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ournal of Infection and Public Health (2013) 6, 41—54

remarital Screening and Genetic Counselingrogram: Knowledge, attitude, and satisfaction ofttendees of governmental outpatient clinics ineddah

ahla Khamis Ibrahima,b,∗, Jamel Bashawria, Hussein Al Bara,awaher Al Ahmadia, Adnan Al Bara, Mahdi Qadia,aleed Milaata, Hashim Fedaa

Family and Community Medicine Department, Faculty of Medicine, King Abdulaziz University, Jeddah,audi ArabiaEpidemiology Department, High Institute of Public Health, Alexandria University, Egypt

eceived 3 November 2011; received in revised form 29 March 2012; accepted 25 May 2012

KEYWORDSKnowledge;Attitude;Satisfaction;Premarital;Outpatient attendees

Summary Premarital care (PMC) is a worldwide activity that aims to diagnose andtreat unrecognized disorders and reduce the transmission of diseases to couples andchildren.Objectives: To assess the knowledge and attitude of individuals attending govern-mental outpatient clinics regarding the Premarital Screening and Genetic Counseling(PMSGC) programs, to identify predictors of high knowledge scores and to determinethe satisfaction and recommendations of clients of the program.Methods: A cross-sectional study was conducted from January to April 2009. Indi-viduals who attended three governmental hospital outpatient clinics on the day ofthe interview and agreed to participate in the study were recruited. The three hos-pitals were the two hospitals in Jeddah that offer the PMSGC programs and theKing Abdulaziz University Hospital. Ethical considerations were followed and datawere collected through an interview questionnaire that had been constructed for

the study. The questionnaire asked for personal and socio-demographic data and forresponses, on a 5-point Likert scale, to 30 knowledge items and 14 attitude state-ments. Individuals who participated in the PMSGC program were asked questionsregarding the services and activities of the program to ascertain their satisfac-tion with the program and their recommendations for program improvement. Thestatistical analysis was performed using SPSS version 16 (SPSS Inc., Chicago, IL).

∗ Corresponding author at: Family and Community Medicine Department, Faculty of Medicine, King Abdulaziz University, Jeddah,A, P.O. Box 42806, 21551 Jeddah, Saudi Arabia. Tel.: +96 6501632237; fax: +96 62 6893248.

E-mail address: nahlakhamis@yahoo.com (N.K. Ibrahim).RLs: http://nibrahim.kau.edu.sa/ (N.K. Ibrahim), http://www.kau.edu.sa/nibrahim (N.K. Ibrahim).

876-0341/$ — see front matter © 2012 King Saud Bin Abdulaziz University for Health Sciences. Published by Elsevier Ltd. All rights reserved.

ttp://dx.doi.org/10.1016/j.jiph.2012.05.001

42

Results: The sample includedprogram. The participants’ ktion was the first predictor odegree obtained a higher scowas the nationality of the par95% CI: 1.002—4.16). The ththe vast majority of participagram. Concerning the satisfa80.0% gave an excellent or vescores were given for counse11.7% of the study participatesting for other genetic diseConclusion: Knowledge in tlow. Implementation of scho

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Improved counseling andpsychiatric problems; bumended.© 2012 King Saud Bin AbLtd. All rights reserved.

Introduction

Premarital care (PMC) involves the promotion ofhealth and well-being of a woman and her part-ner before pregnancy and is considered a primarypreventive approach for couples planning for con-ception and an important step towards protectingsociety and allowing people to enjoy life [1—8].PMC includes premarital health counseling anda general medical examination [1]. Premaritalexaminations can particularly be important in theprevention of the spread of disease [2]. PMC canidentify and modify, through prevention and man-agement, some behavioral, medical, and otherhealth risk factors known to impact pregnancy out-comes [1—7]. The process should educate couplesand provide them with accurate and unbiased infor-mation. Premarital education and counseling seemto be effective in strengthening marriages and haveclearly been shown to be beneficial [9]. Carroll andDoherty [10] conducted a meta-analytic review of23 well-designed premarital programs and foundthat premarital prevention programs are generallyeffective in producing immediate and short-termgains in interpersonal skills and the overall qualityof relationships.

The Saudi Premarital Screening and GeneticCounseling (PMSGC) program was established by lawin December 2003 and implemented in February2004 [11—16]. The program, named the ‘‘HealthyMarriage Program,’’ is part of a national project

spearheaded by the Saudi Ministry of Health [15].By late 2003, comprehensive PMSGC program guide-lines were distributed to all workers in the program.According to these guidelines, couples with

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N.K. Ibrahim et al.

655 participants, of whom 38.8% completed the PMSGCnowledge about the program was generally low. Educa-f a high knowledge score; individuals having ≥ universityre (aOR = 2.73; 95% CI: 1.77—4.20). The second predictorticipants, with Saudis gaining a higher score (aOR = 2.04;

ird predictor was monthly income. Regarding attitudes,nts (96.0%) strongly agreed on the importance of the pro-ction levels of those who benefited from the program,ry good score for program confidentiality, whereas lowerling. Counseling before the tests was conducted for onlynts. The majority of participants recommended addingases and STDs as well as additional topics for counseling.he general population about the PMSGC program wasol and university educational campaigns is important.ing new topics for counseling on genetic, chronic, and

g healthy families; reproduction and fertility are recom-

ziz University for Health Sciences. Published by Elsevier

arriage proposals were required to report to theearest health care clinic to apply for premaritalertificates [16].

