Numidhorizon Journal Vol2 No1 PDF

NUMID
HORIZON
An International Journal of Nursing and Midwifery
VOL
VOL.21NO.
NO.11
NUMID
HORIZON
An International Journal of Nursing and Midwifery
VOL 2 NO.
VOL. 1 1
1 NO.
Copyright© 2018
Nursing and Midwifery Council of Ghana
All Rights Reserved. No part of this document or work may be re-

produced or used in any form or by any means: graphic, elec-
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the Nursing and Midwifery Council of Ghana. Upon request, how-
ever, copies of this document or work may be obtained from the
Editorial Board.
ISSN (Print Version): 2026-5883
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NUMID HORIZON: An International Journal of Nursing and Midwifery
Dr. Abigail A. Kyei

Editor-in-Chief
Prof. Lydia Aziato

Deputy Editor-in-Chief
Prof. Ernestina Donkor
Member
Editorial Board
Prof. Eric M. Wilmot
Member
Nii Teiko Tagoe
Member
Mrs. Mercy M. Avogo

Member
Nana Boateng Agyeman
Member
Dr. Aaron Abuosi

University of Ghana, Legon
Dr. Anita Fafa Dartey
University of Health and Allied Sciences, Ho
Dr. Roger Atinga

Dr. Veronica Dzomeku

KNUST, Kumasi
Dr. Judith Anaman
University of Health and Allied Sciences, Ho
Dr. Jerry Ninnoni

University of Cape Coast, Cape Coast
Reviewers for Dr. Andrew Druye
this Issue University of Cape Coast, Cape Coast
Dr. Adelaide Ansah-Offei

Dr. Mary Ani Amponsah

Dr. Gideon Puplampu

Mr. Charles Ampong
Mr. Samuel Adjorlolo
Dennis Boamah-Boateng
Proof Reader Department of English, University of Ghana
http://www.numidhorizon.com Volume 2 No. 1, June 2018 iii

In this Issue
vi Mesage from Registrar
Felix Nyante (MPA, MA, FWACN, FGCNM, BEd, Dip, SRN)
vii Editorial
Abigail A. Kyei (DHA, MPH, BA (Nursing), FGCNM, RN, RM)
1 Stress and Coping Strategies among Nurse

Managers at Three District Hospitals in the Eastern
Region, Ghana
Adelaide Maria Ansah Ofei (PhD, MPhil, MBA, BA, RM, SRN, WACN, FGCNM)1
Atswei Adzo Kwashie (PhD candidate, MPhil, BA, SRN, WACN, FGCNM) 1
Ernestina Asiedua (PhD candidate, MPhil, BA, SRN, RM, WACN, FGCNM) 2
Nana Serwaa Twum Duodu (BSc, Dip. RGN) 3
Alfred Nene Akotiah (MBA, BA) 4
14 The Effects of Stigma on Mental Health Nurses:

A study at Ankaful Psychiatric Hospital
Sampson Opoku Agyemang (BSc, BA, RMN) 1
Jerry Paul Ninnoni (PhD, MBA, RMN) 2
21 Continuing Formal Education for Non–professional

Nurses in Ghana: Exploring the Motivational Factors
Edith Buamah Agyepong (MPhil, BSc. Nursing, RGN) 1
Adelaide Maria Ansah Ofei (PhD) 2
Adzo Kwashie (PhD Candidate, MPhil) 3
30 Maternal Satisfaction with Labour at the University of

Ghana Hospital Accra: A Cross Sectional Survey
Decker Sheila (BSc, RM) 1
Joanne Chiwaula (MSc RN CNM) 2
Veronica Millicent Dzomeku (PhD, MPhil, BA, RM, RN) 3
Emmanuel Nakua (MSc, BSc) 4
Bemah Adwoa Bonsu (MPhil, BSc, RN) 5
39 Menopause as a Rite of Passage: Exploring the

Experience and Management among Women in
Walewale in the Northern Region of Ghana
Jaliu Abubakari (MPhil, BSc) 1
Adadow Yidana (PhD, MSc, BA) 2
Shamsu-Deen Ziblim (PhD, MPhil, BA) 3
iv Volume 2 No. 1, June 2018 http://www.numidhorizon.com

50 Determinants of Contraceptive Use among Women

of Reproductive Age in Asankragwa in the Western
Region of Ghana
Nancy Innocentia Ebu (PhD, MN, MPH, BSN, SRN, FWACN, FFGCNM) 1
Doreen Owusu Boateng (BSN, RN) 2
Kingsley Asare Pereko (PhD) 3
Thomas Hormenu (PhD) 4
62 Knowledge of Pregnant Women on Caesarean

Section and their Preferred Mode of Delivery in
Northern Ghana
Richard Adongo Afaya (MPhil Student, BSN, DIP, RN) 1
Victoria Bam (PhD, RN, RM, RPHN) 1
Felix Apiribu (PhD Candidate, FGCNM, MPhil, MSc, BA, DIP, SRN) 1
Victor Atiah Agana (BSA, DIP. RN) 2
Agani Afaya (MSN, BSN, DIP. RN) 3
74 Knowledge, Attitudes and Practices of Dietary

Modification among Diabetic Patients: A Descriptive
Cross-sectional Study at Ejisu-Juaben Municipality,
Ghana
Yaa Obirikorang (MPhil, BSc, RGN) 1
Christian Obirikorang (PhD. BSc) 2
Enoch Odame Anto (MPhil, BSc) 2, 3
Emmanuel Acheampong (MPhil, BSc) 2,
Emmanuella Nsenbah Batu (MPhil, BSc) 2
Fatima Sani Dange (BSc, RGN) 1
Nuhu Abdulbasir (BSc, RGN) 1
Bright Amankwaa (MPhil, BSc)2
http://www.numidhorizon.com Volume 2 No. 1, June 2018 v

Message
from the
Registrar, It is my great
pleasure to see
nal to endorse these new initiatives and in-
novations portrayed in the articles published
N&MC the publication of
the 3rd edition of
and, in doing so, encourage many more au-
thors to submit their articles and findings to
the Numid Hori- the secretariat of the Numid Horizon: An In-
zon: An international Journal of Nursing and ternational Journal of Nursing and Midwifery
Midwifery. for publication. This, in the long run will uplift
the image of the nursing and midwifery pro-
This journal aims to provide a vehicle for fession in Ghana and globally.
nurses and midwives as well as the general
public to publish original research and aca- In addition, I would like to thank the Editorial
demic papers about all areas of nursing, Board who have contributed to the making
midwifery and other health related issues. of this 3rd edition and whose work have in-
creased the quality of articles even more. I
The articles published in this edition number am pretty much aware that some manu-
up to eight (8) and they were through the scripts were rejected but work so far shows
ideas and efforts of different authors in the that the Board members' motivation was to
field of nursing and midwifery. I must admit make the publications possible rather than
that having read through all the articles cov- to block them.
ering the most diverse range of topics, all of
them are inspiring, interesting and innova- It is my hope and expectation that this
tive. This is the journal that you hold in your overview of the various components of this
hands now. 3rd edition will arouse our readers' interest,
boost their inspiration and provide effective
I thank the editorial Board and the Numid learning experiences and referenced re-
Secretariat for their generous support in or- sources for all health professionals.
ganizing the writers’ workshop at the Head
Office and bringing together the virtual com- Felix Nyante (MPA, MA, FWACN, FGCNM, BEd, Dip, SRN)
munity of writers for this journal. Registrar
I gladly join the Editorial Board of the Jour-
vi Volume 2 No. 1, June 2018 http://www.numidhorizon.com

Challenges in Giving Versus

Receiving Care
A common belief ex- providers to be more knowledgeable to
Editorial ists among children

growing up that
address the needs of current clients. This
situation can be stressful not just for the
mothers never expe- providers but even more stressful for the
rience hunger be- managers of the providers who are ex-
cause of the sacrificial nature of most pected to ensure the provision of quality
mothers that makes them forego their care to the satisfaction of clients and their
meals on several occasions in order to families and communities.
make their children eat in times of scarcity. This edition of the Numid Horizon: An In-
Along a similar line of thought, many peo- ternational Journal of Nursing and Mid-
ple think healthcare providers possess a wifery, addresses the challenges
higher tolerance over the conditions their experienced both by the providers and
clients suffer to the extent that some peo- their clients as the former group seeks to
ple are surprised when healthcare meet the expectations of the latter group.
providers become sick. Patients and their The first article in this edition on the coping
families as well as the communities from mechanism on stress among nurse man-
which they come, oblivious of the health agers brings out the realities in terms of
needs of the providers of healthcare, ex- the challenges these managers face as
pect the providers to understand the con- they manage the team under them to
dition of the sick and adequately take care meet the high expectations of their clients.
of them without any thought to their The article supports a similar study by
(providers) own health status. Sanchez- Udod, Cummings, Care and Jenkins,
Reilly and others (2013) however affirm (2017) who stress on the importance of
that notable among other conditions, adequate interventions to reduce the level
many clinicians suffer from burnout and of stress nurse managers face in their
moral distress in the course of their duty of roles.
delivering care to others. The second article on stigmatization of
In the healthcare industry both inside and mental health nurses is another example
outside the hospital environment, clients of challenging situations many healthcare
expect and demand satisfaction from their providers face in their line of duty. The
providers in terms of provision of knowl- question of how much sacrifice is enough
edge and skilled care. The health clientele keeps recurring as these nurses recount
is becoming more and more curious about the stigmatization they undergo as they
health conditions and it behooves continue to play their roles.
http://www.numidhorizon.com Volume 2 No. 1, June 2018 vii

The complex nature of nursing and the ho- sues like contraceptives use among
listic nature of quality care expected by pa- women in the fertility age and pregnant
tients, families and communities demand women’s discussions on caesarian sec-
higher education for an upgrade in the tion.
knowledge, skills and ability to think criti- The management of chronic diseases
cally among nurses to enable them cope usually falls in the domain of preventive
with the current challenges in their jobs health with the primary “focus on promo-
(Alamri, & Sharts-Hopko, 2015). Nurses, tion of informed lifestyle choices, risk-fac-
especially those who play auxiliary roles tor modification, and active patient
and are not considered professional, self-management of chronic diseases”
therefore, try to face the challenges they (Adams, 2010, p.61). The last article in this
meet in the workplace by opting for higher edition speaks to the need to address the
education and this is expressed in the third challenges clients face in management of
article in this edition, on motivational fac- chronic diseases by delving into the effect
tors for continuing higher education of knowledge on practice in terms of di-
among non-professional nurses. etary modification among diabetic pa-
On the part of the beneficiaries of health- tients.
care the articles on maternal satisfaction In summary, this third edition of the Numid
on birth experience and the experiences Horizon addresses questions arising on
and management of menopause among the challenges providers go through as
some clients express the expectations of they sacrifice to take care of others as well
clients as they look up to their providers as as the equally challenging actual experi-
the experts in the health field. The part that ences patients and clients go through as
knowledge plays in clients’ understanding they receive care and the role knowledge
of health issues is buttressed in the articles of the conditions plays in the process.
delving into knowledge on reproductive is-
References
Adams, R. J. (2010). Improving health outcomes with better patient understanding and education. Risk
Management and Healthcare Policy, 3, 61–72. http://doi.org/10.2147/RMHP.S7500
Alamri, M., & Sharts-Hopko, N. (2015). Motivational factors and barriers related to Saudi Arabian
nurses' pursuit of a bachelor of science in nursing degree. Nursing Education Perspectives,
36(3), 157-162. https://search-proquest-com.contentproxy.phoenix.edu/docview/1683082243?ac-
countid=134061
Sanchez-Reilly, S., Morrison, L. J., Carey, E., Bernacki, R., O’Neill, L., Kapo, J., … Thomas, J. deLima.
(2013). Caring for oneself to care for others: physicians and their self-care. The Journal of Sup-
portive Oncology, 11(2), 75–81.
Udod, S., Cummings, G. G., Care, W.D., & Jenkins, M. (2017). Role stressors ‘and coping strategies
among nurse managers. Leadership in Health Services, 30 (1), 29-43. https://doi-org.content-
proxy.phoenix.edu/10.1108/LHS-04-2016-0015
viii Volume 2 No. 1, June 2018 http://www.numidhorizon.com

Original Article
Stress and Coping Strategies among Nurse

Managers at Three District Hospitals in the
Eastern Region of Ghana
Adelaide Maria Ansah Ofei (PhD, MPhil, MBA, BA, RM, SRN, WACN, FGCNM)1
Atswei Adzo Kwashie (PhD candidate, MPhil, BA, SRN, WACN, FGCNM) 1
Ernestina Asiedua (PhD candidate, MPhil, BA, SRN, RM, WACN, FGCNM) 2
Nana Serwaa Twum Duodu (BSc, Dip. RGN) 3
Alfred Nene Akotiah (MBA, BA) 4
Abstract
Nurses have been found to experience high levels of stress which contributes to
health challenges and decreases their efficiency. Nurse managers may experience
higher levels of stress due to their complex and multi-faceted roles and responsi-
bilities. A quantitative descriptive cross-sectional approach was used to identify
how nurse managers experience stress and strategies used to reduce stress.
Three hospitals were randomly selected, and 45 nurse managers were also se-
lected using disproportionate stratified sampling technique. Simple random sam-
pling was employed to select 15 nurse managers from each hospital. Structured
questionnaire was used for data collection, and the data was analyzed using both
inferential and descriptive statistics to describe the sample and determine factors
that influence stress. The study revealed that common causes of stress among
nurse managers are lack of break period during shifts (95.6%), staff shortage
(97.8%), inadequate support from management (93.3%), poor working conditions
(91.1%) and inadequate resources (91.1%). The major predictor of stress among
nurse managers is the type of unit (F = 9.546, p < .05, R2 = .205). Headache
(78.3%), backache (73.9%) and fatigue (82.6%) are the major physical stress ex-
perienced by nurse managers. Frustration (84.8%) is the major emotional stress
experienced by nurse managers and the major type of psychological stress expe-
rienced by nurse managers is lack of concentration (67.4%). The major coping
strategies of stress among nurse managers are expression of feelings instead of
bottling them up (91.1%), accepting the things one cannot change (88.9%) and
time management (86.7%) whereas eating excessively is the least mechanism
(8.9%) used to cope with stress. It is recommended that nurse managers should
mature in age, practice, knowledge and experience to cope better with the chal-
lenges that confront their position. Nurse managers should also take intermittent
breaks during shifts, and hospitals.
Keywords:
Ghana; Infertility; Psychological threats; Social threats; Women
1. Dept. of Research, Edu. & Admin., School of Nursing and Midwifery, University of Ghana
2. Dept. of Maternal and Child Health, School of Nursing and Midwifery, University of Ghana
3. New Tafo Government Hospital, Ghana Health Service, Eastern Region
4. The Construction Bank, Accra, Ghana
Corresponding Author:
1. Dept. of Research, Edu. & Admin., School of Nursing and Midwifery, University of Ghana
Email: adelaideofei@gmail.com/aansahofei@ug.edu.gh
Tel: +233-244653065
http://www.numidhorizon.com Volume 2 No. 1, June 2018 1

Introduction that 45% of participants cited poor relationship

Stress is a typical phenomenon of everyday life es- among colleagues as the most cause of work related
pecially, for professionals who make decisions about stress among nurses, 50% cited lack of financial in-
life and death such as nurses (Hardwick, 2010). centives from hospital authorities and only 5% cited
Stress ensues when an individual’s capabilities, work load, poor working environment and conflicting
needs and resources are misaligned to the necessi- roles in the ward (Dawson, Stasa, Roche, Homer, &
ties of the job, and healthcare professionals experi- Duffield, 2014). Thus, major causes of stress among
ence high levels of work related stress especially, nurse managers are mainly financial and human re-
nurses (Gandi, Wai, & Karick, 2011) which may com- lation related.
promise their health thus, decrease effectiveness,
and efficiency. This may have significant implications, Stress may cause nurse managers to display nega-
as nurses constitute the largest professional group in tive behaviours towards their subordinates, thus, af-
any health care system with critical responsibilities fecting the overall experience of nurses, other
as frontline service providers. paramedical staff and the patient. This may lead to
high turnover rates among both nurse managers and
Johansson, Sandahl and Hasson (2013) acknowl- their subordinates (Mokoka, 2010) thereby, exacer-
edged that nurse managers usually experience high bating the challenge of nurse shortages. Nakamura
levels of stress due to their multi-facetted roles and et al. (2011) also stated that, the health of managers
responsibilities. For instance, nurse managers are re- has a significant impact on the health of their subor-
quired to deal with daily issues of patient complaints, dinates, as an embittered person will usually create
nurse shortages, doctor-led hospital systems, tough a hostile workplace environment, thus influencing the
schedules (Anthony, Standing, & Glick, 2005) and at- emotional state of staff which can culminate in client
taining financial targets. All these challenges are and staff dissatisfaction.
within the context of a dynamic system, where there
are increased demands for efficiency and stringent Friedman (2013) acknowledged that, stress can be
requirements for quality healthcare as well as patient classified into physical, emotional and psychological
safety (Johannson et al., 2013). stress. Physical stress can progress to distress,
which is a negative stress reaction. Physical mani-
Although, nurses in management positions have festations include headaches, stomach upsets, ele-
more control than their subordinates, Nakamura et vated blood pressure, chest pains and trouble
al. (2011) asserted that it is this very control which in- sleeping. Emotional stress can affect all aspects of
creases stress vulnerability among nurse managers. one’s life and includes feeling overwhelmed, difficulty
This is due to the fact that nurse managers are re- in relaxing, low self-esteem, loneliness, worthless-
sponsible for identifying and managing stress among ness, becoming easily agitated, frustrated, moody
subordinates (Wright, 2014), offer 24-hour service for and avoiding others. Psychological stress ensues
the operational, fiscal and performance accountability when stressful situations affect an individual’s behav-
(Warshawsy & Havens, 2014), and they have to deal ior and thinking abilities, leading to forgetfulness, lack
with abridged staff job satisfaction (Munyewende, of concentration, memory loss and withdrawal (Har-
Rispel, & Levin, 2014), increased rates of absen- grove & Ahmed, 2014).
teeism and long term sick leave of staff (Sandmark
& Renstig, 2010). Consequently, the mirage of re- Furthermore, stress can adversely affect one’s phys-
sponsibilities that nurse managers encounter thrusts ical (Owolabi, Owolabi, Oluron, & Olofin, 2012), emo-
them to the phenomena of stress. tional, mental and social wellbeing. Physically, Lim,
Chow and Poon (2013) found a correlation between
Warshawsy and Havens (2014) recognized the nurse stress and several diseases due to reduced immune
manager's role to be stressful due to the physical system, which predispose affected individuals to dis-
labour, long working hours, staffing, and interper- eases such as cardiovascular and hypertension or
sonal relationships that are central to nurses’ work. ultimately death. Stress can also facilitate depression
A study in Australia among nurse managers revealed (Nakamura et al., 2011), exhaustion and burnout
2 Volume 2 No. 1, June 2018 http://www.numidhorizon.com

(Klopper, 2012), and patient care can be severely to ineffective coping; getting sick as a way of coping
compromised due to abridged compassion and care with stress more often than male nurse managers
(Wright, 2014) ensuing from stress. (Hutchinson & Hurley, 2013).
Coping with stressful events is challenging, highly dy- Although, it may not be possible to eliminate stress,
namic and is directed toward moderating the effect of certain individual and organizational strategies can
events in an individual’s physical, social and emo- be used to reduce stress (World Health Organization,
tional functioning (Chang & Chan, 2015; Miyata, Arai 2007). The purpose of this study therefore, is to iden-
& Suga, 2015) as well as the individual’s ability to tify and describe the experiences of nurses in man-
work engagement. Murphy (1995) declared that the agement positions with regards to stress and
serenity prayer from the philosopher Reinhold stressful situations.
Niebuhr; “Grant me the courage to change the things
I can change, the serenity to accept those that I can- Design and Methods
not change and the wisdom to know the difference” A descriptive cross-sectional design was employed
has been the inspiration for many nurse managers to to study the phenomenon of stress among nurse
successfully manage their lives by consciously stim- managers in three selected hospitals (two public and
ulating their perceptions to change their emotions one private facilities) in the East Akim Municipality in
about situations. Nurse managers also manage stress the Eastern Region of Ghana. The settings were cho-
by engaging in realistic workloads, expressive and sen because the towns are periurban, far away from
useful tasks, tolerable levels of control, and explicit the regional capital with inadequate infrastructure for
job expectations (Downey, Parlsow, & Smart, 2011). certain social amenities such as quality schools.
Again, the choice of these hospitals was influenced
Rothmann, Jorgensen and Hill (2011) have identified by the fact that the hospitals render primary health
positive (active) and negative (avoidant) coping care services, staff refuse posting to these areas and
strategies used in dealing with stress and stressful sit- the areas are prone to road traffic accidents. By using
uations. Positive coping strategies used particularly Yamane’s (1967) formula, with a margin of error of
by nurse managers include time management, relax- 5%, confidence interval of 95% and a population of
ation techniques, exercise, good eating habits, skills 52 nurse managers from the three hospitals, the
development and support. On the contrary, negative sample size calculation was 46. This is based on the
coping strategies are associated with addictive behav- proposition from Bartlet, Higgins, and Kotrlik (2001)
iours such as smoking (Pagon, Spector, Cooper & that “if the population is within the region of 52, a
Lobnika, 2011), excessive eating (Onasoga, Ogbebor sample of 45 is ideal.” 45 respondents were selected
& Ojo, 2013), taking drugs and alcohol abuse (Roth- from the three hospitals using disproportionate strat-
mann et al., 2011). ified sampling technique. That is regardless of the
number of nurse managers in each hospital, 15 were
Generally, gender has been recognized to play a role selected from each hospital to participate in the
in the management of stress. Female nurse man- study. Simple random sampling was employed to se-
agers tend to use more social emotional strategies to lect participants from each hospital. A structured
cope with stress, whereas male nurse managers are questionnaire with both closed and open-ended
more likely to use behavioural/mental or drug/alcohol questions was used to collect the data.
disengagement. Male nurse managers tend to cope
by way of problem focused strategies while female Ethical clearance was obtained from the Noguchi Me-
nurse managers are characteristically affective in their morial Institute for Medical Research IRB (096/17-
management of stress (Wong, Laschinger, & Cum- 18). An introductory letter from the School of Nursing
mings, 2010). and Midwifery, University of Ghana which described
the purpose of the study, the research team and con-
Again, a descriptive explorative study conducted in fidentiality of data as well as samples of the question-
Nepal among nurse managers suggests that social- naire was sent to the general administration of each
ization of female nurse managers predisposes them hospital. This was forwarded to the Research Devel-
http://www.numidhorizon.com/ Volume 2 No. 1, June 2018 3

opment Unit (RDU) of the hospitals, then a permis- tionnaire was piloted at the University of Ghana hos-
sion letter for data collection was sent to heads of the pital using 10 nurse managers. Reliability was en-
units for approval. Participants were selected based sured by validation of the questionnaire by
on their designation as a nurse manager of a unit in colleagues who have worked many years as nurse
the hospitals. Participants were given a detailed de- managers on the ward and an expert in nursing man-
scription of the study and the fact that the study was agement. Internal consistency of the questionnaire
purely for academic purposes. No reward was of- was tested using Cronbach alpha for each section;
fered for participation and no one declined. A written causes of stress (.78), types of stress (.89), and cop-
consent was sought from each participant. Validity of ing (.86). All questionnaires were examined for com-
the study was ensured by the construction of a stan- pleteness and coded before data input. Analysis was
dardized questionnaire relevant to the objectives of done using both descriptive (frequencies, percent-
the study and formulation of questions that required ages) and inferential statistics (Pearson correlation,
appropriate response from respondents. The ques- linear regression) to describe the sample.
Table 1: Socio-Demographic Characteristics of Nurse Managers

Variables Hospital
Age groups Hosp. A Hosp. B Hosp. C Total
< 31 years 3 (27.3%) 5 (45.5%) 3 (27.3%) 11 (24.4%)
31- 40 years 8 (33.3%) 7 (29.2%) 9 (37.5%) 24 (53.3%)
41 – 50 years 3 (75.0%) 0 (0%) 1 (25.0%) 4 (8.9%)
51 – 60 years 1 (20.0%) 2 (40.0%) 2 (40.0%) 5 (11.1%)
> 61 years 0 (0.0%) 1 (100.0%) 0 (0.0%) 1 (2.2%)
Marital Status
Single 2 (20.0%) 4 (40.0%) 4 (40.0%) 10 (22.2%)
Married 12 (36.4%) 10 (30.3%) 11 (33.3%) 33 (73.3%)
Separation 0 (0.0%) 1 (100.0%) 0 (0.0%) 1 (2.2%)
Widow 1 (100.0%) 0 (0.0%) 0 (0.0%) 1 (2.2%)
Religious Affiliation
Christian 15 (34.1%) 14 (31.8%) 15 (34.1%) 44 (97.8%)
Traditional 0 (0.0%) 1 (100.0%) 0 (0.0%) 1 (2.2%)
Designation
DDNS 1 (25.0%) 2 (50.0%) 1 (25.0%) 5 (8.9%)
PNO 1 (50.0%) 1 (50.0%) 0 (0.0%) 2 (4.4%)
SNO 3 (42.9%) 3 (42.9%) 1 (14.3%) 7 (15.6%)
NO 4 (33.3%) 2 (16.7%) 6 (50.0%) 12 (26.7%)
SSN 6 (30.0%) 7 (35.0%) 7 (35.0%) 20 (44.4%)
Gender
Male 4 (26.7%) 5 (33.3%) 3 (20.0%) 12 (26.7%)
Female 11 (33.3%) 10 (30.3%) 12 (36.4%) 33 (73.3%)
Total 15 (33.3%) 15 (33.3%) 15 (33.3%) 45 (100.0%)
Belief
Beliefsystem
system .175
Unfriendly relationships
relationshipsamong
amongteam
teammembers
1.701 2 .850 3.806 .032
Unfriendly .171
1.613 2 .806 3.710 .034
members
Source: Field data 2017

