literature review on managing attitudes

Acute-care nurses' attitudes towards older patients: a literature review

Affiliation.

• 1 Centre for Nursing Research, School of Nursing, Queensland University of Technology, Victoria Park Road, Kelvin Grove, Queensland 4059, Australia. [email protected]
• PMID: 11111490
• DOI: 10.1046/j.1440-172x.2000.00192.x

With increases in life expectancy and increasing numbers of older patients utilising the acute setting, attitudes of registered nurses caring for older people may affect the quality of care provided. This paper reviews recent research on positive and negative attitudes of acute-care nurses towards older people. Many negative attitudes reflect ageist streotypes and knowledge deficits that significantly influence registered nurses' practice and older patients' quality of care. In the acute setting, older patients experience reduced independence, limited decision-making opportunities, increased probability of developing complications, little consideration of their ageing-related needs, limited health education and social isolation. Available instruments to measure attitudes towards and knowledge about older people, although reliable and valid, are outdated, country-specific and do not include either a patient-focus or a caring perspective. This paper argues for the development and utilisation of a research instrument that includes both a patient focus and a caring dimension.

Publication types

• Research Support, Non-U.S. Gov't
• Aged, 80 and over
• Attitude of Health Personnel
• Education, Nursing
• Health Knowledge, Attitudes, Practice
• Health Services for the Aged*
• Nurse-Patient Relations*
• Quality of Health Care
• Stereotyping*

Financial planning behaviour: a systematic literature review and new theory development

• Original Article
• Open access
• Published: 03 October 2023

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• Kingsley Hung Khai Yeo 1 ,
• Weng Marc Lim 1 , 2 , 3 &
• Kwang-Jing Yii 1  

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Financial resilience is founded on good financial planning behaviour. Contributing to theorisation efforts in this space, this study aims to develop a new theory that explains financial planning behaviour. Following an appraisal of theories, a systematic literature review of financial planning behaviour through the lens of the theory of planned behaviour (TPB) is conducted using the SPAR-4-SLR protocol. Thirty relevant articles indexed in Scopus and Web of Science were identified and retrieved from Google Scholar. The content of these articles was analysed using the antecedents, decisions, and outcomes (ADO) and theories, contexts, and methods (TCM) frameworks to obtain a fundamental grasp of financial planning behaviour. The results provide insights into how the financial planning behaviour of an individual can be understood and shaped by substituting the original components of the TPB with relevant concepts from behavioural finance, and thus, leading to the establishment of the theory of financial planning behaviour, which posits that (a) financial satisfaction (attitude), (b) financial socialisation (subjective norms), and (c) financial literacy, mental accounting, and financial cognition (perceived behavioural controls) directly affect (d) the intention to adopt and indirectly shape, (e) the actual adoption of financial planning behaviour, which could manifest in six forms (i.e. adoption of cash flow, tax, investment, risk, estate, and retirement planning). The study contributes to establishing the theory of financial planning behaviour, which is an original theory that explains how different concepts in behavioural finance could be synthesised to parsimoniously explain financial planning behaviour.

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Introduction

Background of financial planning.

Personal financial planning is critical to maintaining a healthy financial status and fulfilling future financial needs (Mahapatra et al. 2019 ). In essence, personal financial planning is a process of managing personal wealth to obtain economic satisfaction (Kapoor et al. 2014 ). This encompasses six areas of financial planning, namely cash flow planning, tax planning, investment planning, risk management, estate planning, and retirement planning (Altfest 2004 ). Ideally, comprehensive financial planning should involve all six areas. However, the specific life stage of an individual, such as retirees, and life realities, such as retrenchment, may dictate the primary focus and/or relevance of these areas. For example, retirees might not be actively engaged in tax planning, and a retrenched worker might not be in a position to engage in investment planning. More importantly, personal financial planning is a profound concept that theoretically reflects and practically safeguards individuals’ financial resilience, and thus, it can be understood from two unique lenses: academic and practice.

From an academic perspective, the field of personal finance is interdisciplinary; it covers a wide range of areas, including economics, family studies, finance, information technology, psychology, and sociology (Schuchartdt et al. 2007 ). Different disciplines have varied theories that play a supporting role in understanding individuals’ financial behaviour and money management (Copur and Gutter 2019 ). However, the theories explaining personal finance are often borrowed rather than created, a situation that is common for emerging interdisciplinary fields (Murray and Evers 1989 ) such as personal finance (Lyons and Neelakantan 2008 ), which encompasses close to 250 publications only in Scopus by the end of 2022. Footnote 1

From a practice standpoint, Palmer et al. ( 2009 ) argued that it is necessary to develop financial planning for each individual that can deal with the uncertainty of the economic environment. Hanna and Lindamood ( 2010 ) echoed that personal financial planning can provide individuals sufficient economic benefits such as increasing wealth, preventing financial loss, and smooth consumption. Footnote 2 However, many individuals lack sufficient financial capability, skills, and knowledge to be able to effectively manage their personal finances (Chen and Volpe 1998 ).

Problems and importance of financial planning

Over time, the society is facing increasing challenges of high living expenses and various financial difficulties given the constant development of complexity in financial matters (Baker et al. 2023 ; Mahapatra et al. 2019 ). Individuals’ ability to manage their personal finances and financial affairs has been gaining attention across the world, wherein being financially healthy gets prioritised by individuals in their lives (e.g. changing investment approach and contributing more to retirement savings to hedge against inflation; Personal Capital 2022 ).

Birari and Patil ( 2014 ) state that individuals should practice and gain basic financial skills to manage their expenditures and acquire well-developed planning to avoid being in financial difficulties. Many factors may lead to irrational financial behaviours from individuals—for example, excess consumption, aggressive trading, lack of savings, and retirement planning. However, one of the major root causes that propels irrational financial behaviour as well as the many financial difficulties that people encounter is inarguably the lack of financial literacy (Organization for Economic Cooperation and Development 2020 ).

According to the Organization for Economic Cooperation and Development ( 2013 ), financial literacy consists of financial knowledge, skill, attitude, awareness, and behaviour to make a rational financial decision and achieve individual financial well-being. In other words, financial literacy is the ability to utilise knowledge and skills to manage financial matters effectively (Pailella, 2016 ; Tavares et al. 2023 ).

Noteworthily, financial behaviour in individuals’ daily lives cannot be separated from financial literacy. Tan et al. ( 2011 ) state that the process of personal financial planning requires individuals to acquire not only cognitive ability but also financial literacy. According to Ali et al. ( 2014 ), financial literacy should be given serious attention from individuals because it is able to affect their welfare. Indeed, financial literacy has been proven to have a positive impact on financial planning. Specifically, individuals who lack financial literacy will often end up in debt (Lusardi and Tufano 2009 ) and will most likely increase their financial burden (Gathergood 2012 ). By having sufficient relevant information, individuals can analyse their financial situation and make decisions wisely.

Gaps and necessity to theorise financial planning behaviour

As mentioned, extant understanding of financial planning is mainly derived from borrowed theories. While this practice remains acceptable, it is important that new theories are developed to enrich understanding of financial planning, particularly from a behavioural perspective, as the issue of good or poor financial planning is dependent on the individual and his or her financial planning behaviour. With the maturity of the literature on financial planning, the time is now opportune to engage in new theory development (Kumar et al. 2022 ).

The need for theory development is further accentuated as there is a notable lack of theory development in explaining financial planning behaviour. Noteworthily, existing frameworks and models remain piecemeal and do not fully cover the whole spectrum of financial planning. After an appraisal of theories related to financial planning (“ Evolution of theories ” Section), the theory of planned behaviour (TPB) has been found to be the most suitable theory on parsimonious grounds (i.e. the capability and capacity of the theory’s core components to act as an organising frame) and its track record of theory spinoffs (e.g. the theory of behavioural control; Lim and Weissmann 2023 ) to explain an individual’s financial planning behaviour. Therefore, an integration of the respective antecedents, decisions, and outcomes (ADO) to form a new, holistic theory is required to document the complexity and the extent of considerations required to explain financial planning behaviour. Such an integration can and will be pursued via a systematic literature review (Lim et al. 2022a , b ).

Goals and contributions of this study

The goal of this study is to establish a formal theory to explain financial planning behaviour. To do so, a systematic literature review is conducted, wherein the SPAR-4-SLR protocol is adopted to guide the review process, whereas the antecedents, decisions, and outcomes (ADO) framework (Paul and Benito 2018 ) and the theories, contexts, and methods (TCM) framework (Paul et al. 2017 ) are adopted and integrated to analyse the findings of the review—a best practice demonstrated and recommended by Lim et al. ( 2021 ). In doing so, this study makes two noteworthy contributions.

From a theoretical perspective, the integrated framework contributes to integrate fragmented knowledge and reduce the production of isolated knowledge on financial planning behaviour. In addition, the framework clarifies the state of existing insights and empowers the discovery of new insights on financial planning behaviour. Certainly, insights gathered from a well-structured framework can provide a better start to add to existing knowledge and increase growth in the field (Kumar et al. 2019 ; Lim et al. 2022a , b ). More importantly, the nomological structure of the framework also enables the study to establish a new theory called the theory of financial planning behaviour , which can act as a multi-dimensional behavioural guideline that involves planning, developing, and assessing the operation of cash flow, tax efficiency, investment planning, risk management, estate planning, and retirement planning within an individual.

From a practical standpoint, the insights from the study are expected to contribute to future financial service professionals gaining advantages in the understanding of financial planning behaviour in catering to the future needs of the public. Additionally, policymakers would benefit from utilising the information to effectively provide financial education programs to enhance individuals’ financial well-being. Further implications for this study focusing on consumers and managers are also discussed towards the end of this study.

Theoretical background

Evolution of theories.

Over the past decades, several theories have been used by researchers on financial planning and the determining factors that influence it. The evolution of theories relating to financial planning is based on the concept of behavioural finance. These theories remain important in financial planning research (Asebedo 2022 ; Overton 2008 ). The most well-known theory related to behavioural finance is the TPB (Ajzen 1991 ). It has been widely used on different research topics to predict and explain individuals’ behaviour or the insufficient control of their behaviour (Ajzen 1985 , 1991 , 2002 ). Noteworthily, the TPB is an extension of the theory of reasoned action, which suggested that human behaviour is determined by the intention to perform a certain behaviour, whereby the intention can be determined by attitudes and subjective norms (Fishbein and Ajzen 1975 ).

