https://doi.org/10.15218/ejnm.2019.18 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov 2020 Original Article Scope of Mothers’ Knowledge Regarding Child Fever Management in Ranya City, Iraq Kurdistan Region ABSTRACT INTRODUCTION Fever is a common problem in children and one of the most common reasons parents seek medical attention for their children. It accounts for 20–30% of all practical vis- iting, and in most of the cases, nothing harmful is diagnosed [1, 2].Fever is one of the most common symptoms of childhood disease, which in turn causes several concerns among families. Almost every child has a fever of 37.8 - 40.8°C at least once during childhood [3-5].While fever is well recognized to be a natural defence mechanism, it is a significant source of family fear. Even a slight increase in body temperature will trigger attempts to re- duce the temperature and cause Background and objective: Children’s caregivers around the world are often unaware of the level of body temperature that indicates a fever. The way that they deal with a fever- ish child is sometimes incorrect or inappropriate. This study aimed to assess the mothers’ knowledge regarding fever management of a child under the age of five. Methods: A quantitative descriptive study was carried out in Ranya in the Kurdistan Re- gion of Iraq in 2018-2019. A purposive sample of 120 participants was initially selected from the mothers who attended two Primary Healthcare Centers (Kewarash and Paparin) in Ranya. The questionnaire was utilized as a tool for data collection, and both descriptive and inferential statistical methods were used to analyze the data. Descriptive statistical data analysis included frequencies, percentages, and mean scores and the inferential sta- tistical data analysis provided mean scores and Chi-square. Results: A total of 110 mothers participated in the study after the exclusion of 10 women. The findings showed that 76% of participants did not know which measurement is the best to measure child temperature, 82% were not sure about the best place to take child’s temperature, and 63% did not have knowledge about what temperature is consid- ered to be a fever. According to the results, 72% of mothers believed that a cold sponge or ice pack is suitable for lowering body temperature, while 87% of mothers knew the most common complication of high fever. There was a positive association between level of education and mothers' knowledge regarding child fever management. Conclusions: While mothers have some knowledge about fever and its management, they are unable to utilize this knowledge correctly. An educational program should be devel- oped for mothers who attend primary healthcare centres to teach them about child fever management. Keywords: Child, Mothers, Fever Management, Knowledge, Primary Health Care Blend Barzan Ameen; Department of Nursing, College of Nursing, University of Raparin, Sulaymaniyah, Iraq. Correspondence: (blend.ameen@uor.edu.krd) 157 Erbil Journal of Nursing & Midwifery Received: 22/04/2020 Accepted: 27/07/2020 Published: 30/11/2020 https://doi.org/10.15218/ejnm.2019.18 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov 2020 Original Article panic among family members [6].Fever causes a high level of anxiety and fear in a child’s caregiver regarding its possible complications [7]. Fever is generally harm- less and usually manifests that the body is fighting an illness or infection. It can be considered a good sign that the child’s im- mune system is working, and the body is trying to heal itself. At the same time, it is essential to look at the cause of fever [8]. Most mothers quickly administer an anti- pyretic (Paracetamol or Ibuprofen) to their children if they feel that the child has a fe- ver. Paracetamol is a safe medicine if it is given correctly, but giving too much can be dangerous and causes death in rare cases. Overdose is the leading cause of liver fail- ure in children. Ibuprofen can cause gut problems and kidney damage in some chil- dren, even when it is given at the recom- mended dose [9]. Fever is one of the most common problems in paediatrics for which parents seek health care. Nurses can pro- vide parents with correct information re- garding the fever and the appropriate man- agement for it. The study was carried out from August 2, 2018, to January 14, 2019, at Kewarash and Raparin primary health care centres (PHC) in Ranya in the Kurdistan Region of Iraq. The researcher obtained ethical approval for the study from the Research Ethics Committee of the College of the