Children with cancer in lower-middle-income countries (LMICs) are 20–30 times more likely to die from fever episodes and infections (1–3), which is likely multifactorial in etiology (1, 3, 4). A high incidence of bloodstream infections, exceeding 28% (5), with an increased prevalence of multidrug-resistant organisms has been reported (6, 7). Children with cancer in LMICs frequently present with severe illness at the time of infection (1, 3), with up to 55% requiring intensive care (3). Staffing shortages are commonplace and low nurse-to-patient ratios contribute to delays, worse outcomes (8), and higher sepsis-related mortality (9). Many pediatric oncologists in LMICs employ reduced-intensity treatment regimens to mitigate the increased infection and treatment-related mortality. While this approach improves outcomes in LMIC settings, survival remains lower compared with high-income country (HIC) settings (10, 11). Improving infection management—a leading cause of death in children with cancer in LMICs (12),—not only benefits those with infections but also brings oncologists in LMICs closer to safely implementing conventional regimens (11, 12).

Effective fever management in children with cancer—that is, the early detection of severe illness and prompt management with blood cultures and antibiotics—remains challenging at LMIC centers (13, 14). The risk of infection-related mortality increases with moderate (>3 h) and severe (>24 h) treatment delays (1, 15, 16). A multicenter study in Africa revealed that few antibiotics were administered within 3 h of fever detection, almost half were administered after >24 h, and nearly all blood cultures were drawn after antibiotics (1). Early detection and management of fever episodes can reduce cancer mortality risk (17, 18), decrease adverse events (19), lower intensive care unit admissions (20), reduce sepsis-related mortality (15, 18, 20), and improve overall outcomes in pediatric oncology fever episodes in LMICs (4).

Despite the known poor outcomes associated with fever episodes, improving fever management in children with cancer in LMICs is complex. Improved understanding of the barriers and facilitators of a sepsis screening tool in LMICs (21) enabled researchers to identify strategies (22) that enhanced implementation and reduced mortality (23). Conducting a needs assessment that includes the description of barriers and facilitators is a valuable first step before implementing an evidence-based intervention (24–27). However, the barriers and facilitators of timely fever management in children with cancer in LMICs are not well described. Our team applied the Consolidated Framework for Implementation Research (CFIR) (28) and developed the Fever Theoretical Framework (29) ( Figure 1 ) to comprehensively describe fever management, which facilitated the identification of strategies and interventions for future quality improvement initiatives in our large, tertiary public referral hospital in Kenya.

We recruited a heterogeneous group of 16 healthcare providers: bedside and charge nurses, clinical officers, pediatric oncology medical officers, consultant pediatric oncologists, phlebotomists, pediatric oncology clinical pharmacists, an antimicrobial clinical pharmacist, pharmacy technicians, microbiology laboratory technicians, microbiology laboratory management, and doctoral clinical microbiologists. Participants described multiple barriers, facilitators, and proposed interventions to improve management. The average interview length was 55 min (range: 24–111 min). We identified recurrent themes and organized the barriers, facilitators, and interventions under the most appropriate thematic categories, though the complexities of fever management in children with cancer were evident. Table 1 includes supportive quotations from participants for major themes and subthemes. Participants readily recalled memorable scenarios where multiple challenges in fever management—such as lack of standardization, delayed results reporting, poor communication, and delays in detection and management—resulted in poor outcomes for a child:

To our knowledge, this is the first qualitative research study to provide novel insights into the complex relationships among barriers and facilitators of fever management in children with cancer in a tertiary referral hospital in Kenya, while also describing interventions and strategies to improve management. Most barriers were located within the hospital system (e.g., high workload/low staffing, delays in results reporting), whereas most facilitators of effective fever management were characteristics of healthcare providers (e.g., eagerness to learn, motivation to deliver excellent care). Participants also suggested interventions that addressed multiple barriers (e.g., guideline implementation, facilitating communication). Task shifting from overburdened healthcare providers to patient caregivers emerged as a potentially cost-effective, impactful, yet underutilized strategy to improve management effectiveness. The complexities of fever management highlighted the importance of an effective healthcare system to support care delivery and the value of a multidisciplinary team approach. Pragmatically, this comprehensive description of fever management practices enabled strategy mapping and identification of interventions directed toward barriers to improve clinical practice. This study established a valuable foundation for our team in selecting implementation strategies to improve aspects of fever management, such as blood culture and antibiotic processes.

