KNOWLEDGE AND ATTITUDE AS CORRELATE OF ADDHERENCE TO PREMARITAL SICKLE CELL SCREENING AMONG ADULT STUDENTS’ OF NNAMDI AZIKIWE UNIVERSITY AWKA, ANAMBRA STATE.

ABSTRACT
Premarital sickle cell screening is a test done to screen intending couples in order to determine their genotype before marriage. This study investigated the knowledge and attitude of adult students of Nnamdi Azikiwe University (NAU), Awka as correlate of adherence to premarital sickle cell screening.  A cross sectional descriptive research design was used for the study. A sample size of 370 adult students was drawn from an estimated population of 10,400 through a proportional, stratified, sampling technique. Data were collected using a researcher developed questionnaire. Data were analyzed descriptively using frequencies, percentages, mean and standard deviations. Chi-square test was used to test the hypotheses. Findings revealed that the participants had high knowledge about premarital sickle cell screening. There was also positive attitude by the participants towards pre-marital sickle cell screening. Reasons for not going for the test by few married adult students were lack of knowledge of premarital sickle cell screening and its consequences to an affected individual, while the unmarried stated their reasons to be fear of exposing ones genotype to the public and fear of stigma following an affected individual. The percentage of unmarried adult that indicated willingness to go for screening test were higher than the percentage of married adults that adhered to premarital screening. There was no significant relationship between knowledge and adherence to premarital sickle cell screening among married and unmarried adult students. There was significant relationship between attitude and adherence to premarital sickle cell screening among unmarried adult students; however no significant relationship was found among married adult students. Based on the findings, it was concluded that university students can serve as advocates for creating awareness on premarital sickle cell screening due to their high knowledge. There is need for enlightment campaign to address the issue of stigma and discrimination about sickle cell disorder.
 
 
 
 
 
 
 
 
 
 
 
CHAPTER ONE
INTRODUCTION
Background to the study
One of the biggest health challenges to the human race is sickle cell disorder (WHO, 2008).  It is a genetic disorder transmitted from parents to their offsprings. The disorder is associated with many challenges resulting from frequent hospitalization of the affected individual. Despite major advances in our understanding of the molecular pathology, pathophysiology, and causes of the inheritable disorders, thousands of infants and children are dying through lack of appropriate preventive measures such as lack of premarital sickle cell screening by intending couples to know their genotype before marriage (Akowe, 2010).
 
According to World Health Organization (WHO, 2008),  sickle cell disorder contributes to 5% of under five deaths on the African continent; more than 9% of such deaths occur in West Africa and up to 16% of under-five deaths in individual West African countries. Akinyanju,  (2009), states that about one hundred and fifty thousand children are born each year with sickle cell diseases and about 2-3% of Nigerians live with the disease while 25-30% of Nigerians carry the gene that can give rise to sickle cell disease (SCD) . It is estimated that by the year 2025, a total number of 50,000 children born in Nigeria will be affected with sickle cell disorder, and this poses a great concern , (George,   2011).  In order to prevent this disorder, sickle cell screening and testing have been recommended for couples before marriage (Akinyanju,  2009)
 
Premarital sickle cell screening/testing has been defined by different people in different ways,  Littleton and Engebretson (2010),  see it as a process for screening couples going into marriage for genetic and blood transmitted diseases to prevent any risk of transmitting diseases to their children. Gharaibe and Mater (2009),  see it as an important tool used by intending couples to control, minimize and prevent sickle cell disorders.  Invariably sickle cell testing serves as a tool for diagnosis of SCD, it also provides individual couples with an accurate understanding of sickle cell inheritance and what it means to be at risk.  In addition, information about premarital sickle cell screening and counseling has become part of marriage course counseling and regular medical practice.  It has also helped to achieve desired level of knowledge and a change in attitude.  However, this is not always the case as many people go into marriage without having insight into their genotype especially in developing countries where diagnosis is usually made when the individual presents in the clinic with severe complications, (Akinyanju, 2009).  Undertaking premarital sickle cell screening and counseling may depend on individual’s knowledge of sickle cell disorder.
 
