KWAME NKRUMAH UNIVERSITY OF SCIENCE AND TECHNOLOGY, KUMASI

COLLEGE OF HEALTH SCIENCES

SCHOOL OF NURSING AND MIDWIFERY.

RESEARCH PROPOSAL ON:

Knowledge, Attitude and Practices towards Neonatal Jaundice among Parents Whose Babies
are Receiving Jaundice Treatment in The Hospitals within Kumasi Metropolis

By

MICHAEL ANNIN

MARGARET DUFIE SARPONG

ABIGAIL NYARKOAA MINTAA

LYDIA OWUSU

MARCH, 2024
 CHAPTER 1

INTRODUCTION

1.1 BACKGROUND

Neonatal jaundice (NNJ), or neonatal hyperbilirubinemia results from elevated total serum

bilirubin (TSB) and clinically manifests as yellowish discoloration of the skin, sclera, and

mucous membrane. Newborns show clinical signs which start from the head and face while

spreading down the trunk and limbs as a result of high serum levels of bilirubin (Ogunfowora

and Daniel, 2012; Alhassan et al., 2023). In most cases, it is a mild, transient, and self-limiting

condition and is referred to as "physiological Jaundice." However, it is imperative to distinguish

this from a more severe form called "pathological Jaundice." Failure to identify and treat this

entity may result in bilirubin encephalopathy and associated neurological sequelae. Neonatal

Jaundice is the most commonly encountered medical problem in the first two weeks of life and a

common cause of readmission to the hospital after birth. Approximately 60% of term and 80% of

preterm newborns develop clinical jaundice in the first week after birth (Salia et al., 2021).

There are two distinct types of Neonatal hyperbilirubinemia: Unconjugated Hyperbilirubinemia

(UHB) or Indirect Hyperbilirubinemia and conjugated hyperbilirubinemia or direct

hyperbilirubinemia. Unconjugated hyperbilirubinemia is the more common type and is either

physiological or pathological. Physiological jaundice accounts for 75% of neonatal

hyperbilirubinemia and results from a physiological alteration in neonatal bilirubin metabolism.

Even in healthy full-term newborns, there is an increased bilirubin load as a result of the

increased red blood cells (RBC) mass and a decreased RBC lifespan. Clearance of bilirubin is

also compromised due to impaired activity of uridine diphosphate glucuronosyltransferase

(UGT), the enzyme needed for bilirubin conjugation. The UGT enzyme in a newborn has an

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activity of about 1% of the adult level. (Ansong and Shah et al., 2023). Moreover, these infants

also have increased enterohepatic circulation, further contributing to elevated TSB levels.

Physiological jaundice typically appears after 24 hours of age, peaks at around 48-96 hours, and

resolves by two to three weeks in full-term infants. (Mitra et al., 2017). Jaundice is considered

pathological if it presents on the first day of life, TSB is more than the 95th centile for age based

on age-specific bilirubin nomograms, levels rise by more than 5 mg/dL/day or more than 0.2

mg/dL/hour, or jaundice persists beyond 2 to 3 weeks in full-term infants (American Academy of

pediatrics).

Conjugated hyperbilirubinemia, also referred to as neonatal cholestasis, is characterized by

elevation of serum conjugated/direct) bilirubin (> 1.0 mg/dL) and is due to impaired

hepatobiliary function. Distinguishing CHB from UHB is critical because cholestatic

jaundice/CHB is almost always pathologic and warrants prompt evaluation and treatment.

(Fawaz et al.,2017). The causes of neonatal cholestasis/CHB are extensive and can be classified

into the following categories: obstruction of biliary flow, infections such as CMV, HIV, rubella,

herpes virus, syphilis, toxoplasmosis and many others, genetic factors such as Alagille syndrome,

alpha-1 anti-trypsin deficiency, galactosemia, fructosemia, Tyrosinemia type 1, cystic fibrosis,

progressive familial intrahepatic cholestasis (PFIC) and others.

Understanding the etiology and distinguishing between physiological and pathological jaundice

is crucial for appropriate management and prevention of complications (Ansong-Assoku et al.,

2023).

Breastfeeding jaundice, also known as breastfeeding failure jaundice, occurs in the first week of

life and is due to inadequate intake of breast milk leading to dehydration and sometimes

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hypernatremia. Breastfeeding failure leads to decreased intestinal motility and decreases the

elimination of bilirubin in the stool or meconium.

