Religious Leaders Role in Sickle Cell Disease Prevention

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Introduction

Nigeria has been overwhelmed by Sickle Cell Disease (SCD) with high rates of mortality and morbidity (Aneke & Okocha, 2016). SCD is an inherited disorder of hemoglobin that is responsible for abnormal sickle-shaped hemoglobin (Saraf et al., 2014). The burden of SCD is huge as it results to strain on health facilities, loss of labor man hours, and poor quality of life. In Nigeria, SCD is widespread with statistics indicating that 20 to 30 % of the population is affected (WHO, 2015). The mortality from SCD in the country, especially for children under five, is unacceptably high in the country. Estimates indicate that up to 90% of affected children in Nigeria will die before they reach the age of five because of lack of adequate and timely intervention (Piel, Hay, Gupta, Weatherall, & Williams, 2013).  SCD is thus a major public health concern in the country. The treatment of SCD has improved in recent years, and bone marrow (stem cell) transplantation is known to achieve cure (Shenoy, 2011). Furthermore, the cost implication for the patient to have the treatment, the risks involved, and the infrastructural inadequacies hinder the adoption of this treatment in Nigeria and is beyond the reach of many patients (Aneke & Okocha, 2016).  Thus, the government of Nigeria has intensified efforts to reduce the prevalence of the disease through various epidemiological interventions such as the introduction of genetic counseling clinics and prenatal screening (Aneke & Okocha, 2016).

However, awareness of SCD remains low in Nigeria especially among the reproductive age group (Durotoye, Salaudeen, Babatunde, & Bosah, 2013). Thus, only a small number of Nigerian couples attend these clinics for screening and counseling. As such, the involvement of religious leaders can play a significant role in the prevention of SCD through promoting screening for premarital couples and offering counseling to hemoglobinopathy partners. A study by Toni-Uebari and Inusa (2013) found out that involvement of religious leaders and faith organizations is potentially effective in improving the participation, level of acceptance, and positive health outcomes among their congregants.

The chapter describes the background of the study, the problem statement, and the purpose of the study. The chapter also discusses the theoretical framework that guides the study, the research questions as well as the nature and significance of the study.

Background of the Study

Hemoglobinopathies are the most common group of inherited disorders in the world, (Durotoye et al., 2013). These disorders of hemoglobin affect the shape or the number of red blood cells in the body. Estimates indicate that 7% of the population in the world are carriers and between 300,000 and 400,000 children with various forms of hemoglobinopathies are born every year (Durotoye et al., 2013). The two commonest forms of hemoglobinopathies are Thalassemia and the Sickle Cell Disease (SCD) (Toni-Uebari & Inusa, 2009). On the one hand, halassemia occurs as a result of abnormal formation of hemoglobin chains resulting in reduced production of hemoglobin. On the other hand, SCD results from the substitution of a single amino acid in the beta chain of hemoglobin which causes abnormal hemoglobin to be formed (Toni-Uebari & Inusa, 2009). Approximately 250, 000 of children born with cases of hemoglobinopathies suffer from SCD (Durotoye et al., 2013). According to World Health Organization (WHO) (2015), three-quarters of these children are born in Sub-Saharan Africa, and almost half of them die within the first five years of life. The prevalence of SCD in Nigeria is between 20% and 30% of the population (WHO, 2013) and is thus a major public concern.

There is no definite healthcare for hemoglobinopathies. For instance, the only cure for SCD is bone marrow transplants but rarely done in Africa because of the significant risks that are involved (Okyay, Çelenk, Nazlıcan, & Akbaba, 2016). It is mostly done in advanced countries. Thus, the World Health Organization recommends primary prevention measures to avoid the birth of an affected child including increasing public enlightenment, genetic counseling, screening for carriers, and antenatal detection.  Thus, there has been an introduction of premarital screening programs in many of the affected countries including Nigeria. The success of these programs in reducing cases of hemoglobinopathies has highlighted the importance of creating awareness and knowledge about the disorders (Okyay et al., 2016). Durotoye et al. (2013) opined that the main factors that have contributed to high prevalence of SCD in Nigeria are limited knowledge about SCD and inadequate centers for genetic counseling. The study by Durotoye et al. (2013) established that knowledge about SCD is low in Nigeria, especially among the reproductive age group despite its prevalence in the country. Inadequate knowledge indicates that there is a lot to be done to increase awareness about this life-threatening disorder among Nigerians. One of the feasible ways to increase awareness and increase testing is to involve religious leaders such as priests, pastors, and Imams among others.

The significant role played by religious leaders towards the promotion of health and interventions programs has been a subject of study by many scholars in recent years (Mendel, Derose, Werber, Palar, Kanouse, & Mata, 2014). Research has indicated that religious leaders play a major role in the delivery of intervention programs that promote positive health outcomes. A study conducted by Asekun-Olarinmoye, Asekun-Olarinmoye, Fatiregun, & Fawole (2013) in Ibadan, Nigeria, revealed that faith leaders can play an important role in individual and community health intervention programs. Catanzaro, Meador, Koenig, Kuchibhatla, and Clipp (2007) asserted that faith-based organizations provide culturally appropriate avenues through which promotion of activities can be done. Furthermore, a study by Williams, Glanz, Kegler, and Davis (2012) found that faith leaders are community gatekeepers who frequently have access to members of the community and are thus better positioned in delivering information to both the healthcare providers and their congregation. Religious leaders also exert influence that may encourage members to take part in the intervention (Baruth, Wilcox, Laken, Bopp, & Saunders, 2008; Webb, Bopp, & Fallon, 2013). Another study revealed that religion leaders may offer advice and guidance related to health-related issues and intervention measures regarding chronic diseases (Stansbury, Harley, King, Nelson, & Speight, 2012).

Although the positive impact of engaging religious leaders in the promotion of intervention programs among their congregation is well established, there is limited research with regard to how its application in Nigeria may enhance prevention of SCD and thus reduction of the prevalence of the disease in Nigeria. Gaining an understanding of how religious leaders’ knowledge on SCD enhances genetic counseling may help in guiding and improving efforts to prevent the disease.

Problem Statement

SCD is the most common genetic condition in Nigeria with one out of 2000 children who are born being affected. Approximately one in 300 of these births occur in rural areas (Nnodu, 2014). SCD is responsible for high mortality rates, especially for children under five years of age. In addition, it presents significant economic challenges in managing SCD sufferers. The costs of looking after a child with SCD as well as the financial resources involved are substantialNnodu, 2014). Furthermore, SCD presents significant physical, psychological, and social challenges (Nnodu, 2014). Prevention of SCD is possible if two carriers are encouraged not to marry or to have children (WHO, 2015). Premarital screening and genetic counseling entails examination of blood samples of couples intending to marry and the results of the tests as well as the implications are shared with the couples (Memish & Saeed, 2011).  A study established that two-thirds of couples in Nigeria are at risk of having children with SCD.  (Nnaji, Ezeagwuna, Nnaji, Osakwe, Nwigwe, & Onwurah, 2013). Thus, this may be a realistic solution given the magnitude of the problem especially in Nigeria. If correctly applied, premarital genetic counseling and genotype testing have the potential of reducing the number of births affected by the disease and consequently the prevalence of the disease in the long term (Aneke, & Okocha, 2016). However, the current utilization of premarital genetic counseling and testing in the country is unacceptably low (Aneke & Okocha, 2016).

Therefore, there is a need for massive education of Nigerians to enhance knowledge of the population on the importance of voluntary counseling and testing of sickle cell traits as a means of reducing future occurrence of the disease in children.  . Premarital counseling and genetic testing as epidemiological intervention of SCD can be enhanced through the efforts of religious leaders, who wield tremendous power among the people. (BBC, 2015). Robust partnerships between healthcare professionals and religious leaders can raise the number of premarital couples who get tested and consequently identification of carriers. The involvement of religious leaders as change agents in the drive to prevent SCD in Nigeria was worth trying because not only are they very influential in important decision-making processes of most Nigerians (Asekun-Olarinmoye et al., 2013), but they have also been successfully used in the past in promoting  other health activities  (Lumpkins Cameron, & Frisby, 2012). The engagement of religious leaders in genetic testing and counseling would likely influence the society to embrace these epidemiological interventions thereby creating informed population-based knowledge on prevalence of SCD in the country.

A study by Gbenol, Brisibe, and Ordinioha (2015) established that some religious bodies in Nigeria at times carry out premarital genetic counseling and testing for SCD as part of marriage requirements.  However, it was unclear whether premarital counseling offered by religious bodies was effective and whether the quality of counseling offered to at- risk couples met the expected scientific standards and were in line with the global best practices. Thus, it was imperative to establish whether religious leaders had enough knowledge and understanding of SCD that enhance their counseling and enable would-be spouses make informed decisions.

Purpose of the Study

The purpose of this quantitative study was to explore the role of religious leaders in the prevention of SCD in Nigeria. Specifically, the study aimed to establish the level of knowledge and how the understanding of SCD and other hemoglobinopathies among religious leaders could translate to improve marital counseling. In addition, the study explored how the knowledge of religious leaders with regards to SCD could be applied to improve early testing among premarital couples and to improve on marital counseling outcomes.

Theoretical Framework

The study was grounded within two theoretical frameworks; Health Belief Model (HBM) and Social Cognitive Theory (SCT). HBM is a psychological model that aims to elucidate and predict preventive health-related behaviors. The model was developed in 1952 by Hochbaum, Rosenstock, and Kegelsin. The model has been adapted in exploring a variety of health behaviors such as prevention of tuberculosis, sexual behaviors, and transmission of HIV/AIDs, and breast cancer detection behaviors among others (Abolfotouh, Ala’a., Mahfouz, Al-Assiri, Al-Juhani, & Alaskar, 2015). The model focuses on the beliefs and attitudes of individuals. The model stipulates that the perceptions of an individual with regard to a threat posed by a health problem and the value of the actions to reduce the threat will influence health-related behavior of the individual (Canbulat & Uzun, 2008). As such, an individual will take a health-related action if the individual feels that it is possible to avoid a negative health condition, positively expects that taking an advised action facilitates avoidance of the negative health condition, and believes that the recommended health action can be taken successfully. HBM was constructed from six domains which include perceived susceptibility, perceived severity, perceived barriers, perceived benefits, cue to action, and perceived self-efficacy (Ayele, Tesfa, Abebe, Tilahun, & Girma, 2012).

The first four domains account for readiness of individuals to act. Perceived susceptibility involves the opinion of individuals that they can get a condition while perceived severity relates to the opinion of individuals about the seriousness of a condition as well as its consequences. The third concept, perceived benefits, involves the belief of individuals in the efficacy of the recommended actions in reducing the seriousness or risk of the condition while perceived barriers revolve around the opinion of an individual with regard to the costs of the recommended action (Ayele et al., 2012). The fifth domain, cues to action, activates the readiness thereby stimulating the healthy behavior. The last domain involves the confidence of an individual in the ability to perform an action successfully (Ayele et al., 2012).

