CHRONIC LIVER DISEASE AND ASSOCIATED FACTORS AMONG

PATIENTS ATTENDING CHRONIC FOLLOW-UP CLINICS AT

EASTERN ETHIOPIA’S PUBLIC HOSPITALS

MSC THESIS

KADIR ABDU (BSC)

JUNE 2023
HARAMAYA UNIVERSITY, HARAR, ETHIOPIA
Chronic Liver Disease and Associated Factors Among Patients Attending
Chronic Follow-Up Clinics at Eastern Ethiopia’s public hospitals

A Thesis Submitted to the Department of Nursing and Midwifery

School of Graduate Studies
HARAMAYA UNIVERSITY

In Partial Fulfillment of the Requirements for the Degree of

MASTER OF SCIENCE IN ADULT HEALTH NURSING

Kadir Abdu
 APPROVAL SHEET
HARAMAYA UNIVERSITY

SCHOOL OF GRADUATE STUDIES

I hereby certify that I have read and evaluated this thesis entitled “Chronic Liver Disease and
Associated Factors Among Patients Attending Chronic Follow-Up Clinics at Eastern Ethiopia’s
public hospitals” prepared under my guidance by Kadir Abdu. I recommend that it can be
submitted as fulfilling the thesis requirement.

Dr. Biftu Geda ____________ ___________

Major Advisor Signature Date

Dr. Maleda Tefera ____________ ___________

Co-Advisor Signature Date

As a member of the board of examiners of the MSc Open Thesis Defense Examination, I certify
that I have read and evaluated the Thesis prepared by Kadir Abdu and examined the candidate.
I recommend that the Thesis be accepted as fulfilling the thesis requirement for the degree of
Masters of Science in Adult Health Nursing.

Mr. Sisay Habte ______________ _____________

Chairperson Signature Date
Dr. Aboma Motuma _____________ _____________
Internal Examiner Signature Date
Mr. Gezahegn Bekele _____________ _____________
External Examiner Signature Date
Final approval and acceptance of the Thesis are contingent upon the submission of its final copy
to the Council of Graduate Studies (CGS) through the candidate’s department or school
graduate committee (DGC or SGS).

ii
 STATEMENT OF THE AUTHOR
I declare and confirm that this Thesis is my work by my signature below. I have followed all
ethical and technical principles of scholarship in the preparation, data collection, data analysis,
and compilation of this Thesis. Any scholarly matter included in the Thesis has been recognized
through citation.

This Thesis is submitted in partial fulfillment of the requirements for a master’s degree at
Haramaya University. The Thesis is deposited in the Haramaya University library and it is made
available to borrowers under the rules of the library. I solemnly declare that this Thesis has not
been submitted to any other institution for the award of any academic degree, diploma, or
certificate.

Brief quotations from this Thesis may be made without special permission provided that
accurate and complete acknowledgment of the source is made. Requests for permission for
extended quotations from or reproduction of this Thesis in whole or in part may be granted by
the Head of the School or Department when in his or her judgment the proposed use of the
material is in the interest of scholarship. In all other instances, however, permission must be
obtained from the author of the Thesis.

Name: Kadir Abdu Signature: ____________________________

Date: ____________

School: Nursing and Midwifery

iii
 BIOGRAPHICAL SKETCH
My name is Kadir Abdu Mohammed. I was born on June 09, 1993, in Asebot (01) Kebele,
Mi’esso Woreda, West Hararge zone, Oromia National Regional State, Ethiopia. I attended my
primary education at Oda Asebot Elementary School (2002-2009), and secondary and
preparatory education at Asebot Secondary and preparatory school from 2010-2013.

I joined the University of Jimma in 2014 and graduated with a BSc degree in Nursing in 2017.
After working as a junior nursing professional at Deder general hospital (Deder Woreda, East
Hararge Zone) for three years, I joined Haramaya University to attend my master’s degree in
Adult Health Nursing in November 2020.

iv
 ACKNOWLEDGEMENT
First and foremost, all praise is due to Allah who keeps me healthy and safe. Next, I would like
to acknowledge Haramaya University, College of Health and Medical Sciences, School of
Nursing and Midwifery for allowing me to join the postgraduate study program and for
providing me with sponsorship to prepare this thesis. And also, my deepest gratitude goes to
Deder General Hospital for providing me with financial support for this postgraduate study.

Secondly, I would like to express my heartfelt thanks, appreciation, and acknowledgment to my

advisors, Dr. Biftu Geda and Dr. Maleda Tefera for their invaluable constructive comments,
guidance, and timely feedback in the course of this thesis preparation.

Finally, my heartfelt thanks go to my data collectors, supervisors, study participants, and all
others who directly or indirectly supported my work.

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 TABLE OF CONTENTS

APPROVAL SHEET ii

STATEMENT OF THE AUTHOR iii

BIOGRAPHICAL SKETCH iv

ACKNOWLEDGEMENT v

LIST OF TABLES ix

LIST OF FIGURES x

ACRONYMS AND ABBREVIATIONS xi

ABSTRACT xii

1. INTRODUCTIONS 1
Background 1

Statement of the problem 2

Significance of the Study 4

Objectives 4

1.2.1. General objective 4

1.2.2. Specific objective 4

2. LITERATURE REVIEWS 5
2.1. Magnitude of CLD 5

2.2. Factors Associated with CLD 6

2.2.1. Socio-demographic factors 6

2.2.2. Behavioral and Socio-cultural related factors 7

2.2.3. Clinically related factors 7

vi
 2.3. Conceptual Framework 9

3. MATERIALS AND METHODS 10

3.1. Study Area and Period 10

Study Design 10

3.2. Population 11

3.2.1. Source population 11

3.2.2. Study population 11

3.2.3. Study unit 11

Inclusion and Exclusion Criteria 11

3.2.4. Inclusion criteria 11

3.2.5. Exclusion criteria 11

Sample Size Determination 11

Sampling Techniques 13

Data Collection Methods 14

3.2.6. Data collection instrument 14

3.2.7. Data collectors 15

3.2.8. Data collection procedures 15

Variables of the Study 15

3.2.9. Dependent variable 15

3.2.10. Independent Variables 15

Operational Definitions 16

Data Quality Control 16

Data Processing and Analysis 17

Ethical Considerations 18

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4. RESULTS 19
Socio-demographic and Behavioral Characteristics of Respondents 19

Magnitude of CLD among chronic follow-up patients 20

Magnitude of CLD by Residence and Sex 21

Magnitude of CLD by Age 22

Clinical characteristics of the patient with CLD 23

Investigation and Laboratory findings of the study subjects with CLD. 24

Factors Associated with CLD 25

5. DISCUSSION 26

6. CONCLUSION AND RECOMMENDATIONS 29

7. REFERENCES 30

8. ANNEXES 33
Annex I: Information Sheet and Informed Voluntary Consent Form for Head of Public Health
Institutions 33

Annex II: English Version of Information Sheet and Informed Voluntary Consent Form for
the study participants 35

Annex V: English Version of Questionnaire 37

Annex III: Afan Oromo Version of Information Sheet and Informed Voluntary Consent Form
for the study participants 41

Annex VI: Afan Oromo Version of Questionnaire 43

Annex IV: Amharic Version of Information Sheet and Informed Voluntary Consent Form for
the study participants 47

Annex VII: Amharic Version of Questionnaire 49

viii
 LIST OF TABLES
Table Page

Table 1: Sample size calculation for the factors associated with CLD among patients attending
chronic follow-up clinics at Eastern Ethiopia’s public hospitals, 2022 12
Table 2: Sociodemographic and behavioral characteristics of chronic liver disease and
associated factors among patients attending chronic follow-up clinics at Eastern Ethiopia’s
public hospitals, 2022 (n = 418) 19
Table 3: Clinical characteristics of chronic liver disease and associated factors among patients
attending chronic follow-up clinics at Eastern Ethiopia’s public hospitals, 2022 (n = 99) 23
Table 4: Investigation and Laboratory findings of chronic liver disease and associated factors
among patients attending chronic follow-up clinics at Eastern Ethiopia’s public hospitals, 2022
(n = 99) 24
Table 5: Bi-variable and multivariable logistic regression analysis for factors associated with
the chronic liver disease among patients attending chronic follow-up clinics at Eastern
Ethiopia’s public hospitals, 2022 (n = 418) 25

ix
 LIST OF FIGURES
Figure Page

Figure 1: Conceptual framework of chronic liver disease and associated factors among patients
attending chronic follow-up clinics at Eastern Ethiopia’s public hospitals, 2022 (developed by
reviewing different kinds of literature) 9
Figure 2: Schematic presentation of sampling technique to assess chronic liver disease and
associated factors among patients attending chronic follow-up clinics at Eastern Ethiopia’s
public hospitals, 2022 14
Figure 3: Magnitude of chronic diseases among patients attending chronic follow-up clinics at
Eastern Ethiopia’s public hospitals, 2022 (n = 418) 20
Figure 4: Magnitude of CLD by residence and sex at Eastern Ethiopia’s public hospitals, 2022
(n = 99) 21
Figure 5: Magnitude of CLD by age at Eastern Ethiopia’s public hospitals, 2022 (n = 99) 22

x
 ACRONYMS AND ABBREVIATIONS
ALD Alcoholic Liver Disease

AOR Adjusted Odd Ratio

CDC Center for Disease Control

CGH Ciro General Hospital

CHB Chronic Hepatitis B Infection

CLD Chronic Liver Disease

COR Crude Odd Ratio

DGH Deder General Hospital

DRH Dilchora Referral Hospital

GGH Galamso General Hospital

GMGH Gara Mulata General Hospital

HBSAg Hepatitis B Surface Antigen

HBV Hepatitis B Virus

HCC Hepatocellular Carcinoma

HCV Hepatitis C Virus

HE Hepatic Encephalopathy

HFCSH Hiwot Fana Comprehensive Specialized Hospital

LD Liver Disease

NAFLD Nonalcoholic Fatty Liver Disease

SRS Simple Random Sampling

SYRS Systematic Random Sampling

WHO World Health Organization

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 ABSTRACT
Background: Chronic liver disease is the long-term degradation of liver processes such as the
manufacture of clotting factors and other proteins, the detoxification of toxic metabolic
products, and the excretion of bile. Chronic liver disease complications are the primary cause
of morbidity and mortality. Although chronic liver disease is affecting patients’ lives, there is a
scarcity of comprehensive data on the magnitude of chronic liver disease and associated factors
in the study setting. Therefore, this study aimed to determine the magnitude and factors related
to chronic liver disease among patients attending chronic follow-up clinics at Eastern Ethiopia’s
public hospitals.

Methods: A facility-based cross-sectional study was employed using simple random sampling
to select 422 chronic disease patients. A pre-tested and interviewer-administered structured
questionnaire accompanied by a review of medical records was used to collect data. Data related
to chronic liver disease were extracted from medical records. Data were entered into Epi-Data
3.1 and exported to STATA 17.0 for analysis. A crude and adjusted logistic regression analysis
was done to identify factors associated with chronic liver disease. All variables with a p-value
of < 0.25 in the crude analysis were entered into the multivariable analysis. Finally, significance
was set at a p-value < 0.05.

Results: Of a total of 418 respondents, the overall magnitude of chronic liver disease was
23.68% (95%CI: 19.59%-27.77%). Among the age group 18-34 (AOR: 3.05; 95%CI: 1.52-
6.13), from rural areas (AOR: 1.77; 95%CI: 1.04–3.03), those with a history of substance abuse
like khat (AOR: 2.09; 95%CI: 1.18-3.67), and herbal medicine non-users (AOR: 0.35; 95%CI:
0.20-0.60) were factors significantly associated with chronic liver disease.

Conclusion: The magnitude of chronic liver disease was high among chronic patients, with one
out of every four patients having chronic liver disease. This study reported statistically
significant associations between CLD and age, residence, khat usage history, and herbal
medicine non-users.

Keywords: Chronic liver disease, magnitude, associated factors, eastern Ethiopia

xii
 1. INTRODUCTIONS

Background

Chronic liver disease (CLD) is the progressive destruction and regeneration of liver tissue with
subsequent necrosis that persists for at least 6 months. Chronic liver disease (CLD) is a long-
term degradation of liver processes, such as the manufacture of clotting factors and other
proteins, the detoxification of toxic metabolic products, and the excretion of bile. It is also a
continual process of liver parenchyma inflammation and regeneration that leads to fibrosis and
cirrhosis (Kasper D. et al., 2015). Cirrhosis is the last stage of chronic liver disease,
characterized by disturbance of hepatic architecture, the creation of extensive nodules, vascular
reorganization, neo-angiogenesis, and extracellular matrix deposition (Sharma A. and Nagalli
S., 2022). Jaundice, weariness, itching, pain in the right upper quadrant, nausea, low appetite,
abdominal distention, and intestinal hemorrhage are all common presenting signs of liver
disease (Masters B.R. et al., 2012).

Chronic liver disease has a wide range of etiologies, including toxins, long-term alcohol
addiction, infection, autoimmune diseases, and hereditary, and metabolic abnormalities
(Albillos A. et al., 2020). Hepatocellular necrosis and persistent inflammation produced by a
viral infection or toxic substances are the pathophysiology of CLD, which results in a
regenerative process that destroys normal liver structure and function (Tabassum F., 2000).
Whatever the origin, liver inflammation is the key mechanism for the advancement of chronic
liver disease (Asselah T. et al., 2003).

Chronic Liver Disease complications are the primary cause of morbidity and mortality (ascites,
hepatic encephalopathy, hepatorenal syndrome, variceal hemorrhage, and hepatocellular
carcinoma). Due to the frequent etiologies of CLDs in a context, the distribution of CLD
complications will differ once more. Chronic HBV infection, for example, is responsible for
more than 70% of hepatocellular carcinoma cases in Africa and Asia, but only around 50% of
cases worldwide (Wang X. et al., 2014).

In Ethiopia, the focus is on interventions that include promotive services, primary, secondary,
and tertiary prevention measures, raising awareness, providing safe and effective HBV
vaccines, preventing non-mandatory blood transfusion, strengthening national blood screening

1
policies and strategies, implementing quality control measures, and sustain routine infection
control practices in healthcare settings and facilitating vaccination against HBV for health
workers (FMOH, 2016).