1.2 PROBLEM STATEMENT

The effectiveness of treatment of NNJ is influenced not only by healthcare interventions but also

by parental knowledge, attitudes, and practices regarding neonatal jaundice. Understanding

parental perspectives is crucial as parents play a central role in recognizing jaundice symptoms,

seeking medical care, and adhering to treatment recommendations. Yet, limited research has

been conducted to explore the knowledge, attitudes, and practices of parents whose babies are

receiving jaundice treatment, especially within the context of Kumasi Metropolis. Therefore, this

study seeks to address this gap by investigating the knowledge, attitudes, and practices towards

neonatal jaundice among parents whose babies are undergoing treatment in healthcare facilities

within Kumasi Metropolis.

1.3 MAIN AIM AND SPECIFIC OBJECTIVE

1.3.1 Main aim

To investigate and assess parental knowledge, attitudes, and practices towards neonatal jaundice

among parents whose babies are receiving jaundice treatment in healthcare facilities within

Kumasi Metropolis?

1.3.2 Specific objective

1. To determine the perception of parents on neonatal jaundice.

2. To examine the level of knowledge of parents on the risk factors of neonatal jaundice.

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3. To examine parents' health seeking behavior towards neonatal jaundice.

4. Determine the practices among parents in managing neonatal jaundice.

1.5 RESEARCH QUESTIONS

1. What are the perception of parents on neonatal jaundice?

2. What is the level of knowledge of parents on the risk factors of neonatal jaundice?

3. What are parents' attitudes towards health on neonatal jaundice?

4. What are the common practices among parents for managing neonatal jaundice at home?

1.6 JUSTIFICATION

The reduction of neonatal mortality, aligned with the health goals of the United Nations

Sustainable Development Goals (SDGs), is crucial. Improving paerental awareness, knowledge,

attitudes, and practices is essential for achieving this goal, particularly in resource-limited

settings (Ezeaka et al., 2014).

The study aims to inform targeted interventions by understanding parental knowledge gaps and

barriers to healthcare-seeking behaviors. Additionally, it seeks to enhance parental education and

support through tailored programs addressing misconceptions and promoting positive attitudes

towards seeking medical care. Furthermore, the findings can inform healthcare policy and

practice by providing evidence to policymakers and practitioners, ensuring culturally sensitive

interventions. Finally, the study contributes to global health research by filling a gap in the

literature on NNJ management in low- and middle-income countries like Ghana. Sharing these

findings with the broader research community adds to the knowledge base on neonatal health and

informs future research directions globally.

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 CHAPTER 2

LITERATURE REVIEW

This chapter entails the available data on the prevalence of neonatal jaundice, the treatment

options and the existing literature available for analysis and identification of research gap.

2.1 Prevalence

Globally, neonatal jaundice is a major public health problem and is present among 50-60% of

full term and 80% of preterm (WHO, 2016). NNJ being a leading cause of hospital admissions or

readmission in the first week of life also constitute a cause of neonatal mortality (Onyearugha et

al., 2011). Severe neonatal jaundice affects around 481,000 late-preterm and term newborns

worldwide every year, resulting in 114,000 deaths and over 63,000 survivors with long-term

disabilities (Olusanya et al., 2018).

Sub-Saharan Africa shares the largest burden of neonatal jaundice-related morbidity and

mortality. The incidence of severe neonatal jaundice in these countries were 667.8 per 10,000

live births (Slusher et al.,2017). NNJ account for 75% of neonatal mortality in Sub-Saharan

Africa (Mohammad et al., 2016; Amidu et al., 2023).

In Ghana, there have been an increasing trend of cases of NNJ from 2015 to 2019 with 3,031,

4,251, 5,338, 7,175, and 9,273 cases of NNJ, respectively (Ghana Health Service, 2019; Salia et

al., 2021). A cross-sectional study was conducted in the Central Region of Ghana and 66.7%

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prevalence of NNJ was reported (Adoba et al., 2018). Another study found that the severe form

of NNJ was a common presentation among children receiving care at a neurologic clinic in

Ghana (Adei-Atiemo et al., 2015). In the Tamale Metropolis, another cross-sectional study

reported a 9.7% prevalence of severe NNJ (Abdul-Mumin et al., 2021). Most previous studies on

knowledge, attitudes, and practices towards NNJ across the globe have largely been limited to

parents (Al-Zamili & Saadoon, 2020; Onyearugha et al., 2016; Saud et al., 2016).