In addition, Maslow’s ( 1943 ) hierarchy of needs has been used by Chieffe and Rakes ( 1999 ) to identify and rate the different segments of financial services best suited to each level of income group. The hierarchical approach of this theory provides a framework that explains different financial planning services related to each income group. According to Xiao and Noring ( 1994 ) and Xiao and Anderson ( 1997 ), the notion of Maslow’s hierarchy of needs clearly explains an individual’s financial needs in the form of a hierarchy. The framework of a hierarchical form of financial planning indicates that individuals would only strive for a high level of financial needs after a lower level of financial needs is met. It is recommended for individuals to fulfil their needs step by step to avoid facing financial difficulties.

Another theory that has been applied to financial planning is the life-cycle hypothesis (Modigliani and Brumberg 1954 ), which is an economic theory that explains an individual’s saving and spending behaviour throughout their lifetime. The theory also points out that individuals want to have smooth consumption by saving more if their income increases and borrowing more when their income ceases. Shefrin and Thaler ( 1988 ) state that individuals mentally place their assets into three different accounts, which are current income, current assets, and future income. According to Modigliani and Brumberg ( 1954 ), this theory assumes that individuals will fully utilise their utility for future consumption and aim to accumulate savings and resources for future consumption after retiring. The model explains that individuals’ consumption and saving decisions are formed from a life-cycle perspective. Such individuals will begin with low income when they start working, and their income will slowly increase until it reaches a peak level. Taking a behavioural enrichment (or behaviourally realistic) perspective of the life-cycle theory, Shefrin and Thaler ( 1988 ) state that the behavioural life-cycle hypothesis includes mental accounting, self-control, and framing, which represent three important behavioural features that are usually missing in the economic perspective of the traditional life-cycle theory. The authors mention that individuals use mental accounting to control their propensity to spend on their assets. The willingness to spend is usually related to their current income. According to Warneryd ( 1999 ), individuals usually have a specific method to mentally allocate their expenditures into different accounts. In addition, the marginal propensity to save and consume will be different in each account. According to Shefrin and Thaler ( 1988 ), individuals may face difficulties in controlling their spending, and thus, these individuals may form personal behavioural incentives and constraints. For example, individuals would possess the intention to save and create assets when constraints are available. They also explain that individuals’ preferences are not fixed but vary depending on the constantly changing economic environment and social stimuli (Duesenberry and Turvey 1950 ; Katona 1975 ). Furthermore, the life-cycle theory faces some challenges while explaining individuals’ behaviour, such as assuming that individuals will act rationally, be consistent, and make wise intertemporal choices throughout their lifetime (Deaton 2005 ). The life-cycle theory explains that individuals’ saving decisions are based on their preferences for either present or future consumption. The theory also assumes that individuals determine a desirable age of retirement and level of consumption to fully utilise their utility throughout their lifetime.

Prospect theory is an economic theory that assumes individuals treat losses and gains differently, showing how an individual decides among several choices that involve uncertainties (Kahneman and Tversky 1979 ). This theory explains that their decisions are easily affected by psychological factors and that they are logical decision-makers. However, when individuals decide on whether to purchase or not, they are most likely affected by their cognitive biases. The theory also postulates that making losses will cause a larger emotional impact on individuals rather than a comparable amount of gain. Thus, individuals will prefer choosing the option with perceived gains. For example, individuals would prefer the option of a sure gain instead of a riskier option with a chance of receiving nothing or making a loss. Hence, the theory summarises that individuals are mostly loss averse when they face several choices. Individuals are more sensitive towards losses and would most likely prefer avoiding losses and prefer sure wins. This can be explained by the fact that the emotional impact of losses on an individual is greater than an equivalent gain.

The financial capability model is another prominent theory. Financial capability, which has been gaining prominence across the globe, is defined as the capability and skills of individuals to make rational and effective judgements on managing their financial resources (Noctor et al. 1992 ). Nowadays, individuals have been urged to ensure that they acquire sufficient resources for their retirement and provide a financial safeguard for any sudden occurrence. According to Atkinson et al. ( 2007 ), the financial capability model has been studied and is related to individuals’ financial behaviour, attitude, and knowledge. The researchers identified five different components under the financial capability model: (1) making ends meet (managing personal financial resources, i.e. individuals who have acquired financial knowledge skill sets can finance their resources well and meet financial goals); (2) keeping track (managing money, i.e. planning and recording personal daily expenses to avoid overspending); (3) planning ahead (this helps individuals to be future oriented, i.e. always planning and managing their financial resources to be prepared for any financial uncertainties in the future); (4) choosing products (accumulating resources and managing different assets’ risks, i.e. making a rational decision in choosing financial products and diversifying risks); and (5) staying informed (being updated and studying financial matters in the current market and economy, i.e. individuals have to be eager to keep track on financial matters happening in the market, such as changes in the overnight policy rate (OPR) and stock market movement).

After a review of all the theories (Table 1 ), the TPB has been found to be the most suitable theory to serve as a foundational lens for a review on financial planning behaviour with the aim of establishing a new theory in this field. Unlike the other theories (e.g. Maslow’s hierarchy of needs, life-cycle hypothesis including behavioural life-cycle hypothesis, financial capability model, prospect theory), the TPB is an adaptable yet parsimonious theory that has a track record of spinning off new theories (e.g. the theory of behavioural control; Lim and Weissmann 2023 ). Noteworthily, the TPB can be applied to financial behaviours (Bansal and Taylor 2002 ; East 1993 ; Xiao and Wu 2006 ), wherein the three antecedents of the TPB (attitude, subjective norms, and perceived behavioural control) are found to be associated with intention and contribute to financial behaviour (Shim et al. 2007 ; Xiao et al. 2007 ). Unlike other theories, the mediating effect of financial literacy, which provides an important lens to understand good and poor financial planning, can be applied to the TPB to explain an individual’s intention on financial behaviour. More importantly, it is necessary to understand how the TPB can further explain individuals’ behaviour before examining financial literacy through a behavioural approach. The theory assumes that intention is the best factor to predict an individual’s behaviour, which, in turn, is examined by attitude and social normative perceptions towards an individual’s behaviour (Montano and Kasprzyk 2015 ). Furthermore, individuals’ experiences normally affect their financial decision-making and the way they manage their personal finances. Therefore, financial literacy can be explained as an individual’s confidence and capability to make full use of their financial knowledge (Huston 2010 ) and manage financial matters (Lusardi and Mitchell 2014 ), which they would have perceived control over. In this regard, the theory can be applied to examine how the financial literacy process works on each individual. Moreover, Lusardi and Mitchell ( 2014 ) explain that the favour of financial literacy is more than that of financial capability, where individuals are responsible for their own financial decisions. Hence, financial literacy acknowledges the perceived control of individuals on their financial decisions. That being said, an individual will only show positive financial behaviour when they perceive the value of their behaviour based on their attitude. Therefore, financial behaviour will not be decided based on their financial knowledge but based on their attitude, which is the main component of this theory. In other words, the evaluation of financial knowledge will be better captured through the components of the TPB (e.g. perceived behavioural control), though conceptual contextualisation is necessary to better resonate with the financial planning behaviour of individuals. To aid this task, the next section provides a deeper discussion to understand the fundamental tenets of the TPB.

Theorisation of the theory of planned behaviour

According to Xiao ( 2008 ), the TPB is one of the best and most suitable theories related to financial behaviour that studies and predicts human behaviour. In essence, the TPB is an extension of the theory of reasoned action, which initially posits that attitude and subjective norms shape the intention to perform a behaviour, which, in turn, predicts the actual performance of that behaviour (Ajzen 1991 ). However, behavioural intention does not always translate into behavioural performance (Lim and Weissmann 2023 ), which is the main reason why the TPB was proposed to overcome the limitation of the theory of reasoned action, with the inclusion of perceived behavioural control in the TPB as a mechanism to recognise the volitional control that individuals possess in translating or not translating behavioural intention into behavioural performance (Ajzen 1991 , 2002 ).

Perceived behavioural control can be expressed as follows: Given an individual’s available resources and choices, how easy or hard it is to display a certain behaviour or act in a certain way? In this regard, the performance of an individual’s behaviour depends on his or her ability to act on said behaviour (Ajzen 1991 ). The TPB posits that the perceived control on certain behaviour will be greater when the individual has greater resources (social media, money, time) and choices (Lim and Weissmann 2023 ). Indeed, several researchers have found that perceived behavioural control has a positive relationship with intention and behaviour (Fu et al. 2006 ; Lee-Patridge and Ho 2003 ; Mathieson 1991 ; Shih and Fang 2004 ; Teo and Pok 2003 ).

Subjective norms can also be used to predict individual behavioural intention. As one of the original components of the theory of reasoned action, subjective norms refer to social influence and the social environment affecting an individual’s behavioural intention (Fishbein and Ajzen 1975 ). It is defined as an individual’s perception of the possibility that social agents approve or disapprove a behaviour (Ajzen 1991 ; Fishbein and Ajzen 1975 ). It focuses on everything around individuals, such as social networks, cultural norms, and group beliefs. This is known as a direct determinant of behavioural intention in the theory of reasoned action and the TPB. Through the lens of subjective norms, an individual is said to be willing to perform a certain behaviour even though he or she does not favour performing such behaviour while being under social pressure and social influence (Venkatesh and Davis 2000 ). Kuo and Dai ( 2012 ) state that as subjective norms become more positive, an individual’s behavioural intention to perform or act on a certain behaviour becomes more positive. Several studies have shown a significant relationship between subjective norms and intention (Chan and Lu 2004 ; May 2005 ; Teo and Pok 2003 ; Venkatesh and Davis 2000 ). Sharif and Naghavi’s ( 2020 ) research on family financial socialisation also finds that the behaviour of acquiring relevant norms and information on financial socialisation is associated with subjective norms. The informational subjective norms are known to predict perceived information. Ameliawati and Setiyani ( 2018 ) mention that subjective norms in the TPB represent financial socialisation. Their study describes subjective norms as financial socialisation to research the influence of financial management behaviour. In addition, the research of Jamal et al. ( 2015 ) on the effects of social influence and financial literacy on students’ saving behaviour used the TPB to develop the model. The author uses subjective norms to represent the social pressures influencing students’ intentions to save. It analyses the influences of parents and peers on the impact on the students’ saving behaviour. Hence, subjective norms have a significant effect on the intentions of individuals towards financial planning behaviour.

