Community health worker knowledge and perceptions of neonatal jaundice in Kumasi, Ghana

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Moyer, Rexford Amoah, Benjamin Otoo, Elizabeth Kaselitz, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4662211/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 27 Sep, 2024 Read the published version in Discover Public Health → Version 1 posted 12 You are reading this latest preprint version Abstract Background: This study sought to understand community health workers’ (CHW) knowledge and perceptions of community beliefs surrounding neonatal jaundice (NNJ), a treatable but potentially fatal condition prevalent in sub-Saharan Africa. Methods: In this cross-sectional qualitative study, CHWs in Kumasi, Ghana, completed in-depth interviews with trained research assistants using a semi-structured interview guide. Interviews were audiotaped, transcribed verbatim, and analyzed using grounded theory methodology. Results: Knowledge of NNJ varied widely among the 23 respondents: 74% knew NNJ could cause death, 57% knew how to screen for NNJ. 35% of CHWs favored home treatment (sunlight therapy or watchful waiting). Three main themes emerged: CHWs perceived that caregivers prefer home treatment, equating hospital care with death; sunlight and herbs are the most common home treatments; and caregivers attribute NNJ to supernatural causes, delaying jaundice diagnosis. Interpretation: Incomplete understanding of NNJ among trained CHWs and local communities will require improved education among both groups to improve outcomes. sub-Saharan Africa newborn jaundice community health workers Introduction Neonatal jaundice (NNJ) is a common, treatable condition that continues to cause disproportionately high morbidity and mortality in sub-Saharan Africa. It is estimated that as many as 60–80% of newborns worldwide will develop jaundice in their first week of life [ 1 , 2 ], While many cases are self-limiting, others can progress to hearing loss, brain damage (kernicterus), cerebral palsy, and death [ 3 ]. Globally, NNJ is the seventh leading cause of death in the early neonatal period (0–6 days) [ 4 ]. However, progression to death or disability can be prevented by proper recognition of jaundice and rapid treatment [ 5 ]. Approximately 35% of deaths due to neonatal jaundice occur in Sub-Saharan Africa, with a prevalence of 119/100,000 live births. In comparison, the prevalence in high-income countries (HICs) is 1/100,000 live births [ 5 ]. The genetically inherited condition glucose-6-phosphate - which is prevalent in Sub-Saharan African - is a risk factor for the development of severe NNJ [ 3 ]. Moreover, infants in Sub-Saharan Africa are more likely to be born at home, or, if born at a hospital, less likely to be screened for conditions predisposing them to severe jaundice [ 4 , 6 ]. Most infants develop NNJ after 48 hours and hospital discharge [ 7 , 8 ]. These conditions place the burden of NNJ recognition and care-seeking on infant caretakers and community health workers (CHWs), who are in charge of both maternal education and neonatal home visits. At the same time, we know that most new mothers interviewed at health facilities in Ghana report not knowing the main signs of severe jaundice [ 3 ]. It is therefore crucial that caregivers and CHWs are prepared to recognize jaundice and take appropriate next steps. Since Community Health Workers are an important intermediary between facilities and women discharged home after birth (or who give birth at home), this study sought to understand CHW knowledge and perceptions of community beliefs surrounding NNJ. Methods Study Site This cross-sectional study was conducted at Suntreso Government Hospital (SGH), in Kumasi, Ghana. Kumasi is the capital city of Ghana’s Ashanti region, and the nation’s second largest city, with a population of 3.3 million. SGH is a district hospital serving Kumasi’s Bantama District, which comprises 52 communities, 32 public and private health facilities, 23 community-based health planning and services (CHPS) zones, and 19 electoral areas. Research participants The community health workers at SGH are responsible for home health visits, family planning, pregnancy care, postnatal outreach, immunizations, growth monitoring, child welfare clinics, and school health services. Of the 25 CHWs working directly with the SGH Public Health Office, 23 were available for interview during the study time period. Data collection Interviews were conducted by two local, trained research assistants (RAs) using a structured interview guide. Each interview was conducted privately, recorded on the interviewer’s iPhone, and transcribed verbatim. Although all interviews were conducted in English, the CHWs occasionally used Twi, the local language in Kumasi; in these cases, the RAs – fluent in Twi – translated the response to English. After interviews, each participant was offered a small gift worth approximately 1USD. Interviews were conducted from April – May 2021, at which point the research team determined that thematic saturation was reached. Interview guide The interview guide used by the RAs was designed to examine community perceptions and behaviors surrounding neonatal jaundice, as part of a larger study assessing the feasibility of a home screening tool for NNJ. The RAs used open-ended and short-answer questions, as well as occasional follow-up probes, to elicit insights into each CHW’s own experiences diagnosing jaundice; her individual community’s beliefs and practices regarding jaundice; and potential barriers to acceptance and use of the home screening tool. The interview questions and responses were reviewed regularly throughout the study, to ensure that unanticipated issues worthy of further inquiry were not being overlooked. Analysis Grounded Theory, a qualitative approach for collecting and analyzing data without imposing previously constructed theoretical frameworks [ 9 , 10 ] anchored this research. This approach was chosen to capture participants’ perspectives without assuming they would conform to the researchers’ ideas. Open-ended discussions with community health workers were used to generate a preliminary interview guide (rather than anchoring the interview guide in established health behavior frameworks). The preliminary interview guide was then pilot tested and refined to ensure it reflected women’s language and common understanding of neonatal jaundice. All transcripts were read by at least two members of the research team, and a coding schema was developed to reflect emerging themes. All transcripts were merged into a single Microsoft Word / Google Doc document and coded via highlights and comments. This mechanism was chosen to maximize engagement of research team members without access to NVIVO qualitative software, as the coded document was easily shareable and additional inputs were possible. At the same time, frequencies were tabulated to illustrate the distribution of knowledge and attitudes across respondents. Split frame methodology in the mixed methods tradition [ 11 ] was used to compare quantitative and qualitative responses. Ethics All procedures and experimental protocols were reviewed and approved by the ethical review board of the Kwame Nkrumah University of Science and Technology (CHRPE/AP/145/21). The University of Michigan (HUM00198232) exempted the study from ongoing review. All methods were carried out in accordance with relevant guidelines and regulations. All participants were taken through a written informed consent process prior to participation, and consent was obtained from all research subjects. Results Of the 23 respondents, 20 were female (86.96%) and three were male (13%). Their ages ranged from 23–46, with a median of 33. Their official job titles were Community Health Nurse (21, 91%), Public Health Nurse (1, 4%), and Rotation Nurse (1, 4%). Post-qualification experience ranged from three months to 13 years, with a mean of 6.8 years. Further demographic and professional information is detailed in Table 1 . Table 1 CHW Demographics and Professional Statistics CHW Characteristics