ORIGINAL

Niger J Paed 2013; 40 (3) : 270 –274

Abdulkadir MB

Johnson WBR

Caregivers’ perceptions of childhood

fever in Ilorin, North-Central

Nigeria

DOI:http://dx.doi.org/10.4314/njp.v40i3,13

Accepted: 22nd January 2013

Abstract Background: Fever

remains a common clinical indica-

tor of disease, accounting alone

for over 25% of paediatric emer-

gency rooms consultations. Per-

ception of this important sign is a

crucial prelude and determinant of

outcome in febrile children. The

aim was to determine knowledge

and attitudes of parents regarding

fever in their children.

Methods: The study is a cross-

sectional descriptive study carried

out at the Emergency Paediatric

Unit of the University of Ilorin

Teaching Hospital (UITH). Four-

hundred under-five children

30.3% of caregivers could cor-

rectly describe what fever was.

The most frequently utilised fever

detection method was tactile as-

sessment. Only 3.2% of the care-

givers used a thermometer to de-

tect fever. Social class, maternal

age and religion significantly in-

fluenced the decision to use ther-

mometers. The most common

remedies caregivers would use for

fever in their children were to give

paracetamol (96.3%), sponging

(73.2%) and a warm bath (63.8%).

About 61% of caregivers had a

wrong perception of the possible

complications of fever.

Abdulkadir MB

Johnson WBR

(

)

Department of Paediatrics and Child

Health, University of Ilorin /University

of Ilorin Teaching Hospital, Jebba

Road, Ilorin, Kwara State.

Email: docmohng@yahoo.com

presenting with fever were

Conclusions: Caregivers in this

study had a poor knowledge of

fever, and parental educational and

socioeconomic status impacted on

their responses to fever. There is a

need for education of caregivers at

all contacts with the healthcare

system on fever, and its manage-

ment.

recruited along with their caregiv-

ers. A semi-structured question-

naire was administered to collect

information on sociodemograph-

ics, and caregiver’s knowledge

and

attitudes regarding fever in their

wards.

Results: The mean age of the

caregivers was 29.5 ± 4.46 years

Keywords: Antipyretic, Attitude,

(

Range 21 – 41 years). Only

Fever, Thermometry

Introduction

unnecessary, and potentially dangerous. This so called

5

“

fever phobia” may result in parents taking potentially

Fever represents a perception of an elevated tempera-

ture. In clinical practice, the relevance of fever is that it

is a sign of a current illness. It remains one of the most

harmful actions, such as use of herbal concoctions,

1

scarification, and excess_-i₁v₁e use of antipyretics, amongst

7

others. Several studies have attempted to determine

frequently encountered paediatric problems, accou_-n₄ting

the knowledge and perceptio₇_,n₈ of parents regarding fe-

ver. Some of these studies have implicated factors,

such as the level of education, ethnic group, and socio-

economic status, as possible determinants of parental

knowledge and perception of fever. There have been few

2

for 25% of visits to paediatric emergency rooms. In-

deed, it is often the first symptom noted by parents, and

frequently, the initial “signal” of illness in the child.

Parents have been known to have fears of the harmful

effects of fever in their children, and often see fever as

1

published studies from Nigeria on the subject matter.

the main₅_,p₆roblem rather than a symptom of a variety of

This relative gap in knowledge on this issue, in Nigeria

and indeed the West African Sub-region forms the justi-

fication for this study. The aim of the study is to deter-

mine parental knowledge about fever and their percep-

tion of it in their children.

5

diseases.

It was Schmitt that first referred to this

parental fear about fever as “fever phobia”, in order to

emphasize the high prevalence, as well as the unrealistic

nature o₅f these fears. These fears, as described by

Schmitt, often lead to parents taking actions that are

2

71

Materials and Methods

ratio of 1.5:1. All caregivers recruited were the mothers.

The mean maternal age was 29.5 ± 4.46 years (Range 21

– 41 years). Majority of the mothers [298(74.5%)] were

of the Yoruba ethnic group. Other ethnic groups in-

cluded Hausa (13.5%), Ibo (3.3%) and others (8.8%).

