Abstract
Background
Gastroesophageal reflux disease (GERD) is a prevalent chronic digestive disorder that significantly affects patients’ quality of life. The aim of this study was to assess the relationships among sociodemographic characteristics, social functioning, sleep quality, and symptom severity in patients with GERD.
Methods
A cross-sectional study was conducted among 261 GERD patients in Syria, recruited via convenience sampling through social media platforms (Facebook, Telegram, WhatsApp) and hospital visits, with no geographic or institutional clustering, from August–October 2024. Participants were included if they had a physician-confirmed GERD diagnosis or an FSSG score ≥ 10. Participants completed a self-administered electronic questionnaire in Arabic, comprising validated scales: the Frequency Scale for GERD Symptoms (FSSG), Pittsburgh Sleep Quality Index (PSQI), and Social Functioning Questionnaire (SFQ). Statistical analyses were conducted via SPSS version 25, with t tests, ANOVA, Spearman’s correlation and logistic regression applied to assess relationships among variables.
Results
The study population had a mean age of 28.69 years (SD: ±10.62) and a mean BMI of 24.11 kg/m² (SD: ±5.11). Females comprised 69% of the sample. The prevalence of GERD was 90%, with a mean FSSG score of 22.31 (SD: ±10.05). Social challenges were significant (mean SFQ score: 9.25, SD: ±3.88), with 88% experiencing stress and 59% facing financial difficulties. The patients’ sleep quality was poor, with an average PSQI score of 7.93 (SD: ±3.42). Significant associations were found between financial status and both social (P < 0.001) and sleep quality scores (P = 0.030). Correlation analysis revealed significant positive relationships between FSSG scores and both PSQI (r = 0.286, P < 0.001) and SFQ scores (r = 0.336, P < 0.001).
Conclusion
GERD symptom severity was significantly associated with poorer social functioning and sleep quality, with financial status as a key correlate Addressing psychosocial factors alongside medical treatments may enhance symptom management and improve the quality of life of GERD patients.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12876-025-04098-1.
Keywords: Gastroesophageal reflux disease (GERD), Sleep quality, Social functioning, Socioeconomic factors cross sectional, Syria
Introduction
Gastroesophageal reflux disease (GERD) is a chronic digestive disorder characterized by reflux of stomach contents into the esophagus, leading to symptoms such as heartburn, regurgitation, and chest discomfort [1].It is a prevalent condition globally, significantly impacting patients’ quality of life and contributing to various health complications when left unmanaged [2]. GERD is associated with complications such as esophagitis, Barrett’s esophagus, and an increased risk of esophageal adenocarcinoma [3], necessitating timely and effective management. Additionally, chronic GERD can lead to dental erosion due to sustained acid exposure [4] and may contribute to respiratory conditions such as COPD, bronchitis, pneumonia, lung cancer and pulmonary embolism [5].
The diagnosis of GERD is typically based on patient-reported symptoms and medical history, complemented by diagnostic procedures such as endoscopy or esophageal pH monitoring when required to confirm acid reflux [6]. Management strategies for GERD prioritize lifestyle modifications, including weight loss, dietary adjustments, and smoking cessation, as these measures are essential for symptom relief and disease control. Pharmacological treatments, such as antacids, H2 receptor antagonists, and proton pump inhibitors, are frequently employed to reduce gastric acid production and alleviate symptoms [7]. In severe or refractory cases, surgical interventions like fundoplication may be performed to reinforce the lower esophageal sphincter (LES) and prevent reflux [8]. A global consensus has been reached that the primary goals of GERD treatment should focus on alleviating symptoms and preventing complications.
Notably, GERD ranks among the most prevalent gastrointestinal disorders globally, with increasing prevalence [9]. In terms of global impact, GERD affects a considerable portion of the population. In the United States, estimates suggest that 40% of individuals experience GERD-related symptoms [10], whereas approximately 20% of the population worldwide is affected [11]. This extensive prevalence highlights the substantial burden that GERD imposes on the public health system. Various factors contribute to the development and exacerbation of GERD, including obesity, pregnancy, smoking, and the use of specific medications [12]. Furthermore, dietary habits such as the consumption of fatty foods, chocolate, caffeine, alcohol, and large meals can aggravate symptoms [13]. Anatomical abnormalities, such as hiatal hernias, are also recognized as predisposing factors for GERD [14].
While these estimates reflect global trends, regional variability exists, particularly in the Middle East, where prevalence ranges from 8.7–33.1%.This variation underscores the importance of region-specific studies to understand the unique risk factors and prevalence rates within different populations [15]. These insights highlight the need for targeted public health interventions in Syria, focusing on modifiable lifestyle factors such as smoking cessation and dietary habits, to effectively manage and prevent GERD within the population.
