Retrospective Perspectives on Premarital Sickle Cell Screening Among Parents of Children Living With Sickle Cell Disease at University of Benin Teaching Hospital, Benin City

Retrospective Perspectives on Premarital Sickle Cell Screening Among Parents of Children Living With Sickle Cell Disease at University of Benin Teaching Hospital, Benin City | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Retrospective Perspectives on Premarital Sickle Cell Screening Among Parents of Children Living With Sickle Cell Disease at University of Benin Teaching Hospital, Benin City Lilian Ezeuko, Magdalene Odunvbun This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8785678/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 13 You are reading this latest preprint version Abstract Background Sickle cell disease (SCD) remains a major public health problem in Nigeria and West Africa. Premarital Counselling and screening (PMC) are effective strategies for preventing the birth of children with SCD; however, their uptake remains suboptimal despite increasing awareness Objective To assess the socio-demographic characteristics, knowledge, attitude and practices regarding SCD and PMC and to identify factors associated with awareness and uptake of PMC among participants Methods This was a descriptive cross- sectional study involving 80 participants. Data were collected using a structured questionnaire assessing the socio-demographic characteristics, knowledge of SCD and PMC, attitudes toward PMC and uptake. Data were analyzed using descriptive and inferential statistics. Associations between socio-demographic variables, awareness and uptake were tested using chi-square and Fisher’s exact tests with the level of significance set at p < 0.05. Results Awareness of SCD was universal (100%), with the health workers being the main source of information (46.3%). Although 62.5% correctly identified SCD as an inherited condition, only 51.3% has heard of PMC. Sixty percent of participants did not undertake any PMC and 55% did not check their genotype before marriage. Older age (≥ 45 years) was significantly associated with lower uptake of PMC (ꭓ 2 = 7.069, p = 0.029). Awareness of PMC was strongly associated with uptake (ꭓ 2 =38.557, p < 0.001). Conclusion Despite high awareness of SCD, awareness and uptake of PMC and screening remain inadequate. Strengthening public health education and integrating PMC into routine reproductive health services are essential to reducing the burden of SCD. Awareness Genotype screening Premarital counselling Sickle cell disease Figures Figure 1 Figure 2 Introduction Sickle cell disease (SCD) is one of the most common inherited hemoglobin disorders worldwide and remains a major public health challenge, particularly in sub-Saharan Africa 1,2 . It is an autosomal recessive genetic condition resulting from a point mutation in the β-globin gene, which leads to the production of abnormal hemoglobin S. The disease is characterized by chronic hemolytic anemia, recurrent vaso-occlusive episodes, increased susceptibility to infections, and progressive multi-organ damage, all of which contribute to significant morbidity, reduced quality of life, and increased childhood mortality 1-3 . Globally, more than 300,000 infants are born each year with SCD, with over 70% of these births occurring in Africa 4 . Nigeria bears the highest burden of SCD worldwide, accounting for an estimated 150,000 affected births annually, while approximately 20–30% of the population carry the sickle cell trait (HbAS) 5,6 . Despite improvements in supportive care and increasing availability of disease-modifying therapies such as hydroxyurea, families affected by SCD continue to experience considerable physical, emotional, and financial strain 7 .These challenges are particularly profound for parents who provide long-term care for children living with SCD. Premarital sickle cell screening is a key preventive strategy aimed at identifying carrier status before marriage, thereby enabling informed partner selection and reproductive decision-making 8 . When combined with effective genetic counselling, premarital screening has been shown to significantly reduce the incidence of SCD in several high-prevalence regions 9 . Many countries, including Nigeria, have adopted premarital screening policies or recommendations, often integrated into religious, community, or health institution requirements prior to marriage 10 .Despite the widespread promotion of premarital screening, the continued high incidence of SCD suggests persistent gaps in awareness, utilization, interpretation of results, or application of screening information to marital and reproductive decisions 11 . Some couples proceed with marriage despite incompatible genotypes due to emotional attachment, social pressure, religious beliefs, misinformation, or limited access to accurate genetic counselling 12 . Others may undergo screening but fail to fully understand its implications, highlighting deficiencies in communication and counselling services 13 . Parents of children living with SCD represent a unique and critical population for examining the effectiveness of premarital screening programs. Their perspectives are shaped not only by prior knowledge and beliefs at the time of marriage but also by lived experience of caring for an affected child. Retrospective assessment of their awareness, perceptions, and decision-making processes regarding premarital screening provides valuable insight into missed opportunities, systemic gaps, and sociocultural influences that may not be apparent when studying the general population alone 14 .Evidence suggests that caregiving experience significantly alters parental understanding of SCD and attitudes toward genetic screening 15 . Parents often report heightened awareness of disease severity, increased appreciation of preventive strategies, and reconsideration of earlier reproductive choices after experiencing the realities of raising a child with SCD 16 . However, feelings of regret, guilt, stigma, and emotional distress may also influence how parents reflect on premarital screening and discuss it with others 17 . Cultural and religious contexts play a central role in shaping attitudes toward premarital screening and marriage decisions in many African societies 18 . In some settings, strong beliefs in destiny or divine will may reduce the perceived relevance of genetic risk information, while societal expectations surrounding marriage and childbearing may limit the feasibility of genotype-based partner selection 19 . Understanding how these factors interact with individual experiences is essential for developing culturally sensitive screening and counselling interventions. Despite the importance of this perspective, there is limited empirical research focusing specifically on retrospective views of premarital sickle cell screening among parents who already have children with SCD, particularly in high-burden settings such as Nigeria 20 . Most existing studies emphasize awareness and attitudes among adolescents, unmarried adults, or the general population, with insufficient attention to families who have directly experienced the consequences of ineffective or absent premarital screening. This study therefore seeks to explore retrospective perspectives on premarital sickle cell screening among parents of children living with SCD. By examining their prior awareness, perceptions, decision-making processes, and reflections following lived experience with the disease, the study aims to identify gaps in screening programs, counselling services, and community education efforts. Findings are expected to inform the strengthening of premarital screening policies, improve genetic counselling practices, and contribute to more effective strategies for reducing the burden of SCD. Research Questions What was the level of awareness of premarital sickle cell screening among parents prior to marriage? How did parents perceive premarital sickle screening before they got married? How did access to genetic counselling affect parent’s decisions? What socio-cultural, religious or personal factors influenced parent’s decisions regarding premarital screening? Aim and Objectives General Aim: To assess the awareness, perception and decision-making processes of parents of children with SCD concerning premarital SCD screening Specific Objectives To determine the level of awareness of premarital genotype screening among parents of children with SCD prior to marriage To assess parent’s knowledge of sickle cell disease inheritance and genotype compatibility To explore parent’s perceptions and attitudes towards premarital genotype screening before they got married. To identify the sources of information on premarital genotype screening among parents To examine sociodemographic, religious and personal factors associated with awareness and perception of premarital genotype screening. Methodology The study was a hospital-based descriptive cross-sectional study. It was conducted in the Paediatric sickle cell out- patient clinic of the University