THE PREVALENCE OF IRRITABLE BOWEL SYNDROME AMONG PRIMARY HEALTH CARE DOCTORS IN

Background: Irritable Bowel Syndrome is found to be more common among health care workers. There are no studies yet that focuses on this issue among primary health care doctors in Makkah AL-Mukarramah, Saudi Arabia and the definite factors affecting IBS are not yet established. Aim To measure the prevalence of Irritable Bowel Syndrome among primary health care doctors in AL-Mukarramah, Saudi Arabia and to determine associated factors. Methodology: study a cross-sectional study design, care in Makkah AL-Mukarramah A self-administered questionnaire was used for data collection. It included socio-demographic variables and the variables used in Rome IV criteria. Results: Irritable Bowel Syndrome is found to be common among

In Egypt, the prevalence of Irritable Bowel Syndrome was studied at Ain Shams University among medical students from October 2017 to February 2018 (12). 382 students were asked to fill out a questionnaire, and 121 of those were positive with IBS. The prevalence rate of IBS was 31.7%, with a higher percentage among woman and students having relatives that are IBS positive; however, IBS was accordingly less observed among students who regularly exercise. Lastly, it was also observed that there was a statistically significant association between IBS and anxiety.
Irritable Bowel Syndrome was also found to be prevalent in Europe. 255 patients admitted to six varied hospitals near Bristol, UK, were given questionnaires (13). These 255 patients were diagnosed with a gastrointestinal problem. 30% were assessed to have IBS and 14% other have functional diseases. Individuals with IBS were more often female and more often evaluated by their doctors to be polysymptomatic and to have unrecognized symptoms.
In the United States of America, quota sampling and screening interviews via random-digit telephone dialing were done to identify individuals diagnosed with IBS or even the ones that are not formally diagnosed (14). Information 605 on IBS symptoms, lifestyle, status of health, and how the symptoms affect the individuals' lives was gathered through comprehensive follow-through interviews. The total number of screening interviews done was 5009 and the prevalence rate was 14.1%; of which 3.3% were medically diagnosed and 10.8% were undiagnosed but met the irritable bowel syndrome criteria. Most that suffer from Irritable Bowel Syndrome in the United States of America are undiagnosed; and it should not remain that way because IBS has a significant effect on the individual's wellbeing and health, as well as socio-economic consequences.
There are also cases of Irritable Bowel Syndrome in Asian countries. In Japan, a large-scale internet survey was conducted to 10,000 subjects to determine the prevalence of Irritable Bowel Syndrome (15). The prevalence of IBS and subtypes were identified and the results were analyzed for correlation. The IBS overall prevalence rate is 13.1%; while the rate of prevalence of IBS with diarrhea subtype accounted for 29% of these cases, IBS with constipation subtype corresponds to 24% of cases, and mixed IBS subtype to 47%.
In India, the prevalence of Irritable Bowel Syndrome was also observed (16). A study was conducted among the slum population of Mumbai, India to determine the prevalence of IBS and to study epidemiological factors relating to it through systematic random sampling with a questionnaire. The prevalence of IBS was found to be 12.27%; 56% of whom were males and 44% were females. Most that experienced IBS were aged between 25 and 44 years old, married; and their most common symptoms were pain relief after defecation and variation in frequency of stools.

Factors associated with Irritable Bowel Syndrome: Psychological Factors:
Almutatairi et al. (17) determined the factors associated with Irritable Bowel Syndrome among medical students in Qassim, Saudi Arabia, and they found out that depression has a significant impact on the prevalence of IBS. The study also showed that IBS prevalence is more common in students with a high level of anxiety in comparison to those with mild anxiety; nevertheless, there was no numerically significant difference. Consequently, the researchers also stated that although anxiety and depression affect the symptoms of IBS, psychological factors alone affect the abdominal function and reactivity of the intestine.
Afetni et al. (18) conducted a study in Makkah Almukarramah, Saudi Arabia among its adult male population regarding the prevalence of Irritable Bowel Syndrome and its correlated factors. Psychological distress such as anxiety and depression are recognized contributing factor for IBS. Based on the result of the study, there was a significant relationship between psychological upset and loss of interest in things as a manifestation of bad quality of life. The definite effect of psychological stress on abdominal pain and discomfort is yet to be proved; although, many researchers attested that there is an interrelationship between the central nervous system of the brain and the digestive system.