The PMSGC program began in 2004 as acreening program for hemoglobinopathies, par-icularly sickle cell anemia and thalassemias.emoglobinopathies are the most frequently inher-

ted disorders worldwide. According to the WHO,pproximately 240 million people are heterozygousor inherited hemoglobinopathies, including tha-assemia and sickle cell disease [2]. Saudi Arabiaas a high prevalence of hereditary hemoglobin dis-rders [16].

On January 2008, viral pathogen screening wasncluded in the Saudi PMSGC to test participantsor human immunodeficiency virus (HIV), hepatitis

virus (HBV) and hepatitis C virus (HCV) as a prereq-isite for issuing a marriage certificate [2,5,14,16].ll couples with marriage plans are required toe tested for these diseases and to have theppropriate counseling (if required) before com-leting their marriage plans. However, complianceith the counseling recommendation remained vol-ntary [16]. Premarital screening can potentiallyeduce the burden of inherited hemoglobin dis-ases by reducing the number of high-risk marriages5,14,16,17]. In addition, the implementation ofremarital infectious disease screening is an ambi-ious and massive project with regard to cost andmpact [2,15]. Premarital programs are most suc-essful when they address social, religious, ethnic,nd cultural factors [16].

Al-Sulaiman et al. [4] conducted a studyn Riyadh among three groups of participants:ne representing the general population, one of

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MSGC program for attendees of governmental out

ouples applying for PMSGC and one of couplesho had received the results of their testing. They

ound a fair degree of knowledge among the threeroups of Saudi participants regarding the naturef the tests and the targeted disorders. Other stud-es found a significant lack of knowledge, evenmong educated persons, about premarital care1,2]. Some studies have been conducted to assesshe knowledge of university students in Jeddahegarding the PMSGC program [2,18,19]. However,o date, few studies have been performed in Jed-ah to assess the knowledge and attitude of theeneral population about the PMSGC program ando determine the level of satisfaction of programarticipants regarding the PMSGC program. Such atudy regarding PMSGC is urgently needed.

The objectives of the present study were tossess the knowledge and attitudes of the atten-ees of governmental outpatient clinics regardinghe Premarital Screening and Genetic Counselingrogram, to identify the predictors of high knowl-dge scores and to determine the satisfaction andecommendations of clients of the program.

ethodology

cross-sectional study was conducted during theourth Year Field Health Survey of the Familynd Community Medicine Department from Januaryo April 2009. Three governmental hospitals wereelected: the 2 hospitals which provide PMSGC ineddah, namely El-Mahjar King Abdulaziz Hospitalnd El-Mesadayah Maternal and Child Hospital, andhe King Abdulaziz University Hospital. Approval foronducting the study was obtained from the Headf the Jeddah Directorate of Health Affairs, fromhe heads of the selected hospitals, and from theean of the Faculty of Medicine. The team followedhe ethical standards of confidentiality and free-om of participation in recruiting the subjects forhe study.

The sample size was calculated using the follow-ng equation:

Z2 × p × q

d2

As the prevalence of knowledge regarding pre-arital counseling among the general population

p) was unknown, it was estimated to be 50% = 0.5,

= 1 − p = 0.5, and the value of 0.04 was chosens an acceptable limit of precision (d). At a 95%onfidence limit, the calculated size of the sampleas 600 participants. This number was exceeded,

Ttru

nt clinics in Jeddah 43

s the number of participants reached 655 duringhe fieldwork. All attendees of outpatient clinicsincluding predominantly the well-baby, hemato-ogy, and genetic clinics, among others) who werevailable on the day of the interviews were invitedo participate in the study. The topic of the researchas discussed with each attendee separately and,pon acceptance, verbal consent was obtained.ndividuals who gave consent and met the require-ents for the study were recruited to participate.he questionnaire for interviewing the subjectsas anonymous and confidential and had beenre-constructed for the study. The validity and reli-bility of the questionnaire were tested.

The first part of the questionnaire elicited infor-ation regarding the respondents’ personal and

ocio-demographic characteristics. The subjectsere asked about consanguinity and a family historyf hereditary diseases, such as thalassemia, sickleell anemia and glucose 6 phosphate dehydro-enase deficiency (G6PD). The questionnaire alsosked the subjects about their sources of knowl-dge for the PMSGC program.

In addition, questions assessing the knowledgend attitudes of participants towards the PMSGCrogram were asked, using the following format:

articipants’ knowledge

hirty multiple-choice questions with a single cor-ect answer were used. These questions were usedo obtain:

. General knowledge regarding the PMSGC pro-gram (5 items): these questions inquired aboutthe starting year of the program in KSA and thehospitals in Jeddah that offer the PMSGC pro-gram.

. Knowledge regarding investigations: thesequestions asked about investigations conductedthrough the PMSGC (15 items).

