SECTION ONE

INTRODUCTION

1.1 Background to the study

Sickle Cell Disease (SCD) is one of the most common life-threatening inherited hematological
blood disorder in the world, Individuals with SCD require special attention and frequent hospital
care and management of the acute physical complications. They are mostly suffering from
numerous physical conditions, such as anemia, acute vasoocclusive causing excessive pains in
various locations of the body and psychological health challenges, such as sleep disturbances,
negative body satisfaction, fatigue, anxiety, depression and stigma. (Mitchell and M.J. 2007)

Sickle cell disease (SCD) with the aid of advanced technology can be curable through bone
marrow transplant for children and stem cell therapy for adults but it is rarely used because of its
high risk, high cost of treatment and the lack of suitable marrow donors. Therefore, the available
treatment for the disease is managing the patient with analgesics, blood transfusion, hydration,
hydroxyurea therapy, antibiotics and avoiding anything that will trigger crisis (pains). All these
illness and treatment issues result in multiple challenges and demands on parents of children with
SCD, as those parents are often the primary caregivers. SCD in children inflects high physical,
economic, social, and psychological cost on parents/caregivers as parenting stress is significantly
greater among them because of the significant hardship they endure as a result of the daily
provision of care and financial strain than it is among parents of healthy children. (Wonkam et al.
2014)

The genetic hematological disorder is common in Nigeria, which has the highest number of
people suffering from sickle cell disease (SCD) in the world (Bosede Afolabi 2010). Over
150,000 children are born with SCD in Nigeria each year and about 40 million people suffer
According to World Health Organization’s African Region, sickle cell is the most prevalent
genetic disease with an estimated more than 300,000 babies born with severe forms of abnormal
hemoglobin worldwide each year, while 75 percent of all patients with SCD live in Sub-Saharan
Africa, Nigeria alone accounts for more than 150,000 new births every year. (W.H.O 2006).
The genesis of the disease for an individual is the mis-matching of genotype of the parent of
those living with the disease. Genotype is simply refers to all genes of cells constituents that an

1
individual has in the body for inheritable trait. There are many types of genotype, these are:
AA,AS, SS and AC there wouldn’t be a problem when one of the gene is abnormal e.g. AS or
AC which is called sickle cell carrier (sickle cell trait) but when the two are abnormal then there
is a problem which is the cause of sickle cell disease.

Adjusting of the system of a genotype to different conditions determines its ability of surviving
normal, carrier or sick cell since different species have different genotype adaptability as there is
a constant natural selection. The parent’s socioeconomic status is an important factor to consider
in care and treatment of their children with sickle cell disease as there is need for individual to
know their financial constrain while taking any step that requires spending.

1.2 Statement of the problem

In developing countries medical dilemmas are sometimes handled with cultural and traditional
solutions instead of viewing it through clinical perspectives. In many African countries a number
of individuals with SCD do not seeing as patients but rather spiritually victims (Adeolu and
Olaide 2012). World Health Organization (WHO, 2006) noted that Sickle cell disease has
become a global public health dilemma as the disease is the cause of death among 20% of those
with the disease. People with SCD in developed countries have experienced improvements in
quality of health and longer life expectancy unlike in developing countries like Nigeria, the most
populous African country (CDC 2011).

Nigeria being one of the countries with highest rate of sickle cell disease in the world just as any
developing country faces a lot of challenges but the most crucial cause of complications of sickle
cell disease is the financial constrain of the caregivers/parents of the patients and lack of
awareness about the disease especially in the areas where poverty and illiteracy have solid
foundation, then the belief about the disease as spiritual (jinn) and this may affect the
understanding of the affected families towards the condition thereby not giving the disease an
appropriate attention and management that is required to maintain a healthy life. Socioeconomic
status mostly influences health outcomes of individual living with sickle disease and its
complication causing the patient to be frequently hospitalized as well as strain on family’s
financial security (Anie et al., 2010).

2
Frequent treatment and management of the disease creates a serious socio-economic burden,
which may affect the quality of the care and treatment of the disease. Studying the influence of
the socio-economic factors will enable exploration for a deeper understanding of reasons for
variations in the types and quality of the care and treatment of the disease.

1.3 Research questions

1. Does parent’s income influence the care and treatment of their children with sickle cell
disease?

2. Does the parent’s level of educational influence the care and treatment of their children with
sickle cell disease?

3. Does parent’s occupation determine the type of care and treatment of their children with sickle
cell disease?

4. Does parent’s age influence the care and treatment of their children with sickle cell disease?

5. Does parent’s marital status influence the care and treatment of their children with sickle cell
disease?

1.4 Objective of the study.

The broad objective of this study is to examine the influence of parent’s socioeconomic status on
the care and treatment of their children with sickle cell disease in Kano, Pediatric hematology
clinic of Aminu Kano Teaching Hospital, Kano Nigeria.

The specific objective of this research is:

1. To find out the influence of parent’s income on the care and treatment of their
children with sickle cell disease.
2. To find out the influence of parent’s occupation on the care and treatment of their
children with sickle cell disease.
3. To identify the influence of parent’s level of education on the care and treatment of
their children with sickle cell disease.

3
 4. To find out whether marital status of the parents has influence on the care and
treatment of their children with sickle cell disease.
5. To examine the influence of parent’s age on the care and treatment of their children
with sickle cell disease.

1.5 Scope of the study

this study is limited to Aminu Kano Teaching Hospital (AKTH) Pediatric hematology clinic
units which each clinical day consist of about eighty five patients, and I intend to covered four
clinical days which is every tuesday i.e. four times in month to atleast interview two hundred and
eighty parents due to the cost involved, accessibility of data and time constrains, so as to
achieved the validity and reliability of the findings. It is therefore, hoped that the findings of the
study could be applied to the larger society.

1.6 Significance of the study

This study is important because it focuses on understanding the influence of parent’s

socioeconomic status on care and treatment of their children with Sickle cell disease in Nigeria,
as the number of sickle cell patients always continues to increase rapidly with no strategic
programmatic efforts geared towards improving the quality of life of the affected persons. This
may be due to rampant misconceptions about the disease and the misdiagnosis of hemoglobin
genotypes (Kotila, 2012).

After determining the influence of socioeconomic status, researchers and providers can explore
public health awareness that changes in health behavior and beliefs towards sickle cell disease,
and it may help as a reminder for parents to budget, plan or savings for the unexpected
hospitalization which can improve the management of the disease and the quality of life for
individuals with sickle cell disease.

4
1.7 Operational definition

World Health Organization (WHO 1946) defines Health as a” state of complete physical, mental,
and social well-being and not merely the absence of disease or infirmity”.

Sickle cell disease (SCD): is a genetic blood disease that can cause complications.(Desai &
Dhanani,

2004).

Hematology: the branch of medicine involving study and treatment of blood.

Anemia: is a decrease in the total amount of red blood cells (RBCs) or a lowered ability of the
blood to carry oxygen.

Socioeconomic status: is the social standing and economic position of an individual in his
society.

Income: refers to individual annual earnings.

Education refers to the development of the abilities of the mind (learning to know).