Psychosocial Factors:
In China, Jiang et al. investigated the association between psychosocial factors and the danger of contracting Irritable Bowel Syndrome in college freshmen (19). Psychosocial factors were found to supplement to IBS prevalence among college freshmen. Experience of abuse such as emotional, physical and sexual abuse was also associated with increased exposure to IBS. Consequently, another research also reiterated that people with IBS experienced more abuse compared to those who do not have IBS, and abuse was correlated with cases of increased gastrointestinal symptoms. Moreover, psychological factors such as depression and anxiety are commonly observed among individuals with abdominal discomfort or IBS.
Social and psychological factors can intercede with the interaction between the central and centric nervous systems and it has been proven that it is involved in the commencement of IBS. There is evidence that people who were abused and had a stressful life are prone to gastrointestinal disorders. Two studies concluded that history of trauma and abuse, either a childhood or adult experience, are associated with an increased risk of having IBS (20). In a study involving veteran women, who experienced occupational trauma as well as sexual trauma, the IBS prevalence was 33.5%. Although depressions and traumatic stress were more common in cases of IBS, the association between trauma and the risk of IBS has not yet been proven.

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Occupational Stress: In Northern Saudi Arabia, a lot of psychological factors were found to be associated with the analysis of Irritable Bowel Syndrome (21). In the study done by Alharbi, he stated that the possibility of anxiety as a factor of IBS was analytically significant as well as the risk of emotional stress. The results of his study also showed that the occupational stress level was higher in patients diagnosed with IBS compared to healthy individuals, in fact, IBS was found to be more common in healthcare professionals. Alharbi, therefore, concluded that IBS symptoms are linked with anxiety, depression, and to a less likely chance, may be associated with occupation and daily working hours.
Medical students in Pakistan were surveyed to figure out the prevalence of IBS and the factors affecting it (22). Stress is said to be one of the major contributing factors to IBS since it triggers colonic spasms. Stress is identified to be very common among these individuals; thus, the prevalence of IBS is also common among medical students, in fact, 55.8% of IBS cases were found to be positive for anxiety. According to Naeem et al., (22) anxiety, depression, and sleeping disorders are commonly associated with IBS, so students who regularly experience anxiety and mental stress are more likely to be tested positive with IBS.

Sex-Gender Factor:
In Lebanon, social factors and health behaviors on Irritable Bowel Syndrome prevalence were identified among university students (23). The probability of having IBS is more evident among women than men, among the 22 years old or younger, and those who are living in their own, private home, or dormitory, and those with belong to the middle class society or higher.
The presentation of symptoms as well as treatment may vary for male and female with Irritable Bowel Syndrome since according to studies, there is a sex-gender difference shown in its physiological and psychological factors (24). Gender differences and sex hormones were believed to be a factor in the pathology of IBS; however, its etiology is still unidentified and its association is still limited. In this study, female individuals with IBS have been recorded to feel wear-out, anxious, or depressed than men with IBS. Moreover, there has been proof of differences in the suitable treatment for men and women.

Behavioral Factors:
In the study done by Constanian et al., (23) when it comes to behavioral factors, the result showed that students who do not immerse in physical exercise are more likely to have IBS. According to the researchers, physical activity has a renowned function in managing stress, so it's possible that students who do not exercise don't handle stressful situations very well, thereby increasing their chance of contracting IBS symptoms.
An interventional study was done on increasing the physical activity of IBS patients (25). The result of the study stated that a modest increase in physical exercise relives IBS symptoms. Engaging in physical activities still has not proven to be a treatment for Irritable Bowel Syndrome. One way to look at it is that exercising in order to overcome the IBS gives a feeling of control over that disease. The prevalence of IBS which ranges from 11.2% (95% CI, 9.8%-12.8%) worldwide according to a meta-analysis was added and to compensate for the nonresponses and incomplete answers from questionnaires, 10% was added also to the sample. Therefore, the sample size of the study is 116 which will be proportionally distributed among physicians.

Sampling Technique:
The researcher distributed the population size of 135 on all primary health care in Makkah city by using stratified random sampling, according to the percentage of the doctors inside all the four sectors in Makkah City. Then, the doctors were randomly chosen by a random sample generation from the exclusive list of all doctors in the four sectors. Their names were checked and compiled and those who were selected were contacted and were asked to fill out the questionnaire.

