https://doi.org/10.15218/ejnm.2021.11 Erbil j. nurs. midwifery, Vol. 4, No. (2), Nov 2021 Original Article Attitudes of Couples attending Family Counselling Clinic in Sulaimani City towards the Premarital Screening and Genetic Counseling Programme ABSTRACT INTRODUCTION The choice of a marriage partner is normal- ly unrestricted. Many intended partners, however, join the lifetime union of mar- riage with no information about their fu- ture partner's health status. Many medical problems, especially those related to the health of the offspring, may be diagnosed and treated before or after marriage. This could aid in the avoidance or reduction of certain regrettable long-term obligations [1]. Premarital screening (PMS) is a test performed before getting married to diag- nose certain inherited blood disorders (such as sickle cell anaemia and thalasse- mia) as well as infectious diseases (such as hepatitis B and C/HIV"AIDS"). Pre-marital testing is an effective method for monitor- ing, reducing, and avoiding genetic abnor- malities and certain viral infections; re- stricting the transmission of infectious Background and objectives: Premarital screening is an effective method for monitoring, reducing, and avoiding genetic abnormalities and certain viral infections. This study aimed to explore the attitudes of couples who attended a family counselling clinic in Sulimani City towards the premarital screening and genetic counselling programme. Methods: A cross-sectional, descriptive-analytic study was carried out on 310 couples attending the family counselling clinic in Sulaimani City. The statistical analysis was performed by using descriptive and inferential statistical data analysis including frequency, percentage, mean and stranded deviation, independent samples T-Test and one way ANOVA (F-test). Results: The study findings revealed that the majority of the study participants were 20-30 years old. In terms of attitudes, 73.55% of the couples had a favourable attitude toward premarital screening and genetic counselling. There were statistically significant differences between couples' attitudes and age (p=0.012), educational level (p=0.013), and consanguinity (P < 0.001), but there were no statistically significant differences between couples' attitudes and gender (p=0.49), employment (p=0.785), residential area (0.116), and family history of hereditary blood disease (p=0.45) because of p-value >0.05. Conclusion: Couples' attitudes about premarital screening and genetic counselling programmes are positive. Keywords: Premarital screening; Genetic counselling; Attitude; Couple. Nyan Luqman Aziz; Department of Nursing, College of Nursing, Sulaimani University, Sulamani, Iraq. (Correspondence: nyanluqman1@gmail.com) Salih Ahmed Abdulla;Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. 96 Erbil Journal of Nursing & Midwifery Received: 18/09/2021 Accepted: 10/11/2021 Published: 30/11/2021 mailto:nyanluqman1@gmail.com?subject=nyanluqman1@gmail.com https://doi.org/10.15218/ejnm.2021.11 Erbil j. nurs. midwifery, Vol. 4, No. (2), Nov 2021 Original Article diseases; and reducing the prevalence of some genetic blood diseases. Stopping social and psychological issues for families with children that have inherited diseases encourages the idea of universal healthy marriage [2].Currently, premarital counsel- ling (PMC) is one of the most important strategies for the prevention of genetic disorders, congenital anomalies and sever- al medical and psychological marital prob- lems [4]. The community health nurses play a fundamental role in providing pre- marital care services that include assessing a hereditary risk, providing information, discussing available testing options and providing appropriate counselling [5]. It is therefore important for couples to have adequate knowledge and a positive attitude towards PMC and thus increase the possibility of a successful marriage [6]. In the Iraqi Kurdistan Region, a programme to avoid significant hemoglobinopathies was established in 2008. In the three prov- inces of the region, a premarital screening programme to detect hemoglobinopathies carriers was established in Duhok, Erbil and Sulaimani. The programmes' application was assisted by legislation enacted by the provincial parliament rendering premarital hemoglobinopathies screening obligatory. In the programmes, the are no attempts by the counsellors to influence the couples' decision-making; rather they focus on providing qualified information on the many alternatives for couples who are at high risk of having affected children. The couples pay a little fee for premarital screening for major hemoglobinopathies, which also includes blood group screening, hepatitis B surface antigen, and hepatitis C antibodies [7]. This study aimed to identify the attitudes of couples regarding premari- tal screening and genetic counselling and