Caregiver religion was Islam amongst 293(73.3%)

mothers and Christianity in 107 caregivers (26.8%).

Regarding educational status of the mothers, only 107

(26.8%) had attained tertiary education. One hundred

and twenty four (31.0%) mothers had secondary educa-

tion; 92(23.0%) had acquired primary education; and 77

(19.3%) had no formal education. Using the metho₂d of

This is a cross-sectional study in which the subjects are

children aged between 2 months and 59 months, and

their parents/caregivers. The study was carried out at the

Emergency Paediatric Unit (EPU) of the University of

Ilorin Teaching Hospital (UITH). The hospital is located

in Ilorin, which is the capital city of Kwara State, situ-

ated in the North Central geopolitical zone of Nigeria.

Four hundred children/ caregiver pairs were recruited

over a four month period. Ethical clearance was ob-

tained from the University of Ilorin Teaching Hospital’s

Ethical Review Committee. Individual informed consent

was also obtained from the mother, father, or the care-

giver of the child as applicable. Caregivers of children

aged less than five years, admitted into the EPU with

fever were recruited consecutively. Subject recruitment

was done as early as possible after presentation, after

institution of the required immediate care as determined

by the clinical condition of the child. It was considered

pertinent to exclude caregivers of children with critical

illness from the study. Siblings of children who had al-

ready been recruited into the study were also excluded.

1

Social Classification recommended by Oyedeji, 38

(9.5%) of mothers were categorised as social classes I,

69(17.3%) as social class II, 112(28.0) as social class

III, and 156(39.0%) and 25(6.3%) as social classes IV

and V respectively. The mode of the social class of the

children was IV, and the median III.

In response to the open question, “what is fever”, only

121 parents/ caregivers (30.3%) were able to correctly

identify fever as an increase in body temperature above

what is considered normal. The most commonly utilised

method for detecting fever by respondents was by touch-

ing the child; this was used by 390(97.5%) mothers

(Table 1). Seventy-four percent of these used the back of

their hands to “feel for fever” in their children, while the

remaining 104(26%) used their palm. The parts of the

body palpated (to assess for fever) by the respondents

who used palpation were the head in 306(76.5%), and

the abdomen in 182(45.6%). Other parts felt were the

chest in 43.3% and the neck in 31.8% of respondents.

Various combinations of parts were felt to assess for

fever amongst those mentioned above, of which the

most common was the head and chest (35.4%).

A semi-structured study proforma was administered on

all subjects recruited. Socio-demographic data compris-

ing age and gender of the child, parental religion and

ethnic group(s), as well as age, educational status and

occupation of parents was obtained. Information on par-

ent(s)/caregivers’ knowledge, and perceptions regarding

fever were obtained The items used to determine knowl-

edge and perception explored the spheres of: definition

of fever; causes of fever; best means to detect fever;

complications of fever; and management of fever, inclu-

sive of their sources of knowledge. Others include steps

that should be taken if a child has fever; current con-

cerns regarding fever in your child; and use of antipyret-

ics. For the purpose of the study, convulsions were con-

sidered to be an appropriate concern in relation to fever.

Others such as brain damage, dehydration, death, were

considered inappropriate concerns. Data entry and

analysis were carried out with a micro-computer using

the Epi-Info version-6 software package.Frequency dis-

tribution tables and cross-tabulation of variables were

generated. Measures of central tendency and dispersion

of quantitative variables, as well as proportion for quali-

tative variables were also determined. A thematic ap-

proach was used to analyse some qualitative variables.

The chi-square and student-t tests were used to identify

significant differences for categorical and continuous

variables respectively. Mean, standard deviations, and

range were provided as appropriate. Yates correction

and Fisher’s exact tests were utilised as appropriate.

A p-value of <0.05 was considered significant.