Number Percent Mean Median Sex (n = 23) Female 20 87.0% Male 3 13.0% Age (n = 23) 32.9 33 Position (n = 23) CHN 21 91.3% Public health nurse 1 4.4% Rotation nurse 1 4.4% Sees babies at: (n = 23) Home visits 20 87.0% CHPS 16 69.6% Hospital 12 52.2% Other 1 4.4% Has seen baby with jaundice (n = 23) Yes 20 87.0% No 3 13.0% Years of post- qualification experience (n = 23) < 1 1 4.4% 6.8 8 1–4 7 30.4% 5–9 9 39.1% 10+ 6 26.1% Years at current site (n = 23) < 1 4 17.4% 5.0 5 1–4 6 26.1% 5–9 12 52.2% 10+ 1 4.4% Babies seen per month (n = 20) 200 5 25% Jaundiced babies seen per month (n = 20) 0 8 40% 1.4 0.75 1–2 8 40% 3 + 4 20% CHW Knowledge of Neonatal Jaundice CHW knowledge of neonatal jaundice physiology ranged (Table 2 ). Twenty CHWs (87%) thought NNJ preventable, with preventive measures including breastfeeding (7, 30.4%), antenatal care (ANC) visits (7, 30.4%), good maternal nutrition (7, 30.4%), early detection of jaundice (4, 17.4%), good hygiene (3, 13%), and education (3, 13%). Risk factors the CHWs identified for jaundice included preterm birth/low birth weight, sickle cell disease, Rh incompatibility, liver disease, formula feeding, and poor maternal diet. Table 2 CHW Knowledge of Jaundice Physiology Question Responses Number Percent Can we prevent jaundice? (n = 23) Yes 20 87.0% No 1 4.4% Don't know 2 8.7% How can we prevent jaundice? (n = 23) Breastfeeding 7 30.4% ANC visits 7 30.4% Proper nutrition for mother 7 30.4% Early detection and treatment 4 17.4% Infection prevention/hygiene 3 13.0% Education 3 13.0% What puts babies at higher risk of developing NNJ? (n = 22) Preterm birth/LBW 10 43.5% Sickle cell disease 4 17.4% Rh incompatibility 2 8.7% Liver disease 2 8.7% Formula feed 2 8.7% Poor maternal diet 2 8.7% What kind of treatment are babies with NNJ given at the hospital? (n = 23) Phototherapy 16 69.6% Blood transfusion 7 30.4% Unknown medication 6 26.1% Antibiotics 3 13.0% Fluid resuscitation 3 13.0% Breast milk 2 8.7% Don't know 3 13.0% What are the consequences if NNJ is not treated? (n = 23) Death 17 73.9% Brain damage 7 30.4% Liver damage 7 30.4% Growth restriction 6 26.1% Eye damage/blindness 5 21.7% Cerebral palsy 2 8.7% Many CHWs were aware that jaundice is treated with phototherapy (16, 69.6%) and possible blood transfusion (7, 30.4%). Three CHWs (13%) said they did not know how jaundice was treated, and others listed inefficient treatment methods, including antibiotics, medications, and fluid resuscitation. The majority of CHWs (17, 73.9%) knew that NNJ can lead to death. They listed brain and liver damage, growth restriction, and ophthalmologic complaints as other potential outcomes. When asked about physical exam screening for neonatal jaundice (Table 3 ), 13 of the CHWs (56%) mentioned both blanching the baby’s skin and checking the baby’s eyes for yellowing; the remaining 10 CHWs (44%) missed these key screening techniques. While 17 CHWs (74%) believed that there was a difference in assessing neonatal jaundice indoors versus outdoors, only 12 (52%) were able to accurately explain the difference. Two CHWs, for instance, said that outdoor sunlight allowed for better skin assessment, but that it was better to check the eyes indoors. Table 3 CHW Assessment and Management of Jaundice Question Responses Number Percent Salient Quotes Does the CHW have an accurate screening method for NNJ? (n = 23) Yes (mentions checking eyes and blanching skin) 13 56.5% Yes, with error (does not check eyes or does not blanch skin) 10 43.5% Is there a difference in assessing babies for NNJ indoors vs. outdoors? (n = 23) Yes 17 73.9% "There may not be light in the room. So you cannot see the baby's eye very well. You have to come outside and check it." "If you are okay with it, I will do it indoors, where you are comfortable." No 6 26.1% Is the CHW able to explain the difference between indoor and outdoor assessment for NNJ? (n = 23) Yes, clearly 12 52.2% "When the baby is inside, you will not see that the person has jaundice, because of the darkness of the room. But if you are outside, because of the sun and the light, you can really see it." "What we do is in the room, with their eyes - that is when the babies are sleeping. You can easily detect it from the whiter part of their eye. With their skin, that's outside." "Physical examination will be done inside, because. .. The child needs privacy. If they have abnormality, their parent does not want the other person to know. For them, we provide privacy." Yes, with error 5 21.7% No 6 26.1% What do you advise when you see a baby with NNJ? (n = 23) Report to hospital immediately 15 65.2% "If I check and it's not severe, and I think it's mild, then I tell the mother to continue to give her breastmilk." "Maybe after exposing the baby for about three to four days to the sun, when the sun rises, and continuous breastfeeding, every thirty Expose baby to sunlight 6 26.1% Watchful waiting 5 21.7% minutes you breastfeed the child, and still the condition is like that - the yellowish is there, doesn't change, the tongue is yellow, the feet, everything - nothing has changed. And the baby cannot suckle well. And the baby is a little bit weak. They can't be moving their limbs like the normal babies. You can see that there's no improvement - it's becoming severe. So we refer it." Depends on level of NNJ 4 17.4% What makes you refer a baby with NNJ to the hospital? (n = 23) Color only 13 56.5% "If I see any sign [of jaundice] on that baby, I tell the mother to immediately bring the baby to the facility." "[The danger signs are] difficulty in breathing. And also if she can't suckle very well. Sometimes she will be really uncomfortable." "When the skin is turning yellow, that is when we refer. If it's only the eyes, after three days it's only seen in the yes, then we advise on exclusive breastfeeding. But when you can see it on the feet or the tummy or the palm, that's very alarming. They have to send the baby quick for treatment." "If after a weekend, three to four days, it's still there, I will refer the mother to come to the hospital." Danger signs 4 17.4% Location/intensity of jaundice 4 17.4% Lack of improvement/worsening 4 17.4% Upon identifying jaundice in a neonate, 15 of the CHWs (65%) said they would refer the child to the hospital immediately. The remainder advised sunlight exposure (6, 26%) or watchful waiting (5, 22%), or they said that their next steps would depend on how severe the jaundice was (4, 17%). For instance, one CHW recommended hospital care for any skin yellowing, but watchful waiting for eye yellowing. Another CHW said, We can tell if it’s mild or severe. When, after a week, it’s still there, it becomes severe in the forehead and the whole body turns yellow. In that one, we know it’s severe. All CHWs were interested in learning more about jaundice physiology, diagnosis, and treatment. Community Perceptions of Neonatal Jaundice CHWs reported different community knowledge and management of neonatal jaundice (Table 4 ). The majority of communities (13, 57%) believed the cause of NNJ to be spiritual, such as ghosts, witchcraft, or the evil eye. As one CHW said, Table 4 Community Knowledge and Management of Neonatal Jaundice Question Response Number Percent What do people in your community believe causes jaundice? (n = 23) Spiritual causes/evil eye 13 56.5% Oily maternal diet 5 21.7% Lack of ANC/poor maternal health 5 21.7% Don't know 2 8.7% How do people in your community manage NNJ? (n = 23) At home 5 21.7% In the hospital 6 26.1% Split between home/hospital 12 52.2% How do people in your community treat NNJ at home? (n = 23) Sunlight 15 65.2% Herbs 10 43.5% Breastmilk 4 17.4% Enema 3 13.0% Baths 3 13.0% Most of them [the mothers] think it’s a curse, like someone has bought it for them. It’s a spiritual something. That is what most of them think. When they give birth, they don’t want to come out. They want to stay indoors for some time, so that no one will see their baby. If someone sees their baby, they might give something...bad. Other communities attributed NNJ to an oily maternal diet (5, 22%), or to poor maternal health and lack of ANC attendance (5, 