The Prevalence of Helicobacter pylori Infection and Its Associated Risk Factors Among Patients Undergoing Upper Gastrointestinal Diagnosis in Shashemene Referral Hospital in Shashemene, Ethiopia

Background: - Helicobacter pylori infection is the principal cause of chronic active gastritis in developing countries including Ethiopia. Objective:- The main objective of the present study is to evaluate the prevalence of H. pylori infection colonization and its associated risk factors among upper gastrointestinal patients aged ≥14 years. Method:- Hospital-based retrospective and cross-sectional study was conducted at Shashemene referral Hospital among upper gastrointestinal positive patients who underwent diagnosis in the Hospital from September 2012-August 2017. Results:- After organizing the recorded data of the 1966 upper gastrointestinal patients, the overall prevalence of five consecutive years (September 2012-August 2017)  H. pylori infection in this study was found to be 30.3% (n= 592/1966). The majority of the patients were in the age range of 20-29 (218/657(33.03%)) and ≥60 (46/149(30.9%)). The overall prevalence of H. pylori in this study dropped from 45.5% in September 2012 -August 2013 to 15.2% in September 2016 - August 2017. The most important risk factors in this study were large family size, age, poor personal hygiene, poor hygiene in nutrition and life style, poor economic status, stress, alcohol, overcrowding and educational level. Marital status of the patients (2.793 OR; 95%CI: p=0.038 < 0.05) and age groups (1.345 OR; 95%CI: p=0.006< 0.05) were statistically significant predictors or were significantly associated with H. pylori infection. In this study the prevalence of H. pylori infection is highest in the youngest group, because of the exacerbation of the youngest to multi substance use, and environmental hygienic condition. Conclusion and recommendation:- This study has shown that gastritis and H. pylori infection were the major problems in the study area and, therefore, further in-depth epidemiological 0research and identification of other potential environmental and personal related risk factors of H. pylori infection and gastritis are suggested. Keywords: Helicobacter Pylori ; gastritis; prevalence; risk factor; Ethiopia; retrospective study; cross–sectional study DOI: 10.7176/JHMN/73-01 Publication date: April 30 th 2020


INTRODUCTION
Helicobacter pylori are a gram-negative, spiral-shaped, urease-producing bacterium with multiple unipolar flagella usually colonizes gastric pits under the mucus layer and in close association to gastric epithelial cells. Humans are a major reservoir for H. pylori. It is proven that H. pylori are the principal cause of chronic gastritis, peptic ulcer disease as well as gastric cancer (Sepulveda and Graham, 2002). Chronic gastritis and peptic ulceration are prevalent in a high magnitude throughout the world (Ghazzawi and Obidat, 2004). H. pylori are the principal cause of chronic active gastritis and have major complications like gastric adenocarcinoma and mucosa associated lymphoid tissue lymphoma (Ozbek et al., 2010).
H. pylori neutralize the acid in its environment by producing large amounts of urease, which breaks down the urea present in the stomach to carbon dioxide and ammonia, the ammonia then neutralizes stomach acid (Stingl et al., 2002). There are many other etiological factors such as smoking, non-steroidal anti-inflammatory drugs (NSAIDS), and reflux of gastric juice (chemical gastritis) that are also implicated to cause chronic gastritis. H. pylori, though is regarded as the primary cause of gastritis, it can act as a synergist in addition with other etiological factors (Parkin et al., 1999). A wide range of laboratory investigations are available for diagnosis of H. pylori. The tests belong to non-invasive group and invasive group. Non-invasive tests include urea breath test, serological Immunoglobulin G (IgG) and Immunoglobulin M (IgM) detection, saliva and urinary antibody test, and stool antigen test (Malfertheiner et al., 2007). The invasive tests are endoscopy based tests, which include histopathological examination, rapid urease test (RUT) and polymerase chain reaction. The role of non-invasive tests such as serology is limited in areas of high prevalence, because of non-distinction between previous and current infection (Graham and Sung, 2006).