. Knowledge regarding the infectious diseasesscreened in the program (2 items): these ques-tions asked about hepatitis and AIDS.

. Knowledge regarding hemoglobinopathy andenzymopathy (8 items): these questions inquiredabout the manifestations and complications ofhemoglobinopathy, such as G6PD, thalassemiaand sickle cell anemia.

articipants’ attitude

hese items addressed attendees’ attitudesowards the PMSGC program. This inquiry waselied on participants’ responses to 14 statements,sing a 5 point Likert scale (range from 1 = strongly

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agree to 5 = strongly disagree). Participants wereasked about their attitude towards the PMSGC andabout the misconception that the PMSGC violatesIslamic rules. The subjects’ opinions regardingwhether consanguinity may increase the riskof hereditary diseases and whether the PMSGCprogram is expected to decrease the prevalenceof some genetic and sexually transmitted diseases(STDs) were also addressed. Questions were askedregarding the importance of counseling in reducingand preventing the spread of genetic diseases orSTDs and whether religious leaders should adoptthe ideas of the PMSGC to be discussed on differentoccasions. The attendees’ opinions about whethera Ma’zoon (an authorized individual who performsthe religious marriage for Muslim prospectivecouples) should only be allowed to complete themarriage contract if the couple complete thePMSGC program was also elicited.

Participants were asked if they took part in thePMSGC program, and if so, where and when thecounseling took place. The participants were alsoasked about the services and activities providedby the program. The questionnaire asked whetherresponsible health care providers took a personalor family history of hereditary diseases, conducteda physical examination, ordered laboratory tests,and provided counseling before screening. Partici-pants were also asked about whether a health careworker provided them with knowledge regardingthe screened diseases and the chance of transmis-sion of these diseases, if present, to their partneror a baby. The participant was also asked if therewas a description of the counseling and the benefitsand accuracy of screening for these diseases.

Each subject was asked about the confidential-ity of screening and if the health care workerchecked the identification card (ID) of the personwho received the test results. Participants wereasked whether the results revealed the presence ofany hereditary disease (in themself or their futurepartner) and whether this information led to thecancellation of the marriage proposal.

The study assessed the satisfaction level of theparticipants in the PMSCG with respect to the indi-viduals who conducted the screening, the programitself and the provided service (i.e., place of pro-viding the service inside the hospital, place ofsample taking and waiting place in the hospital andconfidentiality). The participants in the programwere also asked about their recommendations forextra topics that need to be added to counseling.

After the questionnaire was completed, andonly as service for the study participants, apre-constructed, computer-based CD-ROM withmultimedia interactive animated presentations was

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N.K. Ibrahim et al.

iven to and discussed with interested participants.he CD-ROM contained a lecture in Arabic on theMSGC program. The CD-ROM was supported byttractive images related to the details of all knowl-dge items. The total showing took approximately0 min. In addition, 5 brochures, each on a dif-erent theme, were given to participants. Copiesf the educational CD-ROM were given to admin-strators in the hospitals to be used again later.n addition, hundreds of posters (consisting of fiveifferent styles with different PMSGC educationalessages) were distributed throughout the visited

ospitals.A pilot study was conducted among 10 partic-

pants to pre-test the questionnaire, identify theeasibility of conducting the study, determine theifficulties that may arise during the course of thetudy and estimate the time required to completeach questionnaire.

tatistical analysis

he collected data were reviewed, coded, verified,nd statistically analyzed. The computer programsed was SPSS version 16 (SPSS Inc., Chicago, IL)20]. A knowledge scoring system was developed forhe 30 items. ‘‘Do not know’’ answers were treateds incorrect and given a score of ‘‘0’’, whereasach correct answer was given a score of ‘‘1’’. Theotal knowledge score was calculated and rangedrom 0 to 30. The knowledge score was classified asoor score, <15; fair score, 15 to <20; and satisfac-ory score, ≥20. The chi-squared test was used foromparisons between proportions. The odds ratioOR) and 95% confidence intervals (CI) were alsoalculated. The significant variables obtained fromhe bivariate analysis were used for multivariateogistic regression analysis through construction of

binary logistic regression model to identify theredictors of a high knowledge score (fair and sat-sfactory) versus a poor knowledge score. Adjusteddds ratios (aORs) and 95% confidence intervalsCIs) were calculated. Statistical significance wasefined as P < 0.05.

esults

he total number of participants enrolled in thetudy was 655, and the mean age of the participantsas 30.63 ± 9.1 years. There were 332 male partic-

pants (50.7%) and a male to female ratio of 1.02:1.ore than four-fifths (82.9%) of the participantsere Saudis. Approximately one-half of the sub-

ects (46.7%) had a university degree or higher. Most

PMSGC program for attendees of governmental outpatient clinics in Jeddah 45

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igure 1 Sources of knowledge about pre-marital screen.B. Each question is separately asked.

f the participants (70.1%) were from the westernegion of Saudi Arabia. A similar percentage (71%)ad a monthly income ≥5000 SR/month. Consan-uinity was reported by 44.5% of the participants31.1% having first degree cousin consanguinity and3.4% having other types of consanguinities).

