Sociocultural factors affecting uptake of home-based neonatal thermal care practices in Africa: A qualitative review

Abstract

Neonatal hypothermia is a major contributor to neonatal mortality in sub-Saharan Africa, often as a comorbidity of severe infections, preterm births or asphyxia. Simple, cost-effective thermal care practices (TCPs) immediately at birth and in the post-natal period are recommended in the World Health Organization ‘warm chain’. Current practices are suboptimal in the home in low-resource settings, where approximately half of neonatal deaths occur. Several databases (PubMed, OVID SP, Web of Science, The Cochrane Library and Google Scholar) were searched for original research on home-based TCPs. Seventeen articles were identified, and the results were analysed using a ‘thermal care behavioural model’. This review of the qualitative literature on home-based practices across Africa illuminates the sociocultural factors affecting the uptake of recommended practices and strategies for behaviour change. Findings from the review confirm that potentially harmful cultural norms and traditions influence the sequence of TCPs in different contexts across Africa. Furthermore, caregiver factors and contextual barriers or facilitating factors to TCPs and behaviour change exist. Hypothermia and home-based TCPs are areas for further research. Thermal care behaviour change interventions tailored to the sociocultural context are necessary to improve neonatal outcomes in Africa.

Keywords

Africa attitudes hypothermia neonatal thermoregulation

Introduction

Neonatal hypothermia, defined as an abnormally low body temperature of less than 36.5^oC, occurs following 11–92% of home deliveries globally and is associated with an increased risk of neonatal mortality (deaths under the age of 28 days) (Lunze et al., 2013). The highest rates of neonatal deaths are in sub-Saharan Africa (SSA) (Lawn et al., 2005). There is no estimate of the burden of hypothermia in African communities; however, there is a ‘silent epidemic’ of neonatal hypothermia (Lunze et al., 2013). High-risk thermal care practices (TCPs) are prevalent due to a lack of awareness or poor adherence to simple cost-effective thermal care interventions, which are often packaged with other essential newborn care (ENC) practices (Knippenberg et al., 2005; Kumar et al., 2009). The World Health Organization (WHO) ‘warm chain’ recommends TCPs that should be implemented in the home, community and facilities. Recent studies have analysed components of home-based TCPs and results suggest thermal care behaviours in communities in SSA are suboptimal (see Figure 1) (Lunze et al., 2014). This is the first review to explore sociocultural factors affecting the uptake of home-based TCPs in SSA. Behavioural change required contextual analysis at the household level and areas for future research are recommended.

Figure 1.

WHO ‘warm chain’ procedures in the home. Source: adapted from (WHO, 1997).

Methods

Literature was identified through searching databases for the terms outlined in Table 1.

Table 1.

Search Terms.

Databases: PubMed, OVID SP, Web of Science and The Cochrane Library
	(thermal care) OR (hypothermia) OR (thermogenesis) OR (thermoregulation) OR (thermal control) OR (cold injury) OR (cold stress) OR (heat loss) OR (warm) OR (dry) OR (wrap) OR (bath) OR (breastfeeding) OR (dress*) OR (skin to skin)
AND	neonatal OR newborn
AND	community OR home
AND	(qualitative) OR (sociolog) OR (ethnograph) OR (anthropolog) OR (narrative) OR (focus group) OR (interview)) AND (percep) OR (belief) OR (attitude) OR (attit) OR (opinion) OR (expectat*) OR (understanding)
AND	Africa OR African
AND	qualitative OR sociolog* OR ethnograph* OR anthropolog* OR narrative OR focus group* OR interview* OR perception* OR belief* OR attitude*

After deleting duplicates, the titles and abstracts of 2178 publications were read and inclusion criteria applied, leaving 25 publications (see Table 2). Access to the 25 articles were sought and inclusion criteria applied to the full texts. The reviewers were blinded from each other while data was collected. Once this was completed, disagreements were settled by consensus or by deferral to a senior colleague (or a third party who had relevant research experience). A total of 17 studies were included in the final synthesis.

Table 2.

Inclusion criteria.

Original research

Thermal care practices in the home

Beliefs, attitudes, perceptions, motivations, opinions, expectations, understanding

Setting: African community, household level, urban or rural

Methods: Qualitative (interviews, focus group discussions, observations, ethnography, narratives and/or participatory methods)

Participants: Caregivers – community workers or members and/or family members

Findings derived from qualitative methods

In English

The Critical Appraisal Skills Programme appraisal tool for qualitative studies was adapted to ensure quality assessment was adequate prior to synthesis using a meta-ethnographic approach, an approach similar to that by Campbell et al. (2003). The quality of each study was assessed with 34 subquestions, and consistency was calculated (see Supplemental material 1). All studies were considered to be of high quality overall. Qualitative research was appropriate to meet the aims outlined, ethnical approval was sought and findings were important for practice and policy.