Since H. pylori were first discovered by Warren and Marshall in 1983, it has radically changed our understanding and clinical management of gastro duodenal disease and much has been researched about its clinical aspects and its epidemiology (Suk, 2011). Its incidence and prevalence differs in relation to different factors like geography, age, and socio-economic factors high in developing countries and lower in the developed world (Veldhuyzen van zantel, 1995). Researchers found a consistent pattern in most developing nations, where 70 to from the study subjects (attending diagnosis in Shashemene referral hospital from September 2012 -August 2017) using structured questionnaire.

Sample Size Determination and Sampling Method
A 5 years retrospective data of patients undergoing upper gastrointestinal diagnosis in the Shashemene referral hospital from September 2012-Augest2017 were used. The information was collected from secondary data of the examined gastritis patients including H. pylori positive patient's documents recorded in the shashemene referral hospital from September 2012 -August 2017. The sample size for the cross sectional study was determined by using statistical formula and the information about risk factors was be collected from upper gastrointestinal patients that undergoing diagnosis in this Hospital from September 2016 to August 20017. The sample size was determined by using the formula provided by Daniel (2004) and the required sample size at 95% confidence level, and level of precision (5%) was determined.
n= t 2 ( ) . . = 384.16 = 384 and another 10% to minimize errors arising from the likelihood of non-responsive individuals, 10% of the sample size is added to the normal sample size allow, a total of 422. 422 fresh stool samples were collected from 422 gastritis patients. Systematic random sampling method will be used to collect stool samples from both sexes and from different age groups.

Stool Sample Collection and examination techniques
This part of the study was done with the laboratory technicians. At the beginning of stool collection orientation regarding the handling and avoidance of contamination of stool specimens was given to all the subjects by senior laboratory technicians. Then disposable plastic cups with labels of their own unique codes and clean applicator sticks were provided to all respondents to collect fresh stool specimen. The resulting suspension was added to the sensitive test strip and examined for positive and negative results. This also used by (Shimoyama and Kato, 2009).
Standard procedure was used during stool sample collection. From each stool sample, small portions of the fecal material was taken using a sterile applicator stick which was screw on the collection tube and placed the stick in the tube and tighten securely. The samples was diluted using the extraction buffer (Buffer for H. pylori AG feces strip) contained in a vial and vigorously shaken by hand. The resulting diluted material will added in drops on to the test strip (H. pylori AG feces strip) and the results was read after 15 minutes according to the manufacture's instruction. Appearance of color band on the device on both test line and control line was interpreted as positive and as negative if it is only on the control line.

Data Collection
A total of 1966 subjects whose data were completely registered were included in the study. Five-year data from September 2012-August 2017 were taken from the serology log book in Shashemene referral hospital. Sociodemographic characteristics (age and sex) of the study subjects were collected using a checklist. Data of all consecutive individuals referred from outpatient as well as inpatient department which had undergone diagnosis for H. pylori infection and primary data from those visited the hospital in September 2016-August 2017 for various dyspeptic symptoms like pain abdomen, nausea, vomiting, belching, throat pain, upper gastrointestinal bleeding, weight loss, gastrointestinal symptoms. And copies of the structured questionnaire was distributed for 422 patient respondents to obtain information on socio-demographic factors; age, sex, residence, family size, educational level, monthly income, marital status and awareness about H. pylori. The questionnaire was developed in English and the translated in Afan Oromo (their local language). For those respondents who cannot read questionnaire items were read and their answers was immediately recorded by the researcher. Permission was taken from the hospital's staffs interviewed. The study was approved by the hospital ethical review committee.