Attitude has been identified as a construct that guides an individual’s intention, which results in them acting on a particular behaviour. In essence, attitude can be defined as the evaluation of the positive and negative effects on individuals performing an act or behaviour (Fishbein and Ajzen 1975 ), and by extension, reflects the individual’s belief in certain behaviours or acts that contribute positively or negatively to a person’s life (Ajzen and Fishbein 2000 ). There are two components of attitude: the attitude towards a physical object (money, savings, pension) and the attitude towards behaviour or performing a certain act (using savings or money to practice financial planning). Keynes ( 2016 ) and Katona ( 1975 ) state that most individuals possess positive attitudes towards personal saving. Many studies have determined a significant relationship between attitudes and intention (Lu et al. 2003 ; Ramayah et al. 2020 ; Wu and Chen 2005 ). Therefore, attitude can be one of the most important factors to determine and predict human behaviour (Ajzen 1987 ). According to Xiao ( 2008 ), the more favourable the attitude of an individual on performing a behaviour, the easier it is for the individual to perform the behaviour and the stronger the behavioural intention. Further understanding of an individual’s attitude can help to predict their intention and behaviour.

Intention can be defined as an individual’s perception of performing a particular act or behaviour (Fishbein and Ajzen 1975 ). In this regard, intention is said to produce a direct effect on an individual’s behaviour as it signals the willingness of an individual to act (Ajzen 1991 ). The TPB explains that the degree of intentions that are converted into behaviour is determined by the amount of volitional control. Behaviour such as saving money is not considered as full volitional control given the lack of resources and opportunities able to affect the capability to perform the behaviour. While individuals can control their behaviour, their actual behaviour can easily be predicted by their intention accurately, but this does not prove that the measure of correlation is perfect between intention and behaviour (Fishbein and Ajzen 1975 ). Moreover, strong bias always exists in individuals, where they will overestimate the possibility of acting on desired behaviour and underestimate the possibility of acting on undesired behaviour. This can cause inconsistencies between intention and behaviour (performing an actual action) (Ajzen et al. 2004 ). Behaviour and intention will show high correlation whenever the interval time between them is low (Fishbein and Ajzen 1981 ). Yet, intention is known to change over time, and thus, if the interval between intention and behaviour is greater, the possibility of change in intention is higher (Ajzen 1985 ).

Behaviour refers to an observable response to a specific target (Fishbein and Ajzen 1975 ). In essence, the performance of a given behaviour is a direct outcome of the intention to perform that behaviour as well as an indirect result of attitude, subjective norms, and perceived behavioural control (Ajzen 1991 ), as discussed above.

The TPB has been widely used in different fields of research over the past decades: medicine (Hagger and Chatzisarantis 2009 ; McEachan et al. 2011 ), marketing and advertising (King et al. 2008 ; Yaghoubi and Bahmani 2010 ), tourism and hospitality (Han 2015 ; Quintal et al. 2010 ), information science (Lee 2009 ; Shih and Fang 2004 ), and, last but not least, human behaviour (Kobbeltvedt and Wolff 2009 ; Perugini and Bagozzi 2001 ). All the studies listed above have concluded on the positive and significant effect of attitude, subjective norms, and perceived behavioural control on an individual’s intention to act on behaviour. In the financial context, Shih and Fang ( 2004 ) apply the TPB to an individual’s financial decisions regarding internet banking. The study concludes that the TPB can be successfully applied to understand an individual’s intention to use internet banking. Lau et al. ( 2001 ) and Lee ( 2009 ) also apply the TPB to study investors’ intentions on online banking and trading online. To provide a more accurate account for financial planning behaviour, a systematic literature review is conducted and reported in the next sections.

Methodology

Study approach: systematic literature review.

This study conducts a systematic literature review to develop comprehensive insights into financial planning behaviour based on the TPB. As mentioned above, the TPB is the extension of the theory of reasoned action, and it strongly posits that an individual’s behaviour is determined by the three factors (attitude, subjective norms, and perceived behavioural control) and is backed by their behavioural intention (Ajzen 1991 ).

A systematic literature review is known as a ‘research synthesis’, an extensive process of summarising primary research based on an explicit research question, where it attempts to identify, select, synthesise, and assess all the evidence by providing answers to the research question (Donthu et al. 2021 ; Lim et al. 2022a , b ). In this regard, systematic literature reviews not only summarise and synthesise existing knowledge but also facilitate knowledge creation (Kraus et al. 2022 ; Mukherjee et al. 2022 ). Moreover, systematic literature reviews gathered eligible and pertinent evidence based on a preset criterion to answer a specific research question, and thus, a transparent and explicit systematic methodology can be used for systematic literature reviews to analyse and reduce biases (Harris et al. 2014 ; Paul et al. 2021 ).

Systematic literature reviews can be conducted through various methods. Generally, systematic literature reviews can be domain-based, theory-based, and method-based (Palmatier et al. 2017 ; Paul et al. 2021 ). In this study, a theory-based review was used for new theory development. Specifically, the theory-based review is chosen over the other approaches because it serves the purpose of analysing a specific role played by a theory in a given field. One of the examples given by Hassan et al. ( 2015 ) is the role of the TPB in the field of consumer behaviour. In this study, the TPB was applied to financial planning behaviour.

Study procedure: SPAR-4-SLR

Few protocols exist for systematic literature reviews. The most common protocol used by researchers in conducting systematic literature reviews is the preferred reporting items for systematic reviews and meta-analysis (PRISMA) by Moher et al. ( 2009 ). PRISMA is a comprehensive protocol that helps researchers to develop systematic literature reviews. It gathers and reports decisions that researchers have justified from their reviews. However, an uprising protocol was proposed by Paul et al. ( 2021 ) to address the existing limitations of PRISMA, namely the Scientific Procedures and Rationales for Systematic Literature Reviews protocol or the SPAR-4-SLR protocol. As shown in Fig.  1 , the protocol consists of three stages and six sub-stages, followed by sequences.

Assembling This stage constitutes the (1a) identification and (1b) acquisition of literature that is yet to be synthesised.

Arranging This stage entails the (2a) organisation and (2b) purification of literature in the stage of being synthesised.

Assessing This stage reflects the (3a) evaluation and (3b) reporting of literature that has been synthesised.

Review process

Systematic reviews assembling, arranging, and assessing the literature according to the SPAR-4-SLR protocol are expected to: (1) provide significant insights and (2) stimulate nuanced agendas for knowledge advancement in the review domain. Substantially, by providing such significant insights and agendas using the SPAR-4-SLR protocol, (1) the review is comprehensively justified for logical and pragmatic reasons, and (2) each stage and sub-stage is reported with full transparency.

The researchers begin with assembling in the (1a) identification stage, identifying the research domain and research question. The research domain of this study is behavioural finance with a specific focus on financial planning. The research question of this study is ‘How can the TPB be contextualised to develop a theory of financial planning behaviour?’ Thus, academic articles selected should focus on financial planning (i.e. the focus of this review) and the TPB (i.e. the theory contextualised for this review). The source quality was established based on Scopus or Web of Science indexing in line with Paul et al. ( 2021 ). Moving on to the (1b) acquisition stage, the search mechanism will rely on Google Scholar, which is free and can be easily accessed for article search. Footnote 3 The search period will begin from 2000 to 2020 (20 years) as most articles on the TPB and financial planning behaviour started to appear in the early 2000s. Related articles searched between these years are included in this study. The search was conducted multiple times with different keywords based on American and British spelling as well as different combinations: (1) ‘financial planning’ + ‘theory of planned behavior’, (2) ‘financial planning’ + ‘theory of planned behaviour’, (3) ‘personal financial planning’ + ‘theory of planned behavior’, and (4) ‘personal financial planning’ + ‘theory of planned behaviour’. Footnote 4

Next, the researchers move onto arranging in the (2a) organisation stage, wherein the organising code for this study is ADO and TCM, which rely on the suggested frameworks used, the ADO framework (Paul and Benito 2018 ; Pansari and Kumar 2017 ) and the TCM framework (Paul et al. 2017 ). Refer to Fig.  2 for the overview of ADO on the insights of the TPB on financial planning behaviour and its supporting TCM. In the (2b) purification stage, the articles gathered are filtered in this process. The researchers decided which articles to include and exclude from the study. The criteria to exclude articles in this stage include duplicate articles, irrelevant articles, inaccessible articles, and lastly, non-journal-title articles; 41 articles were excluded based on the criteria, and 30 articles proceeded to the next stage.

The state of the art of the antecedents, decisions, and outcomes of financial planning behaviour and its supporting theories, contexts, and methods

Finally, the researchers move into assessing in the (3a) evaluation stage, which involves the analysis and the agenda proposal. The study utilised content analysis, a methodical approach for coding and interpreting textual data from the selected articles to draw meaningful conclusions (Kraus et al. 2022 ). This systematic technique, which was executed by one author (a doctoral scholar) and cross-validated by another author (a senior academic) with an intercoder reliability of ± 95% and differences clarified and resolved, enabled the researchers to identify, categorise, and analyse patterns within the text, contributing to a comprehensive understanding of the subject matter (Patil et al. 2022 ). The theory development and future research agenda were formulated through conceptual extrapolation and sensemaking (i.e. scanning, sensing, and substantiating) (Lim and Kumar 2023 ). This process entailed critically examining the existing theories, extracting key concepts, and extrapolating these to propose new research directions. Thus, this study provided a roadmap for future studies, fostering further evolution in the field of financial planning behaviour. In the (3b) reporting stage, the reporting conventions used include figures, tables, and words. No ethical approval is required since the review is based on accessible secondary data (journal articles), which can be accessed by anyone with subscription (Lim et al. 2022a , b ).

Profile of TPB and financial planning behaviour research

The systematic review of 30 articles covered different insights into the existing research of the TPB and financial planning behaviour, covering the six components of financial planning (i.e. cash flow planning, tax planning, risk management, investment planning, estate planning, and retirement planning) (Fig.  2 ). Appendix 1 summarises the articles in Appendix 2 based on the approaches of Paul and Mas ( 2019 ) and Harmeling et al. ( 2016 ). The articles are classified based on author citations, years, number of citations, methods, sample, related financial planning components and variables, and lastly findings. The findings of each article briefly explained how the construct of the TPB is a predictor or shows a significant effect on financial planning behaviour.

Based on this review, which begins from 2000 to 2020, the past two decades of research in the field of behavioural economics (later known as behavioural finance) have been on continuously identifying and explaining an individual's finances from an extended social science perspective, which includes psychology and sociology. Behavioural finance can be defined as the field of study where psychological factors affect an individual's financial behaviour (Shiller 2003 ). The combination of the TPB and financial planning has proven to be impactful with over 3000 citations among the 30 articles. The articles utilised four different methods: the quantitative approach ( n  = 24), the qualitative approach ( n  = 3), the mixed method approach ( n  = 1), and the conceptual approach ( n  = 2).

