Childhood fever: a qualitative study on parents' expectations and experiences during general practice out-of-hours care consultations

[Facing fever in the pediatric patient: Checklist as a tool for parents]

INTRODUCTION

In Western Europe, 20%-40% of children with fever request health care. Most of them present trivial viral infections, however, it is essential in pediatrics to distinguish patients who present a severe infection. This process begins with the recognition of the seriousness and the subsequent search for medical attention by the parents.

METHODOLOGY

Analytical and cross-sectional observational study. One hundred patients were selected in two health centers. Sociodemographic data were collected, together with the responses to a checklist containing the signs and symptoms to request health care in case of fever. Subsequently, the checklist was filled out by the pediatrician.

RESULTS

The mean age of the patients was 5.41 years. 50% consulted in the first 48h of fever evolution. In 42%, the response to all the items on the checklist was exactly the same between the companion and the pediatrician. There were no significant differences according to variables: first episode of fever (P=.262), age of the patient (P=.859), having a sibling (P=.880), family relationship of the companion (P=.648) or educational level of the companion (P=.828).

CONCLUSIONS

Medical consultations for fever in pediatrics are carried out very early. A high percentage do not present alarm signs when they consult. There is a need to expand training on the alarm signs of fever in all parents, regardless of the number of children, age or educational level. The checklist as a tool for home assessment of fever has received high marks for its usefulness.

Reducing post-operative caregiver after-hours phone calls to pediatric urology providers: A quality improvement study

INTRODUCTION

Caregiver phone calls are an important part of caring for pediatric patients. At our institution, residents respond to after-hours caregiver calls. While it is critical for families to be able to reach us for urgent concerns, the ease of access has led to overutilization with many phone calls not meeting the urgent nature that is intended for these calls. The primary aim of this quality improvement project was to decrease the number of non-urgent caregiver calls after-hours. Our secondary aim was to improve compliance with telephone encounter documentation and to standardize the documentation content.

STUDY DESIGN

We conducted a single institution, multiphase quality improvement project. This started with a preintervention phase which included evaluation of our current state, identifying that most calls were for post-operative patients and that our discharge instructions inadequately detailed when caregivers should call. Notes were also inconsistently documented with no standard format. In the first PDSA cycle, launched on November 1, 2021, a standardized note template was created for documentation of caregiver telephone encounters. The PDSA cycle began on January 1, 2022 and included updates to our post-operative instructions with explicit guidance detailing when to call after-hours. Call data from September 2021 to February 2022 was reviewed including variables such as caller demographics, reason for call, and operative details. Primary outcomes were proportion of post-operative calls within 30 days and non-urgent calls. Secondary outcome was proportion of calls documented appropriately. Phases were categorized as current state (Sep/Oct 2021), PDSA cycle 1 (Nov/Dec 2021), PDSA cycle 2 (Jan/Feb 2022).

RESULTS

In our current state, the majority of the calls (66%) were for post-operative patients and 59% of all calls during this period were non-urgent. The proportion of post-operative phone calls stayed stable at 67% during PDSA cycle 1, but decreased to 38% with PDSA cycle 2 with implementation of updated post-operative instructions (Summary figure) (p < 0.001). The proportion of non-urgent calls was similar (current state - 68%, PDSA cycle 1 - 72%, PDSA cycle 2-73%, p = 0.39) (Summary figure). Call documentation was also similar with a documentation rate of 79% pre-intervention and 87% post-intervention (p = 0.21) (Summary figure).

CONCLUSIONS

With interventions focused on post-operative caregiver instructions, the number of post-operative phone calls decreased. Standardization of documentation was achieved. However, the overall call volume did not change, nor the proportion of non-urgent calls.

How patients in general practice voice and value their gut feelings about health: a qualitative interview study

BACKGROUND

GPs consider their gut feelings a valuable tool in clinical reasoning. Research suggests patients' gut feelings may be a useful contribution to that process. Describing these feelings more precisely could improve primary care professionals' (PCPs) recognition of patients' gut feelings and insight into the underlying reasons. These descriptions would also enable a thorough examination of the validity of patients' gut feelings and their contribution to professionals' clinical reasoning.

AIM

To gather the words and phrases that patients or their relatives use to share their gut feelings with primary care professionals and what they convey and imply.

DESIGN AND SETTING

Qualitative study of Dutch and Belgian patients visiting an out-of-hours GP service or a GP's office.

METHOD

Face-to-face semi-structured interviews were carried out with 47 patients. Interviews were coded using a descriptive content analysis in an iterative process until data sufficiency.

RESULTS

Patients or their relatives expressed their gut feelings by using words relating to trusting or not trusting the situation, or to changes in normal patterns. Their gut feelings are most often felt as a sense of alarm. In general, patients experiencing a sense of alarm, particularly mothers of sick children, were convinced that something was wrong and had often learned to trust their gut feeling. A gut feeling was the main reason to contact a PCP. Patients generally felt that their gut feelings were taken seriously.

CONCLUSION

The findings of this study provide an insight into how patients and relatives may express their gut feelings about their own or their relative's health and how they share these feelings with healthcare professionals. This may help clinicians improve their recognition of patients' gut feelings, being particularly alert to a patient or relative using phrases that relate to feelings of not trusting a situation, things seeming wrong or different from normal, and experiencing a sense of alarm. Further research should be carried out into the validity of patients' gut feelings.

Acute Gastroenteritis: A Qualitative Study of Parental Motivations, Expectations, and Experiences During Out-of-Hours Primary Care

PURPOSE

Acute gastroenteritis is a common infectious disease in children younger than 6 years of age. Although it is a self-limiting disease, it nevertheless has a high consultation rate in primary care, especially during out-of-hours primary care (OOH-PC). Reasons for this high consultation rate remain unclear.

METHODS

The aim of this qualitative study was to explore parental motivations, expectations, and experiences of OOH-PC contacts for children with acute gastroenteritis. We conducted 14 semistructured interviews with parents who contacted OOH-PC in the Netherlands. Interviews were audio-recorded, transcribed, and analyzed using elements of grounded theory and a constant-comparison approach.

RESULTS

Unusual behavior of the sick child, absent micturition, and ongoing vomiting and/or diarrhea, with decreased or no fluid intake, motivated parents to contact OOH-PC. Parents initiated contact to prevent symptom deterioration and to be reassured by a general practitioner (GP), expecting them to perform a thorough physical examination, provide information, and make follow-up plans. Parents reported dissatisfaction if they felt unheard, misunderstood, or not taken seriously, and this increased their likelihood of seeking another consultation. General practitioners did not always meet parental expectations.

CONCLUSION

Multiple factors affect the decision for parents to contact OOH-PC for their child with gastroenteritis. There is a mismatch between parental expectations and actions of the GP. Awareness regarding parental feelings and understanding their expectations can guide GPs in the interaction with parents, which could improve satisfaction with primary health care and OOH-PC specifically.

Analysis of the perceptions, knowledge and attitudes of parents towards fever in children: A systematic review with a qualitative meta-synthesis

Fever is the most common symptom in childhood. Despite its prevalence and decades of education and research, the treatment of fever and febrile illnesses continues to cause concern and anxiety in parents. The objective of this systematic review with meta-synthesis is to analyse parents' perceptions, knowledge and attitudes towards the febrile child and how they influence the construction of the concept of fever. The PRISMA international standards and PRISMA checklist, as well as the Cochrane recommendations, were followed. Articles with qualitative methodology have been selected that analyse what fever means to parents, what their concerns about this sign are, where they get their information and what their expectations are of healthcare professionals during treating their feverish child. Finally, 17 articles that met the inclusion criteria were added in the qualitative meta-synthesis. The concept of fever has been represented as a non-harmful sign in and of itself, an aspect that emerges in fathers and mothers' discourse. Meanwhile, the perceived need to lower the temperature still appears to be the main aim of their approach, with attitudes implying an emergency to reach normothermia, focusing on temperature as the primary indicator of severity.

Development over time in point-of-care test use in Danish daytime and out-of-hours general practice: a register-based study

OBJECTIVE

To describe the development over time of the use of C-reactive protein (CRP) and rapid streptococcal detection test (RADT) point-of-care tests (POCT) in Danish general practice and to explore associations between patient characteristics and POCT use (i.e. CRP and RADT).

