KNOWLEDGE, ATTITUDE AND PRACTICE
REGARDING EPILEPSY AMONG NURSES IN
ASUTIFI NORTH DISTRICT
Richard Opoku Asare
Akwasi Boakye-Yiadom
Paul Armah Aryee
American Journal of Health, Medicine and Nursing Practice
ISSN 2520-4017 (Online)
Vol.5, Issue 1 No.4, pp 43 - 65, 2020
www.ajpojournals.org
KNOWLEDGE, ATTITUDE AND PRACTICE REGARDING EPILEPSY AMONG
NURSES IN ASUTIFI NORTH DISTRICT
Richard Opoku Asare1
MPhil, BEd, RN (Dip)-RMN, Cert.Ed.
College of Nursing, Ntotroso
Corresponding Author’s Email: asareor@gmail.com
Akwasi Boakye-Yiadom2
MSc, B.Ed
Department of Public Health, School of Allied Health Sciences, UDS, Tamale, Ghana
Paul Armah Aryee3
PhD, MPhil, MMEdSc, BSc
Department of Public Health, School of Allied Health Sciences, UDS, Tamale, Ghana
ABSTRACT
Purpose: To assess the knowledge, attitude and practice regarding epilepsy among nurses within the
Asutifi North District with the aim of understanding their subjective experiences and knowledge on
epilepsy in a sociocultural context and how their attitude shape their practice towards people with
epilepsy.
Methodology: The study employed an exploratory descriptive cross-sectional design. The study population
consisted of nurses who have been licensed by the Nursing and Midwifery Council of Ghana and working
in government facilities. The exclusion criteria were private health facilities, non-trained health
professionals and other health professionals without nursing background, and student nurses on clinical
attachment during the period of study in the district. Multistage sampling technique was used to select the
study participants from the communities. A standard statistical formula was used to arrive at a sample size
of 102. Data was collected by using a semi-structured questionnaire. Descriptive statistics involving
frequencies and percentages were used in representing data. Responses on other items were cross-tabulated.
The statistical tool that was used for analyzing the data was by STATA version 12.
Results: Findings showed that 67.7% (69/102) of the nurses were aware of the causes of epilepsy, 59.8%
have low level of knowledge on the disease. Though 82.4% of the nurses suspect people with epilepsy to
have mental illness, 70.6% of the nurses had positive attitude towards epilepsy. However, 52.9% exhibited
poor practices towards the disease. The socio-demographic characteristics of religion (Muslim) (p=0.017),
area of specialty (RMN) (p=0.045) as well as close family relationship with epilepsy (p=0.001) were
significantly associated with knowledge on epilepsy. Factors that were found to influence attitude towards
epilepsy were sex (Female) (p=0.037), religion (Muslim) (p=0.012) and specialty area (RMN) (p=0.054).
The area of specialty statistically influences their practices on epilepsy (p=0.001). There was no statistically
significant association between knowledge on epilepsy and practice (p=0.134). However, attitude
significantly related to practices on epilepsy (p=0.008) and indicated that negative attitude was more likely
to be associated with poor practice.
Conclusion: Nurses at the Asutifi North District tended to have low knowledge, positive attitude and poor
practices on epilepsy.
Recommendation: The Ghana Health Service in collaboration with the Ministry of Health should run
intermediary workshops, at least every six months, to train nurses in epilepsy diagnoses to reduce the
treatment gap. The health directorate should raise awareness and educate the communities on epilepsy to
reduce stigma. Enhancing nursing education and training on epilepsy by the Ministry of Health and its
agencies is imperative to improving health care delivery for people living with the disease.
Key words: Knowledge, Attitude, Practice, Epilepsy, Asutifi North District
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INTRODUCTION
Epilepsy and psychiatry have historical links. The three ancient Indian medical systems of Siddha,
Ayurveda (Science of life), and Unani all recognized epilepsy [1]. Epilepsy comes from the Greek
word “epilambanein”, which means to be attacked or to be seized [2,3]. In the Arabic language,
the term used for epilepsy is called “Al-Saraa”. The Arab and Muslim scientists like Al-Tabari and
Al-Razi also described epilepsy in their books, thousand years ago, as a disease of the brain,
making a clear distinction between it and the psychiatric disorders, by stating clearly that epilepsy
is not related to evil spirits or supernatural powers [2].
Epilepsy is one of the world’s oldest known brain disorders among several medical conditions
[4,5]. It is the second most commonly seen neurological condition in primary care, and the most
commonly seen among neurologists [13]. A recent study has indicated that 70 million people are
estimated to suffer from this disease [3]. Persons with epilepsy are at risk of developing a variety
of psychological problems including depression, anxiety and psychosis [6,7]. Because epileptic
seizures typically include convulsions, the term convulsion is sometimes used as a synonym for
seizure. However, not all epileptic seizures lead to convulsions, and not all convulsions are caused
by epileptic seizures. The word “fit” is sometimes used to mean a convulsion or epileptic seizure
[8]. Epilepsy as one of the major brain disorders worldwide and should be considered a health care
priority in Africa. It is triggered by abnormal electrical activity in the brain resulting in an
involuntary change in body movement, function, sensation, awareness and behaviour. The
condition is characterized by repeated seizures or “fits” as they are commonly called. These take
many forms ranging from the shortest lapse of attention to severe and frequent convulsions.
Epilepsy is not only a medical condition; it also includes sociological, economical, and cultural
dimensions. [9] Unlike other neurological conditions, epilepsy can be completely controlled in the
majority of cases by medication or surgical procedures [13] as most of the causes of symptomatic
epilepsy are preventable and treatable [9].
In spite of global advances in diagnosis and treatment in recent years, about eight million people
with epilepsy (PWE) in Africa are not treated with modern anti-epileptic drugs [9]. It is also
estimated that 80 percent of the burden of epilepsy is in the developing world, where in some areas
80 to 90 percent of people with epilepsy receive no treatment at all [10]. Many individuals with
epilepsy are perceived by the community as weak, inhuman, dangerous or inferior because of their
symptoms, and as result of the stigma, these people are excluded. But epilepsy is treatable and up
to 70 percent of the seizure can be cured and the risk of reoccurrence is about 25 percent” [11].
Despite the fact that highly effective, low-cost treatments are available, as many as 9 of 10 people
with epilepsy in Africa go untreated. The reasons for the unavailability of treatment include:
inadequate health delivery systems, lack of trained personnel, lack of essential drugs, and
traditional beliefs and practices that often do not consider epilepsy as a treatable condition. This
treatment gap greatly increases the burden of epilepsy and disability [12].
Because there is public fear and misunderstanding about the disorder, it makes many people
unwilling to talk about it. The unwillingness leads to lives lived in the shadows, discrimination in
workplace and communities, and a lack of funding for new therapies research [5]. This is evident
in a report that literate adults in urban population of Ghana are ignorant of the cause of epilepsy.
When quizzed, 172 (45.3%) out of the 380 respondents did not know the cause of epilepsy. Out of
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the 358 responses to the cause of epilepsy, 114 (31.8%) said it was inherited disease, 100 (27.9%)
said it was due to witchcraft/juju or spiritual [14]. A similar study conducted on beliefs on epilepsy
in Northern Ghana highlighted that the most interesting perceived cause of seizures in males is
habouring anal worms, and spirituality a strong notion as a perceived cause. Besides, there is the
belief that spells of epilepsy are cast on women as a form of punishment when they engage in
adultery [16]. It is worth noting that when someone has seizure does not necessarily mean that
person has epilepsy, though. Certain things can sometimes trigger seizures in people with epilepsy.
They include: Flashing or bright lights; A lack of sleep; Overstimulation (like staring at a computer
screen or playing video games for too long); certain medications; and Hyperventilation (breathing
too fast or too deeply). In addition, seizures can be triggered in anyone under certain conditions,
such as life-threatening dehydration or high temperature. But when a person experiences repeated
seizures for no obvious reason, that person is said to have epilepsy [39]. It is therefore important
to make behavioural and psychosocial adjustments with epileptic patients to control seizure and
improve and attain higher quality of life by sticking to medication regimen, having adequate sleep,
good nutrition and reducing stress [40].
In connection with the manifestations of epilepsy, the disease is also referred to as saturation of
the foams in the stomach which overflow and rise to the head, resulting in a seizure [18]. However,
the most common symptoms proffered by most respondents as manifestations of epilepsy include
convulsion, falling down, rolling of eyes, foaming of mouth, urination, and biting of tongue [7,19].
Interestingly, surveys in developing countries with different cultures reveal common beliefs, for
example, that epilepsy is a contagious illness or a kind of mental retardation [20]. Although a lot
of misconceptions about epilepsy exist, it is reported that epilepsy can be spread by contact and
that epileptics must be isolated or avoided [14]. This assertion was supported in a study among
people with epilepsy that indicated 2.2% of the respondents admitted that epilepsy is transmitted
through contacts with epileptic patients [21].
The attitude of a person towards a certain object (person, word, or behavior) can be defined as a
subjective evaluation of this object. The subjective value of an object can be negative, neutral or
positive [24,25]. Though attitude is a complex and abstract construct [26], people suffering from
epilepsy have been discriminated against in several ways [27]. Report from other studies have
shown that people with less awareness and knowledge about epilepsy tend to have negative
attitudes toward the disease and misperceptions such as epilepsy being a form of insanity,
untreatable, contagious, and hereditary or a form of mental retardation. Cultural beliefs,
superstition, and lack of information about epilepsy have perpetuated such misconceptions in
developing countries [28]
In terms of practice on epilepsy, report indicates that about 90% of patients with epilepsy are not
under hospital supervision at any one time; for that matter the role of the general practitioner in
the care of these individuals is important. There is no doubt that community care of people with
epilepsy needs much improvement [31]. Nurses are professionals who play a very important role
in providing coordinated care and education to patient with epilepsy. Since people with epilepsy
receive treatment from primary care providers rather than neurologists, an understanding of the
diagnosis and treatment provide optimal patient care. This is evident by the statement that out of
127 patients who were randomized to a nurse run clinic, 106 (83%) attended the clinic. This was
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attributed to the fact that the nurse was able to identify possible improvements in the drug
management of over a fifth of the patients she saw [33]. Consequently, a study to test patients with
uncontrolled epilepsy has shown that one hundred fourteen adults with epilepsy have a significant
effect in quality of life of patient with epilepsy due to nurse-led intervention programs which
include dissemination of accurate information to the clients, performing epilepsy audit towards
creation of a profile of epilepsy in general practice to improve care, and devising treatment plans
and goals [32]. Therefore, nursing care for patients with epilepsy is a very important issue because
such patients are exposed to many risks and complications. Nurses must take special care to
decrease the risk. The most important nursing intervention is to keep up an adequate airway,
breathing and circulation during seizures and to prevent any injury of the patients with epilepsy.
Also, an oral airway suction apparatus should be available at bedside at all times [34] to reduce
danger whiles optimizing results in the management of the patient [35].
In line with whether epilepsy is treatable or not, approximately one-third of clinical nurses (36.5%)
believed that epilepsy was incurable [30]. This notion is strongly perpetuated by the statement that
some epilepsy cases cannot be cured [36], and a study claimed that epilepsy cannot be cured with
medication arguing that about 3 in 10 people experienced seizures, despite medication [37]. It was
therefore concluded that when seizures persist beyond a certain age, families and health care
personnel placed child in the “sickness sphere,” meaning that the child is incurable and treatment
attempts are futile [38]. However, a survey indicated that 79% of nurses are of the view that
epilepsy can be controlled or cured in this case 25% of the nurses. Regarding the aim of treatment
of epilepsy, it is highlighted that 60% of respondents claimed that medications decrease the
frequency of seizures, and 36.6% opined that epilepsy could wholly be cured [21]. A reported on
the possibility of treatment of epilepsy, both basic (72.73%) and clinical (86.49%) medical
students were of the view that epilepsy can be treated. They share the view that the disease can be
treated in the hospital as indicated by 68.60% of the basic medical students and 87.39% by the
clinical students [17].
An observation made between October and November 2016 at the Asutifi North District Health
Directorate in Brong Ahafo Region of Ghana indicated that among the top 10 diseases in the
district, epilepsy was not captured, and that the district has minimal information on epilepsy. This
was evident by data gathered from the Ghana Health Service (GHS) District Health Information
Management System (DHIMS) which indicated that the Brong Ahafo Region had recorded 17,666
for cases of epilepsy in 2012, with 104 cases of epilepsy for Asutifi South District, but none for
the Asutifi North. In 2013, there was a rise in reported cases of the condition up to 1,888, but a
slight decline in Asutifi South with reported cases being 100. In 2014 and 2015, the number of
reported cases increased to 3,166 and 3,495 respectively, whilst the Asutifi South recorded 128
and 125 within the same period, but none for the Asutifi North Health Directorate. However, there
was a sharp fall in the reported cases of epilepsy in the Region with a figure of 1,377 with the
Asutifi North Health Directorate recording 10 cases from January to June, 2016, and in the same
duration Asutifi South recorded 33 cases [15].
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Despite the increase education and health care, some health professionals continue to linger in
darkness about cause and treatment options of the disease. As efforts to improve care of people
living with epilepsy are a major concern, little has been done to identify the extent of subjective
knowledge, attitude and practice among nurses.
METHODOLOGY
This was a an exploratory cross sectional study on knowledge, attitude and practice of nurses in
epilepsy working in the Asutifi North District in the Brong Ahafo Region of Ghana. The study
population consisted of nurses (both males and females) who have been licensed by the Nursing
and Midwifery Council of Ghana and working in government facilities. The exclusion criteria were
private health facilities, non-trained health professionals and other health professionals without
nursing background, and student nurses on clinical attachment during the period of study in the
district.
Multistage sampling technique was used to select the study participants from the communities. A
standard statistical formula from Rumsey, 2016, was used to arrive at a sample size of 102. The
starting point was randomly selected and a systematic random sampling method was used to select
the study participants.
The research tool used for data collection for this study was a semi-structured questionnaire.
Descriptive statistics, which involves frequencies and percentages, were used in representing data
for the socio-demographic characteristics of all respondents. Besides, responses on other items and
other relevant questions were cross-tabulated. The statistical tool that was used for analyzing the
data was statistics and data, syllabic abbreviated as STATA, version 12.
A bivariate logistic regression analysis was conducted to test the association between independent
variables and outcome variables. In responding to the questionnaire, participants who
demonstrated positive responses on multiple options were operationally categorized into high
knowledge and those with poor responses as having low knowledge of the disease under study.
This was done to see how significant the variables influence the outcomes of the study. This was
also done for attitude and practices on epilepsy as having positive and negative attitude and
practice respectively on their categorizations.
RESULTS
Socio-demographic characteristics
The response rate was 100%. Majority of the nurses 80 (78.43%) were between the ages 21 and
30 years. More than half 75 (73.5%) were females. Concerning religion, 89 (87.3%) were
Christians, eight (7.8%) Muslims and four (3.9%) practiced African Traditional Religion, with
only one (1.0%) belonging to Buddhism. About 40 (39.2%) were Community Health Nurses, while
seven (6.9%) were Registered Midwives, and 29 (28.4%) were Health Assistant Clinical (HAC).
About nine (8.8%) had a close family member with a history of epilepsy. Table 1 depicts the sociodemographic data of the respondents.
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Table 1: Socio-demographic Data of Respondents
Variable
Age
- 21-30
- 31-40
- 41-50
- 51-60
Sex
- Male
- Female
Religion
- Christianity
- Muslim
- African Traditional
- Others
Specialized Area
- RGN
- RMN
- RM
- CHN
- Others
Close Family with Epilepsy
- Yes
- No
Source: Field data (2017)
Frequency
(102)
Percentage
(100%)
80
14
5
3
78.43
13.73
4.90
2.94
27
75
26.5
73.5
89
8
4
1
87.3
7.8
3.9
1.0
15
11
7
40
29
14.7
10.8
6.9
39.2
28.4
9
93
8.8
91.2
Knowledge of factors contributing to the development of epilepsy
Table 2 below shows the result of respondents’ knowledge on factors contributing to the
development of epilepsy. The results of the perceived causes of epilepsy showed that 48.0% of the
nurses associated birth trauma to be the cause of epilepsy which is correct response. In terms of
hereditary, 22.5% of the respondent gave their accent to it which is a wrong response, whilst 13.7%
of the respondents attributed the onset of the disease to brain injury which they were right. Though
the same number of the nurses indicated witchcraft as the perceived cause of epilepsy, they were
wrong with that notion. Notwithstanding the perceived causes of epilepsy, the result of the data
indicated that 57.8% of the respondents agreed that convulsion contribute to the development of
epilepsy, 21.6% of the respondents agreed that high body temperature contribute to the
development of epilepsy whilst 14.7% of the respondents concurred malaria as a contributing
factor to the development of epilepsy. It is worth noting that all those responses given by the nurses
were all correct. In connection with maternal factors, the result showed that 68.6% of the
respondents agreed that maternal alcohol consumption is a risk factor in epilepsy, 64.7% of the
respondents agreed that malnutrition is a risk factor in epilepsy, 49.0% of the respondents were in
accord that drug use is a risk factor in epilepsy, while only a few 23.6% of the nurses knew maternal
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age above 30 years to be a risk factor for developing epilepsy. The above responses given by the
nurses on the maternal risk factors to the development of epilepsy were all right.
Critical assessment of the maternal risk factors led to the ascertainment of some activities that
sometimes trigger seizure in people with epilepsy. Out of the 102 respondents, 8.8% nurses said
“Yes” staring at TV/Computer screen for too long could trigger seizure. Besides, 36.3% of the
nurses cited Stress as a triggering factor. In terms of breathing too fast/deeply could trigger seizure
in PWE, 3.9% of the nurses accented to that fact. More so, 12.7% of the nurses claimed Flashing
or bright light could trigger seizure, 45.1% of them identified lack of sleep as a contributory factor
that could trigger seizure in PWE. The responses given by the few nurses on this variable were all
correct.
Data collected on the manifestation of epilepsy from the nurses depicted that out of the 102
respondents, 31.4% of the nurses said “Yes” to Shrill cry (Shouting) as a clinical feature of
epilepsy. In addition, 49.0% of the respondents indicated positive to loss of consciousness. Whilst
falling down was accepted by 48.0% nurses as a manifestation of epilepsy, majority 60.8% of the
nurses claimed jerking of the body as the cardinal manifestation of epilepsy, and Rolling of the
eyes was accepted by 30.4% of the nurses, and 45.1% of the respondents said “Yes” to foaming
of the mouth. When it came to the biting of the tongue as a manifestation of epilepsy, 30.4%
(31/102) of the nurses affirmed it as a clinical feature; urination was mentioned by 23.5% of the
respondents. Few 15.7% of the nurses responded “Yes” to abnormal behaviour as a manifestation.
A critical assessment of the findings on manifestations of epilepsy from the respondents depicted
that the responses afore-given were all right. It was deduced from the data that majority of the
nurses do not know the clinical features of the disease. This is evident from the negative responses
cited by the majority of the respondents. However, the manifestations serve as indicators in
monitoring people with epilepsy so that urgent or immediate attention could be given to PWE.
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Table 2: Knowledge of respondents on factors contributing to the development
of epilepsy
Factors contributing to the Development of
Response rate (N=102)
Epilepsy
Correct (%)
Wrong (%)
Perceived causal factors
- Curse
- Hereditary
- Brain injury
- Witchcraft
- Birth trauma
- Spiritually possessed
- Brain infection
- Poison/Bad blood
Personal factors
- Convulsion
- High temperature
- Malaria
- Parasitic infections
- Others factors
Maternal factors in epilepsy
- Maternal alcohol
- Malnutrition
- Drug use
- Maternal age >30 years
Triggering factors
- Lack of sleep
- Stress
- Flashing/Bright light
- Staring at screen for long
- Breathing too fast
Manifestation of Epilepsy
- Jerking of the body
- Loss of consciousness
- Falling down
- Foaming of the mouth
- Shrill cry (Shouting)
- Rolling of the eye
- Biting of tongue
- Urination
- Abnormal behaviour
Source: Field data (2017)
50
95 (93.1%)
79 (77.5%)
14 (13.7%)
88 (86.3%)
49 (48.0%)
90 (88.2%)
10 (9.8%)
96 (94.1%)
7 (6.9%)
23 (22.5%)
88 (86.3%)
14 (13.7%)
53 (52.0%)
12 (11.8%)
92 (90.2%)
6 (5.9%)
59 (57.8%)
22 (21.6%)
15 (14.7%)
9 (8.8%)
4 (3.9%)
43 (42.2%)
80 (78.4%)
87 (85.3%)
93 (91.2%)
98 (96.1%)
70 (68.6%)
66 (64.7%)
50 (49.0%)
24 (23.6%)
32 (31.4%)
36 (35.3%)
52 (52.0%)
78 (76.4%)
46 (45.1%)
37 (36.3%)
13 (12.7%)
9 (8.8%)
4 (3.9%)
56 (54.9%)
65 (63.7%)
89 (87.3%)
93 (91.2%)
98 (96.1%)
62 (60.8%)
50 (49.0%)
49 (48.0%)
46 (45.1%)
32 (31.4%)
31 (30.4%)
31 (30.4%)
24 (23.5%)
16 (15.7%)
40 (39.2%)
52 (51.0%)
53 (52.0%)
56 (54.9%)
70 (68.6%)
71 (69.6%)
71 (69.6%)
78 (76.5%)
86 (84.3%)
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Categorization of level of knowledge on epilepsy
Participants who scored 16 correct or more out of the 31 items on the knowledge of factors
contributing to the development of epilepsy were operationally labelled as having “high”
knowledge and those who scored less or equal to 15 seen as having “low” knowledge. This is
shown in table 3 below.
Table 3: Level of knowledge of participants
Level of knowledge
Frequency
Percentage
(N=102)
(100%)
41
40.2
- High
61
59.8
- Low
Source: Field data (2017)
The categorization indicates that majority, 59.8% (61/102) of the nurses were less knowledgeable
on the epilepsy.
Nurses’ attitude towards People with Epilepsy
Since the nurses’ attitude could influence their practice towards the disease, it was important to
assess the nurses’ position towards epilepsy. In terms of PWE having the same intelligence as nonepileptics, out of the 102 respondents, 34.3% supported that idea. About 8.8% respondents were
of the view that PWE could have the same employment as the general public do. When it came to
relationship, 6.9% of the nurses said they would have amorous relationship with PWE for which
they were also right in their responses, and 17.6% of the nurses do not suspect PWE to have mental
illness.
Ways of transmission of epilepsy
Results on this item showed clearly that out of the 102 study participants, majority responded in
the negative to the items given on the questionnaire, which they were all correct. In terms of Urine,
99.0% answered “No,” likewise response for Flatus (97.1%) and Faeces (95.1%). In connection
with Marriage, majority (91.2%) opted “No,” and the same negative response for Physical contact
(89.2%) and Sharing of food (85.3%) respectively. Furthermore, results on this item indicated that
95.1% (97/102) of the nurses responded “No,” meaning that breathe of epileptic patient is not
infectious. Also, 97.1% (99/102) of the nurses responded “No” the droppings of animals cannot
spread epilepsy. Notwithstanding, none of the respondents could mention any animal(s) whose
droppings can spread epilepsy. Furthermore, 97.1% (99/102) of the respondents disclaimed that
coming in contact with the excretions (body fluids) from PWE can be infectious. It was observed
from the data that all the nurses (100%) agreed to the fact that saliva could not be a way of
transmission of epilepsy. It was observed from the result that respondents disclaimed, denied and
refuted the fact that epilepsy is neither an air-borne disease, nor an animal dropping transmitted
disease, and is not contagious through the excretion of body fluids. The detail result of the attitude
towards epilepsy is in Table 4.