Lastly, the TPB (i.e. attitude, subjective norms, perceived behavioural control, and behavioural intention) has been found to be a good predictor of financial planning behaviour (i.e. cash flow planning, tax planning, risk management, investment planning, estate planning, and retirement planning) and possesses positive relationships with each component of financial planning. For example, the TPB was found to be positively related to the intention to invest, mental budgeting behavioural intention, influencing savings and investment, and the intention to prevent risky credit behaviour, among others.

Contextualising the TPB for financial planning behaviour

Table 2 and Fig.  3 show the contextualisation of the TPB for financial planning behaviour, leading to the establishment of the theory of financial planning behaviour. Pansari and Kumar ( 2017 ) suggest the use of such a table to compare and explain each construct of the framework. The table, which leverages the findings from the review depicted in Fig.  2 , clearly illustrates how the TPB can be contextualised to explain financial planning behaviour. Attitude can manifest as financial satisfaction, wherein individuals who are dissatisfied, not fully satisfied, or wish to be more satisfied with their financial state will develop a positive disposition towards financial planning. Subjective norms can manifest as financial socialisation, wherein individuals learn about societal expectations of financial planning when they socialise with others (e.g. family, friends, work colleagues). Perceived behavioural control can manifest as financial literacy, mental accounting, and financial cognition, wherein the effect of financial satisfaction and financial socialisation is mediated through financial literacy, which may be shaped by the capability to perform mental accounting and the capacity for financial cognition. These factors can collectively shape the individual's intention to engage in financial planning, which, in turn, motivates the actual behaviour of engaging in financial planning, which can take six forms, namely cash flow planning, tax planning, investment planning, risk management, estate planning, and retirement planning.

Visual representation of contextualising the TPB into the theory of financial planning behaviour

Reflections and ways forward

Behavioural decision-making has been one of the most significant research interests for economists over the past decades. Past researchers (Xiao and Wu 2006 ; East 1993 ; Bansal and Taylor 2002 ) have applied the TPB to financial behaviour. The three antecedents of the TPB (attitude, subjective norms, and perceived behavioural control) were found to be associated with the intention of an individual and contribute to financial behaviour (Shim et al. 2007 ; Xiao et al. 2007 ). Unlike other theories, the mediating effect of financial literacy can be applied to the TPB to explain financial behaviour intentions. The variables of mental accounting and financial cognition were not frequently used by the researchers in the study of financial planning, while in this study, both variables are positioned as relevant components of perceived behavioural control in the TPB.

The concept of mental accounting has been extensively studied in the research area of psychology on financial decisions (Mahapatra and Mishra 2020 ). However, past studies on mental accounting in financial planning are insufficient. The formation and influences of mental accounting as a cognitive process—which consists of the concepts of current income, current assets, and future income as well as mental budgeting—play an important role in the personal financial planning process to each individual. It serves as a guideline in the process of financial planning and provides useful insights. Budgeting plays a key role in managing the financial life of an individual in terms of short-term (e.g. prioritising spending in different categories) and long-term (e.g. setting aside money for investment and future use) financial planning.

Previous research has applied mental accounting with the theory of the behavioural life-cycle model. Shefrin and Thaler ( 1988 ) mentioned that people mentally divide their incomes into current income, current assets, and future income, where the marginal propensity to consume (MPC) for each account is relatively different. Mental accounting is helpful and crucial for individuals to plan for their future financial needs so that they can deal with any unexpected financial difficulties in the future. However, there are still gaps to fill to come out with optimal financial decisions. Therefore, given the need of individuals for personal financial planning, it is necessary to apply mental accounting to each individual by determining their spending and saving tendencies.

Moreover, the 2008 global financial crisis and the COVID-19 pandemic have also taught the world painful lessons; the need for financial literacy and cash flow control has been highlighted and considered by the public. A study conducted by Shahrabani ( 2012 ) on the effect of financial literacy and intention to control personal budget concludes that individuals with high levels of financial knowledge and literacy can influence the intention to have budgetary control. The study shows a positive relationship between the intention to budget and financial knowledge. Selvadurai and Siraj ( 2018 ) study financial literacy education and retirement planning in Malaysia. The authors mention that mental accounting is closely related to financial literacy education. Financial literacy can enhance mental accounting as it affects the behaviour of an individual in planning their savings and expenditure. In particular, individuals who acquire financial literacy education are most likely able to control their expenditure by not spending more than their income, which results in having sufficient savings in the long run. The relationship between mental accounting and financial literacy has been proven to be indispensable.

Cognitive ability also plays an important role in financial literacy as it entails understanding financial knowledge and the ability to perform with available resources. While the relationship between financial cognition and financial literacy is strong, individuals can use their cognitive abilities to solve financial problems. Yet, the cognitive biases exist and influence financial decision-making. Agarwal and Muzumder ( 2013 ) state that individuals with no cognitive ability are most likely to face difficulties while making financial decisions. Also, individuals must at least acquire good memory skills, conceptual ability, and financial sophistication to be involved in financial activities. According to Fu et al. ( 2010 ), understanding the attitude of an individual enables one to predict their intentions and behaviour. This could also influence the formation of their attitude. Lusardi and Mitchell ( 2014 ) mention that cognitive abilities are a significant component of financial literacy to determine desirable financial decision-making. In the case of financial literacy, a link between cognitive abilities and the adaptability of financial decision-making has been studied extensively in the field of personal finance. An individual must acquire cognitive skills to make a sound financial decision in an effortless way, which consists of the ability to recall and utilise financial knowledge (memory) and to implement various numerical operations (numeracy) (Chirstelis et al. 2010 ; McArdle et al. 2009 ). Three variables were discussed under the model of financial cognition: financial attitude, risk attitude, and financial knowledge.

Based on the information mentioned above, the mediating effect of financial literacy on mental accounting and financial cognition is indispensable. Policymakers and researchers should work on improving financial literacy and forming positive financial behaviours. Several studies have proven that financial literacy has slowly become a significant component of rational financial decision-making and that it also provides implications for financial behaviour. Individuals or families with higher levels of financial literacy will have an advantage compared to others and higher wealth accumulation as they have the knowledge and skills to participate in financial activities (Schmeiser and Seligman 2013 ). Past studies have proven that financial literacy plays a remarkable role in determining financial outcomes in terms of the components of financial planning (Hilgert et al. 2003 ). Hence, the need for financial literacy in financial planning is indispensable, and it should be considered by individuals as it affects their welfare.

However, no one has attempted to contextualise the TPB and financial planning with the variable of mental accounting and financial cognition with the mediating effect of financial literacy to understand and determine financial behaviour. Thus, this new theory clarifies the conceptualisation and operationalisation of the theory of financial planning behaviour between the variables of mental accounting and financial cognition, and, most importantly, the mediating effect of financial literacy. However, the new theory, in its present and encompassing form, has yet to be tested empirically, and therefore, this warrants future research across different financial products across countries and populations to establish its generalisability.

Discussion and conclusion

This study developed a new theory called the theory of financial planning behaviour using the TPB of Ajzen to understand the financial behaviour of individuals in managing their personal finances. This study examines how the TPB can be contextualised into a theory that more relevantly explains financial planning behaviour. The theoretical background section of this study presents a comprehensive review of the evolution of theories as well as theorisation for the TPB. With a systematic review of the literature, it can be concluded that the constructs of the TPB can be contextualised to better explain financial planning behaviour—that is, the review results showed how different concepts and factors affect the financial planning of an individual by substituting the original components of the TPB with financial variables. Moving on, this study concludes with an articulation of its implications for academics, consumers, and managers.

Implications for academics

The main theoretical contribution of this study is the establishment of the theory of financial planning behaviour. Noteworthily, this new theory represents a noteworthy attempt to demonstrate how a grand theory such as the TPB can be contextualised and thus transformed into a new theory that resonates with realities in the field, in this case, financial planning. The systematic literature review methodology has also proven itself as a useful approach to source for scholarly evidence to offer preliminary support for the new theory.

Another noteworthy contribution is the extrapolation of perceived behavioural control, which answers the call by Lim and Weissmann ( 2023 ) to identify or source for new forms of behavioural control, going beyond the traditional psychological conceptualisation of self-efficacy. Through this study, three types of perceived behavioural control were revealed: financial literacy, mental accounting, and financial cognition. Moreover, the interdependent relationships between these three forms of perceived behavioural control were also identified and theorised, wherein the capability of mental accounting and the capacity for financial cognition shape the financial literacy of the individual, which, in turn, mediates the effects of financial satisfaction (attitude) and financial socialisation (subjective norms) on that individual’s intention and actual behaviour to engage in financial planning.

For researchers seeking to apply the theory of financial planning behaviour in a study, they might operationalise the variables in the following way. Financial satisfaction, financial socialisation, and financial literacy could be assessed using the scales validated by Madinga et al. ( 2022 ). Financial cognition and mental accounting, being somewhat newer constructs in the literature, might require the development of new scales, which could be validated through exploratory and confirmatory factor analysis. For data analysis, researchers might employ a structural equation modelling (SEM) approach to test the relationships between these constructs, as SEM allows for the simultaneous examination of multiple relationships among observed and latent variables. This technique also enables researchers to test the mediating role of financial literacy in the relationship between financial satisfaction, financial socialisation, and financial planning behaviour, thereby assessing the robustness of the proposed theory. If researchers are interested in examining the moderating effects of certain variables (e.g. age, education, or household income), they could use moderation analysis to determine whether the strength or direction of these relationships varies under different conditions.

To this end, the theory of financial planning behaviour should serve as a useful foundational theory to understand a myriad of individual financial planning behaviour such as cash flow planning, tax planning, investment planning, risk management, estate planning, and retirement planning. In this regard, future research is encouraged to explore for new mechanisms that can positively influence or strengthen the variables espoused by the new theory, such as financial satisfaction (e.g. mechanisms that can prompt individuals to evaluate their financial satisfaction—e.g. advertising), financial socialisation (e.g. platforms to encourage individuals to socialise within a financial setting—e.g. metaverse and social media groups), and financial literacy (e.g. ways to enhance mental accounting capability and financial cognition capacity). Nonetheless, this study does not discount the possibility of discovering additional attitudinal, normative, and control variables, which could lead to possible extensions to the theory of financial planning behaviour, as in the case witnessed by TPB. Thus, the new theory herein is intended to inspire new ideas, not to limit them.

Implications for consumers

This study reaffirms the importance of financial planning to safeguard financial resilience in individuals' daily lives. Adopting financial planning entails endless benefits for consumers who do so. Noteworthily, it is important to determine short-term and long-term financial goals and to achieve them via financial planning. Having these goals in mind can provide a sense of direction and purpose in life.

