{"paper_id":"2db44417-358d-493f-9cd4-3224c4e87ac0","body_text":"‘Asram' is not for hospital’: Perceptions and management of newborn illnesses in two urban slums in Accra, Ghana | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article ‘Asram' is not for hospital’: Perceptions and management of newborn illnesses in two urban slums in Accra, Ghana Edward Akolgo Adimazoya¹*, John Kumuuori Ganle²†, Emmanuel Asampong³†, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5434704/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 4 You are reading this latest preprint version Abstract Background: Neonatal mortality remains a significant public health challenge globally, and Ghana is no exception. In Ghana, neonatal deaths accounts for 61% of infant deaths and 43% of under-five deaths. While the illnesses that affect neonates and contribute to neonatal mortality are widely known, and interventions for managing these illnesses exist, it is not clear how these illnesses are perceived and managed in many local communities including urban slums in Ghana. This paper explored the illnesses affecting neonates and their perceptions and management in two urban slums in Accra, Ghana. Methods: This qualitative study forms part of a concurrent mixed methods cross-sectional study that was conducted in two large urban slums (Ashaiman and Sodom and Gomorrah) in Accra. The qualitative component of the study involved 14 focus groups discussions and 13 in- depth interviews with purposively sampled mothers, traditional birth attendants, caregivers, community leaders and health workers at national and sub national level. Interviews were tape-recorded, transcribed and analyzed thematically using NVivo 12 Pro. Results: Several common newborn illnesses were reported including diarrhoea, fever, cough, acute respiratory infections, neonatal jaundice, and rashes. There were also other locally themed newborn illnesses including “tomatoes”, “asram”, “obopremu”, “obobre” “bosu -bosu”. Most locally themed illnesses were generally perceived as caused by evil spirits and therefore “not for hospital”. Rather, these illnesses are managed by pastors, mallams, herbalists through exorcism and herbal concoctions. Key barriers to newborn care in the slums include inadequate infrastructure, lack of newborn resuscitation equipment, poor provider skills and competencies, and negative attitude of health service providers. Conclusion: The main illnesses affecting newborns in the slums are diarrhoea, fever, cough, acute respiratory infections, “asram”, “obobre” neonatal jaundice, rashes, “tomatoes” and “bosu-bosu”. The key barriers to newborn care included cost, waiting time, distance and negative attitude of health care providers. Importantly, the findings suggested that how people in urban spaces perceive the cause of their newborn illness determined the nature and type of treatment. It is critical therefore that targeted health educational interventions are designed and implemented in these urban slums to address misconceptions and improve care for newborns. urban slum newborn illness perception ‘‘asram” barriers management newborn care qualitative Ghana Background In 2020, nearly half (47%) of all under -five deaths occurred in the newborn period (i.e. the first 28 days of life), an increase of 40% from 1990 [ 1 , 2 ]. This represents about 2.4 million newborns globally. Most of these deaths occur during labour, delivery and the immediate post-partum period [ 2 – 4 ]. Despite significant investments in interventions to reduce neonatal morbidity and mortality, progress has been especially slow in Sub Saharan Africa, where newborns have a ten times risk of dying within the first 28 days after birth compared to high income countries [ 2 , 5 ]. Newborn survival in the first few days after birth is thus a critical public concern, because the neonatal period which marks the interval from birth to the first 28 days of life, is the most vulnerable period for any newborn. This vulnerability is linked to the stress of delivery and the transition and adaptation from uterine life to ex-utero with the associated exposures to infections and other dangers [ 6 ]. Among other things, majority of newborns die because mothers lack adequate quality care during labour and delivery [ 7 ]. Coupled with inadequate care is inadequate knowledge and understanding of care for newborns, including the mother’s ability to identify danger signs for newborn illnesses [ 8 ]. Generally, newborn deaths result from a combination of medical causes, social factors and health system failures. These factors vary not only by context but also by culture. Among the several contributory factors to the burden of neonatal morbidity and mortality, preterm birth complications are the single largest cause of death, responsible for an estimated 36% of all neonatal deaths with intrapartum-related conditions (previously called birth asphyxia; 23%) and infections notably sepsis, meningitis and pneumonia, contributing 23% [ 4 ]. A key observation however is that the causes of newborn deaths shift as the newborn progresses from the early neonatal to the late neonatal period. During the early neonatal period (0–6 days), sepsis accounts for only (8%) of neonatal mortality compared to 37% in the late period (7–28 days), where pneumonia, tetanus, diarrhoea, congenital disorders and other factors contribute marginally to the morbidity and mortality burden of neonates [ 3 , 4 , 9 ]. Available evidence also suggests that the causes of death in urban slum children include poor neonatal care [ 10 ], neonatal tetanus [ 11 , 12 ], diarrhoea and respiratory infections [ 10 , 13 ]. Tetanus immunisations routinely provided during antenatal care services and clean deliveries have been shown to potentially prevent neonatal tetanus [ 14 ]. Urban slum residency has been characterized by earth floors, which often serve as breeding grounds for many infectious agents [ 15 ]; living in earth floor houses has been associated with increased risk of diarrhoea [ 16 ], and being a carrier of streptococcus pneumoniae, a bacteria that commonly causes acute respiratory infections in children [ 17 ]. Ghana, like many middle-income countries, experienced rapid urbanisation over the past decades, resulting in the growth and spread of slums across its major cities. Roughly about 39.7% of the country’s 5.4 million urban population are now residing in slums [ 18 ]. Neonatal health outcomes are even worse in poor urban slums [ 19 , 20 ]. Most slums lack improved water, adequate sanitation, hygiene, sufficient living area and durable housing [ 20 ]. In 2018 the Ashaiman Municipality and the Ashiedu-Keteke Sub Metropolitan area where Sodom and Gomorrah are located recorded neonatal mortality rates that were higher than the national average of 25 deaths per thousand live births [ 21 , 22 ]. In Ghana, newborn deaths account for 61% of infant deaths and 43% of under-five deaths [ 23 , 24 ]. About one in every 24 Ghanaian children dies before reaching age one, and one in every 17 does not survive to his or her fifth birthday [ 24 ]. While infant and under-five mortality rates declined by 28% and 44% respectively since 1998, neonatal mortality rate marginally declined from 29 to 25 deaths per 1000 live births [ 25 ]. With this rate, Ghana will most likely miss the UN Sustainable Development Goal 3 target of reducing neonatal deaths to 12 deaths per thousand live births by 2030 [ 26 ]. Illness perceptions are major determinants of the nature, type and sources of treatment for those particular illnesses. For example, in their study on child deaths in Dhaka’s slums, Bangladesh, Caldwell et al, observed that two- thirds of child deaths occurred in a context of beliefs in harmful spirits or forces, and the need to appease or combat them [ 27 ]. Local etiologies that attribute illness to evil spirits are often linked to culturally prescribed action, necessitating home management or local treatment [ 10 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 ]. In Bangladesh, community members asserted that if symptoms were caused by evil spirits, then there was no use going to a modern doctor [ 32 ]. Similarly, in Ghana, hospitals were regarded as useless against spiritual attacks [ 29 ]. Convulsions as a result of malarial fever were also thought to have spiritual undertones, and negative outcomes of childbirth were often attributed to witchcraft in Northern Ghana [ 29 ]. While the extant literature suggests that newborn illnesses have different interpretations both in the rural population in Ghana [ 35 ], and among ultra-poor rural households in Bangladesh [ 32 ], and urban slums in India [ 34 ], few studies have been carried out in urban slums in Ghana to explore the common illnesses affecting neonates, and how these illnesses are perceived and managed. This knowledge gap could limit full understanding of local community perceptions and management of newborn illnesses in urban slums in Ghana. This could potentially hamper efforts to design effective community-based interventions to reduce neonatal deaths to 12 deaths per thousand live births by 2030 as envisaged under the UN Sustainable Development Goal 3 target [ 26 ]. This qualitative study therefore aimed to contribute to filling this knowledge gap by exploring newborn illnesses, local perceptions and management practices among residents in two urban slums in Ghana’s capital city, Accra. Methods Study design and population The data used for this paper form part of a concurrent mixed methods cross-sectional study. In this current paper, data from the qualitative component of the study are reported. The study was conducted among women of reproductive age with live neonates aged 0–28 days, slum based traditional birth attendants who delivered a live baby between January 1st and June 30th 2020, care givers, community leaders in the slums, and public and private healthcare managers at national, regional, and sub national level. Study area, sampling, and recruitment The study was conducted in two large urban slums (Ashaiman and Sodom and Gomorrah) in Accra. Both slums have similar characteristics: they are ethnically diverse, mostly poor, barely educated and generally unemployed. Their residents are mostly engaged in odd, non-permanent jobs including head porterage popularly called Kayayei. They also have poor access to health services. The sample size was determined using guidelines for determining saturation [ 36 , 37 , 38 ]. The sample comprised 138 participants (14 focus groups and 13 in-depth interviews) comprising 121 females and 17 males. The size of the focus groups ranged between 8–10 participants. All the FGD participants were female except one group with community leaders. In-depth interviews were conducted with 2 national newborn experts, 2 district directors of health services, 2 district newborn coordinators, 6 midwives from the sub district level in charge of maternal and newborn health service delivery and a midwife from a private maternity home. As the emphasis in qualitative research is not on large sample sizes for representational purposes, but on trustworthiness and reliability of the findings [ 39 , 40 ], recruitment of participants was purposive, and continued until saturation was reached on major issues that the research explored [ 37 , 38 ].Participant recruitment was based on the homogenous, expert and maximum variation or heterogenous purposive sampling methods [ 41 ]. Using purposive or judgmental sampling therefore, participants were deliberately recruited based on their unique knowledge, experiences and expertise on the subject matter [ 42 , 43 ] and their availability and willingness to participate [ 44 ].Thirteen health professionals were recruited for in-depth interviews, based on their experience, professional knowledge and expertise in newborn care through referral or snowball sampling and the expert sampling method [ 43 ], while a total of 76 mothers with with live neonates aged 0–28 days and 16 slum based traditional birth attendants who delivered a live baby in the past six months prior to data collection were recruited for focus groups based on the homogeneous sampling method. They were recruited because of the similar attributes, traits and characteristics that they share as a group. Finally, sixteen caregivers comprising grand mothers’, mother in-laws and older women in the communities and seventeen community or tribal leaders were selected in focus groups based on the heterogeneous sampling method to solicit their views and perspectives on multiple angles of newborn care, as gate keepers of the community and repositories of community indigenous knowledge, norms and practices on newborn care. All participants were selected through referral and stakeholder mapping. Discussions in focus groups lasted between 45 minutes and 1 hour. All discussions were conducted in one of three local dialects Twi, Ewe and Dagbani depending on the dialect that was mostly spoken and understood by the participants. In-depth interviews were conducted in English with 13 healthcare managers. The interviews usually lasted between 45 minutes and 1 hour. All FGDs and IDIs were tape-recorded, and notes taken to document observations about the interview content, the participants and the context. All interviews were conducted in private rooms, while focus group discussions were held in open spaces in either churches or classrooms. Before the commencement of data collection, all data collection tools were pre-tested and refined based on the pre-test results. We also trained three data collection assistants from January 2–4, 2020. The training offered a hands-on approach on how to conduct qualitative studies as well as interviewing skills, and interpretation of the questions, The training also covered ethics and compliance with research issues on human subjects. Instruments and data collection The data collection tools comprised semi structured open ended topic guides for both focus groups and in-depth interviews. The instruments were designed to elicit responses to answer research questions 1, 3 and 5 namely; what kinds of illnesses affect neonates during the first 28 days of life in Ashaiman and Sodom and Gomorrah; what is the health seeking behaviours for newborn illnesses among mothers and caregivers in Ashaiman and Sodom and Gomorrah and what are the barriers to newborn care in Ashaiman and Sodom and Gomorrah. Data processing and analysis The qualitative data were analyzed thematically. This involved several processes. The audio recordings were transcribed verbatim and transcribes in the local languages were translated into English. Back translations were done on selected transcripts to check the accuracy of the translations and to verify inconsistencies. All the transcripts and interview notes were then read and reviewed thoroughly, and notes made on hard copies of the transcripts. A preliminary coding structure and code book was developed which led to the next phase. We then exported all the transcripts into NVivo 12.x64 windows, where the data were both deductively and inductively coded. Data coding continued until theoretical saturation was reached (i.e., where no new concepts emerged from successive coding of the data). The completed code structure was then applied to develop and report themes with verbatim quotes. Results Characteristics of participants For the qualitative research participants, Table 1 describes the essential characteristics of the participants. The ages of the qualitative sample ranged from 15--70 years, with approximately 72 (52.2%) being in the modal age range of 25--34 years. With respect to education, the majority (74, 53.6%) had no formal education, and only 13 (9.4%) had tertiary education. Approximately 53.6% were currently married, whereas 87% were female. With respect to religion, approximately 56.5% were Christian, 30.4% were Muslim, and 13.1% had other faiths. Table 1: Characteristics of qualitative research participants Characteristics National n (%) Ashaiman n (%) Sodom & Gomorrah n (%) Total n (%) N 2 65 71 138 Age of qualitative participants mean ± SD 29.4 ± 5.9 26.8 ± 5.8 28.1 ± 6.0 Age group of participants <25 - 17 (26.1) 22 (31.0) 39 (28.2) 25-34 - 35 (54.0) 37 (52.1) 72 (52.2) 35-44 - 4 (6.1) 3 (4.2) 7 (5.1) 45-54 - 4 (6.1) 4 (5.6) 8 (5.8) 55-64 1(50.0) 5 (7.7) 5 (7.1) 11 (8.0) 65-74 1(50.0) - (0.0) - (0.0) 1 (0.7) Marital status Currently married 2 (100) 40 (61.5 32 (45.1) 74 (53.6) Co-habiting - 20 (30.8) 20 (28.2) 40 (29.0) Not in union - 5 (7.7) 19 (26.7) 24 (17.4) Highest level of education No Formal Education 29 (44.6) 32 (45.1) 61 (44.2) Primary - 9 (13.9) 10 (14.1) 19 (13.8) Middle School/JHS/JSS - 8 (12.3) 9 (12.7) 17 (12.3) Senior High School/SSS/VOC/TECH - 13 (20.0) 15 (21.1) 28 (20.3) Tertiary 2 (100) 6 (9.2) 5 (7.0) 13 (9.4) Sex Male 1(50.0) 8 (12.3) 9 ( 12.7) 18 (13.0) Female 1(50.0) 57 (87.7) 62 (87.3) 120 (87) Religion Christian 2 (100) 37 (56.9) 39 (54.9) 78 (56.5) Muslim - 15 (23.1) 27 (38.0) 42 (30.4) Other religion - 13 (20.0) 5 (7.1) 18 (13.1) Table 2 describes the venues and locations where focus groups and In-depth interviews were conducted. Table 2 :Participants of FGD and IDIs by study location Focus Group Discussions and In -Depth Interviews In-Depth Interviews Focus Group Discussions Participants/Groups Number of Participants Location Number of FGD’s Number of Participants Location Mothers with newborns 0-28 - - 1 9 Gbemi Mothers with newborns 0-28 - - 1 9 Blakpatsona Mothers with newborns 028 - - 1 9 Amuidjor Mothers with newborns 0-28 - - 1 9 Tulaku Mothers with newborns 0-28 - - 1 10 Onion Mar. Mothers with newborns 0-28 - - 1 10 Presby C Mothers with newborns 0-28 - - 1 10 Yam Market Mothers with newborns 0-28 - - 1 10 GPRTU Slum Based TBAs - - 1 8 Ashaiman Slum Based TBAs - - 1 8 Yam Market Caregivers of newborns - - 1 8 Ashaiman Caregivers of newborns - - 1 8 Methodist Community leaders - - 1 8 Ashaiman Community leaders - - 1 9 GPRTU Newborn Coordinator 1 National, Accra - - - Newborn Consultant 1 National, Accra - - - District Director of Health 1 Ashaiman District Director of Health 1 Ashiedu -Keteke - - - District Newborn Coordinator 1 Ashaiman District Newborn Coordinator 1 Ashiedu- Keteke - - - Midwife (Sub -district head) 1 Blakpatsona, Ashaiman - - - Midwife (Sub -district head) 1 Gbemi-Ashaiman - - - Midwife (Sub -district head) 1 Amuidjor, Ashaiman - - - Midwife (Sub -district head) 1 Onions Market, Fadama - - - Midwife (Sub-district head) 1 Presby Church, Fadama - - - Midwife (Sub -district head) 1 Yam Market, Fadama - - - Midwife Private Maternity home 1 St. James M. Home, Usher - - - Sub total 13 14 125 Common newborn illnesses and perceived causes In our qualitative interviews, participants reported several newborn illnesses that are commonly experienced in urban slums. Several mothers reported that newborns suffered from heat or skin rashes, measles, tonsilitis, ”hot body” and pemphigus neonatorum. According to the mothers, some babies naturally develop what they described as “hot body” once you give birth to them. Rashes, the mothers reported were generally caused by heat, hence the name “heat rashes”. However, there are some rashes that have fluids inside them. “Tomatoes” commonly used to refer to the condition described by health professionals as “pemphigus” is believed to be a kind of rash that contains fluid. Mothers reported that “tomatoes” is a serious kind of newborn illness caused by “heat” or “smoke” from corn husks that have been burnt as fuel for bathing the newborn or preparing meals for the family. Once a mother baths the baby with warm water prepared from corn husks or a mother eats food prepared from corn husks used as fuel, her newborn will suffer from “tomatoes”. One mother said: There is this illness called “tomatoes”. It normally has water inside and comes on the skin of babies; sometimes it worries them. It is caused by heat (20-year-old mother, FGD, Sodom and Gomorrah). Regarding the cause of “tomatoes” here is what a traditional birth attendant said: When you use corn husks to make fire to heat water to bath the baby, the baby can get “tomatoes” (40-year-old Traditional Birth Attendant, FGD, Sodom and Gomorrah). The participants identified another form of heat rash known as “ nappy rash ”. Although this kind of rash is believed to be caused by heat, the mothers reported that this kind of heat rash is caused by the “babies’ nappies”, hence the name “ nappy rash” . Nappy rash is believed to be caused by keeping the nappies too long on the baby, without removal or replacement of soaked nappies usually for more than four hours. Regarding the cause of “ nappy rash” , here is what one participant said: Nappy rash is caused by heat. When you delay in removing the baby’s diapers for a long time, it causes nappy rash (33-year-old mother, FGD, Ashaiman). Another said: When you wear the baby a diaper and the baby urinate, and you do not remove it early, then, it becomes red and causes rash (34-year-old caregiver, FGD, Sodom & Gomorrah). Some mothers in Ashaiman reported that they had education from healthcare providers and on radio to apply “joy ointment” (a locally produced gel/ointment in Ghana) on the baby’s buttocks prior to wearing the nappy. This conception of nappy rash is shared by community leaders. Here is what one community leader shared about rashes on newborns. What I will say is that in the past, nursing mothers used cloth napkins for the children but now they use pampers and because of that, you see that the child’s private part becomes reddish … I think it does not make the child healthy (51-year-old community leader, FGD, Sodom & Gomorrah). Yet others believe that the rashes are caused by sweat from overcrowding. Here is what one community member said: Because of overcrowding, when the child is delivered, instead of the baby and mother sleeping alone, they sleep in a room with other mothers. I feel that somebody’s sweat and other things can also make the baby sick in future (48-year-old community leader, FGD, Sodom & Gomorrah). There were mixed reactions about vaccinations for newborns. While some participants believed that some vaccinations can cause illnesses in newborns, others argued that vaccinations rather protected newborns from illnesses. The quote below explains why there appears to be a confusion as to whether vaccinations protect or cause illnesses in newborns. Some of the injections given by nurses also make the children have diarrhoea (47-year-old community leader, FGD, Sodom & Gomorrah). However, one mother counted this assertion and intimated that: When we give birth and they (the nurses) give those injections, the first stool that comes from the baby helps to remove the toxins in the baby, so it is not a sickness (34-year-old mother, FGD, Sodom & Gomorrah). Other newborn illnesses reported by the mothers included acute respiratory infections, yellowish eyes, fever, cough, catarrh, “ asram ”, difficulty in urination, discoloration of the skin which makes the babies colour to change, stomachache, convulsion and diarrhoea. Note that the condition described as “yellowish eyes” “discoloration of the skin and changes in the skin colour” all refer to neonatal jaundice. Mothers believe yellowing of the neonates’ eyes is caused by contamination of the amniotic fluid during delivery, which makes the baby’s eyes yellowish and discolours the skin. Mothers therefore urged midwives to ensure that the amniotic fluid does not enter the babies’ eyes during labour, otherwise it will cause the babies’ eyes to change to yellow, as if the baby has “apollo”. Here is what one mother said: Yellow eyes are due to giving birth… sometimes the water that passes before the child comes out may have entered the baby’s eyes, but they (the midwives) may not have checked, and you bring the child home, then it shows on the baby’s eyes (32-year-old mother, FGD, Sodom and Gomorrah). While majority carried this perception, a minority reported that yellowing of the eyes of newborns was a result of delayed initiation of breastfeeding. According to one participant: There is a condition where sometimes the eyes of the baby changes to yellow. When I went to ask the Midwife, she said if we don’t breastfeed our babies early that is the condition ( 30-year-old mother, FGD, Ashaiman) Another reported that: My sister’s baby also experienced it, and they said she should breastfeed the baby fast, fast it will go (28-year-old mother, FGD, Ashaiman) Yellowing of the eyes of newborns as described by mothers in FGDs is a sign of neonatal jaundice. Neonatal Jaundice is a yellowish discoloration of the white part of the eyes and skin in newborns due to high bilirubin levels. These perceptions were confirmed by the National Newborn Coordinator of the Ghana Health Service at the Family Health Division who affirmed that neonatal jaundice is actually on the rise and has become one of the newborn public health threats in Ghana. According to the National Newborn Coordinator: Neonatal jaundice is one of the newborn illnesses we are focusing on. We are seeing many cases of neonatal jaundice in our facilities and we are working with partners (USAID and UNICEF) to address the condition through social and behaviour change communication (IDI, National, Newborn Coordinator). Neonatal jaundice is common in preterm babies, and it is often caused by an immature liver, infection, medication or blood disorders. Its symptoms include yellowing of the skin, and the whites of the eyes that appear within days after birth. What most of the participants referred to as yellow eyes which they believed is caused by ‘contaminated’ amniotic fluid entering the baby’s eyes during childbirth is a sign of neonatal jaundice. Catarrh, cough and diarrhoea were mentioned as some of the other common illnesses affecting newborns in the slums. While some mothers believed that newborn babies could get catarrh while sleeping under fans, others reported that cough is transmitted by evil people who visit the newborn baby. Here is what one participant said: Sometimes when you give birth someone can come to visit you and if the person has the illness and the person coughs, the child can get infected (31-year-old mother, FGD, Sodom and Gomorrah). According to the mothers, some babies develop stomach problems because of prolonged breastfeeding. One participant said: Some of the babies, when they breastfeed for a long time and you do not give enema, it worries their stomach. When you give enema, it helps to cleanse the babies stomach (21-year-old mother, FGD, Sodom and Gomorrah). An enema, also known as a clyster, is an injection of fluid usually prepared from herbal concoctions into the lower bowel by way of the rectum. Also, the word enema refers to the liquid so injected or the device used for administering the injection. Using the enema syringe together with varied herbal concoction periodically, is therefore practiced by mothers whose babies are perceived to have stomach problems, and the reason behind this practice is to cleanse the baby’s stomach and allow them to pass stool freely without problems. Some mothers however attributed the stomach problems to “gas that causes pain” in the newborns. Usually, such babies have distended and bloated stomachs. According to one participant: It is gas that makes the babies’ stomachs to pain them (21-year-old mother, FGD, Sodom and Gomorrah). Another illness frequently reported in FGDs included tonsilitis. Mothers described the illness as a disease that does not allow the baby to cry normally. Here is what one participant said: When you give birth to some babies, you will notice that while they are crying there is something under their tongue; it is like a thread, so it does not allow their crying to be heard (40-year-old mother, FGD, Ashaiman). Other categories of illnesses reported in the FGDs included “ asram” “obepremu””bosu-bosu” and “obobre”. “Asram” was reported by mothers in both Ashaiman and Sodom and Gomorrah. According to one participant, “ asram” : “Is a spiritual illness that makes the newborn grow very small and tiny, usually with a big head. When your baby has asram, you will pray over it or they will apply some herbs and the baby can become normal again” (22-year-old mother, FGD, Sodom and Gomorrah). Another participant said: “Asram” is not for hospital. Our parents taught us that it is not a hospital sickness, so you must give the baby herbal medicine (37-year-old mother, FGD, Ashaiman). While some mothers attributed “ asram” to either “evil eyes” or spells cast on the baby by “bad people” usually out of envy or jealousy, others reported that mothers with babies suffering from “asram” were either cursed or promiscuous. Regarding the cause of “asram” one participant opined that it depends on the type of dress that is worn by the mother while pregnant: Sometimes it depends on the dress you wear when you are pregnant. When you wear clothes showing your navel your child will have “asram” when she/he is born (32-year-old mother, FGD, Sodom & Gomorrah). According to the participants, during pregnancy when mothers wear dresses that expose their navels, they are more likely to give birth to babies with “asram”. Upon further probing, it was revealed that the charm or spell passes through the mothers’ navel and affects the unborn baby. It was revealed that for fear of giving birth to babies with “asram”, pregnant mothers delayed seeking prenatal care especially in the first trimester. Another illness that was frequently mentioned by participants is a kind of fever that affects newborns with spiritual connotations. The illness is called “bosu-bosu” in the Twi dialect. One participant described the illness in this quote: There is another condition, it is babies’ fever, and we call it “bosu –bosu”, that’s what we call it. It is fever for babies. When you deliver, and you often sit outside in the evenings, the cold will enter your body and since the baby breastfeeds, you will transfer the cold to the baby and that brings “bosu-bosu” and the baby’s faeces will be greenish, but it is fever so that also happens to newborns (29-year-old mother, FGD, Sodom & Gomorrah). Similarly, another illness perceived to have some spiritual undertones described by the participants is “obobre” in Twi. According to one participant: There are some children too that when they are born, they will be “obobre”. Such children look weak with pale eyes and sometimes they pass greenish stools. For this sickness it is not for the hospital, so you must look for a spiritualist (20-year-old mother, FGD, Sodom & Gomorrah). While most of the illnesses were mentioned in both study sites, specific illnesses were reported by participants in Ashaiman. These illnesses included high body temperature, convulsion or asinism in T wi or “twitching”. “Asinism” or twitching is said to be caused by too much phlegm in the newborns body while “impremu” is an illness that is believed to make the newborn develop a big head (macrocephaly). Participants were not clear if “impremu” was the same illness as “puni” described in previous literature. Newborn illness symptom recognition among mothers Recognition of newborn danger signs is an important cue for action and care seeking for newborns. Generally, participants described illness symptoms in categories that they were familiar with. During FGDs, paleness of the body and eyes were the most common symptoms reported. According to one mother: My baby looked pale, and it was as if he had no blood (19-year-old mother, FGD, Sodom and Gomorrah). Other reported symptoms included high body temperature “ningbinduyle” literally meaning “hot body” in Dagbani. Other symptoms included difficulty in breathing, excessive crying without tears, inability to cry, discharging of the eyes, constipation and convulsion. When the child’s breathing changes, sometimes it comes fast and at times too it is low and with that you don’t have to waste any time (29-year-old mother, FGD, Sodom and Gomorrah). When the child is not breastfeeding well, when the child is vomiting too much … Also, there are some children that when they want to urinate, they will cry for a while before they urinate. There are some children too that while they are crying, they will be stretching themselves (39-year-old caregiver, FGD, Sodom and Gomorrah). In most of the neonatal illness cases, the mothers were the first to recognize the symptoms. The mothers’ mother, mothers -in -law (husband’s mother) peers and husbands were also involved in the symptom recognition process. The opinion of the husband was sought when the mothers’ mother or mothers- in-law was not available. Men were considered inexperienced in diagnosing newborn illness symptoms. The mothers’ mother or the mother -in-law were the household members frequently mentioned as significant others within the household that validated the symptoms after being recognized by the mother. Perceptions of severity were influenced by previous experience and beliefs about unusual behaviours. For example, one mother in Ashaiman described her baby’s abnormal crying thus: She was crying excessively, and I thought that something must be wrong with my child, because babies do not usually cry the way she was crying (29-year-old mother, FGD, Ashaiman). The mothers often looked for visible signs of deviations from normality. For example, one mother described her baby’s swollen or distended stomach as abnormal, which suggested that the baby was ill. Additionally, a baby refusing to breastfeed was considered a serious symptom of newborn illness. Severity was judged by symptom magnitude; how widespread the condition was, and the level of discomfort associated with the symptom. According to one mother: The rashes on my baby’s body were serious because they covered her entire body, and she was crying excessively (32-year-old mother, FGD, Sodom and Gomorrah). Mothers or caregivers were likely to seek care for the symptoms of the illness of their newborn if they perceived the symptoms to be severe and serious. For example, one mother intimated that: My baby had cough, but it was not serious because it did not last long (21-year-old mother, FGD, Sodom and Gomorrah). A symptom that was short-lived was therefore not considered serious as it could not pose any danger to the newborn. Management of newborn illnesses The appropriate management of newborn illness is an important predictor of newborn survival. The type of treatment given to a sick newborn is a major determinant of survival, growth and development. In this regard, mothers were asked to describe any actions that they had taken when their newborns presented with symptoms of illness. During FGDs we probed to gain a deeper understanding of the illnesses reported in and how these illnesses were managed. The following section discusses specific actions taken by mothers following recognition of the signs and symptoms signifying ill health of their newborns. Management of Diarrhoea Acute diarrhoea with or without vomiting is a major cause of newborn morbidity and mortality. It is against this background that diarrhoea in newborns must be taken seriously. Mothers reported that they will only seek care for their sick newborn with diarrhoea when the eyes become pale or white. While some mothers reported giving their babies ORS, others said they gave antibiotics and others did enema[1]. “ As for me when my newborn has diarrhoea, I do enema to cleanse the dirt from the babies stomach. Some of the babies, when they breastfeed for a long time and you don’t give enema, it worries the baby’s stomach ” (31-year-old mother, FGD, Sodom and Gomorrah). “ When my newborn had diarrhoea, I gave her ORS, but I also bought “tupaye”[an antibiotic] from the drugstore, which I dissolved in water for the baby, and the diarrhoea stopped” (28 -year-old mother, FGD, Ashaiman). Management of fever The mothers however intimated that, they will seek care for their baby with fever, when the baby’s body becomes hot or when the newborn begins to “ twitch” or “ obepremu ”. One mother described how she treated her newborn with symptoms of fever: I first bath the newborn with cold water and if there is no improvement then I will either go to the drug store or hospital (19-year-old mother, FGD, Sodom and Gomorrah). However, some mothers argued that newborn babies are “delicate’ and “fragile” so the best place to seek treatment for them when they are ill is the health facility. This action was however reported to be contingent on the availability of money at the time of the illness. When my baby is sick, and I have money, I will take the baby to the hospital, because I do not know what is wrong with the baby (22-year-old mother, FGD, Sodom and Gomorrah). One mother also argued that: For the babies, you cannot tell exactly where the pain is. That is why it is not fine to take the baby to the drugstore, but we take them to the hospital, because the owner of the drugstore may not have the machines to check where the sickness is (24-year-old mother, FGD, Sodom and Gomorrah). Despite a preference for health facility care for newborn fevers, some mothers indicated that there are some fevers that cannot be treated at the hospital and require other sources of treatment, including prayer camps, pastors, mallams, herbalists and fetish priests: When a baby has fever, sometimes it is not a hospital sickness, so you have to send the baby to the pastor in the prayer camp for prayers (37-year-old mother, FGD, Ashaiman). Management of cough Regarding cough, the mothers generally believed that cough is transmitted by people who visit the newborn baby. Some deliberately transmit the cough to the baby through the evil eye. The mothers indicated that for the spiritually induced cough, you have to consult a mallam, fetish priest or a pastor. For the coughs that are physically induced they bought cough syrup from chemical shops, while others reported using herbs. Mothers generally believed unless the cough was serious, there was no need to seek treatment, as it will clear after some days. “ Sometimes when you give birth someone can come to visit you and if the person has the illness and the person coughs, the child can get infected (29-year-old mother, FGD Participant, Sodom and Gomorrah). “ There are others who also visit the newborn baby and it may be possible some can have evil eyes, so if the person come, the person can give the sickness to the baby intentionally. As for this type of cough, it cannot be treated in the hospital” (24-year-old mother, FGD Participant, Ashaiman). Management of ARTI Some mothers reported that catarrh is caused by cold, when you put on the fan, and you don’t cover the newborn. Others believe that ARTI is caused by the damp floor and due to overcrowding. According to one mother: Catarrh is caused by sleeping under the fan and is treated with herbs called ‘‘opro’’ in the Twi dialect. The herb is passed over fire and the liquid are dropped into the nostrils of the newborn (26-year-old mother, FGD, Sodom and Gomorrah). Another mother intimated that: “When my baby’s breathing changes, I send her to the hospital, because, you don’t know what is wrong with the baby, but if you send the baby to the hospital and they check the baby they will know what is wrong with the baby and give you help. Management of “asram”, “obepremu”, “obobre” and “bosu-bosu” “Asram” “bosu-bosu”, “obobre” and convulsion “asinisim” are newborn illnesses that were categorised as “not -for -hospital” and requiring spiritual treatment by herbalists and witch doctors. These illnesses, according to the participants, could best be treated or managed outside of the hospital because these illnesses are believed to be caused by spiritual forces and must be attacked from the spiritual realm. Some of these illnesses are believed to be transferred to newborns by “bad people” pretending to be visiting the newborn baby and the mother, but intentionally through their “evil eyes”, transfer illness to the newborn. According to one mother: “ There are some people out of jealousy, once you give birth, they will pretend to be visiting you and the newborn, but through their “evil eyes”, they transfer illnesses such as ‘asram” and “bosu-bosu” to the newborn. These illnesses cannot be treated in the hospital”. Participants outlined a process for determining a course of treatment for illnesses such as “ asram ” and those that cannot be treated by biomedicine. They narrated that usually to determine a course of treatment for a baby perceived to be suffering from “ asram” , mothers reported that the spirit of the baby is consulted through divination by either mallams or herbalists to determine the real cause of the illness to provide an appropriate remedy. Once the mallams or herbalists identify the real cause, in some cases, herbal concoctions are prepared for the baby to drink while others take the baby to prayer camps for pastors to exorcise the evil spirits. Management of Neonatal Jaundice Regarding the management of neonatal jaundice, one participant said: When your baby has yellow eyes, we normally squeeze the mothers breast milk into the eyes of the child (19-year-old mother, FGD, Sodom & Gomorrah). The mothers believe that when a mother’s breastmilk is squeezed into the eyes of the newborn, the yellowish coloration in the baby’s eyes will be cleared and the baby will have normal eye colour. The mothers also believe that it is only a mothers’ breastmilk that can cure the illness and not the breastmilk of another woman. Management of “Tomatoes” Pemphigus Neonatorum In relation to the treatment for “tomatoes”, some mothers said: When your newborn has “tomatoes” …. you buy red powder and apply on the baby’s body. Others burn either the leaves of tomatoes or the seed; this mixture is then grinded with groundnuts and mixed with shea-butter to apply to the newborns body for four days (25-year-old mother, FGD, Sodom and Gomorrah). As for me when my baby had “tomatoes”, I went and teared the tomatoes leaves and the seeds then I burned it and mixed it with shea butter then I applied it on the baby by four days and all was gone (36-year-old mother, FGD, Ashaiman ). The mothers generally believe that for female neonates, the mixture should be applied for a period of four days while for male neonates the mixture should be applied for a period of three days. [1] An enema, also known as a clyster, is an injection of fluid, usually prepared from herbal concoctions into the lower bowel by way of the rectum. Also, the word enema refers to the liquid so injected or the device used for administering the injection. Using the enema syringe together with varied herbal concoction periodically is therefore practiced by mothers whose babies have stomach problems, and the reason behind this practice is to cleanse the baby’s stomach and allow them to pass stool freely without problems. Discussion This qualitative study explored newborn illnesses, local perceptions and management practices among residents in two urban slums in Ghana’s capital city, Accra. Findings show that diarrhoea, fever, cough and acute respiratory tract infections were the common illnesses affecting newborns in the slums. These illnesses appear to be similar to illnesses affecting newborns and infants in the general population in Ghana, although given the general environment of slums, diarrhoea, fever and acute respiratory infections are most likely to be severe and acute in the slums. These illnesses are also not unique to the slums studied. Similar findings in previous studies showed that diarrhoea and acute respiratory tract infections were among the causes of death in urban slum children [ 10 , 13 , 16 ]. This is not surprising because most slum households are characterised by earth floors, which can be breeding grounds for many infectious agents likely to pose risk for diarrhoeal disease incidence in neonates. Additionally, given the overcrowding, poor environmental sanitation, poor water supply characteristic of urban slums, it is not surprising that some mothers in both slums reported diarrhoea in their newborns during the first 28 days after birth. In an earlier study, Woldemicael & Tenkorang observed that earth floor households in slums were associated with an increased risk of diarrhoea and a carrier of streptococcus pneumoniae, the bacteria that cause acute respiratory infections in children [ 16 ]. These findings emphasize a need for observance of proper hygiene and handwashing during the neonatal period to substantially reduce diarrhoeal disease incidence in newborns. To address the incidence of diarrhoea and acute respiratory infections in newborns particularly in urban slums, it is imperative to improve the housing, water and sanitary conditions of slum neighborhoods. An important finding in this study is the belief that some illnesses “are not for hospital”. These illnesses included “asram”, “ asinisim” or convulsion, “ impremu ”, “ obobre ”, “ bosu-bosu” and a kind of cough believed to be spiritually induced. In this study the type of illness and their perceived cause determined whether treatment will be sought either biomedically through hospitals/clinics/pharmacies or outside of hospitals from alternative sources as indicated for some of the newborn illnesses such as “ asram ”, “ obobre” , “ bosu-bosu ” “ asinism ” and “ obepremu ” from mallams, herbalists, pastors and fetish priests. These findings are similar to those reported in earlier studies in the general population that established that “ asram” was a newborn illness that is believed to be caused by evil spirits and therefore cannot be treated in formal health care settings [ 32 , 33 , 34 , 35 ]. The current study is the first in Ghana that has found similar beliefs and perceptions about “asram” in slums. In previous studies in rural Ghana too, asram and puni were regarded as a range of illnesses affecting neonates and