The vast majority (93.7%) of participants hadeard about the PMSGC program. Fig. 1 depictshe participants’ source of knowledge regardinghe program. Friends and family were cited ashe most common source of information for theajority of participants (78.5%). Approximately

alf (52.2%) of the participants obtained their infor-ation from television, and a similar proportion

48.7%) obtained their information from magazinesnd newspapers. A substantial proportion of par-icipants (39.5%) obtained their information fromtreet advertisements. The Internet and radio were

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igure 2 Knowledge score about pre-marital screening amon

mong attendees of outpatient clinic in Jeddah hospitals.

ources of information for approximately one-thirdf the participants.

It is apparent from Fig. 2 that the participants’nowledge regarding the PMSGC program score wasenerally low. Most of the subjects (80.5%) had aow knowledge score, and only 14.0% and 5.5% hadair and satisfactory scores, respectively.

Table 1 portrays the relationship between partic-pants’ knowledge scores regarding the PMSGC andhe studied variables. It is apparent from the tablehat participants aged <30 years had a higher pro-ortion (22.4%) of fair and satisfactory scores whenompared with those aged ≥30 years (16.0%), with atatistically significant difference (p = 0.02). There

as no statistically significant difference regarding

he level of knowledge between the sexes. Saudisad significantly higher knowledge scores than non-audis (X2 = 9.68, p = 0.002). Individuals who had

g attendees of outpatient clinics in Jeddah hospitals.

46 N.K. Ibrahim et al.

Table 1 Relationship between knowledge level about premarital screening and personal, socio-demographic char-acteristics of attendees of Jeddah outpatient clinics.

Knowledge level Poor Fair and satisfactory Total X2 (P) OR, 95% CI

Variable No. % No. %

Age<30 281 77.6 81 22.4 362 4.13 0.66≥30 246 84.0 47 16.0 293 (0.02) 0.45—0.98

SexMale 270 81.3 62 18.7 332 0.32 1.12Female 257 79.6 66 20.4 323 (0.05) 0.76—1.64

NationalitySaudi 425 87.0 118 21.7 543 9.68 0.35Non-Saudi 102 91.1 10 8.9 112 (0.002) 0.18—0.69

EducationLess than university 310 88.8 39 11.2 349 33.26 3.26University or above 217 70.9 89 29.1 306 (0.000) 2.15—4.93

Income<5000/month 252 87.5 36 12.5 288 16.2 2.34≥5000/month 275 74.9 92 25.1 367 (0.000) 1.54—3.57Parental consanguinity

Yes 231 82.2 50 17.8 281 0.96 1.22No 296 79.1 78 20.9 374 (0.33) 0.82—1.80Family history of genetic diseases

No 95 76.6 29 23.4 124 1.44 0.75Yes 423 81.4 99 18.0 531 (0.2) 0.47—1.20

Conduct the premarital examination23.716.7

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Yes 203 76.3 63No 324 83.3 65

a monthly income ≥5000 SR/month demonstratedsignificantly higher knowledge scores comparedwith the others (aOR = 2.34; 95% CI: 1.54—3.57).Individuals who participated in the PMSGC programalso had higher knowledge scores than the others.

Results of the logistic regression analysis forpredictors of high knowledge scores (fair and sat-isfactory), after controlling for other confounders,are presented in Table 2. Education was the firstpredictor of a high knowledge score; individualswith a university degree or above demonstrateda higher knowledge score (aOR = 2.73; 95% CI:1.77—4.20). The second predictor was the nation-ality of the subject; the score for Saudis wasapproximately two times higher than that fornon-Saudis (aOR = 2.04; 95% CI: 1.002—4.16). Thelast predictor for a high knowledge score was amonthly income ≥5000 SR/month (aOR = 1.59; 95%CI: 1.005—2.505).

Table 3 portrays the attitudes of participants

towards the PMSGC. It is apparent from the tablethat the vast majority of participants (96.0%, 89.1%and 94.0%) strongly agreed with the importance of

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he PMSGC program, that the program will con-ribute to a reduction in the prevalence of someenetic diseases and STDs, and on the importancef raising awareness regarding the PMSGC beforearriage, respectively. Approximately two-thirds

f the participants (65.2%) strongly agreed thathen a genetic disease is detected, the marriageroposal should be cancelled. Another two-thirdstrongly agreed that when an STD or genetic dis-ase is discovered, the marriage decision must beeft to the discretion of the couple. The major-ty of participants disagreed or strongly disagreed71.1%) with the misconception that the PMSGC vio-ates Islamic rules, whereas 11.7% strongly agreedhat the PMSGC violates Islamic rules.

Among the study population, 254 individuals38.8%) participated in the PMSGC. Genetic dis-ases were diagnosed in 6.7% of the interviewedersons or in a future partner. The marriage pro-osal was cancelled in 41.2% of cases where a

enetic disease was discovered. Infectious diseasesHBV, HCV, and HIV) were diagnosed in 1.97% of theouples.

PMSGC program for attendees of governmental outpatient clinics in Jeddah 47

Table 2 Multiple logistic regression analysis of predictors of high knowledge score about premarital screeningprogram among attendees of Jeddah outpatient hospital clinics.