This study is important for all consumers who wish to make ideal financial decisions. Consumers may adopt better cash flow management by implementing financial planning to have a stable financial flow. A cash flow plan can provide an estimation of future income and expenses to achieve financial efficiency and create an emergency fund. Hence, implementing financial planning may help to relieve financial stress and plan for future needs.

Also, consumers can not only gain monetary benefits but also improve their financial literacy. The world has slowly become more financialised, where financial products have developed rapidly and become more complex (Kumar et al. 2023 ; Goodell et al. 2021 ), which requires consumers to be financially literate before making ideal financial decisions (She et al. 2023 ; Bannier and Schwarz 2018 ). Thus, financial institution managers and policymakers are working on improving the financial literacy of consumers and forming positive financial behaviour.

Indeed, financial literacy is a significant component of rational financial decision-making, and it also provides implications towards financial behaviour. Individuals or families with higher levels of financial literacy will have an advantage compared to others as well as higher wealth accumulation as they have the knowledge and skills to participate in financial activities.

Crucial to developing financial literacy is the capability to do mental accounting and the capacity for financial cognition. That is to say, consumers must seek financial education, be it formally or informally, so that they are able to identify and evaluate the different options for financial planning. Similarly, consumers should allocate adequate resources (effort, time) to think about financial planning, which is not a low but rather high involvement process.

Implications for managers

Promoting financial planning has always been a major challenge for financial managers. The newly established theory of financial planning behaviour emerging from the grand TPB can be put into practice by authorities. The findings of this study can be used by financial managers to understand the financial planning behaviour of consumers.

Based on the results and implications of past studies, introducing financial planning behaviour can benefit banks as well as investment and insurance companies that aim to promote consumer financial well-being. It can provide insights into how different factors affect the intention and adoption of financial planning.

Financial literacy needs to be considered as it is an important mediating factor that influences the intentions and behaviour of consumers. For example, whenever a bank introduces financial products to a prospect, that bank must ensure that the prospect is financially literate or else provide sufficient financial knowledge before the prospect develop a financial plan or purchase any financial product from that bank. This is to ensure that their customers possess knowledge of and clarity on the program or product.

In addition, financial institution managers are encouraged to focus on factors (i.e. mental accounting, financial cognition, financial socialisation, financial satisfaction, and financial literacy) that influence customer behaviour towards financial planning before implementing financial programs. For example, understanding the budgeting styles and minimum level of financial satisfaction of customers may help to develop relevant and applicable financial plans for them. Consider a middle-aged client, John, who has recently experienced a job loss. John is feeling uncertain about his financial future and seeks advice from a financial advisor. The financial advisor, following the theory of financial planning behaviour, would first evaluate John's financial literacy level to assess his understanding of financial products and concepts. Then, the advisor would use the theory's constructs such as mental accounting (how John organises his finances and prioritises spending), financial cognition (how John understands his financial situation), and financial satisfaction (how content John is with his current financial state) to develop a comprehensive financial plan. For instance, the financial advisor may realise that John's financial cognition is low, indicating a lack of understanding of the severity of his financial situation. Therefore, to improve his financial cognition, the advisor would emphasise financial education and assist John in developing better mental accounting habits, such as setting up separate 'pots' for his savings, expenses, and investments. This approach is aligned with promoting financial literacy and ensuring the client's knowledge and clarity on his financial plan, which are aspects underscored in our theory.

Implications for policymakers

The findings of this study serve to inform and guide policymaking in significant ways. Policymakers play a crucial role in shaping the financial landscape that influences financial planning behaviour. A key aspect is the importance of financial literacy, which suggests that national education policies should incorporate financial education from early learning stages. Special focus should be given to underprivileged and marginalised communities, who may lack access to financial literacy resources. This might involve legislation mandating financial institutions to fund these education programs as a part of their corporate social responsibility.

This study also illuminates the role of mental accounting and financial cognition in financial planning behaviour. This could inspire policymakers to collaborate with technology developers to create user-friendly digital tools and applications that promote mental accounting practices. Such initiatives should be supported by national policies encouraging technological innovation in the financial sector.

Furthermore, the impact of financial satisfaction on financial planning behaviour underscores the need for regulation in financial advertising. Policymakers should ensure that financial advertising does not create unrealistic expectations that lead to dissatisfaction, and transparency should be mandated, with severe penalties for institutions found to be misleading consumers.

Moreover, the study's findings encourage the creation of financial socialisation platforms. Policies should support the development of both online and offline platforms for learning, sharing, and discussing financial planning strategies and experiences. Policymakers should work with technology companies, local communities, and financial institutions to ensure these platforms are safe, accessible, and inclusive.

Lastly, the responsibility of policymakers extends to the protection of citizens from unfair financial practices. Legislation should ensure transparency in financial markets, particularly regarding fees, interest rates, and risks associated with financial products. Policymakers may also consider mandating financial counselling for complex financial decisions, such as mortgages or large investments, to increase financial satisfaction.

Limitations and future research directions

Notwithstanding the contributions of this study, several limitations exist that may pave the way for future research.

First, financial planning behaviour remains in the infant stage and thus the newly established theory was limited to available evidence. In this regard, this study does not discount the possibility of extending the theory of financial planning behaviour in enriching ways, such as by adding new dimensions of the original TPB components (e.g. additional forms of perceived behavioural control).

Second, the theory of financial planning behaviour has not been empirically examined in its entirety. Thus, future research is encouraged to adopt or adapt this newly established theory in empirical investigations to ascertain its reliability, validity, and generalisability.

Third, the systematic literature review herein was limited to a single theoretical lens (TPB). As indicated through the theoretical foundation discussion, multiple theories exist to explain financial planning behaviour. In this regard, it is important to acknowledge that the development of theories in this area is continuously evolving. As other theories mature, it would be beneficial for future research to consider conducting similar reviews using those theories, to provide a more comprehensive understanding of financial planning behaviour. This could potentially uncover novel insights and lead to the development of new frameworks that could more holistically explain individuals' financial behaviours.

Fourth, the outcomes of financial planning have not been theorised. While the assumption is that good financial planning results in financial resilience, further investigation is needed to empirically verify this assumption. Further exploration of other possible outcomes is also encouraged, both at the micro-level (e.g. life satisfaction, quality of life) and at the macro-level (e.g. country happiness and financial strength).

Fifth, the relationships in the theory of financial planning behaviour are inherently linear. Nonetheless, as experience in financial planning accumulates over time, this study does not discount the possibility of a cyclical loop that reinforces the said relationships. In this regard, future research that extrapolates the theory through a longitudinal perspective is also encouraged.

Sixth, the research landscape of financial behaviour is broad and includes other aspects such as financial counselling and financial therapy. Although these areas were not covered in this study, they may be relevant in the context of the TPB and could contribute to a more comprehensive understanding of financial behaviours. Thus, future research could consider investigating these areas using the TPB, which could also include other related theories, as a guiding theoretical framework. The expansion of search terms in subsequent studies would allow for a more diverse exploration of financial behaviours, potentially enhancing the generalisability and applicability of the findings. Furthermore, it may also reveal a broader range of factors influencing financial planning behaviour and related areas. Hence, researchers are encouraged to extend the current study by exploring the use of TPB alongside related theories in different areas of financial behaviour.

In closing, while this study viewed financial planning within the context of behavioural finance, it is crucial to underscore the fact that financial planning is a distinct profession with its own body of literature. Financial planning transcends the boundary of understanding and predicting individual financial behaviours. It encompasses a broad spectrum of activities, from cash flow management to estate planning, which are geared towards enhancing an individual's economic satisfaction. Each of these areas possesses a unique set of complexities and necessitates a specialised set of knowledge and skills. The profession of financial planning is dedicated to addressing these complexities and enhancing individuals' financial well-being. Our exploration of financial planning behaviour through behavioural finance should be seen as a facet of the broader, multi-dimensional discipline of financial planning. Future research should therefore endeavour to add to the rich and varied literature of financial planning to offer a more holistic and nuanced understanding of financial behaviour.

Based on a search for “personal finance” in the “title, abstract and keywords” and the subject area of “business, management and accounting” in Scopus on 25 December 2022.

Smooth consumption refers to consumption that balances or optimises spending and saving during different life phases to achieve the greatest overall standard of living (Morduch 1995 ).

Instead of Scopus or Web of Science, which are subscription-based, Google Scholar was used as the search mechanism because it is free to use and thus more accessible. Source quality can still be maintained by referring to Scimago Journal Ranks, which relies on Scopus, and Web of Science Master Journal List, albeit manually. With the journal lists acting as a cross-check mechanism and without the need for bibliometric data, Google Scholar is deemed to be adequate for the search and review. This practice is similar to that of existing reviews (e.g. Lim and Weissmann 2023 ; Lim et al. 2021 ).

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Appendix 1: Articles on financial planning behaviour and TPB

• NA not available, TPB theory of planned behaviour.

Appendix 2: List of articles reviewed

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Yeo, K.H.K., Lim, W.M. & Yii, KJ. Financial planning behaviour: a systematic literature review and new theory development. J Financ Serv Mark (2023). https://doi.org/10.1057/s41264-023-00249-1

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Parental knowledge, attitudes, and practices towards childhood fever among South-East and East Asian parents: A literature review

Roles Conceptualization, Formal analysis, Methodology, Writing – original draft, Writing – review & editing

Affiliation Faculty of Medicine, The Nethersole School of Nursing, The Chinese University of Hong Kong, Hong Kong, China

Roles Writing – original draft, Writing – review & editing

Affiliation The School of Nursing, Nanjing University of Chinese Medicine, Nanjing, China

Roles Supervision, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

• Hoi Lam Ng, 
• Huiyuan Li, 
• Xiaohuan Jin, 
• Cho Lee Wong

• Published: September 8, 2023
• https://doi.org/10.1371/journal.pone.0290172
• Reader Comments

The aim of this literature review was to identify, summarize, and critically appraise available empirical articles on the knowledge, attitudes, and practices towards childhood fever management among South-East and East Asian parents.

A literature review following PRISMA.

Articles were limited to those available in the English language. Articles had to be empirical studies that used a qualitative or quantitative research design with full-text available; focus on parental knowledge, attitudes, and practices towards fever; and be published in South-East and East Asia. Searches were conducted with CINAHL, PubMed and Scopus from inception to June 2022, and eleven articles were included after removing duplicates and excluding irrelevant articles.

Narrative synthesis was conducted according to four themes: source of fever information, knowledge level, attitudes, and practices towards childhood fever. Parents showed different fever knowledge needs and various information-seeking behaviors. A low level of fever knowledge was revealed in terms of temperature, fever causes, potential harms and influencing factors. South-East and East Asian parents mainly reported anxiety, concerns and fever phobia. Fever assessment methods and fever management strategies varied based on parents’ cultural background and beliefs.