22%). Most communities (12, 52%) were split between home and hospital management of jaundice. Six communities (26%) relied exclusively on hospital management, and five communities (22%) relied exclusively on home management. The most popular method of home management was sun exposure (15, 65%), but multiple CHWs also mentioned herbal supplements, breastmilk, enemas, and herbal baths as home regimens. Several CHWs noted that caregivers in their communities preferred home management to hospital care, until jaundice became severe and potentially irreversible. They reported, They will just sit at home for it to get deteriorated before they are brought to the hospital. Yeah, they know everything needs to be treated at the hospital. They know it. But they will stay at home and do home remedies – herbal drugs and all those things. But when it gets to the later part, when you can’t do anything about it, that’s when they think, let me send the baby to the hospital. Five CHWs also noted that most mothers equate hospitals with death, and avoid taking their babies there out of fear: “The moment [I refer to the hospital], they start crying; they won’t go. They will not go at all, because they think that place is for serious conditions. So the moment you are referring her to them, then their baby’s going to die – they start crying. .. No matter what, she will not go. So when we look at such a mother, we try to manage at our level [of healthcare facility]. Because they don't like going to the higher level. They think when they go there their baby will die. So they prefer the CHPS compound, the health center – [hospitals], they won't go." "When you refer them to the hospital, they think when they go they will not come back - they will die. They have that superstition. So when you refer them, they will accept the letter, but they will not go." Discussion This study demonstrated incomplete understanding of NNJ, its diagnosis, and its treatment, among both trained CHWs and local communities, as perceived by CHWs. Among CHWs, 74% knew that NNJ could cause neonatal death. However, only 57% knew how to appropriately screen for NNJ, and 35% favored home treatment for jaundice, in the form of either sunlight therapy or watchful waiting. Regarding CHW understanding of community perceptions of NNJ, several themes emerged: most caregivers prefer to treat jaundice at home, equating hospital care with death; the most common home treatments are sunlight and herbs, followed by increased breastfeeding, enemas, and baths; and many caregivers attribute NNJ to supernatural causes. One notable finding was the repeated mention of the fear of the “evil eye,” causing mothers to keep their babies indoors and wrapped in blankets, in turn complicating or delaying jaundice diagnosis. The majority of previous studies assessing CHW knowledge of NNJ in Africa have taken place in Nigeria [ 12 , 13 , 14 , 15 ]. Nevertheless, these studies revealed similar shortcomings in CHW diagnosis and treatment of jaundice, with only 35.5–75.8% demonstrating proper exam techniques and 58–74.2% referring NNJ cases to the hospital [ 12 , 15 ]. More CHWs in Nigeria recommended inappropriate glucose water (67.1%) or natural phototherapy (66.7%) treatments for jaundice [ 15 ]. However, Nigerian CHWs had greater knowledge of NNJ complications, with 88.5–100% identifying death as a possible outcome. Our study, conducted in the Ashanti Region of Ghana, provides a valuable complement to the limited existing research in Ghana related to NNJ understanding amongst expentant mothers. Seneadza et al (2022) explored knowledge, attitudes and perceptions among mothers attending antenatal and postnatal clinics in the southern and eastern areas of the country [ 3 ]. Despite being conducted at least in part in the capital city (Accra), where rates of maternal education are the highest in the country, women’s knowledge of neonatal jaundice was extremely variable [ 3 ]. Similarly, a study conducted in 2013 at two healthcare facilities in Accra found that only 5% of expectant mothers attending antenatal clinics could identify one or more correct methods of NNJ treatment, and less than half could identify danger signs [ 16 ]. This suggests a persistent deficiency in community-health education related to NNJ in Ghana, despite its prevalence within the population. Our study had numerous strengths, including open-ended questions to elicit CHW ideas and perspectives, and thematic saturation of the CHWs serving a large catchment area in an urban center. One limitation was that our assessment of community practice was focused on perceptions of CHWs, and not on interaction with primary sources. Additionally, the interviews took place during early 2021, in the middle of the SARS-CoV-2 pandemic. While the COVID-19 impact in Ghana was significantly smaller than many other places (with less than 100,000 total cases by the time of this study, in a country of nearly 30 million), it is possible that CHW perceptions were swayed by pandemic changes in behavior [ 17 ]. Nevertheless, this study has several important implications. CHWs play an important role in caregiver education and neonatal assessment, but currently possess inadequate knowledge to assess and treat jaundice. Of particular salience is the lack of understanding of the importance of proper lighting to assess for NNJ, as well as the importance of hospital referral for all cases of suspected jaundice. Communities too displayed knowledge gaps surrounding NNJ. The commonly held fears of witchcraft, outside exposure, and hospital treatment of neonates combine to reduce the likelihood of early jaundice identification and treatment, in turn increasing morbidity and mortality from this treatable condition. Given that CHWs are a primary source of education and medical assessment for many neonatal caregivers, we hypothesize that improved CHW education around NNJ will benefit communities many-fold. Reductions in NNJ morbidity and mortality will require improved education among both CHWs and community members, with a focus on newborn caregivers. Further research is needed into the most effective educational modalities for each group, to ensure rapid NNJ diagnosis and treatment. Declarations The authors have no competing interests to declare that are relevant to the content of this article. Role of the funding source: AW and AB were supported by the Fogarty International Center of the National Institutes of Health under grant number D43TW009345 awarded to the Northern Pacific Global Health Fellows Program. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Author Contribution The authors made substantial contributions to the manuscript in the following ways: AW, AB, and CM to the conceptualization and design of the study, analysis and interpretation of the data, and the manuscript drafting, RA and BO to the acquisition and analysis of data, and EK to the drafting and critical revision of the manuscript. All authors approved the manuscript for submission. Data Availability Data are available from the authors upon reasonable request. Ethical Statement All procedures were reviewed and either approved or exempted from ongoing review from the ethical review boards at the Kwame Nkrumah University of Science and Technology (CHRPE/AP/145/21) and the University of Michigan (HUM00198232). All participants were taken through a written informed consent process prior to participation. References Smitherman H, Stark AR, Bhutan VK. Early recognition of neonatal hyperbilirubinemia and its emergent management. Seminars Fetal Neonatal Med. 2006;11(3):214–24. https://doi.org/10.1016/j.siny.2006.02.002 . Gamber AC, Toth EM, Vreman HJ, Slusher TM. Neonatal Hyperbilirubinemia in Low-Income African Countries. Int J Pediatr Res. 2021;7:073. https://doi.org/10.23937/2469-5769/1510073 . Seneadza NAH, Insaidoo G, Boye H, Ani-Amponsah M, Leung T, Meek J, et al. Neonatal jaundice in Ghanaian children: Assessing maternal knowledge, attitude, and perceptions. PLoS ONE. 2022;17(3):e0264694. https://doi.org/10.1371/journal.pone.0264694 . 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BMC Public Health. 