Fever phobias, perception among caregivers across Nigerian states: A systematic review and meta-analysis

Abstract

BACKGROUND

There is a need to synthesize the different patterns of fever treatment and phobias in Nigeria and to document these behavioral issues among caregivers. Although, fever is commonly seen in children and this make the mothers to seek medical care when all effort of theirs have failed. Yet, this behavioral and anxiety disorders among mothers still persists several years after the word “Fever phobia” was coined.

AIM

To document the knowledge of fever among Nigerian mothers and to determine heterogeneity in these practices across the nation.

METHODS

A search of articles on fever phobias among mothers or caregivers in Nigeria was performed via the Cochrane Database of Systematic Reviews, PubMed, Google Scholar, and MEDLINE. Articles published between 2008, and 2023 were included in the study. The keywords used in the literature search included fever, phobias, perceptions, mothers, caregivers, perceptions, drugs, knowledge, and practices. Boolean operators were also used in the search for items, such as “fever AND phobia”, “fever AND perception”, “fever AND mothers”, “fevers AND/OR phobia”, “AND OR mothers/caregivers”, to help narrow parameters in the search engine and enhance reproducibility. Studies that fulfilled the inclusion criteria were presented via the PRISMA model. I² statistics were used to assess heterogeneity.

RESULTS

The studies show wide variation in the reported levels of knowledge about fever, with proportions ranging from as low as 35% to as high as 94%. The pooled proportion estimate using the common effect model is 65% (95%CI: 64%-67%), assuming that all studies reflect a single underlying value. However, the random effects model, which accounts for differences among studies, yields a higher estimate of 70% (95%CI: 56%-82%). This divergence reflects significant heterogeneity in the data, with a Tau² of 0.7007, I² of 95.7%, and, an H statistic of 4.80, all indicating that most of the variability is due to actual differences among studies rather than random chance. The Q test further confirms this, with a P value less than 0.0001, reinforcing that the variability across studies is statistically significant. The subgroup analysis revealed that studies in Group A (six studies) reported a pooled knowledge proportion of 75%, with a confidence interval ranging from 56% to 88%, and relatively lower heterogeneity (Tau² = 0.5709, Tau = 0.7556), indicating greater consistency in their findings. In contrast, Group B (four studies) had a lower pooled estimate of 62%, but with a much wider confidence interval (27% to 88%) and greater heterogeneity (Tau² = 0.8380, Tau = 0.9154), suggesting greater variation across studies in that group. Fear of brain damage, convulsions, witches/wizards, and death was high in many of the studies. Herbal concoctions, and prayers were the mostly used measures to cure fever by mothers.

CONCLUSION

Mothers’ knowledge of fever detection in children is low. There was heterogeneity in the sample size of the studies, which may have affected the knowledge of fever.

Key Words: Fever; Phobia; Heterogeneity; Children; Mothers; Meta-analysis

Core Tip: In Nigeria, childhood fevers are often mistaken as malaria and this had led to majority of deaths among under-five children. Similarly, fever as a result of vaccination of childhood killer diseases accounts for over 30% of all presenting complaints to children hospital. Regrettably, caregivers still consider childhood fever as a disease and not as a sign of an underlying disease. This makes them to indulge in unacceptable practices. Fever phobias is a global issue among caregivers and goes beyond cultures, race and language.

INTRODUCTION

Fever is not necessarily a harmful occurrence. Rather, it is an immunologic mechanism that prevents the child from certain deleterious events[1-4]. More than two-thirds of the presenting complaints among children who present to a paediatrician are fever[5]. There are several misconceptions associated with fever in children. The term fever phobia has been used for more than 4 decades to describe fears and incorrect perceptions of fever in children. This has led to many errors in the management of children with fever[6,7].

Fever is commonly observed in children, which makes caregivers seek medical care when all efforts have failed[8]. However, this behavioral approach among caregivers persists 40 years after the word “fever phobia” was coined[8-13].

Mothers’ fear of fever prevents them from understanding or identifying other severe symptoms with which the child may present[14]. For example, the caregiver might not understand the signs and symptoms of a child who is malnourished or who presents with signs of dehydration, which may require the urgent attention of the paediatrician. Studies have shown that more than 80% of febrile illnesses, which are often mistaken for malaria, are treated at home[15-18].