Data Analysis
After the data have been collected, the raw data was analyzed. This was through coding and tabulation and then drawing statistical inference. Descriptive and frequency analysis of the data from the study was expressed as counts and percentage as appropriate to provide the overall picture. The data was analyzed using Statistical Package of Social Sciences (SPSS) version 20. Chi-square test with exact test was used where applicable. A p value of < 0.05 was considered to denote statistical significance. Qualitative data obtained from various sources was examined and presented in different forms. It was discussed under different headings, narrated and summarized. Quantitative data was edited, coded and entered into computer using SPSS analyzed. Descriptive statistics, frequencies, percentage and chi-square was under taken. Multiple response questions were analyzed so as to give frequencies and percentages. The different variables were presented with the help of Tables and graphs. After analyzed, the result was interpreted and the research report was written to communicate information. The final results were

The Prevalence of H. Pylori infection colonization among upper gastrointestinal patients
3.1.1.1. Socio-Demographic Characteristics of the Study subjects As can be observed from Table1, the number of female patients was (64.6%) of which (65.03%) was H. pylori positive and male patients (35.4%) of which (34.97%) were H. pylori positive. The higher positive for the infection is seen in female patients which is 65.03%.The differences between H. pylori positivity of male and female subjects were not statistically significant (χ 2 = 0.020; P=0.465). Besides, the majority of the patients were in the age range of 20-29 years (33.6%) of which (33.03%) was H. pylori positive and ≥60 years 149(7.6%) of which 46(30.9%) was H. pylori positive. The highest positive for the infection is seen in ≥60 year patients which is 30.9%.The differences between H. pylori positivity among different age groups of the subjects were not statistically significant (χ 2 =7.510; P >0.185). Likewise, majority (60.3%) of the study participants of which 342(29%) H. pylori positive were rural residents and 786 (39.7%) patients of which 250(32%) was H. pylori positive were urban residents. The higher positive for the infection is seen in urban resident's patients which is 32%. But, it is statistically not significant with the infection (Table1 As shown in Figure3, exposure to H. pylori seems to be higher among participants in the age group 20 -29 years relatively (217) and lower among participants in the age group ≥60. When we see the prevalence in different years, as can be seen from Regarding the sex-specific prevalence of H. pylori, of the 248 male patients examined for H. pylori from September 2012-August 2013, 122(49.2%) were positive, and of the 488 female patients examined in the same year, 214(43.6%) were found to be positive. The higher positive for the infection is seen in male patients which is 49.2%. In this year the prevalence found higher in males than in females and was statistically significant (χ 2 = 4.986; P= 0.026). Similarly, the prevalence was higher in males 35(30.4%) than in females 35(21%) in the year Septembar2015-August 2016 was statistically significant (χ 2 =3.675; P=0.049). However, the prevalence of H. pylori in the year September2014-August2015 was higher in females 23 (26.1%) than in males 7(15%) which was not statistically significant (χ 2 = 0.016; P= 0.899). Similarly, the prevalence was higher in females 69 (25.9%) than males 23 (17.2%) in the year September2013-August 2014 and September 2016-August 2017 in females 44(16.5%) than in males 20(12.9%), but both are not significant (Table 3). . And the frequency of the Patients was lower than the four previous years. Generally, in this study, the researcher found high but fluctuating prevalence of H. pylori infection among symptomatic patients (Table 3).

Prevalence of H. Pylori Infection among Different Age and Gender Groups of Year September 2012-August 2017
As it can be observed from the figure 6 below, the overall frequency of H. pylori infection among different gender and age groups from September 2012-August 2017 was 30.30%. The distribution of colonization in <20 years, 20-29 years, 30-39 years, 40-49 years, 50-59 years, and ≥60 years age groups was 26.53%, 33.03 %, 31.05%, 25.1%, 30.7%, and 30.9% respectively. The majority of the patients were in the age range of 20-29 (33.03%), 30-39 (31.05%), > 60 (30.9%), and 50-59 (30.7) ( Figure 6). As can be seen from figure 6, compared to the other age groups in both male and females, the age group 20-29 and 30-39 years old showed relatively higher prevalence. The prevalence of H. pylori in this study was highest in the ≥60 age group (30.9%) and lowest among <20 age group (26.5%). Similarly, the overall prevalence among male and female was slightly similar (29.9% and 30.2%, respectively) (figure 6). As a general, during this consecutive five years the result indicated that the frequency of the infection is highest in the age range of >60 (30.9%) and age range of 20-29 (33.03%) is the second highest.    The prevalence of H. pylori infection by age among gastritis patients visiting Shashemene referral hospital from September 2016 to August 2017 is shown in table 4 below. The majority of the respondents were in the age range of 30-39 years 133 (31.5%) and 20-29 years 99(23.5%) (Table4). For this the relationship across 6 age groups of patients were examined, the highest positive for the infection is seen in age group less than 20 which is 25.4%. For the participants it can be seen that the test statistic value for Pearson chi-square is 14.997, 5 degrees of freedom and, as the p value is smaller than 0.005, it was concluded that there is a significant association between the infection and this age group.