Statement of the problem

Chronic liver disorders (CLDs) are a major public health issue around the world. The liver is a
representation of a person's health in many ways, and it should be prioritized in global public
health initiatives (Marcellin P. and Kutala B.K., 2018). Chronic Liver Disease was ranked 12th
among the 15 main causes of death by the Centers for Disease Control and Prevention (CDC)
in 2015, with an estimated mortality of 40,326 (1.5% of total fatalities) (Mokdad A.A. et al.,
2014). Over 30 million people in the United States are expected to have some kind of chronic
liver disease, and annual deaths climbed by 65% from 1999 to 2016, with people aged 25-34
experiencing the biggest relative rise in mortality, led by deaths due to alcoholic chronic liver
disorders (Blachier M. et al., 2013).

Cirrhosis has increased by 57% in Sub-Saharan Africa during the last two decades, with HBV,
HCV, and alcohol accounting for 69% of cirrhosis mortality (Spearman C.W. and Sonderup
M.W., 2015). In Sub-Saharan Africa, the Global Burden of Diseases (GBD) projected that CLD
caused 157,558.69 deaths (2.11% of all-cause mortality) in 2017. CLD is projected to have
caused 16,068.94 fatalities in Ethiopia this year. HBV, HCV, and alcohol accounted for 0.008%,
0.01%, and 0.004% of all deaths in Ethiopia due to CLD, respectively (Metrics I.f.H. and
Evaluation, 2017). For every four admissions with CLD, one death was observed (Terefe T.B.
et al., 2019).

Chronic liver disorders were linked to alcohol usage, herbal drug use, positive serum hepatitis
B (HBV), and parenteral medication use (Bihonegn W.T. and Ayalewu T.K., 2020). In eastern
Ethiopia, daily khat intake is prevalent at 78 %; yet, because khat is cultivated using insecticides
that are hazardous to the liver, it could be the likely source of unknown factors that play a role
in the disease's development. Chronic HBV infection was found in roughly one-third of people
hospitalized with CLD in eastern Ethiopia. However, in more than half of the cases, the cause
of liver disease was unknown (Orlien S.M.S. et al., 2018a).

2
Accurate epidemiological data on liver-related mortality in sub-Saharan Africa are lacking, and
verbal autopsy remains the predominant method of ascertaining the cause of death, which is
highly likely to underestimate the true burden of disease (Byass P., 2014). In Ethiopia as in
other Sub-Saharan Africa, the magnitude of liver disease is high. They account for 12% of
hospital admissions and 31% of the mortality in medical wards of Ethiopian hospitals (Tsega
E., 2000).

In Ethiopia, only a small amount of study has been done on the magnitude of CLD and
associated variables. Furthermore, there is a scarcity of recent data on the magnitude and
associated variables of CLD in the research area. A cross-sectional study of hospital-based
magnitude and related variables studies on chronic liver disease aids in determining the true
nature of the problem, the volume of diseases in a community, and the development of
preventative strategies. As a result, the purpose of this study was to determine the magnitude of
CLD and associated factors among chronic patients in Eastern Ethiopia.

3
Significance of the Study

The information generated through this study will help the eastern Ethiopian regional health
bureau and donors, knowing the burden of CLD, plan and develop appropriate strategies and
programs to promote CLD patient care. This study enables regional and zonal health bureaus in
eastern Ethiopia to forecast future healthcare costs for patients with chronic liver disease and to
develop policies and programs to promote the health of chronic liver disease patients.
Healthcare providers in Harari Regional State, Dire Dawa city administrations, and East and
West Hararge zones can use this study finding to manage CLD patients and recommend
integrated care, as well as detect and treat chronic liver disease early on, which is crucial in
preventing the development of related complications.

In addition, the study findings can help stakeholders recognize the importance of chronic care
utilization among CLD patients and provide support to improve their health. It can also be used
as a reference by another researcher or as the subject of a larger study. Moreover, the research
thesis will serve as partial fulfillment of the requirements for the degree of Master of Science in
Adult Health Nursing for the principal investigator.

Objectives

1.2.1. General objective

 To assess chronic liver disease and associated factors among patients attending chronic
follow-up clinics at eastern Ethiopia’s public hospitals, from November 20, to December
20, 2022.

1.2.2. Specific objective

✓ To determine the magnitude of chronic liver disease among patients attending chronic
follow-up clinics at eastern Ethiopia’s public hospitals.
✓ To identify factors associated with the chronic liver disease among patients attending
chronic disease follow-up clinics at eastern Ethiopia’s public hospitals.

4
 2. LITERATURE REVIEWS
This section includes reviews on chronic liver disease and associated factors among patients
attending chronic follow-up clinics at Eastern Ethiopia’s public hospitals from different
literatures using different computerized data bases such as Google Scholar, PubMed, HINARI,
SCI-HUB, CINAHIL, and PLOSONE. Literature search was made using key terms such as
chronic liver disease, associated factors, public hospitals, and Ethiopia.

2.1. Magnitude of CLD

An estimated 1.5 billion persons have CLD worldwide (Moon A.M. et al., 2020). Liver disease
has a worldwide distribution. According to World Health Organization, 2010 G.C. report the
worldwide magnitude of CLD is 18.5% with the magnitude of cirrhosis ranging from 4.5 to 9.5
%. It was estimated that over one million deaths in 2010, which equates to approximately 2%
of all deaths worldwide were due to liver cirrhosis (WHO, 2010). According to National Health
and Nutrition Examination Surveys conducted in 2010 in the USA, the estimated magnitude for
CLD was 302 per / 100, 000 population and also, Routinely collected health data from Ontario,
Canada in 2016 reported 840 per / 100,000 population (Scaglione S. et al., 2015, Flemming J.A.
et al., 2021).

According to current estimates, 844 million people worldwide suffer from CLDs, with a
mortality rate of 2 million fatalities each year (Byass P., 2014). Cirrhosis (1.2 million fatalities)
and liver cancer (790,000 deaths) are the two most common consequences of CLD, accounting
for 3.5% of all deaths globally (Asrani S.K. et al., 2019). According to the American
Association for the Study of liver disease multi ethnic cohort study the magnitude of CLD
ranged from 3.9% in African Americans and Native Hawaiians to 4.1% in whites, 6.7% in
Latinos, and 6.9% in Japanese (Setiawan V.W. et al., 2016).

In Italy, a study done on young/middle-aged adults depicted that the overall magnitude of CLD
was 11.1/1000 population (95% CI: 10.9–11.2) among males and 6.4/1000 (95% CI: 6.3–6.5)
among females and also the overall magnitude of CLD was higher in immigrants than in Italians,
except for older males, where rates were slightly higher in the native population (Fedeli U. et
al., 2019).

5
In Ethiopia hospital-based study conducted among patients admitted to the medical ward
reported magnitude of CLD was 2.3% (Adhanom M. and Desalegn H., 2017), and in
another hospital-based study conducted at Ras Desta Damtew memorial hospital among patients
admitted with liver disease (90.1%) of them found to have Chronic liver disease (Erkabu S. et
al., 2021).

2.2. Factors Associated with CLD

2.2.1. Socio-demographic factors

In an Indian study, 150 (75 %) of the 200 cases and 200 controls were males, with median ages
of 58.5±11.8 and 57±11.7 for cases and controls, respectively. Most of the study participants
were between the ages of 41 and 65, accounting for 72.5% of cases and 70% of controls. Patients
with CLD had statistically significant differences in socioeconomic indicators and educational
status as compared to controls, with p-values of <0.001(Banait S. et al., 2021). According to a
study conducted in Ghana, the magnitude of CLD in males is 72.2%, with the majority of
patients aged 18 to 86 years and the majority of them lacking a high school education (Matthew
Aidoo and Mohammed B.S., 2020).

A total of 109 individuals, 87 (80% male) diagnosed with CLD, were included in a study
conducted in the country utilizing a cohort study design. The individuals' median age was 38
(IQR, 30–48), and 39 (35.8%) of them tested positive for HBsAg, whereas 12 (11%) tested
positive for anti-HCV (Terefe T.B. et al., 2019). According to case-control research conducted
in Addis Ababa, alcohol usage is associated with chronic liver disease (AOR: 8.23 95 % CI:
3.76 – 12.70). Liver enzymes are higher in hepatitis patients who consume alcohol than in non-
hepatitis patients who do not consume alcohol (Abdelmenan S. et al., 2018). In another study
done in Addis Ababa utilizing a prospective study design, Hepatitis B surface antigen was found
in 43 (35.8%) and anti-HCV antibody in 27 (22.5%) individuals clinically diagnosed with
chronic liver diseases (Abel G. and Solomon G., 2012).

In a retrospective study conducted at Jimma Medical Center, the records of 96 CLD patients
were reviewed. Most of the patients, 76 (79.2%), were between the ages of 20 and 49 overall,
31.2% of people tested positive for HBsAg, 19.8% tested positive for alcohol, and 7.2% tested
positive for HCV and the cause of the chronic liver disease was not determined in nearly half
of the cases (45.8%) (Desu G., 2019).
6
 2.2.2. Behavioral and Socio-cultural related factors
The study conducted in India showed that the recreational substance abuse history ever use of
alcohol, smoking, and tobacco was found to have a statistically significant association with CLD
with a p-value of <0.001 (Banait S. et al., 2021).

A study conducted in three tertiary teaching hospitals in Ethiopia revealed that the history of
social drug use habits, 52(47.7%), 39(35.8%), and 16(14.7%) of the participants reported khat
chewing, alcohol consumption, and cigarette smoking history, respectively. In-hospital
survivors were more likely to be khat chewers as compared to no survivors (55.1% vs. 29%) (p
= 0.014) (Terefe T.B. et al., 2019). Among the total respondents, 53(56.4%) of cases and
51(27.3%) of controls were alcohol consumers (CAGE score ≥2) and 33(62.3%) of cases, and
21(41.2%) of controls were consuming alcohol for ≥10 year. Of the total respondents,
34(36.2%) of cases and 24(12.8%) of controls had a tattoo on their body, and also 77(81.9%)
of cases and 42(22.5%) controls had a history of herbal medication use (Bihonegn W.T. and
Ayalewu T.K., 2020).

According to previously done research in the study area, the overall reported magnitude of daily
khat use was 78.0%. Khat use was more common among men than women (92.6% vs. 40.5%;
p < 0.001); overall khat exposure was also higher in men than women (36 vs. 0.6 khat-years; p
< 0.001). Women were more likely to have unexplained CLD than men (71.4% vs. 49.1%; p =
0.013) (Orlien S.M.S. et al., 2018a).

2.2.3. Clinically related factors

According to the report by WHO, the most common cause of CLD is attributed to HBV (43%),
HCV (24%), ALD (19%), NAFLD (10%) and other causes contribute to about 5% (WHO,
2010). The study from Italy reported that the most common cause of CLD was HCV infection
(43.1%), followed by HBV (20.7%) and alcohol (11.3%). The proportion of CLD related to
HCV infection was higher in males, and the proportion related to HBV infection was larger in
females. About one out of four patients (25.4%) could not be attributed to any of the above
categories (Fedeli U. et al., 2019). Contrary to this, a study done in India depicted that on
univariate analysis, hepatitis B was found statistically significant (p-value 0.00025) with CLD,
while hepatitis C was not found to be statistically significant. Provided that, the commonest

7
probable reason for the development of CLD was alcohol in 69% of the participants, while
NAFLD and hepatitis B were found in 26% and 7.5% respectively (Banait S. et al., 2021).

The etiologies among the patients showed that Hepatitis B viral infection was the leading cause
of CLDs in the patients, accounting for 96 (53.3%), followed by hepatitis C viral infection 39
(21.7%), unknown 17 (9.4%), hepatocellular carcinoma 16 (8.9%), and alcoholic liver disease
12 percent (6.7%). The etiologies of CLD were shown to be strongly linked with age, education
background, and history of herbal medication usage in CLD patients (p=0.001), (0.005), and
(0.001), respectively (Matthew Aidoo and Mohammed B.S., 2020). Another study conducted
in Benin utilizing prospective study design reported that the study individuals who had several
sexual partners 62 (56.4%), alcohol intake 54 (49.1%), tattooing 44 (40.0), smoking and blood
transfusions 16 (14.5%) each, and intravenous drug usage 2 (1.8%) as risk factors for chronic
liver disease (Ibegu M.I., 2017).

Study conducted in Addis Ababa revealed that, chronic viral hepatitis and hepatitis B virus
(HBV) were found in 56% and 44.4% of CLD cases respectively. 17.9% tested positive for
HCV antibodies and 2.6% had both HBV and HBV infections. Cirrhosis and hepatocellular
carcinoma were found in 34% and 10.3% respectively, while an alcoholic liver illness (2%) was
found in a lower percentage of people (Adhanom M. and Desalegn H., 2017). Another study
done in the study area depicted that the etiology of liver disease was previously identified in 67
(44.7%) of the 150 patients in the study area and was attributed to chronic HBV infection in 55
(36.7%), hepatic schistosomiasis in four (2.7%), alcohol misuse in three (2.0%), chronic HCV
infection in two (1.3%), autoimmune hepatitis in two (1.3%), and visceral leishmaniasis in one
(0.7%). The remaining 83 (55.3%) individuals had no identifiable cause, leaving their liver
illness unexplained (Orlien S.M.S. et al., 2018a).

8
 2.3. Conceptual Framework

This Conceptual framework is developed by the principal investigator after reviewing different
literature related to the topic (Orlien S.M.S. et al., 2018a, Orlien S.M.S. et al., 2018b, Terefe
T.B. et al., 2019, Erkabu S. et al., 2021, Tesfaye B.T. et al., 2021), it describes factors associated
with chronic liver disease. These factors include socio-demographic factors, clinical-related
factors, and socio-behavioral-related factors. Factors are grouped into three major categories
(i.e., Distal, Intermediate, and Proximal) by considering their distance from the outcome
variable. Solid lines indicate a direct relationship among variables while broken lines indicate
an indirect relationship.

