The human red blood cells are very important components of the human circulatory system necessary for the exchange of gases in the body and it is when these cells undergo structural changes leading to their malfunctioning that Sickle Cell Disease (SCD) may occur [1] . SCD is a hereditary condition of several different variants with the most common type being Haemoglobin S (Hb S) which is different from the normal haemoglobin usually designated as Hb A. In Hb S, glutamic acid, an amino acid situated at the sixth position of the beta globin chain in the normal haemoglobin molecule is substituted by valine [2] . Individuals with two Hb S genes suffer a chronic blood disorder referred to as Sickle Cell Anaemia [2] [3] . Persons who carry one normal gene and one Hb S gene are said to have the sickle cell trait (SCT) and referred to as carriers are usually asymptomatic and unaware of their genetic makeup [4] . Clinical manifestations in persons with SCD crises include arthralgia, anorexia, fatigue, splenomegaly as well as destructive and painful bone and joint problems [2] . The World Health Organization estimated that 5.2% of the world’s population and more than 7% of pregnant women present variants of SCD of which 40% is the Hb S type [5] . Also, a screening of newborns in Ghana revealed that 1.9% of them had at least one Hb S gene [6] . Socioeconomic impact of SCD on affected persons, families, communities and nations is enormous since recurrent sickle cell crises adversely affects the patient’s life, in relation to education, work and psychosocial development. For instance, the management of a sickle cell patient in a hospital in the Democratic Republic of Congo cost US $1000, an amount way beyond the income of majority of Africans [5] . There is currently no cure for SCD hence experts have suggested various strategies to control this disease which include among others, prenatal diagnosis (PND), selective abortion, preconception/premarital genetic testing and counselling, education for SCT parents as well as a holistic management of persons with SCD [5] [6] . Although there are no figures on the comparative cost analysis on the management of SCD in Ghana, for developing countries, preconception genetic screening and counselling seems the cheapest option [6] . This suggestion is emphasized by the SCD strategy for the WHO African Region which seeks to increase individual and community awareness about SCD and strengthen primary prevention, reduce disease incidence, morbidity and mortality and improve quality of life [5] . For persons to readily opt to undergo genetic screening and counseling, they must in the first place possess good knowledge of SCD and its effects which will enable them appreciate the full consequences of having children who may suffer SCD [7] . It is reported that about 30% or 5 million out of the total of about 25 million Ghanaians carry the Sickle Cell Trait [8] [9] . This is a significant number who must be provided with enough information to make the most desirable choices in relation to conception and marriage, so as to reduce future transmission and hence incidence of SCD. Although some studies have been conducted in several countries that measured the awareness and knowledge on SCD among sections of their population, there is no literature on such a study in Ghana. This study therefore assessed the knowledge level and attitude towards SCD among married public servants in Tamale, a city in northern Ghana.

Sickle cell disease causes serious emotional, psychosocial, and economic problems for sufferers and their parents or caregivers [3] [12] [13] . The results of this study showed that majority of respondents have heard of SCD mainly through the mass media but health workers and family were the first source of information on SCD in the Middle East countries of Oman and Saudi Arabia [14] [15] Cultural differences may account for this difference. Ghana, being a secular country permits free discussion of issues of sexuality in the mass media unlike in Islamic states of Saudi Arabia and Oman. The moderate overall knowledge score of 50.7% is higher than those recorded among Nigerian local government workers in Ile Ife and youth corps in Lagos [16] [17] . Other studies in the UK and Nigeria recorded higher knowledge level between 75% - 86% [7] [18] [19] . Gender, level of education and type of working institution were the socio-demographic factors that significantly influence knowledge of respondents. The effects of gender on knowledge of SCD could be attributed to the fact that females while attending antenatal clinics during pregnancy were tested and educated on SCD. For respondents working in health related institutions to possess better knowledge on SCD is understandable since they may have acquired this knowledge at school or in their working environment. A study in Saudi Arabia reported health science female university students possessed higher knowledge on SCD than their non-science counterparts [15] .

This study recorded only 12.2% of respondents undergoing premarital screening and counseling on SCD and also just about a third of respondents knew their own sickling status or that of their spouses before marriage or first child. Again less than half of respondents knew their own status or that of their children at the time of the study. Even for those who later knew their status after marriage, only 21.6% was by voluntary request. The overall attitude of respondents towards SCD of 40.8% is rather poor. Similar poor attitudes towards SCD were reported in Oman, US and Nigeria [12] [14] [20] . Age, gender, religious affiliation just as reported in other countries did not influence a person’s attitude towards SCD [16] [21] [22] . Several reasons could be responsible for the poor attitude of respondents in this study despite their moderate knowledge level. Critical knowledge areas that may change the behaviour of the respondents such as the epidemiology, incurability, adverse effect of disease on life expectancy of SCD were knowledge areas respondents were most deficient in. This study therefore showed that prospective Ghanaian couples are negligent and do not consider the consequences of having children with blood disorder. Just as was reported in Oman and Nigeria, factors such as love, beauty, ethnicity, parental influence, and socioeconomic status rather greatly influence the choice of partners, relegating issues of genetic incompatibility to the background [18] [21] [22] .

Possessing knowledge about a disease is said to influence behaviour adaptation if it is paired with the belief that a behaviour change will positively contribute to good health [23] . The positive correlation between knowledge and attitude in this study was clearly demonstrated in respondents from the health sector and those with tertiary education possessing better attitude towards SCD. Therefore, provision of more information on SCD through the media, empowering religious leaders with appropriate knowledge to influence their follower’ marriage decisions in relation to SCD, training of health workers and provision of accessible testing and counseling centres; strategies recommended by the WHO if adopted by countries will reduce the incidence of SCD among the population. For some respondents to decide to continue with relationships even when genetic incompatibility is detected due to love emotions means, public education alone would not lead to the drastic reduction of this disease but some compulsory and fee free premarital counseling and screening must be pursued by all nations especially those in Africa since mandatory Pre-marital counselling and screening programme have reduced the incidence of SCD in several countries [14] . Although 75.6% of respondents just as reported in Saudi Arabia strongly agreed or agreed to the suggestion of not allowing two SCD or SCT persons to marry to reduce SCD prevalence, genetic testing and separation of prospective couples due to genetic incompatibility can be emotionally stressful [15] [24] . To reduce this stress of separating persons who may have dated for years and close to marriage, intense education and testing should be directed towards early adolescent stages before individuals begin conjugal relationships. Compulsory presentation of certificate of genotype compatibility before marriages at our law courts, churches, mosques, marriage registries or anywhere marriages can be contracted would also support the drive towards the reduction in SCD cases.

This study had some limitations. The use of closed questions requiring respondents to choose among the options did not permit them to explain their answers hence the introduction of some bias. This study involved the use of self-administered questionnaire rather than interviews hence reliability of answers could not be verified. This study was conducted among only public servants in Tamale; hence the result might not represent the knowledge and attitude towards SCD among the Ghanaian population.

This study showed that although public servants had moderate knowledge about Sickle Cell disease, their overall attitude towards the disease was poor. Majority of respondents did not know their personal or spousal premarital sickling status with half of them still unaware of spouses’ status after marriage. A positive correlation exists between the knowledge and attitude; hence persons working in the health sector and with tertiary education who exhibited better knowledge of SCD had a more positive attitude towards it. Since the media was the most common source of information on SCD, its role in the effort to reduce the incidence of SCD and its attendant morbidity and mortality across the world and especially Africa is crucial.

Authors have no conflict of interests, and the work was not supported or funded by any person or organization.