In Table 1, frequencies and percentages were used Nurses (SSN). The designation of nurse manager ac-
to describe the demographic characteristics of par- cording to the job description of the Ghana Health
ticipants. Majority (53.3%) of the participants are be- Service (GHS, 2006) is for either Principal Nursing
tween the ages of 31-40 years, the average age is Officers (PNOs) or Senior Nursing Officers (SNOs),
36.8 years and the oldest nurse manager is 74 years however, majority of the participants are SSNs be-
who happens to be the nurse manager of the private cause the research setting is peri-urban, and staff
hospital (Deputy Director of Nursing Service). Most generally refuse postings to such areas.
of the participants are females (73.3%) and 68.8% of
them are married while 97.8% are Christians. Major- Consequently, though the SSNs are not nurse man-
ity (44.4%) of the nurse managers are Senior Staff agers, they function as such.
Table 2: Causes of Stress among Nurse Managers

RESPONSES
CAUSES OF STRESS N YES NO
1. Working with incompetent staff. 44 29 (64.4%) 15 (33.3%)
2. Lack of break period during shifts. 45 43 (95.6%) 2 (4.4%)
3. Long working hours 45 37 (82.2%) 8 (17.8%)
4. Family issues 45 28 (62.2%) 17 (37.8%)
5. Heavy workload 45 40 (88.9%) 5 (11.1%)
6. Belief system 44 23 (51.1%) 21 (46.7%)
7. Poor communication system 45 35 (77.8%) 10 (22.2%)
8. Poor organization climate – hostile environment 45 29 (64.4%) 16 (35.6%)
9. Inadequate support from management 45 42 (93.3%) 3 (6.7%)
10. Poor working conditions 45 41 (91.1%) 4 (8.9%)
11. Inadequate resources to work with 45 41 (91.1%) 4 (8.9%)
12. Poor culture within the organization 45 28 (62.2%) 17 (37.8%)
13. Lack of incentives for overtime 45 40 (88.9%) 5 (11.1%)
14. Inadequate delegation of responsibilities 44 31 (68.9%) 13 (28.9%)
15. Unfriendly relationships among team members 45 27 (60.0%) 18 (40.0%)
16. Death and dying 42 19 (42.2%) 23 (51.1%)
17. Staff shortage 45 44 (97.8%) 1 (2.2%)
18. Conflicts with physicians 45 29 (64.4%) 16 (35.6%)
Belief system
1.701 2 .850 3.806 .032
Unfriendly relationships among team
1.613 2 .806 3.710 .034
members

In Table 2, frequencies and percentages were used (88.9%) and lack of incentives for overtime (88.9%)
to describe the causes of stress among nurse man- are the major causes of stress among nurse man-
agers. Staff shortage (97.8%), lack of break period agers. Hypothesis was tested to find out predictors
during shifts (95.6%), inadequate support from man- of stress among nurse managers. H0 = there is no
agement (93.3%), poor working conditions (91.1%) relationship between socio-demographic character-
inadequate resources (91.1%), heavy workloads istics of nurse managers and causes of stress.
Table 3: Tests of Between-Subjects Effects between Causes of Stress and Socio-

demographic Characteristics
Dependent variable Sum of Squares df Mean Square F Sig. R2
Independent Variable – Age Group
Heavy workload .975 4 .244 2.809 .038 .219
Poor working conditions 1.011 4 .253 3.840 .010 .277
Inadequate resources to work with 1.011 4 .253 3.840 .010 .277
Lack of incentives for overtime 1.019 4 .255 2.976 .030 .229
Independent variable – Religious Affiliation
Lack of incentives for overtime .780 1 .780 8.064 .007 .179

Lack of break period during shift .924 1 .924 3.510 .000 .487
Independent variable – Designation
Poor working conditions .815 4 .204 2.498 .061 .227

Inadequate resources to work with .815 4 .204 2.498 .061 .227
Staff shortage .224 4 .056 2.543 .057 .230
Family issues 2.316 4 .579 3.099 .028 .267
Independent Variable – Hospital
Belief system .175

1.701 2 .850 3.806 .032
Unfriendly relationships among team .171
1.613 2 .806 3.710 .034
members
Belief system .175
1.701 2 .850 3.806 .032
Unfriendly relationships among team .171
1.613 2 .806 3.710 .034
members
In Table 3, linear regression analysis was used to de- lack of incentives for overtime (F = 8.064, p < .05, R2
termine the relationship between nurse manager = .179) and lack of break period during shift (F =
characteristics and causes of stress. The causes of 3.510, p < .05, R2 = .487). Causes of stress for des-
stress under age group are heavy workloads (F = ignation is family issues (F = 3.099, p < .05, R2 =
2.809, p < .05, R2 = .219), inadequate resources to .267). Whereas, for the hospital, the causes of stress
work with (F = 3.840, p < .05, R2 = .277), lack of in- are the belief system (F = 3.806, p < .05, R2 = .175),
centives for overtime (F = 2.976, p < .05, R2 = .229), and unfriendly relationships among team members
and poor working conditions (F = 3.840, p < .05, R2 (F = 3. 710, p < .05, R2 = .171).
= .277). Causes of stress for religious affiliation are

Table 4: Types of Stress among Nurse Managers

RESPONSES
TYPES OF STRESS N Yes No No response
Headache 45 36 (78.3%) 8 (17.8%) 1 (2.2%)
Weight loss/gain 45 31 (67.4%) 11 (23.9% 3 (6.7%)
1.PHYSICAL Anxiety 45 29 (63.0%) 14 (30.4%) 2 (4.4%)
STRESS
Insomnia 45 23 (50.0%) 20 (43.5%) 2 (4.4%)
Fatigue 45 38 (82.6%) 4 (8.7%) 3 (6.7%)
Increase blood pressure 45 24 (52.2%) 18 (39.1%) 5 (11.1%)
Backache 45 34 (73.9%) 8 (17.4%) 3 (6.7%)
Diabetes 45 9 (19.6%) 29 (60.0%) 7 (15.5%)
Others 45 8 (17.4%) 4 (8.7%) 33 (73.3%)
2.EMOTIONAL Anger 45 30 (65.2%) 12 (26.1%) 3 (6.7%)

STRESS
Over reaction 45 31 (67.4%) 11 (23.9%) 3 (6.7%)
Frustration 45 39 (84.8%) 4 (8.7%) 2 (4.4%)
Others 45 7 (15.2%) 5 (10.9%) 33 (73.3%)
Total
Forgetfulness 45 25 (54.3%) 18 (39.1%) 2 (4.4%)
3.PSYCHOLO Lack of concentration 45 31 (67.4%) 13 (28.3%) 1 (2.2%)
GICAL
STRESS Withdrawal 45 17 (37.0%) 23 (50.0%) 5 (11.1%)
Memory loss 45 15 (32.6%) 25 (54.3%) 5 (11.1%)

Others 45 6 (13.0%) 6 (13.0%) 33 (73.3%)
In Table 4, frequencies and percentages were used and anger (65.2) are the key emotional stress expe-
to describe types of stress identified among nurse rienced by nurse managers.
managers. Fatigue (82.6%), headache (78.3%),
backache (73.9%) and weight loss/gain (67.4%) are The main types of psychological stress experienced
the major physical stress experienced by nurse man- by nurse managers is lack of concentration (67.4%).
agers. Frustration (84.8%), over reaction (67.4%)

Table 5: Correlation between Types of Stress and Socio-demographic characteristics

Type of Stress Dependent Variable Age Marital status Rank Unit Gend
Physical Headache r .215 -.076 -.294 .190 .041
Sig. .161 .623 .053 .217 .790
Weight loss/weight gain r -.215 -.138 .225 -.043 -.237
Sig. .139 .382 .151 .788 .130
Anxiety r .252 .199 -.144 -.121 .046
Sig. .102 .200 .356 .438 .771
Insomnia r .160 .028 .012 -.045 -.020
Sig. .304 .857 .939 .773 .900
Fatigue r .082 .220 -.092 -.144 -.151
Sig. .604 .161 .564 .364 .338
Increased blood pressure r -.402** -.076 .345* -.289 -.114
Sig. .008 .633 .025 .063 .472
Backache r .006 .218 .055 .286 .139
Sig. .969 .166 .730 .066 .379
Diabetes r -.004 -.129 -.078 -.175 .009
Sig. .983 .442 .641 .294 .955
Emotional Anger r -.048 .101 .067 .008 .048
Sig. .760 .521 .670 .958 .758
Over reaction r .208 -.138 -.104 .125 -.014
Sig. .187 .382 .512 .430 .931
Frustration r .398** .225 -.288 -.186 -.031
Sig. .008 .146 .061 .233 .842
Forgetfulness r .172 .096 -.071 .004 .097
Sig. .271 .541 .650 .979 .536
Psychological Lack of concentration r .050 -.021 -.032 -.069 .105
Sig. .748 .894 .835 .655 .499
Withdrawal r .124 .028 -.083 .056 .078
Sig. .447 .863 .609 .733 .633
Memory loss r .111 .012 -.169 -.236 .029
Sig. .497 .943 .296 .142 .859
*correlation significant at the 0.05 level **correlation significant at the 0.01 level
In Table 5, Pearson’s correlation was used to meas- pressure (-.402) and strong positive correlation be-
ure the strength of linear relationship between type tween rank and increased blood pressure (.345).
of stress and demographic characteristics of partici- Whereas, under emotional stress, there is a strong
pants. Under physical stress, there is a strong nega- positive correlation between age and frustration
tive correlation between age and increased blood (.398).

Table 6: Coping Strategies of Stress among Nurse Managers

Coping Strategies N YES NO No Respons
Break time 45 31 (68.9%) 14 (31.1%) 0 (0.0%)
Relaxation 45 37 (82.2%) 8 (17.8%) 0 (0.0%)
Meditation 45 29 (64.4%) 14 (31.1%) 2 (4.4%)
Delegation of work/ duties 45 36 (80.0%) 7 (15.6%) 2 (4.4%)
Exercise 45 33 (73.3%) 10 (22.2%) 2 (4.4%)
Taking of drugs 45 15 (33.3%) 26 (57.8%) 4 (8.9%)
Time management 45 39 (86.7%) 4 (8.9%) 2 (4.4%)
Express your feelings instead of bottling them up 45 41 (91.1%) 3 (6.7%) 1 (2.2%)
Accept the things you can’t change 45 40 (88.9%) 4 (8.9%) 1 (2.2%)
Eating excessively 45 4 (8.9%) 37 (82.2%) 4 (8.9%)
Acknowledging your sphere of influence 45 33 (73.3%) 9 (20.0%) 3 (6.7%)
Giving up/ slow down 45 21 (46.7%) 22 (48.8%) 2 (4.4%)
Frequencies and percentages were used to describe role in healthcare which often ensue in stress and this un-
strategies used by participants to cope with stress derscores the basis for the study.
and Table 6 indicates that, the key strategies used in The study indicated that due to the site of the hospitals,
coping with stress are expression of their feelings in- most of the nurse managers are SSNs instead of PNOs
stead of bottling them up (91.1%), accepting the or SNOs as found in other units in regional capitals. PNOs
things that can’t be changed (88.9), time manage- and SNOs are responsible for the management of nursing
ment (86.7%), relaxation (82.2%) and delegation of units/department in the hospitals. They are accountable
duties (80.0%) whereas, eating excessively is the for the planning, organizing, leading, and control of nurs-
least mechanism (8.9%) used to cope with stress. ing units in the hospitals and are known as the ward man-
agers or nurse managers. This implies that there will be
Discussion higher levels of stress due to the limited competencies of
The role of the nurse manager is critical in the provision SSNs in ward management. The average age is 37
of effective and quality health service in any clinical set- years, this age represents critical periods in one’s life;
ting, enabling accountability, patient and staff satisfaction. marriage and management of family responsibilities es-
Essentially, the role is to guide organizations toward goal pecially, children. This conforms to Burns et al. (2002) who
accomplishment by interpreting the mission and vision argue that age and ageing cannot be separated from
into reality. Effectiveness and efficiency are vital to the sur- stress and how to cope with it, as age comes with expo-
viving and thriving of the nurse manager’s role, and this sure and experience on the positive note, as well as wear-
requires the nurse manager to possess administrative ing out which could be a major source of stress.
confidence, appropriate educational preparation, skills to
manage the business turbulence in the ward, broad clin- The findings revealed that, the main causes of stress
ical expertise and a thorough understanding of leadership among nurse managers are basically organisational
principles (Ansah Ofei, 2015; Beheshtifar & Nazarian, factors. Prominent among these factors are staff
2013; Davidson, Elliott & Daly, 2006). The role is an shortage, lack of break period during shift, poor work-
enigma; observed to be the hardest and most complex ing conditions, inadequate resources to work with,

lack of incentives for overtime and heavy workloads. of Kath et al. (2012) that severities of occupational
These findings have been reported by several stud- stressors are significantly associated with age. Thus,
ies (Obiora, 2015; Chan, Tam, Lung, Wong & Chau, young nurse managers should be empowered and
2013; Najimi et al., 2012; Circenis & Millere, 2012; supported with their responsibilities in order to excel
Aiken et al., 2011; Davidson, Elliott & Daly, 2006; especially, with training and adequate resources.
Luchinger, Almost, Purdy & Kim, 2004).
Family issues under designation predispose nurse
Generally, the working environment of nurses reflects managers to stress (26.7%) and this again, can be
its influence on the nurse manager. Obiora (2015) it- explained by the age group of the participants. Most
erated that how the immediate physical environment of the nurse managers are in the child bearing age;
affects the nurse manager determines largely his/her getting married and having babies which conflict with
efficiency, effectiveness and predisposition to stress work. As explained earlier, all the hospitals are sited
and this has been acknowledged by many studies. in peri-urban homogenous environment where mystic
The study has contributed to the levels of stress beliefs thrive. Belief systems about the dead, way of
among nurse managers and the importance of ade- life, etc. impose several challenges on the lives of
quate preparation for junior nurses who get appoint- people living in that area. Thus, belief system, ac-
ment to administrative positions due to inadequate cording to the study, accounts for stress among nurse
numbers of senior nurses. managers (17.5%), whereas unfriendly relationships
among team members account for 17.1% of stress
The study again, revealed that, inadequate support amongst nurse managers. Anecdotally, as most of the
from management, poor organisational culture, inad- nurse managers are young and inexperienced, they
equate delegation of responsibilities, unfriendly rela- may be having challenges with the management and
tionships among team members and conflicts with staff as they try to cope with their responsibilities.
physicians are stressors arising from administrative
or leadership lapses. This may result from incompe- The findings in this study revealed that nurse man-
tence, neglect, bad policies or a combination of all. agers experience the same types of stress in execut-
Findings from this study reaffirm the above as causes ing their duties. Three main types of stress were
of stress among nurse managers. This conforms with identified among the nurse managers: physical, emo-
Warshawsy and Havens’ (2014) view on causes of tional, and psychological stress. The most psycho-
stress among nurse managers. Judging from the out- logical stress experienced among nurse managers is
come of this study, nurse managers need to be ade- lack of concentration. This issue is serious and needs
quately prepared for this role; how to delegate to be addressed quickly as it will undoubtedly have
effectively without inhibition and how to effectively en- effect on the administration of the unit. Emotional
gage staff to cut down on the long hours of working, stress identified includes anger, frustration and over
as this enables inefficiency in managerial roles. reaction while physical stress includes headache,
weight loss/weight gain, anxiety, insomnia, fatigue,
As most of the participants are SSNs and young, the increased blood pressure and backaches. It can be
study revealed that age is a predisposition to stress inferred that these types of stress are all interrelated,
among nurse managers especially when the work- as the occurrence of one will usually lead to the other
load is heavy (21%). Thus, there is a relationship be- thereby causing intense stress. The finding conforms
tween socio-demographic characteristics and stress to the works of Hargrove et al. (2014) and Friedman
among nurse managers. When the conditions in the (2013) who reported that the types of stress experi-
ward is also poor, nurse managers are inclined to de- enced by nurse managers can be classified under
velop stress (27.7%), the same is for inadequate re- three categories which are physical, emotional and
sources to work with. Additionally, lack of incentives psychological stress. Physical, emotional and psy-
for overtime exposes nurse managers to stress chological stress are therefore, common to the work
(22.9%). This clearly shows that experience plays a of nurse managers due to the implicit and dynamic
critical role in the predisposition to stress. As nurse nature of the job.
managers advance in age and proficiency in the
management of the ward, they become familiar with The study further revealed that age has a negative
their environment thus, resilient in the management correlation to increased blood pressure; that is, the
of their environment. This is in line with the findings younger your age, the more your inclination to develop

stress as a nurse manager due to the challenges they widely that stress among nurses affects both their
encounter as managers and their lack of experience. health and practice which ultimately affects patients’
Designation, on the other hand, had a fairly strong care. Thus, periodic training session about stress,
positive correlation with increased blood pressure, sig- and its management should be organized for nurses
nifying that a move upward in rank predisposes nurse especially, nurse managers for them to effectively
managers to stress. Increase in designation comes manage stress personally and to offer support and
with aging, active work and experience, these naturally counselling services to nurses. This would help avoid
pose a lot of challenges to the person’s disposition. the devastating effects of stress on both nurses and
There is also a fairly strong positive correlation be- clients. Nurse managers should therefore, be encour-
tween age and frustration, thus increase in age brings aged to take intermittent breaks during shifts, and
about increasing frustrations among nurse managers. hospitals should ensure proper staffing practices,
provide positive working conditions and make ade-
In the midst of all the stress encountered by these quate resources available for work.
nurse managers, it was found that while some are
usually overwhelmed by the stress, others develop Conclusion
coping strategies to deal with the pressures associ- Based on the findings of the study, it can be concluded
ated with their work and ensured that they do not that, indeed working as a nurse manager in all the three
breakdown in the course of executing their duties. hospitals is associated with stress which, if not carefully
This confirmed the study by Lazarus (2000) who de- attended to, can reduce effectiveness and efficiency of
fined coping as consisting of all the things people do the units. Furthermore, it can be concluded that there is
to control, tolerate or reduce the effects of stressors. no difference in the types of stress experienced by nurse
managers in the various hospitals.
The study found that, the coping strategies adopted
by these nurse managers are relaxation, break time, Additionally, based on the statistics about the designa-
acknowledging their sphere of influence, expressing tions of the nurse managers, most of them being SSN;
their feelings instead of bottling them up, accepting it can be concluded that their stress was mainly due to
the things they cannot change, meditation, delegat- their limited knowledge in ward management. In sum,
ing work to other nurses instead of trying to do all the it can be posited that nurse managers should mature
work by themselves, indulging in exercise and being in age and practice as well as knowledge and experi-
able to manage their time very well. The above find- ence to cope better with the challenges that confront
ings correspond with the findings of Seyedfatemi, the nurse manager position. Hospitals should ensure
Tafreshi and Hagani (2007) who acknowledged that adequate resources, proper staffing practices, and pe-
the coping strategies adopted by nursing students in riodic training to enable the resilience nurse managers
the face of stress included sharing of problems with need to manage the challenges of the unit.
family and friends, talking to parents/friends, practic-
ing relaxation activities, positive thinking, praying, The study is limited by the fact that causality could
meditating and effective time management. Interest- not be established, and response bias and social de-
ingly, most of the SSN cope with stress by acknowl- sirable responses might have also occurred.
edging their sphere of influence and this strategy
helps them in avoiding stress. The SSN used this Conflict of interest
strategy because they acknowledged the fact that, The authors acknowledge that there was no conflict
they lack the experience and knowledge to handle of interest.
the challenges of the unit thus, accepting their limita-
tions helped them cope better with the issues that Acknowledgement
confront them as managers. The authors thank all the participants who took part
in the study.
Relevance to clinical practice
Stress is a common phenomenon among nurses es-
pecially nurse managers. The study has proven

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Original Article
The Effects of Stigma on Mental

Health Nurses: A study at Ankaful
Psychiatric Hospital
Sampson Opoku Agyemang (BSc, BA, RMN) 1
Jerry Paul Ninnoni (PhD, MBA, RMN) 2
Abstract
Society’s perception of the causes of mental disorder is one of the factors that
influence how thementally ill is treated. Stigma affects not only people with
mental illnesses but nurses and other professionals working with individuals
diagnosed with mental illness. This study assessed the effect of stigma on
mental health nurses. A cross-sectional descriptive design was adopted for
this study, and a structured questionnaire was used to collect data from 101
mental health nurses. Data was analyzed and summarized descriptively using
frequency tables and graphs. An inferential analysis was conducted by Pear-
son Product Moment of correlation and Independent sample t test. The results
show that the respondents perceive stigma to stem largely from the society.
Females reported a higher level of stigma and discrimination from the general
public than males. The majority of the participants view stigma as discrimina-
tion. Public education and expansion of community care are important meas-
ures to reduce the effects of stigma and discrimination.
Keywords:
Stigma; mental illness; mental health nurses; help seeking behavior.
1. School of Nursing and Midwifery

University of Cape Coast, Ghana
2. Head, Department of Mental Health

1. Corresponding Author:
School of Nursing and Midwifery
E-mail: popesampson10@gmail.com
Tel. 233243373271

Introduction Effects of stigma on mental health nurses include a

Mental disorders account for at least 160 million lost delay in health seeking behaviors, loss of job, social
years of healthy life of which about 30% could be pre- exclusion and the emotional impact of stigma. Stud-
vented with existing interventions (World Health Or- ies which investigated stigma among mental health
ganization, WHO, 2008). The WHO further reports patients reported that certain demographic variables
that there are over two million Ghanaians suffering such as age and gender appear to influence patients’
from moderate to mild mental disorders, and about experiences of stigma. In a cross-sectional study in
650,000 are suffering from severe mental illnesses Ho municipality of Ghana involving outpatients and
(WHO, 2014). It is further estimated that Ghana’s their relatives, females reported that they were more
treatment gap (defined as the number of people stigmatized than males (Tawiah et al, 2015). Simi-
whose illness goes untreated) stands at 98% (WHO, larly, in a facility-based cross-sectional study con-
2014). Several reasons, including stigma, may ac- ducted on 422 consecutive samples of people with
count for this treatment gap. Stigma is defined as the mental illness in Ethiopia, females showed higher
negative effect of a label and the result of disgrace self-stigma than males. It was identified that educa-
that sets a person apart from others in a society tional background has inverse relationship with
(Tawiah, Adongo & Aikins, 2015). stigma. As an individual’s education level increases,
discrimination experience scores decrease signifi-
Stigma is classified into felt or perceived stigma and cantly (Girma et al, 2013). Although research regard-
enacted stigma. Felt or perceived stigma refers to ing mental health nurses is well documented, little is
real or imagined fear of societal attitudes and poten- known how stigma impacts on nurses in Ghana.
tial discrimination arising from a particular undesir-
able attribute, disease (such as mental disorders), or This study examined the prevalence and effect of
association with a particular group (people with men- stigma on mental health nurses and how demo-
tal illness). Enacted stigma, on the other hand, refers graphic variables such as gender and marital status
to the real experience of discrimination experienced influence the experience of stigma. The following hy-
by a person or group of people with a particular un- potheses were formulated and tested:
desirable attribute or disease such as mental disor-
ders (Tawiah et al, 2015). Hypothesis 1: There is significant correlation be-
tween nurses understanding of stigma, effects of
In recent years, the concept of stigma has been at- stigma and measures to reduce stigma.
tracting increased attention among health profession-
als and the general population. It is reported that Hypothesis 2: There are gender differences in
stigma relating to mental illness does not only affect nurses’ understanding of stigma, effects of stigma
patients but also their caregivers and in particular, and measures taken to reduce stigma.
nurses. Mental health nurses are mostly identified
with mental health patients and as a result have re- Design and Methods
ported stigma resulting from their association with pa- A descriptive cross-sectional design was used to col-
tients (Eddington et al, 2008; Hanafiah & Van Bortel, lect information from the participants.
2015). Jack-Ide, Uys and Middleton (2013), in a qual-
itative study at the Neuro Psychiatric Hospital, Port Research setting
Harcourt- Nigeria, claim that reports of stigma and The study was conducted at Ankaful Psychiatric Hos-
negative attitudes towards mental health nurses were pital. The Hospital is located in the Komenda-Edina-
reflected in a lack of interest in following a career in Eguafo-Abrim Municipality in the Central Region of
mental health practice. Mental health professionals Ghana. It is the only psychiatric hospital outside the
feel stigmatized by other staff due to the nature of capital of Ghana (Accra) to serve the Central, West-
their work (Opare et al, 2017). Nurses reported that ern and Northern sectors of Ghana. It was estab-
many people in need of mental health care avoid lished in 1965 with a bed capacity of 500. Currently,
going to the psychiatric hospital for fear of being la- the hospital has a total bed capacity of 311. It oper-
beled (Kapungwa et al, 2010). ates 4 male wards, 2 female wards, 1 drug and alco-

hol rehabilitation center and a general and psycho- Data collection procedure
logical Out Patients Department. The hospital is re- A written permission was secured from the hospital
sponsible for the treatment, welfare, training and authority to interact with nurses at the hospital. The
rehabilitation of the mentally ill and serves as a train- objectives of the study were explained to participants
ing centre for health training institutions in mental for their consent. A consent form stating the purpose
health across the country. The hospital also receives and significance of the study was explained to re-
psychiatric patients from all over Ghana and from spondents and given to them to fill. The researchers
neighboring countries, namely, Benin, Burkina Faso, were solely responsible for the administration of the
La Cote D‘lvoire, Nigeria and Togo. The hospital re- questionnaire and data collection from the respon-
ceives an average of 40,000 out-patients every year. dents. The questionnaire was administered at the
Ankaful Psychiatric hospital was chosen because the various wards and departments of the respondents.
hospital admits and treats large numbers of mentally The data was collected within 21 days.
ill patients and there are about 185 Registered Men-
tal Health Nurses who work at the hospital who may Data processing and Analysis
experience effects of stigma. The data was analyzed and summarized descrip-
tively into frequency tables and graphs. Inferential
Target population statistical tests, specifically Pearson Product Moment
The target population for this study was made up of of correlation and Independent t test, were used.
Registered Mental Health Nurses [RMN] who work at
the Ankaful Psychiatric Hospital and were at post dur- Ethical consideration
ing the time of the study. An introductory letter was obtained from the School
of Nursing, University of Cape Coast to the Ankaful
Sampling procedure Psychiatric Hospital. It stated the purpose of the
A census method was used for this study because: study and expected outcomes. A written permission
the population was not very large, there was enough was secured from the hospital authority to interact
time to collect data and a higher degree of accuracy with nurses at the hospital. The objectives of the
was required from the study. At the time of the study, study were explained to the participants for their con-
the hospital had a total population of 185 RMN, com- sent, and they were also informed that they had the
prising 106 males and 79 females. 42 nurses out of right to withdraw from the study at any point if there
the 185 nurses were on study leave, leaving a total was any form of discrimination. Information collected
of 143 nurses at post at the time of the study, of which was treated confidentially and the identities of the re-
101 were sampled. spondents were not disclosed in writing the report.
Data collection instrument Results

A structured questionnaire was used to collect data The results showed that, out of 101 respondents,
from the respondents. The researcher developed the 61.4% were males whilst 38.6% were females. It was
questionnaire following consultation with mental found that 76.2% were between 18 to 30 years whilst
health nurses who have suffered from the effect of 2.0% were above 40 years (Table 1). The results also
stigma before. To ensure reliability, pretesting of the revealed that 50.5% were married whilst 49.5% were
questionnaire was carried out and ambiguous ques- single. It was further observed that 95.0% were
tions were restructured in a way that could be easily Diploma holders whilst 5.0% were Degree holders as
understood. The Chronbac’s alpha of the question- indicated in the table below.
naire was 0.80. The tool was designed in English
since all the respondents were educated at least to
the Diploma level.

