CHAPTER 1

INTRODUCTION

1.1  Background of the study.

Hemorrhoid is a very common health problem that affects millions of people around the world, and represents a major medical and socio-economic problem (Kibret et al., 2021). It is so common both in developed and developing world that one in three Americans has hemorrhoids on screening colonoscopy (Sandler et al., 2019). In another study, it is argued that about 4.4% of the general population worldwide is affected by hemorrhoids, irrespective of gender. The same study indicates that it is more frequent in females than in males with age between 45 and 65 years (Bartels et al., 2021). In Africa, hemorrhoids represented 38.5% of ano-rectosigmoid disease in Gabon, 58.88% of anorectal pathology in Bangui (CAR) and 30.4% of anorectal consultations in Mali (Coulibaly et al., 2016).  In Cameroon, in a retrospective study carried out in Yaoundé on anus diseases, hemorrhoid was the most common scoring 70.1%, followed by anal fissures with just about 20% (Ankouane et al., 2015)

Hemorrhoids, also known as piles, are swollen veins in the anus and lower rectum, similar to varicose veins (Bartels et al., 2021). Hemorrhoids can develop inside the rectum (internal hemorrhoids) or under the skin around the anus (external hemorrhoids). It occurs frequently as an inflammatory process of the hemorrhoidal plexus (Riss et al., 2012).

Generally, hemorrhoids are classified by their location; internal (originates above the dentate line and covered by anal mucosa), external (originates below the dentate line and covered by anoderm) and mixed type. Internal hemorrhoids are further graded based on their appearance and degree of prolapse (Lohsiriwat, 2015). So, hemorrhoids are classified into four grades (degrees); internal hemorrhoids that do not prolapse and appear as a bulge into the lumen of the anal canal with or without bleeding are classified as first degree. Second-degree hemorrhoids prolapse and reduce spontaneously. Third- degree hemorrhoids require digital (manual) reduction of prolapsed tissue. Fourth-degree hemorrhoids are not reducible (Riss et al., 2012).

They are often not associated with any symptoms and people may not know they have them. When symptoms do occur, they present as bleeding and/or pain on passing stool, sense of incomplete bowel emptying, a lump around or inside the anus, itchiness or soreness around the anus, and mucus discharge from the anus (Bartels et al., 2021). However, not all hemorrhoids are symptomatic- for instance, Internal hemorrhoids, which do not prolapse can only be found during endoscopy, (Riss et al., 2012) as some of these patients do not have anal complaints at all. In contrast, external hemorrhoids are more likely to be associated with symptom such as pains due to activation of perianal innervations associated with thrombosis (Sun et al., 2016). Researchers have identified a number of risk factors that can contribute to the development of hemorrhoids. Amongst which are Long-term constipation, diarrhoea, long duration of sitting, strenuous manual performance involving lifting, aging, obesity, overuse of laxatives, and pregnancy (Sun et al., 2016). 

Depending on the severity, many treatment options have been proposed for the management of haemorrhoids. Management can be broadly classified as; conservative, alternative and surgical. Conservative treatment is based on dietary modifications (high fibre intake, high liquid intake, stool soſteners), stimulants or depressants of the bowel transit (depending if the patient has constipation or diarrhoea) and local treatments (sitz baths, creams, ointments or suppositories containing anaesthetics, anti-inflammatories, and steroids, alone or in combination), and  drugs of the family of the flavonoids such as rutosides (that theoretically cause decreased capillary fragility, improving the microcirculation in venous insufficiency) (Quijano et al., 2005).

 For grades I and II (lower grade of haemorrhoids), conservative treatments like dietary interventions, lifestyle modification and medication treatment are usually adopted. A meta-analysis showed that fibre supplementation could reduce the risk of bleeding after defecation and also provide consistent beneficial effect on perianal pain and itching (Chen et al., 2020). Prebiotics and probiotics improve the symptoms of constipation which is an identified risk factor for the development of haemorrhoids, and therefore are helpful as supplements for managing haemorrhoids (Sakai et al., 2015).

1.2 Statement of the problem.

Given that hemorrhoids (responsible for significant economic cost and personal suffering such as pain, bleeding, discomfort and itching) is a rampant disease in Cameroon as indicated by a retrospective study carried out on anus diseases in Cameroon, which showed hemorrhoid being the most common scoring 70.1%, followed by anal fissures with just about 20% (Ankouane et al., 2015), and also given the fact that, in Cameroon, very limited researches have focused on the knowledge aspect, especially on the clinical or treatment part of hemorrhoidal disease (Mvogo et al., 2020). Also, conservative management (nutritional management) of hemorrhoids cannot be overemphasized (Chen et al., 2020),  however, unfortunately, though Cameroon has a very diverse culture with her own unique dietary practices, little in terms of research has been put forward linking dietary practices, attitude and knowledge in relation to hemorrhoids.  By necessity, this study therefore aims to find out what hemorrhoids patients are consuming, their awareness of whether what they are consuming causes hemorrhoids or not, and do they put what they know into practice and demonstrate good   attitudes towards the nutritional management of the disease.

1.3 Research Questions

The following research questions pillared the project:

1.3.1 Main Research Question

How do nutritional knowledge, attitude and practice associate with each other with respect to the nutritional management of hemorrhoids?

1.3.2 Specific Research Questions

1. How is the dietary practice of hemorrhoid patients in the NWR?
2. How is the nutritional knowledge and attitude of patients towards the nutritional management of hemorrhoids?
3. Is there an association between nutritional knowledge and practice of patients, and attitude and dietary practice of patients?

1.4 Main Objective

To assess the nutritional knowledge, attitude and practice of hemorrhoids patients in relation to the nutritional management of hemorrhoids in the North West Region of Cameroon.

1.4.1 Specific objectives

1. To assess the dietary habits of hemorrhoid patients (male and female) in the NWR.
2. To evaluate the nutritional knowledge and attitudes of patients towards the nutritional management of hemorrhoids.
3. To determine the association between knowledge and practices of patients, and attitude and practices of patients