Nursing, University of Raparin, the Research Centre Department, University of Raparin, the Raparin Directorate of Health, and the two involved primary health care centres. The study used a quantitative descriptive de- sign. The researcher recruited a non- probability, convenient sample of 120 mothers and excluded 10 women. Criteria for selection included: mothers who attend PHCs with children under the age of five with fever. A questionnaire was constructed after a review of the literature to achieve the objectives of the study and consisted of two parts. The first part in- cluded the socio-demographic characteris- tics of mothers, and part two included 12 items related to the mothers’ knowledge regarding child fever management. The data were collected using a face to face interview approach. Items were measured by using three levels of Likert scales and rated as the: a correct answer - 3, not sure - 2, and an incorrect answer - 1 [10]. The mean of the score from 1 - 1.66 was con- sidered insufficient knowledge, 1.67 - 2.33 was considered moderate knowledge, and 2.34 - 3 was considered high knowledge. Statistical Package for Social Sciences (SPSS) version 20 was used for data analy- sis. Descriptive statistical data analysis in- cluded frequencies, percentages, and mean scores and inferential statistical data analysis calculated mean scores and Chi- square. Out of 110 mothers who participated in this study, 25.0 % were 23-27 years old. Concerning the level of education, 42% of the study sample was illiterate, and 18% of participants graduated from college. More than 68% of mothers were housewives, 30% were governmental employees, and less than 2% were self-employed. Further- more, 27.5% of subjects had one child, 25% had two children, and 47.5% had three or more children. Finally, more than 94% of mothers lived in suburban areas, and 5.5% of participants lived in a rural setting (Table 1).Table 2 shows that the mothers had a low level of knowledge re- garding the best method to measure tem- perature, when they should give unwell child paracetamol rectally, and when to use a cold sponge or ice pack. Also, moth- ers had limited knowledge regarding nor- mal body temperature and fever, sites 158 Erbil Journal of Nursing & Midwifery METHODS RESULTS https://doi.org/10.15218/ejnm.2019.18 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov 2020 Original Article for treating children with fever, when to give children paracetamol, and which tool is accurate in determining the right dose of paracetamol syrup. for temperature measurement, indications for treatment, and visiting a health facility. In contrast, mothers had adequate knowledge regarding the most common complication of high fever in children, which medication is effective and safe 159 Erbil Journal of Nursing & Midwifery Table 1: Socio-demographic characteristics of mothers participating in the study. Age (years) F (%) 18 – 22 7 (6) 23 - 27 28 (25) 28 - 32 26 (24) 33 – 37 23 (21) 38 – 42 26 (24) 110 (100) Level of Education F (%) Illiterate 23 (21) Able to Read and Write 23 (21) Primary School Graduate 10 ( 9) Secondary School Graduate 21 (19) Institute Graduate 13 (12) College Graduate 20 (18) 110 (100) Occupational status F (%) Governmental Employment 33 (30) Self-Employed 2 (1.8) Housewife 75 (68.2) 110 (100) Number of Children F (%) One child 30 (27.5) Two children 28 (25) ≥ Three children 52 (47.5) Residential Area F (%) Suburban 104 (94.5) Rural 6 (5.5) Total 110 (100) F= Frequency %= Percentage https://doi.org/10.15218/ejnm.2019.18 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov 2020 Original Article 160 Erbil Journal of Nursing & Midwifery Table 2: Mothers’ knowledge regarding child fever management. No Items Correct Incorrect Not Sure MS K.L F (%) F (%) F (%) 1 The best place to take the temperature of a child under five years is: a. Rectal b. Mouth. c. Axilla. d. Not sure 14 (12) 8 (6) 88 (82.3) 2.06 M.K 2 The normal body temperature of a child: a. 36°C b. 37°C c. 38°C d. ≥ 39°C f. Not sure 34 (33) 10 (9) 66 (58) 2.21 M.K 3 Above what temperature would you consid- er child have a fever: a. 36.5°C b. 37°C.5 c. 38°.5C d. ≥39.5°C e. Not sure 35 (33) 5 (4) 70 (63) 2.27 M.K 4 Above what temperature would you give child treatment: a. 37.5°C b. 38.5°C c. ≥39°C e. Not sure 39 (36) 2 (1) 69 (63) 2.33 M.K 5 If a child has a fever, how high temperature you call the doctor or go to the hospital or consulting health care worker: a. 37.5 b. 38°C c, 39.5°C d. ≥40°C 5.e. Not sure 24 (24) 6 (6) 80 (70) 2.16 M.K 6 The most common complication