Demographic Backgrounds
Table 1: Demographic of the Participants
Backgrounds of the (N=101)
Participants
(N=101)
Variable Frequency Percentage %

Sex
Male 62 61.4
Female 39 38.6
Age
18-30 77 76.2
31-40 22 21.8
41-50 1 1.0
50 and above 1 1.0
Marital status
Single 50 49.5
Married 51 50.5
Qualification
Diploma 96 95.0
Degree 5 5.0
Ward or Department
Acute ward 49 48.5
Chronic Ward 14 13.9
Outpatient department 27 26.7
Rehabilitation center 10 9.9
Administration 1 1.0
Number of years worked in the facility

1-5 years 85 84.2
6-10 years 14 13.9
11-15 years 1 1.0
16 years and above 1 1.0
Religion
Christianity 98 97.0
Islam 2 2.0
Traditional Religion 1 1.0

Hypothesis One show that understanding of stigma correlated signif-

H1: There is significant correlation between nurses’ icantly with measures to reduce stigma (r = .46, p ˂
understanding of stigma, effects of stigma and meas- 0.001), whereas it shows no significant association
ures to reduce stigma. with effects of stigma (r = -.05, p = .172).
Hypothesis Two
The purpose of hypothesis one was to find out the H1: There are gender differences in nurses’ under-
correlation between nurses’ understanding of stigma, standing of stigma, effects of stigma and measures
effects of stigma and measures to reduce stigma. taken to reduce stigma. This hypothesis was tested
Pearson product moment correlation analysis was using independent t test and the result presented in
conducted at 0.05 level of significance. The results Table 2.
Independent Samples
Table 2: Independent t-Test of Gender of Nurses’ Understanding,
of Effects and Measures
to Reduce Stigma
Samples t-Test of
Nurses
Gender Understanding, Effects and Measu
to Reduce Stigma
Variables N M SD t -value p-value
Understanding of stigma -.62 0.314

Male 62 24.40 2.97
Female 39 24.77 2.87
Effects of stigma -.18 0.421
Male 62 23.48 2.26
Female 39 23.56 2.16
Measures taken to reduce stigma
Male 62 6.23 1.46 -.02 0.754
Female 39 6.23 1.59
As can be seen, there was no significant effect of adults in Ghana concludes that the majority of people
gender on the understanding of stigma, effects of regard mentally ill persons and people associated
stigma, and measures taken to reduce stigma (p ≥ with them as inferior (Barke, Nyarko & Klecha, 2011).
0.05). This implies that both male and female nurses In this study, females shared a higher view of stigma
did not differ in terms of understanding, effects and and discrimination than males. Similarly, in a cross-
measures to reduce stigma. sectional study conducted on 422 consecutive sam-
ples of people with mental illness in Ethiopia, females
Discussion showed higher self-stigma than males (Girma et al,
The majority of nurses admitted they feel stigmatized 2013). The study further found that participants who
when they are discriminated against because of their reported high understanding of stigma also reported
profession and when people perceive them to be- high effects of stigma. However, there was an inverse
have the same as their patients. The views of the re- relationship between understanding of stigma and ef-
spondents confirm the definition of stigma by Tawiah fects of stigma. The participants who reported high
et al (2015), which states that stigma is the negative understanding of stigma again reported low effects
effect of a label and a result of disgrace that sets a of stigma. Female respondents obtained higher
person apart from others in a society. Similarly, two scores in understanding of stigma and effects of
independent surveys using convenience samples of stigma compared to males.

Effects of stigma they are discriminated against because of their pro-

The majority of mental health nurses felt other nurses fession, and this causes lack of interest in following
perceive them to behave the same as their patients. a career in mental health nursing. Mental health
In support of the above, Sartorius (2007) concludes nurses were of the view that people treat them with
that there is evidence to suggest that mental health contempt due to their profession and the majority of
professionals feel stigmatized by other staff due to them felt other nurses perceive them to behave the
the nature of their work. It is therefore unsurprising same as their patients. Stigmatization and name call-
that health professionals are reluctant to take up psy- ing can affect their self-esteem and make them with-
chiatric practice due to stigma and a lack of institu- draw from other health care providers. The findings
tional support (Kapungwa et al, 2010). Furthermore, reported here suggest that there is the need for policy
this study points out that mental health nurses were makers, including those from the Mental Health Au-
of the view that people treat them with contempt due thority and Ministry of Health to address the chal-
to their profession. This negative attitude towards lenges of stigmatization in mental health nursing.
Mental Health Nurses negatively influences their in- Measures to reduce stigma should be targeted at the
terest in the profession. This observation largely cor- mental health nurses. Bagley and King (2005), for in-
roborates the finding by Jack-Ide et al. (2013), as stance, argue that, rather than focusing on public ed-
discussed previously. ucation, stigma-busting campaigns should focus on
educating people with experience of mental illness to
Notwithstanding the above, the study is limited in the help them reject self-stigma and confront or construc-
following ways. First, the study design does not per- tively avoid public stigma. This may help improve
mit the establishment of cause and effect relation- upon the quality of mental health care delivery in
ship, given that the demographic characteristics of Ghana.
the nurses at Ankaful Psychiatric Hospital may differ
from their counterparts in other psychiatric hospitals Conflict of interest
in the country. Furthermore, the findings may not be The authors acknowledge that there was no conflict
generalized beyond the current sample. Lastly, there of interest.
is the possibility that the participants were motivated
to respond in a biased manner given that mental ill- Acknowledgement
ness is highly stigmatized in Ghana. The authors thank all the participants who took part
in the study.
Implication for nursing practice
The findings of the study raised many issues that af- Funding
fect mental health nurses in the performance of their No funding was received for this study.
duties. Nurses admitted they feel stigmatized when

Jack-Ide, I. O., Uys, L. R. & Middleton, L. E. (2013). Men-

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www. who.int/mental health

Original Article
Continuing Formal Education for

Non-Professional Nurses in Ghana:
Exploring the Motivational Factors
Edith Buamah Agyepong (MPhil, BSc. Nursing, RGN) 1
Adelaide Maria Ansah Ofei (PhD) 2
Adzo Kwashie (PhD Candidate, MPhil) 3
Abstract
Non - professional nurses are trained to assist professional nurses to perform
their duties. In – service training programmes are designed to augment the
knowledge of these nursing assistants in the profession, but they yearn to pur-
sue continuing formal education to upgrade their professional and academic
qualification. The purpose of this study was to find out factors that motivate
non - professional nurses to continue their education. The qualitative ex-
ploratory descriptive design was employed to explore the experiences of non–
professional nurses with continuing formal education. Twenty three (23)
participants were purposively selected for the study, and a semi-structured in-
terview guide with open - ended questions was used in gathering data from
December 2016 to January 2017. The findings from the study indicated that
non–professional nurses are motivated to continue their education because
they had low academic qualifications, lacked professional competencies, were
self-determined to progress in life, their employers recognized a higher aca-
demic qualification than several years of working experience and they were
practicing outside their job descriptions. The study concludes that staff devel-
opment plans should be designed by employers and educational institutions
responsible for the training of non–professional nurses should have flexible
programmes to enhance access.
Keywords:
Continuing Formal Education; Continuing Education; Nurses; Motiva-
tional Factors, Non - Professional Nurses; Continuing Professional De-
velopment.
1. 1Nurses’ Training College, Pantang
2. School of Nursing and Midwifery, University of Ghana
3. School of Nursing and Midwifery, University of Ghana.
1. Corresponding Author:
Nurses’ Training College, Pantang
P. O. Box 1236, Legon-Accra, Ghana.
Email: biamahagyepong@yahoo.co.uk

Introduction they are lacking in knowledge and wish to continue

Nurses engage in two types of education. These are their education to augment their basic knowledge in
in - service training and continuing formal education. nursing (Shahhosseini & Hamzehgardeshi 2015).
In - service training may be in the form of continuing Periodically, in – service training programmes are or-
professional development, workshops, and seminars ganized for non- professional nurses, but these nurse
which are designed to assist nurses develop profes- assistants aspire to excel academically as their pro-
sionally. Also, continuing formal education leads to fessional counterparts (Badu-Nyarko, 2015). This
the acquisition of undergraduate and post – graduate study therefore explored the factors that motivate
qualifications. non–professional nurses to further their education.
The motivation to continue one’s education originates Design and Methods

from an inward desire to develop academically (Pool,
Poell & Ten Cate 2013). According to Richards and Research Design
Potgieter (2010), updating professional knowledge to The qualitative exploratory descriptive design was
enhance skills is the reason for returning to school. used for the study. This approach allowed the re-
Warren and Mills (2009) found that commitment to searcher to gain a deeper understanding into the fac-
the nursing profession is a motivator for nurses pur- tors that motivate non–professional nurses to engage
suing further studies. Acquiring extra knowledge to in continuing formal education (Neergaard, Olesen,
enhance one’s professional status, clinical practice Andersen, & Sondergaard, 2009).
as well as obtaining a scholarship encourages regis-
tered nurses to continue their education (Ni et al., Research Setting
2014; Richards & Potgieter, 2010). Furthermore, ed- The study was conducted in a teaching hospital in
ucational programmes that have flexible duration are the Greater Accra Region of Ghana. This setting was
easily accessible and meet the needs of the learners, chosen because the hospital is located on the same
and this inspires participation in a continuing educa- premises with two nurses’ training colleges estab-
tion programme (Brekelmans, Maassen, Poell, West- lished to train professional nurses. The proximity of
strate & Geurdes, 2016 ; Nalle, Wyatt & Myers, 2010; the hospital to the school is likely to heighten non–
Perfetto, 2015 ; Power et al., 2011). professional nurses’ interest in pursuing further stud-
ies.
Registered nurses who pursue continuing formal ed-
ucation are exposed to opportunities such as attend- Target Population
ing international and national conferences, assuming The target population for this study comprised all
leadership positions and acquiring critical thinking non–professional nurses working at the hospital. The
and research. (Plunkett, Iwasiw, & Kerr, 2010; Oster- inclusion criteria were:
man, Asselin, & Cullen, 2009; Warren & Mills, 2009; a) Non - professional nurses who have worked
Witt, 2009). The aforementioned studies highlight the for at least five years at the hospital and have
reasons for registered nurses’ participation in further not engaged in continuing formal education.
studies but there is paucity of literature on factors that
motivate non–professional nurses to pursue contin- b) Non-professional nurses who have worked for
uing formal education. at least five years at the hospital and are cur-
rently pursuing continuing formal education.
Non–professional nurses are trained to assist the
professional nurse on the clinical field. In Ghana, c) Non - professional nurses who have worked
there are two categories of non–professional nurses: for at least five years at the hospital and have
1) Nurse Assistant Clinical (Enrolled Nurse) who work completed any form of continuing formal edu-
in the community or hospital. 2) Nurse Assistant Pre- cation.
ventive (Community Health Nurse) who assist the
public health nurse. Non–professional nurses, after The exclusion criteria was non-professional nurses
practicing on the field for a number of years, realize who were sick at the time of data collection.

Sampling Technique and Sample Size findings represented the information participants
The purposive sampling technique was used in re- shared.
cruiting 23 non–professional nurses to give a detailed
account of the factors that motivate them in pursuing Ethical Consideration
continuing formal education. Saturation was reached Ethical approval was obtained from the Institutional
with the 23rd participant. Review Board at Noguchi Memorial Institute for Med-
ical Research, University of Ghana. The Institutional
Research Tool review board number for conducting this research is
Data were gathered using a semi-structured inter- IRB 00001276. Non-professional nurses were con-
view guide with open-ended questions developed by tacted and the nature, purpose, procedure and the
the researchers which allowed probing on the moti- importance of the research explained to aid their un-
vational factors for pursuing formal continuing edu- derstanding of the research. The selection of partic-
cation. ipants was voluntary and no coercion was applied.
Non-professional nurses who consented to be part of
Data Collection the study were recruited and given the chance to
Formal permission was obtained from the adminis- withdraw from the study without any consequences.
trator and the Deputy Director of Nursing Services Participants were assured of confidentiality and were
(DDNS) of the hospital to select study participants. identified by identification codes.
Non-professional nurses at the hospital were con-
tacted by the researcher and briefed on the purpose Results
and procedure of the study. Information sheets re-
garding the study were given for further illumination Demographic Characteristics of
on the research topic. Non-professional nurses who Participants
met the inclusion criteria and consented to participate The study involved 23 non–professional nurses com-
in the study were recruited. During the interviewing prising 22 females and a male. Eight participants had
sections, consent was obtained from participants to not engaged in continuing formal education whilst six
record the interview. The first author conducted all had completed continuing formal education. With the
the interviews in this study. six, two had graduated with Diploma in Community
Psychiatry, two with Certificate in Post Basic Mid-
Data Analysis wifery, one with Bachelor of Science in Nursing and
Content analysis was used in analyzing the data. The one with Diploma in Health Promotion. Nine partici-
recorded interviews were transcribed and read sev- pants were in School. Out of the nine, eight were pur-
eral times to fully understand the views of partici- suing Certificate in Post Basic Midwifery and one in
pants. Content analysis techniques were followed Bachelor of Science in Nursing. The age of partici-
where codes were inductively generated from the pants ranged from 29 and 37years. Fourteen partic-
data to form themes and sub-themes. The identified ipants were married and nine of them were single.
themes and sub–themes were compared with their The participants who were married had at most two
collated data extracts and these were used in the re- children whose ages ranged between eight months
port to provide voice to the participants. and five years.
Rigour of the Research The data revealed that, the motivation for non–pro-
The researchers acquainted themselves with the tar- fessional nurses to continue their formal education
get population and reviewed appropriate documents originated from their interaction with colleagues at the
on non–professional nurses and continuing formal workplace and the public. In analysing the data, the
education. The research methodology and the data main theme “motivations to continuing formal educa-
gathering process were described into details. The tion” had eight sub - themes emerging from the data.
research setting and the inclusion and exclusion cri-
teria for selecting participants were also described. Self - determination
Also the transcribed data were verified to ensure that Participants who had completed school and those in

school were determined to continue their education. cation required that they worked under supervision
They felt they were young, full of capabilities and had even though they considered themselves competent.
the right to education.
“On the field, you may have the skill to carry out
“I was personally motivated to go back to a particular assignment, but because your qual-
school. After completing the basic certificate ification is basic, you still have to be supervised
programme, I was in my early twenties so I told and I hated this when I knew I have much skill
myself that I had to go back to school within the than the one supervising me. So I made the de-
next three years, I improved on my senior high cision to go back to school” P14
school grades and pursued a diploma pro-
gramme in health promotion” P1 Progression in Life
Participants were motivated to engage in continuing
Participants who had completed school and those formal education because they wanted to progress
enrolled on a programme maintained that, at school, in life. Non–professional nurses wanted to take ad-
the academic environment was full of pressure, but vantage of all the opportunities life had to offer rather
they were determined to complete their programmes than being static in life.
of study successfully.
“I am not comfortable with my level in the pro-
“Before I went to school, I was told the profession, I can’t just be at one place and be work-
gramme was difficult. I got to school and re- ing, I need to move on in life. I believe there are
alised it for myself, the first year was not easy; several opportunities out there waiting to be ex-
but with determination, I told myself I would plored” P23
complete this programme” P2
“Living in the village as a community health
A number of participants in school reiterated that their nurse delays your plans… so I needed to read-
determination to complete their programmes was just my thinking to progress in life” P4
backed by trust in God.
Employers’ recognition for higher aca-
“The programme is not easy, I am going through demic qualification than experience
pressure because I have no care taker assisting Generally, all the participants were motivated to fur-
with the family chores and this makes learning ther their education because they realised the health
difficult, but I trust God will see me through this sector recognises advanced qualification for practice
programme successfully” P6 than years of working experience.
Low Academic Qualification “After working for six years on the ward, some-
All the participants were motivated to further their ed- one will come with a higher qualification with no
ucation because their low academic qualifications in experience, you will be teaching the person
the nursing profession hindered their opportunity of what to do, but that person will become your
being employed by private health care facilities. boss, so why don’t you upgrade yourself to take
that position?” P16
“Do you know that some private institutions in
this country do not employ us because of our A number of participants who had not returned to
low academic qualification? Sometimes you go school felt that irrespective of their years of working
for interview at these hospitals and you are experience, suggestions they made on the ward
turned down. So obviously you will be motivated were ignored and this sometimes led to fatal conse-
to go back to school” P20 quences.
Participants who are engaged in continuing formal “During one clinical section, I saw a four-year-
education lamented that their low academic qualifi- old girl with burns on the left thigh who was in

pain. I suggested how this could be managed “I worked at the CHPS center alone with an or-
effectively to the ward in charge but because I derly; in the mornings, I do consultations and
was a nurse assistant I was brushed over… with around 12pm when the place is less busy, I
time the girl’s burns got infected and she died. close the centre and go for home visits looking
This story really hurts me. If the in - charge had for child welfare clinic defaulters, family planning
listened to me, that child would not have died so defaulters as well as tracing the aged with
I am motivated to learn hard to complete my wound. I return to the facility and there will be
programme so that I can help save more lives” clients waiting to be attended to. I rarely had
P5 time to eat. So I decided to go back to school to
become a Psychiatric Nurse which I believe is
Lack of professional competencies more flexible” P7
Majority of participants were motivated to further their
education because they believed continuing formal Participants acknowledged that, challenging physical
education would enable them build on their profes- situations such as working in rural areas with limited
sional competencies. Some non-professional nurses social amenities motivated them to pursue further
acknowledged that even though they were proficient studies.
with the practical aspect of nursing, they had some
deficiencies in their nursing skills which they needed “At the village where I worked before pursuing
to build on. further studies, there were no lights, place of
convenience and washroom; In fact it was a real
“As a community health nurse, I was supposed ghetto so I advised myself to continue my edu-
to do everything. Aside weighing babies, giving cation so that I could get a better career” P1
immunisation and health education which I did
without supervision; I had challenges conduct- The unfair treatment meted out to participants at their
ing deliveries and this could affect the lives of workplaces motivated the majority of them to return
my patient, so I decided to further my education” to school.
P14
“I assumed duty with a professional nurse, after
Ambition and Drive for Better Career Options three years we were all expecting our promo-
All the participants declared they were motivated to tions, she was promoted and I was told to wait
return to school because they had personal ambi- for five years. In fact, I felt cheated, so I decided
tions to attain in life. Others also recounted that their to further my education to become a profes-
low educational backgrounds would not lead them to sional nurse” P2
better career options, they would always remain aux-
iliaries, hence the need to further their education to Practicing outside one’s Job Description
access other career opportunities. Non-professional nurses were trained to assist pro-
fessional nurses, but they found themselves carrying
“For me, I want to aspire higher. This wasn’t my out the duties of professional nurses and midwives.
aim, it wasn’t where I wanted to start from. I Practising outside one’s job description was a major
want to pursue midwifery, specifically bachelor’s factor for pursuing continuing formal education. Par-
degree in midwifery and that has been my ticipants realized it was illegal and could have landed
dream” P22 them in trouble.
A number of participants who worked as community “Majority of non–professional nurses are not
health nurses wanted different career options be- midwives, but we have been performing the role
cause their work was difficult and stressful. Some of midwives without having any license, so it is
participants worked for long hours alone without any important you go to school and pursue mid-
assistance. wifery so that you can also practice well” P10

Although some participants knew the consequences knowing my competence recommended me to

of practising outside their job description, they always the woman, but she said no! I am not a good
considered the plight of their patients and performed nurse, so from that point on, the doctor asked
such tasks which further motivated them to pursue me not to be wearing my uniform to the consult-
higher education. ing room but rather an ordinary dress. All these
instances are humiliating; it makes you feel bad
“I know I am to assist a senior colleague on and you are motivated to go back to school” P14
duty, but sometimes you are only two non–pro-
fessional nurses on a shift and there is no senior Influence of Mentors and Role Models
nurse or a doctor. If a patient has to be fed you Role models play an influential role in participants’
have no option than to pass a nasogastric tube decision to return to school for further studies. Par-
for the patient but this is not my duty” P3 ticipants acknowledged that role models made richer
contributions to decision making and were highly ad-
Lack of Respect mired by their works.
Participants experienced lack of respect. This is a
major factor which motivated them to continue their “When you attend programmes, you realized
education. Professional nurses and other health care that individuals who have pursued continuing
professionals disrespected the non-professional formal education made richer contributions and
nurses. Other participants also felt humiliated by the their knowledge is far richer than yours so I also
general public. wanted to pursue continuing formal education
so that I will stay on top of issues like my col-
“I wanted a change of job title from a community leagues” P17
health nurse to a midwife and this comes with
respect because when you are in the brown uni- Participants who had completed school admitted they
form, people believe you are not a good nurse. had become role models and are encouraging col-
I felt my identity was at stake” P15 leagues to further their education.
A number of participants felt they had to go back to “My ability to pursue Bachelor of Science in
school because their efforts were not appreciated by Nursing has motivated some of my colleagues
their senior colleagues. to go back to school. Some are pursuing degree
nursing. Now everyone talks to me, I have be-
“I worked in remote villages which sometimes I come a role model and a mentor; people are
would have to walk for one hour forty minutes asking me how I did it” P4
while carrying the items I will need to work with.
You are at times beaten by rain but our superi- Discussion
ors humiliated us if we did not meet our target Participating in continuing formal education requires
for the month. Out of this hard work, if you are a diligent effort from the student. Self-determination
not appreciated it really hurts” P8 was identified as a motivator that propels non-profes-
sional nurses to pursue further studies. Amid chal-
Participants who worked within the communities also lenging situations such as juggling family and work
narrated that the general public did not regard them responsibilities, participants enrolled in continuing
in spite of the services they provided. Although the formal education. Richards and Potgieter (2010) af-
public did not know the academic qualifications of firmed that registered nurses who were on a pro-
non-professional nurses, they identified them by the gramme of study wanted to abandon the programmes
colour of their uniforms. because they could not catch up with class sched-
ules. Alternatively, Perfetto (2015) opined that, com-
“I was once assisting a doctor to do consultation mitment and dedication on the part of nurses are
in his office when a woman came in requesting motivating factors for nurses to complete their pro-
the services of a private nurse. The doctor grammes of study. These findings may indicate that,

despite the challenges surrounding non-professional delayed while others were divorced. This finding
nurses’ return to school, a greater number of them supports that of Nsemo, John, Etifit, Mgbekem &
are personally motivated to continue their education. Oyira (2013), Pool et al. (2013) and Witt (2011) that
confirmed that registered nurses engaged in contin-
This study further showed that the majority of non - uing formal education as a result of their personal
professional nurses return to school because they interest, prospect of unraveling opportunities that are
are young and have the potential to do more for associated with continuing formal education. This
themselves and the nursing profession. This finding finding may require that, measures are put in place
corroborates that of Alamri and Sharts-Hopko (2015) to promote the continuing formal education of non-
who found that younger nurses between the ages of professional nurses to assist them contribute signifi-
26 to 29 years and had worked for 6 years were cantly to the profession.
greatly motivated to continue their education. Simi-
larly, non-professional nurses in this study pursued Lack of employer’s recognition for non–professional
continuing formal education because they wanted to nurses’ long years of service is another reason they
excel within the profession and not remain perpetual would continue their education. Participants main-
nursing assistants. This finding implies that nurses tained that after working for so many years, a neo-
should be encouraged to continue their education at phyte nurse without much experience in the
an early age so as to contribute to the development profession becomes their superior because he or she
of the nursing profession. holds a higher qualification. Previous studies con-
firmed that nurses pursue further studies to acquire
Registered nurses return to school to build on their academic qualifications to build on their professional
previous knowledge (Richards & Potgieter, 2010). status (Ni et al. 2014; Nsemo et al.2013).
This study revealed that non - professional nurses
are motivated to further their studies due to their low The study found that the aspiration to build on one’s
academic qualification which, some participants dis- professional competence is a motivator for non-pro-
closed, made them embarrassed and stumbled their fessional nurses to go back to school. Participants
chances of being employed by private healthcare fa- made it known that, though they had a firm grasp of
cilities. Other participants maintained that their low the practical aspect of nursing, they did not under-
academic qualification necessitated that they were stand the theory behind what they practiced. This
supervised to carry out some procedures on the ward finding supports other studies which corroborated
even though they could perform it better. Hutchinson, that nurses return to school to learn new things and
Mitchell & St John (2011) opined that enrolled nurses build on their proficiency (Ni et al., 2014; Shahhos-
who were on a Bachelor of Science in nursing pro- seini & Hamzehgardeshi, 2015). This finding empha-
gramme felt ashamed when they were prevented sises that nurses no longer want to practice with the
from participating in advanced nursing procedures on trial and error means of caring for patients, thus the
the ward. This finding may suggest that non - pro- need for evidence-based practice to be introduced
fessional nurses concede their basic knowledge into the nursing curriculum to aid nurses understand
about the profession as an obstacle to delivering the underlying principles supporting their practice.
quality care to their clients, hence, their determination
to further their education (Ni et al., 2014). The fear of being caught up by the law is a major rea-
son why non-professional nurses return to school.
The study further found that non-professional nurses The study confirmed that majority of non-professional
are motivated to return to school because they want nurses on the field performed duties outside their job
to progress in life. Participants affirmed they were dis- description; they carried out activities such as pass-
pleased with their ranking in the profession as nursing naso-gastric tubes and conducting deliveries
ing assistants as it impeded their development in life. which are to be done by professional nurses. Conse-
Non–professional nurses who worked in rural areas quently, the majority of participants are eager to con-
felt the village life was not conducive for their per- tinue their education to acquire the right qualification
sonal growth; their chances of getting married were to practice.

