Educational interventions on fever management in children: A scoping review

Abstract Background Numerous studies have been conducted specifically to target “fever phobia” and inappropriate fever management skills. However, despite educational intervention, caregivers continue to adopt inappropriate and non‐evidence‐based practices. Aims To collect and examine peer‐reviewed literature for active educational interventions aimed at improving fever management in children and profile them based on: who provided the training, training location, how the intervention was delivered, outcomes of training, and how it was measured. Design Scoping Review. Methods MEDLINE, EMBASE, CINAHL, PubMED, PsycINFO, and IPA were searched from January 1980–December 2016. Study location, type of intervention, intervention target, study aim(s), sample size, instruments, outcome measures, and results were extracted. Results Thirty‐seven studies met the inclusion criteria. Most targeted parents with the remainder focused on healthcare professionals. The interventions and their outcome measures varied significantly from structured group training sessions to video interventions and many using a combination of methods. Most interventions reported a positive impact in outcomes such as knowledge, health service use, or fever management skills. Conclusion More standardized educational platforms targeted at both caregivers and healthcare professionals with appropriate evaluation methods should be developed and made widely available.

The overuse of healthcare services stems from both caregivers and healthcare providers viewing fever as a sign of severe underlying illness and treating it as a disease, rather than a symptom (El-Radhi, 2008). This inherent exaggerated fear has been coined "fever phobia" (Abdullah, Ashong, Al Habib, Karrar, & Al Jishi, 1987;Schmitt, 1980). Caregivers fear that untreated fever leads to harmful effects such as febrile seizures, brain damage, and death (Blumenthal, 1998).
These fears lead to overtreatment and overuse of public health care (Richardson & Purssell, 2015). Similarly, healthcare providers also harbour misconceptions (Demir & Sekreter, 2012;May & Bauchner, 1992) and may add to anxiety of caregivers. One study showed that up to 65% of physicians indicated that fever was harmful and 90% believed that febrile convulsions could cause brain damage (Demir & Sekreter, 2012).
This creates a difficult obstacle, as fever management skills of caregivers may be informed by healthcare providers, friends, family beliefs, the Internet, or written literature (So & Moles, 2014;Walsh, Edwards, & Fraser, 2008). Information originating from multiple sources can be highly conflicting and can cause increased uncertainty (Walsh et al., 2008). Some common errors include the following: not taking temperatures; relying on temperature measurements independent of symptoms; using physical means such as sponging or bathing; and inappropriate use of medicines including incorrect doses, dosing intervals, or combinations of treatments (So & Moles, 2014). Numerous studies have been conducted specifically to target "fever phobia" and inappropriate fever management skills. Interventions directed at caregivers were found to target different concerns such as reducing fever anxiety (O'Neill-Murphy, Liebman, & Barnsteiner, 2001), increasing the amount of information given to parents (Considine & Brennan, 2007), or focusing on measuring and improving knowledge (Emmerton et al., 2014). Despite educational intervention, caregivers continue to adopt inappropriate and non-evidence-based practices (Chiappini et al., 2013;Monsma, Richerson, & Sloand, 2015;O'Neill-Murphy et al., 2001;So & Moles, 2014;Zyoud et al., 2013).
The aim of fever management is to protect and comfort the child until a diagnosis of the underlying condition is made (National Collaborating Centre for Women's and Children's Health (UK), 2013). Caregivers can often manage their child's temperature at home with regular fluids and rest. Worrying symptoms include the following: skin colour or texture changes; rash; drowsiness and breathing difficulty; and detection of fever in very young children (<3 months). These symptoms certainly warrant further medical attention (National Collaborating Centre for Women's and Children's Health (UK), 2013). Antipyretics should not be used with the purpose of lowering temperature but merely to comfort a child with pain associated with fever (Hewson, 2000). While guidelines are available outlining how to correctly manage children's fever, "fever phobia" is a persistent issue. Adherence of healthcare providers to new guidelines could make a huge impact in dissemination of upto-date evidence-based information (Chiappini et al., 2013;Crocetti et al., 2001); however, identifying and overcoming local barriers is essential in changing healthcare provider's behaviours to adopt and implement such guidelines (Grimshaw et al., 2004).
A literature review by Walsh and Edwards (2006) aimed to understand caregiver's attitudes, practices, and behaviours regarding treatments, medication dosing, and information seeking of caregivers. The study concluded that despite the previous success of many educational interventions, many caregiver's attitudes and practices did not change long term and interventions that targeted behavioural change and correcting caregiver influences were necessary (Walsh & Edwards, 2006). Following this, Young, Watts, and Wilson (2010) supported the notion that behavioural change is necessary to improve fever management outcomes in parents and concluded that formal education including mixed methods in either structured or repeated sessions was most effective in improving parental knowledge. In addition, a review by Monsma et al. (2015) looked at factors that should be considered when designing educational interventions aimed at caregivers and recommended that interventions that were structured, one-on-one and reinforced over time would provide the most effective fever management interventions.
The aim of this scoping review was to collect and examine the peer-reviewed literature for all active educational interventions aimed at improving fever management in children and profile them based on: who provided the training, where the training took place, how the intervention was delivered, the outcomes of the training, and how they were measured. A collation of this information allows us to try to ascertain effective methods to teach fever management.

