Factors Associated with Childhood Tonsillitis in Somalia

Background: Tonsillitis, acute or chronic, is more common among children than adults. Risk factors associated with the occurrence of tonsillitis among Somali children are not well-defined mainly due to lack of health research in Somalia. The purpose of this study is to identify the main risk factors of childhood tonsillitis to better prevent and avoid further complications of the disease. Methods: The study included the caregivers of 60 children with tonsillitis receiving treatment, at the time of the study, from Garowe General Hospital. A convenience sampling method was used and data were entered into SPSS and analyzed for frequency and percentages. Results: This study shows that the majority of the study participants with tonsillitis 32 (53%) were 1-7 years old and 39 (65%) of the participants were female. Childhood tonsillitis was associated with parents’ lower educational levels: illiterate 32 (53.3%), primary education 20 (33.3%), secondary school 6 (10%), and university level 2 (3.3%). The importance of personal hygiene was believed in by 31 (52%) of the caregivers, while 18 (17%) of the caregivers reported that their children do not brush their teeth at all. The majority of the caregivers 50 (83%) believed that tonsillitis is a disease with less severity. A family history of tonsillitis 49 (82%) was also associated with childhood tonsillitis. Conclusion: Low socioeconomic status, family history of tonsillitis, and poor personal hygiene were all associated with childhood tonsillitis. Furthermore, in addition to tonsillitis, some of the children in this study had malnutrition, asthma, and allergies. To successfully prevent and control childhood tonsillitis, identification of its risk factors is crucial.


Background
Anatomically, the tonsils are two glands in the posterior of the oropharynx. They are part of the body's defense system upon the antigen's entry through the nasal or oral cavities [1][2][3]. Tonsillitis is the bacterial or viral inflammation of the tonsils. This disease manifests in two forms: acute and chronic, however, the literature has various terminologies for tonsillitis [3].
Acute tonsillitis is an episode of tonsillitis lasting for a shorter period of time and "refers to viral or bacterial tonsillitis with odynophagia, swelling, and redness of tonsils, possibly with tonsillar exudate, cervical lymphadenopathy, and fever" [3]. On the other hand, chronic tonsillitis is a recurring inflammation of the tonsils with a number of episodes per year which could lead to tonsillectomy [1][2][3][4].
Tonsillitis affects more children than adults around the world with more chronic and recurrent infections during childhood [1,3,4]. In a single year, a child may get a sore throat 7 sore throat episodes [5]. Currently, there is not enough data on the global incidence of tonsillitis [4]. However, in primary care, sore throat makes up to 1.3% of outpatient visits [6,7]. Studies have shown that there is a gender difference in the occurrence of tonsillitis with more recurrent tonsillitis in females and more peritonsillar abscesses in males [8] Although studies on genetic and environmental predisposing factors for tonsillitis are limited, some studies have established the possibility of the heritability of recurrent tonsillitis [9]. Studies have also suggested that poor living conditions and indoor pollution could exacerbate sore throat risk factors [5].
Unfortunately, with long-lasted instability, lack of holistic health research, and insufficient health records [10,11], there is no sufficient data on the morbidity of tonsillitis in Somalia. Socioeconomic factors affect the health of children, especially in developing countries where nutrition, personal hygiene, family income, and health services accessibility and utilization, all significantly impact children's health status [12][13][14][15].
The aim of this study is to identify and assess the risk factors associated with childhood tonsillitis in Somalia. To our knowledge, this is the first study conducted on the risk factors of childhood tonsillitis in Puntland, Somalia.

Methods
This study was conducted in Garowe General Hospital, 2020. Garowe is the capital city of the Nugal region, Puntland, Somalia. This study utilized a descriptive cross-sectional design. The aim of this study was to epidemiologically assess the risk factors associated with childhood tonsillitis. Garowe General Hospital is a regional hospital providing health services for residents of the Nugal region as well as residents from neighboring regions of Puntland. Therefore, this hospital is optimal for the purpose of this study.
This study included caregivers of children (under the age of 15) diagnosed with tonsillitis, and, at the time of the study, receiving treatment in Garowe General hospital. A convenient sample of 60 caregivers was selected for this study. A convenient sampling technique was utilized which satisfies the goal of this study as well as the accessibility of the study population. A close-ended questionnaire was used to collect data from the study participants. The data collected and generated by the study were analyzed using the Statistical Package for Social Sciences (SPSS) to obtain the percentages and frequencies of data.