Parent: refers to the person who gave birth to the child or the caregiver who has the custody of
the child.

Education: Acquired formal knowledge.

Knowledge: the act of knowing something with familiarity gained through experience.

Children: a young human being below the age of puberty.

Occupation: is an individual or a person's job or a role in society for a living.

Care: the attention and provision of what is necessary for the health, protection and maintenance
of the child.

Treatment: refers to the medical management and care of a patient.

Age: the duration of a person's life.

Marital status: the state of being either married or not married:

5
 SECTION TWO

LITERATURE REVIEW AND THOERITICAL FRAMEWORK

2.1 Introduction

This section contains a reviewed of various scholars works found in journals, articles, and
publication and text books about the influence of parent’s socioeconomic status on the care and
treatment of their children with sickle cell disease and factors behind their burden.

2.2 The Concept of Sickle cell disease

Sickle cell disease (SCD) is a chronic genetic disease, which affects the red blood cells of its
carriers. The sickle cell gene causes the body to produce abnormal hemoglobin (Hemoglobin is a
type of protein in the red blood cells that carries oxygen to the tissues of the body), the
hemoglobin clumps together and makes red blood cells to become stiff and develop a C-shaped
(sickle) form, which makes it difficult to pass through small blood vessels, the vessels become
clogged making it difficult for oxygen to reach a particular part of the body and Lack of
sufficient oxygen restricts normal blood flow which makes the normal cells die early and causes
a constant shortage of red blood cells and the complications of sickle cell disease.
People with sickle cell disease (SCD) start to have signs of the disease during the first year of
life, usually around 8 months of age. Symptoms and complications of SCD are different for each
person and can range from mild to severe. The reason that infants don’t show symptoms at birth
is because baby or fetal hemoglobin protects the red blood cells from sickling till when the infant
is around 6 to 7 months of age, the baby or fetal hemoglobin is replaced by sickle hemoglobin
and the cells begin to sickle, it is a disease that worsens over time. Treatments are available that
can prevent complications and lengthen the lives of those who have this condition as started
earlier.(Kotila, 2012)

2.3.1 Diagnosis of sickle cell disease and its process

Patients with sickle cell disease are diagnosed first through several blood tests such as blood
counts which reveal the abnormal Hb level in the range of 6 to 8 grams per deciliter (1/10 of a
litres), blood films may show red blood cells (RBCs) that appear as irregularly contracted cells
and Hb electrophoresis, it is the test that confirm the diagnosis of sickle cell disease, It measures

6
the different types of hemoglobin in the blood then the sickle cell disease occurs as a result of the
hemoglobin S (HbS) molecule, when the sickle hemoglobin molecule loses its oxygen, it forms
rigid rods called polymers that change the red blood cells into a sickle or crescent shape, these
sickle-shaped cells stick to the walls and cannot squeeze through the capillaries, the blood flow
through tiny blood vessels becomes slowed or stopped in many parts of the body, When this
blood flow slows or stops suddenly in a certain part of the body, the decrease in oxygen
(hypoxia) can cause severe pain (the sickle cell crisis). Over time, it leads to gradual destruction
in organs and tissues throughout the body, the higher the concentration of sickle hemoglobin and
the more acidic the environment, the faster the sickle cell process. When blood cells dry out
(dehydrate), the density of hemoglobin S within the cell increases, thereby speeding the sickling
process. (Bloom M. 1995)
2.3.2 Types of sickle cell disease

There are five main types of sickle cell disease which is the hemoglobin types, Hemoglobin is
the protein in red blood cells that carries oxygen and it normally has two alpha chains and two
beta chains which are caused by different mutations in these genes.

Hemoglobin SS disease: Hemoglobin SS disease is the most common type of sickle cell disease,
It occurs when you inherit copies of the hemoglobin S gene from both parents, this forms
hemoglobin known as Hbss as the most severe form of SCD, individuals with this form also
experience the worst symptoms at a higher rate.

Hemoglobin SC disease: Hemoglobin SC disease is the second most common type of sickle cell
disease, it occurs when you inherit the Hbsc gene from one parent and the Hb S gene from the
other. Individuals with HbSC have similar symptoms to individuals with HbSS. However, the
anemia is less severe but high bone pains than SS.

Hemoglobin SD, Hemoglobin SE and Hemoglobin SO are all types of the sickle cell disease,
though the most common here in Nigeria are HBSS and HBSC, the difference between abnormal
hemoglobin S and abnormal hemoglobin C is that HBSS are anemic and have frequency
occurrence of crisis but it heals within short period of time, mostly after blood transfusion, while
the HBSC are not anemic but they are the ones with the episode of critical bone pains that even

7
collapsing the bones i.e. Avascular necrosis (AVN) from age 7yrs old of their life unlike those
with HBSS they got (AVN) when they are at the age of 18 and some when they are
matured(note, there are exceptional patients how with no AVN). HBSC don’t have often crisis, it
takes long before they fall ill and also takes them a long period before healing, both of them are
experiencing unpredictable different episode of pains and many complications. While, HBSD,
HBSE and HBSO are the rare type of sickle cell disease which is mostly found in Europe, Arabs
and Asians part of the world.( Bloom M.1995).

2.3.3 Symptoms of sickle cell disease/anemia

Symptoms of sickle cell disease usually show up at a young age, mostly it appear in babies as
early as 6 months old, but generally occur around the first year of life, all the sickle cell types
have similar symptoms, which vary in severity. These include:

 excessive fatigue or irritability from anemia

 bedwetting from associated kidney problems
 jaundice which is yellowing of the eyes and skin
 swelling and pain in hands and feet
 frequent infections
 pain in the chest, back, arms, or legs

2.3.4 Triggers of the crisis (pains)

The Pains or the blood vessels blockages are called sickle cell crises. They can be caused by a
variety of circumstances, including:

 illness
 changes in temperature
 stress
 poor hydration
 poor diet
 malaria

8
2.3.5 Complications of sickle cell disease

Sickle cell disease is a chronic, painful and potentially life threatening illness. The first crisis
usually appears when child turns six months after birth and it occurs in different forms, the most
common crisis are:

 vasoocclusive which is very painful episode resulting from obstruction in blood vessels
that causes fever, abdominal pain and necrosis due to lack of inadequate blood flow to the
specific region of tissue or organ.
 Anemia: Anemia is a shortage of red blood cells (RBCs). Sickle cells are easily broken,
the normal RBCs generally live for about 120 days but in sickle cells, it lives for a
maximum of 10 to 20 days.
 Hand-foot syndrome: Hand-foot syndrome occurs when sickle-shaped RBCs block blood
vessels in the hands or feet, this causes the hands or feet to swell, swollen hands and feet
are often the first sign of sickle cell disease in babies.
 Splenic sequestration: Splenic sequestration results from spleen pulling a large amount of
blood that may cause severe drop in blood volume which causes abdominal distention,
hypertension and painful enlargement of the spleen. The spleen may have to be removed
due to complications of sickle cell disease in an operation known as a splenectomy, but
Patients without a spleen are at higher risk of infections from bacteria.
 Delayed growth: Delayed growth often occurs in children with SCD, they are generally
shorter but regain their height by adulthood. Sexual maturation may also be delayed, this
happens because sickle cell RBCs can’t supply enough oxygen and nutrients.
 Neurological complications: Seizures, strokes or even coma can result from sickle cell
disease because of brain blockages.
 Eye problems: Blindness is caused by blockages in the vessels supplying the eyes which
can damage the retina.
 Skin ulcers: Skin ulcers in the legs can occur if small vessels are blocked.
 Heart disease: SCD as interferes with blood oxygen supply, it also cause heart problems
which can lead to heart attacks, heart failure and abnormal heart rhythms

