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) | < 50 | 5 | 25% | 167 | 100 |
50–200 | 10 | 50% |
> 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."