Score and variables ˇ aOR P CI

Participants’ knowledgeEducation (university and above) 1.003 2.73 0.000 1.77—4.20Nationality (Saudi) 0.714 2.04 0.049 1.002—4.161Monthly income ≥ 5000 SR/month 0.462 1.59 0.048 1.005—2.505

Constant −4.513 0.011 0.000

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Measures taken during premarital screening, aseported by the participants who completed theests, are presented in Fig. 3. It is evident from thegure that laboratory testing was the most commononducted measure (83.1%). Determining a historyf diseases, determining a family history of geneticiseases and physical examinations were reportedo have been conducted in 35.1%, 34.6% and 38.5%f participants, respectively. Only 11.7% of the par-icipants reported that they received premaritalounseling before the test.

Counseling was provided regarding the screenediseases, the susceptibility of transmission, theypes of testing, and the benefits of screening,

n 13.4%, 14.3%, 11.3% and 16.3% of participants,espectively.

The satisfaction level regarding the program forhe participants who took part in the screening is

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igure 3 Activities done during premarital screening amongeddah’s hospitals. N.B. Each question is separately asked.

resented in Table 4. The majority (80.0%) gaven excellent or very good score for program con-dentiality. More than 60% said that the place of

mplementation of the program inside the hospitalnd the place of sample taking were either excel-ent or very good. One-half of the beneficiaries gavexcellent or very good scores regarding the waitingrea in the hospital. The areas of least satisfac-ion were related to counseling (approximately 40%f the participants gave excellent and very goodcores for the questions related to counseling).

Approximately 90% of the participants recom-ended adding screening for other genetic diseases

nd STDs to the program. A similar percentage

ecommended adding more genetic counseling andounseling about building a healthy family. A highercentage of participants recommended addingounseling for chronic diseases (83.7%), fertility,

outpatient clinic attendees who conducted screening in

48

N.K.

Ibrahim et

al.

Table 3 Attitude of attendees of Jeddah outpatient hospital clinics towards premarital screening program.

Sentence Degree of agreement

Strongly agree Agree No opinion Disagree Strongly disagree

No % No % No % No % No %

PMS is important 545 83.2 84 12.8 15 2.3 7 1.1 4 0.6PMS is against Islamic roles 84 7.3 29 4.4 112 17.1 141 21.5 325 49.6Consanguinity may leads to hereditary diseases 242 36.9 288 44 71 10.8 43 6.6 11 1.7PMS will contribute to reduction of prevalence of some genetic and STDs 424 64.7 160 24.4 47 7.2 18 2.7 6 0.9It is important to raise awareness about PMS before marriage to reduce

genetic and STDs481 73.4 135 20.6 29 4.4 8 1.2 2 0.3

Religious people should adopt the ideas of PMS in their discussion 363 55.4 184 28.1 90 13.7 18 2.8 0.0 0.0Ma’zoon should has the right to accept conducting marriage contract only

if future couple did PMS301 46.0 165 25.2 112 17.1 56 8.5 21 3.2

The law that obligate all future couples to do PMS is important 363 55.4 183 27.9 56 8.5 36 5.5 17 2.6No one should obligate any person to conduct genetic testing, but only

encourage to do180 27.5 202 30.8 65 9.9 107 16.3 101 15.4

In a case of discovery having or carrying STDs, marriage decision must beleft for freedom of the couple

225 34.4 202 30.8 81 12.4 64 9.8 83 12.7

In the case of discovery having or carrying inherited disease in PMS,marriage decision must be left for freedom of couple

199 30.4 246 37.6 73 11.1 67 10.2 70 10.7

Test results that shows presence of genetic diseases should changemarriage decision

248 37.9 179 27.3 168 25.6 40 6.1 20 3.1

It is important to apply a law that stop marriage upon discovery presenceof a genetic disease

242 36.9 132 20.2 126 19.2 108 16.5 47 7.2

PMS breaks personal privacy 49 7.5 40 6.1 67 10.2 227 34.7 272 41.5

N.B. Each question is separately asked.

PMSGC program for attendees of governmental outpatient clinics in Jeddah 49

Table 4 Percentage of participants’ satisfaction regarding premarital screening program.

Sentence Opinion

Excellent Very good Good Bad Very bad

Place of PMC in the hospital 30.7 29.9 23.5 10.2 5.7Place for taking samples 28.7 35.2 20.9 11.9 3.3Waiting place 21.7 28.3 23.8 17.2 9.0Waiting Place for laboratory sample 24.2 22.5 27.0 13.5 12.7Way of dealing of doctors in the program 38.3 29.6 25.1 5.3 1.6The confidentiality 47.9 22.1 15.0 5.4 9.6Place for counseling 19.3 17.6 23.3 16.1 23.3Dealing of staff responsible for counseling 20.7 21.6 22.1 14.0 21.6Doctors cooperation during counseling 26.6 17.1 24.8 13.1 18.5

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nd reproduction (81.5%), and psychiatric problems76.3%) (Fig. 4).