9
  Lung disease: SCD cause lungs damage over time due to decreased of blood flow, which
makes it more difficult for the lungs to transfer oxygen into the blood.
 Acute chest syndrome: acute chest syndrome result from sickling in small blood vessels
in the lungs and the reason may be either vasoocclusive crisis or infection, it causes
severe chest pain and is associated with symptoms such as cough, fever, and sputum
production, shortness of breath and low blood oxygen levels. Abnormalities observed on
chest X-rays can represent either pneumonia or death of lung tissue which is the major
cause of death in children with sickle cell disease younger than 5 years of age.
 Osteomyelitis. It’s an inflammation of bone caused by infection generally in the legs, arm
or spine when there is blood blockage in the vain. (Mitchell and M.J. 2007)

2.4 Care and Treatment:

Care and Treatment simply refers to the process parents are taking in managing their children
with sickle cell disease either at home or in the hospital.

Care: care of child (ren) with sickle cell disease is to maintain healthy habits, introduce healthy
practices into the child's daily life such as drinking plenty of fluids to help prevent dehydration,
eating balanced diet, avoiding excessive humid or cold places and stress of any kind. It’s also
important that parents beside medical care and attention to take good care of their children or
patients to take good care of their self at home as well as to follow the instructions given by their
physicians in order to have improvement of life quality (Bloom 1995).

There are some precautions and homecare methods that ease mild sickle cell pains immediately:

 Use heating pads for pain relief.

 Take folic acid supplements as recommended by your doctor.
 Eat an adequate amount of fruits, vegetables, and whole-wheat grains which can help the
body make more RBCs.
 Drink more water to reduce the chances of sickle cell crises.
 Exercise regularly and reduce stress to reduce crises too.

10
Treatment: treatment of child (ren) with sickle cell disease is to make sure the patient takes its
routine drugs at the right time and visit hospital wherever the patient is in pain though most of
the treatments are aimed at relieving symptoms or preventing complications, majority of the
patients are experiencing pains nearly on daily basis and the severity of the pain may vary from
mild and moderate to severe, sometimes painful episode can be manage at home but only for a
while due to severe pain, the patient must seek immediate treatment in hospital and emergency
units (Hill 1994). Such as:

 Rehydration with intravenous fluids helps red blood cells return to a normal state, the red
blood cells are more likely to deform and assume the sickle shape if the patient is
dehydrated.
 Treating underlying or associated infections is an important part of managing the crisis as
the stress of an infection can result in a sickle cell crisis. An infection may also result as a
complication of a crisis.
 Blood transfusions improve transport of oxygen and nutrients as needed.
 Supplemental oxygen is given through a mask, it makes breathing easier and improves
oxygen levels in the blood.
 Pain medication is used to relieve the pain during a sickle crisis which is given either
orally, through intravenous or intramuscular.
 Hydroxyurea helps to increase production of fetal hemoglobin, it may reduce the number
of blood transfusions.
 Immunizations can help prevent infections as most of the Patients have lower immunity.
 Bone marrow transplant is the ultimate cure for sickle cell disease but finding a matched
donor is often difficult and the procedure is costly and sometimes leads to life threatening
complications.

2.4.1 Rationale on Socioeconomic status

Parents are the keepers for their children’s health, they are the ones who make decisions about
the quantity and quality of health care their children may be able to receive. For example, parents
largely choose the type of food their children eat, select the physical activity their children
should engage in, recognize their kids’ physical and mental health situations and provide

11
appropriate living environments. These choices are influenced by parents’ material resources,
their knowledge of health practices and programs, and their own health and health behavior.
Also, Parents of children with sickle cell disease or any chronic illness experience heavy burden
leading to their own negative health outcomes and decreased quality of life as the disease is
characterized by intermittent hospitalizations, recurrent painful crises, lack of sleep, isolation,
depression, spending more than budget, emotional trauma and reduced life expectancy (Muscarri
2005). However, with physical, economic and psychological support sickle cell disease can be
manage through the care and treatment but both the care and treatment requires time, attention
and money which can only be achieved through considering the parent/individual socioeconomic
status.

Parents of children with sickle cell disease or any chronic illness experience heavy burden
leading to their own negative health outcomes and decreased quality of life as the disease is
characterized by intermittent hospitalizations, recurrent painful crises, lack of sleep, isolation,
depression, spending more than budget, emotional trauma and reduced life expectancy,
(Muscarri 2005). However, with physical, economic and psychological support sickle cell
disease can be manage through the care and treatment but both the care and treatment requires
time, attention and money which can only be achieved through considering the influence of
parent/individual socioeconomic status.

2.5.2. Socioeconomic status: is an economic and sociological combined total measure of a

person's work experience of an individual's or family's economic and social position in relation
to others based on income, education, age, marital status, occupation etc. When analyzing a
family's socioeconomic status it’s typically categorized into three levels (high, middle and low)
and when placing a family or individual into one of these categories, any or all of the factors can
be consider. This study is going to focus on only five among the many factors of socioeconomic
status that determined health, these include: income, education, age, marital status and
occupation.

These factors: income, education, age, marital status and employment are relates to and
influence one another. For example, your employment will dictate your income, your income
level often correlates to your level of education and your level of education helps to dictate your

12
employment. E.g. a person with higher level of education can never be compare with the one
with low level of education in a place of work, the one with high level of education is in a prime
position to earn a large income and this usually leads to expectations upon both that of higher
and lower level of education, so also their children to achieve a similar level of education and
employment because of their parent’s income and the socioeconomic status then influence
health. (Robert, 2002).

2.5.3 Income: Income as one of the socioeconomic factor refers to any source or flow of
earnings received such as salaries, profits, pensions, interest, worker’s compensation, alimony or
family financial assistance has influence in determining person level of health. Wikinson (1998)
underline the chronic illness within the family that may contribute to the suffering from severe
stress. He further reveals that the degree of reorganization of the family often profound and
affecting issues such as finances, time, school, peer group as well as emotional and interpersonal
interactions. Boss and Mulligan (2003) pointed out that chronic illness leads to disruption of
normal family process such as routines and rituals in their efforts to meet the demands related to
illness very often family members must restrict some activities or even give up. The family
system also have to think and establish the role for accomplishing the basic task such as earning
the family income, child care, meal preparation and household maintenance, some family may
share the task according to gender while in some family both gender share most of the roles.

