ID Design Press, Skopje, Republic of Macedonia

Open Access Macedonian Journal of Medical Sciences. 2018 Oct 25; 6(10):1928-1933.
https://doi.org/10.3889/oamjms.2018.339
eISSN: 1857-9655
Public Health

Knowledge and Concerns of Parents Regarding Childhood Fever

at a Public Health Clinic in Kuching, East Malaysia

*
Wan-Tsien Bong, Chai-Eng Tan

Department of Family Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia

Abstract
Citation: Bong WT, Tan CE. Knowledge and Concerns BACKGROUND: Parental anxiety regarding fever may be unwarranted as most cases are owing to self-limiting
of Parents Regarding Childhood Fever at a Public Health
Clinic in Kuching, East Malaysia. Open Access Maced J
causes.
Med Sci. 2018 Oct 25; 6(10):1928-1933.
https://doi.org/10.3889/oamjms.2018.339 AIM: To assess the level of knowledge and concerns regarding childhood fever among parents with young
Keywords: Fever; Child; Parents; Knowledge; Concerns children in a public health clinic in Kuching, East Malaysia.
*Correspondence: Chai-Eng Tan. Department of Family
Medicine, Universiti Kebangsaan Malaysia Medical METHODS: This cross-sectional study was conducted among parents recruited from a maternal and child health
Centre, Kuala Lumpur, Malaysia. E-mail: clinic, with children aged 6 months to 6 years. The participants completed a self-administered questionnaire
tce@ppukm.ukm.edu.my
regarding their knowledge and concerns about childhood fever. Descriptive statistical analyses were performed,
Received: 24-Aug-2018; Revised: 01-Oct-2018; and associations between dependent and independent variables were determined.
Accepted: 02-Oct-2018; Online first: 23-Oct-2018
Copyright: © 2018 Wan-Tsien Bong, Chai-Eng Tan. This RESULTS: Only 26.1% of participants were found to have good knowledge. Knowledge regarding childhood fever
is an open-access article distributed under the terms of
the Creative Commons Attribution-NonCommercial 4.0 was significantly associated with parent’s ethnicity, education level, and household income. About 72% of parents
International License (CC BY-NC 4.0) were always worried about their child’s illness. Three major reasons for their concerns were persistently rising
Funding: This research was supported by the UKMMC temperature; discomfort caused by the fever, and feared complications of fever.
fundamental research fund (FF-2016-385)
Competing Interests: The authors have declared that no CONCLUSION: Excessive parental anxiety due to poor knowledge and misconceptions about fever may lead to
competing interests exist poor quality of life and inappropriate management of fever. Healthcare providers may help by educating parents
about fever and serious signs that indicate the need to seek healthcare advice.