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Attitude
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Table 4: Attitude towards epilepsy
Response rate (N=102)
Correct (%) Wrong (%)
Nurses attitude towards PWE
- Have same intelligence
- Have same employment
- Amorous relationship
- Suspicion of mental illness
Ways of transmission
- Urine
- Flatus
- Animal dropping
- Excretions/body fluids
- Breath from epileptics
- Faeces
- Marriage
- Physical contact
- Sharing of food
- Saliva
Source: Field data (2017)
35 (34.3%)
9 (8.8%)
7 (6.9%)
18 (17.6%)
67 (65.7%)
93 (91.2%)
95 (93.1%)
84 (82.4%)
101 (99.0%)
99 (97.1%)
99 (97.1%)
99 (97.1%)
97 (95.1%)
97 (95.1%)
93 (91.2%)
91 (89.2%)
87 (85.3%)
102 (100.0%)
1 (1.0%)
3 (2.9%)
3 (2.9%)
3 (2.9%)
5 (4.9%)
5 (4.9%)
9 (8.8%)
11 (10.8%)
15 (14.7%)
0 (0.0%)
Categorization of attitude towards epilepsy
Attitude towards epilepsy was operationally classified into positive and negative attitudes.
Respondents who had three appropriate responses on the attitude were seen as having “positive”
attitude towards epilepsy, and those who had four or more inappropriate responses were thus
classified as having “negative” attitude towards epilepsy. The table 5 below highlights on the
attitude categorization.
Table 5: Categorization of attitude towards epilepsy
Attitude
Frequency (N=102)
Percentage (100%)
-
Positive
72
70.6
-
Negative
30
29.4
Source: Field data (2017)
Looking at the categorization above, it is clear that 70.6% (70/102) of the nurses have positive
attitude towards PWE.
However, when the nurses’ behaviour was tested with knowledge on epilepsy, no statistical
significance was observed (p=0.120). More so, when the attitude was cross-tabulated with
knowledge on epilepsy, there was no statistical association between them (p=0.192). When the
attitude was observed in connection with practices on epilepsy, a significant difference was
observed for positive attitude (p=0.008). Table 6 below throws light on it.
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Table 6: Attitude and practices on epilepsy
Attitude
Practices on epilepsy
p-value
Good (N=48)
Poor (N=54)
(100%)
(100%)
- Positive
40 (83.3%)
32 (59.3%)
0.008*
- Negative
8 (16.7%)
22 (40.7%)
(*)=p is statistically significant based on chi square analysis
Source: Field data (2017)
Practices on Epilepsy
This covers items such as what to do when seizures occurs, counselling nurses offer to PWE, and
the preferred choice for the treatment of epilepsy. When the skills of the nurses were assessed on
managing epilepsy during the attack, out of the 102 respondents for the study, majority (87.3%)
said they “No” they would not keep/run away in the face of epileptic crisis, 81.4% also indicated
same response that they would not touch the patient, and most said “Yes” to performing first aid
measures (68.6%). All the above responses were correct. In terms of counselling the patient, the
responses of the study participants were all in the affirmative for which they were right. Avoid
heights was positively indicated by 24.5% of the participants, Avoid alcohol (32.4%), Take drugs
as prescribed (26.5%), Regular exercise (10.8%), and Get plenty of sleep (14.7%).
In the case of preferred choice for treatment, with the exception of Orthodox medicine which the
respondents answered “Yes” for 66.7% (68/102) of the nurses and they were right, the rests of the
responses were all in the negative for which the study participants were also correct for their
answers. For those who said they would not encourage Prayer camp healing were 80.4%,
Traditional/herbal treatment (50.8%), Fetish healing (85.3%) and Animal sacrifice (93.1%).
Despite the fact that epilepsy is treatable, their choice of treatment for epilepsy was against the
religiospiritual domain. Table 4 highlights the details of the practices on epilepsy.
The fact that some of the nurses complained of lack of supply of anticonvulsants or antiepileptic
agents (AEDs) from the district medical store, some of the agents mentioned in the management
of epilepsy in their facilities or clinics include Phenobarbitone 34.3% (35/102), Diazepam 19.6%
(20/102), Carbamazepine 14.7% (15/102) and Phenytoin 24.5% (25/102) among other drugs. It is
therefore worth mentioning that at least the respondents were aware of some of the
anticonvulsants/antiepileptics. Therefore, managing cases of seizure attacks in their communities
should not be a problem.
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Table 7: Practices on Epilepsy
Practices
Response rate (N=102)
Correct (%)
Wrong (%)
What to do when seizure occurs
- Keep/Run away
- Touching patient
- Perform first aid measures
Counselling to patient
- Avoid heights
- Avoid alcohol
- Take drugs as prescribed
- Regular exercise
- Get plenty of sleep
Preferred choice for treatment
- Prayer camp healing
- Traditional/herbal
- Fetish healing
- Animal sacrifice
- Orthodox medicine
Drugs used in the treatment
- Phenobarbitone
- Diazepam
- Carbamazepine
- Phenytoin
- Other drugs
Source: Field data (2017)
89 (87.3%)
83 (81.4%)
70 (68.6%)
13 (12.7%)
19 (18.6%)
32 (31.4%)
26 (24.5%)
33 (32.4%)
27 (26.5%)
11 (10.8%)
15 (14.7%)
76 (74.5%)
69 (67.7%)
75 (73.5%)
91 (89.2%)
87 (85.3%)
82 (80.4%)
61 (50.8%)
87 (85.3%)
95 (93.1%)
68 (66.7%)
20 (19.6%)
41 (40.2%)
15 (14.7%)
7 (6.9%)
34 (33.3%)
35 (34.3%)
20 (19.6%)
15 (14.7%)
25 (24.5%)
7 (6.9%)
-
Categorization of practices on epilepsy
On the practices on epilepsy, participants who had nine or more appropriate (correct) responses
out of the 18 items were operationally labelled as having “good” practices, and those who scored
from one to eight were operationally categorised as having “poor” practices. This is shown in table
8 below.
Table 8: Level of practices on epilepsy
Practice
- Good
- Poor
Source: Field data (2017)
Frequency (N=102)
48
54
Percentage (100%)
47.1
52.9
Analysis from the table above indicates that more than half 52.9% (54/102) of the nurses had poor
practices on epilepsy.
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Bivariate Analyses
These analyses were carried out to see the strength of the independent variables as against the
dependent variables to ascertain their statistical significance to the study. When the sociodemographic characteristics was cross-tabulated with knowledge of epilepsy, a significant
difference was observed among religion (p=0.017), specialty area (p=0.045), and close family
relationship with epilepsy (p=0.001). This is shown in Table 9. More so, when the sociodemographic characteristics was cross-tabulated with practice on epilepsy, area of specialty
(RMN) (p=0.001) appeared statistically significant. This is also indicated in table 10.
Table 9: Socio-demographic factors and knowledge on epilepsy
Variable
Knowledge on epilepsy
High (N=41)
Low (N=61)
(100%)
(100%)
p-value
Age
30 (73.3%)
50 (82.0%)
- 21 – 30 years
7 (17.1%)
10 (16.4%)
0.234
- 31 – 40 years
2 (4.8%)
1 (1.6%)
- 41 – 50 years
2 (4.8%)
0 (0.0%)
- 51 – 60 years
Sex
6 (14.6%)
7 (11.5%)
0.133
- Male
35 (85.4%)
54 (88.5%)
- Female
Religion
30 (73.2%)
53 (86.9%)
- Christianity
7 (17.1%)
5 (8.2%)
0.017*
- Muslim
4
(9.7%)
0
(0.0%)
- Traditionalist
0 (0.0%)
3 (4.9%)
- Others
Speciality area
4 (9.8%)
5 (8.2%)
- RGN
2 (4.9%)
0 (0.0%)
0.045*
- RMN
3 (7.3%)
0 (0.0%)
- RM
16 (39.0%)
36 (59.0%)
- CHN
16 (39.0%)
20 (32.8%)
- Others
Close family
relationship with
epilepsy
8 (12.2%)
1 (8.2%)
0.001*
- Yes
34 (87.8%)
56 (91.8%)
- No
(*)=p is statistically significant based on chi square analysis
Source: Field data (2017)
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Table 10: Socio-demographic factors and practices
Variable
Practices on epilepsy
p-value
Good (N=48)
Poor (N=54)
(100%)
(100%)
Age
34 (70.8%)
47 (87.0%)
0.192
- 21 – 30 years
8 (16.6%)
6 (11.1%)
- 31 – 40 years
3
(6.3%)
1 (1.9%)
- 41 – 50 years
3 (6.3%)
0 (0.0%)
- 51 – 60 years
Sex
13 (14.6%)
6 (13.04%)
0.189
- Male
43 (85.4%)
40 (87.0%)
- Female
Religion
44 (73.2%)
38 (82.6%)
0.065
- Christianity
8 (17.1%)
5 (10.9%)
- Muslim
4 (9.7%)
0 (0.0%)
- Traditionalist
0 (0.0%)
3 (6.5%)
- Others
Speciality area
9 (16.2%)
5 (10.9%)
- RGN
6 (10.7%)
0 (0.0%)
0.001*
- RMN
5
(8.9%)
0
(0.0%)
- RM
18 (32.1%)
31 (67.4%)
- CHN
18 (32.1%)
10 (21.7%)
- Others
Close family
relationship with
epilepsy
12 (21.4%)
6 (13.0%)
0.269
- Yes
44 (78.6%)
40 (87.0%)
- No
(*)=p is statistically significant based on chi square analysis
Source: Field data (2017)
Knowledge on epilepsy and practices
This section looks at the strengths of association between practices on epilepsy among other
independent variables. Their statistical significance is determined by their p-values (p<0.050).
When the strength of knowledge on epilepsy was associated with practices on epilepsy based on
the categorisation, no significant difference was observed. This is indicated in table 11 below. As
shown in table 12, none of the independent variables under practices on epilepsy showed a
statistical significance with knowledge on epilepsy.
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Table 11: Knowledge and practices on epilepsy
Knowledge on
epilepsy
Practice
Good (N=48)
Poor (N=54)
(100%)
(100%)
- High
23 (47.9%)
18 (33.3%)
- Low
25 (52.1%)
36 (66.7%)
Source: Field data (2017)
p-value
0.134
Table 12: Practices and knowledge on epilepsy
Variable
Knowledge on epilepsy
High (N=41)
Low (N=61)
(100%)
(100%)
What do you do when seizure occurs?
Keep/Run away
- Yes
4 (9.8%)
9 (14.8%)
- No
37 (90.2%)
52 (85.2%)
Not touching the
person
- Yes
10 (24.4%)
6 (9.8%)
- No
31 (75.6%)
55 (90.2%)
Perform first-aid
measures
27 (65.9%)
47 (77.0%)
- Yes
14 (34.1%)
14 (23.0%)
- No
Counselling a person with epilepsy
Avoid heights
8 (19.5%)
23 (37.7%)
- Yes
33 (80.5%)
38 (62.3%)
- No
Avoid alcohol
28 (68.3%)
38 (62.3%)
- Yes
13
(31.7%)
23 (37.7%)
- No
Take drug as
prescribed
11 (26.8%)
14 (23.0%)
- Yes
30 (73.2%)
47 (77.0%)
- No
Regular exercise
7 (17.1%)
6(9.8%)
- Yes
34 (82.9%)
55 (90.2%)
- No
Get plenty of sleep
5 (12.2%)
9(14.8%)
- Yes
36 (87.8%)
52 (85.2%)
- No
p-value
0.583
0.087
0.310
0.057
0.426
0.837
0.288
0.801
Source: Field data (2017)
When knowledge on epilepsy was associated with preferred treatment for epilepsy, no significant
association was observed. Table 13 gives the highlights of the association.
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Table 13: Knowledge on epilepsy and Preferred treatment
Variable
Knowledge on epilepsy
p-value
High (N=41)
Low (N=61)
(100%)
(100%)
Preferred choice of
treatment
Payer camp healing
- Yes
6 (14.6%)
12 (19.7%)
0.504
- No
35 (85.4%)
49 (80.3%)
Traditional/Herbal
medicine
- Yes
15 (36.6%)
27 (44.3%)
0.470
- No
26 (63.4%)
34 (55.7%)
Orthodox medicine
- Yes
8 (19.5%)
5 (8.2%)
0.407
- No
33 (80.5%)
56 (91.8%)
Fetish healing
- Yes
3 (7.3%)
4 (6.6%)
0.602
- No
48 (92.7%)
57 (93.4%)
Animal sacrifice
- Yes
0 (0.0%)
3 (4.9%)
0.926
- No
41 (100.0%)
58 (95.1%)
Source: Field data (2017)
DISCUSSION
This study assessed the knowledge, attitude and practice regarding epilepsy among nurses in
Asutifi North District in the Brong Ahafo Region of Ghana.
The knowledge of the study participants on epilepsy regarding the causes in the development of
epilepsy was analyzed. The results on knowing the cause of epilepsy indicated that a majority 69
(67.7%) of the nurses responded ‘Yes’ knowing the causes of epilepsy whilst 33 (32.4%) said
‘No’. This implies that majority of the nurses have basic knowledge about the causes of epilepsy.
This assertion was in sharp contrast to a study in Ghana that indicated 172 (45.3%) of the
respondents did not know the cause of epilepsy among literate adults in urban population, saying
they are ignorant of the cause of the disease [14].
On the perceived causes of epilepsy, 49 (48.0%) of the nurses associated birth trauma to be the
cause of epilepsy, 25 (24.5%) knew of brain injury, 23 (22.6%) claimed hereditary as a cause of
epilepsy whilst 10 (9.8%) of the nurses said brain infection is also a cause of epilepsy. However,
14 (13.7%) of the respondents attributed witchcraft to be the cause of epilepsy, spiritual possession
accounting for 12 (11.8%) of the respondents, few 7 (6.7%) of the respondents said it is caused by
curses and 6 (5.9%) also said epilepsy could be caused by poisoning or bad blood. This result is in
harmony with other studies conducted in Ghana [14,16] and Uyo, Southern Nigeria [17]. It can be
deduced that the causes of epilepsy within the Asutifi North District are categorized into
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physiological and cultural superstitious causes of the disorder. Specifically, the physiological
causes took the form of brain injury, birth trauma and brain infection whilst the cultural
superstitious causes also manifested through curse, heredity, spiritual possession and poisoning or
bad blood. When knowledge on epilepsy was associated with socio-demographic characteristics,
a significant difference was observed among Muslim religion (p=0.017), specialty area (RMN)
(p=0.045) and close family relationship with epilepsy (p=0.001).
When factors that could trigger seizure in people with epilepsy were assessed, 46 (45.1%) of nurses
identified lack of sleep as a contributory factor that could trigger seizure in epileptic patients, 37
(36.3%) cited stress whilst 4 (3.9%) attributed fast breathing to trigger seizure in epileptic patients
with few 9 (8.8%) affirming staring at computer screen for too long. This result is indicating that
majority of the nurses did not know what could trigger seizure in people living with epilepsy as
most of their responses were in the negative. However, seizures could be triggered in anyone under
certain conditions such as life-threatening dehydration or high temperature among other factors
[39].
Regarding manifestation of epilepsy, 62 (60.8%) nurses said jerking of the body is a manifestation
of epilepsy, followed by loss of consciousness 50 (49.0%); 46 (45.1%) of nurses knew foaming of
the mouth as a manifestation of epilepsy; 49 (48.0%) knew falling down to be a manifestation of
epilepsy, while shouting was described by 32 (31.4%) nurses as manifestation of epilepsy. 31
(30.4%) of respondents identified rolling of the eye and tongue biting as manifestation of epilepsy,
24 (23.5%) respondents said urination is manifestation of epilepsy with only a few 16 (15.7%)
respondents associating abnormal behaviour to epilepsy. The few who responded in the affirmative
result was in consonance with other studies that cited responses such as convulsion, falling down,
rolling of eyes, foaming of mouth, urination, and biting of tongue as manifestations of epileptic
attack [7,19]. This indicates that majority of the nurses did not the manifestations of epilepsy.
Though majority of the nurses did not consent to this notion of transmission of the disease, the few
15 (14.7%) respondents perceived sharing of food could possibly transmit epilepsy, and 11
(10.8%) nurses said physical contact with a patient can facilitate transmission of the disease whilst
9 (8.8%) respondents said it could be transmitted through marital union. On other ways of
transmission of the disease, 5 (4.9%) indicated breath from an epileptic patient is infectious,
3(2.9%) said animal dropping and contact with excretions respectively from epileptic patients
could spread the disease. This result confirms other studies where respondents were of the view
that epilepsy is contagious and could be spread through contact (physical), saliva, blood, urine,
and faeces/flatus [14,21,17,22,23].
In terms of amorous relationship, 95 (93.1%) of the respondents posited that they will not engage
themselves in amorous relationship with a person with epilepsy. It was reported that 44.8 percent
of respondents refused to marry people with epilepsy [41]. This is in consistent with the findings
of this research report. In support of the findings of this research, it has been reported that
approximately 25 percent of health care workers would not allow their child to marry someone
with epilepsy and 20 percent thought people with epilepsy should not marry [43].
In sharp contrast to the findings of this study, epilepsy does not appear to be a major stress factor
in marriage as long as the spouse is knowledgeable about the condition. Such couples often exhibit
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a greater degree of mutual concern and support [46]. In support of the counter argument, it has
also been indicated that 85.1 percent of their respondents approved marrying an epileptic [29].
When attitude towards epilepsy was associated with the socio-demographic characteristics to
determine its influence, a significant difference was observed among sex (female) (p=0.037),
religion (Muslim) (p=0.012), and specialty area (RMN) (p=0.054), and there was no statistical
significance on how age and close family relationship with epilepsy influence knowledge on the
disease.
However, 84 (82.4%) of the nurses suspect epileptic people to have mental illness. In tune with
the result from this analysis, a cited report has argued that 10 percent of respondents equated
epilepsy with insanity [42]. More so, report from other studies have shown that people with less
awareness and knowledge about epilepsy tend to have negative attitudes toward the disease and
misperceptions such as epilepsy being a form of insanity [28]. It is obvious from the discussions
on this issue of suspicion of mental illness that majority of the nurses for this study associate
epilepsy with mental illness and this points to lack of knowledge of the disease. In sharp contrast
to the findings of this research is the revelation that the highly educated did not view epileptics as
not mentally sick persons [14].
Data from this study further stressed that 67 (65.7%) of the respondents agreed that people with
epilepsy do not have the same intellectual capabilities as the general public. In affirming the
findings of this research, people with mild to moderate intellectual disability (ID) lifetime epilepsy
have been reported to have prevalence at between six and 15 percent. In those with severe ID
epilepsy occurs in around 25 percent whilst in those with profound ID (IQ<20) [44]. These findings
show a strong correlation between epilepsy and intellectual capabilities of PWE. However, there
is a disagreement with the findings of this research as it is purported that most people with epilepsy
do not have intellectual disabilities [45]. By endorsement of this view, it is published in a study
that 60 (88.23%) of their respondents support the idea that persons with epilepsy can have
university education [28].
In connection with employment, nine (8.8%) of respondents were of the view that persons with
epilepsy be employed in the same job as other people, with majority 93 (91.2%) saying “No”.
Deductions from this data showed that the nurses have poor attitude towards PWE as this is evident
by their utmost responses given that epileptic people have psychological deficiencies, mental
disorders and behaviour leading to a deficiency in their intellectual abilities, and for that matter
cannot be employed in the same job as other people. A statement confirmed this assertion in this
research by saying that persons with epilepsy are shunned and discriminated against in
employment in Africa because epilepsy is seen as a highly contagious and shameful disease in the
eyes of the public [7]. A similar finding in a study has estimated 25 percent of their respondents
reported that people with epilepsy cannot work like others [22]. Notwithstanding, a publication
contradicts this study where it is observed in that study that the majority of the respondents would
offer a job (90.4%) [29]. In defense of this notion is a publication in a study that 57 (86.36%) of
their respondents believe that persons with epilepsy can get opportunities of appropriate
occupation [28].
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Due to the training nurses have gone through, 70 (68.6%) of the nurses responded that they will
perform recommended first-aid measures on epileptic person when seizure occurs, 19 (18.6%) of
the nurses responded that they will not touch the patient whilst 13 (12.8%) of the nurses responded
that they will keep/run away for fear of the attack. For the nurses who claimed they will perform
recommended first-aid measures, 54 (77.1%) of them said they will reassure the patient that he or
she will be well and refer him or her for appropriate medical treatment, whilst 16 (22.9%) after the
recommended first-aid is given they will clean the person up and ask him to continue his or her
journey. This result is not far from a description that portrays that the most important nursing
intervention is to keep up an adequate airway, breathing and circulation during sei¬zures and to
prevent any injury of the patients with epilepsy. Besides, an oral airway suction apparatus should
be available at bedside at all times [34] to reduce danger whiles optimizing results in the
management of the patient [35].
CONCLUSION
Nurses at the Asutifi North District tended to have low knowledge, positive attitude and poor
practices on epilepsy. This is because there still exist cultural beliefs among some of the
respondents on the spread of the disease as heredity, spiritual possession and curse. These serve as
a drawback to the positive attitudes shown towards epilepsy. It is therefore important to improve
training and health care delivery for epilepsy.
RECOMMENDATION
The Ghana Health Service in collaboration with the Ministry of Health should run intermediary
workshops, at least every six months, to train nurses in epilepsy diagnoses to reduce the treatment
gap. The health directorate of the district should raise awareness and educate the communities on
epilepsy. Enhancing nursing education and training on epilepsy by the Ministry of Health and its
agencies is imperative to improving health care delivery for people living with the disease. Health
education and promotion programs should be geared towards destigmatizing epilepsy among
health professionals and the general public.
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from http://www.eajournals.org/wp-content/uploads/Public-Attitude-and-Social-Supporttowards-People-Living-With-Epilepsy-PWE-Amongst-Communities.pdf.
25. World Health Organization. World Health Report (2007). Mental health: New
understanding, new hope. Geneva: WHO.
26. Al-Hashemi, E., Ashkanani, A., Al-Qattan, H., Mahmoud, A., Al-Kabbani, M., Al-Juhaidli,
A., Jaafar, A., & Al-Hashemi, Z. (2016). Knowledge about epilepsy and attitudes toward
students with epilepsy among middle and high school teachers in Kuwait. International
Journal of Pediatrics, Volume 2016, Article ID 5138952, 15 pages. doi:
http://dx.doi.org/10.1155/2016/5138952.
27. Ghanean, H., Nojomi, M., & Jacobsson, L. (2013). Public awareness and attitudes towards
epilepsy in Tehran, Iran. Global Health Action, 6(1), 21618. doi: 10.3402/gha.v6i0.21618.
doi: https://doi.org/10.3402/gha.v6i0.21618.
28. Karimi, N., & Akbarian, S. A. (2016). Knowledge and attitude toward epilepsy of close
family members of people with epilepsy in North of Iran. Advances in Medicine, Volume
2016, Article ID 8672853, 6 pages. doi: http://dx.doi.org/10.1155/2016/8672853.
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29. Falavigna, A., Teles, A. R., Roxo, M. R. R., Velho, M. C., da Silva, R. C., Mazzocchin, T., &
Vedana, V. M. (March, 2009). Awareness and attitudes on epilepsy among undergraduate
health care students in Southern Brazil. Journal of Epilepsy Clinical Neurophysiology,
15(1):19-23. doi: http://dx.doi.org/10.1590/S1676-26492009000100005. Retrieved January
20, 2018 from http://www.scielo.br/scielo.php?script=sci_arttext&pid=S167626492009000100005.