The prevalence of H. pylori infection by sex among gastritis patients visiting Shashemene referral hospital from September 2016 to August 2017 is also showed in the table 4 below. The results showed that the number of female was higher 267(63.3%) of which 44(16.9) were H. pylori positive than male patients 155 (36.7%) of which 20(13.5%) were H. pylori positive males and 44(16.9%) females (Table 4).For this the relationship across 2 groups of patients, males and females were examined, the highest positive for the infection is seen in females which is 16.9%. For the participants it can be seen that the test statistic value for Pearson chi-square is 0.975, 1 degrees of freedom and, as the p value is greater than 0.005, then it can be concluded that the association of the infection and the different sex group is not statistically significant.
The prevalence of H. pylori infection by level of by family size among gastritis patients visiting Shashemene referral hospital from September 2016 to August 2017 is shown in the table 4 below. Most of the study participants have family size of ≥4 that was 372 (88.2%) persons per house hold only 50 (11.8%) study participants have family size of <4. For this the relationship across 2 groups of patients, <4 and ≥4 family size were examined, the highest positive for the infection is seen in the Family size of ≥4 which is (88.2%). For the participants it can be seen that the test statistic value for Pearson chi-square is 0.060, 1 degrees of freedom and, as the p value is greater than  (Table 4). For this the relationship across 3 groups of patients, Illiterate, Can read and write and diploma and above were examined, the highest positive for the infection is seen in those diploma and above which is 14(17.3%). For the participants it can be seen that the test statistic value for Pearson chi-square is 0.452, 2 degrees of freedom and, as the p value is greater than 0.05, then it can be concluded that this pattern of scores is not significant.
The prevalence of H. pylori infection by Monthly income among gastritis patients visiting shashemene referral hospital from September 2016 to August 2017 is shown in the table 4 below. Most of the study participants have monthly income of < 700ETB 292(69.2%) of which 40(13.7%) are H. pylori positive and the rest 130(30.8%) of which 24(18.55%) are H. pylori positive have Monthly income of ≥ 700ETB.But those with ≥ 700ETB monthly income 24(18.55%) were relatively higher H. pylori positivity. For the participants it can be seen that the test statistic value for Pearson chi-square is 1.586, 1 degrees of freedom and, as the p value is greater than 0.005, then it can be concluded that this pattern of scores is not significant.

. Respondents' level of perceptions on factors aggravating gastritis
Responses of study participants to some possible factors that might aggravate gastritis visiting Shashemene referral hospital from September 2016 to August 2017 are shown in the table 5 below. For this the relationship across 5 groups of patients, smoking, drinking alcohol, Eating spicy food, hunger, stress and anger were examined, the highest positive for the infection is seen in patients with stress and anger which is 34(17.4%) and Eating spicy food which is 13(16.1%). For the participants it can be seen that the test statistic value for Pearson chi-square is 4.158, 1 degrees of freedom and, as the p value is greater than 0.005, then it can be concluded that this pattern of scores is not significant.  (15) were H. pylori positive. But, the highest positive for the infection is seen in respondents who had awareness about H .pylori which is 13(16.0).
The source of water used by most respondents was unprotected well water 178(42.2%). Only 139 (32.9%) of the respondents were obtaining their drinking water from tap water. The highest positive for the infection is seen in respondents who used spring water which is 26.3%. As the p value is greater than 0.005, then it can be concluded that this pattern of scores is statistically not associated with the infection.
Most of them had no toilet 260(61.6%) of which 37(14.2%) were H. pylori positive and only 162(38.4%) had toilet of which 27(16.7%). The highest positive for the infection is seen in respondents who had toilet which is 16.7%. As the p value is greater than 0.005, then it can be concluded that this pattern of scores is statistically not associated with the infection.
About 259 (61.4%) of the respondents were from rural of which 37(14.3) were H.pylori positive and 163(38.6) were from urban of which 27(16.6%) were H.pylori positive. The highest positive for the infection is seen in patients from urban of which is16.6%. As the p value is greater than 0.005, then it can be concluded that this pattern of scores is statistically not associated with the infection.