of Benin Teaching hospital. Parents/caregivers who brought their children to sickle cell clinic between July and December 2025 were recruited. A total of 80 parents were recruited consecutively for this study Ethical approval/ consideration Ethical approval was sought and obtained from the Human research and Ethics Committee of University of Benin Teaching hospital Benin city (NHREC -UBTH- HREC/24/12/2022B). Informed consent was obtained from the parents. Data collection Procedure Two research assistants (1 registrar and 1 house officer) were trained to assist in this study with administration of the questionnaires. Parents/caregivers were given clear and adequate information in English and/or Bini Languages and allowed to make an informed decision. Research assistants trained for the process administered questionnaires privately to ensure confidentiality. Study tool : Demographics and awareness on prenatal screening were collected using a semi-structured interviewer- administered questionnaire. The questionnaire was in two sections: the first section focused on the socio-demographic characteristics of the respondents (age, gender, education, tribe, occupation); the second section sought to establish respondent’s knowledge (awareness, source of information and understanding of methods) and perception/attitudes about premarital genotype screening for SCD . Data Analysis Data were processed and analysed using IBM SPSS version 26.0 for windows. Data presentation involved frequency tables and charts. Means and standard deviations were used as summary indices for numerical data such as age while non- numerical data were presented as frequencies or percentages or as charts. Chi-square and logistic regression were used to assess associations between socio-demographic variables and knowledge/perception levels. A p-value of <0.05 was considered statistically significant. Results Table I: Socio-demographic characteristics of the participants. Approximately 46% (46.3%) of the participants were aged 35-44 years; 32.5% were aged 45-54 years, while 16.3% were aged 25-34 years. The majority (86.3%) of the participants were female. Approximately 58% (57.5%) of the participants were of the Benin ethnicity. The majority (82.5%) of the participants were married. More than a half (53.8%) had done traditional marriage. Approximately 61% (61.3%) of the participants had secondary education as highest level of education. Approximately 63% (62.5%) of the participants had semi-skilled occupations. Table I: Socio-demographic characteristics of participants Variable Frequency (n = 80) Percent (%) Age 15-24 years 2 2.5 25-34 years 13 16.3 35-44 years 37 46.3 45-54 years 26 32.5 55 years and older 2 2.5 Gender Female 69 86.3 Male 11 13.8 Ethnicity Benin 46 57.5 Esan 4 5.0 Etsako 4 5.0 Igbo 11 13.8 Owan 3 3.8 Urhobo 7 8.8 Other 5 6.3 Marital status Single 8 10.0 Married 66 82.5 Separated 4 5.0 Widowed 2 2.5 Level of marriage Single 8 10.0 Traditional 43 53.8 Christian 29 36.3 Highest level of education Primary 6 7.5 Secondary 49 61.3 Tertiary 25 31.3 Occupation Semi-skilled 50 62.5 Skilled 22 27.5 Professional 8 10.0 Table II: Knowledge of SCD and premarital counselling and screening among participants. All (100%) of the participants have heard about SCD. The greater proportion (46.3%) of the participants heard about SCD from health workers. The greater proportion (62.5%) of the participants alluded that SCD is inherited from parents; whereas 2.5% reported that they do not know the cause of SCD. Slightly more than half (51.3%) have heard about premarital counselling, while 48.8% reported that they have not heard about it. The greater proportion (56.3%) of the participants reported that they do not know the best time for premarital counselling. The majority (97.5%) alluded that SCD can be prevented. Likewise, the majority (93.8%) of the participants agreed that SCD cannot be cured. Table II: Knowledge of SCD and premarital counselling and screening among participants Variable Frequency (n = 80) Percent (%) Have you heard about SCD? No 0 0 Yes 80 100 Source of information Affected relative 24 30.0 Family and friends 9 11.3 Health workers 37 46.3 Internet 10 12.5 What is the cause of SCD? Blood disorder 28 35.0 Inherited from parents 50 62.5 Don't know 2 2.5 Have you heard about premarital counselling? No 39 48.8 Yes 41 51.3 What is the best time for premarital counselling? When dating 8 10.0 At the beginning of courtship 20 25.0 Later during courtship 7 8.8 Don't know 45 56.3 Can SCD be prevented? No 2 2.5 Yes 78 97.5 Can SCD be cured? No 75 93.8 Yes 5 6.3 Table III: Descriptive statistics of the children of the participants Approximately two-thirds (66.3%) of the participants had 3-4 children. Half of the participants (50%) had only one child with SCD; another 40% had two children with SCD; 8.8% had three children with SCD, while only one (1.3%) of the participants had five children with SCD. Table III: Descriptive statistics of the children of the participants Variable Frequency (n = 80) Percent (%) How many children do you have? Median = 3.0 IQR = 1 1-2 children 17 21.3 3-4 children 53 66.3 5 children or more 10 12.5 How many have SCD? Median = 1.5 IQR = 1 1 40 50.0 2 32 40.0 3 7 8.8 5 1 1.3 Table IV: Attitude of the participants to premarital counselling and screening . Sixty percent of the participants had not undertaken any premarital counselling. The greater proportion (55%) of the participants did not check their genotype before marriage. Table IV: Attitude to premarital counselling and screening Variable Frequency (n = 80) Percent (%) Did you undertake any premarital counselling? No 48 60.0 Yes 32 40.0 Why did you have a child with SCD? Didn't check genotype before marriage 44 55.0 Decided to try 5 6.3 Lab error 31 38.8 Table V: Association between age and gender of participant and awareness of premarital counselling and screening. The greater proportion (18, 64.3%) of the participants aged 45 years or older are unaware of premarital counselling and screening. However, this association was not statistically significant (ꭓ 2 = 4.163, P = 0.125). The greater proportion (7, 63.6%) of the participants who were male are unaware of premarital counselling and screening. However, this association was not statistically significant (ꭓ 2 = 1.131, P = 0.288). Table V: Association between age of participants and awareness of SCD prenatal counselling and screening Variable Awareness of premarital counselling ꭓ 2 statistic P-value Unaware Aware Age 34 years or younger 6 (40.0%) 9 (60.0%) 4.163 0.125 35-44 years 15 (40.5%) 22 (59.5%) 45 years or older 18 (64.3%) 10 (35.7%) Gender Fisher’s exact Female 32 (46.4%) 37 (53.6%) 1.131 0.288 Male 7 (63.6%) 4 (36.4%) Table VI: Association between age, gender, and the awareness and uptake of premarital counselling and screening. The greater proportion (22, 78.6%) of the participants aged 45 years or older have not undertaken premarital counselling and screening. This association was statistically significant (ꭓ 2 = 7.069, P = 0.029). The greater proportion (37, 94.9%) of the participants unaware of PMC have not undertaken premarital counselling and screening. This association was statistically significant (ꭓ 2 = 38.557, P < 0.001). Table VI: Association between age, gender, and the awareness and uptake of premarital counselling and screening. Variable Uptake of premarital counselling ꭓ 2 statistic P-value Not undertaken Undertaken Age 34 years or younger 9 (60.0%) 6 (40.0%) 7.069 0.029* 35-44 years 17 (45.9%) 20 (54.1%) 45 years or older 22 (78.6%) 6 (21.4%) Awareness of premarital counselling Fisher’s exact Unaware 37 (94.9%) 2 (5.1) 38.557 < 0.001* Aware 11 (26.8%) 30 (73.2) * Statistically significant Discussion The majority of participants were aged 35-44 years, female, married and of Benin ethnicity. This age distribution is similar to findings from hospital- based and community studies in southern Nigeria, where caregivers of children with SCD are predominantly in their middle reproductive years, reflecting cumulative childbearing and exposure to SCD outcomes over time 21,22 . The female predominance observed in this study aligns with reports from Nigeria and Ghana, where mothers are more likely to accompany children to health facilities and participate in SCD- related research possibly due to their traditional caregiving roles 4,23 . More than half of the participants had secondary education and majority were semi- skilled. Similar educational patterns have been reported in studies from Edo, Lagos and Oyo states where secondary education was the most common level attained among caregivers of children with SCD 24,25 . Although secondary education suggests basic literacy, it may not be sufficient to ensure comprehensive understanding of genetic inheritance and preventive strategies for SCD, which could partly explain gaps observed in awareness and uptake of PMC. Awareness of SCD was universal in this study with health workers being the most common source of information. This finding is consistent with Nigerian and West African studies reporting near- universal