2006;6(1):1–5. https://doi.org/10.1186/1471-2458-6-19 . Adebami OJ. Assessment of knowledge on causes and care of neonatal jaundice at the Nigerian primary and secondary health institutions. Int J Res Med Sci. 2015;3(10):2605–12. http://dx.doi.org/10.18203/2320- 6012.ijrms20150799 . Opara PI, Alex-Hart BA, Dotimi DA. Knowledge, Attitude and Practice towards Neonatal Jaundice among Community Health Workers in Southern Nigeria. Int J Trop Disease Health. 2014;4(11):1171–8. https://doi.org/10.9734/IJTDH/2014/13024 . Orimadegun AE, Ojebiyi AO. Primary health workers’ knowledge and practices relating to neonatal jaundice in Ibadan, Nigeria. Afr J Prim Health Care Family Med. 2017;9(1). https://doi.org/10.4102/phcfm.v9i1.1081 . Amegan-Aho KH, Segbefia CI, Glover NDO, Ansa GA, Afaa TJ. Neonatal Jaundice: awareness, perception and preventive practices in expectant mothers. Ghana Med J. 2020;53(4). https://www.ajol.info/index.php/gmj/article/view/192113 . 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Cite Share Download PDF Status: Published Journal Publication published 27 Sep, 2024 Read the published version in Discover Public Health → Version 1 posted Editorial decision: Revision requested 02 Aug, 2024 Reviews received at journal 02 Aug, 2024 Reviews received at journal 25 Jul, 2024 Reviewers agreed at journal 21 Jul, 2024 Reviewers agreed at journal 17 Jul, 2024 Reviewers agreed at journal 16 Jul, 2024 Reviews received at journal 15 Jul, 2024 Reviewers agreed at journal 10 Jul, 2024 Reviewers invited by journal 08 Jul, 2024 Editor assigned by journal 04 Jul, 2024 Submission checks completed at journal 04 Jul, 2024 First submitted to journal 30 Jun, 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. 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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-4662211","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":331505132,"identity":"01fae1c7-1208-4d55-a17f-143cdeb9472f","order_by":0,"name":"Ann Wolski","email":"","orcid":"","institution":"University of Michigan Medical School","correspondingAuthor":false,"prefix":"","firstName":"Ann","middleName":"","lastName":"Wolski","suffix":""},{"id":331505133,"identity":"5c01f687-9fd1-4145-b705-7023e94cf1e8","order_by":1,"name":"Cheryl A. Moyer","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAvElEQVRIiWNgGAWjYBADOQYGxgZmBhBJrBZj0rUkglQSp4W//XTiY56Ke+kbrh1u/FzAYCO74QABLRJncjcb85wpzt1wO7FZegZDmjFBLQYMudukedsSQFramHkYDicS1sL/FqjlX0K6AUTLfyK0SIBsaUhIgGo5QFiLxI23mw3nHEswnAnyC49BsvFMQlr4+3M3PnhTkyDPdzv94WeeCjvZPkJaQICJB+FOIpSDAOMPIhWOglEwCkbBCAUAzrlDhFMWoxgAAAAASUVORK5CYII=","orcid":"","institution":"University of Michigan Medical School","correspondingAuthor":true,"prefix":"","firstName":"Cheryl","middleName":"A.","lastName":"Moyer","suffix":""},{"id":331505134,"identity":"2ae4ac07-1c95-4fe6-a42e-3da19bc79e5f","order_by":2,"name":"Rexford Amoah","email":"","orcid":"","institution":"Ghana Health Service","correspondingAuthor":false,"prefix":"","firstName":"Rexford","middleName":"","lastName":"Amoah","suffix":""},{"id":331505135,"identity":"81d505b2-4f7d-469a-a653-5a9f522b94a9","order_by":3,"name":"Benjamin Otoo","email":"","orcid":"","institution":"Ghana Health Service","correspondingAuthor":false,"prefix":"","firstName":"Benjamin","middleName":"","lastName":"Otoo","suffix":""},{"id":331505136,"identity":"4ad1669f-8594-4d9f-a59a-84813d25c330","order_by":4,"name":"Elizabeth Kaselitz","email":"","orcid":"","institution":"University of Pittsburgh School of Public Health","correspondingAuthor":false,"prefix":"","firstName":"Elizabeth","middleName":"","lastName":"Kaselitz","suffix":""},{"id":331505137,"identity":"116da997-8f4a-4529-9757-191b0c8300a9","order_by":5,"name":"Ashura Bakari","email":"","orcid":"","institution":"Ghana Health Service","correspondingAuthor":false,"prefix":"","firstName":"Ashura","middleName":"","lastName":"Bakari","suffix":""}],"badges":[],"createdAt":"2024-06-30 10:08:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4662211/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4662211/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12982-024-00235-5","type":"published","date":"2024-09-27T15:57:21+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":65627182,"identity":"b5068cf8-27d7-4f22-98a1-4bb9a9c68e08","added_by":"auto","created_at":"2024-09-30 16:13:03","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":525514,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4662211/v1/468b4b71-7970-413b-878c-c2d9811feba0.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Community health worker knowledge and perceptions of neonatal jaundice in Kumasi, Ghana","fulltext":[{"header":"Introduction","content":"\u003cp\u003eNeonatal jaundice (NNJ) is a common, treatable condition that continues to cause disproportionately high morbidity and mortality in sub-Saharan Africa. It is estimated that as many as 60\u0026ndash;80% of newborns worldwide will develop jaundice in their first week of life [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], While many cases are self-limiting, others can progress to hearing loss, brain damage (kernicterus), cerebral palsy, and death [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Globally, NNJ is the seventh leading cause of death in the early neonatal period (0\u0026ndash;6 days) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. However, progression to death or disability can be prevented by proper recognition of jaundice and rapid treatment [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eApproximately 35% of deaths due to neonatal jaundice occur in Sub-Saharan Africa, with a prevalence of 119/100,000 live births. In comparison, the prevalence in high-income countries (HICs) is 1/100,000 live births [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The genetically inherited condition glucose-6-phosphate - which is prevalent in Sub-Saharan African - is a risk factor for the development of severe NNJ [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Moreover, infants in Sub-Saharan Africa are more likely to be born at home, or, if born at a hospital, less likely to be screened for conditions predisposing them to severe jaundice [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Most infants develop NNJ after 48 hours and hospital discharge [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. These conditions place the burden of NNJ recognition and care-seeking on infant caretakers and community health workers (CHWs), who are in charge of both maternal education and neonatal home visits. At the same time, we know that most new mothers interviewed at health facilities in Ghana report not knowing the main signs of severe jaundice [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIt is therefore crucial that caregivers and CHWs are prepared to recognize jaundice and take appropriate next steps. Since Community Health Workers are an important intermediary between facilities and women discharged home after birth (or who give birth at home), this study sought to understand CHW knowledge and perceptions of community beliefs surrounding NNJ.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eStudy Site\u003c/p\u003e \u003cp\u003eThis cross-sectional study was conducted at Suntreso Government Hospital (SGH), in Kumasi,\u003c/p\u003e \u003cp\u003eGhana. Kumasi is the capital city of Ghana\u0026rsquo;s Ashanti region, and the nation\u0026rsquo;s second largest city, with a population of 3.3\u0026nbsp;million. SGH is a district hospital serving Kumasi\u0026rsquo;s Bantama District, which comprises 52 communities, 32 public and private health facilities, 23 community-based health planning and services (CHPS) zones, and 19 electoral areas.\u003c/p\u003e \u003cp\u003eResearch participants\u003c/p\u003e \u003cp\u003eThe community health workers at SGH are responsible for home health visits, family planning, pregnancy care, postnatal outreach, immunizations, growth monitoring, child welfare clinics, and school health services. Of the 25 CHWs working directly with the SGH Public Health Office, 23 were available for interview during the study time period.