Five Chapters CCCCCCCCCCCCCCCCDDDDDDDDDDDD 2 (22) .

Peptic Ulcer
STATUS OF PEPTIC ULCER DIEASE
Determinants of the Status of Peptic Ulcer among Peptic Ulcer Patients in Borama
District, Somaliland.
Bureeqa I. Egeh
Amoud University
A Thesis Submitted in Partial Fulfilment of the Requirements for the Master Degree of
Health Promotion in Public Health
May, 2017
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DELARATION AND APPROVAL
Declaration by the Student
I, Bureeqa I. Egeh, declare that this proposal titled ‘Determinants of the Status of
Peptic Ulcer in Borama distric’, is my original work and to the best of my knowledge, it has
not been submitted to any University, or institution for an academic award whatsoever.
-------------------------------------------------------- Date:
---------------------------------
Bureeqa Ibraahim Egeh
MPH/01/0165/BR
Approval by the Supervisor
This proposal was done under my supervision and has been submitted to the School of
Postgraduate Studies and Research, Amoud University for examination by my approval as
the candidate’s supervisor.
------------------------------------ Date ------------------------------------
Dr. Oso W. Yuko
School of Postgraduate Studies and Research,
Amoud University, Somaliland
TABLE OF CONTENTS
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iii
REFERENCES.........................................................................................................................19
APPENDIX A: DISTRIBUTION OF PATIENTS BY HOSPITAL.......................................68
APPENDIX B: TABLE OF SAMPLE SIZE...........................................................................69
APPENDIX C: QUETIONAIRE FOR PEPTIC ULCER PATIENTS....................................38
APPENDIX D: DOCUMENT ANALYSIS CHECK LIST.....................................................32
APPENDIX E: TIME FRAME WORK...................................................................................33
APPENDIX F: RESEARCH BUDGET...................................................................................34
LIST OF FIGURES
Figure 1. Conceptual framework ...............................................................................................7

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Peptic Ulcer
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LIST OF ABBREVIATIONS AND ACRONYMS
WHO - World Health Organization
PU - Peptic Ulcer
CVI - Context Validity Index

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ABSTRACT
This study investigated the determinants of the status of peptic ulcer among peptic ulcer
patients in Borama district. Determinant is a condition which decisively affects the nature or
outcome of something. Determinants were conceptualized as socio-economic and socio-
demographic factors, and lifestyle. Peptic ulcer is the painful sores in the lining of the stomach,
or first part of the small intestine (duodenum). Peptic ulcer is a serious health problem in the
world. It has affected about 10% of the world’s population and there are about 301,000
deaths associated with peptic ulcer globally each year. In Africa, it caused 230,000 deaths in
2000-2010 and affected 7 million. In Somalia, peptic ulcer affects about 152,658 persons
annually. In Borama district, the prevalence of peptic ulcer was estimated 457 in 2015 up
from 350 in 2014, which reflected an increase of 23.41%. The problem of this study was the
increasing number of peptic ulcer among patients in Borama district. The study specifically
investigated the association between socio-economic and socio-demographic factors, and
lifestyle among peptic ulcer patients in Borama district. Guided by the Lifestyle Modification
Theory, the study was conducted through a cross-sectional survey research design, on a
random sample of 204 peptic ulcer patients selected from patients attending hospitals in
Borama district. The study found that socio-demographic factors, (age χ2 [5, N = 204] =
11.577, p = .037, gender χ2 [2, N = 204] = 8.889, p = .034, C = .204 and marital status χ2 [10,
N = 204] = 18.307, p = .027) and lifestyle factors χ2 (8, N = 204) = 18.578, p = .018 are
significant determinants of the status of peptic ulcer. But socio-economic status is not χ2 (8, N
= 204) = 12.095, p = .147. The study concludes that lifestyle is the major determinant of
status of peptic ulcer among peptic ulcer patients in Borama district. The study recommends
that the Ministry of Health and other related government units to carry out awareness
campaigns on relationships between age, gender and marital status with certain diseases with
particular focus on peptic ulcer. The study also recommends that Ministry of Health of
Somaliland should mount and promote a health education and awareness programmes on
lifestyle modification at grassroots to help reduce development of peptic ulcer related
complications that may arise from poor lifestyles. The study further recommends that the
Ministry of Health of Somaliland and government of should create a scheme for free
treatment and free drugs for peptic ulcer patients in Somaliland as whole. The researcher
realized that there are several other high prevalence diseases such as pneumonia and diarrhea
in Borama district. For example, pneumonia caused 30 deaths in 1000 in 2015 in Borama
district. The researcher recommends that a study be done to investigate the determinants of
pneumonia in Borama district. This could lead to new strategies for managing the disease in
Borama district and in Somaliland as whole
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CHAPTER ONE
INTRODUCTION
1.1 Background of the Study
The first known case of peptic ulcer was diagnosed in China in a corpse of 2200 years
ago (Baron, 1980), and one of the earliest examples of a death caused by a peptic ulcer is
found in the 1984 autopsy report of the exhumed body of a Chinese man who died in 167 BC
(Cheng, 1984). Peptic ulcer has since increased in frequency. Other cases of peptic ulcer were
diagnosed in Australia and its etiological association with helicobacter pylori was discovered
from Australia about the fifteenth century (Marshal, 1984). In Africa, peptic ulcer was
diagnosed in 1944 (Wienbeck, Lubke, Motilitat, Peptisches Ulkus, Mogliche, 1987). The
bacterium spread from East Africa around 58,000 years ago (Linz and Moodley, 2007). In
Somalia peptic ulcer was first diagnosed in 1989 (Theodore, 2014).
Peptic ulcer has infected at least 20% of the world’s human population (Sandler, 2002).
About 180,000 people are infected each year and about 5000 of who die each year as a result
of the disease (Sandler, 2002). Peptic ulcer is the most prevalent disease over the world; in
Europe it affects 30% to 50%. In North America, it has been reported as 20% to 40%, in
Southern Europe as 4.1% to 8% and in Northern Europe as 10% to 15% (Musumba,
Jorgensen, Sutton, Eker, Moorcroft, Hopkins, Pirmohamed, 2012). The prevalence rate of
peptic ulcer and the helicobacter pylori infection varies widely according to geographical
area, patient age and socioeconomic status (Graham & Malaty, 2001). The prevalence of
peptic ulcer in Africa was as high as 94% (Ramsey Graham, Shaib, Shiota,Velez, and Serag,
2014). In various regions of sub Sahara Africa about, 60% -100% may harbour the pathogen
that cause peptic ulcer (Holcombe, 1992; Rat et al., 2004). In Somalia, peptic ulcer affects
about 152,658 persons annually (WHO, 2014).

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Peptic ulcer disease also known as a peptic ulcer or stomach ulcer is a break in the
lining of the stomach, first part of the small intestine, or occasionally the lower oesophagus
(Najm, 2011). An ulcer in the stomach is known as a gastric ulcer while that in the first part
of the intestines is known as a duodenal ulcer (Garg, Kumar, Rath and Goyal 2014). Peptic
ulcer is characterized by high acidity resulting in mucosal erosions causing extreme pain and
discomfort (Bhat et. al., 2013). Clinical manifestations of peptic ulcer include discomfort and
pain. The pain, which is burning, gnawing, or cramp like, is usually rhythmic and frequently
occurs when the stomach is empty - between meals (Furuta and Dechier, 2009).
There are several factors that are claimed to be associated with peptic ulcer globally.
Such factors include socio-demographic factors such as age (more common in people over
the age of 50); lifestyle (alcohol use and smoking), and family history (Stanley, 2008). Others
factors include socioeconomic status and medication such as non steroid anti inflammatory
drugs (aspirin) (Hansen, 1984); and diet such as consumption of spicy foods. This study will
focus on socio-economic, socio-demographic and lifestyle factors. A socio-demographic
factor describes an element of a group within a society using factors like age, sex, marital
status (WHO, 2002). The basic socio-demographic factors are age, sex, and marital status.
Socioeconomic factors are the social and economic experiences and realities that help
mould one's personality, attitudes, and lifestyle (Chase, 2016). The basic measures of
socioeconomic factors are education, occupation, income, and wealth (Parker, 1994). The
key elements of socioeconomic factors are education, income, occupation (Marc, 2007).
Lifestyle is a set of attitudes, habits or possessions associated with a particular person or
group (Dewangan, 2016). Some common elements of life-style factors are interest, opinions,
behaviours, orientations, culture (Yang, 2016). The major aspects of life-style are exercise,
balanced diet, and body weight. While these factors have been advanced as influencing
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prevalence of peptic ulcer globally and particularly in Africa, their influence on the
prevalence of peptic ulcer in Somaliland have not been empirically investigated
Peptic ulcer is a common disease around the world. It has affected about 10% of the
world’s population and there is about 301,000 deaths associated peptic ulcer globally each
year (Moghal, 2015). In Africa, it caused 230,000 deaths in 2006-2010 and affected 7 million
(Rickard, 2016). In Somaliland, the estimated death due to peptic ulcer in a 100,000
population is 3.56 (WHO, 2014). But more importantly, the number of peptic ulcer cases in
the country has been increasing. In 2010, peptic ulcer affected 3.38 in 100,000. In 2013 in
peptic ulcer was estimated at 8,594 (WHO, 2013), and in 2014, it affected about 152,658
persons (WHO, 2014). In Borama district, the prevalence was estimated about 457 persons in
2015 (Ministry of Health, 2015) and 350 in 2014 (Ministry of Health, 2014). The high
prevalence of peptic ulcer makes it one of the most serious problems of health in Borama
district. While peptic ulcer is prevalent in Borama district, the factors responsible had not
been investigated.
Guided by the Theory of Lifestyle Modification, this study determined the
determinants of the prevalence of peptic ulcer among patients attending Hospitals in Borama
District. The Lifestyle Modification Theory, developed by Pagano in 1986, presented a useful
framework for describing a series of stages that people go through to change life style habits
(Pagano, 1986). The stages may depend on socio-demographic, socio-economic and a
lifestyle factors, among others (Chase, 2016). This study was concerned with identification
of factors that are significant in the management peptic ulcer and it investigated the
variables that the theory postulates. This congruence made the Life Modification Theory
relevant to the study.

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1. 2 Statement of the Problem
Peptic ulcer is a serious health problem in the world. It has affected about 10% of the
world’s population and there are about 301,000 deaths associated with peptic ulcer globally
each year. In Africa, it caused 230,000 deaths in 2000-2010 and affected 7 million. The
prevalence of peptic ulcer in Somaliland is high. In Somaliland, the estimated death due to
peptic ulcer in a 100,000 population is 3.56. But more importantly, the number of peptic ulcer
cases has been increasing. In 2010, peptic ulcer affected 3.38 in 100,000. In 2013 peptic ulcer
prevalence was at 8,594 and in 2014, it was152, 658. In Borama district, the prevalence of
peptic ulcer was estimated 457 in 2015 up from 350 in 2014, which reflects an increase of
23.41%. While the prevalence of peptic ulcer had continuously increased, the factors
responsible had not been empirically investigated. Socio-economic, socio-demographic and
lifestyle factors had been presented as possible determinants of peptic ulcer in Africa. But the
actual factors leading to the increased prevalence of peptic ulcer in Borama town had not
been investigated. If these factors remained unknown, peptic ulcer would not be properly
managed, and this could lead to continued yet preventable suffering and deaths due to peptic
ulcer.
1.3 Research Objectives
1.3.1 General Research Objective
The general objective of this study was to ascertain the determinants of the status of
peptic ulcer among peptic ulcer patients in Borama district, Somaliland.