DESIGN AND SETTINGS

A register-based study including all general practice clinic consultations in daytime and out-of-hours (OOH) settings in Denmark between 2003 and 2018.

SUBJECTS

All citizens who had at least one clinic consultation in daytime or OOH general practice within the study period.

MAIN OUTCOME MEASURES

We estimated the total and relative use of CRP and RADT POCTs and described the development over time. Crude and adjusted proportion ratios (PRs) were calculated to explore associations between patient characteristics and POCT use.

RESULTS

Overall, the relative use of CRP POCTs increased. At OOH, a steep increase was noticed around 2012. The relative use of RADT decreased. Patient age 40-59 years and existing comorbidity were significantly associated with a higher use of CRP testing in both settings. A significantly lower use of CRP testing was found for patients with higher educational level. We found a significantly higher use of RADT testing for patients aged 0-19 years and with higher household educational level, whereas comorbidity was associated with a lower use of RADT testing.

CONCLUSION

The use of CRP POCT increased over time, whereas the use of RADT POCT decreased. Perhaps the success of implementing CRP as a tool for reducing antibiotic use has reached it limit. Future studies should focus on how and when POCT are used most optimal.Key pointsCRP POC tests and RADT POCTs are frequently used diagnostic tools in general practice, both in daytime and in the out-of-hours setting.There was an increased use of CRP POCTs, particularly in out-of-hours general practice, whereas the use of RADT POCTs declined between 2003 and 2018.CRP POCTs were associated with age of 40-59 years and co-morbidity, while the use of RADT was mostly associated with younger age.

Navigating the unknown: understanding and managing parental anxiety when a child is ill

BACKGROUND

Parents are often confronted with a difficult decision when their child falls ill: should they go to the general practitioner (GP) or not? This study aims to describe this process comprehensively in order to allow clinicians to assess the extent to which parents can recognise clinical warning signs and act accordingly. The purpose of this study is to describe parents' decision-making processes when deciding whether or not to consult a GP for their sick child.

METHODS

We used a qualitative study design based on semistructured interviews to investigate the decision-making process of 25 parents. Four case scenarios describing a developing illness in a child were presented.

RESULTS

Parents' reasons for seeking medical attention could be divided into two main categories. First, non-specific fears lead parents to consult a doctor. Parents were alarmed by the persistence and progression of symptoms, the combination of symptoms or changes in their child's behaviour or they needed reassurance. Second, several specific fears were identified. Sometimes, parents fear a specific disease, while at other times, they are concerned about warning signs. Some parents, however, would not seek medical attention at any decision point even though their child could be in a potentially life-threatening situation.

CONCLUSIONS

Although parents make carefully considered decisions on whether or not to consult a doctor, many appear to miss red flags, including more experienced parents. Conversely, some become overly concerned with certain specific symptoms such as fever, and few parents are familiar with self-management strategies.

New insights into fever phobia: a pilot qualitative study with caregivers and their healthcare providers

Despite the availability of clinical guidelines on the correct symptomatic management of fever in children, several studies have reported inaccurate knowledge about this symptom and inappropriate management behaviours among caregivers. There is evidence that caregivers' management of fever is largely influenced by unrealistic and unwarranted concerns about the potential harm that elevated body temperature can cause, a phenomenon commonly referred to as fever phobia. Research on fever phobia has predominantly focused on the role of fever misconceptions in triggering anxiety and impeding a proper fever management, in terms of both concept and operationalization, with little attention to the influence of the relationship between caregivers and the healthcare team. The aim of this pilot study was to explore and describe fever-related knowledge, experience and behaviour among a sample of caregivers, paediatricians and their medical assistants in the Canton of Ticino, Switzerland. We used a qualitative study design with semi-structured, one-to-one interviews with paediatricians employed in private healthcare facilities, their medical assistants and caregivers with at least one child between the ages of 0 and 3 years. We conducted individual interviews either in person or by phone, according to participants' preferences, between October 2020 and February 2021. We performed an inductive-deductive analysis of the transcripts to identify the most meaningful themes from participants' reports. The analysis of the transcripts yielded three main themes. The first theme refers to participants' awareness of the emotional component in managing the child's fever and the challenges this component presents. The second theme refers to the risk of overtreating when the child's right to be sick is not recognized and respected. The third theme refers to the importance of the relational component, showing how a solid therapeutic alliance with the healthcare team helps caregivers develop self-confidence in managing the child's fever. This study contributes to advance our understanding of fever phobia and to a better conceptualization and operationalization of this phenomenon.

CONCLUSION

Our results point out to the importance of going beyond a knowledge gap paradigm and recognizing both the emotional and the relational component of fever phobia, the former being entrenched in latter, that is, the unique relationship caregivers establish with their child's paediatrician and the medical assistant.

WHAT IS KNOWN

• Research on fever phobia has predominantly focused on the role of fever misconceptions in triggering anxiety and impeding a proper fever management, in terms of both concept and operationalization, with little attention to the relational component of this phenomenon.

WHAT IS NEW

• Our results point out to the importance of recognizing the emotional component of fever phobia, beyond its declarative and procedural knowledge dimensions. They also suggest that overtreating is not necessarily and not only the result of a phobia but also of a particular conception of health and the relational component of this phenomenon, which is entrenched in the unique relationship caregivers establish with their child's paediatrician and the medical assistant.

Short stay hospital admissions for an acutely unwell child: A qualitative study of outcomes that matter to parents and professionals

BACKGROUND

Numbers of urgent short stay admissions (SSAs) of children to UK hospitals are rising rapidly. This paper reports on experiences of SSAs from the perspective of parents accessing urgent care for their acutely unwell child and of health professionals referring, caring for, or admitting children.

METHODS

A qualitative interview study was conducted by a multi-disciplinary team with patient and public involvement (PPI) to explore contextual factors relating to SSAs and better understand pre-hospital urgent care pathways. Purposive sampling of Health Board areas in Scotland, health professionals with experience of paediatric urgent care pathways and parents with experience of a SSA for their acutely unwell child was undertaken to ensure maximal variation in characteristics such as deprivation, urban-rural and hospital structure. Interviews took place between Dec 2019 and Mar 2021 and thematic framework analysis was applied.

RESULTS

Twenty-one parents and forty-eight health professionals were interviewed. In the context of an urgent SSA, the themes were centred around shared outcomes of care that matter. The main outcome which was common to both parents and health professionals was the importance of preserving the child's safety. Additional shared outcomes by parents and health professionals were a desire to reduce worries and uncertainty about the illness trajectory, and provide reassurance with sufficient time, space and personnel to undertake a period of skilled observation to assess and manage the acutely unwell child. Parents wanted easy access to urgent care and, preferably, with input from paediatric-trained staff. Healthcare professionals considered that it was important to reduce the number of children admitted to hospital where safe and appropriate to do so.

CONCLUSIONS

The shared outcomes of care between parents and health professionals emphasises the potential merit of adopting a partnership approach in identifying, developing and testing interventions to improve the acceptability, safety, efficiency, and cost-effectiveness of urgent care pathways between home and hospital.

Cross-sectional study of parental knowledge, behaviour and anxiety in management of paediatric fever among German parents

OBJECTIVES

Fever is a common symptom among children. Parental lack of knowledge about fever could cause anxiety and lead to unnecessary measures to subside fever. There is little evidence about German parents' knowledge and their fever management.

DESIGN

A cross-sectional study using a paper-based questionnaire.

SETTING

16 kindergartens in Saarbrücken and Saarlouis regional association accepted to participate in the study. Parents from these kindergartens were requested during the pickup time to answer the questionnaire.

PARTICIPANTS

481 German parents participated in the study, 394 of them were women. Inclusion criteria were good understanding of German and being a parent of at least one child below the age of 7 years.

PRIMARY AND SECONDARY OUTCOME MEASURES

Knowledge and behaviour of parents on paediatric fever management and the factors influencing fever anxiety.