awareness of SCD, particularly among parents of affected children 26,27 . The prominent role of health workers underscores the importance of health facilities as key channels for SCD education. Most participants correctly identified SCD as an inherited condition, similar in southwest Nigeria and Ghana, where 60-80% of respondents demonstrated correct knowledge of the genetic basis of SCD 9,24 . However, a substantial proportion still described SCD simply as a “blood disorder”, reflecting partial understanding. Comparable misconceptions have been documented across West Africa, highlighting persistent knowledge gaps regarding autosomal recessive inheritance 4 . Only about half of the participants had heard of premarital counselling and more than half did not know the appropriate timing for PMC. This level of awareness is lower than reports among university students and urban populations in Nigeria where awareness rate of PMC range from 60% to over 80% as reported by Omuemu et al. and Akinwale et al. respectively 25,26 . The difference may be due to variations in educational attainment, urban-rural mix and targeted health messaging. The majority of participants believed SCD can be prevented but not cured. This perception is consistent with findings from Nigeria and Ghana, where prevention through carrier screening an informed marital decisions is widely acknowledged, while cure is often considered unattainable despite the availability of bone marrow transplantation in limited settings 11,25 . Most participants had three to four children and up to 40% had 2 children each with SCD. Similar family patterns have been reported in Nigerian studies where repeated births of children with SCD occur due to premarital or preconception genotype screening and possibility of having birthed all the children before diagnosis of SCD is made in the children 11,26 . These findings underscore the significant familial and psychosocial burden of SCD in West Africa. Despite relatively high awareness of SCD, 60% of participants did not undertake PMC and more than half did not check their genotype before marriage. This poor uptake mirrors finding from studies in Edo, Lagos and northern Nigeria, where uptake of PMC ranged from 20% to 45% despite moderate to high awareness 22,27 . Cultural beliefs, emotional attachment, religious considerations and fear of relationship dissolution have been cited as barriers to PMC uptake in Nigeria and Ghana 11,28 . The reason given for having children with SCD- particularly failure to check genotype and perceived laboratory error prior to marriage- are consistent with previous Nigerian studies, where trust in laboratory results and misconceptions about genotype testing accuracy influence reproductive decisions 24 . Although older participants and males were more likely to be unaware of PMC, these associations were not statistically significant. Similar non- significant associations between socio-demographic factors and awareness have been reported in some Nigerian studies, suggesting that awareness of PMC cuts across age and gender groups but may be influenced more to targeted health education 26 . However, age and awareness of PMC were significantly associated with uptake of PMC. Participants aged 45 years and older were significantly less likely to have undertaken PMC, possibly reflecting generational differences as PMC and genotype screening were less emphasized in public health messaging several decades ago. This pattern has been observed in studies from southwest Nigeria, where younger adults were more likely to utilize PMC services compared to older cohorts 29 . Awareness of PMC showed a strong and statistically significant association with uptake, with participants who were unaware being far less likely to have undertaken counselling. This finding is consistent with evidence from Nigeria and Ghana demonstrating that awareness is a key determinant of PMC utilization 11,28 . It highlights the critical role of sustained public health education in improving preventive practices. Conclusion This study demonstrates universal awareness of sickle cell disease among participants; however, awareness and uptake of premarital counselling and screening remain suboptimal. Although most participants correctly identified SCD as an inherited condition and believed it is preventable, only about half had heard of premarital counselling and a smaller proportion had actually undertaken PMC or genotype screening before marriage. Older age was significantly associated with lower uptake of PMC while awareness of PMC was a strong predictor of its utilization. Despite having one or more children affected by SCD, many participants reported not checking their genotype prior to marriage, underscoring persistent gaps between knowledge and preventive practice. Overall, the findings highlight missed opportunities for primary prevention of SCD through effective PMC and screening in this population Recommendations Targeted community- based education on SCD inheritance and the importance of premarital counselling and screening should be intensified, using culturally appropriate messages and local languages Premarital counselling and genotype screening should be incorporated into routine reproductive health, antenatal and family planning services especially in primary healthcare settings School- based and youth- focused interventions including secondary schools and tertiary institutions should be strengthened to encourage genotype screening before courtship and marriage Limitations Participants were recruited from healthcare setting, which may limit generalizability of the study to the wider community The retrospective nature of the study may be subject to recall bias and social desirability bias. Declarations Conflict of Interest: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Funding : This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The study was self-funded by the authors. Clinical trial number : Not applicable Consent for publication: Written informed consent was obtained from all individual participants (or their legal guardians) for publication of this study and its accompanying data. Availability of data and materials : The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Authors' contributions : All authors contributed equally to the conception, design, data collection, analysis, interpretation, and writing of the manuscript. All authors read and approved the final version of the manuscript. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8785678","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":600380801,"identity":"ec81ee2f-797b-4a10-91fa-6cb049dff855","order_by":0,"name":"Lilian Ezeuko","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABFklEQVRIie2RvWrDMBCAzxjsRak6lQspzSvIBEoGQ15FwtC1HTUaBNlK1oQ+QpeCwbNMVpuuLl2SpVvBWwPtUMkhFErsrBn0DeI47uN+BOBwnCW+Ms+UXIBfbBqGhNokf+gWCHgKNCAJIEiipYxvhqlV2GkFAiC3I1LeTZi2+R5lFhZq0ki8DpAzHMzXInt9Fs2GwZhe6eNdiFBcl2Yw5JwNjZLXn5nRIVo98Y7BhNLFvFU0j1qlerEKZ+8dCt0eFJFqYQdbVtmuV0Ez2F5JvFTb9elj3t+l3ipW2l3Ih++l5shYD/KpOUXnLuEiWaOU8YyG91/fP/YrF1X2tpPxmI6OK39cHgqwDfBEuYXq/4HD4XA49vwCj6Vh4AtPoI8AAAAASUVORK5CYII=","orcid":"","institution":"University of Benin Teaching Hospital","correspondingAuthor":true,"prefix":"","firstName":"Lilian","middleName":"","lastName":"Ezeuko","suffix":""},{"id":600380802,"identity":"5978704b-ae09-43df-8e8e-f1dfb9ca7f0d","order_by":1,"name":"Magdalene Odunvbun","email":"","orcid":"","institution":"University of Benin Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Magdalene","middleName":"","lastName":"Odunvbun","suffix":""}],"badges":[],"createdAt":"2026-02-04 11:23:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8785678/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8785678/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104404246,"identity":"dfb34196-fc8c-4170-9709-78f6884fa393","added_by":"auto","created_at":"2026-03-11 12:19:55","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":46741,"visible":true,"origin":"","legend":"\u003cp\u003eParticipants’ awareness of premarital counselling\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8785678/v1/64b663da28b5c735ab5aad9e.png"},{"id":104182390,"identity":"21e618c7-b519-4220-827f-293c11b96fc9","added_by":"auto","created_at":"2026-03-08 17:37:51","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":58474,"visible":true,"origin":"","legend":"\u003cp\u003eParticipants’ uptake of premarital counselling and screening\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8785678/v1/be890e6f16f07ffa16564ec3.png"},{"id":104408800,"identity":"9d7799ba-23b7-4b01-89cb-a6d847f23c48","added_by":"auto","created_at":"2026-03-11 12:43:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1489681,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8785678/v1/f823f539-da4c-4c7d-89a9-79fbd793d429.