Lubotsky and Paxson (2002) in the United States, and Currie and Stabile (2003) in Canada have
further revealed that the influence of income on health is greater for older children, implying that
the effect of income on health accumulates as one ages. This means that, not only are poorer
children in worse health from birth, but their health falls further behind as they age, with likely
adverse consequences for educational attainment and earnings, they further underline the
relationship between parental income and child health: Higher household income allows parents
to provide better nutrition for their children, to purchase medical care and health insurance, and
possibly also to provide access to a safer environment. Children’s health is also likely to be
determined at least in part by parental characteristics that are correlated with parental income.

A major determinant of child health in Ghana is poverty. To provide risk protection to poor
households and improve equity in the provision of healthcare, the country has turned to social
health insurance. Ghana’s National Health Insurance Scheme (NHIS) was launched in 2004 with

13
the aim of providing a pro-poor healthcare finance system. The NHIS is an implementation of
the World Health Assembly’s resolution that urged member states to ensure financial protection
to all citizens, particularly children and reproductive-aged women. The implementation of the
NHIS has recorded many success stories, such as helping to reduce out-of-pocket health
expenditure, particularly for the aged. (Quansah, 2016).

It was revealed that income has a significant positive relationship with health and it is the major
protection factor against poor health. Poor health is a liability, it impairs learning and
productivity of citizens, draining savings and limiting earnings. low income earners are at a
greater risk of falling ill given their limited access to information and health care facilities, as
most of the constraints to accessing good healthcare are affordability and lack of information.

Nigerians remain vulnerable to illnesses as a result of the nation’s poor healthcare system, the
lack of access and affordability to quality healthcare is likely the greatest challenge. Low quality
public sector facilities available to the poor are unable to effectively address health needs and
consequently keep poor people and ill. The National Health Insurance Scheme (NHIS),
established under Act 35 of 1999 constitution, set out to close this gap by providing easy and
affordable access to healthcare for all Nigerians but public sector providers are saddles with poor
human and material resources, while private sector health facilities of better quality are not
affordable to most Nigerians. (Babatunde, 2012)

The relationship between income and health does not merely reflect worse health among children
in poverty; Health continues to improve with income up into the highest income quintile.
Although children, like adults, generally become less healthy as they get older, higher incomes
buffer children against this erosion as poor health leads to lower earnings, and these earnings fall
farther behind as those in poor health grow older. The positive relationship between income and
health appears for a variety of other health measures, Children who are poorer miss more days of
school because of illness and experience more hospitalization episodes. Some chronic conditions
are not related to income. However, Paul Newacheck argues that, on balance, the most serious
chronic conditions are more common for poor children, those from poorer families have worse
overall health status, spend more days in bed and experience more hospitalization
episodes. Money not only appears to protect children from having a number of serious health

14
problems but also appears to buffer them from the adverse consequences of health problems.
Although family income is positively associated with children’s health status. Policies designed
to improve children’s health must be based on an understanding of why health and income are
related. A variety of mechanisms may underlie the relationship. It could be that higher incomes
buy more and better-quality health care, or that richer parents are able to allocate more resources
to other goods (such as better food or cleaner home environments) that improve health. It also
may be that income is not the direct source of better health among wealthier children. Instead,
parents who are more productive in the labor market may also adopt behavior that results in
better health for their children. (Boss and Mulligan, 2003).

2.5.4 Education: Education is another socioeconomic factor that determines health, education
wouldn’t only influence the choice of employment but will directly impact your health.
Education does not just refer to level of education. I.e. it does not just refer to whether person
complete University or not but the level of education and health can be specific, this include
knowledge about the disease and what a healthy diet is, how much exercise a person should do,
knowing where to get information from, how to know if it is reliable and then interpreting the
information in order to make a good decision about their health, unlike People who have lower
levels of education mostly have lower levels of health knowledge and Low level of education
and income mostly cause series range of physical and mental health problems even if they have
more experience about the disease. To know every detail of the illness and its treatment may
reduce anxiety of unknown and helps the patient and the family to have that feeling of control
over the illness, beside acquiring the knowledge from different source, the knowledge should
also be from learning experience through normalization because coping mechanism are directed
towards personal adaptation, i.e. the more they know about the illness the better adjustment to
the situation will take place. (Wikinson,1998).

The importance of parent’s education in the improvement of child health (including both
physical and mental) is well-established, indeed, it has been argued that education has
contributed more to mortality decline than has the provision of health services. It has been
generally maintained that the mother’s education is the significant determinant of child health
According to Aslam and Kingdon (2010), the relationship between parental education and child
health may arise because better-educated parents are more efficient of child health through

15
adopting better child-care practices or superior hygiene standards. Alternatively, it may be
because they choose health input mixes that generate more health output than those selected by
less-educated parents. This may be because education instills greater knowledge of the health
production function or the ability to respond to new knowledge rapidly. Children raised by
parents with more educational experience usually develop healthier habits and receive better care
from professional services. (Lindeboom, Llena-Nozal, & van der Klaauw, 2009).

Parent’s level of education influences family income significantly, family income can aid or
hinder children’s health outcomes as the formative living conditions are clearly linked to family
income. The difference in health status between children from rich families and children from
poor families increases through childhood, so that it is possible that poor children grow up with
worse health situations. Individuals with a higher education level prefer to marry partners with
higher levels of education, which positively affects family income. Aslam and Kingdon (2010)

Around the world, research has found positive correlations between parent’s level of education
and children’s health and cognitive development. For example, studies have found that higher
parent’s education is associated with things like increased prenatal care and improved infant
health, improved child nutrition and superior cognitive abilities. The correlations between
parent’s level of education and children's health and cognitive development could in part be
driven by other factors that cause both higher parental education and child development, for
example if areas that provide greater access to education also provide greater access to health
care or have lower food prices. A large body of work investigates intergenerational relationships
between the socioeconomic status and health of parents and children and has stressed the
importance of parent’s education, income and health for child outcomes. Income gradients in
health begin in childhood and increase with child age. Parent’s education may enter the child
health production function directly e.g. through increased knowledge and associated increased
efficiency in health investments and indirectly e.g. through increased income resulting in
increased spending on health inputs. Parents with low levels of education may be less able to
invest in the health of their children, and this may have long-reaching implications for the adult
outcomes of the child (Almond and Currie, 2009).

16
2.5.5 Occupation: is an individual or a person's job or a role in society for a living, and it is also
the indicator that encompasses both income and educational attainment. Individual’s
occupational status has a large impact on his health. Occupational status reflects the educational
attainment required obtaining the job and income levels that vary with different jobs and within
ranks of occupations and achievement in skills required for the job.

According to Marnot (2004), Occupations are ranked into most prestigious occupation and lower
ranking occupation. The most prestigious occupations are physicians, surgeons, lawyers,
chemical & biomedical engineers, and communication analysts. While lower ranking occupation
are food preparation workers, counter attendants, dishwashers, janitors, maids and housekeepers,
vehicle cleaners and parking lot attendants. The job consider as high status in classification
provides more challenging works, ability and greater control over working conditions. While
those considered less valued in classification paid significantly less and more laborious, very
hazardous and provided less autonomy. Gachathi (1979) indicated that occupational prestige is a
component of socioeconomic status encompasses both income and educational attainment. To
him, occupational status reflects the educational attainment required to obtain a job and income
levels, when parents have a better occupation, they make adequate provision for their children
education, they provide economic, social, psychological and emotional support to their children,
and this would make it possible for the children to perform well in their educational attainment.