Table 1: Distribution of respondents by method of fever

detection

Method of fever detection*

Frequency(%)

Touch

390(97.5)

19(4.8)

47 (11.8)

10(2.5)

Thermometer

Appearance**

Others

*Some mothers gave multiple responses

**Appears weak, appears sick, rigors

All caregivers that would use a thermometer to measure

temperature belonged to social classes I-II, as compared

to the group that would not use a thermometer to meas-

ure temperature where 31.0% belonged to social class I-

II (p <0.000001) (Table 2). The mean maternal age of

caregivers that would use thermometers to measure their

child’s temperature was significantly lower at 25.8 ±

2

.11 years (p = 0.00018) as compared to the group that

would not use thermometers which was 29.7 ± 4.47

years (Table 2). About 48% of caregivers who would

measure temperature with a thermometer were Muslims,

while among those who would not use a thermometer to

detect fever, 74.5% were Muslims (p = 0.0045)

Results

Caregivers of four-hundred under-five children aged 2-

5

6 months were recruited. The mean age of the children

(

Table 2).

was 25.6 ± 16.8 months, with a Male: Female (M:F)

2

72

Table 2: Sociodemographic indices of mothers versus

detection of fever by thermometer

Regarding the attitude of caregivers to the use of

paracetamol for fever, there was no significant differ-

ence in mean maternal age (p = 0.647) and maternal

educational status (p = 0.156) between caregivers that

would use paracetamol and those that would not

2

Variable

Use a ther-

mometer

Not use a

thermometer

(n=381)

χ

P

(n=19)

Social class

I - II

III

(

Table 4). All caregivers (100%) that would not use

19(100%)

0(0%)

88(23.1%)

112(29.4%)

181(47.5%)

paracetamol were Muslims, as against 72.2% of those

who would use paracetamol (Table 4). This difference

was statistically significant (p = 0.0085).

54.62

<0.00

0001

IV-V

Educational status-

None/ Islamic

Primary/ Secondary

Tertiary

0(0.0%)

19(100.0%) 88(23.1%)

77(20.2%)

216(56.7%)

0.000

0001

Table 4: Sociodemographic indices of caregivers versus

attitude to use of paracetamol in febrile children

2

Maternal age(years)

Mean ± SD

Variable

Use

paracetamol

Would not

use paraceta-

mol (n=15)

χ

p

25.8 ± 2.11

29.7 ± 4.47

t=3.7

8

0.000

18

(n=385)

Social class

I - II

III

IV-V

Educational status

None/Islamic

Caregiver religion

Islam

Christianity

102

112

171

5

0

10

6.20

0.0451

9(47.4%)

10(52.6%)

284(74.5%)

97(25.5%)

6.819

0.004

5

77(20.0%)

0(0.0%)

10(66.7%)

5(33.3%)

Fig 1 shows that 360(90.0%) caregivers had obtained

information about fever recognition from their parents,

Primary/Secondary 206(53.5%)

Tertiary

3.716

0.156

102(26.5%)

1

32(33.3%) obtained information from other relatives,

Maternal age

Mean ± SD

29.46 ± 4.55

30.0 ± 0.85

t=0.45

9

0.6466

0.0085

and 125(31.3%) obtained information from their friends.

Others are as shown in Fig 1. Amongst mothers who

would use a thermometer to measure temperature, 19

Caregiver religion

Islam

278(72.2%)

107(27.8%)

15(100%)

0(0%)

5.69

(

100%) of them had their source of information from

Christianity

doctors, as against 40(10.5%) of those who would not

2

use a thermometer (χ = 115.3 p<0.0001).

Table 5 shows the spectrum of major concerns of care-

givers regarding the possible consequences of fever in

their children. The most frequently identified concern

was convulsion which was indicated by 331 (82.8%)

caregivers, followed by death (43.0%); and brain dam-

age (27.5%). There was a significant difference between

the social classes and educational status of mothers who

had appropriate concerns as compared to those whose

caregivers had inappropriate concerns regarding conse-

quences of fever (p = 0.0000001 and p=0.000151 re-

spectively)(Table 5).