Understanding GERD burden in specific subpopulations, particularly those exposed to lifestyle-related risk factors, is equally critical. For instance GERD is a notable health concern among university Syrian students. A study at Damascus University reported a 16% prevalence of GERD, identifying risk factors such as smoking, low body mass index (BMI), and tea consumption. Notably, even moderate habits, such as drinking two cups of tea daily or smoking one to five cigarettes per day, were linked to increased GERD symptoms. Additionally, there was a significant overlap between GERD and other gastrointestinal disorders, with 8.6% of students experiencing both GERD and uninvestigated dyspepsia. These findings highlight the need for targeted public health interventions to address modifiable lifestyle factors and raise awareness of GERD prevention and management within the Syrian student population [16].
This study aimed to explore the relationships among sociodemographic characteristics, social functioning, sleep quality, and GERD symptom severity. This multifaceted approach provides a holistic perspective on the interaction between these variables variables in a multi-province cohort within a conflict affected population as no prior study assessed that. By examining the associations among these variables, this study sought to provide a deeper understanding of the factors contributing to GERD symptomatology and inform more holistic approaches to patient care and management. This study is limited by its reliance on self-reported data and convenience sampling, which may affect generalizability and causal interpretation of findings.
Methods
Study design
This cross-sectional descriptive study assessed the potential effect of GERD on sleep quality and social performance among individuals in Syria. A cross-sectional design was chosen because it allows for the collection of data at a single point in time, enabling an efficient and comprehensive analysis of GERD-related symptoms, their severity, and their potential impact on social and daily life activities. The study was conducted over a two-month period, from August 1, 2024, to October 1, 2024, during which data were collected through self-administered electronic questionnaires. Given the widespread use of social media in Syria, this method was selected to maximize reach and engagement while ensuring cost-effectiveness. The questionnaire was designed to be user friendly and accessible on mobile devices and computers, allowing participants from diverse backgrounds and geographic locations to participate conveniently.
The study followed a structured approach to data collection to ensure the standardization and reliability of the responses. The questionnaire included a mix of validated scales, and multiple-choice questions, to capture quantitative data. The survey was distributed in Arabic to ensure its accessibility to the target population. The participants were encouraged to respond honestly, with reassurance regarding anonymity and confidentiality provided at the beginning of the questionnaire. We pilot-tested the questionnaire with a small group of GERD-diagnosed individuals to ensure the clarity, relevance, and ease of understanding of the questions. On the basis of this feedback, minor revisions were made before the final version was launched. Given the nature of an online self-report survey, potential biases such as recall and response biases were considered. Measures such as randomized question order and clear response instructions were implemented to minimize these biases. The study was noninterventional, meaning that the participants did not receive any medical treatment or advice as part of the research. Instead, the collected data aimed to provide insights into the broader impact of GERD and inform potential future public health initiatives.
Participants and data collection
The study included 261 participants aged 16–72 years who were diagnosed with GERD. The electronic questionnaire was disseminated across all Syrian provinces by the authors. Participants were selected through convenience sampling via social media platforms (WhatsApp, Facebook, and Telegram) to ensure broad reach, and hospital visits, with no geographic or institutional clustering that would require design effect adjustment, and all participants were self-selected volunteers. To ensure participants’ comprehension and engagement, the study’s objectives and significance were explained in advance, highlighting its role in increasing GERD awareness. Each participant was permitted to complete the questionnaire only once to maintain data integrity and prevent duplicate responses. The questionnaire was anonymous, and no personal identifiers were collected at any stage. Data confidentiality was maintained throughout the study.
Validation and data processing
The questionnaire was pretested on a small subset of patients with GERD (not included in the final analysis) to ensure the clarity, validity, and reliability of the questions. Necessary modifications were made before the final distribution. Incomplete questionnaires and responses with missing critical data (e.g., age, confirmation of GERD diagnosis, or key study variables) were excluded from the analysis. Logical validation checks were performed to ensure consistency in the responses.
Inclusion and exclusion criteria
Participants were included in the study if they had been diagnosed with GERD, either through self-reporting with FSSG score ≥ 10 (validated screening cutoff) or physician confirmation. Eligible individuals were required to be 16 years or older and to have fully completed the questionnaire to ensure completeness and reliability. Exclusion criteria applied to individuals who did not provide consent to participate. Patients with significant neurological or psychiatric conditions that could impair their ability to respond were excluded. Responses were also removed if they contained incomplete or missing data, such as skipping mandatory questions. To maintain data integrity, duplicate entries or suspected bot-generated responses, identified through irregular answer patterns, were also excluded from the final analysis.