infants that do not have any clear biomedical equivalents [ 45 , 46 , 47 ]. The term asram has therefore been blamed for delayed care seeking because asram is perceived to be caused by evil spirits [ 33 ]. Both asram and puni are considered untreatable by biomedicine, and their diagnosis were interpreted as a significant barrier to appropriate care seeking [ 35 ]. Bazzano and colleagues for example reported that asram was universally described by caretakers as causing green veins on a baby’s body, persistent crying and growing lean [ 35 ]. It is believed that asram is the main serious illness (in local language terms), which affects newborns and is thought to be conveyed to the baby by other people intentionally because of jealousy or antipathy, either in utero or in the neonatal period. This often causes many pregnant women to delay seeking prenatal care during pregnancy [ 48 ]. Closely related to asram , is puni , which is described as an illness characterised by changes in the baby’s skull, i.e. there is either a gap at the centre of the baby’s head or an enlarged head with a gap; and both asram and puni are considered illnesses not for hospital [ 49 ]. While some respondents in Ghana thought it is possible to treat asram in health facilities, caregivers in Bangladesh concluded that categorising an illness as “not for hospital” could serve in some cases as a means of assuaging emotional concerns on the part of the family who cannot afford to pursue, or do not trust medical treatment [ 48 ]. In this study, “tomatoes” or pemphigus vulgaris was also highlighted. It is an infection of the newborn. Usually, rashes appear all over the body of the newborn with whitish fluid. Blisters break open and form sores on the skin of the neonate causing pain and making the babies to cry. Pemphigus vulgaris occurs when the immune system mistakenly makes antibodies against protein in healthy skin and mucous membranes [ 50 ]. The antibodies break down the bonds between the cells and fluids collects between the cell layers of the skin. This leads to blisters and erosions on the skin. The blisters are soft and break open easily to form painful sores. However, the perceived cause of “tomatoes” and how community members in the slums treated this condition is at variance with medical practice. “ Asinism ” or convulsion has been perceived in this study as a newborn illness that cannot be treated in formal care settings. This finding also resonates with an earlier study in northern Ghana that found that convulsions resulting from malarial fever were thought to have spiritual undertones [ 29 ]. Similar findings about convulsion or “ asinism” being an illness caused by supernatural forces such as the “evil eye” or witchcraft have been reported in Ghana [ 29 , 30 ] as well as in Anand Gujarat, an urban Indian slum [ 34 ]. While it is likely that these beliefs originated from the home regions of the slum residents who are mostly migrants, it will be important to understand how local aetiologies influence disease classifications especially in urban slums and how these beliefs affect newborn care in slums. This said, the findings suggest that beliefs about the causes of “ asram” and other common newborn illnesses have persisted among caregivers both in the general population and in urban slums in Ghana. The findings have implications for care seeking for newborn illnesses in slums as illnesses that are attributed to evil spirits are often linked to culturally prescribed actions that either necessitate home treatment, treatment by herbalists or in prayer camps. Mothers are also more likely to delay seeking appropriate care for some of the illnesses reported in this study such as “ asram ”, “ asinism ” “ impremu” “obobre” “bosu-bosu” and the “ spiritually induced cough” because of the belief that all these illnesses are caused by “evil spirits” and therefore untreatable in formal care settings. This is because local aetiologies that attribute illness to “evil spirits” and “witchcraft” are often linked to tradition, religion and culturally prescribed actions necessitating either managing the condition at home, through ingestion of local or herbal concoctions or remedial action by mallams, pastors in prayer camps or divine healers. Delayed care seeking for these illnesses in formal healthcare settings can affect positive health outcomes of newborns. The findings partly confirm the fact that individual level factors such as the knowledge and perception of the illness cause (cultural/traditional, biomedical) are important determinants of the type of care that will be sought for particular illnesses. The findings thus suggest a need to explore the role of social and behaviour change communication to dispel potentially harmful beliefs and practices while seeking opportunities for integrating alternative care providers such as faith and traditional healers, mallams, herbalists, pastors’ and traditional birth attendants into the continuum of care for pregnant, post-partum and postnatal mothers. If mothers of newborns are seeking the services of alternative care providers such as traditional birth attendants and herbalists, then efforts must be made to link up these providers to the biomedical health system through referral. In addition, seeking collaborative partnerships with alternative care providers including training to recognize when to refer patients to the formal health system may be a strategy that could limit failure to seek care or delayed care seeking for pregnant women, skilled delivery and for newborn illnesses perceived “not for hospital”. Another major finding in this study with implications for newborn care is the belief that neonatal jaundice is caused by contamination of the newborn’s eyes by burst amniotic fluid during the birthing process; and secondly that it is caused by not giving colostrum to the newborn after birth. These findings contrast with earlier studies conducted in the Greater Accra and Eastern regions of Ghana [ 51 ] and in Ogun State, Southwest Nigeria [ 52 ]. In these studies, the mothers attributed the causes of neonatal jaundice to eating foods like palm oil and to spiritual forces, although they correctly associated the disease with yellowing of the newborn’s eyes in Ghana [ 51 ] and blood group incompatibilities, blood infections and prematurity in Nigeria [ 52 ]. Neonatal jaundice is generally perceived by the mothers in this study not to be a serious illness unlike in the previous studies, and many mothers believe that over time the baby’s eyes will become clear and normal. To this effect, the lack of knowledge regarding the symptoms of neonatal jaundice by the mothers can endanger the lives of their newborns. This low-risk perception of neonatal jaundice as not a serious newborn illness can delay care seeking with likely consequences of disease developing into a serious condition and death. This is likely because newborn mothers who perceive an illness condition in their newborns to be severe and potentially life threatening will be more likely to seek urgent care for their newborn’s condition than those who perceive the condition to be low risk, less severe and low life threatening. In the present study, the mothers do not perceive neonatal jaundice as potentially life threatening and high risk, although neonatal jaundice when not treated early can lead to fatalities. Profound misconceptions about illnesses such as neonatal jaundice, are more likely to negatively impact on appropriate care seeking in formal health care settings. Delayed care seeking for these illnesses from professional healthcare providers can affect neonatal outcomes. The Ghana Health Service should collaborate with the private sector and non-governmental organizations to launch an investigation into these illnesses and the associated misconceptions and devise ways to support newborn mothers to better manage these illness conditions. The findings of this study should however be interpreted with certain limitations in mind. First, only two of Ghana’s urban slums were covered in this study. The findings may therefore not be generalisable to the rest of the country, nor to other countries with different contexts. Second, the study collected first-hand information from the participants. Given the potential for recall bias, however, much depended on the participants’ ability to recall services events during the first 28 days of their babies’ life. Finally, translation errors and errors resulting from interpretation of concepts in the qualitative data could have affected the study findings. However, we believe these errors, if at all, have been kept to the minimum given the data quality measures we implemented including rigorous training of research assistants and back-to-back translation of some transcripts. Conclusions Overall, the findings revealed that the main illnesses affecting newborns in the urban slums during the first 28 days of life included diarrhoea, fever, cough and acute respiratory tract infections. Other illnesses included neonatal jaundice, rashes, “tomatoes” pemphigus neonatorum, “asram” “obepremu” “obobre” and “bosu-bosu”. Generally, some of these illnesses are believed to have spiritual underpinnings and as such “not for hospital” (i.e. they cannot be treated by biomedicine in formal healthcare settings). The perceived causes of these illnesses influenced the type of treatment and care seeking. Illnesses that were perceived to be caused by supernatural forces were also perceived to be treatable by spiritual means, through pastors, mallams, traditional healers and herbalists. The illnesses perceived to be caused by germs and dirt were those perceived to be treatable by modern allopathic medicine. Given the issues surrounding neonatal illnesses in the urban slums and the identification of new illness categories that are perceived to be untreatable by biomedicine and its implications for newborn health outcomes as evidenced in this study, it is highly recommended that the Ghana Health Service and Ministry of Health lead a policy dialogue on the underlying causes of newborn illnesses such as neonatal jaundice, “tomatoes” pemphigus neonatorum, “bosu-bosu”, “obobre” “obepremu” and “asram” to better understand community perceptions and perspectives of these illnesses and their management, since the local perceptions of these illnesses influence how they are managed. Finally, it is recommended that the study be replicated in the general population to better understand the newborn illnesses, care and management practices at the household, community and health facility level to inform behaviour change communication strategies to address gaps in knowledge, attitudes and practices. Abbreviations ANC, Antenatal Care, BCG- Bacillus Calmette-Guérin , CHPS- Community Based Health Planning and Services, ENBC-Essential Newborn Care, FGD- Focus Group Discussion, GAR -Greater Accra Region, KMC- Kangaroo Mother Care, LBW- Low Birth Weight, MICS- Multiple Indicator Cluster Survey, SP- Suphurdoxine pyrimethamine, WHO- World Health Organisation Declarations Acknowledgements The authors acknowledge the staff of the Ghana Health Service, Dr. Isabella-Sagoe Moses, National Coordinator of Newborn Care at the Family Health Division, Dr. George Amofah, Former Deputy Director General, Dr. Linda Vanotto and Dr (Mrs) Charity Sarpong, Former Regional Directors of Health Services, Greater Accra, Dr. Patrick Amo-Mensah, Medical Director for Usher Polyclinic and Head, Ashiedu-Keteke Sub -Metropolitan Area, Mrs., Patience Ami Mamata, Municipal Director of Health Services, Ashaiman Municipality, the staff, midwives, nurses, Community Health Officers, the mother infant pairs in both slums, the community leaders, caregivers and slum based traditional birth attendants who volunteered information and made the study possible. We are also grateful to Williams Kwarah, Emmanuel Ofori Yartey, Peter Ntim Ofori, Noah Cudjoe and Anthony Pharin Amuzu for leading the data collection. Finally we thank Yakubu Alhassan for cleaning the quantitative data. Authors’ Contribution EAA conducted the study, designed and developed data collection tools, collected data, analysed and prepared the draft manuscript. JKG, PBA, EA and FG provided scientific advice on the design, data collection and analysis. All authors read and approved the final manuscript. Funding The authors received no specific funding for this work. Availability of Data The dataset (s) supporting the conclusions of this article are available from the lead author upon request. Ethical approval and consent to participate Ethical clearance was obtained from the Ghana Health Service Ethics Review Committee registration number GHS –ERC: 024/05/19). The study was conducted in accordance with the terms of the Helsinki Declaration. All study participants either thumb printed or signed informed consent forms before participating in the study. All interviews were conducted in private rooms, while focus group discussions were held in open spaces in either churches or classrooms. All participants were assured of confidentially. They were informed that participation was voluntary and they could refuse to answer any sensitive question/s or withdraw from the study at any point without any consequences. All ethical protocols regarding the handling of newborn babies such as taking their weights and temperature was adhered to in accordance with guidelines on research with human subjects. Consent to Publish All participants gave consent for the study’s findings to be published. All authors also consented to the publication of this manuscript. Competing interest The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article References World Health Organization. Newborns: improving survival and well-being. 2020. Available from: https://www.who.int/news-room/fact-sheets/detail/newborns-reducing-mortality [cited Jan 5 2021] UNICEF. Levels and Trends in Child Mortality Report November 2020. Available from: https://www.unicef.org/publications/index_101071.html Bhutta, Z. A., Das, J. K., Bhal, R., Lawn, J. E., Salam, R. A., Paul, V. K., & Walker, N. (2014). Can available interventions end preventable deaths in mothers, newborn babies, and still births, and at what cost? The Lancet, 384 (9940), 347-370. Lawn, J. E., Blencowe, H., Shefali, O., Danzhen, Y., Anne, L., Peter, W., . . . Cousens, S. N. (2014). Every Newborn: progress, priorities, and potential beyond survival. Lancet, 384, 189-205. Wang, H., Dwyer -Lindgren, L., & Lofgren, K. T. (2014). Global, regional, and national levels of neonatal, infant, and under-5 mortalities during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet, 384 (9947), 957–979. WHO. (2006). Pregnancy, Childbirth, Postpartum and Newborn Care: A Guide for Essential Practice. Thiede, M., & Koltermann, K. C. (2013). Access to health services: analyzing non-financial barriers in Ghana, Rwanda, Bangladesh and Vietnam using household survey data; a review of the literature. A review of the literature. New York: UNICEF , 61 . Bazzano, A. N., Taub, L., Oberhelman, R. A., & Var, C. (2016). Newborn care in the home and health facility:Formative findings for intervention research in Cambodia. Healthcare, 4 , 94. Lee, A. C., Kozuki, N., & Blencowe, H. (2013). Intrapartum -related neonatal encephalopathy incidence and impairment at a regional and global level for 2010 and trends from 1990. Pediatric Research, 74 (1), 50-72. Fry, S., Cousins, B., & Olivola, K. (2002). Health of children living in urban slums in Asia and the near east: Review of existing literature and data. Washington, DC: Environmental Health Project, US Agency for International Development . Awasthi, S., & Pande, V. K. (1998). \"Cause- specific mortality in under fives in the urban slums of lucknow, north India,\". Journal of Tropical Pediatrics, 44 (6), 358-361. Hussain, A., Ali, S. M., & Kvale, G. (1999). \"Determinants of mortality among children in the urban slums of Dhaka city, Bangladesh\". Tropical Medicine and International Health, 4 (11), 758-764. Vaid, A., Mammen, A., Primrose, B., & Kang, G. (2007). \"Infant mortality in an urban slum,\". Indian Journal of Pediatrics, 74 (5), 449-453. WHO. (2000a). \"Maternal and neonatal tetanus (MNT) elimination\" . Shrivastava, A., K. (2004). Population, Development, Environment and Health; Encyclopaedia of Environmental Pollution, Agriculture and Health Hazzards. In Infectious Disease (Vol. 4, pp. page 80). Woldemicael, G. (2001). \"Diarrhoeal morbidity among young children in Eritrea: environmental and socio- economic determinants\". Journal of Health, Population, and Nutrition, 19 (2), 83-90. Nyandiko, W. M., Greenberg, D., Shany, E., Yiannoutsos, C. T., Musick, B., & Mwangi, A. W. (2007). “Nasopharyngeal Streptococcus pneumoniae among under-five year old children at the moi teaching and referral hospital, Eldoret, Kenya,”. East African Medical Journal, 84 (4), 156-162. GSS. (2014a). Ghana Demographic and Health Survey. Rockville, Maryland. Beguy, D., Elung'ata, P,; Mberu, B.; Oduor, C; Wamukoya, M.; Nganyi, B.; Ezeh, A. (2015). Health & Demographic Surveillance Systems Profile:The Nairobi Urban and Demographic Surveillance System (NUHDSS), International Journal of Epidemiology, 44 (2) 462-471. doi:https://doi.org/10.1093/ije/dyu251 Lilford, J. R., Oyebode, O., Satterthwaite, D., Melendez-Torres, G. J., Chen, Y.-F., Mberu, B., . . . Ezeh, A. (2017). Improving the health and welfare of people who live in slums. Lancet, 389, 559-570. AMHD. (2019). Annual Report. AKSM. (2018) Annual Report GSS & ICF (2023). Ghana Demographic and Health Survey, 2022: Key Indicators Report, Accra, Ghana, and Rockville, Maryland, USA: GSS and ICF. GSS. (2020). 2021 Population and Housing Census . GSS. (2018a). Ghana Multiple Indicator Cluster Survey, 2018. UN. (2013). World Economic and Social Survey 2013; Sustainable Development Challenges. New York: Caldwell, B. K., Caldwell, J. C., & Pieres, I. (2002). Why do the Children of the poor die in Dhaka, Bangladesh? Population Research and Policy Review, 21 (3), 159-178. Rashid, S. F., Hadi, A., & Afsana, K. (2001). Acute respiratory infections in rural Bangladesh: cultural understandings, practices and the role mothers and community health volunteers. Tropical Medicine & International Health, 6 (4), 249-255. Adongo, P. B., Kirkwood, B., & Kendall, C. (2005). How local community knowledge about malaria affects insecticide- treated net use in northern Ghana. Tropical Medicine & International Health, 10 (4), 366-378. Galaa, S. Z., & Daare, K. (2008). Understanding barriers to maternal child health services utilisation in northern Ghana. Journal of Social Development in Africa, 23 (2). Syed, U., Khadka, N., & Khan, A. (2008). Care- seeking practices in South Asia: using formative research to design program interventions to save newborn lives. Journal of Perinatology, 28 , S9-S13. Choudhury, N., & Ahmed, S. M. (2011). Maternal care practices among the ultra poor households in rural Bangladesh: a qualitative exploratory study. BMC Pregnancy and Childbirth, 11 (1), 15. Farnes, C., Beckstrand, R. L., & Callister, L. C. (2011). Help-seeking behaviours in child bearing women in Ghana, West Africa. International Nursing Review, 58 (4), 491-497. Nimbalkar, A. S., Shukla, V. V., Phatak, A. G., & Nimbalkar, S. M. (2013). Newborn Care Practices and Health Seeking Behaviour in Urban Slums and Villages of Anand Gujarat. Indian Pediatrics, 50 , 409 -413. Bazzano, A. N., Kirkwood, B. R., Tawiah‐Agyemang, C., Owusu‐Agyei, S., & Adongo, P. B. (2008). Beyond symptom recognition: care‐seeking for ill newborns in rural Ghana. Tropical medicine & international health , 13 (1), 123-128. Glaser, B., G.; & Strauss, A. (1967). The discovery of Grounded Theory: Strategies for qualitative research. Chicago, IL.Aldine Transaction. Guest, G.; Bunce, A.; Johnson, L.(2006). How many interviews are enough?An experiment with data saturation and variability. Field Methods , 18, 59-82. Francis, J., J.; Johnston, M.; Robertson, C. et al.