Interestingly, the majority 244(57.8%) of the respondents of which 35(14.3%) were H. pylori positive revealed that they do not share utensils with their family members and 178(42.2%) of the respondents of which 51(28.7%) H.pylori positive were share utensils with their family members. The highest positive for the infection is seen in patients do not share utensils with their family members which were 28.7%(table 6).As the p value is greater than 0.005, then it can be concluded that this pattern of scores is statistically not associated with the infection. Table6

Association between Prevalence of H. Pylori Infections and Its Major Associated Risk Factors among Gastritis Patients Visiting Shashemene Referral Hospital from September 2012-August 2017
The distribution of H. pylori in different risk factors is indicated in Table 7. Of different risk factors considered in this study, marital status of the patients accounted the bigger number (2.793 OR; 95%CI: p=0.038 < 0.05). This is statistically significant predictors or was significantly associated with H. pylori infection. The higher cases of gastritis among the married respondents could also be due to stress experienced as people (married couples) start new independent life. The next largest value was for age groups (1.345 OR; 95%CI: p=0.006< 0.05) which is also significantly associated with the infection. Age groupsand marital status were one and two times more likely associated with the infection H. pylori.The third next largest value is sharing of utensils accounted the bigger number (1.431 OR; 95%CI: p= 0.403> 0.05). However, this is not statistically significant predictors or is not significantly associated with H. pylori infection. Most of the study participants were from rural residents 259 (61.4%) (Table7). For this the relationship across 2 groups of patients, urban and rural were examined. For the participants it can be seen that the p value is greater than 0.005, then it can concluded that this pattern of scores is not significant. Other risk factors like family size, monthly income, gastritis aggravate,awareness of personal hygiene and environmental sanitation,usually wash hands with soap after latrine, awareness about H. pylori,having The distribution of colonization in <20 years, 20-29 years, 30-39 years, 40-49 years, 50-59 years, and ≥60 years age groups was 26.53%, 33.03 %,31.05%, 25.1%, 30.7%, and 30.9% respectively. The majority of the patients were in the age range of 20-29 (33.03%), 30-39 (31.05%), >60(30.9%), and 50-59(30.7%).In line with current findings, Hunt et al. (2011) also found that in most developing nations, 70 to 90% of adults harbored the bacteria. In contrast, a similar Indian study conducted by Kumar et al.(2006) showed maximum prevalence in the age group of 36-45 years (43.47%) and minimum in the age group of 66-75 years (3.26%).According to Ddine et al. (2012), in situations where there is high stress and anxiety, the secretion of HCl increases and causes erosion of the stomach. Compared to the other age groups in both male and females, the age group 20-29 and 30-39 years old showed relatively higher prevalence showing the uniqueness of the age groups in the lifestyle because these were the ages at which most people in Ethiopia shoulder family and social responsibilities and hence encounter real challenges in life which in turn might lead to stressful can change gastric motility, a very hot intake leads to congestion (burden) of mucosa and raise the secretion of acid. This result is in agreement with the study by Khan et al.(2017) age wise distribution showed maximum prevalence in the age group of 15-25 years 84.2% followed by >65years 83% and minimum in the age group of 55-65 (25%).
The increase in prevalence observed in this study from young age <20 (26.5%) to adult age ≥60 (30.9%) for both sexes. Similarly, Alem Alemayehu (2011) reported that H. pylori infection rate was higher in adult population than in children and that the prevalence increased with age. The prevalence of H. pylori infection in this study was highest in the ≥60 age group 30.9%and lowest among <20 age group 26.5% which is similar to the study by Ozen et al. (2011), on children and adolescents in Asia showed prevalence rates ranging from 20% to 84%. Similarly, the overall prevalence among male and female in this study was slightly similar 29.9% and 30.5%, respectively.This is consistent with studies in Ethiopia (Tadege et al., 2005, Mathewos et al., 2013, Tadesse et al., 2014. But it is inconsistent with the study (Khan et al. 2017) in which sex specific prevalence in female was 61.6% which was significantly high from that of males 38.4%. It is also not in agreement with previous studies shown by others in Kenya (Shmuely et al. 2003 And the frequency of the Patients was lower than the four previous years. In the age range of <20 (25.4%) and 20-29 (20.2%), it is higher relatively. This evidence showed that the infection is decreasing. Interestingly, the overall frequency (prevalence) of H. pylori infection among different gender and age groups from September 2012-August 2017 was 30.3%. The total frequency of H. pylori infection among the five years and gender from September 2012-August 2013 was higher in females 214and 122 in males. As a general, during this consecutive five years the result indicated that the frequency of the infection is highest in the first year September 2012-August 2013 (335) and decreased in the recent 4 years.