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eRetrospective Perspectives on Premarital Sickle Cell Screening Among Parents of Children Living With Sickle Cell Disease at University of Benin Teaching Hospital, Benin City\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSickle cell disease (SCD) is one of the most common inherited hemoglobin disorders worldwide and remains a major public health challenge, particularly in sub-Saharan Africa\u003csup\u003e1,2\u003c/sup\u003e. It is an autosomal recessive genetic condition resulting from a point mutation in the \u0026beta;-globin gene, which leads to the production of abnormal hemoglobin S. The disease is characterized by chronic hemolytic anemia, recurrent vaso-occlusive episodes, increased susceptibility to infections, and progressive multi-organ damage, all of which contribute to significant morbidity, reduced quality of life, and increased childhood mortality\u003csup\u003e1-3\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eGlobally, more than 300,000 infants are born each year with SCD, with over 70% of these births occurring in Africa\u003csup\u003e4\u003c/sup\u003e. Nigeria bears the highest burden of SCD worldwide, accounting for an estimated 150,000 affected births annually, while approximately 20\u0026ndash;30% of the population carry the sickle cell trait (HbAS)\u003csup\u003e5,6\u003c/sup\u003e. Despite improvements in supportive care and increasing availability of disease-modifying therapies such as hydroxyurea, families affected by SCD continue to experience considerable physical, emotional, and financial strain\u003csup\u003e7\u003c/sup\u003e.These challenges are particularly profound for parents who provide long-term care for children living with SCD.\u003c/p\u003e\n\u003cp\u003ePremarital sickle cell screening is a key preventive strategy aimed at identifying carrier status before marriage, thereby enabling informed partner selection and reproductive decision-making\u003csup\u003e8\u003c/sup\u003e. When combined with effective genetic counselling, premarital screening has been shown to significantly reduce the incidence of SCD in several high-prevalence regions\u003csup\u003e9\u003c/sup\u003e. Many countries, including Nigeria, have adopted premarital screening policies or recommendations, often integrated into religious, community, or health institution requirements prior to marriage\u003csup\u003e10\u003c/sup\u003e.Despite the widespread promotion of premarital screening, the continued high incidence of SCD suggests persistent gaps in awareness, utilization, interpretation of results, or application of screening information to marital and reproductive decisions\u003csup\u003e11\u003c/sup\u003e. Some couples proceed with marriage despite incompatible genotypes due to emotional attachment, social pressure, religious beliefs, misinformation, or limited access to accurate genetic counselling\u003csup\u003e12\u003c/sup\u003e. Others may undergo screening but fail to fully understand its implications, highlighting deficiencies in communication and counselling services\u003csup\u003e13\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eParents of children living with SCD represent a unique and critical population for examining the effectiveness of premarital screening programs. Their perspectives are shaped not only by prior knowledge and beliefs at the time of marriage but also by lived experience of caring for an affected child. Retrospective assessment of their awareness, perceptions, and decision-making processes regarding premarital screening provides valuable insight into missed opportunities, systemic gaps, and sociocultural influences that may not be apparent when studying the general population alone\u003csup\u003e14\u003c/sup\u003e.Evidence suggests that caregiving experience significantly alters parental understanding of SCD and attitudes toward genetic screening\u003csup\u003e15\u003c/sup\u003e. Parents often report heightened awareness of disease severity, increased appreciation of preventive strategies, and reconsideration of earlier reproductive choices after experiencing the realities of raising a child with SCD\u003csup\u003e16\u003c/sup\u003e. However, feelings of regret, guilt, stigma, and emotional distress may also influence how parents reflect on premarital screening and discuss it with others\u003csup\u003e17\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eCultural and religious contexts play a central role in shaping attitudes toward premarital screening and marriage decisions in many African societies\u003csup\u003e18\u003c/sup\u003e. In some settings, strong beliefs in destiny or divine will may reduce the perceived relevance of genetic risk information, while societal expectations surrounding marriage and childbearing may limit the feasibility of genotype-based partner selection\u003csup\u003e19\u003c/sup\u003e. Understanding how these factors interact with individual experiences is essential for developing culturally sensitive screening and counselling interventions. Despite the importance of this perspective, there is limited empirical research focusing specifically on retrospective views of premarital sickle cell screening among parents who already have children with SCD, particularly in high-burden settings such as Nigeria\u003csup\u003e20\u003c/sup\u003e. Most existing studies emphasize awareness and attitudes among adolescents, unmarried adults, or the general population, with insufficient attention to families who have directly experienced the consequences of ineffective or absent premarital screening.\u003c/p\u003e\n\u003cp\u003eThis study therefore seeks to explore retrospective perspectives on premarital sickle cell screening among parents of children living with SCD. By examining their prior awareness, perceptions, decision-making processes, and reflections following lived experience with the disease, the study aims to identify gaps in screening programs, counselling services, and community education efforts. Findings are expected to inform the strengthening of premarital screening policies, improve genetic counselling practices, and contribute to more effective strategies for reducing the burden of SCD.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResearch Questions\u003c/strong\u003e\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eWhat was the level of awareness of premarital sickle cell screening among parents prior to marriage?\u003c/li\u003e\n \u003cli\u003eHow did parents perceive premarital sickle screening before they got married?\u003c/li\u003e\n \u003cli\u003eHow did access to genetic counselling affect parent\u0026rsquo;s decisions?\u003c/li\u003e\n \u003cli\u003eWhat socio-cultural, religious or personal factors influenced parent\u0026rsquo;s decisions regarding premarital screening?\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003eAim and Objectives\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGeneral Aim:\u003c/strong\u003e To assess the awareness, perception and decision-making processes of parents of children with SCD concerning premarital SCD screening\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSpecific Objectives\u003c/strong\u003e\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eTo determine the level of awareness of premarital genotype screening among parents of children with SCD prior to marriage\u003c/li\u003e\n \u003cli\u003eTo assess parent\u0026rsquo;s knowledge of sickle cell disease inheritance and genotype compatibility\u003c/li\u003e\n \u003cli\u003eTo explore parent\u0026rsquo;s perceptions and attitudes towards premarital genotype screening before they got married.\u003c/li\u003e\n \u003cli\u003eTo identify the sources of information on premarital genotype screening among parents\u003c/li\u003e\n \u003cli\u003eTo examine sociodemographic, religious and personal factors associated with awareness and perception of premarital genotype screening.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Methodology","content":"\u003cp\u003eThe study was a hospital-based descriptive cross-sectional study. It was conducted in the Paediatric sickle cell out- patient clinic of the University of Benin Teaching hospital.\u003c/p\u003e\n\u003cp\u003eParents/caregivers who brought their children to sickle cell clinic between July and December 2025 were recruited. A total of 80 parents were recruited consecutively for this study\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval/ consideration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was sought and obtained from the Human research and Ethics Committee of University of Benin Teaching hospital Benin city (NHREC -UBTH- HREC/24/12/2022B). Informed consent was obtained from the parents.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection Procedure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTwo research assistants (1 registrar and 1 house officer) were trained to assist in this study with administration of the questionnaires. Parents/caregivers were given clear and adequate information in English and/or Bini Languages and allowed to make an informed decision. Research assistants trained for the process administered questionnaires privately to ensure confidentiality. \u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy tool\u003c/strong\u003e: Demographics and awareness on prenatal screening were collected using a semi-structured interviewer- administered questionnaire. The questionnaire was in two sections: the first section focused on the socio-demographic characteristics of the respondents (age, gender, education, tribe, occupation); the second section sought to establish respondent\u0026rsquo;s knowledge (awareness, source of information and understanding of methods) and perception/attitudes about premarital genotype screening for SCD\u003c/p\u003e\n\u003cp\u003e.