Health Care Utilization and Attitude Surveys Associated with the Global Enteric Multicenter Study (GEMS)
  • ISSN: 0002-9637
  • E-ISSN: 1476-1645



We performed serial Health Care Utilization and Attitudes Surveys (HUASs) among caretakers of children ages 0–59 months randomly selected from demographically defined populations participating in the Global Enteric Multicenter Study (GEMS), a case-control study of moderate-to-severe diarrhea (MSD) in seven developing countries. The surveys aimed to estimate the proportion of children with MSD who would present to sentinel health centers (SHCs) where GEMS case recruitment would occur and provide a basis for adjusting disease incidence rates to include cases not seen at the SHCs. The proportion of children at each site reported to have had an incident episode of MSD during the 7 days preceding the survey ranged from 0.7% to 4.4% for infants (0–11 months of age), from 0.4% to 4.7% for toddlers (12–23 months of age), and from 0.3% to 2.4% for preschoolers (24–59 months of age). The proportion of MSD episodes at each site taken to an SHC within 7 days of diarrhea onset was 15–56%, 17–64%, and 7–33% in the three age strata, respectively. High cost of care and insufficient knowledge about danger signs were associated with lack of any care-seeking outside the home. Most children were not offered recommended fluids and continuing feeds at home. We have shown the utility of serial HUASs as a tool for optimizing operational and methodological issues related to the performance of a large case-control study and deriving population-based incidence rates of MSD. Moreover, the surveys suggest key targets for educational interventions that might improve the outcome of diarrheal diseases in low-resource settings.

[open-access] This is an Open Access article distributed under the terms of the American Society of Tropical Medicine and Hygiene's Re-use License which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.


Article metrics loading...

Loading full text...

Full text loading...