Distal Proximal Outcome

Intermediate

Sociodemographic
factors:
Socio-Behavioral Clinical factors
✓ Age
✓ Sex factors ✓ Hepatitis C virus
✓ Marital status ✓ Hepatitis B virus
✓ Education ✓ Khat chewing ✓ NAFLD CLD
✓ Occupation ✓ Cigarette smoking ✓ ALD
✓ Residence ✓ Herbal drug use ✓ HCC
✓ Income ✓ Alcohol drinking ✓ Autoimmune hepatitis
✓ Religion ✓ Intravenous drug use ✓ Blood transfusion
✓ Family hx of ✓ Sniff Glue (Mastish) history
LD

Figure 1: Conceptual framework of chronic liver disease and associated factors among patients
attending chronic follow-up clinics at Eastern Ethiopia’s public hospitals, 2022 (developed by
reviewing different kinds of literature)

9
 3. MATERIALS AND METHODS

3.1. Study Area and Period

The study was conducted in selected public hospitals found in Harari Regional State, Dire Dawa
city administration, East Hararge Zone, and West Hararge Zones. East Hararge zone is in the
Eastern part of the country Oromia regional state, Ethiopia. The zone has 7 public hospitals
(four general hospitals and three primary hospitals) and 121 health centers. All hospitals are
providing inpatient, outpatient, emergency, and delivery services. In addition to this, Bisidimo
General Hospital is giving service as a center of the leprosy treatment center in the eastern part
of Ethiopia (Source: East Hararge zonal health bureau office). West Hararge Zone has 6 public
hospitals including 2 hospitals that graduated currently 80 health centers and 449 health posts
in the zone. Five hospitals are providing inpatient, outpatient, emergency, and delivery services.
Two hospitals that currently graduated are only giving outpatient service (Source: West Hararge
zonal health bureau office).

Harari regional state is one of the ten states in Ethiopia, which is 523 Km away from the capital
city, Addis Ababa to the east. There is one federal police, and two public hospitals in the Harari
region. Two of the public hospitals are Hiwot Fana comprehensive specialized hospital
(HFCSH) and Jugal Hospital. HFCSH is the only teaching and referral hospital in the Harari
region. (HFCSH and JH human resource, 2020). Dire Dawa City Administration is in the eastern
part of the country 515 km from the capital city. Currently, there are two public hospitals in this
city; Dilchora referral hospital and Sabian general hospital. Dilchora referral hospital is serving
the population living in Dire Dawa City, Oromia, and the Somali region. Therefore, six hospitals
mean Hiwot Fana comprehensive specialized hospital (HFCSH), Dilchora (DRH), Dadar
(DGH), Gara Muleta (GMGH), Chiro (CGH), and Galamso (GGH) hospitals where the study
was conducted. The study was conducted from November 20, to December 20, 2022.

Study Design

A hospital-based cross-sectional study was conducted.

10
 3.2. Population

3.2.1. Source population

All patients attending chronic follow-up clinics at eastern Ethiopia’s public hospitals were
considered as the source population.

3.2.2. Study population

All adult chronic patients attending chronic follow-up clinics at selected eastern Ethiopia’s
public hospitals during the data collection period.

3.2.3. Study unit

Each randomly selected chronic disease patients attending chronic follow-up clinics at selected
eastern Ethiopia’s public hospitals.

Inclusion and Exclusion Criteria

3.2.4. Inclusion criteria

All patients aged 18 and above years who have their follow-up for chronic disease for at least
six months at their respective hospitals and were present during the study period were included.

3.2.5. Exclusion criteria

Patients who were critically ill or unable to respond and who were not mentally intact were
excluded from the study.

Patients who were not willing to give consent to be part of the study.

Sample Size Determination

The sample size was calculated for each specific objective separately and the largest sample
size was used for this study.

For the first objective: The minimum sample size required for the study was determined by
using a single population proportion formula and proportionate systematic random sampling
technique.

𝑧 2 𝑃(1 − 𝑃)
𝑛=
𝑑2

Where: n = the minimum required sample size

11
 P = the estimated proportion of chronic liver disease 50%.
z = standard normal distribution with the constant value of 1.96 at 95% CI:.
d = the preferred precision level, which is 0.05.

Replacing the values for the above formula:

(1.96)2 ∗0.5(1−0.5)
𝑛= (0.05)2
= 384

Thus n= 384 by adding a 10% non-response rate, a sample size of 422 was yielded.

For the second specific objective: By considering factors that were significantly associated with
chronic liver disease in the previous studies; considering their confidence interval (narrow CI
relatively), those had shown consistent significant association with the dependent variable in most
of the previous studies. The sample size for the objective no.2 was calculated using Epi Info
v.7.2.4.0 considering the following assumptions: power = 80%, 95% CI:, 10% non-response rate,
and equal allocation of the exposed and unexposed groups, summarized in (table 1) below:

Table 1: Sample size calculation for the factors associated with CLD among patients attending
chronic follow-up clinics at Eastern Ethiopia’s public hospitals, 2022

Total sample size

Factors Assumption References
(by adding 10%)
Khat Confidence level = 95%
exposure Power = 80%
Exposed to unexposed ratio = 1:1 (Orlien S.M.S. et
277
% Of outcome among unexposed: 67.7% al., 2018b)
% Of outcome among exposed: 84.7%
AOR: 2.64
Alcohol Confidence level = 95%
consumption Power = 80%
Exposed to unexposed ratio = 1:1 (Abdelmenan S. et
201
% Of outcome among unexposed: 2.01% al., 2018)
% Of outcome among exposed: 14.4%
AOR: 8.23
Herbal Confidence level = 95%
medicine Power = 80%
use Exposed to unexposed ratio = 1:1 (Bihonegn W.T.
% Of outcome among unexposed: 22.5% 35 and Ayalewu T.K.,
2020)
% Of outcome among exposed: 81.9%
AOR: 14

12
Finally, the required sample size for this study was decided by the maximum sample size from
the 1st and 2nd objectives. So, the final sample size (n) was taken from the objective 1st sample
size, i.e., 422.

Sampling Techniques

Six of the twenty-one hospitals found in the eastern Ethiopian catchments were selected by
simple random sampling. Public hospitals in Eastern Ethiopia: Hiwot Fana Comprehensive
Specialized Hospital (HFCSH), Dilchora Referral Hospital (DRH), Deder General Hospital
(DGH), Gara Mulata General Hospital (GMGH), Galamso General Hospital (GGH), and Chiro
General Hospital (CGH) were included in the study. The average number of patients having
their follow-up at those public hospitals was estimated from the last six months' reports: HFCSH
(484), DRH (678), DGH (320), GMGH (259), GGH (445), and CGH (396), before data
collection. Averagely, a total of 2,582 patients visited follow-up clinics in respective public
hospitals, as estimated from their average flow of patients over the last six months. The sample
size was allocated to each hospital proportionally based on the estimated number of patients in
each hospital over the past two months when the data collection was conducted.

A simple random sampling technique was employed to select a total of 422 chronic disease
patients. The first participant patient was recruited by lottery from patients at the follow-up
clinic hospital. Other participants were recruited by simple random sampling until the desired
amounts of samples were obtained. The final sample proportion allocation was calculated as
(Figure 2 below):

13
 Selected public hospitals in Harari region, Dire Dawa city, East and West Hararge
Zone

SRS

HFCSH DRH = DGH = GMGH GGH = CGH =

= 484 678 320 445 396
= 259

79 111 52 42 73 65

Proportionally
422
Allocated (ni =
Ni*n/N)

Figure 2: Schematic presentation of sampling technique to assess chronic liver disease and
associated factors among patients attending chronic follow-up clinics at Eastern Ethiopia’s
public hospitals, 2022

Data Collection Methods

3.2.6. Data collection instrument

The questionnaires were developed after reviewing previously published literature (Orlien
S.M.S. et al., 2018a, Orlien S.M.S. et al., 2018b, Terefe T.B. et al., 2019, Erkabu S. et al.,
2021). A pre-tested, structured, checklist-based questionnaire that was delivered by an
interviewer along with a review of medical records for patients with chronic liver disease were
used to collect data during face-to-face interviews and chart reviews. The questionnaire contains
four main parts: socio-demographic variables, behavioral factors, socio-cultural factors, and
clinical variables.

14
 3.2.7. Data collectors
Six BSc nurses who can speak the local language were recruited out of the study area for data
collection and three 2nd year master’s students who have clinical experience were recruited for
the supervision of data collectors. The principal investigator was given training for data
collectors, closely supervise and facilitate the data collection process.
3.2.8. Data collection procedures
After the proposal got approval, the investigator visited the hospital administrator’s office and
explain the aims and methods of the study to obtain permission to conduct the study. Two days
of training were given to data collectors and supervisors. A combination of data collection
methods was used and data were collected daily; both in the morning and afternoon sessions.
Facilitators (data collectors) collected the data through face-to-face interviews and chart review
using pretested structured interviewer-administered questionnaires and checklists. Secondly,
additional data such as Ultrasound findings, liver function test, renal function test, serologic
test, and CLD complications, were collected from the patient’s medical records as per prepared
checklists. For the questionnaire, facilitators informed the data collectors about all details of the
research. The patients were encouraged to feel free and told that the confidentiality of their
responses was assured and no information was shared with third parties, except the investigator.
On-site supervision was carried out daily by the supervisors during the whole period of data
collection.

Variables of the Study

3.2.9. Dependent variable

Chronic liver disease (CLD)

3.2.10. Independent Variables

Socio-demographic factors: Age, sex, religion, residence, income, marital status, educational
status, occupation ,and family history of liver disease

Behavioral and Socio-cultural related factors: Smoking, khat chewing, alcohol, herbal
medicine ,and intravenous drug use

Clinically related factors: Hepatitis virus B AND C, NAFLD, ALD, HCC, autoimmune
hepatitis ,and blood transfusion history

15
Operational Definitions

Acute disease: - Is a disease that resolves within six months period.

Alcohol Consumption: - Was assessed by CAGE standard Screening Tool. The tool has four
yes/no questions if the patient responds yes, two and above, was considered alcoholic (Afdhal
N. et al., 2008).

Chronic liver disease (CLD): - is a disease of the liver which has persisted for six or more
months without complete resolution (Sharma A. and Nagalli S., 2022).

Eastern Ethiopia: - In this study context eastern Ethiopia means Harari Regional State, Dire
Dawa City Administration, East Hararge Zone, and West Hararge Zones.

Khat use: - Information on the use of khat was obtained and quantified in grams using a visual
analog scale.

Major Chronic diseases: - These are Diabetes Mellitus, Hypertension, Bronchial Asthma,
Depression, Cardiac disease, Chronic liver disease, and Epilepsy.

The frequency of khat chewing: - Was categorized using the Drug Use Disorders
Identification Test (DUDIT) (Berman A.H. et al., 2005).

The frequency and duration of khat usage: - Was used to classify lifetime khat exposure in
‘khat years.’ One khat year was defined by the daily use of 200 grams of fresh khat for one year
(Orlien S.M.S. et al., 2018b).

Unknown: - if the determination of the specific etiology of CLD is not possible with clinical
and /or available investigation modalities.

Data Quality Control

The final version of the questionnaire prepared in English was translated into a local language
(Afan Oromo and Amharic) and then re-translated back to English to verify the consistency and
content of the questionnaire. Finally, a structured and consistent questionnaire prepared in the
local language (Afan Oromo and Amharic) was used. Before conducting actual data collection,
a pre-test was done on data collection tools, on 5% of the sample size (21) at Haramaya general
hospital one week before the actual data collection period. Later on, any ambiguity, difficult

16
words, and differences in understanding were revised based on the pretest experience. Each
questionnaire was coded with a unique identification number. Adequate training was given to
data collectors and supervisors on the objective of the study, ways of data collection, ethical
considerations for the participants, and impact of data if they did not do what is expected from
them, and a brief explanation was given for each question included in the study.

Throughout the data collection, interviewers were closely and consistently supervised, and
regular meetings were held between the data collectors, supervisors, and the principal
investigator together in which problematic issues arising from interviews were discussed and
addressed. Data was kept in the form of a file in a secure place where no one can access it,
except the principal investigator and confidentiality of the data was ensured by not recording
names or any personal identity. Finally, after checking for data completeness, Epi-Data was
utilized for data entry as it has a controlling mechanism for error detection. Double data entry
by two separate data clerks was employed to validate the data entry.

Data Processing and Analysis

The data were manually checked for completeness, cleaned, coded, and entered using Epi-Data
3.1, and then finally exported to STATA 17.0 for analysis. Variables were recoded and
computed through the transform function of the STATA and then both descriptive statistics and
logistic regression analyses were computed. Descriptive statistical analysis such as simple
frequencies and cross-tabulations were done to look for missing values and outliers; measures
of central tendencies and measures of variations were computed to summarize and describe the
characteristics of study participants and presented using frequencies, summary measures,
graphs, and tables.

Multicollinearity was checked to see the linear correlation among the associated independent
variables by using the variance inflation factor (VIF) and standard error. VIF of >10 or standard
error of >2 or tolerance test < 0.1 were considered suggestive of the existence of
multicollinearity. For that reason, variables with VIF > 10 or standard error > 2 or tolerance test
< 0.1 were checked to be dropped from the multivariable analysis. No Multicollinearity was
detected during the analysis accordingly.

17
Bivariable analysis (COR with 95% CI:), was used primarily to check which variables had
associated with the dependent variable (CLD). To control possible confounding factors,
variables with a p-value of < 0.25 in the bivariable analysis were taken to the multivariable
analysis. Hosmer-Lemeshow goodness-of-fit test was done to check for model fitness and it was
found to be insignificant at p-value = 0.3599; which indicates the model was good-fitted. The
adjusted odds ratio (AOR), with 95% CI, was used to identify the independent variables
associated with the dependent variable (CLD). Statistical significance was declared at a P-value
of < 0.05 and which does not include the null value in the 95% CI.

Ethical Considerations

The technical proposal of this study was submitted to the institutional health research ethics
review committee (IHRERC) of Haramaya University, a College of Health and medical
sciences, and a formal letter of ethical clearance and approval with the Ref. No:
IHRERC/135/2022 was obtained. After ethical clearance was obtained, the official letter of
cooperation was written to each selected hospital to allow the execution of the research.
Permission was obtained from respective hospital administrators to recruit the study
participants. After explaining the purpose, data collection procedure, benefits, and risks of the
study in the local language, informed, voluntary, written, and signed consents were obtained
from all the study participants for their participation. The participants were informed and
guaranteed that they have the right to participate, refuse, or stop at any time during the data
collection process. All the interviews were taking place in separate rooms or areas to keep the
privacy of participants and cultural norms were respected. Besides, all personal identifiers were
omitted from the data collection tool to ensure the confidentiality of the participants. To prevent
the transmission of COVID-19 during the data collection process, all the standard safety
measures had been followed strictly.