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5
1.3.2 Specific Research Objectives
The specific research objectives of this study were to:
1. Determine if the status of peptic ulcer is dependent on socio-economic status of peptic
ulcer patients in Borama district.
2. Determine if the status of peptic ulcer is dependent on lifestyle of peptic ulcer patients in
Borama districtd.
3. Determine if the status of peptic ulcer is dependent on socio-demographic factors among
peptic ulcer patients in Borama district.
1.4 Research Hypotheses
1.4.1 General Research Hypothesis
The study was guided by the general hypothesis that status of peptic ulcer is
dependent on socio-economic status, socio-demographic factors and on lifestyle of peptic
ulcer patients in Borama district, Somaliland, both individually and together.
1.4.2 Specific Research Hypotheses
This study was be guided by the following specific research hypotheses:
1. The status of peptic ulcer is significantly dependent on socio-economic status of peptic
ulcer patients in Borama district.
2. The status of peptic ulcer is significantly dependent on lifestyle of peptic ulcer patients in
Borama district.
3. The status of peptic ulcer is significantly dependent on socio-demographic factors of
peptic ulcer patients in Borama district.

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1.5 Research Questions
1.5.1 General Research Question
The general research question of this study was - What are the major determinants of
the status of peptic ulcer among peptic ulcer patients in Borama district, Somaliland?
1.5.2 Specific Research Questions
The specific research questions of this study are:
1. Does the status of peptic ulcer depend on socio-economic status of peptic ulcer patients
in Borama district?
2. Does the status of peptic ulcer depend on lifestyle of peptic ulcer patients in Borama
district?
3. Does the status of peptic ulcer depend on socio-demographic factors of peptic ulcer patients in
Borama district?
1.6 Scope of the Study
This study investigated the determinants of the status of peptic ulcer among peptic
ulcer patients in Borama district, Somaliland. The study particularly focused on socio-
economic status, socio-demographic factors and lifestyle of peptic ulcer patients and their
relationship with status of peptic ulcer. It was conducted among peptic ulcer patients
attending the three main hospitals in Borama District. Guided by the Lifestyle Modification
Theory, the study adopted a cross-sectional survey: data was collected from a random sample
of 204 patients in Borama district in February 2017 using questionnaire and document
analysis methods, analysed Chi square test of independence and reported in tables and
figures.
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1.7 Significant of Study
This study should contribute to the reduction in the prevalence of peptic ulcer in
Borama district and in Somaliland as a whole. The study should also benefit the peptic ulcer
patients in Borama district, especially if it is used as a basis of health education and
promotion of general information on peptic ulcer. The study has provided useful information
that should help the series patients that need special care. Moreover, the study has made
recommendations for improving health status of peptic ulcer patients. This study has
produced new knowledge and acts as a reference material to public health students and other
researchers, and to general readers as well.
1.8 Limitations of the Study
The study was localized in Borama district, though peptic ulcer is a major health
problem in the whole Somaliland. It would have been better for the study to be done in a
larger area, but resources could allow. Due to resource constraints, only Borama district was
covered. This could lower the generalizability of the study, due to low coverage.
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1.9 Conceptual Framework
Guided by the Life Style Modification Theory, this study was based on the framework
depicted in the Figure 1.
Determinants of Peptic Ulcer Peptic Ulcer Disease
- Mild = nausea, vomiting.

Socio-economic Status - Moderate = nausea,
 Income. vomiting, epigastria pain
 Occupation. and, head ache.
 Education. - Severe = vomiting of
blood, lethargic, severe
Socio-demographic Factors weight loss, looks wasted
 Age. and epigastria pain
 Gender.
 Marital status.
Lifestyle - Family history

 Exercise. - Medication
 Diet.
 Weight.
Figure 1. Conceptual framework for determining of peptic ulcer.
Determinants of status of peptic ulcer were conceptualized socio-economic status,
socio-demographic factors and life style. Socio-demographic factors were operationalized as
age, gender, and marital status; socio-economic status as education, occupation and income;
and life style as diet, smoking, and weight management. Peptic ulcer was operationalized as a
sore in the lining of stomach, intestine and esophagus. The framework suggests that if socio-
economic; socio-demographic and lifestyle factors are favourable, then few people in Borama
would have sore in the lining of stomach, intestine and esophagus. But this study relationship
could be modified by medication and family history.

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1.10 Assumption of the Study
The study assumes that medication and family history did not contribute significantly
of status of peptic ulcer in this study. This assumption should hold because the sample was
selected at random and the effect of medication and family would be randomly distributed. In
any case, medication is prescribed by qualified doctors to all patients. The hospitals are also
the same and should not create variance.

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CHAPTER TWO
REVIEW OF RELATED LITERATURE
2.1 Introduction
This chapter reviews literature related peptic ulcer. The chapter particularly focuses on
socio-economic factors, socio-demographic and life style as they related to peptic ulcer.
2.2 Socio-Demographic Factors and Peptic Ulcer
Socio-demographic factor is a factor that is both demographic and social in nature
(Lewis, 2012). Social factors refer to the facts and experiences that influence individuals'
personality, attitudes and lifestyle (Koukouli, 2002). Common examples of social factors are
religion, ethnicity, family, physical attitudes, economic status, education and locality, life
partners, children and political systems (Hediger et al., 2002). Demographic factors are
personal characteristics used to collect and evaluate data on people in a given population
(Labby, 1981). Typical demographic factors include age, gender, marital status, race,
education, income, occupation, birth rate and death rate (Bracken, 2002). A socio-
demographic factor therefore refers to a factor that is both sociological and demographic in
nature. Basic socio-demographic factors are age, education, gender and marital status (WHO,
2002).
Age is the length of time that a person has lived or a thing has existed (Dawkins,
2016). Age is an important demographic factor, because it is often associated with incedence
of disease (Sanders, 2013). For example some diseases are more prominant across certain
ages then others (Whiteford, 2013). Gender refers to the socially-constructed roles and
relationships between men and women (Rey, 2014). It concerns men and women, and
includes conceptions of both femininity and masculinity (Lindsey, 2015). Like age, gender
also tends to be associated with certain diseases; for example, ovarian diseases such as breast
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11
cancer are found solely in the female gender (Wolk, 2001). Marital status is the condition of
being married or unmarried law, jurisprudence and the collection of rules imposed by
authority (Allison, 2016).
Many authors associated socio-demographic factors to several diseases. A study
conducted in Marilia city Brazil by Carlos (2012) found that demographic factors (age and
gender) had a significant association with peptic ulcer incidence, (Carlos, 2012). Another
study done by Brunson and Jianfeng (2014) at first First Affiliated Hospital of Kunming
Medical University investigate in-patient peptic ulcer and gastritis, they found a significant
association between age, peptic ulcer and gastritis (Brunson & Jianfeng, 2014). Another
study by Musyoka (2009) in Nairobi also found that socio-demographic factors (sex, age and
marital status) correlated with occurrence of peptic ulcer disease (Musyoka, 2009). He found
that most of the patients who had peptic ulcers were males. These studies suggest a positive
relationship between socio-demographic factors and diseases prevalence, even if they are not
in the context of Peptic ulcer disease or in the context of Borama district.
2.3 Socio-Economic Factors and Peptic Ulcer
A socio-economic factor is both economic and social in character. Social factors are
things that affect lifestyle, such as religion, wealth or family (Viner, 2012). Economic factors
are set of fundamental information that affects business or investments value (Pearlson et al.,
2014). Socioeconomics is the social science that studies how economic activities affect and is
shaped by social processes (Paula et al., 2012). It is a way of looking at how individuals and
families fit into the society using economic and social measures that have been shown to
impact on individual’s and well-being health (Bracken, 1999). Socioeconomic factors define
the social and economic experiences and realities that help mould one's personality, attitudes,
and lifestyle, especially income, level of education, and occupation (Leimbach et al., 2005).
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The major elements of socio-economic factors are income, level of education, occupation
(WHO, 2000).
Income is money received in exchange for providing a good or service or through
investing capita (Ratha, 2007). In terms of health, Income inequality may affect directly
some health outcomes (Adler et al., 2002). Pickett (2015) found that income can affect health,
and improving income of poorest members of the society is often proposed as a way of
improving their health. Education is the wealth of knowledge acquired by an individual after
studying a particular subject matter or experiencing life lessons that provide an understanding
of something (Stringer et al., 2013). Education offers opportunities to learn more
about health and health risks, both in the form of health education in the school curriculum
and also by giving individuals the health literacy to draw on, later in life, and absorb
messages about important lifestyle choices to prevent or manage diseases (Zimmerman,
2014). Occupation is a person's usual or principal work or business, especially as a means of
earning a living (Cohen, 2013). Sindelar (2008) found that occupation is a social determinant
of health and as an initial condition in life that affects later health outcomes.
The basic link between socio-economic factors and disease has been established. A
study done by Milbank (1993) in Russia on individuals of lower socioeconomic status,
generally have faced higher mortality rates than individuals of higher status. Another study
by Kablan in (1998) in the United States on Socioeconomic factors, there is a considerable
body of evidence for a relation between socioeconomic factors and all-cause diseases. A
study done by Winkleby and Jatulis in (1992) in the United States on Socioeconomic status
and health found as socio-economic status decreased the prevalence of peptic ulcer is
increasing. These studies suggest a positive relationship between socio-economic factors and
diseases prevalence, even if they are not in the context of Peptic ulcer disease or in the
context of Borama District.

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2.4 Lifestyle Factors and Peptic Ulcer
Lifestyle is the way one lives (Aziz et al., 2009). The term lifestyle can denote the
interests, opinions, behaviours, and behavioural orientations of an individual, group, or
culture (Jackson, 2009). It can also denote interest, opinions, behaviours, orientations, and
culture (Yang, 2016). A lifestyle including smoking, a well-balanced diet, and maintaining a
healthy body weight, may reduce the risk of poor health (Messier, 2004). Lifestyle is
expressed in both work and leisure behaviour patterns and (on an individual basis) in
activities, attitudes, interests, opinions, values, and allocation of (Demby, 2000). Generally,
lifestyle
Smoking is a practice in which a substance is burned and the resulting smoke breathed
in to be tasted and absorbed into the bloodstream (Elshikh, 2015). The most obvious effects
of smoking can appear on your skin and teeth because the compounds found in tobacco have
the capability of changing the structure of your skin (Simone, 1992). The effects usually
appear in the form of wrinkles, discoloration, and other skin issues (Vander, 2001). Weight is
a body’s relative mass (Oxtoby, 2015). Maintaining a healthy weight is important for health
(Reiner, 2013). People who are obese, compared to those with a normal or healthy weight,
are at increased risk for many serious diseases and health conditions (Hoeger, 2001).
Dieting is the practice of eating food in a regulated and supervised fashion to decrease,
maintain, or increase body weight (Sarafino, 2014). Dietary fibre has a role in preventing
formation or recurrence of peptic ulcer disease. In terms of health, healthy diet helps to
prevent certain chronic (long-term) diseases such as heart disease, stroke and diabetes (Yach,
2009).
Studies by Dutta (2010) in Iran on Impact of lifestyle on health concluded that diet is
the greatest factor in lifestyle with a direct and positive relation with health. Another study
done by Rosenstock (2003) among 2416 Danish adults with no history of peptic ulcer, found
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14
that tobacco smoking was related to a significant increase in the risk of developing peptic
ulcer. Another study by Rafi (2013) in Dhaka on the effect of dietary and smoking habits on
peptic ulcer among patients with abdominal pain. He found that smoking increases the risk of
peptic ulcer and impairs the process of healing. These findings add weight to hypothesis,
even if they do not directly refer to Borama context.