Based on this model, religious leaders who perceived that SCD is a serious disease with significant health and economic impacts and that their congregation was susceptible to the disease since they might be carriers were likely to recommend genotype screening and counseling. Similarly, religious leaders who perceived that there were more benefits of testing and fewer barriers would advise would-be spouses to undergo screening before considering marriage. Furthermore, if religious leaders perceive that genotype screening was effective towards prevention of SCD, they would likely offer genotype screening counseling recommendation to their congregants. The model thus provided a framework for exploring the knowledge, beliefs, and attitudes of religious leaders regarding SCD and how it impacted on the way they counseled would-be spouses in their congregation. The figure 1 below presents the HBM model.

Figure 1. The Health Belief Model. Source: Glanz, Lewis, & Rimer (2015).

The Social Cognitive Theory

SCT was developed by Bandura in 1986 to explain and predict human behavior (Bandura, 2011). The theory stipulates that a triadic interaction exists between an individual, behavior, and environment. People acquire cognitive and behavioral competencies through observational learning from experiences of others. When people see similar others (models) gain desirable outcomes through performing certain actions, the observer may replicate the actions. Conversely, if they see others get punished because of certain actions, they will refrain from repeating those actions (Bandura, 2011).

The theory encompasses two main constructs, self-efficacy and outcome expectations. Self-efficacy is the confidence that an individual has over exercise control over health habits (Bandura, 2006). Self-efficacy has a direct and indirect behavior on the behavior of an individual.  Outcome expectations entail the judgments of an individual over the possible consequences that will arise as a result of performing or failure to perform particular behaviors. An assumption that is central to SCT is that people will behave in ways that they expect will result in positive outcomes and avoid those behaviors that they believe will result in negative outcomes (Young, Plotnikoff, Collins, Callister, & Morgan, 2014). The third construct within SCT is goals. Goals exhibit a direct effect on behavior as well as mediate the influence of the other two constructs (Bandura, 2006). Goals serve as a general guide that assists in informing the current actions (Young, et al., 2014). The last construct that was outlined in this theory is the socio-structural factors. These include the facilitators to behavior as well as the impediments. The theory posits that they indirectly influence health behavior through influencing goal setting (Bandura, 2006). They are also stipulated to mediate self-efficacy’s influence on behavior.

The theory provides a framework for developing and implementing health interventions related to SCD, mainly premarital testing and counseling decisions. The importance of managing SCD in Nigeria is evident given the increased prevalence and its role in mortality and morbidity. It is possible to prevent and manage through the interventions that aim at changing the behavior of individuals and thus improve the health outcomes. In 2014, Mirabolghasemi et al, used this model in evaluating the factors that affect the effectiveness of social networks on cancer patients. Religious leaders exert influence over their congregation and thus might influence decisions made by premarital testing, counseling and marriage between premarital couples. Religious leaders were likely to have come across couples affected by the hemaglobinopathies and understand the essence of testing among premarital partners. As such, they were likely to offer concrete guidance with regard to the issue and thus their understanding of SCD may translate to improved marital counseling outcomes. Figure 2 represents the social cognitive model of behavior.

Figure 2. Social Cognitive Model of Behavior. Source: Baker, M. J., & Saren, M. (2010)

Research Questions

The research question that guided the study was: Are religious leaders in Nigeria qualified to and interested in counseling couples on SCD genotype screening?

Sub-questions are:

  1. What is the perceived level of knowledge of SCD among religious leaders in Nigeria?
  2. What is the perceived level of knowledge of genotype testing among religious leaders in Nigeria?
  3. What is the relationship between health knowledge and recommendations for genotype testing among followers?.

Hypothesis

The independent variables in this study were the perceived knowledge and the attitude of the religious leaders towards SCD. The dependent variable was their ability to convince premarital couples to attend genetic screening and counseling as an intervention to prevent SCD.  It would be measured using the models above. This is a qualitative study. The hypothesis in this study was that;

H0: There is no significant relationship in the religious leader’s knowledge and positive recommendations, and testing and genetic counseling among their congregants.

H1: There is a significant relationship in the religious leader’s knowledge and positive recommendations, and testing and genetic counseling among their congregants.

Nature of Study

This was a correlational study design. Correlational designs involve the systematic investigation of the nature of relationships, or associations between and among variables, rather than direct cause and effect. (Souza et al, 2007). This design builds on existing research, proposes relationships and explores why and how of a variable. (Sousa et al, 2007). Correlational coefficient ranges from -1.0 to +1.0 and this relates to identifying a pattern in terms of the direction and strength of a relationship between two factors.

Possible Types and Sources of Information or Data

Survey design provides a qualitative or numeric description of trends, attitudes or opinions of a population by studying a sample of that population. (Creswell, 2008). A survey would be administered to a sample of religious leaders in Ibadan North Local Government area, Nigeria in form of questionnaire via telephone text. The internet too presented very useful opportunities for data gathering from large populations and in this study it was a useful source of data.

Significance of the Study

The study helped to establish the different levels of SCD knowledge among Nigerian religious leaders and the impact of their knowledge towards improved marital counseling for hemoglobinopathy partners. The problem was the high prevalence of SCD in the country despite various awareness programs by health workers. It was hoped that public knowledge on its prevention could be matched to taking the necessary action by having their genotype tested before marriage. Religious leaders were therefore in a better position to make sure that prospective couples among their followers undergo genetic testing before performing marriage rites for them by demanding test results.  Involving religious leaders in this process required ascertaining their own knowledge level first and finding out those factors that dictated their understanding of SCD so that they could become change agents in the prevention of SCD in Nigeria. The study revealed if SCD knowledge among religious leaders translated to improved counseling on couples planning marriage. Religious leaders could thus take a more proactive role in promoting improved health by supporting would-be spouses on the relevance of premarital counseling and testing. The study established the quality of counseling offered to individuals at risk. This might facilitate making of informed decisions by couples and hence reduce the possibility of having offspring with SCD. As such, it might reduce the physical, psychological, social, and financial challenges encountered by individuals when they bear children affected by SCD.

It was hoped that the study would provide a link between the religious leaders and other SCD stakeholders. Sensitization of religious leaders on how to prevent SCD could have a ripple effect on the congregation to accept genotype screening as an important medical routine for every individual before having children. By involving religious leaders in the campaign against SCD, hopefully a large number of Nigerians might be informed about how to prevent having children with SCD. This could ultimately bring down under-5 mortality rate (CIA, 2015).

Different groups of people had been involved in educating the public on the importance of genotype testing, but the involvement of religious leaders in passing this important message to their followers needed to be intensified. Religious leaders could reach large targeted audience with culturally accepted messages that would be acceptable to specific religious groups. (Lumpkins et al, 2012). By implication, genotype result certificates could be included in wedding requirements or suggestions so that nobody would be married without understanding the implications of the possibilities of having children with SCD if genotype tests are not carried out prior to procreation. The premarital screening was hoped to reduce the number of at-risk marriages and subsequently reduce SCD burden in Nigeria. The study provided evidence-based data for further training of health professionals on cultural competence for improved diagnoses and treatment among health professionals.

Summary

SCD is a genetic disorder because it is inherited from parents by children. Despite the fact that SCD is preventable, it is still a public health challenge worldwide especially in some developing countries such as Nigeria. Over 150,000 babies are born every year in Nigeria and it has the largest population of SCD worldwide (WHO, 2015). Its impact on under-5 morbidity and mortality is considerable and its effects on healthcare and family resources may be overwhelming. Although different groups of people have been involved with creating public awareness on how to prevent SCD, babies with SCD are still being born in Nigeria (Nnodu, 2014). The involvement of religious leaders in curbing the incidence of SCD was therefore worthy of exploration. British Broadcasting Corporation (2014) reported the outcome of a US-based PEW Research Center survey in which 87 percent of participants (Africans) confirmed their reverence and confidence in their religious leaders and most African societies often look up to them for guidance and direction in important matters. They have also been successfully involved in the past in health promotion activities (Lumpkins et al, 2012).

Chapter 2.0 Literature Review

Introduction

This chapter reviewed previously published studies in the domain of sickle cell disease (SCD). Through garnering of relevant information, it was easier to produce a succinct as well as an appropriate piece of literature concerning the selected area of interest. The literature review outlined the already published literature on the precise and closely related topics, including the role of religious leaders in health promotion. To accomplish the main objective of the study, different databases, such as EBSCOhost, ProQuest, PubMed, MEDLINE, and EMBASE were used to retrieve journal articles.

Overview of Sickle Cell Disease

According to Doss et al. (2016), SCD is among the common inherited hemoglobinopathies globally. About 90,000-100,000 people in the United States have SCD. The authors further argued that there is higher prevalence of the disease in Africa. Grosse et al. (2011) posited that the mortality among African children has increased as a result of SCD among children that are below five years.

A study by Chakravorty and Williams (2014) indicated that there are also high cases of mortality among adults that are affected by SCD in Africa.  However, the authors stated that mortality cases within high income nations have dramatically reduced as a result of the introduction of newborn screening as well as the implementation of penicillin (Chakravorty & Williams, 2014). According to Nelson (2011), individuals with SCD have a considerable impaired quality of life because targeted interventions tend to improve the quality of life. Some experts are of the notion that SCD evolved over years and it affects millions of people worldwide. Nevertheless, the disease does not have a known cure; interventions only reduce the complications related to SCD. Basically, the key symptoms of SCD are as a result of abnormally shaped sickle cells that block blood flow through the tissues leading to damage of the affected organs due to inadequate blood flow (Nelson, 2011).

Genetic Cause of Sickle Cell Disease

Serjeant (2013) stressed that SCD entails a cluster of genetic conditions where pathology takes place from the inheritance of sickle cell gene i.e. double heterozygote or homozygote. Subsequently, the SCD mainly results by individual hemoglobin genes. The common genotype that is experienced during birth is homozygous sickle cell disease. This is attributed to the fact that this type of genotype tends to manifest greater mortality rate. The genotype is also influenced by geographical distribution and age of individual genes (Serjeant, 2013).

According to Serjeant (2013), SCD is more common in Africa especially in central Africa, Benin, and Senegal. Ellithy, Yousri, and Shahin (2015) also stressed that SCD is predominately determined by genetic factors as well as environmentally modified factors. The authors also pointed out that physiologic alterations, such as multiple genetic mutation and polymorphisms can end up modifying the presentation of SCD.  Inherited polymorphisms within specific Glutathione S-transferases (GST) hormones can result in deficiency in the activity of the enzymes. GST is a family of multifunctional enzymes that catalyze reactions between glutathione (GSH), an antioxidant, and various potentially carcinogenic and toxic compounds. The polymorphism of GST gene might result in loss of the defensive role of GSH against possible oxidation stress that leads to manifestation of SCD (Ellithy et al., 2015).