Knowledge about premarital sickle cell screening can be gained through information from educational programmes. This in turn establishes a health awareness program in order to explain the benefits of premarital sickle cell screening to the public and increase their awareness on the serious consequences of sickle cell disorder. Knowledge gained about premarital sickle cell screening will help to prevent SCD and the prevention will depend on the attitude of couples towards the screening. Attitude according to encyclopedia dictionary is a set way of thinking or feeling typically reflected in a person’s behaviour. It is the totality of those states that lead to a point towards some particular activity of the organism, (Ferguson,   2010).   Attitude to premarital sickle cell screening can be a dynamic element in human behaviour, and it can be positive or negative.  People who have positive attitude about the benefits associated with premarital sickle cell screening may like to adhere to premarital screening, according to Lockock and Joe (2009),   may affect their adherence to premarital sickle cell screening.
 
Adherence to premarital sickle cell screening is an act of sticking to behaviour, or the process of engaging in an activity for the purpose of mastering or improving on it.  People may agree to comply to premarital sickle cell screening when they see that the behaviour will yield positive results, like reducing the risk of having children with sickle cell disease. On the other hand, individuals may fail to adhere to sickle cell screening due to reasons such as fear of stigma, emotional or financial consequences and or reliability of the test result. (Lockock & Joe,  2009).
Premarital screening helps to educate people about inherited disorders.  Although, WHO  has repeatedly recommended several measures for the prevention of genetic diseases including sickle cell  diseases through health education and improvement of community knowledge and attitude towards the control of this hereditary genetic diseases (WHO, in Awatif, 2006), adherence to premarital sickle cell screening is still very low (Al kindi, Salha & Al kendi, 2012).
It has been recommended that it is time we start ascertaining the compatibility of  intending couples to make marriages work better and on a more realistic grounds by way of premarital screening and testing, WHO, (2008). There is need to encourage the practice of premarital sickle cell screening.  Prevention of sickle cell disorder and risk minimization through screening and carrier identification remains the only realistic approach to reduce the impact of the disease especially in an adult population. Tertiary institutions have large concentration of adult population and they form important sub groups of the population since they are at a relatively high level of education and in the manageable age group. The study targeted this group of students at Nnamdi Azikiwe University Awka, Anambra State, since there was no available data for Anambra State on premarital sickle cell screening.
 
 Statement of the Problem
Akinyanju (2009), stated that Nigeria has the highest population of people living with sickle cell diseases with about 150,000 births annually. Similar statement made by WHO (2008), shows that of the 100,000 individuals born annually worldwide, 14,306 have sickle cell trait, while 474 have sickle cell diseases.  Al- kindi, Salha & Al kendi, (2012), stated that despite current advances in diagnosis and the increasing campaigns through mass media and health professionals all are supposed to increase people’s knowledge about premarital sickle cell counseling and screening with a view to causing a drop in high risk marriages. In spite of these efforts, sickle cell diseases are still very common in our society. In addition, non adherence to premarital sickle cell screening before marriage can lead to birth of a child with the disorder, separation and divorce among  parents, frequent going in and out of the hospital, and infant mortality and morbidity.
 
A good example of such increase was at Nnamdi Azikiwe University Teaching hospital (NAUTH) Nnewi, which is a sickle cell screening centre in Anambra state, the sickle cell clinic in 2012 revealed an estimated weekly attendance of fifty-two adult patients.  Anecdotal reports and personal experiences of the researcher both in hospitals and neighbourhood also show that many couples lose their children in quick succession. On close enquiry, it was observed that some of these children die as a result of sickle cell disease.
 
 
Their believe was that if intending couples were favourably disposed to do premarital screening, it will help  in the detection of carriers of sickle cell trait  and prevent birth of an affected offspring.
Although premarital sickle cell screening programs has a high potential to reduce the incidence of SCD in an adult population and preventing marriages among high risk couples, many people do not adhere to it. The question being raised in this study is; what knowledge does an adult student of NAU have about premarital sickle cell screening, what is their attitude towards premarital sickle cell is screening
 
Purpose of the Study
The purpose of the study was to determine if there is a relationship between knowledge, attitude and adherence to premarital sickle cell screening among adult (both married and unmarried) students of NAU.
The objectives of the study were to:

1. Determine knowledge of premarital sickle cell screening among married and unmarried adult students of NAU.
2. Assess the attitude of married and unmarried adult students of NAU towards premarital sickle cell screening.
3. Identify adult unmarried students of NAU that are willing to go for premarital sickle cell screening.
4. Ascertain adult married students that adhered to premarital sickle cell screening before marriage
5. Determine the relationship between knowledge and adherence to premarital sickle cell screening among married and unmarried adult students of NAU.
6. Determine the relationship between attitude and adherence to premarital sickle cell screening among married and unmarried adult students of NAU.