18
 4. RESULTS

Socio-demographic and Behavioral Characteristics of Respondents

In this study, out of 422 planned participants, 418 patients participated yielding a response rate
of 99.1%. Two hundred fifty-two (60.3%) participants were male. The mean and standard
deviation (SD) of the respondents’ age was 43.84 ± 13.7 years. One hundred thirty-five
participants (32.30%) had no formal schooling. Three hundred thirty-one 331(79.2%)
respondents were married. Majority of the study participants, 234 (55%) were urban residents
and 239(57.18%) of the respondents currently use khat (Table 2).
Table 2: Sociodemographic and behavioral characteristics of chronic liver disease and
associated factors among patients attending chronic follow-up clinics at Eastern Ethiopia’s
public hospitals, 2022 (n = 418)

Characteristics Category Frequency(n) Percent (%)

Sex Male 252 60.3
Female 166 39.7
Age 18-34 115 27.51
35-44 110 26.32
45-54 88 21.05
55+ 105 25.12
Marital status Married 331 79.2
Single 52 12.4
Divorced 14 3.4
Widowed 21 5.0
Education level No formal education 135 32.30
Primary (grades 1–8) 58 13.88
Secondary (grades 9–12) 135 32.30
Tertiary (12+) 90 21.53
Occupation Gov’t employee 118 28.23
Farmer 126 30.14
Self-employ 87 20.81
Daily labor 28 6.70
Others a 59 14.11
Religion Muslim 257 61.48
Orthodox 132 31.58
Protestant 17 4.07
Others b 12 2.87
Residence Rural 184 45
Urban 234 55
Monthly Income <1000 151 36.12
1000-5000 132 31.58
>5000 135 32.30
Family history of liver Yes 76 18.18
disease No 342 81.81
19
 Previous blood Yes 81 19.38
transfusion No 337 80.62
Traditional herbal Yes 148 35.41
medicine No 270 64.59
History of Khat use Current 239 57.18
Never use 168 40.19
stopped 11 2.63
History of alcohol Current 42 10.05
consumption Never use 367 87.80
stopped 9 2.15
History of cigarette Current 85 20.34
smoking Never use 325 77.75
stopped 8 1.91
Others a:- (merchant, housewife, retired); others b:- (Waaqeffata, Catholic, Adventist)

Magnitude of CLD among chronic follow-up patients

The study's findings revealed that among the participants, 23.68% (95% CI: 19.59-27.77) (n =
99) were CLD patients (Figure 3) below.

Magnitude of chronic disease patients

130
140 108
120 99
Frequency

100
80
60 32 26
40 13 10
20
0

Types of chronic disease

Figure 3: Magnitude of chronic diseases among patients attending chronic follow-up clinics at
Eastern Ethiopia’s public hospitals, 2022 (n = 418)

20
Magnitude of CLD by Residence and Sex

The results of this study showed that 70.7% of CLD patients were male, with 62.9% of them
from rural and 37.1% from urban areas as their place of residence (Figure 4) below.

Magnitude of CLD by Residence and Sex

70
70 63
60
50
Urban
Frequency

40 36
29 Rural
30 Male
20 Female

10
0
Residence Sex

Figure 4: Magnitude of CLD by residence and sex at Eastern Ethiopia’s public hospitals, 2022
(n = 99)

21
Magnitude of CLD by Age

The majority of study participants with CLD were between the ages of 18 and 34 (42%),
followed by 45-54 (25%).

CLD Magnitude by age

17%
42%
16% 18-34
35-44
45-54
25% 55+

Figure 5: Magnitude of CLD by age at Eastern Ethiopia’s public hospitals, 2022 (n = 99)

22
Clinical characteristics of the patient with CLD

From overall CLD patients, 70.71% (70) were HBsAg positive, and 19.19% (n=19) were Anti-
HCV positive. Ascites 31.31% (31) were the most common complication and nodular liver
surfaces were common Ultrasound findings (Table 3).

Table 3: Clinical characteristics of chronic liver disease and associated factors among patients
attending chronic follow-up clinics at Eastern Ethiopia’s public hospitals, 2022 (n = 99)

Variable Category Frequency Percent (%)

Risk factors from the chart Alcoholism 7 7.07
HBV 70 70.71
HCV 19 19.19
Other 3 3.03
Complication from chart Ascites 31 31.31
Variceal bleeding 9 9.09
Hepatic encephalopathy 3 3.03
Spontaneous bacterial 1 1.01
peritonitis
No complication 55 55.56
Ultrasound findings of the Ascites 31 31.31
patient from the chart Smooth liver surface 30 30.30
Nodular liver surface 37 37.37
Heterogeneous echotexture 1 1.01
HBV, hepatitis B virus; HCV, hepatitis C virus

23
Investigation and Laboratory findings of the study subjects with CLD.

In the current study, the mean (SD) values for ALT, AST, Serum albumin, and Creatinine level
of CLD patients were 113.18 (±59.92) IU/L, 112.91 (±46.96) IU/L, 5.01(±1.62) g/dL and
0.90(±0.13) mg/dL, respectively (Table 4).

Table 4: Investigation and Laboratory findings of chronic liver disease and associated factors
among patients attending chronic follow-up clinics at Eastern Ethiopia’s public hospitals, 2022
(n = 99)
Variable Test results Frequency Percent (%)
Hepatitis B surface Positive 70 70.71
antigen Negative 29 29.29
Anti-Hepatitis C Positive 19 19.19
antibody Negative 80 80.91
HIV test result Positive 3 3.03
Negative 96 96.97
Antinuclear antibody Not determined 94 94.95
Negative 5 5.05
Variable Mean Std. dev. 95% CI:
9
WBC (10 /L) 10.13 3.64 9.40-10.86
9
Platelet (10 /L) 231.26 101.27 211.06-251.46
Hgb (g/dL) 12.87 2.30 12.41-13.33
Hematocrit (%) 38.61 5.89 37.43-39.78
MCV (fl) 86.89 7.89 85.32-88.47
MCH (pg) 29.22 3.44 28.53-29.90
MCHC (g/dL) 33.25 1.67 32.92-33.59
ALT (IU/L) 113.18 59.92 101-125
AST (IU/L) 112.91 46.96 104-122
ALP (IU/L) 203.83 83.96 187-221
PT (seconds) 9.53 0.76 9.38-9.68
INR 1.00 0.11 0.98-1.03
APTT (seconds) 31.80 3.85 31.04-32.57
Total Bilirubin (mg/dL) 3.08 1.81 2.72-3.44
Ser. Creatinine (mg/dL) 0.90 0.13 0.87-0.93
BUN (mg/dL) 25.57 2.24 25.12-26.02
Ser. Albumin (g/dL) 5.01 1.62 4.69-5.33
WBC-White Blood Cell Count; Hgb-Hemoglobin; MCV-Mean Corpuscular Volume; MCH-Mean
Corpuscular Hemoglobin; MCHC-Mean Corpuscular Hemoglobin Concentration; ALT- Alanine
aminotransferase; AST-Aspartate aminotransferase; INR-International Normalized Ratio; Ser-Serum; BUN-
Blood Urea Nitrogen

24
Factors Associated with CLD

In the binary logistic regression analysis, age, sex, residence, family history of liver disease,
khat use history, and herbal medicine use history, showed statistical association with CLD at p-
value < 0.25. Finally, after checking for multicollinearity and controlling for potential
confounders; age, residence, khat use history, and herbal medicine non-use history remained
statistically significant with CLD at p-value < 0.05 in multivariable analysis.

The odds of developing CLD were 3.05 (AOR: 3.05; 95%CI: 1.52-6.13) times higher among
the age group 18-34 compared to the other age group. Patients from rural residents were 1.77
(AOR: 1.77; 95%CI: 1.04-3.03) times more likely to develop CLD compared to patients from
urban residents. The likelihood of developing CLD was 2.09 (AOR: 2.09; 95%CI: 1.18-3.67)
folds higher among patients with khat use history than non-users, CLD is less likely among
Herbal medicine non-users (AOR: 0.35; 95%CI: 0.20-0.60) (Table 5).

Table 5: Bi-variable and multivariable logistic regression analysis for factors associated with
the chronic liver disease among patients attending chronic follow-up clinics at Eastern
Ethiopia’s public hospitals, 2022 (n = 418)
Variable Chronic liver disease (CLD) COR (95% CI:) AOR (95% CI:) p-value
Yes (%) No (%)
Sex
Male 70 (27.8) 182 (72.2) 1.81(1.11-2.95) 1.67(0.97-2.87) 0.06
Female 29 (17.5) 137 (82.5) 1 1
Age
18-34 41 (35.7) 74 (64.3) 3.13(1.60-6.14) 3.05(1.52-6.13) 0.002*
35-44 25 (22.7) 85 (77.3) 1.30 (0.64-2.64) 1.10 (0.53-2.28) 0.79
45-54 16 (18.2) 72 (81.8) 1.19 (0.54-2.5) 1.04(0.47-2.33) 0.90
≥55 17 (16.2) 88 (83.8) 1 1
Residence
Rural 63 (34.3) 121 (65.7) 2.86(1.79-4.57) 1.77 (1.04-3.03) 0.03*
Urban 36 (15.4) 198 (84.6) 1 1
Family hx of liver diseases
Yes 25 (32.9) 51 (67.1) 1.77 (1.0-3.05) 1.52 (0.83-2.77) 0.16
No 74 (21.6) 268 (78.4) 1 1
Herbal medicine
Yes 57 (38.5) 91 (61.5) 1 1
No 42 (15.6) 228 (84.4) 0.29 (0.18-0.46) 0.35(0.20-0.60) 0.00*
Khat use hx
Yes 75 (30) 175 (70) 2.57 (1.54-4.28) 2.09(1.18-3.67) 0.011*
No 24 (14.3) 144 (85.7) 1 1
*Significant at p-value < 0.05, 1, reference, COR, Crude odds ratio, AOR, Adjusted odds ratio, hx,
History

25
 5. DISCUSSION
This study assessed the magnitude of chronic liver disease and associated factors among patients
attending chronic follow-up clinics at Eastern Ethiopia’s public hospitals. The study revealed
that the overall magnitude of CLD was 23.68% (95%CI: 19.59%-27.77%). Age, residence,
khat use history, and herbal medicine non-user, showed statistical association with CLD.

The finding of this study is consistent with the study done in Southwest China 25% (Li H. et
al., 2009). However, the finding of this study is lower than the study in Addis Ababa-Ethiopia
90.1% (Erkabu S. et al., 2021), and Systematic review and meta-analysis report in Ethiopia 45%
(Tesfaye B.T. et al., 2021). This difference could be due to a limited number of patients enrolled
in this study and study area. But, the finding of this study is much higher than others in Ethiopia
2.3% (Adhanom M. and Desalegn H., 2017), and Nigeria (7.9%) (Nwokediuko S. et al., 2013).
The reason for this difference could be a demographic and toxic liver injury from the usage of
Khat (Abebe M. et al., 2015, Mahamoud H.D. et al., 2016, Hegazy M.A.E. et al., 2017, Orlien
S.M.S. et al., 2018a, Yeshaw Y. and Zerihun M.F., 2019).

The present study also revealed that the age group 18-34 has a risk of CLD 3.05 times more
than other ages (AOR: 3.05; 95%CI: 1.52-6.13). The community has greater exposure, and more
social interactions and they consume Khat regularly compared to their elderly counterparts. This
may create an opportunity to facilitate the transmission of liver disease in the community. This
is consistent with studies in Eastern India (Ray G., 2014).

This study presented rural residences also associated with the magnitude of CLD than urban
(AOR: 1.77; 95%CI: 1.04-3.03). It was found that most of the study participants were unable
to read and write, showing a poor rate of literacy. This lower level of education could have an
impact on the community, preventing them from having easy access to information about liver
diseases, from various sources. This is a major obstacle in implementing an effective healthcare
practice and hence contributes to the continued spread of the infection (Ngaira J.A.M. et al.,
2016, Rajamoorthy Y. et al., 2019).

The present study also revealed that the risk of developing CLD was lower among clients who
have no history of herbal medication (AOR: 0.35; 95%CI: 0.20-0.60). this is consistent with a
study in Calabar (Kooffreh-Ada M. et al., 2015) and Hong Kong (Hong M. et al., 2015). This

26
could be explained that herbal products are not tested with the scientific approval required for
conventional drugs and cannot be marketed for the diagnosis, treatment, cure, or prevention of
the diseases (Thakkar S. et al., 2020). One of the roles of the liver is to act as a filter for toxins
through a complex metabolic process by taking the nontoxic components and flushing toxins
out of the body (Navarro V.J. et al., 2017).

The present study reported risk of CLD increases 2.09-fold among those with a khat use history
(AOR: 2.09; 95%CI: 1.18-3.67). This result is consistent with the study conducted in eastern
Ethiopia (Orlien S.M.S. et al., 2018a) this could be due to high khat-related hepatotoxicity has
been convincingly in animal models (Alsalahi A. et al., 2012) and identified high Magnitude
(53.2%) of khat use in Harari region (Haile D. and Lakew Y., 2015).

Nursing Implications

People with CLD must adhere to lifelong care plans to control the condition. There is no simple
solution to these problems. Chronic therapy is needed for diseases, and routine check-ups are
crucial to preventing them from progressing to life-threatening levels. In an era where chronic
diseases like CLD are widespread, nurses make up the majority and spend 24 hours with
patients. Therefore, raising public awareness is essential. Patient education is one of the nurse's
most significant duties; it is crucial in the management of chronic disorders like CLD.

Nurses are essential for awareness creation and patient education in the management of chronic
diseases like CLD. This requires nurses to stay up-to-date on potential risk factors and the
current status of chronic liver disease, which can help them detect and treat CLD early and
provide specific care to CLD patients.

Strengths and Limitations

Strengths

The strength of this study was the use of interviews complemented by a review of medical
records for obtaining comprehensive information about the CLD patient.