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CHAPTER THREE
RESEARCH METHODOLOGY
3.1 Introduction
This chapter describes the research design, location of the study, sampling technique,
sample size, research instruments, data collection procedures, and data analysis techniques
that will be used in the study.
3.2 Research Area
This study conducted in Borama district, the main town in Awdal region; Borama
town located 120 km west of Hargeisa and 3km to north Ethiopia. It lies at latitude 9 oand
Longitude 23o (Little Petter & Borama Municipality Council, 2003). The population of
Borama town is approximately 415,616 residents (Food Agricultural Organization, 2015).
Borama town has the largest numbers of Hospitals in Awdal region and therefore a good
location to get a critical number of patients. This made it a good cite for a study of this
magnitude.
3.3 Research Design
This study adopted a cross-sectional survey research design, which is one type of
survey research (Oso, 2013). Survey is the collection of information from a sample of
individuals through their responses to questions (Schutt, 2015). Survey is the most suitable
design for studies without manipulation (Oso, 2013). Socio-demographic, socio-economic
and lifestyle could not be manipulated (especially as they relate to health) because the
researcher had no capacity to change them. Inability to manipulate variables pointed to
survey design (Oso, 2013). Cross-sectional survey was adopted in place of longitudinal
survey. Cross-sectional survey is a type of observational study that analyzes data collected

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16
from a population or a representative subset, at a specific point in time (Robert, 2009). Cross-
sectional survey was used to enable the researcher to describe determinant of status of peptic
ulcer among patients attending hospitals in Borama district at just one point in time (Oso,
2013). It was also cheaper and more effective than longitudinal design for this study in less
time available.
3.4 Study Population
3.4.1 Target population
The target population of the study was 777 registered peptic ulcer patients in the three
hospitals in Borama district, Somaliland, see Appendix A (Hospital Records, Borama
District, 2016).
3.4.2 Accessible Population
The accessible population of the study was the same as target population as described
3.4.1. The researcher could trace and reach all registered peptic ulcer patients in the three
Hospitals in Borama district.
3.5 Sample and Sampling
3.5.1 Sample Size
The sample was 204 registered peptic ulcer patients made up from 92 from Alhayatt
hospital, 58 from Allaleh hospital and 54 from Borama regional hospital as summarized in
Appendix A. The sample size was determined according to Kregcie and Morgan (as cited by
Oso, 2013) tables of samples. This is a very popular table for determining sample size in
research. It recommends a sample of 204 for a population of 777 at 95% level of confidence .
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17
05 level of significance, and 5% margin of error, which were the same parameters set on the
study (see Appendix B).
3.5.2 Sampling Techniques
The study used stratified sampling method. Stratified sampling is a
probability sampling technique where in the researcher divides the entire population into
different subgroups or strata, and then randomly selects the final subjects proportionally from
the different strata (Wison, 2009). It used in used to determine the number of patients in each
hospital to be included in the sample size. This ensures the representation of each hospital in
the sample size (Oso, 2016). This technique was allowed the researcher to determine the
correct number of peptic ulcer patients from each hospital to include in the sample (Oso,
2013). It also ensured that each hospital was proportionately represented in sample (Oso,
2013). This improved the representation of each hospital in the sample, and accounted for any
sub group differences that could exist (Oso, 2013). The sample size for each hospital was
¿ group population
determined as Sub group sample size = x total sample ¿ ¿ for example,
Total population
351
The sample size of Alhayatt hospital was x 204=92 the sample size for each hospital
777
was determined in a similar manner (see Appendix G).
The individual member of each patient for each hospital was selected through a simple
random sampling method. Simple random sampling is a simple random sample is a subset of
a statistical population in which each member of the subset has an equal probability of being
chosen similar ( ). It was used to select individual peptic ulcer patient from each hospital for
sample. This enable the researcher to get the correct sample size the list of peptic ulcer
patients are available in each hospital and were associated and used to select the patients.
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3.6 Data Collection
3.6.1 Data Collection Methods
This study used questionnaire and document analysis as the basic data collection
method because the sample was large (260), and only the questionnaire method can guarantee
collection of sufficient data over the short period available (Oso, 2013). A questionnaire is
collection of items to which a respondent is expecting to react in writing (Oso, 2016).
Questionnaire method was used to collect data on peptic ulcer patients. Questionnaire
methods will also ensure that each participant receives the same set of questions phrased in
exactly the same way (Oso, 2013), and this will add to consistency of responses. This study
was also used document analysis method to collect data on status of peptic ulcer. Information
on peptic ulcer can only be obtained from existing records.
3.6.2 Data Collection Instruments
The study was used semi-structured questionnaire, (see Appendix C). Because of the
blend of close and open-end items, it was enable the researcher to balance between the
quantity and quality of data collected, and also made data analysis simpler (Oso, 2013). Semi
structured questionnaire also made data analysis much simpler if entire unstructured
questionnaire were used (Oso, 2016). The instrument had sections on demographic factors,
socio-economic, and lifestyle factors and on peptic ulcer disease. The study was used
document analysis kit (Appendix D), to collect data on the status of peptic ulcer of each
patient.
3.6.3 Research Procedures
The researcher was obtained permission from Amoud University, from the Ministry
of Health and from the Directors of Hospitals in Borama district. When all permissions were
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19
granted, the researcher was piloted the instruments in Gabiley Hospital. After validation, the
researcher was proceed to collect data from the 204 peptic ulcer patients, using document
analysis and questionnaire, using drop-collect method in February, 2017.The questionnaire
were admistered through drop and collect method, by the researcher herself. For those who
were illiterate, the researcher was read the questionnaire and recorded their response with
respect of them. The documents analysis was conducted by the researcher. The researcher
was done by calls and several visits to encourage them to complete the questionnaire. Data
was analyzed using chi-square technique and reported in tables and figures.
3.7 Quality Control
3.7.1 Piloting of Instrument
The instrument was piloted in Gabiley hospital. This is the next large Hospital after
Hospitals in Borama district. During piloting, the researcher was worked to ensure that the
data collection tools attained validity and reliability coefficients of at least 0.70 as required in
social science research (Oso, 2013).
3.7.2 Validity of Instruments
Validity was controlled through use of expert judgement method. In this technique,
two experts were assessed and rate each item on the instrument to the study objectives on a 1-
4 scale. Content validity index was determined from items rating by both judges, as CVI =
n3 /4
(Oso, 2013). This method was ease to use, focus on agreement of relevance and
N
provision of both item and scale information (Wiley, 2007). Two experts assessed the
relevance of each item in the instruments to the study objectives and rated each item on the 1-
4 scale. Generally, 1 is Not Relevant (NR), 2 is Somewhat Relevant (SWR); 3 is Quite

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20
Relevant (QR); 4 is Very Relevant (VR) (Oso, 2013). The assessor’s assessment report is
summarized in Table 1.
Table 1
Experts’ Assessment Reports
Judge 2
1 2 3 4 Total
1 0 0 0 0 0
2 0 0 0 0 0
Judge 1
3 0 0 0 0 0
4 2 0 4 25 31
Total 2 0 4 25 31
Note. Shaded region indicates 3 and 4 which are the items rated quite relevant and very
relevant by both judge.
Validity was determined from items rated 3 and 4 by both judges as CVI = n 3/4/N;
where n3/4 is the item rated 3 or 4 by both judges, and N = total number of items. A CV1 =
29/31 = 0.94 as reported. This was an accepted tool validity measure because it was higher
than the .70 value recommended in social science research (Oso & Onen, 2009). Hence the
instruments captured sufficient information needed to answer the research questions.
3.7.3 Reliability of Instruments
The test-retest method was used to ascertain reliability. The test-retest method is one
of the simplest ways of testing the stability of an instrument over time (Anderson, 2005). The
researcher was administered the instrument to a pilot sample of 30 respondents twice in two
Peptic Ulcer
21
weeks and then correlate results, using Oso (2013) reliability formula. This method was
selected because it is a very simple way of testing the stability and reliability of an instrument
over time (Anderson, 2005). The instrument was administered a random sample of 30 peptic
ulcer patients in Gabiley Hospital and collected back. This was the test stage. At this stage,
all responses were coded 1 regardless of the response. The scores for each respondent were
added together to obtain the total score for each respondent on the instrument. This produced
a total of 31. At this stage, the researcher had 31 scores of 31 of each. After 14 days, the same
tools were administered to the same sample of 30 respondents. The responses were coded
according to Oso (2013) recommendation such that if a respondent provided the same
response to the same item as in the test stage, it was coded 1. But it was coded 2 if the
response was different no matter how different. Reliability was calculated using Oso
1105−930
Reliability Formula as R = 1-Σ ((T2-T1))/T1 =1− = 0.81 where T1 is test 1 and T2
930
is re-test 2. Hence reliability index of 0.81 was reported. This means that out of ten items in
the instrument, at least eight of them produced same responses at different times.
3.8 Data Analysis
The study used chi-square test of independence method to identify significant
determinants of the status of peptic ulcer. Chi-square is a statistical test commonly used to
compare observed frequencies with frequencies expected to be obtained according to a
specific hypothesis (Donald, 2015). It is a technique of a statistical measurement used to
assess how expected frequencies compare to actual results (Levinger, 2016); so as to
determine whether there is a significant association between two variables (Catalona, 2014).
Chi-square is the ideal test when the data is in the form of categorical frequencies. A
categorical frequency is a group frequencies where a case can only belong to one group,
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22
without any overlapped (Oso, 2016). This study collected data on peptic ulcer patients within
each status of a determinant. For example, the number of peptic ulcer patients with severe
peptic ulcer under low socio-economic status was a category without any overlap. One
patient could not belong to more than one group at the same time. This is the domain of chi-
square.
Chi-square test of independence is different from chi-square goodness of fit. The
independence test is used to determine significant relationships between two nominal
(categorical) variables. The goodness of fit test determines the fit in only one variable. This
study had two nominal variables: Determinant and status of peptic ulcer.
Chi square test is generally based on the assumptions that the sample is drawn at
random from a population about which inference is to be made; that the observations are
made independently, and that a sample of a sufficiently large size is used (Oso, 2015). These
assumptions were fulfilled in this study because the sampling method used was simple
random as described in 3.5.2; the observations were made independently and the sample size
used (260) was large enough. Chi-square was applied as;
χ2 =Σ ¿ ¿, with = (C-1) (R-1) degree of freedom.....Eq...1.
where fo = observed frequency and fe = expected frequency; R = number of rows and C =
number of columns. Where a significant difference was detected, contingency coefficient (c)
was used to determine the strength of association as;
❑ χ 2 ---------------- Eq--2.
C=
√ n+ χ 2
where n = sample size and x 2value of chi-squared. Contingency coefficient is a measure of
association between statistical variables which have quantitative categories of
unequal magnitude or at least one of which can be classified only qualitatively
(John, 2013). Contingency coefficient was preferred over other measures of strength of an
association such as Cramer’s V coefficient because; it is the way to calculate the strength of
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23
association in tables more than 2x2 tables (Oso, 2016). In this study, the researcher had
5×3 contingency table. The data was analyzed at 5% margin of error, confidence level of
95% and 0.05 level of significance. These statistics were selected because they are the
conventional measures in social science research (Oso, 2016).
3.9 Ethical Considerations
The researcher will notify each participant of the intentions of the study. The
researcher will obtain informed consent of each respondent. The researcher will also take
permission from all gate-keepers before conducting in study. The researcher will ensure data
collected is not made to confirm to predetermine opinion. Further, the researcher will ensure
any information provided is confidential and shall not be to others without permission of the
client.
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24
CHAPTER FOUR
RESULTS AND FINDINGS
4.1 Introduction
This study investigated the determinants of Peptic ulcer in Borama district.
Determinants are factors that influence the state of something, and cause it to assume a new
and relatively permanent form. Determinants were conceptualized as socio-economic status,
socio-demographic factors and lifestyle. Peptic ulcer is the painful sores in the lining of
the stomach or first part of the small intestine (duodenum). The study arose from fact that the
prevalence of peptic ulcer in Borama district was quite high; being diagnosed in 457 persons
in 2015 alone. The high prevalence of peptic ulcer makes it one of the most serious problems
of health in Borama district. While peptic ulcer is prevalent in Borama district, the factors
responsible had not been empirically investigated. Efforts to control the diseases have been
made on government directives and policies but without empirical evidence.
The sample size designed for this study was 260, but 204 respondents returned
complete data. This was a 78.46% response-return-rate which was acceptable since it was
more than the 70% response return-rate recommended in social science research (Oso, 2016).
Data was collected on demographic characteristics of the respondents, on lifestyle and
socioeconomic factors and socio-demographic factors. This chapter presents the results and
findings of the study along these major themes