\u003c/p\u003e \u003cp\u003eData collection\u003c/p\u003e \u003cp\u003eInterviews were conducted by two local, trained research assistants (RAs) using a structured interview guide. Each interview was conducted privately, recorded on the interviewer\u0026rsquo;s iPhone, and transcribed verbatim. Although all interviews were conducted in English, the CHWs occasionally used Twi, the local language in Kumasi; in these cases, the RAs \u0026ndash; fluent in Twi \u0026ndash; translated the response to English. After interviews, each participant was offered a small gift worth approximately 1USD. Interviews were conducted from April \u0026ndash; May 2021, at which point the research team determined that thematic saturation was reached.\u003c/p\u003e \u003cp\u003eInterview guide\u003c/p\u003e \u003cp\u003eThe interview guide used by the RAs was designed to examine community perceptions and behaviors surrounding neonatal jaundice, as part of a larger study assessing the feasibility of a home screening tool for NNJ. The RAs used open-ended and short-answer questions, as well as occasional follow-up probes, to elicit insights into each CHW\u0026rsquo;s own experiences diagnosing jaundice; her individual community\u0026rsquo;s beliefs and practices regarding jaundice; and potential barriers to acceptance and use of the home screening tool. The interview questions and responses were reviewed regularly throughout the study, to ensure that unanticipated issues worthy of further inquiry were not being overlooked.\u003c/p\u003e \u003cp\u003eAnalysis\u003c/p\u003e \u003cp\u003eGrounded Theory, a qualitative approach for collecting and analyzing data without imposing previously constructed theoretical frameworks [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] anchored this research. This approach was chosen to capture participants\u0026rsquo; perspectives without assuming they would conform to the researchers\u0026rsquo; ideas. Open-ended discussions with community health workers were used to generate a preliminary interview guide (rather than anchoring the interview guide in established health behavior frameworks). The preliminary interview guide was then pilot tested and refined to ensure it reflected women\u0026rsquo;s language and common understanding of neonatal jaundice.\u003c/p\u003e \u003cp\u003eAll transcripts were read by at least two members of the research team, and a coding schema was developed to reflect emerging themes. All transcripts were merged into a single Microsoft Word / Google Doc document and coded via highlights and comments. This mechanism was chosen to maximize engagement of research team members without access to NVIVO qualitative software, as the coded document was easily shareable and additional inputs were possible. At the same time, frequencies were tabulated to illustrate the distribution of knowledge and attitudes across respondents. Split frame methodology in the mixed methods tradition [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] was used to compare quantitative and qualitative responses.\u003c/p\u003e \u003cp\u003eEthics\u003c/p\u003e \u003cp\u003e All procedures and experimental protocols were reviewed and approved by the ethical review board of the Kwame Nkrumah University of Science and Technology (CHRPE/AP/145/21). The University of Michigan (HUM00198232) exempted the study from ongoing review. All methods were carried out in accordance with relevant guidelines and regulations. All participants were taken through a written informed consent process prior to participation, and consent was obtained from all research subjects.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eOf the 23 respondents, 20 were female (86.96%) and three were male (13%). Their ages ranged from 23\u0026ndash;46, with a median of 33. Their official job titles were Community Health Nurse (21, 91%), Public Health Nurse (1, 4%), and Rotation Nurse (1, 4%). Post-qualification experience ranged from three months to 13 years, with a mean of 6.8 years. Further demographic and professional information is detailed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCHW Demographics and Professional Statistics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eCHW Characteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercent\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMedian\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSex (n\u0026thinsp;=\u0026thinsp;23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e87.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (n\u0026thinsp;=\u0026thinsp;23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e32.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003ePosition (n\u0026thinsp;=\u0026thinsp;23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCHN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e91.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePublic health nurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRotation nurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eSees babies at:\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHome visits\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e87.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCHPS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e69.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e52.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eHas seen baby\u003c/p\u003e \u003cp\u003ewith jaundice\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e87.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eYears of post- qualification experience\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e6.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u0026ndash;9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eYears at current site\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e5.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u0026ndash;9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e52.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eBabies seen per month\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e167\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50\u0026ndash;200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eJaundiced babies seen per month (n\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e1.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.75\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u0026ndash;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 +\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eCHW Knowledge of Neonatal Jaundice\u003c/p\u003e \u003cp\u003eCHW knowledge of neonatal jaundice physiology ranged (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Twenty CHWs (87%) thought NNJ preventable, with preventive measures including breastfeeding (7, 30.4%), antenatal care (ANC) visits (7, 30.4%), good maternal nutrition (7, 30.4%), early detection of jaundice (4, 17.4%), good hygiene (3, 13%), and education (3, 13%). Risk factors the CHWs identified for jaundice included preterm birth/low birth weight, sickle cell disease, Rh incompatibility, liver disease, formula feeding, and poor maternal diet.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCHW Knowledge of Jaundice Physiology\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuestion\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eResponses\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercent\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eCan we prevent jaundice?\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e87.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDon't know\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003eHow can we prevent jaundice?\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBreastfeeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e30.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eANC visits\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e30.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProper nutrition for mother\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e30.