Conclusions

The findings of this review highlight that inadequacy of fever knowledge and negative attitudes towards childhood fever exist in South-East and East Asian parents. Parents have diverse cultural practices during their children’s febrile episodes. However, some of them conflict with current medical guidelines, as they prioritize fever and body temperature reduction. This raises questions about their effectiveness and safety. Although some of them are medically discouraged, there are others that have been proven beneficial for the symptomatic relief of childhood fever. The results indicate an urgent need to develop a cultural-sensitive educational intervention for childhood fever management among South-East and East Asian parents. Unified educational interventions are needed to address parental concerns and fever-related knowledge needs.

Citation: Ng HL, Li H, Jin X, Wong CL (2023) Parental knowledge, attitudes, and practices towards childhood fever among South-East and East Asian parents: A literature review. PLoS ONE 18(9): e0290172. https://doi.org/10.1371/journal.pone.0290172

Editor: Chai-Eng Tan, Universiti Kebangsaan Malaysia, MALAYSIA

Received: February 1, 2023; Accepted: August 3, 2023; Published: September 8, 2023

Copyright: © 2023 Ng et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: Due to the nature of the review, all relevant data are available within the manuscript, including Tables 1 , 2 and 3 , Fig 1 , and S1 and S2 Files.

Funding: The author(s) received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Fever is a temporary elevation of body temperature above the average daily range of 36.6°C–38°C, as measured by a rectal thermometer [ 1 , 2 ]. It is a common symptom experienced by almost every child at some point. Fever can be an indicator of benign (e.g., the common cold) or severe conditions (e.g., lethal diseases and meningitis) and is usually self-limiting in children [ 2 ]. However, even in mild cases, most parents seek information about fever management and worry about the potentially severe consequences of fever, such as seizures, brain damage, and even death, although these outcomes are rare [ 2 ], leading to heightened anxiety.

Despite being common, a recent systematic review of 36 studies on information needs related to childhood fever found that parents have a low level of knowledge about fever [ 3 ]. Furthermore, a review of scientific literature indicated that parental knowledge regarding the definition and management of fever is deficient [ 4 ]. Parents rarely define fever correctly and tend to have misconceptions regarding fever and engage in practices which differ from recommendations [ 5 – 7 ].

Parental knowledge greatly influences attitudes and fever management in their children [ 8 ]. A lack of knowledge regarding the pathophysiology and management of fever is an essential driver of fever phobia among parents; this can cause parents to become overly concerned about the height of the fever, how quickly the fever rises, the appearance and behavior of their child, and the underlying cause of the fever [ 9 ]. Parents’ inadequate knowledge about fever may also lead to unnecessary and inappropriate treatments, such as being unaware of the correct frequency of administering antipyretics at incorrect doses or intervals, which can increase healthcare-seeking behavior [ 10 , 11 ]. These practices can negatively affect children’s health, such as toxicity from supratherapeutic doses [ 12 ].

Parents’ unscientific and irrational attitudes towards fever can significantly impact the management of childhood fever [ 13 , 14 ]. Although appropriate levels of anxiety in parents are paramount to promoting health-protective behaviors in febrile children, which include close monitoring of symptoms and increasing fluid intake, studies have found that many parents (57%–68%) exhibit moderate to high anxiety levels during their children’s febrile episodes [ 15 – 18 ]. These findings align with the long-lasting phenomenon of fever phobia, which refers to an “unrealistic fear of fever expressed by parents” [ 19 ]. Parents’ fever-related anxiety and concern often lead them to practice non-evidence-based strategies to reduce temperature, which can cause further stress for children and parents [ 14 ] and increase emergency room visits [ 20 ]. A study in Hong Kong showed that caregivers of paediatric patients with fever symptoms were more than twice as likely to consult more than one doctor during an illness episode without a referral [ 21 ]. These actions inflict adverse psychological and financial consequences for families and burden the healthcare system unnecessarily [ 21 ].

Strategies for childhood fever management can vary in different countries. Thompson et al. conducted a first systematic review on childhood fever, and the results showed that treatments ranged from supportive care at home to seeking assessment in the emergency department [ 3 ]. Using antipyretic medications, including acetaminophen and ibuprofen alone, in combination or alternating, was the most common response to a febrile episode, with adjunct fever management practices, such as light clothing and sponge baths, also being adopted. Other literature views indicated that parents’ conceptualizations of fever in children and information-seeking behaviors in fever management differ according to country of origin [ 8 , 22 ]. However, most studies and reviews have focused on Western or global populations [ 3 , 8 , 22 ], ignoring the impacts of cultural factors on parents’ management of fever in different countries, especially cultural beliefs in South-East and East Asian countries. Growing evidence suggests that racial differences and cultural beliefs can influence parents’ attitudes and management approaches to fever in children [ 3 , 18 , 23 ]. One of the examples is alternative medicine, which is greatly influenced by traditional values. It has a different perspective on the pathophysiology and treatments of febrile diseases compared to modern Western medicine. For instance, in Traditional Chinese Medicine, fever is associated with warm-pathogen diseases involving the Taiyin meridian, and consuming Chinese herbal medication and a light diet are recommended to restore body equilibrium [ 24 ]. On the contrary, conventional medicine focuses on managing the accompanying symptoms rather than targeting the fever itself and temperature reduction [ 10 ].

Unfortunately, the use of alternative medicine for fever management remains understudied. In a systematic review of 74 national and international guidelines regarding childhood fever management, only five studies investigated the use of alternative medicine, while most focused on conventional treatments such as antipyretic drugs and water baths [ 10 ]. However, some traditional practices based on cultural beliefs (i.e., South-East and East Asia) may contradict the principle of modern Western medicine and harm children. For instance, some parents in Singapore give spirit water to their febrile children, but the effect is unknown [ 15 ]. This highlights the need for further research on the potential benefits and drawbacks of alternative approaches to fever management.

To date, no scientific synthesis of the literature has been conducted, and the evidence regarding the knowledge, attitudes, and practices of South-East and East Asian parents towards childhood fever remains unclear. Data from Western populations may not represent the Asian region due to cultural differences. Therefore, it is essential to summarize the literature regarding fever management by South-East and East Asian parents regarding their knowledge, attitudes, and practice and improving scientific fever management for children outside the hospital setting.

This literature review aimed to identify and summarize the evidence related to knowledge, attitudes, and practices of South-East and East Asian parents towards fever in healthy children. The results may guide the development of future research and education programs specific to this population Asian parents .

This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines ( S1 File ).

This literature review aimed to identify, summarize, and critically appraise current evidence on (1) South-East and East Asian parents’ knowledge, attitudes, and practices towards fever in healthy children and (2) factors associated with parents’ knowledge, attitudes, and practices towards fever.

Literature search

Three English language databases (CINAHL, PubMed, and Scopus) were searched from inception to June 2022. The search terms include ‘parents’, ‘children’, ‘fever’, ‘knowledge’, ‘attitude’, and ‘practice’ were combined in each database using free-text terms and Medical Subject Headings (MeSH) where available. A sample search strategy in CINAHL is illustrated in the S2 File . A manual search of the references of the included articles was conducted to locate additional relevant articles.

Inclusion criteria

Articles were included if they (1) were empirical studies that used a qualitative or quantitative research design with full-text available; (2) focused on parental knowledge, attitudes and practices towards fever and (3) were published in East Asia (China including Hong Kong, Macau, and Taiwan, Mongolia, Japan and South Korea) or South-East Asia (Brunei, Myanmar, Cambodia, Indonesia, Laos, Malaysia, the Philippines, Singapore, Thailand, Timor-Leste and Vietnam).

Exclusion criteria

The following items were excluded: (1) studies focusing on other febrile symptoms, e.g. febrile convulsion and febrile seizure; (2) editorials, letters, case reports or commentaries; (3) in vivo or in vitro studies without human data and (4) conference abstracts or poster abstracts without full-text publication. Articles conducted in countries from the Middle East, South Asia, and Central Asia were also excluded because of economic, cultural, and social differences. Diverse religious beliefs can also significantly influence social norms, values, and traditions, bringing differences in medical practices.

Study selection

Two investigators (NHL and WCL) reviewed the search results independently on three successive levels. (1) the article titles were initially screened to find the potential studies relevant to this review’s objectives (title stage). (2) The abstracts of these articles were then further reviewed (abstract stage). (3) In the final stage, the full texts of the remaining articles were reviewed based on the inclusion and exclusion criteria (full-text stage). Any discrepancies were discussed with the third reviewer (LH) to reach a consensus.

Quality appraisal

The primary investigator (NHL) evaluated the selected articles and cross-checked them by a coinvestigator (LH) using the Joanna Briggs Institute Critical Appraisal Tool (JBI) for cross-sectional studies [ 25 ], which was used to criticise cross-section study designs. The JBI critical appraisal checklist for cross-sectional studies includes eight items to assess inclusion criteria, study sample, measurements, confounding factors, and statistical analysis. Each item was evaluated using four responses: yes, no, unclear or not applicable. Disagreements were solved by consulting a third reviewer (CLW) to reach a consensus. A global rating of each study was examined by combining all component ratings ( Table 1 ). No studies were excluded based on the quality assessment ratings.

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https://doi.org/10.1371/journal.pone.0290172.t001

Data extraction

Data were extracted by one investigator (NHL) and checked for accuracy by the other investigator (LH) independently. Discrepancies were resolved through discussion. The following details were summarized from all articles: author(s), year, region of research, study design, study setting, data collection method, eligibility/recruitment, sample size, characteristics of caregivers, characteristics of children and synthesis themes.

Data synthesis

Data synthesis is the process of integrating findings from the included articles. A narrative synthesis was used in this review to examine the study findings from the articles. A narrative synthesis framework was adopted, including the following steps: (1) developing a preliminary synthesis of findings of included articles, (2) exploring relationships in the data, and (3) assessing the robustness of the synthesis [ 26 ].