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25
4.2 Demographic Characteristics of Respondents
The demographic information on respondents was collected on age, gender, marital
status, on employment, on level of formal education and area of residence. The aim of
presenting demographic information is to aid users in determining the generalizability of the
study to their populations. Data on demographic characteristics was organized using
percentages, and are presented in figures, in the following sub-sections.
4.2.1 Distribution of Respondents by Age
The respondents were asked to indicate their ages. It was necessary to determine if
Peptic ulcer is popular among a particular age set in the district. This could lead to age
specific interventions in the district. They responded as indicated in Figure 2.
80
70 68
60
48
Percent/Frequency
50
40
32.8
Frequency
30 28 27
23.5 Percent
20
20
12.7 13.2 13
9.8 7.8
10
0
0-19 20-29 30-39 40-49 50-59 above 60
Age of respondents (Years)
Figure 2. Age of respondents.
Figure 2 shows the distribution of respondents by age. It shows that most (32.8%) of
the respondents were aged 20-29 years while only 7.8% of the respondents were aged above
60 years. But 69.5% of the peptic ulcer patients surveyed was aged between 20-49 years. This
Peptic Ulcer
26
shows that Peptic ulcer affects the most active age of population in Borama district.
Therefore any intervention suggested by the study should focuses mostly on this age group.
But data was collected from among all ages. This makes the sample representative across age.
4.2.2 Distribution Respondents by Gender
The respondents were asked to indicate their gender. This information was necessary
to determine whether Peptic ulcer varies across gender. They responded as shown in Figure
3.
120 112
100 92
80
Percent/Frequency
60 54.9
45.1 Frequency
40 Percent
20
0
Female Male
Gender of respondents
Figure 3. Distribution of respondents by gender.
Figure 3 shows the distribution of respondents by gender. It shows that a majority
(54.9%) of respondents were male and 45.1% were female. But generally, Peptic ulcer is
common males as it is common among females. Hence interventions on prevention and
management of Peptic ulcer suggested by this study should focus on both gender equally.
Further, data was collected from males and females and should therefore apply to both
gender. Hence this sample representative across gender.

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27
4.2.3 Distribution of Respondents by Employment
The respondents were also asked to indicate their employment status. This
information was necessary because it could help to gauge whether peptic ulcer patients are
able to meet incidental costs of management of the disease. They responded as shown in
Figure 4.
120
104
100
100
80
Percent/Frequency
60
49 51
Frequency
40 Percent
20
0
Employed Unemployed
Employment
Figure 4. Distribution of respondents by employment.
Figure 4 shows the distribution of respondents by employment. It shows that a
majority (67%) were unemployed, and 33% were employed. This indicates that most Peptic
ulcer patients may not afford the treatment costs and there could be economic problems for
case management of Peptic ulcer. But the populations of employed and unemployed are
almost the same. Therefore the data should represent all cases of employed and non-
employed patients.
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28
4.2.4 Distribution of Respondents by Type of Employment
The respondents were also asked to indicate their type of employment. This
information was necessary because, some types of employment tend to aggravate ulcer
condition more than others. They responded as shown in Figure 5.
120
103
100
80
Frequency/Percent
60
50.5
Frequency
38 Percent
40
31 30
18.6
20 15.2 14.7
2 1
0
None Formal Self employed Casual Other
Type of employment
Figure 5. Distribution of respondents by type of employment.
Figure 5 shows that a majority (50.5%) of respondents had no employment, but
49.5% were employed. While the figures are not exactly equal as in Figure 4, they reflect the
same information on employment. Among those who were employed, most (18.6%) were
self-employed and another 14.7% were casuals. Thus most (33.3%) of peptic ulcer patients
were in jobs that could easily aggravate their conditions. But data was collected from across
all types of employment, and should be representative across the population.
4.2.5 Distribution of Respondents by Education.

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29
The respondents were also asked to indicate their level of education. This was
necessary because management of personal health tend to be related to educational level.
They responded as shown in Figure 6.
80
70 68
60
50 48
Percent/Frequency
40
33.3 Frequency
31
29 28
30 Percent
23.5
20 15.2
14.2 13.7
10
0
None Primary Secondry Intermediate University
Level of education
Figure 6. Distribution of respondents by education.
Figure 6 shows the distribution of respondents by educational level. It shows that
most (33.3%) had no education while only 13.7% had secondary level of education. But
majority (52.5%) of peptic ulcer patients had secondary education and above. However, the
fact that 47.5% of patients had primary education or none shows that a high proportion of
peptic ulcer patients had low formal education and this could negatively influence
management of peptic ulcer at the personal level. But patients across all levels of education
were represented in the sample.
4.2.6 Distribution Respondents by Marital Status

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30
The respondents were asked to indicate their marital status. This information was
necessary to determine if people affected had family support. This could be useful in
designing interventions. They responded as indicated in Figure 7.
140
119
120
100
Percent/Frequency
80
58.3 57
60 Frequency
Percent
40
28
20 10 10
6 2.9 4.9 4.9 2 0.9
0
Single Monogamy Polygamy Widow Separated Other
Marital Status
Figure 7. Distribution of respondents by marital status.
Figure 7 shows the distribution of respondents by marital status. It shows that a
majority (58.3%) of the respondents were single, 0.9% was “other,” and 2.9% was married
(polygamy). While it cannot be claimed that Peptic ulcer affects mostly the single, it is clear
that the most affected cases are the single. This could negatively influence management of
Peptic ulcer as most such cases would need the support of others in almost all facets.
However like in other cases, all types of marital status were represented in the sample.
4.2.7 Distribution of Respondents by Area of Residence
The respondents were finally asked to indicate their areas of residence. This was
nessaccery to direct interventions especially if one area was found to be popular with the
disease. They responded as summary in Figure 8.

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31
180 171
160
140
120
Percent/Frequency
100
83.8
80 Frequency
60 Percent
40
20 15 14
7.4 6.9 4 2
0
Borama Baki Quljeed Other
Area of residence
Figure 8. Distribution of respondents by residence.
Figure 8 shows that a majority (83.8%) of respondents were from Borama and 7.4%
were from Baki area. It shows that the area highly infected with Peptic ulcer is Borama
district. But this was expected because the health facilities used were in Borama. But data
was collected for persons beyond Borama and this makes the data more representative.
4.3 Determinants of Peptic Ulcer
4.3.1 Measurement of Variables
The purpose of this study was to identify the determinants of peptic ulcer in Borama
district, Somaliland. Determinants were conceptualized as socio-demographic factors, socio-
economic status and lifestyle. To realize this purpose, the study investigated three specific
objectives: it determined the influence of socio-demographic factors; the influence of socio-
economic status and the influence of lifestyle on Peptic ulcer patients in Borama district.
Socio-demographic factors were operationalized as patient age, gender, and marital status;
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32
and lifestyle as smoking, diet and weight, and socio-economic factors were measured from
income, level of education, and occupation.
Demographic characteristics of the respondents were analyzed as individual variables
since it was not possible to obtain common measure socio-demographic factors. Socio-
economic status and Lifestyle was coded and scored on minimum of 1 and maximum of 6.
The scores on each sub variable were added to obtain the score of the main variable. The
scores were converted to the scale of very poor to very good. The scores on socio-economic
status ranged between 11- 63 and were classified such that 11-20 scores were rated very poor
and coded 1; scores of 21- 30 were rated poor and coded 2; scores of 31-40 were rated as
moderate and coded 3; 41- 50 scores were rated good and coded 4; and scores 51-63 were
rated very good and coded 5. The scores on lifestyle ranged between 9-30 and were classified
such that 9-12 scores were rated very poor and coded 1; scores of 13-16 were rated poor and
coded 2; scores of 17-20 were rated moderate and coded 3; 21-24 scores were rated good and
coded 4; and scores 25-30 were rated very good and coded 5. Peptic ulcer was measured from
hospital records and categorised as mild, moderate, and severe based on medical records. The
variable were coded and rated as summarised in Table 2

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Table 2
Coded/Scoring And Range Of Variables

Scale Analysis
Variable Indicator Very Good = 5 Good = 4 Moderate = 3 Very Poor = 2 Poor = 1
Socio-economic - Income. 51-63 41-40 31-40 21-30 11-20 Interval Chi-Square
Status - Occupation
- Education
Lifestyle - Diet, 25-30 21-24 17-20 13-16 9-12 Interval Chi-Square
- Smoking
- Weight
Socio - Age, - - - - -
demographic - Gender
- Marital Status
Summary of Measurement of Variables
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30
The manipulation of data from the operations in Table are summarised in Appendix G.
4.3.2 Socio-economic Status and Status of Peptic Ulcer
The first objective of this study was to determine the influence of socio-
economic status on the status of peptic ulcer among peptic ulcer patients in Borama
district. Socioeconomic status was measured from income, occupation and education.
Peptic ulcer patients were asked to react to several statements on these variables and
the responses were as described in 4.3.1 and used to determine the socioeconomic
status of each patient. The manipulated socio-economic status was compared against
the status of peptic ulcer of each patient, and the results shown in Table 3 were
obtained.
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31
Table 3
Status of Peptic Ulcer with Socioeconomic Status
Status of peptic ulcer

