PREVALENCE AND RISK FACTORS OF SELF REPORTED GASTRITIS AMONG UNIVERSITIES STUDENTS IN HARGEISA SOMALILAND: cross sectional study (Preprint)

Abstract

Background Gastritis is one of the most common and insidious diseases in human beings; hundreds of millions of people worldwide suffer from this inflammatory condition (Maaroos 1. P.-I., 2015). Globally, about 2.7 million people around the world are affected with gastritis (Mohamed Naveed, 2016). 50.8% of the populations in developing countries suffer from gastritis. With a lower, 34.7% of the population in developed countries had health problems due to gastritis (Marcis L O. S., 2018). Compared with developing countries, the prevalence rate of gastritis markedly decreased in developed countries. However, it has remained as a major health problem (Liu Q, 2019). A systematic review of African countries indicated 38% of women and 18% of men suffered from gastritis. In Kenya, among patients who visited health care institutions, 73.3% of children and 54.8% of adults diagnosed clinically as they had gastritis. Similarly, in Uganda, 44.3% of young people less than the age of 12 years were suffering from gastritis. Furthermore, in Nigeria, 40.7% of children with an age range from 6–10 years had gastritis (Smith S, Infections with Helicobacter Pylori and Challenges Encountered in Africa., 2019). A previous study, a total of 145 gastritis students were recruited. The proportion of male and female gastritis students was 63.4% and 36.6% respectively (Alebie G, 2016). There is not much information available about gastritis and related conditions, including the risk factors and the prevalence of gastritis, which is a gap according to this study in Somalia it is reported that 44.1% of patients visiting the health facility had gastritis (Bulur, 2018). However, research on dietary factors affecting gastritis in chronic gastritis patients are rarely conducted in Somaliland that’s why focus in gastritis in universities to know risk factors of gastritis among students. Most studies highlight the dietary factors of patients already suffering from gastric, and few studies focus on their precursors. Moreover, dietary factors as a serious influence are largely underrated in symptomatic gastric patient, and correlation analysis between different symptoms and dietary factors is insufficient. Although there is no clear evidence showing a causal relationship between certain dietary intake and the occurrence of gastric, and there is no large study on the efficacy changes in dietary habits and lifestyle adjustment are part of the treatment of gastritis (Tsukamoto T. N. M., 2017). Diet or food consumption are the types and quantities of food consumed by a person or group at a certain time, students are Unpaid because they found that during university the students generally had unhealthy lifestyles such as lack of attention to food consumed both diet and food types. Providing a variety of foods is very influential, because that can cause boredom, reduce appetite and prefer fast food (Kiela, 2016). In Somaliland acute gastritis is common (SLHDS, 2020) Along these lines, to the best of my knowledge, Limited studies in Somaliland clearly identify the prevalence of gastritis which is either acute or chronic in university students and dietary related factors with gastritis, Cognizant of such gaps and limited evidence in the study setting, the present study aim to identify the risk factors that stimulating self-reported gastritis, and identifying individual self-management. Further, this study contributes by adding dietary factors affects gastritis. While many studies have been done on the factors of gastritis in general, this study was mainly focus risk factors and dietary way contribute in gastritis. 1.2 Problem statement The World Health Organization declared that each year approximately a million people lose their lives due to gastritis worldwide. From records on NCDs (Non-Communicable Diseases) in Somalia, gastritis is seen to be one of the major diseases 44.1% is reported among all patients presented with Gastritis in self- reported. The adolescence student it is a time of critical growth since most of them are in the period of adolescence or adulthood. Adolescents are at a particular nutritional risk because unhealthy life styles and unhealthy dietary management tend to put this category at most risk and other way it can be worsen in ulcer and hospitalized so its problem to continue their education, also it may affect their educational performance and attendance to come in class (Kingsley, 2014). In the western population, there is evidence of declining incidence of infectious gastritis caused by H. pylori with an increasing prevalence of autoimmune gastritis, gastritis is more common in women and older people. The prevalence is estimated to be approximately 2% to 5%. However, the available data do not provide solid information about the incidence and prevalence of autoimmune gastritis, chronic gastritis is still a relatively common disease in developing countries. The prevalence of gastric in children in the western population is approximately 10%. In developing countries, the prevalence of gastric varies depending on geographical region, and socioeconomic conditions. It is approximately 69% in Africa, 78% in South America, and 51% in Asia. The prevalence of H. pylori infection of children in developing countries is higher than 