Introduction excessive anxiety among parents regarding their

child’s fever, also known as ‘fever phobia’, may lead
to unnecessary medication and over-management at
Children, particularly of preschool age, home [6] [7], which may pose safety issues for the
commonly present to primary health care clinics with child.
fever. However, fever in children at the primary care The term ‘fever phobia’ was first coined by
setting is largely caused by self-limiting conditions Schmitt (1980) [7], who defined it as ‘an unrealistic
with a low prevalence of serious infections [1] [2]. fear of fever expressed by parents’, and has been
Parental anxiety can lead to increased healthcare observed in different countries [8] [9] [10]. Parents
service utilisation including consultation with doctors worry about the feared complications of fever such as
after office hours, leading to an increased burden to febrile convulsion, dehydration, brain damage with
healthcare providers and inappropriate requests for subsequent intellectual impairment, and death [4] [11].
antibiotics [3] [4]. Fever is thought to have a beneficial However, most parents lack the knowledge to assess
physiological effect in combating illness [5] and may the severity of their children’s illness [6] [12] [13] and
indicate the presence of serious conditions. However, some parents believe fever to be a disease in itself
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[14]. Parents may experience negative emotions such months to 6 years who visited the clinic were
as helplessness and guilt if they do not act to reduce approached to participate in the study. Eligible
their child’s temperature [12] [13] [15]. Parents’ respondents consisted of adult parents with children
misconceptions about fever increase their anxiety and aged 6 months to 6 years, who were literate in Malay
eventually influence their management strategy [6] or English. If both parents were present, the parent
[15]. who was primarily involved in managing the child with
a fever was chosen as the participant. We excluded
Many parents define normal temperature and
parents of children with serious chronic medical
fever incorrectly [16] [17] [18]. Past studies conducted
o o diseases, such as immunosuppression, congenital
worldwide used core temperatures of 38 C and 39 C
heart disease, and neurological or oncological
to define fever and high fever, respectively [6] [16] [17]
conditions, as well as parents who were not involved
[18]. Varying proportions of parents interpret normal
o in caring for their sick child.
body temperature (less than 38 C) as fever [9] [19]
[20] [21]. About 24.8% to 63.9% of parents administer The sample size was calculated to determine
o
antipyretics to their child with a temperature of 37.8 C the population mean based on the variance derived
[9] [19] leading to a risk of over-medication. Parents from Chang’s study [21]. A minimum sample size of
also have misconceptions regarding antipyretics, 135 respondents was required to achieve a 95%
believing that they can prevent febrile convulsion and confidence interval and 0.5% precision. However, this
brain damage [22] despite understanding that was increased to 169 participants to allow for the
excessive antipyretics can be dangerous and lethal possibility of a 20% non-response rate. Data were
[23]. Some parents have unrealistic expectations for collected from June to August 2017 using
the fever to resolve within 1 to 2 days. When the convenience sampling. Parents were approached in
duration of fever exceeds their expectations, they the waiting area of the MCH and screened according
bring their children to a doctor [24]. to the inclusion and exclusion criteria. Parents who
agreed to participate provided written consent before
With improved healthcare education, ‘fever
the study materials were administered with researcher
phobia’ has generally reduced from 12–43% in the
assistance.
1980s [7] [25] to 2–18% in the 2000s [6] [26].
However, it is still prevalent in Asian countries such as This study received ethical approval from both
Taiwan and Singapore, where 68.8–77.7% of parents the Ministry of Health Medical Research Ethics
believe that fever causes brain damage, compared to Committee (Approval number: NMRR-16-1337-31628)
only 14.4–21% in developed countries like the USA as well as the Medical Research Ethics Committee
and Australia [9] [19] [20] [21]. This reflects lower (Project code number FF-2016-385). Permission was
health literacy levels among Asian parents regarding also obtained from the local District Health Office.
fever.
The study instrument comprised 3 main
Most studies conducted in Malaysia regarding sections: sociodemographic data of parents,
health-seeking behaviour are related to antibiotic use knowledge regarding childhood fever, and parental
for common minor illness. One study on the predictors concerns regarding fever. The section regarding
of health-seeking behaviour in upper respiratory tract knowledge and concerns regarding childhood fever
infection among children found that ethnicity and low- was adapted from a Taiwanese study with the
income level were associated with early visits to seek permission of the original authors [21]. The
medical advice [27]. Another study on parental questionnaire underwent back-to-back translation
knowledge focused on over-the-counter medications from the original Chinese version into English and
usage and found similar results in insufficient Malay. The translated versions were pre-tested with
knowledge among parents [28]. To the best of our five parents to determine face validity and
knowledge, there are no published studies on parental comprehensibility. The questionnaire items were
knowledge regarding childhood fever in Malaysia. reviewed for content validity by an expert panel
comprising a consultant paediatrician, two family
Thus, this study aimed to assess the
medicine specialists, and a clinical psychologist. The
knowledge and concerns of parents of young children
expert panel also evaluated the correct answers for
regarding childhood fever in this country.
each item. The questionnaire was modified and
adjusted accordingly. Finally, a pilot study was
conducted on 17 participants to test the questionnaire.
Results showed satisfactory internal consistency
Methods reliability with a Cronbach’s alpha of 0.7. The mean
knowledge score obtained from the pilot study was 13,
which was arbitrarily selected as the cut-off point for
This cross-sectional study was conducted at good knowledge.
the Maternal and Child Health Clinic (MCH) of an The first 18 questionnaire items were true-
urban public primary care clinic in Kuching, in false questions regarding parents’ understanding of
Sarawak, a state in East Malaysia with an ethnically fever. For this part, parents were awarded 1 point for
diverse population. Parents of young children aged 6
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each correct answer, while no points were given for The knowledge score of parents was normally
other responses. This was followed by 5 open-ended distributed, with a mean score of 10.03 ± 3.6 (Table
questions about temperature. We adopted the World 2).
Health Organization (WHO) definitions for fever for
this study: normal body temperature was defined as Table 2: Parental knowledge regarding childhood fever
an axillary temperature of 36.2–37.4˚C, fever as 37.5– Mean (SD) n (%)
41˚C, and high fever as 38.5–41˚C [29]. A body Parental knowledge regarding childhood fever
Good knowledge (score >13)
10.03 (3.62)
41 (26.1)
temperature exceeding 39˚C was considered as a Poor knowledge (score < 13) 116 (73.9)