(2010). What is an adequate sample size? Operationalising data saturation for theory -based interview studies. Psychol Health, (25), 1229-45. Guba, E., G. (1981). Criteria for assessing the trustworthiness of naturalistic inquiries. Educational Communication and Technology Journal, 29, 75-91. Silverman, D. (2001). Interpreting qualitative data: methods for analysing talk, text and interaction. (Vol. 2). London: SAGE. Zhi., H. L. (2014). A comparison of convenience sampling and purposive sampling. PubMed, 105-11. Bernard, H. R. (2011). Research Methods in Anthropology : Qualitative and Quantitative Approaches. (5th ed.). Plymouth, U.K.: Altamira Press. Spradley, J. P. (1979). The ethnographic interview. New York: Holt, Rinehart & Winston. Creswell, J., W. (2009). Research design: Qualitative, quantitative, and mixed methods approaches (3rd Edition ed.). Thousand Oaks, California: SAGE Publications Inc. Hill, Z. C., & Kendall, P. A. (2003). Recognizing Childhood Illnesses and their traditional explanations: exploring options for care - seeking interventions in the context of the IMCI strategy in rural Ghana. Tropical Medicine and Intenational Health, 8 (7), 668-676. Okyere, E. C., & Tawiah-Agyemang Manu, A. (2010). Newborn Care: the effect of a traditional illness, asram, in Ghana. Annals of Tropical Paediatrics: International Child Health, 30 (4), 321-328. Marah, A. (2011). Assessing household practices that influence neonatal survival in the Asante-Akim North District of Ashanti region-Ghana (Doctoral dissertation). Caldwell, B. K., Caldwell, J. C., & Pieres, I. (2002). Why do the Children of the poor die in Dhaka, Bangladesh? Population Research and Policy Review, 21 (3), 159-178. Hill, Z. C., & Kendall, P. A. (2003). Recognizing Childhood Illnesses and their traditional explanations: exploring options for care - seeking interventions in the context of the IMCI strategy in rural Ghana. Tropical Medicine and Intenational Health, 8 (7), 668-676. Carvalho, A. A., Santos, D. A. D., Carvalho, M. A. D. R., Eleutério, S. J. P., & Xavier, A. R. E. D. O. (2019). Neonatal pemphigus in an infant born to a mother with pemphigus vulgaris: a case report. Revista Paulista de Pediatria , 37 , 130-134. Seneadza, N., . A., H., Insaidoo, G., Boye, H., Ani- Amponsah, M., Leung, T., Meek, J., & Enweronu-Laryea, C. (2022). Neonatal jaundice in Ghanaian children: Assessing maternal knowledge, attitude, and perceptions. PLoS One, 17 (3). Ogunlesi, T., A., & Abdul, A., R. (2015). Maternal knowledge and care‑seeking behaviors for newborn jaundice in Sagamu, Southwest Nigeria. Nigerian Journal of Clinical Practice, 18 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 15 Nov, 2024 Editor assigned by journal 13 Nov, 2024 Submission checks completed at journal 13 Nov, 2024 First submitted to journal 11 Nov, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-5434704\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":378479442,\"identity\":\"c522d8cf-78d4-4266-bc18-29653ac629ff\",\"order_by\":0,\"name\":\"Edward Akolgo Adimazoya¹*\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4ElEQVRIiWNgGAWjYHACgwMQmhlES8iQooUtAaSFhygtUJoHzCCshZ/98MZDN2rq5AyOn/n86kaNBQ8D++GjG/BpkexJKzicc4zN2OBM7jbrnGNAh/Gkpd3A66oDOQaHc9h4EjccyN1mnMMG1CLBY4ZXi/35N0At/yQSN5x/88wYyCCsxUACaEtum0Hihhs5zI9z24jQInHjWcHh3L4EY8kbz8yYc/skeNgI+YW/P3nz55xvdXJ855MfgxnAMDyGVwscKBxgYJMAMdiIUg4C8g0MzB+IVj0KRsEoGAUjCgAAwmxL9rn4c9UAAAAASUVORK5CYII=\",\"orcid\":\"\",\"institution\":\"Johns Hopkins University\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Edward\",\"middleName\":\"Akolgo\",\"lastName\":\"Adimazoya¹*\",\"suffix\":\"\"},{\"id\":378479443,\"identity\":\"0281acec-75e1-40c5-9745-50e2cdd5c332\",\"order_by\":1,\"name\":\"John Kumuuori Ganle²†\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University of Ghana\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"John\",\"middleName\":\"Kumuuori\",\"lastName\":\"Ganle²†\",\"suffix\":\"\"},{\"id\":378479444,\"identity\":\"a2942e4a-a023-489b-8e33-36157e3d54b7\",\"order_by\":2,\"name\":\"Emmanuel Asampong³†\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University of Ghana\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Emmanuel\",\"middleName\":\"\",\"lastName\":\"Asampong³†\",\"suffix\":\"\"},{\"id\":378479446,\"identity\":\"cc15c6f2-1818-4f26-b931-a93de4b828bb\",\"order_by\":3,\"name\":\"Franklin Glozah³†\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University of Ghana\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Franklin\",\"middleName\":\"\",\"lastName\":\"Glozah³†\",\"suffix\":\"\"},{\"id\":378479447,\"identity\":\"38c9e984-7492-4cbb-8eeb-de289af46591\",\"order_by\":4,\"name\":\"Philip Baba Adongo³†\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University of Ghana\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Philip\",\"middleName\":\"Baba\",\"lastName\":\"Adongo³†\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2024-11-11 21:53:09\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-5434704/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-5434704/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":71220804,\"identity\":\"fe5ebdf0-20d6-43f8-a5ec-4dec61382f5c\",\"added_by\":\"auto\",\"created_at\":\"2024-12-12 09:18:55\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":822984,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-5434704/v1/aacabdc5-67c3-4e58-b16e-cbca99b5d791.pdf\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"‘Asram' is not for hospital’: Perceptions and management of newborn illnesses in two urban slums in Accra, Ghana\",\"fulltext\":[{\"header\":\"Background\",\"content\":\"\\u003cp\\u003eIn 2020, nearly half (47%) of all under -five deaths occurred in the newborn period (i.e. the first 28 days of life), an increase of 40% from 1990 [\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e]. This represents about 2.4\\u0026nbsp;million newborns globally. Most of these deaths occur during labour, delivery and the immediate post-partum period [\\u003cspan additionalcitationids=\\\"CR3\\\" citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eDespite significant investments in interventions to reduce neonatal morbidity and mortality, progress has been especially slow in Sub Saharan Africa, where newborns have a ten times risk of dying within the first 28 days after birth compared to high income countries [\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e]. Newborn survival in the first few days after birth is thus a critical public concern, because the neonatal period which marks the interval from birth to the first 28 days of life, is the most vulnerable period for any newborn. This vulnerability is linked to the stress of delivery and the transition and adaptation from uterine life to ex-utero with the associated exposures to infections and other dangers [\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eAmong other things, majority of newborns die because mothers lack adequate quality care during labour and delivery [\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e]. Coupled with inadequate care is inadequate knowledge and understanding of care for newborns, including the mother\\u0026rsquo;s ability to identify danger signs for newborn illnesses [\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e]. Generally, newborn deaths result from a combination of medical causes, social factors and health system failures. These factors vary not only by context but also by culture. Among the several contributory factors to the burden of neonatal morbidity and mortality, preterm birth complications are the single largest cause of death, responsible for an estimated 36% of all neonatal deaths with intrapartum-related conditions (previously called birth asphyxia; 23%) and infections notably sepsis, meningitis and pneumonia, contributing 23% [\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e]. A key observation however is that the causes of newborn deaths shift as the newborn progresses from the early neonatal to the late neonatal period. During the early neonatal period (0\\u0026ndash;6 days), sepsis accounts for only (8%) of neonatal mortality compared to 37% in the late period (7\\u0026ndash;28 days), where pneumonia, tetanus, diarrhoea, congenital disorders and other factors contribute marginally to the morbidity and mortality burden of neonates [\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eAvailable evidence also suggests that the causes of death in urban slum children include poor neonatal care [\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e], neonatal tetanus [\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e], diarrhoea and respiratory infections [\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e]. Tetanus immunisations routinely provided during antenatal care services and clean deliveries have been shown to potentially prevent neonatal tetanus [\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e]. Urban slum residency has been characterized by earth floors, which often serve as breeding grounds for many infectious agents [\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e]; living in earth floor houses has been associated with increased risk of diarrhoea [\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e], and being a carrier of streptococcus pneumoniae, a bacteria that commonly causes acute respiratory infections in children [\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e]. Ghana, like many middle-income countries, experienced rapid urbanisation over the past decades, resulting in the growth and spread of slums across its major cities. Roughly about 39.7% of the country\\u0026rsquo;s 5.4\\u0026nbsp;million urban population are now residing in slums [\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e]. Neonatal health outcomes are even worse in poor urban slums [\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e]. Most slums lack improved water, adequate sanitation, hygiene, sufficient living area and durable housing [\\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eIn 2018 the Ashaiman Municipality and the Ashiedu-Keteke Sub Metropolitan area where Sodom and Gomorrah are located recorded neonatal mortality rates that were higher than the national average of 25 deaths per thousand live births [\\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e21\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e]. In Ghana, newborn deaths account for 61% of infant deaths and 43% of under-five deaths [\\u003cspan citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR24\\\" class=\\\"CitationRef\\\"\\u003e24\\u003c/span\\u003e]. About one in every 24 Ghanaian children dies before reaching age one, and one in every 17 does not survive to his or her fifth birthday [\\u003cspan citationid=\\\"CR24\\\" class=\\\"CitationRef\\\"\\u003e24\\u003c/span\\u003e]. While infant and under-five mortality rates declined by 28% and 44% respectively since 1998, neonatal mortality rate marginally declined from 29 to 25 deaths per 1000 live births [\\u003cspan citationid=\\\"CR25\\\" class=\\\"CitationRef\\\"\\u003e25\\u003c/span\\u003e]. With this rate, Ghana will most likely miss the UN Sustainable Development Goal 3 target of reducing neonatal deaths to 12 deaths per thousand live births by 2030 [\\u003cspan citationid=\\\"CR26\\\" class=\\\"CitationRef\\\"\\u003e26\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eIllness perceptions are major determinants of the nature, type and sources of treatment for those particular illnesses. For example, in their study on child deaths in Dhaka\\u0026rsquo;s slums, Bangladesh, Caldwell et al, observed that two- thirds of child deaths occurred in a context of beliefs in harmful spirits or forces, and the need to appease or combat them [\\u003cspan citationid=\\\"CR27\\\" class=\\\"CitationRef\\\"\\u003e27\\u003c/span\\u003e]. Local etiologies that attribute illness to evil spirits are often linked to culturally prescribed action, necessitating home management or local treatment [\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR28\\\" class=\\\"CitationRef\\\"\\u003e28\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR29\\\" class=\\\"CitationRef\\\"\\u003e29\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR30\\\" class=\\\"CitationRef\\\"\\u003e30\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR31\\\" class=\\\"CitationRef\\\"\\u003e31\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR32\\\" class=\\\"CitationRef\\\"\\u003e32\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR33\\\" class=\\\"CitationRef\\\"\\u003e33\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR34\\\" class=\\\"CitationRef\\\"\\u003e34\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR35\\\" class=\\\"CitationRef\\\"\\u003e35\\u003c/span\\u003e]. In Bangladesh, community members asserted that if symptoms were caused by evil spirits, then there was no use going to a modern doctor [\\u003cspan citationid=\\\"CR32\\\" class=\\\"CitationRef\\\"\\u003e32\\u003c/span\\u003e]. Similarly, in Ghana, hospitals were regarded as useless against spiritual attacks [\\u003cspan citationid=\\\"CR29\\\" class=\\\"CitationRef\\\"\\u003e29\\u003c/span\\u003e]. Convulsions as a result of malarial fever were also thought to have spiritual undertones, and negative outcomes of childbirth were often attributed to witchcraft in Northern Ghana [\\u003cspan citationid=\\\"CR29\\\" class=\\\"CitationRef\\\"\\u003e29\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eWhile the extant literature suggests that newborn illnesses have different interpretations both in the rural population in Ghana [\\u003cspan citationid=\\\"CR35\\\" class=\\\"CitationRef\\\"\\u003e35\\u003c/span\\u003e], and among ultra-poor rural households in Bangladesh [\\u003cspan citationid=\\\"CR32\\\" class=\\\"CitationRef\\\"\\u003e32\\u003c/span\\u003e], and urban slums in India [\\u003cspan citationid=\\\"CR34\\\" class=\\\"CitationRef\\\"\\u003e34\\u003c/span\\u003e], few studies have been carried out in urban slums in Ghana to explore the common illnesses affecting neonates, and how these illnesses are perceived and managed. This knowledge gap could limit full understanding of local community perceptions and management of newborn illnesses in urban slums in Ghana. This could potentially hamper efforts to design effective community-based interventions to reduce neonatal deaths to 12 deaths per thousand live births by 2030 as envisaged under the UN Sustainable Development Goal 3 target [\\u003cspan citationid=\\\"CR26\\\" class=\\\"CitationRef\\\"\\u003e26\\u003c/span\\u003e]. This qualitative study therefore aimed to contribute to filling this knowledge gap by exploring newborn illnesses, local perceptions and management practices among residents in two urban slums in Ghana\\u0026rsquo;s capital city, Accra.\\u003c/p\\u003e\"},{\"header\":\"Methods\",\"content\":\"\\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eStudy design and population\\u003c/h2\\u003e \\u003cp\\u003eThe data used for this paper form part of a concurrent mixed methods cross-sectional study. In this current paper, data from the qualitative component of the study are reported. The study was conducted among women of reproductive age with live neonates aged 0\\u0026ndash;28 days, slum based traditional birth attendants who delivered a live baby between January 1st and June 30th 2020, care givers, community leaders in the slums, and public and private healthcare managers at national, regional, and sub national level.\\u003c/p\\u003e \\u003c/div\\u003e\\n\\u003ch3\\u003eStudy area, sampling, and recruitment\\u003c/h3\\u003e\\n\\u003cp\\u003eThe study was conducted in two large urban slums (Ashaiman and Sodom and Gomorrah) in Accra. Both slums have similar characteristics: they are ethnically diverse, mostly poor, barely educated and generally unemployed. Their residents are mostly engaged in odd, non-permanent jobs including head porterage popularly called Kayayei. They also have poor access to health services.\\u003c/p\\u003e \\u003cp\\u003eThe sample size was determined using guidelines for determining saturation [\\u003cspan citationid=\\\"CR36\\\" class=\\\"CitationRef\\\"\\u003e36\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR37\\\" class=\\\"CitationRef\\\"\\u003e37\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR38\\\" class=\\\"CitationRef\\\"\\u003e38\\u003c/span\\u003e]. The sample comprised 138 participants (14 focus groups and 13 in-depth interviews) comprising 121 females and 17 males. The size of the focus groups ranged between 8\\u0026ndash;10 participants. All the FGD participants were female except one group with community leaders. In-depth interviews were conducted with 2 national newborn experts, 2 district directors of health services, 2 district newborn coordinators, 6 midwives from the sub district level in charge of maternal and newborn health service delivery and a midwife from a private maternity home. As the emphasis in qualitative research is not on large sample sizes for representational purposes, but on trustworthiness and reliability of the findings [\\u003cspan citationid=\\\"CR39\\\" class=\\\"CitationRef\\\"\\u003e39\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR40\\\" class=\\\"CitationRef\\\"\\u003e40\\u003c/span\\u003e], recruitment of participants was purposive, and continued until saturation was reached on major issues that the research explored [\\u003cspan citationid=\\\"CR37\\\" class=\\\"CitationRef\\\"\\u003e37\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR38\\\" class=\\\"CitationRef\\\"\\u003e38\\u003c/span\\u003e].Participant recruitment was based on the homogenous, expert and maximum variation or heterogenous purposive sampling methods [\\u003cspan citationid=\\\"CR41\\\" class=\\\"CitationRef\\\"\\u003e41\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eUsing purposive or judgmental sampling therefore, participants were deliberately recruited based on their unique knowledge, experiences and expertise on the subject matter [\\u003cspan citationid=\\\"CR42\\\" class=\\\"CitationRef\\\"\\u003e42\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR43\\\" class=\\\"CitationRef\\\"\\u003e43\\u003c/span\\u003e] and their availability and willingness to participate [\\u003cspan citationid=\\\"CR44\\\" class=\\\"CitationRef\\\"\\u003e44\\u003c/span\\u003e].Thirteen health professionals were recruited for in-depth interviews, based on their experience, professional knowledge and expertise in newborn care through referral or snowball sampling and the expert sampling method [\\u003cspan citationid=\\\"CR43\\\" class=\\\"CitationRef\\\"\\u003e43\\u003c/span\\u003e], while a total of 76 mothers with with live neonates aged 0\\u0026ndash;28 days and 16 slum based traditional birth attendants who delivered a live baby in the past six months prior to data collection were recruited for focus groups based on the homogeneous sampling method. They were recruited because of the similar attributes, traits and characteristics that they share as a group. Finally, sixteen caregivers comprising grand mothers\\u0026rsquo;, mother in-laws and older women in the communities and seventeen community or tribal leaders were selected in focus groups based on the heterogeneous sampling method to solicit their views and perspectives on multiple angles of newborn care, as gate keepers of the community and repositories of community indigenous knowledge, norms and practices on newborn care. All participants were selected through referral and stakeholder mapping.\\u003c/p\\u003e \\u003cp\\u003eDiscussions in focus groups lasted between 45 minutes and 1 hour. All discussions were conducted in one of three local dialects \\u003cem\\u003eTwi, Ewe and Dagbani\\u003c/em\\u003e depending on the dialect that was mostly spoken and understood by the participants. In-depth interviews were conducted in English with 13 healthcare managers. The interviews usually lasted between 45 minutes and 1 hour. All FGDs and IDIs were tape-recorded, and notes taken to document observations about the interview content, the participants and the context. All interviews were conducted in private rooms, while focus group discussions were held in open spaces in either churches or classrooms.\\u003c/p\\u003e \\u003cp\\u003eBefore the commencement of data collection, all data collection tools were pre-tested and refined based on the pre-test results. We also trained three data collection assistants from January 2\\u0026ndash;4, 2020. The training offered a hands-on approach on how to conduct qualitative studies as well as interviewing skills, and interpretation of the questions, The training also covered ethics and compliance with research issues on human subjects.\\u003c/p\\u003e\\n\\u003ch3\\u003eInstruments and data collection\\u003c/h3\\u003e\\n\\u003cp\\u003eThe data collection tools comprised semi structured open ended topic guides for both focus groups and in-depth interviews. The instruments were designed to elicit responses to answer research questions 1, 3 and 5 namely; what kinds of illnesses affect neonates during the first 28 days of life in Ashaiman and Sodom and Gomorrah; what is the health seeking behaviours for newborn illnesses among mothers and caregivers in Ashaiman and Sodom and Gomorrah and what are the barriers to newborn care in Ashaiman and Sodom and Gomorrah.\\u003c/p\\u003e\\n\\u003ch3\\u003eData processing and analysis\\u003c/h3\\u003e\\n\\u003cp\\u003eThe qualitative data were analyzed thematically. This involved several processes. The audio recordings were transcribed verbatim and transcribes in the local languages were translated into English. Back translations were done on selected transcripts to check the accuracy of the translations and to verify inconsistencies. All the transcripts and interview notes were then read and reviewed thoroughly, and notes made on hard copies of the transcripts. A preliminary coding structure and code book was developed which led to the next phase. We then exported all the transcripts into NVivo 12.x64 windows, where the data were both deductively and inductively coded. Data coding continued until theoretical saturation was reached (i.e., where no new concepts emerged from successive coding of the data). The completed code structure was then applied to develop and report themes with verbatim quotes.\\u003c/p\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eCharacteristics of participants\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026nbsp;For the qualitative research participants, Table 1 describes the essential characteristics of the participants. The ages of the qualitative sample ranged from 15--70 years, with approximately 72 (52.2%) being in the modal age range of 25--34 years. With respect to education, the majority (74, 53.6%) had no formal education, and only 13 (9.4%) had tertiary education. Approximately 53.6% were currently married, whereas 87% were female. With respect to religion, approximately 56.5% were Christian, 30.4% were Muslim, and 13.1% had other faiths.