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEarly detection and treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInfection prevention/hygiene\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEducation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003eWhat puts babies at higher risk of developing NNJ?\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePreterm birth/LBW\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e43.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSickle cell disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRh incompatibility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLiver disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFormula feed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePoor maternal diet\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003eWhat kind of treatment are babies with NNJ given at the hospital?\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhototherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e69.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBlood transfusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e30.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnknown medication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e26.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAntibiotics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFluid resuscitation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBreast milk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDon't know\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003eWhat are the consequences if NNJ is not treated?\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDeath\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e73.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBrain damage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e30.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLiver damage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e30.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrowth restriction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e26.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEye damage/blindness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e21.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCerebral palsy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eMany CHWs were aware that jaundice is treated with phototherapy (16, 69.6%) and possible blood transfusion (7, 30.4%). Three CHWs (13%) said they did not know how jaundice was treated, and others listed inefficient treatment methods, including antibiotics, medications, and fluid resuscitation. The majority of CHWs (17, 73.9%) knew that NNJ can lead to death. They listed brain and liver damage, growth restriction, and ophthalmologic complaints as other potential outcomes.\u003c/p\u003e \u003cp\u003eWhen asked about physical exam screening for neonatal jaundice (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e), 13 of the CHWs (56%) mentioned both blanching the baby\u0026rsquo;s skin and checking the baby\u0026rsquo;s eyes for yellowing; the remaining 10 CHWs (44%) missed these key screening techniques. While 17 CHWs (74%) believed that there was a difference in assessing neonatal jaundice indoors versus outdoors, only 12 (52%) were able to accurately explain the difference. Two CHWs, for instance, said that outdoor sunlight allowed for better skin assessment, but that it was better to check the eyes indoors.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCHW Assessment and Management of Jaundice\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuestion\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eResponses\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercent\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSalient Quotes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eDoes the CHW have an accurate screening method for NNJ?\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes (mentions checking eyes and blanching skin)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e56.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes, with error (does not check eyes or does not\u003c/p\u003e \u003cp\u003eblanch skin)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e43.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eIs there a difference in assessing babies for NNJ indoors vs. outdoors?\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e73.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\"There may not be light in the room. So you cannot see the baby's eye very well. You have to come outside and check it.\"\u003c/p\u003e \u003cp\u003e\"If you are okay with it, I will do it indoors, where you are comfortable.\"\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eIs the CHW able to explain the difference between indoor and outdoor assessment for NNJ?\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes, clearly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e52.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\"When the baby is inside, you will not see that the person has jaundice, because of the darkness of the room. But if you are outside, because of the sun and the light, you can really see it.\"\u003c/p\u003e \u003cp\u003e\"What we do is in the room, with their eyes - that is when the babies are sleeping. You can easily detect it from the whiter part of their eye. With their skin, that's outside.\"\u003c/p\u003e \u003cp\u003e\"Physical examination will be done inside, because. .. The child needs privacy. If they have abnormality, their parent does not want the other person to know. For them, we provide privacy.\"\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes, with error\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eWhat do you advise when you see a baby with NNJ?\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReport to hospital immediately\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e65.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\"If I check and it's not severe, and I think it's mild, then I tell the mother to continue to give her breastmilk.\"\u003c/p\u003e \u003cp\u003e\"Maybe after exposing the baby for about three to four days to the sun, when the sun rises, and continuous breastfeeding, every thirty\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExpose baby to sunlight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e\u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWatchful waiting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eminutes you breastfeed the child, and still the condition is like that - the yellowish is there, doesn't change, the tongue is yellow, the feet, everything - nothing has changed. And the baby cannot suckle well. And the baby is a little bit weak. They can't be moving their limbs like the normal babies. You can see that there's no improvement - it's\u003c/p\u003e \u003cp\u003ebecoming severe. So we refer it.\"\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDepends on level of NNJ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eWhat makes you refer a baby with NNJ to the hospital?\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eColor only\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e56.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\"If I see any sign [of jaundice] on that baby, I tell the mother to immediately bring the baby to the facility.\"\u003c/p\u003e \u003cp\u003e\"[The danger signs are] difficulty in breathing. And also if she can't suckle very well. Sometimes she will be really uncomfortable.\"\u003c/p\u003e \u003cp\u003e\"When the skin is turning yellow, that is when we refer. If it's only the eyes, after three days it's only seen in the yes, then we advise on exclusive breastfeeding. But when you can see it on the feet or the tummy or the palm, that's very alarming. They have to send the baby quick for treatment.\"\u003c/p\u003e \u003cp\u003e\"If after a weekend, three to four days, it's still there, I will refer the mother to come to the hospital.