Severe Moderate Mild Total
Count 48 35 14 97
% within socioeconomic status 49.50% 36.10% 14.40% 100.00%
Very Poor
% within Status of Peptic ulcer 53.30% 45.52% 37.80% 47.54%
% of Total 23.52% 17.15% 6.90% 47.54%
Count 38 29 16 83
% within socioeconomic status 45.80% 34.90% 19.30% 100.0o%
Poor
% of Total 18.62% 14.22% 7.84% 40.70%
Count 4 8 3 15
Moderate
Socioeconomic Status % of Total 1.96% 3.92% 1.5% 7.35%
Count 0 3 2 5
Good
% of Total 0.00% 1.47% 1.00% 2.45%
Count 0 2 2 4
Very Good
% of Total 0.00% 1.00% 1.00% 1.96%
Count 90 77 37 204
Total % within socioeconomic status 44.12% 37.75% 18.14% 100.00%
% of Total 44.12% 37.70% 18.14% 100.00%
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32
Table 3 shows the status of peptic ulcer among peptic ulcer patients in Borama district with
socio-economic status. Data on the last column show the socioeconomic status of peptic ulcer patients.
It shows that most (47.50%) of peptic ulcer patients surveyed had very poor socio-economic status and
only 1.96% of the peptic ulcer patients had very good socioeconomic status. In general, a majority
(88.20%) of the peptic ulcer patients surveyed had poor socioeconomic status and 4.42% had good
socioeconomic status. Thus, the socioeconomic status of peptic ulcer patients in Borama district was
generaly poor.
Data on the last raw show the status of peptic ulcer of the patients. It shows that most (44.11%)
of peptic ulcer patients surveyed had severe peptic ulcer and 18.13% of peptic ulcer patients surveyed
had mild peptic ulcer. Another 37.70% had moderate peptic ulcer. In general, this indicates that peptic
ulcer is not well managed among most patients. Majority (81.82%) of the patients surveyed had
moderate and severe status.
On socioeconomic status and status of peptic ulcer matrix, most (23.52%) patients with very
poor socioeconomic status had severe peptic ulcer, while no patient (0.00%) with very good
socioeconomic status had severe peptic ulcer. Further, most (17.15%) patients with very poor
socioeconomic status had moderate peptic ulcer while only 1.00% of patients with very good
socioeconomic status had moderate peptic ulcer. Moreover, most (7.84%) of patients with poor
socioeconomic status had mild peptic ulcer while only 1.0% of patients with very good socioeconomic
status and 1.00% of patients with good socio-economic status had mild peptic ulcer. These results
show a relationship between the status of peptic ulcer and socioeconomic status: the poorer the
socioeconomic status, the more severe the peptic ulcer. Hence peptic ulcer patients with poor socio-
economic status tend to develop severe conditions than peptic ulcer patients with good socio-
economic status. Socio-economic status can be viewed as a significant determinant of peptic ulcer.
Peptic Ulcer
33
To further investigate this objective, the data in Table 3 was subjected to chi-square test of
independence to investigate if the status of peptic ulcer is dependent on socioeconomic status of peptic
ulcer patients in Borama district. The claim was investigated under the hypothesis that;
There is no significant difference in the status of peptic ulcer among patients with different
socio-economic status.
H o 1: f oSES∗PUD =f eSES∗PUD .where SES = Socio-economic status and PUD = peptic ulcer disease.
The results of analysis are summarized in Table 4.
Table 4
Summary of χ2 Test of Socio-economic Status with Status of Peptic Ulcer

Variable N df χ2 Sig. Decision C
SES* Status of Peptic ulcer 204 8 12.095 .147 Accept H o 1 .237
2
Note. χ (8, .05) = 15.507. SES is socio-economic status.
Data in Table 4 summarizes the chi square results of socio-economic status and status of peptic
ulcer among peptic ulcer patients in Borama district. The data shows that χ2 (8, N = 204) = 12.095, p =
.147, which led to acceptance of the null hypothesis. The hypothesis that there is no significant
difference in status of peptic ulcer among patients with different socioeconomic status was therefore
accepted. This means that there is no significant difference in the status of peptic ulcer patients who
have different socioeconomic status: Severe, moderate and mild peptic ulcer are found equally among
patients of all levels of socio-economic status. Therefore the status of peptic ulcer does not depend on
socioeconomic status of patients attending hospitals in Borama district. Socio-economic status is not a
significant determinant of the status of peptic ulcer among peptic ulcer patients in Borama district.
The contingency value (C = .237) shows that peptic ulcer is 23.70% dependent on socio-
economic status, and that peptic ulcer can be can be reduced by 23.7% through improving the socio-
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34
economic status of peptic ulcer patients. However, this claim cannot be relied on because the
association is not significant, χ2 = 12.095 ˂ χc2 = 15.507, p = .147.
4.3.3 Lifestyle and Status of Peptic Ulcer
The second objective of this study was to determine the influence of lifestyle on the status of
peptic ulcer among peptic ulcer patients in Borama district. Lifestyle was measured from weight,
smoking and diet of patients. Peptic ulcer patients were asked to react to several statements on these
variables and the responses were used to determine the lifestyle of each patient. The lifestyle was
compared against the status of peptic ulcer of each patient, and the results shown the in Table 5 were
obtained.
.
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35
Table 5
Status of Peptic Ulcer with lifestyle.
Status of peptic ulcer

Severe Moderate Mild Total
Count 21 16 6 43
% within lifestyle coded 48.80% 37.20% 14.00% 100.00%
Very Poor
% within Status of peptic ulcer 23.30% 20.80% 16.20% 21.10%
% of Total 10.30% 7.80% 2.90% 21.10%
Count 31 27 15 73
Poor
% of Total 15.19% 13.23% 7.35% 35.78%
Count 23 24 13 60
Moderate
Lifestyle % of Total 11.30% 11.80% 6.40% 29.40%
Count 14 9 2 25
Good
% of Total 6.90% 4.40% 1.00% 12.30%
Count 1 1 1 3
Very Good
% of Total 0.50% 0.50% 0.50% 1.50%
Count 90 77 37 204
Total % within lifestyle coded 44.10% 37.70% 18.10% 100.00%
% of Total 44.10% 37.70% 18.10% 100.00%
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37
Table 5 shows the status of peptic ulcer among peptic ulcer patients in Borama district
with lifestyle. Data on the last column shows the lifestyle of peptic ulcer patients. It show that
most (35.78%) of peptic ulcer patients surveyed had poor life style and only 1.50% of the
peptic ulcer patients had very good lifestyle. In general, a majority (56.88%) of the peptic
ulcer patients surveyed had poor lifestyle and 13.80% had good lifestyle. Thus, the lifestyle
of peptic ulcer patients in Borama district is generally poor.
Data on the last row show the status of peptic ulcer in the patients surveyed. It shows
the same information that was presented in Table 3: most (44.10%) of peptic ulcer patients
surveyed had severe peptic ulcer and 18.10% had mild peptic ulcer. Another 37.70% had
moderate peptic ulcer. As explained in Table 3, this indicates that peptic ulcer is not well
managed among most patients. Majority (81.80%) of the patients surveyed had moderate and
severe status.
On cross-examination of lifestyle and status of peptic ulcer, and beginning from
severe status, most (15.19%) of patients with poor lifestyle had severe peptic ulcer, while
only 0.50% of patients with very good lifestyle had severe peptic ulcer. Most (13.23%) of
patients with poor lifestyle had moderate status of peptic ulcer and only 0.50% of patients
with very good lifestyle had moderate status of peptic ulcer. Further, 7.35% of patients with
poor lifestyle had mild status of peptic ulcer and only 0.50% of patients with very good
lifestyle had mild peptic ulcer. Hence peptic ulcer patients with poor lifestyle tend to develop
to severe conditions than peptic ulcer patients with good lifestyle. Lifestyle can be viewed as
a significant determinant of peptic ulcer.

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38
The data in Table 5 was subjected to chi-square test of independence to investigate if
the status of peptic ulcer is dependent on lifestyle of peptic ulcer patients in Borama district.
The data was investigated under the hypothesis that;
There is no significant difference in the status of peptic ulcer among patients with
different lifestyles.
H o 2: f oLS∗PUD=f eLS∗ PUD, where LS = lifestyle and PUD = peptic ulcer disease.
Table 6
Summary of χ2 Test of Lifestyle with Peptic Ulcer

LF* Status of Peptic ulcer 204 8 18.58 .018 Reject H o .289
7
2
Note. χ (8, .05) = 15.507. LS is Lifestyle.
Data in Table 6 summarizes the chi square results of lifestyle and peptic ulcer among peptic
ulcer patients in Borama district. The data shows that χ2 (8, N = 204) = 18.578, p = .018,
which led to rejection of the null hypothesis. The hypothesis that there is no significant
difference in the status of peptic ulcer among patients with different lifestyles was therefore
rejected. There are significant differences in status of peptic ulcer among patients with
different lifestyles. Peptic ulcer patients with severe, moderate and mild status are found
differently across different lifestyles. Patients with poor lifestyle tend to develop more severe
peptic ulcer than patients with good life style. Therefore, lifestyle has significant influence on
the status of peptic ulcer among patients attending hospitals in Borama district. Status of
peptic ulcer is dependent on lifestyle. Therefore lifestyle is a significant determinant of the
status of peptic ulcer among peptic ulcer patients in Borama district.

Peptic Ulcer
39
The contingency confident (C = .289) shows that peptic ulcer is 28.9% dependent on
lifestyle. It can be reduced by 28.90% through improving the lifestyle of peptic ulcer patients.
This model can be relied on because the association is significant, p = .018, χo2 = 18.587 ˃ χc2
= 15.507.
4.3.4 Socio-demographic and Peptic ulcer
The third objective of this study was to determine the influence of socio-demographic
factors on the status of peptic ulcer among patients attending hospitals in Borama district.
Socio-demographic factors were measured from age, gender and marital status. Each
variable was related to the status of peptic ulcer, and the results summarized in the following
tables were obtained.
4.3.4.1 Age and Status of Peptic Ulcer
The respondents were asked to indicate their age in order to determine the influence
of age on the status of peptic ulcer among peptic ulcer patients attending hospitals in Borama
district. Age was classified as 0-19, 20-29, 30-39, 40-49, 50-59 and above 60 of patients. The
ages were compared against the status of peptic ulcer of each patient and the results shown
the Table 7 were obtained.

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40
Table 7
Status of Peptic Ulcer with Ages

Status of peptic ulcer Total
Severe Moderate Mild
Count 13 9 4 26
% within Age of respondents 50.00% 34.60% 15.40% 100.0%
0-19
% of Total 6.40% 4.40% 2.00% 12.70%
Count 36 20 11 67
20-29
% of Total 17.60% 9.80% 5.40% 32.80%
Count 16 20 12 48
30-39
% of Total 7.80% 9.80% 5.90% 23.50%
Age of respondents (years)
Count 10 11 6 27
40-49
% of Total 4.90% 5.40% 2.90% 13.20%
Count 6 12 2 20
50-59
% of Total 2.90% 5.90% 1.00% 9.80%
Count 9 5 2 16
Above 60
% of Total 4.40% 2.50% 1.00% 7.80%
Count 90 77 37 204
Total
% of Total 44.10% 37.70% 18.10% 100.00%
Peptic Ulcer
41
Peptic Ulcer
41
Table 7 shows the status of peptic ulcer among peptic ulcer patients attending
hospitals in Borama district with age. Data on the last column show the age of the peptic
ulcer patients. It shows that most (32.50%) of peptic ulcer patients surveyed were aged 20-29
years and only 7.80% of the peptic ulcer patients surveyed were aged of above 60 years.
Data on the last row show the status of peptic ulcer of the patients surveyed. It shows
the same information that was presented in Table 3 and Table 5: most (44.10%) of peptic
ulcer patients surveyed had severe peptic ulcer and 18.10% had mild peptic ulcer. Another
37.70% had moderate peptic ulcer. As explained in Table 3 and Table 5, this indicates that
peptic ulcer is not well managed among most patients. Majority (81.80%) of the patients
surveyed had moderate and severe status.
On cross-examination of age and status of peptic ulcer, most (17.60%) patients aged
20-29 years had severe peptic ulcer, while only 4.40% of the patients aged 60 years above
had severe peptic ulcer. Further, most (9.80%) patients aged 20-29 years and those aged 30-
39 years had moderate status of peptic ulcer, but only 2.50% of the patients aged above 60
years had moderate status of peptic ulcer. Further, 5.90% of the patients aged 20-29 years had
mild status of peptic ulcer and 1.00% of patients aged above 60 years had mild peptic ulcer.
Hence peptic ulcer tends to vary across age, and to increase in status with middle aged
patients. It is more common among patients aged 20-29 years.
the status of peptic ulcer is dependent on age of peptic ulcer patients in Borama district. The
data was investigated under the hypothesis that;
There is no significant difference in the status of peptic ulcer among patients of
different age.
H o 3.1: f oAge∗ PUD=f eAge∗PUD where PUD = status of peptic ulcer.