After applying the inclusion criteria and excluding the duplicated articles, 11 articles were selected from the three English electronic databases. An article selection flow chart is presented in Fig 1 . These studies were conducted in different South-East and East Asian countries including China (n = 3), Japan (n = 3), Malaysia (n = 2), Indonesia (n = 1), Korea (n = 1) and Singapore (n = 1) ( Table 2 ). All of the included studies were quantitative designs involving 3,429 participants. Ten included studies adopted convenience sampling, while one adopted purposive sampling. All studies collected cross-sectional data with either a self-administered survey or a structured interview questionnaire. Critical appraisal information is detailed in Table 1 .

https://doi.org/10.1371/journal.pone.0290172.g001

https://doi.org/10.1371/journal.pone.0290172.t002

Narrative synthesis

The following four themes were established after applying the synthesis framework: (1) source of fever knowledge, (2) knowledge level, (3) attitudes towards childhood fever and (4) practices towards childhood fever (Tables 2 and 3 ).

https://doi.org/10.1371/journal.pone.0290172.t003

Source of fever knowledge

Six studies investigated parental information-seeking behavior toward childhood fever [ 15 , 27 – 31 ]. Healthcare professionals, namely doctors and nurses, were found to be parents’ most common source of information in five studies [ 15 , 27 – 31 ]. Although medical literature was reported as the primary source in Chinese (Taiwan) research, most of the participants (80%) indicated that they would like to receive medical information from healthcare professionals [ 27 ]. Other information sources included spouses, friends and relatives, courses, media, books, own parents, parents from spouses and the internet [ 27 – 31 ].

The desired fever information included management practices (81.5%), causes (74%), symptoms (65%) and benefits and risks of fever as a biological mechanism (50%) [ 27 ].

Knowledge level

Ten studies assessed parental knowledge levels, and all of them reported low levels of parental knowledge regarding childhood fever [ 15 , 27 – 35 ]. Studies in East Malaysia and Indonesia found that only 26.1% and 21.1% of parents had good knowledge about childhood fever, respectively [ 32 , 33 ]. Similarly, the median knowledge score was only 10 of 23 in Chinese (Taiwan) research [ 27 ]. Although the majority of parents (74%–80.9%) could correctly identify the cause of fever (as an immune response), some of them attributed it to exposure to wind and cold (32.4%, [ 27 ]) and an imbalance of heat and cold within the body (15.6%–86%) [ 27 , 33 ]. Nearly two-thirds of Malaysian parents (71.3%) believed that fever causes diseases [ 33 ].

Temperature.

Regarding the definition of fever, a significant proportion of parents (48.6%–100%) could not correctly identify a febrile temperature. Except for the Korean study that reported the lowest incorrect rate at 14.2% [ 35 ], Japanese parents had the highest false rate, which ranged from 62% to 100%, as reported in two studies [ 29 , 30 ]. In addition, a small proportion of Singaporean (4.3%), Korean (10.5%) and the majority of East Malaysian (84.7%) parents believed that fever could rise to 43.3°C or infinitely if left untreated [ 15 , 33 , 35 ].

Cause of fever.

Only two studies investigated parental knowledge regarding the cause of fever [ 27 , 33 ]. Although most parents correctly identified it as an immune response, some still had different misconceptions. For instance, parents in Malaysia and Taiwan would explain fever from the perspective of Chinese medicine, e.g., the imbalance of heat and cold [ 27 , 33 ].

Potential harm.

Almost all parents (91.4%–98%) in the studies believed that childhood fever could bring about harm, including brain damage, febrile seizure, dehydration, loss of hearing and vision or even mortality [ 15 , 27 – 31 , 33 , 35 ]. Of note, brain damage (20%–77.7%) and febrile seizure (28%–67.5%) were mainly reported [ 15 , 27 – 31 , 33 , 35 ]. Only a tiny proportion of Japanese parents (2.6%–2.8%) believed that fever would not harm children [ 29 , 30 ]. Most parents thought these complications needed to be triggered by elevated temperatures in three Japanese studies (threshold <40°C) [ 29 – 31 ].

Influential factors.

Factors that influenced parental knowledge levels were also investigated. Family demographics, such as age, education level, job and monthly income, were associated with parental knowledge of fever [ 27 , 29 , 31 , 32 , 34 ]. For instance, higher education levels and careers as professionals and management were associated with higher knowledge levels in Taiwan, China [ 27 ]. Furthermore, ethnicity and religion also affect parents’ knowledge, as Indians and Chinese were reported to better understand childhood fever than other ethnicities [ 33 , 34 ]. Parents with no religion had a higher knowledge level than those who believed in Buddhism [ 27 ]. Results also found that mothers had a better understanding than fathers [ 27 ].

Attitudes towards childhood fever

Types of attitudes..

Six studies investigated parental attitudes during a child’s febrile episode and found that most of the parents expressed a high level of anxiety and concern [ 15 , 27 , 28 , 30 , 33 , 34 ]. The majority of Asian parents reported moderate to high levels of anxiety (47%–86.6%) [ 15 , 27 , 28 , 30 , 33 ]. Of note, in In China, Japan, and Singapore, nearly half of the parents reported being “very worried”, while over one-third of the Chinese parents (34.3%) even reported being “extremely worried” [ 15 , 28 , 30 ]. In addition, a significant proportion of Malaysian (72%) and Chinese (Taiwan) parents (86.6%) were found to have the highest concern level [ 27 , 33 ]. The results illustrated that the phenomenon of fever phobia also exists in South-East and East Asia.

Bong and Tan [ 33 ] explored factors influencing parents’ anxiety levels. High anxiety was associated with low parental knowledge levels [ 27 ]. It also reported that discomfort of children (68.8%), persistently rising body temperature (68.2%) and fear of harm (63.7%) were the chief reasons for parental concern [ 33 ]. Their concerns were mainly influenced by their own or a family member’s previous experience with child fever (59.9% and 42%, respectively), not knowing the cause of the fever (39.5%) and doctor advice upon consultation (35.7%) [ 33 ].

Practices toward childhood fever

Assessments..

Five studies investigated fever assessment methods performed by parents [ 28 , 29 , 34 – 36 ]. Most Malaysian parents (86%) reported using a thermometer to assess their children’s temperature, while others reported using a touching technique [ 34 ]. Regarding sites of measurement, assessment strategies varied in different countries. In Malaysia and Korea, the eardrum thermometer was the most commonly used instrument, while the auxiliary was the preferred site of the Japanese [ 30 , 34 , 35 ]. Both methods were popular in China [ 36 ]. Nearly all parents in China (99.4%) and Japan (100%) would check their children’s temperature at regular intervals [ 28 , 30 ]. The majority of Singaporean (70.5%) and Korean parents (62.1%) would check their child’s temperature every hour or less [ 15 , 35 ].

Management strategies.

A wide variety of fever management practices, which aimed to relieve discomfort, promote sleep, and prevent brain damage and seizure, were used by Japanese parents [ 30 , 31 ]. Common practices included encouraging fluid intake, tepid sponging, and cooling the head and body [ 15 , 27 – 31 , 36 ].

In addition, traditional medicine and folk treatments were applied. For instance, some Taiwanese parents in China adopted traditional Chinese medicine techniques and Taiwanese folk remedies, e.g., ingestion of “cold” and “hot” drinks, “Shou Jing”, “scraping, Gua sha”, and intake of Chinese herbal medicine [ 27 ]. However, some traditional interventions were adopted by parents [ 37 ]. For example, some Japanese parents warm their children’s bodies, while a small proportion of Chinese parents would apply cold and wine sponging [ 28 , 29 ]. The combined therapy of traditional treatment and modern Western treatment were also found. Some Singaporean parents consult a conventional medical practitioner, and 11.1% administer traditional medicine concomitantly with polyclinic consultation [ 15 ].

Practices regarding the use of antipyretics varied in different regions. Most parents would administer antipyretics to their children in febrile conditions [ 15 , 28 – 31 , 33 , 34 , 36 ]. Reasons for antipyretic use included relieving the discomfort, promoting sleep, and preventing brain damage, seizures, and deterioration of diseases [ 29 , 31 ]. Only a minority of Taiwanese parents (14.2%) reported that they would not give antipyretics to their children because they did not want to disrupt doctors’ evaluations [ 27 ]. Common concerns included drug resistance (41.9%) and over-dependency (39.7%) [ 35 ].

Seven studies analysed the use of antipyretics concerning the degree of temperature [ 15 , 28 – 31 , 35 , 36 ]. Nearly all parents in Korea would check their child’s body temperature before giving an antipyretic medication [ 35 ]. Nevertheless, about one-third (33.9%) of parents in Japan did not rely on it to decide on the use of antipyretics [ 31 ]. Most parents responded that a temperature >38°C was the timing of giving medications [ 15 , 29 , 31 , 36 ]. Only a minority (2%–40%) of parents reported giving antipyretics at 38°C [ 15 , 28 , 30 , 36 ].

Nearly three-quarters of the Korean parents recognised the trade names of the antipyretics used, while only a few of them (9.4%) knew their generic names [ 35 ]. The most common antipyretics chosen by Chinese parents were ibuprofen (79.4%), followed by acetaminophen (9.5%) [ 28 ]. If the child remained febrile after having the antipyretic agent, common management adopted by parents included a tepid bath, visiting the hospital, alternating to diclofenac sodium suppository and readministering the same medication [ 35 , 36 ].

Chang et al. [ 36 ] further explored the common misunderstandings of parents toward antipyretics, which included side effects of overdose possibility (e.g., liver toxicity), the maximum number of doses during a day, medication dose and duration of taking medication. Grandmothers, immigrant mothers, and parents with lower academic qualifications and older age were found to have higher misconception rates [ 36 ]. Over one-third of the parents misunderstood the drug package insert instructions and medication envelope instructions, which were attributed to the tiny words printed and the incomprehension of Chinese [ 36 ]. It highlighted the insufficient knowledge of using antipyretics among parents.

Several factors affected parental management practices regarding childhood fever. For instance, Korean parents with an only child tended to seek medical attention more than those with more than one offspring [ 35 ]. Parents worried about brain damage would check the child’s body temperature more frequently [ 35 ]. Of note, parents with poor knowledge of fever showed a four times chance of showing poor management strategies compared to those with good knowledge [ 32 ].

This study is the first review summarising parental knowledge, attitude, and management regarding childhood fever in South-East and East Asia. The results highlight the unmet childhood fever information needs, inadequacy of fever knowledge, negative attitudes, and diverse fever management practices in South-East and East Asian parents. Our results indicated that educating them about childhood fever and providing psychological support are warranted for better decision-making on childhood fever management at home.

Parents’ knowledge about fever

Consistent with previous Western studies [ 3 ], this review suggests that South-East and East Asian parents generally have insufficient knowledge about childhood fever, including diverse perspectives on febrile temperature and inadequate understanding of potential harm. Although different questionnaires were used across studies, making head-to-head comparisons was difficult because of the various definitions of fever concerning the site of thermometer measurement [ 38 ]. Nevertheless, the current study’s results consistently show that most parents could not identify febrile temperature correctly. The correct rate of fever temperature identification often ranged from ~0% to 50%, comparable to another systemic review (19%–45%) [ 3 ]. The results highlight the lack of basic understanding of childhood fever for most South-East and East Asian parents. The possible reasons could be related to the information provided by healthcare professionals, traditional perspectives on the cause of fever, and the influential demographic factors.