Ethical considerations
Ethical approval for this study was obtained from the Ethical Committee of Damascus University, Faculty of Medicine, Syria (serial number 4245). Written informed consent was obtained from all participants. For those under 18 years of age, consent was obtained from their parents or legal guardians. This study adhered to the ethical principles outlined in the Declaration of Helsinki.
Response rate
Among the 300 individuals who accessed the questionnaire, 261 completed it, resulting in a response rate of 87%. The remaining 13% were excluded because of incomplete responses or failure to meet the inclusion criteria.
Measures
A structured questionnaire comprising four main components to assess demographic information, GERD symptoms, sleep quality, and social functioning was employed in this study. Each instrument was selected on the basis of its validity, reliability, and applicability in measuring the respective constructs.
Questionnaire translation and validation
Since the study was conducted in Syria, where Arabic is the primary language, the original English questionnaires were translated into Arabic via a standardized forward-backwards translation process to ensure accuracy and cultural relevance. First, two independent bilingual translators performed forward translation from English to Arabic. The translated version was then reviewed by a panel of experts in gastroenterology, sleep medicine, and psychometrics to assess semantic and conceptual accuracy. Next, a different set of bilingual translators, blinded to the original text, conducted a backwards translation from Arabic to English. Any discrepancies between the original and back-translated versions were discussed and refined to ensure linguistic and conceptual equivalence. The final Arabic version was then pilot tested on 30 GERD patients (not included in the main study) to assess clarity, comprehensibility, and cultural appropriateness, leading to minor refinement on the basis of participant feedback. To confirm the reliability of the translated questionnaire, internal consistency was measured via Cronbach’s alpha, yielding a coefficient of 0.85, indicating good reliability and internal consistency.
Demographic information
This section includes age, height, weight, sex, education level, employment status, smoking habits, residency, marital status, financial status, and accompanying diseases.
The frequency scale for the symptoms of GERD (FSSG)
In the present study, we utilized the FSSG questionnaire to assess the frequency and severity of symptoms associated with GERD. This is a validated 12-item questionnaire, with each item rated on a Likert scale ranging from 0 (never) to 4 (always). The sensations of heartburn and regurgitation are determined as reflux. The total score ranges from 0 to 48, with scores above ten considered positive for GERD. This cut-off has been validated, with a sensitivity, specificity, and accuracy of 55%, 69%, and 63%, respectively [17].
The Pittsburgh sleep quality index (PSQI)
The PSQI is a self-reported measure that includes 19 items assessing various aspects of sleep over the past month. These items are aggregated into seven components: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleep medication, and daytime dysfunction. The participants rated each item on a 4-point Likert scale, and the scores from the individual items were combined to form component scores. The total score ranges from 0 to 21, with higher scores reflecting poorer sleep quality. The PSQI has consistently demonstrated strong reliability and validity across numerous studies and is extensively utilized in sleep disorder research [18].
Social functioning questionnaire (SFQ)
The SFQ is an eight-item scale that assesses social functioning in various domains, including work and home tasks, financial concerns, familial relationships, sexual activities, social contacts, and spare time activities. Each item is scored on a four-point scale (0–3). The total score can range from 0 to 24. Scores greater than ten indicate poor social functioning. The SFQ has demonstrated good reliability and construct validity [19].
Statistical analysis
Data were collected, and responses were recorded via Google Forms and then exported from an Excel sheet for analysis. Statistical analyses were conducted via SPSS, version 25. Descriptive statistics, including means and standard deviations, were computed for all the variables. T tests and ANOVA were used to evaluate the relationships among patient variables, PSQI scores, FSSG scores, and social performance. Logistic regression analysis was performed to identify factors associated with a positive FSSG outcome. The significance level for all analyses was set at p < 0.05.
Continuous variables are presented as mean ± standard deviation for clinical interpretability and consistency with comparable GERD literature. While formal normality tests were not conducted, parametric tests were deemed appropriate given the sample size and their robustness to mild non-normality.
Sample size
To calculate the necessary sample size (n), Cochran’s sample size formula was utilized by the research team. The formula takes into consideration a 95% confidence level, represented by Z = 1.96, a margin of error of 7%, represented by e, and an estimated proportion (p) of 50% or 0.5 for the attribute of interest within the population. Additionally, q was determined as 1 − p:
 |
By using the formula, the necessary sample size for this study was determined to be 196.
As this was a convenience sample, no design effect adjustment was applied.
Result
The study included 261 participants (mean age: 28.69 years, SD: ±10.62), with a mean BMI of 24.11 kg/m² (SD: ±5.11). Females comprised 69% of the sample, and 77% had a university-level education. Most participants were nonsmokers (75%), urban residents (64%), and single individuals (60%). Financially, 79% reported a good status. While 69% had no health conditions, common issues included endocrine (6%), vascular (5%), and gastrointestinal disorders (4%) (Table 1).