Data Collection Tool:
Self-administered questionnaires were distributed to all health care providers involved in the study. The first page was about the title of the research and information plus the contact number of the researcher while the second page included consent and confidentiality approval. Then there were three main sections: the first part is concerned with the biography information of the participants (name, age, gender, marital status, nationality, job title).
The second and third section was concerned with the diagnosis of IBS and its associated factors. It was measured using the original Rome IV criteria questionnaire, which is valid and used in many studies. In the diagnosis of IBS, Rome IV criteria require that patients should have chronic abdominal discomfort or paint that lasts for at least 3 days per month for the last 3 months that is combined with two or more of the following symptoms: relieved by defecation, change in stool frequency, and change in stool appearance. Moreover, associated symptoms include the following: altered stool frequency, altered stool form, altered stool passage, leucorrhea and abdominal bloating. In addition, there could be four bowel patterns visible in Irritable Bowel Syndrome. These patterns consist of IBS-D (diarrhea predominant), IBS-C (constipation-predominant), IBS-M (mixed diarrhea and constipation), and IBS-U (unspecified diarrhea and constipation).
The present questionnaire was translated into the Arabic language by Dr. AbduljabbarAlfetni and the necessary modification was made to meet the objectives. It was validated by two family medicine consultants and the reliability was also tested by the internal consistency measurements

Data Collection Technique:
The researcher herself collected the data. Firstly, the doctors were randomly selected. Then, the researcher asked the selected doctors to fill out these questionnaires, which by the way, are self-administered questionnaires. After that, the questionnaires were collected a day after in order to give time to properly answer it and to not disturb the doctors from their work. Also, any unclear questions were explained thoroughly. 608

Data Entry and Analysis:
The data were entered and statistically analyzed using MS Excel and SPSS software version 23 (IBM Corp., Armonk, NY). The demographic data were presented using Mean and Standard Deviation SD. Subsequently, the data were analyzed to test the significance of the statistical difference. For qualitative data, Chi-square test and Fisher's exact test were used. Moreover, the test result was considered statistically significant if the P-value is less than 5% (P <0.05) at a confidence interval of 95%.

Pilot Study:
A pilot study was conducted in one of the Primary Health Care in Jeddah, and it was done on 12 doctors (10% of population size), with the application of the full methodology and analysis of results to outline the feasibility of data collection and to identify the practical difficulties and find ways of minimizing it. Results:-

Characteristics of the Study Population:
The study population is composed of 140 physicians.

Symptoms of Irritable Bowel Syndrome:
The participants were asked to answer some questions about whether they feel symptoms of Irritable Bowel Syndrome. The tables and figures below show the summary of the result. Table 2 shows the frequency of pain and discomfort they experience. For the past three months, a quarter (25%) of the study population have never felt pain or discomfort in any part of the abdomen, another quarter (26.4%) have felt pain or discomfort in the same area for 2-3 days a month, while a few have felt pain or discomfort every day, for one day, or less than a day in a month.
Among the 105 participants who have felt abdominal pain, most (61.9%) did not have persistent pain or discomfort in the abdomen for six months or more, while others (38.1%) had felt it. Consequently, for the last three months, half (51.4%) had a rigid or lump stool sometimes, almost a quarter (22.9%) have never had or rarely, while the remaining had it most of the time. In addition, for the last three months as well, half (50.5%) of them have had a liquid or soft stool for some time, 23.8% of those who feel abdominal pain and discomfort have never had a liquid or soft stool, while the remaining population has it most of the time.
40 participants who have felt pain and discomfort in the abdomen for the past six weeks were asked to answer another series of questions. Most (35%) of them sometimes had an increase in the number of defecations alongside pain and discomfort, while 20% had never or rarely, 25% mostly had it, and 20% had it most of the time. For the decrease in defecation, on the other hand, almost half (45%) never had it. Furthermore, 35% of them sometimes had a soft stool, 30% had a soft tool most of the time. Lastly, almost half (47%) have said that they never or rarely had a rigid tool, while 35% have agreed that sometimes they do.  Figure 1 show the medical and personal history of the 105 participants who have felt and pain discomfort for the last three months. Only 10% suffer from anorexia and also 10% had relatives who suffer from the digestive system tumor. Around 7% had a kind of pain and discomfort that wakes them up from sleep. Also, 4% suffered from weight loss for no reason. 3% had blood in their stool since the onset of symptoms, 2% had their symptoms of IBS to begin at the age of 50, and lastly, only 1% had claimed to use antibiotics to relieve the symptoms.