The findings of the study indicated that the majority fessional training for role models and clinical nurse
of the participants return to school because they mentors to impact knowledge on nurses as well as
lacked respect from colleagues and the general pub- nursing students.
lic. Participants complained they were considered in-
ferior at their work places and were discriminated by Implication for Nursing Education
the public as unqualified nurses. Pool et al. (2013) Consumers of healthcare demand competent and
confirmed that obtaining a higher academic qualifica- quality healthcare. This requires that non–profes-
tion to enhance one’s self– esteem is a motivating sional nurses are well trained and equipped to face
factor for nurses to pursue further studies. This find- this demand, hence non-professional nurses should
ing is pertinent and demands immediate attention. A be encouraged to pursue further studies as per their
decreased self–respect has several implications for institutional policy.
nursing practice. The nurse assistant may feel humil-
iated, and this is likely to affect the care she renders Conclusion
to her patients and subsequently affect the produc- The study concludes that non–professional nurses
tivity of her organisation. This finding highlights the have genuine reasons for furthering their education.
need for counselling services to be provided for Enhancing their academic progression in the nursing
nurses at their places of work to discover factors that profession requires collaboration between all stake-
hinder the development of self - respect among holders to create opportunities for further education.
nurses and the appropriate interventions put in place In addition, management of health care facilities
to resolve them. should create an enabling organizational environ-
ment that motivates non-professional nurses to pur-
The achievement of mentors and role models within sue further studies.
the health sector is a motivating factor for non–pro-
fessional nurses to further their education. This find- Conflict of Interest
ing complements that of Richards and Potgieter The author declares no conflict of interest
(2010) and Skela - Savič and Kiger (2015) who main-
tained that role models and mentors play a role in Acknowledgement
nurses’ pursuance of further studies. Skela - Savič Special thanks go to all non–professional nurses who
and Kiger (2015) underscored the importance of pro- participated in the study.

Perfetto, L. M. (2015). Facilitating educational advance-

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https://doi.org/10.1097/NND.0b013e3181a566be

Original Article
Maternal Satisfaction with Labour

at the University of Ghana Hospital
Accra: A Cross Sectional Survey
Decker Sheila (BSc, RM) 1
Joanne Chiwaula(MSc RN CNM) 2
Veronica Millicent Dzomeku (PhD, MPhil, BA, RM, RN) 3
Emmanuel Nakua (MSc, BSc) 4
Bemah Adwoa Bonsu (MPhil, BSc, RN) 5
Abstract
Information on maternal experience with institutional birth is dearth in Ghana, and
the few studies on this subject did not employ standardized internationally vali-
dated questionnaires/instruments. Using a structured questionnaire including a
modified-Women’s Views of Birth Labour Satisfaction Questionnaire four
(WOMBLSQ4), this study seeks to evaluate women’s birth experience with care
during labour, birth, and lying-in period, at the University of Ghana Hospital in
Accra. Using a quantitative cross-sectional study approach, 50 puerperal women
in the lying-in ward and those seeking postnatal care less than three months after
delivery at the University of Ghana Hospital were selected. A structured question-
naire comprising, amongst others, the internationally validated Women’s Views of
Birth Labour Satisfaction Questionnaire fourth edition (WOMBLSQ4) was admin-
istered to respondents. In general, the maternal satisfaction with birth experience
at the University of Ghana Hospital was high, with 52% and 38% of mothers rating
their overall experience as excellent and good respectively. However, 20% of the
participants expressed dissatisfaction with their overall birth experience at the
health facility. Partner support received the highest negative rating on the birth ex-
perience accounting for 18% followed by continuity of care where 16% of the re-
spondents reported not knowing their caregivers at the time of delivery. Though
positive maternal birth experience among respondents was high, steps need to
be taken to reduce the gaps in care identified by this study.
Keywords:
maternal experience; birth experience; maternal satisfaction; puerperal;
labour.
1. University of Ghana, P. O. Box LG 79. Legon, Accra-Ghana

2. Peoples Community Clinic 2909 N. 1-35 Texas US
3. Dept. of Nursing, Kwame Nkrumah University of Science and Technology, Kumasi-Ghana
4. Sch. of Public Health, Kwame Nkrumah University of Science & Technology, Kumasi-Ghana
5. Dept. of Nursing, Kwame Nkrumah University of Science and Technology, Kumasi-Ghana
1. University of Ghana, P. O. Box LG 79. Legon, Accra-Ghana

Introduction of Birth Labour Satisfaction Questionnaire Four

The experience of labour and delivery, though unique (WOMBLSQ4), this study evaluated, in a standard-
for each woman, significantly involves and impacts ized way, women's birth experiences focusing on
the physical, psychological and emotional self of an care received during recent labour, birth, and the
individual. The experience is associated with physical lying-in period at the University of Ghana Hospital in
strain, pain, psychological adjustment, and vulnera- Accra.
bility (Naghizadeh, Kazemi, Ebrahimpour, & Egh-
dampour, 2013). Despite the various interventions for Design and Methods
encouraging facility-based deliveries, 27% of deliv-
eries still occur outside health facilities in Ghana Study area
(Ghana Demographic and Health Survey, 2014). The study was carried out at the University of Ghana
Among the contributory factors of non-facility delivery Hospital’s maternity ward that is found in West
in Ghana are poor attitude of health workers and poor Wagon Sub-metropolitan within Accra Metropolitan
quality maternity care (Esena & Sappor, 2013). In sit- Area. The University of Ghana (UG) established the
uations where persons opt for home birth without University of Ghana Hospital in 1957. It is a quasi-
skilled attendants, each individual attends at least government hospital originally established to care for
one antenatal clinic during the course of the preg- the health needs of UG students, staff and depend-
nancy (Nakua et al, 2015). Most significantly, the rate ents. As the community started developing, the in-
of unskilled care rendered to these women is high. habitants began to seek health care from the
Largely accounting for this anomaly are unpleasant hospital. With time, the hospital became a District
verbal expressions from health personnel and delay Hospital and has extensive catchment area. It has a
in responding to the calls of the women in labor. Ex- capacity of 130 comprising of general ward, maternity
periences women have in labour are important to im- unit, emergency unit, dental unit, surgical unit and op-
prove care particularly to make care provision erative theatre. Service provided include outpatient,
patient-centered. This makes it imperative to investi- in-patient and specialist service. The hospital has a
gate the experiences of mothers during labour in well-known primary care outreach programme aimed
other settings within Ghana. at teaching and advising pregnant women, nursing
mothers and the general public about personal hy-
International, national and traditional clinical meas- giene, good nutrition, child care, and immunization
ures of the quality of care have been limited to the against vaccine preventable diseases, family plan-
maternal and perinatal mortality and morbidity rates ning and school health services. The hospital re-
(Smith, 2001). However, the need for a complemen- ceives about 150 antenatal clients monthly and
tary patient-centered measure of quality led to the ac- conducts an average of about 60 deliveries in a
ceptance of the mother’s satisfaction during the month. The antenatal clinic is done from Mondays
birthing process as the indicator of choice in the eval- to Thursdays and the postnatal clinic is on Fridays.
uation of the quality of maternity services (Bélanger- The maternity ward where respondents were inter-
Lévesque et al, 2014; Smith, 2001). A number of viewed has a bed capacity of 17 and a 24 hour serv-
instruments have been developed to assess ice and is headed by an obstetrician gynecologist.
women’s satisfaction with intra partum care and
childbirth. These indicators have stemmed from an Study Population
appreciation of mothers’ experiences of institutional The study targeted puerperal mothers at the Univer-
childbirth over recent decades (Gärtner et al., 2014; sity of Ghana. The inclusion criterion was women
Sawyer et al., 2014). However, the information on who have experienced recent labour and delivery at
maternal satisfaction with institutional birth in low and the University of Ghana hospital. Also, those receiv-
middle income countries is scarce and the studies on ing post-natal care for less than 3 months and con-
this subject found in the literature did not employ sented to the study were included. Mothers receiving
standardized internationally validated question- post-natal care for 3 months and beyond were ex-
naires/instruments. Using a modified-Woman’s Views cluded from the study.

Study Design and Participant Computer based statistical packages Graph pad 6,
Recruitment was used to analyse the data.
A cross-sectional approach was adopted to evaluate
women's birth experiences with care during a recent Results
labour, delivery and immediate lying-in period. Using
a convenience sampling technique, a total of 50 par- Socio-Demographic Data
ticipants were involved in the study. Puerperal moth- General Demographic Information of Mothers
ers in the lying-in ward and those seeking postnatal Seeking Maternity Care at the University of
care at the University of Ghana Hospital within the Ghana Hospital
period of the study were selected and those who vol- The average age of respondents surveyed for this
untarily accepted to participate in the study were en- study was 29.58 ranging from a minimum of 24 years
rolled. A structured questionnaire including an to a maximum of 41 years. The majority of the moth-
internationally validated Women’s Views of Birth ers (58%) who participated in this study were
Labour Satisfaction Questionnaire fourth edition younger than 30 years. Eighty eight percent (88%) of
(WOMBLSQ4) (Smith, 2001) was administered. respondents were married and 86% of them had at-
tained at least secondary education at the time of this
Statistical analysis study. Most of the mothers (84%) were Christians
Each variable was analyzed and the outcome of the and the majority were gainfully employed working in
analysis was presented using tables and figures. the formal sector (64%). (Table 1).
Table 1: General Demographic Information of Mothers Seeking Maternity Care at the University of Ghana Hospital, Accra
Parameter Frequency Percentage
Total Respondent 50 100
Age Range
<30 29 58.00
30-35 14 28.00
>35 7 14.00
Marital Status
Single 3 6.00
Co-Habitation 3 6.00
Married 44 88.00
Educational Status
None 2 4.00
Basic 5 10.00
Secondary 16 32.00
Tertiary 27 54.00
Maternal Religion
Christian 42 84.00
Muslim 4 8.00
Traditional 2 4.00
Others 2 4.00
Employment Status
Formal 32 64.00
Informal 13 26.00
None 5 10.00

Maternal Experience with Labour and Immediate were allowed to have control over the delivery
Lying-In Care at The University of Ghana Hospi- process. As seen in Table 4, though most of the par-
tal, Accra ticipants in the study felt their expectation for the de-
In general, the maternal satisfaction with birth expe- livery experience was met, 6% of the respondents felt
rience at the University of Ghana Hospital was high, it did not meet their expectation. Partner support re-
with 52% of mothers rating their overall experience ceived the highest negative rating of 18% followed
as excellent and 38% rated good. However, 20% of by continuity of care. Ten percent (10%) of mothers
the participants expressed dissatisfaction with their indicated that pain management before delivery was
overall birth experience at the health facility. Partici- poor while 14% also felt pain management after de-
pants reported positive experiences with the support livery was poor. Most of the women said their babies
they received from the health professionals at the fa- were presented to them to hold within one hour after
cility during the period of delivery and immediate birth. The participants were also very happy with the
lying–in care with none rating this domain of birth ex- delivery environment and the education they re-
perience as poor. On the maternal control domain, ceived after birth. (Table 4).
most of the participants surveyed (98%) felt they
Table 2: Rating of Maternal Experience with Labour at the University of Ghana Hospital stratified by various domains.
Parameters Poor Good Very Good Excellent
General Satisfaction 5(10) 19(38) 0(0) 26(52)
Birth Experience Domains
Professional Support 0(0) 7(14) 12(24) 31(62)

Control 1(2) 29(58) 16(32) 4(8)
Expectation 3(6) 6(12) 15(30) 26(52)
Partner Support 9(18) 9(18) 6(12) 26(52)
Pain Mgt before Delivery 5(10) 11(22) 10(20) 24(48)
Holding Baby 2(4) 17(34) 15(30) 16(32)
Pain Mgt after Delivery 7(14) 13(26) 25(50) 5(10)
Continuity 8(16) 10(20) 8(16) 24(48)
Environment 2(4) 2(4) 11(22) 35(70)
Education after Birth 0(0) 9(18) 24(48) 17(34)
Data is presented as figure with corresponding percentage in parenthesis. Mgt-management. Poor (< 50%), Good (50-
59%) Very Good (60-69) and Excellent (൑ 70%) of percentage total domain score

Pregnancy Outcome with General Satisfaction of of mothers whose babies were diagnosed as sick at
Birth Experience At University of Ghana Hospital delivery rated their birth experience as excellent, this
As shown in Figure 1A, negative maternal birth ex- group had a higher number of dissatisfaction (16.5%)
perience was higher among primiparous mothers compared to those who delivered healthy babies
(14.3%) compared to their multiparous counterparts (9.3%) (Figure 1C). Mothers whose babies were ad-
(8.3%). Mothers who underwent caesarean section mitted to the Mother Baby Unit recorded higher neg-
had less negative maternal birth experience (7.1%) ative maternal birth experience (20%) than those who
than those who underwent spontaneous vaginal de- were not admitted (9.1%) (Figure 1D).
livery (11.8%) (Figure 1B). Though the vast majority
Figure 1: General Satisfaction of Birth Experience among Women Seeking Maternal Care at the University Hospital Stratified by
Obstetric and Gynaecological Outcome. A-Number of Birth, B-Mode of Delivery, C-Diagnosis at Birth and D-Admission after Birth.
Socio-Demographic Characteristics With General Discussion

Satisfaction of Birth Experience at a Hospital In the current study, the frequency of antenatal care
in Ghana (ANC) attendance was very satisfactory with the ma-
Positive maternal satisfaction with birth experience jority of the mothers attaining the minimum required
was associated with lower level of maternal educa- four visits. The obstetric information showed that
tion with only mothers with maternal educational lev- most of the mothers delivered through spontaneous
els above basic education expressing negative birth vaginal delivery (SVD).The fact that a majority of the
experience (Figure 2A). Higher antenatal attendance mothers utilised ANC is encouraging and this might
was also associated with positive maternal birth ex- be related to the educational level of the mothers.
perience with greater percentage of mothers who at- This assertion is supported by a study conducted in
tended less than four times of antenatal reporting northern Nigeria which observed that there was a sig-
negative birth experience (14.35%) than those who nificant association between education and ANC
attended ANC four or more times during pregnancy service utilisation (Ejembi, Alti-Muazu, Chirdan,
(7.7%) (Figure 2C). Ezeh, & Sheidu, 2004). Previous studies have pro-

posed that ignorance of and misconceptions about care during pregnancy and childbirth. This could re-
the purpose of ANC, and financial constraints are the sult in reduction of maternal mortality which is seen
dominant underlying factors in delayed utilisation of as a key indicator of women’s health status (Akum,
ANC (Gharoro & Igbafe, 2000; Oyibo, Ebeigbe, & 2013). Childbirth changes life forever in a process
Nwonwu, 2011). that is renewed with every child that the woman gives
birth to (Lundgren, Karlsdottir, & Bondas, 2009) and
The experience of childbirth is an important life event extends far beyond the specific experience in birth
for women. Generally, a high maternal satisfaction (Brathwaite & Williams, 2004). The health profes-
with birth experience at the University of Ghana Hos- sionals at the University of Ghana Hospital should be
pital was observed with most of the mothers rating encouraged to do more to reduce childbirth compli-
their overall experience as excellent. However, a sig- cations as a traumatic birth experiences could have
nificant minority (20%) expressed dissatisfaction with a long lasting effect on the woman’s health and well-
their overall birth experience at the health facility. Par- being as well as the relationship to the baby (Beck,
ticipants reported very positive experiences with the 2006).
support they received from the health professionals
at the facility during the period of delivery and imme- Existing literature expresses labour support as the
diate lying–in care. None of the participants rated this presence of an empathic individual who comforts a
domain of birth experience as poor. Available guide- woman and provides other physical and psychosocial
lines in high income countries in midwifery care assistance to help her cope with the difficulties of
highly advocate continuous support for mothers labour, and birth (Hodnett, 2002). The presence of
throughout labour (Munro & Spiby, 2000). All the family members/partners is one of the key aspects
puerperal mothers in the current study received sup- that women believe constitutes good care, whether
port from the Ghanaian health professionals and this they deliver at home or at an institution. The pres-
promoted mothers’ satisfaction in their labour and im- ence of a family member provides the labouring
mediate post-natal experience. On the maternal con- woman with emotional support in an unknown hospi-
trol domain, majority of the participants surveyed tal environment (Mahdi & Habib, 2010). The Mother-
reported they were allowed to have control of the en- Friendly Childbirth Initiative recommends that a birth
tire delivery process and were not ordered about on centre should offer the mother unrestricted access to
what to do. Although most of the participants in the the birth companion of her choice including father,
study thought their expectations for a positive deliv- partner, children, family members and friends
ery experience were met, a few of the respondents (Shobha & Jayprakashkumar, 2013). Interestingly,
were disappointed. Hence, it is imperative that the partner support received the highest negative rating
hospital management identifies why the few respon- in the current survey. This is because the structural
dents’ expectations were not met so as to take steps layout of the maternity unit, particularly the labour
to address them. Partner support received the high- wards, does not accommodate partners in labour. Ef-
est negative ratings followed by continuity of care forts should be made to change the physical struc-
whereas a smaller proportion of the respondents re- ture of the labour ward in order to facilitate the
ported not knowing their careers at the time of deliv- presence of male partners at deliveries without com-
ery. Some of the mothers reported that pain promising the privacy of other labouring women.
management before and after delivery was poor. Fi- Women’s emotional experiences are an important
nally, most of the women said their babies were pre- outcome of labour (Waldenstrom, 2003). Birth expe-
sented to them to hold at the appropriate time. riences are very individual and have personal mean-
Participants were also very happy with the delivery ing for women.
environment and the education they received after
birth. Patient satisfaction is widely recognized as a legiti-
mate measure of quality health care (Sharma &
Since pregnancy and childbearing have brought risks Kamra, 2013; Singh, Goswami, & Nagaonkare,
to women throughout history, it is very important that 2013). The current survey observed that positive ma-
health professionals give mothers first class obstetric ternal satisfaction with birth experience was associ-

ated with lower level of maternal education as only care to help improve care and evidence-based mid-
mothers with educational levels above basic educa- wifery care.
tion expressed negative birth experience. This find-
ing agrees with a study by Mselle, Moland, Mvungi, Conclusion
Evjen-Olsen, & Kohi (2013) which posited that be- The study observed a high maternal satisfaction with
cause of higher expectations, educated groups and birth experience at the University of Ghana Hospital
patients with higher social class are often less satis- as mothers rated their overall experience as excellent
fied than less educated groups. Higher antenatal at- and good respectively. High Maternal satisfaction
tendance was also associated with positive maternal with the birth experience was associated with low lev-
birth experience with greater percentage of mothers els of maternal education and also among multi-
who attended less than four times of antenatal ex- parous mothers. Exposure to regular care influences
pressing negative birth experiences than those who the pregnant woman’s expectations. Also, mothers
attended ANC four or more times during pregnancy. who underwent (cesarean section) C/S had a better
Pregnancy is considered a phase in life that makes birth experience with those who had (spontaneous
great demands on the woman’s ability to adapt and vaginal delivery) SVD reporting negative birth expe-
adjust physically, psychologically and socially. There- riences. The study also identified that the incidence
fore, the antenatal period provides an opportunity for of the sick child and hospitalization of the child neg-
reaching out to pregnant women and providing them atively impacted on the satisfaction and experience
with care that will enhance their optimum health and of most women during their maternal stay at the Uni-
the wellbeing of their unborn infants. Our findings versity of Ghana.
suggest that exposure to “routine” antenatal care can
also guide or influence the pregnant woman’s ex- Conflicts of interest
pectations (Mathibe-Neke, 2008). The authors have no competing interests to disclose
Implications for midwifery practice Acknowledgement

The findings indicated that though positive maternal We thank the participants for participating in the
birth experience among respondents was high, steps study and Chiwaula Joanne for her comments that
need to be taken to improve care during labour, de- greatly improved the manuscript.
livery and the immediate lying-in. Regular patient
surveys on maternal satisfaction should be con- Funding
ducted on regular bases to inform quality of midwifery The study was funded by the authors.