RESULTS

The older the parents were, the more anxiety they reported. Their definition of fever had a wide range of 30°C-41°C (mean 38.46, SD=0.67) and almost 90% (mean 3.05, SD=2.03) of participants reported fever as useful, whereby they felt more confident the more they found fever useful. 69% of parents felt calm when their child has fever (mean 4.47, SD=2.27). In case of fever, 55% of parents administer paracetamol, 72% ibuprofen and 32% of them would alternate between the two. Paracetamol and ibuprofen are used more by more anxious parents. In explorative factor analysis, reasons to reduce temperature were summarised in three main factors: damage prevention, illness control and well-being protection, whereby the first two were positively related to parental anxiety.

CONCLUSIONS

Both knowledge as well as level of confidence/anxiety vary largely. Taking antipyretics is related to higher level of anxiety, indicating the need for further education. Fever anxiety depends on multiple factors, which have to be further investigated.

Non-contact infrared thermometers compared with current approaches in primary care for children aged 5 years and under: a method comparison study

BACKGROUND

Current options for temperature measurement in children presenting to primary care include either electronic axillary or infrared tympanic thermometers. Non-contact infrared thermometers could reduce both the distress of the child and the risk of cross-infection.

OBJECTIVES

The objective of this study was to compare the use of non-contact thermometers with the use of electronic axillary and infrared tympanic thermometers in children presenting to primary care.

DESIGN

Method comparison study with a nested qualitative study.

SETTING

Primary care in Oxfordshire.

PARTICIPANTS

Children aged ≤ 5 years attending with an acute illness.

INTERVENTIONS

Two types of non-contact infrared thermometers [i.e. Thermofocus (Tecnimed, Varese, Italy) and Firhealth (Firhealth, Shenzhen, China)] were compared with an electronic axillary thermometer and an infrared tympanic thermometer.

MAIN OUTCOME MEASURES

The primary outcome was agreement between the Thermofocus non-contact infrared thermometer and the axillary thermometer. Secondary outcomes included agreement between all other sets of thermometers, diagnostic accuracy for detecting fever, parental and child ratings of acceptability and discomfort, and themes arising from our qualitative interviews with parents.

RESULTS

A total of 401 children (203 boys) were recruited, with a median age of 1.6 years (interquartile range 0.79-3.38 years). The readings of the Thermofocus non-contact infrared thermometer differed from those of the axillary thermometer by -0.14 °C (95% confidence interval -0.21 to -0.06 °C) on average with the lower limit of agreement being -1.57 °C (95% confidence interval -1.69 to -1.44 °C) and the upper limit being 1.29 °C (95% confidence interval 1.16 to 1.42 °C). The readings of the Firhealth non-contact infrared thermometer differed from those of the axillary thermometer by -0.16 °C (95% confidence interval -0.23 to -0.09 °C) on average, with the lower limit of agreement being -1.54 °C (95% confidence interval -1.66 to -1.41 °C) and the upper limit being 1.22 °C (95% confidence interval 1.10 to 1.34 °C). The difference between the first and second readings of the Thermofocus was -0.04 °C (95% confidence interval -0.07 to -0.01 °C); the lower limit was -0.56 °C (95% confidence interval -0.60 to -0.51 °C) and the upper limit was 0.47 °C (95% confidence interval 0.43 to 0.52 °C). The difference between the first and second readings of the Firhealth thermometer was 0.01 °C (95% confidence interval -0.02 to 0.04 °C); the lower limit was -0.60 °C (95% confidence interval -0.65 to -0.54 °C) and the upper limit was 0.61 °C (95% confidence interval 0.56 to 0.67 °C). Sensitivity and specificity for the Thermofocus non-contact infrared thermometer were 66.7% (95% confidence interval 38.4% to 88.2%) and 98.0% (95% confidence interval 96.0% to 99.2%), respectively. For the Firhealth non-contact infrared thermometer, sensitivity was 12.5% (95% confidence interval 1.6% to 38.3%) and specificity was 99.4% (95% confidence interval 98.0% to 99.9%). The majority of parents found all methods to be acceptable, although discomfort ratings were highest for the axillary thermometer. The non-contact thermometers required fewer readings than the comparator thermometers.

LIMITATIONS

A method comparison study does not compare new methods against a reference standard, which in this case would be central thermometry requiring the placement of a central line, which is not feasible or acceptable in primary care. Electronic axillary and infrared tympanic thermometers have been found to have moderate agreement themselves with central temperature measurements.

CONCLUSIONS

The 95% limits of agreement are > 1 °C for both non-contact infrared thermometers compared with electronic axillary and infrared tympanic thermometers, which could affect clinical decision-making. Sensitivity for fever was low to moderate for both non-contact thermometers.

FUTURE WORK

Better methods for peripheral temperature measurement that agree well with central thermometry are needed.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN15413321.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 53. See the NIHR Journals Library website for further project information.

Feeling Informed Versus Being Informed: Mixed-Methods Analysis of Family Perceptions and Behavior Following a Pediatric Emergency Department Visit

PURPOSE

To examine perceptions of family-centered care, satisfaction, and quality of communication with health professionals during a pediatric emergency department visit, and to evaluate the perceived usefulness of the information received and whether provider treatment recommendations were followed after discharge.

DESIGN

Embedded mixed methods design with two concurrent phases. Participants in phase 1 were 385 adult relatives of children (age 6 days-17 years, mean 5.0 years, SD 4.5) seen in a pediatric emergency department. On the day of the visit, relatives completed questionnaires exploring perceptions of family-centered care, satisfaction (CSQ-8), and quality of communication with professionals (ad hoc instrument). For phase 2, we conducted daily structured telephone interviews with 37 of these parents over the six consecutive days following the emergency visit.

RESULTS

Satisfaction with the visit was significantly related to the perception of family-centered care (B = 0.25; 95% CI [0.20, 0.29]; p < .001). Follow-up interviews revealed that 45.9% (n = 17) of families did not follow the prescribed treatment and 32.4% (n = 12) made a further appointment with their primary care pediatrician. Qualitative analysis suggested that families lacked certain information from care providers.

CONCLUSIONS

Elements of a family-centered approach were rated positively and families believed that the information they received was useful. Importantly, more than half of the families who were followed up by telephone had doubts about provider treatment recommendations.

PRACTICE IMPLICATIONS

Family-centered care in the pediatric emergency department could enhance communication and help to ensure that treatment recommendations are followed at home.

Influence of Alternative Lifestyles on Antibiotic Use during Pregnancy, Lactation and in Children

Alternative lifestyles are likely to be associated with distinct usage of specific medicinal products. Our goal was to find out whether the intake of antibiotics during pregnancy and by children differs according to whether the mothers have alternative or conventional lifestyles. Therefore, we investigated the use of antibiotics by pregnant women and by children up to 11 years of age participating in the KOALA Birth Cohort Study. This cohort comprises two recruitment groups of mother–infant pairs, one with alternative lifestyles (selected via organic food shops, anthroposophic clinicians and midwives, anthroposophic under-five clinics, Rudolf Steiner schools and relevant magazines, n = 491) the other with conventional lifestyles (no selection based on lifestyle, n = 2343). Mothers in the alternative lifestyle group more frequently adhered to specific living rules and identified themselves with anthroposophy more than mothers in the conventional lifestyle group. The results revealed significant differences in antibiotic use during pregnancy and in children from 3 months to 10 years of age between the two groups. The rate of antibiotic use in children was consistently lower in the alternative lifestyle group than in the conventional lifestyle group. Antibiotic use in pregnancy was higher in low educated women, and maternal antibiotic use during lactation was higher after an instrumented delivery in hospital. Antibiotic use in the infant was higher when they had older sibs or were born in hospital, and lower in those who had been longer breastfed. After adjustment for these factors, the differences in antibiotic use between the alternative and conventional groups remained. The results suggest that an alternative lifestyle is associated with cautious antibiotic use during pregnancy, lactation and in children.

