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Review Article - (2022) Volume 16, Issue 10


Israel Shiferaw1*, Nigussie Tadesse2 and Sileshi Shiferaw2
1BSc in Nurse Debre Birhan University, Ethiopia
MSc Assit. Prof Microbiologist, Debre Birhan University, Ethiopia
*Correspondence: Israel Shiferaw, BSc in Nurse Debre Birhan University, Ethiopia, Tel: 251932798519, Email:

Received: 20-Aug-2022, Manuscript No. iphsj-22-12958; Editor assigned: 23-Aug-2022, Pre QC No. iphsj-22-12958 (PQ); Reviewed: 26-Sep-2022, QC No. QC No. iphsj-22-12958; Revised: 01-Oct-2022, Manuscript No. iphsj-22-12958 (R); Published: 08-Oct-2022, DOI: 10.36648/1791- 809X.16.10.974


A pressure ulcer (PU) (also known as bed sore) is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. A number of contributing or confounding factors are also associated with pressure ulcers the significance of this factor is yet to be elucidated. Pressure ulcers are generally defined as restricted cell necrosis areas occurring bony prominence sun protected to pressure for sufficiently long time to cause tissue ischemia. Pressure ulcers are usually happening over bony prominences such as sacrum, shoulders, occiput, ear lobes, elbows, and trochanters depending on patients’ position


An estimated pressure ulcer incidence rate of 8.3% to 25.1% in developed countries, and 2.1% to 31.3% in developing countries is exhibited [1-3]. Despite advances in medical technology and the use of formalized prevention programs based on clinical practice guidelines, the prevalence of pressure ulcers during hospitalization continues to increase [4]. Therefore, enormous effort is required to find effective and reliable techniques for preventing the initiation of ulcers and eliminating them once they develop [5].

Patent with pressure ulcer suffer from additional problem like pain and discomfort, prolong illness, delay rehabilitation, increase patient’s hospital stay, and may lead to disability and even death [6].

There are intrinsic factors and extrinsic factors that determine the tolerance of soft tissue to the adverse effects of pressure. Intrinsic risk factors are physiologic factors or disease states that increase the risk for pressure-ulcer development (e.g., age, nutritional status, and decreased arteriolar blood pressure). Extrinsic factors are external factors that damage the skin (e.g., friction and shear, moisture, and urinary or fecal incontinence, or both) [7]. In Ethiopia, based on a study conducted in Wolaita Sodo University Teaching Hospital, among 239 hospitalized patients with the prevalence rate of 13.4% [8].

In the study area there is no any evidenced data that show the prevalence and associated risk factors of pressure ulcer. Therefore, the main aim of this study was to assess the prevalence and associated factors of pressure ulcer among hospitalized patents at Debre Birhan referral hospital.

Study have suggested that pressure ulcer development can be directly affected by the number of nurses and time spent at bedside the Pressure ulcers are challenging to treat, and treatment tends to be lengthy and costly. Pressure ulcer is a common problem in the world and also it is the most common cause of negative health quality indicator of life. Many studies suggest that the assessment of the magnitude of pressure ulcer in hospital admitted patient is very important .It has also a great impact in the health institutions as well as in the individual social life and socio economic status [9, 10].

The study focused on determining the prevalence of pressure ulcer and identifying associated risk factors with ulcer development in Debre Birhan referral hospital.

Therefore, this study will be important:-

• To know the exact magnitude of pressure ulcer in Debre Birhan referral hospital.

• To give scientific information for professional team and take action in prevention measures based on the result and also for care givers.

• To help the responsible body of policy maker to address health policy issue.

• To have additional source for other researchers to do wider and further research exploration on this issue.


Description of the study Area

The study was conducted at Debre Birhan town, Debre Birhan referral hospital. Debre Birhan town is found in Amhara regional state which is found 130 Km way from Addis Ababa, a capital City of Ethiopia and 695 km way from Bihar Dar which is capital city of Amhara region with total population of 103450 and there is 9 urban kebele [11].

In Debre Birhan, there is one governmental Referral Hospital, one private general hospital and three health centers. The study was conducted in Debre Birhan referral hospital, Amhara region. The hospital is expected to give service for greater than 2 millions of people for the nearby zones and Woreda. This hospital has different wards. Among these wards medical, surgical, Pediatrics, gynaecological and obstetrics and ICU wards are important to this research. DBRH have 264 health workers among this Midwifery 26, Pharmacists 32, Lab technician 31, Health officer 1, Specialists 12, General physicians 19, Nurses 143 [12].

Study design and period

Institution based cross-sectional study design was conducted in Debre Birhan referral hospital from April 23, 2018 to May 18, 2018.

Source population

The source populations were all admitted patients in Debre Birhan referral hospital.