Hodnett, E. D. (2002). WITHDRAWN: Caregiver support
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Original Article
Menopause as a Rite of Passage: Exploring the

Experience and Management among Women in
Walewale in the Northern Region of Ghana
Jaliu Abubakari (MPhil, BSc) 1
Adadow Yidana (PhD, MSc, BA) 2
Shamsu-Deen Ziblim (PhD, MPhil, BA) 3
Abstract
Menopause is a natural process that every woman at a particular point in time
experiences. Menopausal experience comes with certain symptoms some of
which appear stressful. This study sought to understand the experiences and
management of menopause in Walewale in northern Ghana. The study design
was qualitative, and the technique of data collection was an in-depth interview.
Fifteen participants within the menopausal age were selected for the study
using the purposive sampling technique. The data was audio recorded and later
transcribed for analysis, using content analysis. The majority of the participants
understood menopause as a natural process. However, some of them concep-
tualized it as a disease. Participants, in recounting their individual account of
menopausal symptoms, espoused varying degree of experiences including hot
flushes, sexual disinterest, memory problems, mood swings, headaches, mus-
cles and joint pain and aches, and abdominal pains. The management was in-
dividualized but some claimed they saw the symptoms as normal occurrences.
Others stated that they tried remedies like self-medication, exercise, and con-
sumption of good diet as part of their management strategies. Based on the
above, it is important that public enlightenment and community-based interven-
tions be undertaken to increase women's awareness regarding menopause.
Keywords:
Menopause; Experiences; Management; Qualitative study; Symptoms.
1. Department of Public Health, School of Allied Health Sciences, University for Development
Studies, Tamale, Ghana.
2. Department of Community Health and Family Medicine, School of Medicine and Health
Science, University for Development Studies, Tamale, Ghana.
Science, University for Development Studies, Tamale, Ghana.
Science, University for Development Studies, Tamale, Ghana
Email: adadowy@yahoo.com
Tel: 0207036468

Introduction not all women experience and manage menopause

Menopause is a stage in life that every woman expe- the same way (Agwu, Umeora & Ejikeme, 2008). The
riences as they age (Hui-Koon & Sandra, 2012). It managerial style a woman adopts towards
has been indicated that as women get older and menopausal symptoms may be influenced by her
progress towards the end of childbearing years, tran- level of education and perception. Some women con-
siting into menopausal phase, they become exposed sider menopause as a natural phase of their life. This
to different symptoms, often caused by changes in notion has influenced the style they adopt in the man-
hormones (Lusti-Narasimhan & John, 2013). As a bi- agement of menopausal symptoms (Mackey, Teo,
ological process in women, menopause occurs 12 Dramusic & Boughton, 2014). A study conducted in
months after the last menstrual period, marking the Nigeria indicates that women used spiritual remedies
end of menstrual cycles (Izetbegovic, Stojkanovic, including prayers and experience of older women to
Ribib & Mehmedbasic, 2013). Others have argued manage symptoms (Emelifeonwu & Adika, 2014). In
that symptoms experienced as a result of Ghana, a study by Odiari and Chambers (2014) indi-
menopause are due to the depletion of estrogen level cates that women used herbs and nutritional supple-
as women approach the menopausal stage (Rah- ments to manage menopausal symptoms.
man, Zainudin, & Mun, 2010). A study by Jacob, Re-
becca, Isaac, Sika, & Steiner-Asiedu (2012) has Menopausal women are often subjective when ex-
revealed that the mean age of menopause in Ghana plaining their experiences. To better understand and
is approximately 48 years. The symptoms women ex- appreciate an individual’s experience, one is required
perience as a result of menopause vary among to apply a theory that can give meaning to the daily
women in both intensity and form (Clark, 2005). In a experiences. As people interact with other members
survey study by Oyewole, Ibraheem, and Olaseha of society, they get understanding of their social en-
(2015), they found out that about 83.8% of partici- vironment and interpret it as such (Groenewald,
pants who took part had experienced at least one 2004). People acquire social capital as they interact
symptom that is associated with menopause includ- with others within the social environment (Andriani,
ing somatic, hormonal deficiency, emotional and psy- 2013). The social capital enables them to actively in-
chological symptoms. terpret their own experiences and events in their
lives. With this approach, menopausal women were
According to Rabiee, Nasirie and Zafarqandie (2014) able to articulate and interpret their experiences in
as well as Ande, Omu, Ande, and Olagbuji (2011), relation to menopause, including the cultural re-
women in their menopause often experience reduced sources they relied upon to explain these experi-
sexual desire and arousal. The menopausal experiences. Almost all the studies conducted on
ences often come with mixed reactions, as re- menopause around the world, and particularly in
searchers have established. Researchers have Ghana, are medically and quantitatively oriented
established that many menopausal women experi- (Jacob et al., 2012). Little attention has been given
ence a great deal of stress as they struggle to cope to qualitative analysis of women’s experiences and
with the associated symptoms (Nosek, Kennedy, & management strategies in Ghana as a whole and
Gudmundsdottir, 2012). Some of the symptoms northern region of Ghana in particular. For this rea-
causing the stress includes night sweats, mood son, together with the fact that the inevitable
swings, hot flushes, decreased libido, feeling of sad- menopause has become a milestone in the reproduc-
ness and irritation (Setorglo, Keddey, Agbemafle, Ku- tive life of every woman, this study sought to explore
mordzie & Steiner-Asiedu, 2012; Nosek, Kennedy, & the experiences and management of menopause
Gudmundsdottir, 2010; Jack-Ide, Emelifeonwu & among women aged 40 to 65 years.
Adika, 2014).
Design and Methods
It is worth noting that the attitude of some women to- The study employed a descriptive exploratory quali-
wards menopause and its management is influenced tative design to get understanding of the experiences
by both socio-cultural and multicultural factors. It has and management of menopause among women.
been argued that due to socio-cultural differences,

Research setting were deemed qualified to make sure that the right
The study was conducted in Walewale in the West data was collected during the interview. There were
Mamprusi Municipality in the Northern Region of follow-up probes for clarification on answers that
Ghana. West Mamprusi Municipality, which has were not clear. This was done to ensure that the find-
Walewale as its capital, is one of the 26 municipali- ings were rich and robust. Member checking was in-
ties/districts in the Northern Region. The municipality troduced during the interview to go back to
shares boundaries with six (6) other districts; it is bor- participants on emerging themes. Dependability was
dered to the North by the Talensi district to the East achieved by engaging third party analysts who ana-
by the East Mamprusi, Gushegu and Karaga districts, lyzed and confirmed the findings. The credibility of
to the South by the Savelugu\Nantong and Kum- the data was achieved by making sure that all the re-
bungu districts and to the West by the Mamprugu spondents selected were knowledgeable and have
Moaduri district. The district has a total population of had experience in menopause. Transferability was
one hundred and fifty-nine thousand, one hundred assured by describing participants’ characteristics for
and eighty-two (159,182) (GSS, 2010). There are dif- any researcher who might want to conduct a similar
ferent tribes in Walewale, but the major tribes are study.
Mamprusis and Kasenas. Other minority tribes in-
clude Frafras, Dagaabas, Bimobas, and Builsas. Ethics Consideration
Walewale was chosen because of its location as the An informed consent was obtained before the com-
municipal capital. mencement of the interviews. Upon agreement to
participate, each woman was given a written consent
Sampling and Data Collection Procedure to sign/thumb print to prove willingness to participate
The study population was menopausal women aged in the study. All of the documents were also explained
40 to 65 years living in Walewale in the West Mam- to the participants in English or Mampruli since some
prusi Municipality whose menopausal status was nat- of them did not have any form of formal education
ural. In view of the fact that this study was qualitative, and therefore could not read. Each woman was in-
the sample selection was not fixed but was depend- formed of her right to opt out of any section or at any
ent on the point at which thematic saturation was point.
reached (Morse, 1994). In all, 15 participants were
purposively selected for the study. The participants Results
were made up of nurses, teachers and uneducated
women. This category was selected to solicit views Socio-Demographic Characteristics
of women with different backgrounds. The data col- The average age of the participants was 50 years
lection technique was an in-depth interview, using a and above. Among the participants who were uned-
semi-structured interview guide as the data collection ucated, one person was a petty trader, one was a
tool. The research language was English and Mam- cleaner/cook whereas 2 participants were house-
pruli, (the dialect of the local people of Walewale). All wives. Again, 5 of the participants noted they were
interviews were audio recorded and later transcribed teachers. In the same vein, 3 of them were midwives,
and analyzed using content analysis. A manual ap- while 2 were community health nurses. As regard
proach to thematic analysis was used to form themes their educational attainment, 5 of them did not have
and sub-themes from the transcripts. This was any form of formal education, 2 had tertiary educa-
deemed the most appropriate analytical method tion, 4 had their education to diploma level, and 4 had
since the purpose of the interview was to gain under- obtained [omission] certificates as their academic
standing of the experiences and management of qualification.
menopause among women (Ritchie, Spencer, &
O’Oonnor, 2003). Age at Menopause
All the participants at the point of the interview were
Rigour of the study postmenopausal. Findings from the study revealed
Credibility and trustworthiness of the study were that 2 of the participants were 48 years, 3 of them
achieved through engagement with participants who were 49 years and 10 of them were 50 years or more.

The age of menopause was directly recorded for par- pregnancy test was conducted to rule out the possi-
ticipants who could quote the dates correctly. Assis- bility of being pregnant.
tance was given to those who could not remember
the exact year, by making reference to dates of im- I gave birth to three children and I still needed
portant events, the date of last confinement, the age more when my menses ceased. I was actually
of last child and other information retrieval strategies. disturbed and even at some point, I thought I
However, 12 of the participants could remember their was pregnant and quickly, I went and did UPT
menopausal age accurately while the remaining 3 and it came out negative.
had to estimate it by a recall. A 59-year-old nurse de-
scribes her experience as follows: This finding supports the fact that many people ex-
perience menopause at a period that they never ex-
I had my last period in the year 2000, which is pected it.
about 16 years ago. I had it as my normal pe-
riod for 5 days and after that, that was all. Menopause as sign of ageing
Two of the participants conceptualized menopause
The reference to the year 2000 was the point to cal- as a sign of a transition from being young to being
culate from taking into account her year of birth. old. Some of the participants felt they did not have
much control over their ageing bodies and the asso-
Conceptualization of menopause ciated decline in health and appearance, a situation
There was no word found in the local dialect (Mam- they largely perceived to be the direct result of
pruli) which meant menopause. It was however de- menopause.
scribed as “poa yi bulanyeri u soobu” which means
the period when a woman ceases to experience her Menopause is a period women experience
menses. From the discussion, the explanations pro- when they are ageing, and this depends on the
vided by participants regarding menopause could be individuals, some experience their menopause
categorized into six key areas: cessation of monthly very early while some experience it late.
period, menopause as sign of ageing, menopause as
a disease, menopause as end of childbirth, Menopause as a disease
menopause as hormonal change in women and don’t Two of the participants said menopause is a disease.
know what menopause means. They felt that the experience of ill-health and bodily
ailments among women are attributed to menopause.
Cessation of monthly period
Six of the participants interviewed were of the view The meaning of menopause is a small dis-
that menopause is the cessation of a menstrual pe- ease. When you are getting sick every time
riod. They contend that menopause is a term that de- and your health begins to trouble you then it is
scribes the period when a woman stops experiencing a sign of menopause.
her regular monthly period.
This narration may be attributed to the symptoms that
The term menopause means the end of your women experience during menopause.
menses; that is your monthly periods. When
you get to between 40-50 years and have your Menopause as end of childbirth
menses ceased then it is menopause. Two of the participants indicated that they believed
the cessation of child birth marks the onset of
The age range provided by participants is an indica- menopause. They further reported that menopause
tion of their understanding that there is no fixed age marks the period the sexual usefulness of a woman
for the onset of menopause. comes to an end as her fertility ends.
The cessation of the monthly period was often mis- Menopause is like when you are in your child-
taken for pregnancy among some participants and a bearing years and after giving birth to all your

children you start to age. Childbirth is what Another participant, a 56-year-old teacher explains
brings about your menses and when you stop this natural process of menopause in the following
giving birth then your menses will also stop manner:
due to your age and there is no need to have
sex because your ability to give birth ends. When you reach a certain stage in life, you get
menopause. I think it is natural and comes at
Menopause as hormonal change in a particular time in the life of every woman. No
women woman can escape this process except when
Only one participant, a 59-year-old midwife, concep- you die before the time of menopause.
tualized menopause as a hormonal change in
women with the assertion that: Four participants were of the view that menopause
is caused by old age.
Menopause is a hormonal change; it is a sys-
tem change in a woman. When you have your The cause of menopause is just when you are
menses regularly the way your hormones work of age and you no longer bear children. It will
is different from when you are old and your come at a time that this bleeding will cease
hormones change, then your menses stops. and you will be free. That is how I know it.
Don’t know what menopause means. Menopausal experience

Two participants were of the view that they did not Participants were asked to describe the menopausal
know what menopause meant. These two partici- changes they experienced or were experiencing. The
pants coincidentally were uneducated. According to information they provided pointed to two central
them, it was in the hospital that they learnt they were themes: final menstrual period they had and the
in their menopause. Prior to that, they had no clue symptoms they experienced during menopause. The
what was happening to them. experience of menopause among participants was
assessed by asking them to describe the unique en-
I don’t know anything; I only know what is hap- counters they have had and to indicate the changes
pening to me. I cannot tell what is happening experienced during that period.
in the body of another woman unless I am told
by her and no one will agree to tell you what is Final menstrual period
happening in her body so I do not have any in- Participants were able to describe their experience
formation about menopause. Everybody and during the transition phase into menopause and how
her characteristics, for me anytime I give birth the final menstrual period ended. Six of the partici-
I will not see my menses for up to one year pants indicated they have had irregular periods for
and if it comes and I have sex again on that some months, leading to the final menstrual period.
same period I will become pregnant again.
It happens like; sometimes it will come and
Causes of menopause stop, and will not come and later come and
In explaining the causes of menopause, the majority stop come and stop. Normally in a month, the
of the participants were of the view that menopause flow used to last for up to 7 days but this time
is a natural process and a transition from being it will come and flow for three days and stop.
young to old age. And sometimes it will not come for a whole
month and later come. It continued like this for
Menopause is a normal process in the life of a some time and stopped all of a sudden.
woman, at a stage during puberty, you start
with menstruation and in menarche, you are A 60-year-old nurse indicated that her menses
sure that at a certain age your menses will ceased because she was using family planning
cease so it is a normal process. method called Depo (a 3-monthly contraceptive in-
jection which is given every 12 weeks as a single in-

tramuscular injection into the buttock or upper arm). a separate room away from him. It was that se-
She lamented that she was on it for three months and rious. You have a husband but you cannot help
within that period, she did not experience her menses him all because I do not have an interest in sex
and after she stopped using the drug, her menses again.
still did not flow and all efforts to menstruate failed.
She had a bad feeling about menopause because Recall problem
she felt she still needed more children when it hap- For many women, memory lapses were one of the
pened. most unsettling symptoms. Memory problem was ex-
perienced by 7 of the participants. This was the sec-
First, I was on Depo, a family planning method ond most experienced symptom among participants.
which is for three months and I was not bleed-
ing while I was on the method and when I As for the memory problems, when you are in
stopped it, I never experienced my menses up the state of forgetfulness you can forget about
till now. That is how the menses ceased. some important things and later when you re-
member the time has already past, so it af-
Menopausal symptoms fected my life.
The experience of menopause among participants
was explored using the symptoms they experienced. A 57-year-old teacher described her experience of
The study relied on the ability of participants to recall, memory difficulty, and how she accused family mem-
the signs and changes observed within their bodies bers of stealing her monies and other items because
in relation to menopause and the year they had their she forgot where she placed the money. She
menopause. The participants recounted different ex- lamented how she sometimes put too much salt in
periences. her soup because she always forgets that she has
put salt in the soup.
Lack of interest in sex
There was a general concern from participants re- I easily forget about a lot of things. It is easy to
garding the experience of sexual disinterest. Most of put something down and forget where I kept it
the participants reported a decline in their desire to and accuse people of stealing it. When I am
have sex. A 57-year-old nurse explained her experi- cooking, I can put more salt or other ingredi-
ence of low libido when menopause started. She pro- ents because I easily forget I added some be-
vided the following narration in response to a fore. Even during school meetings and other
question that sought to find out the last time she had gatherings, I get there late because I either for-
a sexual encounter. get the time or even forget the meeting entirely.
Hahahaha, hmmm, this is a serious talk, I do Night Sweats

not even know what you are saying. It’s about Respondents experienced night sweats to some de-
6-10 years now I have not had sex with my gree which is one of the disturbing problems among
husband all because I do not have the desire the study participants. A number of the participants
to have sex. mentioned night sweats as one of the symptoms they
experienced.
The above view was reechoed by another participant;
a 57-year-old teacher, who expressed how her desire When I get the hot flushes, my whole body will
for sex declined, compelling her to change a room be so hot and wet, sometimes I feel like taking
just to avoid sexual contact with her husband. my clothes off. And the next minute I feel so
cold as if nothing had happened.
When it gets to that stage I don’t even think
about men. As for that one, it’s out. I don’t feel This explains the discomfort some of the women in
anything. It got to a time when I did not even their menopausal period go through. Another partici-
want any contact with my husband. I sleep in pant, a 60-year-old uneducated participant attributed

her hot flush to a spiritual attack. It took a while be- Changes in mood
fore she was told it was a menopausal symptom. Some of the participants expressed how they felt ir-
ritated, with sudden changes in mood from happiness
As for me, I am a Christian and I believe in to sadness and vice versa. The sudden changes in
spiritual things, so when I first experienced this mood affected women in their relationship with their
hotness during midnight, I mistook this for a family members.
spiritual attack and started offering prayers.
The next time was in the evening around 5:30- Hmm, yes just like I explained, someone will
6:00 pm so I rushed to my pastor for prayers be joking with you and you take it to be some
believing it was one of the attacks. It was later serious thing and become annoyed, maybe,
I went to the hospital and I was told by a nurse the fellow does not mean to hurt you but you
that this experience is called hot flush and it’s can easily be annoyed and get irritated. When
part of the symptoms of menopause. you sit down for some time, your mood will
change again and it will be like you were not
Body aches the one highly annoyed so such things it will
Five participants (3) complained about muscle, joint let you regret.
pains and aches.
Management of menopause
Eeei, I always experienced pains and aches Participants were asked to state what they did and
all over my body. The way I use to be healthy, continue to do to deal with their menopausal symp-
I am no longer that healthy. These are some toms. Some of the participants reported using no
of the changes I experienced. treatment for menopausal complaints. However, oth-
ers took actions as a management strategy.
Other participants complained of headaches and mi-
graine. No management of menopause
From the study, 6 participants felt menopausal symp-
I felt a discomfort within my system and at first, toms were natural and did nothing to manage the ex-
I thought it was malaria and treated malaria but perience they have had.
it still continued. It was getting serious, the
headaches and migraines; this is my main As for menopausal symptoms, it is natural so
problem since I entered into menopause. nothing can be done and, even if you try to do
anything, you will end up causing harm to your
A participant complained of lower abdominal pains own self.
and narrated her experience as:
Use of medication
In relation to the stoppage of my menses, Among the participants who had used remedies to
sometimes I will be there and when the time alleviate symptoms, five participants resorted to tak-
for my monthly periods comes like the days I ing painkillers to reduce the bodily pains; but did
used to menstruate I used to feel pains in my nothing when it comes to the other symptoms.
lower abdomen and something fluid like water
will come out and it comes like the beginning Sometimes, I get medications to relieve myself
of menses how it normally starts coming small of the pains. For the other symptoms, because
and small. Anytime the days in which I used to I know menopause is natural, I ignore it, know-
have my menses come, I start feeling some ing that the symptoms will go with time.
pains in my lower abdomen and some fluid will
try coming out like blood but it’s not blood and Taking healthy food and doing exercise
this will happen for some time and stop. Some participants were of the view that they used to
exercise and rest with a good and balanced diet to re-
lieve themselves from their menopausal symptoms.

The things I do are to have enough rest and where the rate of mood changes among participants
also good diet. When I take a good diet, it increased at the beginning of menopause. The com-
helps in reducing the rate at which I get irri- plaint of muscle joint pains and aches is consistent
tated when someone approached me. When with the study conducted by Szoeke, Cicuttini,
you take good diet and vitamins with exercise, Guthrie, and Dennerstein, (2008) which established
it helps you. an association between menopausal transition and
aches and pains.
Discussion
Participants in the study had different experiences of In the management of menopause, 6 of the partici-
menopause. Overall, they expressed a reduction in pants interviewed felt the symptoms were natural,
sexual desire with their husbands and almost all the and they did not put in efforts to manage them. This
participants reported a decrease in sexual activity is in agreement with a study by Jacob et al. (2012)
with decreased libido. This is in line with a study by who found that in self-management of menopausal
Preira, Oscar, Sergio, Antonio, and Adriana, (2013) symptoms, the majority of women felt it was a natural
that reported a decreased sexual activity, libido, in- process and needs no intervention. In the manage-
cluding avoidance of sexual intercourse. In this re- ment of associated pains, headaches, and migraine,
gard, men with little knowledge about these dynamics participants indicated that they used painkillers. This
may end up having issues with their wives. Men need corroborates the result of the study carried out by
to be educated well on these changes to help their Jacob et al. (2012) which indicated that 10.7% of
wives manage with menopausal experiences. A study women used medication to relieve them of their
conducted by Fallahzadeh, Dehghani, Dehghani, Ho- menopausal symptoms. About 20% of participants
seini and Hoseini, (2011) has found memory disorder used to exercise, rest and eat good diet to help them
among 10 most common complaints during relieve menopausal symptoms. This corroborates the
menopause. This current study has also found that finding of another study conducted by Farzaneh, et
memory problem appears to be a commonly experi- al. (2013) which reported that exercise was beneficial
enced symptom among participants. As Ameh, in helping participants to manage menopausal symp-
Madugu, Onwusulu, Eleje, and Oyefabi (2016) have toms. In this current study, 6 of the participants had
alluded to; that many people suffer memory loss and no idea about menopause before experiencing it,
amnesia during menopause. Current results show which is consistent with the findings by Taherpour,
that symptoms such as hot flushes and night sweats Sefidi, Afsharinia, and Hamissi (2015) and Helena
were emphasized by 6 of the participants. This is in (2013), where more than half of the participants re-
line with the finding of a study conducted by Eun-OK, ported not having any knowledge about menopause
Marjorie, Young, and Wonshik, (2014) which reported prior to experiencing it.
the experience of hot flushes during menopause.
Though it corroborates finding of Hodson, Thomp-
son, and al-Azzawi (2000), as well as MacGregor Implications of the study
(2006), where the majority of menopausal women ex- This study will serve as a source of information for
perienced headaches, it is different in this current healthcare providers, especially nurses, working di-
study. This may be due to the use of painkillers by rectly with women to appreciate the experience and
some of the participants. management of menopause among women. The
Ghanaian society should be educated that
The irritable state of participants in this study seemed menopause is an important transition for women at a
to interfere with their family relationships. The feeling point in time. Appreciating the point of view of these
of irritation and/or mood swing during menopause women and bringing to the fore their experiences of
was a source of concern but appear to be consistent the process of menopause can help healthcare staff
with Farzaneh, Mozhgan, and Fahimeh (2013) who to design appropriate health education and treatment
report that emotional instability and irritability com- for menopausal women.
mon complaints from menopausal women. The cur-
rent study is, similar to Samantha and David (2010)

Conclusions needs of these women to be taken into consideration

The study found that women experienced different to design a comprehensive health education and pro-
symptoms during their menopausal years. The study motion plan for them in their menopausal years. This
again revealed that the nature of the symptoms ex- would help minimize the feeling of discomfort as ex-
perienced by women in menopause and the way they perienced by many of them.
conceptualize it could be helpful in determining the
management styles they are likely to adopt. The Conflict of interest
study also appear to support the notion that notwith- The authors declare that there is no conflict of interest.
standing the occupational and social standing of
women in society, they are likely to share similar ex- Acknowledgement
periences relating to menopause. There is the need The authors thank all the participants who took part
for the physical, psychological, social, and mental in the study.

Hodson, J., Thompson, J., & al-Azzawi, F. (2000).

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Original Article
Determinants of Contraceptive Use among

Women of Reproductive Age in Asankragwa
in the Western Region of Ghana.
Nancy Innocentia Ebu (PhD, MN, MPH, BSN, SRN, FWACN, FFGCNM) 1
Doreen Owusu Boateng (BSN, RN) 2
Kingsley Asare Pereko (PhD) 3
Thomas Hormenu (PhD) 4
Abstract
Contraceptive use is an important intervention in reducing unplanned pregnancies and other
sexually transmitted infections (STIs). This study investigates the knowledge of contraceptive
use, identify the barriers of contraceptive use, and determine the predictors of contraceptive
use among women in a peri-urban community in Ghana. Using a cross-sectional survey de-
sign, a total of 189 women of childbearing age was sampled in a peri-urban community in
Ghana. Data were collected with questionnaires and analyzed using chi-square and binary
logistic regression. The result shows that more than half of the participants ( 63.6% (n = 56)
of contraceptive users knew seven to twelve types of contraceptives, whereas 46.6% of non-
contraceptive users indicated they knew seven to twelve types of contraceptives. Knowledge
of the types and uses of contraceptive was significantly associated with contraceptive usage.
Spousal consent, adverse effects, lack of knowledge about the benefits and religion were the
main barriers to contraceptive use. There was a strong association between marital status,
income, age and contraceptive use among women (p <0.05). Women with no children and
women with one to two children were 7 times (95%CI, 2.00, 27.78) more likely to use contra-
ceptives. Those with more than three children were 11 times (95%CI 2.34, 54.87) more likely
to use contraceptives. Although the women knew about the uses and types of contraceptives,
utilisation was low. Parity was high among the factors that predicted the non-usage of contra-
ceptives among women. The findings of this study call for a comprehensive education on con-
traceptives at various levels of the health delivery system.
Keywords:
Contraceptives; Knowledge; Utilization; Barriers; Women; Peri-urban commu-
nity in Ghana.
1. Dept. of Public Health, School of Nursing & Midwifery,

University of Cape Coast, Cape Coast, Ghana
2. Catholic Hospital, Asankragwa, Ghana
3. Department of Community Medicine, School of Medical Sciences