  1. Fischer Walker CL, Perin J, Aryee MJ, Boschi-Pinto C, Black RE, , 2012. Diarrhea incidence in low- and middle-income countries in 1990 and 2010: a systematic review. BMC Public Health 12: 220.[Crossref]
  2. El Arifeen S, Baqui AH, Victora CG, Black RE, Bryce J, Hoque DM, Chowdhury EK, Begum N, Akter T, Siddik A, , 2008. Sex and socioeconomic differentials in child health in rural Bangladesh: findings from a baseline survey for evaluating integrated management of childhood illness. J Health Popul Nutr 26: 2235.
  3. Burton DC, Flannery B, Onyango B, Larson C, Alaii J, Zhang X, Hamel MJ, Breiman RF, Feikin DR, , 2011. Healthcare-seeking behaviour for common infectious disease-related illnesses in rural Kenya: a community-based house-to-house survey. J Health Popul Nutr 29: 6170.[Crossref]
  4. Bigogo G, Audi A, Aura B, Aol G, Breiman RF, Feikin DR, , 2010. Health-seeking patterns among participants of population-based morbidity surveillance in rural western Kenya: implications for calculating disease rates. Int J Infect Dis 14: e967e973.[Crossref]
  5. Jordan HTPP, Areerat P, Anand S, Clague B, Sutthirattana S, Chamany S, Flannery B, Olsen SJ, , 2009. A comparison of population-based pneumonia surveillance and health-seeking behavior in two provinces in rural Thailand. Int J Infect Dis 13: 355361.[Crossref]
  6. Kotloff KL, Blackwelder WC, Nasrin D, Nataro JP, Farag TH, van Eijk A, Adegbola RA, Alonso PL, Breiman RF, Golam Faruque AS, Saha D, Sow SO, Sur D, Zaidi AK, Biswas K, Panchalingam S, Clemens JD, Cohen D, Glass RI, Mintz ED, Sommerfelt H, Levine MM, , 2012. The Global Enteric Multicenter Study (GEMS) of diarrheal disease in infants and young children in developing countries: epidemiologic and clinical methods of the case/control study. Clin Infect Dis 55 (Suppl 4): S232S245.[Crossref]
  7. WHO, 2002. Generic Protocols for (i) Hospital-Based Surveillance to Estimate the Burden of Rotavirus Gastroenteritis in Children and (ii) a Community-Based Survey on Utilization of Health Care Services for Gastroenteritis in Children, Field Test Version. Geneva: World Health Organization.
  8. Goodall RM, , 2012. About Diarrhea, Dehydration, Oral Rehydration Salts, Oral Rehydration Therapy. Available at: http://rehydrate.org/faq/all-questions.htm. Accessed December 9, 2012.
  9. Biswas K, Carty C, Horney R, Nasrin D, Farag TH, Kotloff KL, Levine MM, , 2012. Data management and other logistical challenges for the GEMS: the data coordinating center perspective. Clin Infect Dis 55 (Suppl 4): S254S261.[Crossref]
  10. Searle SR, , 1971. Linear Models. New York: Wiley, 57.
  11. Filmer D, Pritchett LH, , 2001. Estimating wealth effects without expenditure data–or tears: an application to educational enrollments in states of India. Demography 38: 115132.
  12. Rosenstock IM, Strecher VJ, Becker MH, , 1988. Social learning theory and the Health Belief Model. Health Educ Q 15: 175183.[Crossref]
  13. UNICEF, 2012. The State of the World's Children 2012. Available at: http://www.unicef.org/sowc/files/SOWC_2012-Main_Report_EN_21Dec2011.pdf/. Accessed December 9, 2012.
  14. UNDP, 2012. Human Development Reports. Available at: http://hdr.undp.org/en/statistics/. Accessed December 9, 2012.
  15. WHO, MDG 6, 2012. HIV/AIDS, Malaria and Other Diseases. Available at: http://www.who.int/topics/millennium_development_goals/diseases/en/index.html/. Accessed December 9, 2012.
  16. Viera AJ, Garrett JM, , 2005. Understanding interobserver agreement: the kappa statistic. Fam Med 37: 360363.
  17. Shapiro RL, Kumar L, Phillips-Howard P, Wells JG, Adcock P, Brooks J, Ackers ML, Ochieng JB, Mintz E, Wahlquist S, Waiyaki P, Slutsker L, , 2001. Antimicrobial-resistant bacterial diarrhea in rural western Kenya. J Infect Dis 183: 17011704.[Crossref]
  18. Hill Z, Kendall C, Arthur P, Kirkwood B, Adjei E, , 2003. Recognizing childhood illnesses and their traditional explanations: exploring options for care-seeking interventions in the context of the IMCI strategy in rural Ghana. Trop Med Int Health 8: 668676.[Crossref]
  19. Winch PJ, Gilroy KE, Doumbia S, Patterson AE, Daou Z, Diawara A, Swedberg E, Black RE, Fontaine O, , 2008. Operational issues and trends associated with the pilot introduction of zinc for childhood diarrhoea in Bougouni district, Mali. J Health Popul Nutr 26: 151162.
  20. Ellis AA, Winch P, Daou Z, Gilroy KE, Swedberg E, , 2007. Home management of childhood diarrhoea in southern Mali–implications for the introduction of zinc treatment. Soc Sci Med 64: 701712.[Crossref]
  21. Nyamongo IK, , 2002. Health care switching behaviour of malaria patients in a Kenyan rural community. Soc Sci Med 54: 377386.[Crossref]
  22. Burgert CR, Bigogo G, Adazu K, Odhiambo F, Buehler J, Breiman RF, Laserson K, Hamel MJ, Feikin DR, , 2011. Impact of implementation of free high-quality health care on health facility attendance by sick children in rural western Kenya. Trop Med Int Health 16: 711720.[Crossref]
  23. Breiman RF, Olack B, Shultz A, Roder S, Kimani K, Feikin DR, Burke H, , 2011. Healthcare-use for major infectious disease syndromes in an informal settlement in Nairobi, Kenya. J Health Popul Nutr 29: 123133.[Crossref]
  24. Rheingans R, Kukla M, Faruque AS, Sur D, Zaidi AK, Nasrin D, Farag TH, Levine MM, Kotloff KL, , 2012. Determinants of household costs associated with childhood diarrhea in 3 South Asian settings. Clin Infect Dis 55 (Suppl 4): S327S335.[Crossref]
  25. Rheingans R, Kukla M, Adegbola RA, Saha D, Omore R, Breiman RF, Sow SO, Onwuchekwa U, Nasrin D, Farag TH, Kotloff KL, Levine MM, , 2012. Exploring household economic impacts of childhood diarrheal illnesses in 3 African settings. Clin Infect Dis 55 (Suppl 4): S317S326.[Crossref]
  26. WHO, 2005. Handbook: IMCI Integrated Management of Childhood Illness. Geneva: WHO.
  27. Taffa N, Chepngeno G, , 2005. Determinants of health care seeking for childhood illnesses in Nairobi slums. Trop Med Int Health 10: 240245.[Crossref]
  28. Boschi-Pinto C, Bahl R, Martines J, , 2009. Limited progress in increasing coverage of neonatal and child-health interventions in Africa and Asia. J Health Popul Nutr 27: 755762.
  29. Ramakrishnan R, Venkatarao T, Koya PK, Kamaraj P, , 1999. Influence of recall period on estimates of diarrhoea morbidity in infants in rural Tamilnadu. Indian J Public Health 43: 136139.
  30. Manesh AO, Sheldon TA, Pickett KE, Carr-Hill R, , 2008. Accuracy of child morbidity data in demographic and health surveys. Int J Epidemiol 37: 194200.[Crossref]
  31. Alam N, Henry FJ, Rahaman MM, , 1989. Reporting errors in one-week diarrhoea recall surveys: experience from a prospective study in rural Bangladesh. Int J Epidemiol 18: 697700.[Crossref]

Data & Media loading...

Supplementary Data

Supplementary PDF

  • Received : 13 Dec 2012
  • Accepted : 18 Mar 2013

Most Cited This Month

This is a required field
Please enter a valid email address
Approval was a Success
Invalid data
An Error Occurred
Approval was partially successful, following selected items could not be processed due to error