\u003cstrong\u003e\u0026nbsp;Data Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were processed and analysed using IBM SPSS version 26.0 for windows. Data presentation involved frequency tables and charts. Means and standard deviations were used as summary indices for numerical data such as age while non- numerical data were presented as frequencies or percentages or as charts. Chi-square and logistic regression were used to assess associations between socio-demographic variables and knowledge/perception levels. A p-value of \u0026lt;0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eTable I: Socio-demographic characteristics of the participants.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eApproximately 46% (46.3%) of the participants were aged 35-44 years; 32.5% were aged 45-54 years, while 16.3% were aged 25-34 years. The majority (86.3%) of the participants were female. Approximately 58% (57.5%) of the participants were of the Benin ethnicity. The majority (82.5%) of the participants were married. More than a half (53.8%) had done traditional marriage. Approximately 61% (61.3%) of the participants had secondary education as highest level of education. Approximately 63% (62.5%) of the participants had semi-skilled occupations. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable I: Socio-demographic characteristics of participants\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency (n = 80)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercent (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e15-24 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e25-34 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e16.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e35-44 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e46.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e45-54 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e32.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e55 years and older\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e86.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e13.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEthnicity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eBenin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e57.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eEsan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e5.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eEtsako\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e5.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eIgbo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e13.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eOwan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e3.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eUrhobo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e8.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e6.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarital status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e10.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e82.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eSeparated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e5.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eWidowed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLevel of marriage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e10.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eTraditional\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e53.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eChristian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e36.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHighest level of education\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003ePrimary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e7.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eSecondary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e61.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eTertiary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e31.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOccupation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eSemi-skilled\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e62.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eSkilled\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e27.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eProfessional\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e10.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable II: Knowledge of SCD and premarital counselling and screening among participants.\u0026nbsp;\u003c/strong\u003eAll (100%) of the participants have heard about SCD. The greater proportion (46.3%) of the participants heard about SCD from health workers. The greater proportion (62.5%) of the participants alluded that SCD is inherited from parents; whereas 2.5% reported that they do not know the cause of SCD. Slightly more than half (51.3%) have heard about premarital counselling, while 48.8% reported that they have not heard about it. The greater proportion (56.3%) of the participants reported that they do not know the best time for premarital counselling. The majority (97.5%) alluded that SCD can be prevented. Likewise, the majority (93.8%) of the participants agreed that SCD cannot be cured.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable II: Knowledge of SCD and premarital counselling and screening among participants\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 337px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency (n = 80)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercent (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 337px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHave you heard about SCD?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 337px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 337px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 337px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSource of information\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 337px;\"\u003e\n \u003cp\u003eAffected relative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e30.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 337px;\"\u003e\n \u003cp\u003eFamily and friends\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e11.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 337px;\"\u003e\n \u003cp\u003eHealth workers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e46.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 337px;\"\u003e\n \u003cp\u003eInternet\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e12.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 337px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWhat is the cause of SCD?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 337px;\"\u003e\n \u003cp\u003eBlood disorder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e35.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 337px;\"\u003e\n \u003cp\u003eInherited from parents\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e62.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 337px;\"\u003e\n \u003cp\u003eDon\u0026apos;t know\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 337px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHave you heard about premarital counselling?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 337px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e48.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 337px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e51.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 337px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWhat is the best time for premarital counselling?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 337px;\"\u003e\n \u003cp\u003eWhen dating\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e10.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 337px;\"\u003e\n \u003cp\u003eAt the beginning of courtship\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e25.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 337px;\"\u003e\n \u003cp\u003eLater during courtship\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e8.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 337px;\"\u003e\n \u003cp\u003eDon\u0026apos;t know\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e56.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 337px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCan SCD be prevented?