Results
The majority of the study participants with tonsillitis (53%) were 1-7 years old. In this study, 39 (65%) of the participants were female and 21 (35%) were male. The educational levels of the caregivers in this study were: illiterate 32 (53.3%), primary education 20 (33.3%), secondary school 6 (10%), and university level 2 (3.3%). 55% of the caregivers were homemakers, 20% were employed, and 25% were business owners or self-employed. The study shows that 35% of the families had a monthly income of over 200 dollars, 57% of them reported an income of 100-200 dollars, and 8% of them reported an income of less than a 100 dollars. The study also shows that 36 (60%) of the affected children were from larger families (4 to 5 members)Approximately, 31 (52%) of the caregivers in this study understood that personal hygiene is essential in disease prevention in general, and in tonsillitis, specifically. in addition, 31 (52%) of the children in this study brush their teeth only once a day, 12 (20%) of them do it twice a day, only 6 (10%) do it three times a day, and 18 (17%) of the study participants do not brush their teeth at all.
Furthermore, the study found that 40 (67%) of the caregivers held the belief that consuming cold drinks in excess by the children could potentially cause or lead to tonsillitis. Also, poor hygiene 16 (27%), malnutrition 4 (7%), and weather change 10 (16%) were all considered causes or main contributors to childhood tonsillitis by the caregivers. When asked about whether tonsillitis is a severe disease, 50 (83%) of the caregivers answered that tonsillitis is less severe, and only 10 (17%) of them saw tonsillitis as a potentially severe disease with complications.
A family history of tonsillitis was reported by 49 (82%) of the study participants. Comorbidity of tonsillitis with malnutrition (10%), asthma (5%), and allergies (7%) were also reported by the participants. The study also found that 39 (65%) of the children had chronic rhinitis and chronic sinusitis. Moreover, the children in this study had adenoid hypertrophy and nasopharyngitis 47 (78%), peritonsillar abscess (48%), emesis/hemorrhage 50 (83%), other upper respiratory infections, and 45 (75%) of them were mouth breathers. Only 18 (30%) of the caregivers believed that their children were receiving adequate treatment for tonsillitis.

Discussion
It is well known that, epidemiologically, tonsillitis incidence is much higher in children, however, it is not common in children under 2 years of age [16]. Approximately 53% of the children in this study with childhood tonsillitis were 7 years old or younger. Tonsillitis in children age 5-15 is usually due to a bacterial cause, where it is mainly a viral cause in ages under 5 [16]. Studies have found Sex differences in pediatric infectious diseases and their immune responses [17,18]. Females in this study were more affected by tonsillitis (65%) than males (35%). It is generally reported that childhood tonsillitis and peritonsillar abscess are more common and frequent in girls [17,18] but, after the age of 14, peritonsillar abscess becomes higher in boys [18].
It is well documented that the educational level of the parents, as well as their awareness, have a great influence on the prevention and control of childhood illnesses and the utilization of health services [25,26]. Thus, this study found that only 17% of the caregivers believed in the severity of tonsillitis and that it could have complications. Therefore, parents' level of education is not only crucial in fully understanding the health information but also in transforming information into practices and seeking health care when needed by family members [28,29].
Moreover, tonsillitis is very common among family members and can easily be transmitted [30,31]. Our study found that 82% of the study participants had a family history of tonsillitis. In addition, only 52% of them believed the effectiveness of personal hygiene against tonsillitis. However, 52% of the caregivers reported that their children brush their teeth once a day and 17% of them reported no teeth-brushing at all. Doctors recommend and emphasize on personal hygiene since it is very effective in halting the spread and can successfully prevent tonsillitis [32].
Due to the convenience sampling method used in this study, the generalization of its results may be limited, however, the results are true on the study group and could give insight into the risk factors of childhood tonsillitis and set the foundations for future researches.

Conclusion
This study found that childhood tonsillitis is associated with a family history of tonsillitis, poor personal hygiene, and low socioeconomic status. We also found comorbidity of malnutrition, asthma, and allergies with tonsillitis. In the case of Somalia, a prolonged political and economic instability exacerbate the severity of infectious diseases and other childhood health issues. For effective preventive health programs, identifying factors associated with the occurrence of childhood tonsillitis is crucial in its control and prevention and to avoid further complications of the disease.