to determine the association between so- cio-demographical data and the couples' attitudes regarding premarital screening and genetic counselling. A cross-sectional, descriptive study was carried out on the couples in Sulaimani City in the Kurdistan Region of Iraq from 20th January 2021 to 30th January 2022. The duration of data collection was three months.A convenience sampling technique was used for the data collection. There were 310 couples included in the study based on the inclusion criteria and an ag- reement to participate. This study was ac- cepted by the Scientific Committee of the College of Nursing and approved by the Ethical Committee of the College of Medi- cine of the University of Sulaimani. An offi- cial letter from the College of Nursing of the University of Sulaimani was presented to the General Directorate of Health (DOH) in Sulaimani to obtain an agreement for data collection, which was then provided to the family counselling clinic. The couples were chosen according to the inclusion criteria, which included age ≥ 16, both gen- ders, ability to communicate in Kurdish language, willingness to participate in the study and the first marriage. The couples who had mental health disorders were excluded. The data were collected through the face to face interviews by using a ques- tionnaire, which consisted of two parts based on the proposed research objecti- ves. The first part contained the couple's socio-demographic information such as age, gender, educational level and employ- ment, consanguinity, personal history of hereditary disease, and family history of hereditary disease. The second part included an assessment of the couple's attitudes regarding the premarital scree- ning and genetic counselling programme that consisted of 17 items with 5 points Likert scale (1 = strongly disagree, 2 = disagree, 3 = unsure, 4 = agree, and 5 = strongly agree). 97 Erbil Journal of Nursing & Midwifery METHODS https://doi.org/10.15218/ejnm.2021.11 Erbil j. nurs. midwifery, Vol. 4, No. (2), Nov 2021 Original Article blood diseases. The consanguinity marriag- es represented 26.8% of couples, out of which, 65.1% were first-degree cousins, and 34.9% were second-degree cousins. Regarding the family history of hereditary blood disease, it was found that only 1.3% of the study population had a genetic dis- ease in the family (thalassemia 50% and G6PD 50%). The data in Table 4 reveal the distribution of couples according to their attitudes in a five-point Likert scale and three levels of attitude, The table shows that out of seventeen items couples had a good attitude in twelve items, fair attitude in four items and poor attitude in one item, with total mean and standard devia- tion 2.55±0.59, and a good level of attitude in general. As shown in Table 5, the stud- ied factors of age, educational level, and consanguinity were significantly associated with the attitude level of the couples to- ward premarital screening and genetic counselling programme because the result of the p-value was less than the common alpha 0.05, whereas there were no statisti- cally significant differences between cou- ples’ attitude and gender, employment and a residential area. Twelve of the items were written positively and the remaining seven items were word- ed negatively. The scores of the negative items were reversed to calculate the atti- tudes. The validity of the questionnaire was checked initially by a panel of 10 experts specialized in nursing and medi- cine, and their comments were taken into consideration. Alpha Cronbach was used to determine the reliability of the question- naire. As a result, the value of reliability (alpha Cronbach) was equal to 0.912 and the validity was 0.832, which indicates a highly reliable questionnaire. All statistical computations were enhanced using statis- tical software (SPSS 24). The data were coded, tabulated, and presented in a descriptive form and analyzed using basic statistical methods including alpha- Cronbach used for testing the reliability of the questionnaire. Descriptive statistical data analysis included frequency, percent- age, mean and standard deviation. Inferen- tial data analysis included the Parametric Test: Independent samples T-Test and one Way ANOVA (F-Test). The criteria of the probability level and determining the sig- nificance of the test P -value were: highly significant (P< 0.001), significant (P< 0.05), and non-significant (P> 0.05). Table 1 shows that the reliability and validi- ty of the couple's attitudes were 0.912 and 0.832 respectively. Table 2 demonstrates that the majority of couples were 20-30 years old. The lowest percentage of partici- pants (8.4%) was more than 30 years old with a mean ± SD of 24.00 ± 4.64 years. Most of the study sample (30%) achieved a secondary school educational level, most of them (53.9%) were employed in differ- ent sectors, and 