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 337px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 337px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e97.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 337px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCan SCD be cured?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 337px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e93.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 337px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e6.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable III: Descriptive statistics of the children of the participants\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Approximately two-thirds (66.3%) of the participants had 3-4 children. Half of the participants (50%) had only one child with SCD; another 40% had two children with SCD; 8.8% had three children with SCD, while only one (1.3%) of the participants had five children with SCD.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable III: Descriptive statistics of the children of the participants\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency (n = 80)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercent (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHow many children do you have?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eMedian\u003cstrong\u003e\u0026nbsp;=\u0026nbsp;\u003c/strong\u003e3.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eIQR = 1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e1-2 children\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e21.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e3-4 children\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e66.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e5 children or more\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e12.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHow many have SCD?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eMedian\u003cstrong\u003e\u0026nbsp;=\u0026nbsp;\u003c/strong\u003e1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eIQR = 1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e50.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e40.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e8.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable IV: Attitude of the participants to premarital counselling and screening\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003eSixty percent of the participants had not undertaken any premarital counselling. The greater proportion (55%) of the participants did not check their genotype before marriage.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable IV: Attitude to premarital counselling and screening\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency (n = 80)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercent (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDid you undertake any premarital counselling?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003e60.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003e40.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWhy did you have a child with SCD?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003eDidn\u0026apos;t check genotype before marriage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003e55.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003eDecided to try\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003e6.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003eLab error\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003e38.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable V: \u0026nbsp;Association between age and gender of participant and awareness of premarital counselling and screening.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe greater proportion (18, 64.3%) of the participants aged 45 years or older are unaware of premarital counselling and screening. However, this association was not statistically significant (ꭓ\u003csup\u003e2\u003c/sup\u003e = 4.163, P = 0.125). The greater proportion (7, 63.6%) of the participants who were male are unaware of premarital counselling and screening. However, this association was not statistically significant (ꭓ\u003csup\u003e2\u003c/sup\u003e = 1.131, P = 0.288).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable V: Association between age of participants and awareness of SCD prenatal counselling and screening\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eAwareness of premarital counselling\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eꭓ\u003csup\u003e2 \u0026nbsp;\u003c/sup\u003estatistic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 110px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eUnaware\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eAware\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e34 years or younger\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e6 (40.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e9 (60.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e4.163\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e0.125\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e35-44 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e15 (40.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e22 (59.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e45 years or older\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e18 (64.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e10 (35.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFisher\u0026rsquo;s exact\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e32 (46.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e37 (53.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e1.131\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e0.288\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e7 (63.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e4 (36.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable VI: Association between age, gender, and the awareness and uptake of premarital counselling and screening.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe greater proportion (22, 78.6%) of the participants aged 45 years or older have not undertaken premarital counselling and screening. This association was statistically significant (ꭓ\u003csup\u003e2\u003c/sup\u003e = 7.069, P = 0.029). The greater proportion (37, 94.9%) of the participants unaware of PMC have not undertaken premarital counselling and screening. This association was statistically significant (ꭓ\u003csup\u003e2\u003c/sup\u003e = 38.557, P \u003cstrong\u003e\u0026lt;\u0026nbsp;\u003c/strong\u003e0.001).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable VI: Association between age, gender, and the awareness and uptake of premarital counselling and screening.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 249px;\"\u003e\n \u003cp\u003eUptake of premarital counselling\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eꭓ\u003csup\u003e2\u003c/sup\u003e\u003c/strong\u003e\u003cstrong\u003e\u003csup\u003e\u0026nbsp;\u0026nbsp;\u003c/sup\u003e\u003c/strong\u003e\u003cstrong\u003estatistic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 81px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003eNot undertaken\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eUndertaken\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e34 years or younger\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e9 (60.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e6 (40.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e7.069\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.029*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e35-44 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e17 (45.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e20 (54.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e45 years or older\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e22 (78.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e6 (21.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAwareness of premarital counselling\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFisher\u0026rsquo;s exact\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003eUnaware\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e37 (94.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e2 (5.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e38.557\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt; 0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003eAware\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e11 (26.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e30 (73.