Test for Irritable Bowel Syndrome:
Rome IV Criteria was used to identify the dependent variable. A simple additive method is used to total each of the criteria. After the criteria was computed, "Recurrent abdominal pain or discomfort" as the main criteria and associated with the remaining criteria with a score of ≥2 combined was suspected to have Irritable Bowel Syndrome. All 140 participants were asked a series of questions to determine whether they are positive with IBS. The variables considered are the recurrence of abdominal pain or discomfort, defecation, change in frequency of stool, and change in the appearance of stool. Almost (74.3%) all had felt pain or discomfort in the abdomen for the past three months, while 100 (71.4%) participants had felt pain or discomfort in the same area for the past six months. Moreover, 51.4% have said that the pain and discomfort was not improved after defecation, while the 48.6% have said that it was improved. Consequently, the number of defections of most of the participants did not increase or decrease when the pain or discomfort started to begin. For the appearance of the stool, only a few had stated that there stool are either soft or rigid, and most have answered that there stool did not change in form. Based on the following criteria, it was found out that 39 out of 140 participants are positive with Irritable Bowel Syndrome. The prevalence rate of IBS is 27.9%. Categorical Variables: Table 4 shows the demographic information of the participants, the prevalence of IBS for each demographic, and the corresponding p-value using the Chi-square test. According to the result, the social status has a p-value of 0.004 which is greater than 0.05; therefore, this variable is significant. This means that the social status of an individual can be associated with having Irritable Bowel Syndrome. When it comes to increased nervousness and pressure at work or at home, 35(48.6%) of those who agreed have IBS, while only 4(5.9%) who disagreed yet positive with IBS. The resulting p-value for social relationships (p-value=0.001), first degree relatives with IBS (p-value=0.003), and increased nervousness and pressure (p-value<0.001) are less than 0.05 which means they are all significant; therefore, IBS may be related to having first degree relatives with IBS, increased nervousness and pressure at home or work, and having an effect in daily life and social relationships.  1%) did not agree, but were also diagnosed with IBS. The resulting p-value computed for each variable showed that experiencing a decreased mood (p-value=0.008) and losing interest (p-value=0.048) for the last two weeks are both greater than 0.05; therefore, they are significant in the diagnosis of IBS. This means that these two variables may be related to and can be linked to the existence of IBS.   Q40=During the past two weeks, have you experienced a decreased mood? Q41=During the past two weeks, have you suffered from a loss of interest in your loved things and works? b-Significant using Binary Logistic Regression Model, with Backward Conditional Elimination with Enter Criteria=0.05, Elimination =0.10.

Chapter 5:
Discussion:-Irritable Bowel Syndrome is the most well-known gastrointestinal disease defined by bloating, abdominal pain, constipation, or diarrhea. Studies have shown that IBS tend to have a negative impact on the affected individual's quality of life (26).

Prevalence of Irritable Bowel Syndrome:
In this study, the prevalence of Irritable Bowel Syndrome among primary health care physicians in Makkah Al-Mukarramah, Saudi Arabia is 27.9%. The result was higher compared to the one that was reported by AlAmeel et al. which has an IBS prevalence of 16.3% among physicians and surgeons in Saudi Arabia. The difference in the prevalence rate among the two studies may be attributed to the scope of the study. The current study was more focused while the study done by AlAmeel et al. (10) was too broad for it focused on all doctors in Saudi Arabia. Also, the questionnaires in the study were answered digitally through a web-based survey, while the present study had a manual filling out of the questionnaire.
In addition, the current study has a higher IBS prevalence rate compared to Turkey (11.17%), United States of America (14.1%), Japan (13.1%), and India (12.27%). Although, it has a lower IBS prevalence rate compared to Egypt (31.7%) and the United Kingdom (30%).
The reason behind the high IBS prevalence rate (27.9%) of the current study is because the study population already focuses on the physicians. As discussed earlier, Irritable Bowel Syndrome is common among healthcare workers due to the nature of their work. They have a stressful working environment and long working hours. Aside from that, they are exposed to different diseases which make them more vulnerable.