50% (Coati I, 2015) A non-communicable disease (NCD) such as gastritis and its related disability has put an increasing strain on health systems, economic development and the well-being of large parts of the population. Consequently, NCDs are one of the major challenges for sustainable development in the 21st century and are the leading cause of death globally, the situation is still alarming in that it is the WHO region with the highest burden of NCDs. Action is necessary across all sectors and settings to mitigate, prevent and control NCDs. If linear trends continue, the European Region was exceed the target of reducing NCD by one third by 2030. It is proposed that the Region should aim to reduce premature mortality from NCDs by 45% or more between 2010 and 2030 as part of an accelerated effort (WHO, 2017) Previous study in other context shows that the Factors that can increase the risk of gastritis include bacterial infection such as Helicobacter pylori (H. pylori), the risk factors like smoking, spicy and citrus foods, NSAIDS and stress can lead to excessive gastric secretion and ruptured the stomach mucosal lining. Some other study shows that changes in lifestyle patterns can be significant in the development of gastritis. Ageing also can increase the risk of gastritis as the stomach lining tends to get thin. A proper stress management is significant as it is one of the major causes of gastritis among university students. The factors like pressure and excess freedom give a gate to achieve lifestyle changes through smoking, fast and spicy food which influence the occurrence of gastritis (Jannathul F, 2016). Despite the available knowledge, there’s limited studies in Somaliland report in gastritis and their dietary related factors and it is a gap to manage that diseases and change of behavior of dietary intake, thus study was focus on the prevalence of self-reported gastritis and dietary related factors and also self-care management among university students in Hargiesa Somaliland. 1.3 objectives 1.3.1 General objectives To assess the Prevalence and risk factors of self-reported gastritis among university students in Hargiesa, Somaliland 1.3.2 Specific objectives 1. To determine the prevalence of self-reported gastritis among university students in Hargeisa, Somaliland 2. To determine the dietary related factors associated with self-reported gastritis among university students in Hargeisa, Somaliland 3. To find out the self-care management of self-reported gastritis among university students in Hargeisa, Somaliland. 1.4 Research questions 1. What is the prevalence of self-reported Gastritis among University Students in Hargiesa, Somaliland? 2. What are the dietary related factors associated with self-reported Gastritis among University Students in Hargeisa, Somaliland? 3. What is the self-care management of self-reported gastritis among University Students in Hargeisa, Somaliland? 1.5 Significance of the study The findings in this study may be useful to students in university, health care planners, as they have empirical evidence of the level of students, and factors influencing gastritis among university students. This may prompt them to work on improving their diet habits and knowledge about gastritis. Such action may enhance the prevention of gastritis. The findings would create awareness of diet in relation to risk factor of gastritis, especially University students. The result of this study allows also an orientation for further research in this field. 1.6 Limitation of the Study The fact that only a group of students in selected in university students were Included in the study was limitation. The students who participated in this study were selected only in hargiesa city. This study was based on cross-sectional data, the causal relationship was not determined. Confidence interval and margin of error could also be a limitation. 1.7 Scope of study 1.7.1 Geographical scope This study were carried out in selected universities in marodijex district in hargiesa Somaliland, it has a lot of universities but this study focuses on 2 or 3 universities in hargiesa Somaliland according to limited time. 1.7.2 Time scope Data were collect at one point in time. The study period were begin 3-4 months starting from February to June 2021. 1.7.3 Content scope This study was based on the prevalence of self-reported gastritis and dietary factors associated and self–care management. 1.8 Operational framework To make clear the study variables and how they were used in this study, the researcher developed the operational framework, which provided details on the study variables. Its hypothesized used the evidence from literature review (Kingsley, 2014). That dietary related factors and self-management are among the key factors that can influence the gastritis in university students in hargiesa city, Somaliland. That can lead increasing the prevalence, it’s also hypothesized that the interaction between dietary factors and self-care management can contribute to the prevention and management of gastritis among the students in university in hargiesa/Somaliland. There for the causes of gastritis is classified much more, so this study aims to focus the prevalence, risk factors in dietary way and their self-management in university student in hargiesa city. Independent variable dependent variable Figure 1.1: operational framework showing factors influence gastritis.