of high fever in children if don’t treat it: a. Febrile seizure b. Death c. Brain damage d. Coma e. Nothing will happen f. Not sure 96 (87) 5 (5) 9 (8) 2.82 G.K 7 Which measurement is the best way to measure unwell child temperature: a. Your hand b. Glass thermometer c. Electron- ic thermometer d. Not sure 7 (7) 84 (76) 19 (17) 1.30 L.K 8 Which drug is best to give to your unwell child for fever: a. Acetaminophen b. Aspi- rin c. Ibuprofen (Prufen) d. Antibiotic e. Not sure 81 (77) 13 (7) 16 (16) 2.61 G.K 9 Which instrument is best accurate to deter- mine the right dose of paracetamol syrup: a. Tablespoon b. Teaspoon c. Specific measures spoon/Syringe drugs d. Not sure 70 (66) 25 (19) 15 (15) 2.40 G.K 10 Mothers should give unwell child paraceta- mol rectally if: a. She wants more useful b. She wants to become a more practical c. Unable to give him orally because of vom- iting or child refusal. d. Not sure 25 (25) 61 (52) 24 (23) 1.67 L.K 11 How do you decide the right fever lowering drugs to give to your child: a. According to label instructions or consulting Health care worker b. According to information gathered previously c. I decide by myself what I think is right d. Not sure 81 (72) 10 (9) 19 (19) 2.64 G.K 12 Cold sponge or Ice pack is good for lowering body temperature in addition to drugs that reduce fever in children: a. Correct b. Incorrect c. Not sure 29 (29) 72 (62) 9 (9) 1.60 L.K G.K= Good knowledge M.K= Moderate knowledge L.K= Low knowledge M.S= Mean of score K.L= Knowledge Level . https://doi.org/10.15218/ejnm.2019.18 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov 2020 Original Article mothers and their knowledge regarding child fever management (P-value < 0.05). Table 5 shows that there is no significant correlation between the number of chil- dren in the family and mothers’ knowledge regarding child fever management (P-value > 0.05). 161 Erbil Journal of Nursing & Midwifery Table 3 shows there is no significant asso- ciation between the age of the mothers who participated in the study and their knowledge regarding child fever manage- ment (P-value >0.05). Table 4 indicates that there is a significant association between the level of education of Table 3: The association between mothers’ knowledge regarding child fever manage- ment and the age of mothers. Mothers respond to answer Age groups (years) Correct Incorrect Not Sure F (%) F ( %) F (%) Total 18-22 23-27 28-32 33-37 38 (7.1) 15 (4.94) 31 (6.44) 84 153 (28.6) 64 (21.05) 107 (22.25) 324 129 (24.12) 80 (26.31) 115 (23.9) 324 105 (19.62) 71 (23.35) 100 (20.7) 276 110 (20.56) 74 (24.35) 128 (26.61) 312 Total 535 (100) 304 (100) 481 (100) 1320 χ² obs= 13.4 df=8 χ² crit= 15.5 p>0.05 F=Numbers of (correct, incorrect and not sure answers that had been answered by the sample regarding each question related to infant fever and its management in table 2 Table 4:The association between mothers’ knowledge regarding child fever management and mothers’ level of education. Mothers respond to answer Level of education Correct Incorrect Not Sure F (%) F (%) F (%) Total Illiterate Primary school graduate Secondary school graduate Institution graduate College graduate 161 (30.09) 133 (43.75) 263 (54.68) 557 47 (8.78) 24 (7.90) 49 (10.19) 120 120 (22.46) 59 (19.41) 73 (15.17) 252 82 (15.33) 35 (11.51) 38 (7.91) 155 125 (23.36) 53 (17.43) 58 (12.05) 236 535 (100) 304 (100) 481 (100) 1320 χ² obs=74.7 df=8 χ² crit=15.51 p<0.05 F=Numbers of (correct, incorrect and not sure answers that had been answered by the sample regarding each question related to infant fever and its management in table 2 https://doi.org/10.15218/ejnm.2019.18 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov 2020 Original Article 162 Erbil Journal of Nursing & Midwifery Available research studies report that par- ents have false beliefs, limited knowledge and misconception regarding fever man- agement, complications and its role in ill- ness [11,12]. Mothers know the most common complications of high fever. Chil- dren with fever are not at increased risk of seizures, dehydration, brain damage, or death, except in high fever when the child may develop febrile seizures [13]. In the current study, 82.3% of mothers were not sure about which body site is the best for taking the temperature. This finding sup- ports the conclusion of Desnous et al. (2011), who indicated that most of the mothers measured the body temperature of the children using a rectal route [14]. This means mothers often do not know the best place for checking the child’s temperature as