Impact of Pediatric COVID-19 on Family Health-Related Quality of Life: A Qualitative Study from Latvia

Information on family health-related quality of life (FHRQoL) among families of children with the coronavirus disease 2019 (COVID-19) is limited. This qualitative study explores the impact of pediatric COVID-19 on FHRQoL from the parents' perspective. Semi-structured interviews were conducted with parents (n = 20) whose children had tested positive for the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Inductive thematic analysis revealed the following 10 themes that represented parents' perception of FHRQoL while taking care of a child with COVID-19: pediatric COVID-19 as a disease with many unknowns; emotional saturation; internal family relationships in the context of "a new experience"; routine household activities and daily regimen while family is in lockdown; plenty of free time; a wide social support network; social stigma associated with COVID-19; different options for work; savings and debts; challenges with family housing and transport availability. Our results show that parents experience multiple effects of pediatric COVID-19 with regard to FHRQoL.

Sociodemographic Characteristics and Interests of FeverApp Users

The FeverApp Registry is a model registry focusing on pediatric fever using a mobile app to collect data and present recommendations. The recorded interactions can clarify the relationship between user documentation and user information. This initial evaluation regarding features of participants and usage intensity of educational video, information library, and documentation of fever events covers the runtime of FeverApp for the first 14 months. Of the 1592 users, the educational opening video was viewed by 41.5%, the Info Library was viewed by 37.5%, and fever events were documented by 55.5%. In the current sample, the role of a mother (p < 0.0090), having a higher level of education (p = 0.0013), or being registered at an earlier date appear to be cues to take note of the training video, Info Library, and to document. The FeverApp was used slightly less by people with a lower level of education or who had a migration background, but at the current stage of recruitment no conclusion can be made. The user analyses presented here are plausible and should be verified with further dissemination of the registry. Ecological momentary assessment is used more than the information option, in line with the task of a registry. Data collection via app seems feasible.

Fever in children: parents' search for urgent and emergency services

The study analyses the understanding of parents or guardians of children aged zero to five years old about fever, the conduct and care for this condition, carried out in the urgent and emergency service. The qualitative research, which used the thematic analysis technique, was carried out through interviews with 14 parents or guardians who sought an urgent and emergency Pediatric Service in a municipality in the countryside of São Paulo for this reason. The experiences of parents who seek these services are associated to three main topics: fear of fever; care for a febrile child; and the experience of care at the urgent and emergency services. It was identified that an exaggerated fear of fever predominates and that parents / guardians feel safe regarding the existing technology found in urgent and emergency services. The adopted precautions, however, are not always those recommended for the existing situation.

Respiratory infections in children: an appropriateness study of when parents should home care or seek medical help

Background

Children with respiratory tract infections (RTIs) use more primary care appointments than any other group, but many parents are unsure if, and when, they should seek medical help and report that existing guidance is unclear.

Aim

To develop symptom-based criteria to support parental medical help seeking for children with RTIs.

Design and setting

A research and development/University of California Los Angeles (RAND/UCLA) appropriateness study to obtain consensus on children’s RTI symptoms appropriate for home, primary, or secondary health care in the UK.

Method

A multidisciplinary panel of 12 healthcare professionals — six GPs, two pharmacists, two NHS 111 nurses, and two emergency paediatric consultants — rated the appropriateness of care setting for 1134 scenarios in children aged >12 months.

Results

Panellists agreed that home care would be appropriate for children with ≤1 week of ‘normal’ infection symptoms (cough, sore throat, ear pain, and/or runny nose, with or without eating adequately and normal conscious level). The presence of ≥2 additional symptoms generally indicated the need for a same-day GP consultation, as did the presence of shortness of breath. Assessment in the emergency department was considered appropriate when ≥3 symptoms were present and included shortness of breath or wheezing.

Conclusion

The authors have defined the RTI symptoms that parents might regard as ‘normal’ and therefore suitable for care at home. These results could help parents decide when to home care and when to seek medical help for children with RTIs.

Parents' concerns and beliefs about temperature measurement in children: a qualitative study

Background

Nearly 40% of parents with children aged 6 to 17 months consult a healthcare professional when their child has a high temperature. Clinical guidelines recommend temperature measurement in these children, but little is known about parents’ experiences of and beliefs about temperature measurement. This study aimed to explore parents’ concerns and beliefs about temperature measurement in children.

Methods

Semi-structured qualitative interviews were conducted from May 2017 to June 2018 with 21 parents of children aged 4 months to 5.5 years, who were purposively sampled from the METRIC study (a method comparison study comparing non-contact infrared thermometers to axillary and tympanic thermometers in acutely ill children). Data analysis followed a thematic approach.

Results

Parents described the importance of being able to detect fever, in particular high fevers, and how this then influenced their actions. The concept of “accuracy” was valued by parents but the aspects of performance which were felt to reflect accuracy varied. Parents used numerical values of temperature in four main ways: determining precision of the thermometer on repeat measures, detecting a “bad” fever, as an indication to administer antipyretics, or monitoring response to treatment. Family and social networks, the internet, and medical professionals and resources, were all key sources of advice for parents regarding fever, and guiding thermometer choice.

Conclusions

Temperature measurement in children has diagnostic value but can either empower, or cause anxiety and practical challenges for parents. This represents an opportunity for both improved communication between parents and healthcare professionals, and technological development, to support parents to manage febrile illness with greater confidence in the home.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-020-01355-y.

Examining differences in out-of-hours primary care use in Belgium and the Netherlands: a cross-sectional study

Background

The organizational model of out-of-hours primary care is likely to affect healthcare use. We aimed to examine differences in the use of general practitioner cooperatives for out-of-hours care in the Netherlands and Belgium (Flanders) and explore if these are related to organizational differences.

Methods

A cross-sectional observational study using routine electronic health record data of the year 2016 from 77 general practitioner cooperatives in the Netherlands and 5 general practitioner cooperatives in Belgium (Flanders). Patient age, gender and health problem were analyzed using descriptive statistics.

Results

The number of consultations per 1000 residents was 2.3 times higher in the Netherlands than in Belgium. Excluding telephone consultations, which are not possible in Belgium, the number of consultations was 1.4 times higher. In Belgium, the top 10 of health problems was mainly related to infections, while in the Netherlands there were a larger variety of health problems. In addition, the health problem codes in the Dutch top 10 were more often symptoms, while the codes in the Belgian top 10 were more often diagnoses. In both countries, a relatively large percentage of GPC patients were young children and female patients.

Conclusion

Differences in the use of general practitioner cooperatives seem to be related to the gatekeeping role of general practitioners in the Netherlands and to organizational differences such as telephone triage, medical advice by telephone, financial thresholds and number of years of experience with the system. The information can benefit policy decisions about the organization of out-of-hours primary care.

Age-related differences in motives for contacting out-of-hours primary care: a cross-sectional questionnaire study in Denmark

OBJECTIVE

Demands for out-of-hours primary care (OOH-PC) services are increasing. Many citizens call because of non-urgent health problems. Nevertheless, the patients' motives for requesting medical help outside office hours remains an understudied area. This study aimed to examine motives for calling OOH-PC services in various age groups.

DESIGN

Cross-sectional paper based questionnaire study conducted during two weeks in 2015.

SETTING

The OOH-PC services in two Danish regions.

SUBJECTS

Randomly selected patients calling the two healthcare services and accepting to participate in the study received a questionnaire on patient characteristics, health problems, and 26 pre-defined motives based on the Andersen Behavioural Model. Multivariate regression analyses were conducted for various age groups to calculate the probability of each motive to be a significant factor for the decision to call.

RESULTS

A total of 1,871 patients were included in the study; half were parents of children aged 0-12 years. Young adults (18 to 39 years) differed significantly from other age groups as they more often stated perceived barriers and benefits such as "Own GP no time available soon enough" and "Need for quick help because of work".

CONCLUSION

Young adults more often perceive barriers and benefits, which may suggest af difference in expectations regarding the purpose of out-of-hours services and accessibility. Further research is needed to address this issue and further explore the potential gap between the citizens' expectations to the OOH-PC services and the prevailing health policies. Key points The out-of-hours primary healthcare services are increasingly contacted for non-urgent problems, but little is known about the citizens' motives for calling. Age is associated with differences in the perceived importance of various motives for calling out-of-hours care. Young adults are more often than other age groups motivated to call due to logistical issues, such as their job.

The Impact of Influenza Vaccination on Antibiotic Use in the United States, 2010-2017

Background

Influenza, which peaks seasonally, is an important driver for antibiotic prescribing. Although influenza vaccination has been shown to reduce severe illness, evidence of the population-level effects of vaccination coverage on rates of antibiotic prescribing in the United States is lacking.