objectives 1.3.1 General objectives To assess the Prevalence and risk factors of self-reported gastritis among university students in Hargiesa, Somaliland 1.3.2 Specific objectives 1. To determine the prevalence of self-reported gastritis among university students in Hargeisa, Somaliland 2. To determine the dietary related factors associated with self-reported gastritis among university students in Hargeisa, Somaliland 3. To find out the self-care management of self-reported gastritis among university students in Hargeisa, Somaliland.

Study Area The study was conducted in selected universities in hargiesa Somaliland, There are approximately 9 universities (Golis, Hargiesa University, Admas, Fands-Farnon, Addis Ababa, Edna, Alpha, Beder, and New Generation) in the city, with an average of 50,000 students. They are located in Hargeisa in various regions such as Jigjiga yer, bebsi and sinay region, they offer a variety of faculties including various medical disciplines, arts, Islamic law, Islamic banking, and online courses, as well as diplomas and certificates. 3.2 Study Setting This study was conducted with selected 2 universities by using simple Radom (lottery method) which was give us a good representation of the universities in hargeisa city, which name Golis University and Hargiesa University. 3.3 Study Population The target population in this study was the university students, the universities is 2 universities at golis and Hargiesa University located in the Pepsi area and tima-ade area. 3.4 inclusion and exclusion Inclusion criteria was students in 2 universities that have been selected. Exclusion criteria was those who is not health science and in fresh year. 3.5 Study Design A cross-sectional study design using quantitative methods was gathered in this study to assess the prevalence and risk factors influencing Gastritis among university students in selected universities in Hargeisa, Somaliland. 3.6 Data Collection Method The research instrument was a self-administered questionnaire with close ended questions which comprised two parts. Part I deity related factors of gastritis, Part II self-care management. Questionnaires were preferred because they were reliable, relatively cheap and quick means of collecting data from a high population in a reasonable period. They also offer anonymity and increase accuracy in case of required sensitive information and target population. The questions are uniform; each respondent received the same set of questions. The questionnaire were tested and adjusted before it is fully certified for use. The researcher ensured that he was present at the site and also cross checked all questionnaires for completeness and correctness. Thereafter, all the filled in instruments were collected and kept safe. 3.7 Study Period This study is the prevalence and risk factors of self-reported gastritis among university students, the study was conducted two weeks in june 2021. 3.8 Sample Size Determination The sample size is 300 main respondents was selected according to the sloven formula. It shows that when the population size in 2 universities specially in health science departments is approximately 1300 of students 95% confidence with a margin of error of 5.0%. Therefore a sample size of 300 students were randomly selected from the total population to participate in the study. Using solvent formula of calculating the sample size to proportions, the appropriate sample size based on the total number of students. n = N/1+N (e) 2 = 1300/1+1300(0.05)2 = 1300/1+1300 (0.0025) = 1300/1+3.25 = 1300/4.25 = sample size = 300 3.9 Sampling Method Multistage sampling procedure were used to select respondents. Who met the study inclusion criteria in each class for the two universities this gave a good representation of the population of the two universities. 3.10 Data Analysis Quantitative data were enter in IBM SPSS 20 data were cleaned by running frequencies of all the variables to check for incorrectly coded data, incorrectly coded data were begin double checked with raw data in the questioner and corrected. Statistical methods were used to analysis the data collection such as descriptive statistics, for example numerical summation, graphs, and tables. The analysis software performed using the data was a statistical package for social science. 