Fig 1: Distribution of respondents by source of informa-

tion on detecting fever.

Parents

Relatives

Friends

360

132

125

Doctors

59

Nurses

53

Other Healthcare…

School

38

Table 5: Distribution of caregivers’ concerns regarding fever

Consequence(s) of fever*

Frequency (%)

0

100 200 300 400

Convulsions

Dehydration

Brain damage

Death

331(82.8)

80(20.0)

110(27.5)

172(43.0)

15(3.8)

Frequency

With regard to steps that caregivers would take if their

children have fever, the most common steps that would

be taken are to give paracetamol (385 mothers), and

sponging with tepid water(289 mothers). Others are as

shown in Table 3.

No concerns

*

Some mothers had more than one concern

Table 6: Social class of mother versus concerns regarding

childhood fever

2

Variable

Appropriate Inappropriate

χ

p

Table 3: Distribution of caregivers regarding steps that should

be taken for a febrile child

concerns*

concerns †

(n=244)

(n=156)

Action taken

Frequency(%)

Social class

I-II

III

63(40.4%)

55(35.3%)

38(24.3%)

44(18.0%)

57(23.4%)

143(58.6%)

Paracetamol

Sponging with tepid water

Warm bath

Undressing

Others**

385(96.3)

289(73.2)

144(36.0)

251(62.8)

112(28.0)

47.25

17.6

0.000

0001

IV-V

Educational status

None/ Islamic

Primary/ Secondary

Tertiary

15

88

53

62

128

54

0.000

151

*

Some mothers used more than one method

** Fanning, praying and the use of herbal concoctions

2

73

*

†

in combination, including respondents who identified convulsions in

addition to any of the above

Convulsions alone

Other concerns, such as brain damage, dehydration, death, singly or

of this tactile method of assessin₁₅g fever has remained

limited to that of a screening tool.

Also, it is equally noteworthy that with the prevalence of

7

4% in the present study the most commonly used site

for tactile assessment of fever by respondents was the

dorsum of the h₁₆and. This is similar to the findings of

Akinbami et al in Ibadan, where 77.1% preferred to

use the dorsal surface of the hand to assess for fever.