Faisal Ibrahim, M.A. (2014) in his research conducts to find out the influence of parental
socioeconomic status on their involvement in their children’s education in Nigeria. He revealed
that the relationship between parental occupation and parental involvement at home was
moderate in some strategies. It shows that parent with the prestigious occupations is more likely
to identify their children’s problem to give a possible solution. They also help them to do their
homework by providing facilities necessary for learning development. It is possible as a
prestigious occupation is connected with income level. Prestigious occupation parents have
better income stability that would make it easier for them to make adequate provisions to their
children’s learning development.

Muscari (2005) states that social class and its establishment has great influence due to
differences in child practices and attitudes towards health, children are raised in different ways

17
by parents whose education may vary as well as communication skills, occupation and income.
It’s also well established that low socio-economic status has adverse influence on health and this
may be due to escalating health care costs and unaffordable health insurance, eating unbalance
and insufficient food, inadequate housing that may result in overcrowding, poor sanitation and
greater chance to expose to communicable disease. From sociological point of view, health and
illness are differently distributed along social classes, meaning that in lower classes the level of
illness experience will be higher than in higher class (Field & Taylor 1998).

.2.5.6 Marital status: the parent’s marital status have much influence on their children health
care, when a child is happy and not under any emotional stress tend to learn more and cooperate
more. Nash 1994 stated that Painful episode is especially difficult for children who may
experience fearfulness or helplessness and inability or limited ability to describe pain to their
parents and health care professionals, the crucial point of quality of life in chronic illness is
certainly maintenance of mental stability as is the key element for the patient and their family.
Therefore, having a psychological support is as important as medical treatment, the
psychological support helps patient and their families to adjust better and overcome crisis
through positive thinking.

Family structure as a key element of parental behavior also has an important role in determining
children’s wellbeing. Children from divorced or single-parent families experience a higher risk
of facing emotional, behavioral, physical and academic problems than children living in a
coupled father-mother family (Kovar, 1991). Recent research on the relationship between family
structure and children’s health outcomes indicates that differences across non traditional
(separated parents) family structures are particularly prominent for child outcomes, and children
in single-father families have less access to health care than those in other families, controlling
for economic resources (Conway & Li, 2012).

Studies in sub-Saharan Africa have examined the influence of family structure and
characteristics on child health status and survival, few paid specific attention to single mother
households. Hence, little is known in the region about the influence of single mother households
on child health status and survival, and the particular factors that account for differences between
single mother families and two-parent households, relative to children raised in two-parent

18
households, many studies particularly in Western countries, associated single motherhood with
poorer physical and mental health, and higher risk of mortality for children. On the other hand, a
few studies have also found that in spite of lower earnings, children in female-headed households
experience better or equal advantage in wellbeing compared to those in male-headed or two-
parent households. The relative advantage of children in two-parent families in well-being is
associated more with stable unions, especially of two biological parents. Living in step-parent
households has adverse effects on child well-being. Conflictual marriages lead to as much
disadvantage in child welfare as disrupted unions. In some cases, single parenting by a mother
after separation is more advantageous for children particularly for the children with special
needs. The economic resource model posits that child well-being is closely linked to economic
resources available in a family, Although in some cases health issues and malnutrition persists in
spite of increase in income and households wealth status, if the parents are so occupied with their
job and leave their preschool children for domestic servants, relatives or nannies during working
hours have little or no control over the quantity of food a child gets during those hours. (Lancet.
2010).

2.5.7 Age: parent’s age is another important socioeconomic factor that has a great influence on
the care and treatment of children with sickle cell disease as there are limit to both either young
or old parent i.e. there are certain kind of care that is beyond the capacity of young parent, so
also to the old parent. However, when there is chronic illness the patient is not the only one
affected by the illness but the whole family, in such situation psychological support will prevent
family from falling apart and gives strength to face the illness as best as they can, while the
medical support is taking care of physical conditions. Combined medical and psychological
support will contribute in establishing the balance between physical and mental wellbeing of the
patient and their family.

According to Max Planck and Gesellschaft (2016)Young parents have so much more energy to
take care of their children in terms of physical strength, Young parent can survive occasional
sleepiness nights and still get through the day without much incident. Kids of young parents have
more chances to live long and more memorable relationships with their parents because the
parents have more active role in helping to raise the children, they also find it easier for their
body to bounces back much more quickly and with much less effort without back pain despite

19
carrying their sick children for long time as they are more flexible and they can go extra miles to
get the best medical help for their children without even knowing.
Zondervan (2010) said "We believe that older parents are more often able to create favorable
environments for their children, older parents may be more sensitive to the child's needs and provide
more structure. She added that older parents also likely have better financial resources and may
have a higher education. Another possibility is that younger parents who have more "externalizing"
behaviors may be more impulsive, which could be related to having children at a younger age.
Parents might pass down more impulsive traits that could lead to a higher risk of behavior problems.

Parents are very important in all the stages of life, If it is better to have younger or older parents
depends on each person. The most important is getting on well with the children and give them
what is necessary. (Planck, 2016).

2.6 Theoretical Framework

This research uses the Sick role theory and Health belief model theory as the theoretical frame
reference of the study

2.6.1 Health belief model

The health belief model (HBM) is a psychological health behavior change model developed to
explain and predict health-related behaviors, particularly in regard to the uptake of health
services.

Health Belief Model is one of the first theories of health behavior, it was developed in the 1950s
by social psychologists Irwin M. Rosenstock, Godfrey M. Hochbaum S. Stephen Kegeles and
Howard Leventhal at the U.S. Public Health Service to better understand the widespread failure
of screening programs for illness. The theory has been applied to predict a wide variety of
health-related behaviors such as being screened for the early detection of asymptomatic diseases
and receiving immunizations. More recently, the model has been applied to understand patients'
responses to symptoms of disease, compliance with medical regimens, lifestyle behaviors and
behaviors related to chronic illnesses which may require long-term behavior maintenance in
addition to initial behavior change. Amendments to the model were made as late as 1988 to

20
incorporate emerging evidence within the field of psychology about the role of self-efficacy in
decision-making and behavior. ( Becker, et al 1984).

However, the theoretical constructs of health belief model are well understood through its four
components:

Perceived severity: refers to the subjective assessment of the severity of a health problem and
its potential consequences. The health belief model proposes that individuals who perceive a
given health problem as serious are more likely to engage in behaviors to prevent the health
problem from occurring or reduce its severity. Perceived seriousness encompasses beliefs about
the disease itself (e.g. a sickle cell patient even a child may never expose themselves to what will
trigger the crisis)

Perceived susceptibility: Perceived susceptibility refers to subjective assessment of risk of

developing a health problem. The health belief model predicts that individuals who perceive that
they are susceptible to a particular health problem will engage in behaviors to reduce their risk of
developing the health problem. Individuals with low perceived susceptibility may deny that they
are at risk for contracting a particular illness. Others may acknowledge the possibility that they
could develop the illness but believe it is unlikely. Individuals who believe they are at low risk of
developing an illness are more likely to engage in unhealthy or risky behaviors. Individuals who
perceive a high risk that they will be personally affected by a particular health problem are more
likely to engage in behaviors to decrease their risk of developing the condition.