30. Dayapoğlu, N., &Tan, M. (August, 2016). Clinical nurses’ knowledge and attitudes toward
patients with epilepsy. Epilepsy and Behaviour, 61: pages 206-209. doi:
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31. Thapar, A. K. (January, 1996). Care of patient with epilepsy in the community: Will new
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33. Ridsdale, L., Robins, D., Williams, H., & Cryer, C. (1997). Feasibility and effects of nurse
run clinics for patients with epilepsy in general practice: randomised controlled trial. British
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34. Shehata, G. A., El-Lateef, Z. A., Ghanem, H. M., & El-Masry, M. A. (2015). Knowledge,
attitude and practice regarding people with epilepsy among nurses. Aktualności
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families and health care personnel toward children with epilepsy in Kilifi, Kenya. Epilepsy
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39. Goodman, M. H. (Ed.). (2004). What causes seizures? The triggering factor. New York:
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management process for epileptic patients: A qualitative study. Iranian Journal of Nursing
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PMC4776561.
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related to epilepsy: a community-based study. Neuropsychiatric Disease and Treatment, 11,
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42. Mustapha, A. F., Odu, O. O., & Akande, O. (2013). Knowledge, attitudes and perceptions of
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43. Chomba, E. N., Haworth, A., Atadzhanove, M., Mbewed, E., & Birbeck, G. L. (February,
2007). Zambian health care workers’ knowledge, attitudes, beliefs, and practices regarding
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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2153557/pdf/canfamphys00227-0109.pdf.
65
KNOWLEDGE AND ATTITUDE REGARDING
EPILEPSY AMONG NURSES IN ASUTIFI
NORTH DISTRICT
Richard Opoku Asare
Akwasi Boakye
Paul Armah Aryee
European Journal of Health Sciences
ISSN 2520-4645 (online)
Vol.5, Issue1 No.2, pp 12-32, 2020
www.ajpojournals.org
KNOWLEDGE AND ATTITUDE REGARDING EPILEPSY AMONG NURSES IN
ASUTIFI NORTH DISTRICT
Richard Opoku Asare1
MPhil, BEd, RN (Dip)-RMN, Cert.Ed.
College of Nursing, Ntotroso
Corresponding Author’s Email: asareor@gmail.com
Akwasi Boakye2
MSc, BSc
Department of Public Health, School of Allied Health Sciences
University for Development Studies
Tamale, Ghana
Paul Armah Aryee3
PhD, MPhil, MMEdSc, BSc
Department of Public Health, School of Allied Health Sciences
University for Development Studies
Tamale, Ghana
ABSTRACT
Background: Epilepsy is one of the world’s oldest known brain disorders among several medical
conditions. A recent study has indicated that 70 million people are estimated to suffer from this disease.
Despite the increase education and health care, some health professionals continue to linger in darkness
about cause and treatment options of the disease.
Purpose. The main objective of this study was to assess the knowledge and attitude regarding epilepsy
among nurses within the Asutifi North District with the aim of understanding their subjective experiences
and knowledge on epilepsy in a socio-cultural context and how their attitude shaped their practice towards
people with epilepsy.
Methodology. The study employed an exploratory descriptive cross-sectional design with 102 participants
using a standard statistical formula. Data was collected using a paper based semi-structured selfadministered questionnaire and analysis was by STATA version 12.
Results. Findings showed that 67.7% (69/102) of the nurses were aware of the causes of epilepsy whereas
59.8% have low level of knowledge on the disease. Results indicated that 82.4% of the nurses suspect PWE
have mental illness, 70.6% of the nurses had positive attitude towards epilepsy. The socio-demographic
characteristics of religion (Muslim) (p=0.017), area of speciality (RMN) (p=0.045) as well as close family
relationship with epilepsy (p=0.001) were significantly associated with knowledge on epilepsy. Factors that
were found to influence attitude towards epilepsy were sex (Female) (p=0.037) and religion (Muslim)
(p=0.012). However, specialty area (RMN) (p=0.054) did not statistically impact on the study. Nurses at
the Asutifi North District therefore tended to have low knowledge and positive attitude on epilepsy. It is
important to improve training and health care delivery for epilepsy.
Recommendation. The Ghana Health Service in collaboration with the Ministry of Health should run
intermediary workshops, at least every six months, to train nurses in epilepsy diagnoses to reduce the
treatment gap. The health directorate should raise awareness and educate the communities on epilepsy to
reduce stigma. Enhancing nursing education and training on epilepsy by the Ministry of Health and its
agencies is imperative to improving health care delivery for people living with the disease.
Key words: Nurses knowledge, Attitude, Epilepsy, Asutifi North District
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INTRODUCTION
Epilepsy and psychiatry have historical links. The three ancient Indian medical systems of Siddha,
Ayurveda (Science of life), and Unani all recognized epilepsy.[1] Epilepsy comes from the Greek
word “epilambanein”, which means to be attacked or to be seized.[2,3] In the Arabic language, the
term used for epilepsy is called “Al-Saraa”. The Arab and Muslim scientists like Al-Tabari and
Al-Razi also described epilepsy in their books, thousand years ago, as a disease of the brain,
making a clear distinction between it and the psychiatric disorders, by stating clearly that epilepsy
is not related to evil spirits or supernatural powers.[2]
A study in Ghana indicated that 172 (45.3%) of the respondents did not know the cause of epilepsy
among literate adults in urban population, saying they are ignorant of the cause of the disease.[19]
Concerning the aetiology of epilepsy, responses identified among medical students in Uyo,
Southern Nigeria showed that 18 (14.88%) of the basic students and six (5.41%) of the clinical
students were positive that epilepsy was caused by evil spirits. Eleven (9.09%) of the basic students
compared to six (5.41%) of the clinical students believe that epilepsy was caused by witches. Ten
of the basic students as against only three (2.70%) of the clinical students identified palm oil as a
cause. In relation to trauma as the cause of epilepsy, only 54 (44.63%) of the preclinical students
were in the affirmative as against a whopping 92 (82.88%) of the clinical students. The result
further added that a large number of clinical students 95 (85.59%) know that birth injuries can
cause epilepsy as against 54 (47.11%) of the basic students. Only 44 (36.36%) of the preclinical
students were aware that infections can cause epilepsy as against 98 (88.29%) of the clinical
students. On brain tumours, 98 (88.29%) of the clinical students were aware that brain tumours
can cause epilepsy in comparison with 87 (71.90%) of the basic students.[22]
Since epilepsy is one of the world’s oldest known brain disorders among several medical
conditions,[4,5] it is the second most commonly seen neurological condition in primary care, and
the most commonly seen among neurologists.[17] A recent study has indicated that 70 million
people are estimated to suffer from this disease.[3] Persons with epilepsy are at risk of developing
a variety of psychological problems including depression, anxiety and psychosis. [6,7] Because
epileptic seizures typically include convulsions, the term convulsion is sometimes used as a
synonym for seizure. However, not all epileptic seizures lead to convulsions, and not all
convulsions are caused by epileptic seizures. The word “fit” is sometimes used to mean a
convulsion or epileptic seizure.[8] Epilepsy as one of the major brain disorders worldwide and
should be considered a health care priority in Africa. It is triggered by abnormal electrical activity
in the brain resulting in an involuntary change in body movement, function, sensation, awareness
and behaviour. The condition is characterized by repeated seizures or “fits” as they are commonly
called. These take many forms ranging from the shortest lapse of attention to severe and frequent
convulsions. Epilepsy is not only a medical condition; it also includes sociological, economical,
and cultural dimensions. Secondary causes of symptomatic epilepsy in Africa are mainly related
to the cerebral complications of endemic parasitic and infectious diseases, to head trauma and to
the poor perinatal care for both the mother and the child. Poverty and unsafe environment play an
important role as determinant factors.[9] The prevalence of active epilepsy in developing countries
range from 5–10 per 1000 people, and the disorder to a significant degree is associated with a host
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of parasitic and bacteria infectious diseases that are largely absent in industrial countries. Parasitic
infestations, such as Onchocerca volvulus, Taenia solium and Toxoplasma gondii are believed to
increase the risk of epilepsy.[10,7] Unlike other neurological conditions, epilepsy can be completely
controlled in the majority of cases by medication or surgical procedures[17] as most of the causes
of symptomatic epilepsy are preventable and treatable.[9]
In spite of global advances in diagnosis and treatment in recent years, about eight million people
with epilepsy in Africa are not treated with modern anti-epileptic drugs.[9] It is also estimated that
80 percent of the burden of epilepsy is in the developing world, where in some areas 80 to 90
percent of people with epilepsy receive no treatment at all.[11]
In Ghana, children with convulsive disorder made up 3% of new patients seen in the paediatric
department over a ten-year period, and that 51.5% of children consecutively enrolled in a paediatric
neuro-developmental clinic of a teaching hospital in Ghana were also suffering from seizures.[9,18]
Based on extrapolated statistics, the prevalence of epilepsy in Ghana is about 175,519 for a
population of 20,757,032. The annual mortality rate per 100,000 people from epilepsy in Ghana
has decreased by 4.2 percent since 1990, an average of 0.2 percent a year. For men, the deadlines
of epilepsy in the country peaks at age 80+. It kills men at lowest rate age 10-14. Women are killed
at the highest rate at age 80+. It was least deadly to women at age 10-14.[12] At 27.8 deaths per
100,000 women in 2013, the peak mortality rate for women was higher than that of men, which
was 9.9 per 100,000 men.[13]
Information gathered cited Dr. James Boakye Fordjour, the Head of Obstetrics and Gynaecology
at Brong Ahafo Regional Hospital, as saying that the Brong-Ahafo Regional Hospital has been
recording an increasing number of epilepsy cases since 2013 and that the public should pay much
attention to and support people with epilepsy to live meaningful lives.[14] Speaking at the World
Epilepsy Day, Dr. Patrick Adjei urged Ghanaians to support and encourage epileptics to live
normal lives. According to him, “Epilepsy once diagnosed can go away, do not despise people
with epilepsy because epilepsy is not contagious as many have assumed. Epilepsy had nothing do
with witchcraft and spirits but comes about as result of physical condition of the brain. Many
individuals with epilepsy are perceived by the community as weak, inhuman, dangerous or inferior
because of their symptoms, and as result of the stigma, these people are excluded. But epilepsy is
treatable and up to 70 percent of the seizure can be cured and the risk of reoccurrence is about 25
percent.”[15] Despite the fact that highly effective, low-cost treatments are available, as many as 9
of 10 people with epilepsy in Africa go untreated. The reasons for the unavailability of treatment
include: inadequate health delivery systems, lack of trained personnel, lack of essential drugs, and
traditional beliefs and practices that often do not consider epilepsy as a treatable condition. This
treatment gap greatly increases the burden of epilepsy and disability.[16]
Because there is public fear and misunderstanding about the disorder, it makes many people
unwilling to talk about it. The unwillingness leads to lives lived in the shadows, discrimination in
workplace and communities, and a lack of funding for new therapies research [5]. This is evident
by the report that literate adults in urban population of Ghana are ignorant of the cause of epilepsy.
When quizzed, 172 (45.3%) out of the 380 respondents did not know the cause of epilepsy. Out of
the 358 responses to the cause of epilepsy, 114 (31.8%) said it was inherited disease, 100 (27.9%)
said it was due to witchcraft/juju or spiritual.[19] A similar study conducted on beliefs on epilepsy
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in Northern Ghana highlighted that the most interesting perceived cause of seizures in males is
harboring anal worms, and spirituality a strong notion as a perceived cause. Besides, there is the
belief that spells of epilepsy are cast on women as a form of punishment when they engage in
adultery.[21]
When medical students in Uyo, Southern Nigeria were asked about their knowledge, attitude, and
perception towards epilepsy, the result was as follows: on the etiology of epilepsy, 14.88% of the
basic students and 5.41% of the clinical students were positive that epilepsy was caused by evil
spirits. 9.09% of the basic students compared to 5.41% of the clinical students believe that epilepsy
was caused by witches. 10 of the basic students as against only three (2.70%) of the clinical
students identified palm oil as a cause. The result further added that a large number of clinical
students 85.59% know that birth injuries can cause epilepsy as against 47.11% of the basic
students. Only 36.36% of the preclinical students were aware that infections can cause epilepsy as
against (88.29%) of the clinical students.[22]
It is worth noting that when someone has seizure does not necessarily mean that person has
epilepsy, though. Certain things can sometimes trigger seizures in people with epilepsy. They
include: Flashing or bright lights; A lack of sleep; Overstimulation (like staring at a computer
screen or playing video games for too long); Certain medications; and Hyperventilation (breathing
too fast or too deeply). In addition, seizures can be triggered in anyone under certain conditions,
such as life-threatening dehydration or high temperature. But when a person experiences repeated
seizures for no obvious reason, that person is said to have epilepsy.[37] It is therefore important to
make behavioural and psychosocial adjustments with epileptic patients to control seizure and
improve and attain higher quality of life by sticking to medication regimen, having adequate sleep,
good nutrition and reducing stress.[38]
In connection with the manifestations of epilepsy, the disease is also referred to as saturation of
the foams in the stomach which overflow and rise to the head, resulting in a seizure [23]. However,
the most common symptoms proffered by most respondents as manifestations of epilepsy include
convulsion, falling down, rolling of eyes, foaming of mouth, urination, and biting of tongue. [7,24]
Interestingly, surveys in developing countries with different cultures reveal common beliefs, for
example, that epilepsy is a contagious illness or a kind of mental retardation.[25] Although a lot of
misconceptions about epilepsy exist, it is reported that epilepsy can be spread by contact and that
epileptics must be isolated or avoided.[19] This assertion was supported in a study among people
with epilepsy that indicated 2.2% of the respondents admitted that epilepsy is transmitted through
contacts with epileptic patients.[26] Among the medical students studied, 24.79% basic and 9.91%
clinical students respectively believed that epilepsy is transmitted by saliva; 38.02% basic and
5.41% clinical students affirmed blood as a means of spread of the disease; urine was made up of
8.26% basic and 5.41% clinical students; faeces/flatus 4.96% basic and 3.60% clinical students
respectively during a convulsive episode or at all times. This they indicated results in isolation and
unwillingness of witnesses to touch and protect the patient from injury during a seizure. The study
stressed further that epilepsy is also believed to be transferable from one person to another by
various routes. As a result it leads to “courtesy stigma” where relatives, friends, and companions
of persons with epilepsy are stigmatized as well.[22] Another survey indicated that nearly 5%
nursing population believed that epilepsy is contagious.[27] In Ghana, a survey conducted by the
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Ankaful Psychiatric Hospital OPD health team in 2003 proved also that most of the family
members who accompanied their relatives to the hospital for treatment on epilepsy believed that
epilepsy is infectious and they might have gotten the condition through physical contact of an evilintended person through whose spell the condition spreads. So individuals with such conditions
are shunned, people refusing to even neither shake hands nor eat with them, and would not assist
the individuals when they have the attack, not to talk of marriage.[28]
The attitude of a person towards a certain object (person, word, or behavior) can be defined as a
subjective evaluation of this object. The subjective value of an object can be negative, neutral or
positive.[29,30] Though attitude is a complex and abstract construct,[31] people suffering from
epilepsy have been discriminated against in several ways.[32] Report from other studies have shown
that people with less awareness and knowledge about epilepsy tend to have negative attitudes
toward the disease and misperceptions such as epilepsy being a form of insanity, untreatable,
contagious, and hereditary or a form of mental retardation. Cultural beliefs, superstition, and lack
of information about epilepsy have perpetuated such misconceptions in developing countries.[33]
However, the Koran clearly chastises that people suffering from different types of disorders should
be treated with respect because their fate might be attributed to the will of Allah rather than
personal weaknesses or sinful behaviour.[32] It is important that health care professionals be well
informed about epilepsy and take an appropriate attitude towards the disease.[34] Clinical nurses
lack of knowledge and negative attitudes regarding epilepsy may affect the quality of health care
for patients with epilepsy.[35]
An observation made between October and November 2016 at the Asutifi North District Health
Directorate in Brong Ahafo Region of Ghana indicated that among the top 10 diseases in the
district, epilepsy was not captured, and that the district has minimal information on epilepsy. This
was evident by data gathered from the Ghana Health Service (GHS) District Health Information
Management System (DHIMS) which indicated that the Brong Ahafo Region had recorded 17,666
for cases of epilepsy in 2012, with 104 cases of epilepsy for Asutifi South District, but none for
the Asutifi North. In 2013, there was a rise in reported cases of the condition up to 1,888, but a
slight decline in Asutifi South with reported cases being 100. In 2014 and 2015, the number of
reported cases increased to 3,166 and 3,495 respectively, whilst the Asutifi South recorded 128
and 125 within the same period, but none for the Asutifi North Health Directorate. However, there
was a sharp fall in the reported cases of epilepsy in the Region with a figure of 1,377 with the
Asutifi North Health Directorate recording 10 cases from January to June, 2016, and in the same
duration Asutifi South recorded 33 cases.[20]
Despite the increase education and health care, some health professionals continue to linger in
darkness about cause and treatment options of the disease. As efforts to improve care of people
living with epilepsy are a major concern, little has been done to identify the extent of subjective
knowledge and attitude among nurses.
METHODOLOGY
This was a an exploratory cross sectional study on knowledge and attitude of nurses in epilepsy
working in the Asutifi North District in the Brong Ahafo Region of Ghana. The study population
consisted of nurses (both males and females) who have been licensed by the Nursing and
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Midwifery Council of Ghana and working in government facilities. The exclusion criteria were
private health facilities, non-trained health professionals and other health professionals without
nursing background, and student nurses on clinical attachment during the period of study in the
district.
Sample procedure
Multistage sampling technique was used to select the study participants from the communities. A
standard statistical formula from Rumsey, 2016, was used to arrive at a sample size of 102. The
starting point was randomly selected and a systematic random sampling method was used to select
the study participants.
Research tool and data collection
The research tool used for data collection for this study was a semi-structured questionnaire.
Data Analysis and presentation of results
Descriptive statistics, which involves interpretation using frequencies and percentages, were used
in representing data for the socio-demographic characteristics of all respondents. Besides,
responses on other items and other relevant questions were cross-tabulated. The statistical tool that
was used for analyzing the data was statistics and data, syllabic abbreviated as STATA, version
12.
A bivariate logistic regression analysis was conducted to test the association between independent
variables and outcome variables. In responding to the questionnaire, participants who
demonstrated positive responses on multiple options were operationally categorized into high
knowledge and those with poor responses as having low knowledge of the disease under study.
This was done to see how significant the variables influence the outcomes of the study. This was
also done for attitude on epilepsy as having positive and negative attitude on the categorisations.
Ethical consideration
To obtain data for this study, an introductory letter was collected from the Graduate School, School
of Allied Health Sciences, and Department of Public Health of the University for Development
Studies, Tamale, which was presented to the Health Directorate of Ghana Health Service in the
Asutifi North District. It was to explain the purpose of the study and to seek permission to involve
the nurses. Besides, the purpose of the study was explained to the participants by the researcher to
gain their maximum cooperation and also to conform to research ethics.
RESULTS
Socio-demographic characteristics
Majority of the respondents 78.4% (80/102) were between the ages 21 to 30 years. More than half
(73.5%) of the respondents were females. Concerning religion, 87.3% of the respondents were
Christians, 7.8% were Muslims and 3.9% practiced African Traditional Religion, with only 1.0%
belonging to the Buddhism. About 39.2% of the respondents were Community Health Nurses,
while a few (6.9%) were Registered Midwives, and 28.4% were Health Assistant Clinical (HAC).
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Most respondents (91.2%) had no close family member with epilepsy with 8.8% having a close
family history of epilepsy.
Table 1: Socio-demographic Data of Respondents
Variable
Frequency
Percentage
(102)
(100%)
Age
- 21-30
80
78.4
- 31-40
14
13.7
- 41-50
5
4.9
- 51-60
3
2.9
Sex
- Male
27
26.5
- Female
75
73.5
Religion
- Christianity
89
87.2
- Muslim
8
7.8
- Traditional
4
3.9
- Others
1
1.0
Specialized Area
- RGN
15
14.7
- RMN
11
10.8
- RM
7
6.9
- CHN
40
39.2
- Others
29
28.4
Close Family with Epilepsy
- Yes
9
8.8
- No
93
91.2
Source: Field data (2017)
Awareness on the causes of epilepsy
Majority of the nurses 67.7% (69/102) said “Yes” they are aware of the causes of epilepsy. This
implies that more than half of the nurses have knowledge about the causes of epilepsy.
Knowledge of factors contributing to the development of epilepsy
The various factors contributing to the development of epilepsy have been captured under this
session. The results of the perceived causes of epilepsy show that 48.0% of the nurses associated
birth trauma to be the cause of epilepsy which is correct response. In terms of hereditary, 22.5%
of the respondent gave their accent to it which is a wrong response, whilst 13.7% of the respondents
attributed the onset of the disease to brain injury which they were right. Though the same number
of the nurses indicated witchcraft as the perceived cause of epilepsy, they were wrong with that
response. Notwithstanding the perceived causes of epilepsy, the result of the data indicated that
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57.8% of the respondents agreed that convulsion contribute to the development of epilepsy, 21.6%
of the respondents agreed that high body temperature contribute to the development of epilepsy
whilst 14.7% of the respondents concurred malaria as a contributing factor to the development of
epilepsy. It is worth to say that all those responses given by the nurses were all correct. In
connection with maternal factors, the result showed that 68.6% of the respondents agreed that
maternal alcohol consumption is a risk factor in epilepsy, 64.7% of the respondents agreed that
malnutrition is a risk factor in epilepsy, 49.0% of the respondents were in accord that drug use is
a risk factor in epilepsy, while only a few 23.6% of the nurses knew maternal age above 30 years
to be a risk factor for developing epilepsy. The above responses given by the nurses on the maternal
risk factors to the development of epilepsy were all right.
Critical assessment of the maternal risk factors led to the ascertainment of some activities that
sometimes trigger seizure in people with epilepsy. Out of the 102 respondents, 8.8% nurses said
“Yes” staring at TV/Computer screen for too long could trigger seizure. Besides, 36.3% of the
nurses cited Stress as a triggering factor. In terms of breathing too fast/deeply could trigger seizure
in PWE, 3.9% of the nurses accented to that fact. More so, 12.7% of the nurses claimed Flashing
or bright light could trigger seizure, 45.1% of them identified lack of sleep as a contributory factor
that could trigger seizure in PWE. The responses given by the few nurses on this variable were all
correct.
Data collected on the manifestation of epilepsy from the nurses depicted that out of the 102
respondents, 31.4% of the nurses said “Yes” to Shrill cry (Shouting) as a clinical feature of
epilepsy. In addition, 49.0% of the respondents indicated positive to loss of consciousness. Whilst
falling down was accepted by 48.0% nurses as a manifestation of epilepsy, majority 60.8% of the
nurses claimed jerking of the body as the cardinal manifestation of epilepsy, and Rolling of the
eyes was accepted by 30.4% of the nurses, and 45.1% of the respondents said “Yes” to foaming
of the mouth. When it came to the biting of the tongue as a manifestation of epilepsy, 30.4% of
the nurses affirmed it as a clinical feature; urination was mentioned by 23.5% of the respondents.