Study population

The study populations were those patients who have been admitted in medical, surgical, pediatrics, gynaecological and obstetric wards and ICU in Debre Birhan referral hospital during study period.

Study unit

The selected individual with the K interval in those wards were our study unit.

Inclusion and Exclusion Criteria

Inclusion Criteria: All admitted patients who were staying in hospital greater than or equal to 24 hrs included.

Exclusion criteria: Patients who was admitted for the second time during data collection period, <= 5 years old and Patients who developed pressure ulcer before admission at Debre Birhan Referral hospital were excluded.

Determination of sample size

Sample size was computed based on a single proportion population formula with Margin error(d) is 5%, Confidence level (CI) is 95% and prevalence (p) of PU is 16.8% taken from previous study at Felegehiwot Referral hospital, Bahir Dar(17). A sample size (n) at a Z-value of 1.96 with 95% CI and d of 5%


Because of the total population size of the study area are less than 10,000, the population correction formula was applied:

By taking number of source of population, 498 and sample size 214.78; Nf=n/ (1+n/N)=214.78/ (1+214.78/498) = 150 Adding non respondent rate of 5% =150×5%=8; then total sample size =150 + 8=158.

Sample and sampling technique

(Figure 1)


Figure 1: Schematic Presentation of Sampling Technique Assesse the Prevalence of Pressure Ulcer and Associated Factors at Debre Birhan Referral Hospital, 2018.

Study variable

Dependent Variable

• Pressure Ulcer

Independent Variables

• Socio demographic factors (sex, age, marital status, education status and residence)

• Braden scales of PU risk assessment tools:

â?? Sensory perception


â?? Activity

â?? Friction/shear

â?? Mobility

â?? Nutrition


â?? Position change

â??Bed ridden

â?? Length of stay in hospital

â?? BMI & Smoking

Data collection techniques and tool

Data was collected by face to face interviews using a structured and pretested interviewer administered questionnaire and observational checklist to meet our objective. The data was collected by group members from the selected bed and ask the patent if the patent is not responsive ask the nearest person [13].

Data quality control

A brief orientation about the whole purpose of the research was given for all participants. The questionnaire was translated in to Amharic and back to English. Pretest was done on five percent of the sample in Debre sina primary hospital before the actual data collection take place. Overall activities were supervised by principal investigators. The data was check for completeness and consistency on a daily basis & the data was cleaned [14].

Data processing and Analysis

After the data were checked and cleaned for its completeness, it were entered to Epi data software and exported to SPSS-20 version for analysis. Descriptive, Bivariate and Multivariate data analysis method were applied in the study [15].


Socio-Demographic Characteristics

A total of 158 admitted patients at Debre Birhan referral hospital were included in this study with the response rate of 100%. Majority of 61.4% (97) and 50.6% (80) respondents were rural residents and males in sex respectively and the respondents 60.8% (96) were married. In addition 49% (31) of the respondents were not educated (Table 1).

Variables Frequency Percent
Sex Male Females 80 78 50.6 49.4
Place of residence Urban Rural 61 97 38.6 61.4
Marital status Single Marred Divorced Widowed 59 96 2 1 37.3 60.8 1.3 0.6
Educational level Not educated Read & write Grade 1-4 Grade 5-8 Grade 9-10 Grade 11& above 49 25 31 27 16 10 31 15.8 19.6 17.1 10.1 6.3

Table 1. Socio-demographic Characteristics of the respondents who were admitted at Debre Birhan referral hospital, North Shoa zone, Ethiopia, 2018(N=158).

Prevalence of pressure ulcer

A total of 40 pressure ulcer was detected from 158 patients with the prevalence rate of 25.3%. Majority of respondents 14.55% developed pressure ulcer came from the rural area and 8.22% patients developed ulcer was not educated (Table 2).

Variables Pressure ulcer Yes                                   %                               no                 No%                        
Over all pressure ulcer 40 25.3 118 74.7
Age Jun-18 19-31 32-43 44-55 >=56  
7 13 6 7 7 4.43 8.22 3.79 4.43 4.43 29 35 14 11 29 18.35 22.15 8.86 6.96 18.35
Sex Male Female 16 24 10.12 15.18 64 54 40.5 34.17
Residence Urban Rural 17 23 10.75 14.55 44 74 27.84 46.83
Marital status Single Married Divorced Widowed 12 27 1 0 7.59 17.08 47 69 1 1 29.74 43.67
Educational status NOT Educated Read and Write Grade1-4 Grade5-8 Grade9-10 Grade11orGreater 13 4 9 9 2 3 8.22 36 21 22 18 14 7 22.78 13.29 13.92 11.39 8.86

Table 2. Descriptive statistics of socio-demographic variables in pressure ulcer development who were admitted at Debre Birhan Referral Hospital, North shoa, Ethiopia, 2018 (n=158).