Nelson (2011) stated that SCD is termed as a genetic disorder that is hereditary in that it is inherited from parent by children. Children are born with SCD in case they inherit two abnormal genes i.e. one from each parent. The inherited genes results in alteration in terms of red blood cells shape.  The disease affects protein in red blood cells known as hemoglobin. Individuals affected by SCD have a type of hemoglobin referred to as HBS or hemoglobin S.  Besides, the HBS molecules clumps together hence makes the red blood cells sticky as well as fragile (Nelson, 2011).

Statistics of Sickle Cell Disease

According to Centers for Disease Control and Prevention (2016), SCD affects millions of individuals across the world. The disease is common among people whose ancestral lineage originated from sub-Saharan Africa, Spanish regions, India, Saudi Arabia, and Mediterranean nations, such as Italy, Turkey, and Greece. In the United States, the disease affects about 100,000 individuals. WHO (2011) pointed out that about 5% of the world population carry trait genes for hemoglobin disorders, mainly SCD. Approximately 300,000 children are born with severe hemoglobin disorders every year. Grosse, Odame, Atrash, Amendah, Piel & Williams (2011) indicated that within sub-Saharan Africa, 3% of the children born are affected by SCD. The mortality rate within the early life is between 50% and 90% of children born in Africa. This is attributed to the fact that health ministries do not prioritize this disease.

Management of Sickle Cell Disease

SCD continues to cause early death and morbidity in Nigeria and other parts of Africa despite recent advances its management such as improved care and bone marrow transportation. However, the medical care needed for SCD is long term because of its chronic nature and this significantly impacts both economically and psychologically on the patients and the affected families (Abioye-Kuteyi, Oyegbade, Bello, & Osakwe, 2009). Bone marrow transplantation is the only known cure for SCD but is rarely done because of the significant risks and high costs that are involved (Okyay et al., 2016). Thus, prevention of birth of affected children is recommended. Methods used in preventing birth of children with hemoglobinopathies includes premarital screening and genetic counseling, utero-therapy using stem cell transplantation, and prenatal and preconceptional diagnosis (Adeyemo et al., 2007). However, the only realistic approach towards prevention of an affected child is through identification of carriers and genetic counseling. In addition, it is cost-effective in terms of resources needed to support it in the low-income countries where the disease is most prevalent as opposed to other methods (Abioye-Kuteyi et al., 2009).  Pre-marital screening ad genetic counseling programs can significantly reduce the number of children born with SCD and other hemaglobathies (Adewoyin, 2015; Adeyemo et al., 2007). However, the success of the program depends to a great extent on the knowledge of SCD among the target population, the altitude towards genetic screening and counseling, and the understanding of the consequences of having an affected child (Aneke & Okocha, 2016; Adeyemo et al., 2007).

Genetic Testing for Sickle Cell Disease

Premarital screening for the diagnosis of SCD is crucial towards reducing the condition among newborns (Omuemu, Obarisiagbon, & Ogboghodo, 2013). This is because it allows the assessment of an individual’s health-related reproductive risk. Oyedele, Emmanuel, Gaji, & Ahure (2015) stated that premarital genetic screening offers a chance for people to become aware with regard to their genetic predisposition to disease. The test helps the couples to understand the possible genetic composition of their children. Therefore, the premarital testing is one of the most reliable methods of preventing genetic diseases, such as SCD. This is because screening facilitates the identification of carriers and thus at-risk marriages. As such, it is possible to minimize the occurrence of the disease. According to Fernandes, Januario, Cangussu, Macedo & Viana (2010), neonatal screening program can also be used to assess the possibility of deaths among children affected by SCD. The type of genotype is likely to facilitate the identification of SCD as well as its complications. The authors recommended that patient’s family members be enlightened so as to minimize SDC related mortality (Fernandes Januario, Cangussu, Macedo & Viana, 2010).

Premarital screening programs have been introduced in Nigeria some years ago (Umar & Oche, 2012). These programs have been shown to be successful in reducing cases of hemoglobinopathies in countries such as Turkey and Saud Arabia (Okyay et al., 2016). The authors highlighted the importance of creating awareness and knowledge about the disorders in order to encourage would-be spouses to attend genetic counseling clinics before considering marriage. However, the role of religious leaders in promoting screening in Nigeria has not been explored.

Status of Premarital Screening in Nigeria

There is a mandatory HIV/AIDS premarital screening in Nigeria (Umar & Oche, 2012). However, the authors (Umar & Oche, 2012) established that religious leaders in the country have a poor understanding of HIV/AIDS screening which negatively affects on their congregants. Given the high prevalence of SCD in Nigeria, Arulogun and Adefioye (2010) asserted that there is a need to expand the premarital screening program in order to include SCD. Religious leaders are in charge of ensuring that would-be spouses undergo premarital screening since most of the marriage licenses are granted by religious bodies.  It is thus important to involve religious leaders in premarital screening to enhance the success of the program (Dibua, 2010). A study by Moronkola and Fadairo (2007) found that the knowledge and attitude towards of sickle cells anemia among Nigerians is positive in spite of the high mortality rate that results in inadequate health care. This implies that with counseling by  the religious leaders, the number of Nigerians who attend premarital screening and genetic counseling would increase. However, there were no studies that have examined the understanding of the religious leaders with regard to SCD and how their understanding of the disease translates to improved marital counseling and how it influences decisions among would-be spouses.

Sickle Cell Disease among the Nigerian Population

SCD is highly prevalent in Nigeria and approximately 20 to 30 % of the population is affected. The number of affected individuals has been increasing despite the efforts undertaken by the government to address the issue. This is attributed mainly to low level of awareness about SCD as well as inadequate centers for counseling in the country (Durotoye et al., 2013). The disease is widespread even among the urban residents and elite communities that have access to effective healthcare. This indicates that there is low level of knowledge about SCD among many Nigerians. With the SCD prevalence in Nigeria, there are  misinformation, myths, inaccurate diagnosis, and stigmatization (Adeyemo, Omidiji, & Shabi, 2007). According to Afolayan and Jolayemi (2011), has a population of approximately 150 million with a year growth rate of about 3.2%. However, the number of individuals affected by SCD is not clearly known because the majority of them are born in rural areas and do not survive past childhood. It is, however, estimated that 2.3% of the Nigerian population suffer from SCD, and 25% of the nation’s population are carriers of the abnormal hemoglobin gene (Afolayan & Jolayemi, 2011).

Anie, Egunjobi, and Akinyanju (2010) stressed that SCD is a worldwide challenge with considerable psychosocial implications. The authors pointed out that Nigeria has the highest population of individuals with SCD with estimated 150,000 births per year. In addition, in Nigeria beliefs are normally determine religious as well as cultural values which in return impact health behaviors, for example, coping strategies (Anie et al., 2010).

According to Adewoyin (2015), SCD in Nigeria forms a small part of current clinical practice of the majority of general medical practitioners. The author also stressed that there is a lack of devoted sickle cell centers. Modell and Darlison (2008) indicated that approximately 5% to 7% of the world population carriers’ abnormal hemoglobin gene. A majority of the SCD cases are reported in sub-Saharan Africa, especially Nigeria. Prevalence of sickle cell trait ranges from 10% to 45% in varying parts of sub-Saharan Africa (Adewoyin, 2015). Specifically in Nigeria the carrier prevalence is approximately 20% to 30% of the population. Moreover, the disease affects approximately 2% and 3% of the total population of Nigeria of about 160 million.

Mortality Rate in Nigeria due to SCD

According to Ogun, Ebili, and Kotila (2014), SCD has a high mortality rate in the Nigerian population. The high rate of mortality among individuals affected by the sickle cell is attributed to acute chest syndrome that might present thromboembolism or infections in the respiratory system. Nonetheless, the use of bacterial prophylaxis during childhood is projected to minimize early mortality and thus enhance the level of life expectancy of SCD patients. Adewoyin (2015) stressed that cerebrovascular disease (stroke) is the main cause of mortality and morbidity among SCD patients. In Nigeria, the prevalence of stroke among SCD children is approximate 4.3% in Port Harcourt. On the other hand, Abuja, Nigeria, stroke prevalence of SCD children is at 5.2%.  Acute chest syndrome is also considered a principal cause of SCD related mortality among Nigeria patients (Adewoyin, 2015).

According to Ogun et al., (2014), the leading causes of mortality among SCD patients entail infections, anemia, acute sequestration crisis, acute chest syndrome, and stroke. The study revealed that the average age of mortality was at 21.3 years. The authors further stressed that most of the mortality cases tend to take place in the second as well as the third decade of their lives. Nonetheless, some of the patients are currently attaining the fifth decade (Ogun et al., 2014).

Religion and Health Promotion

According to Rumun (2014), religion is communal and mainly defined by boundaries. The author indicated that religion tends to influence health behaviors. Subsequently, religion has the potential of promoting a healthy lifestyle. Nevertheless, Levin (2014) argued that faith-based organizations, as well as institutions, have been underutilized in the promotion of health and disease prevention. Again, religion has been found to influence health indirectly in various ways and in Nigeria, some people believe that some diseases are caused by lack of faith. (Rumun, 2014). In such cases, it is only the religious leaders that can correct this notion and encourage premarital genotype testing. Religious institutions have also been involved in the delivery of human services, such as healthcare. A majority of earliest health institutions were established by religious communities. Mainly, they focused on health promotion within the underserved societies. The author further pointed out that faith-based institutions considerably contribute towards health promotion as well as disease prevention. The religious participation has for the past been associated with decreased rate of morbidity and mortality. The author recommended the establishment of health-based partnership in the health sector as means of promoting health (Levin, 2014).

Campbell et al. (2007) indicated that church-founded health promotion intervention can reach broad population and has a great impact for minimizing health issues and disparities. The authors further stressed that church as well as other religious institutions may determine members’ behavior.  Anshel and Smith, (2014) examined the role of religious leaders in promoting health behaviors within religious institutions. The authors argued that religious communities are not immune to various societal conditions. Subsequently, altering health behavior of the community requires input from individuals who possess credibility, knowledge as well as a receptive audience. Nonetheless, the authors pointed out that one group of people, i.e. religious leaders, who are exceptionally positioned to boost societal change tend to be ignored. In addition, religious leaders have extraordinary influence and credibility towards the promotion of health behaviors. This is attributed to their power of persuasion, weekly captive audience, exposure to health living as well as capability to lead health-related actions. The authors came to a conclusion that religious leaders have a critical role towards boosting healthy living among their followers (Anshel & Smith, 2014).

Ruijs, Hautvast, Kerrar, Van der Velden & Hulscher (2013) argued that the engagement of religious leaders in a given health-related intervention is associated with the enhanced participation of followers in health interventions. Consequently, the involvement of religious leaders has been linked with progressive health outcomes. Health organizations are, therefore, encouraged to work in partnership with religious leaders as well as religious groups. The authority of religious leaders might convince the congregation to accept or reject advocated health interventions. For example, religious leaders can be engaged by health organizations, such as UNICEF to accept vaccination (Ruijs et al., 2013).

