Addressing inequalities in childhood febrile illness Version 01
Research type
Research Study
Full title
Addressing inequalities in childhood febrile illness associated with paediatric emergency department attendance in Liverpool.
IRAS ID
300685
Contact name
Courtney Franklin
Contact email
Sponsor organisation
University of Liverpool
Duration of Study in the UK
1 years, 8 months, 31 days
Research summary
Research Summary:
Despite evidence to show an association between infectious diseases and disadvantaged socioeconomic conditions (SECs), it is unclear what is driving the current increase in Emergency Department (ED) use for febrile illness. This may plausibly reflect greater unmet healthcare need, or a lack of access and use of appropriate primary care services. A report forecasting the future burdens in paediatric health care has predicted a ‘significant decline’ in the global burden of infections. However, it is expected that with worsening poverty and the widening gap in health inequalities, challenges in child health will continue to rise and with it, the number of children requiring care in an ED. If drivers of emergency healthcare use and child poverty are not addressed, healthcare activity, healthcare outcomes and the strain on our healthcare services will worsen. A better understanding of these pathways is needed to inform policy and to reduce the increasing burden of ED admissions.It is unclear whether the views of parents presenting to the ED with an unwell child and healthcare professionals influence the clinical management of febrile children, and whether SECs influence tests being performed and antibiotics being administered. This research will provide evidence to ensure that already disadvantaged children with febrile illness are not further disadvantaged by existing care pathways.
This study will address the following research question:
How do childhood SECs and other key exposures (such as health behaviours and family income) influence important child health outcomes from febrile illness due to differences in pathways for febrile illness?In the context of rising admissions for children with paediatric febrile illness, and deteriorating social conditions for families in disadvantaged areas, the overall aim of this study is to investigate the effect of SECs on clinical outcomes and healthcare in children with paediatric febrile illness.
Summary of Results:
Study 1 used routinely collected data on the management and outcome of all children presenting to the emergency department (ED) at Alder Hey over 4 years between 2016 and 2019, and explored the association between deprivation and risk of admissions. The crude association between deprivation and risk of admissions showed that the most affluent children were approximately 70% more likely to be admitted than their least affluent peers. Even after adjusting for confounding factors (age, gender, arrival year and season), this association remained consistent. Upon adjustment of potential mediators, an opposite association between odds of admission and deprivation was observed, resulting in children from the most disadvantaged areas experiencing a 30% increased likelihood of admission, than their most affluent counterparts. This suggests that these variables, used as proxy measures to determine disease severity, are significant and sit on the causal pathway between deprivation and risk of admission. Consequently, these may have masked the true relationship between deprivation and admission risk, which was not observed in the unadjusted model. Further, children from deprived areas were more likely to have less investigations performed, be triaged as green of ‘GP appropriate’, attend the ED out of hours, self referrals and also referrals from other primary care (not requiring an appointment), shorter inpatient stay, and diagnoses of infectious disease and respiratory conditions than their most affluent counterparts.Study 2 aimed To critically explore the relationship between socioeconomic conditions (SECs) and ED admission and admission duration, and potential mediating factors for febrile illness associated with infectious disease in England. The study investigated trends in neighbourhood unemployment (as a measure of SECs) related to febrile illness associated with infectious disease. Between 2012-2017 admission rates for febrile conditions increased across all ages. I find that increasing trends in neighbourhood unemployment was associated with increases in emergency admission rates for febrile illness associated with infectious disease, in England. Each 1 percentage point increase in unemployment was associated with a 3% increase in the rate of emergency admissions for febrile illness associated with infectious disease for children aged 0-14 years, compared to 0.5% for non-febrile conditions. Despite this, no association between unemployment and admission duration was observed for febrile children. Adjustment for primary and secondary care access did not meaningfully impact the magnitude of these associations. Therefore, other factors relating to SECs may play a larger role in driving these associations, instead of access to care measures.
Study 3 used thematic analysis of semi-structured interviews with parents and doctors who have experienced treating a febrile child attending the ED. The objectives were to understand To understand parental (1) and healthcare professionals (HCP) (2) perceptions of the reasons for ED presentation for children with febrile illness in England. This study also included emotional journey map analysis of parent interviews and investigated the perceptions of reasons for attending an ED with a febrile child, including perceptions of other healthcare services. I highlight five key factors influencing the use of unscheduled care: parental proficiency and experience; social networks and access to services; fever phobia, uncertainty and anxiety; and reassurance. Ultimately, the ED was not a primary choice of health service when parents seek care for their febrile child, with many parents facing barriers when seeking appropriate primary care, before finally attending the ED. Finally, doctors acknowledged a parental need to be well-informed and listened to, and further identified an educational gap between parents and doctors of the risk of fever. The emotional journey maps further showed the complex and faceted nature of the reasons for attending the ED, and provided a holistic parent-centred perspective of care that characterised healthcare interactions across the whole patient journey, identifying areas for policy entry points.
REC name
West Midlands - South Birmingham Research Ethics Committee
REC reference
22/WM/0050
Date of REC Opinion
1 Mar 2022
REC opinion
Further Information Favourable Opinion