3.11 Ethical Consideration The researcher undertook to observe all relevant ethical and legal consideration that applicable to scientific research and I got the consent from the principle of hargeisa university before the study also permeation is got from head of that two universities, data were collected by respecting the right of the students and not harming anyone this research is beneficial for students to identify the problem of students towards the self-reported gastritis to find solution about that problem, all information obtaining in the course of study was being treated with almost confidentiality and not be used outside of scope of study. Which seek to protect the identity of the research subject against potential abuse /stigmatization. 3.12 Plan for Result Dissemination The finding of the study were presented to the University Of Hargiesa. It were also be disseminated through presentation in different professional association meeting and annual conference. The paper were also be submitted to national or international peer reviewed scientific journal for possible publication. 3.13 Study Variable Dependent variable: the dependent variable in this study is presence of self-reported gastric among students. Independent variables: the possible independent variables in this study include dietary habit included increasing salt intake, irregular meal time, spicy food, fast food and also possible independent variable is low self-management 3.14 validity and reliability Validity These questionnaire were then passed into the supervisors for further scrutiny before they were administered in the field. Direct translation from English to Somali was done by class teachers to explain the Questionnaire items to the students. Twenty students from one university not necessarily randomly selected were used for testing the research instruments. Reliability Since questionnaire was constructed by the researcher, the estimation of reliability was Ascertained by pilot testing the instrument and applying Cranach’s Alpha coefficient by Means of a statistical Package for Social Sciences. Cronbach’s Alpha coefficient were being Used to measure internal consistency of the research tool. Then the instrument was considered reliable because Cronbach’s Alfa was 0.8. CHAPTER

Demographic characteristic of respondents Most of the participants that had gastritis (57%) and did not have gastritis (51%) were females Majority of the participant that had gastritis (82%) and did not have gastritis (85%) were single. In occupation the majority (73.7%) were self-employed and had gastritis, nearly (66%) self-employed had no self-reported gastritis. Participants. Most of the respondents with self-reported gastritis (90%) and without gastritis (80%) were aged between 20 – 29 years. Majority with both self-reported gastritis (93%) and with no gastritis (92%) came from middle income families. Table 4.1: Socio-demographic characteristic of respondents Variable Gastritis Total Gender Yes No Male 69 (42.6%) 68 (49.3%) 137 (45.7%) Female 93 (57.4%) 70 (50.7%) 163 (54.3%) Marital status Single 132 (81.5%) 117 (84.8%) 249 (83.0%) Married 29 (17.9%) 21 (15.2%) 50 (16.7%) Divorced 1 (0.6%) 0 (0%) 1 (0.3%) Occupation Public employee 18 (11.1%) 15 (10.9%) 33 (11.0%) Private employee 26 (16.0%) 32 (23.2%) 58 (19.3%) Self-employee 118 (73.7%) 91 (66.0%) 209 (69.7%) Age <20 years 6 (3.7%) 9 (6.5%) 15 (5.0%) 20 – 29 years 149 (92.0%) 122 (88.4%) 271 (90.3%) ≥30 years 7 (4.3%) 7 (4.3%) 14 (4.7%) Educational level First year 15 (9.3%) 18 (13%) 33 (11.0 %) Second year 48 (29.6%) 52 (37.7%) 100 (33.3%) Third year 58 (35.8%) 44 (31.9%) 102 (34.0%) Fourth year 41 (25.3%) 24 (17.4%) 65 (21.7%) Family income Lower income 8 (4.9%) 5 (5.6%) 13 (4.3%) Middle income 150 (92.6%) 127 (92%) 277 (92.3%) High income 4 (2.5%) 6 (4.3%) 10 (3.3%) 4.2. Prevalence of Self- Reported Gastritis in University Students From the total respondents of university students 54% had self-reported gastritis. Figure 1 below shows the prevalence of self-reported