Almost all 89.87% (142) admitted patients at Debre Birhan referral hospital had <7 day’s length of stay in the hospitals. All participants those who included in this study had not used pressure relieving device and 6.96% [11] had not been changed their position frequently by nurses. BMI for <19 years old was calculated & classified by WHO AnthroPlus software (Table 3).

Variables Pressure ulcer
  Yes                   %                           %                        no
BMI >=19        
underweight 1 0.63 12 7.59
normal 23 14.55 75 47.46
overweight 5 3.16 6 3.79
Sever under weight 2 1.26 2 1.26
underweight 1 0.63 3 1.89
Normal 7 4.43 13 8.22
overweight 0 0.63 3 1.89
Obese     4 2.53
Cigarette smoke 1      
Currently smoking 1 0.63 0  
Previously smoking 38 0.63 2 1.26
No smoking   24.05 116 73.41
Length of stay 33      
<=7day 7 20.88 109 68.98
8-15day   4.43 9 5.69
Supportive device 40      
No   25.31 118 74.68
Position change service        
Yes 33      
No 7 20.88 114 72.15
    4.43 4 2.53
Patient bedridden 32      
Yes 8 20.25 68 43.03
No   5.06 50 31.64

Table 3. Descriptive statistics of other variables in pressure ulcer development who were admitted at Debre Birhan Referral Hospital, North shoa, Ethiopia, 2018 (n=158).

The prevalence of pressure ulcer in terms of wards was identified that medical ward ulcer Prevalence was 10.12% [16] (Figure 2).


Figure 2: Pressure Ulcer with Wards of the respondents who were admitted at Debre Birhan Referral Hospital, North shoa zone, Ethiopia, 2018 (n=158).

The prevalence of pressure ulcer based on the patients cases were also identified then from the total prevalence of pressure ulcer the patients who had DM accounts 3.17% (5), CHF 1.9% (3), SBO1.9% (3), SCAP1.9% (3), Anaemia 1.26% (2), ACS 1.26% (2), G. peritonitis 1.26% (2) the rest each accounted 12.65% [17].

From those who developed pressure ulcer in terms of anatomical location most of the participants 11.39% [18] developed ulcer on Greater trochanter area and 0.63% (1) patients developed pressure ulcer at Occipital area (Figure 3).


Figure 3: Anatomical location of pressure ulcer in patients who were admitted at Debre Birhan Referral Hospital, North shoa, Ethiopia, 2018 (n=158).

Among pressure ulcer developed participants, 17.08% (27) develop stage I pressure ulcer (Figure 4).


Figure 4: Stages of pressure ulcer in patients who were admitted at Debre Birhan Referral Hospital, North shoa, Ethiopia, 2018 (n=158).

Most of respondents 59.5% (94) had slightly limited in sensory perception and from the total respondents 5.1% (8) were completely immobile. 60.1% (95) participants were probable inadequate in nutrition and 55.7% (88) of the patients had potential problem in Friction & Shear (Table 4).

Variables Frequency %
1.Sensery perception    
Completely limited 3 1.9
Very limited 29 18.4
Slightly limited 94 59.5
No impairment 32 20.3
Constantly moist 2 1.3
Very moist 51 32.3
Occasionally 60 38
Rarely moist 45 28.5
Bedfast 71 44.9
Chair fast 31 19.6
Walks occasionally 49 31
Walks frequently 7 4.4
Completely immobile 8 5.1
Very limited 47 29.7
Slightly limited 92 58.2
No limitation 11 7
Very poor 26 16.5
Probably inadequate 95 60.1
Adequate 37 23.4
6. SHEAR Friction and shear    
Problem 15 9.5
Potential problem 88 55.7
No apparent problem 55 34.8

Table 4. Braden Scale Pressure Ulcer Risk Assessment characteristics of the respondents Who were admitted at Debre Birhan Referral Hospital, North shoa, Ethiopia 2018(N=158).

Of the respondents 63.9% (101) were potentially at risk to develop pressure ulcer and 36.1% (57) were not at risk in developing pressure ulcer (Figure 5).


Figure 5: Braden scale risk assessment score of the patients who were admitted at Debre Birhan Referral hospital, North shoa Zone, Ethiopia 2018.

Factors Associated with pressure ulcer

Those respondents whose BMI underweight had 68.1times [95% CI: AOR, 68.191(3.055-1522.261)] more likely to develop pressure ulcer than those who are overweight and those who had got position change service were 34.2 times [95% CI: AOR, 34.205 (3.955-295.866] more likely to develop pressure ulcer than who did not get the service (Table 5).