62.9% resided in urban areas. Table 3 shows the distribution of the sample according to consanguinity, and personal and family history of hereditary 98 Erbil Journal of Nursing & Midwifery RESULTS Table 1: Reliability and Validity Methods Reliability (alpha Cronbach) Validity Couple’s attitude 0.912 0.832 https://doi.org/10.15218/ejnm.2021.11 Erbil j. nurs. midwifery, Vol. 4, No. (2), Nov 2021 Original Article 99 Table 2: Distribution of the samples according to age, gender, educational level, employment and residential area characteristic Variables Items Frequency Percentage Age Less than 20 years old 45 (14.5) 20-30 years old 239 (77.1) More than 30 years old 26 (8.4) Mean ± S.D 23.9 24.00 ± 4.64 Gender Female 155 (50) Male 155 (50) Educational level Illiterate 2 (0.6) Primary school graduated 31 (10) Intermediate school 49 (15.8) Secondary graduated 93 (30) Institute 61 (19.7) College 74 (23.9) Employment Governmental employed 14 (4.52) Private sector employed 32 (10.32) Self-employed 121 (39.03) Unemployed 143 (46.13) Residential area Urban 195 (62.9) Sub-urban 115 (37.1) Total 310 (100) Table 3: Distribution of the sample according to consanguinity, personal and family history of hereditary blood disease characteristic Variables Frequency Percentage Consanguinity Yes 83 (26.8) No 227 (73.2) Total 310 (100) If Yes Type of relation 1st cousins 54 (65.1) 2nd cousins 29 (34.9) Total 310 (100) Personal history of hereditary blood disease Yes 0 (0) No 310 (100) Total 310 (100) Family history of hereditary blood disease Yes 4 (1.3) No 306 (98.7) Total 310 (100) If Yes Type of Family history of heredi- tary blood disease Thalassemia 2 (50) Skill cell anaemia 0 (0) G6PD 2 (50) Others 0 (0) Total 4 (100) Erbil Journal of Nursing & Midwifery https://doi.org/10.15218/ejnm.2021.11 Erbil j. nurs. midwifery, Vol. 4, No. (2), Nov 2021 Original Article 100 Erbil Journal of Nursing & Midwifery Table 4: Distribution of the sample according to the attitudes towards premarital screening and genetic counselling program Note / No.: Frequency (Number) , Weight average (mean) for 3point Likert scales: 1.0-1.66 : Poor attitudes , 1.67-2.33: Fair attitudes,2.34-3.0: Good attitudes. Questions Poor attitudes Fair attitudes Good attitudes Mean (S.D) level of attitudes No. No. No. (%) (%) (%) PMSGC must be done for every partner before marriage 1 0 309 2.99 (0.11) Good attitude (0.3) (0) (99.7) PMS is to detect some diseases that transmitted to my offspring 8 15 287 2.9 (0.38) Good attitude (2.6) (4.8) (92.6) PMSGC is to avoid transmission of diseases to me 31 16 263 2.75 (0.62) Good attitude (10) (5.2) (84.8) It is important to raise awareness about PMSGC before marriage to reduce genetic and STDs 5 9 296 2.94 (0.3) Good attitude (1.6) (2.9) (95.5) PMSGC should be performed only for cou- ples who have a family history of genetical- ly inherited diseases 8 16 286 2.9 (0.38) Good attitude (2.6) (5.2) (92.3) PMSGC is interference with God's will for a sick baby to be born 11 27 272 2.84 (0.45) Good attitude (3.5) (8.7) (87.7) PMSGC brings conflict between couples 214 32 64 1.51 (0.82) Poor attitude (69) (10.3) (20.7) I prefer consanguineous marriage 114 44 152 2.12 (0.92) Fair attitude (49) (14.2) (49) In a case of carrying genetic or inherited diseases, marriage decisions must be left to the couples 43 21 246 2.65 (0.71) Good attitude (13.9) (6.8) (79.4) Positive test results that indicate the pres- ence of genetic diseases should affect and change marriage decisions. 111 65 134 2.07 (0.89) Fair attitude (35.8) (21) (43.2) You would decide to stop the marriage if there was a communicable disease. 186 41 83 1.67 (0.87) Fair attitude (60) (13.2) (26.8) There should be a law to prevent marriage in case of positive results for the presence of genetic diseases. 127 40 143 2.05 (0.93) Fair attitude (41) (12.9) (46.1) The National Premarital screening and counselling program has an important role in preventing genetic diseases in the com- munity 23 28 259 2.76 (0.58) Good attitude (7.4) (9) (83.6) Hereditary diseases have a psychological impact on families 18 31 261 2.77 (0.55) Good attitude (5.8) (10) (84.2) Hereditary diseases have an economic impact on families 21 26 263 2.78 (0.54) Good attitude (6.8) (8.4) (84.8) PMSGC is against my religious/cultural beliefs. 19 27 264 2.79 (0.54) Good attitude (6.1) (8.7) (85.2) Religious leaders should deliver messages about the importance of PMCS and ge- netics counselling 9 7 294 2.92 (0.36) Good attitude (2.9) (2.3) (94.8) Total 949 445 3876 2.55 (0.59) Good attitudes (%) (18.01) (8.44) (73.55) https://doi.org/10.15218/ejnm.2021.11 Erbil j. nurs. midwifery, Vol. 4, No. (2), Nov 2021 Original Article Less than three-quarters of couples strong- ly agreed that pre-marital screening and genetic counselling PMSGC must be done for every partner before marriage, while 0.3% disagreed that it should be done for everyone. Furthermore, when asked about the negative items, most of the partici- pants (92.6%) disagreed that PMSGC should be performed only for couples that have a family history of genetically inherit- ed diseases. Previously, it was reported that the majority of students (97.3%) believe that premarital screening should be done for both men and women. [8]. 