Table 1.
General characteristics
| Age | |
|---|---|
| Mean (± SD) | 28.69 (± 10.62) |
| Lowest value | 16 |
| Highest value | 72 |
| Hight | |
| Mean (± SD) | 165.87 (± 8.81) |
| Lowest value | 145 |
| Highest value | 195 |
| Weight | |
| Mean (± SD) | 66.80 (± 17.31) |
| Lowest value | 40 |
| Highest value | 155 |
| BMI | |
| Mean (± SD) | 24.11 (± 5.11) |
| Lowest value | 15.61 |
| Highest value | 51.78 |
| Gender | N (%) |
| Male | 82 (31) |
| Female | 179 (69) |
| Education level | |
| Illiterate | 7 (3) |
| Elementary school | 15 (6) |
| High school | 39 (15) |
| University | 200 (77) |
| Working | |
| Freelancing | 47 (18) |
| Retired | 4 (2) |
| Employee | 69 (26) |
| Do not work | 141 (54) |
| Smoking | |
| Yes | 66 (25) |
| No | 195 (75) |
| Residency | |
| Urban | 166 (64) |
| Rural | 95 (36) |
| Marital status | |
| Single | 156 (60) |
| Married | 87 (33) |
| Engaged | 13 (5) |
| Divorced | 5 (2) |
| Financial status | |
| Bad | 50 (19) |
| Good | 206 (79) |
| Excellent | 5 (2) |
| Do you have any diseases | |
| Nothing | 179 (69) |
| Cardiac | 7 (3) |
| Neurological | 9 (3) |
| Endocrinological | 16 (6) |
| Hypertension and vascular disease | 12 (5) |
| Gastrointestinal | 11 (4) |
| Respiratory | 2 (1) |
| Urological | 7 (3) |
| Hematological | 3 (1) |
| Endocrinological + Gastrointestinal | 1 (0.3) |
| Cardiac + Hypertension and vascular disease | 3 (1) |
| Cardiac + Endocrinological | 1 (0.3) |
| Neurological + Gastrointestinal | 2 (1) |
| Neurological + Endocrinological | 3 (1) |
| Neurological + Hematological | 1 (0.3) |
| Gastrointestinal + Hematological | 2 (1) |
| Respiratory + Neurological | 2 (1) |
The Social Functioning Questionnaire (SFQ) highlighted diverse well-being levels among participants. Most (91%) managed tasks satisfactorily at least occasionally, but 88% reported experiencing stress, and 59% faced financial challenges. While 73% reported some difficulties in relationships, 77% indicated no issues in their sex lives, and 77% maintained good relationships with family. Feelings of loneliness were frequent for 43%, and 33% reported minimal enjoyment in their free time. The average SFQ score was 9.25 (SD: ±3.88), reflecting varying degrees of social and functional challenges (Table 2).
Table 2.
Social functioning questionnaire
| N (%) | |
|---|---|
| I complete my tasks at work and home satisfactorily | |
| Most of the time | 75 (29) |
| Quite often | 66 (25) |
| Sometimes | 97 (37) |
| Not at all | 23 (9) |
| I find my tasks at work and at home very stressful | |
| Most of the time | 52 (20) |
| Quite often | 58 (22) |
| Sometimes | 121 (46) |
| Not at all | 30 (11) |
| I have no money problems | |
| No problems at all | 29 (11) |
| Slight worries only | 78 (30) |
| Definite problems | 126 (48) |
| Very severe problems | 28 (11) |
| I have difficulties in getting and keeping close relationships | |
| Severe difficulties | 34 (13) |
| Some problems | 80 (31) |
| Occasional problems | 75 (29) |
| No problems at all | 72 (28) |
| I have problems in my sex life | |
| Severe difficulties | 1 (0.3) |
| Some problems | 19 (7) |
| Occasional problems | 41 (16) |
| No problems at all | 200 (77) |
| I get on well with my family and other relatives | |
| Yes, definitely | 115 (44) |
| Yes, usually | 87 (33) |
| No, some problems | 52 (20) |
| No, severe problems | 7 (3) |
| I feel lonely and isolated from other people | |
| Almost all the time | 19 (7) |
| Much of the time | 94 (36) |
| Not usually | 98 (38) |
| Not at all | 50 (19) |
| I enjoy my spare time | |
| Very much | 58 (22) |
| Sometimes | 118 (45) |
| Not often | 68 (26) |
| Not at all | 17 (7) |
| Overall Social Functioning Questionnaire | |
| Mean (± SD) | 9.25 (± 3.88) |
| Lowest value | 1 |
| Highest value | 21 |
The Pittsburgh Sleep Quality Index (PSQI) results revealed poor sleep quality among the participants, with a global PSQI score of 7.93 (SD: ±3.42). The participants reported low subjective sleep quality (mean: 1.39, SD: ±0.90), moderate sleep latency (mean: 1.47, SD: ±0.92), and reduced sleep duration (mean: 1.00, SD: ±0.94). Sleep efficiency was low (mean: 0.57, SD: ±0.97), and sleep disturbances were frequent (mean: 1.54, SD: ±0.59). Sleep medication use was infrequent (mean: 0.55, SD: ±1.00), and daytime dysfunction (mean: 1.37, SD: ±0.81) highlighted the impact on daily activities and alertness (Table 3).