Limitations

The study also got a certain limitation, though. Biases related to self-report, recall, and social
acceptability may have an impact on the study's findings. Temporality and causal inferences

27
could not be established because of the nature of the cross-sectional study design. In addition to
these, the lack of adequate studies done in Ethiopia on this topic makes comparison and
discussion difficult so, only related studies were used to discuss findings.

28
 6. CONCLUSION AND RECOMMENDATIONS
Conclusion

The magnitude of CLD among patients on follow-up in this study is high. We found that at a
chronic follow-up clinic, one out of every four patients had chronic liver disease. This study
notified that Age, residence, khat use history, and herbal medicine non-user, showed statistical
association with CLD.

Recommendations

Based on the study findings, we recommend the following;

To Harari Region, Dire Dawa City Administration, East, and West Hararge Zone Health
Bureau,
➢ Implementing and enhancing CLD prevention and treatment programs, stepping up the
country's prevention efforts, and promoting initiatives aimed at easing the burden of CLDs
on the country's population.
➢ To take into account additional potential risk factors, such as khat use, and conduct a
thorough search for recognized but less common CLD etiologies to reduce the number of
reports of unknown CLD etiologies in the country.

To participating hospitals
✓ To take action to prevent and manage chronic liver disease among chronic patients,
including lifestyle modifications such as avoiding khat consumption, herbal medicine use,
and maintaining a healthy diet. And providing vaccination against hepatitis B and C.

To healthcare personnel
 Healthcare professionals must remain vigilant in their efforts to raise awareness about
chronic liver disease and associated factors. By emphasizing the importance of
prevention, early detection, and management, healthcare professionals can significantly
reduce the incidence of chronic liver disease among chronic patients.
Future researchers
 To explore the appropriateness of management (i.e., care, timely management of
complications, and specific intervention) given to the chronic liver disease patient using
longitudinal studies.

29
 7. REFERENCES
Abdelmenan S., Abate B., Yemane B., Abebe M. & Wandall J. 2018. Etiology of chronic liver
disease in Ethiopia: a case-control study with special reference to viral hepatitis and
alcohol. EC gastroenterology and digestive system, 5, 120.
Abebe M., Kindie S. & Adane K. 2015. Adverse health effects of khat: a review. Fam Med Med
Sci Res, 4, 2-5.
Abel G. & Solomon G. 2012. Sero-prevalence of HBV and HCV among chronic liver disease
patients visiting OPD in public hospitals in Addis Ababa. ISRN, 2013, 1-7.
Adhanom M. & Desalegn H. 2017. Magnitude, clinical profile and hospital outcome of chronic
liver disease at St. Paul’s hospital millennium medical college, Addis Ababa, Ethiopia.
Ethiopian Medical Journal, 55.
Afdhal N., McHutchison J., Brown R., Jacobson I., Manns M., Poordad F., et al. 2008.
Thrombocytopenia associated with chronic liver disease. Journal of hepatology, 48,
1000-1007.
Albillos A., De Gottardi A. & Rescigno M. 2020. The gut-liver axis in liver disease:
Pathophysiological basis for therapy. Journal of hepatology, 72, 558-577.
Alsalahi A., Abdulla M.A., Al-Mamary M., Noordin M.I., Abdelwahab S.I., Alabsi A.M., et al.
2012. Toxicological features of Catha edulis (Khat) on livers and kidneys of male and
female Sprague-Dawley rats: a subchronic study. Evidence-Based Complementary and
Alternative Medicine, 2012.
Asrani S.K., Devarbhavi H., Eaton J. & Kamath P.S. 2019. Burden of liver diseases in the world.
Journal of hepatology, 70, 151-171.
Asselah T., Boyer N., Guimont M., Cazals-Hatem D., Tubach F., Nahon K., et al. 2003. Liver
fibrosis is not associated with steatosis but with necroinflammation in French patients
with chronic hepatitis C. Gut, 52, 1638-1643.
Banait S., Badole S.M., Jain J. & Thorat A. 2021. Risk factors for chronic liver disease in
population of Central India: a case-control study from rural India. Egyptian Liver
Journal, 11, 10.
Berman A.H., Bergman H., Palmstierna T. & Schlyter F. 2005. Evaluation of the Drug Use
Disorders Identification Test (DUDIT) in criminal justice and detoxification settings and
in a Swedish population sample. European addiction research, 11, 22-31.
Bihonegn W.T. & Ayalewu T.K. 2020. Determinants of Chronic Liver Diseases among adult
patients attending Gastroenterology clinic of Ayder Comprehensive Specialized
Hospital, Mekelle, Ethiopia. (Unpublished work).
Blachier M., Leleu H., Peck-Radosavljevic M., Valla D.-C. & Roudot-Thoraval F. 2013. The
burden of liver disease in Europe: a review of available epidemiological data. Journal
of hepatology, 58, 593-608.
Byass P. 2014. The global burden of liver disease: a challenge for methods and for public health.
BMC medicine, 12, 1-3.
Desu G. 2019. Clinicoepidemiological pattern of chronic liver disease among adults admitted
to medical wards. (Unpublished work).
Erkabu S., Demeke B., Desallegn H. & Getachew S. 2021. Liver Disease: A Retrospective
Hospital Based Study in AddisAbaba-Ethiopia. Journal of Spleen And Liver Research.
Fedeli U., Avossa F., Ferroni E., De Paoli A., Donato F. & Corti M.C. 2019. Prevalence of
chronic liver disease among young/middle-aged adults in Northern Italy: role of
hepatitis B and hepatitis C virus infection by age, sex, ethnicity. Heliyon, 5, e02114.

30
Flemming J.A., Djerboua M., Groome P.A., Booth C.M. & Terrault N.A. 2021. NAFLD and
Alcohol‐Associated Liver Disease Will Be Responsible for Almost All New Diagnoses
of Cirrhosis in Canada by 2040. Hepatology, 74, 3330-3344.
FMOH 2016. National Strategy For Prevention and Control of Viral Hepatitis. p. 14-15.
Haile D. & Lakew Y. 2015. Khat chewing practice and associated factors among adults in
Ethiopia: further analysis using the 2011 demographic and health survey. PloS one, 10,
e0130460.
Hegazy M.A.E., Tawfik N.M. & Elrawi H.A.-E. 2017. Liver Injury and Khat Leaves: A
Common Toxic Effect. Euroasian Journal of Hepato-Gastroenterology, 2, 70-75.
Hong M., Li S., Tan H.Y., Wang N., Tsao S.-W. & Feng Y. 2015. Current status of herbal
medicines in chronic liver disease therapy: the biological effects, molecular targets and
future prospects. International journal of molecular sciences, 16, 28705-28745.
Ibegu M.I. 2017. PREDICTORS OF MORTALITY IN PATIENTS WITH CHRONIC LIVER
DISEASE AT THE UNIVERSITY OF BENIN TEACHING HOSPITAL, BENIN
CITY. Faculty of INTERNAL MEDICINE.
Kasper D., Fauci A., Hauser S., Longo D., Jameson J. & Loscalzo J. 2015. Harrison's principles
of internal medicine, 19e, Mcgraw-hill New York, NY, USA:.
Kooffreh-Ada M., Okpara H., Oku A. & Ikekwaba P. 2015. Risk factors of chronic liver disease
amongst patients receiving care in a Gastroenterology practice in Calabar. IOSR J Dent
Sci, 14, 6-13.
Li H., Wang Y.-J., Tan K., Zeng L., Liu L., Liu F.-J., et al. 2009. Prevalence and risk factors of
fatty liver disease in Chengdu, Southwest China. Hepatobiliary & pancreatic diseases
international: HBPD INT, 8, 377-382.
Mahamoud H.D., Muse S.M., Fader T., Roberts L.R., Fischer P.R. & Torbenson M.S. 2016.
Khat chewing and cirrhosis in Somaliland : case series : original research. African
Journal of Primary Health Care and Family Medicine, 8, 1-4.
Marcellin P. & Kutala B.K. 2018. Liver diseases: A major, neglected global public health
problem requiring urgent actions and large‐scale screening. Liver International, 38, 2-
6.
Masters B.R., Longo D.L., Fauci A.S., Kasper D.L., Hauser S.L., Jameson J.L., et al. 2012.
Harrisons’s Principles of Internal Medicine, two volumes and DVD. ISBN-13:
9780071748896 McGraw Hill. Springer.
Matthew Aidoo & Mohammed B.S. 2020. Distribution and Determinants of Etiologies and
Complications of Chronic Liver Diseases Among Patients at a Tertiary Hospital in a
Lower Economic Region of Ghana. Central African Journal of Public Health, vol. 6,
No. 5, 2020, pp. 280-287.
Metrics I.f.H. & Evaluation 2017. GBD compare data visualization.
Mokdad A.A., Lopez A.D., Shahraz S., Lozano R., Mokdad A.H., Stanaway J., et al. 2014.
Liver cirrhosis mortality in 187 countries between 1980 and 2010: a systematic analysis.
BMC medicine, 12, 1-24.
Moon A.M., Singal A.G. & Tapper E.B. 2020. Contemporary epidemiology of chronic liver
disease and cirrhosis. Clinical Gastroenterology and Hepatology, 18, 2650-2666.
Navarro V.J., Khan I., Björnsson E., Seeff L.B., Serrano J. & Hoofnagle J.H. 2017. Liver injury
from herbal and dietary supplements. Hepatology, 65, 363-373.
Ngaira J.A.M., Kimotho J., Mirigi I., Osman S., Lwembe R. & Ochwoto M. 2016. Prevalence,
awareness and risk factors associated with Hepatitis B infection among pregnant women

31
 attending the antenatal clinic at Mbagathi District Hospital in Nairobi, Kenya. The Pan
African Medical Journal, 24.
Nwokediuko S., Osuala P., Uduma U., Alaneme A., Onwuka C. & Mesigo C. 2013. Pattern of
liver disease admissions in a Nigerian tertiary hospital. Nigerian Journal of Clinical
Practice, 16, 339-342.
Orlien S.M.S., Ismael N.Y., Ahmed T.A., Berhe N., Lauritzen T., Roald B., et al. 2018a.
Unexplained chronic liver disease in Ethiopia: a cross-sectional study. BMC
gastroenterology, 18, 1-12.
Orlien S.M.S., Sandven I., Berhe N.B., Ismael N.Y., Ahmed T.A., Stene-Johansen K., et al.
2018b. Khat chewing increases the risk for developing chronic liver disease: A hospital-
based case-control study. Hepatology, 68, 248-257.
Rajamoorthy Y., Taib N.M., Munusamy S., Anwar S., Wagner A.L., Mudatsir M., et al. 2019.
Knowledge and awareness of hepatitis B among households in Malaysia: a community-
based cross-sectional survey. BMC public health, 19, 1-11.
Ray G. 2014. Trends of chronic liver disease in a tertiary care referral hospital in Eastern India.
Indian Journal of Public Health, 58, 186.
Scaglione S., Kliethermes S., Cao G., Shoham D., Durazo R., Luke A., et al. 2015. The
epidemiology of cirrhosis in the United States. Journal of clinical gastroenterology, 49,
690-696.
Setiawan V.W., Stram D.O., Porcel J., Lu S.C., Le Marchand L. & Noureddin M. 2016.
Prevalence of chronic liver disease and cirrhosis by underlying cause in understudied
ethnic groups: the multiethnic cohort. Hepatology, 64, 1969-1977.
Sharma A. & Nagalli S. 2022. Chronic Liver Disease. StatPearls. Treasure Island (FL):
StatPearls Publishing, Copyright © 2022, StatPearls Publishing LLC.
Spearman C.W. & Sonderup M.W. 2015. Health disparities in liver disease in sub‐Saharan
Africa. Liver International, 35, 2063-2071.
Tabassum F. 2000. Identification of Marker Protein. Patient with Chronic Liver Disease.
Pakistan Journal of Biological Sciences, 13, 1509-1510.
Terefe T.B., Gudina E.K., Bosho D.D. & Mega T.A. 2019. Short-term clinical outcomes of
patients admitted with chronic liver disease to selected teaching hospitals in Ethiopia.
PloS one, 14, e0221806.
Tesfaye B.T., Feyissa T.M., Workneh A.B., Gudina E.K. & Yizengaw M.A. 2021. Chronic
Liver Disease in Ethiopia with a Particular Focus on the Etiological Spectrums: A
Systematic Review and Meta-Analysis of Observational Studies. Canadian Journal of
Gastroenterology and Hepatology, 2021, 8740157.
Thakkar S., Anklam E., Xu A., Ulberth F., Li J., Li B., et al. 2020. Regulatory landscape of
dietary supplements and herbal medicines from a global perspective. Regulatory
Toxicology and Pharmacology, 114, 104647.
Tsega E. 2000. Epidemiology, prevention and treatment of viral hepatitis with emphasis on new
developments. Ethiopian Medical Journal, 38, 131-141.
Wang X., Lin S.-X., Tao J., Wei X.-Q., Liu Y.-T., Chen Y.-M., et al. 2014. Study of liver
cirrhosis over ten consecutive years in Southern China. World journal of
gastroenterology: WJG, 20, 13546.
WHO 2010. World health statistics 2010, World Health Organization.
Yeshaw Y. & Zerihun M.F. 2019. Khat chewing prevalence and correlates among university
staff in Ethiopia: a cross-sectional study. BMC research notes, 12, 1-6.

32
8. ANNEXES

Annex I: Information Sheet and Informed Voluntary Consent Form for

Head of Public Health Institutions

My name is Kadir Abdu I am working as a principal investigator of the study being conducted
at this institution. I am an MSc student at Haramaya University, College of Health and Medical
Sciences. I kindly request you to lend me your attention to explain to you about the study and
your institution being selected as the study setting.

The study title: Magnitude of chronic liver disease and associated factors among patients
attending chronic follow-up clinics at Eastern Ethiopia’s public hospitals, 2022.

Purpose of the study: The main objective of this study is to write a thesis as a partial
requirement to achieve a master's degree in adult health nursing for the principal investigator.
Moreover, the study result will be used as a guide and input for Eastern Ethiopian regional and
zonal health bureaus and donors to develop appropriate strategies and programs to promote the
health of patients with chronic liver disease.