| DE S I G N
A scoping review was chosen, due to the heterogeneity of fever educational interventions.

| Search methods
Articles written in English aimed at human patients from January 1980-December 2016 were identified using MEDLINE, EMBASE, CINAHL, PubMED, PsycINFO, and International Pharmaceutical Abstracts (IPA). Search strategy and keywords can be viewed in Appendix S1 and S2. Hand searches of references in included articles were also undertaken.

| Analysis
One author (D.A.) screened titles and abstracts, and from those deemed relevant, full articles were obtained and reported in accordance with PRISMA guidelines (Moher, Liberati, Tetzlaff, & Altman, 2009) (Figure 1). All three authors (DA, TC, and RM) met regularly to apply specific study inclusion and exclusion criteria. Studies were included if the primary focus was on an active educational intervention which incorporated improving fever management skills for children and included at least one outcome measure for evaluating the educational intervention. For the purpose of this review, an educational intervention was defined as a tool, activity, simulation, or discussion. An "active" educational intervention was defined as a model of delivering the information where the participant was taught the information by a third party. This included all audio, video, presentation, lecture/seminar/tutorial, one-on-one, peer-to-peer, demonstration, and computer-guided interventions. Studies which involved an intervention not defined as "active" were excluded such as those requiring participants to take self-directed initiative without external aid, including but not limited to paper-based written materials such as guidelines, pamphlets, and posters.
Educational interventions aimed at all trained or untrained participants, caregivers/parents, and students or healthcare professionals F I G U R E 1 Flow chart following search strategy and study selection based on the PRISMA guidelines. * Removed all articles not concerning fever or management were included. Similarly, all interventions were included regardless of training style, location, country of origin, or timeframe of the study. Data were included regardless of the level of bias or quality of the intervention.
Studies which detailed an educational intervention covering multiple topics areas not limited to children's fever were included if the intervention contained content and outcome on improving children's fever management. Studies, which covered an educational intervention concerning a disease or issues whose primary manifestation were children's fever, were included providing that they included fever management in these scenarios. This included interventions with a focus on urinary tract infections (UTIs), serious bacterial infections (SBIs), and malaria. In addition, studies which included educational interventions created as a proof of concept with no intervention and only participant satisfaction as an outcome was excluded. All manuscripts that were not primary research papers including secondary texts, literature reviews, conferences, editorials, abstracts, and posters were excluded.

| Data abstraction
Author; year of publication; study design; location of study; type of intervention; target of intervention; study aim(s), sample size used; measurement instruments; outcome measures; and results were extracted from each manuscript.

| Search outcome
The search strategy identified 9,887 articles. After removing duplicates and applying inclusion criteria, a total of 37 manuscripts were reviewed ( Figure 1). A reference list of all reviewed manuscripts is found in Appendix S3. It should be noted that three studies by Considine et al. (2007) [S9-S11] and 2 studies by Edwards H. et al. (2007) [S15, S16] collected data from the same samples. However, the objective in each manuscript was disparate enough for these studies to be considered as separate studies for the purpose of this review.