Methods

We conducted a retrospective analysis of influenza vaccination coverage and antibiotic prescribing rates from 2010 to 2017 across states in the United States, controlling for differences in health infrastructure and yearly vaccine effectiveness. Using data from IQVIA’s Xponent database and the US Centers for Disease Control and Prevention’s FluVaxView, we employed fixed-effects regression analysis to analyze the relationship between influenza vaccine coverage rates and the number of antibiotic prescriptions per 1000 residents from January to March of each year.

Results

We observed that, controlling for socioeconomic differences, access to health care, childcare centers, climate, vaccine effectiveness, and state-level differences, a 10–percentage point increase in the influenza vaccination rate was associated with a 6.5% decrease in antibiotic use, equivalent to 14.2 (95% CI, 6.0–22.4; P = .001) fewer antibiotic prescriptions per 1000 individuals. Increased vaccination coverage reduced prescribing rates the most in the pediatric population (0–18 years), by 15.2 (95% CI, 9.0–21.3; P < .001) or 6.0%, and the elderly (aged 65+), by 12.8 (95% CI, 6.5–19.2; P < .001) or 5.2%.

Conclusions

Increased influenza vaccination uptake at the population level is associated with state-level reductions in antibiotic use. Expanding influenza vaccination could be an important intervention to reduce unnecessary antibiotic prescribing.

Parents' experiences and information needs related to childhood fever: A systematic review

OBJECTIVE

To synthesize current evidence about experiences and information needs of parents/caregivers managing pediatric fever.

METHODS

We used systematic review methodology with an a priori protocol. We searched Medline, Embase, PsycINFO, CINAHL and ProQuest Dissertations and Theses Global, from 2000 to May 2018.

RESULTS

We included thirty-six studies (n = 29 quantitative, n = 7 qualitative; 15,727 participants). Quantitative data contained four themes; 1) caregivers seek information about pediatric fever, 2) low knowledge is coupled with misconceptions and anxiety, 3) fever assessment and management practices vary, 4) demographic factors (e.g., ethnicity, age, socioeconomic status, education) influence information needs and health practices. Qualitative data contained three themes; 1) tension between logic and emotion, 2) responsibility contrasted with sense of vulnerability, 3) seeking support and information to build confidence.

CONCLUSION

Parents often overestimate the risks associated with pediatric fever and struggle to make decisions during a child's febrile illness - leading to caregiving actions that may not reflect current clinical recommendations. Parents seek knowledge about how to care for a febrile child at home and what indicators should prompt them to seek medical attention.

PRACTICE IMPLICATIONS

In addition to providing clear, reliable information, interventions that address educational, pragmatic, and emotional domains may be effective in supporting parents.

Patient motives for contacting out-of-hours care in Denmark: a cross-sectional study

BACKGROUND

Patients in need of acute health care do not always contact the most suitable health care service provider. Contacting out-of-hours primary care for an urgent problem may delay care, whereas contacting emergency medical services for a non-urgent problem could ultimately affect patient safety. More insight into patient motives for contacting a specific health care provider may help optimise patient flows. This study aims to explore patient motives for contacting out-of-hours primary care and the emergency medical services in Denmark.

METHODS

We conducted a cross-sectional observational study by sending a questionnaire to patients contacting out-of-hours primary care and emergency medical services, both of which can be directly contacted by patients, in two of five Danish regions in 2015. As we aimed to focus on the first access point, the emergency department was not included. The questionnaire included items on patient characteristics, health problem and 26 pre-defined motives. Descriptive analyses of patient characteristics and motives were conducted, stratified by the two health care service providers. Factors associated with contacting each of the two service providers were explored in a modified Poisson regression analysis, and adjusted risk ratios were calculated.

RESULTS

Three key motives for contacting the two service providers were identified: 'unpleasant symptoms', 'perceived need for prompt action' and 'perceived most suitable health care provider'. Other important motives were 'need arose outside office hours' and 'wanted to talk to a physician' (out-of-hours primary care) and 'expected need for ambulance' and 'worried' (emergency medical services). Higher probability of contacting the emergency medical services versus out-of-hours primary care was seen for most motives relating to own assessment and expectations, previous experience and knowledge, and own needs and wishes. Lower probability was seen for most motives relating to perceived barriers and benefits.

CONCLUSIONS

Patient motives for contacting the two health care service providers were partly overlapping. The study contributes with new knowledge on the complex decision-making process of patients in need of acute health care. This knowledge could help optimise existing health care services, such as patient safety and the service level, without increasing health care costs.

Drivers of ‘clinically unnecessary’ use of emergency and urgent care: the DEUCE mixed-methods study

Background

There is widespread concern about the pressure on emergency and urgent services in the UK, particularly emergency ambulances, emergency departments and same-day general practitioner appointments. A mismatch between supply and demand has led to interest in what can be termed ‘clinically unnecessary’ use of services. This is defined by the research team in this study as ‘patients attending services with problems that are classified as suitable for treatment by a lower urgency service or self-care’. This is a challenging issue to consider because patients may face difficulties when deciding the best action to take, and different staff may make different judgements about what constitutes a legitimate reason for service use.

Objectives

To identify the drivers of ‘clinically unnecessary’ use of emergency ambulances, emergency departments and same-day general practitioner appointments from patient and population perspectives.

Design

This was a sequential mixed-methods study with three components: a realist review; qualitative interviews (n = 48) and focus groups (n = 3) with patients considered ‘clinically unnecessary’ users of these services, focusing on parents of young children, young adults and people in areas of social deprivation; and a population survey (n = 2906) to explore attitudes towards seeking care for unexpected, non-life-threatening health problems and to identify the characteristics of someone with a tendency for ‘clinically unnecessary’ help-seeking.

Results

From the results of the three study components, we found that multiple, interacting drivers influenced individuals’ decision-making. Drivers could be grouped into symptom related, patient related and health service related. Symptom-related drivers were anxiety or need for reassurance, which were caused by uncertainty about the meaning or seriousness of symptoms; concern about the impact of symptoms on daily activities/functioning; and a need for immediate relief of intolerable symptoms, particularly pain. Patient-related drivers were reduced coping capacity as a result of illness, stress or limited resources; fear of consequences when responsible for another person’s health, particularly a child; and the influence of social networks. Health service-related drivers were perceptions or previous experiences of services, particularly the attractions of emergency departments; a lack of timely access to an appropriate general practitioner appointment; and compliance with health service staff’s advice.

Limitations

Difficulty recruiting patients who had used the ambulance service to the interviews and focus groups meant that we were not able to add as much as we had anticipated to the limited evidence base regarding this service.

Conclusions

Patients use emergency ambulances, emergency departments and same-day general practitioner appointments when they may not need the level of clinical care provided by these services for a multitude of inter-related reasons that sometimes differ by population subgroup. Some of these reasons relate to health services, in terms of difficulty accessing general practice leading to use of emergency departments, and to population-learnt behaviour concerning the positive attributes of emergency departments, rather than to patient characteristics. Social circumstances, such as complex and stressful lives, influence help-seeking for all three services. Demand may be ‘clinically unnecessary’ but completely understandable when service accessibility and patients’ social circumstances are considered.

Future work

There is a need to evaluate interventions, including changing service configuration, strengthening general practice and addressing the stressors that have an impact on people’s coping capacity. Different subgroups may require different interventions.

Study registration

This study is registered as PROSPERO CRD42017056273.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 15. See the NIHR Journals Library website for further project information.