\"\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDanger signs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLocation/intensity of jaundice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLack of improvement/worsening\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eUpon identifying jaundice in a neonate, 15 of the CHWs (65%) said they would refer the child to the hospital immediately. The remainder advised sunlight exposure (6, 26%) or watchful waiting (5, 22%), or they said that their next steps would depend on how severe the jaundice was (4, 17%). For instance, one CHW recommended hospital care for any skin yellowing, but watchful waiting for eye yellowing. Another CHW said,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWe can tell if it\u0026rsquo;s mild or severe. When, after a week, it\u0026rsquo;s still there, it becomes severe in the forehead and the whole body turns yellow. In that one, we know it\u0026rsquo;s severe.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAll CHWs were interested in learning more about jaundice physiology, diagnosis, and treatment.\u003c/p\u003e \u003cp\u003eCommunity Perceptions of Neonatal Jaundice\u003c/p\u003e \u003cp\u003eCHWs reported different community knowledge and management of neonatal jaundice (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The majority of communities (13, 57%) believed the cause of NNJ to be spiritual, such as ghosts, witchcraft, or the evil eye. As one CHW said,\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCommunity Knowledge and Management of Neonatal Jaundice\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuestion\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eResponse\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercent\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eWhat do people in your community believe causes jaundice?\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSpiritual causes/evil eye\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e56.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOily maternal diet\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e21.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLack of ANC/poor maternal health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e21.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDon't know\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eHow do people in your community manage NNJ? (n\u0026thinsp;=\u0026thinsp;23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAt home\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e21.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIn the hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e26.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSplit between home/hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e52.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eHow do people in your community treat NNJ at home?\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSunlight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e65.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHerbs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e43.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBreastmilk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEnema\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBaths\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eMost of them [the mothers] think it\u0026rsquo;s a curse, like someone has bought it for them. It\u0026rsquo;s a spiritual something. That is what most of them think. When they give birth, they don\u0026rsquo;t want to come out. They want to stay indoors for some time, so that no one will see their baby. If someone sees their baby, they might give something...bad.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003eOther communities attributed NNJ to an oily maternal diet (5, 22%), or to poor maternal health and lack of ANC attendance (5, 22%). Most communities (12, 52%) were split between home and hospital management of jaundice. Six communities (26%) relied exclusively on hospital management, and five communities (22%) relied exclusively on home management. The most popular method of home management was sun exposure (15, 65%), but multiple CHWs also mentioned herbal supplements, breastmilk, enemas, and herbal baths as home regimens.\u003c/p\u003e \u003cp\u003eSeveral CHWs noted that caregivers in their communities preferred home management to hospital care, until jaundice became severe and potentially irreversible. They reported,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThey will just sit at home for it to get deteriorated before they are brought to the hospital.\u003c/p\u003e\u003cp\u003eYeah, they know everything needs to be treated at the hospital. They know it. But they will stay at home and do home remedies \u0026ndash; herbal drugs and all those things. But when it gets to the later part, when you can\u0026rsquo;t do anything about it, that\u0026rsquo;s when they think, let me send the baby to the hospital.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eFive CHWs also noted that most mothers equate hospitals with death, and avoid taking their babies there out of fear:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;The moment [I refer to the hospital], they start crying; they won\u0026rsquo;t go. They will not go at all, because they think that place is for serious conditions. So the moment you are referring her to them, then their baby\u0026rsquo;s going to die \u0026ndash; they start crying. .. No matter what, she will not go. So when we look at such a mother, we try to manage at our level [of healthcare facility]. Because they don't like going to the higher level. They think when they go there their baby will die. So they prefer the CHPS compound, the health center \u0026ndash; [hospitals], they won't go.\"\u003c/p\u003e\u003cp\u003e\"When you refer them to the hospital, they think when they go they will not come back - they will die. They have that superstition. So when you refer them, they will accept the letter, but they will not go.\"\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study demonstrated incomplete understanding of NNJ, its diagnosis, and its treatment, among both trained CHWs and local communities, as perceived by CHWs. Among CHWs, 74% knew that NNJ could cause neonatal death. However, only 57% knew how to appropriately screen for NNJ, and 35% favored home treatment for jaundice, in the form of either sunlight therapy or watchful waiting. Regarding CHW understanding of community perceptions of NNJ, several themes emerged: most caregivers prefer to treat jaundice at home, equating hospital care with death; the most common home treatments are sunlight and herbs, followed by increased breastfeeding, enemas, and baths; and many caregivers attribute NNJ to supernatural causes. One notable finding was the repeated mention of the fear of the \u0026ldquo;evil eye,\u0026rdquo; causing mothers to keep their babies indoors and wrapped in blankets, in turn complicating or delaying jaundice diagnosis.\u003c/p\u003e \u003cp\u003eThe majority of previous studies assessing CHW knowledge of NNJ in Africa have taken place in Nigeria [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Nevertheless, these studies revealed similar shortcomings in CHW diagnosis and treatment of jaundice, with only 35.5\u0026ndash;75.8% demonstrating proper exam techniques and 58\u0026ndash;74.2% referring NNJ cases to the hospital [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. More CHWs in Nigeria recommended inappropriate glucose water (67.1%) or natural phototherapy (66.7%) treatments for jaundice [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. However, Nigerian CHWs had greater knowledge of NNJ complications, with 88.5\u0026ndash;100% identifying death as a possible outcome.