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e* Statistically significant\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe majority of participants were aged 35-44 years, female, married and of Benin ethnicity. This age distribution is similar to findings from hospital- based and community studies in southern Nigeria, where caregivers of children with SCD are predominantly in their middle reproductive years, reflecting cumulative childbearing and exposure to SCD outcomes over time\u003csup\u003e21,22\u003c/sup\u003e. The female predominance observed in this study aligns with reports from Nigeria and Ghana, where mothers are more likely to accompany children to health facilities and participate in SCD- related research possibly due to their traditional caregiving roles\u003csup\u003e4,23\u003c/sup\u003e. More than half of the participants had secondary education and majority were semi- skilled. Similar educational patterns have been reported in studies from Edo, Lagos and Oyo states where secondary education was the most common level attained among caregivers of children with SCD\u003csup\u003e24,25\u003c/sup\u003e. Although secondary education suggests basic literacy, it may not be sufficient to ensure comprehensive understanding of genetic inheritance and preventive strategies for SCD, which could partly explain gaps observed in awareness and uptake of PMC.\u003c/p\u003e\n\u003cp\u003eAwareness of SCD was universal in this study with health workers being the most common source of information. This finding is consistent with Nigerian and West African studies reporting near- universal awareness of SCD, particularly among parents of affected children\u003csup\u003e26,27\u003c/sup\u003e. The prominent role of health workers underscores the importance of health facilities as key channels for SCD education. Most participants correctly identified SCD as an inherited condition, similar in southwest Nigeria and Ghana, where 60-80% of respondents demonstrated correct knowledge of the genetic basis of SCD\u003csup\u003e9,24\u003c/sup\u003e. However, a substantial proportion still described SCD simply as a \u0026ldquo;blood disorder\u0026rdquo;, reflecting partial understanding. Comparable misconceptions have been documented across West Africa, highlighting persistent knowledge gaps regarding autosomal recessive inheritance\u003csup\u003e4\u003c/sup\u003e. Only about half of the participants had heard of premarital counselling and more than half did not know the appropriate timing for PMC. This level of awareness is lower than reports among university students and urban populations in Nigeria where awareness rate of PMC range from 60% to over 80% as reported by Omuemu et al. and Akinwale et al. respectively\u003csup\u003e25,26\u003c/sup\u003e. The difference may be due to variations in educational attainment, urban-rural mix and targeted health messaging. The majority of participants believed SCD can be prevented but not cured. This perception is consistent with findings from Nigeria and Ghana, where prevention through carrier screening an informed marital decisions is widely acknowledged, while cure is often considered unattainable despite the availability of bone marrow transplantation in limited settings\u003csup\u003e11,25\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eMost participants had three to four children and up to 40% had 2 children each with SCD. Similar family patterns have been reported in Nigerian studies where repeated births of children with SCD occur due to premarital or preconception genotype screening and possibility of having birthed all the children before diagnosis of SCD is made in the children\u003csup\u003e11,26\u003c/sup\u003e. These findings underscore the significant familial and psychosocial burden of SCD in West Africa. Despite relatively high awareness of SCD, 60% of participants did not undertake PMC and more than half did not check their genotype before marriage. This poor uptake mirrors finding from studies in Edo, Lagos and northern Nigeria, where uptake of PMC ranged from 20% to 45% despite moderate to high awareness\u003csup\u003e22,27\u003c/sup\u003e. Cultural beliefs, emotional attachment, religious considerations and fear of relationship dissolution have been cited as barriers to PMC uptake in Nigeria and Ghana\u003csup\u003e11,28\u003c/sup\u003e. The reason given for having children with SCD- particularly failure to check genotype and perceived laboratory error prior to marriage- are consistent with previous Nigerian studies, where trust in laboratory results and misconceptions about genotype testing accuracy influence reproductive decisions\u003csup\u003e24\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eAlthough older participants and males were more likely to be unaware of PMC, these associations were not statistically significant. Similar non- significant associations between socio-demographic factors and awareness have been reported in some Nigerian studies, suggesting that awareness of PMC cuts across age and gender groups but may be influenced more to targeted health education\u003csup\u003e26\u003c/sup\u003e. However, age and awareness of PMC were significantly associated with uptake of PMC. Participants aged 45 years and older were significantly less likely to have undertaken PMC, possibly reflecting generational differences as PMC and genotype screening were less emphasized in public health messaging several decades ago. This pattern has been observed in studies from southwest Nigeria, where younger adults were more likely to utilize PMC services compared to older cohorts\u003csup\u003e29\u003c/sup\u003e. Awareness of PMC showed a strong and statistically significant association with uptake, with participants who were unaware being far less likely to have undertaken counselling. This finding is consistent with evidence from Nigeria and Ghana demonstrating that awareness is a key determinant of PMC utilization\u003csup\u003e11,28\u003c/sup\u003e. It highlights the critical role of sustained public health education in improving preventive practices.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study demonstrates universal awareness of sickle cell disease among participants; however, awareness and uptake of premarital counselling and screening remain suboptimal. Although most participants correctly identified SCD as an inherited condition and believed it is preventable, only about half had heard of premarital counselling and a smaller proportion had actually undertaken PMC or genotype screening before marriage. Older age was significantly associated with lower uptake of PMC while awareness of PMC was a strong predictor of its utilization. Despite having one or more children affected by SCD, many participants reported not checking their genotype prior to marriage, underscoring persistent gaps between knowledge and preventive practice. Overall, the findings highlight missed opportunities for primary prevention of SCD through effective PMC and screening in this population\u003c/p\u003e \u003cp\u003e \u003cb\u003eRecommendations\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTargeted community- based education on SCD inheritance and the importance of premarital counselling and screening should be intensified, using culturally appropriate messages and local languages\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePremarital counselling and genotype screening should be incorporated into routine reproductive health, antenatal and family planning services especially in primary healthcare settings\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eSchool- based and youth- focused interventions including secondary schools and tertiary institutions should be strengthened to encourage genotype screening before courtship and marriage\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eLimitations\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eParticipants were recruited from healthcare setting, which may limit generalizability of the study to the wider community\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eThe retrospective nature of the study may be subject to recall bias and social desirability bias.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of Interest:\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The study was self-funded by the authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e: Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eWritten informed consent was obtained from all individual participants (or their legal guardians) for publication of this study and its accompanying data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e: All authors contributed equally to the conception, design, data collection, analysis, interpretation, and writing of the manuscript. All authors read and approved the final version of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eRees DC, Williams TN, Gladwin MT. Sickle-cell disease. Lancet. 2010;376(9757):2018\u0026ndash;31.\u003c/li\u003e\n \u003cli\u003eWare RE, de Montalembert M, Tshilolo L, Abboud MR. Sickle cell disease. Lancet. 2017;390(10091):311\u0026ndash;23.\u003c/li\u003e\n \u003cli\u003eKato GJ, Piel FB, Reid CD, Gaston MH, Ohene-Frempong K, Krishnamurti L, et al. Sickle cell disease. Nat Rev Dis Primers. 2018;4: 18010.\u003c/li\u003e\n \u003cli\u003ePiel FB, Patil AP, Howes RE, Nyangiri OA, Gething PW, Dewi M, et al. Global epidemiology of sickle haemoglobin in neonates. Lancet. 