2.2 Exploring parental knowledge

Previous research has highlighted the importance of parental knowledge, attitudes, and practices

in influencing the outcomes of neonatal jaundice management. A study by Ogunlesi et al. (2011)

found that parental knowledge about neonatal jaundice symptoms and treatment options

significantly influence their healthcare-seeking behavior and adherence to medical

recommendations. Similarly, a systematic review by Olusanya et al. (2015) identified parental

education and awareness as key factors in improving the early detection and management of

neonatal jaundice in low-resource settings. In the context of Kumasi Metropolis, limited research

has been conducted to explore parental perspectives on neonatal jaundice management.

However, a study by Seneadza et al. (2022) examined healthcare-seeking behaviors among

parents of jaundiced newborns in Ghana and found that cultural beliefs, financial constraints, and

lack of awareness about available healthcare services were significant barriers to accessing

timely medical care. Despite the importance of parental involvement in neonatal jaundice

management, there remains a gap in understanding the specific knowledge, attitudes, and

practices of parents whose babies are receiving jaundice treatment in Kumasi Metropolis.

Therefore, this study aims to address this gap by investigating the factors influencing parental

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knowledge, attitudes, and practices towards neonatal jaundice in the study population. Through a

combination of surveys and qualitative interviews, this research seeks to gain insights into

parental experiences and perceptions related to neonatal jaundice management, identify potential

barriers to accessing healthcare services, and explore opportunities for improving parental

education and support programs in Kumasi Metropolis.

By understanding the knowledge, attitudes, and practices of parents towards neonatal jaundice,

this study aims to inform targeted interventions and policy initiatives aimed at improving

neonatal health outcomes and reducing the burden of neonatal jaundice in Kumasi Metropolis.

2.3 Available treatments of Neonatal jaundice

Treatment options include phototherapy, exchange transfusions, and intravenous

immunoglobulin in some cases. Understanding the etiology and distinguishing between

physiological and pathological jaundice is crucial for appropriate management and prevention of

complications (Ansong-Assoku et al., 2023).

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 CHAPTER 3

METHODOLOGY

This chapter encompasses the principles, procedures and techniques that will be used to conduct

this study in order to ensure validity, reliability and rigor of this study outcomes. This chapter

also outlines the framework within which our data will be collected, analyzed and be interpreted

to guide us to address our research questions.

3.1 REESEACH DESIGN.

This study will involve the use of qualitative and quantitative data collection and analysis

technique. The qualitative component has as its foci the perspective and subjective live

experiences, and its aim is understanding. This research method will enable us to explore the

concepts and the experience of parents whose babies are victims of NNJ. This study will involve

a cross-sectional study to assess parental knowledge, attitudes, and practices towards neonatal

jaundice.

The qualitative and quantitative components of the study will consist of in-depth interviews and

a questionnaire study with scalable questions, respectively, to explore their experiences and

perceptions in greater depth.

3.2 STUDY AREA

The Kumasi Metropolitan is centrally located in the Ashanti Region of Ghana. It is the second

largest city in the country and the administrative capital of Ashanti. Some of the hospitals within

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this metropolitan assembly include: KNUST hospital, Manhyia Government hospital, Kumasi

South hospital, Kwadaso SDA hospital and Tafo Government hospital. This study will be

conducted at the pediatric units where parents bring their babies for jaundice treatment.

3.3 STUDY POPULATION

The study population consists of parents of newborn infants who are diagnosed with neonatal

jaundice and are currently receiving jaundice treatment in healthcare facilities within Kumasi

Metropolis.

3.3.1 Inclusion Criteria: Parents whose babies are receiving jaundices treatments in the selected

hospitals

3.3.2Exclusion Criteria: Parents whose babies are receiving jaundice treatment but refuse to be

part in the survey, or have a health condition that prevents their participation.

3.4 SAMPLING TECHNIQUES:

A convenience sampling method will be used to recruit participants for the study. Parents of

infants receiving jaundice treatment at selected healthcare facilities will be invited to participate.

Purposive sampling will also be employed to select a subset of survey participants for in-depth

interviews, ensuring diversity in demographics and experiences.

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3.5 SAMPLE SIZE

The following population were obtained from the target hospitals , 25, 42, 26, 35, and 22 from

KNUST, Manhyia government hospital, Tafo government hospital, Kumasi south hospital and

MCH respectively. The population were taken per average monthly attendance in each hospital .