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eTable 1: Characteristics of qualitative research participants\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003ctable border=\\\"1\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\" width=\\\"670\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 273px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eCharacteristics\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 95px;\\\"\\u003e\\n \\u003cp\\u003eNational\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003en (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 94px;\\\"\\u003e\\n \\u003cp\\u003eAshaiman\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003en (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003eSodom \\u0026amp; Gomorrah\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003en (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003eTotal\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003en (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 273px;\\\"\\u003e\\n \\u003cp\\u003eN\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 95px;\\\"\\u003e\\n \\u003cp\\u003e2\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 94px;\\\"\\u003e\\n \\u003cp\\u003e65\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e71\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e138\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 273px;\\\"\\u003e\\n \\u003cp\\u003eAge of qualitative participants\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003emean \\u0026plusmn; SD\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 95px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 94px;\\\"\\u003e\\n \\u003cp\\u003e29.4 \\u0026plusmn; 5.9\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e26.8 \\u0026plusmn; 5.8\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e28.1 \\u0026plusmn; 6.0\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 273px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eAge group of participants\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 95px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 94px;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 273px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp;\\u0026lt;25\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 95px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 94px;\\\"\\u003e\\n \\u003cp\\u003e17 (26.1)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e22 (31.0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e39 \\u0026nbsp;(28.2)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 273px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp;25-34\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 95px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 94px;\\\"\\u003e\\n \\u003cp\\u003e35 (54.0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e37 (52.1)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e72 (52.2)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 273px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp;35-44\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 95px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 94px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; 4 (6.1)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; 3 (4.2)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; 7 \\u0026nbsp; \\u0026nbsp;(5.1)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 273px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp;45-54\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 95px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 94px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; 4 (6.1)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; 4 (5.6)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; 8 \\u0026nbsp; \\u0026nbsp;(5.8)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 273px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp;55-64\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 95px;\\\"\\u003e\\n \\u003cp\\u003e1(50.0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 94px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; 5 (7.7)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; 5 (7.1)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e11 \\u0026nbsp; \\u0026nbsp;(8.0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 273px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp;65-74\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 95px;\\\"\\u003e\\n \\u003cp\\u003e1(50.0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 94px;\\\"\\u003e\\n \\u003cp\\u003e- (0.0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; - (0.0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; 1 \\u0026nbsp; \\u0026nbsp;(0.7)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 273px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eMarital status\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 95px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 94px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 273px;\\\"\\u003e\\n \\u003cp\\u003eCurrently married\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 95px;\\\"\\u003e\\n \\u003cp\\u003e2 (100)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 94px;\\\"\\u003e\\n \\u003cp\\u003e40 (61.5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e32 (45.1)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e74 (53.6)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 273px;\\\"\\u003e\\n \\u003cp\\u003eCo-habiting\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 95px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 94px;\\\"\\u003e\\n \\u003cp\\u003e20 (30.8)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e20 \\u0026nbsp;(28.2)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e40 (29.0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 273px;\\\"\\u003e\\n \\u003cp\\u003eNot in union\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 95px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 94px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; 5 (7.7)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e19 \\u0026nbsp;(26.7)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e24 (17.4)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 273px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eHighest level of education\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp;No Formal Education \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp;\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 95px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 94px;\\\"\\u003e\\n \\u003cp\\u003e29 (44.6)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e32 \\u0026nbsp;(45.1)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e61 (44.2)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 273px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp;Primary\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 95px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 94px;\\\"\\u003e\\n \\u003cp\\u003e9 (13.9)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e10 (14.1)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e19 (13.8)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 273px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp;Middle School/JHS/JSS\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 95px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 94px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; 8 (12.3)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; 9 (12.7)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e17 (12.3)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 273px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp;Senior High School/SSS/VOC/TECH\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 95px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 94px;\\\"\\u003e\\n \\u003cp\\u003e13 (20.0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e15 (21.1)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e28 (20.3)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 273px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp; \\u0026nbsp; Tertiary \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp;\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 95px;\\\"\\u003e\\n \\u003cp\\u003e2 (100)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 94px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; 6 \\u0026nbsp;(9.2)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; 5 \\u0026nbsp;(7.0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e13 \\u0026nbsp;(9.4)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 273px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eSex\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 95px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 94px;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 273px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp;Male\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 95px;\\\"\\u003e\\n \\u003cp\\u003e1(50.0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 94px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; 8 \\u0026nbsp;(12.3)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; 9 ( 12.7)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; 18 (13.0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 273px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp;Female\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 95px;\\\"\\u003e\\n \\u003cp\\u003e1(50.0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 94px;\\\"\\u003e\\n \\u003cp\\u003e57 (87.7)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e62 (87.3)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e120 (87)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 273px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eReligion\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 95px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 94px;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 273px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp;Christian\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 95px;\\\"\\u003e\\n \\u003cp\\u003e2 (100)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 94px;\\\"\\u003e\\n \\u003cp\\u003e37 (56.9)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e39 \\u0026nbsp;(54.9)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e78 (56.5)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 273px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp;Muslim\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 95px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 94px;\\\"\\u003e\\n \\u003cp\\u003e15 (23.1)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e27 \\u0026nbsp;(38.0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e42 \\u0026nbsp;(30.4)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 273px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp;Other religion\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 95px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 94px;\\\"\\u003e\\n \\u003cp\\u003e13 \\u0026nbsp;(20.0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; 5 \\u0026nbsp; \\u0026nbsp;(7.1)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e18 (13.1)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003eTable 2 describes the venues and locations where focus groups and In-depth interviews were conducted.\\u003c/p\\u003e\\n\\u003cp\\u003eTable 2 :Participants of FGD and IDIs by study location\\u003c/p\\u003e\\n\\u003ctable border=\\\"1\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\" width=\\\"716\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 196px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"6\\\" valign=\\\"bottom\\\" style=\\\"width: 520px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eFocus Group Discussions and In -Depth Interviews\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 196px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" valign=\\\"bottom\\\" style=\\\"width: 246px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eIn-Depth Interviews\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"4\\\" valign=\\\"bottom\\\" style=\\\"width: 274px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eFocus Group Discussions\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 196px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eParticipants/Groups\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eNumber of Participants\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eLocation\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eNumber of FGD\\u0026rsquo;s\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eNumber of Participants\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" valign=\\\"bottom\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eLocation\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 196px;\\\"\\u003e\\n \\u003cp\\u003eMothers with newborns 0-28\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" valign=\\\"bottom\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e9\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003eGbemi\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 196px;\\\"\\u003e\\n \\u003cp\\u003eMothers with newborns 0-28\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" valign=\\\"bottom\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e9\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003eBlakpatsona\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 196px;\\\"\\u003e\\n \\u003cp\\u003eMothers with newborns 028\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" valign=\\\"bottom\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e9\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003eAmuidjor\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 196px;\\\"\\u003e\\n \\u003cp\\u003eMothers with newborns 0-28\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" valign=\\\"bottom\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e9\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003eTulaku\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 196px;\\\"\\u003e\\n \\u003cp\\u003eMothers with newborns 0-28\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" valign=\\\"bottom\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e10\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003eOnion Mar.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 196px;\\\"\\u003e\\n \\u003cp\\u003eMothers with newborns 0-28\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" valign=\\\"bottom\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e10\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003ePresby C\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 196px;\\\"\\u003e\\n \\u003cp\\u003eMothers with newborns 0-28\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" valign=\\\"bottom\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e10\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003eYam Market\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 196px;\\\"\\u003e\\n \\u003cp\\u003eMothers with newborns 0-28\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" valign=\\\"bottom\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e10\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003eGPRTU\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 196px;\\\"\\u003e\\n \\u003cp\\u003eSlum Based TBAs\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" valign=\\\"bottom\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e8\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003eAshaiman\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 196px;\\\"\\u003e\\n \\u003cp\\u003eSlum Based TBAs\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" valign=\\\"bottom\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e8\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003eYam Market\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 196px;\\\"\\u003e\\n \\u003cp\\u003eCaregivers of newborns\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" valign=\\\"bottom\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e8\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003eAshaiman\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 196px;\\\"\\u003e\\n \\u003cp\\u003eCaregivers of newborns\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" valign=\\\"bottom\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e8\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003eMethodist\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 196px;\\\"\\u003e\\n \\u003cp\\u003eCommunity leaders\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" valign=\\\"bottom\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e8\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003eAshaiman\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 196px;\\\"\\u003e\\n \\u003cp\\u003eCommunity leaders\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" valign=\\\"bottom\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e9\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003eGPRTU\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 196px;\\\"\\u003e\\n \\u003cp\\u003eNewborn Coordinator\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003eNational, Accra\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" valign=\\\"bottom\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 196px;\\\"\\u003e\\n \\u003cp\\u003eNewborn Consultant\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003eNational, Accra\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" valign=\\\"bottom\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 196px;\\\"\\u003e\\n \\u003cp\\u003eDistrict Director of Health\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003eAshaiman\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" valign=\\\"bottom\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 196px;\\\"\\u003e\\n \\u003cp\\u003eDistrict Director of Health\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003eAshiedu -Keteke\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" valign=\\\"bottom\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 196px;\\\"\\u003e\\n \\u003cp\\u003eDistrict Newborn Coordinator\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003eAshaiman\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" valign=\\\"bottom\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 196px;\\\"\\u003e\\n \\u003cp\\u003eDistrict Newborn Coordinator\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003eAshiedu- Keteke\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" valign=\\\"bottom\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 196px;\\\"\\u003e\\n \\u003cp\\u003eMidwife (Sub -district head)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e1\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003eBlakpatsona, Ashaiman\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" valign=\\\"bottom\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 196px;\\\"\\u003e\\n \\u003cp\\u003eMidwife (Sub -district head)\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e1\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003eGbemi-Ashaiman\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" valign=\\\"bottom\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 196px;\\\"\\u003e\\n \\u003cp\\u003eMidwife (Sub -district head)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e1\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003eAmuidjor, Ashaiman\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" valign=\\\"bottom\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 196px;\\\"\\u003e\\n \\u003cp\\u003eMidwife (Sub -district head)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e1\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003eOnions Market, Fadama\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" valign=\\\"bottom\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 196px;\\\"\\u003e\\n \\u003cp\\u003eMidwife (Sub-district head)\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e1\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003ePresby Church, Fadama\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" valign=\\\"bottom\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 196px;\\\"\\u003e\\n \\u003cp\\u003eMidwife (Sub -district head)\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e1\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003eYam Market, Fadama\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" valign=\\\"bottom\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 196px;\\\"\\u003e\\n \\u003cp\\u003eMidwife Private Maternity home\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e1\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003eSt. James M. Home, Usher\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" valign=\\\"bottom\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 196px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" valign=\\\"bottom\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 196px;\\\"\\u003e\\n \\u003cp\\u003eSub total\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e13\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e14\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" valign=\\\"bottom\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e125\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eCommon newborn illnesses and perceived causes\\u0026nbsp;\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eIn our qualitative interviews, participants reported several newborn illnesses that are commonly experienced in urban slums. Several mothers reported that newborns suffered from heat or skin rashes, measles, tonsilitis, \\u0026rdquo;hot body\\u0026rdquo; and pemphigus neonatorum. According to the mothers, some babies naturally develop what they described as \\u0026ldquo;hot body\\u0026rdquo; once you give birth to them. Rashes, the mothers reported were generally caused by heat, hence the name \\u0026ldquo;heat rashes\\u0026rdquo;. However, there are some rashes that have fluids inside them. \\u0026ldquo;Tomatoes\\u0026rdquo; commonly used to refer to the condition described by health professionals as \\u0026ldquo;pemphigus\\u0026rdquo; is believed to be a kind of rash that contains fluid. Mothers reported that \\u0026ldquo;tomatoes\\u0026rdquo; is a serious kind of newborn illness caused by \\u0026ldquo;heat\\u0026rdquo; or \\u0026ldquo;smoke\\u0026rdquo; from corn husks that have been burnt as fuel for bathing the newborn or preparing meals for the family. Once a mother baths the baby with warm water prepared from corn husks or a mother eats food prepared from corn husks used as fuel, her newborn will suffer from \\u0026ldquo;tomatoes\\u0026rdquo;. One mother said:\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eThere is this illness called \\u0026ldquo;tomatoes\\u0026rdquo;. It normally has water inside and comes on the skin of babies; sometimes it worries them. It is caused by heat\\u0026nbsp;\\u003c/em\\u003e(20-year-old mother, FGD, Sodom and Gomorrah).\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eRegarding the cause of \\u0026ldquo;tomatoes\\u0026rdquo; here is what a traditional birth attendant said:\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eWhen you use corn husks to make fire to heat water to bath the baby, the baby can get \\u0026ldquo;tomatoes\\u0026rdquo;\\u0026nbsp;\\u003c/em\\u003e(40-year-old Traditional Birth Attendant, FGD, Sodom and Gomorrah).\\u003c/p\\u003e\\n\\u003cp\\u003eThe participants identified another form of heat rash known as \\u0026ldquo;\\u003cem\\u003enappy rash\\u003c/em\\u003e\\u0026rdquo;. Although this kind of rash is believed to be caused by heat, the mothers reported that this kind of heat rash is caused by the \\u0026ldquo;babies\\u0026rsquo; nappies\\u0026rdquo;, hence the name \\u0026ldquo;\\u003cem\\u003enappy rash\\u0026rdquo;\\u003c/em\\u003e. Nappy rash is believed to be caused by keeping the nappies too long on the baby, without removal or replacement of soaked nappies usually for more than four hours. Regarding the cause of \\u0026ldquo;\\u003cem\\u003enappy rash\\u0026rdquo;\\u003c/em\\u003e, here is what one participant said: \\u0026nbsp;\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eNappy rash is caused by heat. When you delay in removing the baby\\u0026rsquo;s diapers for a long time, it causes nappy rash\\u0026nbsp;\\u003c/em\\u003e(33-year-old mother, FGD, Ashaiman).\\u003c/p\\u003e\\n\\u003cp\\u003eAnother said:\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eWhen you wear the baby a diaper and the baby urinate, and you do not remove it early, then, it becomes red and causes rash\\u0026nbsp;\\u003c/em\\u003e(34-year-old caregiver, FGD, Sodom \\u0026amp; Gomorrah).\\u003c/p\\u003e\\n\\u003cp\\u003eSome mothers in Ashaiman reported that they had education from healthcare providers and on radio to apply \\u0026ldquo;joy ointment\\u0026rdquo; (a locally produced gel/ointment in Ghana) on the baby\\u0026rsquo;s buttocks prior to wearing the nappy. This conception of nappy rash is shared by community leaders. Here is what one community leader shared about rashes on newborns.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eWhat I will say is that in the past, nursing mothers used cloth napkins for the children but now they use pampers and because of that, you see that the child\\u0026rsquo;s private part becomes reddish \\u0026hellip; I think it does not make the child healthy\\u003c/em\\u003e\\u003cem\\u003e\\u0026nbsp;\\u003c/em\\u003e(51-year-old community leader, FGD, Sodom \\u0026amp; Gomorrah).