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42
Table 8
Summary of χ2 Test of Status of Peptic Ulcer with Age

AGE* Status of Peptic ulcer 204 5 11.57 .037 Reject H o 3.1 .230
7
2
Note. χ (5, .05) = 11.070, p = .037.
Data in Table 8 summarizes the chi square results of the status of peptic ulcer among peptic
ulcer patients in Borama district with age. The data shows that χ 2 (5, N = 204) = 11.577, p = .
037, which led to rejection of the null hypothesis. The hypothesis that there is no significant
difference in the status of peptic ulcer among patients with different ages was therefore
rejected. This means that there are significant differences in status of peptic ulcer among
patients of different ages. Severe, moderate and mild status of peptic ulcer is found
differently among patients with different ages. Patients with younger (20-29 years) age tend
to develop more severe peptic ulcer than those with older age. Therefore, age has significant
influence on the status of peptic ulcer among patients attending hospitals in Borama district.
Therefore age is a significant determinant of the status of peptic ulcer among peptic ulcer
patients in Borama district.
The contingency coefficient (C = .230) shows that peptic ulcer is 23.0% dependent on
age, and that it tends to reduce by 23.0% with increasing age. This model can be relied on
because the association is significant, χ2 (5, N = 204) = 11.577, p = .037.
4.3.4.2 Status of Peptic ulcer with Gender
The second sub-variable of socio-democratic factors investigated was gender of
respondents. The study investigated if gender was associated with status of peptic ulcer. The
results summarized in Table 9 were obtained.

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43
Table 9
Status of Peptic Ulcer across Gender

Status of peptic ulcer Total
Count 38 35 19 92
% within Gender of respondents 41.30% 38.00% 20.70% 100.00%
Female
% of Total 18.60% 17.20% 9.30% 45.10%
Gender of respondents
Count 52 42 18 112
Male
% of Total 25.50% 20.60% 8.80% 54.90%
Count 90 77 37 204
Total
% of Total 44.10% 37.70% 18.10% 100.00%
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44
Table 9 shows that a majority (54.90%) of peptic ulcer patients were males and
49.10% of the patients were females. However, 25.50% males had severe status of peptic
ulcer while 18.60% of females had severe status of peptic ulcer. Further, 20.60% of males
had moderate status of peptic ulcer while 17.20% of females had moderate status of peptic
ulcer. Additionally 8.80% males and 9.30% of females had mild peptic ulcer. Generally,
peptic ulcer tends to be more severe in the male gender. Hence the status of peptic ulcer
depends on the gender of patients.
the status of peptic ulcer is dependent on gender of peptic ulcer patients attending hospitals in
Borama district. The data was investigated under the hypothesis that;
There is no significant difference on the status of peptic ulcer among patients with
different gender.
H o 3.2: f oGDN∗ PUD=f eGDN∗PUD, where GDN = Gender and PUD = peptic ulcer disease.
Table 10
Summary of χ2 Test of Status of Peptic Ulcer with Gender

GND*Status of Peptic ulcer 204 2 8.889 .034 Reject H o 3.2 .204
Note. χ2 (2, .05) = 5.991. GND is Gender.
Data in Table 10 summarizes the chi square results of gender of respondents and
peptic ulcer among peptic ulcer patients in Borama district. The data shows that χ 2 (2, N =
204) = 8.889, p = .034, which led to rejection of the null hypothesis. The hypothesis that
Peptic Ulcer
45
there is no significant difference in status of peptic ulcer in patients with different gender was
therefore rejected. This means that there were significant differences in status of peptic ulcer
among male and female patients. Severe, moderate and mild status of peptic ulcer is found
differently among males and females. Males tend to develop more severe peptic ulcer than
females. Therefore, gender has significant influence on the status of peptic ulcer among
patients attending in hospitals in Borama district. Therefore gender is a significant
determinant of the status of peptic ulcer among peptic ulcer patients in Borama district.
4.3.2.3 Status of Peptic Ulcer with Marital Status
The third sub-variable of demographic factors investigated was marital status.
Respondents were asked to indicate their marital status to determine if the marital status was
related to the status of peptic ulcer. The results summarized in Table 11 were obtained.
Peptic Ulcer
46
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46
Table 11
Status of Peptic Ulcer with Marital Status

States of peptic ulcer Total
Count 65 38 16 119
% within Marital status of respondents 54.60% 31.90% 13.40% 100.00%
Single % within States of peptic ulcer 72.20% 49.40% 43.20% 58.30%
% of Total 31.90% 18.60% 7.80% 58.30%
Count 14 27 16 57
Monogamy
% within States of peptic ulcer 15.60% 35.10% 43.20% 27.90%
% of Total 6.90% 13.20% 7.80% 27.90%
Count 3 2 1 6
Polygamy
% of Total 1.50% 1.00% 0.50% 2.90%
Marital status Count 4 4 2 10
Widow
% of Total 2.00% 2.00% 1.00% 4.90%
Count 2 6 2 10
Separated
% of Total 1.00% 2.90% 1.00% 4.90%
Count 2 0 0 2
Other
% of Total 1.00% 0.00% 0.00% 1.00%
Count 90 77 37 204
Total
% of Total 44.10% 37.70% 18.10% 100.00%
Peptic Ulcer
47
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48
Table 11 shows the status of peptic ulcer among peptic ulcer patients in Borama
district with marital status. Data on the last column show the marital status of peptic ulcer
patients. This is the same information that was presented in Figure 7 in section 4.2.6 in the
background information. Data on the last row show the status of peptic ulcer in the patients
surveyed. It shows presents the same information that was presented in Table 3, Table 5 and
Table 7: most (44.10%) of peptic ulcer patients surveyed had severe peptic ulcer and 18.10%
of peptic ulcer patients surveyed had mild peptic ulcer. Another 37.70% had moderate peptic
ulcer. As explained in the mentioned tables, this indicates that peptic ulcer is not well
managed among most patients. Majority (81.80%) of the patients surveyed had moderate and
severe status.
On cross-examination of marital status and status of peptic ulcer, and beginning from
severe status, most (31.19%) with patients of single marital status had severe peptic ulcer,
while only 1.0% of patients with other marital status had severe peptic ulcer. Most (18.60%)
of patients with single marital status had moderate status of peptic ulcer and 0.00% of
patients with ‘other’ marital status had moderate status of peptic ulcer. Further, 7.80% of
patients with single marital also had mild status of peptic ulcer and 0.00% of patients with
‘other’ marital status had mild peptic ulcer. Hence peptic ulcer patients with single marital
status tend to develop to severe conditions than peptic ulcer patients with ‘other’ marital
status. Marital status can be viewed as a significant determinant of peptic ulcer. The data in
Table 11 was subjected to chi-square test of independence to investigate if the status of peptic
ulcer is dependent on marital status of peptic ulcer patients in Borama district. The data was
investigated under the hypothesis that;

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48
There is no significant difference on the status of peptic ulcer among patients with
different marital status.
H o 3.3: f oMST∗ PUD=f eMST∗PUD, where MST = Marital status and PUD = peptic ulcer
disease.
Table 12
Summary of χ2 Test of Marital Status with Peptic Ulcer

MST*Status of Peptic ulcer 204 10 20.26 .027 Reject H o 3.3 .301
5
Note. χ2 (10, .05) = 18.307. MST is Marital Status.
Data in Table 12 summarizes the chi square results of marital status of respondents
and peptic ulcer among peptic ulcer patients in Borama district. The data shows that χ2 (10, N
= 204) = 18.307, p = .027, which led to rejection of the null hypothesis. The hypothesis that
there is no significant difference in status of peptic ulcer among patients with different
marital status was therefore rejected. This means that there are significant differences in
status of peptic ulcer among patients with different marital status. Severe, moderate and mild
status of peptic ulcer is found differently among patients with different marital status. Patients
with single marital status tend to develop more severe peptic ulcer than those with ‘other’
marital status. Therefore, marital status has significant influence on the status of peptic ulcer
among patients attending hospitals in Borama district. Therefore marital status is a significant
determinant of the status of peptic ulcer among peptic ulcer patients hospitals in Borama
district.
The contingency coefficient (C = .301) shows that peptic ulcer is 30.1% dependent on
marital status: Thus patients who are single have 30.1% likelyhood of developing into severe
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49
status. In the overall analysis, the study established that socio-demographic factors (age,
gender and marital status) are significant determinant of status of peptic ulcer among peptic
ulcer patients in Borama district, age χ2 (5, N = 204) = 11.577, p = .037; gender χ2 (2, N =
204) = 8.889, p = .034; and marital status χ2 (10, N = 204) = 18.307, p = .027.
CHAPTER FIVE
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50
SUAMMARY OF FINDINGS, DISCUSSION CONCLUSION AND
RECOMMENDATIONS
5.1 Introduction
This study investigated the determinants of status of peptic ulcer among patients
attending hospitals in Borama district, Somaliland. The determinants were conceptualized as
socio-economic status, lifestyle and socio-demographic factors. Data was collected from 204
peptic ulcer patients attending hospitals in Borama district using questionnaire and document
analysis, and analyzed using chi-square technique. The previous chapters presented the
background and literature review, methodology and data analysis. This chapter summarizes
the findings, draws a conclusion and makes recommendations based on the conclusion and
findings. Each unit is presented along the three main things of the study.
5.2 Summary of the Findings
The first objective of this study was to determine the influence of socioeconomic
status on the status of peptic ulcer among patients attending hospitals in Borama district.
Socioeconomic status was measured from income, occupation and education. Majority
(88.20%) of peptic ulcer patients in Borama district surveyed had poor socio-economic status.
Further, 23.52% of patients with very poor socioeconomic status had severe peptic ulcer,
while no patient with very good socioeconomic status had severe peptic ulcer. Moreover,
7.84% of patients with poor socioeconomic status had mild peptic ulcer while just 1.0% of
patients with very good socioeconomic status and just 1.00% of patients with good socio-
economic status had mild peptic ulcer. But 1.47% of patients with good socio-economic
status had moderate status of peptic ulcer. The study found that socio-economic status was
not a determinant on status of peptic ulcer among patients attending hospitals in Borama
district, χ2 (8, N = 204) = 12.095, p = .147.

