Improving Fever Management of Hospitalized Children with Cancer: Barriers, Facilitators, and Proposed Interventions from Healthcare Providers in Kenya

Everlyn Kisembe¹C. Nathan Nessle^2,3*Julia Dettinger⁴Lenah Nyamusi⁵Sarah Kinja⁵Mercy Ndung'u⁵Sandra Langat^5,6Kenneth M Busby⁷Gilbert Olbara⁸Terry A Vik⁹Cheryl A Moyer¹⁰Festus Njuguna^11*

• ¹School of Arts and Social Sciences, Moi University, Eldoret, Kenya
• ²Pediatric Hematology/Oncology, University of Michigan, Ann Arbor, United States
• ³Fogarty International Center, National Institutes of Health, Bethesda, United States
• ⁴Department of Global Health, University of Washington, Seattle, United States
• ⁵Academic Model for Providing Access to Healthcare, Eldoret, Kenya
• ⁶Vrije Universiteit, Amsterdam, Netherlands
• ⁷Pediatric Hematology/Oncology, University of North Carolina, Chapel Hill, United States
• ⁸Moi Teaching and Referral Hospital, Eldoret, Kenya
• ⁹Pediatric Hematology/Oncology, Indiana University, Indianapolis, United States
• ¹⁰Departmet of Learning Health Sciences, University of Michigan, Ann Arbor, United States
• ¹¹Department of Child Health and Pediatrics, Moi University, Eldoret, Kenya

Children with cancer in lower-middle income countries (LMIC) are at increased risk of dying from infections. Prompt treatment of fever episodes improves outcomes, yet poorly described challenges impair management. This qualitative study explored healthcare provider perspectives of the barriers to and facilitators of inpatient fever management in children with cancer at a public tertiary referral children’s hospital in Kenya. Healthcare providers involved in fever management were recruited. Semi-structured interviews were audio recorded, transcribed verbatim, then entered into NVivo software. Coding was informed by a theoretical fever framework and the Consolidated Framework for Implementation Research. Thematic analysis and mind mapping identified recurrent themes and subthemes. Mapping of strategies to barriers was performed. Sixteen participants included nurses (2), clinicians (6), pharmacists (2), phlebotomists (2), and microbiology lab staff (4). We identified three overarching themes: empowerment of healthcare providers and caregivers, the importance of timely management, and teamwork / human resource availability. Healthcare provider attributes were facilitators: motivation to improve care, eagerness to learn, willingness to change practice, and need for treatment guidance. Factors within the hospital system were barriers, with subthemes of poor communication between cadres, delays in lab results, and staffing shortages. Participants suggested knowledge sharing, a treatment guideline, task shifting, and hiring additional healthcare providers as interventions. Fever episode management in children with cancer is complex, requiring multiple cadres of healthcare providers and caregiver participation. The proposed interventions may overcome barriers, but future studies are needed to measure the outcomes of the strategies in improving fever management.