Our confidence level is 95% thus, there is 5% chance of selecting wrong population size. The

margin of error (e) becomes 0.05. Margin of error ( minimum acceptable variation or error of

how much sample mean vary from the population mean).

Slovin’s formula was used to determine the appropriate sample size with a desired margin of

error .

n : sample size = ?

N: total population size = 150

e : margin of error = 0.05

n = 150/1+150(0.05)2

n = 109.09091

n =109

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Therefore, the sample size that will be as representative of the area as possible that will aid to

achieve adequate statistical power and precision in assessing knowledge, attitudes and practices

of parents on neonatal jaundice will be 109 participants.

The sample size for the qualitative aspect will be determined on the principle of data saturation,

where new information cease to emerge from additional interview.

3.6 DATA COLLECTION INSTRUMENTS

Quantitative: A structured questionnaire will be developed to assess parental knowledge,

attitudes, and practices towards neonatal jaundice. Likert scale questionnaire will be used in this

study.

Qualitative: Semi-structured interview guides will be developed to explore participants'

experiences, beliefs, and behaviors related to neonatal jaundice management. Probing questions

will be used to achieve detailed narratives from participants.

3.7 DATA COLLECTION PROCEDURE:

Quantitative: Questionnaires will be given to the population of interest in the healthcare

facilities. Participants will complete the questionnaire independently, with assistance provided

when the need be.

Qualitative: In-depth interviews will be conducted with a subset of study participants in a

private and comfortable setting within the healthcare facilities. Interviews will be audio-recorded

with participants' consent and transcribed using the NVivo software for analysis.

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3.8 DATA ANALYSIS:

Quantitative: Descriptive statistics, such as frequencies, and percentages, will be used to analyze

the data obtained from the structured questionnaires. Inferential statistics, such as chi-square tests

or regression analysis, may be employed to examine associations between variables. SPSS

software will be used for these analyses.

Qualitative: Audio recording of interviews will be converted into text format and transcribed

data will be analyzed using the NVivo software. Themes will be developed based on the

available transcribed data.

3.9 ETHICAL CONSIDERATIONS:

The study will adhere to the Committee on Human Research and Publication Research Ethics

(CHRPE) guidelines for research involving human participants. Approval will be obtained from

the Dean of the school of Nursing and Midwifery, KNUST. Informed consent will be obtained

from all participants and their identities will be kept anonymous to ensure confidentiality. The

study’s purpose and potential risk will be clearly communicated to participants and they will

have the right to withdraw from the study at any point without any consequences

BUDGET

Items Quantity Unit Price (Ghc) Cost (Ghc)

Transport(Students) 4 50 200
Printing Of Questionnaires 150 3 450
Data Analysis Software 1 150 150
Ethical Approval 1 50 50
Refreshment For Participants 200 5 500
Total Cost 1350

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TIMELINE

2024
Task/Month March April May June July August

Proposal Finalization

Literature review
Ethics Approval and
Participants Recruitment
Data Collection

Data Analysis
Writing of Research
Report
Finalization and
Submission of Report

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REFERENCES

Betty Ansong-Assoku; Sanket D. Shah; Mohammad Adnan; Pratibha A. Ankola.(2023)

Ezeaka C V., Ugwu RO et al. "Pattern and predictors of maternal care-seeking practices for

severe neonatal jaundice in Nigeria: A multi-centre survey." BMC Health Serv Res. 2014;14(1).

doi: 10.1186/1472-6963-14

Ogunlesi TA, Ogunfowora OB, Ogundeyi MM. Knowledge and attitudes of mothers towards

neonatal jaundice in Sagamu, Nigeria. Niger J Clin Pract. 2011;14(1):10-151

Olusanya BO, Osibanjo FB, Slusher TM. Risk factors for severe neonatal hyperbilirubinemia in

low and middle-income countries: a systematic review and meta-analysis. PLoS One.

2015;10(2):e01172292

Preer GL, Philipp BL. Understanding and managing breast milk jaundice. Arch Dis Child Fetal

Neonatal Ed. 2011 Nov;96(6):F461-6

Seneadza NAH, Insaidoo G, Boye H, et al. Neonatal jaundice in Ghanaian children: Assessing

maternal knowledge, attitude, and perceptions. PLoS One. 2022;17(3):e02646943

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