 
 
 
Research questions

1. What knowledge do married and unmarried adult students of NAU have knowledge about

Premarital sickle cell screening?

2. What is the attitude of married and unmarried adult students of NAU towards premarital

sickle cell screening?

3. Are unmarried adult students of NAU willing to have premarital sickle cell screening

before marriage?

4. Did married adult students of NAU adhere to premarital sickle cell screening before

marriage?

5. Is there any relationship between knowledge and adherence to premarital sickle cell

screening among married and unmarried adult students of NAU?

6. Is there any relationship between attitude and adherence to premarital sickle cell screening

among married and unmarried adult students of NAU?
 
Hypotheses
The following null hypotheses guided the study:-

1. There is no significant relationship between knowledge and adherence to premarital sickle

cell screening among unmarried adult students of NAU.

2. There is no significant relationship between knowledge and adherence to premarital sickle cell

screening among married adult students of NAU.
3.. There is no significant relationship between attitude and adherence to premarital sickle cell
screening among unmarried adult students of NAU.

4. There is no significant relationship between attitude and adherence to premarital sickle cell

screening among married adult students of NAU
 
Significance of the Study
The study will help to provide information to the Government and health care providers on the level of knowledge, attitude and adherence of adult students of NAU, to premarital sickle cell screening, and some of the reasons that hinders them from adhering to premarital sickle cell screening despite the benefits associated with it.
The information provided will serve as tools to healthcare providers in identifyings areas of need, If findings shows low level of knowledge, appropriate measures will be devised to strengthen their enlightment campaign in other to health educate them on the importance of the screening. Government will through the information institute policies guiding couples on premarital screening before marriage. However if findings shows high level of knowledge, it will benefit the family and community health wise because, adult student can be able to make wise selections before marriage. The high level of knowledge will help to change their negative attitude to positive attitude and increase their level of adherence. Increase in their level of adherence will reduce high risk marriages, birth of a child with sickle cell disorder, under five mortality and morbidity, divorce and frequent going in and out of the hospital. Information gathered will help to reduce the stigma and fear attached to premarital screening thus enhance adherence of couples to screening before marriage.
Findings from this study will be useful to health educators, counselors and policy makers as it will provide the relationship between knowledge, attitude and adherence to premarital sickle cell screening, such information will be used as a guide in health education campaigns and programs. Furthermore, the findings will also serve as a point of reference for future studies.
 
Scope of the study
The study is confined to undergraduate adult students on part time and regular basis (males and females, both married and unmarried) at Nnamdi Azikiwe University Awka.  NAU was chosen because of the large population of adults running both programmes. The study also covered variables like knowledge, attitude and how they relate to adherence to premarital sickle cell screening.
 
 
 
 
 
 
   
 Operational definition of Terms

1. 1. Premarital sickle cell screening refer to test done by adult male and female students of NAU in order to know  their status on the sickle cell genetic trait before going into marriage.

 

2. Knowledge of premarital sickle cell screening refers to whether adult students have low or high knowledge about premarital sickle cell screening, with regard to the awareness of premarital sickle cell screening, when it should be done, benefits of going for premarital screening before marriage and dangers of not adhering to premarital sickle cell screening. Knowledge was assessed using the mean score of 8.5 from the 17 sub items in items 9-12. Scores above 8.5 were considered good knowledge while scores of 8.5 and below were regarded as low knowledge.
3. Attitude to premarital sickle cell screening refers to favourable and unfavourable feelings and beliefs of adult students of NAU towards Premarital sickle cell screening, which can either be positive attitude or negative attitude. Positive attitudes are the respondents that agree or strongly agree that premarital screening is one of the ways to reduce disease burden in the family, premarital screening is necessary once the couples have agreed to marry. and should be

made compulsory. While negative attitudes were the respondents that said that premarital screening will increase the chances of one not getting married and  will expose their status to the public,
A  Positive attitude is indicated by a mean score above 2.5 while a mean score of 2.5 and below is negative in the modified likert scale scoring.
 

4. Adherence to premarital sickle cell screening refer to the number of unmarried adult student of NAU that have the intention and willingness to go for sickle cell screening before marriage, or the number of married adult students that went for premarital sickle cell screening before marriage.