rectal or oral measure- ments of body temperature should be avoided [15]. Parents should be encour- aged to measure the axillary temperature. In this study, only 34% of the sample knew that normal body temperature is 37.0°C. E Yavuz et al. in their study found that more than 80% of the parents did not know the correct temperature for fever for the measured site. There are similar previous reports in Turkey and culturally diverse populations in different countries [16- 20]. Concerning when to give a child treatment, 36% of the participants would give treatment at 37 °C. World Health Organization (WHO) recommends using treatment when the temperature is above 38.5°C [21].Additionally, mothers in this study had a lack of knowledge about when to call the doctor, go to the hospital, or consult a health care worker if the child has a fever. This is probably because most of the mothers did not know what the normal body tempera- ture was. In contrast, mothers knew the correct medication to use to decrease fever. This finding is consistent with a study by Saed et al., 2013.Using antipy- retics was the most commonly used treatment of fever [10]. In a study in Denmark, Jansen et al. indicated that ac- etaminophen is used by parents for treatment of fever [22]. Acetaminophen and Ibuprofen are the only antipyretic drugs recommended for use [23].In the current study, mothers had insufficient knowledge about the best way to meas- ure temperature, and 76% answered that using a hand is the best method. Parmar et al. (2001) reported that only 15% Table 5:The association between mothers’ knowledge regarding child fever management and mothers’ number of children. Mothers respond to answer Number of children among sample Correct Incorrect Not Sure F (%) F (%) F (%) Total Mothers with one child Mothers with two children Mothers with ≥ three children Total 162 (30.29) 75 (24.68) 123 (25.57) 360 131 (24.48) 76 (25) 129 (26.82) 336 242 (45.23) 153 (50.32) 229 (47.61) 624 535 304 481 1320 χ² obs= 4.7 df= 4 χ² crit= 9.5 p>0.05 F=Numbers of (correct, incorrect and not sure answers that had been answered by the sample regarding each question related to infant fever and its management in table 2 DISCUSSION https://doi.org/10.15218/ejnm.2019.18 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov 2020 Original Article and the age of children were found to be significantly associated with mothers' knowledge of fever. However, the study also shows that there is a highly significant positive association between the mothers' knowledge and the level of education. Many studies have revealed that mothers’ education has a positive impact on their knowledge and practice in child health matters [29-30]. Also, Sharabanou T et al. (2016) indicated a significant correlation between fever management and educa- tional level [31]. This is significant when identifying strategies to help mothers better understand how to treat fever. Fur- thermore, the result of a study by Talebian et al. (2009) shows that with a high educa- tional level, knowledge and attitudes of parents improved significantly [32]. Finally, the findings of the current study show that there is no significant association between the mothers' knowledge and a number of children in the family. Although 70% of mothers in the study had more than one child, they did not have the right knowledge in treating children with fever. However, Anokye R et al. (2018) indicated that the number of children and the level of education was found to be significantly associated with mothers' knowledge of fever [33]. Mothers in this study had some knowledge about fever and its management. Howev- er, they had insufficient information about which method of measurement is best for their children with fever; they did not know the reason and appropriate use of rectal paracetamol. A small number of mothers knew that the physical method (cold sponge or ice pack) is suitable for lowering body temperature only in the cas- es of hyperthermia. Finally, the findings of the study also show that there was a highly significant positive association between of parents had a thermometer at home [24], which is in line with the findings in this study. 