fever that might cause harm to children. Again, a

score of 1 point was awarded for correct temperatures Only 26.1% of parents had good knowledge
written by parents. The scale for knowledge ranged regarding the management of childhood fever. A large
from 0 to 23 points. proportion of parents (71.3%) had the misconception
Parental concerns were assessed using a that fever causes diseases (Item 17) (Table 3). Almost
self-completed close-ended data collection form all parents believed that fever could cause harm to
regarding parents’ concerns in certain situations and children (Item 23, 93.6%) and indicated that they
their common perceptions regarding fever and its would administer fever medication to treat feared
outcomes. Samples with missing data on the fever complications (Item 22, 92.4%). Less than half
knowledge scale were excluded from the analysis. of them knew the correct answer for normal body
temperature (Item 8, 49.7%) and fever (Item 13,
Data were analysed using Statistical Package 39.5%).
for the Social Sciences (SPSS) version 24 (IBM).
Descriptive analysis included frequencies, Table 3: Items in the knowledge scale according to the
percentages, means, and standard deviations. percentage of correct answers
Associations between dependent and independent Items Percentage of correct
variables were determined using a t-test, Pearson’s Fever is a condition when the temperature rises above normal. (T)
answers
91.1
correlation, and a one-way ANOVA. Missing data Fever is an immune reaction. (T)
Fever is the consequence of bacterial or viral infection. (T)
80.9
80.3
were excluded via pairwise analysis. Level of Fever helps alert parents. (T)
Fever is the sign of a disease. (T)
79.0
75.8
significance was set at p < 0.05. Fever is the sign of a potential underlying disease. (T)
Temperature in high fever (38.5-41 C)
o
71.3
51.0
Normal body temperature (36.2-37.4oC) 49.7
It is necessary to treat fever regardless of body temperature. (F) 43.3
Fever is due to exposure to cold weather. (F) 40.8
Maintaining comfort is more important than bringing down the temperature. (T) 40.1
Fever helps to boost immunity. (T) 39.5
The temperature that indicates fever (37.5-41oC) 39.5
Fever helps to combat illness. (T) 36.3
o
The temperature that is harmful (>39 C) 36.3
Results Possible temperature if fever medication is not given (41oC)
Fever causes disease. (F)
34.4
28.7
It is reasonable to wait 3 days before seeing a doctor. (T) 24.2
Fever results from disease. (F) 19.1
Temperature would keep rising if fever medications are not given. (F) 15.3
Fever is due to an imbalance of heat and cold in the body. (F) 14.0
A total of 157 participants were included, Fever medication can treat complications arising from fever (F)
Fever will cause harm to children. (F)
7.6
6.4
providing a response rate of 94.7%. The majority of
participants were young mothers (81.5%), with a
mean age of 30.4 ± 6 years. Participants were Chinese participants were found to have a
distributed almost evenly across different ethnicities. significantly better knowledge score compared to
About 37.5% of the participants were first-time other ethnicities (F (3,146) = 8.584, p < 0.001) (Table
parents. Most of them had completed secondary 4).
education (70.6%) and had a low household income
level (80.9%) (Table 1). Table 4: Association between parental knowledge regarding
childhood fever and sociodemographic characteristics of the
Table 1: Baseline characteristics of respondents parent
Sociodemographic characteristics Mean (SD) n (%) Sociodemographic characteristics Knowledge score Statistical tests P
Age (years) 30.39 (6.07) Mean (SD)
Less than 30 years 53 (33.8) Age Spearman’s correlation 0.847
30 years and above 89 (56.7) R = 0.020
Not stated 15 (9.5) Relationship with the child Student’s t-test 0.628
Relationship with child Father 10.32 (3.84) T = 0.485
Father 28 (17.8) Mother 9.95 (3.60)
Mother 128 (81.5) Ethnicity One way ANOVA < 0.001
Not stated 1 (0.7) Malay 9.18 (2.54) F (3, 146) = 8.584
Ethnic race Chinese 12.12 (3.92)
Malay 40 (25.5) Iban 8.61 (3.45)
Chinese 43 (27.4) Others 9.87 (3.31)
Iban 36 (22.9) Level of education One-way ANOVA < 0.001
Others 31 (19.7) Primary or non-formal education 6.75 (2.53) F (2, 153) = 22.209
Not stated 7 (4.5) Secondary 9.27 (3.18)
Level of education Tertiary 12.49 (3.43)
Primary or non-formal education 12 (7.6) Household income One-way ANOVA < 0.001
Secondary 99 (63.0) Less than RM4000 9.34 (3.34) F (2, 154) = 17.825
Tertiary 45 (28.7) RM4000 to RM7999 12.09 (3.07)
Not stated 1 (0.7) RM8000 and above 15.71 (2.75)
Household income Number of children One-way ANOVA 0.190
Less than RM4000 127 (80.9) One 9.37 (3.43) F (2,152) = 1.677
RM4000 to RM7999 23 (14.6) Two 10.23 (3.75)
RM8000 and above 7 (4.5) Three or more 10.65 (3.73)
Number of children
One 59 (37.5)
Two 53 (33.8)
Three or more 43 (27.4)
Not stated 2 (1.3) This was confirmed by Bonferroni post-hoc
tests (Table 5), which revealed that differences in
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knowledge scores were statistically significant fever would subsequently lead to the more frequent