The perspectives of parents, general practitioners, and community pharmacists about treating an ill child in primary care: a comparative study

As children are unable to make health-related decisions themselves, parents play a central role in consultations with healthcare providers. Parents' perspectives are therefore the focus of this study. Our first aim was to determine parents' expectations of a healthcare visit with a general practitioner and a community pharmacist. The second aim was to determine the general practitioners' and community pharmacists' perspectives about consultations with children. An observational cross-sectional study was conducted in April and May 2018. We developed three questionnaires: one for parents, one for general practitioners, and one for community pharmacists. The questionnaire for parents was only available through an online platform. The healthcare providers were questioned face-to-face and through an online platform. The study included 380 respondents. Parents considered prescribing or proposing medication the least important action by a general practitioner or community pharmacist, respectively. As well, parents expect information in most cases from both healthcare providers. The questionnaire for general practitioners and community pharmacists revealed that prescribing or proposing medication was regarded the least important action.Conclusion: Considering parents' expectations for a consultation with a general practitioner or community pharmacist, there is a substantial resemblance with the healthcare providers' perspective.What is Known:• The previous studies focusing on parents' perspectives were carried out in a hospital setting or focused on a specific disorder.• Parents consider reassurance and advice from their general practitioner to be very important; the treatment is considered less important.What is New:• Parents considered for both general practitioners' and community pharmacists' verbal information, answers to their questions, and reassurance as more important than receiving pharmacological treatment, while general practitioners and community pharmacists consider prescribing/proposing medication and providing written information as less important.• The expectations of the different groups (parents in relation to not only the healthcare providers but also the general practitioners and community pharmacists compared to each other) know a great resemblance.

"How to Recognize if Your Child Is Seriously Ill" During COVID-19 Lockdown: An Evaluation of Parents' Confidence and Health-Seeking Behaviors

Background: Parents' health-seeking behaviors has changed during the COVID-19 pandemic. Providing parents with guidance in decision making might improve their confidence to seek timely advice when a child becomes ill. The aim of this study was to evaluate the "How to recognize if your child is seriously ill" leaflet on parents' confidence, health-seeking behaviors, and usefulness during the COVID-19 lockdown. Method: A nine-item survey, codesigned with parent advisors, was used to measure confidence and health-seeking behavior. Social media was used for data collection in a 6-week period (April-June 2020) during COVID-19 lockdown in the United Kingdom. Categorical data were analyzed as frequencies, and inductive content analysis was performed with the qualitative data. Results: In total, 171 parents responded. Most parents (n = 160, 93.6%) found the leaflet helpful. The leaflet increased the confidence among 116 parents (67.8%) to recognize if their child is ill, and 156 (91.2%) parents had a better understanding of when and where to seek help. Thirty-three (19.2%) parents used the leaflet, while their child was unwell during COVID-19 lockdown, and in 14 (42%) cases, the leaflet resulted in changing health-seeking behavior for that episode. Twelve of these parents decided to seek medical consultation when they had not planned to before. Content analysis revealed three categories. (1) Knowledge-parents found the leaflet an objective source to validate their concerns. (2) Usability-parents reported that the leaflet was clearly designed. (3) Decision aid-parents commented that the leaflet provided clarification around recognition of serious symptoms and when and where to seek appropriate care. Conclusions: Our leaflet provided parents with guidance on decision making and risk assessment of ill children during COVID-19 lockdown. Parents found it helpful; it increased their confidence and positively changed their health-seeking behaviors. Providing parents with targeted information to recognize serious illness in children at home could potentially foster self-care and safely maintain a reduction in pediatric emergency attendances for self-limiting illnesses.

'Clinically unnecessary' use of emergency and urgent care: A realist review of patients' decision making

Background

Demand is labelled ‘clinically unnecessary’ when patients do not need the levels of clinical care or urgency provided by the service they contact.

Objective

To identify programme theories which seek to explain why patients make use of emergency and urgent care that is subsequently judged as clinically unnecessary.

Design

Realist review.

Methods

Papers from four recent systematic reviews of demand for emergency and urgent care, and an updated search to January 2017. Programme theories developed using Context‐Mechanism‐Outcome chains identified from 32 qualitative studies and tested by exploring their relationship with existing health behaviour theories and 29 quantitative studies.

Results

Six mechanisms, based on ten interrelated programme theories, explained why patients made clinically unnecessary use of emergency and urgent care: (a) need for risk minimization, for example heightened anxiety due to previous experiences of traumatic events; (b) need for speed, for example caused by need to function normally to attend to responsibilities; (c) need for low treatment‐seeking burden, caused by inability to cope due to complex or stressful lives; (d) compliance, because family or health services had advised such action; (e) consumer satisfaction, because emergency departments were perceived to offer the desired tests and expertise when contrasted with primary care; and (f) frustration, where patients had attempted and failed to obtain a general practitioner appointment in the desired timeframe. Multiple mechanisms could operate for an individual.

Conclusions

Rather than only focusing on individuals' behaviour, interventions could include changes to health service configuration and accessibility, and societal changes to increase coping ability.

Parents' and primary caregivers' conceptualizations of fever in children: A systematic review of qualitative studies

This study was a systematic review and thematic synthesis of qualitative studies. The aim was to explore parents' and primary caregivers' knowledge and conceptualizations of fever in children aged between 0 and 12 years. A systematic literature search of the Medline, CINAHL, SCOPUS, Web of Science, Cochrane Library, BIREME, CUIDEN, ProQuest, and PsycINFO databases was undertaken for qualitative studies published in English or Spanish up to December 2018. Ten studies were included in the thematic synthesis. Parents' perceptions of their children's fever were classified according to three criteria: fever as a pathology, care for the febrile child, and the search for understandable and reliable information on this topic. Fever was perceived as being harmful to children's health and as a pathology that requires health care. Further studies are necessary to gather key information for improving health action plans and satisfaction with the care received. This information might help us to understand the management of fever and the related fears experienced by caregivers. These perceptions can be influenced by parents' knowledge, attitudes, and beliefs on fever and their previous experiences.

Sense-making strategies and help-seeking behaviours associated with urgent care services: a mixed-methods study

Background

Policy has been focused on reducing unnecessary emergency department attendances by providing more responsive urgent care services and guiding patients to ‘the right place’. The variety of services has created a complex urgent care landscape for people to access and navigate.

Objectives

To describe how the public, providers and policy-makers define and make sense of urgent care; to explain how sense-making influences patients’ strategies and choices; to analyse patient ‘work’ in understanding, navigating and choosing urgent care; to explain urgent care utilisation; and to identify potentially modifiable factors in decision-making.

Design

Mixed-methods sequential design.

Setting

Four counties in southern England coterminous with a NHS 111 provider area.

Methods

A literature review of policy and research combined with citizens’ panels and serial qualitative interviews. Four citizens’ panels were conducted with the public, health-care professionals, commissioners and managers (n = 41). Three populations were sampled for interview: people aged ≥ 75 years, people aged 18–26 years and East European people. In total, 134 interviews were conducted. Analyses were integrated to develop a conceptual model of urgent care help-seeking.

Findings

The literature review identified some consensus between policy and provider perspectives regarding the physiological factors that feature in conceptualisations of urgent care. However, the terms ‘urgent’ and ‘emergency’ lack specificity or consistency in meaning. Boundaries between urgent and emergency care are ill-defined. We constructed a typology that distinguishes three types of work that take place at both the individual and social network levels in relation to urgent care sense-making and help-seeking.Illness workinvolves interpretation and decision-making about the meaning, severity and management of physical symptoms and psychological states, and the assessment and management of possible risks. Help-seeking was guided bymoral work: the legitimation and sanctioning done by service users.Navigation workconcerned choosing and accessing services and relied on prior knowledge of what was available, accessible and acceptable. From these empirical data, we developed a model of urgent care sense-making and help-seeking behaviour that emphasises that work informs the interaction between what we think and feel about illness and the need to seek care (sense-making) and action – the decisions we take and how we use urgent care (help-seeking).

Limitations

The sample population of our three groups may not have adequately reflected a diverse range of views and experiences. The study enabled us to capture people’s views and self-reported service use rather than their actual behaviour.

Conclusions

Much of the policy surrounding urgent and emergency care is predicated on the notion that ‘urgent’ sits neatly between emergency and routine; however, service users in particular struggle to distinguish urgent from emergency or routine care. Rather than focusing on individual sense-making, future work should attend to social and temporal contexts that have an impact on help-seeking (e.g. why people find it more difficult to manage pain at night), and how different social networks shape service use.

Future work

A whole-systems approach considering integration across a wider network of partners is key to understanding the complex relationships between demand for and access to urgent care.