Furthermore, the H. pylori infection and its associated risk factors among patients undergoing upper gastrointestinal diagnosis in shashemene referral hospital from September 2016 to august 2017 were noticed. From a total of 422 study participants, 84.8% negative and overall 15.2% antigens of H. pylori were detected. The results showed that the number of infected female was higher 16.9% than infected males13.5%.The highest positive for the infection is seen in age group less than 20 which is 25.4%. There is a significant association between the infection and this age group (p<0.05). In contrast, there was no sex difference (Shi et al., 2008).
Most of the study gastritis participants visiting Shashemene referral hospital from September 2016 to August 2017 have family size of ≥4 that was 88.2% of which 15.3% H. pylori positive persons per house hold and only 11.8% of which 14% H. pylori positive study participants have family size of <4. The highest positive for the infection is seen in the Family size of ≥4 which is 15.3%. This pattern of scores is not significant (p>0.05), which is parallel to other studies in Ethiopia (Abebaw et al., 2014), but this study is different from other studies elsewhere (Shmuely et al., 2003).This could be attributed to overcrowding of family and scarcity of resource (e.g source of water). For some, they were stressed when they started their new independent life. Using a statistical inference model, Strebel et al. (2010), found "more than three children living in the household", "more persons living per m 2 than average", "home situated at main road" and "using well water" to be strongly associated with H. pylori infection. Ethiopia is one of the African countries in which the prevalence of the same infection is believed Journal of Health, Medicine andNursing www.iiste.org ISSN 2422-8419 An International Peer-reviewed Journal Vol.73, 2020 13 to be very high. This is probably attributed to the poor living conditions and overcrowding of the population (Alem Alemayehu, 2011).
Similar results were observed recently by Laszewicza et al. (2014), (Hu et al. 2013) and Zaterka et al.(2007) reported that crowding, type of drinking water, lack of toilet during childhood, lower family income, and lower educational level has a positive association. In contrast, this study found no association between H. pylori and socio-economic status. Similar results were observed in study in China (Shi et al., 2008) and Benin (Aguemon et al., 2005). In a study from Brazil, Dattoli et al. (2010) reported increased H. pylori infection with a larger number of siblings, nursery schooling, and housing in a street without paved roads and without flushed toilets indicating impoverished living conditions associated with poorer sanitation and overcrowding to be risk factors for H. pylori infection. Similarly, Fialho et al. (2010) demonstrated the number of people per room and number of children in the household as independent risk factors for H. pylori infection.
Most of the study participants earning a monthly income of < 700ETB 292(69.2%) of which 40(13.7%) are H.pylori positive and the rest 130(30.8%) of which 24(18.55%) are H.pylori positive have Monthly income of ≥ 700ETB. But those with ≥ 700ETB monthly income were relatively higher H. pylori positivity. As the p value is greater than 0.005, this pattern of scores is not significant. Results observed recently by Laszewicza et al. (2014), Hu et al. (2013) and Zaterka et al. (2007) showed that crowding, type of drinking water, lack of toilet during childhood, lower family income, and lower educational level has a positive association. These results are slightly similar to an important and interesting study from USA; Epplein et al. (2011) reported a high H. pylori prevalence rate of 79.0% among a subpopulation of poor Americans. Alcohol consumption is the world's third risk factor for diseases; in middle income countries, it is the greatest risk factor (WHO, 2011) The prevalence of H. pylori infection by age among gastritis patients visiting shashemene referral hospital from September 2016 to August 2017 was noticed. The majority of the respondents were in the age range of 30-39 years (31.5%) and 20-29 years (23.5%). For this the relationship across 6 age groups of patients were examined, the highest positive for the infection is seen in age group less than 20 which is 25.4%. There is a significant association between the infection and this age group (p<0.005). Moreover, the prevalence of H. pylori infection by sex among gastritis patients visiting Shashemene referral hospital in the same year was noticed and association of the infection and the different sex group is not statistically significant (p>0.005).This is in agreement with the gender wise distribution of H. pylori seropositivity study (Khan et al. 2017), which constitute 27 (52.94%) males and 24(47.06%) females (OR=1.537). In the study by Alebie G and Kaba D (2016), among1371 subjects, 851(62%) were H. pylori positive. However, no significant differences in the prevalence of H. pylori infection by gender were noted (P = 0.3). Similarly, the prevalence of H. pylori infection among the study participants was 71.0 %. The prevalence among male was 68.5 % and among female was 75.5 %. However, gender was not significantly associated with H. pylori infection (X 2 = 0.799; p = 0.371).