Studies have identified several key factors influencing fever phobia among caregivers, including maternal knowledge and practices regarding febrile illness, the accessibility and availability of maternal and child health services, and sociodemographic variables[18]. Some studies have noted that fever phobias are prevalent both in rural and urban dwellers, as both urban and rural caregivers use drugs and treat their children for fevers at home, as do urban mothers[19,20].

This study aims to determine whether mothers perceive childhood fever as a serious problem. It also compared the knowledge, attitudes and treatment practices of urban and rural mothers towards childhood fever.

MATERIALS AND METHODS

Study participants

The systematic review and meta-analysis involved children of caregivers who had fever from any cause and were between 3 months and 12 years of age.

The concept of fever phobia

Fever phobia in the systematic review refers to mothers' unrealistic and exaggerated fear of fever in the management of their ill children[21]. In this context, mothers and caregivers are too concerned with an overwhelming manner of fever and the possibility of dangerous sequelae[21]. This leads to unwarranted anxiety and overtreatment. This fear is engraved in erroneous beliefs that fever can cause death[21].

Search strategy

We searched for articles on fever phobias among mothers or caregivers in Nigeria via the Cochrane Database of Systematic Reviews, PubMed, Google Scholar, and MEDLINE. Articles published between 2008 and 2025 were included in the study. The literature search was restricted to children under the age of 12 years. The search was performed over 1 month. Besides, a manual search was performed to screen for articles that were not captured in the search engine. Studies that fulfilled the inclusion criteria were presented via the PRISMA model. I² statistics were used to assess heterogeneity. The keywords used in the literature search included fever, phobias, perceptions, mothers, caregivers, perceptions, drugs, knowledge, and practices. Boolean operators were also used in the search for items, such as “fever AND phobia”, “fever AND perception”, “fever AND mothers”, “Fever AND/OR phobia”, “AND OR mothers/caregivers”, to help narrow parameters in the search engine and enhance reproducibility.

Selection of studies

Children and their caregivers/mothers who met the inclusion criteria were enrolled in the study. The inclusion criteria for the study are as follows: Children aged 3 months to 12 years, documented knowledge of fever and practice of fever phobias among caregivers/mothers, studies that documented the prevalence of fever within the given age, studies from the original article that report outcome data on the management of childhood fever were also included in the study. Studies excluded from the meta-analysis included children less than 3 months and more than 12 years of age; articles with abstracts alone; editorials; case reports and series; review articles; and studies involving febrile convulsions. The search for the literature was explored by 2 researchers, and any discordant views, outcomes, or reports between the two researchers were resolved by a third party.

Data extraction

Epidemiological and sociodemographic data were deducted and documented in the meta-analysis. The studies were conducted in all parts of the country, although a major aspect of the study was seen in the south-eastern part of the country.

Risk of bias assessment

This was done via the following formula[19]: SS = z² × p × (1 − p)/d², z = The value fixed at 1.96 across studies (corresponding to the 95%CI). p = The proportion or percentage of the population expected to have a particular characteristic or attribute. d = The desired precision or margin of error. The desirable margin of error is less than or equal to 5% (0.05).

The meta-analyses of children and caregivers/mothers with fever phobias were screened for bias via the modified Newcastle-Ottawa scale for cohort studies[20]. This scale consists of the following eight domains: Cohort size (more than one hundred participants = 1 point, between fifty and ninety-nine participants = 0.5 points, fewer than 50 subjects = 0 points); the number of children and mothers/caregivers in the study population who had a fever (study conducted in a given population = 1 point; multicentre = 0.5 points; single center = 0 points); reported information on the prevalence or knowledge of fever (well-defined information = 1 point, information fairly clear but still has some grey areas = 0.5 points, unclear = 0); reported information on mothers/caregivers’ practices of fever in their children (yes = 1 point, no = 0 points); and scores of more than six in zero to ten points are considered high-quality, 3-4 as medium-quality and < 3 as low-quality (Table 1)[22-31].

Table 1 Scores of the included study using the Newcastle scale (n = 10)¹.