Study registration

This study is registered as UKCRN 32207.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Physician and Parental Decision-Making Prior to Acute Medical Paediatric Admission

Background: The number of acute medical paediatric emergency admissions is rising. We undertook qualitative interviews with parents and clinicians to better understand what factors, other than the health status of the child, may influence decision making leading to emergency admission. Methods: Semi-structured interviews were conducted with parents; clinicians working in general practice, out-of-hours or the emergency department (referring clinicians); and doctors working in acute medical paediatrics (receiving clinicians). Results: Ten parents, 7 referring clinicians and 10 receiving clinicians were interviewed. Parents described “erring on the side of caution” when seeking medical opinion and one mentioned anxiety. Among themes seen among referring clinicians, “erring on the side of caution” was also identified as was managing “parental anxiety” and acting on “gut instinct”. Among receiving clinicians, themes included managing parental anxiety and increasing parental expectations of the health service. Conclusions: The study of parent and referring clinician decision-making prior to a hospital admission can identify “teachable moments” where interventions might be delivered to slow or even arrest the rise in short-stay acute medical admissions in Britain and other countries. Interventions could assure parents or referring clinicians that hospital referral is not required and help clinicians understand what they perceive as “parental anxiety”.

Development and evaluation of a hospital discharge information package to empower parents in caring for a child with a fever

OBJECTIVES

First, to explore parents' views on and experiences of managing their febrile child and to assess their behaviour and needs when in search of information about fever; second, to develop and evaluate a hospital discharge information package about fever in children.

DESIGN

Mixed methods: (A) qualitative study with semistructured interviews and a focus group discussion (FGD) and (B) quantitative survey.

SETTING

Emergency department, non-acute hospital setting and day nursery in Rotterdam, The Netherlands.

PARTICIPANTS

Parents of children <18 years (interviews, n=22) parents of children under 5 years (FGD (n=14), survey (n=38)).

INTERVENTION

Information package about fever in children (leaflet and website including videos).

OUTCOME MEASURES QUANTITATIVE SURVEY

Knowledge of fever and confidence in caring for a febrile child (Likert scale 0-5).

RESULTS

Parents found fever mostly alarming, especially high fever. Help-seeking behaviour was based on either specific symptoms or on an undefined intuition. When parents did not feel recognised in their concern or felt criticised, anxiety increased as well as the threshold to seek healthcare for future illnesses. Information was needed, especially for situations when the general practitioner or social network were less easily available. This information should be reliable, consistent, available in multiple formats and include advice on management of fever at home and precise referral to medical services. Parents reported improved knowledge about fever (p<0.05) and mentioned improved confidence in caring for a child with fever at home after consulting the information package.

CONCLUSION

Parents of children with a fever visiting the hospital are concerned about specific symptoms or based on an undefined intuition. Rather than telling parents that they should manage their child's illness at home, healthcare professionals should recognise parental intuition and provide clear information on alarming signs and potential diagnoses to empower parents in the management of their febrile child.

Booklet for Childhood Fever in Out-of-Hours Primary Care: A Cluster-Randomized Controlled Trial

PURPOSE

Fever is the most common reason for a child to be taken to a physician, yet the level of unwarranted antibiotic prescribing remains high. We aimed to determine the effect on antibiotic prescribing of providing an illness-focused interactive booklet on fever in children to out-of-hours primary care clinicians.

METHODS

We conducted a cluster-randomized controlled trial in 20 out-of-hours general practice centers in the Netherlands. Children aged younger than 12 years with fever were included. Family physicians at the 10 intervention sites had access to an illness-focused interactive booklet between November 2015 and June 2016. The primary outcome was antibiotic prescribing during the index consultation. Analysis was performed by fitting 2-level random intercept logistic regression models.

RESULTS

The trial took place among 3,518 family physicians and 25,355 children. The booklet was used in 28.5% of 11,945 consultations in the intervention group. Compared with usual care, access to the booklet did not significantly alter antibiotic prescribing during the index consultation (odds ratio = 0.90; 95% CI, 0.79-1.02; prescription rate, 23.5% vs 25.2%; intracluster correlation coefficient = 0.005). In contrast, use of the booklet significantly reduced antibiotic prescribing (odds ratio = 0.83; 95% CI, 0.74-0.94; prescription rate, 21.9% vs 25.2%; intracluster correlation coefficient = 0.002). Children managed by family physicians with access to the booklet were less likely to receive any drug prescription, and parents in the booklet group showed a reduced intention to consult again for similar illnesses.

CONCLUSIONS

Benefit of an illness-focused interactive booklet in improving outcomes of childhood fever in out-of-hours primary care was largely restricted to the cases in which family physicians actually used the booklet. Insight into reasons for use and nonuse may inform future interventions of this type.

Need for reassurance in self-care of minor illnesses

AIMS AND OBJECTIVES

This study describes people's need for reassurance in self-care of minor illnesses.

BACKGROUND

Self-care and active surveillance are advocated as important strategies to manage minor illnesses. Reassurance influences patient satisfaction and confidence in the practicing of self-care.

DESIGN

This study is a descriptive and interpretive qualitative study.

METHODS

Twelve persons with experience in self-care and receiving self-care advice were recruited, and data were collected using semi-structured interviews between September-December 2014. Data were analysed using qualitative content analyses.

RESULTS

Having previous experience and the ability to actively manage symptoms using self-care interventions was described as reassuring. Participants became stressed and concerned when the symptoms persisted and interventions lacked the desired effect, which often resulted in a decision to consult. Participants wanted to feel that the nurse was an actual person, who was sympathetic, present and understanding, when they received self-care advice. The nurse's assessment and reasoning of the symptoms facilitated care-seekers' assessments of risk, and clear and concrete advice on how to manage the symptoms exerted a calming effect. Patients needed to trust that the nurse understood their situation to embrace the advice, and being invited to return created a feeling that the nurse had listened and taken them seriously.

CONCLUSIONS

Reassurance has the potential to allay doubts and fears to build confidence, which influences self-care and consultation behaviour. Personal presence in the encounter, receiving an assessment and an explanation of the symptoms and precise advice are reassuring.

RELEVANCE TO CLINICAL PRACTICE

The needs of nursing care may persist despite the absence of medical needs. The encounter between the nurse and care-seeker is a unique possibility for reassurance and confidence that a minor illness is self-limiting in its nature, and self-care interventions provide relief and comfort.

Optimising decision making on illness absenteeism due to fever and common infections within childcare centres: development of a multicomponent intervention and study protocol of a cluster randomised controlled trial

Background

Evidence has shown that children 0-4 year-old attending childcare are prone to acquire infections compared to children cared for at home, with fever being the most common symptom. Illness absenteeism due to fever and common infections is substantial and mostly driven by unrealistic concerns and negative attitude towards fever of both childcare staff and parents, resulting in illness absenteeism from childcare, work absenteeism among parents and healthcare service use. The objective of this study is to optimise decision making among childcare staff on illness absenteeism due to fever and common infections in childcare. Underlying determinants of behavioural change were targeted by means of a multicomponent intervention.

Methods

A multicomponent intervention was developed to improve decision making, using the stepwise approach of Intervention Mapping, and in close collaboration with stakeholders and experts. The intervention consisted of 1) a two-hour educational session on fever among childcare staff; 2) an online video for childcare staff and parents emphasising key information of the educational session; 3) a decision tool for childcare staff and parents in the format of a traffic light system to estimate the severity of illness and corresponding advices for childcare staff and parents; 4) an information booklet regarding childhood fever, common infections, and self-management strategies for childcare staff and parents.

The multicomponent intervention will be evaluated in a cluster randomised trial with a 12-week follow-up period and absenteeism due to illness (defined as the percentage of childcare days absent due to illness on the total of childcare days during a 12-week period) as primary outcome measure. Secondary outcome measures are: incidence rate and duration of illness episodes, knowledge, attitude, self-efficacy, and risk perception on fever and common infections of childcare staff and parents, healthcare service use in general and paracetamol use, and work absenteeism of parents.

Discussion

This study aims to develop a multicomponent intervention and to evaluate to what extent illness absenteeism due to fever and common infections can be affected by implementing a multicomponent intervention addressing decision making and underlying determinants among childcare staff and parents of children attending daycare.