66.0% of participants in the cur- rent study used the specific measuring spoon/syringe drug to determine the right dose of paracetamol syrup. It is recom- mended that mothers should never use kitchen spoons to give a child medication as they can vary in size [25]. Nearly half of the mothers in this study thought it was more useful and practical to give the un- well child paracetamol rectally. It has been recommended to use oral administration of acetaminophen rather than rectal ad- ministration, except in the presence of any conditions that prevent oral administra- tion, such as vomiting or refusal [21]. This study's results show that most of the moth- ers gave paracetamol according to label instructions, or they consulted the dosage with a health care provider. In terms of cold sponge or ice pack being effective for lowering body temperature, only 29.0% answered correctly. Studies have found that physical methods used to reduce fever such as bathing, cold sponging, application of ice bags, and rubbing the body with al- cohol might have adverse effects. These methods may paradoxically increase fever, shaking, shiver, severe hypoglycemia, or lead to coma [26]. Consequently, physical methods to reduce fever are not recom- mended except in cases of hyperthermia [27]. There is a necessity to provide par- ents with appropriate fever management strategies, such as giving their febrile chil- dren more fluids and rest and keeping them comfortable, as well as guidelines on when to use medications and seek medical advice, to reduce fever phobias and the probability of overdosing [28].The results of the current study showed no significant correlation between mothers' knowledge regarding child fever management and their age. In contrast, Reindolf Anokye et al. (2018) indicated that the age of mothers 163 Erbil Journal of Nursing & Midwifery CONCLUSION https://doi.org/10.15218/ejnm.2019.18 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov 2020 Original Article [6] Arica SG, Arica V, Onur H, Gülbayzar S, Dağ H, Obut Ö. Knowledge, attitude and re- sponse of mothers about fever in their chil- dren. Emergency Medicine Journal. 2012 Dec 1;29(12):e4- [7] Jalil HA, Jumah NA, Al-Baghli AA. Mothers' knowledge, fears and self-management of fever: a cross-sectional study from the capi- tal governorate in Kuwait. Kuwait Medical Journal. 2007;39(4):349. [8] Fever and Your Child. American Academy of Pediatrics. 2007. updated 21/11/2015). Available on: https:// www.healthychildren.org/English/health- issues/conditions/fever/Pages/Signs-and- Symptoms-of-Fever.aspx#:~:text=A20fever% 20is%20usually%20a,is%20trying%20to% 20heal%20itself. [9] Star K, and Choonara I. How safe is paraceta- mol? (2015): 73-74 [10] Polit FB., & Hungler PB. Nursing Research Principles and methods. 6th Edition. Lip- pincott Williams & Wilkins; January 1, 1999. [11] Crocetti M, Moghbeli N, Serwint J. Fever phobia revisited: have parental misconcep- tions about fever changed in 20 years?. Pedi- atrics. 2001 June 1;107(6):1241-6 [12] Demir F, Sekreter O. Knowledge, attitudes and misconceptions of primary care physi- cians regarding fever in children: a cross- sectional study. Italian Journal of Pediatrics. 2012 Dec 1;38(1):40 [13] Green R, Jeena P, Kotze S, Lewis H, Webb D, Wells M. Management of acute fever in chil- dren: guideline for community healthcare providers and pharmacists. South African Medical Journal. 2013 December 9;103 (12):948-54. [14] Desnous B, Goujon E, Bellavoine V, Merdariu D, Auvin S. Perceptions of fever and fever management practices in parents of children with Dravet syndrome. Epilepsy & Behavior. 2011 August 1;21(4):446-8. [15] Richardson M, Lakhanpaul M. Assessment and initial management of feverish illness in children younger than 5 years: summary of NICE guidance. BMJ. 2007 May 31;334 (7604):1163-4. [16] Yavuz E, Yayla E, Cebeci SE, Kırımlı E, Gümüştakım RŞ, Çakır L, Doğan S. Parental beliefs and practices regarding childhood fever in Turkish primary care. Nigerian jour- nal of clinical practice. 2017;20(1):93-8 [17] Kilmon CA. Parents' knowledge and practices related to fever management. Journal of mothers’ knowledge regarding child fever management and level of education and a number of children that the mother has. An educational program should be devel- oped for mothers who attend primary health care centres for all issues related to child fever management. Health care pro- viders such as nurses, health visitors or vaccinators can increase mothers' aware- ness and level of knowledge regarding fe- ver management at home. The author reports no conflict of interest. I would like to express my thanks to all mothers who participated in this study for their valuable time and responses. My gratitude goes to the PHCs in Ranya for their generosity in allowing this research to be carried out and cooperation during the period of study. 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