i 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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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
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.
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.
v
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.
vi
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.
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
1.1 Introduction 1
1.2.1 Childhood Fever 2
1.3 Health Professionals and Childhood Fever Management 6
1.4 Febrile Convulsions 7
1.5 Theoretical Framework 8
1.6 Thesis Outline 9
viii
2.3.1 Febrile Convulsions 27
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
3.3.1 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
4.5 Summary 116
5.1 Introduction 118
5.2.5 Data Analysis 124
5.3.2 Fever is Beneficial 125
5.3.3 High Fever is Harmful 126
5.3.4 Influencing Factors 127
5.3.6 Managing Fever 133
5.4 Discussion 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
6.1.6 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
198
7.4 Approach to Analysis 206
7.5 Model Estimation 208
7.6.2 Goodness-of-fit Index 210
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
7.8.2 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
7.8.7 Conclusions 258
8.1 Introduction 261
8.3 Theoretical Implications 270
8.5 Practice Implications 276
8.6 Implications for Future Studies 281
8.6 Overall Conclusions 284
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
xii
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
160
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 6.9 Participant demographics 186
Table 7.1 Participant demographics 219
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
226
Table 7.6 Standardised and non-standardised effects of TPB constructs and demographic variables on parents’ intentions to reduce fever
230
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
xiii
TABLE OF FIGURES Figure 2.1 Schematic representation of the classical concept of the sequential mechanisms in infections fever induction
20
Figure 4.1 Diagrammatic representation of research methods 93
Figure 4.2 Questions used in semi-structured individual interviews and group discussions
99
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
190
Figure 6.3 Temperature at which parents who believe medications harmful, administer medications
190
Figure 7.1 Conceptual fever model of the hypothesised relationships predicting parents’ intentions to reduce their child’s next fever
203
Figure 7.2 Conceptual medication model of the hypothesised relationships predicting parents’ intentions to reduce their child’s next fever with medications
205
Figure 7.3 Respecified conceptual fever model of the hypothesised relationships predicting parents’ intentions to reduce their child’s next fever ‘fever model’
217
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
xiv
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
xv
GLOSSARY OF ACRONYMS AND TERMS TPB: Theory of Planned Behavior
PBC: Perceived Behavioural Control
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
fever, paracetamol and ibuprofen
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
(This manuscript can be found in Chapter 5)
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
(This manuscript can be found in Chapter 6)
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
(This manuscript can be found in Chapter 6)
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)
xvii
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)
xviii
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
Financial assistance for the sum of:
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 assistance for the sum of:
Confederation research funding was received for the purpose of data collection
Financial support received in the year 2004
Royal College of Nursing Australia Joyce Wickham Scholarship
Financial assistance for the sum of:
Confederation research funding was received for the purpose of data collection
Financial support received in the year 2006
Grant in Aid
Financial assistance for the sum of:
Funding was received for the purpose of presenting papers at an international
conference
xix
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, Page 19 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
xx
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.
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
2
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
3
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,…
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
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.
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.
v
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.
vi
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.
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
1.1 Introduction 1
1.2.1 Childhood Fever 2
1.3 Health Professionals and Childhood Fever Management 6
1.4 Febrile Convulsions 7
1.5 Theoretical Framework 8
1.6 Thesis Outline 9
viii
2.3.1 Febrile Convulsions 27
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
3.3.1 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
4.5 Summary 116
5.1 Introduction 118
5.2.5 Data Analysis 124
5.3.2 Fever is Beneficial 125
5.3.3 High Fever is Harmful 126
5.3.4 Influencing Factors 127
5.3.6 Managing Fever 133
5.4 Discussion 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
6.1.6 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
198
7.4 Approach to Analysis 206
7.5 Model Estimation 208
7.6.2 Goodness-of-fit Index 210
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
7.8.2 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
7.8.7 Conclusions 258
8.1 Introduction 261
8.3 Theoretical Implications 270
8.5 Practice Implications 276
8.6 Implications for Future Studies 281
8.6 Overall Conclusions 284
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
xii
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
160
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 6.9 Participant demographics 186
Table 7.1 Participant demographics 219
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
226
Table 7.6 Standardised and non-standardised effects of TPB constructs and demographic variables on parents’ intentions to reduce fever
230
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
xiii
TABLE OF FIGURES Figure 2.1 Schematic representation of the classical concept of the sequential mechanisms in infections fever induction
20
Figure 4.1 Diagrammatic representation of research methods 93
Figure 4.2 Questions used in semi-structured individual interviews and group discussions
99
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
190
Figure 6.3 Temperature at which parents who believe medications harmful, administer medications
190
Figure 7.1 Conceptual fever model of the hypothesised relationships predicting parents’ intentions to reduce their child’s next fever
203
Figure 7.2 Conceptual medication model of the hypothesised relationships predicting parents’ intentions to reduce their child’s next fever with medications
205
Figure 7.3 Respecified conceptual fever model of the hypothesised relationships predicting parents’ intentions to reduce their child’s next fever ‘fever model’
217
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
xiv
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
xv
GLOSSARY OF ACRONYMS AND TERMS TPB: Theory of Planned Behavior
PBC: Perceived Behavioural Control
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
fever, paracetamol and ibuprofen
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
(This manuscript can be found in Chapter 5)
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
(This manuscript can be found in Chapter 6)
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
(This manuscript can be found in Chapter 6)
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)
xvii
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)
xviii
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
Financial assistance for the sum of:
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 assistance for the sum of:
Confederation research funding was received for the purpose of data collection
Financial support received in the year 2004
Royal College of Nursing Australia Joyce Wickham Scholarship
Financial assistance for the sum of:
Confederation research funding was received for the purpose of data collection
Financial support received in the year 2006
Grant in Aid
Financial assistance for the sum of:
Funding was received for the purpose of presenting papers at an international
conference
xix
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, Page 19 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
xx
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.
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
2
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
3
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,…
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