\\u003c/p\\u003e\\n\\u003cp\\u003eYet others believe that the rashes are caused by sweat from overcrowding. Here is what one community member said:\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eBecause of overcrowding, when the child is delivered, instead of the baby and mother sleeping alone, they sleep in a room with other mothers. I feel that somebody\\u0026rsquo;s sweat and other things can also make the baby sick in future\\u003c/em\\u003e (48-year-old community leader, FGD, Sodom \\u0026amp; Gomorrah).\\u003c/p\\u003e\\n\\u003cp\\u003eThere were mixed reactions about vaccinations for newborns. While some participants believed that some vaccinations can cause illnesses in newborns, others argued that vaccinations rather protected newborns from illnesses. The quote below explains why there appears to be a confusion as to whether vaccinations protect or cause illnesses in newborns.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eSome of the injections given by nurses also make the children have diarrhoea\\u0026nbsp;\\u003c/em\\u003e(47-year-old community leader, FGD, Sodom \\u0026amp; Gomorrah).\\u003c/p\\u003e\\n\\u003cp\\u003eHowever, one mother counted this assertion and intimated that:\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eWhen we give birth and they (the nurses) give those injections, the first stool that comes from the baby helps to remove the toxins in the baby, so it is not a sickness\\u003c/em\\u003e (34-year-old mother, FGD, Sodom \\u0026amp; Gomorrah).\\u003c/p\\u003e\\n\\u003cp\\u003eOther newborn illnesses reported by the mothers included acute respiratory infections, yellowish eyes, fever, cough, catarrh, \\u0026ldquo;\\u003cem\\u003easram\\u003c/em\\u003e\\u0026rdquo;, difficulty in urination, discoloration of the skin which makes the babies colour to change, stomachache, convulsion and diarrhoea. Note that the condition described as \\u0026ldquo;yellowish eyes\\u0026rdquo; \\u0026ldquo;discoloration of the skin and changes in the skin colour\\u0026rdquo; all refer to neonatal jaundice. Mothers believe yellowing of the neonates\\u0026rsquo; eyes is caused by contamination of the amniotic fluid during delivery, which makes the baby\\u0026rsquo;s eyes yellowish and discolours the skin. Mothers therefore urged midwives to ensure that the amniotic fluid does not enter the babies\\u0026rsquo; eyes during labour, otherwise it will cause the babies\\u0026rsquo; eyes to change to yellow, as if the baby has \\u0026ldquo;apollo\\u0026rdquo;. Here is what one mother said:\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eYellow eyes are due to giving birth\\u0026hellip; sometimes the water that passes before the child comes out may have entered the baby\\u0026rsquo;s eyes, but they (the midwives) may not have checked, and you bring the child home, then it shows on the baby\\u0026rsquo;s eyes\\u0026nbsp;\\u003c/em\\u003e(32-year-old mother, FGD, Sodom and Gomorrah).\\u003c/p\\u003e\\n\\u003cp\\u003eWhile majority carried this perception, a minority reported that yellowing of the eyes of newborns was a result of delayed initiation of breastfeeding. According to one participant:\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eThere is a condition where sometimes the eyes of the baby changes to yellow.\\u003c/em\\u003e\\u003cem\\u003e\\u0026nbsp;When I went to ask the Midwife, she said if we don\\u0026rsquo;t breastfeed our babies early that is the condition (\\u003c/em\\u003e30-year-old mother, FGD, Ashaiman)\\u003c/p\\u003e\\n\\u003cp\\u003eAnother reported that:\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eMy sister\\u0026rsquo;s baby also experienced it, and they said she should breastfeed the baby fast, fast it will go\\u003c/em\\u003e\\u003cem\\u003e\\u0026nbsp;\\u003c/em\\u003e(28-year-old mother, FGD, Ashaiman)\\u003c/p\\u003e\\n\\u003cp\\u003eYellowing of the eyes of newborns as described by mothers in FGDs is a sign of neonatal jaundice. Neonatal Jaundice is a yellowish discoloration of the white part of the eyes and skin in newborns due to high bilirubin levels. These perceptions were confirmed by the National Newborn Coordinator of the Ghana Health Service at the Family Health Division who affirmed that neonatal jaundice is actually on the rise and has become one of the newborn public health threats in Ghana. According to the National Newborn Coordinator:\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eNeonatal jaundice is one of the newborn illnesses we are focusing on. We are seeing many cases of neonatal jaundice in our facilities and we are working with partners (USAID and UNICEF) to address the condition through social and behaviour change communication\\u0026nbsp;\\u003c/em\\u003e(IDI, National, Newborn Coordinator).\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eNeonatal jaundice is common in preterm babies, and it is often caused by an immature liver, infection, medication or blood disorders. Its symptoms include yellowing of the skin, and the whites of the eyes that appear within days after birth. What most of the participants referred to as yellow eyes which they believed is caused by \\u0026lsquo;contaminated\\u0026rsquo; amniotic fluid entering the baby\\u0026rsquo;s eyes during childbirth is a sign of neonatal jaundice.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eCatarrh, cough and diarrhoea were mentioned as some of the other common illnesses affecting newborns in the slums. While some mothers believed that newborn babies could get catarrh while sleeping under fans, others reported that cough is transmitted by evil people who visit the newborn baby. Here is what one participant said:\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eSometimes when you give birth someone can come to visit you and if the person has the illness and the person coughs, the child can get infected\\u0026nbsp;\\u003c/em\\u003e(31-year-old mother, FGD, Sodom and Gomorrah).\\u003c/p\\u003e\\n\\u003cp\\u003eAccording to the mothers, some babies develop stomach problems because of prolonged breastfeeding. One participant said:\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eSome of the babies, when they breastfeed for a long time and you do not give enema, it worries their stomach. When you give enema, it helps to cleanse the babies stomach\\u0026nbsp;\\u003c/em\\u003e(21-year-old mother, FGD, Sodom and Gomorrah).\\u003c/p\\u003e\\n\\u003cp\\u003eAn enema, also known as a clyster, is an injection of fluid usually prepared from herbal concoctions into the lower bowel by way of the rectum. Also, the word enema refers to the liquid so injected or the device used for administering the injection. Using the enema syringe together with varied herbal concoction periodically, is therefore practiced by mothers whose babies are perceived to have stomach problems, and the reason behind this practice is to cleanse the baby\\u0026rsquo;s stomach and allow them to pass stool freely without problems. Some mothers however attributed the stomach problems to \\u0026ldquo;gas that causes pain\\u0026rdquo; in the newborns. Usually, such babies have distended and bloated stomachs. According to one participant:\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eIt is gas that makes the babies\\u0026rsquo; stomachs to pain them\\u0026nbsp;\\u003c/em\\u003e(21-year-old mother, FGD, Sodom and Gomorrah).\\u003c/p\\u003e\\n\\u003cp\\u003eAnother illness frequently reported in FGDs included tonsilitis. Mothers described the illness as a disease that does not allow the baby to cry normally. Here is what one participant said:\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eWhen you give birth to some babies, you will notice that while they are crying there is something under their tongue; it is like a thread, so it does not allow their crying to be heard\\u0026nbsp;\\u003c/em\\u003e(40-year-old mother, FGD, Ashaiman).\\u003c/p\\u003e\\n\\u003cp\\u003eOther categories of illnesses reported in the FGDs included \\u0026ldquo;\\u003cem\\u003easram\\u0026rdquo; \\u0026ldquo;obepremu\\u0026rdquo;\\u0026rdquo;bosu-bosu\\u0026rdquo; and \\u0026ldquo;obobre\\u0026rdquo;. \\u0026ldquo;Asram\\u0026rdquo;\\u0026nbsp;\\u003c/em\\u003ewas reported by mothers in both Ashaiman and Sodom and Gomorrah. According to one participant, \\u0026ldquo;\\u003cem\\u003easram\\u0026rdquo;\\u003c/em\\u003e:\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003e\\u0026ldquo;Is a spiritual illness that makes the newborn grow very small and tiny, usually with a big head. When your baby has asram, you will pray over it or they will apply some herbs and the baby can become normal again\\u0026rdquo;\\u0026nbsp;\\u003c/em\\u003e(22-year-old mother, FGD, Sodom and Gomorrah).\\u003c/p\\u003e\\n\\u003cp\\u003eAnother participant said:\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003e\\u0026ldquo;Asram\\u0026rdquo; is not for hospital. Our parents taught us that it is not a hospital sickness, so you must give the baby herbal medicine\\u0026nbsp;\\u003c/em\\u003e(37-year-old mother, FGD, Ashaiman).\\u003c/p\\u003e\\n\\u003cp\\u003eWhile some mothers attributed \\u0026ldquo;\\u003cem\\u003easram\\u0026rdquo;\\u003c/em\\u003e to either \\u0026ldquo;evil eyes\\u0026rdquo; or spells cast on the baby by \\u0026ldquo;bad people\\u0026rdquo; usually out of envy or jealousy, others reported that mothers with babies suffering from \\u0026ldquo;asram\\u0026rdquo; were either cursed or promiscuous. Regarding the cause of \\u003cem\\u003e\\u0026ldquo;asram\\u0026rdquo;\\u003c/em\\u003e one participant opined that it depends on the type of dress that is worn by the mother while pregnant:\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eSometimes it depends on the dress you wear when you are pregnant. When you wear clothes showing your navel your child will have \\u0026ldquo;asram\\u0026rdquo; when she/he is born\\u003c/em\\u003e (32-year-old mother, FGD, Sodom \\u0026amp; Gomorrah).\\u003c/p\\u003e\\n\\u003cp\\u003eAccording to the participants, during pregnancy when mothers wear dresses that expose their navels, they are more likely to give birth to babies with \\u0026ldquo;asram\\u0026rdquo;. Upon further probing, it was revealed that the charm or spell passes through the mothers\\u0026rsquo; navel and affects the unborn baby. It was revealed that for fear of giving birth to babies with \\u0026ldquo;asram\\u0026rdquo;, pregnant mothers delayed seeking prenatal care especially in the first trimester.\\u003c/p\\u003e\\n\\u003cp\\u003eAnother illness that was frequently mentioned by participants is a kind of fever that affects newborns with spiritual connotations. The illness is called \\u0026ldquo;bosu-bosu\\u0026rdquo; in the \\u003cem\\u003eTwi\\u003c/em\\u003e dialect. One participant described the illness in this quote:\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eThere is another condition, it is babies\\u0026rsquo; fever, and we call it \\u0026ldquo;bosu \\u0026ndash;bosu\\u0026rdquo;, that\\u0026rsquo;s what we call it. It is fever for babies. When you deliver, and you often sit outside in the evenings, the cold will enter your body and since the baby breastfeeds, you will transfer the cold to the baby and that brings \\u0026ldquo;bosu-bosu\\u0026rdquo; and the baby\\u0026rsquo;s faeces will be greenish, but it is fever so that also happens to newborns\\u0026nbsp;\\u003c/em\\u003e(29-year-old mother, FGD, Sodom \\u0026amp; Gomorrah).\\u003c/p\\u003e\\n\\u003cp\\u003eSimilarly, another illness perceived to have some spiritual undertones described by the participants is \\u0026ldquo;obobre\\u0026rdquo; in \\u003cem\\u003eTwi.\\u003c/em\\u003e According to one participant:\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026nbsp;\\u003cem\\u003eThere are some children too that when they are born, they will be \\u0026ldquo;obobre\\u0026rdquo;. Such children look weak with pale eyes and sometimes they pass greenish stools. For this sickness it is not for the hospital, so you must look for a spiritualist\\u0026nbsp;\\u003c/em\\u003e(20-year-old mother, FGD, Sodom \\u0026amp; Gomorrah).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026nbsp;While most of the illnesses were mentioned in both study sites, specific illnesses were reported by participants in Ashaiman. These illnesses included high body temperature, convulsion or \\u003cem\\u003easinism\\u0026nbsp;\\u003c/em\\u003ein T\\u003cem\\u003ewi or\\u003c/em\\u003e \\u0026ldquo;twitching\\u0026rdquo;. \\u003cem\\u003e\\u0026ldquo;Asinism\\u0026rdquo;\\u003c/em\\u003e or twitching is said to be caused by too much phlegm in the newborns body while \\u0026ldquo;impremu\\u0026rdquo; is an illness that is believed to make the newborn develop a big head (macrocephaly). Participants were not clear if \\u0026ldquo;impremu\\u0026rdquo; was the same illness as \\u0026ldquo;puni\\u0026rdquo; described in previous literature.\\u003c/p\\u003e\\n\\u003ch5\\u003eNewborn illness symptom recognition among mothers\\u003c/h5\\u003e\\n\\u003cp\\u003eRecognition of newborn danger signs is an important cue for action and care seeking for newborns. Generally, participants described illness symptoms in categories that they were familiar with. During FGDs, paleness of the body and eyes were the most common symptoms reported. According to one mother:\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eMy baby looked pale, and it was as if he had no blood\\u003c/em\\u003e\\u003cem\\u003e\\u0026nbsp;\\u003c/em\\u003e(19-year-old mother, FGD, Sodom and Gomorrah).\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eOther reported symptoms included high body temperature \\u003cem\\u003e\\u0026ldquo;ningbinduyle\\u0026rdquo;\\u0026nbsp;\\u003c/em\\u003eliterally \\u0026nbsp;meaning \\u0026ldquo;hot body\\u0026rdquo; in Dagbani. Other symptoms included difficulty in breathing, excessive crying without tears, inability to cry, discharging of the eyes, constipation and convulsion.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eWhen the child\\u0026rsquo;s breathing changes, sometimes it comes fast and at times too it is low and with that you don\\u0026rsquo;t have to waste any time\\u0026nbsp;\\u003c/em\\u003e(29-year-old mother, FGD, Sodom and Gomorrah).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eWhen the child is not breastfeeding well, when the child is vomiting too much\\u003c/em\\u003e\\u0026hellip; \\u003cem\\u003eAlso, there are some children that when they want to urinate, they will cry for a while before they urinate.\\u003c/em\\u003e \\u003cem\\u003eThere are some children too that while they are crying, they will be stretching themselves\\u003c/em\\u003e\\u003cem\\u003e\\u0026nbsp;\\u003c/em\\u003e(39-year-old caregiver, FGD, Sodom and Gomorrah).\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eIn most of the neonatal illness cases, the mothers were the first to recognize the symptoms. The mothers\\u0026rsquo; mother, mothers -in -law (husband\\u0026rsquo;s mother) peers and husbands were also involved in the symptom recognition process. The opinion of the husband was sought when the mothers\\u0026rsquo; mother or mothers- in-law was not available. Men were considered inexperienced in diagnosing newborn illness symptoms. The mothers\\u0026rsquo; mother or the mother -in-law were the household members frequently mentioned as significant others within the household that validated the symptoms after being recognized by the mother. Perceptions of severity were influenced by previous experience and beliefs about unusual behaviours. For example, one mother in Ashaiman described her baby\\u0026rsquo;s abnormal crying thus:\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eShe was crying excessively, and I thought that something must be wrong with my child, because babies do not usually cry the way she was crying\\u0026nbsp;\\u003c/em\\u003e(29-year-old mother, FGD, Ashaiman).\\u003c/p\\u003e\\n\\u003cp\\u003eThe mothers often looked for visible signs of deviations from normality. For example, one mother described her baby\\u0026rsquo;s swollen or distended stomach as abnormal, which suggested that the baby was ill. Additionally, a baby refusing to breastfeed was considered a serious symptom of newborn illness. Severity was judged by symptom magnitude; how widespread the condition was, and the level of discomfort associated with the symptom. According to one mother:\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eThe rashes on my baby\\u0026rsquo;s body were serious because they covered her entire body, and she was crying excessively\\u0026nbsp;\\u003c/em\\u003e(32-year-old mother, FGD, Sodom and Gomorrah).\\u003c/p\\u003e\\n\\u003cp\\u003eMothers or caregivers were likely to seek care for the symptoms of the illness of their newborn if they perceived the symptoms to be severe and serious. For example, one mother intimated that:\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eMy baby had cough, but it was not serious because it did not last long\\u0026nbsp;\\u003c/em\\u003e(21-year-old mother, FGD, Sodom and Gomorrah).\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eA symptom that was short-lived was therefore not considered serious as it could not pose any danger to the newborn.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eManagement of newborn illnesses\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe appropriate management of newborn illness is an important predictor of newborn survival. The type of treatment given to a sick newborn is a major determinant of survival, growth and development. In this regard, mothers were asked to describe any actions that they had taken when their newborns presented with symptoms of illness. During FGDs we probed to gain a deeper understanding of the illnesses reported in and how these illnesses were managed. The following section discusses specific actions taken by mothers following recognition of the signs and symptoms signifying ill health of their newborns.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eManagement of Diarrhoea\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eAcute diarrhoea with or without vomiting is a major cause of newborn morbidity and mortality. It is against this background that diarrhoea in newborns must be taken seriously. Mothers reported that they will only seek care for their sick newborn with diarrhoea \\u003cem\\u003ewhen the eyes become pale or\\u0026nbsp;\\u003c/em\\u003ewhite. While some mothers reported giving their babies ORS, others said they gave antibiotics and others did enema[1].\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026ldquo;\\u003cem\\u003eAs for me when my newborn has diarrhoea, I do enema to cleanse the dirt from the babies stomach. Some of the babies, when they breastfeed for a long time and you don\\u0026rsquo;t give enema, it worries the baby\\u0026rsquo;s stomach\\u003c/em\\u003e\\u0026rdquo; (31-year-old mother, FGD, Sodom and Gomorrah).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026ldquo;\\u003cem\\u003eWhen my newborn had diarrhoea, I gave her ORS, but I also bought \\u0026ldquo;tupaye\\u0026rdquo;[an antibiotic] from the drugstore, which I dissolved in water for the baby, and the diarrhoea stopped\\u0026rdquo;\\u003c/em\\u003e (28 -year-old mother, FGD, Ashaiman).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eManagement of fever\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe mothers however intimated that, they will seek care for their baby with fever, when the baby\\u0026rsquo;s body becomes \\u003cem\\u003ehot\\u003c/em\\u003e or when the newborn begins to \\u0026ldquo;\\u003cem\\u003etwitch\\u0026rdquo;\\u0026nbsp;\\u003c/em\\u003eor \\u0026ldquo;\\u003cem\\u003eobepremu\\u003c/em\\u003e\\u0026rdquo;. One mother described how she treated her newborn with symptoms of fever:\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eI first bath the newborn with cold water and if there is no improvement then I will either go to the drug store or hospital\\u0026nbsp;\\u003c/em\\u003e(19-year-old mother, FGD, Sodom and Gomorrah).\\u003c/p\\u003e\\n\\u003cp\\u003eHowever, some mothers argued that newborn babies are \\u0026ldquo;delicate\\u0026rsquo; and \\u0026ldquo;fragile\\u0026rdquo; so the best place to seek treatment for them when they are ill is the health facility. This action was however reported to be contingent on the availability of money at the time of the illness.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eWhen my baby is sick, and I have money, I will take the baby to the hospital, because I do not know what is wrong with the baby\\u0026nbsp;\\u003c/em\\u003e(22-year-old mother, FGD, Sodom and Gomorrah).\\u003c/p\\u003e\\n\\u003cp\\u003eOne mother also argued that:\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eFor the babies, you cannot tell exactly where the pain is. That is why it is not fine to take the baby to the drugstore, but we take them to the hospital, because the owner of the drugstore may not have the machines to check where the sickness is\\u0026nbsp;\\u003c/em\\u003e(24-year-old mother, FGD, Sodom and Gomorrah).\\u003c/p\\u003e\\n\\u003cp\\u003eDespite a preference for health facility care for newborn fevers, some mothers indicated that there are some fevers that cannot be treated at the hospital and require other sources of treatment, including prayer camps, pastors, mallams, herbalists and fetish priests:\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eWhen a baby has fever, sometimes it is not a hospital sickness, so you have to send the baby to the pastor in the prayer camp for prayers\\u0026nbsp;\\u003c/em\\u003e(37-year-old mother, FGD, Ashaiman).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eManagement of cough\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eRegarding cough, the mothers generally believed that cough is transmitted by people who visit the newborn baby. Some deliberately transmit the cough to the baby through the evil eye. The mothers indicated that for the spiritually induced cough, you have to consult a mallam, fetish priest or a pastor. For the coughs that are physically induced they bought cough syrup from chemical shops, while others reported using herbs. Mothers generally believed unless the cough was serious, there was no need to seek treatment, as it will clear after some days.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026ldquo;\\u003cem\\u003eSometimes when you give birth someone can come to visit you and if the person has the illness and the person coughs, the child can get infected\\u0026nbsp;\\u003c/em\\u003e(29-year-old mother, FGD Participant, Sodom and Gomorrah).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026ldquo; \\u003cem\\u003eThere are others who also visit the newborn baby and it may be possible some can have evil eyes, so if the person come, the person can give the sickness to the baby intentionally. As for this type of cough, it cannot be treated in the hospital\\u0026rdquo;\\u003c/em\\u003e (24-year-old mother, FGD Participant, Ashaiman).