4. Department of Health, Physical Education and Recreation

1. School of Nursing , University of Cape Coast, Ghana Email: nebu@ucc.edu.gh

Introduction ing in slums, and women living with HIV (Darroch,

Contraceptive use is a critical intervention in improv- Sedgh & Ball, 2011; WHO, 2014).
ing the health of women. Over the past decade,
there has been an increase in contraceptive use The family planning services in Ghana are provided
globally (Ahmed, Li, Liu, & Tsui, 2012). It is estimated by three major institutions, namely the Ministry of
that 62% of women who are in marital relationships Health/Ghana Health Service, Planned Parenthood
in developing countries might be using one form of Association of Ghana and the Ghana Social Market-
contraceptive (United Nations, 2013). In sub-Saharan ing Foundation. Despite the supposed availability of
Africa [SSA], 25% of women in the reproductive age contraceptive services in the country, there are indi-
group who are married or in some form of the union cations that the fertility rate in Ghana, especially
have an unmet need for family planning compared to among rural and peri-urban populations, has not
4% in Eastern Asia and 10% in Latin America as of seen any reduction. Illustrating, the 2014 Ghana De-
2011 (United Nations, 2013). According to the United mographic and Health Survey (GDHS) reported a
Nations, the prevalence of maternal mortality seems total fertility rate of 4.2 per woman, compared to 4.0
to be lower in settings where contraceptive use is high per woman as indicated in the 2008 GDHS (Ghana
(United Nations, 2013). Indeed, given that the use of Statistical Service [GSS], 2009). The report further
contraceptives among women of reproductive age is suggests that rural women are having more children
among the indicators of a decrease in the incidence than their urban counterparts, as women in rural
of unsafe abortion, maternal morbidity, and mortality areas had 5.1 children per woman, compared to 3.4
(Ahmed et al., 2012; United Nations, 2013), it follows per woman for those in urban areas. Additionally,
that contraceptive use could facilitate the achieve- only 50% of women had used a method of contra-
ment of universal access to reproductive health. This ception at some point in time. Contraceptives were
notwithstanding, it should be noted that women’s abil- also found to be high among sexually active unmar-
ity to effectively use contraceptives depends on a host ried women (GSS, 2009).
of factors, including health education on contracep-
tives, counseling, and availability of a wide range of A study conducted by Hindin, McGough and Adanu
culturally acceptable modern contraceptive methods. (2014) found a low level of knowledge of contracep-
tives among a cross-section of Ghanaian women. It
Contraceptives are agents, various devices, drugs, seems plausible to assume that women might have
sexual practices and surgical procedures that pre- some misconceptions about contraceptive usage and
vent unplanned pregnancies (Desi, 2014). Condom conception, including difficulty in becoming pregnant
is the only contraceptive known to protect individuals (Jones, Mosher & Daniels, 2012). This could impact
from sexually transmitted infections (Nordquvist, negatively on the health and well-being of women
2009). Additionally, the most reliable or effective birth and their children (Guttmacher Institute, 2014).
control methods are sterilization in the form of vasec- Therefore, determining the knowledge gaps, barriers
tomy and tubal ligation, as well as implants and in- and the predictors of contraceptive use among
trauterine devices. Hormonal contraceptives such as
women is necessary for adopting strategies to in-
injections, vaginal rings, and oral pill might also be
crease usage.
effective. The less effective ones are fertility aware-
ness methods and the barriers including diaphragms,
Design and Methods
condoms and contraceptive sponges (World Health
The study was carried out in Asankragwa, which is a
Organisation [WHO], 2011).
peri-urban community and the capital of the Wassa
Unplanned pregnancies due to unmet need for family Amenfi West District in the Western Region of
planning could affect the health of women, especially Ghana. The town is situated on the Bawdie-Enchi
those within the childbearing age. It has been esti- Road and the indigenes belong to the Wassa ethnic
mated that 222 million women have an unmet need group and speak the Wassa dialect. The inhabitants
for family planning. This need is very high among are mostly cocoa farmers. The town also has a vi-
populations where maternal death is on the rise brant economic activity. This setting was selected for
(Guttmacher Institute, 2012), particularly among vul- the study due to the high rate of teenage pregnancy.
nerable populations, including women with low so- A cross-sectional study was conducted among
cioeconomic status, adolescents, those living in rural women in fertility age. Data from the Health Informa-
communities, internally displaced women, those liv- tion Unit suggest that a total of 4,138 women were of

fertility age in the Asankragwa sub-district (DHMIS, Cronbach’s alpha of the various scales was calculated
2017). The inclusion criteria involved sexually active with results ranging from 0.754- 0.853. Five female
females within 15 to 49 years, but those who actually health assistants were trained to collect the data. The
participated in the study were within 16 to 45years. The questionnaires were administered to women who were
estimated number of women likely to use family plan- available at the time of data collection. The data were
ning within the Asankragwa sub-district was 2,199 analyzed using Statistical Package for Social Sciences
(DHMIS, 2013), whereas it was estimated that about version 20.0. Descriptive statistics of frequencies and
400 women may be using family planning in percentages were used. Chi-square test was used to
Asankragwa (Health Facility Report, 2013). According determine associations between variables at a signif-
to Krejcie and Morgan (1970), for a population of 400, icant level of p<0.05, and the binary logistic regression
a sample of 196 will be adequate. Therefore, 196 par- analysis was used to establish the relationship be-
ticipants took part in the study, but only 189 question- tween the dependent (contraceptive use) and inde-
naires were correctly filled and used in the analysis. pendent variables (participants’ characteristics).
The sample was conveniently selected. Approval for
the study was obtained from the Wassa Amenfi West Results
District Assembly. Permission was also obtained from Table 1 shows the knowledge of women (contracep-
the community leadership and verbal and written con- tive users and non-users) on the types and uses of
sent were sought from participants before involving contraceptives. With respect to the users, more than
them in the study. The purpose of the study was ex- half (63.6%, n = 56) knew seven to twelve types of
plained to the participants, and they were assured of contraceptives, 36.4% knew one to six types of con-
confidentiality. They were made to understand that par- traceptives, 34.8% (n = 31) knew one to three uses
ticipation was optional and they could withdraw from of contraceptives while 65.2% (n = 58) knew four or
the study at any time without offering any explanations. more uses of contraceptives. For the non-users,
46.6% (n = 41) knew seven to twelve types of con-
Questionnaires were used to collect the data. The traceptives and 52.1% (n = 50) knew one to three
questionnaires were pre-tested in a nearby commu- uses of contraceptives. Knowledge of uses and
nity with similar characteristics as the study population. types of contraceptives were significantly associated
with contraceptive use.
Table 1: Knowledge on Types and Uses of Contraceptives and Contraceptive Usage

g yp p p g
Contraceptive users Non-users of
contraceptives
Variables n=88 % n=88 % Total
Knowledge on Types of
contraceptives*
Know 1 to 6 32 36.4% 47 53.4% 79 (44.9%)
contraceptives
Know 7 to 12 56 63.6% 41 46.6% 97 (55.1%)
contraceptives
Knowledge on uses of n=89 n=96
contraceptives *
Know 1-3 uses of 31 34.8% 50 52.1% 81 (43.8%)
contraceptives
Know 4 and above uses of 58 65.2% 46 47.9% 104(56.2%)
contraceptives
*variables that showed significant association chi-square (p<0.05)

Regarding the reasons for using contraceptives, the assertion that contraceptives were used to space
65.1% (n = 56) of the women strongly disagreed with births (Table 2).
Table 2: Reasons for Contraceptive Usage
Reasons SA n(%) A n(%) I n(%) D n(%) SD n(%) Total

Birth control (spacing) 1(1.2) 29(33.7) 56(65.1) 86(100)
Prevention of sexually 5(5.9) 12(14.1) 9(10.6) 35(41.2) 24(28.2) 85(100)
transmitted diseases
Prevention of Abortion 13(15.9) 16(19.5) 15(18.3) 25(30.5) 13(15.9) 82(100)
Curbing menstrual pain 13(17.6) 21(28.4) 28(37.8) 10(13.5) 2(2.7) 74(100)
Regulation of menstrual 10(13.9) 12(16.7) 22(30.6) 24(33.3) 4(5.6) 72(100)
cycle
Prevention of Acne 14(19.2) 9(12.3) 42(57.5) 6(8.2) 2(2.7) 73(100)
Prevention of 11(14.3) 13(16.9) 36(46.8) 14(18.2) 3(3.9) 77(100)
endometriosis,
trophoblastic diseases
Prevention of venous 13(18.3) 10(14.1) 32(45.1) 14(19.7) 2(2.8) 71(100)
thromboembolic diseases
few weeks following
child birth and breast-
feeding
Prevention of pregnancy 21(23.6) 68(76.4) 89(100)
SA- Strongly Agree A-Agree I-indifferent D-Disagree SD- Strongly disagree
Of those who were using contraceptives at the time ported that contraceptives cost between two to five
of the study or had ever used contraceptives, 49.4% Ghana cedis. Most of the participants obtained their
(n = 42) indicated that contraceptives were effective contraceptives from the hospital, pharmacy shops
while 40.0% (n = 34) viewed it as very effective. and antenatal clinics (Table 3).
About 52% of the users of contraceptives (n = 45) re-

Table 3: Users’ Response on the Effectiveness, Cost and Sources of Contraceptives

Variables n %
Effectiveness
Very effective 34 40.0%
Effective 42 49.4%
Not effective 9 10.6%
Total 85 100%
Cost
Below Ghana cedis 1 19 22.4%
Ghs 2-5 45 52.9%
Ghs 6-10 9 10.6%
Above Ghana cedis 10 12 14.1%
Total 85 100%
Sources of contraceptives
Antennal clinic 15 17.2%
Hospital 27 31.0%
Maternity home 5 5.7%
Home of practitioner 8 9.2%
Pharmacy shop 25 28.7%
Family planning unit 1 1.1%
Others 6 6.9%
Total 85 100%
On the barriers to contraceptive use (Table 4), 56.8% the assertion that contraceptives have adverse ef-
(n = 101) of the participants agreed and strongly fects. Sixty-four percent (n = 112) identified a lack of
agreed that they had to obtain consent from their knowledge about the benefits and 56.4% (n = 98)
husbands before they could use contraceptives. stated that one’s religion could hinder the use of con-
About 62% (n = 113) agreed and strongly agreed with traceptives.

Table 4: Barriers to Contraceptive Usage
Barriers SA n(%) A n(%) I n(%) D n(%) SD n(%) Total

(%)
Consent of husband 53(29.8) 48(27.0) 6(3.4) 43(24.2) 28(15.7) 178(100)
Irregular sex or no sex 34(19.8) 46(26.7) 35(20.3) 35(20.3) 22(12.8) 172(100)
Menopause/hysterectomy 17(9.8) 28(16.1) 48(27.6) 54(31.0) 27(15.5) 174(100)
Desire for many children 27(15.7) 20(11.6) 15(8.7) 65(37.8) 45(26.2) 172(100)
Religious background 45(25.9) 53(30.5) 16(9.2) 26(14.9) 34(19.5) 174(100)
Generally oppose the use 27(16.5) 44(26.8) 22(13.4) 40(24.4) 31(18.9) 164(100)
of contraceptives
Husbands discourage their 28(15.9) 45(25.6) 25(14.2) 50(28.4) 28(15.9) 176(100)
wives
Do not know the benefits 48(27.4) 64(36.6) 15(8.6) 25(14.3) 23(13.1) 175(100)
Contraceptives have 50(27.5) 63(34.6) 27(14.8) 25(13.7) 17(9.3) 182(100)
adverse side effects
Contraceptives are too 12(6.8) 19(10.8) 28(15.9) 57(32.4) 60(34.1) 176(100)
expensive
Contraceptives interrupt 28(15.5) 40(22.1) 57(31.5) 36(19.9) 20(11.0) 181(100)
normal body process
Contraceptives are 23(12.8) 34(19.0) 34(19.0) 60(33.5) 28(15.6) 179(100)
inconvenient to use
Do not know where to get 18(9.9) 26(14.4) 17(9.4) 49(27.1) 71(39.2) 181(100)
contraceptives
SA- Strongly Agree A-Agree I-indifferent D-Disagree SD- Strongly disagree
The bivariate analysis (Table 5) showed some asso- age with contraceptive use among women (p < 0.05).
ciation between marital status, income status and

Table 5: Socioeconomic and Demographic g

Characteristics
p and Contraceptive Usagep g
Variables Contraceptive users Non users of contraceptives Total
n=89 % n=100 %
Marital status*
Never Married 29 32.6 48 48.0 77 (40.8%)
Ever Married/ 60 67.4 52 52.0 112(59.2%)
Married
Educational
level
JHS and below 55 65.5 50 51.5 105 (58%)
SHS and above 29 34.5 47 48.5 76 (42%)
Income status*
500 GHS and 53 73.7 54 73.0 107
below (71.3%)
501 and above 23 26.3 20 27.0 43 (28.7%)
Residence
status
Own residence 45 50.6 49 49.0 94 (49.7%)
Don’t own 44 49.4 51 51.0 95 (50.3%)
residence
Age*
≤24 years 23 25.8 41 41.0 64 (33.9%)
25 to 30 years 31 34.8 43 43.0 74 (39.2%)
30 years plus 35 39.4 16 16.0 51 (26.9%)
*variables that showed significant association chi-square (p<0.05)
Further analysis using binary logistic regression in ceptives. Those with more than three children were
predicting the likelihood of women using contracep- 11.32 times (95%CI 2.34, 54.87) more likely to use
tives after controlling for socio-economic and demo- contraceptives than those who did not have any chil-
graphic factors showed that parity significantly dren. No significant relationships were drawn from
influenced the likelihood of women using contracep- the model on women's earnings, age, marital status,
tives. This contributed to 27% of the variations ob- and educational status, ownership of residency and
served. Women with one to two children were 7.45 knowledge of contraceptives usage (Table 6).
times (95%CI 2.00, 27.78) more likely to use contra-
Table 6: Binary Logistic Regression on the Predictors of Contraceptive usage among Women
Variable Exp(B) 95% CI
*Age (24 years and below) -
Age (25 to 30 years) 0.73 (0.25, 2.10)
Age ( 30 years plus) 2.19 (0.64, 7.51)
*Married/Ever Married -
Never Married 0.36 (0.11, 1.12)

*No child -
1-2 children 7.45 (2.00, 27.78)
3 plus children 11.32 (2.34, 54.87)
*500 GHS and below -
501 and above 2.05 (0.71, 5.87)
*Own Residence -
Don’t own residence 0.86 (0.38, 1.94)
*JHS and below -
SHS and above 0.56 (0.19, 1.66)
*Know 1 to 6 contraceptives -
Know 7 to 12 contraceptives 1.61 (0.62, 4.16)
*Know 1-3 uses of contraceptives -
Know 4 and above uses of contraceptives 2.28 (0.89, 5.81)
*= ref or comparison group
Discussion that could influence practice. An earlier study con-

Increasing contraceptive coverage will demand that ducted in Ghana reported that women were aware of
women have access to family planning options which at least one method of contraception and slightly over
could decrease the incidence of unintended pregnan- 55% had heard of three or more modern methods of
cies (Ahmed et al., 2012; WHO, 2011). While this is family planning (Aryeetey, Kotoh & Hindin, 2010).
necessary, contraceptive usage was relatively low in
the present study. A possible explanation may be that Women involved in this study had knowledge on the
the women sampled for this study may not have ad- uses of contraceptives. However, 65.1% disagreed
equate knowledge of contraceptives which could af- with the assertion that, contraceptives could be used
fect their use. Previous studies have reported low use to space births although they were sexually active.
of contraceptives among women in Nigeria and This suggests a general lack of information on the
Kenya (Eko, Osonwa, Osuchukwu & Offiong, 2013; fundamental role of contraceptives. Contraceptives
Okech, Wawire & Mburu, 2011). In a study by are essential in spacing births by reducing the inci-
Jabeen, Gul, and Wazir (2011), although half of the dence of unwanted pregnancies (Somba, Mbonile,
sampled participants were aware of contraceptive Obure & Mahande, 2014; Stover & Ross, 2010; Chor,
methods, few actually practiced some of the modern Patil, Goudar, Kodkany & Geller, 2012; Stover &
methods of contraception. It is evident from the find- Ross, 2010). Information on contraceptives is critical
ings of this study that 63.6% of the users of contra- in enabling women to make an informed choice. It
ceptives had knowledge of seven and more types of will offer them the opportunity to obtain and use con-
contraceptives. It seems knowledge of a reproduc- traceptives. The findings suggest that women ob-
tive health commodity may be an important factor tained information on contraceptives from the

hospital, antenatal clinics, and pharmacy shops. This potentially hinder the uptake of contraceptives (Rah-
findings partly contradict the report that the mass nama et al., 2010).
media, friends, relatives, and educational institutions
were good sources of contraceptive information The findings highlight that the side effects of some
among female adolescents in Eastern Cape (O'Ma- contraceptives could deter women from using them.
hony, Yogeswaran & Wright, 2013). Perceived side effects of family planning commodi-
ties prevented some women from using contracep-
The findings further suggest that 49.4% of the tives in Ghana (Aryeetey et al., 2010). The current
women viewed contraceptives to be effective in pre- study also observed that religion could be an impor-
venting pregnancy. A possible explanation is that the tant barrier to the use of contraceptives. This is con-
effectiveness of a particular contraceptive device sistent with the findings of Jabeen et al. (2011) who
might depend on the type and the correct usage of identified religion as a hindrance to the practice of
the contraceptive product (Aryeetey et al., 2010). contraception, as it was perceived to be a sinful act.
Women who fail to use contraceptives correctly and This finding was not surprising since some religions,
consistently have a high chance of becoming preg- especially the Roman Catholics, strongly oppose the
nant (Jones, Mosher & Daniels, 2012). Modern con- use of modern contraceptives. However, in Mozam-
traceptives, however, have proven to be more bique, evidence suggests a high prevalence in the
effective in reducing unintended pregnancies, com- use of modern contraceptives among Catholics
pared to the traditional methods (Sonfield, Hasstedt (Agadjanian, 2013). In the United States, contracep-
& Gold, 2014; Guttmacher Institute, 2014). In Ghana, tive usage was found to be high among sexually ac-
contraceptive products are not offered for free at the tive women of all religious affiliations, including
various reproductive health centres. Women are re- women of the Catholic faith (Guttmacher Institute,
quired to choose and purchase a product of their 2012; Jones & Dreweke, 2011).
choice. Evidence suggests that the cost of obtaining
contraceptives could contribute to the unmet need for This study identified parity as a determinant of con-
family planning services in low-middle income traceptive use. This is not surprising because an ear-
economies (Guttmacher Institute, 2014). Women lier study conducted in the Upper East Region of
could have the desire and social support to use fam- Ghana found a strong association between parity and
ily planning interventions but might not be able to af- contraceptive use (Achana et al., 2015). Women may
ford the cost of contraceptives while in their fertility use contraceptives to space births in order to regain
age. Aryeetey and others (2010) explained that the their strength from the last pregnancy and also pre-
cost of obtaining family planning services could deter vent unplanned pregnancies. This finding highlights
women from using the services. the critical role parity plays in enabling women to use
contraceptives. Although evidence suggests a strong
Similarly, spousal support in family planning is crucial relationship between age, marital status, income sta-
in meeting the reproductive health needs of women tus and contraceptive use (Aryeetey et al., 2010; Dar-
and limiting the number of unwanted pregnancies roch et al., 2011; Okech et al., 2011), the present
and unsafe abortions. In Ghana, most women in an findings did not observe a relationship between these
urban area (73.0%) used contraceptives because socio-demographic factors and contraceptive usage.
their partners influenced their decision to do so (Ary- The differences in findings could be due to how these
eetey et al., 2010). On the contrary, partner or socio-demographic variables were measured in this
spousal support was a barrier to contraceptive use in study. It could also be due to the fact that this study
the present study. This corroborates the findings of employed convenience sampling in selecting the par-
Gebremariam and Addissie (2014) as they reported ticipants.
fear of side effects and partner’s support as factors
limiting the use of long-acting and permanent contra- Implications for Nursing and Midwifery
ceptive methods among women in Ethiopia. Men The findings have implications for nursing and mid-
playing a dominant role in decisions regarding the wifery practice, education and research. Education
number of children their partners should have could of women on the different types of contraceptives,

their uses and benefits by nurses and midwives connection with family planning, with the necessary
needs to be intensified at all levels of the health care skills and information to make an informed decision
delivery, as adequate knowledge about contracep- concerning their reproductive health, as male domi-
tives is required in ensuring their usage. Additionally, nance in reproductive health decisions of women
midwives should intensify education on the use of could significantly impact women’s health. Health
contraceptives among women who have had one or communication messages on contraceptive use
more children as they may have higher chances of should demonstrate how partner and spousal support
using contraceptives. The findings also call for an ur- could improve contraceptive use. Involvement of men
gent need for men to support their partners to use in reproductive health issues may enable them to
contraceptives. It is worth mentioning that nursing gain understanding of matters relating to women’s re-
and midwifery curriculum should highlight the barriers productive health and may be likely to appreciate the
to the use of contraceptives in order to equip nurses challenges and complications women experience
and midwives to address these barriers in interven- due to an inappropriate spacing of births which may
tions to increase contraceptive uptake. Further re- contribute to maternal morbidity and mortality. Men
search to explore the meaning and interpretation may be highly informed if they are involved, and they
men give to women’s use of contraceptives is highly could motivate their partners to use contraceptives.
advocated.
Conflict of interest
Conclusion The authors have no competing interests to disclose
The use of contraceptives by women is critical in im-
proving their health. This paper has highlighted the Acknowledgments
relatively low use of contraceptives among women in The authors express their profound gratitude to all
Asankragwa. The issues raised in this paper call for the women who voluntarily participated in this study.
a comprehensive education on contraceptives at var- They also thank the health assistants who volun-
ious levels of the health delivery system. This in- teered to be part of the data collection team.
cludes targeted community-level education, focusing
on different types of contraceptives, their uses, pos- Funding
sible benefits as well as side effects. Additionally, The study was solely funded by the authors.
women need to be empowered by all stakeholders in

Guttmacher Institute (2014). Contraceptive use in the

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Original Article
Knowledge of Pregnant Women on

Caesarean Section and their Preferred
Mode of Delivery in Northern Ghana
Richard Adongo Afaya (MPhil Student, BSN, DIP, RN) 1
Victoria Bam (PhD, RN, RM, RPHN) 1
Felix Apiribu (PhD Student, FGCNM, MPhil, MSc, BA, DIP, SRN) 1
Victor Atiah Agana (BSA, DIP. RN) 2
Agani Afaya (MSN, BSN, DIP. RN) 3
Abstract
In maternal health, though caesarean section (CS) has contributed significantly to
reducing maternal morbidity and mortality worldwide, there are still concerns about
women’s knowledge on caesarean section. Although there is an accelerating rate of
caesarean section in both developed and developing countries, some recent studies
have insinuated that African women have an aversion for caesarean section. There-
fore, the study aimed to assess pregnant women’s knowledge towards caesarean
section at the Tamale Teaching Hospital. A descriptive cross-sectional study was
conducted between February to April 2017 among pregnant women attending ante-
natal clinic. The simple random sampling method was adopted in recruiting 360 preg-
nant women. The Chi square test was used to determine the associations between
women’s demographics and their knowledge of caesarean section. Thirty-two per-
cent (32%) of respondents had good knowledge regarding caesarean section, 48%
and 20% had fair and poor knowledge on the procedure respectively. There was sig-
nificant association between knowledge on caesarean section and respondents’
characteristics (education p=0.035, gravida p=0.012, and previous CS p=0.001).
Even though there was a high awareness level (80%) among women who attended
antenatal clinic, there was a low level of knowledge on caesarean section. Women’s
preferred mode of delivery was influenced by their knowledge of the indications for
CS and the perceived consequences of the procedure. Education should target
women without formal education and primigravida as well as men since they are the
major decision makers in most families in developing countries.
Keywords:
Caesarean section; knowledge; preferred mode of delivery; women.
1. Department of Nursing, College of Health Sciences

Kwame Nkrumah University of Science and Technology, Ghana
2. Department of Anaesthesia, Tamale Central Hospital, Ghana
3. Department of Nursing, School of Nursing and Midwifery

University of Health and Allied Sciences, Ho, Ghana
1. Department of Nursing, School of Nursing and Midwifery,
University of Health and Allied Sciences, Ho, Ghana.
Email: aagani.@uhas.edu.gh
Phone: +233557481435

Introduction global deaths due to various challenges impeding the

Caesarean section (CS) is the most common surgical delivery of quality healthcare services. Caesarean
procedure performed worldwide (Jagruti, Sonal & section is still being viewed as an abnormal means
Arti, 2009; Ghotbi et al., 2014) and has contributed of delivery by some women in developing countries
significantly to the reduction of maternal morbidity (Qazi, Akhtar, Khan & Khan, 2013). Although knowl-
and mortality (Ajeet, Jaydeep, Nandkishore & Nisha, edge of women towards CS is changing, there is still
2011; Betrán et al., 2016; Agnihotri, Aruoma, & Agni- a wide knowledge gap between the developed coun-
hotri, 2016; Prah, Kudom, Lasim & Abu, 2017). It is tries and the developing countries (Amiegheme et al.,
essential to note that caesarean section is known to 2016).There is a broadly held belief and view that
be related with increased risk of maternal and neona- women in the West African sub-region have an aver-
tal morbidity as well as high cost of healthcare than sion for caesarean section delivery (Adageba et al.,
vaginal delivery (Ajeet, Jaydeep, Nandkishore & 2008). Some sociocultural factors hinder the accept-
Nisha, 2011; Faremi, Ibitoye, Olatubi, Koledoye, & ance of CS. According to Chiamaka and Adetomi
Ogbeye, 2014). The rate of CS in developed coun- (2017), it is traditionally believed that achieving a
tries is rising as there has been a higher rate of ac- vaginal delivery portrays the woman’s power and
ceptability over time while developing countries are ability but a pregnant woman who delivers through
struggling with the problems of non-acceptance of CS is seen as being lazy. Women refuse CS for fear
CS even in the face of eminent danger on pregnancy of being abandoned by their husbands and in-laws
(Betran et al., 2007; Chigbu & Iioabachie, 2007; (Chiamaka & Adetomi, 2017) and are accused of
Amiegheme, Adeyemo & Onasoga, 2016). The rate being unfaithful (Mboho, 2013). This phenomenon
of CS in developed countries is above the World leads to low acceptability of the procedure among
Health Organisation’s (WHO) estimated target of African women, even in the face of obvious clinical
15% mark in many of the countries (WHO Human justification. Many women perceive the process of
Reproduction Programme, 2015). The lowest rates not giving birth vaginally as a sign of ‘failure’. A lot of
of CS are found in Africa (7.3%) and more specifi- them perceive vaginal birth as a right route of pas-
cally, in Western Africa (3%) (Betran, Torloni, Zhang, sage hence most of them crave for it (Robinson-
& Gu¨lmezoglu, 2016). The proportion of CS among Bassey & Uchegbu, 2017). The knowledge of society
total deliveries in Ghana increased steadily from surrounding CS may have a significant role in the de-
4.3% in 1999 to 6.9% in the year 2012 (Gulati & cision making process of pregnant women accepting
Hjelde, 2012). Though the figure has increased, it is to undergo the procedure. The lack of knowledge
still below the WHO target of 15% of all deliveries. Al- about CS by women in the developing countries has
though women’s preferred mode of delivery vary led to underutilization of the procedure compared to
widely between different countries (D'Souza, 2013; the large burden of obstetric morbidity requiring res-
Kuan, 2014), a plethora of cross-sectional studies olution by CS (Qazi et al., 2013). This attitude of
from Sub-Saharan Africa have revealed that the ma- some women towards CS influences their accept-
jority of women prefer vaginal birth over CS (Aziken, ance of the procedure and more often than not, re-
Omo-Aghoja & Okonofua, 2007; Chigbu & sults in psychological depression that women and
Iloabachie, 2007; Enabudoso, Ezeanochie & Olag- their families usually experience (Faremi, Ibitoye,
buji, 2011) even though there might be pregnancy Olatubi, Koledoye & Ogbeye, 2014). In the northern
dangers. Some studies conducted in Ghana showed part of Ghana, due to strong cultural values, women
that an overwhelming majority of women had a pref- are most of the times reluctant in accepting CS when-
erence for vaginal delivery over CS (Adageba, ever indicated. This normally delays the operation,
Danso, Adusu-Donkor & Ankobea-Kokroe, 2008; which may pose damage to the mother and foetus.
Danso et al., 2009; Prah et al., 2017). The WHO in Few studies have been conducted on women’s
2013 estimated that 298,000 women were dying from knowledge about CS and preferred mode of delivery
pregnancy and birth related causes globally (WHO, in Ghana and little is known about it in Northern
UNICEF, UNFPA, 2013). Most of these deaths oc- Ghana. Therefore, the study aimed to assess preg-
curred in developing countries and Sub-Saharan nant women’s knowledge of CS and their preferred
Africa alone accounted for 62% (179 000) of the mode of delivery.