Perceived benefits: Health-related behaviors are also influenced by the perceived benefits of
acting. Perceived benefits refer to an individual's assessment of the value or efficacy of engaging
in a health-promoting behavior to decrease risk of disease. If an individual believes that a
particular action will reduce susceptibility to a health problem or decrease its seriousness, then
he or she is likely to engage in that behavior regardless of objective facts regarding the
effectiveness of the action. For example, individuals who believe that wearing sunscreen
prevents skin cancer are more likely to wear sunscreen than individuals who believe that wearing
sunscreen will not prevent the occurrence of skin cancer.

21
Perceived barriers: Health-related behaviors are also a function of perceived barriers to taking
action. Perceived barriers refer to an individual's assessment of the obstacles to behavior change,
even if an individual perceives a health condition as threatening and believes that a particular
action will effectively reduce the threat, barriers may prevent engagement in the health-
promoting behavior. In other words, the perceived benefits must outweigh the perceived barriers
in order for behavior change to occur. For instance, lack of access to affordable health care.

Self-efficacy: Self-efficacy refers to an individual's perception of his or her competence to

successfully perform a behavior. Self-efficacy was added to the health belief model in an attempt
to better explain individual differences in health behaviors. The model was originally developed
to explain engagement in one-time health-related behaviors, developers of the model recognized
that confidence in one's ability to effect change in outcomes i.e. self-efficacy is a key component
of health behavior change.

The health belief model has been used to develop effective interventions to change health-related
behaviors by targeting various aspects of the model's key constructs. Interventions based on the
health belief model may aim to increase perceived susceptibility to and perceived seriousness of
a health condition by providing education about prevalence and incidence of disease,
individualized estimates of risk and information about the consequences of disease e.g. medical,
financial, and social consequences. Interventions may also aim to alter the cost-benefit analysis
of engaging in a health-promoting behavior i.e. increasing perceived benefits and decreasing
perceived barriers by providing information about the efficacy of various behaviors to reduce
risk of disease, identifying common perceived barriers, providing incentives to engage in health-
promoting behaviors and engaging social support or other resources to encourage health-
promoting behaviors. Furthermore, interventions based on the health belief model encourage
individuals to engage in health-promoting behaviors such as changing diet or physical activity,
working one-on-one with individuals to increase engagement in health-related behaviors.

The constantly growing awareness about sickle cell disease helps change the behaviors of the
family and the patients toward that feeling of being discriminated or stigmatized, instead they
gain their confidence through social and psychological support that ease their tension and
thinking and become more focus on what triggered their problems, i.e. the patient or parents

22
should avoid negative thinking like feeling threat or vulnerability to crisis/illness, the patient or
parent’s beliefs about the severity of the illness, they should have a positive expectation by
taking recommended action, i.e. their perception of the benefits associated with action is to get
well and reduce the level of vulnerability, believed that there is success taking recommended
action i.e. the evaluation of potential barriers associated with propose action.

In view of the above, the concepts of perceived susceptibility is the patient’s view of his/her
vulnerability to the illness, perceived severity is the patient’s belief about the severity of the
illness which may be defined in terms of physical or social disability, perceived benefits is the
patient’s perception of the benefits associated with actions is to get well or reduce the level of
threat or vulnerability, perceived barriers is the patients estimates on physical, psychological,
financial and other costs are overweighed by the benefits resulting from adopting the health
behavior, while the concept of self-efficacy refers to one’s confidence in the ability to
successfully perform an action was however added to these constructs by Rosenstock and others
in 1988 to help the Health Belief Model better fit the challenge of changing habitual unhealthy
bahaviours. The basic argument of this theoretical model is that an individual’s attitude and
beliefs direct his/her line of action in health seeking (preventive and curative). It also assumes
that motivation is a necessary condition for action and focuses on the focus and variables whose
interplay determines the decision to seek or not to seek health care and from what sources to
seek, but then the motivational level of the individual is the overriding factor behind the decision
to use preventive medicine, which is the pro-healthy behavior to ensure healthy life through
preventive action.

To relate this model with the topic of study is the motivation of parent's experience and
knowledge on the care and treatment of sickle cell disease which helps the children/patients lives
healthy life and carries an important value determinant that the child survival without any
crisis/pains reduces the level of feeling vulnerable of disease and gain self-confidence and happy
life.

Criticism

23
The theory lack explanation of how people with severe mental illness deal with fear associated
with seeking medical care. E.g. people with severe mental illness face increased stigma and often
hold a fear of hospitalization. The theory also lack explanation of availability and monetary
access to care, i.e. many people with severe mental illness lack medical insurance or denied
insurance coverage due to frequent occurrence of their condition.

The health belief model attempts to predict health-related behaviors by accounting for individual
differences in beliefs and attitudes. However, it does not account for other factors that influence
health behaviors. For instance, Environmental factors outside an individual's control may prevent
engagement in desired behaviors. For example, an individual living in a dangerous neighborhood
may be unable to go for a jog outdoors due to safety concerns. Furthermore, the health belief
model does not consider the impact of emotions on health-related behavior. Evidence suggests
that fear may be a key factor in predicting health-related behavior. (Christopher et al, 2010). 

2.6.3 Sick role theory

Sick role is a term used in medical sociology regarding sickness and the rights and obligations of
the affected. It is a concept created by American sociologist Talcott Parsons in 1951. Parsons
was a functionalist sociologist, who argued that being sick means that the sufferer enters a role of
'sanctioned deviance'. This is because from a functionalist perspective, a sick individual is not a
productive member of society. Therefore, this deviance needs to be policed, which is the role of
the medical profession. Genuinely, Parsons argued that the best way to understand illness
sociologically is to view it as a form of deviance which disturbs the social function of the
society.

The general idea is that the individual who has fallen ill is not only physically sick but now stick
to the specifically patterned social role of being sick. ‘Being Sick’ is not simply a ‘state of fact’
or ‘condition’ it contains within itself customary rights and obligations based on the social norms
that surround it. The theory is a way of explaining the particular rights and responsibilities of
those who are ill, since those who are diagnosed with a medical condition cannot always fulfill
the same duties that a person in good health can, society adapts to this situation and allows for a
reasonable amount of deviation from behavior that would be viewed as typical of a well person.

24
Parsons saw the sick role as a form of deviance, or going against societal expectations, because
an ill person has different patterns of behavior than the norm. He argued that people are
generally expected to be productive members of society. However, if an ill person is not able to
carry out his or her usual duties, such as work in an office, go to school or care for family
members, this deviance from the usual is positively sanctioned, or approved by the community or
authority figures. For instance, if you don't show up for school, teachers and administrators will
see this as deviant, but if it is because you are sick in bed, they will allow your absence. For the
deviance to be sanctioned, a medical expert, such as a doctor, must certify that a person is
actually ill, a process that legitimates their illness.  movies.