The integrated behavioural model (IBM) was used as an a priori framework to understand behaviours and underlying beliefs (Montano and Kasprzyk, 2008). According to this model, behavioural intention is determined by both individual and contextual factors (Montano and Kasprzyk, 2008). Key factors were identified from the results of the 17 review articles and mapped onto the IBM. Then a meta-ethnographic approach using Noblit and Hare’s seven-step process was applied to produce new insights while preserving the original detail of each study (Britten et al., 2002). Key themes and subthemes relating to individual and contextual factors were identified and mapped across all studies to appreciate how they reciprocally translate (see Supplemental material 2 for interpretations). A ‘best fit’ thermal care behavioural model (TCBM) was constructed (see Figure 2) (Carroll et al., 2013). According to this model, TCPs are determined by caregiver and contextual factors characterized by temporal relationships.

Figure 2.

Thermal Care Behavioural Model.

Results

Of the 17 studies reviewed, three focused on TCPs only and the remaining studies dealt with thermal care as part of broader topics: neonatal hypothermia and neonatal care practices (see Supplementary material 4 for data extraction tables). Fourteen studies were qualitative only and three were mixed methods. Despite the overall paucity of qualitative research on thermal care in SSA, there has been an increase in studies over the last 8 years, most markedly over the past 2 years (see Supplemental material 3 for results table).

The synthesis of qualitative findings is based on the constructs of the TCBM: cultural norms and traditions, salience of behaviours, associated beliefs, social influence, personal agency, knowledge and skill, and contextual barriers and facilitating factors. In the studies, home-based TCPs outlined in the WHO ‘warm chain’ were analysed (see Figure 1).

Cultural norms, traditions and salience of behaviours

Cultural or traditional TCPs that are believed to be superior to recommendations disrupted the WHO ‘warm chain’ in all studies. Nevertheless, behaviours to keep the baby warm were considered salient in Ethiopia (Degefie et al., 2014; Tura and Fantahun, 2015), Tanzania (Dhingra et al., 2014; Shamba et al., 2014; Thairu and Pelto, 2008), Uganda (Byaruhanga et al., 2011; Waiswa et al., 2008) and Zambia (Lunze et al., 2014). Seclusion periods, placing warm cloths on the joints and warming babies by smoked fires were also perceived as salient. Furthermore, in all studies that focused on preterm babies (Nigeria, Uganda, Zambia and Malawi), respondents believed that preterm babies need special care and extra warmth (Adejuyigbe et al., 2008; Gondwe et al., 2014; Lunze et al., 2014; Nabiwemba et al., 2014).

Preparing the birthplace to ensure warmth, purchasing new clothes or improvising with alternative items of clothing was reported in Pemba Tanzania, Ethiopia, Zambia, Uganda, Malawi, Ghana, Nigeria (Adejuyigbe et al., 2008; Degefie et al., 2014; Gondwe et al., 2014; Hill et al., 2010; Lunze et al., 2014; Nabiwemba et al., 2014). Immediate drying was often not performed due to an urgency to wash off the vernix, cutting the cord or prioritization of the mother and placental delivery (Adejuyigbe et al., 2015; Degefie et al., 2014; Hill et al., 2010; Salasibew et al., 2014; Tura and Fantahun, 2015). In Zambia, mabono leaves (castor oil plant) were used for wrapping for at least one month and were often reused (Sacks et al., 2015). Behaviours such as placing the baby away from the mother were more commonly reported than skin-to-skin care (STSC) (Adejuyigbe et al., 2015; Degefie et al., 2014; Hill et al., 2010; Lunze et al., 2014). Bathing practices show variations across countries, for example, delayed bathing for more than 24 hours was reported in the Sidama, East Shewa and West Arsi zones (Degefie et al., 2014). For preterm babies in Malawi, most respondents delayed bathing until nine months corrected age (Gondwe et al., 2014). Frequent bathing, bathing with cold water, soap, herbs, coconut oil or traditional medication were also common across the studies.