| Quality appraisal
Study bias was assessed using either the STROBE checklist (von Elm et al., 2007) or Cochrane checklist for randomized control trials (Higgins et al., 2011) where applicable and was rated using a lowhigh scale. All manuscripts were also mapped to Miller's framework for clinical competency to extrapolate whether participants demonstrated knowledge, competence, performance, or action following intervention (Miller, 1990). Further, data were evaluated for constructive alignment of the teaching method and assessment used (Biggs, 2003).

| Ethics approval
Ethics approval was not required for this review.

| Intervention outcomes and tools used to measure them
Outcome tools used varied. These included pre-post questionnaires/ surveys (20/37) [S2, S4, S6, S9-S11, S15, S16, S18, S19, S21-S25, S29, S30, S33, S35, S36], post-only intervention questionnaire/surveys (2/37) [S12, S32], structured interviews (including telephone) (5/37) [S5, S9, S10, S17, S37], semi-structured interviews (7/37) [S1, S3, S8, S23, S27, S28, S30], audits of healthcare facilities (including chart data, personnel, return visits, equipment/stock, and laboratory/diagnostic data) (13/37) [S5, S7, S12-S17, S20, S26, S31, S34, S37], and finally, one-off measurement tools included the following: The data contained in Table 1 were sorted firstly based on the type of intervention presented in the manuscript and then secondly sorted by the target audience of the interventions. Due to the large heterogeneity of the data, it is difficult to form many trends or assumptions regarding how effective the different types of interventions were. However, it can be extrapolated that video interventions were all aimed at parents/caregivers and provided positive improvements in the outcome measures "knowledge" and "satisfaction." Peer-to-peer education interventions were all aimed at nurses and provided positive improvement in the outcome measure of "knowledge." One-on-one session interventions were all aimed at parents/ caregivers and provided positive improvements in the outcome mea- Study bias was measured using either the STROBE checklist or Cochrane checklist for randomized control trials where applicable.