Few 15.7% of the nurses responded “Yes” to abnormal behaviour as a manifestation. A critical
assessment of the findings on manifestations of epilepsy from the respondents depicted that the
responses afore-given were all right. It is deduced from the data that majority of the nurses do not
know the clinical features of the disease. This is evident from the negative responses cited by the
majority of the respondents. However, the manifestations serve as indicators in monitoring people
with epilepsy so that urgent or immediate attention could be given to them. Table 2 depicts the
detail results on knowledge of respondents on factors contributing to the development of epilepsy.
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Table 2: Knowledge of respondents on factors contributing to the development
of epilepsy
Factors contributing to the Development of
Response rate (N=102)
Epilepsy
Correct (%)
Wrong (%)
Perceived causal factors
- Curse
- Hereditary
- Brain injury
- Witchcraft
- Birth trauma
- Spiritually possessed
- Brain infection
- Poison/Bad blood
Personal factors
- Convulsion
- High temperature
- Malaria
- Parasitic infections
- Others factors
Maternal factors in epilepsy
- Maternal alcohol
- Malnutrition
- Drug use
- Maternal age >30 years
Triggering factors
- Lack of sleep
- Stress
- Flashing/Bright light
- Staring at screen for long
- Breathing too fast
Manifestation of Epilepsy
- Jerking of the body
- Loss of consciousness
- Falling down
- Foaming of the mouth
- Shrill cry (Shouting)
- Rolling of the eye
- Biting of tongue
- Urination
- Abnormal behaviour
Source: Field data (2017)
20
95 (93.1%)
79 (77.5%)
14 (13.7%)
88 (86.3%)
49 (48.0)
90 (88.2%)
10 (9.8%)
96 (94.1%)
7 (6.9%)
23 (22.5%)
88 (86.3%)
14 (13.7%)
53 (52.0%)
12 (11.8%)
92 (90.2%)
6 (5.9%)
59 (57.8%)
22 (21.6%)
15 (14.7%)
9 (8.8%)
4 (3.9%)
43 (42.2%)
80 (78.4%)
87 (85.3%)
93 (91.2%)
98 (96.1%)
70 (68.6%)
66 (64.7%)
50 (49.0%)
24 (23.6%)
32 (31.4%)
36 (35.3%)
52 (52.0%)
78 (76.4%)
46 (45.1%)
37 (36.3%)
13 (12.7%)
9 (8.8%)
4 (3.9%)
56 (54.9%)
65 (63.7%)
89 (87.3%)
93 (91.2%)
98 (96.1%)
62 (60.8%)
50 (49.0%)
49 (48.0%)
46 (45.1%)
32 (31.4%)
31 (30.4%)
31 (30.4%)
24 (23.5%)
16 (15.7%)
40 (39.2%)
52 (51.0%)
53 (52.0%)
56 (54.9%)
70 (68.6%)
71 (69.6%)
71 (69.6%)
78 (76.5%)
86 (84.3%)
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Categorization of level of knowledge on epilepsy
Participants who scored 16 correct or more out of the 31 items on the knowledge of factors
contributing to the development of epilepsy were operationally labelled as having “high”
knowledge and those who scored less or equal to 15 seen as having “low” knowledge. This is
shown in table 3.
Table 3: Level of knowledge of participants
Level of knowledge
Frequency (N=102)
41
- High
61
- Low
Source: Field data (2017)
Percentage (100%)
40.2
59.8
The categorization indicates that majority, 59.8% (61/102) of the nurses were less knowledgeable
on the epilepsy.
Attitude towards epilepsy
Since the nurses’ attitude would influence their practice towards the disease, it was important to
assess the nurses’ position towards epilepsy. In terms of PWE having the same intelligence as nonepileptics, out of the 102 respondents, 34.3% supported that idea and they were right. About 8.8%
were of the view that PWE could have the same employment as the general public do, and their
response was correct. When it comes to relationship, 6.9% of the nurses said they would have
amorous relationship with PWE for which they were also right in their response, and 17.6% of the
nurses do not suspect PWE to have mental illness which is also correct in their response.
Results on this item show clearly that out of the 102 study participants, majority responded in the
negative to the items given on the questionnaire, which they were all correct. In terms of Urine,
99.0% answered “No,” likewise response for Flatus (97.1%) and Faeces (95.1%). In connection
with Marriage, majority (91.2%) opted “No,” and the same negative response for Physical contact
(89.2%) and Sharing of food (85.3%) respectively, for which the respondents were right in their
answers. Furthermore, results on this item indicated that 95.1% of the nurses responded “No,”
meaning that breathe of epileptic patient is not infectious, for which their response was correct.
Also, 97.1% of the nurses responded “No” the droppings of animals cannot spread epilepsy, for
which response was correct. Notwithstanding, none of the respondents could mention any
animal(s) whose droppings can spread epilepsy. Furthermore, 97.1% of the respondents disclaimed
that coming in contact with the excretions (body fluids) from PWE can be infectious, which was a
correct response from the study participants. It was observed from the data that all the nurses
(100%) agreed to the fact that saliva could not be a mean of transmission of epilepsy as their
response to that item were in the negative, which was also correct. It was observed from the result
that respondents disclaimed, denied and refuted the fact that epilepsy is neither an air-borne
disease, nor an animal dropping transmitted disease, and is not contagious through the excretion
of body fluids. The detail results of the attitude towards epilepsy are in Table 4.
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Attitude
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Table 4: Attitude towards epilepsy
Response rate (N=102)
Correct (%) Wrong (%)
Nurses attitude towards PWE
- Have same intelligence
- Have same employment
- Amorous relationship
- Suspicion of mental illness
Ways of transmission
- Urine
- Flatus
- Animal dropping
- Excretions/body fluids
- Breath from epileptics
- Faeces
- Marriage
- Physical contact
- Sharing of food
- Saliva
Source: Field data (2017)
35 (34.3%)
9 (8.8%)
7 (6.9%)
18 (17.6%)
67 (65.7%)
93 (91.2%)
95 (93.1%)
84 (82.4%)
101 (99.0%)
99 (97.1%)
99 (97.1%)
99 (97.1%)
97 (95.1%)
97 (95.1%)
93 (91.2%)
91 (89.2%)
87 (85.3%)
102 (100.0%)
1 (1.0%)
3 (2.9%)
3 (2.9%)
3 (2.9%)
5 (4.9%)
5 (4.9%)
9 (8.8%)
11 (10.8%)
15 (14.7%)
0 (0.0%)
Categorization of attitude towards epilepsy
Attitude towards epilepsy was operationally classified into good and poor attitudes. Respondents
who had three appropriate responses on the attitude were seen as having “good” attitude towards
epilepsy, and those who had four or more inappropriate responses were thus classified as having
“poor” attitude towards epilepsy. The table 5 below highlights on the attitude categorisation.
Table 5: Categorization of attitude towards epilepsy
Attitude
Frequency (N=102)
Percentage (100%)
72
70.6
- Positive
30
29.4
- Negative
Source: Field data (2017)
Looking at the categorisation above, it is clear that 70.6% (70/102) of the nurses have good attitude
towards epilepsy.
Socio-demographic determinants on knowledge and attitude on epilepsy
The influence of socio-demographic characteristics on knowledge and attitude on epilepsy were
assessed to test their statistical strength on the study. The table 6 (a, b) below highlights the detail
of the associations.
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Table 6a: Socio-demographic factors and knowledge on epilepsy
Variable
Knowledge on epilepsy
p-value
High (N=41)
Low (N=61)
(100%)
(100%)
Age
30 (73.3%)
50 (82.0%)
- 21 – 30 years
7 (17.1%)
10 (16.4%)
0.234
- 31 – 40 years
2
(4.8%)
1
(1.6%)
- 41 – 50 years
2 (4.8%)
0 (0.0%)
- 51 – 60 years
Sex
6 (14.6%)
7 (11.5%)
0.133
- Female
35 (85.4%)
54 (88.5%)
- Male
Religion
30 (73.2%)
53 (86.9%)
- Christianity
7 (17.1%)
5 (8.2%)
0.017*
- Muslim
4 (9.7%)
0 (0.0%)
- Traditionalist
0 (0.0%)
3 (4.9%)
- Others
Speciality area
4 (9.8%)
5 (8.2%)
- RGN
2 (4.9%)
0 (0.0%)
0.045*
- RMN
3 (7.3%)
0 (0.0%)
- RM
16 (39.0%)
36 (59.0%)
- CHN
16 (39.0%)
20 (32.8%)
- Others
Close family
relationship with
epilepsy
8 (12.2%)
1 (8.2%)
- Yes
34 (87.8%)
56 (91.8%)
0.001*
- No
(*)=p is statistically significant based on chi square analysis
Source: Field data (2017)
When the socio-demographic characteristics was cross-tabulated with knowledge of epilepsy, a
significant difference was observed among religion (p=0.017), specialty area (p=0.045), and close
family relationship with epilepsy (p=0.001).
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Table 6b: Socio-demographic factors and attitude
Variable
Attitude towards epilepsy
p-value
Good (N=72)
Poor (N=30)
(100%)
(100%)
Age
54 (75.0%)
20 (66.7%)
0.345
- 21 – 30 years
12 (16.6%)
9 (30.0%)
- 31 – 40 years
3 (4.2%)
1 (3.3%)
- 41 – 50 years
3 (4.2%)
0 (0.0%)
- 51 – 60 years
Sex
57 (79.2%)
26 (86.7%)
0.037*
- Female
15 (20.8%)
4 (13.3%)
- Male
Religion
60 (83.3%)
24 (80.0%)
- Christianity
8 (11.1%)
5 (16.7%)
0.012*
- Muslim
4 (5.6%)
0 (0.0%)
- Traditionalist
0 (0.0%)
1 (3.3%)
- Others
Speciality area
12 (16.6%)
5 (16.7%)
- RGN
9 (12.5%)
0 (0.0%)
0.054
- RMN
7 (9.7%)
0 (0.0%)
- RM
22 (30.6%)
15 (50.0%)
- CHN
22 (30.6%)
10 (33.3%)
- Others
Close family
relationship with
Epilepsy
6 (8.3%)
5 (16.7%)
0.216
- Yes
66 (91.7%)
25 (83.3%)
- No
(*)=p is statistically significant based on chi square analysis
Source: Field data (2017)
When the socio-demographic characteristics was cross-tabulated with attitude towards epilepsy, a
significant difference was observed among sex (p=0.037), and religion (0.012). The area of
specialty (p=0.054) was statistically insignificant.
DISCUSSION
Knowledge on epilepsy
The knowledge of the study participants on epilepsy regarding the causes in the development of
epilepsy was analyzed. The results on being aware of the cause of epilepsy indicated that a majority
67.7% (69/102) of the nurses responded ‘Yes’ of their awareness of the causes of epilepsy. This
implies that majority of the nurses have basic knowledge about the causes of epilepsy. This
assertion was in sharp contrast to a study in Ghana that indicated 172 (45.3%) of the respondents
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did not know the cause of epilepsy among literate adults in urban population, saying they are
ignorant of the cause of the disease. [19]
On the perceived causes of epilepsy, 48.0% of the nurses associated birth trauma to be the cause
of epilepsy, 24.5% knew of brain injury, 22.6% claimed hereditary as a cause of epilepsy whilst
9.8% of the nurses said brain infection is also a cause of epilepsy. However, 13.7% of the
respondents attributed witchcraft to be the cause of epilepsy, spiritual possession accounting for
11.8% of the respondents, few 6.7% of the respondents said it is caused by curses and 5.9% also
said epilepsy could be caused by poisoning or bad blood. This result is in harmony with other
studies conducted in Ghana [19,20] and Uyo, Southern Nigeria.[22] It can be deduced that the causes
of epilepsy are categorized into physiological and cultural superstitious causes of the disorder.
Specifically, the physiological causes took the form of brain injury, birth trauma and brain
infection whilst the cultural superstitious causes also manifested through curse, heredity, spiritual
possession and poisoning or bad blood.
When factors that could trigger seizure in people with epilepsy were assessed, 45.1% of nurses
identified lack of sleep as a contributory factor that could trigger seizure in epileptic patients,
36.3% cited stress whilst 3.9% attributed fast breathing to trigger seizure in epileptic patients with
few 8.8% affirming staring at computer screen for too long. This result is indicating that majority
of the nurses did not know what could trigger seizure in people living with epilepsy as most of
their responses were in the negative. However, seizures could be triggered in anyone under certain
conditions such as life-threatening dehydration or high temperature among other factors.[37]
Regarding manifestation of epilepsy, 60.8% nurses said jerking of the body is a manifestation of
epilepsy, followed by loss of consciousness 49.0%; foaming of the mouth (45.1%) of nurses knew
as a manifestation of epilepsy; 48.0% knew falling down to be a manifestation of epilepsy, while
shouting was described by 31.4% nurses as manifestation of epilepsy. 30.4% of respondents
identified rolling of the eye and tongue biting as manifestation of epilepsy, 23.5% respondents said
urination is manifestation of epilepsy with only a few 15.7% respondents associating abnormal
behaviour to epilepsy. The few who responded in the affirmative result was in consonance with
other studies that cited responses such as convulsion, falling down, rolling of eyes, foaming of
mouth, urination, and biting of tongue as manifestations of epileptic attack.[7,25] The sociodemographic characteristics of religion (Muslim) (p=0.017), area of speciality (RMN) (p=0.045)
as well as close family relationship with epilepsy (p=0.001) were significantly associated with
knowledge on epilepsy.
Attitude towards epilepsy
The results of this study on amorous relationship showed that 93.1% of the respondents posited
that they will not engage themselves in amorous relationship with a person with epilepsy. This was
in congruent with the assertion that epileptic persons suffer untold social deprivations and
discrimination in marital life.[7] It was reported that 44.8% of their respondents indicated their
refusal to marry people with epilepsy.[41] This is in consistent with the findings of this research
report. Further discussion indicated that nearly 35% of the students believed that persons with
epilepsy could not lead a happy married life.[27] In support of the findings of this research,
approximately 25% of health care workers would not allow their child to marry someone with
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epilepsy and 20% thought people with epilepsy should not marry.[46] Findings from another study
indicated that a person with epilepsy should not be married and bear children and majority agreed
to have a divorce or separate spouse if diagnosed of epilepsy.[47] To buttress the assertion aforeindicated, a study in South West Cameroon gave the results in support of this research that about
33 percent of student nurses and 52 percent of laboratory assistants would object to their children
marrying people with epilepsy.[40] In support of these assertions, it has been published that nearly
one-third (32.2%) felt that epilepsy interferes with marriage,[43] as one study confirmed that the
divorce rate is higher in PWE.[48] In sharp contrast to the findings of this study, epilepsy does not
appear to be a major stress factor in marriage as long as the spouse is knowledgeable about the
condition. Such couples often exhibit a greater degree of mutual concern and support.[49] In support
of the counter arguments, a report has indicated that 85.1% of their respondents approved marrying
an epileptic.[34] Besides 75% of a study’s respondents would allow their son or daughter to marry
someone with epilepsy.[46] Similar findings has showed that 84% and 85% of nurses and physicians
would maintain a relationship with a person with epilepsy, with 61% of nutritionists doing the
same.[50]
When attitude towards epilepsy was associated with the socio-demographic characteristics to
determine its influence, a significant difference was observed among sex (female) (p=0.037) and
religion (Muslim) (p=0.012). However, specialty area (RMN) (p=0.054), did not statistically
impact on the study, and there was no statistical significance on how age and close family
relationship with epilepsy influence knowledge on the disease.
The findings of this study also revealed that 82.4% of the nurses suspect epileptic people to have
mental illness. In tune with the result from this analysis is a report where 10% equated epilepsy
with insanity,[45] thus confirming the notion put forth by majority of the nurses for this research.
More so, report from other studies have shown that people with less awareness and knowledge
about epilepsy tend to have negative attitudes toward the disease and misperceptions such as
epilepsy being a form of insanity.[33] To support the assertion, a report cited that nearly 35 percent
of the nursing students believed epilepsy is a mental illness.[27] This assertion is similar to the
findings of this research report. Consequently, it has been observed in another study that 26.4
percent of the university students correlated epilepsy with mental disease.[34] Similar findings by
various authors showed that respondents equate epilepsy to mental illness.[39,40,41,42] It is obvious
from the discussions on this issue of suspicion of mental illness that majority of the nurses for this
study associate epilepsy with mental illness and this points to lack of knowledge of the disease.
In sharp contrast to the findings of this research is the revelation that the highly educated did not
view epileptics as not mentally sick persons.[19] More so, a publication claimed that 67.8 percent
of their respondents believed persons with epilepsy were neither mad nor insane[43] to defend the
earlier assertion. In support of this defense is the publication that 68 respondents thought “epilepsy
is not a form of mental illness,” and 66 (97.05%) believed that people with epilepsy are not
insane.[33]
Though epilepsy may co-exist with mental illness, in some cases, and some PWE have exhibited
abnormal behaviour after the crisis phase of the attack, as per personal clinical observations, most
PWE are intellectually sound and have excel both academically and in other professions. To
conclude, epilepsy is not a psychotic disorder.
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Data from this study further stressed that 65.7% (67/102) of the respondents agreed that people
with epilepsy do not have the same intellectual capabilities as the general public. In connection
with epileptics’ intellectual capabilities, there is evidence of association between epilepsy and
specific learning disabilities as 42.7% of their respondents knew that the person with epilepsy may
have learning problems.[44] In affirming the findings of this research, people with mild to moderate
intellectual disability (ID) lifetime epilepsy have been reported to have prevalence at between six
and 15 percent. In those with severe ID epilepsy occurs in around 25 percent whilst in those with
profound ID (IQ<20) (Ring, 2013). These findings show a strong correlation between epilepsy and
intellectual capabilities of PWE.
Though majority of the nurses 57.8% did not give any answer to the mode of transmission of
epilepsy, few 14.7% respondents perceived sharing of food could possibly transmit epilepsy, and
10.8% nurses said physical contact with a patient can facilitate transmission of the disease while
9(8.8%) respondents said it could be transmitted through marital union. On other ways of
transmission of the disease, 4.9% indicated breath from an epileptic patient is infectious, 2.9% said
animal dropping and contact with excretions respectively from epileptic patients could spread the
disease. This result confirms other studies where respondents are of the view that epilepsy is
contagious and could be spread through contact (physical), saliva, blood, urine, and faeces/flatus
[19,26,22,27,28]
. When the attitudes of the nurses towards epilepsy were classified, it tends out that
majority 70.6% (72/102) had positive attitude towards the disease. This led to investigating the
strength of the socio-demographic characteristics as against the attitude of the nurses. It tends out
that the variables that influence attitude were sex (female) (p=0.037), Muslim religion (p=0.012),
and area of specialty (RMN) (p=0.054). There were no statistical associations between other ways
of transmission of epilepsy and attitude.
CONCLUSION
Nurses at the Asutifi North District tended to have low knowledge and positive attitude on
epilepsy. It is important to improve training and health care delivery for epilepsy. This is because
there still exist cultural beliefs among some of the respondents on the spread of the disease as
heredity, spiritual possession and curse. These serve as a drawback to the positive attitudes shown
towards epilepsy.
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practice of epileptic patients towards their illness and treatment in Jimma University
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Nursing, Midwife and Health Related Cases, 2(1): pages 18-48. Retrieved January 20, 2018
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32. Ghanean, H., Nojomi, M., & Jacobsson, L. (2013). Public awareness and attitudes towards
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35. Dayapoğlu, N., &Tan, M. (August, 2016). Clinical nurses’ knowledge and attitudes toward
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36. Chilopora, G. C., Kayange, N. M., Nyirenda, M., & Newman, P. K. (2001). Attitudes to
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Nursing, Midwife and Health Related Cases, 2(1): pages 18-48. Retrieved January 20, 2018
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32
PRECONCEPTION CARE: AWARENESS, KNOWLEDGE, ATTITUDE
AND PRACTICE OF PREGNANT WOMEN, TAMALE WEST HOSPITAL
AKWASI BOAKYE-YIADOM
ESTHER SAGRU-LARR
EMELIA ODURO
OBED KWAKU DUAH ASUMADU
JOEL AFRAM SAAH
RICHARD OPOKU ASARE
American Journal of Health, Medicine and Nursing Practice
ISSN 2520-4017 (Online)
Vol.5, Issue 1 No.5, pp 66 - 83, 2020
www.ajpojournals.org
PRECONCEPTION CARE: AWARENESS, KNOWLEDGE,
ATTITUDE AND PRACTICE OF PREGNANT WOMEN,
TAMALE WEST HOSPITAL
AKWASI BOAKYE-YIADOM (MSc, B.Ed) 1
Department of Public Health, School of Allied Health Sciences
University for Development Studies, Tamale, Ghana
ESTHER SAGRU-LARR (BSc. Midwifery) 2
Department of Midwifery, School of Allied Health Sciences
University for Development Studies, Tamale, Ghana
EMELIA ODURO (BSc. Midwifery) 3
Department of Midwifery, School of Allied Health Sciences
University for Development Studies, Tamale, Ghana
OBED KWAKU DUAH ASUMADU (BSc. Nursing) 4
Department of Nursing, School of Allied Health Sciences
University for Development Studies, Tamale, Ghana
JOEL AFRAM SAAH (B.Ed. Health Science) 5
Department of Public Health, School of Allied Health Sciences
University for Development Studies,Tamale, Ghana
*RICHARD OPOKU ASARE (MPhil, B.Ed, RN (Dip)-RMN, Cert.Ed.) 6
College of Nursing, Ntotroso
Ahafo Region, Ghana.
Corresponding Author’s Email: asareor@gmail.com
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ABSTRACT
Purpose: The aim was to assess the awareness, attitude, knowledge level and practice of pregnant
women on preconception care at the Tamale West Hospital Antenatal clinic in the Northern region
of Ghana.
Methodology: This study used a descriptive cross-sectional design with a quantitative approach.
A quota sampling procedure was used to arrive at 200 participants. The starting point was
randomly selected and a systematic random sampling method was used to select the study
participants. Simple random sampling using the lottery approach was used to select the participants
for the study. The target population was women (literate and illiterate) within the age range of 16
and 40 years attending the Tamale West Hospital for antenatal care. The list of all the women who
fell within the target population was obtained from the register of the unit. The inclusion criteria
were pregnant women who visited the Tamale West Hospital within a month’s duration for
antenatal care services. A semi-structured questionnaire which had both open-ended and closeended questions was used to generate the data. Descriptive statistics which involves frequencies
and percentages was used to represent both independent and dependent variables of the study.
Close-ended responses were inputted using the Microsoft Office Excel 2016. Open-ended
responses were compiled in relation to the objectives of the study. Other relevant outcomes were
cross-tabulated using SPSS version 21.
Results: Though 20.0% of the pregnant women had positive attitude towards preconception care,
only 34.5% were aware of preconception care and 42.5% and 23.5% had poor and high knowledge
levels on preconception care respectively. When the age group was cross-tabulated with
awareness, the results showed no statistical significance between the two variables (χ2=9.1;
p=0.58). However, there was an association between the educational status (Tertiary level)
(χ2=49.6; p=0.01) and religious affiliation (Muslim) (χ2=43.3; p=0.01) of the respondents on
awareness. Educational status (Tertiary level) (χ2=45.4; p=0.01) and religion (χ2=21.3; p=0.01)
were found to influence knowledge statistically. In terms of overall attitude, only Muslim (χ2=4.12;
p=0.04) statistically impacted on the study.
Conclusion: Pregnant women who attend Antenatal clinic at Tamale West Hospital tended to have
low level of awareness and poor knowledge, they have negative attitude towards preconception
care services and seldom practice preconception care. There is the need for health care authorities
to intensify awareness and implement preconception care policies.
Recommendation: The present study demonstrated that there was a need to create awareness
which can also increase the knowledge and practices of reproductive age women or couples.