Procedure and duration: Information will be collected through face-to-face interviews of

patients by using a questionnaire that contains around 25 questions and with supplementation
of medical record reviews, to provide me with pertinent data that is helpful for the study. The
entire process only takes 24-36 minutes to complete.

Risks and benefits: The risk of being a participant in this study is minimal, but only taking a
few minutes from the patient's time. There would not be any direct payment for participating in
this study. However, the findings from this research may reveal important information for local
health planners. It’s hoped that the results of the study will provide a better understanding of
chronic liver disease and associated factors among patients attending chronic follow-up clinics
at eastern Ethiopia’s public hospitals.

Confidentiality: The information and data to be collected will be kept confidential. The name
of the participants will not be written in the questionnaires. Study results will be general to the
study population and will not reflect anything specific to the individual.

33
Rights: Permitting this study is entirely voluntary. You have the right to allow or disallow this.
If there are any questions that you do not want to be answered, please remind me that I will
move on to the next question and you have the right to end the interview at any time if you wish.

Contact address: If at any time there are any questions or inquiries about the study or
procedures, please contact these addresses:

o Kadir Abdu Mohammed

o Emails: 3kabdu3@gmail.com
o Mobiles: +251-914-988-319; +251906397881
Haramaya University, Institutional Health Research Ethics Review Committee, Harar Campus;
Phone: +251-254-66-2011; P.O. Box: 235, Harar.

Declaration of informed voluntary consent

I have read the participant information sheet. I have clearly understood the purpose of the
research, the procedures, the risks and benefits, issues of confidentiality, the rights of
participating, and the contact address for any queries. I have been allowed to ask questions about
things that may have been unclear. I was informed that participants have the right to withdraw
from the study at any time or not to answer any question that they do not want. I am also
informed that the Hospital has the right to stop this study from being conducted if any misdeeds
and unethical procedures are observed during the data collection process on the Hospital’s
premises.

Therefore, I declare my voluntary consent on behalf of ________________________________

management to allow this study to be conducted in the Hospital with my initials (signature).

Name and Signature of Head of the Hospital: __________________ ________ Date ________

Name and Signature of Principal Investigator: _________________ ________ Date ________

34
Annex II: English Version of Information Sheet and Informed Voluntary
Consent Form for the study participants

My name is __________________. I work as a data collector for the study being conducted in
this area on Chronic Liver Disease and associated factors among patients attending chronic
follow-up clinics at eastern Ethiopia’s public hospitals. Please kindly give me your interest to
explain to you the study and its objectives

The study title: Magnitude of chronic liver disease and associated factors among patients
attending chronic follow-up clinics at Eastern Ethiopia’s public hospitals, 2022.

Purpose of the study: The main objective of this study is to write a thesis as a partial
requirement to achieve a master's degree in adult health nursing for the principal investigator.
Moreover, the study result will be used as a guide and input for Eastern Ethiopian regional and
zonal health bureaus and donors to develop appropriate strategies and programs to promote the
health of patients with chronic liver disease.

Procedure and duration: Information will be collected through face-to-face interviews of

patients by using a questionnaire that contains around 25 questions and with supplementation
of medical record reviews, to provide me with pertinent data that is helpful for the study. The
entire process only takes 24-36 minutes to complete.

Risks and benefits: There are no proven risks in the study other than your interview time. It’s
hoped that the results of the study will provide a better understanding of chronic liver disease
and associated factors among patients attending chronic follow-up clinics at eastern Ethiopia’s
public hospitals.

Confidentiality: The information and data to be collected will be kept confidential. The name
of the participants will not be written in the questionnaires. Study results will be general to the
study population and will not reflect anything specific to the individual.

Rights: Permitting this study is entirely voluntary. You have the right to allow or disallow this.
If there are any questions that you do not want to be answered, please remind me that I will
move on to the next question and you have the right to end the interview at any time if you wish.

35
Contact address: If at any time there are any questions or inquiries about the study or
procedures, please contact these addresses:

o Kadir Abdu Mohammed

o Emails: 3kabdu3@gmail.com
o Mobiles: +251-914-988-319; +251906397881
o Haramaya University, Institutional Health Research Ethics Review Committee, Harar
Campus; Phone: +251-254-66-2011; P.O. Box: 235, Harar.

Declaration of informed voluntary consent:

I have read the information sheet. I clearly understand the purpose of the research, procedures,
risks and benefits, confidentiality issues, right to participate, and contact address for any
inquiries. I have had the opportunity to ask any questions about things that might be unclear. I
have been informed that I can end the study at any time. Therefore, I hereby declare my
voluntary consent to fully participate in this study with my signature as set forth below.

Name and signature________________________________________

Data collector’s name and signature ___________________________________
Thank you for your cooperation
Investigator’s Statement: I, the undersigned, explained to the volunteer in language that he/she
understood the procedures to be followed in the study and any risks/benefits that might be
involved.

Name of interviewer______________________________________
Interviewer signature__________________ Date _______________

36
Annex V: English Version of Questionnaire

Data collection tool for assessing Magnitude of CLD and associated factors among
patients attending chronic follow-up clinics at Eastern Ethiopia’s public hospitals

Dear all, this data collection tool is designed to assess chronic liver disease and associated
factors among patients attending chronic follow-up clinics at eastern Ethiopia’s public hospitals.
For realizing this study, kind participation of chronic liver disease patients is required. Before
any participant engages in this study, they are recommended to read the patient information
sheet and give their written informed consent on the paper ready for this purpose, if they agree
to participate.

Thank you in advance!

Section I: Questions related to sociodemographic characteristics of the patients. Please circle

the code.

S.no. Item Response Code Skip to

MRN ………………………………….
SD1 Age ……………………………year’s
SD2 Sex Male…………………………. 1
Female………………………. 2
SD3 Residence Urban………………………….. 1
Rural……………………….. 2
SD4 Occupation Farmer………………………….. 1
Government employee………………. 2
NGO………………………………… 3
Self-employed………………………. 4
Daily laborer……………………….. 5
Others (specify)……………………. 6
SD5 Educational status Illiterate…………………………… 1
Can read & write……………………. 2
Elementary (1st cycle)………………. 3
Elementary (2nd cycle)……...……….. 4
Secondary…………………………. 5
Preparatory……………………….. 6
College/University…………………… 7
SD6 Marital status Not married…………………………. 1
Married……………………………….. 2
Separated……………………………. 3
Widow/widower……………………. 4
Divorced……………………………. 5
Others (specify)…………………….. 6
SD7 Religions Muslims…………………………….. 1

37
 Orthodox…………………………….. 2
Protestant…………………………….. 3
Catholic……………………………… 4
Others (specify)…………………….. 5
SD8 Average monthly income ……………………………………birr
SD9 Family history of liver Yes…………………………. 1
disease No………………………. 2
Section II: Questions related to Behavioral and Socio-cultural related factors. Please circle the
code.
S.no. Item Response Code Skip to
BS1 Cigarette Smoking history Yes…………………………. 1
No………………………. 2
BS2 Currently Smoking Yes…………………………. 1
Cigarette No…………………….……. 2 If No go to
BS4
BS3 If yes, to question BS2, the ¼ packets…………………….. 1
amount of current cigarette ½ packets…………………… 2
smoking per day? 1 ≥ packets…………………... 3
BS4 Khat Chewing history Yes………………………….. 1
No……………………….. 2
BS5 Did you chew khat Yes………………………….. 1
currently? No……………………….. 2 If No go to
BS7
BS6 If yes, to question BS5 How Once 1
many times do you chew Two times 2
khat per week? ≥ 3 times 3
BS7 Herbal medication use Yes………………………….. 1
history No……………………….. 2 If No go to
BS9
BS8 If yes, to BS7 how many Once 1
times are used in a lifetime?Two times 2
≥ 3 times 3
BS9 Intravenous drug use history Yes………………………….. 1
No……………………….. 2
BS10 Alcohol use history Yes………………………….. 1
No………….………………… 2
BS11 Drinking alcohol currently Yes………………………….. 1
No………….………………… 2 If No go to
BS13
BS12 If yes, to question BS11 Once 1
Frequency of current alcohol Two times 2
drinking (per week) ≥ 3 times 3
BS13 Sniff glue (Mastish) usage Yes………………………….. 1
history No……………………….. 2
BS14 Currently using Sniff glue Yes………………………….. 1
(Mastish) No……………………….. 2 If No go to
BS16
BS15 Once 1

38
 If yes, to question BS14 Two times 2
Frequency of Sniff glue ≥ 3 times 3
(Mastish) use (per week)
BS16 The following four questions are only for patients who have an alcohol use history (Screening
of alcohol abuse using CAGE criteria. If the answer is `yes` write 1 if `no` write 0 in the code
box)
Item Code Skip to
a. Have you ever felt you should cut down on your drinking?
b. Have people annoyed you by criticizing your drinking?
c. Have you ever felt bad or guilty about your drinking?
d. Have you ever had a drink first thing in the morning to steady your
nerves or to get rid of a hangover(eye-opener)?
Section III: Questions related to the Clinical characteristics of the patient will be collected from the
medical record. Please circle the code.
S.no. Item Response Code Skip to
CF1 Does the patient have which of Diabetes Mellitus 1
the following diseases? Hypertension 2
Chronic liver disease 3
Bronchial Asthma 4
Cardiac disease 5
Depression 6
Chronic kidney disease 7
Epilepsy 8
CF2 History of blood transfusion Yes………………………….. 1
No……………………….. 2
CF3 If the answer to question CF1 is Chronic liver disease (3), continue with CF4, if not thank the
patient.
What is the etiology of chronic Alcoholism 1
CF4 liver disease in this patient? HBV 2
HCV 3
NFLD 4
Biliary Cirrhosis 5
Wilson’s disease 6
Hepatic schistosomiasis 7
Cryptogenic 8
AIH 9
Unknown 10
Other(s) 11
CF5 Does the patient have any Ascites 1
CLD complication(s) Variceal bleeding/gastrointestinal 2
bleeding
Hepatic encephalopathy 3
Spontaneous bacterial peritonitis 4
Hepatocellular carcinoma 5
Others (please specify) 6
Laboratory tests/Investigations
LI1 Ultrasound findings (Please Ascites 1
circle in the corresponding Smooth liver surface 2

39
 box based on the ultrasound Mild uneven liver surface 3
finding) Nodular liver surface 4
Heterogeneous echotexture 5
Coarse echotexture 6
Hepatic steatosis 7
Periportal fibrosis 8
For other (s), please specify briefly 9
LI2 COMPLETE BLOOD RBC count:
COUNT(CBC) WBC count:
Platelet count:
Hemoglobin:
Hematocrit:
Neutrophil count:
Lymphocyte count:
Monocyte count:
Basophil count:
Eosinophils:
MCV:
MCH:
MCHC:
LI3 LIVER FUNCTION TEST ALT:
(LFT) AST:
ALP:
LI4 COAGULATION PROFILE PT:
INR:
aPTT:
LI5 SERUM BILIRUBIN Direct:
Indirect:
Total:
LI6 RENAL FUNCTION Serum creatinine
TEST(RFT) BUN
LI7 ASCITIC FLUID PMN cells count:
ANALYSIS
LI8 SERUM ALBUMIN(g/dL): ………………………………..
LI9 SEROLOGIC TESTS HBsAg: Positive 1
Negative 2
Anti-HCV: Positive 1
Negative 2
Anti-nuclear Reactive 1
antibody (ANA) Non-reactive 2
HIV(PIHCT) Reactive 1
Non-reactive 2
Thanks for your cooperation!

40
Annex III: Afan Oromo Version of Information Sheet and Informed
Voluntary Consent Form for the study participants

Maqaan koo __________________. Dhukkubsattoota hospitaalota mootummaa baha

Itiyoophiyaa keessatti kilinika hordoffii yeroo dheeraa irratti hirmaatan biratti qorannoo
dhukkuba Tiruu yeroo dheeraa fi sababoota isaa waliin walqabatan irratti qorannoo gama
kanaan gaggeeffamaa jiruuf odeeffannoo walitti qabaa ta’ee hojjedha. Qorannichaa fi kaayyoo
isaa akkan isiniif ibsuuf fedhii keessan gaarummaadhaan naaf kennaa

Mata duree qorannichaa: Dhukkuba Tiruu yeroo dheeraa fi sababoota isaa wajjin walqabatan
dhukkubsattoota kilinika hordoffii yeroo dheeraa hospitaalota mootummaa baha Itoophiyaa
keessatti argaman biratti, 2022.

Kaayyoo qorannichaa: Kaayyoon qorannoo kanaa inni guddaan qorataa muummeedhaaf

narsii fayyaa ga’eessotaatiin digrii lammaffaa argachuuf barruu qorannoo akka gartokkeetti
barreessuudha. Kana malees, bu’aan qorannichaa biiroolee fayyaa naannoo fi zoonii Baha
Itiyoophiyaa fi arjoomtoota tarsiimoo fi sagantaalee fayyaa dhukkubsattoota dhukkuba Tiruu
yeroo dheeraa qaban guddisuuf mijatoo ta’an qopheessuuf akka qajeelfamaa fi galteetti kan oolu
ta’a.

Hojimaataa fi yeroo: Odeeffannoon kan walitti qabamu af-gaaffii dhukkubsattootaa fuula-

fuulatti taasifamuun gaaffilee naannoo 25 of keessaa qabu fayyadamuun fi gamaaggama galmee
yaalaa dabalataa waliin yoo ta’u, kunis daataa barbaachisaa qorannichaaf gargaaru naaf
kennuufi. Adeemsi guutuun xumuramuuf daqiiqaa 24-36 qofa fudhata.

Balaa fi faayidaa: Yeroo af-gaaffii keetiin alatti balaan qorannoo keessatti mirkanaa’e hin jiru.
Bu’aan qorannoo kanaa dhukkubsattoota hospitaalota mootummaa baha Itiyoophiyaa keessatti
kilinika hordoffii yeroo dheeraa irratti hirmaatan biratti dhukkuba Tiruu yeroo dheeraa fi
wantoota kanaan walqabatan hubannoo gaarii akka kennu abdii qaba.

Iccitii: Odeeffannoo fi daataa walitti qabamuu qabu iccitii ta’ee ni eegama. Maqaan
hirmaattotaa gaaffilee irratti hin barreeffamu. Bu’aan qorannoo ummata qorannichaaf
waliigalaa kan ta’u yoo ta’u, nama dhuunfaaf adda ta’e tokkollee hin calaqqisu.