This may be accounted for by the similarity in the

Ibadan and Ilorin study populations, which are predomi-

nantly of the Yoruba ethnic group. Furthermore, an ad-

ditional observation from the present study was the com-

mon parental perception that the head and abdomen con-

stituted the important parts of the body from which fever

could be most reliably₁₇detected. This is similar to the

findings of Singh et al in India, where majority of the

adult patien₁₆ts felt the forehead to identify fever. Akin-

bami et al reported slightly different findings as the

head and neck were the most preferred parts felt in their

study. It is interesting to observe that about 12% of

Discussion

Overall, the findings of the present study suggest that

caregivers in the study population had a poor knowledge

of fever. This ob₁servation is consistent with the findings

1

of Tagbo et al in Enugu. In that study none of the

mothers could identify what temperature actually indi-

cates fever. Though the current study did not examine if

mothers could identify the correct temperature that con-

stitutes fever, it is instructive to note that only 30.3% of

caregivers could identify fever as an increase in body

temperature above what is considered normal. Rather

most of the responses obtained suggested that parents

view fever as a disease, as against a symptom of many

possible diseases. This probably relates to the traditional

perception of fever, and the fact that words in some local

dialects used to describe fever (Eg Zazzabi in Hausa) are

used synonymously with “malaria”. It is evident from

the current study that only a few parents recognised that

the use of a thermometer was the best method for detect-

ing fever. This observation is similar to the finding₁₁s of

respondents would use the “appearance of the

child” (appears weak, appears sick, rigors) to detect the

presence of fever in their children. This is similar to the

9

finding of Al-Eissa in Egypt. With very few respon-

dents answering in the affirmative, the present study

shows that most of the caregivers who would use

thermometers to measure temperature had received this

information from doctors. The operational import of this

finding is the apparent need to involve the lower level

healthcare manpower (who are expected to have more

frequent contact with parents) in the education of par-

ents regarding the timely value of use of thermometers

for detecting fever in their children. In the current study,

socioeconomic status of caregivers appears to influence

the decision to use thermometers to measure tempera-

9

Al-Eissa et al in Saudi Arabia and Tagbo et al in

Enugu. This₁₃was however, in stark contrast to those of

Blumenthal in the presumably much more enlightened

British population, where about 73% of caregivers

reportedly used thermometers for ident₃ifying fever and

1

rated them better than use of palpation. This difference

may be explained by the obvious dissimilarity in the

literacy level and the socioeconomic classes of caregiv-

ers in the two study populations. In the current study,

9

ture. This is not in keeping with the reports of Al-Eissa

4

2.3% of mothers had no formal education or only pri-

where there was no difference in the use of thermome-

ters amongst parent of high and low socioeconomic

classes. The statistically significant younger age of care-

givers who would use a thermometer as against those

who would not, may suggest a positive change in per-

ceptions with the younger generation. This may also be

a reflection of increasing education in the younger age

group.

mary education. Their educational status was compara-

tively poorer than the study populations in Enugu (22%

had no formal education or primary education) and

Saudi Arabia (25.4% of mother₃s had no formal educa-

1

tion). In Blumenthal’s study, however, the authors

deliberately left out the presumably “uneducated” moth-

ers who could not read English. This is further supported

by the finding in this study that families with higher

socioeconomic status were more likely to use ther-

mometers. The effect of a higher socioeconomic class on

knowledge of fever was further demonstrated, in this

study, by the relationship between social class and con-

cerns regarding fever. This is similar to the findings of

Concerns about fever and its potential harmful effects

may lead to parental behaviour that may be harmful to

the child’s health, such as use of herbal concoctions,

scarification, and covering the child, or indeed under-

mine a successful treatment outcome of the underlying

disease. In this regard, it is noteworthy that 44% of care-

givers in the current study had correctly identified con-

vulsions as a possible complication of fever. This is

7

8

14

Tessler, Taveras, and Kramer.

It is pertinent to observe that the use of touch to assess

fever has been an age old tradition passed down by par-

ents, and indeed grandparents to the younger generation.

Indeed it is a practice that is common in most communi-

ties, and to a large extent, considered fairly useful. The

above statement is supported by the finding in this study

that 81.8% of caregivers would use touch alone to detect

fever in their children, and 58.0% of caregivers had

obtained this knowledge from friends and family. How-

ever, in view of its suboptimal specificity, the usefulness

14

similar to 48% reported by Kramer. Th₁₀is was higher,

however, than 32% reported by Crocetti, and 15% re-

5

ported by Schmitt. With regard to other potential harm

emanating from fever in children, a large proportion of

caregivers also identified brain damage, dehydration and

death as possible complications. In the present study,

2

7.5% of caregivers identified brain damage as a possi-

ble complication of fever, an observation that is similar

2

74

1

4

to those of Kramer in America, in which 27% of par-

ents felt brain damage could result from a fever.

Whereas the fear of brain damage remains a common

concern of parents and practitioners, this complication

had rarely been shown to be₈ caused by fever (even a

regarding the home management of fever, presentation

at a health facility, and the eventual outcome of febrile

illnesses. This strengthens the need for increasing

knowledge of parents regarding the import of fever and

its appropriate management.

1

temperature as high as 42°C). Instead, it is the

underlying cause of the febrile illness, rather than the

fever itself that is lar₅g_,₁e₉ly responsible for this morbidity

Authors’ Contributions

MBA conceptualized the work, coordinated the study,

collected and analysed the data, and prepared the manu-

script. WBRJ participated in the conceptualization,

analysis and supervision of the study, and the prepara-

tion of the final manuscript. All authors read and

approved the final manuscript.

(

i.e. brain damage).