On the one hand, the current review demonstrates that healthcare professionals are parents’ most common source of information. It offers an excellent opportunity for them to deliver appropriate and effective education during clinical consultation while preventing parents from being exposed to unreliable information sources. However, some misconceptions (e.g., higher temperatures create more significant risks to the child) might be unintentionally reinforced through health consultations, especially when healthcare professionals ask about body temperatures. As such, temperature-focused questioning coupled with parents’ misconceptions or fears may create a false sense of importance associated with numerical fever values rather than the child’s overall well-being [ 3 ]. Therefore, it is valuable to standardize the knowledge about childhood fever for healthcare professionals in the paediatric department, incorporating the health guidelines on fever management in their own country, which will help ensure the accuracy of parents’ understanding of childhood fever.

On the other hand, certain traditional beliefs (i.e., the perspective of Chinese medicine on explaining fever) [ 27 , 33 ] may mislead parents into focusing on the level of fever instead of its origin (i.e., infection); it may lead to excessive temperature monitoring and overusing antipyretics [ 15 ]. Therefore, additional studies are warranted to promote parental knowledge about fever’s origin in different South-East and East Asian countries, providing insights for further education programs. Thus, the parents’ abilities to identify fever should be enhanced [ 33 ].

In addition, studies reported that immigrants, old age, and low education levels were associated with a higher level of the misconception of fever and its management [ 27 , 29 , 31 , 32 , 34 , 36 ]. Therefore, health literacy is suggested to be taken into consideration. Hospitals and paediatric clinics, and primary healthcare clinics can be an ideal platform for healthcare professionals to deliver tailored education concerning parents’ abilities and needs. Developing accessible and easy-understanding educational interventions about childhood fever will benefit parents of different socio-demographic characteristics and levels, realizing their information-seeking. Hence, the impact of low health literacy can be minimised.

Parents’ attitude towards fever

The current review demonstrates that the anxiety levels of South-East and East Asian parents towards childhood fever are comparable to Western studies. The majority of Asian parents reported moderate to high levels of anxiety (47%–86.6%), which is consistent with findings from another systematic review (57%–68%) [ 3 , 15 , 27 , 28 , 30 , 33 ]. It reveals that fever phobia also exists in the South-East and East Asian population. Of note, a significant proportion of parents in Malaysia (72%) and China (Taiwan, 86.6%) expressed the highest level of concern [ 27 , 33 ]. The reason behind the disparities in anxiety levels in different countries can be further investigated. Nevertheless, among all the perceived harms of childhood fever, South-East and East Asian parents were concerned more about brain damage and mental retardation [ 15 , 16 , 27 , 28 , 33 , 35 , 37 , 39 , 40 ]. These findings are more apparent in China, Singapore and Malaysia. The possible reason is that South-East and East Asian parents, especially Chinese, emphasise children’s academic attainment, which heavily relies on their intelligence level [ 15 ]. Therefore, they would worry more about their children’s intellectual development. Moreover, due to cultural impacts (e.g., endurance/control in Chinese Confucian culture), some parents tend to take excessive control of fever to alleviate their anxiety, such as alternatively using antipyretic drugs, ignoring children’s health, and thus aggravating their anxiety [ 8 ]. This phenomenon could be further explored, hence contributing to a theoretical framework for a culturally sensitive educational scheme to address parents’ concerns in this area. Studies to compare groups from different social and cultural backgrounds are also paramount to identify the factors influencing fever phobia.

Of note, a study revealed that doctors’ advice upon consultation contributed to parents’ concerns, indicating that information provided may also heighten their anxiety level [ 33 ]. In this regard, in addition to giving education, healthcare professionals should also focus on the psychological status of parents. Reassuring parents and reducing their mental burdens are essential. Otherwise, elevated anxiety levels may lead to the chain reactions of over-treatment and over-consultation, which are undesirable outcomes for the family and healthcare system. Psychological support designed in the future is suggested to emphasize the correct understanding of childhood fever and its harmfulness, focusing on the child’s well-being rather than using irrational ways to relieve their concerns and increase children’s burdens.

Parents’ practices toward fever

Being influenced by cultural-bounded thoughts, parents in different countries share distinct cultural responses to fever. Some of them would adopt alternative medicine and seek advice from traditional medical practitioners instead of relying only on Western medicine. For instance, Taiwanese parents in China applied conventional Chinese medicine and Taiwanese folk remedies at home, such as the ingestion of “cold” drinks and “hot” drinks, “Shou Jing”, and “Gua Sha". This could be deeply influenced by the tenets of traditional Chinese medicine [ 27 ]. Singaporean parents would give talisman water for their children to drink and put oil on their fontanelles. This may be influenced by the inconsistent advice from information resources under the multicultural population in Singapore [ 15 ]. In contrast, Western medicine upholds a different viewpoint regarding fever management practices. Treatments focus on reduction of distress rather than temperature [ 10 ]. For instance, guidelines suggested giving antipyretics only in cases of discomfort [ 41 ].

Despite the prevalence of traditional fever management practices, there is a lack of evidence regarding their effectiveness. For instance, the practice of giving talisman water to febrile children in Singapore has not been studied, and evidence related to the effectiveness of warming children’s bodies in Japan is also limited to a theoretical level [ 10 , 15 , 29 ]. Although it is believed to reduce the energy needed to develop fever and, thus, alleviate the discomfort of the febrile child, this theory has not been supported by any empirical studies [ 10 ]. Similarly, the effectiveness of Gua sha, a traditional Chinese practice, for fever discomfort is unclear as most studies focus on its use for sports injuries and pain relief [ 42 ]. Additionally, the potential harm associated, such as bruising and soreness, raises doubts about its worthiness for fever management [ 42 ]. Moreover, some traditional practices are discouraged by current medical guidelines, e.g., cold sponging and wine sponging by Chinese parents [ 10 , 28 ]. These practices can result in a mismatch between the hypothalamic set point and skin temperature due to manual cooling, leading to discomfort in the child due to peripheral vasoconstriction, metabolic heat production, and increased shivering [ 10 ]. The findings have highlighted the potential risks and consequences of various cultural practices.

On the contrary, some traditional management can indeed provide beneficial clinical effects. For instance, ingesting “cold’ and “hot” drinks can foster fluid consumption, alleviating discomfort during a febrile episode [ 10 ]. Some active ingredients in traditional Chinese medications, such as Bupleuri Radix (Chaihu) and Scutellariae Radix (Huangqin), have also been proven effective as antipyretic agents [ 43 ]. However, being aware of the drug-drug interactions between traditional remedies and western medications is crucial. Despite this, by recognizing the positive impacts of these widespread practices, healthcare providers can enhance treatment effects and improve parents’ adherence to the education given. Further research can focus on the effectiveness and contraindications of various cultural practices to facilitate their utilization.

As mentioned, healthcare professionals serve as the primary information source for parents. They inflict a significant impact on parents’ management practices. Chang et al. [ 27 ] found that Taiwanese parents in China were prone to use an ice pack as a management practice instead of promoting comfort, a misconception rooted in earlier acceptance by medical professionals. However, this practice still existed over the previous decade [ 27 , 37 ]. In addition, early Japanese nursing practice suggested that warming a febrile child could help manage the symptom [ 29 , 44 ]. Although it would raise the child’s body temperature, some Japanese parents still adhered to this practice [ 29 ]. This discrepancy could be related to the core goal of improving fever guided by healthcare professionals and the personal experience of parents. Compared to Chinese parents, Japanese parents tend to rely on their personal experiences to accurately control seizures by warming the body when their child develops a high fever [ 29 ]. In light of this, formulating a uniform, updated, evidence-based guideline for healthcare professionals in different countries is paramount to preventing inappropriate suggestions given to parents. It is also essential to implement tailored management strategies according to children’s physical condition, unmet parental needs and cultural issues.

Limitations

The current literature review has some limitations. First, only studies published in English were included, and studies published in other languages were excluded. Nevertheless, the current review included studies from different countries, including China, Malaysia and Japan, which ensure the coverage of findings in various South-East and East Asian populations. Second, six studies showed low quality, resulting in a methodological weakness, especially on unreliable measurement. However, this study aimed to investigate the phenomenon of parental knowledge, attitude and management, and using a weaker quantitative design (cross-sectional study) may only bring a trivial limitation to the adequacy of the study results. Third, no qualitative studies were included in this review. The current review suggests an absence of qualitative studies conducted in the South-East and East Asian region. Therefore, further qualitative research is paramount to know about parental unmet information needs on childhood fever and the potential cultural issues influencing their beliefs, hence providing insights for developing a culturally sensitive educational frame.

Research and practice implications

Implications for future research..

The results of this review provide several meaningful implications for future research. Firstly, qualitative studies are warranted to explore the South-East and East Asian parent’s experience managing childhood fever and their perspective in their cultural contexts. Secondly, as the current study is only a literature review, it is suggested to systematically summarize the scientific measurements of fever and effective management strategies for childhood fever in South-East and East Asian countries. Thirdly, as the review indicated, parents’ access to information about childhood fever is multifaceted, especially through the internet and the media, so considering the convenience of the internet, designing a friendly-using online information platform about childhood fever will promote parents obtaining evidence-based information in real-time.

Implications for clinical practice.

This review also indicates implications for clinical practice. As healthcare professionals are the primary source of information, and most parents would seek advice for managing childhood fever, they serve as an ideal platform for education with high credibility. Therefore, the results of the current study highlight the need to develop an educational framework to unify information, providing consistent knowledge and management approaches to parents. First, the theoretical knowledge about childhood fever must be regularly updated for clinical healthcare professionals in the paediatric department. Health education program services are highly recommended to be integrated into broader primary care systems. Second, culturally specific and evidence-based education programmes should equip parents with correct information, appropriate attitudes, and skills to manage mild to moderate fevers without emergency and medical consultation.

The current literature review provides a comprehensive understanding of parental knowledge, attitude, and management of childhood fever among South-East and East Asian parents. The results found that a low state of parental knowledge and negative attitudes toward fever exists in South-East and East Asian parents. Nevertheless, differences in perception and management of childhood fever still exist in South-East and East Asia compared to other countries. Evidence-based approaches based on cultural contexts to effectively manage childhood fever in South-East and East Asian countries warrant further systematic investigation. Evidence-based information also deserves attention from healthcare professionals.

Supporting information

S1 file. prisma checklist..

https://doi.org/10.1371/journal.pone.0290172.s001

S2 File. A sample search strategy in CINAHL.

https://doi.org/10.1371/journal.pone.0290172.s002

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