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eManagement of ARTI\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eSome mothers reported that catarrh is caused by cold, when you put on the fan, and you don\\u0026rsquo;t cover the newborn. Others believe that ARTI is caused by the damp floor and due to overcrowding. According to one mother:\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eCatarrh is caused by sleeping under the fan and is treated with herbs called \\u0026lsquo;\\u0026lsquo;opro\\u0026rsquo;\\u0026rsquo; in the Twi dialect. The herb is passed over fire and the liquid are dropped into the nostrils of the newborn\\u0026nbsp;\\u003c/em\\u003e(26-year-old mother, FGD, Sodom and Gomorrah).\\u003c/p\\u003e\\n\\u003cp\\u003eAnother mother intimated that: \\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003e\\u0026ldquo;When my baby\\u0026rsquo;s breathing changes, I send her to the hospital, because, you don\\u0026rsquo;t know what is wrong with the baby, but if you send the baby to the hospital and they check the baby they will know what is wrong with the baby and give you help.\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eManagement of \\u0026ldquo;asram\\u0026rdquo;, \\u0026ldquo;obepremu\\u0026rdquo;, \\u0026ldquo;obobre\\u0026rdquo; and \\u0026ldquo;bosu-bosu\\u0026rdquo;\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003e\\u0026ldquo;Asram\\u0026rdquo; \\u0026ldquo;bosu-bosu\\u0026rdquo;, \\u0026ldquo;obobre\\u0026rdquo; and convulsion \\u0026ldquo;asinisim\\u0026rdquo;\\u003c/em\\u003eare newborn illnesses that were categorised as \\u0026ldquo;not -for -hospital\\u0026rdquo; and requiring spiritual treatment by herbalists and witch doctors. These illnesses, according to the participants, could best be treated or managed outside of the hospital because these illnesses are believed to be caused by spiritual forces and must be attacked from the spiritual realm. Some of these illnesses are believed to be transferred to newborns by \\u0026ldquo;bad people\\u0026rdquo; pretending to be visiting the newborn baby and the mother, but intentionally through their \\u0026ldquo;evil eyes\\u0026rdquo;, transfer illness to the newborn. According to one mother:\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026ldquo; There are some people out of jealousy, once you give birth, they will pretend to be visiting you and the newborn, but through their \\u0026ldquo;evil eyes\\u0026rdquo;, they transfer illnesses such as \\u0026lsquo;asram\\u0026rdquo; and \\u0026ldquo;bosu-bosu\\u0026rdquo; to the newborn. These illnesses cannot be treated in the hospital\\u0026rdquo;.\\u003c/p\\u003e\\n\\u003cp\\u003eParticipants outlined a process for determining a course of treatment for illnesses such as \\u0026ldquo;\\u003cem\\u003easram\\u003c/em\\u003e\\u0026rdquo; and those that cannot be treated by biomedicine. They narrated that usually to determine a course of treatment for a baby perceived to be suffering from \\u0026ldquo;\\u003cem\\u003easram\\u0026rdquo;\\u003c/em\\u003e, mothers reported that the spirit of the baby is consulted through divination by either mallams or herbalists to determine the real cause of the illness to provide an appropriate remedy. Once the mallams or herbalists identify the real cause, in some cases, herbal concoctions are prepared for the baby to drink while others take the baby to prayer camps for pastors to exorcise the evil spirits.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eManagement of Neonatal Jaundice\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eRegarding the management of neonatal jaundice, one participant said:\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eWhen your baby has yellow eyes, we normally squeeze the mothers breast milk into the eyes of the child\\u0026nbsp;\\u003c/em\\u003e(19-year-old mother, FGD, Sodom \\u0026amp; Gomorrah).\\u003c/p\\u003e\\n\\u003cp\\u003eThe mothers believe that when a mother\\u0026rsquo;s breastmilk is squeezed into the eyes of the newborn, the yellowish coloration in the baby\\u0026rsquo;s eyes will be cleared and the baby will have normal eye colour. The mothers also believe that it is only a mothers\\u0026rsquo; breastmilk that can cure the illness and not the breastmilk of another woman.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eManagement of \\u0026ldquo;Tomatoes\\u0026rdquo; Pemphigus Neonatorum\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eIn relation to the treatment for \\u0026ldquo;tomatoes\\u0026rdquo;, some mothers said:\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eWhen your newborn has \\u0026ldquo;tomatoes\\u0026rdquo; \\u0026hellip;. you buy red powder and apply on the baby\\u0026rsquo;s body. Others burn either the leaves of tomatoes or the seed; this mixture is then grinded with groundnuts and mixed with shea-butter to apply to the newborns body for four days\\u0026nbsp;\\u003c/em\\u003e(25-year-old mother, FGD, Sodom and Gomorrah).\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eAs for me when my baby had \\u0026ldquo;tomatoes\\u0026rdquo;, I went and teared the tomatoes leaves and the seeds then I burned it and mixed it with shea butter then I applied it on the baby by four days and all was gone\\u0026nbsp;\\u003c/em\\u003e(36-year-old mother, FGD, Ashaiman\\u003cem\\u003e).\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe mothers generally believe that for female neonates, the mixture should be applied for a period of four days while for male neonates the mixture should be applied for a period of three days.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e[1] An enema, also known as a clyster, is an injection of fluid, usually prepared from herbal concoctions into the lower bowel by way of the rectum. Also, the word enema refers to the liquid so injected or the device used for administering the injection. Using the enema syringe together with varied herbal concoction periodically is therefore practiced by mothers whose babies have stomach problems, and the reason behind this practice is to cleanse the baby\\u0026rsquo;s stomach and allow them to pass stool freely without problems.\\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eThis qualitative study explored newborn illnesses, local perceptions and management practices among residents in two urban slums in Ghana\\u0026rsquo;s capital city, Accra. Findings show that diarrhoea, fever, cough and acute respiratory tract infections were the common illnesses affecting newborns in the slums. These illnesses appear to be similar to illnesses affecting newborns and infants in the general population in Ghana, although given the general environment of slums, diarrhoea, fever and acute respiratory infections are most likely to be severe and acute in the slums. These illnesses are also not unique to the slums studied. Similar findings in previous studies showed that diarrhoea and acute respiratory tract infections were among the causes of death in urban slum children [\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e]. This is not surprising because most slum households are characterised by earth floors, which can be breeding grounds for many infectious agents likely to pose risk for diarrhoeal disease incidence in neonates. Additionally, given the overcrowding, poor environmental sanitation, poor water supply characteristic of urban slums, it is not surprising that some mothers in both slums reported diarrhoea in their newborns during the first 28 days after birth. In an earlier study, Woldemicael \\u0026amp; Tenkorang observed that earth floor households in slums were associated with an increased risk of diarrhoea and a carrier of streptococcus pneumoniae, the bacteria that cause acute respiratory infections in children [\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e]. These findings emphasize a need for observance of proper hygiene and handwashing during the neonatal period to substantially reduce diarrhoeal disease incidence in newborns. To address the incidence of diarrhoea and acute respiratory infections in newborns particularly in urban slums, it is imperative to improve the housing, water and sanitary conditions of slum neighborhoods.\\u003c/p\\u003e \\u003cp\\u003eAn important finding in this study is the belief that some illnesses \\u0026ldquo;are not for hospital\\u0026rdquo;. These illnesses included \\u0026ldquo;asram\\u0026rdquo;, \\u0026ldquo;\\u003cem\\u003easinisim\\u0026rdquo;\\u003c/em\\u003e or convulsion, \\u0026ldquo;\\u003cem\\u003eimpremu\\u003c/em\\u003e\\u0026rdquo;, \\u0026ldquo;\\u003cem\\u003eobobre\\u003c/em\\u003e\\u0026rdquo;, \\u0026ldquo;\\u003cem\\u003ebosu-bosu\\u0026rdquo;\\u003c/em\\u003e and a kind of cough believed to be spiritually induced. In this study the type of illness and their perceived cause determined whether treatment will be sought either biomedically through hospitals/clinics/pharmacies or outside of hospitals from alternative sources as indicated for some of the newborn illnesses such as \\u0026ldquo;\\u003cem\\u003easram\\u003c/em\\u003e\\u0026rdquo;, \\u0026ldquo;\\u003cem\\u003eobobre\\u0026rdquo;\\u003c/em\\u003e, \\u0026ldquo;\\u003cem\\u003ebosu-bosu\\u003c/em\\u003e\\u0026rdquo; \\u0026ldquo;\\u003cem\\u003easinism\\u003c/em\\u003e\\u0026rdquo; and \\u0026ldquo;\\u003cem\\u003eobepremu\\u003c/em\\u003e\\u0026rdquo; from mallams, herbalists, pastors and fetish priests. These findings are similar to those reported in earlier studies in the general population that established that \\u0026ldquo;\\u003cem\\u003easram\\u0026rdquo;\\u003c/em\\u003e was a newborn illness that is believed to be caused by evil spirits and therefore cannot be treated in formal health care settings [\\u003cspan citationid=\\\"CR32\\\" class=\\\"CitationRef\\\"\\u003e32\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR33\\\" class=\\\"CitationRef\\\"\\u003e33\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR34\\\" class=\\\"CitationRef\\\"\\u003e34\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR35\\\" class=\\\"CitationRef\\\"\\u003e35\\u003c/span\\u003e]. The current study is the first in Ghana that has found similar beliefs and perceptions about \\u0026ldquo;asram\\u0026rdquo; in slums. In previous studies in rural Ghana too, \\u003cem\\u003easram\\u003c/em\\u003e and \\u003cem\\u003epuni\\u003c/em\\u003e were regarded as a range of illnesses affecting neonates and infants that do not have any clear biomedical equivalents [\\u003cspan citationid=\\\"CR45\\\" class=\\\"CitationRef\\\"\\u003e45\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR46\\\" class=\\\"CitationRef\\\"\\u003e46\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR47\\\" class=\\\"CitationRef\\\"\\u003e47\\u003c/span\\u003e]. The term \\u003cem\\u003easram\\u003c/em\\u003e has therefore been blamed for delayed care seeking because \\u003cem\\u003easram\\u003c/em\\u003e is perceived to be caused by evil spirits [\\u003cspan citationid=\\\"CR33\\\" class=\\\"CitationRef\\\"\\u003e33\\u003c/span\\u003e]. Both \\u003cem\\u003easram\\u003c/em\\u003e and \\u003cem\\u003epuni\\u003c/em\\u003e are considered untreatable by biomedicine, and their diagnosis were interpreted as a significant barrier to appropriate care seeking [\\u003cspan citationid=\\\"CR35\\\" class=\\\"CitationRef\\\"\\u003e35\\u003c/span\\u003e]. Bazzano and colleagues for example reported that \\u003cem\\u003easram\\u003c/em\\u003e was universally described by caretakers as causing green veins on a baby\\u0026rsquo;s body, persistent crying and growing lean [\\u003cspan citationid=\\\"CR35\\\" class=\\\"CitationRef\\\"\\u003e35\\u003c/span\\u003e]. It is believed that \\u003cem\\u003easram\\u003c/em\\u003e is the main serious illness (in local language terms), which affects newborns and is thought to be conveyed to the baby by other people intentionally because of jealousy or antipathy, either in utero or in the neonatal period. This often causes many pregnant women to delay seeking prenatal care during pregnancy [\\u003cspan citationid=\\\"CR48\\\" class=\\\"CitationRef\\\"\\u003e48\\u003c/span\\u003e]. Closely related to \\u003cem\\u003easram\\u003c/em\\u003e, is \\u003cem\\u003epuni\\u003c/em\\u003e, which is described as an illness characterised by changes in the baby\\u0026rsquo;s skull, i.e. there is either a gap at the centre of the baby\\u0026rsquo;s head or an enlarged head with a gap; and both \\u003cem\\u003easram\\u003c/em\\u003e and \\u003cem\\u003epuni\\u003c/em\\u003e are considered illnesses not for hospital [\\u003cspan citationid=\\\"CR49\\\" class=\\\"CitationRef\\\"\\u003e49\\u003c/span\\u003e]. While some respondents in Ghana thought it is possible to treat \\u003cem\\u003easram\\u003c/em\\u003e in health facilities, caregivers in Bangladesh concluded that categorising an illness as \\u0026ldquo;not for hospital\\u0026rdquo; could serve in some cases as a means of assuaging emotional concerns on the part of the family who cannot afford to pursue, or do not trust medical treatment [\\u003cspan citationid=\\\"CR48\\\" class=\\\"CitationRef\\\"\\u003e48\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eIn this study, \\u0026ldquo;tomatoes\\u0026rdquo; or pemphigus vulgaris was also highlighted. It is an infection of the newborn. Usually, rashes appear all over the body of the newborn with whitish fluid. Blisters break open and form sores on the skin of the neonate causing pain and making the babies to cry. Pemphigus vulgaris occurs when the immune system mistakenly makes antibodies against protein in healthy skin and mucous membranes [\\u003cspan citationid=\\\"CR50\\\" class=\\\"CitationRef\\\"\\u003e50\\u003c/span\\u003e]. The antibodies break down the bonds between the cells and fluids collects between the cell layers of the skin. This leads to blisters and erosions on the skin. The blisters are soft and break open easily to form painful sores. However, the perceived cause of \\u0026ldquo;tomatoes\\u0026rdquo; and how community members in the slums treated this condition is at variance with medical practice.\\u003c/p\\u003e \\u003cp\\u003e\\u0026ldquo;\\u003cem\\u003eAsinism\\u003c/em\\u003e\\u0026rdquo; or convulsion has been perceived in this study as a newborn illness that cannot be treated in formal care settings. This finding also resonates with an earlier study in northern Ghana that found that convulsions resulting from malarial fever were thought to have spiritual undertones [\\u003cspan citationid=\\\"CR29\\\" class=\\\"CitationRef\\\"\\u003e29\\u003c/span\\u003e]. Similar findings about convulsion or \\u0026ldquo;\\u003cem\\u003easinism\\u0026rdquo;\\u003c/em\\u003e being an illness caused by supernatural forces such as the \\u0026ldquo;evil eye\\u0026rdquo; or witchcraft have been reported in Ghana [\\u003cspan citationid=\\\"CR29\\\" class=\\\"CitationRef\\\"\\u003e29\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR30\\\" class=\\\"CitationRef\\\"\\u003e30\\u003c/span\\u003e] as well as in Anand Gujarat, an urban Indian slum [\\u003cspan citationid=\\\"CR34\\\" class=\\\"CitationRef\\\"\\u003e34\\u003c/span\\u003e]. While it is likely that these beliefs originated from the home regions of the slum residents who are mostly migrants, it will be important to understand how local aetiologies influence disease classifications especially in urban slums and how these beliefs affect newborn care in slums. This said, the findings suggest that beliefs about the causes of \\u0026ldquo;\\u003cem\\u003easram\\u0026rdquo;\\u003c/em\\u003e and other common newborn illnesses have persisted among caregivers both in the general population and in urban slums in Ghana. The findings have implications for care seeking for newborn illnesses in slums as illnesses that are attributed to evil spirits are often linked to culturally prescribed actions that either necessitate home treatment, treatment by herbalists or in prayer camps. Mothers are also more likely to delay seeking appropriate care for some of the illnesses reported in this study such as \\u0026ldquo;\\u003cem\\u003easram\\u003c/em\\u003e\\u0026rdquo;, \\u0026ldquo;\\u003cem\\u003easinism\\u003c/em\\u003e\\u0026rdquo; \\u0026ldquo;\\u003cem\\u003eimpremu\\u0026rdquo; \\u0026ldquo;obobre\\u0026rdquo; \\u0026ldquo;bosu-bosu\\u0026rdquo;\\u003c/em\\u003e and the \\u0026ldquo;\\u003cem\\u003espiritually induced cough\\u0026rdquo;\\u003c/em\\u003e because of the belief that all these illnesses are caused by \\u0026ldquo;evil spirits\\u0026rdquo; and therefore untreatable in formal care settings. This is because local aetiologies that attribute illness to \\u0026ldquo;evil spirits\\u0026rdquo; and \\u0026ldquo;witchcraft\\u0026rdquo; are often linked to tradition, religion and culturally prescribed actions necessitating either managing the condition at home, through ingestion of local or herbal concoctions or remedial action by mallams, pastors in prayer camps or divine healers. Delayed care seeking for these illnesses in formal healthcare settings can affect positive health outcomes of newborns. The findings partly confirm the fact that individual level factors such as the knowledge and perception of the illness cause (cultural/traditional, biomedical) are important determinants of the type of care that will be sought for particular illnesses.\\u003c/p\\u003e \\u003cp\\u003eThe findings thus suggest a need to explore the role of social and behaviour change communication to dispel potentially harmful beliefs and practices while seeking opportunities for integrating alternative care providers such as faith and traditional healers, mallams, herbalists, pastors\\u0026rsquo; and traditional birth attendants into the continuum of care for pregnant, post-partum and postnatal mothers. If mothers of newborns are seeking the services of alternative care providers such as traditional birth attendants and herbalists, then efforts must be made to link up these providers to the biomedical health system through referral. In addition, seeking collaborative partnerships with alternative care providers including training to recognize when to refer patients to the formal health system may be a strategy that could limit failure to seek care or delayed care seeking for pregnant women, skilled delivery and for newborn illnesses perceived \\u0026ldquo;not for hospital\\u0026rdquo;.\\u003c/p\\u003e \\u003cp\\u003eAnother major finding in this study with implications for newborn care is the belief that neonatal jaundice is caused by contamination of the newborn\\u0026rsquo;s eyes by burst amniotic fluid during the birthing process; and secondly that it is caused by not giving colostrum to the newborn after birth. These findings contrast with earlier studies conducted in the Greater Accra and Eastern regions of Ghana [\\u003cspan citationid=\\\"CR51\\\" class=\\\"CitationRef\\\"\\u003e51\\u003c/span\\u003e] and in Ogun State, Southwest Nigeria [\\u003cspan citationid=\\\"CR52\\\" class=\\\"CitationRef\\\"\\u003e52\\u003c/span\\u003e]. In these studies, the mothers attributed the causes of neonatal jaundice to eating foods like palm oil and to spiritual forces, although they correctly associated the disease with yellowing of the newborn\\u0026rsquo;s eyes in Ghana [\\u003cspan citationid=\\\"CR51\\\" class=\\\"CitationRef\\\"\\u003e51\\u003c/span\\u003e] and blood group incompatibilities, blood infections and prematurity in Nigeria [\\u003cspan citationid=\\\"CR52\\\" class=\\\"CitationRef\\\"\\u003e52\\u003c/span\\u003e]. Neonatal jaundice is generally perceived by the mothers in this study not to be a serious illness unlike in the previous studies, and many mothers believe that over time the baby\\u0026rsquo;s eyes will become clear and normal. To this effect, the lack of knowledge regarding the symptoms of neonatal jaundice by the mothers can endanger the lives of their newborns. This low-risk perception of neonatal jaundice as not a serious newborn illness can delay care seeking with likely consequences of disease developing into a serious condition and death. This is likely because newborn mothers who perceive an illness condition in their newborns to be severe and potentially life threatening will be more likely to seek urgent care for their newborn\\u0026rsquo;s condition than those who perceive the condition to be low risk, less severe and low life threatening. In the present study, the mothers do not perceive neonatal jaundice as potentially life threatening and high risk, although neonatal jaundice when not treated early can lead to fatalities. Profound misconceptions about illnesses such as neonatal jaundice, are more likely to negatively impact on appropriate care seeking in formal health care settings. Delayed care seeking for these illnesses from professional healthcare providers can affect neonatal outcomes. The Ghana Health Service should collaborate with the private sector and non-governmental organizations to launch an investigation into these illnesses and the associated misconceptions and devise ways to support newborn mothers to better manage these illness conditions.\\u003c/p\\u003e \\u003cp\\u003eThe findings of this study should however be interpreted with certain limitations in mind. First, only two of Ghana\\u0026rsquo;s urban slums were covered in this study. The findings may therefore not be generalisable to the rest of the country, nor to other countries with different contexts. Second, the study collected first-hand information from the participants. Given the potential for recall bias, however, much depended on the participants\\u0026rsquo; ability to recall services events during the first 28 days of their babies\\u0026rsquo; life. Finally, translation errors and errors resulting from interpretation of concepts in the qualitative data could have affected the study findings. However, we believe these errors, if at all, have been kept to the minimum given the data quality measures we implemented including rigorous training of research assistants and back-to-back translation of some transcripts.\\u003c/p\\u003e\"},{\"header\":\"Conclusions\",\"content\":\"\\u003cp\\u003eOverall, the findings revealed that the main illnesses affecting newborns in the urban slums during the first 28 days of life included diarrhoea, fever, cough and acute respiratory tract infections. Other illnesses included neonatal jaundice, rashes, \\u0026ldquo;tomatoes\\u0026rdquo; pemphigus neonatorum, \\u0026ldquo;asram\\u0026rdquo; \\u0026ldquo;obepremu\\u0026rdquo; \\u0026ldquo;obobre\\u0026rdquo; and \\u0026ldquo;bosu-bosu\\u0026rdquo;. Generally, some of these illnesses are believed to have spiritual underpinnings and as such \\u0026ldquo;not for hospital\\u0026rdquo; (i.e. they cannot be treated by biomedicine in formal healthcare settings). The perceived causes of these illnesses influenced the type of treatment and care seeking. Illnesses that were perceived to be caused by supernatural forces were also perceived to be treatable by spiritual means, through pastors, mallams, traditional healers and herbalists. The illnesses perceived to be caused by germs and dirt were those perceived to be treatable by modern allopathic medicine.