In addition, Rivera-Hernandez (2015) indicated that clergy within Mexico plays a key part towards addressing healthcare-related needs of their followers. The authors further stated that clergy can offer guidance as well as advice concerning health-related challenges. This is attributed to the fact that religious leaders have a positive influence on the wellness and health of their followers (Rivera-Hernandez, 2015). A study by Rakotoniana, Jean de Dieu, and Barennes (2014) examined the role played by churches in combating HIV/AIDS epidemic. The authors focused on attitudes of religious leaders in Madagascar. The authors emphasized that churches occupy a critical cultural and social position. (Rakotoniana et al., 2014).

According to Lewis (2008), religious institutions contribute to the overall health of the community to a larger extent. This is primarily attributed to religious leaders’ positive impact on the manners of the society. Gill and Carlough (2008) pointed out that the partnerships between the public health sector and faith-based institutions are a prospective strategy for addressing child mortality within high-burden nations. For the past decades, faith-based institutions have been playing a primary role towards the global attempt to improve the welfare and health mostly among the disadvantaged populations. The scope of faith-based activities in the health service has expanded over the past years. There have also been calls for religious-based institutions to enhance the health service through filling the current gaps within the health sector (Gill & Carlough, 2008). Widmer, Betran, Merialdi, Requcjo & Karpf (2011) revealed that encouraging partnerships between faith-based institutions and health services is an effective means of addressing issues of child mortality in Africa.

Summary

From the reviewed literature it is evident that cases of SCD are numerous in Nigeria. It is also clear that the children are the ones that are heavily affected by the disease. Millions of people are affected by SCD worldwide. The disease lowers the quality of life and life expectancy of the affected individuals. The disease is believed to have originated from sub-Saharan Africa. Subsequently, African nations, especially the western ones record high number of SCD cases compared to other nations.  Five percent (5%) of the world population is affected by SCD and about 300,000 babies are born with hemoglobin disorder. Further, 3% of the babies born in sub-Saharan are affected by SCD. The disease is inherited by children from their parents through genetic means. Children are born with SCD if they inherit two abnormal genes, one from each parent.  Premarital testing is usually used to determine the genetic disposition of individuals. It can be used by couples to understand if they are potential carriers of abnormal genes.

There has been an increase in the number of SCD cases in Nigeria for the past years. There is also a high rate of mortality among peopled affected by SCD which is attributed to acute chest syndrome that presents thromboembolism or infections in the respiratory system. Religious leaders in Nigeria can be used as change agents in the prevention of SCD. It is evident that religious leaders and faith-based institutions have a potential role in addressing health issues since they have persuasion power over their followers. Nevertheless, their role in addressing health issues is to some extent being ignored by the health service sector.

In spite of the importance of religious leaders toward successful offering health promotion programs, there is minimal research that has been carried out to examine the religious leaders’ role in addressing SCD in Nigeria. Further, Widmer et al. (2011) argued that the contribution of religious leaders in health delivery is not sufficiently recognized or mapped. Therefore, the study aims to address the literature gap by exploring the role of religious leaders in preventing sickle cell disease in the country.

Chapter 3.0 Methodology

Introduction

The goal of this study was to explore the role of religious leaders in the prevention of sickle cell disease (SCD). The knowledge and attitudes of religious leaders in Nigeria about SCD and their impacts on the marital counseling offered to would-be spouses to prevent SCD was evaluated. Possible relationship between the religious leaders’ knowledge and positive recommendations that might improve early testing among premarital couples and improve marital counseling outcomes were explored. The chapter offered a thorough description of the research design that was used as justification for the methodology. The section expounded on the population and the sampling technique that was employed in recruitment of participants. The chapter also outlined the data collection instrument, method of data collection, and data analysis. The section also discussed threats to validity, feasibility and appropriateness, and ethical considerations.

Research Design

This study is quantitative in nature. Quantitative research can utilize both non-experimental and experimental research methods and focuses on expressing certain trends and attitudes in numerals and statistics (Creswell, 2009). Quantitative methodology is more objective than the qualitative research design. Rajasekar et al. (2006) stated that qualitative research is process oriented but is often subjective in nature as it depends on the researcher’s interpretation.  Experimental research methods involve correlational studies, covariance studies or factorial designs that entail measurements of the interactions and effects. In this study, quantitative methods were used to gather numerical data which could then be generalized to Nigerian population of religious leaders.

Quantitative methodology involves the use of structured instruments and a large sample that represents the general population (Johnson & Christensen, 2008). The methodology was a good approach as the research study can be repeated due to the high level of reliability. The research design would facilitate exploration of the relationship between religious leader’s perceptions and knowledge about SCD and the prevention of the disease. This quantitative study entailed a survey that facilitated a standardized measure of the opinions, trends, attitudes and views of the sample population. Surveys are versatile and can be carried out through face to face interviews, mail, computer, paper platforms, and telephone or emails (Creswell, 2009).

A correlation research design was employed to explore and measure the nature of a relationship between the dependent variable; a level of knowledge and positive recommendations by the religious leaders and quality of genetic counseling and testing offered to followers. A correlational study investigates the strength of the relationship of the key variables and offers direction (Sousa et al., 2007). Correlation coefficients are within the range of -1.0 to +1.0 and are useful in establishing a pattern between the two factors. As such, a correlational research would facilitate the recognition of the trends and the key patterns in the collected data. A correlational study does not engage in an analysis to explain the cause of the observed patterns (Sousa et al., 2007). Correlational studies only focus on collecting the data, the relationships, and the distributions of the variables. The key areas of this research were designed before data collection which was in the form of numbers (statistics). The data were then represented in figures, tables and charts. The results from this study could be used widely to predict individual future results and other causal relationships.

The survey helped the researcher to come up with a reference value that might be of use in future research studies. These might be used to assess whether health education campaigns about SCD had been effective or not. The result could help in coming up with a strategy for intervention that mirrors the actual picture on the ground as well as the cultural influences that occur (Ngimbudzi et al., 2016). Moreover, this might help in designing activities that suit the population in question. Questionnaire was used to collect and analyze the attitudes, trends and opinions of the religious leaders in Ibadan, Nigeria.

Research questions

Are religious leaders in Nigeria qualified and interested in counseling prospective couples on genotype testing and genetic counseling?

The following sub-questions will be used to refine the study;

  1. What is the perceived level of knowledge of SCD knowledge among religious leaders in Nigeria?
  2. 2. Is there a relationship between their knowledge level and recommendation for genotype testing?

Population and Sample

The population targeted by the study was Nigerian religious leaders, such as pastors, priests, and Imams drawn from the Nigerian Religious Council, Ibadan North Local government area. Members were approximately 240 and all religions were equally represented on the council. Nigeria is one of the high populated countries in sub-Saharan Africa. The population was selected since Nigeria is highly affected with sickle cell anemia. In Nigeria, SCD is among the most common genetic conditions where 1 in every 200 live births is affected (Nnodu, 2014). The effects of SCD are the loss of lives and economic impacts due to the high cost of managing the disease. Ibadan is a good site for this study as it is one of the largest cities in Nigeria with diverse religious affiliations.

Probability (Random) sampling was used to select 150 religious leaders from the general population of 240 religious leaders in Ibadan NLGA.  (based on Slovin’s formula). Probability sampling was the most appropriate for this study as “it facilitates recruitment of a sample that can be generalized to the general population as opposed to non-probabilistic sampling that recruits a given sample of participants though not for generalization to the general public” (Silverman, 2011).  Probability sampling is thus more effective as the researcher would be able to choose a given number of individuals as representative of the general population (Grafstrom & Lundstrom, 2013). Random sampling technique was employed to allow for the generalization of the population. Samples were drawn from the population until the given percentages were achieved as illustrated in the table 1 below.

Equal number of participants (religious leaders) was recruited from each of the three main religious communities. Christian leaders reflected all the Christian denominations in Nigeria including Catholic, Anglican Communion, Methodist, Baptist, Salvation Army, Jehovah witness, and the Pentecostal movement. Christian religious leaders were recruited from the Catholic community, Pentecostal, white garment and other orthodox churches. Muslim leaders also must include all Muslim sects in Nigeria such as Ahmadiyah, Ansarudeen, Nawarudeen, AnsarulIalam, ZumuratulIslamiya and NASFAT sects. Traditional religious leaders were recruited from across the various practitioners of traditional religions available in the local government area. The inclusion criteria involved religious leaders who have more than three years’ experience in the particular church or religious community. The study excluded those religious leaders who have served less than three years since they may not be familiar with the religious community attitudes and beliefs and might also not have had enough experience so as to explore their knowledge of the SCD. The religious leaders with more than three years of experience were important in this study as they could have an influence on their congregation. The researcher would be able to measure their level of knowledge about SCD and find out their attitudes towards the disease. It also enabled the researcher to explore their influence on the community and how it may impact on genetic screening before any couple can consider having children.

If the required sample size and the necessary percentage distribution are not attained, more samples will be drawn from the population to achieve the required sample size and representation from each group. Demographic information (Appendix B) would be used to assist in determining if the participant should be included in the study. Articles, publications and reports from the internet will also be used to gather more information on the topic under study. These articles were accessed through databases such as PubMed, ProQuest, university library, NCBI and EBSCO host since these sources contain academic journals that are peer reviewed. This ensured that the information gathered was reliable and valid.

Data Collection Instruments

A questionnaire is an effective approach to carry out quantitative research. Questionnaires enable the researcher to collect valid data in a simple and economical way.  Survey questionnaire was therefore the best suitable method to gather information from the religious leaders as it could be employed to a large group of participants and even replicated to another population. It was easy to disperse questionnaire via telephone text messages since mobile telephones are easy form of communication in Nigeria. The research began by identifying the purpose of the survey questionnaire, which was to gather critical data on the knowledge, attitudes and beliefs of religious leaders towards the SCD and their current role towards reducing its prevalence among their congregation.

The criterion for selecting the use of survey questionnaires was due to the practical nature of this form of instrumentation. The other reason for selecting the use of questionnaires was the ability to receive a large amount of data even with a big group of people. More than two hundred participants could be evaluated and could be used as a representative of the general population. It would be economical to distribute the questionnaires to the sample population and give them time to fill them which would enhance its reliability and validity. It was also easy to quantify the results through the use of software packages and it was also possible to compare the results with other studies.

However, there is a limitation while using questionnaires to gather data. One may be unable to tell how truthful the respondent is while filling the questionnaire. However, participants were encouraged to be honest beforehand by explaining that there was no wrong or correct answer. The researcher must also be objective while developing the questionnaire to avoid making personal decisions and judgments.

Questions addressed areas of SCD and genotype screening before marriage. Both open-ended and close-ended questions were asked. The questionnaires included statements that represented the beliefs of the religious leaders with regard to SCD using a pre-determined scale. The response categories were; strongly agree (1), agree (2), neither agree nor disagree (3), disagree (4), and strongly disagree (5). These statements assessed demography, importance, and significance of genotype screening and the need to seek health care. Questions also assessed the practices of religious leaders with regards to SCD and their recommendations to the congregation. Questions covered premarital counseling, genotype screening, and the understanding of SCD..