iscussion

any nations have begun to realize the importancef premarital counseling as a public health mea-ure [21—23]. PMSGC is an important means byhich newly married couples can consider mar-

iage and learn about reproductive health [1]. Inhe Arabian Peninsula, high proportions of con-

anguineous marriages and the tribal nature ofarriages have resulted in a high incidence of

enetically based disorders [24]. The consanguin-ty rate in the region ranges from 25% to 60%,

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igure 4 Recommended activities to be added to premaritutpatient clinic attendees in Jeddah.

ith a high incidence of first-cousin marriage2,18,19,21,24]. This finding is in agreement withesults of the present study, where the consan-uinity rate was 44.5%; 31.1% of the participantsad first-degree cousin consanguinity with theirartner. The consanguinity rate is slightly higherhan that reported in a study conducted by Abdel-eguid et al. [25], in which the corresponding

ate among the general population in Egypt was6.8%.

The present study showed that friends and familyere cited as the most common source of infor-ation regarding PMSGC, followed by television

nd then magazines and newspapers, which agreesith our previous findings regarding premaritalounseling among unmarried female university stu-ents in Jeddah [2]. Other studies have shown that

al screening by those who conducted tests among the

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50

television is the most common source of knowledge[1]. Dabbous et al. [26] found that radio and tele-vision were the most common reported means ofhealth education (65%). The discrepancy betweenthe current and previous studies may result fromthe low number of educational television programsregarding the PMSGC in KSA or from the reportingof more than one type of mass media in other stud-ies. Therefore, the media plays a prominent rolein enlightening the populace regarding the PMSGCprogram.

The current study showed that the participants’knowledge regarding the PMSGC was generally low;80.5%, 14.0% and 5.5% of participants demonstratedpoor, fair, and satisfactory scores, respectively.Similar rates were obtained from the pre-test inour previous study in unmarried students; the cor-responding rates were 80.9%, 12.5% and 6.6%,respectively [2]. The gap in knowledge among par-ticipants demonstrates a need for more efforts toimproving knowledge through the mass media orthrough the PMSGC program. The results of thecurrent study also agree with those of a studyconducted at King Abdulaziz University, Jeddah,that found that university students had inadequateknowledge about the program [18,19]. An olderstudy conducted by Eshra et al. [27] in 1989 amongvillagers in Egypt also revealed gaps in knowledgeregarding premarital screening. In contrast, a studyconducted among nursing students in Alexandriarevealed that 46.5% had an average score for knowl-edge regarding premarital counseling [6]. Anotherstudy in Syria in 2009, showed that university stu-dents had considerable knowledge about premaritaltesting [28]. In Nigeria, a cross-sectional surveyconducted among university students in 2006 foundthat most study respondents (63.6%) knew the ben-efits of genetic counseling [29]. The discrepancybetween the current and the previous studies maybe attributed to differences in the target popula-tions because the previous studies were conductedamong university and nursing students rather thanin the general population.

The present study showed that education wasthe first predictor of a high knowledge score, whichcoincides with the results of a study in Emirates[30]. Income was also a predictor, which agrees withour previous study that found that university stu-dents who have a higher family income have moreknowledge about the PMSGC program [2].

In recent years, premarital counseling has gainedacceptance [2,25]. The present study showed a pos-

itive attitude towards PMSGC among most of thegeneral population of outpatient clinic attendees,which coincides with the findings of several otherstudies [4,11—13,18,19,31—34]. A study conducted

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N.K. Ibrahim et al.

mong the general population in Riyadh in 2008howed a positive attitude toward the program andhat the majority of participants agreed with thedea of applying the PMSGC program to all couples inll regions of the country [4]. An older Riyadh studyndicated that 75.0% of consumers supported com-ulsory participation in the PMSGC program [31].imilarly, an assessment of the attitudes of uni-ersity students in Abha in 2002 showed that 70%articipation in the PMSGC program [32]. El-Hazmi11] conducted a community-based attitude studynd found that 94% of the participants consideredremarital testing and counseling to be importantn preventing genetic blood diseases, whereas 87%hought testing should be mandatory. A study con-ucted among 800 university participants in Jeddahevealed that most participants favor the program,ut there were concerns regarding mandating theesting and interference with individual decisionaking [18,19]. An educational program conducted

mong female students at King Saud University iniyadh found that the students’ attitudes were pos-

tive [12]. A study conducted in Iran to evaluatehe attitudes of the young adult population towardsremarital screening for HBV found that 73.2% ofhe participants agreed with HBV screening [13].esults from Germany in 2009 found that there wasn overall positive attitude toward genetic testingmong respondents aged 14—95 years [33]. In 2002,assan et al. [34] reported that 80.9% of medicaltudents in Alexandria, Egypt supported the idea ofremarital examinations.

In the present study, few of the participants11.7%) had religious misunderstandings regardinghe PMSGC. Al-Khaldi et al. [32] also found that fewtudents in Abha showed negative attitudes aris-ng from religious misunderstandings and concludedhat the respondents could benefit from intensiveeligious health education. Two older studies fromiyadh [12,31] had findings and implications similaro these studies. In a study conducted in Al-Fayoum,gypt, the majority of participants who rejectedcreening believed that it interfered with God’s will1].