Caregivers’ factors: Beliefs, social influence and personal agency

The reviewed studies revealed strong cultural beliefs that are linked to protecting the baby but can compromise thermal care. These are compounded by the social influence of family members and influential others in the community. Grandmothers had an influential role in several studies; however, they can transfer inaccurate knowledge (Degefie et al., 2014; Hill et al., 2010). Chief advisors and church leaders also emphasized the importance of keeping babies warm (Lunze et al., 2014). Nonetheless, some caregivers who demonstrated personal agency were not influenced by others (Nabiwemba et al., 2014). Perceived behaviour change barriers were reported, and respondents in Ghana and Tanzania felt there would be resistance to change for deeply rooted behaviours (Hill et al., 2010; Shamba et al., 2014). However, behaviour change was thought to be possible with education (Shamba et al., 2014), through home visits (Waiswa et al., 2008) or by adapting recommendations (Byaruhanga et al., 2011; Waiswa et al., 2008).

Caregivers’ sociodemographic characteristics influenced the uptake of TCPs. In two studies from Tanzania, mothers from rural areas that were illiterate did not perceive TCPs to be salient (Shamba et al., 2014; Tura et al., 2015). In Uganda, Zambia and Malawi, caring for newborns was challenging as women had labour-intensive work in the house or fields (Gondwe et al., 2014; Lunze et al., 2014; Waiswa et al., 2010). In lowland areas in Ethiopia, water temperature varied and many mothers opted for cold water (Adejuyigbe et al., 2015). In Uganda, the roles of men varied, for example, in Iganga and Mayuge districts, some men thought kangaroo mother care was exclusively for women (Waiswa et al., 2008). The total number of assistants to help during home deliveries varied; however, in Tanzania, Zambia and Ghana, there was often only one or two people to help (Hill et al., 2010; Lunze et al., 2014; Shamba et al., 2014).

Contextual factors: Knowledge and skill, barriers and facilitating factors

In rural Tanzania and Uganda, mothers and fathers understood TCPs (Shamba et al., 2014; Waiswa et al., 2010) but inaccurate explanations were provided by respondents in Ethiopia, Zambia, Tanzania and urban Uganda (Adejuyigbe et al., 2015; Degefie et al., 2014; Kayom et al., 2015; Lunze et al., 2014; Tura and Fantahun, 2015). In different regions in Ethiopia and Uganda, women who delivered in the hospital had better home-based practices compared to others who delivered in the home (Adejuyigbe et al., 2015; Nabiwemba et al., 2014; Salasibew et al., 2014). Some mothers in rural Ethiopia did not perform traditional practices because of advice from health professionals (Salasibew et al., 2014). The radio in Malawi was an effective channel of communication but did not change practices (Gondwe et al., 2014).

In some studies, healthcare workers (HCWs) demonstrated good knowledge; however, they were paternalistic (Nabiwemba et al., 2014; Shamba et al., 2014; Waiswa et al., 2010). Dangerous practices such as using plastic bottles and bags with hot water inside for preterm babies were reported in Malawi and Zambia (Gondwe et al., 2014; Lunze et al., 2014). Conversely, HCWs in Nigeria were concerned about the health impacts of certain practices (Adejuyigbe et al., 2008). Trained HCWs were more likely to abide by the WHO recommendations (Dhingra et al., 2014). Furthermore, HCWs training and awareness raising has reduced the practice of certain traditional practices. TCPs are considered challenging in the absence of protocols and behaviour change material (Waiswa et al., 2010).

Discussion

The reviewed studies confirm that caregivers practice within certain social and cultural constraints. The perceived salience of warmth was reported and communities in SSA are willing to improve TCPs. This is promising as similar opportunities for improvement were identified in South Asia during formative research prior to successful trials of interventions (Kumar et al., 2008).

Many of the inadequate practices identified have also been identified in South Asia, for example, heating the newborn by a fire in Bangladesh (Winch et al., 2005). Furthermore, similarities of findings across studies suggest that many deep-rooted beliefs are prevalent in communities. This may be explained by the clustering of beliefs within communities due to both individual and contextual factors. Similar beliefs have been identified in South Asia, for example, with regard to immediate bathing to remove the vernix in Pakistan (Fikree et al., 2005).

This review identified an association between poverty and poor coverage of TCPs. Research has shown that poverty undermines both maternal and newborn health due to numerous confounding factors (Aber et al., 1997). Conversely, it has been theorized that religion may encourage positive health behaviours (Abbott et al., 1990). Elders and church leaders were influential in the studies reviewed, and this is reflective of the strong tradition of transferring religious beliefs down generations in African communities (Mbiti, 2015). Health workers must be aware of the diversity of ethnicities and religious beliefs that can exist within regions, to ensure family-centred care (Selepe and Thomas, 2000).