Parsons describes two rights and two responsibilities that an ill person has: a patient has a right
not to be blamed for the illness and a right to be given some leeway by others in regards to
normal obligations. However, a patient has the responsibility (obligations) to make getting well a
priority and the obligation to seek appropriate treatment for his or her condition. These rights and
responsibilities may be in effect only during a certain period while a person is ill and so may be
temporary. The specific of these expectations will vary depending on the seriousness of an
illness and how much the condition interferes with everyday life.

In relation to sickle cell disease, sick role theory explaining the particular rights and
responsibilities of those who are ill, since those who are diagnosed with a medical condition
cannot always fulfill the same duties that a person in good health can, society adapts to this
situation and allows for a reasonable amount of deviation from behavior that would be viewed as
typical of a well person. Parsons saw the sick role as a form of deviance or going against societal
expectations because an ill person has different patterns of behavior than the normal. He argued
that people are generally expected to be productive members of society, however, if an ill person
is not able to carry out his or her usual duties such as work at office or go to school or care for
family members, this deviance from the usual is positively sanctioned or approved by the
community or authority figures. For instance, if a sickle cell child don't show up for school,
teachers and administrators will see this as deviant, but if the child is in pain because of the
disease and the parent reported the child sickness to school authority, they will allow his/her
absence and for the deviance to be sanctioned, a medical expert (doctor) must certify that a
person is actually ill, a process that legitimates their illness. Legitimization is proof that the

25
person is truly sick and in need of a more lenient set of expectations. This is the equivalent of a
doctor's note that the parent could take to school to prove that the child didn't simply skip classes
for no reason.

The two rights and two responsibilities that an ill person has, shows that a patient has a right not
to be blamed for his/her illness and a right to be given some leeway by others in regard to normal
obligations. However, a patient has the responsibility to make getting well a priority and the
responsibility to seek appropriate treatment for his or her condition. These rights and
responsibilities may be in effect only during a certain period while a person is ill and so may be
temporary, the specifics of these expectations will vary depending on the seriousness of an
illness and how much the condition interferes with everyday life, though in chronic illness acting
the sick role is less appropriate and less functional for both individual and social system.
(Burnham, 2014). 

Criticism

One challenge with Parsons' theory is that it does not specifically apply to those with chronic
conditions that are not likely to improve. For instance, as a person with sickle cell disease
fulfilling one of the obligations could be difficult as they are mostly sick and sometimes it takes
long time before healing which if it is a wish, they would have prefer to be healthy and energetic
like any other person without chronic illness.

Feminists have also criticised Parsons’ theory of the sick role. Ann Oakley (1974) suggested that
the rights of the sick role were not afforded to women in the same way they are for men. When a
woman is ill they are rarely excused from their ‘normal social role’ of being the housekeeper/
mother. Also in his theory there is no provision for working class mothers when their children
are sick.

Weberian theorist Elliot Friedson (1970) found in his studies that when people become ill, they
on average ask the opinion of a dozen friends and family members before approaching a doctor.
Friedson called these ‘lay-referrals’ and claimed that gaining access to the sick role was not just
legitimized by a doctor but others around, the patient needed to be convinced that the individual
really was ill. Friedson highlights one of the biggest problems with Parsons’ theory, which is that

26
it only takes into account acute illnesses and not long-term chronic illnesses and disabilities.
(Davis 1999). 

27
 SECTION THREE

METHODOLOGY

3.1 Introduction

This section contains a brief historical background of the area of study and the method of data
collection and analysis, the target population of the study, sampling techniques and sample size
all of which are explained.

3.2 A brief history of the study area

Kano state is a state located in northern Nigeria (North West), created on 27 may, 1967. The
state consist of 44 Local governments, it’s the commercial nerve centre of northern Nigeria and
is the largest city in Nigeria according 2006 PON census. Kano is the second-largest industrial
centre after Lagos state in Nigeria and the largest in northern Nigeria with textile, footwear,
cosmetics, plastics, enamelware, pharmaceuticals, ceramics, furniture, agricultural implements,
soft drinks, food and beverages, dairy products, vegetable oil, animal feeds, schools, private and
government hospitals and a teaching hospital that is well known with modern and advance
medical facilities. The official language of the State is Hausa language.

Aminu Kano Teaching Hospital (AKTH) is a tertiary Government Teaching hospital located in
Kano State, Nigeria. AKTH was established in August, 1988 when the Kano State Government
formally handed over the then Aminu Kano Cottage Hospital to the Federal Government to be
used as a Teaching Hospital. The hospital which temporarily started operation at Murtala
Mohammed Specialist Hospital moved to its permanent site in 1996. Today the hospital has
grown to be a full 500 bedded Teaching hospital with some modern equipment and facilities. Its
core function is service delivery i.e. Teaching and Research. The hospital has a staff strength of

28
two thousand four hundred out of which over one hundred are consultants in various specialties.
The hospital recorded success over years including being the first government hospital to
perform a successful kidney transplant in the year 2002. (Kurawa, 2003).

3.3 Target population

The target population of this study are parents/guardians of children attending one of the
pediatric department’s unit: hematology (sickle cell) clinic of AKTH which is a weekly clinic for
children with sickle cell disease, each weekly clinic conduct routine check-up for different set of
patients with an average of one hundred and thirty patient as the clinic is based on appointment
from the patient’s consultant for review/check-up, and the appointment time could be long or
short depending on the patient’s condition.

3.4 Research design

This research is going to use descriptive method to study the influence of socioeconomic status
of parent on the care and treatment of children with sickle cell disease in one of the pediatric
Unit (sickle cell clinic) of Aminu Kano Teaching Hospital, Kano, Nigeria.

3.5 Population of the Study

According to AKTH 2018 database the pediatric hematology unit (sickle cell clinic) has one
thousand eight hundred and fifty patients as one of every ten birth of the babies per month has
sickle cell disease. Base on the database, this study will sample two hundred and eighty
respondents and selection is from every clinical day, the target groups for the research study are
different parents/caregivers of children with sickle cell disease. The researcher will also seek the
consent of each of the respondent and explains everything about the research both verbally and
in writing in order for the respondent to know fully what he/she is going to participate after
seeking the management permission.

3.6 Sample size

29
This study is going to use availability sampling technique as there is no chance of choosing the
respondents for interview randomly but to only those who are available and willing to
participate. Purposive sampling will be use for selection of 280 respondents for IDI.
Questionnaires will be distributed to 280 respondents.

3.7 Method of Data Collection

The research is going to use primary sources of data collection to gather relevant information
concerning the topic of the research and the instrument to be use are questionnaire and face to
face interview since the topic is directly to first hand information, which will cover what the
researcher is interesting in the topic.

The questionnaire is going to be administered in English and to be translating in Hausa for those
who cannot read English. IDI will also be conducted with 280 parents/guardian to be selected by
using purposive sampling, this will provide a degree understanding of their personal and income
socioeconomic expenses on the treatment of their children with sickle cell disease. The
questionnaire will contain both open and close ended questions.