Variables Pressure ulcer   COR AOR
      (95%CI) (95%CI)
  Yes No    
Jun-18 7 29 1.000(.311-3.213) .355(.068-1.841)
19-31 13 35 .650(.229-1.843) .543(.114-2.575)
32-43 6 14 .563(.159-1.992) .367(.059-2.297)
44-55 7 11 .379(.108-1.333)* .418(.072-2.414)
>=56 7 29 1 1
Male 16 64 1.778(.858-3.685)* 2.288 (.768-6.811)
Female 24 54 1 1
Urban 17 44 .804(.388-1.669)  
Rural 23 74 1  
Marital status        
Single 12 47 .000(.000-.)  
Marred 27 69 .000(.000-.)  
Divorced 1 1 .000(.000-.)  
Widowed 0 1 1  
Educational status        
Not educated 13 36 1.187(.266-5.286)  
Read &write 4 21 2.250(.401-12.617)  
Grade 1-4 9 22 1.048(.220-4.981)  
Grade 5-8 9 18 .857(.178-4.126)  
Grade 9-10 2 14 3.000(.404-22.303)  
Grade 11&grater 3 7 1  
Length of stay        
<=7day 33 109 2.569(.889-7.428)* 3.481(.747-16.211)
Aug-15 7 9 1 1
Sever under wt 2 2 .000(.000-.)  
Under weight 1 3 .000(.000-.)  
Normal 7 13 .000(.000-.)  
Over weight 1 3 .000(.000-.)  
Obese 0 4 1  
Under weight 1 12 10.000(.944-105.921)* 68.191(3.055-1522.261)**
Normal 23 75 2.717(.759-9.729)* 9.701(1.751-53.736)**
Over weight 5 6 1 1
Cigarette smoke        
Currently smoke 1 0 .000(.000-.)  
Previously smoke 1 2 .655(.058-7.429)  
No smoke 38 116 1  
Position change        
Yes 33 114 6.045(1.667-21.921)* 34.205(3.955-295.866)**
No 7 4 1 1
Patient bedridden        
Yes 32 68 .340(.144-.801)* .169(.021-1.378
No 8 50 1 1
Supportive device        
Yes 0      
No 40 118 2.95  
Risk status        
Risk 31 70 .423(.185-.969)* 1.221(.169-8.801)
Not Risk 9 48 1 1

Table 5. Factors of association variables with pressure ulcer of the respondents who were admitted at Debre Birhan referral hospital, North shoa, Ethiopia, 2018 (n=158).


In this study the overall prevalence of pressure ulcer was 25.3%. This result was higher than studies conducted in Debre Markos, Wolaita Sodo University Teaching Hospital, Felege Hiwot Hospital (Bahir Dar) 3.4%, 13.4% 16.8% respectivly [19-21]. Higher prevalence in this study might be due to inappropriate nursing care, inadequate feeding habit and no resource of pressure relieving devices and also different study population.

It was also found that the prevalence rate was lower than a study conducted in Germany 26.5% and Canada (Ontario) 25.7% [22, 23]. This discrepancy might be due to different environmental condition, characteristics of participants, disease condition of patients and also the variation of study period & length of stay in hospital.

In this study prevalence of pressure ulcer due to anatomical location was higher (Greater trochanter 11.39%, Occipital 0.63% & sacral 5.69%) than a study conducted in Debre Markos (Sacral, G. Trochanter & Elbow 2.5%, 1.7% & 0.8% respectively). It was also found that the prevalence rate was lower than a study conducted in Brazil, Sacral (82.5%), Trochanteric37.5%, Calcaneal (27.5%), Lumbar (6.3%) and Elbow (3.7%) [24, 25] This difference might be due to the disease condition of patients and variation of study area, study population, & length of stay in hospital.

In this study prevalence of pressure ulcer in stages I, II & III were17.08, 6.96 & 1.26 lower than a study conducted in Brazil stage I (30.3%), stage II (32.4%) and stage III (22.8%) [19]. this difference was due to hospital factors like nursing care & study participants.

This study showed that pressure ulcer was significantly associated with position change (p<0.017) this is almost similar with study conducted in Jimma medical centre [18]. In these study BMI >=19 had significantly associated with pressure ulcer (p<0.008 and 0.010) this value almost similar with study conducted in Norway [15, 26].


Majority of patents admitted in Debre Birhan Referral hospital had less than seven day stay of length and all of admitted patent have no supportive device. In this study the highly prevalent stage is stage I and in terms of anatomical location Grater trochanter is more observed area.

The prevalence of pressure ulcer was slightly high among hospitalized patients especially when compare to study contacted in Ethiopia. Patients were more liable to develop pressure ulcer when they are underweight and not change their position frequently.


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Citation: Shiferaw I, Tadesse N, Shiferaw S (2022) Prevalence and Associated Factors of Pressure Ulcer among Hospitalized Patients in Debre Birhan Referal Hospital, North Shoa Zone, Amhara, Debre Birhan, Ethiopia. Health Sci J. Vol. 16 No. 10: 974