Hence, there is the need for health authorities to put together comprehensive preconception care
policies for health institutions to abide by.
Key words: Preconception, Awareness, Knowledge, Attitude, Practice, Tamale
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INTRODUCTION
Preconception cares are interventions that are provided to women or couples prior to conception.
As it is important for every woman to attend the antenatal clinic during pregnancy, so is it
important for them (including their partners), to patronize preconception care before they decide
to conceive.
Every woman deserves good health in mind and body especially before, during and after birth.
This also goes for the babies they deliver; hence, giving birth to preconception care. Preconception
care provides biomedical, behavioral and social health interventions to women and couples before
conception occurs.[1] It consists of preventive, promotive or curative health and social interventions
before pregnancy occurs. It is also seen as the period between 3 months before conception to 3
months after conception.[2] It is defined as any intervention provided to women of childbearing
age, regardless of their pregnancy status or desire before pregnancy, to improve health outcomes
for women, newborns and children. It is a very important aspect of maternal health care which has
been neglected over the years especially in developing countries.[3]
In countries, such as Canada, the United Kingdom, Spain, Australia, Hungry and the Netherlands,
where preconception cares (PCC) are available and patronized, it is seen that there has been
improvement in the health of women and also reduction of pregnancy related complications as
well as abnormalities affecting newborns during and after pregnancy. Even if preconception care
aims primarily at improving maternal and child health, it brings health benefits to adolescents,
women and men, irrespective of their plans to become parents.[1] Also, the benefit of preconception
care is the improvement of public health which is achieved by improving individual health.[4]
Preconception care is highly associated with increasing antenatal care, delivery care and post-natal
care service utilizations which are the corner stones to improve maternal and child health.
Unfortunately, a study conducted on maternal and child health in sub-Saharan Africa in 2011
reported that preconception care is poorly practiced due to inadequate health care workers,
unstable financial standing, illiteracy and lack of awareness on the subject matter.[5] Regrettably,
these social and personal factors have made implementing and practicing preconception care very
unstable and inconsistent even for countries which have facilities that provide preconception
services.
A study discovered that 63.5% of the participants were aware of preconception care and their
source of information being the antenatal clinics, whereas 54.7% of them claimed to be aware of
folic acid supplementation and also to avoid certain lifestyles like smoking and alcohol before
pregnancy.[2] It is important for women of childbearing age to consume vitamins containing folic
acid to get the daily requirement of 400 micrograms.[6] Another study also found that 55.9% of
their respondents were aware of preconception care, and most of the respondents constituting
90.30% mentioned promoting health as the components of preconception care.[7] More so, it was
reported in a study that 31.8% of their sample size were aware of preconception care with the
major source of information coming from the health institution, and friends and the mass media as
the minority sources.[8] Additionally, it was reported that 35.5% of the participants were aware of
preconception care and majority also agreed that preconception care is important.[4] These findings
were much higher than that of a report which had 11.0% awareness level.[9] However, it is
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documented in other studies that women were more aware of certain preconception care topics
than men.[10,11]
A research conducted in low-income Mexican-American population revealed that 80% of the
respondents had knowledge on preconception care (they agreed that improved preconception care
benefits pregnancy). They also had high knowledge certain facts; the benefits or disadvantages of
the use of folic acid, the use of alcohol; verbal, physical and sexual abuse.[12] A study has it that
majority of the participants took folic acid before pregnancy or within the first trimester of their
pregnancy.[13] Notwithstanding, other reports have documented relatively poor knowledge levels
among their participants.[14,15]
A similar research found that 15.5% of the respondents had adequate knowledge of preconception
care, 64.5% of the respondents had moderate knowledge and 20% of respondents had inadequate
knowledge regarding preconception care. This is a clear indication that practice of preconception
care might be low or not practiced at all.[16] Another study conducted in Iran reported a moderate
knowledge level of preconception care among 30–67% of healthcare providers. According to the
report, providers with poor knowledge of PCC were 11.7%.[17]
Generally, studies have shown that nurses and health care workers have a positive attitude towards
preconception care, but there is lack of implementation.[18,19] An Iranian cross-sectional study
among midwives revealed that their attitude score was good.[20] Most studies have also shown that
respondents with knowledge on preconception care believe that it is an important part of maternal
and child health care. However, a study conducted on adolescent girls showed that 96.7% of them
had unfavorable attitude towards preconception care, 3.30% had moderate attitude, and none had
favorable attitude during the pre-test level; whereas all the respondents (100%) had favorable
attitude during the post-test.[16]
Current researches have shown that most women are unaware of their pregnancy status until
several weeks have passed; hence exposing the fetus to unhealthy risks and this can be a factor
why most women do not show positive attitude towards preconception care.[12] More so,
worldwide statistics showed that few people have an idea on preconception care but most of them
have moderate or no knowledge on preconception care. However, it is not certain whether this
knowledge motivates people to practice or patronize preconception care. There is reason to believe
that the knowledge and awareness level of people with regards to preconception care (PCC) is
directly proportional to their practice or patronize level. It is revealed in a study that 65.9% of
respondents had never practiced preconception care or never sought the services. Besides, those
who had ever practiced preconception care (less than 35%) had heard it from their antenatal
sessions at the clinic when they were already pregnant. This then emphasizes the theory that most,
if not all of them, never practiced preconception care before their first conception or pregnancy.[2]
However, it is established that there are poor preconceptional practices.[14]
In Ghana, there is lack of awareness of this kind of care, not to talk of the patronage of this care.
Even those who are aware of the preconception care, due to reasons or factors like inadequate
resources, time and health facilities are not able to patronize the services of preconception care.
Most women due to the cultural nature of the people in the Tamale Metropolis do not have a say
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especially when it comes to their sexual life. The culture which puts the man in charge, therefore
makes it difficult for most women (especially those with low or no educational background and
even some educated women) to suggest things like the number of children or when they would
like to have kids. This is because they believe that “it is ok for a man to produce lots of offspring
without being rich”. Also, these women who probably have rivals would be interested in giving
birth to more children for their husbands or partner without caring about the health consequences.
These have caused most women to give birth between 8 and 10 children. It is also noted that most
of the hospitals and clinics in the Tamale Metropolis do not have units where preconception care
services are rendered. Preconception care is not regularly given to all women in the general
population and for that matter they are exposed to drinking of alcohol, smoking, drug use, and lack
access to folic acid supplementation unless they are recognized to have risk factors.[21] Because
there is minimal information on pregnant women on preconception care in Ghana, this study aimed
to assess the awareness, knowledge, attitude and practice of pregnant women attending antenatal
clinic (ANC) at the Tamale West Hospital.
METHODOLOGY
This was a descriptive cross-sectional study using a quantitative approach on awareness,
knowledge, attitudes and practices among women attending antenatal clinic at the Tamale West
Hospital on their preconception care. Inclusion criteria were pregnant women who attended ANC
at Tamale West Hospital within a month’s duration.
The researchers conducted the study on a quota of 200 respondents. The starting point was
randomly selected and a systematic random sampling method was used to select the study
participants. Simple random sampling using the lottery approach was used to select the participants
for the study. The target population was women (literate and illiterate) within the age range of 16
and 40 years attending the Tamale West Hospital for antenatal care. The list of all the women who
fell within the target population was obtained from the register of the unit.
Data for the study was collected using a semi-structured questionnaire which had both open-ended
and close-ended questions; subdivided into six sections. Section one comprised the sociodemographic characteristics which include age, gender, religion, occupation, marital status and
educational levels of the respondents. The second section was associated with the past obstetric
history of the participants which has the following questions: number of pregnancies, number of
children; patronage of a health facility before conception and the utilization of antenatal services
during previous pregnancies. Section three consisted of three questions to assess the level of
awareness of respondents on preconception care. The fourth section comprised questions to assess
the level of knowledge of the participants. The fifth section is characterized by “yes” or “no”
questions on the level of patronage, and the sixth section included questions to assess their attitude
towards preconception care.
Descriptive statistics which involves frequencies and percentages were used in representing data
for the socio-demographic characteristics of all respondents. Data analysis was done
systematically using a quantitative study approach. Data was imputed using the Microsoft Office
Excel 2016. The entry sheets were designed with appropriate definitions and codes to help
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minimize errors during data entry. Open ended questions on the questionnaire which were
supposed to yield qualitative data were compiled in relation to the set aims and objectives of the
study. Besides, responses on other items and other relevant questions were cross-tabulated. The
close ended data were analyzed using Statistical Package for Social Sciences (SPSS) version 21.
RESULTS
Socio-demographic characteristics
All 200 questionnaires administered merited inclusion for analysis. Majority of the pregnant
women 75 (37.5%) were between the ages 21 and 25 years. The highest were married 183 (91.5%)
with educational status as tertiary being 62 (31.0%) of the respondents. In terms of religious sects,
the Muslims 157 (78.5%) were the majority with none (0.0%) practicing the African Traditional
Religion. However, more than half of the respondents were self-employed 111 (55.5%) when it
comes to their occupational status.
On the obstetric history of the participants for the study, a total number of 60.5% (N=200) stated
“yes” that it was not their first pregnancy. A greater number of the respondents (62.5%) claimed
to have planned for the pregnancies they carried. Remarkably, in the interviews with respondents,
60.0% of them said: “there is no reason whatsoever, they just didn’t go to the health facility”.
Almost all of the respondents (60.0%) had attended ANC during other pregnancies. For those
whose partners were not able to accompany them gave reasons like; “my husband was not around
then”, “because of his work, he hardly has time.”, and interestingly some of them gave “my
husband just refused to come with me for no good reason” as the reason even though the
respondents insisted on it. Table 1 depicts the socio-demographic data of the respondents.
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Table 1: Socio-demographic characteristics (N=200)
Background information
Age
16-20
21 – 25
26 – 30
31 -35
36 – 40
Marital status
Single
Married
Divorced
Educational level
Nil
Primary
Junior high
Senior high
Tertiary
Religious affiliation
Christianity
Muslim
African Traditionalist
Occupation
Unemployed
Students
Self-employed
Formal salary earner
Obstetric History
N
(%)
25
75
64
20
16
12.5%
37.5%
32.0%
10.0%
8.0%
16
183
1
8.0%
91.5%
0.5%
22
17
48
51
62
11.0%
8.5%
24.0%
25.5%
31.0%
43
157
0
21.5%
78.5%
0.0%
24
12.0%
25
12.5%
111
55.5%
40
20.0%
Response Rate (N=200)
Yes (%)
No (%)
79 (39.5%)
121 (60.5%)
125 (62.5%)
75 (37.5%)
75 (37.5%)
125 (62.5%)
44 (22.0%)
156 (78.0%)
70 (35.0%)
130 (65.0%)
120 (60.0%)
80 (40.0%)
70 (35.0%)
130 (65.0%)
Response Rate (N=200)
First pregnancy
Plan for pregnancy
Visit to health facility
Pre-existing medical condition
Screened
Attend ANC
Went with partner
How many times attended ANC
with partner?
1-5
6-10
62 (31.0%)
138 (69.0%)
Number of Children
0-3
4-6
191 (95.5%)
9 (4.5%)
Attendance Rate
1-6
7-12
43 (21.5%)
157 (78.5%)
Response
Parity
Response
Number of ANC attendance
Response
Source: Field data, 2019
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Awareness of Preconception Care (PCC)
When respondents were asked what they knew about PCC, 69 (34.5%) of them claimed to have
heard about preconception care with majority 65.5% (N=200) claiming unawareness of it. When
those who responded in the affirmative were asked about their sources of information, the mass
media recorded 7 (3.50%), friends 6 (3.00%), health worker 15 (7.50%), and from the health
facility 41 (20.50%).
This shows that most of the pregnant women for this study were less aware of the availability of
preconception care interventions/services for them.
Knowledge of Respondents on PCC
Respondents knowledge on PCC was further were assessed based on 10 questions from that section
of the questionnaire. An operational definition was assigned to determine their scoring rates. A
score of 0-3 correctly answered questions were deemed as having low knowledge; 4-6 as moderate
knowledge; and 7-10 symbolized higher knowledge on preconception care.
However, observation from the table below shows that most of the respondents answered “no” to
the questions that were asked indicating low level of knowledge. In view of this their overall
knowledge was computed to assess their scoring rate. The overall findings on knowledge towards
PCC are presented in Table 2 below where a higher percentage of respondents 42.5% (N=85/200)
had poor knowledge whiles 34% had moderate knowledge and a lesser percentage of 23.5% has
high knowledge on PCC.
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Table 2: Responses on Knowledge of PCC
Variables
PCC is care given to women/couples prior to
pregnancy
Response Rate (N=200)
Yes (%)
No (%)
122 (61.0%)
78 (39.0%)
PCC can be patronized only during pregnancy
56 (28.0%)
144 (72.0%)
PCC ends at the beginning of pregnancy
48 (24.0%)
152 (76.0%)
Early detection and management of ill health
couples are some of services provided by PCC
110 (55.0%)
90 (45.0%)
PCC also provides preventive treatment
113 (56.5%)
87 (43.5%)
ANC is an extended part of PCC
96 (48.0%)
104 (52.0%)
PCC is not a neglected part of maternal and child
welfare
57 (28.5%)
143 (71.5%)
PCC is more important than ANC
27 (13.5%)
173 (86.5%)
Inter-conception care is part of PCC
63 (31.5%)
137 (68.5%)
Inter-conception care is PCC that is given in
between pregnancies
62 (31.0%)
138 (69.0%)
Overall Knowledge Score Rate (N=200)
Knowledge
Score
Poor knowledge
0–3
Moderate knowledge
4–6
High knowledge
7 – 10
Source: Field data, 2019
N (%)
85 (42.5%)
68 (34.0%)
47 (23.5%)
Attitude of Respondents towards PCC
Table 3 describes the attitude of respondents towards PCC. Observation from the table shows that
96 (48.0%) of the respondents strongly agreed that it was very important for every woman to
receive preconception care; and 4 (2.0%) strongly disagreed with the view that preconception care
was important in the reproductive years. A total of 171 (85.5%) respondents gave support to private
hospitals as the best for PCC whilst a total of 29 (14.5%) respondents were against that view,
which they were right. In view of this their overall attitude towards PCC was evaluated and
categorised into positive and negative based on the score chalked on the correct or wrong answers
they responded to on the items under the attitude. A score of seven or more correctly out of the 10
appropriate responses from the 25 scores were operationally labelled as having “positive” attitude;
and those who had 11 or more from the 15 wrong answers were operationally categorised as having
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“negative” attitude. The data finally showed that majority 160 (80%) had negative attitude towards
PCC. The Results are also shown in table below.
Table 3: Attitude towards PCC
Attitude
Response Rate (N=200)
Correct (%)
Wrong (%)
PCC is important for every woman
Strongly agree
96 (48.0%)
Agree
60 (30.0%)
Neutral
Disagree
Strongly disagree
Total
156 (78.0%)
PCC is important during reproductive years
Strongly agree
51 (25.5%)
Agree
84 (42.0%)
Neutral
Disagree
Strongly disagree
Total
135 (67.5%)
PCC has implications on pregnancy and delivery
Strongly agree
Agree
Neutral
Disagree
25 (12.5%)
Strongly disagree
9 (4.5%)
Total
34 (17.0%)
Government hospitals are the best for PCC
Strongly agree
21 (10.5%)
Agree
74 (37.0%)
Neutral
Disagree
Strongly disagree
Total
95 (47.5%)
Private hospitals are the best for PCC
Strongly agree
Agree
Neutral
Disagree
20 (10.0%)
Strongly disagree
9 (4.5%)
Total
29 (14.5%)
Overall Attitude of Respondents
Attitude
Score
N
Positive
10
40
Negative
15
160
Total
25
200
Source: Field data, 2019
75
22 (11.0%)
18 (9.0%)
4 (2.0%)
44 (22.0%)
38 (19.0%)
23 (11.5%)
4 (2.0%)
65 (32.5%)
37 (18.5%)
59 (29.5%)
70 (35.0%)
166 (83.0%)
36 (18.0%)
52 (26.0%)
17 (8.5%)
105 (52.5%)
61 (30.5%)
79 (39.5%)
31 (15.5%)
171 (85.5%)
%
20.0
80.0
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Practices of Preconception Care (PCC)
In order to assess the practices of the respondents, participants were asked as to what kind of
preconception services they practiced or benefited from among other items. According to the data,
majority (85%) of the respondents had never patronized preconception care services and only a
few (15%) of them ever sought the services. Interestingly, majority (56.5%) of the respondents
said that there were no PCC units in Tamale with 43.5% accentuating to the statement that there
is. Table 4 gives frequency distribution of the practices on PCC.
Table 4: Practices on preconception care
Variables
Patronage of PCC services
PCC Units in Tamale
Are there PCC units in TWH
Ever patronized PCC services?
Was it helpful?
Intention to continue seeking PCC services
Kind of practices
- Do you undertake exercises within each
week?
What kind of exercises do you do?
- Sweeping
- Walking
- Jogging
- Swimming
- Skipping
- Squatting
Do you eat well before and during conception?
How does your food look like often?
- Not balanced
- Semi-balanced
- Balanced-diet
Have you ever used folic acid before conception?
Was it prescribed at a health facility?
Source: Field data, 2019
76
Response Rate (N=200)
Yes (%)
No (%)
30 (15%)
170 (85%)
87 (43.5%)
113 (56.5%)
25 (12.5%)
175 (87.5%)
11 (5.5%)
189 (94.5%)
10 (5.5%)
190 (94.5%)
147 (73.5)
53 (23.5%)
127 (63.5%)
73 (36.5%)
1 (0.5%)
177 (88.5%)
13 (6.5%)
2 (1.0%
1 (0.5%)
6 (3.0%)
156 (78.0%)
44 (22.0%)
13 (6.5%)
83 (41.5%)
104 (52.0%)
68 (34.0%)
168 (84.0%)
132 (66.0%)
32 (16.0%)
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Bivariate Analyses of Independent and Dependent Variables
Socio-demographics and Awareness of PCC
These analyses were carried out to see the strength of the independent variables as against
the dependent variables to ascertain their statistical significance to the study. Though the
age group of 21-25 had the highest number of participants being aware of PCC services,
when it was cross-tabulated with awareness, results showed no statistical significance
between the two variables (χ2=9.1; p=0.58). More so, there was no association between the
marital status and the level of awareness of the respondents as the p-value and significant
difference showed. Besides, there was an association between the educational level
(Primary level) (χ2=49.6; p=0.01) and religious affiliation (Christianity) (χ2=43.3; p=0.01)
of the respondents. This is shown in table 5.
Table 5: Socio-demographics and Awareness of PCC
Variable
Awareness of PCC
Yes (%)
χ2
Pvalue
9.120
0.58
0.584
1.00
49.639
0.01*
No (%)
Age group
16-20
21-25
26-30
31-35
36-40
4 (16.0%)
29 (38.7%)
26 (40.6%)
8 (40.0%)
2 (12.5%)
21 (84.0%)
46 (61.3%)
38 (59.4%)
12 (60.0%)
14 (87.5%)
Marital status
Single
Married
Divorced
5 (31.3%)
64 (65.0%)
0 (0.0%)
11 (68.7%)
119 (35.0%)
1 (100.0%)
Educational level
Nil
Primary
JHS
SHS
Tertiary
5 (22.7%)
0 (0.0%)
7 (14.6%)
15 (29.4%)
42 (67.7%)
17 (77.3%)
17 (100.0%)
41 (85.4%)
36 (70.6%)
20 (32.3%)
Religious status
Christian
33 (76.7%)
10 (23.3%)
Muslim
36 (22.9%)
121 (77.1%)
(*)=p is statistically significant based on chi square analysis
77
43.259
0.01*
Source: Field data, 2019
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Socio-demographics and Knowledge of PCC
This section looked at the strengths of association between socio-demographic
characteristics and knowledge of respondents on PCC. Their statistical significance was
determined by their p-values (p<0.050). When the strength of socio-demographics was
associated with knowledge of PCC, educational status (Primary level) (χ2=45.4; p=0.01)
and religion (χ2=21.3; p=0.01) were found to show relation and impact on the study
statistically. This is indicated in table 6 below.
Table 6: Socio-demographics and Knowledge of PCC
Variable
Poor
Knowledge
Moderate
χ2
P-value
High
Age group
16-20
21-25
26-30
31-35
36-40
14 (56.0%)
31 (41.3%)
24 (37.5%)
8 (40.0%)
8 (50.0%)
8 (32.0%)
27 (36.0%)
19 (29.7%)
9 (45.0%)
5 (31.3%)
3 (12.0%)
17 (22.7%)
21 (32.8%)
3 (15.0%)
3 (18.7)
Marital status
Single
7 (43.7%)
5 (31.3%)
4 (25%)
Married
Divorced
77 (42.1%)
1 (100.0%)
63 (34.4%)
0 (0.0%)
45 (23.5%)
0 (0.0%)
Educational level
Nil
Primary
JHS
SHS
Tertiary
15 (68.2%)
13 (76.5%)
27 (56.3%)
23 (45.1%)
7 (11.3%)
5 (22.7%)
3 (17.6%)
15 31.3%
16 (31.4%)
29 (46.8%)
2 (9.1%)
1 (5.9%)
6 (12.5%)
12 (23.5%)
26 (41.9%)
7.029
0.536
1.591
1.00
45.429
0.01*
Religious status
Christian
7 (16.3%)
16 (37.2%)
20 (46.5%)
Muslim
78 (49.7%)
52 (33.1%)
27 (17.2%)
21.371
0.01*
(*)=p is statistically significant based on chi square analysis
Source: Field data, 2019
Socio-demographic characteristics and Attitude of respondents
Table 7 below discussed the relationship between independent and dependent variables.
When the socio-demographic characteristics were paired in association with overall
attitude of respondents, the data gathered shows Religion (Christianity) (χ2=4.12; p=0.04)
had a statistical relation with attitudes. More so, none of the independent variables had a
statistical association with practices on PCC.
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Table 7: Socio-demographics and Attitude
Background information
Overall Attitude
Positive (N=40)
Negative (N=160)
(100%)
(100%)
Age group
16-20
21-25
26-30
31-35
36-40
8 (20.0%)
12 (30.0%)
7 (17.5%)
7 (17.5%)
6 (15.0%)
17 (10.6%)
63 (39.4%)
57 (35.6%)
13 (8.1%)
10 (6.3%)
Marital status
Single
Married
Divorced
9 (22.5%)
30 (75.0%)
1 (2.5%)
52 (32.5%)
107 (66.9%)
1 (0.6%)
Educational level
Nil
Primary
JHS
SHS
Tertiary
6 (15.0%)
8 (20.0%)
9 (22.5%)
10 (25.0%)
7 (17.5%)
16 (10.0%)
9 (5.6%)
39 (24.4%)
41 (25.6%)
55 (34.4%)
χ2
P-value
3.470
0.428
1.680
0.637
6.882
0.104
Religious status
Christian
13 (32.5%)
30 (18.8%)
Muslim
27 (67.5%)
130 (81.2%)
4.123
0.042*
(*)=p is statistically significant based on chi square analysis
Source: Field data, 2019
DISCUSSION
This study assessed the awareness, knowledge, attitude and practice among women attending
antenatal clinic at Tamale West Hospital in Ghana as far as preconception care services are
concerned. The awareness level of the study participants on preconception care was analyzed. In
affirming the findings of this study that 34.5% of the respondents had low level of awareness, a
study’s report showed low levels of awareness among men and women on preconception health.[10]
However, this study was contradicted in a report that indicated that females had a higher awareness
level than the males in a research conducted on undergraduate students.[11] Notwithstanding, in
Nigeria, it has been indicated that 43.1% of respondents were aware of preconception care in a
scientific investigation conducted in that country.[22]
Results from this study further showed that the main source of awareness was from the health
facility (20.5%). This validated the findings that most of the participants who sought preconception
care, heard about it during their ANC sessions.[2] In support of this assertion, study participants
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showed a strong preference for obtaining information about preconception healthcare from their
personal physician instead of obtaining information from the Internet.[23] However, there was an
association between the educational status (Tertiary level) (χ2=49.6; p=0.01) and religious
affiliation (Muslim) (χ2=43.3; p=0.01) of the respondents on awareness of preconception care.