The majority of the gastritis participants visiting Shashemene referral hospital from September 2016 to August 2017 was able to read and write 73.7% while the rest were illiterate 7.1% and diploma and above 19.2% of which Illiterate 16.7% read and write 14.5%, diploma and above 17.3% are H. pylori patients. The highest positive for the infection is seen in that diploma and above which is 17.3%. Statistically significant difference was not obtained for educational attainment(x 2 = 0.452, p= 0.798 > 0.05) which is in agreement to studies (Shi et al., 2008, Aguemon et al., 2005 and inconsistent to other studies (Shmuely et al., 2003, Abebaw et al., 2014. Similarly, in the study by Dilnessa Tebelay and Amentie Muluwas (2017), no significant association was observed in the prevalence of H. pylori with family size, educational status and marital status (p>0.05), but a statistically significant association was observed between H. pylori infection and residence (p<0.05), which is inconsistent with the current study. H. pylori infection and perceived symptom's aggravating factors (smoking, drinking alcohol, Eating spicy food, hunger, stress and anger) that might aggravate gastritisvisiting shashemene referral hospital from September 2016 to August 2017 was also noticedand the highest positive for the infection is seen in patients with stress and anger habits which is 17.4% and Eating spicy food which is 16.1%. As the p value is greater than 0.005, then this pattern of scores is not significant.7 In this study there was no statistical association between alcohol consumption and H. pylori infection (p>0.05) which is similar to other studies in South Africa (Tanih et al., 2010) andChina (Shi et al., 2008).The absence of association in this study might be due to less number of alcohol users, the type and amount of alcohol consumed has effect on the association. But this study is inconsistent with other studies done in Ethiopia (Moges et al., 2006, Abebaw et al., 2014. Despite no significant association observed, life style factors such as smoking, drinking, hunger, stress and anger, ingestions of spicy foods and drugs were found to aggravate symptoms of H. pylori gastritis than H. pylori negative gastritis. The reason for this contradictory result might be due to the difference in the type of alcoholic beverages consumed and the life time history of alcohol consumption. According to the data obtained by Megan (2006), in northern Canada prevalence of Gastritis from alcohol user 43%, fruit and vegetable user 49%, and smoker user was 52%.Other studies done in Ethiopia by Moges (2006) and Abebaw et al. (2014) showed alcohol, the type and amount of alcohol consumed has effect on the association.
The percentage of respondents who had good awareness about their personal hygiene and environmental sanitation 19.2% was lower than that of the respondents who had poor awareness about their personal hygiene and environmental sanitation 80.8%. But, the highest positive for the infection is seen in respondents who had good awareness about their personal hygiene and environmental sanitation which is 21%. In a study from Brazil, Dattoli et al. (2010) reported increased H. pylori infection with a larger number of siblings, nursery schooling, and housing in a street without paved roads and without flushed toilets indicating impoverished living conditions associated with poorer sanitation and overcrowding to be risk factors for H. pylori infection.
The percentage of respondents who had awareness about H. pylori were 19.2% of which 16% were H.pylori positive and those who had no awareness about H. pylori were 80.8% of which 15% were H. pylori positive. But, the highest positive for the infection is seen in respondents who had awareness about H. pylori which is 16.0%. In contrast, the study at Jigjiga University, Jigjiga, Somali Regional State of Ethiopia, lack of awareness on the transmission ways of H. pylori was significantly associated with the prevalence of the infection (p= 0.025) and those who had not awareness about the transmission ways of H. pylori had 2.53 times higher odds of being infected with this bacterium than aware participants (Alebie G and Kaba D, 2016).
