An institution based cross-sectional study design was conducted from February to May 2020 G.C among adult surgical patients who visited the surgical outpatient department (OPD) at the UoGCSH. The hospital was found in1954 and it is located in the Central Gondar administrative zone, Amhara National Regional State, which is about 750 km Northwest of Addis Ababa (the capital city of Ethiopia). According to the 2015 population projection of major cities in Ethiopia, the total population size of Gondar town was estimated to be 323,900. Currently, Gondar town has one Referral Hospital and eight government Health Centers. University of Gondar Comprehensive Specialized Hospital is a teaching hospital, which serves more than five million people of the North Gondar zone and peoples of the neighboring zones. It is estimated that around 21,000 patients visit the surgical OPD per year.

The source population of the study was all adult patients above 18 years’ old who visited the surgical OPD at the UOG Comprehensive Specialized Hospital. The study population was all adult patients above 18 years’ old who visited the surgical OPD during the time of data collection in the UOG Comprehensive Specialized Hospital. Patients who were unable to communicate, mentally ill, and severely ill were excluded from the study. The sample size was determined using a single population proportion formula, by using a 95% confidence interval, 0.05 margin of error, 5% non-response rate. As far as our search is concerned, there was no previous study conducted in the area and the expected proportion of hemorrhoids was considered to be 50%. Therefore, the final sample size was 403 and participants were selected using a systematic random sampling technique with skipping intervals of three.

The outcome variable of this study was hemorrhoids. Patients were diagnosed based on history and anorectal examination which includes inspection, digital examination and anoscopy. Grading of hemorrhoids was documented and classified according to the international classification recommended by Banov et al: Hemorrhoids that do not prolapse and appear as a bulge into the lumen of the anal canal with or without bleeding (grade I). Hemorrhoids that prolapse and reduce spontaneously (grade II). Hemorrhoids that require digital reduction of prolapsed tissue (grade III).Hemorrhoidal piles prolapse is irreducible(grade IV) [12]. The first group of factors assessed was socio-demographic characteristics including age, sex, residence, educational status, occupation, marital status, and average monthly income. The second was clinical factors which includes a Family history of hemorrhoids, constipation, body mass index (BMI), hypertension, fiber diet intake, and chronic diarrhea. The third group of characteristics assessed was Behavioral and obstetric factors mainly focused on Smoking, alcohol intake and parity. Blood pressure(BP) was measured three times in a sitting position using a standard mercury sphygmomanometer BP cuff with the appropriate cuff size that covers two-thirds of the upper arm after the participant rested for at least five minutes and no smoking or caffeine 30 minutes before measurement. The second and the third measurements were taken five-to-ten minutes after the first and the second measurement, respectively. Finally, the average of the three BP measurements was calculated to determine the BP status of the participant. An individual was diagnosed as hypertensive if systolic blood pressure (SBP) is ≥130mmHg or diastolic blood pressure(DBP) is ≥80 mmHg or previous diagnosis of hypertension or current use of the anti-hypertensive drug [19]. Constipation means unsatisfactory defecation characterized by infrequent stool, difficulty in defecation or both at least for previous 3 months [20]. Fiber diet intake was measured, if participants took fiber diet once in a week considered as they had a history of adequate fiber diet intake. Weight and height to calculate BMI and was taken using calibrated equipment and BMI was calculated by dividing weight in kg by height in meters square. BMI <18.5 kg/m² was considered as underweight 18.5–24.9 kg/m² as normal, 25–29.9 kg/m² overweight and ≥30 kg/m²as obese [21].

The interviewer-administered questionnaire was adopted from different works of literature. The questionnaire was first developed in English and then translated into Amharic language and back to English and consistency was checked. The data was completed by trained five B. Sc nurses who were working at the surgical OPD using the Amharic version questionnaire. Data quality was controlled through the provision of one-day training to the data collectors. To evaluate the general approachability and feasibility of the questionnaire, a pretest was carried out using 10% of a sample size at Debretabor Primary Hospital. Hence, correction and modification were made to the questionnaire accordingly.

After data collection, each questionnaire was checked visually for completeness. Data were coded and entered using EPI DATA 3.1 version and exported to the STATA 14 for analysis. Data cleaning was done by identifying and correcting missed values and inconsistencies. Descriptive statistics like frequency, percentage, median, and Interquartile range (IQR) was done to describe the study population in relation to different variables. A Chi-square test was done for all variables to check the assumptions. The binary logistic regression model was fitted as a primary method of analysis. Variables having p-value ≤ 0.2 from the bivariable analysis were chosen as a candidate for the final multivariable logistic regression model and variables having p-value <0.05 were considered to have a significant association with the outcome variable. An adjusted odds ratio with 95% CI was used as a measure of association. The model goodness of fit was assessed by the Hosmer-Lemeshow test.

The study protocol was approved by the ethical review committee of the College of Medicine and Health Sciences, University of Gondar (Reference SOM 950/12 dated February 15, 2020). Verbal informed consent was taken from all respondents enrolled in the study. Since most of our participants were an able to read and write so that we were not able to take written consent. The verbal consent was taken after introducing the topic of the research to the study participants, initially the data collectors give a brief description about the main aim of the research and telling them there honest and genuine participation by responding to the questions prepared is very important and highly appreciated to attain this purpose. Finally enable the study participants to know about their response to personal question are confidential and also can have a right to not answer any question if they do not want to and stop the interview at any time. The Institutional Review Board (IRB) approved use of consent. To keep confidentiality, respondent’s names and other personal identifiers were not included. The collected data were password protected and properly discarded.

In the present study, a total of 403 study participants were involved with a response rate of 100%. The median age of the participants was 38 years old (IQR: 28, 52). Both sexes had nearly equal frequency, 207 (51.3%) female subjects and more than half of the study participants 210 (52.15%) had no formal education. Of the participants, 135 (33.5%) were farmers and 290 (72%) were married. Almost half of the study participants 200 (49.6%) had an average monthly income less than 1210 ETB (Table 1).

Of the total participants, 30 (7.4%) had a family history of hemorrhoids and one fourth 102 (25.3%) had a history of alcohol intake. Among female study participants, the majority of them 153 (74%) gave at least one birth. Out of the total study participants, 96 (24%) had constipation and 151 (37.4) had a history of taking a high fiber diet (Table 2).

The result of this study revealed that among 403 study participants 53 had hemorrhoids with an overall prevalence of 13.1% (95%CI; 10.1, 16.8). Participants having hemorrhoid were classified as grade I to IV and the prevalence of grade I, II, III, and IV were 34 (64.1%), 12 (22.7%), 6 (11.3%), and 1 (1.9%), respectively. The prevalence of hemorrhoids among male and female participants was 18.8% (95% CI: 13.6, 25.0) and 7.7% (95%CI: 4.48, 12.4), respectively. Out of the total of hemorrhoid cases that occurred among females, 11 (68.7%) of them were diagnosed from those who gave one and above birth (Fig 1).

From the multivariable logistic regression analysis constipation and BMI had a significant association with the occurrence of hemorrhoid. The odds of having hemorrhoid was 4.32 times higher among participants who had constipation as compared to their counterparts (AOR = 4.32, 95%CI; 2.20, 8.48). The patients who had BMI ≥25 kg/m² were 2.6 times higher odds of having hemorrhoid as compared to BMI < 25 kg/m² (AOR = 2.6, 95%CI; 1.08, 6.23) (Table 3).