Participants got information on the research study through planned sensitization meetings with the Nigeria Religious Council. Participants were selected and identified by individual phone numbers only as provided by the leadership of the Nigerian Religious Council. No names were required and the study was entirely voluntary. Implied consent was sent via individual phones and participation served as consent. No, it was suggested by the IRB because it was an implied consent. Potential participants were provided with information regarding the purpose of the survey and what was required of them by text message. Formal invitation letters were then sent to participants via text before data collection.

This study involved 150 participants. Participants were required to sign an informed consent form (Appendix C) before filling out the survey questionnaire (Appendix D) and were to be kept by the participants for future reference. Demographic information on the questionnaire includes age, religion, denomination/sect, educational status, leadership position and length of service. Participants were asked to answer all the questions in the questionnaires but they were free to leave those that they were uncomfortable with.  They were encouraged to be honest while filling the questionnaire since there was no wrong answer as it was based on one’s knowledge, beliefs, and opinions The time allocated for this survey data collection was 4 weeks. Participants took approximately thirty minutes to fill in the survey questions in the questionnaires and their answers were sent by text to the researcher. Participants received N3000 (about $10) telephone cards for agreeing to participate in the study.

Internet sources. Different academic sources, publications, and reports were used to collect information on the role of religious leaders in prevention of SCD in Nigeria. Various educational sites such as ProQuest, EBSCOhost, and NCBI were explored. These sources were used because they contain peer reviewed journals and articles and thus offered reliable and valid information. As such, reports and publications on the SCD knowledge among religious leaders in Nigeria were obtained.  In addition, secondary data from previous studies on the role of religious leaders in preventing SCD in Nigeria were gathered. The study focused only on articles published within the last five years in order to gather up-to-date data that was valid and reliable.

Data Analysis

Analysis of the data collected from  the questionnaire was carried out using the Statistical Package for the Social Sciences (SPSS) software. The alpha level was set at 0.05 to evaluate the statistical significance. There were nine questions that were employed in the knowledge sections of the survey questionnaire, which was evaluated on the scale of 0 to 9 points. The average scores ranged from 0 to 9 where a score higher than 5.4 was considered “high knowledge” and one below that as “low knowledge.” The rate of knowledge awareness was clarified as the percentage of those participants rated as “high-level knowledge.” The questions on the attitudes of religious leaders were also be ten in each section and evaluated on the scale of 0 to 9 points. The scores on the practices of the religious leaders in a prevention of SDC also varied from 0 to 9 but these scores were then be categorized into three parts, the 7.5 to 9.0 points as good practice, 4.5 to 7.4 as fair practice and 0 to 4.4 as poor practice.

The questionnaires were used to gain an insight into how the understanding of SCD among religious leaders translate to improved marital counseling and how their knowledge might be applied in reducing SCD in the country through encouraging early premarital testing and counseling.

The use of internet sources was also an appropriate methodology in this study. Academic sources such ProQuest, EBSCOhost, and NCBI offered up to date data that was useful for this study. The articles and journals in these sites were peer reviewed and thus provided highly valid and reliable information. The use of latest publications and reports assisted in gathering more data on the role of religious leaders in the prevention of sickle cell anemia. The results from the survey were compared with other previous studies and recommendations were given.

Ethical Considerations

The study was conducted after an approval was sought and granted by the Institutional Review Board (IRB) as outlined in Appendix E.  In addition, data will be collected from participants after they signed an informed letter of consent (Appendix C). Participants were required to go through the form which outlined the purpose of the study and what was needed of them during the study. The document were signed to show that they willingly agreed to participate in the study. No personal identifiers were used in the survey interviews, and each participant’s phone number was the only form of identification. All the data gathered from the participants were downloaded and transferred on to a flash drive and saved in a lockable safe that is accessible only by the researcher. These steps ensured that the participants were protected, and the information given remained confidential.

Threats to Validity

Internal Validity.

According to Onwuegbuzie and Johnson (2006), internal validity is the validity arrived due to the relationship between independent and dependent variables in a research study. In the study, the independent and dependent variables were knowledge of the religious leaders towards SCD, and the number of congregants who undergo genetic screening and counseling respectively. The study excluded other factors that might influence the results of this study such as the researcher’s opinion on the matter. Questions were set with the objective that personal views will not affect the results.

Construct validity.

The procedural concept of arriving at relevant quality operation in a study is construct validity (Onwuegbuzie& Johnson, 2006). It involves considering to what extent shall an investigation take to achieve accurate data. Participants were encouraged to give their honest opinions in order to obtain accurate data and must be told that there is no wrong or right answer. They were also told to avoid questions with multiple choices to discourage them from guessing.

External validity. Eeva-Mari Ihantola, and Lili-Anne Kihn (2011) claim that external validity determines how a researcher shall arrive at the conclusion after collecting data. Threats to external validity will be overcome by use of a stratified sampling technique to ensure the sample closely mirrors the population of the study and can thus be generalized to the wider population.

Statistical conclusion validity. Eeva-Mari Ihantola, and Lili-Anne Kihn. (2011) argued that statistical validity of a research study lays its foundation from methodological activities during research that includes research design, data collection, data analysis and interpretation. The study will use stratified sampling to ensure that the sample taken is a representative of the general population.

Summary

This section provided a description of the research design that would be utilized in this study. Quantitative correlational study was used to explore the role of religious leaders in the prevention of SCD. The target population of the study was religious leaders in Ibadan, Nigeria. Stratified sampling technique was used in the survey to obtain a sample of 180 participants. Participants must have served for a minimum of three years in religious leadership roles in order to be considered for inclusion into the study. The data collection instrument employed in this study was a survey questionnaire. Data were collected from secondary sources available in various databases. The data gathered were analyzed using the SPSS software. The ethical issues considered in this study included approval by IRB to conduct the study. Participant also signed an implied consent form and participation was considered consent. Confidentiality was maintained by the use of telephone numbers only and transferring the data into a flash drive and kept in a lockable safe that is accessible only by the researcher. Threats to validity will be managed through use of a stratified sample.

Chapter 4: Data Analysis and Results

Introduction

The chapter presents the results from the analysis of primary data that was collected from 150 respondents. Further, the chapter also presents related results from other studies done by different scholars. The first section of the chapter covers the response rate and the descriptive statistics that represent the demographic variables of the sampled religious leaders in the study. The second section of the data analysis represents the results in relation to the objective of the study as well as descriptive of the main study variables which include Knowledge, Attitude, and Practices of religious leaders with regards to sickle cell disease. Various statistical tests done to test the validity of the research hypothesis and answer the research question of the study are represented in the chapter.

Response Rate

A total of 150 questionnaires were handed over to a stratified sample of religious leaders. The religious leaders in the study represented Christianity, Muslim, and Other religions. Among the 150 questionnaires, 50 were handed to Christian religious leaders, 50 to Muslim religious leaders, and 50 to other religious leaders. These were leaders of various religious sects and members of the Nigerian Religious Council. The submitted questionnaires were reviewed for completeness, consistency, and whether they met the inclusion criteria. The response rate was based on the number of fully filled questionnaires. Out of the 150 questionnaires, 130 of the questionnaires were completed fully which represents 86.7% response rate. Table 1 below represents the response rate obtained from the all the sampled participants.

Table 2 below illustrates the response rate for each of the stratified groups included in the study; Christianity, Muslim and Other religions. Christianity had a response rate of 90% followed by Muslim with a response rate of 86% while other religion had the least response rate of 84%. Overall primary data used for the analysis was obtained from 45 Christian religious leaders, 43 Muslims religious leaders, and 42 religious leaders from other religions. Primary data used in the analysis was from a total of 130 religious leaders. The questionnaire gathered a wide range of information from the religious leader which is illustrated in the following section.

Information on demography was obtained from the survey instrument. The demographic information analyzed include; gender, age, education, marital status, religion, and years of service. Table 3 below summarizes the demographic characteristics results of the participants included in the study indicating the frequencies and percentages.Based on the descriptive analysis, the total number of participants whose data analyzed was 130. The majority of the participants were male religious leaders representing 90% of the participants while the female religious leaders represented only 10% of the study participants. The majority of the religious leaders involved in the study were aged between 36 and 49 years representing 43.1% of the participants. The age group was followed by participants between the ages of 50 and 64 at 23.1%. The ages of 18 to 35 years of the religious leaders represented 22.3% of the study participants while the least number of the religious leaders fell between the ages above 65 years at 11.5%

Most of the religious leaders in the study were college graduates who represented 33.1 % of all the study participants. Religious leader who were graduates represented 29.2% of the study participants followed by religious leaders who had only finished high school at 18.5%.  Religious leaders whose education level was lower than high school represented 10% of the participants while the least participants were religious leaders who had finished post graduate education at 9.2%. Most of the participants in the study were married and represented 67.7% of the religious leaders. The single religious leaders were represented by 14.6% while those who were neither married nor single were represented by 17.7% of the study participants.

Christian religion was represented by 34.6 % of the participants while Muslim religion was represented by 33.1% of the religious leaders’ participants. Other religions were represented by 32.3% of religious leaders in the study. Most of the religious leaders in the study had worked for 11 to 20 years representing 37.7% of the participants. The religious leaders who had worked between 21 to 30 years represented 30.8% of the participants while those who had worked as religious leaders for over 30 years represented 10% of the participants. The religious leaders who had worked for the least number of years fell in the range between 3 and10 years and represented 21.5% of the study participants.

Study Variables Measures.

The variable testing and genetic counseling (Religious practices on SCD) which was the dependent variable of the research study was measured by 7-Likert scale items. The dependent variable was computed as the mean score of the 7-Likert scale items. The mean score varied from 1 to 9 where 1 represent low testing and genetic counseling while 9 represent a high testing and genetic counseling.

Knowledge and positive recommendation on SCD (knowledge and positive recommendation on SCD) is an independent variable of the research study. The variable was measured by 10-Likert scale items. The variable was computed as the mean score of the 10-Likert scale items. The mean score varied from 1 to 9 where 1 represent low knowledge and positive recommendation on SCD while 9 represented a high knowledge and positive recommendation on SCD.

The attitude of religious leaders towards SCD (Attitude on SCD) is the second independent variable of the research study. The variable was measured by 5-Likert scale items. The variable was computed as the mean score of the 5-Likert scale items. The mean score varied from 1 to 9 where 1 represented low attitude of religious leaders towards SCD while 9 represented high knowledge and positive recommendation on SCD.

Reliability analysis was used to test the internal consistency of the study Likert scale items in measuring the study variables based on the sampled study participants. Results of the reliability analysis were indicated in the following section.