gastritis among University students Figure 1 Prevalence of Self- Reported Gastritis in University Students 4.3 Dietary Factors Related with Self-reported Gastritis in University Students The study showed that majority of the respondents that reported to have gastritis (56%) did not take snacks between meals while 58% that reported they did not have gastritis took snacks between meals. There was a statistical significance between taking snacks and self-reported gastritis (p=0.021). Majority of the respondents with gastritis (51%) skipped morning breakfast, while 59% of those without gastritis did not skip morning breakfast. Majority of the respondents (73%) with no gastritis were taking food with high fat, while only 59% with self-reported gastritis took food with high fat. There was a statistical significance between taking high fat and reported gastritis (p=0.015). Nearly 33% of respondents with gastritis had taken spicy food while 26% with no gastritis took carbonated drinks. Table 4.2 shows the dietary factors related with self-reported gastritis among University students. Table 4.2 Dietary Related with Self-reported Gastritis in University Students Variables (Dietary) GASTIRITS P value Yes No Snack between meals 0.021 Yes 72 (44.4%) 80 (58%) No 90 (55.6%) 58 (42%) Skip morning breakfast 0.104 Yes 82 (50.6%) 56 (40.6%) No 80 (49.4%) 82 (59.4%) High fat consumption 0.015 Yes 96 (59.3%) 101 (73.2%) No 66 (40.7%) 37 (26.8%) High salt consumption 0.160 Yes 73(45.1%) 51 (37%) No 89 (54.9%) 87 (63%) Type of food to eat 0.197 Citreous food 24 (14.8%) 22(15.9%) Spicy food 53 (32.7%) 31 (22.5%) Fatty food 23(14.2%) 29 (21%) Fried food 28 (17.3%) 20 (14.5%) Carbonated drink 34 (21%) 36 (26.1%) Drinking coffee 0.546 Yes 100 (62.1%) 91 (65.9%) No 61 (37.9%) 47 (34.1%) Eating fast food 0.350 Yes 86 (53.4%) 82 (59.4%) No 75 (46.6%) 56 (40.6%) 4.4 Self-Management of Self-Reported Gastritis Most of the respondents (55%) who self-reported gastritis and nearly 51% without gastritis do not visit the hospital when they feel symptoms. Majority of the respondents (51%) who had chest pain self-reported gastritis more than those without gastritis (1%). There was a statistical significance observed between symptoms and reporting gastritis (p=0.000). Majority of the respondents (63%) that reported gastritis and 57% that did not report gastritis took medication to reduce the symptoms felt. Sixty percent (60%) that did not report gastritis and 57% that self-reported gastritis knew that reducing spicy food managed gastritis. Table 4.3 shows results of variables related to self-care management related to gastritis. Table 4.3 Self-care management related to gastritis Variables Self-reported Gastritis P value Going hospital when feel symptoms Yes No Yes 73 (45.3%) 67 (48.6%) 0.642 No 88 (54.7%) 71 (51.4%) Going to pharmacy Yes 93 (57.4%) 68 (49.3%) 0.165 No 69 (42.6%) 70 (50.7%) Symptoms feel Chest pain 82 (50.6%) 2(1.4%) 0.000 Feeling fullness 57 (35.2%) 2 (1.4%) Nausea and vomiting 22 (13.6%) 0 (0.0%) To reduce take medication Yes 102 (63%) 79 (57.2%) 0.344 No 60 (37%) 59 (42.8%) Reducing spicy food Yes 90 (55.6%) 83 (60.1%) 0.482 No 72 (44.4%) 55 (39.9%) Reducing fried and fat foods Yes 89 (54.9%) 73 (52.9%) 0.729 No 73 (45.1%) 65 (47.1%) Cutting back on coffee Yes 72 (44.4%) 60 (43.5%) 0.762 No 90 (55.6%) 77 (55.8%) Eating smaller meal through the Day Yes 76 (46.9%) 71 (51.4%) 0.487 No 86 (53.1%) 67 (48.6%) Managing stress Yes 96 (58.6%) 88 (63.8%) 0.406 No 67 (41.4%) 50 (36.2%) Not lying down for 2 to 3hrs after meal Yes 92 (56.8%) 73 (52.9%) 0.561 No 70 (43.2%) 65 (47.1%) CHAPTER FIVE: DISCUSSION RECOMMENDATION AND CONCLUSION 5.1 Discussion The prevalence of gastritis among the study participants was 54 %, with 57% females and 43% males respectively. The results indicated a higher number of women were suffering with gastritis than men. In comparison to studies conducted this result agrees with the studies conducted by Smith et al. Jannathul et al. and Agbor et al. showed that with prevalence of 47.0% for males and 47.5% for females, so high prevalence of gastritis among females. In this study it’s likely that female self-reported gastritis