Table 3.
The Pittsburgh sleep quality index
| Component 1 | |
|---|---|
| Mean (± SD) | 1.39 (± 0.90) |
| Lowest value | 0 |
| Highest value | 3 |
| Component 2 | |
|---|---|
| Mean (± SD) | 1.47 (± 0.92) |
| Lowest value | 0 |
| Highest value | 3 |
| Component 3 | |
|---|---|
| Mean (± SD) | 1.00 (± 0.94) |
| Lowest value | 0 |
| Highest value | 3 |
| Component 4 | |
|---|---|
| Mean (± SD) | 0.57 (± 0.97) |
| Lowest value | 0 |
| Highest value | 3 |
| Component 5 | |
|---|---|
| Mean (± SD) | 1.54 (± 0.59) |
| Lowest value | 0 |
| Highest value | 3 |
| Component 6 | |
|---|---|
| Mean (± SD) | 0.55 (± 1.00) |
| Lowest value | 0 |
| Highest value | 3 |
| Component 7 | |
|---|---|
| Mean (± SD) | 1.37 (± 0.81) |
| Lowest value | 0 |
| Highest value | 3 |
| Global PSQI Score | |
|---|---|
| Mean (± SD) | 7.93 (± 3.42) |
| Lowest value | 2 |
| Highest value | 18 |
Table 4 shows that 90% of the participants (236 out of 261)) were identified as positive for GERD based on the FSSG, with a mean score of 22.31 (SD ± 10.05). Common symptoms included heartburn, bloating, and stomach heaviness, which were reported by 25–50% of the participants. Many patients also experienced discomfort, such as nausea, acid reflux, and burping. Less frequent symptoms include a burning sensation in the throat and difficulty swallowing. The FSSG scores ranged from 2 to 46, indicating varying severity of GERD.
Table 4.
Frequency scale for the symptoms of GERD
| N (%) | |
|---|---|
| Do you get heartburn? | |
| Never | 20 (8) |
| Occasionally | 50 (19) |
| Sometimes | 71 (27) |
| Often | 65 (25) |
| Always | 55 (21) |
| Does your stomach get bloated? | |
| Never | 25 (10) |
| Occasionally | 39 (15) |
| Sometimes | 58 (22) |
| Often | 75 (29) |
| Always | 64 (25) |
| Does your stomach ever feel heavy after meals? | |
| Never | 13 (5) |
| Occasionally | 38 (15) |
| Sometimes | 59 (23) |
| Often | 83 (32) |
| Always | 68 (26) |
| Do you sometimes subconsciously rub your chest with your hand? | |
| Never | 97 (37) |
| Occasionally | 53 (20) |
| Sometimes | 54 (21) |
| Often | 31 (12) |
| Always | 26 (10) |
| Do you ever feel sick after meals? | |
| Never | 63 (24) |
| Occasionally | 71 (27) |
| Sometimes | 67 (26) |
| Often | 39 (15) |
| Always | 21 (8) |
| Do you get heartburn after meals? | |
| Never | 39 (15) |
| Occasionally | 56 (21) |
| Sometimes | 81 (31) |
| Often | 50 (19) |
| Always | 35 (13) |
| Do you have an unusual (e.g. burning) sensation in your throat? | |
| Never | 72 (28) |
| Occasionally | 59 (23) |
| Sometimes | 58 (22) |
| Often | 43 (16) |
| Always | 29 (11) |
| Do you feel full while eating meals? | |
| Never | 20 (8) |
| Occasionally | 51 (20) |
| Sometimes | 78 (30) |
| Often | 64 (25) |
| Always | 48 (18) |
| Do some things get stuck when you swallow? | |
| Never | 110 (42) |
| Occasionally | 72 (28) |
| Sometimes | 45 (17) |
| Often | 21 (8) |
| Always | 13 (5) |
| Do you get bitter liquid (acid) coming up into your throat? | |
| Never | 42 (16) |
| Occasionally | 71 (27) |
| Sometimes | 61 (23) |
| Often | 51 (20) |
| Always | 36 (14) |
| Do you burp a lot? | |
| Never | 69 (26) |
| Occasionally | 50 (19) |
| Sometimes | 49 (19) |
| Often | 46 (18) |
| Always | 47 (18) |
| Do you get heartburn if you bend over? | |
| Never | 84 (32) |
| Occasionally | 62 (24) |
| Sometimes | 56 (21) |
| Often | 30 (11) |
| Always | 29 (11) |
| FSSG Score | |
| Positive | 236 (90) |
| Negative | 25 (10) |
| Mean (± SD) | 22.31 (± 10.05) |