Reliability Analysis

Reliability analysis was conducted to assess the internal consistency of the survey instrument in measuring the study variables through the use of Likert scale items with a score range 1 to 9. The Likert scale items were used to measure and compute the mean scores of each of the three study variables; Knowledge and recommendation of SCD, Attitude on SCD, and practice by religious leaders to counter SCD.  Cronbach Alpha (α) was used as a measure of the internal consistency of the survey instrument. According to Manerikar and Manerikar (2015), the minimum acceptable level of Cronbach Alpha is α = 0.60. However, a Cronbach Alpha where α [image: image4.png] 0.70 indicates a good internal consistency of the scale items in measuring the study variables within the specific sample used in the research study. Table 5 below illustrates the internal consistency of the Likert scale item of the survey instrument used for the study.

Table 5 indicates good reliability results. The internal consistency of the Likert scale items can be termed as good based on the values of the Cronbach alpha statistic (α > .70). There is a high level of internal consistency within the study items for each variable under study within the specific sample used. The Likert scale items measuring each variable are reliable. This further indicates the reliability of the survey instrument and the results of the study.

Descriptive Analysis of Study Variables

Testing and genetic counseling (Religious practices on SCD). The study established the descriptive statistics of the dependent variable; testing and genetic counseling (Religious practices on SCD) as indicated in table 6. The arithmetic mean of the individual item scores and their standard deviations were used to describe the dependent variable. The mean of the individual items measuring the dependent variable was used to determine the item level and importance of the item within the dependent variable construct. The item level was categorized into three parts; good practice ranged from 7.5 to 9.0, fair practice ranged from 4.5 to 7.4 while poor practice ranged from 0 to 4.4.

                Fair Practice

Based on table 6, the arithmetic mean of each of the 7 items used to measure the variable Testing and Genetic Counselling on SCD ranged from 4.35 to 6.01.The highest mean was for the item “My efforts leads to improved marital counselling on SCD” with a mean of 6.01and standard deviation of 1.94. The lowest mean was for the item “I recommend other practices than genotype screening for preventing sickle cell disease” with a mean of 4.35and a standard deviation of 1.66. The overall arithmetic mean and standard deviation of the dependent variable Testing and Genetic Counselling on SCD was 5.13 and 1.21 respectively.

In general conclusion, testing and genetic counseling (Religious practices on SCD) among the religious leaders was fair.The religious leaders made fair efforts  in their fight against SCD among their congregations and the communities they reached to. The religious leaders had a fair ability to convince premarital couples to attend genetic screening and counselling as an intervention to prevent SCD. The scores of the variable Testing and Genetic Counselling on SCD ranged from 1(low)-9 (high). Figure 1 presents the distribution of the scores of Testing and Genetic Counselling on SCD among the religious leaders who participated in the research study. The scores were calculated as mean score of the 7 items under the construct of Testing and Genetic Counselling on SCD.

Figure 1.Distribution of the dependent variable mean score among the religious leaders

Based on the scores of the dependent variable as shown in Figure 1, most of the religious leaders in the study had a mean score of 5 representing 36.15% of the study participants. This further indicates that most of the religious leaders demonstrated fair practice to prevent SCD among their congregations and the communities they reached to. Some of the religious leaders as indicated in Figure 1 had poor practices while others had initiated good practices to prevent the prevalence of SCD.

Knowledge and positive recommendation on SCD. The study established the descriptive statistics of the first independent variable; Knowledge and Positive Recommendation on SCD (Knowledge and recommendation on SCD) as indicated in table 7. The arithmetic mean of the items, their standard deviation, item importance, and item level were used to describe the construct of knowledge and positive recommendation of the religious leaders. The mean of the individual items was used to determine the item level and importance of the item within the independent variable construct. The item level was categorized into two parts; high knowledge for item mean scores above 5.4 and low knowledge for item mean score below 5.4.

Based on table 7, the arithmetic mean of each of the 10 items used to measure the variable knowledge and positive recommendation on SCD ranged between 4.63 and 5.79. The highest mean was for the item “I often talk about health to my congregation” with a mean of 5.79and standard deviation of 1.53. The lowest mean was for the item “What is the level of your religious beliefs towards SCD and its prevention?” with a mean of 4.63and a standard deviation of 1.73.The overall arithmetic mean of knowledge and positive recommendation on SCD was 5.61 with a standard deviation of 0.90.

In general, from the study view point Knowledge and Positive Recommendation on SCD (Knowledge and recommendation on SCD) among the religious leaders was high. The religious leaders had a high level of knowledge on SCD and positively recommendation on SCD. The scores of the variable knowledge and positive recommendation ranged from 1(low)-9 (high). Figure 2 presents the distribution of the scores of Knowledge and positive recommendation on SCD among the religious leaders who participated in the research study. The scores were calculated as mean score of the 10 items under the construct of knowledge and positive recommendation on SCD.

Figure 2. Distribution of the mean score of Knowledge and positive recommendation on SCD

Based on the score of Knowledge and positive recommendations on SCD as shown in Figure 2, most of the religious leaders in the study had score of 5.5. Most of the religious leaders in the study had a higher knowledge on SCD and presented positive recommendations to their congregations and the communities they reached at. A number of the religious leader had low level of knowledge on SCD as well as positive recommendations towards preventing SCD among pre-marital couples in their congregations; such religious leaders had individual mean scores of 3 and 4 representing 2.31% and 4.92% of the participants of the study.

Attitude towards SCD

The study established the descriptive statistics of the first independent variable: attitude towards SCD as indicated in table 8. The arithmetic mean of the items, their standard deviation, item importance, and item level were used to describe the construct of attitude of the religious leaders towards SCD. The mean of the individual items was used to determine the item level and importance of the item within the independent variable construct. The item level for the religious leaders’ attitude towards SCD was based on the mean class interval. The mean class interval was calculated as follows.

Mean class interval

The low item level; Low attitude towards SCD ranged from 1-3.67 while the median item level; Fair attitude towards SCD ranged from 3.68-7.34, and high item level; High attitude towards SCD  ranged from 7.35 and above.

Based on table 8, the arithmetic mean of each of the5items used to measure Attitude towards SCD among the participants ranged between 3.52 and 4.78. The highest mean was for the item “How important is it for couples to be counseled about SCD during pre-marital counseling” with a mean of 4.78 and a standard deviation of 1.68. The lowest mean was for the item “Attitude of your congregation towards sickle cell disease” with a mean of 3.52and a standard deviation of 1.66. The overall arithmetic mean of all the five items measuring Attitude on SCD among the participants was 4.65 with a standard deviation of 1.25.

In general, from the study view point, almost half of the religious leaders sampled reported fair attitude towards SCD.The scores of the variable knowledge and positive recommendation ranged from 1(low)-9 (high). Figure 3 presents the distribution of the scores of Attitude towards SCD among the religious leaders who participated in the research study. The scores were calculated as mean score of the 5 items under the construct of Attitude towards SCD.

Figure 3. The distribution of the mean score of the religious leaders’ attitude towards SCD

Figure 3 further indicates that most of the religious leaders had scores ranging from 4.0-6.0 representing fair attitude towards SCD. A relative number of the religious leader had low attitude towards SCD with scores ranging from 1.0-3.0.

Hypotheses Testing

The hypotheses formulated for the study was tested to ascertain their validity and achieve the objective of the research study. The researcher conducted correlational analysis as a statistical test to assess the validity of the research hypothesis. The researcher also conducted a test for normality. The hypothesis for the research tested by correlation analysis is;

H0: There is no significant relationship in the religious leader’s knowledge and positive recommendations, and testing and genetic counseling their congregants.

H1: There is a significant relationship in the religious leader’s knowledge and positive recommendations, and testing and genetic counseling among their congregants.

Test for Normality

The researcher tested the assumption of normality of the dependent and independent study variables. The assumption of normality assumes that all variables of the study are normally distributed. The null hypothesis of the test for normality was that the data of both the independent and dependent variable was normally distributed. The researcher used the Shapiro-Wilk statistic to test the assumption of normality. The significance results obtained are indicated in table 9 below.

Knowledge and positive recommendation on SCD had a statistically insignificant p-value (p =0.068). Attitude on SCD had a statistically insignificant P–value (p=0.080) while test and genetic counselling (religious practices on SCD) had a statistically insignificant p-value (p=0.243).The Shapiro-Wilk p-values of all the study variables are statistically insignificant (p> 0.5). Hence, the null hypothesis of the test for normality is not rejected and it is concluded that all the study variables are normally distributed. Based on these results, the researcher can apply non parametric statistical test such as Pearson correlation instead of the non-parametric correlation test such as Spearman rank correlation to test the validity of the hypothesis. Pearson correlation analysis was used to test the validity of the research hypothesis.

Relationship between Religious Leaders’ knowledge and Positive Recommendations, and Testing and Genetic Counseling

Pearson correlation was used to test the validity of the research hypothesis.The researcher tested the null hypothesis that there is no statistically significant relationship in the religious leader’s knowledge and positive recommendations, and testing and genetic counseling (religious practices on SCD) among their congregants. The results of the obtained correlation analysis are illustrated in table 10 below.

The P-value between knowledge and positive recommendation on SCD, and testing and genetic counselling is p=0.693. The P-value (p=0.693) is insignificant (p > 0.05). Hence, we do not reject the null hypothesis of the test and we conclude that there is no statistically significant relationship between religious leaders’ knowledge and positive recommendation, and testing and genetic counseling among their congregants. This confirms that the hypothesis of the research study is valid.

Based on the correlation analysis in table 10, There is a no correlation (r= – 0.035) between knowledge and positive recommendation on SCD, and testing and genetic counseling. This supports the validity of the hypothesis indicating there is no statistically significant relationship between the two variables. The results indicate that an increase in knowledge and positive recommendation on SCD among the religious leaders does not result into a change in testing and genetic counseling among their congregants. However, there tends to be a very small increase in the knowledge and positive recommendation among the religious leaders. This illustrates the lack of a statistically significant relationship between the two variables.

This is very confusing. Your focus was on religious leaders, how do you describe the congregation here? This presents as if you also included the “congregants”

The results (p=0.914) further indicate that there is no statistically significant relationship between religious leaders’ Knowledge and positive recommendation on SCD, and their perceived attitude towards SCD. The P-value (p=0.914) is statistically not significant  (p > 0.05).Moreover, there is a no correlation (r=0.010) between the two variables. The result indicates that an increase in knowledge and positive recommendation on SCD among the religious leaders does not affect the change in their attitude towards SCD. However with an increase in knowledge and positive recommendation there tends to be an  increase in their attitude towards SCD or vice versa. This shows there is lack of a statistically significant relationship between the two independent variables.

Additionally, the results (p=0.047) indicates that there is a significant relation between the attitude of religious leaders on SCD and the testing and genetic counseling (religious leaders practices on SCD) among their congregants. The P-value (p=0.047) is significant (p < 0.05). However, there is a weak positive correlation (r=0.174) among the two variables. When the religious leaders’ attitude towards SCD relatively increases, the testing and genetic counseling among their congregants also increases or vice versa. The two variables tend to move in the same direction. This indicates there is a statistically significant relationship between the two variables.