92.5% of participants agreed that manda- tory premarital screening (MPMS) is done to detect some diseases that can be trans- mitted to the offspring. Furthermore, 101 Erbil Journal of Nursing & Midwifery Table 5: Comparing means attitude scores and socio-demographic groups of the respondents. Variables Items No. Mean S.D Significant Test (P-value) Age Less than 20 years old 45 2.4915 0.18181 4.494 ** (0.012) 20 – 30 years old 239 2.5624 0.16475 More than 30 years old 26 2.6018 0.16412 Gender Female 155 2.5488 0.16653 -0.691 * (0.49) Male 155 2.5620 0.17198 Educational level Illiterate 2 2.6176 0.20797 2.942 ** (0.013) Primaryschoolgraduated 31 2.4687 0.23158 Intermediate school 49 2.5450 0.17881 Secondary graduated 93 2.5414 0.15816 Institution 61 2.5921 0.13451 College 74 2.5843 0.15949 Employment Governmental employed 14 2.6008 0.15508 0.356 ** (0.785) Private sector employed 32 2.5570 0.16570 Self-employed 121 2.5527 0.17292 Unemployed 143 2.5529 0.16901 Residential area City 195 2.5613 0.19588 1.576 * (0.116) Out city 115 2.5263 0.17524 Consanguinity Yes 83 2.4848 0.17733 -4.589 * (< 0.001) No 227 2.5812 0.15874 If Yes, Type of relation First cousins 54 2.4935 0.18440 0.898 * (372) Second cousins 29 2.4564 0.16907 Family history of hereditary blood disease Yes 4 2.6176 0.16031 0.757 * (0.45) No 306 2.5532 0.16914 If Yes, Type of Family history of hereditary blood disease Thalassemia 2 2.7353 0.04159 (0.432)* G6PD 2 2.7059 0.00001 Note: G6PD: Glucose-6-phosphate dehydrogenase * Test (Independent samples T-Test), ** Test (One Way ANOVA –F-Test) Weight average (mean) for 3point Likert scales: 1.0-1.66: Poor attitudes, 1.67-2.33: Fair attitudes,2.34-3.0: Good attitudes. DISCUSSION https://doi.org/10.15218/ejnm.2021.11 Erbil j. nurs. midwifery, Vol. 4, No. (2), Nov 2021 Original Article accepted that the positive test results that indicated the presence of genetic diseases should affect and change couples' deci- sions before the marriage, while 35.8% of participants disagreed that the positive test results should affect and change a de- cision to get married. These results demonstrate a fair attitude as hereditary diseases have a great impact on family and community. The results of the present study indicate that most couples (60%) would decide not to get married if there was a communicable disease, however, 26.8% disagreed and would not stop the marriage if a communicable disease was detected. This outcome indicates a fair attitude as there is no need not to proceed with the marriage but the communicable disease should be treated before the sexu- al intercourse. In this study, 46.1 % of cou- ples agreed that there should be a law to prevent marriage in case of positive PMS results but 41% of the participants disa- greed, while 12.9% had no idea about it. Another study also found that the opinions regarding the need for the law to prevent any marriage with positive results varied with 48.16% strongly disagreed, 35% agreed, 19.33% didn't know, and 7% disa- greed [13]. The findings of this study showed that 83.6% of the sample agreed and 7.4 % disagreed that the national pre- marital screening and counselling program has an important role in preventing genetic diseases in the community, which is a good attitude. The premarital screening and counselling programs are important be- cause many people are not aware of their state of health as well as that of the person they want to marry before entering the marriage. In the recent study majority of couples' agreed that genetic disorders have a great psychological and economic impact on families (84.2%, 84.8% respec- tively). This result is in agreement with an- other study, in which most participants sample agreed that PMSGC is meant to avoid the transmission of diseases. A large percentage (92.3%) of couples had a positive attitude regarding the im- portance of raising awareness about PMSGC before marriage to reduce ge- netic diseases and sexually transmitted diseases (STDs) but only 2.6% had a nega- tive attitude. A previous study reported that the majority of students (86.3%) strongly agreed that the PMS program is important and that PMS should be used to reduce some genetic and STDs and raise awareness about the PMS before marriage [9]. In the present study, more than 87.7% of couples disagreed with the notion that PMSGC is interference with God's will for a sick baby. Another survey found that the majority of those who did not accept the PMC believed that it inter- fered with God's will. [10]. The majority (69%) of participants disagreed regarding the conflicting attitudes towards PMSGC among the couples, while 20.7% agreed. The important finding of the study was that almost half (48%) of the study sam- ple disagreed with choosing a consan- guineous marriage, while 36% of the sample agreed with consanguineous mar- riage. One of the previous studies showed that most of the studied sample (82.07%) did not prefer to marry blood relatives whereas 12.87% were confused [11]. Only 5.07% showed a preference to marry a blood relative. Approximately three-quarters of the participants (79.4.