Psychosocial Experience in Goiter Patients

Introduction: Goiter often poses aesthetic disgrace problem. The psychosocial impacts of goiter, in particular in woman may be significant. Objective: studying the psychological and social impacts of the disease in goiter patients within the African context and their consequences on the treatment. Methods: It was a transversal study that took place from May 1to July 31, 2011 in the Collines and Donga departments situated in the center and the north of Benin. The study consisted of a survey conducted through an individual discussion based on questionnaire submitted to goiter patients who accepted to provide their answers. Results: This survey involved 86 patients of which 83 women and 3 men. Their average age was 43.7 ± 13.41. Goiter was noticeable in the totality of the patients. 68.6% of patients declared that they experienced on daily basis the shame caused by the disease. 66% thought that it was a natural disease; however, 27.9% believed that it was caused by bewitchment or sorcery. 46.5% and 37.2% resorted to modern and indigenous medicine respectively; 16.3% made no therapeutic move. Despite the psychosocial impacts of the disease, 50% of the patients rejected surgical intervention possibility. The core motives they raised were lack of financial means (34.8%), disease recurrence fright (23.3%), anesthesia fright (16.3%), and surgical fright (14%). Conclusion: Despite the psychological impacts of the disease, strong resistance exists probably more on cultural aspect than the motives mentioned by thyroidectomy patients.


Introduction
Goiter is a volumetric enlargement of thyroid, whatever its cause [1] [2]. Its  can be diffuse, nodular or multi nodular. It concerns all countries [3] [4]. The majority of patients are asymptomatic [2]. Goiter can be congenital or acquired. Endemic goiter occurs when the disease affects a significant number of people in a given area (5% of the population or more) [2] [3]. The most important single causal factor is an insufficient intake of iodine [5] [6]. Woman predominance of goiter is well known [7] [8]. This is a noticeable condition because of anterior and superficial localization of thyroid at the level of the neck and one of the problems goiter poses is therefore aesthetic disgrace. This problem is even more important that the disease affects mainly women. In fact, women are more anxious about their appearance than men. The occurrence of goiter may be experienced as a real drama. The psychological impacts of the disease may be significant, especially in Africa where goiter may evolve for several years and reach enormous proportions in absence of treatment, knowing that patients do not visit health facilities for their treatment [9] [10]. This study was conducted in order to assess psychological and social impacts in goiter patients within the African context and the consequences on their treatment.

Methods
The study took place from May 1 to July 31, 2011 in Benin, in the commune of Bantè, Dassa, Glazoué and Savalou all in the Collines department in the center of Benin and in the commune of Djougou in the Donga department in north-west Benin. These departments are well known in the country as goiter endemic areas. It was a transversal study based on a structured talk with goiter patients met in their houses thanks to communities' relays. Communities' relays are resourceful persons and volunteers who belong to the community and who are recruited by the Ministry of Public Health to facilitate contact between health agents and the community. The study was non-probabilistic and in terms of sampling, the recruitment of goiter patients was exhaustive. This study systematically took into account all anterior-cervical patients who accepted to participate in the survey and in whom the diagnostic of goiter was retained based on cervical exam and classification system of WHO as follow [3]: Grade 0: thyroid not palpable, or, if palpable, not larger than normal.
Grade 1a: thyroid distinctly palpable and visible with the head in a raised position; the indication is of a thyroid larger than normal, at least, as large as the distal phalanx of the subject.
Grade 1b: thyroid easily palpable and visible with the head in a raised position; the grade also includes all patients with a discrete nodule. The data was processed and analyzed with software Epi info version 3.5.1.

Epidemiological Profile of People Goiter Patients
Over 86 goiter patients that participated in the survey, three were men and 83 women. The average age of the sample was 43.7% ± 13.41%. 80% were married, 9% as husband and wife, and 11% divorced.

Goiter Classification
Goiter is clearly visible when the head/neck is in normal position (goiter grade 2 according to WHO classification) in 23.3% of the sample and it was voluminous, visible from distance (goiter grade 3 according WHO classification) in 76.7% of the sample.

Feelings Experienced at the Discovery of Goiter
The feelings experienced by the sample at the discovery of goiter are summed up in Figure 1.

Therapeutic Remedy for Goiter Patients
Over 86 of goiter patients of the survey, 40 (46.5%) referred to modern medicine against 32 for indigenous medicine (37.2%); 14 (16.3%) stated that they did not make any therapeutic move.

Goiter Impacts on Life
For 16 goiter patients (18.6%), the disease had no impact on their life, unlike 70 of them (81.4%) who stated that goiter affected their life. The feeling they experienced is described in Figure 2. Table 2 shows the distribution of goiter patients according to their perception on their entourage behavior.

Disability in Life
For 61 goiter patients (70.9% of the sample), the goiter disease was a disability in their life, unlike 25 of goiter patients (29.1%). Table 3 shows the reasons for which goiter is a disability in goiter patients life of these 61 goiter patients.

Surgical Treatment
Forty-three goiter patients (50.0%) were against the possibility of surgical treatment. The reasons are in Table 4.

Discussion
The study is not probabilistic and rests essentially on the statements of people with goiter. However, it has the merit to address an aspect of the disease which the caregivers often neglect, particularly surgeons in the treatment process of goiter in Africa. In fact, the health system often focuses on trying to solve problems related to geographical and financial accessibility of the populations to health care, little interest is paid in general to cultural accessibility of the populations to health facilities. Taking into account feeling by goiter patients diagnosed with the disease, it is surprising that some patients made no therapeutic move.
Whilst prior to suffering from the disease 66% of the patients thought that goiter was a "natural disease" and 28% believed that it was caused by bewitchment or sorcery, the therapeutic care they referred to was the modern medicine and indigenous medicine by 46.5% and 37.2% respectively. This reflects the important ratio of the indigenous medicine in our society but this also allows some uncertainty about the reliability of the patients in terms of their statements over their use or reference to indigenous medicine. It is common to notice in common practice that patients lose sight of their use of indigenous medicine while they bear the marks such as scarifications. Different cultural and social interpretations out of diseases generally in Africa could explain this situation. As far as Benin culture is concerned, the role of indigenous healer is dominating in the disease process [11] [12]. He/she is the only person to identify the initial factors of the disease: the cause of the illness (sorcery, divinity, spirit) and historical factor, medium of the disease (transgression of prohibition, relational conflict).

Conclusion
As unsightly phenomenon goiter leads to an alteration of self-image and bad life quality of people with goiter. It is clear that goiter disturbs the setting of relational things and the expected balance in social situations. Despite the considerable psychosocial impact of goiter, strong resistance to surgical treatment exists. This treatment should be multidisciplinary and should not rest on the surgeon alone. It must involve the entire personality of goiter patients with equal focus on their physical, psychological and spiritual state. It is only at this price that we will have the accession of a larger number of goiter patients in surgical treatment within the context of the developing African countries.