3.8 Method of Data Analysis

Both quantitative and qualitative methods of data analysis will be used. For the qualitative,
frequencies and percentages will be used and for the quantitative, representative and narrative
methods will be used as appropriate.

30
References

An article ‘why sociologist abandon the sick role theory’ by Burnham, 2014.

An article about sickle cell disease by Qaise et al, 2002. www.pdfdrive.net

An article on social conflict theory by Amir Hossein Randgbar, M.S. Philosophy & Literature,
University of Tehran (1991).

Adeolu and Olaide (2012), Health related quality of life and perception of stigmatisation in
adolescents living with sickle cell disease in Nigeria: A cross sectional study. Pediatric Blood &
Cancer, 62: 1245–1251. doi:10.1002/pbc.25503.

Bloom M.1995, Understanding Sickle Cell Disease. Mississippi University Press.

Boss, P & Mulligan C.2003. Family Stress. Sage Publication.

Bradford, R.1997. Children, Families and Chronic Disease. London and New York Routledge.

Brunner &Suddath. 2004. Textbook of Medical surgical Nursing, 10th edition USA. Lippincott
Williams & Wilkins.

Bradley, Robert (2002). "Socioeconomic Status and Child Development".  Annual Review of
Psychology. 53: 371–399. doi:10.1146/annurev.psych.53.100901.135233. PMID 11752490.

Canary, D, Cody, M., &Manusov, V. (2008). Interpersonal communication: A goals-based

approach. Boston, MA: Bedford/St. Martin’s.

31
 Carpenter, Christopher J. (2010). "A meta-analysis of the effectiveness of health belief model
variables in predicting behavior". 

Davis, H.1993. consulting parents of children with chronic illness or disability.

Dr Bosede Afolabi (2010) Burden of Health-Care of Carriers of Children with Sickle Cell
Disease in Nigeria. Health & Social Care in the Community, 18, 289-295.

 Davis (1999). Oxford Textbook of Psychopathology

Field, P.A, Morse J.M. 1989. Sociological Perspectives on Health, Illness and Health Care.
Blackwell Science.

Ferrante, Joan (2007-10-24). Sociology: A Global Perspective. Cengage Learning. ISBN

0495390917.

Griffith W.2007 Complete Guide to symptoms and illness. 5th edition USA.

Health Communication. 25(8): 661669. doi:10.1080/10410236.2010.521906. PMID 21153982.

Hochschild, Arlie (2003). The Managed Heart: Commercialization of Human Feeling.

University of California Press. pp. 214, 218, 224. ISBN 978-0520239333.

Haralambos, Holborn (1995). Sociology: Themes and Perspectives. Hammersmith:

HarperCollins. p. 37. ISBN 000 3223167.

https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0145401

by E Quansah - 2016 

Haralambos, Holborn (1995). Sociology: Themes and Perspectives. Hammersmith:

HarperCollins. p. 37. ISBN 000 3223167.

32
"How Is Sickle Cell Disease Diagnosed?". National Heart, Lung, and Blood Institute. June 12,
2015. Archived from the original on 9 March 2016.Retrieved 8 March 2016.

"How Is Sickle Cell Disease Treated?". National Heart, Lung, and Blood Institute. June 12,
2015. Archived from the original on 9 March 2016.Retrieved 8 March 2016.

Hill, S.A 1994. Managing Sickle Cell Disease in low-income families. Philadelphia: Temple
University.

Hitchcock, J.A, Schubert, P.E & Thomas S.E. 2002. Community Health Nursing: caring in
action 2nd edition. Thomson Delmer learning.

Ibrahim Ado Kurawa (2003). "Brief History of Kano 999 to 2003

Janz NK, Becker MH. The Health Belief Model a decade later. Health Educ Q 1984; 11:1- 47.

Kotila 2012, an article “living with sickle cell diseae”

Lindeboom, M., Llena-Nozal, A., & van der Klaauw, B. (2009). Parental education and child
health Gachathi Multilingual Academic Journal of Education and Social Sciences 2015, Vol. 3,
No. 1 ISSN: 2308-0876 114 www.hrmars.com/journals (1976)

Muscari, M.E 2005. Pediatric Nursing 4th edition Lippincott Williams and Wikkins.

Max-Planck-Gesellschaft, (2016)
www.sciencedaily.com/releases/2016/04/160412104810.htm

Marx, Karl. 1971. Preface to A Contribution to the Critique of Political Economy, Tr. S. W.
Ryanzanskaya, edited by M. Dobb. London: Lawrence & Whishart.

Mitchell and M.J. (2007) Parent Perspectives on Pain Management, Coping, and Family
Functioning in Pediatric Sickle Cell Disease. Clinical Pediatrics, 46, 311-319.
https://doi.org/10.1177/0009922806293985

Nash, KB. 1994. Psychological aspects of sickle cell disease: past, present and future. New
York, the Haworth press.

33
Predictive model and determinants of under-five child mortality, an article by Lubotsky and
Paxson (2002).

and national causes of child mortality in 2008: a systematic analysis,

Lancet, 2010 375: 1969-1987. 10.1016/S0140-6736(10)60549-1.

Regional

Socioeconomic status, poor health in childhood and human capital development

(Currie, J.2009.) Journal of Economic Literature 47 (1), 87–122.

"Sickle-cell disease and other haemoglobin disorders Fact sheet N°308". January 2011.
Archived from the original on 9 March 2016.Retrieved 8 March 2016.

Stretcher, Victor J.; Irwin M. Rosenstock (1997). "The health belief model". In Andrew Baum.
Cambridge handbook of psychology, health and medicine. Cambridge, UK: Cambridge
University Press. pp. 113–117. ISBN 0521430739.

Weber, Max (1978-01-01). Economy and Society: An Outline of Interpretive Sociology.

University of California Press. ISBN 9780520035003.

"What Are the Signs and Symptoms of Sickle Cell Disease?". National Heart, Lung, and Blood
Institute. June 12, 2015. Archived from the original on 9 March 2016.Retrieved 8 March 2016.

"What Is Sickle Cell Disease?". National Heart, Lung, and Blood Institute. June 12, 2015.
Archived from the original on 6 March 2016.Retrieved 8 March 2016.

"What Causes Sickle Cell Disease?". National Heart, Lung, and Blood Institute. June 12, 2015.
Archived from the original on 24 March 2016.Retrieved 8 March 2016.

Wikkinson, I. 1998. Child and Family Assessment: clinical guidance for practitioners, 2nd
edition London New York.

34
Wonkam, A., et al. (2014) Psychosocial Burden of Sickle Cell Disease on Parents with an
Affected Child in Cameroon. Journal of Genetic Counseling, 23, 192-201.

Young and Koopsen Abdelaziz Y. (2005, p231-232). Textbook of clinical pediatrics (2 ed.).
Berlin: Springer. p. 2950.ISBN 9783642022012.

https://doi.org/10.1007/s10897-013-9630-2

https://www.afro.who.int/health-topics/sickle-cell-disease

www.cdc.ng.com

PDHPE (2013)https://www.pdhpe.net/the-3-in-24-principle/

Zondervan(2010) July 31 in the journal Child Development

35