Design and Methods antenatal card marked with a sign (√) to avoid double
recruitment during her subsequent clinic attendance.
Study Design There were seven (7) questions related to knowledge
A descriptive cross-sectional study was conducted to towards caesarean section. Correct, wrong and I
examine the level of knowledge of CS and preferred don’t know responses were scored 3, 2, and 1 re-
mode of delivery of pregnant women in the Tamale spectively. The total knowledge score ranged from 1-
Teaching Hospital. 21. Women that had a total score less than 40% were
considered to have poor knowledge, those with
Study site and Population scores between 40-60% had fair knowledge and
The study was conducted at the Tamale Teaching more than 60% were considered to have good knowl-
Hospital. The hospital is a 470 bed capacity tertiary edge on CS.
level facility located in the Northern part of Ghana.
The obstetrics and gynecological department pro- Reliability and Validity of Instruments
vides antenatal, childbirth and post-partum services. The reliability of the instrument was determined using
The target population was all pregnant women who the Test-Retest method. The structured questionnaire
attended antenatal clinic during the three months that was submitted to two obstetric and gynecological
the study lasted. The average population for the three specialists in measurement and evaluation to assess
months’ period was estimated at 4,743. the face and content validity of the instrument. Their
comments were used to make necessary corrections
Sample size and sampling before administration of the instrument. Pretesting
The sample size for the study was determined by was done at the Tamale West Hospital using ten (10)
using Yamane’s sample size formula (Yamane, pregnant women. Ambiguity of questions were recti-
1967). Using an estimated population of 4,743, a fied and finalized.
sample size of 368 respondents was arrived at for
three months. A simple random sampling technique Data Analysis
was used to recruit respondents attending antenatal Both descriptive and inferential statistics in the form
clinic. The women were required to pick confidentially of frequencies, percentages, and Pearson’s chi-
prepared slips that had either ‘YES’ or ‘NO’ con- square test were used in the analysis. The data col-
cealed inscription on them. Only eligible women that lected was coded and analyzed using the Pearson’s
picked slip with the inscription ‘YES’ had the ques- Moment Correlation coefficient formula which gave a
tionnaire administered to them. Necessary explana- value of 0.99. Frequencies and percentages were
tions and guidance were provided to women aged computed using SPSS (Statistical package for social
twenty (20) years and older who consented to partic- sciences) version 23.0. Association between level of
ipate in the study. Respondents who could not read knowledge, influencing factors on choice of cae-
nor write were assisted by an interpreter in the sarean section and respondents’ characteristics were
process of filling the questionnaire. Two nurses were carried out using a chi-square (χ2) test. Characteris-
recruited as research assistants to support in the ad- tics with significant differences between groups by
ministration of the questionnaire. the χ2 test were included in a multivariate logistic re-
gression analysis (COR [95%CI], AOR [95%CI]) to
Research Instrument predict their independent associations within the
A pre-tested, validated and reliable structured ques- group. Statistical significance was set at p<0.05.
tionnaire was used for the survey. The instrument
was divided into two sections (A & B). Section A fo- Ethical consideration
cused on the demographic characteristics of the re- Approval for the study was obtained from the Ethics
spondents, Section B assessed respondents’ Review Board of TTH and verbal consent sought
knowledge level and preferred mode of delivery. A from respondents. Confidentiality and anonymity was
total of 368 questionnaires were administered, 363 ensured. Anonymity of the questionnaire was
were retrieved and 360 were considered valid. Any adopted to ensure confidentiality of the response.
woman who was selected and interviewed had her

Results mal education. With regards to the number of preg-

nancies, 100(28%) of the women were primigravida,
Demographic data and obstetric while the majority of women 130(36%) had two preg-
characteristics nancies, 88(24%) had three pregnancies and
Table 1 shows the demographic and obstetric char- 42(12%) were gravida four or more. The majority
acteristics of the respondents. Out of the 368 preg- 342(95%) of the respondents were married. Also
nant women recruited for the study, 360 respondents’ 200(55.5%) of the respondents were self-employed.
questionnaires were considered valid for data analy- Out of the 360 respondents, 98(27%) were pregnant
sis. The majority 274(76%) of respondents had for- women that had previous CS.
Table 1: Demographic data and obstetric characteristics
Variable N (%)
Age group
20-24 86 (24)
25-29 112 (31)
30-34 108 (30)
35 and above 54 (15)
Marital status
Single 18 (5)
Married 342(95)
Education
No education 50 (14)
Informal education 36 (10)
Formal education 274 (76)
Occupation
Government Employed 146 (40.5)
Self employed 200(55.5)
Unemployed 14 (4)
Gravida
One 100 (28)
Two 130 (36)
Three 88 (24)
Four or more 42 (12)
Previous Caesarian section
Yes 98 (27)
No 262 (73)
Place of previous delivery
Hospital 280 (78)
Home 80 (22)
Level of Awareness of CS by pregnant formation about CS were antenatal clinic 195(54%),

women and Sources of information and the media 80(22%). Sixty (17%) heard about CS
The majority 288(80%) of respondents were aware from family/friends and the remaining 25(7%) had the
of CS as an obstetric procedure and 72(20%) had not information from other sources.
heard of CS. The main sources of respondents’ in-

Pregnant women’s knowledge of CS knowledge about CS. The majority 173 (48%) had
Table 2 shows the knowledge level of respondents fair knowledge and the remaining 72(20%) had poor
on CS. Only 115(32%) of pregnant women had good knowledge.
Table 2: Knowledge level on CS
Knowledge level N (%)

Good 115 (32)
Fair 173 (48)
Poor 72 (20)
Influencing factors of women’s preferred again. When respondents were questioned about
mode of delivery their reasons for not wanting CS, 288(80%) gave rea-
Table 3 shows influencing factors of women’s pre- sons of prolonged hospital stay, 264(73%) postoper-
ferred mode of delivery. When questioned on what ative pain, 129(36%) feared being mocked, 60(17%)
their preferred mode of delivery for their current preg- were afraid of death. Two-hundred and eighty-eight
nancy was, 330(92%) and 15(4%) preferred vaginal (80%) of the women knew that it was possible to
delivery and caesarean section delivery respectively. have a normal vaginal delivery after CS and 5% said
The remaining 15(4%) were equivocal. When re- it was impossible. When questioned about the rea-
spondents were questioned on whether or not they sons/factors that can lead to CS, approximately
were willing to undergo caesarean section delivery if 200(56%) of the respondents were aware that pro-
indicated, 282(78%) concurred to undergo CS if nec- long labour is one of the factors that can lead to CS.
essary and 78(22%) did not accept to undergo CS. Seventy six (21%) and 78(25%) of the respondents
However, out of the 98 women who had a history of also indicated eclampsia and vaginal bleeding re-
previous CS, 50 (51%) of them would accept to un- spectively as reasons for which CS will be performed.
dergo CS while 48(49%) would not want to have CS
Table 3: Knowledge of CS and Influencing factors for preferred mode of delivery.

Characteristics N (%)
Preferred Mode of Delivery
Vaginal 330(92)
CS 15(4)
Equivocal 15(4)
Acceptance of CS
Willing to accept CS if necessary 282(78
Unwilling to accept CS 78(22)
*
Reasons for not Wanting CS
Fear of death 60(17)
Fear of mockery 129(36)
Fear of Pain 264(73)
Prolonged hospital stay 288(80)

Expensive 53(44)
*
Reason for CS
Prolong labour 270(76)
Eclampsia 76(21)
Breech 104(29)
Bleeding per vagina 78(25)
Small pelvis 12(3)
Don’t know 60(17)
*Multiple Responses
Respondents’ knowledge on CS and factors influenc- were equivocal in this study (AOR=4.82[1.7, 15.01]).
ing preferred mode of delivery Mothers that had good knowledge on CS and indi-
After applying both bivariate and multivariable logistic cating that breech presentation was a reason for CS
regression, two variables showed significant effect on were 6.34 times more likely to prefer CS than those
factors influencing preferred mode of delivery at the who indicated that eclampsia and small pelvis were
5% level of significance (table 4). There was a signif- the reasons for CS (AOR=6.34[3.2, 25.02]). Also,
icant relationship between mother’s knowledge on mothers who had good knowledge of CS and indi-
CS and their preferred mode of delivery. Mothers who cated that prolong labour was a reason for CS had
had good knowledge about CS and preferred CS 2.02 higher odds of accepting CS than mothers that
were 4.82 times more likely to accept CS than moth- indicated eclampsia, small pelvis, and don’t know
ers that preferred vaginal delivery and mothers that (AOR=2.02[0.5, 5.34]).
Table 4: Respondents’ knowledge on CS and factors influencing preferred mode of delivery

Characteristics N (%) GK FK PK COR [95%CI] AOR [95%CI]
Preferred Mode of
Delivery
Vaginal 330(92) 100 166 64 1.8[0.7, 8.24] 0.87[1.2, 10.25]
CS 15(4) 15 - - 5.8[2.6, 12.52] 4.82[1.7, 15.01]
Equivocal 15(4) - 7 8 1.0 1.0
*
Reason for CS
Prolonged labour 270(76) 52 130 88 4.0[0.9, 12.65] 2.02[0.5, 5.34]
Eclampsia 76(21) 10 46 20 1.0 1.0
Breech 104(29) 68 30 6 8.2[1.8, 23.14] 6.34[3.2, 25.02]
Bleeding vagina 78(25) 5 43 30 3.1[0.8, 12.07] 1.80[1.1, 10.73]
Small pelvis 12(3) - 3 9 1.0 1.0
Don’t know 60(17) - - 60 1.0 1.0
Key: GK: Good Knowledge; FK: Fair Knowledge; PK: Poor Knowledge
*Multiple Responses

Association between respondents’ p=0.012, and previous CS p=0.001). However, there

characteristics and knowledge on was no significant association between knowledge
caesarean section about caesarean section and respondents’ charac-
From table 5: There was significant association be- teristics in relation to age, marital status, occupation
tween knowledge about caesarean section and re- and previous place of delivery where 𝑃>0.05.
spondents’ characteristics (education p=0.035, parity
Table 5: Association between respondents’ characteristics and knowledge on caesarean section
Variable GK (n=115) FK (n=173) PK (n=72) X2 P-value

Age group
20-24 20(17%) 48(28%) 18(25%) 6.435
25-29 40(35%) 60(35%) 12(17%) 0.081
30-34 31(27%) 40(23%) 37(51%)
35 and above 24(21%) 25(14%) 5(7%)
Education
No education - 10(6%) 40(56%) 4.235
Informal - 23(13%) 13(18%) 0.035*
education
Formal education 115(100%) 140(81%) 19(26%)
Gravida
One 10(9%) 50(29%) 40(56%) 5.001
Two 20(17%) 90(52%) 20(28%) 0.012*
Three 50(43%) 30(17%) 8(11%)
Four or more 35(30) 3(2%) 4(5%)
Previous
Caesarian
section
Yes 98(85%) - - 1.924 0.001*
No 17(15%) 173(100%) 72(100%)
Key: GK: Good Knowledge; FK: Fair Knowledge; PK: Poor Knowledge
Association between respondents’ association between factors influencing preferred

characteristics and factors influencing mode of delivery and respondents’ education and
preferred mode of delivery whether they had previous CS (Education, p=0.013
In table 6, respondents that were willing to accept and previous caesarian section p=0.001). Associa-
CS were considered to have positive reasons, and tion between perception of factors influencing pre-
those who were unwilling to accept CS, even under ferred mode of delivery and age, marital status,
conditions that were detrimental to their health, were occupation, and previous place of delivery were
said to have negative reasons. There was significant found not to be significant.

Table 6: Association between respondents’ characteristics and factors influencing preferred
mode of delivery
Variable PP (n=280) NP (n=80) X2 P-value

Age group
20-24 56(20%) 30(%) 4.910
25-29 92(33%) 20(%) 0.241
30-34 78(28%) 30(%)
35 and above 54(19%) -
Education
No education 10(4%) 40(50%) 3.926
Informal education 16(6%) 20(25%) 0.013*
Formal education 254(90%) 20(25%)
Gravida
One 60(21%) 40(50%) 2.014
Two 105(38%) 25(31%) 0.096
Three 80(28%) 8(10%)
Four or more 35(13%) 7(9%)
Previous Caesarian
section
Yes 98(35%) - 2.639 0.001*
No 182(65%) 80(100%)
Key: PP: Positive perception; NP: Negative Perception
Discussion might have had regular antenatal visits and benefited

The majority (85%) of the women that participated in from education on pregnancy-related issues includ-
the study were between the ages of 20-34 years. ing CS which might have contributed to the higher
This was expected as this represents the reproduc- knowledge score.
tive age group commonly seen in the antenatal clin-
ics, and it is congruent with most studies carried out As much as 54% and 22% of the pregnant women in
in other countries (Sunday-Adeoye & Kalu, 2011; this study said their main sources of information on
Izugbara & Ukwayi, 2007; Okezie, Oyefara & Chigbu, CS were from antenatal clinics and the media re-
2007) around the world. The high level of awareness spectively. This finding is contrary to the report ob-
(80%) on CS is similar to that found in some previous tained in a study conducted in Cape Coast where
studies conducted in Ghana and Nigeria (Prah et al., 68% of respondents’ main source of information was
2017; Aziken, Omo-Aghoja & Okonofua, 2007). In from the media (Prah et al., 2017). The current result
our study, a smaller proportion (32%) had good is also very different from the findings from Bagdhad,
knowledge on caesarean section, which is consistent in which only 12.7% obtained information from ante-
with a study in Ghana where 39.5% of women had natal clinics (Nasir, 2017) and Ajeet et al. (2011) who
good knowledge (Prah et al., 2017) but lower than a ascertained that only 20.8% of the respondents’
study conducted in Nigeria (Robinson-Bassey & source of information about CS was from the hospi-
Uchegbu, 2017) where they reported 62.42% tal. The higher source of information on CS emanat-
women having good knowledge about CS. The dif- ing from the hospital/antenatal clinic could imply that,
ference could be due to the difference in the educa- the health facility and the health professionals of the
tional level of the respondents in our setting. Tamale Teaching Hospital are playing their respective
Additionally, the respondents in the Nigerian study roles of educating prospective mothers on maternal

and child health issues. Also, the midwives and that formal education was significantly associated
nurses in the antenatal unit are always the first point with knowledge of respondents on CS. This is prob-
of contact when a pregnant woman is visiting the an- ably because educated women would have the op-
tenatal clinic for assessment, and this creates oppor- portunity to access additional information from the
tunities for nurses/midwives to adequately engage electronic and print media on CS that will influence
pregnant women in discussions. The majority (92%) their knowledge level. The study revealed that
of the women, even among women who had previ- gravida was statistically significant with women’s
ous CS, would choose vaginal delivery against CS, knowledge on CS. This could probably be because
as their preferred mode of delivery. Similar findings women who have the opportunity to deliver in the
were noted in other studies conducted in Ghana 94% health facilities or attend antenatal clinics during
(Prah et al., 2017), Nigeria 94% (Owonikoko, Akinola, pregnancies will benefit from some education during
Adeniji & Bankole, 2015), 91.5% (Ajeet et al., 2011) these periods. The current study findings revealed
and in Italy where 80% of women preferred vaginal that a previous experience of CS was significantly as-
delivery (Montilla et al., 2012). Some women attrib- sociated with pregnant women’s knowledge on CS.
uted their preference for vaginal delivery to it being a This may be due to the fact that during pre-operation
natural route for delivery and safer. Most women felt preparations for CS, women are educated on the pro-
CS was more dangerous, painful and might not have cedure (Prah et al., 2017). The findings reveal that
good outcome. the influencing factors for preferred mode of delivery
was statistically significant with women’s education.
In recent times, an increasing number of pregnant Women who were educated had good and fair knowl-
women are requesting cesarean delivery for non-ob- edge on CS. Health education during pregnancy and
stetric indications (Narayanaswamya, Ambikaa & before CS might have increased women’s awareness
Sruthia, 2016). A significant number (22%) of respon- of CS in the Tamale Teaching Hospital, though some
dents in our study will decline having caesarean sec- still held the notion that delivering through CS is be-
tion delivery even when their lives or that of their tween life and death. The significant knowledge on
babies were in danger. In some Sub-Saharan African CS among those with previous CS could be a reflec-
countries including Ghana, there is a broadly held so- tion of their earlier experiences during pregnancy, be-
cietal belief that women who deliver via CS for their fore, during and after CS coupled with their
first pregnancies would have negative consequences knowledge acquired leading to positive influencing
on future pregnancies and child birth and are unable factors about CS (Aziken, Omo-Aghoja & Okonofua,
to have normal vaginal delivery for their subsequent 2007; Naeimi, GHolami & Qasemi, 2015;
pregnancies (Mboho, 2013; Amiegheme, Adeyemo Amiegheme et al., 2016; Prah et al., 2017).
& Onasoga, 2016). Moreover, in most families,
women who undergo CS are often seen as weak and Limitations of the Study
cannot withstand labour pains (Robinson-Bassey & The study did not involve men who are considered the
Uchegbu, 2017), thereby rushing to the hospital in key stakeholders in decision making on caesarean
order to conceal their weakness. Pregnant women section. The study also failed to assess the social, cul-
who undergo CS are often accused of being lazy, crit- tural and economic status of the respondents.
icized for wasting money, considered as not women
enough to have vaginal delivery (Mboho, 2013; Implications for Nursing and Midwifery
Aziken, Omo-Aghoja & Okanofua, 2007). Further- Practice
more, they also involve in stressful post CS activities The results indicate that a significant proportion of
so as to make them stronger (Keedle, Schmied, pregnant women would prefer vaginal delivery even
Burns & Dahlen, 2015). Additionally, some reasons when their condition indicates the need for CS. This
given by pregnant women for not wanting CS were implies that acceptance of CS is still low. It is impor-
fear of mockery, fear of postoperative pain, and fear tant that pregnant women are well informed as to any
of death as well as prolong hospital stay (Owonikoko risks arising during pregnancy or labor by
et al., 2015; Sunday-Adeoye & Kalu, 2011; Adageba nurses/midwives at the antenatal clinics, so that they
et al., 2008; Qazi et al., 2013). The study revealed would be willing to set aside their preferences and

make an informed decision to have CS. These find- should also address negative factors influencing the
ings underscore the need for effective communica- acceptance of CS. The study revealed that though
tion among midwives and pregnant women. some women had formal education, it did not neces-
Nurses/midwives should also intensify health educa- sarily mean they had good knowledge on CS. Efforts
tion on caesarean section, with a major focus on at understanding cultural beliefs regarding CS and
causes and its importance in saving the lives of emphasis on safety of the procedure during antenatal
mother and baby as well as correcting misconcep- care visits are recommended. There is therefore the
tions about CS. The findings from this study would need to conduct further robust research in this sub-
provide baseline information, which can be used in ject area. Future research should focus on under-
planning strategies for improving the knowledge of standing sociocultural factors and beliefs that impede
women towards CS. This will possibly reduce the the acceptance of caesarean section among preg-
delay in opting for CS and improve its utilization and nant women using qualitative approach.
to help in reducing avoidable maternal and fetal com-
plications. Conflict of Interest
None declared.
Conclusion
Although a high percentage had fair and good knowl- Acknowledgements
edge about CS, the majority 92% preferred vaginal The authors extend their appreciation to all the re-
delivery. In this study, there were concerns about the spondents and the research assistants for their con-
safety of the procedure, post-operative pain and tributions.
other social factors influencing the acceptance of CS.
This brings to light the need for nurses/midwives to Funding
intensify education on indications for CS and safety No funding was received for this study from any ex-
of the procedure at the antenatal clinics. Education ternal source.

Danso, K. A., Schwandt, H. M., Turpin, C. A., Seffah, J.

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Original Article
Knowledge, Attitudes and Practices of Dietary
Modification among Diabetic Patients: A Descriptive
Cross-sectional Study at Ejisu-Juaben Municipality, Ghana
Yaa Obirikorang (MPhil, BSc, RGN) 1
Christian Obirikorang (PhD. BSc) 2
Enoch Odame Anto (MPhil, BSc) 2, 3
Emmanuel Acheampong (MPhil, BSc) 2,
Emmanuella Nsenbah Batu (MPhil, BSc) 2
Fatima Sani Dange (BSc, RGN) 1
Nuhu Abdulbasir (BSc, RGN) 1
Bright Amankwaa (MPhil, BSc) 2
Abstract
Adequate knowledge, attitude, and practices are effective in providing baseline
preventive measures in diabetes. This study determined the knowledge, atti-
tude and practices of diabetic patients towards dietary modification. This de-
scriptive cross-sectional study was conducted at Ejisu-Juaben municipality,
Ghana. A structured questionnaire was used to obtain information such as
socio-demographic and knowledge, attitude and practices of diabetic patients
towards dietary modification. In all, 200 diabetic participants were recruited.
The majority of the participants (84.0%) were between the ages 40-60 years.
Ninety-two (46.0%) of the participants correctly identified dietary modification
as a way of adjusting to healthy eating practices. Forty percent (40.0%) of the
participants knew that adjusting to dietary modification help maintain blood
sugar to a near normal. Most of the participants (43.0%) knew that non-com-
pliance to dietary modifications can increase blood sugar level. Eighty six
(86.0%) of the patients knew that dietary modification could help control their
diabetic complications. Most (89.0%) of the participants sometimes adhere to
dietary modifications, 11.0% regularly adhere while 10.0% do not adhere to di-
etary modifications. Diabetic patients had adequate knowledge about their dis-
ease conditions but had poor attitude and practice towards dietary
modifications. Frequent public health and hospital-based education on adjust-
ing to dietary modifications is required.
Keywords:
Attitude; Diabetic Mellitus; Dietary Modification; Knowledge; Practices
1. Department of Nursing, Faculty of Health Sciences

Garden City University College (GCUC), Kenyasi, Kumasi, Ghana
2. Department of Molecular Medicine, School of Medical Science

Kwame Nkrumah University of Science and Technology (KNUST), Kumasi, Ghana
3. Royal Ann College of Health, Department of Medical Laboratory Technology

Atwima Manhyia, Kumasi, Ghana
1. Department of Nursing,
Faculty of Health Sciences,
Garden City University College (GCUC),
P. O. Box 12775, Kumasi, Ghana
Email: obiriyaa@gmail.com

Introduction lenge to healthcare providers. Despite the effort

Diabetes Mellitus (DM) is a chronic disease associ- made by health providers in educating patients on di-
ated with high rate of morbidity and mortality in both etary modification, prevalence and adverse compli-
high and low and middle-income countries (American cations of diabetes are still increasing at faster rates
Diabetic Association, 2014). It affects people worldwide and in Ghana (Danquah et al., 2012).
poses a major public health and socioeconomic chal-
lenges (Iinternational Diabets Fedearation, [IDF], There are quite high numbers of research studies on
2012). This disorder was previously thought to be the prevalence of diabetes, knowledge of risk factors
rare or undocumented in Africa but over the past few associated with diabetes, and diabetic complications
decades it has emerged as an important non-com- in the Ghanaian setting. However, studies on the
municable disease in Sub-Saharan Africa (Motala, knowledge, attitude and practice of dietary modifica-
Omar, & Pirie, 2003). Increasing age, sedentary tion among diabetics are rare to find in the existing
lifestyle, rapid growing of urban culture and modified literature. Therefore, the study aimed at establishing
diets are predicted to triple the global prevalence of the knowledge, attitude and practice of dietary mod-
Diabetes Mellitus by the next 25 years (Mbanya & ification among patients living with diabetes.
Sobngwi, 2003). Studies have shown that increasing
patient knowledge regarding Diabetes Mellitus and Design and Methods
its complications have significant benefits related to Study Design
patient compliance to treatment and reduction of The quantitative research approach was used to as-
complications (Sorganvi, Devarmani, Angadi, & Ud- sess diabetic patients’ level of knowledge, attitude
giri, 2013). and practice of dietary modification and adjustment.
A cross-sectional descriptive study design was
Several interventions are available to manage and specifically used to study the knowledge, attitude and
control diabetes and prevent the development of practice of dietary modification among diabetic pa-
complications. Some of the interventions include in- tients in two-selected hospitals at the Ejisu-Juaben
sulin therapy, drug, dietary modification and physical municipality.
exercise which is intended to slow down the progress
of diabetes (Bello, Owusu-Boakye, Adegoke, & Adjei, Study Setting
2011; Sobngwi et al., 2012). Since dietary modifica- The Ejisu-Juaben Municipality is one of the 30 ad-
tion plays an integral part of the management of dia- ministrative and political districts in the Ashanti Re-
betes, persons living with diabetes often need gion of Ghana. The Municipality stretches over an
personal guidance in order to enrich their knowledge area of 637.2 km2 constituting about 10% of the en-
and aid suitable selection of foods and intake of tire Ashanti Region, and it has Ejisu as its capital. The
healthy diet (Hernández-Ronquillo, Téllez-Zenteno, hospitals (Ejisu Government Hospital and Juaben
Garduño-Espinosa, & González-Acevez, 2003). In Government Hospital) have a total bed capacity of
Ghana, there has been a rise from 0.2% to 6.0% in about 70 beds and twenty-four (24) departments. The
the prevalence of DM (Aikins, Owusu-Dabo, & Agye- following services were available on a 24-hour basis
mang, 2013). Various factors such as inappropriate during the period of study: out-patients’ department,
dietary habits, urbanization, and lifestyle changes pharmacy, surgery, in-patient services, mortuary,
such as smoking and alcoholism, have been impli- emergency, and laboratory. The following services
cated in this condition (Aikins, 2005). Cultural influ- were also available but not on a 24 hour basis: ultra-
ences are known to affect people’s ability to comply sound scan, Prevention of Mother to Child Transmis-
with healthy lifestyle modifications and pharmacolog- sion (PMTCT), Voluntary Counselling and Testing
ical interventions when affected with diabetes. De- (VCT), Anti-Retroviral Treatment Services, Eye, Re-
spite the use of pharmacological interventions in the productive and Child Health, Urology/Obstetrics and
treatment of patients with diabetes in Ejisu and Gynaecology (outreach clinics once per week). Both
Juaben hospitals, available data indicate that there hospitals run weekly diabetic clinics and currently
are no significant improvements in patients’ fasting manage an estimated number of 250 patients from
blood glucose (FBG) levels. This poses a great chal- nearby communities.