\u003c/p\u003e \u003cp\u003eOur study, conducted in the Ashanti Region of Ghana, provides a valuable complement to the limited existing research in Ghana related to NNJ understanding amongst expentant mothers. Seneadza et al (2022) explored knowledge, attitudes and perceptions among mothers attending antenatal and postnatal clinics in the southern and eastern areas of the country [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Despite being conducted at least in part in the capital city (Accra), where rates of maternal\u003c/p\u003e \u003cp\u003eeducation are the highest in the country, women\u0026rsquo;s knowledge of neonatal jaundice was extremely variable [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Similarly, a study conducted in 2013 at two healthcare facilities in Accra found that only 5% of expectant mothers attending antenatal clinics could identify one or more correct methods of NNJ treatment, and less than half could identify danger signs [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. This suggests a persistent deficiency in community-health education related to NNJ in Ghana, despite its prevalence within the population.\u003c/p\u003e \u003cp\u003eOur study had numerous strengths, including open-ended questions to elicit CHW ideas and perspectives, and thematic saturation of the CHWs serving a large catchment area in an urban center. One limitation was that our assessment of community practice was focused on perceptions of CHWs, and not on interaction with primary sources. Additionally, the interviews took place during early 2021, in the middle of the SARS-CoV-2 pandemic. While the COVID-19 impact in Ghana was significantly smaller than many other places (with less than 100,000 total cases by the time of this study, in a country of nearly 30\u0026nbsp;million), it is possible that CHW perceptions were swayed by pandemic changes in behavior [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNevertheless, this study has several important implications. CHWs play an important role in caregiver education and neonatal assessment, but currently possess inadequate knowledge to assess and treat jaundice. Of particular salience is the lack of understanding of the importance of proper lighting to assess for NNJ, as well as the importance of hospital referral for all cases of suspected jaundice. Communities too displayed knowledge gaps surrounding NNJ. The commonly held fears of witchcraft, outside exposure, and hospital treatment of neonates combine to reduce the likelihood of early jaundice identification and treatment, in turn increasing morbidity and mortality from this treatable condition. Given that CHWs are a primary source of education and medical assessment for many neonatal caregivers, we hypothesize that improved CHW education around NNJ will benefit communities many-fold.\u003c/p\u003e \u003cp\u003eReductions in NNJ morbidity and mortality will require improved education among both CHWs and community members, with a focus on newborn caregivers. Further research is needed into the most effective educational modalities for each group, to ensure rapid NNJ diagnosis and treatment.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eThe authors have no competing interests to declare that are relevant to the content of this article.\u003c/p\u003e \u003cp\u003eRole of the funding source:\u003c/p\u003e \u003cp\u003eAW and AB were supported by the Fogarty International Center of the National Institutes of Health under grant number D43TW009345 awarded to the Northern Pacific Global Health Fellows Program. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eThe authors made substantial contributions to the manuscript in the following ways: AW, AB, and CM to the conceptualization and design of the study, analysis and interpretation of the data, and the manuscript drafting, RA and BO to the acquisition and analysis of data, and EK to the drafting and critical revision of the manuscript. All authors approved the manuscript for submission.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eData are available from the authors upon reasonable request.\u003c/p\u003e\u003cp\u003eEthical Statement\u003c/p\u003e\n\u003cp\u003eAll procedures were reviewed and either approved or exempted from ongoing review from the ethical review boards at the Kwame Nkrumah University of Science and Technology (CHRPE/AP/145/21) and the University of Michigan (HUM00198232). All participants were taken through a written informed consent process prior to participation.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSmitherman H, Stark AR, Bhutan VK. Early recognition of neonatal hyperbilirubinemia and its emergent management. 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Accessed on January 25, 2022.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"sub-Saharan Africa, newborn, jaundice, community health workers","lastPublishedDoi":"10.21203/rs.3.rs-4662211/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4662211/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: This study sought to understand community health workers’ (CHW) knowledge and perceptions of community beliefs surrounding neonatal jaundice (NNJ), a treatable but potentially fatal condition prevalent in sub-Saharan Africa.\u003c/p\u003e\n\u003cp\u003eMethods: In this cross-sectional qualitative study, CHWs in Kumasi, Ghana, completed in-depth interviews with trained research assistants using a semi-structured interview guide. Interviews were audiotaped, transcribed verbatim, and analyzed using grounded theory methodology.\u003c/p\u003e\n\u003cp\u003eResults: Knowledge of NNJ varied widely among the 23 respondents: 74% knew NNJ could cause death, 57% knew how to screen for NNJ. 35% of CHWs favored home treatment (sunlight therapy or watchful waiting). Three main themes emerged: CHWs perceived that caregivers prefer home treatment, equating hospital care with death; sunlight and herbs are the most common home treatments; and caregivers attribute NNJ to supernatural causes, delaying jaundice diagnosis.\u003c/p\u003e\n\u003cp\u003eInterpretation: Incomplete understanding of NNJ among trained CHWs and local communities will require improved education among both groups to improve outcomes.\u003c/p\u003e","manuscriptTitle":"Community health worker knowledge and perceptions of neonatal jaundice in Kumasi, Ghana","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-29 07:41:13","doi":"10.21203/rs.3.rs-4662211/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-08-02T11:41:50+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-02T11:41:00+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-25T04:55:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"96174574078371717082376791861720253047","date":"2024-07-21T16:52:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"317583372852412126747745434482013606024","date":"2024-07-17T23:43:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"183464713769267285552872806925102217782","date":"2024-07-16T08:53:50+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-16T01:12:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"326680516387131512717852853312831124830","date":"2024-07-10T09:37:11+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-07-08T09:30:32+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-04T04:53:36+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-04T04:49:03+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Public Health","date":"2024-06-30T09:55:50+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"339a1a80-e5a4-4f15-baa4-e6e8a013559d","owner":[],"postedDate":"July 29th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-09-30T16:02:12+00:00","versionOfRecord":{"articleIdentity":"rs-4662211","link":"https://doi.org/10.1186/s12982-024-00235-5","journal":{"identity":"discover-public-health","isVorOnly":false,"title":"Discover Public Health"},"publishedOn":"2024-09-27 15:57:21","publishedOnDateReadable":"September 27th, 2024"},"versionCreatedAt":"2024-07-29 07:41:13","video":"","vorDoi":"10.1186/s12982-024-00235-5","vorDoiUrl":"https://doi.org/10.1186/s12982-024-00235-5","workflowStages":[]},"version":"v1","identity":"rs-4662211","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4662211","identity":"rs-4662211","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}