When the age group was cross-tabulated with awareness, the results showed no statistical
significance between the two variables (χ2=9.1; p=0.58).
When the participants’ level of knowledge on preconception care was assessed, 42.5% and 23.5%
had poor and high knowledge levels respectively. Poor knowledge was acknowledged in other
studies[22,24,14] which supports this study’s findings. Other studies in Nigeria and among MexicanAmericans respectively, reported that participants have high levels of knowledge on the subject
matter.[17,12,2] Educational status of respondents (Tertiary level) (χ2=45.4; p=0.01) and religious
affiliation (Muslim) (χ2=21.3; p=0.01) were found to influence knowledge statistically.
In terms of attitude, 96 (48.0%) of the respondents strongly agreed that it was very important for
every woman to receive preconception care before conception takes place. Reports from other
studies affirm this study by indicating that more than one-third of their respondents showed
positive attitudes towards preconception care.[9,17] More so, this statement is in line with a study
that claimed that most of the respondents in that study agreed that it was important to receive
preconception care prior to pregnancy.[15] Another 67.5% also agreed that preconception care was
important in the reproductive years. Other authors also indicated that it was important for all
women of child bearing age to receive preconception care.[25,1] When the regression analysis was
done, only Muslim (χ2=4.12; p=0.04) statistically impacted on the attitude.
In terms of practice, findings from this study revealed that only 30 (15%) of respondents visited
the health facility for PCC services. This is conviction that PCC services is rendered in the Tamale
West Hospital at the antenatal clinic. Interestingly, most of them wanted to seek PCC (interconception care) next time which is consistent with findings from other studies.[9,12] Furthermore,
63.5% of the respondents in the present study undertake exercises during the week. This was in
support of other report that indicated that majority of respondents took to exercising, maintaining
good nutrition, and taking well balanced diet.[2]
This study showed a lower percentage 34.0% (68/200) of respondents who used folic acid before
pregnancy. This was in line with other studies that supported women of child bearing age to take
vitamins, including folic acid, within the first trimester of their pregnancy.[2,6,13] However, findings
of this study contradicts the other studies that reported that women in their reproductive age have
inadequate knowledge on folic acid supplementation.[4,26,16]
CONCLUSION
Pregnant women who attend ANC at Tamale West Hospital tended to have low level of awareness
and poor knowledge, they have negative attitude towards preconception care services and seldom
practice preconception care.
There is the need for health care authorities to intensify awareness and implement preconception
care policies.
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RECOMMENDATIONS:
1. The present study demonstrated that there was a need to create awareness which can also
increase the knowledge and practices of reproductive age women or couples. Hence, there
is the need for health authorities to put together comprehensive preconception care policies
for health institutions to abide by..
2. Nursing researchers need to assist in the development of strategies to integrate
preconception care interventions into the existing maternal and child health care
programmes.
3. Organization of outreaches to the communities to create awareness on the subject and to
provide education on the importance of practicing preconception care.
REFERENCES
1. World Health Organization. (2013). Meeting to develop a global consensus on preconception
care to reduce maternal and childhood mortality and morbidity: February 2012 meeting
report. Geneva: WHO.
2. Olowokere, A. E., Komolafe, A., & Owofadeju, C. (2015). Awareness, knowledge and uptake
of preconception care among women in Ife Central Local Government Area of Osun State,
Nigeria. Journal of Community Medicine and Primary Health Care, 27(2): 83-92.
3. Dean, S., Rudan, I., Althabe, F., Girard, A. W., Howson, C., Langer, A., ..., & Venkatraman,
C. M. (2013). Setting research priorities for preconception care in low-and middle-income
countries: Aiming to reduce maternal and child mortality and morbidity. PLoS Medicine,
10(9): e1001508.
4. Gautan, P., & Dhakal, R. (2016). Knowledge on preconception care among reproductive age
women. Saudi J Med Pharm Sci, 2(1): 6.
5. Mason, E., Chandra-Mouli, V., Baltag, V., Christiansen, C., Lassi, Z. S., & Bhutta, Z. A.
(2014). Preconception care: Advancing from ‘important to do and can be done to is being done
and is making a difference’. Reproductive Health, 11(3): S8.
6. Williams, J. L., Abelman, S. M., Fassett, E. M., Stone, C. E., Petrini, J. R., Damus, K., &
Mulinare, J. (2006). Health care provider knowledge and practices regarding folic acid, United
States, 2002–2003. Maternal and Child Health Journal, 10(1): 67-72.
7. Giri, K., & Gautam, S. (2018). Knowledge on preconception care among reproductive aged
women in Kaski District, Nepal. Janapriya Journal of Interdisciplinary Studies, 7(1): 46-56.
8. Ayalew, Y., Mulat, A., Dile, M., & Simegn, A. (2017). Women’s knowledge and associated
factors in preconception care in Adet, West Gojjam, Northwest Ethiopia: A community based
cross-sectional study. Reproductive Health, 14(1), 15.
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9. Ahmed, K. M., Elbashir, I. M. H., Mohamed, S., Saeed, A. K. M., & Alawad, A. A. M. (2015).
Knowledge, attitude and practice of preconception care among Sudanese women in
reproductive age about rheumatic heart disease at Alshaab and Ahmad Gassim hospitals 2014–
2015 in Sudan. Basic Res. J. Med. Clin. Sci., 4(7): 5.
10. Mitchell, E. W., Levis, D. M., & Prue, C. E. (2012). Preconception health: Awareness,
planning, and communication among a sample of US men and women. Maternal and Child
Health Journal, 16(1): 31-39.
11. Delgado, C. E. (2008). Undergraduate student awareness of issues related to preconception
health and pregnancy. Maternal and Child Health Journal, 12(6): 774-782.
12. Coonrod, D. V., Bruce, N. C., Malcolm, T. D., Drachman, D., & Frey, K. A. (2009).
Knowledge and attitudes regarding preconception care in a predominantly low-income
Mexican-American population. American Journal of Obstetrics and Gynecology, 200(6): 686e1.
13. Wilton, D. C., & Foureur, M. J. (2010). A survey of folic acid use in primigravid women.
Women and Birth, 23(2): 67-73. Retrieved 6th August, 2019 from
https://scholar.google.com/scholar.
14. Nepali, G., & Sapkota, S. D. (2017). Knowledge and practice regarding preconception care
among antenatal mothers. International Journal of Perceptions in Public Health, 1(4): 224227.
15. Crusenberry, K. J. (2016). An online study of undergraduates’ knowledge, awareness, and
attitudes of preconception care.
16. Krishnan, G. G., Joseph, J., & Maheswari, B. (2016). Effect of structured West program on
knowledge and attitude regarding preconception care among adolescent girls. IJAR, 2(4): 435439.
17. Bayrami, R., Ebrahimipour, H., Ebrahimi, M., Forootani, M., & Najafzadeh, B. (2013). Health
care providers’ knowledge, attitude and practice regarding pre-conception care. Journal of
Research and Health, 3(4): 519-526.
18. Klein, J., Boyle, J. A., Kirkham, R., Connors, C., Whitbread, C., Oats, J., ..., & Shaw, J. (2017).
Preconception care for women with type 2 diabetes mellitus: A mixed-methods study of
provider knowledge and practice. Diabetes Research and Clinical Practice, 129: 105-115.
19. van Voorst, S., Plasschaert, S., de Jong-Potjer, L., Steegers, E., & Denktaş, S. (2016). Current
practice of preconception care by primary caregivers in the Netherlands. The European Journal
of Contraception & Reproductive Health Care, 21(3): 251-258.
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20. Sattarzadeh, N., Farshbaf-Khalili, A., & Khari, E. (2017). Socio-demographic predictors of
midwives’ knowledge and practice regarding preconception care. International Journal of
Women's Health and Reproduction Sciences, 5(3): 212-217.
21. Temel, S., van Voorst, S. F., Jack, B. W., Denktaş, S., & Steegers, E. A. (2013). Evidencebased preconceptional lifestyle interventions. Epidemiologic reviews, 36(1): 19-30.
22. Ezegwui, H. U., Dim, C., Dim, N., & Ikeme, A. C. (2008). Preconception care in South Eastern
Nigeria. Journal of Obstetrics and Gynaecology, 28(8): 765-768.
23. Frey, K. A., & Files, J. A. (2006). Preconception healthcare: what women know and believe.
Maternal and Child Health Journal, 10(1), 73-77.
24. Fadia, M., Azza Refaat, T., & Emam, E. (2012). Awareness of primary health care providers
in Elminia Governorate about preconception care, Egipt. El-Minia Medical Bulletin, 23(1): 14.
25. Phipps, E. (2016). Using school nurses to deliver preconception health education: A call to
action. British Journal of School Nursing, 11(5): 243-245.
26. Abu-Hammad, T., Dreiher, J., Vardy, D. A., & Cohen, A. D. (2008). Physicians’ knowledge
and attitudes regarding periconceptional folic acid supplementation: A survey in Southern
Israel. Medical Science Monitor, 14(5), CR262-CR267.
83
TEACHERS’ KNOWLEDGE, ATTITUDES AND
PRACTICES TOWARD EPILEPSY IN TARKWANSUAEM MUNICIPALITY
KHALID SALIM AHMED
RICHARD OPOKU ASARE
AKWASI BOAKYE-YIADOM
PAUL ARMAH ARYEE
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TEACHERS’ KNOWLEDGE, ATTITUDES AND PRACTICES
TOWARD EPILEPSY IN TARKWA-NSUAEM MUNICIPALITY
KHALID SALIM AHMED (MSc, B.A, RN (Dip-RMN)1
Tarkwa Municipal Hospital, P. O. Box 10, Tarkwa
Western Region, Ghana
Corresponding Author’s Email: awendarzi@outlook.com
RICHARD OPOKU ASARE (MPhil, BEd, RN (Dip)-RMN, Cert.Ed.)2
College of Nursing, Ntotroso
Ahafo Region, Ghana
AKWASI BOAKYE-YIADOM (MSc, B.Ed)3
Department of Public Health, School of Allied Health Sciences
University for Development Studies, Tamale, Ghana
PAUL ARMAH ARYEE (PhD, MPhil, MMEdSc, BSc)4
Department of Nutritional Sciences, School of Allied Health Sciences,
University for Development Studies, Tamale, Ghana
ABSTRACT
Purpose: The objective of this study was to assess the knowledge, attitudes and practices of basic
school teachers on epilepsy in Tarkwa-Nsuaem Municipality.
Methodology: The study employed a descriptive cross-sectional design. Teachers were sampled
from public basic schools in the municipality using the Yamane’s formula for known sampling
frame to arrive at 226 participants for the study. The multi-stage and convenience sampling
techniques were then used to sample teachers from five of the seven circuits with each circuit being
allocated 62 teachers for the study. A semi-structured questionnaire which was used for the data
collection was adapted from a study in Namibia. Chi squares and P-values were applied to
determine the association between dependent and independent variables as confidence level set at
0.05. Data was analyzed with SPSS version 20.
Results: The study found that majority of the teachers, 167 (73.9%) were knowledgeable about
epilepsy and 191 (84.5%) had positive attitudes toward epilepsy. However, seizure management
practices among the teachers were poor; only 44 (19.3%) of the teachers had appropriate seizure
management practices. Notwithstanding, the religion of the teachers was found to be significantly
associated with knowledge on epilepsy (p=0.041). The study found that marital status had an effect
on attitudes toward epilepsy (p=0.004), whilst educational qualification was also significantly
associated with attitudes toward epilepsy (p=0.001). The self-rated knowledge levels of the
teachers, had no significant relationship with seizure management practices (p=0.508).
Conclusion: Though majority of the teachers had adequate knowledge and positive attitudes
toward epilepsy, it did not reflect in appropriate management of seizure.
Recommendation: The Ghana Health Service should collaborate with the Ghana Education
Service in training teachers on the management of seizure attacks.
Key words: Teachers, Knowledge, Attitudes, Practices, Epilepsy, Tarkwa-Nsuaem
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INTRODUCTION
Epilepsy is a neurological condition that affects people and manifests in repeated seizure activity
in the victim as a result of brain cell malfunction. Seizure is broadly categorized into partial and
generalized types depending on the part of the brain experiencing abnormal neuron activity. The
condition may result from identifiable causes such as head injury, brain tumor, brain infection and
certain genetic disorders. It may also result from unidentifiable causes, in which case a carefully
taken history is used to diagnose the condition.[1]
Epilepsy is one of the commonest neurological disorders in the world, and approximately 50
million people are known to suffer from the condition worldwide. Globally, the annual estimate of
epilepsy diagnosis stands at 2.4 million, affecting between 30 and 50 people per 100,000 of the
general population in high income countries. In low income countries, annual diagnosis is about
double the number in high income countries.[2] Africa has one of the highest prevalence rates of
epilepsy in the world as evidenced by estimates provided by some agencies working on epilepsy
including the Global Campaign Against Epilepsy who puts the prevalence at 11.29 cases per 1000
people.[3] Similar findings were found in a study for selected Sub-Saharan African countries.[4] In
Ghana, the prevalence is reported to be 10.1 per 1000 people.[4,5] The disease as it stands has
enormous effect on the physical health of sufferers, with people with epilepsy (PWE) having a
relatively higher number of physically unhealthy days than those without epilepsy due to frequent
falls.[6]
As found in a study that indicated that teachers generally have poor knowledge regarding the
various manifestations of epilepsy, it explained that many of the teachers mentioned that epilepsy
is always associated with seizure.[20] Notwithstanding, the reported poor knowledge on epilepsy
and its manifestation among teachers, however, is not limited to a single continent. The general
impression is that seizure is the defining feature of epilepsy, and therefore any condition that
closely mimics epilepsy but is short of a seizure is more likely to be seen and may be mistaken for
epilepsy.[12] Nevertheless, teachers in a Zimbabwe study were more likely to encourage
participation of PWE in all school activities and not restrict them from playing with peers who do
not have epilepsy.[7] Contrary to this assertion, there are some teachers who do not think that PWE
are intellectually incapable but would prefer not to have PWE in their class because they may be
unnerved by the spectacle of an attack, a situation attributed to poor knowledge on first aid seizure
management.[15]
Living with epilepsy comes with lots of social challenges as well. This is evidenced by a
publication of the impact social attitudes found widespread negativity towards people living with
epilepsy (PWE) and their families.[2] Indeed, many studies in developing countries have reported
teachers being unwilling to teach in a class with a PWE; epilepsy policies rarely exist.[7,8] However,
many schools in developed countries have epilepsy policies that ensure that PWE are admitted and
taken good care of.[9] However, some teachers are unaware of the leading role they could play in
helping PWE adjust to the social and academic challenges they face, and so in many cases
recommend that PWE be sent to special schools.[21] Nonetheless, after being educated on the
disease and the role to play, some teachers were adamant about changing their behaviour towards
PWE and were often ill-prepared to help in emergency situations.[11] This argument was supported
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by some studies that revealed the many of the teachers even did not know whether there was
someone in their class with epilepsy, with a few being aware of PWE in the class.[16,18]
The poor seizure management practices reported around the world could be the result of inadequate
epilepsy and seizure management training of people. For instance, one study in Brazil made a
startling revelation that almost all the teachers in a study conducted in a special school reported
never having been taken through seizure management training,[22] while some teachers in Sudan
also reported their unwillingness to intervene in the event of a seizure attack.[23] The findings above
illuminates and adds weight to the widely held opinion that PWE are neglected, even to the extent
that teachers in special schools lack the necessary skills to manage seizure. Additionally, in Ghana,
teachers are not trained in epilepsy management while under training. This supports the view that
teachers in Tarkwa-Nsuaem Municipality (TNM) may not be in a position to intervene when a
pupil is seizing. Furthermore, unlike private basic schools where special arrangements exist
between parents of PWE and the teachers, the public schools teachers are mostly unaware of the
health status of their pupils.
As a substantial proportion of PWE receiving treatment at Tarkwa Municipal Hospital are children
of school-going age, many of these children are left to their fate during an attack while in school
with many reported to sustain serious injuries during attacks.[10] Teachers, as being influential in
almost every society and serving as scribes to members of in our communities in Ghana, the intent
of the researchers is therefore to leverage this goodwill of teachers to support PWE. This could
only be possible if the knowledge, attitudes and practices of the teachers are known.
METHODOLOGY
The current study was conducted in Tarkwa-Nsuaem Municipality (TNM) of the Western Region
of Ghana due to the diverse nature of the population. A descriptive cross-sectional research design
was used for the study because the intention was to obtain a snapshot of the knowledge, attitudes
and practices of the teachers in TNM at one point in time. Teachers were sampled from public
basic schools in the municipality using the Yamane’s formula for known sampling frame, giving
a total sample size of 312 for the study. The multi-stage and convenience sampling techniques
were then used to sample teachers from five of the seven circuits with each circuit being allocated
62 teachers for the study. The study variables included the independent variables comprising age,
gender, educational qualification, marital status, years of service, and religion and the dependent
variables comprising knowledge, attitudes and practices.
A semi-structured questionnaire was used for data collection. The instrument was selfadministered and adapted from a study in Namibia which used a similar study.[11] The researchers
administered the questionnaire in a systematic manner, starting from schools closest to them and
ending with those farthest. The administration began in earnest after a meeting was convened to
explain the purpose of the research in each school. The teachers willing to participate in the study
were given a copy of the questionnaire and given a week to fill and submit. The collection of the
questionnaire was done by the researchers themselves and it was collected in a systematic order,
one circuit after the other. The entire process of data collection took a month, starting from May
16, 2017 to June 15, 2017. The collected questionnaire were subsequently inspected and sorted,
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and improperly filled ones, those with arbitrary responses, rejected. Incompletely filled ones, those
that failed to answer any of the questions on socio-demographic characteristics or those that failed
to answer at least five of the questions under knowledge, attitudes and practices, were also rejected.
Questionnaire that were deemed to be appropriately filled were subsequently numbered for
analysis later. The questionnaire was pre-tested in the Prestea-Huni Valley District, a contiguous
district, from March 16 to March 24, 2017. Identified challenges with some of the questions in the
instrument were revised and a report, together with the revised questionnaire, sent to the
researchers’ supervisor who approved it for the study.
Data was analyzed and presented at two levels using SPSS version 20. The first level was the
descriptive part, covering a report of exactly what was written by the teachers; hence, frequency
tables and percentages were used. The second level was the analytic part, involving the use of Chi
squares and P-values to determination association between the dependent and independent
variables. Cross-tabs were used and the confidence level set at 0.05. The research was conducted
in line with ethical guidelines. First, participation in the study was voluntary, and teachers who
agreed to participate in the study given the consent form to sign. Also, no form of identification,
such as names, telephone numbers or addresses, was required from the teachers. The teachers were
also assured of the privacy and confidentiality of shared information. Even though the researcher
did not anticipate harm of any sort to the teachers, a written permission was sought from the Ghana
Education Service, through the Municipal Director of Education, and the Public Health
Department of the University for Development Studies, Tamale, and approval received before data
collection commenced.
RESULTS
The number of respondents who participated in this study numbered 226 teachers, and their sociodemographic characteristics are shown in Table 1. The study found that most of the teachers
(73.9%) possessed adequate knowledge about epilepsy with a few (26.1%) showing inadequate
knowledge, as indicated in Table 2. Besides, when the teachers’ responses were categorized to
evaluate their attitudes toward epilepsy, it was found that majority (84.5%) of them had positive
attitudes with the rests showing negative attitudes toward epilepsy. This is shown in Table 3. When
it came to the practices on epilepsy, 49 (21.6%) of the teachers claimed they would avoid touching
saliva of a seizing person, with 6.1% (n=14/226) saying they would rather lay victims on their
sides. When their responses on the practices were categorized, 182 (80.7%) however, exhibited
inappropriate seizure management practices as shown in Table 4.
Bivariate analyses
On the bivariate analyses, the marital status of the teachers was significantly associated with
knowledge on epilepsy (p=0.002). More so, the religion of the teachers was also found to be
significantly associated with knowledge on epilepsy (p=0.041) as seen in Table 5. Besides, the
study found that marital status had an effect on attitudes toward epilepsy (p=0.004) with
educational qualification showing a strong association with attitudes toward epilepsy (p=0.001) as
indicated in Table 6.
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The practices of the teachers, although generally inappropriate with only 44 (19.3%) having
appropriate practices, there was however, a significant relationship between the age of the teachers
and seizure management (p=0.003). The relationship between the gender of the respondents and
seizure management was found to be significantly associated with seizure management (p=0.001)
as shown in Table 7. However, the study found no significant association between knowledge
levels of the teachers and seizure management practices (p=0.179) as seen in Table 8. The selfrated knowledge levels of the teachers had no significant relationship with seizure management
practices (p=0.508) as depicted in Table 9. In Table 10, however, the attitudes of the teachers had
a significant relationship with seizure management (p=0.001).