between Chinese and other ethnicities. use of antipyretics [3] [30]. This suggests that poor
knowledge regarding the temperature considered as
Parents with tertiary education had better
fever may be a worldwide phenomenon. Efforts to
knowledge compared to those with lower educational
improve health education regarding fever should be
levels (F (2,153) = 22.209, p < 0.001). Finally, parents
considered for the general public, as the ability to
from the high-income group had better knowledge
correctly identify fever would protect against
compared to those from other income categories (F
inappropriate management.
(2,143) = 17.823, p < 0.001). These results were also
confirmed by post-hoc tests. The association between knowledge and
ethnicity, level of education, and income were not
Table 5: Bonferroni post-hoc analysis unexpected. A previous study found that Chinese
Categories (I vs J) Mean Standard error p-value parents were less likely than Malay or Indian parents
difference
to see a medical professional for upper respiratory
Ethnicity tract infection, suggesting they were more comfortable
Chinese vs Malay 2.941 0.737 < 0.001
Chinese vs Iban 3.505 0.758 < 0.001 managing the condition themselves possibly because
Chinese vs Bidayuh and others 2.245 0.790 0.031
Level of education
of better health literacy [27]. Education and income
Tertiary vs secondary 3.216 0.517 < 0.001 are known to influence factors on health literacy [31].
Tertiary vs primary/non-formal 5.739 1.043 < 0.001
education Parents with lower levels of education were found to
Secondary vs primary/non-formal 2.523 0.981 0.033
education
be more likely to believe that fever is dangerous [8].
Household income Therefore, parents’ sociodemographic characteristics
> RM8000 vs RM4000-7999 3.627 1.417 0.036
> RM8000 vs <RM4000 6.438 1.286 < 0.001 could influence their knowledge regarding childhood
RM4000-7999 vs <RM4000 2.811 0.754 0.001
fever.
There were a large proportion of parents in
this study who reported high levels of worry when their
About 72% of participants reported always child had a fever. Other similar studies in Taiwan, the
being worried when their child had a fever. The three United Kingdom, and Singapore also had similar
main reasons for parental concern were the findings [9] [21] [32]. Appropriate levels of anxiety or
discomfort of the child during fever (68.8%), concern are important to promote protective parental
persistently rising body temperature (68.2%), and behaviours including increasing the fluid intake and
feared harms of fever (63.7%). The feared harms of being more attentive towards the child [32]. However,
fever that worried the parents the most were a seizure excessive or inappropriate concerns should be
(67.5%), brain damage (52.2%), mental incapacity addressed to avoid negative emotional outcomes in
(44.6%), and death (38.9%). Participants reported that parents.
their concerns were mainly influenced by their own or
a family member’s previous experience with child Common misconceptions regarding
fever (59.9% and 42.0% respectively), not knowing complications of fever such as seizures, brain
the cause of the fever (39.5%), and doctor’s advice damage, mental incapacity, and death were also
upon consultation (35.7%). reported in other studies [11] [26] [32]. In particular,
more Asian parents reported concern regarding
possible brain damage (35.9–77.7%) compared to
Western parents (7.7–15%) [9] [11] [20] [21] [26] [32].
Soon et al., (2003) [9] postulated that this
Discussion phenomenon could be due to Asian parents’
emphasis on educational attainment. The current
study also showed a larger proportion of parents who
This study showed that the knowledge level of were worried about fever leading to death (38.9%)
parents regarding childhood fever was alarmingly compared to other countries (3.8–18%) [11] [19] [32].
deficient. Many parents did not know the correct The concept of fever among this population could be
normal body temperature, and that considered as further explored in future studies.
fever. They were confused with the causal relationship Teaching parents what to do when their child
between fever and disease and believed that fever develops a fever can help to improve parental
itself is harmful to their child. Parental knowledge knowledge and parental satisfaction and reduce
concerning the purpose of antipyretics was also inappropriate healthcare visits [33]. However, the
incorrect. method of delivering this education needs to be suited
In the present study, only 39.5% and 51% of to the population, particularly among those with lower
participants knew the correct temperature to define health literacy [33]. Important educational points
fever and high fever, respectively. This was should include the definition of fever, the role of fever
comparable to previous studies conducted in in childhood illnesses, what to assess during febrile
Australia, the United States, and the United Arab episodes, and when a healthcare visit is required [33]
Emirates [19] [20] [26]. Incorrect understanding of [34]. Before administering antipyretics, simple
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