Ref.	Cohort size	Population (Multi-center, single center)	Knowledge of fever sample size
Kazeem et al[22]	1	0	0.5-1
Uzochukwu et al[23]	1	1	0.5-1
Tagbo et al[24]	1	0	0.5-0
Balafalma et al[25]	1	0	0.5-0
Emilia et al[26]	0.5	0.5	0.5-1
Chukwuocha et al[27]	0.5	0.5	0.5-0
Ebidor et al[28]	1	0.5	0.5-0
Eberechukwu et al[29]	1	0.5	0.5-1
Nkechi et al[30]	0.5	1	0.5-0
Ibrahim et al[31]	1	1	1-1
Total score	8.5	5	5.5-5

¹Using the Newcastle scale: The score is between 5 to 8.5 which suggests medium to high-quality study.

Quality assessment of individual studies using the Newcastle-Ottawa Scale

The total cohort score of the selected studies was 8.5/10 with an average score of 0.85 per study/ Since there were no control groups, the selection of the non-exposed cohort was not applicable. The score also showed that the ascertainment of the cause of the fever was adequate. Demonstration of the outcome of the study on fever was not present in the study and could not be assessed. When the cohorts were compared based on the design or analysis, a score of 5/10 (i.e., average 0.5 per study) was derived. A score of 5/10 was obtained in the assessment of outcome with an average score of 0.5 per study. A follow-up for children with fever was not seen in any of the studies and they were not assessed. Based on the Newcastle-Ottawa Scale, the studies included in the meta-analysis were classified as medium to high-quality categories.

Statistical analysis

The meta-analysis of the effects on fever knowledge was based on 10 studies, which included a total of 5085 observations (sample size) and 3356 events (persons with knowledge of fever). Subsequent sub-analyses of studies based on the educational status of mothers (where the proportion of mothers with at least secondary education is ≥ 50% of the sample size) were elicited. The meta package in R was used to conduct the meta-analyses. The I² statistic was used to assess potential heterogeneity. A P-value less than 0.05 indicated that the heterogeneity noted was statistically significant.

RESULTS

Thirty-eight thousand, nine hundred and ten citations were identified in the initial random search strategy, this consists of fever of any cause. A total of 161 studies were included after screening for fever phobias among mothers/caregivers of children presenting in the hospital. A total of 151 studies were further excluded from the 161 studies after further screening for incomplete age, abstracts, febrile convulsion, and fever phobias in the world and Africa. A final total of 10 studies that met our inclusion criteria are shown in the PRISMA guidelines, as shown in Figure 1.

Figure 1 PRISMA chart showing a flowchart of a total of 10 studies that met the inclusion criteria. CHD: Congenital heart disease.

The studies showed a wide variation in the reported levels of knowledge of fever, with proportions ranging from as low as 35% to as high as 94%, each study provides its confidence interval to indicate the likely range of true values. For example, Kazeem et al[22] reported that 83% of participants had knowledge of fever, with a 95% confidence interval between 76% and 89%, whereas Eberechukwu et al[29] reported a much lower figure of 35%, with a narrower interval from 30% to 40%. In the meta-analysis, each study's contribution is weighted based on factors such as sample size and precision; under the common effect model, studies such as Ibrahim et al[31] and Ebidor et al[28] contribute substantially—47.8% and 24.5%, respectively—due to their relatively large influence, while the random effects model distributes the weights more evenly, with most studies contributing approximately 10%. The pooled proportion estimate using the common effect model is 65% (95%CI: 64%-67%), assuming that all studies reflect a single underlying value; however, the random effects model, which accounts for differences among studies, yields a higher estimate of 70% (95%CI: 56%-82%). This divergence reflects significant heterogeneity in the data, with a Tau² of 0.7007, I² of 95.7%, and an H statistic of 4.80, all indicating that most of the variability is due to actual differences among studies rather than random chance. The Q test further confirms this, with a P-value less than 0.0001, reinforcing that the variability across studies is statistically significant. Therefore, while the average level of fever knowledge is moderately high, the wide variation across studies suggests that context-specific factors likely play a role, making the random effects model a more suitable approach for interpreting these findings (Figure 2A).

Figure 2 Forest plot. A: All studies; B: Sub-group analyses.