Many primary caregivers had intentions to comply with some recommended practices but reported perceived barriers. Community-based studies from Uttar Pradesh, India (Darmstadt et al., 2006) and Bangladesh (Quasem et al., 2003) have shown that STSC is accepted when introduced through appropriate cultural paradigms. Furthermore, personal agency in performing care practices was positively correlated with the level of knowledge and skill. However, personal illness was cited as a barrier to performing STSC. Research has shown that a sick mother, or baby, can impact STSC practices and bonding (Gathwala et al., 2008; Ramanathan et al., 2001). Top-down approaches have potential to lower self-esteem, but behaviour change interventions have been shown to promote confidence in performing a task (Kumar et al. 2010).

Overall, the level of illiteracy was high and families often trusted HCWs. A review by Onalo (2013) reinforces the need to improve health workers’ knowledge on the pathophysiology of hypothermia and how it presents, in addition to increasing the recognition and documentation of recommended practices in SSA. This review has shown that although mothers who deliver in facilities are usually discharged quickly, they receive higher levels of education following delivery compared to that received in the home, due to the availability of multiple assistants and practical arrangements.

Implications for policymakers

The results of this review can be mapped onto the five key steps of the behaviour change management framework by Kumar et al. (2010), to design contextualized and responsive interventions.

Identify epidemiologically targeted key behaviours

The most harmful behaviours should be the main focus initially, followed by all other non-evidence-based practices. To manage traditional TCPs, national policymakers should review current efforts to eliminate harmful traditional practices in Africa (CARMMA, 2011).

Identify target groups

Key agents of behaviour change exist at multiple levels: individual, family, community and society (Kumar et al., 2010). Both official health workers and alternative cadres can influence behaviour change (Bang et al., 2005). Furthermore, support from project staff and government officials, including ministries of health and education, is necessary to ensure organized efforts for behaviour change (Smith and Neupane, 2011; Kumar et al., 2008).

Develop appropriate behaviour change transactions

The basic principles outlined by WHO should be compiled into context-specific guidelines (Lunze et al., 2013). The effectiveness of compromise behaviours and low-cost medical devices suitable for resource-limited communities should be considered (Nabiwemba et al., 2014; Pejaver et al., 2004). Furthermore, different TCPs and other ENC practices influence each other, therefore interactions must be understood (Kumar et al., 2010).

Leverage the influence of social networks

Dissemination of a new intervention through active participation of support structures in the community is necessary (Kumar et al., 2008). Influential individuals at the centre of social networks should be approached first as they can initiate new behaviours (Nabiwemba et al., 2014). Furthermore, national and international policymakers should promote the diffusion of new ideas within and between communities to increase the cost-effectiveness and long-term success of interventions (Kumar et al., 2010).

Build mechanisms to sustain and institutionalize new behaviours

Different communication strategies may help new practices attain the status of a social norm at the population level (Kumar et al., 2010). Behaviour change communication (BCC) must be adequate along the continuum of care, starting before pregnancy and continuing into the postnatal period (Kerber et al., 2007). However, countries must assess the feasibility of new or alternative strategies in the context of current health system challenges (Dickson et al., 2014). Nevertheless, with time, BCC should continue along the continuum of health service delivery and propagate to outreach services and facilities, to achieve universal coverage of recommended TCPs (Kerber et al., 2007).

Strengths and limitations

This is the first review focusing on home-based TCPs for neonates in SSA. An in-depth analysis was required to identify sociocultural factors underlying current TCPS. The analysis of the WHO ‘warm chain’ relevant to care practices in the home was restricted and other ENC practices not discussed in the reviewed studies may affect the sequence of TCPs or improve thermoregulatory function. It is not possible to generalize findings to a particular country or the whole region of SSA. Nevertheless, the findings suggest that a similar approach to behaviour change for improved TCPs can be applied across South Asia and SSA.

Recommendations for research

Further research is needed to determine the health effects of traditional practices, efficacy of individual TCPs and packages of care. A review of the quantitative research is necessary to understand the frequency of practices across SSA.

Conclusion

Home-based TCPs in communities in SSA are suboptimal and procedures in the WHO ‘warm chain’ are rarely recognized or adhered to. However, behaviour change messages that are tailored to the sociocultural context have the potential to reduce the incidence of hypothermia and neonatal mortality across SSA. Harmful practices have been identified; however, there are reports of recent behaviour change and many individuals are willing to improve TCPs. Appropriate behaviour change interventions have been proposed but sufficient time must be allowed for change especially when attempting to change deep-rooted cultural norms or traditions. TCPs are often packaged in ENC programmes and should be delivered along the continua of care and health service delivery to ensure long-term sustainability for neonatal care in SSA.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Supplemental material

The online data supplements are available at .

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