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The second objective of the study was to determine the influence of lifestyle on the
status of peptic ulcer among patients attending hospitals in Borama district. Lifestyle was
measured from smoking, weight and diet. The analysis of lifestyle factors indicated that
35.78% of patients had poor lifestyle. In general, 56.88% of the peptic ulcer patients surveyed
had poor lifestyle. Further, 7.35% of patients with poor lifestyle had mild status of peptic
ulcer and only 0.50% of patients with very good lifestyle had mild peptic ulcer. Hence peptic
ulcer patients with poor lifestyle tend to develop to severe conditions than peptic ulcer
patients with good lifestyle. The study established that lifestyle was a significant determinant
of status of peptic ulcer, χ2 (8, N = 204) = 18.578, p = .018.
Lastly the study determined the influence of socio-demographic factors on status of
peptic ulcer among patients attending hospitals in Borama district. Socio-demographic factors
were investigated along age, gender and marital status. On age most (17.60%) patients aged
20-29 years had severe peptic ulcer, while only 4.40% of patients aged 60 years above had
severe peptic ulcer, by gender, 25.50% males had severe status of peptic ulcer while 18.60%
of females had severe status of peptic ulcer. Further, 20.60% of males had moderate status of
peptic ulcer while 17.20% of females had moderate status of peptic ulcer. By marital status,
most (31.19%) patients with single marital status had severe peptic ulcer, while only 1.00%
of patients with “other” marital status had severe peptic ulcer. Another 18.60% of patients
with single marital status had moderate status of peptic ulcer and 0.00% patients with other
marital status had moderate status of peptic ulcer. Gender (χ 2 [2, N = 204] = 8.889, p = .034);
age (χ2 [5, N = 204] = 11.577, p = .037), and marital status (χ2 [10, N = 204] = 18.307, p = .
027) all had significant influence on status of peptic ulcer. Hence the study established that
socio-demographic factors are significant determinants of status of peptic ulcer among
patients attending hospital in Borama district.
In general, the study established that:

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i. Socio-economic status is not a determinant of the status of peptic ulcer in patients with
attending hospitals in Borama district, χ2 (8, N = 204) = 12.095, p = .147.
ii. Lifestyle is a significant determent of the status of peptic ulcer among peptic ulcer
patients attending hospitals in Borama district, that χ2 [8, N = 204] = 18.578, p = .018.
iii. Socio-demographic factors is a determinant of the status of peptic ulcer patients attending
hospitals in Borama district, Gender (χ 2 [2, N = 204] = 8.889, p = .034), age (χ2 [5, N =
204] = 11.577, p = .037, marital status (χ2 [10, N = 204] = 18.307, p = .027).
5.3 Discussion
This section discusses the finding summarized in 5.2. The study investigated three
specific objectives and made three key findings: one in each objective. First, study
determined the influence of socio-economic on status of peptic ulcer among patients
attending hospitals in Borama district. The study established that socio-economic is not a
significant on status of peptic ulcer among patients attending hospitals in Borama district.
Patients with different status of peptic ulcer occur across all socio-economic status. The
socio-economic status investigated in this study ware education, income and occupation. This
finding could come from various sources. Agreed, income inequality should affect directly
some health outcomes, because with high-income, individuals tend to be in better health than
low-income persons (Johnson, 2002). People with low income tend to have more restricted
access to medical care (Gaffney, 2015). But in this study, the income of most patients was
generally low. Therefore it could not have a significant effect on status of peptic ulcer.
Moreover, this study investigated status of peptic ulcer rather than prevalence of peptic ulcer.
The relationship between education, occupation and peptic ulcer can also be explained
in the same manner. Education should provide basic understanding
about health and health risks, as well as about important lifestyle choices to prevent or

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manage diseases (Zimmerman, 2014). And occupation can affect health through direct
impacts, such as physical job conditions like exposure to noise, heat and manual labour
(Baker, 1990). Occupation may also affect health through indirect mechanisms such as
through income, health insurance, prestige and authority that are related to occupation
(Bosma, 1997). In this study, the factors of socio-economic status were taken together and
not individually. This could be the source of divergence. Variables tend to behave directly
when alone than when taken together. Hence variables lost their usual expected individual
identities in the group.
The finding fits well in the context of other previous studies. For example, it
compares favourably to studies done by Milbank (1993), by Kablan (1998) and by Winkleby
and Jatulis (1992). Kablan (1998) studied the association between education and incidence of
peptic ulcer among 104 Alameda County Study participants of both gender in United States.
He found that among women, high school dropouts had a higher risk of incidence of ulcer
than those who attended college (Kablan, 1998). But among men, the risk associated with
low education was weaker, OR = 1.9; 95% (Kablan, 1998). Winkleby and Jatulis (1992)
investigated socioeconomic status and health on a sample of 374 patients of both gender,
using logistic regression. They found that as socio-economic status decreased, the prevalence
of peptic ulcer was increasing, r = .72, p ˂ .005 (Winkleby & Jatulis, 1992). Another study
by Koralyn (2012) investigated how socioeconomic status (income, education
and ethnicity directly) contribute to the development of disease and found that people with
lower socioeconomic status are much more likely to develop chronic diseases r = .660. The
relationship between these socio-economic status measures and risk factors was strongest and
most consistent for education (Ozgoz, 2014). These findings all support the fact that socio-
economic status is associated with peptic ulcer. But the presenting finding is different. As
explained already, this could be due to aspects of socio-economic status investigated by each
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54
study. There are several elements of socio-economic status and several combinations could
bring out different effects. But more importantly, while the other previous studies
investigated peptic ulcer prevalence, the presenting study focused on status of peptic ulcer.
The association between socio-economic and prevalence, and between status need not to be
the same.
The second objective was to determine the influence of lifestyle on status of peptic
ulcer among patients attending hospitals in Borama district. The study established that
lifestyle is a determinant of status of peptic ulcer. The lifestyle factors investigated in this
study were diet, weight and smoking. Smoking may interfere with the action of drugs can can
decrease stomach acid production (Sgambato, Capuano, Giuseppa, Miranda, Federico, and
Romano. 2016). Dieting is important health practice because it can help a person to reach and
maintain a healthy weight, reduce risk of chronic diseases, and promote the overall health
(Corleona, 2015). A balanced diet can prevent, treat or even alleviate disease symptoms
including peptic ulcer (Monica, 2012). Peptic ulcer patients with good lifestyle are those who
manage their health and maintain good lifestyle. Therefore good lifestyle (no smoking, good
dieting and weight management) should lower the development of peptic ulcer, as this study
has shown.
This finding is fairly similar to findings of other previous studies. It supports earlier
studies done by Rafi (2013), by Rosenstock (2003) and by Dutta (2009). Rafi (2013) studied
the effect of dietary and smoking habits on peptic ulcer among 196 patients with abdominal
pain in Dhaka. He found that smoking increases the risk of peptic ulcer and impairs the
process of healing (r = .880). This is similar to present study: both studies investigated
smoking and peptic ulcer patients. Another study done by Rosenstock (2003) among 2416
Danish adults with no history of peptic ulcer, found that tobacco smoking was related to a
significant increase in the risk of developing peptic ulcer. Further, peptic ulcer incidence and
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55
tobacco consumption were associated, χ2 = 43.91, p ˂ .001. A study by Dutta (2010) in Iran
on impact of lifestyle on health among peptic ulcer patients concluded that diet is the greatest
factor in lifestyle with a direct and positive relation with health. He found that lifestyle is
predictor of any disease, r = .950. These studies all report positive association between
lifestyle and peptic ulcer. And even if the reported studies did not study status of peptic ulcer,
the link between lifestyle and peptic ulcer is confirmed.
Lastly, the study determined the influence of socio-demographic factors on status of
peptic ulcer among patients attending hospitals in Borama. Gender has unique association
with health in general. First, peptic ulcer is most common among the age group 30-45 and is
twice as common in men as in women (Thorsen, 2015). Further, male gender is an important
determinant to gastrointestinal diseases outcome like peptic ulcer (Marques, 2011). Hence
gender and age could affect health. Marriage is usually associated with a longer lifespan and
fewer health problems, while divorce associated with higher mortality (Randa, 2017).
Therefore socio-demographic factors could influence health including status of peptic ulcer.
Carlos (2012), Brunson and Julianjeng (2014) and Musyoka (2009) arrived at more
or less similar findings. Carlos (2012) investigated the risk factors and development of peptic
ulcer among 1,466 adult patients resident in Marilia city Brazil. He found that demographic
factors (age and gender) had a significant association with peptic ulcer incidence, OR=
1.8631, p = .005 (Carlos, 2012). Brunson and Jianfeng (2014) investigated 244 in-patients
with gastritis and peptic ulcer at the First Affiliated Hospital of Kunming Medical University.
They also found a significant association between age and gastritis (Brunson & Jianfeng,
2014). Musyoka (2009) on the other hand, studied factors associated with peptic ulcer among
40 patients attending Michael digestive diseases and medical care in upper hill; Nairobi
County. Musyoka (2009) also found that socio-demographic factors (sex, age and marital
status) correlated with occurrence of peptic ulcer disease (Musyoka, 2009). He found that
Peptic Ulcer
56
most of the patients who had peptic ulcers were males, p ˂ .002. This shows a positive link
between gender and peptic ulcer. These studies generally report a positive association
between demographic factors and peptic ulcer, as the present study has established.
5.4 Conclusion
This section draws the conclusion of the study in line with general of objective, and
taking in to account the findings and the discussion already made. The general objective of
this study was to ascertain the determinants of the status of peptic ulcer among patients
attending hospitals in Borama district. The study investigated determinants with respect to
socio-demographic, socio-economic status and lifestyle. The study found that status of peptic
ulcer is significantly dependent on lifestyle, χ2 (8, N = 204) = 18.578, p = .018, C = .289 and
socio-demographic factors; (age χ2 [5, N = 204] = 11.577, p = .037, C = .230; gender χ2 [2, N
= 204] = 8.889, p = .034, C = .204 and marital status χ2 [10, N = 204] = 18.307, p = .027, C =
.301). But the status of peptic ulcer was not dependent on socio-economic status, χ2 (8, N =
204) = 12.095, p = .147, C = .237. Based on these findings and on discussion in 5.3, the study
concludes that lifestyle is the major determinant of the status of peptic ulcer among patients
attending hospitals in Borama district. This because lifestyle accounts for the largest variance
of (28.9%) determinants of status of peptic ulcer among peptic ulcer patients in Borama
district. This means that the status of peptic ulcer is largely due to smoking, diet and weight
of patients.
5.5 Recommendations
5.5.1 General Recommendations

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57
This report has established that lifestyle factors, and socio-demographic factors are
significant determinant of status of peptic ulcer among patients attending hospitals in Borama
district. But socio-economic status is not. From the above findings, the researcher makes the
following recommendations.
First, finding that lifestyle is a significant determinant of the status of peptic ulcer
among patients attending hospitals in Boama district means that diet, smoking and weight are
important factors to consider in the management of peptic ulcer. But most (35.78%) of peptic
ulcer patients were found to have poor lifestyle. This means that they are likely to have
advanced stage of peptic ulcer. The study recommends that Ministry of Health of Somaliland
should mount and promote a health education and awareness programmes on lifestyle
modification at grassroots to help reduce development of peptic ulcer related complications
that may arise for poor lifestyles. Such programmes should promote healthy living among the
society and ulcer patients, and help reduce the advancement of peptic ulcer.
Further, the finding that socio-demographic factors are a significant determinant of
status of peptic ulcer among patients attending hospitals in Borama district imply that age,
gender and marital status have important roles in health among the community. The
relationship could arise due to cultural and social activities that people of certain age, gender
and in marriage engage in. There is need for Ministry of Health and other related government
units to create awareness campaign on relationships between age, gender and marital status
with certain diseases with particular focus on peptic ulcer. Such campaigns should explain the
relationship and the basic strategies to avoid their development along age, gender and within
marital status.
Lastly, the study found that socio-economic status is not a significant determinant of
the status of peptic ulcer among patients attending hospitals in Borama district. This means
that income, education and occupation do not determine the status of peptic ulcer among
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58
patients in Borama district. But socio-economic status of most peptic ulcer patients was found
to be poor (47.50%). The study should recommend that the Ministry of Health of Somaliland
and government of should create a scheme for free treatment and drugs to peptic ulcer
patients in Somaliland as whole. This is because their socio-economic status is poor.
5.5.2 Recommendation for Further Research
This study was specific to peptic ulcer patients attending hospitals in Borama district.
Further, time and other resource constraints could not allow inclusion of all relevant
variables. Therefore only three variables: socio-economic status, socio-demographic factors
and lifestyle were investigated. But, there are several other high prevalence diseases such as
pneumonia and diarrhea in Borama district. For example, pneumonia caused 30 deaths in
1000 in 2015 in Borama district. The researcher recommends that a study be done to
investigate the determinants of pneumonia in Borama district. This could lead to new
strategies for managing the disease in Borama district and in Somaliland as whole.
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APPENDIX A
DISTRIBUTION OF PATIENTS BY HOSPITAL
HOSPITAL
Alhayatt Alaale Borama Regional Total
Population 351 222 204 777
Sample 92 58 54 204
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APPENDIX B
TABLE OF SAMPLE SIZE
Sample Size at Confidence = 95% Sample Size at Confidence = 99%