The subgroup analysis revealed that studies in Group A (six studies) reported a pooled knowledge proportion of 75%, with a confidence interval ranging from 56% to 88%, and relatively lower heterogeneity (Tau² = 0.5709, Tau = 0.7556), indicating greater consistency in their findings. In contrast, Group B (four studies) had a lower pooled estimate of 62%, but with a much wider confidence interval (27% to 88%) and greater heterogeneity (Tau² = 0.8380, Tau = 0.9154), suggesting greater variation across studies in that group. When the two groups are compared, the test for subgroup differences yields a Q value of 1.16 and a P value of 0.2823, with no statistically significant difference in the pooled estimates. Under the common effect model, both groups showed similar knowledge proportions of approximately 65%-66%. However, the random effects model reveals that the Group B results are more dispersed and less consistent, whereas the Group A findings cluster more tightly around a higher proportion. Overall, while the average knowledge level appears comparable across subgroups, the wider variability in Group B may be influenced by differences in study design, or participant characteristics. Using the funnel plot, the same finding was obtained (Figures 2B and 3).

Figure 3 Funnel plot for the studies.

The minimum maternal/caregivers age in the meta-analysis was 15 years, and the maximum was 60 years. The majority of the children studied were under the age of 5 years. The prevalence of fever ranged from 35% to 83.3%, with a mean of 64.88% ± 14.38% (95%CI). The minimum sample size was 36, and the maximum sample size was 2400, with a mean of 502.1 ± 434.617 at the 95%CI (Table 2).

Table 2 Demographic characteristics of study participants, recruited from the outpatients and immunization clinics of the teaching hospital of selected study (n = 10).

Ref.	Maternal age	Child’s age	Knowledge of fever sample size
Kazeem et al[22]	NA	< 12	83.3-144
Uzochukwu et al[23]	15-49	< 5	NA-400
Tagbo et al[24]	16-55	NS	NA-179
Balafalma et al[25]	13-54	NS	74.8-151
Emilia et al[26]	18-42	< 5	NA-122
Chukwuocha et al[27]	NA	< 5	NA-36
Ebidor et al[28]	15-60	NS	63-1143
Eberchukwu et al[29]	NS	< 16	35-324
Nkechi et al[30]	23-38	< 5	NA-122
Ibrahim et al[31]	NS	< 12	68.3-2400

NS: Not specified; NA: Not available.

Table 3 shows the various antipyretics used by some of the studies included in the meta-analysis. Paracetamol is the most common antipyretic used in all the studies.

Table 3 Characteristics of study participants, and types of antipyretics used in treating fever recruited from the outpatients and immunization clinics of the teaching hospital of selected study (n = 10), n (%).

Ref.	Paracetamol	Aspirin	Ibuprofen
Kazeem et al[22]	138 (96%)	NA	7 (5)
Uzochukwu et al[23]	7133 (66.5) urban, 63 (87.5) rural	12 (6.0) urban. 8 (11.1) rural	NA
Tagbo et al[24]	167 (93.8)	NA	NA
Balafalma et al[25]	NA	107 (70.9)	NA
Emilia et al[26]	122 (100)	122 (100)	19 (15.6)
Chukwuocha et al[27]	100 (87.5)	NA	NA
Ebidor et al[28]	NS	NS	NS
Eberchukwu et al[29]	217 (67)	NA	6 (1.9)
Nkechi et al[30]	NS	53 (43.4)	NS
Ibrahim et al[31]	1640 (68.3)	NA	1078 (44.9)

NS: Not specified; NA: Not available.

Fear of brain damage, convulsions, witches/wizards, and death was high in many of the studies, and the commonest measures used by mothers were herbal concoctions and prayers, which were high in many studies (Tables 4 and 5).

Table 4 Presumptive causes for phobias documented in the study, n (%).

Ref.	Malaria	Teething	Pneumonia	Dirty environs	Change in weather	Bad food	Diarrhoea	Drugs	Recent immunization	Infections	Witches/wizards
Kazeem et al[22]	NA	48 (33.3)	NA	36 (25.0)	21 (14.6)	39 (27.1)	NA	12 (8.3)	NA	63 (43.7)	6 (4.2)
Uzochukwu et al[23]	U: 232 (84.0); R: 124 (100)	U: 232 (84.0); R: 124 (100)	U: 183 (66.3); R: 99 (79.8)	U: 183 (66.3); R: 99 (79.8)	NA	NA	U: 134 (48.5); R: 75 (60.5)	NA	U: 214 (77.5); R: 97 (78.2)	NA	NA
Balafalma et al[25]	71 (47)	14 (9.3)	NA	5 (3.3)	2 (1.3)	2 (1.3)	NA	NA	NA	NA	NA
Nkechi et al[30]	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA
Tagbo et al[24]	132 (73.7)	143 (79.9)	NA	NA	NA	NA	6 (3.4)	NA	NA	NA	26 (14.5)
Ebidor et al[28]	483 (42)	306 (30)	16 (8.9)	NA	NA	NA	270 (24)	NA	NA	48 (4)	NA
Ibrahim et al[31]	616 (25.7)	576 (24.0)	NA	NA	120 (5.0)	NA	NA	NA	NA	NA	NA
Eberchukwu et al[29]	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA

U: Urban; R: Rural; NA: Not available.

Table 5 Intervention measures for phobias documented in the study, n (%).

Ref.	Antibiotics	Antimalarials	Herbal concoction	Prayers	Tepid sponging	Took to hospital	Exposure	Covering the child
Kazeem et al[22]	13 (7.8)	10 (6.0)	9 (5.5%)	NA	NA	NA	NA	NA
Uzochukwu et al[23]	NA	U: 96 (48.0), R: 32 (44.4)	U: 6 (3.0), R: 4 (5.6)	NA	NA	U: 11 (3.9), R: 0 (0.0)	NA	NA
Balafalma et al[25]	NA	8 (5.3)	NA	NA	76 (50.3)	13 (8.6)	22 (14.6)	NA
Nkechi et al[30]	61 (50.0)	80 (65.6)	18 (25.0)	35 (43.8)	46 (50.5)	53 (63.9)	26 (32.5)	11 (15.1)
Tagbo et al[24]	NS	NS	NA	NA	NA	NA	154 (86.0)	12 (6.7)
Ebidor et al[28]	189 (17)	396 (35)	180 (15)	NA	NA	189 (17)	NA	NA
Ibrahim et al[31]	773 (32.2)	861 (35.9)	NS	NS	NS	NS	NS	NS
Eberchukwu et al[29]	2 (0.6)	11 (3.4)	1 (0.3)	NA	24 (7.4)	87 (26.8)	6 (1.9)	4 (1.2)

U: Urban; R: Rural; NS: Not specified; NA: Not available.

DISCUSSION

The meta-analysis indicated that while individual studies reported different mean effects, there was substantial variability between them. The random effects model provides a more realistic combined estimate given the high heterogeneity. Similarly, the analysis of the prevalence showed substantial variability due to the significant heterogeneity.

Knowledge of fever

There is significant variability in the reported knowledge of fever in different studies. The pooled estimate of knowledge is approximately 65% in the common model, whereas the random effects model, accounting for the large heterogeneity, suggests that it could range from approximately 70%. The heterogeneity implies that differences in study populations, methodologies, or contexts influence the results, so the random effects model, which allows for this variability, is likely more appropriate for interpreting the findings. While the overall knowledge of fever seems consistent across studies, the high heterogeneity suggests that different factors, such as study design or population characteristics, contribute to varying results. For example, Kazeem et al[22] reported a proportion of 0.83 with a 95%CI of (0.76-0.89), whereas Eberechukwu et al[29] reported a much lower proportion of 0.35 (0.30-0.40). The meta-analysis also revealed poor knowledge of fever among mothers and caregivers[22-31]. This figure ranges from 35% in the study of Eberechukwu et al[29] to as high as 94% in the report of Chukwuocha et al[27]. The poor knowledge of fever could be explained by the fact that most caregivers elicit fever by touching the neck or abdomen of their children. A systematic review revealed that the use of thermometers to identify fever in children with febrile illness is an uncommon practice among mothers and caregivers. For example, Ebidor et al[28] noted that only 12% of mothers/caregivers were able to identify fever with the use of thermometers. The poor knowledge of fever among caregivers may be the root cause of fever phobias.

Fever phobias

The caregivers' presumptive diagnoses triggered fever phobias in the meta-analysis among the caregivers. These include fear of death, teething problems in childhood, probable pneumonia, dirty environments, changes in weather, diarrhoea, use of drugs, recent immunization, infection, and attack by witches and wizards[22-31].