In the present study, the prevalence of at-riskarriages where hereditary diseases were iden-

ified was 6.7%. This finding agrees with that ofl-Hamdan et al. from 2007 [35], in which a similarate (7.75%) was observed among 488,315 individ-als screened in the first two years of the PMSGC.n Al-Hassa, Saudi Arabia, the prevalence of the B-halassemia trait with high Hb-A2 and microcytic

ypochromic anemia was determined by premaritalcreening to be 3.4% [36].

A recent retrospective study conducted in KSA74,662 participants) revealed that the prevalence

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f infection among couples in the PMSGC programas 1.67% (0.03%, 1.31% and 0.33% for HIV, HBV,nd HCV, respectively) [14]. These results coincideith results of the present study, as these infectionsere diagnosed by the program in 1.97% of the cou-les. El-Hazmi [37] found prevalence rates of 1.4%or hepatitis B surface antigen (HBsAg) and 0.2% fornti-HCV among Saudi blood donors in Riyadh.

In the present study, the majority of participantsgreed that in the case of the discovery of theresence or carrier status of an inherited disease,he marriage decision must be left to the discre-ion of the couple. This finding agrees with resultsf other studies [2,34,38]. However, approximatelywo-thirds of the participants (65.2%) agreed thatouples contemplating a marriage with a high risk ofenetic disease should change their marriage plans.his finding agrees with the results of Al Sulaimant al. [4], who reported that more than 60% of allarticipants from Riyadh were in favor of cancel-ng at-risk marriages. Approximately two-thirds ofhe students (67.1%) in our previous study of femaleniversity students agreed with the prevention ofigh-risk marriages [2].

Al-Hamdan et al. [35] found that approximately0% of high-risk couples still married, despite know-ng the risk of having a child with a genetic disease,hereas only 10% cancelled their marriage plans.hey concluded at that time that the program’sbjective of decreasing the number of high-riskarriages was unsuccessful. Another study of a

ix-year outcome of the national Saudi PMSGCrogram for sickle cell disease and �-thalassemiaeported that, of the 8925 couples who had beenssued incompatibility certificates between 2004nd 2009, only 26.5% cancelled their marriagelans. The frequency of voluntary cancellation ofarriage plans among the at-risk couples followed

n the study showed more than a 5-fold increaseetween 2004 and 2009 [16]. In the present study,1.2% of couples planning an at-risk marriageancelled their marriage plans. This finding mayndicate an improvement in the program outcome.owever, the finding that 60% of planned at-riskarriages still take place indicates that a great

ultural challenge remains to be addressed by theounselors. More efforts are required in providingounseling for couples contemplating at-risk mar-iages. Counseling is especially necessary becauseur religion and culture do not condone therapeuticbortions. Therefore, it is much better to prevent

high-risk marriage by providing appropriate coun-

eling services.

Regarding the satisfaction of those who partic-pated in the program, the majority (80.0%) gaven excellent or very good score for the level of

tkic

nt clinics in Jeddah 51

onfidentiality of the program. More than 60% gaven excellent or very good score for the location ofhe program inside the hospital and for the place ofample taking, and 50% gave an excellent or veryood score regarding the waiting areas inside theospitals. In Bahrain, 70% of premarital counsel-ng clients reported that the service was generallyxcellent [23].

The goal of the marriage education movements to give contemporary individuals and couples thenowledge, skills, and virtues needed to build andustain healthy marriages [39]. It is important toducate the population about the potential bene-ts of counseling, as well as the ethical dilemmas

nvolved, so that members of the general pub-ic can make the right decisions for themselvesnd their families [40]. Many young women anden enter into marriage with insufficient informa-

ion on sexuality, reproduction, and family planning1,41]. Genetic counseling is the process by whichndividuals or families obtain information about

genetic condition that may affect them, sohat they can make appropriate decisions aboutarriage, reproduction and health management

5,42]. Studies of patient perspectives regardingremarital examinations have revealed a need forhysicians to offer counseling for various healthroblems before the patient asks, so they canecline unwanted help rather than bring up sen-itive issues [5,42]. It was reported in Morocco thatremarital counseling provided to program partic-pants is generally not standardized and is largelyictated by physicians’ priorities, capabilities, andapacity to provide counseling [44]. In the presenttudy, counseling before screening was providedor only 11.7% of the individuals tested. In addi-ion, only approximately 40% of the participantsave excellent or very good scores for the coun-eling. In an older study in 1995, Shiloh et al. [45],ho studied attitudes, beliefs and decisions amongounseled, non-counseled and unrelated couplesn Israel, reported that counselees’ appraisals ofenetic counseling revealed unfulfilled expecta-ions to obtain more definitive answers as wells mixed reactions to the nondirective approachpplied by the counselors. These results disagreeith results obtained from the Bahrain study, which

eported that 97% of counseling clients did not faceny problems during consultation with the genet-cs department and that the level of satisfactionith the service provided at the genetic counselingepartment was higher than that at health cen-

ers. This finding was attributed to the amount ofnowledge provided to the couples by the special-sts and to the adequate time allowed for eachouple [23]. An Australian study evaluated client

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expectations, psychological adjustment and sat-isfaction with genetic counseling and foundthat the majority of clients attending geneticcounseling reported that they were very sat-isfied [46]. Al-Gazali [30] assessed the levelof understanding of genetic advice given inthe genetic clinic in the UAE and concludedthat for effective genetic counseling, it isadvisable to educate the population; Al-Gazalialso recommended the introduction of carrierscreening and preconception diagnosis in affectedfamilies.