Table 1: Socio-demographic characteristics
Variable
Category
Frequency
(n)
130
Percentage
(%)
79.2
Age
Young adults
Middle aged adults
34
20.8
Marital Status
Male
Female
Married
93
133
149
58.8
41.2
66
Educational Qualification
Single
Up to Diploma
77
71
34
31.4
Bachelor’s Degree
140
62
Postgraduate Degree
Up to 10 years
11-20 years
Above 20 years
Christianity
Islam
15
106
39
24
217
9
6.6
62.7
23
14.3
96
4
Gender
Years of service
Religion
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Table 2: Knowledge about epilepsy
Item
Have you ever heard of epilepsy
Do you know anyone with epilepsy
Have you ever taught a student with
epilepsy
Have you witnessed someone
experience a seizure before
Perception of epilepsy
Causes of epilepsy
Is epilepsy communicable
Is epilepsy treatable
Appropriate treatment for epilepsy
Responses
Yes (%)
No (%)
226 (100%)
-169 (74.8%)
57 (25.2%)
62 (27.4%)
164 (72.6%)
Total
n (%)
226 (100%)
226 (100%)
226 (100%)
173 (76.5%)
53 (23.5%)
226 (100%)
126 (55.7%)
121 (53.5%)
43 (21%)
208 (95%)
110 (53%)
100 (44.3%)
105 (46.5%)
161(79%)
11 (5%)
98 (47%)
226 (100%)
226 (100%)
204 (100%)
219 (100%)
208 (100%)
Categorization of knowledge about epilepsy
Knowledge Levels
n
%
Adequate knowledge
167
73.9
Inadequate knowledge
59
26.1
Total
226
100
Table 3: Attitudes toward Epilepsy
Item
Yes
Are you willing to teach a student with epilepsy
192 (85%)
Should PWE attend regular schools
132 (58%)
Can PWE achieve the highest education possible 172 (76%)
Would you allow your ward play with PWE
172 (76%)
Would you allow a close relative marry a PWE
98 (43.4%)
Should PWE have children
167 (73.9%)
Would you associate in social gathering with
186 (82.3%)
PWE
Would you maintain your attitude when
194 (85.8%)
someone you know is diagnosed with epilepsy
Are you willing to have a PWE as a close friend 172 (80.7%)
Categorization of Attitudes
Attitude Category
n
Positive attitude
191
Negative attitude
35
Total
226
56
No
34 (15%)
94 (42%)
54 (24%)
54 (24%)
128 (56.6%)
59 (26.1%)
40 (17.7%)
Total
226 (100%)
226 (100%)
226 (100%)
226 (100%)
226 (100%)
226 (100%)
226 (100%)
32 (14.2%)
226 (100%)
41 (19.3%)
213 (100%)
%
84.5
15.5
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Table 4: Seizure management practices
Practices
Promptly move from danger
Lay victim on their side
Pour water on the face
Let them smell something
Hold legs and arms
Avoid touching a person having a seizure
Avoid touching saliva of a seizing person
Put something in the mouth
N
30
14
20
13
31
28
49
41
Percentage
13.2
6.1
8.8
5.7
15
12.3
21.6
17.3
n
44
182
226
%
19.3
80.7
100%
Seizure management categories
Practices
Appropriate practice
Inappropriate practice
Total
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Table 5: Socio-demographic characteristics and knowledge on epilepsy
Socio-demographic variable
Age
− Young adults
− Middle aged adults
Gender
− Male
− Female
Marital Status
− Married
− Single
Educational Qualification
− Up to Diploma
− Bachelor’s Degree
− Degree Postgraduate
Years of service
− Up to 10 years
− 11-20 years
− Above 20 years
Religion
− Christianity
− Islam
Level of significance (α) = 0.05
Knowledge Level: n (%)
Adequate
Inadequate
p-Value
80 (83.3%)
29 (78.3%
16 (16.7%)
8 (21.7%)
0.506
56 (60.2%)
70 (52.6%)
37 (39.8%)
63 (47.4%)
0.259
94 (63%)
32 (41.5%)
55 (37%)
45 (58.5%)
0.002*
39 (55%)
83 (59.2%)
4 (26.6%)
32(45%)
57 (40.8%)
11 (73.4%)
0.053
59 (64%)
10 (33.3)
10 (58.8%)
33 (36%)
20 (66.7%)
7 (41.2%)
0.120
118 (54.3%)
8 (89%)
99 (45.7%)
1 (11%)
0.041*
*p-values based on the chi-square analysis
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Table 6: Socio-demographic characteristics and attitudes towards epilepsy
Attitude Level: n (%)
Positive
Negative
Socio-demographic variable
Age
− Young adults
87 (83.6%)
18 (16.4%)
− Middle aged adults
21 (72.4%)
8 (27.6%)
60 (64.5%)
33 (35.5%)
72 (54%)
61 (46%)
96 (65.3%)
51 (34.7%)
36 (45.5%)
43 (54.5%)
17 (30.3%)
39 (69.7%)
− Bachelor’s Degree
102 (76.7%)
31 (23.3%)
− Postgraduate Degree
13 (86.6%)
2 (13.4%)
Years of service
− Up to 10 years
73 (87%)
11 (13%)
− 11-20 years
20 (69%)
9(21%)
17 (77.2%)
5 (22.8%)
124 (57%)
93 (43%)
8 (89%)
1(11%)
p-Value
0.208
Gender
− Male
− Female
Marital Status
− Married
− Single
Educational Qualification
− Up to Diploma
− Above 20 years
Religion
− Christianity
− Islam
Level of significance (α) = 0.05
0.119
0.004*
0.001*
0.086
0.058
*p-values based on the chi-square analysis
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Table 7: Socio-demographic characteristics and seizure management practices
Socio-demographic variable
Age
− Young adults
Practice Level: n (%)
Appropriate
Inappropriate
28 (21.5%)
102 (78.5%)
16 (47%)
18 (53%)
− Male
25 (34.2%)
48 (65.8%)
− Female
19 (14.2%)
114 (85.8%)
Marital Status
− Married
29 (19.4%)
120 (80.6%)
15 (19.5%)
62 (80.5%)
− Up to Diploma
11 (15.5%)
60 (84.5%)
− Bachelor’s Degree
29 (20.7%)
111 (79.3%)
− Postgraduate Degree
4 (26.7%)
11 (73.3%)
Years of service
− Up to 10 years
23 (21.7%)
83 (78.3%)
− 11-20 years
12 (30.8%)
27 (69.2%)
− Above 20 years
9 (37.5%)
15 (62.5%)
42 (19.4%)
175 (80.6%)
2 (22%)
7 (88%)
− Middle aged adults
p-Value
0.003*
Gender
− Single
0.001*
0.997
Educational Qualification
Religion
− Christianity
− Islam
0.509
0.209
0.831
Level of significance (α) = 0.05
*p-values based on the chi-square analysis
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Table 8: Knowledge levels and seizure management practices
Knowledge level
Adequate knowledge
Inadequate knowledge
Total
Level of significance (α) = 0.05
Practices
Inappropriate
practices
138 (84%)
44 (74.6%)
182
Appropriate
practices
29 (16%)
15 (25.4%)
44
Total
p-Value
167 (100%)
59 (100%)
226 (100%)
0.179
Table 9: Self-rated knowledge and seizure management practices
Self-rated knowledge
Appropriate
practice
High level
25 (26.3%)
Low level
19 (22%)
Total
44
Level of significance (α) = 0.05
Practices
Inappropriate
practice
70 (73.7%)
67 (78%)
137
Total
p-Value
95 (100%)
86 (100%)
181 (100%)
0.508
Table 10: Attitudes and seizure management practices
Attitude Category
Positive attitude
Negative attitude
Total
Appropriate
practices
30 (15.7%)
14 (40%)
44
Level of significance (α) = 0.05
Practices
Inappropriate
practices
161 (84.3%)
21 (60%)
Total
p-Value
191 (100%)
35 (100%)
0.001*
182
226 (100%)
*p-values based on the chi-square analysis
DISCUSSION
Studies conducted on knowledge about epilepsy among teachers have revealed poor knowledge
about epilepsy in many parts of the world.[12,13] The case is especially troubling in developing
countries where much of knowledge about epilepsy is rooted in culture and so culturally
appropriate treatment is sought.[2] In this study, however, the majority of the teachers were found
to possess adequate knowledge about epilepsy. Similar findings were made in Pakistan and
Southern Saudi Arabia.[14,15] The knowledge levels of teachers in this study is evidenced by the
generally higher scores obtained by the teachers on the adequate knowledge category as against
the other category on the composite scores table, making it imperative to discuss some of the
highlights.
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It was found that, although the teachers generally perceived epilepsy as a brain disorder, an
appreciable number 58 (25.6%) perceived it as a form of mental retardation or mental illness, a
finding that agrees with a study in Turkey.[16] This is worrying because the teachers expressing
this view may not see the need to educate PWE. It is important to mention that many people with
epilepsy have over time, through repeated attacks developed mental problems because of poor
access to anti-epileptic medications.[2] This may have informed the choice of mental illness by
some teachers. The above position is supported by the opinion that teachers in developing nations
tend to associate mental illness with epilepsy more, compared with their counterparts in developed
countries.[14] The finding in this study, therefore, gives support to the above position.
Additionally, despite the fact that modern health facilities abound in the Municipality, as evidenced
by the two public hospitals, dozens of private hospitals as well as specially trained professionals
to treat epilepsy with modern medicine, a significant number of the teachers recommended treating
epilepsy with traditional medicine, a finding similar to a study in Nigeria.[12] This practice is known
to be dangerous and should not be encouraged. There are lots of radio shows locally at TNM that
promote the use of traditional products for treating epilepsy and other conditions. This has really
caught the attention of people and many are patronizing these traditional products. This may have
influenced the choice of traditional medicine by some of the teachers for treating epilepsy.
The marital status of the teachers was also found to influence their knowledge on epilepsy
(p=0.002). The study found that married teachers possessed more adequate knowledge about
epilepsy than their single counterparts, a finding similar to another made in Iran.[16] In Ghana, the
tradition among many ethnic groups requires that comprehensive background checks are made
before marriage is contracted between couples. This is done to rule out any undesirable health
conditions including epilepsy in the family of a potential partner. The married teachers in the study
may have gone through these checks already and may in the lead up to their unions sought
information from different sources regarding epilepsy, perhaps explaining the difference in
knowledge. It is important to point out that, out of the total number of teachers who mentioned
inheritance as a possible cause of epilepsy, 142 (63%) were married while 84 (37%) were single.
It is therefore possible that Ghanaian culture may have played a role in exposing married people
to more information about epilepsy than their single counterparts. However, this position is
strongly contested against that the teachers’ knowledge regarding inheritance may be attributed to
their appreciation of science rather than culture.[17]
The religious affiliation of the teachers was also found to influence their knowledge on epilepsy.
In the study, the majority of the teachers indicated being Christians, and in Christianity, stories
about epilepsy can be found a number of times in the Bible which may have induced interest in
the condition and the desire to read about it and clarify any lingering misconceptions. Surprisingly,
even though epilepsy is rarely mentioned in the Quran and stories about the condition is uncommon
in the religion, Muslim teachers were more knowledgeable about epilepsy than Christians
(p=0.041). The reason for this may lie in the small size of Muslim participants in the study.
On the attitude of teachers towards epilepsy, the study found that a higher number of the teachers
had positive attitude. The attitude of the teachers was found to be positive for eight of the nine
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items that measured attitude towards epilepsy. This aligns with findings made in Zimbabwe and
Nigeria where the majority of the teachers exhibited positive attitudes towards epilepsy.[7,13]
The study found that even though almost half of the teachers 95 (42%) would have preferred PWE
to attend special schools, the reason behind their position was one of personal discomfort and not
that epilepsy is contagious. Indeed, many of the teachers 161 (71.7%) who chose that option were
aware that the condition is not contagious. Additionally, many of the teachers showed willingness
to teach in a class with someone having epilepsy as evidenced by the composite score table on
attitudes. The finding aligns with a study in Nigeria[13] and is encouraging and could be seized on
by the Ghana Education Service to encourage families having PWE to send their wards to school.
Knowledge, to a large extent, forms the basis of peoples’ attitudes. It is instructive to note that
even though the teachers generally had a positive attitude towards epilepsy, one position that they
were unwilling to compromise on was allowing a close relative to marry someone with epilepsy.
The finding is similar to a study in Osogbo in Eastern Nigeria.[13] There appears to be some sort of
relationship between knowledge of cause of epilepsy and willingness to sanction marriage between
people with epilepsy and people without epilepsy. Marriage usually leads to procreation, and by
extension, offspring inheriting genes from parents. The teachers in this study appear to be well
aware that inheritance plays a role in epilepsy as evidenced by the majority of teachers choosing
inheritance twice more than the other causes of epilepsy in the composite score on knowledge.
This may have informed the majority of teachers’ decision to disallow marriage between a close
relative and a PWE.
The study also found that married teachers showed more positive attitude towards epilepsy than
their single counterparts (p=0.004). This finding is not surprising since married teachers in the
study have been found to be more knowledgeable about epilepsy than their single counterparts and
given that knowledge largely influences attitude.
The educational qualification of the teachers was also found to influence attitudes toward epilepsy.
In the study, the attitudes of the teachers who possessed up to Bachelor’s degree and Post Graduate
certificates were more positive than the teachers with up to Diploma certificates (p<0.001). Even
though the reason for this difference in attitude is unclear, the broad nature of University education
could have possibly influenced the teachers’ worldview and their subsequent attitudes toward
epilepsy. The finding here is similar to others made in other studies.[16,17]
Appropriate knowledge on seizure management is key to saving lives of people experiencing
seizure. It is would be good for teachers to learn seizure management given that they spend lots of
time with students in school not only as teachers but as care givers as well.
The current study found that the teachers had poor seizure management practices, a situation that
has serious implications for students in the Municipality. The current study’s finding is similar to
an Ethiopian study[18] as well as another in Nigeria.[19] It is also not different from an Iranian
study.[16] The sources of information may have something to do with the poor seizure management.
It could be seen in the table on sources of information that majority of the teachers sourced
information on epilepsy from friends and relatives; sources that may not exactly be authorities in
epilepsy care.
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However, some differences in seizure management were observed among the various demographic
characteristics. On the ages of the teachers, for instance, it was found that middle aged adults
exhibited more appropriate seizure management practices than their young adult counterparts
(p=0.003). Even though the reason for this difference is not clear, it could be that more middle
aged adults may have witnessed seizure being managed than young adults. Another possible reason
could be marriage, since more middle aged adult teachers than young adult teachers were married
and so may have been exposed more to issues on epilepsy than young adult teachers.
Another observation made in the study is that, male teachers exhibited more appropriate seizure
management practices than females (p=0.001) which may partly be attributed to the higher
knowledge of males on epilepsy 136 (60.2%) compared to females 119 (52.6%), although this is
not statistically significant (p=0.259). Generally, females are considered to be more caring than
males and perhaps would have been expected to know more about seizure management than males.
However, that is not the case here. Knowledge and, perhaps, courage may have an influence in
male teachers showing more appropriate seizure management than their female counterparts.
The relationship between the teachers’ knowledge on epilepsy and seizure management practices
was analyzed and an interesting finding made. It is instructive to note that the teachers found to
possess inadequate knowledge about epilepsy were in fact found to have more appropriate seizure
management practices 57 (25.4%) than those with adequate knowledge on epilepsy 36 (16%) even
though this difference is not statistically significant (p=0.179). However, the teachers who rated
themselves as knowledgeable about epilepsy were found to possess more appropriate seizure
management practices than those who rated themselves as not knowledgeable even though this
difference is not statistically significant (p=0.508).
The relationship between the teachers’ attitudes toward epilepsy and seizure management practices
was also analyzed. Surprisingly, the teachers found to have positive attitudes toward epilepsy
showed more inappropriate seizure management practices 36 (15.7%) than their counterparts with
negative attitudes 90 (40%) and this was found to be statistically significant (p=0.001). This
finding is not encouraging and tells a story of a group of teachers who have the goodwill to help
PWE acquire formal education against all the odds yet are poorly skilled in helping PWE in
emergency situations.
The importance of knowledge in changing the world for the better is invaluable, and even though
knowledge is known to form the basis of action, it is unfortunate to find that the reported high
levels of knowledge and positive attitudes of the teachers toward epilepsy in this study did not
translate into appropriate seizure management practices.
CONCLUSION
The study made some key findings including the finding that majority 167 (73.9%) of the teachers
possessed adequate knowledge about epilepsy. Majority 191 (84.5%) of the teachers were also
found to have positive attitudes toward epilepsy. However, seizure management was found to be
poor among majority 182 (80.7%) of the teachers, a finding with serious implications for PWE.
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It was also found that, even though the teachers had adequate knowledge and positive attitudes
toward epilepsy, this did not necessarily translate into appropriate seizure management practices.
RECOMMENDATION
1. As a matter of urgency, teachers need to be educated on epilepsy so that they are able to identify
pupils with the condition and make appropriate recommendations to their guardians to avoid
complications so as to save lives and prevent injuries.
2. Heads of basic schools periodically should invite community health nurses to their institutions
to give a lecture on causes of seizure and its management, and train teachers to intervene during
attack using recommended first aid measures.
3. The Ghana Education Service in consultation with the Ghana Health Service should set up sick
bays in the schools and employ the services of nurse practitioners to manage the pupils when
they fall sick.
4. An in-depth qualitative study needs to be conducted as to why some individuals would not
allow themselves and/or a close relative marry PWE.
REFERENCES
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Health Organisation.
2. World Health Organization. (2016). Factsheet. Geneva: World Health Organization: Retrieved
December 18, 2016 from www.who.int/mediacentre/factsheets/fs999/en/
3. Winkler, A. S. (2013). Epilepsy and Neurosysticercosis in Sub-Saharan Africa. InTech.
doi://dx.doi.org/10.5772/53289
4. Ngugi. A. K., Bottomley, C., Kleinschmidt, I., Wagner, R. G., Kakooza-Mswesige, A., AeNgibise, K., Owusu-Agyei, S., Masanja, H., Kamuyu, G., Odhiambo, R., Chengo, E., Sander,
J.S., & Newton, J. R. (2013). Prevalence of active convulsive epilepsy in Sub-Saharan Arica
and associated risk factors: Cross-sectional and case control studies. The Lancet, 253-263. doi:
https://dx.doi.org/10.1016/S1474-4422(13)70003-6.
5. Ae-Ngibise, K. A., Akpalu, B., Ngugi, A., Akpalu, A., Agokey, F., Punguyire, D., Bottomlry,
C., Newton, C., & Owusu-Agyei, S. (2015). Prevalence and risk factors for active convulsive
epilepsy in Kintampo, Ghana. The Pan African Medical Journal, 21-29.
6. Cardarelli, W. J., & Smith, B. J. (2010). The burden of epilepsy to patients and payers. The
American Journal of Managed Care, 331-336.
7. Goronga, P., Gatsi, R., Gatahwi, L., & Dozva, M. (2013). Primary school teacher's attitudes
towards pupils with epilepsy: The Zimbabwean experience and implications for Practice.
American Based Research Journal 2(4), 41-50. ISSN (2304-7151).
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8. Al-Hashemi, E., Ashkanani, A., Al-Qattan, H., Mahmoud, A., Al-Kabbani, M., Al-Juhaidli, A.,
Jaafar, A., & Al-Hashemi, Z. (2016). Knowledge about epilepsy and attitudes toward students
with epilepsy among middle and high school teachers in Kuwait. International Journal of
Pediatrics. doi://dx.doi.org/10.1155/2016/5138952.
9. Epilepsy Action. (2005). Epilepsy policy for schools. Retrieved January 8, 2017 from
www.epilepsy.org.uk/sites/epilepsy/files/images/downloads/epilepsyaction_schools_policy.
10. Ghana Health Service. (2016). Mental health annual report. Tarkwa: Tarkwa Municipal
Hospital.
11. Angula, N. P. I. (2016). Knowledge, attitudes and practices towards epilepsy among secondary
school teachers in Oshana region. Retrieved January 29, 2017, from www.repositorar
y.unam.edu.na/handle/11070/1691/text/index/html.
12. Akpan, M. U., Ikpeme, E. E., & Utuk, E. O. (2013). Teachers’ knowledge and attitudes towards
seizure disorder: A comparative study of urban and rural school teachers in Akwa Ibom State,
Nigeria. Nigerian Journal of Clinical Practice, 16(3), 365-70. doi:10.4103/1119-3077.113465
13. Mustapha, A. F., Odu, O. O., & Akande, O. (2013). Knowledge, attitudes and perceptions of
epilepsy among secondary school teachers in Osogbo South-West Nigeria: A community based
study. Nigerian Journal of Clinical Practice, 16(1), 12-18.
14. Bhesania, N. H., Rehman, A., Savul, I. S., & Zehra, N. (2014). Knowledge, attitude and
practices of school teachers towards epileptic school children in Karachi, Pakistan. Pakistan
Journal of Medical Science, 30(1), 220-224. doi://dx.doi.org/10.12669/pjms.301.4307.
15. Alqahtani, J. M. (2015). Knowledge and practice of school teachers towards students with
epilepsy in Khamis Mushate, Southern Saudi Arabia. Journal of Family and Community
Medicine, 22(3), 163-168.
16. Karimi, N., & Heidari, M. (2015). Knowledge and attitudes towards epilepsy among school
teachers in West of Iran. Iranian Journal of Neurology, 14(3), 130-135.
17. Lim, K. S., Lim, C. H., & Tan, C. T. (2011). Attitudes toward epilepsy: A systematic review.
Neurology Asia, 16(4), 269-280.
18. Gebrewold, M. A., Enquselassie, F., Teklehaimanot, R., & Gugssa, S. A. (2016). Ethiopian
teachers: Their knowledge, attitude and practices towards epilepsy. BioMed Central, 16:16-7.
doi:10.1111/epi.12550.
19. Eze, C. N., Ebuehi, O. M., Brigo, F., Otte, W. M., & Igwe, S. C. (2015). Effect of education
on trainee teachers’ knowledge, attiutdes and first aid management of epilepsy: An
interventional study. Elsevier, 46-53.
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20. Owolabi, L. F., Shehu, N. M., & Owolabi, S. D. (2014). Epilepsy education in developing
countries: A survey of school teachers’ knowledge about epilepsy and their attitude towards
students with epilepsy in Northwestern Nigeria. Pan African Medical Journal, 18 (255).
21. Ullah, S., & Nabi, G. (2015). Knowledge, attitude and practices of school teachers towards
epileptic school students at District Dir. Lower, Khyber Pakhtunkhwa, Pakistan. International
Journal of Neuroscience and Behavioral Science, 1-6.
22. Zanni, K. P., Matsukura, T. S., & Filho, H. S. M. (2012). Beliefs and attitudes about childhood
epilepsy among teachers in two cities of Southeast Brazil. Epilepsy Research and Treatment.
23. Babikar, H. E., & Abbas, I. M. (2011). Knowledge, practice and attitude toward epilepsy
among primary and secondary school teachers in South Gezira locality, Gezira State, Sudan.
Journal of Family and Community Medicine, 18(1), 17-21.
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PRECONCEPTION KNOWLEDGE AND PRACTICES AMONG
WOMEN IN FERTILITY AGE IN THE TAMALE TEACHING
HOSPITAL OF GHANA
1*Obed
Kwaku Duah Asumadu (BSc. Nursing)
Department of Nursing, School of Allied Health Sciences
University for Development Studies, Tamale, Ghana
*Email: asumaduobed@yahoo.com
2Sandra
Esi Effrim (BSc. Midwifery)
Department of Midwifery, School of Allied Health Sciences
University for Development Studies, Tamale, Ghana
3Beatrice
Ennin (BSc. Midwifery)
Department of Midwifery, School of Allied Health Sciences
University for Development Studies, Tamale, Ghana
4Angela
Owusuah Amoabeng (BSc. Midwifery)
Department of Midwifery, School of Allied Health Sciences
University for Development Studies, Tamale, Ghana
5Rosina
Darcha (MPhil, RM)
Department of Midwifery, School of Allied Health Sciences
University for Development Studies, Tamale, Ghana
6Akwasi
Boakye-Yiadom (MSc, B.Ed)
Department of Public Health, School of Allied Health Sciences
University for Development Studies, Tamale, Ghana
7Wisdom
Peprah (BSc. Community Nutrition)
Department of Nutritional Sciences, School of Allied Health Sciences
University for Development Studies, Tamale, Ghana
8Joel
Afram Saah (B.Ed Health Science)
Department of Public Health, School of Allied Health Sciences
University for Development Studies, Tamale, Ghana
9Richard
Opoku Asare (MPhil, B.Ed, RN (Dip)-RMN, Cert.Ed)
College of Nursing, Ntotroso
Ahafo Region, Ghana
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ABSTRACT
Purpose: The aim of this study was to assess preconception knowledge and practices and its
effect on birth outcomes among puerperal women in the Tamale Teaching Hospital.
Methodology: The study employed analytic cross-sectional study design with a quantitative
approach. A semi-structured questionnaire was used where questions on knowledge of
preconception were adopted from Southampton Women’s Survey, 2006. Puerperal women in the
postnatal unit of the Tamale Teaching Hospital, who were yet to be discharged, including
referred cases, were selected as target population for this study. The exclusion criteria were
women who have never delivered and menopausal women. The sample size was 363 puerperal
women. Purposive sampling method was used to attain the required sample. Data was analyzed
using SPSS version 25. In the analyses, a p-value<0.05 was considered statistically significant
when variables were cross-tabulated.