In Nigeria, childhood fevers have led to a high number of deaths among children under five years of age and affect approximately 50% of all outpatient department attendance[32]. Caregivers’ inability to understand the signs and symptoms of malaria has contributed immensely to child morbidity and mortality[33]. For example, Salako et al[34] noted that mothers were unable to recognize severe malaria, even when the children presented with obvious signs and symptoms.

The cause of fever phobia (especially infectious diseases) noted in the meta-analysis in this study is comparable across all the studies[35-37]. This may be because infectious diseases are the most common cause of morbidity and mortality among children, especially under-five children. This may further explain why caregivers panic and show several degrees of anxiety. Ibrahim et al[31] noted that most mothers/caregivers, owing to anxiety and uncertainty about childhood febrile illnesses, had false outcomes when non-evidence-based practices were used to manage their wards. In addition, the lack of consensus on the definitive cut-off for fever, the lack of thermometers, and the inconsistencies in the attitudes of health workers in the definition and management of childhood fever may have contributed to this finding.

Intervention by caregivers

The most common intervention in the management of fever in this study was the use of non-steroidal anti-inflammatory drugs (NSAIDs). The past 20 years have revealed a notable increase in the use of NSAIDs for the treatment of fever. NSAIDs are known to have some untoward effects, such as gastrointestinal tract (GIT) ulceration, with a rising prevalence worldwide[38-42]. Varying degrees of heart failure, anaphylaxis, and blood dyscrasias have also been reported in children on NSAIDS. Most of these drugs are purchased over the counter[42].

In many studies worldwide, paracetamol was found to be the most frequently used antipyretic among mothers and caregivers. The wide use of paracetamol may be related to its availability over the counter[43]. Although paracetamol is widely used, many caregivers acknowledge that ibuprofen has a faster onset and greater relief than paracetamol. In addition, adverse side effects are more common with paracetamol than with ibuprofen. This finding was corroborated in the study of Escalante et al[43] among 2117 febrile children from 13 developing countries. They noted greater adverse events for paracetamol only.

Antibiotics were used in most of the studies in the meta-analysis. The use and misuse of antibiotics are prevalent and have also been documented by Obu et al[44], especially among mothers with diarrhoeal illnesses. Fadare et al[45] noted that antibiotic use-associated adverse events were the second most reported adverse events in their cohorts. Easy access to these drugs and their ubiquitous nature over the counter may partly explain their misuse in Nigeria[45].

Other interventions used in the management of fever, as seen in the meta-analysis, include the use of herbal concoctions, prayers, tepid sponging, exposing the child, and covering the child with clothes. Since these practices have endured the test of time and have made a footprint over decades, it is pertinent health workers intensify efforts in curbing these harmful practices. This can be accomplished through information dissemination, and intentional policies that provide primary care in remote areas of the country.

Analysis based on educational level

The meta-analysis assessed the differences between studies where < 50% of mothers had at least secondary education and studies where at least 50% of mothers had at least secondary education. Mothers with secondary education or less had no difference in their knowledge of fever compared with those with secondary education or above. Similarly, when the funnel, common and random effects models were used, no statistically significant differences in knowledge of fever were detected between the groups.

Comparison of fever phobia with that seen in other countries

Comparison with global literature on fever phobia has shown that the burden of the topic is universal. For instance, Enarson et al[46] noted a 74% prevalence of fever phobia among parents while Soon et al[47] in China noted that caregivers noted that fever could cause brain damage, death and convulsion. A study in Turkey has also shown that 60% of mothers believed that seizures were the most frequent complication if fever were untreated, with only 1% noting no complication would occur in a febrile child[48] Furthermore, Wallenstein et al[49] in the United States noted that 0% of parents correctly defined fever.

This study is limited by the heterogeneity in the sample size, age at presentation and country of study.

Recommendations

Guidelines on the management of childhood fever and control measures as well as information education and communication materials on signs and symptoms of childhood fevers should be provided to all mothers and caregivers irrespective of their educational status. Health education on fever management should be incorporated in schools to dispel the fear of fever. In addition, mothers and caregivers should be taught on how to use and read thermometers.

CONCLUSION

Mothers’ knowledge of detection of fever in their children is low. There was heterogeneity in the sample size of the studies, which may have affected the understanding of fever. The maternal level of education also varies and could affect the heterogeneity observed in the knowledge of fever.