Margin of Error – Percent Margin of Error – Percent
Population 5.0 3.5 2.5 1.0 5.0 3.5 2.5 1.0
10 10 10 10 10 10 10 10 10
20 19 20 20 20 19 20 20 20
30 28 29 29 30 29 29 30 30
50 44 47 48 50 47 48 49 50
75 63 69 72 74 67 71 73 75
100 80 89 94 99 87 93 96 99
150 108 126 137 148 122 135 142 149
200 132 160 177 196 154 174 186 198
250 152 190 215 244 182 211 229 246
300 169 217 251 291 207 246 270 295
400 196 265 318 384 250 309 348 391
500 217 306 377 475 285 365 421 485
600 234 340 432 565 315 416 490 579
700 248 370 481 653 341 462 554 672
800 260 396 526 739 363 503 615 763
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67
1,000 278 440 606 906 399 575 727 943

1,200 291 474 674 1067 427 636 827 1119
1,500 306 515 759 1297 460 712 959 1376
2,000 322 563 869 1655 498 808 1141 1785
2,500 333 597 952 1984 524 879 1288 2173
3,500 346 641 1068 2565 558 977 1510 2890
5,000 357 678 1176 3288 586 1066 1734 3842
7,500 365 710 1275 4211 610 1147 1960 5165
10,000 370 727 1332 4899 622 1193 2098 6239
25,000 378 760 1448 6939 646 1285 2399 9972
50,000 381 772 1491 8056 655 1318 2520 12455
75,000 382 776 1506 8514 658 1330 2563 13583
100,000 383 778 1513 8762 659 1336 2585 14227
250,000 384 782 1527 9248 662 1347 2626 15555
500,000 384 783 1532 9423 663 1350 2640 16055
1,000,000 384 783 1534 9512 663 1352 2647 16317
2,500,000 384 784 1536 9567 663 1353 2651 16478
10,000,000 384 784 1536 9594 663 1354 2653 16560
100,000,000 384 784 1537 9603 663 1354 2654 16584
300,000,000 384 784 1537 9603 663 1354 2654 16586
Note. Adopted from “The Principles of Educational Research” by Oso, W. Y, 2013. Borama,
Somaliland: Barkhadle Printers
APPENDIX C
QUESTIONNAIRE FOR PEPTIC ULCER PATIENTS IN BORAMA DISTRICT.
Dear respondents
You have been invited to take part a research study titled ‘‘Determinants of the
prevalence of Peptic ulcer Disease among patients attending in Hospitals in Borama District,
Somaliland’’ The study being conducted by Bureeqa I. Egeh a student of master of public
health at Amoud University. Survey is only you about 10-20 minutes to complete. It has been
approved by directors of Hospitals. There will no problem from perhapiting in the study. All
the responses provided by will be analyzed anonymously, and will not be forced to confirm to
some predetermined opinions. Further, the researcher will treat all information provided with
highest privacy and confidentiality and no information will be passed to a third party without
your expressed permission from the respondents. While you may not be experience any direct
Peptic Ulcer
68
benefits from participation, information collected in this study may benefit the staff of
Hospitals in future through developing better awareness for Hospitals in Somaliland on the
management of peptic ulcer.
Part 1: Background information
Please provide the following information about yourself/ your department to the best of your
ability by filling in blank or checking (/) a suitable item. Do not select more than one
response for one statement.
1. Your name is (optional)---------------------------------------------------------------------------
2. You age (years)
i. 0-19 20-29 30-39 40-49 50-59 60 above
3. Gender 1. Female 2. Male 4.
4. Are you employed? i. Yes ii. No
5. If yes, indicate your employment.
i. None ii. Formal iii. Self employed iv. Casual v. Other
6. Your highest level of education
i. None ii. Primary iii. Intermediate iv. Secondary v. Intermediate
vi. University
7. Your Marital Status
i. Single ii. Married monogamy iii. Married polygamy iv. Widowed/Widow
v. Separate iv. Others specify------------------------------------------------------------
8. Your area of residence

Peptic Ulcer
69
i. Borama ii. Quljeed iii. Baki iv. Other Specify---------
Part11: Socio-economic Factors
Respond to the following statements by checking (/) the most suitable alternative to you or by
filling the blanks whichever is appropriate. Do not choose more than one alternative on one
statement.
1. Indicate the average income of the following persons per months, whichever is applicable.
i. Your average income per month.
0-99$ 100-199$ 200-299$ 300-399$ 400-499$ over 500$
ii. Your father’s income per month.
0-99$ 100-199$ 200-299$ 300-399$ 400-499$ over 500$
iii. Your mother’s income per month.
0-99$ 100-199$ 200-299$ 300-399$ 400-499$ over 500$
iv. Your spouse income per month.
0-99$ 100-199$ 200-299$ 300-399$ 400-499$ over 500$
2. Indicate the level of education of your parents or spouse, whichever is applicable
i. Indicate the level of education of your mother
None primary Secondary University Other specify------------
ii. Indicate the level of education of your father
iii. Indicate the level of education of your spouse
3. Indicate your occupation and occupation of your parents or spouse; whatever is applicable.
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70
i. Your occupation
None Peasant Formal employment Non formal employment
Casual Other Specify------------------------------------------------------------
ii. Occupation of your father
iii. Occupation of your mother
iv. Occupation of your spouse
Part III: life Style Factors
Respond to the following statements by checking (/) the most suitable alternative, or by
filling in blanks whichever is appropriate. Do not choose more than one response in one in
statement.
Statement SA A NC DA SDA
i. I do not smoke cigarettes since I was
diagnosed of peptic ulcer.

ii. I always stay away for cigarette
smokers and cigarette smoke.

iii. I always take food with no species at
all.
iv. I prefer to use natural food like shurro.
Peptic Ulcer
71
v. I watch my weight to ensure it does not
below to my normal (60kg).

vi. I usually prevent to be under weight.
Key SA= Strongly Agree; A= Agree; NC= Neither Agree nor Disagree; DA=Disagree;
SDA=Strongly Disagree.
Document Analysis Check list
1. Name of patient------------------------------------------------------------------------------------
2. Date of clinic---------------------------------------------------------------------------------------
3. File number-----------------------------------------------------------------------------------------
4. Has peptic ulcer Yes No
5. Status of peptic ulcer
Mild moderate severe very severe
6. Other relevant information on
records----------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------
Thank you for your cooperation
Bureeqa I. Egeh Phone No: 0634509271

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72
APPENDIX E
TIME FRAME WORK
No Phrase Time (months) 2016-2017 Dependence

1 Development of 3 Nov-Feb A
proposal
2 Deployment of 1 March B
instruments
,piloting and
quality control
3 Data collection 2 March-April C
4 Data organizing, 1 May D
Interpretation
and Analysis
5 Report writing/ 2 June E

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73
Submission
APPENDIX F
RESEARCH BUDGET
No Items Description Quantity Unit Cost TOTAL
($) ($)
1. Stationary Printing and copying papers 6 Reams 7 42
Sticky notes & Spiral note 3 Box 3 9
book Lump 19 19
Photocopy & printing papers sum
3 pieces 1 3
Pens and Pencils

2. Transportatio Field trips for data collection Lump - 237
n cost will be sum

3. Data entry Typing/Editing/Reporting
Writing and submission 9 days 4.5 40

4. Consistency Other expenses - 35
Total $385
Peptic Ulcer
74

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Peptic Ulcer

STATUS OF PEPTIC ULCER DIEASE

Health Promotion in Public Health

Declaration by the Student

Bureeqa Ibraahim Egeh

Approval by the Supervisor

Postgraduate Studies and Research, Amoud University for examination by my approval as

the candidate’s supervisor.

------------------------------------ Date ------------------------------------

Dr. Oso W. Yuko

School of Postgraduate Studies and Research,

Amoud University, Somaliland

APPENDIX A: DISTRIBUTION OF PATIENTS BY HOSPITAL.......................................68

APPENDIX B: TABLE OF SAMPLE SIZE...........................................................................69

APPENDIX C: QUETIONAIRE FOR PEPTIC ULCER PATIENTS....................................38

APPENDIX D: DOCUMENT ANALYSIS CHECK LIST.....................................................32

APPENDIX E: TIME FRAME WORK...................................................................................33

APPENDIX F: RESEARCH BUDGET...................................................................................34

Figure 1. Conceptual framework ...............................................................................................7

WHO - World Health Organization

CVI - Context Validity Index

1.1 Background of the Study

Somalia peptic ulcer was first diagnosed in 1989 (Theodore, 2014).

Southern Europe as 4.1% to 8% and in Northern Europe as 10% to 15% (Musumba,

about 152,658 persons annually (WHO, 2014).

Peptic ulcer disease also known as a peptic ulcer or stomach ulcer is a break in the

focus on socio-economic, socio-demographic and lifestyle factors. A socio-demographic

Lifestyle is a set of attitudes, habits or possessions associated with a particular person or

prevalence of peptic ulcer in Somaliland have not been empirically investigated

Guided by the Theory of Lifestyle Modification, this study determined the

(Pagano, 1986). The stages may depend on socio-demographic, socio-economic and a

relevant to the study.

1. 2 Statement of the Problem

responsible had not been empirically investigated. Socio-economic, socio-demographic and

1.3 Research Objectives

1.3.1 General Research Objective

peptic ulcer among peptic ulcer patients in Borama district, Somaliland.

1.3.2 Specific Research Objectives

The specific research objectives of this study were to:

1. Determine if the status of peptic ulcer is dependent on socio-economic status of peptic

ulcer patients in Borama district.

3. Determine if the status of peptic ulcer is dependent on socio-demographic factors among

peptic ulcer patients in Borama district.

1.4 Research Hypotheses

1.4.1 General Research Hypothesis

dependent on socio-economic status, socio-demographic factors and on lifestyle of peptic

ulcer patients in Borama district, Somaliland, both individually and together.

1.4.2 Specific Research Hypotheses

This study was be guided by the following specific research hypotheses:

1. The status of peptic ulcer is significantly dependent on socio-economic status of peptic

ulcer patients in Borama district.

3. The status of peptic ulcer is significantly dependent on socio-demographic factors of

peptic ulcer patients in Borama district.

1.5 Research Questions

1.5.1 General Research Question

1.5.2 Specific Research Questions

The specific research questions of this study are:

1.6 Scope of the Study