%) believed that in a case of carry- ing genetic or inherited diseases, mar- riage decisions should be left to the cou- ples, while 13.9% disagree with couples' freedom to decide. Another study [12] showed that the majority of the respond- ents (65.1%) believed that in the case of carrying genetic or inherited diseases, a marriage decision must be made by the affected couple. 43.2% of the participants 102 Erbil Journal of Nursing & Midwifery https://doi.org/10.15218/ejnm.2021.11 Erbil j. nurs. midwifery, Vol. 4, No. (2), Nov 2021 Original Article This study identified an overall good atti- tude towards premarital screening and ge- netic counselling, especially among the re- spondents between 20-30 years of age, of the male gender, a secondary school edu- cational level, living in urban areas and un- employed. The authors are thankful to the staff at the family counselling clinic in Sulaimani city in the Kurdistan Region of Iraq. Our warmest thanks and wishes of good health go to the couples who participated in this study. There is no conflict of interest and no fi- nancial support for any of the authors. [1] Lafta FM, Alshammary AG, Jaafar SM, Sabah E, Dhafer G. Pre-Marital clinical Test among Intending couples in Baghdad: clinical Find- ings Knowledge and Attitudes. Indian Journal of Public Health Research & Development. 2019 May; 10(5):591. [2] Khalil EM, Abdelkader SM, Alsaeed MD, Al- shahrany NM. Knowledge, beliefs and be- haviour intention about premarital screen- ing among King Saud University female stu- dents in Riyadh. Scholars Journal of Applied Medical Sciences. 2014; 2(5E):1797-805. [3] Ali M, Elshabory N, Hassan HE, Zahra N, Al- refai H. Perception about premarital screen- ing and genetic counselling among males and females nursing students. International Organization of Scientific Research Journal of Nursing and Health Science. 2018; 7(1):517. [4] Shaimaa HM, Samah AE, Hanan A. Effect of Application of Health Belief Model on fe- males' Knowledge and Practice regarding the premarital counselling. International Organization of Scientific Research Journal of Nursing and Health Science.2017. agreed that hereditary diseases had psy- chological and economic effects on the families (88.7%, 79.8% respectively) [14].In the current study, the majority (85.2%) of respondents disagreed that the PMSGC was against their religious/ cultural beliefs. In addition, almost all (94.8%) of the studied sample agreed that religious leaders should deliver mes- sages on the importance of the PMCS and genetic counselling, which is a good attitude. Finally, the majority (73.55%) of the sample had a good attitude, 18.1% had a poor attitude and 8.44% had a fair attitude (mean - 2.55). Table 4 compares the means of the partner's attitudes and socio-demographic characteristics. The results of the study show that there were statistically significant differences be- tween couples' attitudes and age (p=0.012), educational level (p=0.013) and consanguinity (p=0.000) because the result of the p-value was less than the common alpha 0.05. But there were no statistically significant differences be- tween couples' attitudes and gender (p=0.49), employment (p=0.785), resi- dential area (0.116), and family history of hereditary blood diseases (p=0.45) be- cause p-value >0.05. This study demon- strated that there is an association be- tween level of attitude toward premarital screening program and socio- demographic factors like female gender (P = <0.001), higher years of study (P = 0.002), and a higher income (P = 0.019), which were significantly associated with better attitude scores toward premarital screening program [15]. 103 Erbil Journal of Nursing & Midwifery CONCLUSION ACKNOWLEDGEMENT CONFLICT OF INTERESTS REFERENCES https://doi.org/10.15218/ejnm.2021.11 Erbil j. nurs. midwifery, Vol. 4, No. (2), Nov 2021 Original Article [14] Melaibari M, Shilbayeh S, Kabli A. University students’ knowledge, attitudes, and practic- es towards the national premarital screening program of Saudi Arabia. Journal of Egyptian Public Health Association. 2017 Mar 1; 92 (1):36-43. [15] Al-Enezi K, Mitra AK.Knowledge, attitude, and satisfaction of university students re- garding premarital screening programs in Kuwait. 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