Chapter Summary

The research study results obtained through descriptive and correlational analysis are from data collected from 130 religious leaders in Nigeria. The criteria for the religious leaders participation in the study was three years of experience. The response rate of the study participants was 86.7%.  Christian leader represented 34.6% of the study participants. Muslims represented 33.1% while other religions were represented by 32.3% of the participants. The religious leaders had a fair practice of initiating testing and genetic counseling among their congregations. The Knowledge and Positive Recommendation on SCD among the religious leaders was high while their attitude towards SCD was moderate. The results from correlation analysis confirmed that there was no statistically significant relationship between religious leaders’ knowledge and positive recommendation, and testing and genetic counseling among their congregants. The results obtained represented the views of the religious leaders sampled in the research study. The next chapter will summarize the findings obtained and interpret them in a discussion based on the peer reviewed literature described in chapter two. The chapter will also discuss the limitations and recommendations of the study and present the implications of the current study.

Chapter 5: Discussion, Conclusions, and Recommendations

Introduction

The chapter presents the discussion of the findings that were established in this quantitative inquiry. The study draws recommendation and conclusion of the study based on the discussion of the findings provided. The study also presents the limitation and implication in the current study on SCD.

The purpose of the study was to explore the role of religious leaders in the prevention and fight against SCD in Nigeria. The study aimed at establishing the level of knowledge of the religious leaders on SCD and how their understanding, attitude, and beliefs of the disease translated in their efforts to prevent the disease by improving genotype counseling on SCD during marital counseling. Further, the study explored how the knowledge on SCD among the religious leaders has been applied in improving  early testing of SCD among premarital couples and improving the marital counseling outcome. Additionally, the study examined the attitude that the religious leaders had on SCD and whether it impacts on their efforts in preventing SCD through genotype testing and genetic counseling.

The study was structured under the framework of health belief model and social cognitive theory. The study was quantitative and employed a correlation design which involved a systematic investigation of the nature of relationships between the study variables. The design assisted in building on the existing literature through establishing of the relationship among variables of the study related to SCD. The correlation coefficients ranged from -1.0 to +1.0 from which  the patterns in relation to the strength and direction of the relationship among the study variables was established based on the religious leaders’ beliefs and religion. The quantitative approach supported the establishment of descriptive results of the items under the construct of the study variables. All statistical analysis done to establish the results of the study were performed using SPSS.

The study established several key findings based on data retrieved from 130 religious leaders’ participants who were recruited from three religious groups; Christians, Muslims, and Other religions. Primary data was collected through survey and an informed consent was provided with the assurance of confidentiality of the information obtained from the survey. Data were obtained through the use of quantitative semi-structured questionnaires that were handed to the religious leaders.  The majority of the participants were male religious leaders, Christians, between the ages of 36-49, Married, College graduates, and with 11- 20 years of service as religious leaders. Previous studies have focused on testing and genetic counseling on SCD offered by religious bodies as part of marriage requirement (Gbenol, Brisibe, & Ordinioha, 2015). It is, however, unclear whether the efforts of the religious bodies in offering premarital counseling is effective in leading to the prevention of SCD, and whether the quality of counseling meets scientific standards. Hence, the current study focused on establishing whether religious leaders have enough knowledge of SCD that enhances their counseling to enable premarital couples to make informed decisions.

Based on the testing and genetic counseling, the study found that most of the religious leaders’ efforts of prevention of SCD through testing and genetic counseling fairly lead to improved marital counseling on SCD among their congregation members. Further, the religious leaders were poor in recommending other practices of preventing SCD rather than genotype screening among their congregation. The religious leaders’ efforts on testing and genetic counseling in relation to their beliefs and religion were found to be fair.

The results from the descriptive and correlational analysis of the data provided were presented in chapter 4. The variables studied included religious leaders’ knowledge and positive recommendation on SCD, religious leaders’ attitude towards SCD, and testing and genetic counseling as the dependent variable of the study. Based on the knowledge and positive recommendation on SCD, the study established that most of the religious leaders often talked and shared their knowledge about health matters related to SCD to their congregation. The level of religious beliefs among the religious leaders towards SCD was a significant contributor to the lack of knowledge on the disease. The religious leader’s knowledge on SCD was found to be high. Based on the religious leaders’ attitude towards SCD, the religious leaders had higher attitudes regarding the counseling on SCD during premarital counseling. The religious leaders believed that their congregation had a low attitude towards SCD. The attitude of the religious leaders towards SCD, in general, was fair.

The study established no significant relationship between the religious leaders’ knowledge and their positive recommendation, and their efforts in leading to testing and genetic counseling among their congregation members. The study further established that there was no relationship between religious leaders’ knowledge and positive recommendation on SCD and their attitude towards SCD. Finally, the study established that there was a significant relationship between the religious leaders’ attitudes on SCD and their efforts in prevention of the disease through testing and genetic counseling.

Interpretation of the Findings

This section interprets and discusses the findings of the study based on existing literature on the discipline of SCD and the theoretical framework employed. The section looks at the interpretation of the descriptive findings as well as the correlational findings established in the study

Perceived level of knowledge of SCD among religious leaders in Nigeria. The knowledge of SCD among the religious leaders in Nigeria was found to be high and as such, the religious leaders were at the forefront of sharing this knowledge through health talk with their congregation. Moronkola and Fadairo (2007) also found that the knowledge of SCD among Nigerians was high. Therefore, the Nigerian religious leaders would also have high knowledge on SCD. However, this finding goes contrary to the findings established by Durotoye, Salaudeen, Babatunde, and Bosah (2013) who indicated that the level of awareness of SCD was low in Nigeria. The findings are consistent with those established by Lumpkins, Cameron, and Frisby (2012) who indicated that religious leaders have successfully been used and are at the forefront in the promotion of health exercises among their congregations and communities.

Perceived attitude towards SCD. The findings indicated that religious leaders perceived that it was important to interpret statistics concerning SCD among the newborns in Nigeria. WHO (2011) pointed out that approximately 300,000 children are born with SCD and related hemoglobin disorders every year. In sub-Saharan Africa, in a country like Nigeria, 3% of the children born there are affected with SCD (Grosse, Odame, Atrash, Amendah, Piel, & Williams, 2011). Statistics indicate that 150,000 births per year are affected with SCD in Nigeria (Anie, Egunjobi, & Akinyanju, 2010). Further, statistics also indicate that the mortality rate of the newborns in African countries is about 50-90% (Grosse et al., 2011). Interpretation of statistics on SCD is significant in creating awareness to the people in African societies of the prevalence of the disease and how the disease has become a serious concern to people in Africa (Grosse et al., 2011). The religious leaders believe that the interpretation of statistics concerning SCD among newborns will aid them in gaining more knowledge of the disease as well as influence on their efforts towards the prevention of the disease through encouraging their congregations to attend premarital testing and genetic counseling on SCD.

Testing and genetic counseling. The study findings indicated that the religious practice on SCD was fair; the religious leaders’ efforts in encouraging and implementing practices on testing and genetic counseling were found to be fair. The religious leaders recommended premarital couples to seek premarital genotype screening and genetic counseling as a prevention measure of SCD prevalence in Nigeria. The results are consistent with the findings by Dibua (2010) who argued that religious leaders’ involvement is important in encouraging premarital screening. Moreover, religions tend to influence positive health behaviors and healthy lifestyle among the followers (Lewis, 2008; Ruijs, Hautvast, Kerrar, Van der Velden, & Hulscher, 2013; Rumun, 2014; Rivera-Hernandez, 2015). Religious leaders in faith-based institutions contribute towards health promotion as well as disease prevention (Rumun, 2014). According to Levin (2014), faith-based organizations have been underutilized in the promotion of health and disease prevention which explains why the religious leaders’ efforts towards prevention of SCD were found to be fair.

The findings further align with Adeyemo et al. (2007) study results which indicated that premarital genotype screening and genetic counseling are effective methods that are used and recommended to prevent the prevalence of SCD. In addition, Adewoyin (2015) indicated that premarital screening and genetic counseling programs and initiatives are significant in reducing the number of cases of children born with SCD and other hemaglobathies. This is also in relation to the findings by Omuemu, Obarisiagbon, and Ogboghodo (2013) who found that premarital screening is a crucial initiative for the diagnosis of SCD and helps reduce the prevalence of the condition among newborns. Premarital genetic screening provides a chance for couples to become aware as well understand their genetic predisposition to SCD. This makes it a reliable method that can be recommended to prevent SCD (Oyedele, Emmanuel, Gaji, & Ahure, 2015). Fernandes Januario, Cangussu, Macedo and Viana (2010) also supported the use of genotype counseling of parental family members of a patient as a strategy to minimize SCD related mortalities.  Hence, premarital counseling and genotype screening is an effective preventive measure of the prevalence of SCD.

The study findings also indicated that the efforts of the religious leaders fairly lead to improved marital counseling on SCD among their congregation members. This concurs with Anshel and Smith (2014) argument that religious leaders who could influence the health behaviors of their congregations tend to be ignored. Their contribution in health delivery is not sufficiently reorganized (Widmer et al., 2011). Hence, their practices towards the fight of SCD turn out to be fair. The findings of the study indicated that religious leaders fairly organize genotype screening campaigns in their community. Such practices are geared towards creating awareness of SCD to the people of the community. The findings are consistent with the results by Okyay et al. (2016) and Umar and Oche (2012) who highlighted the importance of creating awareness and knowledge about SCD in the community to encourage premarital spouses to attend genetic counseling before they consider marriage as a way of preventing the prevalence of the disease among newborns.

The study established that there was a significant relationship between religious attitudes towards SCD and their practices in preventing the prevalence’s of SCD through encouraging premarital testing and genetic counseling among their congregation members. The study supports the arguments that the success of premarital screening and genetic counseling programs and initiatives depends heavily on an individual attitude towards SCD as well as the genetic screening and counseling on SCD (Aneke & Okocha, 2016; Adeyemo et al., 2007). The findings are also consistent with the results of the study by Moronkola and Fadairo (2007) who established that due to the positive attitude towards SCD among Nigerians, the religious leaders may encourage more Nigerians to attend premarital screening and genetic counseling.

The study findings indicated that the religious leaders were poor in recommending other practices of preventing SCD rather than genotype screening among their congregation. This can be attributed to the fact SCD has only one known cure hence there were limited practices that could be exercised in preventing SCD. The results align with findings by Okyay et al (2016) who indicated that bone marrow transplant is the only known cure of SCD, and it is rarely done due to the significant risks involved as well as the high cost of undertaking the procedure. These explain the results obtained why the religious leaders were poor in recommending other practices for prevention of SCD rather than genotype screaming. Additionally, Abioye-Kuteyi, Oyegbade, Bello, and Osakwe (2009) indicated that the medical need for the treatment of SCD is long-term due to the chronic nature of the disease and may have further psychological and economical impacts on the patients and affected families. The high knowledge of such information on SCD by the religious leaders would prevent them in recommending such form of practices among their congregations.