Categorical Variables:
Based on the result of the Chi-square test done in the correlation between the demographic variables and the diagnosis of IBS, only the social status of the individual was found to be significant. Age and nationality don't have much correlation to being diagnosed with IBS, although this is only based on the result of the study. The results from this study agree with other related studies done. AlButaysh et al. (27) conducted a study regarding the prevalence of IBS and health-related quality of life among adults in Saudi Arabia. In the study, it was found out that there is a statistically significant association between IBS and marital status. In another study done by Mansouri et al. (28), a multivariable regression model revealed that marital status is a significant determinant of IBS. Despite a few studies showing the same result, most studies conducting research about factors of IBS stated that social status or marital status does not have significant association with IBS.
Irritable Bowel Syndrome affects not just the body but also the quality of life of the sufferer. Among the categorical variables used in the study are whether IBS affect the individual's daily life and social relationships, have a first degree relative with IBS, and increased nervousness and pressure at work. All of the mentioned variables are found to be significant in association with IBS. Irritable Bowel Syndrome can result in damaged relationships because of the increased possibility of: self-isolation, partner burden, and interpersonal conflict (29). Difficulties will arise in relation to IBS due to its embarrassing nature of symptoms and the society's lack of knowledge about the disease. Consequently, most participants with IBS also have first degree relatives with the same illness. According to Saito, IBS is a common disorder that can aggregate families (30). Relatives of an individual with Irritable Bowel Syndrome are two to three times more likely to have the same disorder, which can affect both genders. Moreover, increased nervousness and pressure at work can result in stress, and stress has been known to be a factor of Irritable Bowel Syndrome. Several studies have shown that psychological stress has an impact on sensitivity of the digestive tract. This finding can have a potential role in the pathogenesis of IBS.
Also included in the categorical variables tested are monthly family incomes, whether the participant smokes, experienced a decreased mood, and loss of interest. Based on the chi-square test, changing of mood and losing interest are statistically significant in association with IBS. According to Mudyanadzo et al. (31) IBS has always 615 been associated with mood and anxiety disorders. Anxiety and mood disorders were looked at as something that causes digestive problems, although, researchers are not ignoring the likelihood that troubled mood may be an effect of having Irritable Bowel Syndrome (32). Whatever the relationship between Irritable Bowel Syndrome and mood changes is, it is still unclear and requires more research in order to expound the association and to give appropriate treatment for both IBS and mood changes. Consequently, Irritable Bowel Syndrome has been characterized with low mood or loss of interest in activities that used to be pleasurable, and it usually comes with other symptoms like low self-esteem, sleep disturbances, loss of appetite, and lack of concentration (31). Another study has listed loss of interest as a factor IBS alongside change in appetite, insomnia, decreased libido and fatigue (33).

Dependent Study Variables:
A Binary Logistic Regression Model with Backward Conditional Elimination was used to identify the relevant predictors of the dependent study variables. These are the variables that were statistically significant using the Chisquare test. Based on the result of the binary outcome, only experiencing an increase in problem in case of nervousness or an extra pressure at work or at home has a significant association with Irritable Bowel Syndrome. The result is quite different with other similar studies. This may be due to fewer factors considered in the current study. In the demographic information alone, gender was not considered, and based on most studies done in determining factors of IBS, gender is statistically significant; in fact, IBS is said to be more prominent in females than males. Also, the working hours were not asked from the participants. Long working hours can result in occupational stress which means higher chance of digestive disturbance. This factor was also proven to be statistically significant in association with Irritable Bowel Syndrome.

Conclusion:-
Based on the result of the current study, the prevalence of Irritable Bowel Syndrome among Primary Health Care physicians in Makkah Al-Mukarramah, Saudi Arabia is significantly high with a rate of 27.9%. There are several factors associated with IBS which include age, social status, gender, occupation, psychological state, psychosocial state, stress level, and behavior. However, according to the tests done in the study, the strongest predictor of Irritable Bowel Syndrome is having an increase in problems in case of nervousness or extra pressure at work or at home. These findings will help researchers to determine the pathology if IBS, develop an improved assessment for the diagnosis of IBS, and establish appropriate treatment. For the assessment being used in the diagnosis of Irritable Bowel Syndrome, such as the Rome III and Rome IV, previous studies suggest that criteria could use improvement. Adding variables that deemed to significant or strongly associated will help in the accuracy of the assessment.
In line with generating an improved and more reliable assessment tool for IBS, more studies should be done in order to unify or compile the significant predictors of IBS.
Since Irritable Bowel Syndrome are more common among health care workers due to the nature of their job, there should be a stress management program dedicated to them or at least lessen the working hours to avoid contracting stress-induced diseases.