Findings: The results of the study revealed a high proportion of puerperal women 161 (44.3%)
were above 30 years. The mean age was 30.56±6.44 years. The study found that 37.2% women
had knowledge on preconception care. There was a significant association between folic acid
intake and postpartum haemorrhage (r=-0.183, p<0.0001). There was no statistical association
between birth outcomes and concurrent loss of pregnancy and number of pregnancies lost except
for birth weight (r=0.202, p=0.000). Albeit preconception care knowledge was low among
puerperal women, it significantly influenced postpartum haemorrhage and pregnancy induced
hypertension but not antepartum hemorrhage and birth weight.
Recommendation: At the community level the study recommended to the Ghana Health Service
that a mother-to-mother support group be formed among women in their reproductive age and
this could help encourage one another to discuss about their health before pregnancy and share
success stories on birth outcomes and report to the facility in case of any problems.
Key words: Preconception, Knowledge, Practices, Tamale Teaching Hospital
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INTRODUCTION
The expansion of access to preconception knowledge and counseling among women in fertility
age is proposed as a strategy for achieving progressive women’s health as captured in the third
Sustainable Development Goal (Chuang, Velott, & Weisman, 2010). Preconception care
involves provision of biomedical, behavioral and social health interventions to women and
couples before conception occurs, aimed at improving their health status, reducing behaviours
and individual and environmental factors that could contribute to poor maternal and child health
outcomes (Al-Akour, Sou’Ub, Mohammad, & Zayed, 2015; Harelick, Viola, & Tahara, 2011).
Maternal, newborn and child health (MNCH) care approach is important during the
preconception period since the health and well-being of women, newborns and children are
closely linked and ought to be managed in a unified manner (Kinney et al., 2010). The
achievement of MNCH include interventions directed at improving nutritional status through
balanced energy-protein supply, folic acid supplementation/fortification, micronutrient
supplementation among others and maintaining healthy lifestyle (Frey & Files, 2006; Gunaratna
et al., 2015; Lassi, Dean, Mallick, & Bhutta, 2014).
Preconception care includes a set of interventions that aims to identify and modify biomedical,
behavioural and social risks to women’s health or pregnancy outcome through prevention and
management (Seshadri, Nelson-Piercy, & Chappell, 2012). This statement was affirmed by the
World Health Organization (WHO) which added that the ultimate aim of preconception care is to
improve maternal and child health, in both the short and long term (WHO, 2013). It is, therefore,
an essential and vital practice, as it lays the foundation for future health of the mother, her child
and her family (Mitchell, Levis, & Prue, 2012). Besides, it is an ongoing component of
healthcare services that must be provided for both men and women in their reproductive age to
ensure that they are healthy (WHO, 2013). In view of this the act of embracing preconception
care serves as a golden opportunity that can identify health risk factors in pregnancy and enable
healthcare givers to conduct any required interventions earlier before pregnancy occurs to
prevent harmful exposures from affecting the developing foetus (Dandekar & Hessler, 2014;
Kinney et al., 2010; Mittal et al., 2016).
These interventions include birth spacing and prevention of teenage pregnancy as young mothers
often are not physically mature enough to deliver a baby, leaving them and their children at risk
for death or disability from obstructed labor, fistulas, premature birth, or low birth weight. At the
same time, early childbearing negatively affects educational and economic opportunities; women
with lower educational attainment have greater risks of adverse pregnancy outcomes, are less
knowledgeable about health-prevention activities, and family planning. Their children have
fewer options for education, optimal growth and development and have a higher risk of mortality
(Lassi et al., 2014). Seshadri et al. (2012) were right when their study concluded that
preconception care was interventions characterized by the need to start and sometimes complete
a designated intervention before conception occurs.
Preconception care knowledge and practices could have multiple positive impacts on birth
outcomes as its ultimate aim is to improve maternal and child health, in both the short and long
term. This was to reiterate the World Health Organization’s assertion that there is widespread
consensus that to reduce maternal and childhood mortality, a continuum of care needs to be
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provided through pregnancy, childbirth, the postnatal period (addressing both mothers and
infants), infancy, childhood, adolescence and adulthood. There is also widespread agreement that
actions are needed at the community, primary care and referral care level to deliver this
continuum of care (WHO, 2013).
Preconception knowledge of women is focused on women’s ability to identify medical and social
conditions that may put the mother or fetus at risk. Therefore, the notion of preconception
knowledge among women aims to provide understanding to the existing risks before pregnancy,
whereby resources may be used to improve reproductive health of women, men and couples in
order to optimize health and knowledge before conceiving a pregnancy (Ojukwu, Patel,
Stephenson, Howden & Shawe, 2016).
Counseling administered to influence knowledge and attitudes about preconception and its
effects on a potential pregnancy is shown to manifest large impact (Mittal, Dandekar, & Hessler,
2014). It is therefore important to note that a reproductive life plan is a brief, cost effective
preconception and contraception counseling tool in the primary care setting for women. This
means that increasing knowledge about reproductive health is incomplete when preconception
knowledge is not present. In view of this lack of knowledge about common preconception risk
factors seems to be one of the critical factors hindering the widespread application of the
practice.
In a population study in Rotterdam, half of the non-pregnant study population (n=631) were
unaware of the adverse effect of smoking and being overweight on fertility. Although, this
outcome is in contrast with other results, specific preconception health knowledge, e.g., folic
acid use, was also scarce (p<0.001) (Gunaratna et al., 2015). Notwithstanding, several studies
have shown that there is positive correlation between women’s preconception care knowledge
and effective reproductive health outcomes (Singh et al., 2010).
In terms of preconception practices, Stephenson and colleagues (2014) reported that despite the
high level of pregnancy planning in their survey of not less than 1000 sample size in three North
London hospitals, and previous miscarriage, stillbirth or termination for fetal abnormalities, 34%
of all women reported acquiring no information about preconception health behaviours and 49%
reported no practice of preconception care knowledge. Just over half (51%) of all women, and
fewer than two thirds (63%) of women with planned pregnancies, took folic acid before
pregnancy.
Since maternal assessment before pregnancy encompasses family history, obstetric history and
general physical examination of the potential mother; family history of chronic disorders, firstdegree consanguineous (relationship by descent) marriages and planning pregnancy has been
shown to be associated with awareness of preconception care. It was reported by Al-Akour and
colleagues (2015) in their study on awareness of preconception care among women and men
from Jordan that close to 50% of participants were aware of the serious impact that a woman’s
and man’s family history can have on the health of their babies. They concluded that a
significant number of their respondents recommended changes be made prior to conception.
Though the world has made significant improvement in saving the lives of mothers and children
since the adoption and implementation of major programmes such as the Millennium
Development Goals 4 and 5 in 2000 (Gunaratna et al., 2015), there were still 287,000 maternal
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and 2.9 million newborn deaths each year, with an additional 2.6 million stillbirths worldwide
(UNICEF, 2010). However, data from the Tamale Teaching Hospital (TTH) showed that the
dynamics of specific maternal and neonatal health outcomes are not pointing in the right
direction. For instance, the prevalence of still birth decreased slightly from 313 to 251 between
2015 and 2016, it later hiked to 342 in 2017 and further increased to 379 in 2018; low birth
weight increased from 1516 to 1708 between 2015 and 2016 but reduced from 2098 to 1602
from 2017 to 2018. Antepartum hemorrhage (APH), postpartum hemorrhage (PPH) and
pregnancy induced hypertension (PIH) was also rife in 2015 where 58,101 and 257 was recorded
respectively. Despite data on APH and PPH were lacking in 2018, PIH which was available
indicated massive increase of 52 cases from the previous year (2017) (Source: TTH Data – 2015,
2016 & 2017). The information, however, gathered may be due to poor preconception
knowledge among women.
Notwithstanding, little has been done to examined women’s knowledge and health behaviors
before and after receipt of targeted preconception education and counseling in Ghana. Besides,
the prevalence of the problems associated with ineffective preconception knowledge on the part
of the reproductive age woman in the country remains unclear. More so, lack of preconception
knowledge is an assumed contributor to several causes of poor pregnancy outcomes most
especially in the Northern sector of the country. As Frey and Files (2006) have observed that the
concept of preconception care has been articulated for a long time, but unfortunately have not
become part of the routine practice especially knowledge and practices on preconception care
among reproductive age women. It is in the light of this that this study intended to determine the
knowledge level and practice of preconception among reproductive age women in the Tamale
Metropolis of Ghana.
METHODOLOGY
The study employed analytic cross-sectional study design with a quantitative approach. The
study was conducted at the Tamale Teaching Hospital in the Tamale Metropolis in the Northern
Region of Ghana. A semi-structured questionnaire which has both open-ended and close-ended
questions was used for data gathering. Questions on knowledge of preconception were adopted
from Southampton Women’s Survey (2006).
Puerperal women in the postnatal unit of the Tamale Teaching Hospital, who were yet to be
discharged, including referred cases, were selected as target population for this study. The
exclusion criteria were women who have never delivered and menopausal women. The sample
size was 363 puerperal women.
Purposive sampling method was used to attain the required sample size. The participants were
recruited during their early puerperal stage. Data was analyzed using SPSS version 25, and
represented by frequencies and percentages. In the analyses, a p-value<0.05 was considered
statistically significant when variables were cross-tabulated.
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FINDINGS
Socio-demographic characteristics
The most represented age category of puerperal women was above 30 years (44.3%), followed
by the 25 to 30 years group (40.5%) and 15.2% were less than 25 years. The mean age was
30.56±6.44 years. More than three fourth (84.8%) of the respondents were married and almost
75% had formal education, but 24.8% of their partners had no formal education. Almost half
(49.6%) of the respondents were Muslims and 42.1% of them were Dagombas. Whiles
respondents’ partners were predominantly public/civil servants (49.0%), the data showed 35.5%
women were petty traders. Most of them (66.1%) also resided in the urban area of the Tamale
Metropolis. Table 1 below gives detail of the background of respondents.
Table 1: Socio-demographic characteristics of respondents (N=363)
Background information
Age
<25
25-30
>30
Mean ±standard deviation of age
Marital status
Single
Married
Co-habitating
Divorced
Maternal educational status
No formal education
Primary
JHS
SHS/Vocational
Tertiary
Educational status of partner
No formal education
Primary
JHS
SHS/Vocational
Tertiary
Others (missing due to divorce or death)
Religion
African Tradition
Islam
Christianity
Tribe
Dagomba
Gonja
Mamprusi
Akan
Others (Frafra, Ewe, etc.)
Frequency
(N)
Percentage
(%)
55
147
161
15.2
40.5
44.3
30.56±6.44
Source: Field data, 2019
6
36
308
18
1
9.9
84.8
5.0
.3
91
32
44
64
132
25.1
8.8
12.1
17.6
36.4
90
21
33
36
179
4
24.8
5.8
9.1
9.9
49.3
1.1
21
180
162
5.8
49.6
44.6
153
53
33
79
45
42.1
14.6
9.1
21.8
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Table 1: Socio-demographic characteristics of respondents (N=363) – cont’d
Background information
Occupation of woman
Farming
Petty trading
Public/civil servant
Others (seamstress, charcoal burning etc.)
Occupation of partner
Farmer
Petty trading
Public/civil servant
Others (drivers, butchers, etc.)
Missing (due to divorce, etc.)
Residence
Urban
Rural
Source: Field data, 2019
Frequency
(N)
Percentage
(%)
55
129
135
44
15.2
35.5
37.2
12.1
91
55
178
25
14
25.1
15.2
49.0
6.8
3.9
240
123
66.1
33.9
Maternal Obstetric History
When the gestational age at birth was assessed, it was realized that higher percentage (76%)
(276/363) of the respondents delivered between 36 to 40 weeks, the post term women were
19.3% of the respondents, and the preterm group 4.7%.
On maternal obstetrics characteristics, majority of the respondents (69.7%) had more than one
live birth (multiparous) whiles about 30.3% were primiparous (single parity). More so, it was
found among the 64 women who claimed to have lost a pregnancy, 76.6% had a single
pregnancy lost, 10 (15.6%) had lost two pregnancies, whiles 7.8% had lost three. Pregnancies
that were lost within the first six months after conception represented 87.5% of the respondents.
It was found that all birth outcomes recorded was significantly associated with parity, there was
no association between the outcome variables and concurrent loss of pregnancy and number of
pregnancies lost except for birth weight (r=0.202, p=0.000). Table 2 highlights the details of the
above information.
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Table 2: Maternal obstetrics characteristics (N=363)
Variables
N (%)
Pregnancy outcomes (r, p-value)
APH
PIH
PPH
Parity
Primiparous
110 (30.3%)
Multiparous
253 (69.7%)
Ever lost
pregnancy
Yes
64 (17.6%)
No
299 (82.4%)
Number of
N=64
pregnancies lost
One
49 (76.6%)
Two
10 (15.6%)
Three
5 (7.8%)
Month at which
baby was lost
At least six months
56 (87.5%)
More than six
8 (12.5%)
months
Mode of delivery
**SVD
288 (79.3%)
**C/S
75 (20.7%)
Source: Field data, 2019
Birth weight
-0.121, 0.021
0.110, 0.037
-0.125, 0.017
0.202, 0.000
-0.003, 0.953
-0.004, 0.937
-0.010, 0.846
-0.003, 0.953
-0.042, 0.738
-0.042, 0.738
0.116, 0.356
0.202, 0.000
0.047, 0.711
-0.047, 0.738
0.116, 0.356
-0.024, 0.852
0.037, 0.476
0.028, 0.590
0.010, 0.848
0.004, 0.940
**Key
C/S=Caesarian Section
SVD=Spontaneous Vaginal Delivery
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Knowledge of puerperal women on preconception care
When respondents were asked if they had heard of preconception care, 37.2% (n=135/363)
claimed to have heard about it, whiles majority 228 (62.8%) denied any hearing of preconception
care. However, when the respondents were asked to describe preconception care, 77.0% of the
respondents who claimed to have heard of preconception care said it is the preparation and care
given to women by health workers before pregnancy. A few (11.9%) said it is care given to
pregnant women and those who stated knowledge of women on conception represented 11.1%.
In view of this the respondents’ idea on preconception health was assessed to evaluate their
knowledge. Majority of the respondents (78.2%) knew it was important to live a healthy life
before conception with a 211 of the participants acquiring the information from health workers
among other sources. A little more than half of the respondents (50.7%) did not know that folic
acid and vitamin supplements were significant for a successful pregnancy. This is shown in
Table 3.
Table 3: Knowledge on preconception health (N=363)
Response Rate (N=363)
Yes (%)
No (%)
Question
Good health life before conception important for you and the
baby
284 (78.2%) 79 (21.8%)
Source of information on the importance of good health before conception
- Health worker
211 (74.3%)
- Family/Friend
21 (7.4%)
- Radio/TV
22 (7.7%)
- School
27 (9.5%)
- Pharmacist
3 (1.1%)
Folic acid and vitamin supplements were good for conception 179 (49.3%) 184 (50.7%)
Source: Field data, 2019
Observation from the above data showed that the study’s participants tended to have a fair
knowledge on preconception care.
However, the correlation between knowledge on the importance of folic acid and vitamin
supplements in pregnancy and birth outcomes showed no significant relationship, except PPH
which showed a strong correlation (r=-0.183, p=0.000). This is shown in Table 4.
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Table 4: Bivariate analysis between knowledge on the importance Folic acid and Birth
outcomes
Variables
Maternal birth outcome
PPH
APH
PIH
Child birth outcome
Low birth weight
Normal birth weight
Macrosomia
Source: Field data, 2019
Knowledge on Folic acid
and Vitamin supplements
Yes (%)
No (%)
99 (27.3%)
35 (9.6%)
100 (27.5%)
N
48
302
13
264 (72.7%)
328 (90.4%)
263 (72.5%)
(%)
13.2
83.2
3.6
r, p-value
-0.183, 0.000
0.014, 0.793
-0.09, 0.086
-0.043, 0.412
Association between preconception care knowledge and birth outcomes
The study found 27.3% prevalence of PPH, 9.6% of APH and 27.5% PIH among the puerperal
women. Bivariate analysis of correlation between knowledge on preconception care and PPH
showed an inverse relation, implying that as maternal knowledge on preconception care
increases, the prevalence of PPH decreases, whiles PPH would decrease among women with
high knowledge level on preconception care on the other hand (r=-0.138, p=0.008). This
observation was different in APH women where there was no significant association with
preconception care knowledge showed by Pearson r of 0.00. Similarly, there was no significant
relation to the birth weight of neonates, but the association between the independent variable and
PIH was significant showing inverse relation (r=-0.104, p=0.047). This is shown in Table 5.
Table 5: Association between preconception care knowledge and birth outcomes
Variables
Maternal birth outcomes
PPH
APH
PIH
Childbirth outcomes
Low birth weight
Normal birth weight
Macrosomia
Source: Field data, 2019
Knowledge on preconception
care among women (N=363)
Yes (%)
No (%)
99 (27.3%)
35 (9.6%)
100 (27.5%)
N
48
302
13
10
264 (72.7%)
328 (90.4%)
263 (72.5%)
(%)
13.2
83.2
3.6
r, p-value
-0.138, 0.008
0.000, 0.995
-0.104, 0.047
-0.04, 0.412
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Practices of preconception care
In terms of practice on preconception care, 73.8% did not modify their diet before conception,
alcoholic beverages consumption before conception was a little higher than smoking among
women. More than half of the respondents (51.2%) were screened for either STIs or genetic
disorders before conception, whiles 79.3% sought for fertility advice. Though 77.4 % haltered
the use of contraception before they conceived, surprisingly, 90.6% continued to use caffeinated
products.
When it comes to preparations made before pregnancy, it was detected that out of the 363
respondents, 37.5% (n=136/363) prepare for their pregnancies whiles the 62.5% made less
attempts to prepare for their pregnancies. For those who prepare before conception, 7.4% sought
preconception care services, 38.9% claimed to purchase their materials or items in wait for the
unborn baby and themselves, and 18.4% took folic acid as a vitamin supplement among other
responses. Table 6 shed light on the preconception practices.
Table 6: Preconception practices among pregnant women
Variables
Response Rate (N=363)
Yes (%)
No (%)
Practices by respondents
Modified diet
Took steps to change weight
Consumed alcohol
Smoking
Vaccinated against infectious diseases
Screened for STIs and genetic disorders
Dental checks
Used contraceptives
Sought fertility advice
Stopped caffeine intake
Preparations made before conception
Financial preparation
Folic acid intake
Halt contraception
Healthy diet intake
Purchase items
Medical checkups
Moderate activities
Seek for preconception care
Total
Source: Field data, 2019
95 (26.2%)
120 (33.1%)
12 (3.3%)
9 (2.5%)
148 (40.8%)
186 (51.2%)
38 (10.5%)
82 (22.6%)
75 (20.7%)
34 (9.4%)
N (%)
22 (16.2%)
25 (18.4%)
6 (4.4%)
11 (8.1%)
53 (38.9%)
7 (5.1%)
2 (1.5%)
10 (7.4%)
136 (100%)
268 (73.8%)
243 (66.9%)
351 (96.7%)
354 (97.5%)
215 (59.2%)
177 (48.8%)
325 (89.5%)
281 (77.4%)
288 (79.3%)
329 (90.6%)
-
Critically looking at the data above on the practices on preconception by the respondents of this
study, majority gave negative responses pointing to the fact that their answers were wrong as
against the few who replied in the affirmative. However, 53 (38.9%) out of the 136 respondents
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purchased household items as a means of preparing towards conception with few (5.1%) having
medical checkups and preparing financially (16.2%) before conception. Consequently, these
assertions pointed to the fact that participants for this study had poor practices of preconception
care.
When the participants’ preparedness for conception was cross-tabulated against maternal and
child birth outcomes respectively, the findings had no statistical association among the variables.
This is shown in Table 7 below.
Table 7: Association between preparations made before pregnancy and birth outcomes
Birth Outcomes
Maternal birth outcomes
PPH
APH
PIH
Childbirth outcome
Low birth weight
Normal birth weight
Macrosomia
Response Rate (N=363)
Preparedness for
conception
Yes
No
99 (27.3%)
35 (9.6%)
100 (27.5%)
N
48
302
13
264 (72.7%)
328 (90.4%)
263 (72.5%)
%
13.2
83.2
3.6
Test-statistic
r, p-value
-0.078, 0.139
-0.060, 0.254
-0.095, 0.070
-0.044, 0.398
DISCUSSION
The study assessed the preconception knowledge and practices among women in fertility age in
the Tamale Teaching Hospital of Ghana.
When participants of the study were asked if they had heard of preconception care as part of
evaluating their knowledge, 37.2% (n=135/363) claimed to have heard about it, whilst majority
228 (62.8%, n=363) denied any hearing of preconception care. This report was in agreement
with Al-Akour and colleague’s (2015) study that indicated 50% of their participants showed
awareness of preconception care among women and men. More so, 74.3% (n=211/263) of this
research had their information on the importance of good health before conception from the
health worker; contrary to this view, only 34% of all women reported acquiring no information
about preconception health behaviours (Stephenson et al., 2014). Mittal and colleagues (2014)
said knowledge about preconception care and its effects on a potential pregnancy manifests large
impact. Gunaratna and colleagues (2015) reported that lack of knowledge about common
preconception care seems to be one of the critical factors hindering widespread application of the
practice and consequently having negative impacts (p<0.001). However, 78.2% of the
participants of this study knew it was important to live a healthy life before conception.
In terms of description of preconception care, 77.0% of this study respondents said it is the
preparation and care given to women by health workers before pregnancy. A few (11.9%)
described it as care given to pregnant women. This implied that some of the respondents were of
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the view that preconception care is the same as antenatal care. It was, therefore, explained in
another study that preconception care was interventions characterized by the need to start and
sometimes complete a designated intervention before conception occurs (Seshadri et al., 2012).
In conclusion, preconception care is the provision of biomedical, behavioural and social health
interventions to women and couples before conception occurs aiming at improving their health
status, and reducing behaviours and individual and environmental factors that contribute to poor
maternal and child health outcomes. Its ultimate aim, therefore, is to improve maternal and child
health, in both the short and long term (WHO, 2013).
As part of the practices made towards preconception care, women are to make preparations prior
to conception. Among this study’s participants, 39% of them purchased household items for the
baby and themselves, whilst 18.4% took folic acid and other vitamin supplements, 16.4% made
financial preparations towards their conception, and 7.4% sought preconception care. These
findings were in agreement by a comment that suggested that resources may be used to improve
reproductive health of women, men and couples in order to optimize health and knowledge
before conceiving a pregnancy (Ojukwu et al., 2016). However, the idea of practicing
preconception care has not been a concept acknowledged among most reproductive age women
(Frey & Files, 2006).
CONCLUSION
Women in fertility age attending the Tamale Teaching Hospital in the Northern Region of Ghana
tended to have a fair knowledge and poor practices on preconception care.
RECOMMENDATIONS
1. At the community level the study recommended to the Ghana Health Service (GHS) that
a mother-to-mother support group be formed among women in their reproductive age and
this could help encourage one another to discuss about their health before pregnancy and
share success stories on birth outcomes and report to the facility in case of any problems.
2. The knowledge gap of preconception care in this part of the country requires the Ministry
of Health, and the GHS in particular, to put in place at the various health delivery levels,
including encouraging women in their reproductive age to seek information about their
health and impending pregnancy.
3. Preconception care needs to be integrated into other social services, such as the
adolescent reproductive health services, and/or social franchises for easy accessibility to
practice but not only assigning to healthcare providers as their duty at the health post.
4. Women and children protecting agencies, such as the Ministry of Gender, Children and
Social Protection in collaboration with the GHS, should publish more information on the
need to seek preconception care before conception.
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