Furthermore, in the present

study, 20% and 43% of caregivers respectively, identi-

fied dehydration and death as the principal dangers of

fever. These values were significantly higher than the

percentages r₁e₄corded earlier by Kramer (4% and 11%

respectively).

Conflict of interests: None

Funding: None

Conclusion

Acknowledgement

Caregivers in the study population had a poor knowl-

edge of fever, especially regarding its method of detec-

tion and possible complications in children. This knowl-

edge gap is likely to impact negatively on decisions

We appreciate the contributions of the paediatric

residents and nurses that assisted in recruitment of the

subjects and data collection.

References

1

2

3

4

.

Mackowiak PA. History of clinical

thermometry. In: Mackowiak PA,

ed. Fever: Basic mechanism and

management. 2nd ed. Philadelphia:

Lippincott-Raven, 1995:1-10.

Eskerud JR, Laerum E, Fagerthun

H, Lunde PKM, Naess A. Fever in

general practice. Frequency and

diagnoses. Fam Pract 1992; 9:263

8. Taveras EM, Durousseau S, Flores

15. Nwanyanwu OC, Ziba C, Redd C,

Luby SP. Palpation as a method of

fever determination in Malawian

children who are less than 5 years

old: how reliable is it? Ann Trop

Med Parasitol 1997;91(4):359-64.

16. Akinbami FO, Orimadegun AE,

Tongo OO, Okafor OO, Akinyinka

OO. Detection of fever in children

emergency care: comparisons of

tactile and rectal temperatures in

Nigerian children. BMC Research

Notes 2010; 3:108.

17. Singh M, Pai M, Kalantri SP. Ac-

curacy of perception and touch for

detecting fever in adults: a hospital

based study from a rural tertiary

hospital in Central India. Tropical

Medicine and International

G. Parents’ beliefs and practices

regarding childhood fever. Pediatr

Emerg Care 2004; 20:579-87.

9. Al-Eissa YA, Al-Aloba SA, Gazal

SS, Al-Wakeel AS. Parental per-

ceptions of fever in children. Ann

Saudi Med 2000;20(3-4):202-05.

10. Crocetti M, Moghbeli N, Serwint

J. Fever phobia revisited: Have

parental misconceptions about

fever changed in the last 20 years?

Pediatrics 2001; 107:1241-46.

11. Tagbo BN, Ibeneme CA, Adimora

GN, Ilechukwu CGA. Mothers’

perception and management of

childhood fever at the University

of Nigeria Teaching Hospital,

Enugu. J Coll of Med 2010; 15

(1):44-50.

-69.

Krauss BS, Harakal T, Fleisher

GR. The spectrum and frequency

of illness presenting to a pediatric

emergency department. Pediatr

Emerg Care 1991;7(2):67-71.

Nelson DS, Walsh K, Fleisher GR.

Spectrum and frequency of pediat-

ric illness presenting to a general

community hospital emergency

department. Pediatrics 1992; 90:5-

Health; 8:408-414.

1

0.

12. Oyedeji GA. Socio-economic and

cultural background of hospital-

ized children in Ilesha. Nig J Paed.

1985; 12: 111-7.

13. Blumenthal I. What parents think

of fever. Family practice 1998; 15

(6):513-18.

18. Bull JMC. Whole body hyperther-

mia as an anticancer agent. CA-a

cancer J Clin. 1982;32(2):123-8.

19. Avner JR. Acute fever. Pediatr

Rev 2009; 30:5-13.

5

6

7

.

Schmitt BD. Fever phobia: Mis-

conceptions of parents about fever.

Am J Dis Child 1980;134:176-81.

Adam D, Stankov G. Treatment of

fever in childhood. Eur J Pediatr

1

994;153:394-402.

Tessler H. Unrealistic concerns

about fever in children. The influ-

ence of cultural, ethnic and Socio-

demographic factors. IMAJ

14. Kramer MS, Naimark L, Leduc

DG. Parental fever phobia and its

correlates. Pediatrics 1985;75:

1110-3.

2

008;10: 346-49.