| Lowest value | 2/48 |
| Highest value | 46/48 |
Table 5 highlights the significant associations between various factors and social, PSQI, and FSSG scores. The FSSG score was significantly influenced by education level (P = 0.0197), with illiterate participants demonstrating lower scores than those with high school or university education. Financial status had a significant effect on both social scores (P < 0.0001) and the PSQI (P = 0.0300). Compared with those with good or excellent financial status, individuals with poorer financial conditions presented lower sleep quality and demonstrated reduced social functioning. Additionally, those with positive FSSG results had significantly higher scores (P < 0.0001 and P = 0.0036) than those with negative results did, indicating poorer sleep quality and reduced social functioning.
Table 5.
Association between patients’ variables and social, PSQI, and FSSG scores
| Variables | Total Social Score | P value | Total PSQI | P value | FSSG Score | P value |
|---|---|---|---|---|---|---|
| Gender* | 0.237 | 0.096 | 0.771 | |||
| Male | 9.69 (± 4.22) | 7.41 (± 3.34) | 22.03 (± 10.75) | |||
| Female | 9.05 (± 3.71) | 8.16 (± 3.44) | 22.44 (± 9.75) | |||
| Education level** | 0.675 | 0.278 | 0.0197* | |||
| Illiterate | 7.71 (± 2.87) | 8.85 (± 2.03) | 11.28 (± 8.51) | |||
| Elementary school | 9.33 (± 3.26) | 8.2 (± 3.66) | 20.4 (± 6.93) | |||
| High school | 9.05 (± 3.80) | 7.07 (± 3.17) | 23.64 (± 9.33) | |||
| University | 9.34 (± 3.98) | 8.04 (± 3.48) | 22.58 (± 10.24) | |||
| Working** | 0.942 | 0.340 | 0.557 | |||
| Freelancing | 9.08 (± 4.20) | 7.25 (± 3.02) | 23.87 (± 9.53) | |||
| Retired | 8.5 (± 2.64) | 7.25 (± 4.03) | 24.5 (± 13.91) | |||
| Employee | 9.15 (± 4.17) | 8.55 (± 4.05) | 22.86 (± 10.25) | |||
| Do not work | 9.37 (± 3.68) | 7.87 (± 3.17) | 21.46 (± 10.04) | |||
| Smoking* | 0.991 | 0.335 | 0.368 | |||
| Yes | 9.25 (± 4.02) | 8.30 (± 3.70) | 23.27 (± 9.92) | |||
| No | 9.25 (± 3.85) | 7.80 (± 3.32) | 21.98 (± 10.10) | |||
| Residency* | 0.224 | 0.506 | 0.136 | |||
| Urban | 9.46 (± 3.98) | 8.03 (± 3.50) | 23.02 (± 9.90) | |||
| Rural | 8.87 (± 3.69) | 7.74 (± 3.29) | 21.07 (± 10.25) | |||
| Marital status** | 0.061 | 0.946 | 0.0869 | |||
| Single | 9.60 (± 3.70) | 8.03 (± 3.55) | 23.19 (± 10.49) | |||
| Married | 8.82 (± 4.12) | 7.58 (± 3.29) | 20.22 (± 9.05) | |||
| Engaged | 7.07 (± 3.14) | 7.30 (± 2.71) | 23.69 (± 10.70) | |||
| Divorced | 11.2 (± 5.26) | 7.6 (± 3.78) | 27.6 (± 5.98) | |||
| Financial status** | < 0.0001* | 0.0300* | 0.263 | |||
| Bad | 11.36 (± 3.53) | 9 (± 2.93) | 22.52 (± 8.96) | |||
| Good | 8.82 (± 3.81) | 7.71 (± 3.50) | 22.05 (± 10.20) | |||
| Excellent | 6 (± 2.34) | 6.2 (± 2.86) | 31 (± 12.54) | |||
| FSSG Score* | < 0.0001* | 0.0036* | --- | |||
| Positive | 9.49 (± 3.92) | 8.12 (± 3.41) | ||||
| Negative | 6.96 (± 2.55) | 6.08 (± 3.05) | ||||
*T-test **ANOVA test
The logistic regression analysis revealed that social score was a significant predictor of a positive FSSG result (OR = 1.21, 95% CI: 1.04–1.44, P = 0.0094), with higher social scores linked to increased odds of testing positive. Other factors, including sex, education, smoking status, residency status, working status, marital status, financial status, PSQI score, age, and BMI, were not significantly associated, as their P values were above 0.05. The social score was the only significant factor affecting a positive FSSG outcome (Table 6).