2013;381(9861):142\u0026ndash;51.\u003c/li\u003e\n \u003cli\u003eAkinyanju O. A profile of sickle cell disease in Nigeria. Ann N Y Acad Sci. 1989;565: 126\u0026ndash;36.\u003c/li\u003e\n \u003cli\u003eWorld Health Organization. Sickle-cell disease: a strategy for the WHO African Region. Brazzaville: WHO Regional Office for Africa; 2010.\u003c/li\u003e\n \u003cli\u003eMakani J, Ofori-Acquah SF, Nnodu O, Wonkam A, Ohene-Frempong K. Sickle cell disease: new opportunities and challenges in Africa. Sci World J. 2013;2013: 193252.\u003c/li\u003e\n \u003cli\u003eModell B, Darlison M. Global epidemiology of haemoglobin disorders and derived service indicators. Bull World Health Organ. 2008;86(6):480\u0026ndash;7.\u003c/li\u003e\n \u003cli\u003eAngastiniotis M, Hadjiminas M. Prevention of thalassaemia in Cyprus. Lancet. 1981;1(8216):369\u0026ndash;71.\u003c/li\u003e\n \u003cli\u003eAdeyemo TA, Ojewunmi OO, Diaku-Akinwumi IN, Akinbami AA. Knowledge, attitude and control practices of sickle cell disease among youth corps members in Lagos, Nigeria. Ann Ib Postgrad Med. 2015;13(2):100\u0026ndash;7.\u003c/li\u003e\n \u003cli\u003eWonkam A, de Vries J, Royal CDM, Ramesar R. Sickle cell disease in sub-Saharan Africa: public health and genetic challeneges. Curr Opin Hematol. 2014;21(3):187-94.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eAnie KA, Egunjobi FE, Akinyanju OO. Psychosocial impact of sickle cell disorder: perspectives from a Nigerian setting. Glob Health. 2010;6 :2.\u003c/li\u003e\n \u003cli\u003eAjayi IO, Adeyemo AA, Osuntokun BO. Knowledge and attitude of pregnant women to prenatal diagnosis of sickle cell disease in a Nigerian teaching hospital. Niger J Med. 2006;15(4):396\u0026ndash;9.\u003c/li\u003e\n \u003cli\u003eMarteau TM, Dormandy E. Facilitating informed choice in prenatal testing. Am J Med Genet. 2001;106(3):185\u0026ndash;90.\u003c/li\u003e\n \u003cli\u003eWonkam A, Hurst S. Ethical aspects of sickle cell disease in Africa. In: Inusa B, editor. Sickle Cell Disease. Rijeka: InTech; 2013. p. 3\u0026ndash;20.\u003c/li\u003e\n \u003cli\u003eOhene-Frempong K, Oduro J, Tetteh H, Nkrumah F. Screening newborns for sickle cell disease in Ghana. Pediatrics. 2008;121(Suppl 2): S120\u0026ndash;1.\u003c/li\u003e\n \u003cli\u003eRowley PT. Ethical, legal, and social issues in prenatal diagnosis. Clin Perinatol. 1994;21(3):523\u0026ndash;40.\u003c/li\u003e\n \u003cli\u003eWonkam A, Njamnshi AK, Angwafo FF. Knowledge and attitudes concerning medical genetics in Cameroon. Genet Med. 2006;8(6):331\u0026ndash;8.\u003c/li\u003e\n \u003cli\u003eAnionwu EN, Atkin K. The politics of sickle cell and thalassaemia. Buckingham: Open University Press; 2001.\u003c/li\u003e\n \u003cli\u003eNnodu OE, Sopekan A, Nwogoh B, Chukwu BF, Adegoke SA, Ohiaeri C, et al. Implementing newborn screening for sickle cell disease in Nigeria. Lancet Haematol. 2020;7(7): e534\u0026ndash;40.\u003c/li\u003e\n \u003cli\u003eAdegoke SA, Abioye-Kuteyi EA, Orji EO. The perception and practice of premarital genetic counselling among parents of children with sickle cell disease in Nigeria. Niger J Med.2014;23(3): 234-40\u003c/li\u003e\n \u003cli\u003eAnimasahun BA, Akitoye CO, Njokanma OF. Sickle cell disease: awareness, knowledge and attitude among parents of affected children in Lagos, Nigeria. Pan Afr Med J.2019;32 :1-9\u003c/li\u003e\n \u003cli\u003eOlatunya OS, Ogundare EO, Fadare JO, Oluwayemi IO, Agaja OT, Adeyefa BS et al. Knowledge and perception of sickle cell disease among caregivers of affected children in southwest Nigeria. J Community Med Prim Health Care. 2015;27(1): 1-8\u003c/li\u003e\n \u003cli\u003eAdewoyin AS, Alagbe AE, Adedokun BO. Knowledge, attitude and control practices of sickle cell disease among youths in southwest Nigeria. Int J Adolesc Med Health. 2017;29(2): 1-7\u003c/li\u003e\n \u003cli\u003eAkinyaju O, Otaigbe A, Ibidapo M. Outcome of comprehensive care for sickle cell disease in a Nigerian tertiary health centre. West Afr J Med. 2018;35(3): 1-7\u003c/li\u003e\n \u003cli\u003eOla BA, Igbokwe DO, Adebiyi AO. Awareness and attitude to premarital screening for sickle cell disease among adults in a Nigerian community. Afr J Med Med Sci. 2016;45(3): 233-40\u003c/li\u003e\n \u003cli\u003eTusuubira SK, Nakayinga R, Mwambi B, Odda J, Kiconco S, Komuhangi A. Knowledge, perception and practces towards sickle cell disease: a community survey among adults in Lubaga divison, Kampala, Uganda. BMC Public Health.2018;18:561. doi:10.1186/s12889-018-5496-4\u003c/li\u003e\n \u003cli\u003eOmuemu VO, Ogboghodo EO. Awareness and uptake of premarital genetic counselling for sickle disease among adults in Benin City, Nigeria. Niger J Clin pract. 2018;21(12): 1542-1549.\u003c/li\u003e\n \u003cli\u003eAkinwale OP, Oyedeji OA, Adeyemo AA. Knowledge and practice of premarital screening for sickle cell disease among young adults in southwest Nigeria. BMC Public Health.2020;20:1-8\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Awareness, Genotype screening, Premarital counselling, Sickle cell disease","lastPublishedDoi":"10.21203/rs.3.rs-8785678/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8785678/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSickle cell disease (SCD) remains a major public health problem in Nigeria and West Africa. Premarital Counselling and screening (PMC) are effective strategies for preventing the birth of children with SCD; however, their uptake remains suboptimal despite increasing awareness\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eTo assess the socio-demographic characteristics, knowledge, attitude and practices regarding SCD and PMC and to identify factors associated with awareness and uptake of PMC among participants\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis was a descriptive cross- sectional study involving 80 participants. Data were collected using a structured questionnaire assessing the socio-demographic characteristics, knowledge of SCD and PMC, attitudes toward PMC and uptake. Data were analyzed using descriptive and inferential statistics. Associations between socio-demographic variables, awareness and uptake were tested using chi-square and Fisher\u0026rsquo;s exact tests with the level of significance set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAwareness of SCD was universal (100%), with the health workers being the main source of information (46.3%). Although 62.5% correctly identified SCD as an inherited condition, only 51.3% has heard of PMC. Sixty percent of participants did not undertake any PMC and 55% did not check their genotype before marriage. Older age (\u0026ge;\u0026thinsp;45 years) was significantly associated with lower uptake of PMC (ꭓ\u003csup\u003e2\u003c/sup\u003e = 7.069, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.029). Awareness of PMC was strongly associated with uptake (ꭓ\u003csup\u003e2\u003c/sup\u003e =38.557, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eDespite high awareness of SCD, awareness and uptake of PMC and screening remain inadequate. Strengthening public health education and integrating PMC into routine reproductive health services are essential to reducing the burden of SCD.\u003c/p\u003e","manuscriptTitle":"Retrospective Perspectives on Premarital Sickle Cell Screening Among Parents of Children Living With Sickle Cell Disease at University of Benin Teaching Hospital, Benin City","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-08 17:37:46","doi":"10.21203/rs.3.rs-8785678/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-10T18:17:50+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-24T19:50:44+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-18T23:56:03+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-09T12:58:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"6639814967772326676853682739879908866","date":"2026-03-08T19:55:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"242696383293904602864157191396068406185","date":"2026-03-08T11:01:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"171614896601044121304389881284763263864","date":"2026-03-07T22:17:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"119102095963477789756181516092920919083","date":"2026-03-06T10:32:23+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-03T09:36:40+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-12T18:13:55+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-12T09:48:17+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-12T09:47:22+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Public Health","date":"2026-02-04T10:40:54+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"90bea6d3-fac0-4042-a108-76c2accedc85","owner":[],"postedDate":"March 8th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-17T21:54:38+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-08 17:37:46","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8785678","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8785678","identity":"rs-8785678","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}