Addressing young couples’ needs regarding infor-mation on reproductive health remains a criticalarea for expanded health education interventions[1,44,47]. Premarital counseling provides an oppor-tunity to intervene according to the identified risks[48]. In the present study, the majority of par-ticipants recommended adding counseling aboutbuilding a healthy family as well as reproductionand fertility issues. A high percentage of respondersalso recommended adding more genetic counseling,which agrees with results of Al Sulaiman et al. [49],who conducted a post-marital follow-up survey onhigh-risk patients who participated in a premaritalscreening program and found that the concept ofgenetic counseling was met with approval by mostparticipants from Riyadh. One successful approachis ‘solution-focused’ premarital counseling. Mur-ray and Murray [50] discussed how this approachfocuses on a couple’s resources and helps them todevelop a shared vision for the marriage.

Strengths and limitations of the study

To our knowledge, the current study is the firstlarge-scale community-based study conducted inJeddah on the knowledge, attitude, and satisfac-tion of the general population regarding the PMSGCprogram. Awareness of the general populationregarding the program is an important part of theeffort. Client satisfaction is becoming an importantpublic health issue in evaluating medical care, andthis study represent the first time that this impor-tant issue of the PMSGC program has been studiedin Jeddah. The clients’ recommendations for pro-gram improvement were also studied. Educationalmaterials regarding the program were distributedto participants and the selected hospitals, and thiseffort could help to increase knowledge regardingthe program. The literature review provides a

comprehensive summary of premarital screeningprograms. However, the satisfaction of the clientsshould be studied in more detail in a separatestudy.

aibf

N.K. Ibrahim et al.

onclusion

his study highlights that knowledge of the gen-ral population regarding the PMSGC program wasimited. However, there was generally a positivettitude towards the importance of the program.his positive attitude provides strength for the suc-ess of the program. These results indicate thathere is a need for more information and educationegarding the PMSGC program. Not all individualsarticipated in the laboratory diagnosis process,hich requires further attention. Approximately0% of couples contemplating at-risk marriagesancelled their marriage plans, whereas 60% con-inued with the marriages. This finding indicateshat the program has been successful in preventingome at risk marriages, but large cultural chal-enges remain to be addressed by the counselors.he beneficiaries of counseling were satisfied withome parts of the program. However, some areaseed further improvement. More attention needso be paid to history taking, physical exami-ation and laboratory investigations. Counselingequires marked improvement, including and theddition of some important topics to prevent at-riskarriages.

ecommendation

ublic education regarding the PMSGC programs needed. Government, community and religiouseaders, organizations and universities, and healthersonnel should cooperate in providing this edu-ation. An educational campaign needs to bemplemented for the general population in highchools and universities. Dissemination of infor-ation regarding the PMSGC, through formal and

nformal education and media publicity, is recom-ended. The educational campaigns should provide

nformation on the PMSGC, its importance, theisorders tested for, and the implications of thecreening. Professionals in the fields of genetics,ealth education and the media can work togethero increase awareness in the adult population. Tele-ision documentaries on specific diseases or videoselated to the program need to be implemented.epeated audits with quality assurance guidelinesre needed in the hospitals that provide this impor-ant service. In addition, the PMSGC could bextended to include a broader spectrum of health

nd genetic disorder issues. Implementing counsel-ng on genetic, chronic and psychiatric problems,uilding healthy families, reproduction issues andertility is recommended. To increase the success

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f counseling in preventing at-risk marriages, theounseling needs to be provided by trained profes-ionals and prior to each genetic test. It is importanto add mandated genetic counseling to the currentrogram. Knowledge could also be provided to theouples by trained specialists with adequate timeor effective counseling allowed for each couple.roup counseling sessions could also be added tohe program. Solution-focused premarital counsel-ng is recommended. Certified training courses onenetic counseling methods specific for those work-ng in the program are recommended.

There is a need for greater research on the goalsf counseling and how they relate to client out-omes. Because client satisfaction is becoming anmportant issue in evaluating medical care, we rec-mmend further research on the assessment of allspects of client satisfaction.

cknowledgment

he authors would like to thank all fourth year med-cal students during the educational year 2009/2010or their enormous efforts during the field worknd data collection. We also thank all staff of theamily and Community Medicine Department. Were very grateful to them for their funding. Theuthors are grateful to the Jeddah Directorate ofealth Affairs, the heads of the selected hospitals,he dean of the Faculty of Medicine, and all of thehysicians in the selected hospitals for the facili-ation of the study. We offer special thanks to theespondents for graciously agreeing to participaten this study.

Funding: The educational materials were fundedy two funding sources (Zmzm Non-Governmentalrganization and another individual sponsor)..Competing interests: None declared.Ethical approval: Not required.

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