Table 6.
Logistic regression of factors associated with positive FSSG score
| Variables | OR (95%CI) | P value |
|---|---|---|
| Gender | ||
| Male | Ref | |
| Female | 2.00 (0.72–5.53) | 0.178 |
| Education level | ||
| School | Ref | |
| University | 1.29 (0.44–3.72) | 0.633 |
| Smoking | ||
| No | Ref | |
| Yes | 1.29 (0.43–3.89) | 0.645 |
| Residency | ||
| Urban | Ref | |
| Rural | 1.24 (0.47–3.21) | 0.656 |
| Working | ||
| No | Ref | |
| Yes | 1.82 (0.62–5.39) | 0.273 |
| Marital status | ||
| Married | Ref | |
| Single | 1.58 (0.48–5.14) | 0.445 |
| Financial status | ||
| Bad | Ref | |
| Good | 1.18 (0.28–4.87) | 0.818 |
| Social Score | 1.21 (1.04–1.44) | 0.0094* |
| PSQI Score | 1.14 (0.98–1.36) | 0.082 |
| Age | 1.04 (0.98–1.12) | 0.143 |
| BMI | 1.05 (0.93–1.20) | 0.362 |
*T-test
Discussion
GERD is considered one of the most prevalent diseases, particularly in developing countries, which is why it was chosen for our cross-sectional study. In addition to its chronic course, GERD significantly deteriorates the quality of life of patients, leading to substantial individual economic burdens and contributing to a global economic impact [20]. These effects include reduced physical activity, disrupted sleep, and decreased overall well-being [21]. Given the aforementioned side effects on GERD patients, this study aimed to evaluate 261 patients via the FSSG questionnaire, which measures the frequency of GERD symptoms [22].
Our findings revealed a predominance of female patients, individuals with higher education levels, nonsmokers, and those with normal body weights. With respect to sex distribution, other studies have reported a greater prevalence of GERD among women [23], likely because medical consultations are more frequent in women than in men.
Interestingly, our research did not establish a relationship between being overweight and smoking, despite these being recognized risk factors for GERD. This finding aligns with a large Chinese study involving approximately 37,000 participants, that reported no link between smoking and GERD outcomes [22]. Similarly, a study of 378 medical students in the U.S. indicated that normal-weight students presented higher GERD rates than their obese counterparts did [24]. Psychological factors, including anxiety and depression, play a significant role in exacerbating GERD symptoms. Psychological distress can influence GERD through mechanisms such as reducing lower esophageal sphincter pressure, increasing gastric acid secretion, and altering esophageal motility. Additionally, anxiety and depression can lead to obsessive‒compulsive behaviors, lowering the threshold of reflux perception and increasing symptom severity [20].
Furthermore, changes in eating habits, sleep difficulties, and the overall physical health impact of depression may ultimately exacerbate GERD symptoms [25]. In addition to the fact that psychological factors lead to a deterioration in quality of life, it is crucial to understand these factors clearly to intervene and provide optimal treatment to these patients [20, 26].
Moreover, psychological problems previously identified as risk factors for GERD patients can be supplemented by considering physical activity, social communication, and sleep quality. These factors will be discussed separately, as our data collection revealed their direct relationship with GERD patients, either as a cause, a consequence, or perhaps both. This finding is comparable to that of another study conducted in Pakistan, which highlighted recumbence and lying down after meals as known risk factors for GERD. The protective effect of normal physical activity on GERD has been emphasized in many studies [27].
Importantly, we also observed issues with social communication in patients with gastroesophageal reflux. The participants reported difficulties in maintaining relationships, a tendency toward loneliness, and stress-related problems. These results can be interpreted by linking them to another study conducted on 124 individuals with gastroesophageal reflux and 224 without the disease, which revealed social problems in both groups. However, the link between them appears to be sleep disturbances [28]. Our findings similarly indicate that sleep, which is crucial for mental and physical health, affects daily functioning when it is impaired, leading to difficulties in social interactions. GERD patients sometimes experience embarrassing symptoms such as bloating, belching, and nausea, further hindering their ability to communicate effectively and increasing feelings of loneliness [28, 29].