| D ISCUSS I ON
This review included 37 manuscripts that assessed the outcome of active educational interventions aimed at improving fever management in children. This is the first scoping review compiling all current "active" children's fever management interventions and aimed to compare the type of intervention used, who they targeted, what outcomes were measured, and what tools were used to measure outcomes. We therefore used these data to determine which intervention types were most effective in presenting fever management information. The results however highlighted that there was vast variation in how fever education has been delivered and assessed. In general, this review found that educational interventions improved knowledge of participant health professionals and caregivers, with video platforms being cited as a preferred medium for parents. Many interventions were created for small-scale use and tailored for specific ethnic or regional groups leading to dispersed content based on individuals' needs. The absence of an overarching generalized intervention makes it difficult to determine whether any specific single medium is appropriate for all target groups.
Three literature reviews on the topic of fever management in children and the success of current education methods have been published previously. Walsh et al. (2006) reviewed the literature concerning parental fever knowledge and beliefs in addition to educational interventions and aimed to understand caregiver's current attitudes, practices, and information seeking behaviours regarding children's fever and its management (Walsh & Edwards, 2006).
They found that despite the reported success of many educational TA B L E 1 Simplified Table of data in Appendix S3 sorted by "Types of Intervention" and then sorted by "Who the training was aimed at" interventions, there is little that has changed in parent's fever knowledge, attitudes, and management practices, suggesting that future interventions should target behavioural change and focus on correcting inappropriate influences. Walsh also published a narrative review, which made no attempt to tabulate or compare the interventions studied (Walsh & Edwards, 2006). Young et al.'s (2010) systematic review supported the notion that interventions based on behavioural change were necessary to improve fever management outcomes in parents. They concluded that multidimensional interventions using mixed methods and repletion/ reinforcement were most effective, but there were few studies to compare (N = 10) to confirm these findings. This review also stated that healthcare providers have difficulty disseminating fever information to parents; however, the review did not focus on healthcare providers. Monsma et al. (2015) reviewed the factors that should be considered when designing an educational intervention aimed at improving caregivers fever management with focus on low health literacy participants, recommending that one to one, structured, multidimensional, and reinforced over time sessions were the most effective educational interventions. They also suggested that culturally sensitive interventions catered to the target audience would maximize translation of best evidence into practice. Monsma's review therefore had a narrower focus than our review.
Therefore, our review, while comparable to the aforementioned published literature, has expanded on their work to include a broader focus on interventions targeted towards all groups as "fever phobia" is not just a parental issue (El-Radhi, 2008). We propose that educational interventions should focus on both caregivers and health professionals as to date focusing on only one group has not seemed to dramatically change either groups' attitudes towards "fever phobia." The most common form of intervention used in the studies included in our review was group training sessions [S1, S6-S8, S12-S14, S17, S18, S20-S22, S27, S35, S37] which included lectures, discussions, tutorials, or a combination of these at any point in the intervention. This provided the highest percentage of intervention type perhaps as these educational interventions require less resources to produce and could be perceived as easier to conduct than their counterparts. Further, this face-to-face form of teaching allows for demonstration. According to a meta-analysis by Theis (1995), demonstration is seen as the teaching strategy to have the greatest influence on effect size in an intervention, followed by computer simulated and audio and visual with verbal instruction seen as the least effective strategy. It was also shown that using multiple teaching methods is a good strategy to allow the highest effect size of the intervention compared with standard care or control groups (Friedman, Cosby, Boyko, Hatton-Bauer, & Turnbull, 2011;Theis & Johnson, 1995). However, it is to be noted that Monsma et al. (2015) stated that interventions, which are largely structured, generally result in better effect size outcomes regardless of the type of intervention used. Of the interventions that specifically listed demonstrations as part of the intervention [S5, S18, S22], they all showed significant improvement in fever management skills [S5, S22], health service utilization [S5, S18], and knowledge [S5, S18, S22].
Abbey [S1] showed that their video intervention was more easily understood and recollected compared with audio and group talks/ seminars [S1] and the study by Robinson [S30] highlighted that participants wanted more audio/visual health programmes [S30]. In both these cases, the satisfaction of the participants receiving video intervention was significantly higher than the control group counterparts. Education through video format has had mixed results in other fields (Friedman et al., 2011). Educational experts will often suggest that a blended approach to learning; that is, a mix of video/ online media plus face-to-face is more effective that either method alone (Means, Toyama, Murphy, & Bakia, 2013). However, video/ online media do have the advantage of gaining further reach as the participant and teacher do not need to be present in the same classroom. Further research in using online or video education that is soundly based on pedagogical principals and is engaging for the learner needs attention, specifically in the area of caregiver fever management where all parents will find themselves needing knowledge to manage a fever at some stage.
Parents and caregivers were by far the largest percentage target of fever management interventions. All but two of the interventions [S26, S28] aimed at parents focused on the outcome measurement of knowledge. It is known that knowledge underpins competency (Miller, 1990) and this is an important outcome to measure, due to the conflicting information that caregivers receive regarding fever management. However, other studies have also highlighted that education should focus on skills development-the higher levels of Millar's competency pyramid (Miller, 1990) as the "Knows" and "Knows how" region are mainly intermediary markers and not true reflections of lasting change in practice. In particular, the functional health literacy of caregivers and their accuracy in measuring doses have been shown to be exceptionally poor (Emmerton et al., 2014;Hietbrink, Bakshi, & Moles, 2014;Parker & Gazmararian, 2003 Many of the studies in fact did not seem to have an assessment measure constructively aligned (Biggs, 2003) Schmitt's (1980) identification of the term "fever phobia" and hoped to capture most literature written after the publication of this idea. Finally, the STROBE checklist was designed originally as a measure of quality for authors rather than a bias assessment tool; hence, its use for bias assessment may lack validity.

| CON CLUS ION
This review compared educational mediums, who they were aimed at, what targets were measured, and what tools were used to measure outcomes of fever educational interventions. Mostly positive data pose a challenge in determining education interventions "effectiveness" and if any long-lasting outcomes on participant's knowledge and behaviours are affected. The absence of wide-scale interventions of any medium makes it difficult to determine whether any of these interventions have had impact on reducing "fever phobia." The lack of standardized approaches to fever education targeted at both caregivers and healthcare providers, and the assessment of their outcomes makes it difficult to draw any firm conclusions on the best educational tools in this field.

ACK N OWLED G EM ENTS
The authors have no acknowledgements to make.

CO N FLI C T S O F I NTE R E S T
The authors have no conflicts of interest to declare.