more than males, in that, they were more aware about their health status due to more visits previously made to hospitals, as males rarely visit healthcare facilities. As long as the age was concerned, the current results showed that (92%) of the study participants had gastritis and were aged between 20-29 years old. This result agrees with the findings of Feyisa ZT,(2021) shows that (55.5%) of the study participants less or equal to 39 years old suffered from gastritis, while 44.5% who were aged above 39 years old suffered from gastritis. Our opinion is that youngest age in Hargeisa University more complain to feel gastritis due to dietary related and much stress about during academic exams. Further that, it was found that earning middle and low income was associated with slightly significantly increased odds of being in gastritis compared with earning high income. Study participants who earned a higher income per month were less likely to suffer from gastritis compared with those earned less. Previous studies Smith S, 2018. Agbor N E, 2018 agrees with our current study finding that explained the general association of income with gastritis, although they did not clarify the association of income level with gastritis in specific ways. This might be people with less income level were less likely to visit health care institutions. Moreover, they had less ability to pay for health services due to having other life expenses. Eating spiced foods were another important variable, which increased the odds of the severity of gastritis. This study identified individuals who ate spiced foods were more likely suffered gastritis than who don’t eat spicy food. For dietary related majority had snacks between meals and had no gastritis and There was a statistical significance between taking snacks and reporting gastritis (p=0.021). The majority with high fat consumption had no gastritis and there was a statistical significance between taking fat and reported gastritis (p=0.015). The previous of the studies, Padmavathi V, 2013 indicated that eating spiced foods resulted in gastritis, this might be due to the spiced food having a flavor or fragrance than other foods; it was commonly preferred to eat. In addition to such special properties, the spiced food has the potential to inflame and burn a gastric mucosa. Most of study participant had a gastritis have no go in hospital, in our opinion for many reasons like family income that is not sufficient for their basic life and other reason had anxiety for hospitals may be contribute to not going hospital. This is similar to other studies found low income and taking medications were contributed to gastritis status (zelalim t, 2021) The majority who had gastritis going to a pharmacy to self-care management, in our opinion pharmacy is less expensive than hospital, nearly (63%) study participants who had gastritis know that medication can reduce gastritis.

Conclusion The current study showed high prevalence of self-reported gastritis among university students. Female gender, age between 20-29 years, middle to low income, reporting chest pain, high fat consumption and eating spicy meals were associated with self-reported gastritis. The implication of this study is that attention should be given to University students and address the high prevalence of self-reported gastritis. 5.3 Recommendations • The high prevalence rate calls for intervention by the University administrations, Ministry of Health Development and Ministry of Higher Education to minimize the incidence of gastritis among students in the university. • Basically, it requires the university and other stakeholders to create awareness and knowledge for students about the causes of gastritis and the way of treating gastritis before it reaches chronic level. • The Ministry of Education should consult competent nutritionists to provide awareness about gastritis and link with high fat consumption and sugar. • The Ministry of Education could form the provision of information on prevention of gastritis as part of the university ‘curriculum. • The students with gastritis should have medical attention in the hospitals for adequate treatment.