The study collected data on sleep quality, revealing short sleep duration, frequent disturbances, and irregular use of sleep aids, indicating significant sleep problems. Good-quality sleep is determined by the ability to wake without fatigue or drowsiness and to feel satisfied with one’s sleep [24]. The sleep disorders identified include insomnia, hypersomnia, circadian rhythm sleep‒wake disorders, sleep apnea, narcolepsy, irregular sleep, and sleep-related movement disorders [30, 31].
The physiological digestive cause of poor sleep efficiency in GERD patients is decreased esophageal peristalsis at night due to reduced saliva production and the swallowing response, leading to nocturnal gastroesophageal reflux. Frequent nighttime symptoms are severe and result in poor sleep quality [24]. Hence, the development of sleep disturbances in GERD patients may be due to physical conditions such as nighttime heartburn, acid regurgitation, or chest pain [28]. Moreover, altering meal times and consuming difficult-to-digest foods can link to the symptoms of gastroesophageal reflux, which often manifests at night [32].
Poor sleep quality in GERD patients undoubtedly has social and economic consequences, leading to reduced work productivity and daily activities, ultimately resulting in significant economic losses and diminished health-related quality of life (HR-QOL) [28]; therefore, nearly half of the participants in our study reported existing financial problems. The critical role of sleep in maintaining well-being has garnered significant attention because of its impact on mental and physical health. There is evidence of a bidirectional association between sleep disturbances, particularly sleep quality, and functional gastrointestinal complications [32].
In our research, we observed similar cases within our Arab community, with an age range close to that of our group. Different studies reported varying prevalences of symptoms: the largest sample size study identified difficulty swallowing as the most common symptom [23], whereas another study reported that reflux and heartburn were predominant [33]. In a study involving medical students at a Saudi university, bloating and heaviness in the forehead were widespread symptoms [21].
The diversity in GERD symptoms among individuals can be attributed to several factors. Anatomical differences in the esophagus, stomach, and lower esophageal sphincter muscle, as well as esophageal sensitivity, play significant roles. Variations in stomach acid production, along with individual medical, surgical, and medication histories, also contribute to symptom variability. Dietary and personal habits, such as consuming spicy, fatty, citrus, or caffeine-containing foods; smoking; and alcohol consumption, further influence the presentation of GERD symptoms. Additionally, the presence of a hiatal hernia and the hormonal changes associated with pregnancy can impact symptomatology. It is important to consider the use of medications such as calcium channel blockers or sedatives, which may affect GERD symptoms [34, 35].
This research study has several limitations that should be acknowledged. The reliance on self-reported symptoms may introduce subjective biases and recall inaccuracies, as the questionnaire required participants to recall events from the past month. Additionally, the study’s specific context may not fully capture the range of experiences across different populations or cultural contexts. We defined sleep disturbances on the basis of the results of a self-administered questionnaire; therefore, objective sleep parameters obtained via polysomnography or actigraphy were not evaluated. Furthermore, the use of a convenience sampling technique due to resource constraints may have limited the generalizability of the study results.
Conclusion
This study provides a detailed analysis of the factors influencing GERD symptomatology among participants. Financial difficulties emerged as a critical determinant, impacting both social functioning and sleep quality, which in turn were linked to GERD symptoms. Addressing these factors through integrated management strategies may enhance patient outcomes. Future research should focus on developing targeted interventions to address the psychosocial and lifestyle determinants of GERD, with the aim of improving symptom management and overall quality of life for affected individuals.
Supplementary Information
Acknowledgements
Not applicable.
Provenance and peer review
Not commissioned, externally peer-reviewed.
Authors' contributions
All authors have participated in writing the manuscript. JA, JS, AA, MYA, TW, RA, YM, SA reviewed the literature. JA, SK did the statistics and the relevant table. All Authors critically and linguistically revised the manuscript. JA, TW, AH, contributed to revision of the manuscript. JA prepared and revised the final manuscript. JA, MZ supervised the conduct of the study. All authors read and approved the final manuscript.
Funding
The authors received no specific funding for this work.
Data availability
All data generated or analysed during this study are included in this published articale.
Declarations
Ethics approval and consent to participate
Ethical approval for this study was obtained from the Ethical Committee of Damascus University, Faculty of Medicine, Syria (serial number 4245). Written informed consent was obtained from all participants. For those under 18 years of age, consent was obtained from their parents or legal guardians. This study adhered to the ethical principles outlined in the Declaration of Helsinki.
Consent for publication
Written informed consent was obtained from all the patients for the publication of this study and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal upon request.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Data Availability Statement
All data generated or analysed during this study are included in this published articale.