Trial registration

NTR6402 (registered on 21-apr-2017).

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-017-4602-3) contains supplementary material, which is available to authorized users.

Pediatric Concussion Management in the Emergency Department: A National Survey of Parents

OBJECTIVE

To examine parental expectations and beliefs about diagnosis and management of pediatric concussion.

STUDY DESIGN

We conducted a cross-sectional web-based survey of a nationally representative panel of US parents in March 2014. Parents of 10- to 17-year-old children responded to questions about their expectations and beliefs about diagnosis and management of pediatric concussion in the emergency department (ED). Weighted percentages for descriptive statistics were calculated, and χ2 statistics were used for bivariate analysis.

RESULTS

Survey participation was 53%, and of 912 parent respondents with a child 10-17 years of age who were presented with a scenario of their child having mild symptoms of concussion, 42% would seek immediate ED care. Parents who would seek immediate ED care for this scenario were more likely than parents who would consult their child's usual provider or wait at home to "definitely expect" imaging (65% vs 21%), definitive diagnosis of concussion (77% vs 61%), a timeline for return to activity (80% vs 60%), and a signed return to play form (55% vs 41%).

CONCLUSIONS

Many parents who bring children to the ED following a possible concussion are likely to expect comprehensive and definitive care, including imaging, a definitive diagnosis, a timeline for return to activity, and a signed return to play form. To manage these expectations, healthcare providers should continue to educate parents about the evaluation and management of concussion.

An illness-focused interactive booklet to optimise management and medication for childhood fever and infections in out-of-hours primary care: study protocol for a cluster randomised trial

Background

Fever is the most common reason for a child to be taken to a general practitioner (GP), especially during out-of-hours care. It is mostly caused by self-limiting infections. However, antibiotic prescription rates remain high, especially during out-of-hours care. Anxiety and lack of knowledge among parents, and perceived pressure to prescribe antibiotics amongst GPs, are important determinants of excessive antibiotic prescriptions. An illness-focused interactive booklet has the potential to improve this by providing parents with information about fever self-management strategies. The aim of this study is to develop and determine the effectiveness of an interactive booklet on management of children presenting with fever at Dutch GP out-of-hours cooperatives.

Methods/design

We are conducting a cluster randomised controlled trial (RCT) with 20 GP out-of-hours cooperatives randomised to 1 of 2 arms: GP access to the illness-focused interactive booklet or care as usual. GPs working at intervention sites will have access to the booklet, which was developed in a multistage process. It consists of a traffic light system for parents on how to respond to fever-related symptoms, as well as information on natural course of infections, benefits and harms of (antibiotic) medications, self-management strategies and ‘safety net’ instructions. Children < 12 years of age with parent-reported or physician-measured fever are eligible for inclusion. The primary outcome is antibiotic prescribing during the initial consultation. Secondary outcomes are (intention to) (re)consult, antibiotic prescriptions during re-consultations, referrals, parental satisfaction and reassurance. In 6 months, 20,000 children will be recruited to find a difference in antibiotic prescribing rates of 25% in the control group and 19% in the intervention group. Statistical analysis will be performed using descriptive statistics and by fitting two-level (GP out-of-hours cooperative and patient) random intercept logistic regression models.

Discussion

This will be the first and largest cluster RCT evaluating the effectiveness of an illness-focused interactive booklet during GP out-of-hours consultations with febrile children receiving antibiotic prescriptions. It is hypothesised that use of the booklet will result in a reduced number of antibiotic prescriptions, improved parental satisfaction and reduced intention to re-consult.

Trial registration

ClinicalTrials.gov identifier: NCT02594553. Registered on 26 Oct 2015​, last updated 15 Sept 2016.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1667-8) contains supplementary material, which is available to authorized users.

Medication management of febrile children: a qualitative study on pharmacy employees' experiences

Background While fever is mostly self-limiting, antibiotic prescription rates for febrile children are high. Although every parent who receives a prescription visits a pharmacy, we have limited insight into pharmacy employees’ experiences with these parents. Pharmacy employees do however exert an important role in ensuring children receive correct dosages and in advising parents on administration of antibiotics. Objective To describe pharmacists’ and pharmacy assistants’ experiences with parents contacting a pharmacy for their febrile child, and to identify ways of improving medication management of these children. Setting Community pharmacies in the Netherlands. Method A qualitative study including 24 Dutch pharmacy employees was conducted, performing four focus group discussions among pharmacy employees. Analysis was based on constant comparative technique using open and axial coding. Main outcome measure Pharmacy employees’ experiences with parents contacting a pharmacy for their febrile child. Results Three categories were identified: (1) workload and general experience, (2) inconsistent information on antibiotic prescriptions, (3) improving communication and collaboration. Pharmacy employees experienced that dosing errors in antibiotic prescriptions occur frequently and doctors provide inconsistent information on prescriptions. Consequently, they have to contact doctors, resulting in a higher workload for both stakeholders. They believe this can be improved by providing the indication for antibiotics on prescriptions, especially when deviating from standard dosages. Conclusion Pharmacy employees experience a high amount of dosing errors in paediatric antibiotic prescriptions. Providing the indication for antibiotics in febrile children on prescriptions, especially when deviating from standard dosages, can potentially reduce dosage errors and miscommunication between doctors and pharmacy employees.

Childhood fever in well-child clinics: a focus group study among doctors and nurses

Background

Fever is common in children aged 0-4 years old and often leads to parental worries and in turn, high use of healthcare services. Educating parents may have beneficial effects on their sense of coping and fever management. Most parents receive information when their child is ill but it might be more desirable to educate parents in the setting of well-child clinics prior to their child becoming ill, in order to prepare parents for future illness management. This study aims to explore experiences of well-child clinic professionals when dealing with childhood fever and current practices of fever information provision to identify starting points for future interventions.

Methods

We held four focus group discussions based on naturalistic enquiry among 22 well-child clinic professionals. Data was analysed using the constant comparative technique.

Results

Well-child clinic professionals regularly received questions from parents about childhood fever and felt that parental worries were the major driving factor behind these contacts. These worries were assumed to be driven by: (1) lack of knowledge (2) experiences with fever (3) educational level and size social network (4) inconsistencies in paracetamol administration advice among healthcare professionals. Well-child clinic professionals perceive current information provision as limited and stated a need for improvement. For example, information should be consistent, easy to find and understand.

Conclusions

Fever-related questions are common in well-child care and professionals perceive that most of the workload is driven by parental worries. The focus group discussions revealed a desire to optimise the current limited information provision for childhood fever. Future interventions aimed at improving information provision for fever in well-child clinics should consider parental level of knowledge, experience, educational level and social network and inconsistencies among healthcare providers. Future fever information provision should focus on improving fever management and practical skills.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1488-1) contains supplementary material, which is available to authorized users.

Acetaminophen administration in pediatric age: an observational prospective cross-sectional study

Background

Parents often do not consider fever as an important physiological response and mechanism of defense against infections that leads to inappropriate use of antipyretics and potentially dangerous side effects. This study is designed to evaluate the appropriateness of antipyretics dosages generally administered to children with fever, and to identify factors that may influence dosage accuracy.

Results

In this cross-sectional study we analyzed the clinical records of 1397 children aged >1 month and < 16 years, requiring a primary care (ambulatory) outpatient visit due to fever. We evaluated the number of children who had received >90 mg/kg/day of acetaminophen, the prescriber, the medication formula and the educational level of the caregiver who administered acetaminophen. Among those children included in our study, 74 % were administered acetaminophen for body temperature ≤ 38.4 °C. 24.12 % of children received >90 mg/kg/day of acetaminophen. Parents with university qualifications most commonly self-administered acetaminophen to their children, in a higher than standard dose. Self medication was also described in 60 % of children, whose acetaminophen was administered for temperatures < 38 °C. Acetaminophen over-dosage was also favored by the use of drug formulations as drops or syrup.

Conclusions

Our study shows that preventive action should be taken regarding the use of acetaminophen as antipyretic drug in children in order to reduce the fever phobia and self-prescription, especially of caregivers with higher educational levels. It is also necessary to promote a more appropriate use of acetaminophen in those parents using drops or syrup formulations.