Relationship between religious leader’s knowledge and positive recommendations, and testing and genetic counseling. The study established no relationship between the religious leaders’ knowledge and positive recommendation on SCD, and their efforts in encouraging testing and genetic counseling. The findings are inconsistent with the results of the study by Moronkola and Fadairo (2007) who contended that the high knowledge on SCD that religious leaders as part of Nigerians citizens have, would enable them to influence an increase in the number of Nigerians that attend premarital screening and genetic counseling. However, this is not the case in the current study as there is neither a positive nor a significant relationship between knowledge and the practices of religious leaders to undergo testing and genetic counseling among their congregation members. The findings are contrary to the argument that premarital screening and genetic counseling programs and initiatives depend heavily on the extent of knowledge an individual has of SCD and understanding of the consequences of having an affected child (Aneke & Okocha, 2016; Adeyemo et al., 2007). Additionally, the findings contrast the argument by Asekun-Olarinmoye et al. (2013) who indicated that religious leaders are very influential in decision-making process of most Nigerians. Through sharing their knowledge on SCD to their congregation as an engagement strategy, it is expected that it would likely influence the decision-making of the members of the congregation especially the premarital couples who would then take the initiative to have genotype testing and genetic counseling as a measure to prevent the prevalence of SCD in Nigeria.

Interpretation in a theoretical perspective. The current study was based on two theoretical frameworks. The first framework was the framework of Health Belief Model (HBM) which was developed by Hochbaum, Rosenstock, and Kegelsin (1952), as well as Bandura’s (1986) Social Cognitive Theory (SCT). Hochbaum, Rosenstock, and Kegelsin (1952) model is a psychological model that aims to elucidate and predict preventive health-related behaviors. The model was adapted in the current study in exploring health behaviors in the prevention of SCD based on the knowledge and attitude of religious leaders towards SCD. The model which mainly focuses on beliefs and attitudes was used as a framework for exploring the religious leaders’ attitude and beliefs towards SCD (Canbulat & Uzun, 2008; Abolfotouh et al., 2015).

Under SCT framework, the intervention of religious leaders in the prevention of SCD was expected to influence the members of the congregation in taking health-related action to prevent the prevalence of SCD. The study established that religious leaders have a high knowledge on genotype screening and believe that genotype screening, as well as premarital genotype screening, is important in the prevention of SCD. The religious leaders also believed that SCD could be prevented. These influenced on religious leaders’ knowledge of SCD. The findings concurred with the model as religious leaders perceived that SCD is a serious disease and have adequate knowledge on it. The religious leaders believed that their congregation were susceptible to the disease and thus made efforts to recommend genotype screening and genetic counseling to their congregations as a prevention measure of the disease. Through their perception that genotype testing is important in the prevention of SCD, the religious leaders offer a positive recommendation to their congregation to undergo genotype screening. Consequently, the study established a relationship between the religious leaders’ attitude towards SCD and their efforts in encouraging their congregation to undergo testing and genetic counseling. This relates to the model in that the religious leaders’ attitude and perception of the benefits of premarital counseling influence them to offer and recommend testing and genetic counseling among their members.

Additionally, Bandura’s theory (1986) suggests that a triadic interaction exists between an individual, behavior, and environment. People tend to acquire cognitive and behavioral competencies through observational learning from experiences of others (Bandura, 2011).The theory provided a framework of influencing testing and genetic counseling as an intervention to the prevalence of SCD. The study established that the religious leaders had a high knowledge of SCD. Based on the framework, the outcome expectation of having a higher knowledge of SCD among the religious leaders is influencing testing and genetic counseling among the congregation members. However, the findings of the study that indicated a lack of a significant relationship between religious leaders’ knowledge and positive recommendation, and the testing and genetic counseling goes contrary with the theory construct of outcome expectation. It is expected that through religious leaders’ knowledge, they are more likely to influence the members of their congregation to undergo testing and genetic counseling as a preventative measure on SCD among the premarital couples. However, the religious leaders’ attitude towards SCD significantly influenced their efforts on premarital testing and genetic counseling among their congregation members. The religious leaders fairly influenced the decision-making of premarital couples on premarital counseling and testing. Hence the social cognitive framework was consistent with the study findings relating attitude of religious leaders on SCD and premarital testing and genetic counseling among their members.

Limitations of the Study

The study had some limitations that impacted it generalizability, validity, and reliability. The study relied entirely on primary information provided by participants. Although the study put in place measures to ensure validity and reliability of the information provided through the survey conducted in the study, the information may have been exaggerated and participants may not have answered all the questions in the study correctly. The multiple selection questions may also have encouraged guessing (Onwuegbuzie & Johnson, 2006). The results may have been influenced by biasness of the participants. Use of secondary sources of information would have enhanced the generalization of the finding obtained in the current study. Moreover, the information provided and analyzed in the study was only from religious leaders in Ibadan, Nigeria, hence the study cannot be generalized to other parts of the countries. A similar study in other countries or similar study that sources information from different countries is needed to generalize the findings of the research to other geographical regions.

Additionally, the exclusion of religious leaders who had served for less than three years was a limitation in the study. The exclusion limited the scope and number of individuals who could participate in the study. The exclusion was made in an attempt to maximize the validity of the information provided. This was grounded on having information obtained from experienced religious leaders which was measured by the number of years that they had served as religious leaders. The study was limited to a quantitative nature through the use of a quantitative questionnaire instrument. Information on knowledge and attitude can best be captured using a qualitative survey instrument. This limits the validity and reliability of the study which could be enhanced in a mixed method approach.

The external variables that might have influenced or affected the relationships of the variables under study limits the validity of the results were not controlled. These external variables might have affected the relationships between the study variables. Such variables are confounded to improve the validity of the results obtained. Therefore, readers should take caution while interpreting the findings of the current research study since the results might be different if other factors are taken into consideration.

Recommendations

The research study employed a quantitative approach to examine knowledge, attitude, and practice. It is recommended that future studies examine such constructs using mixed methodology design as a suitable approach. A qualitative approach could be designed which might provide more comprehensive evidence and an in-depth examination of knowledge, attitude, and practices of religious leaders regarding SCD, its prevalence, and premarital genotype testing and genetic counseling. The research employed a correlation design to establish the nature of the relationship of the variable in the study. Other methods that measure the cause and effects between the response and dependent variables could be utilized in future research to measure the impact of knowledge and positive recommendation on SCD, and attitude on premarital testing and genetic counseling as a dependent variable. Additionally, future research on the topic should consider confounding the external variables that might have influence on either or both the dependent variable and the independent variables of the study. This would improve the internal validity and ensure that the results obtained better reflect on the research objective and better represents the population.

The results of the study rejected the hypothesis that there exists a significant relationship between religious leaders’ knowledge and positive recommendations on SCD, and their efforts in encouraging premarital genotype testing and genetic counseling. The finding suggested that religious leaders do not require having knowledge on SCD to implement practices that lead to premarital genotype testing and genetic counseling. This goes contrary to many of the prior studies. It is recommended, therefore, that future studies examine the relationship between individuals having knowledge on SCD and its impact in having them or related members attend genotype testing and genetic counseling. The study recommended that future studies be conducted in other different areas of Nigeria as well as other countries, in relation to the role of religious leaders in influencing premarital genotype testing and genetic counseling among the members of their congregation before marriage as a preventative measure on SCD. This would enable generalization of the findings of the current and future research on the topic.

Implications

The current study investigated the role of religious leaders in the prevention of SCD through exploring their knowledge, attitude, and practices in relation to SCD. Due to the lack of studies that address the role of religious leaders in the prevention of SCD, more studies that address the influence of religious leaders on their congregation in undergoing premarital genotype testing and genetic counseling as a prevention of SCD are needed. Consequently, the study opens the door for future research about the role of religious in the prevention of SCD and other hemaglobathies.

The findings of the research study provide many possible outcomes. The study reveals the influence of religious leaders’ knowledge in translating to improved counseling on couples’ planning on marriage. Despite not obtaining a significant relationship between religious leaders’ knowledge on SCD and their efforts in encouraging premarital genotype testing and genetic counseling, previous studies have indicated that knowledge on SCD by both the religious leaders and members of the society and its impact in influencing premarital genotype testing and genetic counseling is critical and necessary for further research development (Aneke & Okocha, 2016; Asekun-Olarinmoye et al., 2013; Adeyemo et al., 2007; Moronkola & Fadairo, 2007). The study challenges religious leaders to use more of the knowledge gained on SCD to persuade their congregations to attend premarital genotype screening and genetic counseling programs.  The study provides knowledge on the role of religious leaders in the prevention of SCD through implementing various practices to encourage premarital genotype testing and genetic counseling of their congregation members, especially would-be spouses who are enabled to make informed decisions before marriage.

Conclusion

The statistics on the prevalence of SCD in Nigeria and the mortality rate associated with the disease indicate that the disease is a serious course of concern that requires the attention of influential persons in the community such as religious leaders. Although extensive research has been conducted on preventative measures of SCD, little has been done regarding the role of religious leaders in preventing SCD. SCD has only one known cure, bone marrow transplant, which is very costly for the majority of affected newborns and has a significant risk involved in undertaking such medical procedures that could also be fatal. Hence, other methods can be put in place such as premarital genotype screening and genetic counseling to counter the high prevalence in newly reported incidences of the disease. Such measures can be influenced by religious leaders to members of their congregations, especially the premarital couples who are considering marriage. Therefore, it is important to understand the role that religious leaders play in preventing SCD and factors that influence the impact of their interventions.

The knowledge of SCD and attitude towards SCD among the religious leaders plays a key part in influencing their practices to encourage premarital genotype screening and genetic counseling. The current research results indicated that the religious leaders’ attitude towards SCD is a significant contributor to their practices in preventing the disease while extant studies indicated that knowledge on SCD among the religious leaders is influential in their campaigns to prevent the prevalence of the disease. Religious leaders should focus their attention on having a positive attitude towards the disease as well as gain informed knowledge on the disease to influence people in the societies to have genotype testing and premarital counseling as a way to prevent SCD so that no Nigerian will go into marriage without knowing their genotype status. The social implication of this study is that with time, no Nigerian will go into a marital relationship without adequate understanding of their genotype status and genetic counseling where necessary.  It also highlighted the important role the religious leaders can play in the prevention of SCD in Nigeria by acting as change agents in making sure that every prospective couple is aware of their genotype status before becoming parents. Religious institutions must include genotype screening as part of their premarital counseling topics for would be couples. The government can make it mandatory for prospective couples to present their genotype certificates prior to wedding authorization in any government approved institutions or registries.  However, continued research on the role of religious leaders in preventing SCD is needed to prove their significance in influencing genotype testing and genetic counseling of people in different societies. This can lead to more interventions of the religious leaders and reduction in the prevalence of SCD as well as better health care outcomes.