This study qualitatively expands upon the intricacies of fever management by describing the interactions of barriers, facilitators, and proposed interventions, which largely align with published quantitative reports. Fever management in children with cancer is challenging, and barriers within healthcare systems (e.g., personnel shortages, budget constraints) have been described in LMICs (3, 13). Specifically, nurse shortages contribute to high workloads and lead to delays in fever detection and management (42). Our thematic findings also support quantitative reports of delays in blood culture and antibiotic processes (1, 14), although antibiotic resistance or shortages were not described as barriers in this study (2, 3, 5, 6). Other LMIC centers have highlighted the need to develop fever treatment guidelines, noted challenges to guideline implementation, and recognized the importance of strategies to support guideline implementation (13, 14). Given the described challenges around guideline implementation (13, 14) and the intricate barriers identified here, the use of multiple implementation strategies (e.g., educational activities, facilitating communication) may improve uptake of evidence-based interventions that enhance fever management. Fever and neutropenia have been described as an oncologic emergency associated with death (1, 3, 4). However, early detection and management of sepsis did not appear as either a barrier or facilitator in our study (21, 23). Poor knowledge during task shifting, especially to trainees, was described (43), whereas a facilitator of effective management was strong role-specific knowledge (e.g., phlebotomists performing phlebotomy tasks (42). Task shifting, educational activities, knowledge sharing, innovative solutions such as mobile technology (44), and guideline implementation have been previously suggested to improve fever management (13, 14). Importantly, our results connect pragmatic implementation strategies to the complex barriers described by healthcare providers.

As our team reflected on this study, we initially underappreciated the scope of challenges faced when managing fever in children with cancer at our center. We found that mapping these strategies was a valuable exercise for planning future efforts to improve our management.

This study has several strengths. Internal validity was supported by reflexive reporting of results to participants, while external validity was reflected in the concordance of our findings with existing literature. The study intentionally recruited a heterogeneous group of participants, including all cadres of healthcare providers with varying levels of experience in fever management. Additionally, because the study was conducted at the largest tertiary public referral hospital in western Kenya, the results may be generalizable to other similarly resourced public hospitals managing fevers in children with cancer in LMICs. The thematic results reported here aligned with the Fever Theoretical Framework and CFIR (28) used in the study planning. However, as our team continued to use these results to inform subsequent interventions, we noted that explicit inclusion of sepsis detection, septic shock management, and intensive care unit access was absent from the Fever Theoretical Framework—important clinical challenges that became evident after this study.

Despite these strengths, we recognize several limitations. Recruitment in certain cadres was limited due to staffing shortages, although thematic saturation was achieved. Semi-structured interviews inherently pose a risk of response bias, which we attempted to mitigate by establishing relationships with participants and ensuring confidentiality of responses. Additionally, aspects of fever management such as sepsis screening and intensive care unit access did not emerge in the analysis, though they may represent important interventions to consider—possibly reflecting response bias. Although members of the study team shared the thematic results and strategy mapping with interview participants and multiple healthcare providers across represented cadres (nursing, phlebotomy, physician, pharmacy, microbiology laboratory), not every participant was available. As a phenomenological qualitative study, the findings highlight perceptions and experiences, but a future study is needed to determine the impact of the proposed strategies on mitigating barriers to effective fever management—for example, improving blood culture and antibiotic processes, reducing time-to-antibiotics, and facilitating prompt detection of severe illness during a fever episode. Other aspects of fever management, including sepsis screening, antibiotic resistance, and caregiver involvement, should also be considered in future studies.

Our study advances knowledge of the intricacies of fever management in children with cancer in a public hospital in an LMIC. More importantly, we mapped implementation strategies and described interventions to address barriers to effective fever management, many of which are not resource intensive (e.g., use of champions, model change, iterative training, development of a guideline, and WhatsApp^® to improve communication). Although our public tertiary referral hospital benefits from an advanced clinical research infrastructure (32), MTRH remains a publicly funded hospital with finite resources, similar to other centers (3, 13, 14). While the management barriers may be generalizable to similarly resourced public tertiary referral hospitals in sub-Saharan Africa, the interventions and strategies should be locally tailored.

A multidisciplinary team and comprehensive approach are likely required to improve fever management of children with cancer; a single strategy (e.g., an effective electronic system or hiring more personnel) would be insufficient to advance care delivery without other supportive strategies and interventions (e.g., facilitating communication, task shifting, and increasing healthcare providers). Our team used these qualitative insights to support the implementation of several multilevel interventions, leveraging many of the implementation strategies directed toward the barriers described by participants. We encourage other pediatric cancer centers to evaluate the applicability of these findings—including barriers, facilitators, strategies, and interventions—within their local settings.

A multidisciplinary team must navigate barriers within the healthcare system in the management of fevers in children with cancer in LMICs. Given the complexities in managing fevers in children with cancer in LMICs, a multidisciplinary approach to comprehensively improve clinical practice is likely needed to mitigate the intricate multilevel barriers. Attributes of healthcare providers facilitate effective fever management and should be leveraged in the implementation of strategies and interventions to improve care. Hospital system barriers may be mitigated through knowledge sharing, task shifting, guideline implementation, and effective communication. Future studies should measure the implementation and process outcomes of the proposed strategies mapped to these management barriers.