Study Population Ethical Consideration

In this study, patients who were living with Type I and Approval for this study was obtained from the com-
II Diabetes and accessed follow-up care services at mittee on Human Research, Publication and Ethics
the diabetic clinics in both hospitals during the study of the School of Medical Sciences (SMS), Kwame
period were the target population. Convenience sam- Nkrumah University of Science and Technology
pling techniques were used to recruit 200 diabetic pa- (KNUST) (Ref-CHRPE/RC/157/13). Permission was
tients attending the diabetic clinic during the study also obtained from the Municipal Health Directorate
period. The hospitals have a total of 250 patients at- office at Ejisu. Verbal consent was sought from re-
tending the clinic and using a confidence interval of spondents before collecting the data. Names and ad-
95% and a margin of error of 3.5%, 190 patients were dresses of respondents were omitted from the
to be selected for the study. However, the re- questionnaires to ensure anonymity. The respon-
searchers recruited 200 patients for the study to dents were assured that the information gathered
make the results obtained more statistically signifi- was to be used strictly for research and academic
cant. purposes. In addition, the respondents were given
the freedom to opt out at any time during the study
Subject Selection when they thought they could not continue to partic-
All diabetic patients, attending the diabetic clinic ipate in the research.
within the period of October, 2014 to March, 2015
were eligible to participate in the study. The eligible Data Management and Analysis
respondents were recruited in order of their follow-up Participants were said to have ‘adequate’ knowledge
appointments. The selection of the hospitals for the of dietary modification if they responded to correct
study was done based on the services provided and answers about definition, importance and conse-
the frequency of diabetes cases per month. Health- quences of non-compliance to dietary change. The
care institutions available in Ejisu-Juaben municipal- attitude towards dietary modification was assessed
ity were grouped into public and private. Of these, based on correct responses to questions pertaining
only the two selected hospitals met the inclusion cri- to frequency of adherence to dietary modification, be-
teria of running a diabetic clinic and therefore were lieving dietary modification can affect Diabetes con-
chosen for the study. Out of the 200 participants, trol, daily lifestyle and health status. Data were
most of them were recruited from Ejisu (53.0%) and entered and the analysis was conducted using sta-
Juaben (47.0%). tistical package for social science (SPSS) version 20.
Data were described and presented as frequencies
Data Collection Tool and percentages.
Questionnaires were administered to obtain informa-
tion from all study respondents. These question- Results
naires were administered personally to the diabetic The study constituted 200 diabetic patients. Table 1
patients during their visit to the diabetic clinic. The presented below shows the frequency distributions
questionnaire was divided into three sections and of the socio-demographic characteristics of respon-
had open and close-ended questions. Section A in- dents. Frequency distribution of diabetic-related char-
volved questions that elicited information on socio- acteristics, knowledge about dietary modification and
demographic variables such as age, occupation, knowledge of diabetes control and their sources are
marital status, economic income, levels of education, presented in Tables 2, 3 and 4 respectively Table 5
ethnicity, family type and religion. Section B included depicts the distribution of responses to attitude to-
questions on the knowledge diabetic patients have wards dietary modification.
on dietary modification and adjustment. Section C
was focused on items that elicited information on the Out of a total of 200 participants, majority 84 (84.0%)
attitude and practices of dietary modification among were between the ages 40-60 years. There were
diabetic patients. All questions were in English lan- more females (78.0%) than male (22.0%) partici-
guage but were interpreted to the understanding of pants. Most of the participants (49.0%) were self-em-
participants in the local language where needed. ployed while few (16%) were government employed.

Higher proportions (52.0%) were low income earners by Ga-Adangbe (11%). Christians were in the major-
while 10.0% were high income earners. Most had no ity (91.0%) followed by Moslems (7%). Information
formal education (49.0%). Akans (86.0%) were the on the socio-demographic data is presented in Table
highest in number in terms of ethnic group followed 1.
Table 1: Socio-demographic characteristics
Variables Frequency (n) Percentage (%)
Age group

20-40 years 20 10%
40-60 years 168 84%
60 and above 12 6%
Gender

Male 44 22%
Female 156 78%
Occupation

None 70 35%
Government 32 16%
Self employed 98 49%
Marital Status

Single 74 37%
Married 120 60%
Divorced 60 3%
Socio economic income (GHS)

<500 104 52%

500-1000 (middle) 76 38%
>1000 (high) 20 10%
Highest level of education

None 98 49%
Primary 40 20%
Secondary 22 11%
Tertiary 40 20%
Ethnicity

Akan 172 86%
Ga-Adangbe 22 11%
Mole- dagbani 4 2%
Ewe 2 1%
Religion

Christianity 182 91%
Islam 140 7%
Others 4 2%
Most of the participants (41.0%) had between 3- glucose (FBG) level between 7-10.9 mmol/l (52.0%)
4years of living with diabetes followed by 1-2 years while 18.0% reported with levels of 11.0 mmol/l and
(32.0%), 5 years and more (21.0%) and less than 1 above [Table 2].
year (6.0%). A higher proportion had fasting blood

Table 2: Diabetics- related characteristics of participants
Variables Frequency Percentage
Duration of Diabetes (years)
<1 12 6%
1-2 64 32%
3-4 82 41%
5 and above 42 21%
FBS status (mmol/l)
4.0-6.9 60 30%
7.0-10.9 104 52%
11.0 and above 36 18%
Most of the participants (46.0%) knew the meaning 14.0% knew that it provides knowledge on healthy
of dietary modification as ‘a way of adjusting to eating, 11.0% knew it has no importance while 1.0%
healthy eating practice”. Forty percent (40.0%) knew were ignorant of it. Most of the participants (43.0%)
it as a healthy eating habit while 6% did not know. A knew that non-compliance to dietary modifications
high proportion (40.0%) of the participants knew that can cause a persistent increase in blood sugar,
adjusting to dietary modification helps maintain blood 21.0% knew it can result in sudden death, 20% knew
sugar to a near normal as possible. Thirty four per- it can result in obesity, 12% knew it can result in hy-
cent (34.0%) knew that dietary modifications help to pertension and 4.0% did not know about the effects
reduce the short term complications of diabetes, of non-compliance to dietary modification [Table 3].

Table 3 Respondents’ knowledge about dietary modification
Variable Frequency (n) Percentage (%)
What do you understand by dietary modification?
Adjusting to healthy eating practice 92 46.0%
Healthy eating habit 80 40.0%
Changing patient's diet 12 6.0%
Don't know 12 6.0%
Eating separately from other members of the family 4 2.0%
What are the importance of dietary modification to your condition?
Don't know 2 1.0%
Has no importance 22 11.0%
Provides knowledge of healthy eating 28 14.0%
Reduces the short term complications of diabetes 68 34.0%
Maintains blood sugar to as near normal as possible 80 40.0%
What do you think are some of the consequences of non-compliance
to dietary change?
Don't know 8 4.0%
Hypertension 24 12.0%
Obesity 40 20.0%
Sudden death 42 21.0%
Persistent increase in blood sugar 86 43.0%
Eighty six percent (86.0%) of the patients knew that pants were sugar intake (19.0%), alcoholic beverage
dietary modification could help control their diabetes intake (19.0%), soft drinks (19.0%), saturated fat and
status while 14.0% were not aware of it. Out of 86.0% meat (15.0%), and carbohydrate foods (12.0%). The
of the participants who were aware of dietary modifi- majority (78.0%) of the participants report to the doc-
cation, most (81.0%) of them heard it from the hos- tor as a result of non-compliance to dietary modifica-
pital while 19.0% heard it from the media. The tion, 12.0% report to family members while 10.0% do
common restricted diet known among the partici- not report to anyone [Table 4].

Table 4 Response to knowledge on diabetes control and their sources
Variables Frequency (n) Percentages (%)
Can dietary modification help control diabetes?
Yes 172 86.0%
No 28 14.0%
If yes, where did you hear the information?
Hospital 162 81.0%
Media 38 19.0%
Family member -
Herbalist -
What are some of the diet that you have been told to eat
in moderation?
Excessive salt intake 8 4.0%
Others 12 6.0%
Carbohydrate food 24 12.0%
Saturated fat and meat 30 15.0%
Sugary foods intake 38 19.0%
Alcohol 38 19.0%
Soft drinks 38 19.0%
What immediate action did you take if you were unable
to comply with dietary changes?
Report to doctor 156 78%
Report to family members 24 12%
Report to anyone 20 10%

Eighty nine percent (89.0%) of the participants some- (8.0%), and avoiding the eating of meals outside
times adhere to dietary modification, 11.0% regularly home (4.0%) while 38.0% disagreed. Seventy six
adhere while 10.0% do not adhere to dietary modifi- percent (76.0%) responded that dietary modification
cation. A higher percentage (88.0%) agreed that ad- had affected their lives positively while 24.0% re-
herence to dietary modification could control their sponded that it had affected them negatively. The
diabetic condition while 12.0% disagree. Out of those majority (62.0%) of the participants felt that modifying
who agreed, the majority of the participants (52.0%) their diet was challenging, whilst 26.0% felt that it was
knew that dietary modification can control diabetes good modifying their diet, and 12.0% felt it was bad.
by reducing high blood sugar levels. The majority Eighty-eight percent (88.0%) agreed that there are
(62.0%) of the participants agreed that dietary modi- instances where they fail to adhere to dietary modifi-
fication had affected their daily life while 38.0% dis- cations. The most common reasons stated included
agreed. The common challenge among the festive occasions (57.0%), when favorite foods are
participants was that dietary modification increases cooked (17.0%), when not feeling well (11.0%), dur-
their financial demands (73.0%), making them take ing church meetings (9.0%) and periods of fasting
meals separately from their family members (13.0%), (6.0%) [Table 5].
preventing them from eating their favorite foods
Table 5: Attitude of Diabetic Patients towards Dietary Modification
Attitude Frequency Percentage
How often do you adhere to the dietary modification?

Regularly 22 11%
Sometimes 178 89%
Do not adhere 10 10%
Do you believe that dietary modification can control your diabetes?
Yes 176 88%
No 24 12%
If yes, how?

Reduces body weight 72 36%
Reduces blood sugar level 104 52%
Reduces frequent urination 4 2%
Reduces acute complication e.g. diabetes foot 10 5%
Others 36 18%
Has dietary modification affected your daily lifestyle?

Yes 124 62%

No 76 38%
If yes, how?

Affected my financial demands 146 73%
Made me avoid eating outside home 14 7%
Made me eat separately from my family 26 13%
Made me not eat my favorite food 16 8%
How has dietary modification affected your health status?

Positive 152 76%
Negative 48 24%
How do you feel modifying your diet?

Good 52 26%
Challenging 124 62%
Bad 24 12%
Are there instances when you cannot adhere to dietary modification?
Yes 176 88%
No 24 12%
If Yes, when?

During festive occasions 114 57%
During fasting periods 12 6%
* Values are presented as proportion of positive response to each option

Values are presented as proportion
positive of
response to each option
Discussions pects of lifestyle modification such as regular exer-

Despite numerous medicinal interventions, diabetes cise, avoiding smoking and intake of alcoholic bev-
continues to increase across the globe accompany- erages as a way of managing diabetes (Wing et al.,
ing serious health issues (McMichael, 2000). Lifestyle 2001). However, dietary modification is a major com-
modifications have shown to improve diabetic status ponent of diabetes care which has not been given
of patients when they strictly adhere or comply with much attention. This study for the first time assessed
the specific interventions (Tuomilehto et al., 2001). the knowledge of diabetic patients towards dietary
Previous studies have mostly considered other as- modifications in the Ejisu-Juaben Municipality, Ghana.

The first aspect of the assessment was to understand (11.0%) who had regular adherence practice is small
their general concept and meaning of dietary modifi- compared to evidence from a study by Addisu, Es-
cations. It was observed that ninety-two) (46%) cor- hete, and Hailu (2014) who indicated that 49.7% had
rectly knew the meaning of dietary modification. regular dietary adjustment intake. These disparities
Again, the participants gave several opinions on the could be explained by the differences in socioeco-
importance of dietary modification. A considerable nomic status, study settings, and the types of foods
proportion (40.0%) of them knew that adjusting to di- available in the different countries of study (Khattab,
etary modifications help maintain blood sugar to a Aboifotouh, Khan, Humaidi., & Al-Kaldi, 1999). Other
near normal as possible. Others knew that it helps reasons include, but not limited to, culture, personal
reduce the short term complications of diabetes food choices, the unavailability of food guide pre-
(34.0%), provide knowledge on healthy eating pared for diabetic patients in the country and lack of
(14.0%) while very few (1.0%) did not know. This pre- detailed understanding of the food-disease associa-
supposes that participants knew that strict adherence tion (Worku et al., 2015).
to dietary modifications could reduce their high blood
glucose levels. This study also showed a higher pro- It was observed that more than fifty percent (50%) of
portion of the participants as being knowledgeable of the participants had challenges regarding adherence
the consequences of non-compliance to dietary mod- to dietary modifications. The most common chal-
ifications. The most common reason was that it could lenges were related to financial demands. Seventy
lead to persistent increase in blood pressure (43.0%). three percent (73%) agreed that dietary modification
had affected their daily lives by increasing financial
Dietary modification was essential in controlling dia- demands. This result is in agreement with the finding
betes, and 86.0% agreed that dietary modification that most of the study subjects had low economic in-
could control their diabetic conditions. Based on the come and that could have attributed to the low dietary
above knowledge of patients living with diabetes, we practice among the participants in this study. Reports
assessed their attitude and practice towards dietary by Addisu et al. (2014) observed that patients with
modifications. A large proportion (89.0%) of the par- middle income status had better diabetes self-prac-
ticipants sometime adhere to dietary modifications, tice compared with those with low incomes. Partici-
11.0% regularly adhere while 10.0% did not adhere pants may have thought of the high cost of food
to dietary modification. It can be deduced from the associated with compliance to dietary changes hence
study evidence that higher proportions of the partici- the high proportion of poor dietary practice. Other
pants adhered poorly to dietary modifications despite reasons were that dietary changes make them take
their adequate knowledge on the dietary modifica- meals separately from their family members (13.0%),
tions. Several studies have also reported poor adher- prevent them from eating their favorite foods (8.0%),
ence of diabetic patients towards dietary practice. In make them avoid eating meals outside of home
a recent study by Worku, Abebe, and Mesele (2015), (4.0%) while 38.0% disagreed with the need for di-
the overall occurrence of poor dietary practice among etary changes. Again, the challenge associated with
Type II diabetic patients at Yekatit 12 Medical College socioeconomic status could have explained these dif-
Hospital was found to be 51.4%. A study conducted ferences. In another study, patients living with Type
on the assessment of dietary practice among diabetic II diabetes who never received diabetic nutritional ed-
patients in the United Arab Emirates and Riyadh, ucation, had less access to fruits and vegetables and
Saudi Arabia also indicated inadequate dietary prac- thought of cost of foods had poor dietary practice
tice (Mohamed, Almajwal, Saeed, & Bani, 2013). An- (Worku et al., 2015). This evidence suggests that pa-
other study conducted on compliance and control of tients need nutritional education for optimal manage-
diabetes in a family practice setting in Saudi Arabia ment of their condition regardless of other factors.
has indicated that there was a 60% poor diet compli- Another significant finding of this study was that al-
ance which is higher than the finding of the present most 90.0% of the participants found it difficult to ad-
study. These low proportions compared with 89.0% here to dietary changes due to festive occasions and
in this study show that poor compliance is high. How- preference for certain kinds of foods.
ever, the proportion of participants in this study

Study Limitation sional development programmes in order to assist

Although this study’s findings are comparable to ev- their clients appropriately. Researchers are encour-
idence from previous studies, it had some limitations. aged to engage in qualitative, interventional and lon-
This study may not show conclusive findings on the gitudinal studies into why clients living with diabetes
knowledge of diabetic patients towards dietary mod- are not regularly adhering to their dietary modifica-
ification due to the small sample size. Moreover, the tions. This study’s evidence serves as baseline for di-
use of a self-reported instrument on dietary practice recting future studies in Ghana.
may have introduced social desirability bias. There is
therefore the need to use a validated dietary practice Conclusion
scale to better understand the dietary behaviour of Based on the study’s findings, we conclude that, al-
patients. though the knowledge of people living with diabetes
on dietary modification was good, the practice of di-
Implications etary modification was lower than desirable. There-
This study has implications on nursing practice and fore, there is the need for structured programmes to
research. The study evidence shows that though the improve the practice of dietary modifications among
majority of the participants knew that adjusting to di- patients.
etary modification helps maintain blood sugar to a
near normal level as possible and control their dia- Conflict of Interest
betic complications, quite a significant number did not The authors declare that there is no conflict of interest.
adhere to the dietary modifications at all, with most
of them adhering and just a few regularly adhering to Acknowledgement
dietary modifications. Nurses are in the best position The authors thank all the participants who took part
to educate clients on their health issues and encour- in the study.
age them to adhere to their treatment modalities and
dietary modifications at the facility and community Funding
level. Nurses also need to update their knowledge The study received no funding.
and skill-base in diabetes through continuous profes-

Mbanya, J.-C., & Sobngwi, E. (2003). Diabetes microvas-

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Aikins, A., Owusu-Dabo, E., & Agyemang, C. (2013). Dia- Mohamed, B. A., Almajwal, A. M., Saeed, A. A., & Bani, I.
betes in Ghana: A review of research on prevalence, A. (2013). Dietary practices among patients with
experiences and healthcare. Retrieved from Type 2 Diabetes in Riyadh, Saudi Arabia. Journal of
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show=full Motala, A. A., Omar, M. A., & Pirie, F. J. (2003). Epidemi-
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evidence from rural-urban qualitative study of pean Journal of Cardiovascular Risk, 10(2), 77-83.
Ghanaian diabetes experiences. British Medical Sobngwi, E., Ndour-Mbaye, M., Boateng, K. A., Ramaiya,
Journal, 331(7519), 737. K. L., Njenga, E. W., Diop, S. N., . . . Ohwovoriole,
American Diagnosis Association. (2014). Diagnosis and A. E. (2012). Type 2 diabetes control and complica-
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(Supplement 1), S81-S90. Saharan African countries: The Diabcare Africa
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Journal of General Medicine, 4, 723. Hämäläinen, H., Ilanne-Parikka, P., . . . Rastas, M.
Danquah, I., Bedu-Addo, G., Terpe, K.-J., Micah, F., (2001). Prevention of type 2 diabetes mellitus by
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Kaldi, Y. (1999). Compliance and control of diabetes
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Mediterranean Health Journal, 5(4), 755-765.

Requirements
for renewal of
license expanded
The Nursing and Midwifery Council is pleased to The aim of introducing these CPD programmes
inform all Nurse Assistants, Nurses and Mid- are to ensure that Nurse Assistants, Nurses and
wives that the requirements for renewal of li- Midwives remain up to date in knowledge in re-
cense have been expanded to include accredited spect of changes in health patterns, standards of
Continuous Professional Development (CPD) professional education and practice, health sector
Programmes. reforms and technological advances.
Renewal of license is currently based on accu-
•
mulated CPD points and not solely on participat- Do you know you can:
ing in workshops as was done previously. Participate in a journal club meeting
•
which will earn you 1point?
All Nurse Assistants, Nurses and Midwives reg-
istered with the N&MC are required to obtain Keep a monitored practice journal or
minimum CPD credit points as follows:
•
reflective diary for 2 points?
10 points – Nurse Assistants Facilitate a journal club meeting for
•
2 points?
15points – Staff Nurses
Staff Midwives up toNursing/ Review educational materials, jour-
•
Midwifery Officers nals, articles, books for 10 points?
20points – Senior Nursing/Midwifery Publish journal, article, book chapter

Officer/Health Tutor/ Assistant for 20 points?
Lecturers and above
For more info:

Website: www.nmcgh.org
Tel: 0501079037, 0200862772, 0302541423

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Nursing and Midwifery Council of Ghana

All Rights Reserved. No part of this document or work may be re-

ISSN (Print Version): 2026-5883

Dr. Abigail A. Kyei

Prof. Lydia Aziato

Mrs. Mercy M. Avogo

Dr. Aaron Abuosi

Dr. Roger Atinga

Dr. Veronica Dzomeku

Dr. Jerry Ninnoni

Dr. Adelaide Ansah-Offei

Dr. Mary Ani Amponsah

Dr. Gideon Puplampu

http://www.numidhorizon.com Volume 2 No. 1, June 2018 iii

1 Stress and Coping Strategies among Nurse

14 The Effects of Stigma on Mental Health Nurses:

21 Continuing Formal Education for Non–professional

30 Maternal Satisfaction with Labour at the University of

39 Menopause as a Rite of Passage: Exploring the

iv Volume 2 No. 1, June 2018 http://www.numidhorizon.com

50 Determinants of Contraceptive Use among Women

62 Knowledge of Pregnant Women on Caesarean

74 Knowledge, Attitudes and Practices of Dietary

http://www.numidhorizon.com Volume 2 No. 1, June 2018 v

vi Volume 2 No. 1, June 2018 http://www.numidhorizon.com

Challenges in Giving Versus

A common belief ex- providers to be more knowledgeable to

Editorial ists among children

http://www.numidhorizon.com Volume 2 No. 1, June 2018 vii

viii Volume 2 No. 1, June 2018 http://www.numidhorizon.com

Stress and Coping Strategies among Nurse

http://www.numidhorizon.com Volume 2 No. 1, June 2018 1

Introduction that 45% of participants cited poor relationship

2 Volume 2 No. 1, June 2018 http://www.numidhorizon.com

http://www.numidhorizon.com/ Volume 2 No. 1, June 2018 3

Table 1: Socio-Demographic Characteristics of Nurse Managers

4 Volume 2 No. 1, June 2018 http://www.numidhorizon.com

Table 2: Causes of Stress among Nurse Managers

http://www.numidhorizon.com/ Volume 2 No. 1, June 2018 5

Table 3: Tests of Between-Subjects Effects between Causes of Stress and Socio-

Lack of incentives for overtime .780 1 .780 8.064 .007 .179

Poor working conditions .815 4 .204 2.498 .061 .227

Belief system .175

6 Volume 2 No. 1, June 2018 http://www.numidhorizon.com

Table 4: Types of Stress among Nurse Managers

2.EMOTIONAL Anger 45 30 (65.2%) 12 (26.1%) 3 (6.7%)

Memory loss 45 15 (32.6%) 25 (54.3%) 5 (11.1%)

Source: Field data 2017

http://www.numidhorizon.com/ Volume 2 No. 1, June 2018 7

Table 5: Correlation between Types of Stress and Socio-demographic characteristics

8 Volume 2 No. 1, June 2018 http://www.numidhorizon.com

Table 6: Coping Strategies of Stress among Nurse Managers

Source: Field data 2017

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References Hargrove, M. B., & Ahmed, A. (2014). Stress, Health and

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The Effects of Stigma on Mental

1. School of Nursing and Midwifery

2. Head, Department of Mental Health