According to the study by Brown (2000),H. pylori in drinking water would be an important source of risk factor, pointing to a fecal-oral route of spread and H. pylori may be transmitted orally by means of fecal matter through the ingestion of waste-tainted water, so a hygienic environment could help decrease the risk of H. pylori infection. The source of water used by most respondents in this study was unprotected well water 178(42.2%). Only 139 (32.9%) of the respondents were obtaining their drinking water from tap water. The highest positive for the infection is seen in respondents who used spring water which is 26.3%. This pattern of scores is statistically not associated with the infection (p>0.05).Using statistical inference model, Strebel et al. (2010), found "using well water" to be strongly associated with H. pylori infection. Brown (2000) reported thatH. pylori may be transmitted orally by means of fecal matter through the ingestion of waste-tainted water, so a hygienic environment could help decrease the risk of H. pylori infection.
Most of them had not toilet 260(61.6%) of which 37(14.2%) were H. pylori positive and only 162(38.4%) had toilet of which 27(16.7%) was H. pylori positive. The highest positive for the infection is seen in respondents who had toilet which is 16.7%. This pattern of scores is statistically not associated with the infection (p>0.05). Results observed recently by Laszewicza et al. (2014), Hu et al. (2013) and Zaterka et al. (2007) showed that crowding, type of drinking water, lack of toilet during childhood, lower family income, and lower educational level has a positive association.
About 259 (61.4%) of the respondents were from rural of which 14.3% were H. pylori positive and 163(38.6) were from urban of which 16.6% were H. pylori positive. The highest positive for the infection is seen in patients from urban which 16.6%. This pattern of scores is statistically not associated with the infection (p>0.05).But, Abebaw et al. (2014) reported Slight higher prevalence observed in rural residences, but no statistically association occurred in previous studies in Ethiopia. Prevalence of H. pylori infection in rural residents may be attributed to factors related to the lack of safe water supply and hygiene condition in the rural part of the country.
Interestingly, the majority 244(57.8%) of the respondents of which 14.3% were H. pylori positive revealed that they do not share utensils with their family members and 178(42.2%) of the respondents of which 28.7% were H.pylori positive share utensils with their family members. The highest positive for the infection is seen in patients do not share utensils with their family members which are 28.7%. This pattern of scores is statistically not associated with the infection (p>0.05). Lack of awareness about H. pyloriinfection in the study area may increase the prevalence of H. pylori infection; since the local people do not give care for the infection. In the same way using unprotected well water and sharing of utensils also increased the risk of transmission of bacteria within family.
From different risk factors considered in this study, marital status of the patients accounted the bigger number (2.793 OR; 95%CI: p=0.038 < 0.05. This is statistically significant predictors or was significantly associated with H. pylori infectionwhich is in line with study in Northwest Ethiopia (Abebaw et al., 2014); in this case marital status was associated with prevalence of H.pylori, but different from other studies in Ethiopia (Moges et al., 2006) and China (Shi et al., 2008). According to study by Abebaw et al. (2014), the higher cases of gastritis among the married respondents could also be due to stress experienced as people (married couples) start new independent life. The next largestvalue was for age groups (1.345 OR; 95%CI: p=0.006< 0.05 which is also significantly associated with the infection. But, no association was found between infection and age (Aguemon et al., 2005).The third next largest value is Sharing of utensilsaccounted the bigger number (1.431 OR; 95%CI: p= 0.403> 0.05. However, this is not statistically significant predictors or is not significantly associated with H. pylori infection. But other risk factors like family size, monthly income, gastritis aggravate, Awareness of personal hygiene and environmental sanitation,usually wash hands with soap after latrine, awareness about H. pylori,having toilet,food usually makes pain and source of drinking water were not statistically significant (P> 0.05) or were not significantly associated with H. pylori infection. Similarly, the prevalence H.pylori antibodies was 75.4% in the urban population and 72.3% in rural residence (p= 0.459) and no association was found between infection and