\\u003c/p\\u003e \\u003cp\\u003eGiven the issues surrounding neonatal illnesses in the urban slums and the identification of new illness categories that are perceived to be untreatable by biomedicine and its implications for newborn health outcomes as evidenced in this study, it is highly recommended that the Ghana Health Service and Ministry of Health lead a policy dialogue on the underlying causes of newborn illnesses such as neonatal jaundice, \\u0026ldquo;tomatoes\\u0026rdquo; pemphigus neonatorum, \\u0026ldquo;bosu-bosu\\u0026rdquo;, \\u0026ldquo;obobre\\u0026rdquo; \\u0026ldquo;obepremu\\u0026rdquo; and \\u0026ldquo;asram\\u0026rdquo; to better understand community perceptions and perspectives of these illnesses and their management, since the local perceptions of these illnesses influence how they are managed.\\u003c/p\\u003e \\u003cp\\u003eFinally, it is recommended that the study be replicated in the general population to better understand the newborn illnesses, care and management practices at the household, community and health facility level to inform behaviour change communication strategies to address gaps in knowledge, attitudes and practices.\\u003c/p\\u003e\"},{\"header\":\"Abbreviations\",\"content\":\"\\u003cp\\u003eANC, Antenatal Care, BCG-\\u0026nbsp;Bacillus Calmette-Guérin\\u003cstrong\\u003e,\\u003c/strong\\u003e CHPS- Community Based Health Planning and Services, ENBC-Essential\\u0026nbsp; \\u0026nbsp;Newborn Care, FGD- Focus Group Discussion, GAR -Greater Accra Region, KMC- Kangaroo Mother Care, LBW- Low Birth Weight, MICS- Multiple Indicator Cluster Survey, SP- Suphurdoxine pyrimethamine, \\u0026nbsp;WHO- World Health Organisation\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eAcknowledgements\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors acknowledge the staff of the Ghana Health Service, Dr. Isabella-Sagoe Moses, National Coordinator of Newborn Care at the Family Health Division, Dr. George Amofah, Former Deputy Director General, Dr. Linda Vanotto and Dr (Mrs) Charity Sarpong, Former Regional Directors of Health Services, Greater Accra, Dr. Patrick Amo-Mensah, Medical Director for Usher Polyclinic and Head, Ashiedu-Keteke Sub -Metropolitan Area, \\u0026nbsp; Mrs., Patience Ami Mamata, Municipal Director of Health Services, Ashaiman Municipality, the staff, midwives, nurses, Community Health Officers, \\u0026nbsp;the mother infant pairs in both slums, the community leaders, caregivers and slum based traditional birth attendants who volunteered information and made the study possible. We are also grateful to Williams Kwarah, Emmanuel Ofori Yartey, Peter Ntim Ofori, Noah Cudjoe and Anthony Pharin Amuzu for leading the data collection. Finally we thank Yakubu Alhassan for cleaning the quantitative data.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAuthors\\u0026rsquo; Contribution\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eEAA conducted the study, designed and developed data collection tools, collected data, analysed and prepared the draft manuscript. JKG, PBA, EA and FG provided scientific advice on the design, data collection and analysis. All authors read and approved the final manuscript.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eFunding\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors received no specific funding for this work.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAvailability of Data\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe dataset (s) supporting the conclusions of this article are available from the lead author upon request.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eEthical approval and consent to participate\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eEthical clearance was obtained from the Ghana Health Service Ethics Review Committee registration number GHS \\u0026ndash;ERC: \\u0026nbsp; 024/05/19). The study was conducted in accordance with the terms of the Helsinki Declaration. All study participants either thumb printed or signed informed consent forms before participating in the study. All interviews were conducted in private rooms, while focus group discussions were held in open spaces in either churches or classrooms. All participants were assured of confidentially. They were informed that participation was voluntary and they could refuse to answer any sensitive question/s or withdraw from the study at any point without any consequences. All ethical protocols regarding the handling of newborn babies such as taking their weights and temperature was adhered to in accordance with guidelines on research with human subjects.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eConsent to Publish\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eAll participants gave consent for the study\\u0026rsquo;s findings to be published. All authors also consented to the publication of this manuscript.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eCompeting interest\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n \\u003cli\\u003eWorld Health Organization. Newborns: improving survival and well-being. 2020. Available from: https://www.who.int/news-room/fact-sheets/detail/newborns-reducing-mortality [cited Jan 5 2021]\\u0026nbsp;\\u003c/li\\u003e\\n \\u003cli\\u003eUNICEF. Levels and Trends in Child Mortality Report November 2020. Available from: https://www.unicef.org/publications/index_101071.html\\u0026nbsp;\\u003c/li\\u003e\\n \\u003cli\\u003eBhutta, Z. A., Das, J. K., Bhal, R., Lawn, J. E., Salam, R. A., Paul, V. K., \\u0026amp; Walker, N. (2014). Can available interventions end preventable deaths in mothers, newborn babies, and still births, and at what cost? \\u003cem\\u003eThe Lancet, 384\\u0026nbsp;\\u003c/em\\u003e(9940), 347-370.\\u003c/li\\u003e\\n \\u003cli\\u003eLawn, J. E., Blencowe, H., Shefali, O., Danzhen, Y., Anne, L., Peter, W., . . . Cousens, S. N. (2014). Every Newborn: progress, priorities, and potential beyond survival. Lancet, 384, 189-205.\\u003c/li\\u003e\\n \\u003cli\\u003eWang, H., Dwyer -Lindgren, L., \\u0026amp; Lofgren, K. T. (2014). Global, regional, and national levels of neonatal, infant, and under-5 mortalities during 1990\\u0026ndash;2013: a systematic analysis for the Global Burden of Disease Study 2013. \\u003cem\\u003eLancet, 384\\u0026nbsp;\\u003c/em\\u003e(9947), 957\\u0026ndash;979.\\u003c/li\\u003e\\n \\u003cli\\u003eWHO. (2006). Pregnancy, Childbirth, Postpartum and Newborn Care: A Guide for Essential Practice.\\u0026nbsp;\\u003c/li\\u003e\\n \\u003cli\\u003eThiede, M., \\u0026amp; Koltermann, K. C. (2013). Access to health services: analyzing non-financial barriers in Ghana, Rwanda, Bangladesh and Vietnam using household survey data; a review of the literature. \\u003cem\\u003eA review of the literature. New York: UNICEF\\u003c/em\\u003e, \\u003cem\\u003e61\\u003c/em\\u003e.\\u003c/li\\u003e\\n \\u003cli\\u003eBazzano, A. N., Taub, L., Oberhelman, R. A., \\u0026amp; Var, C. (2016). Newborn care in the home and health facility:Formative findings for intervention research in Cambodia. \\u003cem\\u003eHealthcare, 4\\u003c/em\\u003e, 94.\\u003c/li\\u003e\\n \\u003cli\\u003eLee, A. C., Kozuki, N., \\u0026amp; Blencowe, H. (2013). Intrapartum -related neonatal encephalopathy incidence and impairment at a regional and global level for 2010 and trends from 1990. \\u003cem\\u003ePediatric Research, 74\\u003c/em\\u003e(1), 50-72.\\u003c/li\\u003e\\n \\u003cli\\u003eFry, S., Cousins, B., \\u0026amp; Olivola, K. (2002). Health of children living in urban slums in Asia and the near east: Review of existing literature and data. \\u003cem\\u003eWashington, DC: Environmental Health Project, US Agency for International Development\\u003c/em\\u003e.\\u003c/li\\u003e\\n \\u003cli\\u003eAwasthi, S., \\u0026amp; Pande, V. K. (1998). \\u0026quot;Cause- specific mortality in under fives in the urban slums of lucknow, north India,\\u0026quot;. \\u003cem\\u003eJournal of Tropical Pediatrics, 44\\u003c/em\\u003e(6), 358-361.\\u003c/li\\u003e\\n \\u003cli\\u003eHussain, A., Ali, S. M., \\u0026amp; Kvale, G. (1999). \\u0026quot;Determinants of mortality among children in the urban slums of Dhaka city, Bangladesh\\u0026quot;. \\u003cem\\u003eTropical Medicine and International Health, 4\\u003c/em\\u003e(11), 758-764.\\u003c/li\\u003e\\n \\u003cli\\u003eVaid, A., Mammen, A., Primrose, B., \\u0026amp; Kang, G. (2007). \\u0026quot;Infant mortality in an urban slum,\\u0026quot;. \\u003cem\\u003eIndian Journal of Pediatrics, 74\\u003c/em\\u003e(5), 449-453.\\u003c/li\\u003e\\n \\u003cli\\u003eWHO. (2000a). \\u003cem\\u003e\\u0026quot;Maternal and neonatal tetanus (MNT) elimination\\u0026quot;\\u003c/em\\u003e.\\u003c/li\\u003e\\n \\u003cli\\u003eShrivastava, A., K. (2004). Population, Development, Environment and Health; Encyclopaedia of Environmental Pollution, Agriculture and Health Hazzards. In \\u003cem\\u003eInfectious Disease\\u0026nbsp;\\u003c/em\\u003e(Vol. 4, pp. page 80).\\u003c/li\\u003e\\n \\u003cli\\u003eWoldemicael, G. (2001). \\u0026quot;Diarrhoeal morbidity among young children in Eritrea: environmental and socio- economic determinants\\u0026quot;. \\u003cem\\u003eJournal of Health, Population, and Nutrition, 19\\u003c/em\\u003e(2), 83-90.\\u003c/li\\u003e\\n \\u003cli\\u003eNyandiko, W. M., Greenberg, D., Shany, E., Yiannoutsos, C. T., Musick, B., \\u0026amp; Mwangi, A. W. (2007). \\u0026ldquo;Nasopharyngeal Streptococcus pneumoniae among under-five year old children at the moi teaching and referral hospital, Eldoret, Kenya,\\u0026rdquo;. \\u003cem\\u003eEast African Medical Journal, 84\\u0026nbsp;\\u003c/em\\u003e(4), 156-162.\\u003c/li\\u003e\\n \\u003cli\\u003eGSS. (2014a). Ghana Demographic and Health Survey. Rockville, Maryland.\\u003c/li\\u003e\\n \\u003cli\\u003eBeguy, D., Elung\\u0026apos;ata, P,; Mberu, B.; Oduor, C; Wamukoya, M.; Nganyi, B.; Ezeh, A. (2015). Health \\u0026amp; Demographic Surveillance Systems Profile:The Nairobi Urban and Demographic Surveillance System (NUHDSS), International Journal of Epidemiology, 44 (2) 462-471. doi:https://doi.org/10.1093/ije/dyu251\\u003c/li\\u003e\\n \\u003cli\\u003eLilford, J. R., Oyebode, O., Satterthwaite, D., Melendez-Torres, G. J., Chen, Y.-F., Mberu, B., . . . Ezeh, A. (2017). Improving the health and welfare of people who live in slums. Lancet, 389, 559-570.\\u003c/li\\u003e\\n \\u003cli\\u003eAMHD. (2019). Annual Report.\\u003c/li\\u003e\\n \\u003cli\\u003eAKSM. (2018) Annual Report\\u003c/li\\u003e\\n \\u003cli\\u003eGSS \\u0026amp; ICF (2023). Ghana Demographic and Health Survey, 2022: Key Indicators Report, Accra, Ghana, and Rockville, Maryland, USA: GSS and ICF.\\u003c/li\\u003e\\n \\u003cli\\u003eGSS. (2020). \\u003cem\\u003e2021 Population and Housing Census\\u003c/em\\u003e.\\u003c/li\\u003e\\n \\u003cli\\u003eGSS. (2018a). \\u003cem\\u003eGhana Multiple Indicator Cluster Survey, 2018.\\u003c/em\\u003e\\u003c/li\\u003e\\n \\u003cli\\u003eUN. (2013). World Economic and Social Survey 2013; Sustainable Development Challenges. New York:\\u003c/li\\u003e\\n \\u003cli\\u003eCaldwell, B. K., Caldwell, J. C., \\u0026amp; Pieres, I. (2002). Why do the Children of the poor die in Dhaka, Bangladesh? \\u003cem\\u003ePopulation Research and Policy Review, 21\\u003c/em\\u003e(3), 159-178.\\u003c/li\\u003e\\n \\u003cli\\u003eRashid, S. F., Hadi, A., \\u0026amp; Afsana, K. (2001). Acute respiratory infections in rural Bangladesh: cultural understandings, practices and the role mothers and community health volunteers. \\u003cem\\u003eTropical Medicine \\u0026amp; International Health, 6\\u003c/em\\u003e(4), 249-255.\\u003c/li\\u003e\\n \\u003cli\\u003eAdongo, P. B., Kirkwood, B., \\u0026amp; Kendall, C. (2005). How local community knowledge about malaria affects insecticide- treated net use in northern Ghana. \\u003cem\\u003eTropical Medicine \\u0026amp; International Health, 10\\u0026nbsp;\\u003c/em\\u003e(4), 366-378.\\u003c/li\\u003e\\n \\u003cli\\u003eGalaa, S. Z., \\u0026amp; Daare, K. (2008). Understanding barriers to maternal child health services utilisation in northern Ghana. \\u003cem\\u003eJournal of Social Development in Africa, 23\\u0026nbsp;\\u003c/em\\u003e(2).\\u003c/li\\u003e\\n \\u003cli\\u003eSyed, U., Khadka, N., \\u0026amp; Khan, A. (2008). Care- seeking practices in South Asia: using formative research to design program interventions to save newborn lives. \\u003cem\\u003eJournal of Perinatology, 28\\u003c/em\\u003e, S9-S13.\\u003c/li\\u003e\\n \\u003cli\\u003eChoudhury, N., \\u0026amp; Ahmed, S. M. (2011). Maternal care practices among the ultra poor households in rural Bangladesh: a qualitative exploratory study. \\u003cem\\u003eBMC Pregnancy and Childbirth, 11\\u003c/em\\u003e(1), 15.\\u003c/li\\u003e\\n \\u003cli\\u003eFarnes, C., Beckstrand, R. L., \\u0026amp; Callister, L. C. (2011). Help-seeking behaviours in child bearing women in Ghana, West Africa. \\u003cem\\u003eInternational Nursing Review, 58\\u003c/em\\u003e(4), 491-497.\\u003c/li\\u003e\\n \\u003cli\\u003eNimbalkar, A. S., Shukla, V. V., Phatak, A. G., \\u0026amp; Nimbalkar, S. M. (2013). Newborn Care Practices and Health Seeking Behaviour in Urban Slums and Villages of Anand Gujarat. \\u003cem\\u003eIndian Pediatrics, 50\\u003c/em\\u003e, 409 -413.\\u003c/li\\u003e\\n \\u003cli\\u003eBazzano, A. N., Kirkwood, B. R., Tawiah‐Agyemang, C., Owusu‐Agyei, S., \\u0026amp; Adongo, P. B. (2008). Beyond symptom recognition: care‐seeking for ill newborns in rural Ghana. \\u003cem\\u003eTropical medicine \\u0026amp; international health\\u003c/em\\u003e, \\u003cem\\u003e13\\u003c/em\\u003e(1), 123-128.\\u003c/li\\u003e\\n \\u003cli\\u003eGlaser, B., G.; \\u0026amp; Strauss, A. (1967). The discovery of Grounded Theory: Strategies for \\u0026nbsp;qualitative research. Chicago, IL.Aldine Transaction.\\u003c/li\\u003e\\n \\u003cli\\u003eGuest, G.; Bunce, A.; Johnson, L.(2006). How many interviews are enough?An experiment with data saturation and variability.\\u003cem\\u003e\\u0026nbsp;Field Methods\\u003c/em\\u003e, 18, 59-82.\\u003c/li\\u003e\\n \\u003cli\\u003eFrancis, J., J.; Johnston, M.; Robertson, C. et al.(2010). What is an adequate sample size? Operationalising data saturation for theory -based interview studies. \\u003cem\\u003ePsychol Health,\\u0026nbsp;\\u003c/em\\u003e(25), 1229-45.\\u003c/li\\u003e\\n \\u003cli\\u003eGuba, E., G. (1981). Criteria for assessing the trustworthiness of naturalistic inquiries. Educational Communication and Technology Journal, 29, 75-91.\\u003c/li\\u003e\\n \\u003cli\\u003eSilverman, D. (2001). Interpreting qualitative data: methods for analysing talk, text and interaction. (Vol. 2). London: SAGE.\\u003c/li\\u003e\\n \\u003cli\\u003eZhi., H. L. (2014). A comparison of convenience sampling and purposive sampling. PubMed, 105-11.\\u003c/li\\u003e\\n \\u003cli\\u003eBernard, H. R. (2011). \\u003cem\\u003eResearch Methods in Anthropology : Qualitative and Quantitative Approaches.\\u0026nbsp;\\u003c/em\\u003e(5th ed.). Plymouth, U.K.: Altamira Press.\\u003c/li\\u003e\\n \\u003cli\\u003eSpradley, J. P. (1979). The ethnographic interview. New York: Holt, Rinehart \\u0026amp; Winston.\\u003c/li\\u003e\\n \\u003cli\\u003eCreswell, J., W. (2009). Research design: Qualitative, quantitative, and mixed methods approaches (3rd Edition ed.). Thousand Oaks, California: SAGE Publications Inc.\\u003c/li\\u003e\\n \\u003cli\\u003eHill, Z. C., \\u0026amp; Kendall, P. A. (2003). Recognizing Childhood Illnesses and their traditional explanations: exploring options for care - seeking interventions in the context of the IMCI strategy in rural Ghana. \\u003cem\\u003eTropical Medicine and Intenational Health, 8\\u003c/em\\u003e(7), 668-676.\\u003c/li\\u003e\\n \\u003cli\\u003eOkyere, E. C., \\u0026amp; Tawiah-Agyemang Manu, A. (2010). Newborn Care: the effect of a traditional illness, asram, in Ghana. \\u003cem\\u003eAnnals of Tropical Paediatrics: International Child Health, 30\\u003c/em\\u003e(4), 321-328.\\u003c/li\\u003e\\n \\u003cli\\u003eMarah, A. (2011). \\u003cem\\u003eAssessing household practices that influence neonatal survival in the Asante-Akim North District of Ashanti region-Ghana\\u003c/em\\u003e (Doctoral dissertation).\\u003c/li\\u003e\\n \\u003cli\\u003eCaldwell, B. K., Caldwell, J. C., \\u0026amp; Pieres, I. (2002). Why do the Children of the poor die in Dhaka, Bangladesh? \\u003cem\\u003ePopulation Research and Policy Review, 21\\u003c/em\\u003e(3), 159-178.\\u003c/li\\u003e\\n \\u003cli\\u003eHill, Z. C., \\u0026amp; Kendall, P. A. (2003). Recognizing Childhood Illnesses and their traditional explanations: exploring options for care - seeking interventions in the context of the IMCI strategy in rural Ghana. \\u003cem\\u003eTropical Medicine and Intenational Health, 8\\u003c/em\\u003e(7), 668-676.\\u003c/li\\u003e\\n \\u003cli\\u003eCarvalho, A. A., Santos, D. A. D., Carvalho, M. A. D. R., Eleut\\u0026eacute;rio, S. J. P., \\u0026amp; Xavier, A. R. E. D. O. (2019). Neonatal pemphigus in an infant born to a mother with pemphigus vulgaris: a case report. \\u003cem\\u003eRevista Paulista de Pediatria\\u003c/em\\u003e, \\u003cem\\u003e37\\u003c/em\\u003e, 130-134.\\u003c/li\\u003e\\n \\u003cli\\u003eSeneadza, N., . A., H., Insaidoo, G., Boye, H., Ani- Amponsah, M., Leung, T., Meek, J., \\u0026amp; Enweronu-Laryea, C. (2022). Neonatal jaundice in Ghanaian children: Assessing maternal knowledge, attitude, and perceptions. \\u003cem\\u003ePLoS One, 17\\u0026nbsp;\\u003c/em\\u003e(3).\\u003c/li\\u003e\\n \\u003cli\\u003eOgunlesi, T., A., \\u0026amp; Abdul, A., R. (2015). Maternal knowledge and care‑seeking behaviors for newborn jaundice in Sagamu, Southwest Nigeria. \\u003cem\\u003eNigerian Journal of Clinical Practice, 18\\u0026nbsp;\\u003c/em\\u003e\\u003c/li\\u003e\\n\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-public-health\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"pubh\",\"sideBox\":\"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/pubh/default.aspx\",\"title\":\"BMC Public Health\",\"twitterHandle\":\"@BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true},\"keywords\":\"urban slum, newborn illness, perception, ‘‘asram”, barriers, management, newborn care, qualitative, Ghana\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-5434704/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-5434704/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003e\\u003cstrong\\u003eBackground:\\u003c/strong\\u003e Neonatal mortality remains a significant public health challenge globally, and Ghana is no exception. In Ghana, neonatal deaths accounts for 61% of infant deaths and 43% of under-five deaths. While the illnesses that affect neonates and contribute to neonatal mortality are widely known, and interventions for managing these illnesses exist, it is not clear how these illnesses are perceived and managed in many local communities including urban slums in Ghana. This paper explored the illnesses affecting neonates and their perceptions and management in two urban slums in Accra, Ghana.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eMethods:\\u003c/strong\\u003e This qualitative study forms part of a concurrent mixed methods cross-sectional study that was conducted in two large urban slums (Ashaiman and Sodom and Gomorrah) in Accra. The qualitative component of the study involved 14 focus groups discussions and 13 in- depth interviews with purposively sampled mothers, traditional birth attendants, caregivers, community leaders and health workers at national and sub national level. Interviews were tape-recorded, transcribed and analyzed thematically using NVivo 12 Pro.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eResults:\\u003c/strong\\u003e Several common newborn illnesses were reported including diarrhoea, fever, cough, acute respiratory infections, neonatal jaundice, and rashes. There were also other locally themed newborn illnesses including “tomatoes”, “asram”, “obopremu”, “obobre” “bosu -bosu”. Most locally themed illnesses were generally perceived as caused by evil spirits and therefore “not for hospital”. Rather, these illnesses are managed by pastors, mallams, herbalists through exorcism and herbal concoctions. Key barriers to newborn care in the slums include inadequate infrastructure, lack of newborn resuscitation equipment, poor provider skills and competencies, and negative attitude of health service providers.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConclusion:\\u003c/strong\\u003e The main illnesses affecting newborns in the slums are diarrhoea, fever, cough, acute respiratory infections, “asram”, “obobre” neonatal jaundice, rashes, “tomatoes” and “bosu-bosu”. The key barriers to newborn care included cost, waiting time, distance and negative attitude of health care providers. Importantly, the findings suggested that how people in urban spaces perceive the cause of their newborn illness determined the nature and type of treatment. It is critical therefore that targeted health educational interventions are designed and implemented in these urban slums to address misconceptions and improve care for newborns.\\u003c/p\\u003e\",\"manuscriptTitle\":\"‘Asram' is not for hospital’: Perceptions and management of newborn illnesses in two urban slums in Accra, Ghana\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2024-12-12 09:10:47\",\"doi\":\"10.21203/rs.3.rs-5434704/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"decision\",\"content\":\"Revision requested\",\"date\":\"2024-11-15T08:30:08+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2024-11-14T04:46:54+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2024-11-14T04:46:04+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"BMC Public Health\",\"date\":\"2024-11-11T21:42:46+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-public-health\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"pubh\",\"sideBox\":\"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/pubh/default.aspx\",\"title\":\"BMC Public Health\",\"twitterHandle\":\"@BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"f7027eda-6567-490e-9249-fde961e9d59e\",\"owner\":[],\"postedDate\":\"December 12th, 2024\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"in-revision\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2026-03-24T11:24:57+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2024-12-12 09:10:47\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-5434704\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-5434704\",\"identity\":\"rs-5434704\",\"version\":[\"v1\"]},\"buildId\":\"qtupq5eGEP_6zYnWcrvyt\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}