes are linked [65]. Previous research has suggested that limited health literacy can lead to higher rates of hospitalisation, poorer self-management skills and lower use of preventative services [66‐71]. What is less clear is how that information should be imparted. What we have shown is that a simple information leaflet is an effective means of addressing this need in the area of treating fever and febrile illness in children. It is reported that retention of information following consultations can be low [72], sometimes as low as 20%, however with the incorporation of visual or written information, this can increase to 50% [50]. Our study, though not undertaken at a consultation, has shown that retention of information from a simple information leaflet is extremely high. In fact at 2 weeks post receiving the information leaflet, there was an increase in knowledge level. Further studies are necessary to establish the effect of this information leaflet during a GP consultation. We know that previous research has demonstrated that information resources could potentially decrease consultations with HCPs [52, 57, 74‐77]. Any possible reduction in presentation rates could decrease pressure on healthcare services which we know are at unsustainable levels in Ireland, on a background of an increasing older population and a GP rate of 2.7 per 1000 population [78‐81]. Furthermore, the accessible nature and location of pharmacies could provide a suitable point of contact and distribution area for these leaflets. Further research to establish the leaflet’s viability is needed in this setting.

The strength of this study is that it was a randomised controlled trial, the gold standard methodology for establishing causation. Therefore any findings we infer are deemed to be strong. The leaflet utilised was approved by NALA, thereby reaching as many parents as possible. There were a number of limitations with this study. The leaflet was not individualised. While a strength of the leaflet was that it was generated based on results from our previous studies [1, 2], it did not take into consideration what was already known by parents nor did it take their specific needs into consideration [82]. This may serve as both an advantage and a disadvantage. From an advantageous point of view, the included information is what parents in general want included and therefore is suitable for all parents, a disadvantage is that it is not personalised (e.g. availability in other languages). Furthermore, this trial used a closed question questionnaire design therefore answers may not reflect the answers which parents may freely give, should they have had free choice [52]. There is also a risk that parents in the intervention arm at time-point 1 transferred information from the leaflet to the questionnaire without fully understanding or changing their understanding of the topic. Similarly, social desirability risk cannot be eliminated as parents were aware of the profession of the researcher. There was a drop out between time period one and two, 11 people from the intervention arm and 14 people from the control arm, therefore our sample size calculation does not hold for time period two. It is therefore necessary to interpret this phase of the results with caution. Finally, despite sampling in six purposively selected locations over several days, the included sample are mainly female with high education levels. However, previous research has suggested that mothers often provide the majority of care for children so we do not feel that this has biased our results in this study [45]. The included sample are from the general Cork area with a large proportion of Irish parents, therefore, it could be argued that results indicated in this study are not generalisable to other cultures.

Our prior research has shown that knowledge of the correct definition of fever is key to parents’ management practices for fever. This information leaflet increased the number of parents’ correctly answering questions about managing fever and also showed that information retention is high after 2 weeks. Educational interventions providing simple, clear information is a key step to decreasing concern and anxiety and increasing parents’ confidence in treating fever and febrile illness in their children [73].