41
Mirgoota: Qo’annoo kanaaf hayyama kennuunis guutummaatti fedhii ofiitiin kan
raawwatamudha. Kana hayyamuufis ta’e hayyamuuf mirga qabda. Gaaffiin deebii argachuu hin
barbaanne yoo jiraate gaaffii itti aanutti akkan ce'u na yaadachiisaa yoo barbaaddan yeroo
barbaaddanitti gaaffii fi deebii xumuruuf mirga qabdu.

Teessoo quunnamtii: Yeroo kamiyyuu waa’ee qo’annoo ykn hojimaata gaaffii ykn gaaffii yoo
qabaate, maaloo teessoo kana qunnamaa:

o Kadiir Abduu Mahaammad

o Imeelii: 3kabdu3@gmail.com

o Mobaayila: +251-914-988-319; +251906397881 irratti bilbilaa

o Yuunivarsiitii Haramayaa, Koree Gamaaggama Naamusaa Qorannoo Fayyaa Dhaabbilee

Mooraa Harar; Bilbila: +251-254-66-2011; L.S.P: 235, Harar.

Labsii hayyama fedhii ofiitiin kennamu:

Waraqaa odeeffannoo dubbiseera. Kaayyoo qorannichaa, hojimaata, balaa fi faayidaa,

dhimmoota iccitii, mirga hirmaachuu, fi gaaffii kamiifuu teessoo quunnamtii ifatti nan hubadha.
Wantoota ifa ta’uu dhiisuu danda’an ilaalchisee gaaffii kamiyyuu gaafachuuf carraa argadheera.
Yeroo barbaadetti qo'annoo xumuruu akkan danda'u naaf beeksifameera. Kanaafuu, akka
armaan gadiitti mallattoo kootiin qorannoo kana irratti guutummaatti hirmaachuuf fedhii kootiin
hayyama koo kanaan labsa.

Maqaa fi mallattoo________________________________________ .

Mallattoo walitti qabaa odeeffannoo ___________________________________ .

Tumsa nuuf gootaniif galatoomaa

Ibsa Qorataa: Ani, namni armaan gadii mallatteesse, hojimaata qorannoo keessatti
hordofamuu qabuu fi balaa/faayidaa ta’uu danda’u kamiyyuu akka hubate tola ooltummaaf
afaaniin ibseera.

Maqaa nama af-gaaffii godhu______________________________________ .

Mallattoo nama af-gaaffii godhu__________________ Guyyaa _______________

42
Annex VI: Afan Oromo Version of Questionnaire

Meeshaa odeeffannoo walitti qabuu dhukkubsattoota hospitaalota mootummaa baha Itoophiyaa

keessatti kilinika hordoffii yeroo dheeraa irratti hirmaatan biratti CLD fi wantoota isaa waliin
walqabatan madaaluuf gargaaru

Kabajamtoota hundaa, meeshaan odeeffannoo walitti qabuu kun dhukkubsattoota kilinika

hordoffii yeroo dheeraa hospitaalota mootummaa baha Itiyoophiyaa keessatti argaman biratti
dhukkuba Tiruu yeroo dheeraa fi wantoota isaa waliin walqabatan madaaluuf kan qophaa’edha.
Qorannoon kana dhugoomsuuf hirmaannaan gaarummaa dhukkubsataa dhukkuba Tiruu yeroo
dheeraa barbaachisaadha. Hirmaataan kamiyyuu qorannoo kana irratti osoo hin bobba’iin dura,
yoo hirmaachuuf walii galan, waraqaa odeeffannoo dhukkubsataa dubbisanii waraqaa kaayyoo
kanaaf qophaa’e irratti hayyama isaanii barreeffamaan akka kennan ni gorfama.

Dursinee galatoomaa!

Kutaa I: Gaaffiiwwan amala hawaas-dimoogiraafii dhukkubsattootaa wajjin walqabatan. Mee

koodii irratti geengoo godhaa.

T/L Item Deebii koodii Skip to

LKDh ………………………………….
SD1 Umrii ……………………………waggaan
SD2 Saalaa Dhiiraa…………………………. 1
Dhalaa………………………. 2
SD3 Bakka Jireenya Magaalaa………………………….. 1
Baadiyyaa……………………….. 2
SD4 Hojii Qonnaan bulaa............................ 1
Hojjetaa mootummaa................... 2
Dhaabbata miti mootummaa........ 3
Hojjetaa dhuunfaa......................... 4
Hojjetaa guyyaa guyyaa............... 5
Kanneen biroo (ibsi)……………. 6
SD5 Haala barnootaa Dubbisuu fi barreessuu hin dandeenye……….. 1
Dubbisuu & barreessuu danda'a....................... 2
Sadarkaa tokkoffaa (marsaa 1ffaa)………….. 3
Sadarkaa tokkoffaa (marsaa 2ffaa)…………… 4
Sadarkaa lammaffaa........................................ 5
Qopha’ina...................................................... 6
Kolleejjii/Yuunivarsiitii..................................... 7
SD6 Haala gaa’ilaa Kan hin fuudhin/hin heerumin……………….. 1
Kan fuudhe/heerumte…………………….. 2
Kan addaan bahan............................................ 3
Dubartii abbaan manaa irraa du’e.................... 4

43
 Kan wal hiikaan............................................... 5
Kanneen biroo (ibsi)…………………………. 6
SD7 Amantii Muslima...................................................... 1
Ortodoksii.................................................. 2
Pirootestaantii................................................ 3
Kaatolikii........................................................... 4
Kanneen biroo (ibsi)……………………….. 5
SD8 Galii ji'aa ……………………………………qarshi
giddugaleessaan
SD9 Maatii kee keessa Eeyyee........................................ 1
namni dhibee Tiruu Lakki………………………. 2
qabu jira?
Kutaa II: Gaaffiiwwan Amalaafi Hawaas-aadaa waliin walqabatan. Mee koodii irratti geengoo
godhaa.
S.no. Item Response Code Skip to
BS1 Seenaa tamboo xuuxuu Eeyyee........................................ 1
Lakki………………………. 2
BS2 Yeroo ammaa tamboo Xuuxuu Eeyyee........................................ 1
Lakki………………………. 2 If No go to
BS4
BS3 Yoo BS2 eeyyee ta'e, gaaffii, ¼ paaketaa…………………….. 1
hamma tamboo amma ½ paaketaa…………………… 2
guyyaatti xuuxuu? 1 ≥ paaketaa…………………... 3
BS4 Seenaa Jimaa qama’uu Eeyyee........................................ 1
Lakki………………………. 2
BS5 Yeroo ammaa jimaa qama’uu? Eeyyee........................................ 1
Lakki………………………. 2 If No go to
BS7
BS6 Yoo BS5 eeyyee ta’e, Al tokko 1
gaaffiidhaaf Torbanitti yeroo Yeroo lama 2
meeqa jimaa qama’uu? ≥ Yeroo 3 ta’a 3
BS7 Seenaa itti fayyadama qoricha Eeyyee........................................ 1
baala mukaa Lakki………………………. 2 If No go to
BS9
BS8 Yoo BS7 eeyyee ta'e, umurii Al tokko 1
keessatti yeroo meeqa Yeroo lama 2
fayyadame/te? ≥ Yeroo 3 ta’a 3
BS9 Seenaa itti fayyadama qoricha Eeyyee........................................ 1
ujummoo dhiigaa keessaa Lakki………………………. 2
BS10 Seenaa itti fayyadama alkoolii Eeyyee........................................ 1
Lakki………………………. 2
BS11 Yeroo ammaa alkoolii dhuguu Eeyyee........................................ 1
Lakki………………………. 2 If No go to
BS13
BS12 Yoo BS11 eeyyee ta’e, Irra Al tokko 1
deddeebiin alkoolii torbanitti Yeroo lama 2
yeroo meeqaa dhuguu ≥ Yeroo 3 ta’a 3
BS13 Eeyyee........................................ 1

44
 Seenaa itti fayyadama Sniff Lakki………………………. 2
glue (Mastishii).
BS14 Yeroo amma Sniff glue Eeyyee........................................ 1
(Mastishii) ni fayyadamu Lakki………………………. 2 If No go to
BS16
BS15 Yoo BS14 eeyyee ta’e, Irra Al tokko 1
deddeebiin Sniff glue Yeroo lama 2
(Mastishii) torbanitti yeroo ≥ Yeroo 3 ta’a 3
meeqaa fayyadamu
BS16 Gaaffiiwwan afran armaan gadii dhukkubsattoota seenaa fayyadama alkoolii qaban qofaaf
(Ulaagaalee CAGE fayyadamuun alkoolii fayyadamuu sakatta’uu. Yoo deebiin `eeyyee` ta’e
1 yoo `lakki` ta’e saanduqa koodii keessatti 0 barreessi)
Item Koodii Skip to
a. Dhugaatii dhuguu keessan hirʼisuu akka qabdu sitti dhagaʼamee
beekaa?
b. Namoonni dhugaatii kee qeequun si aarsanii?
c. Dhugaatii dhuguu keetiin miira hamaa ykn balleessaa sitti
dhagaʼamee beekaa?
d. Narvii kee tasgabbeessuuf ykn hangover (ija banaa) ofirraa baasuuf
ganama jalqaba dhugaatii dhugdee beektaa?
Kutaa III: Gaaffiiwwan amala Kilinikaalaa dhukkubsataa wajjin walqabatan galmee Yaalaa
irraa ni walitti qabamu. Mee koodii irratti geengoo godhaa.
S.no. Item Response Code Skip to
CF1 Does the patient have which of Diabetes Mellitus 1
the following diseases? Hypertension 2
Chronic liver disease 3
Bronchial Asthma 4
Cardiac disease 5
Depression 6
Chronic kidney disease 7
Epilepsy 8
CF2 History of blood transfusion Yes………………………….. 1
No……………………….. 2
CF3 If the answer to question CF1 is Chronic liver disease (3), continue with CF4, if not thank the
patient.
What is the etiology of chronic Alcoholism 1
CF4 liver disease in this patient? HBV 2
HCV 3
NFLD 4
Biliary Cirrhosis 5
Wilson’s disease 6
Hepatic schistosomiasis 7
Cryptogenic 8
AIH 9
Unknown 10
Other(s) 11
CF5 Does the patient have any CLD Ascites 1
complication(s) Variceal bleeding/gastrointestinal 2
bleeding

45
 Hepatic encephalopathy 3
Spontaneous bacterial peritonitis 4
Hepatocellular carcinoma 5
Others (please specify) 6
Laboratory tests/Investigations
LI1 Ultrasound findings (Please Ascites 1
circle in the corresponding box Smooth liver surface 2
based on the ultrasound Mild uneven liver surface 3
finding) Nodular liver surface 4
Heterogeneous echotexture 5
Coarse echotexture 6
Hepatic steatosis 7
Periportal fibrosis 8
For other (s), please specify briefly 9
LI2 COMPLETE BLOOD RBC count:
COUNT(CBC) WBC count:
Platelet count:
Hemoglobin:
Hematocrit:
Neutrophil count:
Lymphocyte count:
Monocyte count:
Basophil count:
Eosinophils:
MCV:
MCH:
MCHC:
LI3 LIVER FUNCTION TEST ALT:
(LFT) AST:
ALP:
LI4 COAGULATION PROFILE PT:
INR:
aPTT:
LI5 SERUM BILIRUBIN Direct:
Indirect:
Total:
LI6 RENAL FUNCTION Serum creatinine
TEST(RFT) BUN
LI7 ASCITIC FLUID ANALYSIS PMN cells count:
LI8 SERUM ALBUMIN(g/dL): ………………………………..
LI9 SEROLOGIC TESTS HBsAg: Positive 1
Negative 2
Anti-HCV: Positive 1
Negative 2
Anti-nuclear Reactive 1
antibody (ANA) Non-reactive 2
HIV(PIHCT) Reactive 1
Non-reactive 2
Hirmaannaa keessaniif galatoomaa!

46
Annex IV: Amharic Version of Information Sheet and Informed Voluntary
Consent Form for the study participants

ስሜ __________________ነው. ሥር በሰደደ የጉበት በሽታ እና በምስራቅ ኢትዮጵያ በሚገኙ

የመንግሥት ሆስፒታሎች ሥር የሰደደ ክትትል በሚደረግባቸው ህሙማን ላይ በዚህ አካባቢ እየተካሄደ

ላለው ጥናት መረጃ ሰብሳቢ ሆኜ እሰራለሁ። እባኮትን በደግነት ጥናቱን እና አላማውን ለእርስዎ

ለማስረዳት ፍላጎትዎን ይስጡኝ።

የጥናት ርዕስ፡ ሥር የሰደደ የጉበት በሽታ እና ተያያዥ ምክንያቶች በምስራቅ ኢትዮጵያ የሕዝብ

ሆስፒታሎች ሥር የሰደደ ክትትል በሚደረግላቸው ታካሚዎች መካከል፣ 2022።

የጥናቱ አላማ፡- የዚህ ጥናት ዋና አላማ ለዋና መርማሪ በአዋቂዎች ጤና ነርሲንግ የማስተርስ ዲግሪ

ለማግኘት እንደ ከፊል መስፈርት ተሲስ መፃፍ ነው። በተጨማሪም የጥናት ውጤቱ የምስራቅ ኢትዮጵያ

ክልልና ዞን ጤና ቢሮዎችና ለጋሽ አካላት ሥር የሰደደ የጉበት በሽታ ያለባቸውን ህሙማን ጤና ለማሳደግ

ተገቢውን ስትራቴጂና መርሃ ግብር ለማዘጋጀት መመሪያና ግብአት ሆኖ ያገለግላል።

ሂደት እና የቆይታ ጊዜ፡- መረጃ የሚሰበሰበው 25 የሚጠጉ ጥያቄዎችን የያዘ መጠይቁን በመጠቀም እና ከህክምና
መዛግብት ጋር በማያያዝ ለጥናቱ አጋዥ የሆኑ መረጃዎችን በማቅረብ በታካሚዎች ፊት ለፊት በሚደረግ ቃለ መጠይቅ ነው።
ጠቅላላው ሂደት ከ24-36 ደቂቃዎች ብቻ ይወስዳል።

