A factorial randomised controlled trial of a health literacy modified children's fever education program for parents attending emergency

Background: Fever in children is one of the primary reasons for parents/carers to become concerned for their child’s health, and to consequently seek medical assistance. Considered to be one of the most frequent complaints in children’s diseases, fever is usually reported to Emergency Departments (ED) and primary healthcare centres. While fever management education can improve the knowledge and practices of parents/carers, there was no education program that specifically caters for parents/carers who have limited health literacy. This study sought to address this gap by developing a health literacy modified fever education program suitable for parents/carers with varying health literacy levels. Aims: The aims of this thesis were to explore fever management presentations within local EDs, and to develop, implement and evaluate the effectiveness of a health literacy modified fever education program for parents/carers. It was envisaged that informed parents/carers would reduce their inappropriate use of emergency services for children with fever. Methods: This thesis was composed of three major phases: Phase 1 related to the development the educational intervention; Phase 2 explored ED presentations of children to the study site; and finally Phase 3 was the conduct of a factorial randomised controlled trial testing the effectiveness of the education intervention in a sample of parents/carers with limited and functional health literacy attending emergency. The setting for Phase 2 and 3 was Campbelltown Hospital, South Western Sydney. In Phase 1 the principles of design of health literacy interventions—defining the scope of health information, using pictorial images and plain language, assessing the readability level using established tools, and confirming the content— were utilised. This was followed by secondary analysis of ED presentations for children with fever (N=1581) which highlighted the frequency and seasonal variation in presentation of febrile children during a twelve-month period (January to December 2011), and the non-urgent nature of most presentations (68%). Finally, a factorial randomised controlled trial (F-RCT) was conducted within Campbelltown Hospital ED. One hundred and fifty-five parents/carers of febrile children aged between six months and five years of age participated in the presurvey (98.1% response rate). Participants’ level of health literacy was measured using the Rapid Estimate of Adult Literacy in Medicine Short Form. All participants were randomly allocated to one of four groups: intervention or control with limited or functional health literacy. The intervention group received a health literacy modified fever education program (brochure and DVD), while the control group received the existing Fever Fact Sheet and DVD currently in use. F-RCT Results: A total of forty-six parents/carers participated in the follow-up survey. There were no differences between the intervention and the control groups in their baseline demographics. The planned contrasts analysis revealed that there was no statistically significant difference between the four groups (parents/carers with limited health literacy intervention group, parents/carers with functional health literacy intervention group, and parents/carers with limited health literacy control group, parents/carers with functional health literacy control group), in any of the outcome measures (p ˃ 0.05). Two group analyses (control and intervention) showed improvement in participants’ fever knowledge (mean difference =1.03, 0.2), anticipated fever management practices (mean difference = 1.07, 0.75), and a reduction in the number of visits to the ED (mean difference = -1.57, -1.15) respectively. However, participants in the control group (who received the Fever Fact Sheet) demonstrated a statistically significant improvement in fever knowledge and anticipated fever management practices, and a reduction in the number of visits to the ED/primary care facilities (p < 0.05). No statistically significant difference was found in the intervention group. Conclusion: Providing parents/carers with tailored, appropriate educational interventions improves their fever knowledge and anticipated fever management practices, and thus reduces unnecessary ED/primary care presentations. The Fever Fact Sheet was found to be effective. Further testing of the health literacy modified fever education program, using instruments with improved reliability, within a larger sample of parents/carers with limited health literacy is recommended. Design techniques used in the development of this health literacy modified intervention are supported. Further qualitative research into why parents/carers with children experiencing low grade fevers, continue to attend ED even when well-informed, is recommended