title: 'As soon as the umbilical cord gets off, the child ceases to be called a newborn': sociocultural beliefs and newborn referral in rural Uganda.
abstract: BACKGROUND
  The first week of life is the time of greatest risk of death and disability, and is also associated with many traditional beliefs and practices. Identifying sick newborns in the community and referring them to health facilities is a key strategy to reduce deaths. Although a growing area of interest, there remains a lack of data on the role of sociocultural norms and practices on newborn healthcare-seeking in sub-Saharan Africa and the extent to which these norms can be modified.
  
  
  OBJECTIVE
  This study aimed to understand the community's perspective of potential sociocultural barriers and facilitators to compliance with newborn referral.
  
  
  METHODS
  In this qualitative study, focus group discussions (n=12) were conducted with mothers and fathers of babies aged less than 3 months. In addition, in-depth interviews (n=11) were also held with traditional birth attendants and mothers who had been referred by community health workers to seek health-facility-based care. Participants were purposively selected from peri-urban and rural communities in two districts in eastern Uganda. Data were analysed using latent content analysis.
  
  
  RESULTS
  The community definition of a newborn varied, but this was most commonly defined by the period between birth and the umbilical cord stump falling off. During this period, newborns are perceived to be vulnerable to the environment and many mothers and their babies are kept in seclusion, although this practice may be changing. Sociocultural factors that influence compliance with newborn referrals to seek care emerged along three sub-themes: community understanding of the newborn period and cultural expectations; the role of community health actors; and caretaker knowledge, experience, and decision-making autonomy.
  
  
  CONCLUSIONS
  In this setting, there is discrepancy between biomedical and community definitions of the newborn period. There were a number of sociocultural factors that could potentially affect compliance to newborn referral. The widely practised cultural seclusion period, knowledge about newborn sickness, individual experiences in households, perceived health system gaps, and decision-making processes were facilitators of or barriers to compliance with newborn referral. Designers of newborn interventions need to address locally existing cultural beliefs at the same time as they strengthen facility care.
authors.affiliation: School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda.|Health System Policy, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden; cnalwadda@musph.ac.ug.
authors.forename: Christine K
authors.initials: CK
authors.lastname: Nalwadda
authors.affiliation: School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda.|Health System Policy, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.|Uganda Newborn Study, Iganga-Mayuge Health Demographic Surveillance Site, Kampala, Uganda.
authors.forename: Peter
authors.initials: P
authors.lastname: Waiswa
authors.affiliation: School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda.
authors.forename: David
authors.initials: D
authors.lastname: Guwatudde
authors.affiliation: Saving Newborn Lives, Save the Children, Cape Town, South Africa.
authors.forename: Kate
authors.initials: K
authors.lastname: Kerber
authors.affiliation: School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda.|Health System Policy, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.|Uganda Newborn Study, Iganga-Mayuge Health Demographic Surveillance Site, Kampala, Uganda.|International Maternal and Child Health Unit, Department of Women and Children Health, Uppsala University, Uppsala, Sweden.
authors.forename: Stefan
authors.initials: S
authors.lastname: Peterson
authors.affiliation: School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda.|Uganda Newborn Study, Iganga-Mayuge Health Demographic Surveillance Site, Kampala, Uganda.
authors.forename: Juliet
authors.initials: J
authors.lastname: Kiguli
mesh_terms: D000328:Adult; D002662:Child Health Services / Q000458:organization & administration; D003466:Cultural Characteristics; D005260:Female; D017144:Focus Groups; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D007223:Infant; D007224:Infant Care / Q000458:organization & administration*; D007231:Infant, Newborn; D008297:Male; D008875:Middle Aged; D009034:Mother-Child Relations; D010290:Parents / Q000523:psychology; D010342:Patient Acceptance of Health Care; D018743:Perinatal Care / Q000458:organization & administration*; D012424:Rural Population; D012959:Socioeconomic Factors; D009626:Terminology as Topic; D014454:Uganda; D014470:Umbilical Cord; D055815:Young Adult
keywords: Uganda; care-seeking; neonatal; newborn; qualitative; referral; sociocultural influences
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