ስጋቶች እና ጥቅማ ጥቅሞች፡- በጥናቱ ውስጥ ከቃለ መጠይቅዎ ጊዜ ውጭ ምንም የተረጋገጡ ስጋቶች

የሉም። የጥናቱ ውጤት በምስራቅ ኢትዮጵያ በሚገኙ የመንግስት ሆስፒታሎች ስር የሰደደ የጉበት በሽታ

እና ተያያዥ ክሊኒኮችን ለሚከታተሉ ታካሚዎች የተሻለ ግንዛቤን ይሰጣል ተብሎ ይጠበቃል።

ሚስጥራዊነት፡ የሚሰበሰቡት መረጃዎች እና መረጃዎች በሚስጥር ይያዛሉ። የተሳታፊዎቹ ስም

በመጠይቁ ውስጥ አይጻፍም። የጥናት ውጤት ለጥናቱ ህዝብ አጠቃላይ ይሆናል እናም ለግለሰቡ የተለየ

ነገርን አያንፀባርቅም።

መብቶች፡- ለዚህ ጥናት ፈቃድ መስጠት ሙሉ በሙሉ በፈቃደኝነት ነው። ይህንን ለመፍቀድ ወይም

ላለመፍቀድ መብት አልዎት። እንዲመለሱ የማይፈልጓቸው ጥያቄዎች ካሉ እባክዎን ወደሚቀጥለው

ጥያቄ እንደምሄድ አስታውሱኝ እና ከፈለጉ በማንኛውም ጊዜ ቃለ-መጠይቁን የማቆም መብት አለዎት።

47
የአድራሻ አድራሻ፡- በማንኛውም ጊዜ ስለ ጥናቱ ወይም አካሄዶቹ ማናቸውም ጥያቄዎች ወይም

ጥያቄዎች ካሉ እባክዎን እነዚህን አድራሻዎች ያግኙ፡-

o ከÉ` አብÆ SHSÉ

o ኢሜይል፡ 3kabdu3@gmail.com

o ሞባይሎች፡ +251-914-988-319; +251906397881

o የሐረማያ ዩኒቨርሲቲ፣ የተቋማዊ ጤና ጥናትና ምርምር ሥነምግባር ገምጋሚ ኮሚቴ፣ ሐረር ካምፓስ;

ስልክ፡ + 251-254-66-2011; ፒ.ኦ. ሳጥን፡ 235፣ ሀረር

በመረጃ ላይ የተመሰረተ የፈቃደኝነት ስምምነት መግለጫ፡-

የመረጃ ወረቀቱን አንብቤዋለሁ። የጥናቱ ዓላማ፣ አካሄዶች፣ ስጋቶች እና ጥቅማጥቅሞች፣ ሚስጥራዊ

ጉዳዮች፣ የመሳተፍ መብት እና ለማንኛውም ጥያቄ አድራሻ በግልፅ ተረድቻለሁ። ግልጽ ባልሆኑ ጉዳዮች

ላይ ማንኛውንም ጥያቄ ለመጠየቅ እድሉን አግኝቻለሁ። ጥናቱን በማንኛውም ጊዜ ማቆም እንደምችል

ተነግሮኛል። ስለዚህ፣ ከዚህ በታች በተገለጸው መሰረት ፊርማዬን ይዤ በዚህ ጥናት ላይ ሙሉ በሙሉ

ለመሳተፍ የፈቃዴ ፈቃዴን አውጃለሁ።

ስም እና ፊርማ __________________________________________________

የመረጃ ሰብሳቢ ፊርማ ___________________________________

ለትብብርዎ እናመሰግናለን

የመርማሪው መግለጫ፡ እኔ፣ በስሩ የተፈረመ ሰው፣ በጥናቱ ውስጥ ሊከተሏቸው የሚገቡ ሂደቶችን እና

ሊያጋጥሙ የሚችሉ ስጋቶችን/ጥቅሞችን እንደተረዳ ለበጎ ፈቃደኞች በቋንቋ ገለጽኩት።

የጠያቂው ስም ________________________________________________

የጠያቂው ፊርማ__________________ ቀን _______________

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Annex VII: Amharic Version of Questionnaire
መጠይቅ

በምስራቅ ኢትዮጵያ በሚገኙ የመንግስት ሆስፒታሎች ስር የሰደደ ክትትል በሚደረግላቸው ህሙማን ላይ CLD
እና ተያያዥ ምክንያቶችን ለመገምገም የመረጃ መሰብሰቢያ መሳሪያ

ውድ ሁላችሁም ይህ የመረጃ መሰብሰቢያ መሳሪያ በምስራቅ ኢትዮጵያ በሚገኙ የመንግስት ሆስፒታሎች ስር

የሰደደ የጉበት በሽታ እና ተያያዥ ህሙማንን ለመገምገም የተነደፈ ነው። ይህንን ጥናት ለመገንዘብ ሥር የሰደደ
የጉበት በሽታ ታማሚ ደግ ተሳትፎ ያስፈልጋል። ማንኛውም ተሳታፊ በዚህ ጥናት ውስጥ ከመሳተፉ በፊት፣
ለመሳተፍ ከተስማሙ የታካሚውን መረጃ ወረቀት እንዲያነቡ እና ለዚሁ ዓላማ በተዘጋጀው ወረቀት ላይ በጽሁፍ
ፈቃድ እንዲሰጡ ይመከራሉ።

የቀደመ ምስጋና።

ክፍል I: ከታካሚዎች የሶሺዮዲሞግራፊ ባህሪያት ጋር የተያያዙ ጥያቄዎች. እባክህ ኮዱን አክብብ።

S.no. Item Response Code Skip to

MRN ………………………………….
SD1 ዕድሜ ……………………………
SD2 ፆታ ወንድ ……………………………. 1
ሴት …………………………………. 2
SD3 የመኖሪያ ቦታ ከተማ ……………………………… 1
ገጠር………………………………. 2
SD4 ሥራ ገበሬ ……………………………… 1
የመንግስት ሰራተኛ …………………… 2
መንግሥታዊ ያልሆነ ………………… 3
የራስ ተቀጣሪ ………………………… 4
የቀን ሰራተኛ ………………………… 5
ሌሎች (ይጥቀሱ) …………………… 6
SD5 የትምህርት ደረጃ መሃይም …………………………… 1
ማንበብ እና መፃፍ ይችላል …………… 2
አንደኛ ደረጃ (1ኛ ዙር) ……………… 3
አንደኛ ደረጃ (2ኛ ዙር) ……………… 4
ሁለተኛ ደረጃ ………………………… 5
ዝግጅት ……………………………… 6
ኮሌጅ/ዩኒቨርስቲ ……………………… 7
SD6 የጋብቻ ሁኔታ አላገባም …………………………… 1
ያገባ ………………………………… 2
ተለያይቷል …………………………… 3
ባል የሞተባት/የሟች…………………. 4
የተፋታ ………………………………. 5
ሌሎች (ይጥቀሱ) …………………… 6
SD7 ሀይማኖት ሙስሊም ………………………… 1

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 ኦርቶዶክስ …………………………… 2
ፕሮቴስታንት ………………………… 3
ካቶሊክ …………………………… 4
ሌሎች (ይጥቀሱ) …………………… 5
SD8 አማካይ ወርሃዊ ገቢ ……………………………………birr
SD9 ቤተሰብ ዉስጥ የጉበት አዎ………………………………………. 1
በሽታ ያለበት ሰዉ ኣሌ? አይ………………………. 2
ክፍል II፡ ከባህሪ እና ከማህበራዊ-ባህላዊ ጉዳዮች ጋር የተያያዙ ጥያቄዎች። እባክህ ኮዱን አክብብ።
S.no. Item Response Code Skip to
BS1 የሲጋራ ማጨስ ታሪክ አዎ………………………………………. 1
አይ………………………. 2
BS2 በአሁኑ ጊዜ ሲጋራ ማጨስ አዎ………………………………………. 1
አይ………………………. 2 If No go
to BS4
BS3 አዎ ከሆነ፣ BS2ን ለመጠየቅ፣ ¼ ጥቅሎች…………………….. 1
አሁን ያለው የሲጋራ ማጨስ ½ ጥቅሎች ……………………………. 2
መጠን በቀን? 1 ≥ ፓኬቶች ……………………………. 3
BS4 የጫት መቃም ታሪክ አዎ………………………………………. 1
አይ………………………. 2
BS5 በአሁኑ ጊዜ ጫት ተቃምተዋል? አዎ………………………………………. 1
አይ………………………. 2 If No go
to BS7
BS6 አዎ ከሆነ፣ ለቢኤስ5 ጥያቄ አንድ ጊዜ 1
በሳምንት ስንት ጊዜ ጫት ሁለት ጊዜ 2
ትበላለህ? ≥ 3 ጊዜ 3
BS7 ከዕፅዋት የተቀመሙ መድኃኒቶች አዎ………………………………………. 1
አጠቃቀም ታሪክ አይ………………………. 2 If No go
to BS9
BS8 አዎ ከሆነ፣ ለ BS7 በህይወት አንድ ጊዜ 1
ዘመን ስንት ጊዜ ጥቅም ላይ ሁለት ጊዜ 2
ይውላል? ≥ 3 ጊዜ 3
BS9 የደም ሥር መድሃኒት አጠቃቀም አዎ………………………………………. 1
ታሪክ አይ………………………. 2
BS10 የአልኮሆል አጠቃቀም ታሪክ አዎ………………………………………. 1
አይ………………………. 2
BS11 በአሁኑ ጊዜ አልኮል መጠጣት አዎ………………………………………. 1
አይ………………………. 2 If No go
to BS13
BS12 አዎ ከሆነ፣ ለመጠየቅ BS11 አንድ ጊዜ 1
የአሁን የአልኮል መጠጥ ሁለት ጊዜ 2
ድግግሞሽ (በሳምንት) ≥ 3 ጊዜ 3
BS13 አዎ………………………………………. 1

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 የስኒፍ ሙጫ (ማቲሽ) አጠቃቀም አይ………………………. 2
ታሪክ
BS14 በአሁኑ ጊዜ ስኒፍ ሙጫ (ማቲሽ) አዎ………………………………………. 1
በመጠቀም ላይ አይ………………………. 2 If No go
to BS16
BS15 አዎ ከሆነ፣ ለመጠየቅ BS14 አንድ ጊዜ 1
የSniff ሙጫ (Mastish) ሁለት ጊዜ 2
ድግግሞሽ አጠቃቀም (በሳምንት) ≥ 3 ጊዜ 3
BS16 የሚከተሉት አራት ጥያቄዎች የአልኮሆል አጠቃቀም ታሪክ ላላቸው ታማሚዎች ብቻ ናቸው (የአልኮሆል
አላግባብ መጠቀምን በ CAGE መስፈርት መፈተሽ። መልሱ 'አዎ' ከሆነ 1 ይፃፉ 'አይ' ካልሆነ በኮድ ሳጥን
ውስጥ 0 ይፃፉ)
Item Code Skip to
a. መጠጥህን መቀነስ እንዳለብህ ተሰምቶህ ያውቃል?
b. ሰዎች መጠጥህን በመተቸት አበሳጭተውሃል?
c. በመጠጥህ መጥፎ ወይም የጥፋተኝነት ስሜት ተሰምቶህ ያውቃል?
d. ነርቮችዎን ለማረጋጋት ወይም አንገትን ለማስወገድ (የአይን መክፈቻ)ን
ለማስወገድ በመጀመሪያ ጠዋት ጠጥተው ያውቃሉ?
ክፍል III: የታካሚው ክሊኒካዊ ባህሪያት ጋር የተያያዙ ጥያቄዎች ከህክምና መዝገብ ይሰበሰባሉ. እባክህ
ኮዱን አክብብ።
S.no. Item Response Code Skip to
CF1 Does the patient have which of Diabetes Mellitus 1
the following diseases? Hypertension 2
Chronic liver disease 3
Bronchial Asthma 4
Cardiac disease 5
Depression 6
Chronic kidney disease 7
Epilepsy 8
CF2 History of blood transfusion Yes………………………….. 1
No……………………….. 2
CF3 If the answer to question CF1 is Chronic liver disease (3), continue with CF4, if not thank the
patient.
What is the etiology of chronic Alcoholism 1
CF4 liver disease in this patient? HBV 2
HCV 3
NFLD 4
Biliary Cirrhosis 5
Wilson’s disease 6
Hepatic schistosomiasis 7
Cryptogenic 8
AIH 9
Unknown 10
Other(s) 11
CF5 Does the patient have any CLD Ascites 1
complication(s) Variceal bleeding/gastrointestinal 2
bleeding

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 Hepatic encephalopathy 3
Spontaneous bacterial peritonitis 4
Hepatocellular carcinoma 5
Others (please specify) 6
Laboratory tests/Investigations
LI1 Ultrasound findings (Please Ascites 1
circle in the corresponding box Smooth liver surface 2
based on the ultrasound finding) Mild uneven liver surface 3
Nodular liver surface 4
Heterogeneous echotexture 5
Coarse echotexture 6
Hepatic steatosis 7
Periportal fibrosis 8
For other (s), please specify briefly 9
LI2 COMPLETE BLOOD RBC count:
COUNT(CBC) WBC count:
Platelet count:
Hemoglobin:
Hematocrit:
Neutrophil count:
Lymphocyte count:
Monocyte count:
Basophil count:
Eosinophils:
MCV:
MCH:
MCHC:
LI3 LIVER FUNCTION TEST ALT:
(LFT) AST:
ALP:
LI4 COAGULATION PROFILE PT:
INR:
aPTT:
LI5 SERUM BILIRUBIN Direct:
Indirect:
Total:
LI6 RENAL FUNCTION Serum creatinine
TEST(RFT) BUN
LI7 ASCITIC FLUID ANALYSIS PMN cells count:
LI8 SERUM ALBUMIN(g/dL): ………………………………..
LI9 SEROLOGIC TESTS HBsAg: Positive 1
Negative 2
Anti-HCV: Positive 1
Negative 2
Anti-nuclear Reactive 1
antibody (ANA) Non-reactive 2
HIV(PIHCT) Reactive 1
Non-reactive 2
ስለ ትብብርዎ እናመሰግናለን።

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