title: The burden of pediatric diarrhea: a cross-sectional study of incurred costs and perceptions of cost among Bolivian families.
abstract: BACKGROUND
  Worldwide, acute gastroenteritis represents an enormous public health threat to children under five years of age, causing one billion episodes and 1.9 to 3.2 million deaths per year. In Bolivia, which has one of the lower GDPs in South America, an estimated 15% of under-five deaths are caused by diarrhea. Bolivian caregiver expenses related to diarrhea are believed to be minimal, as citizens benefit from universal health insurance for children under five. The goals of this report were to describe total incurred costs and cost burden associated with caregivers seeking treatment for pediatric gastroenteritis, and to quantify relationships among costs, cost burden, treatment setting, and perceptions of costs.
  
  
  METHODS
  From 2007 to 2009, researchers interviewed caregivers (n=1,107) of pediatric patients (<5 years of age) seeking treatment for diarrhea in sentinel hospitals participating in Bolivia's diarrheal surveillance program across three main geographic regions. Data collected included demographics, clinical symptoms, direct costs (e.g. medication, consult fees) and indirect costs (e.g. lost wages).
  
  
  RESULTS
  Patient populations were similar across cities in terms of gender, duration of illness, and age, but familial income varied significantly (p<0.05) when stratified on appointment type. Direct, indirect, and total costs to families were significantly higher for inpatients as compared to outpatients of urban (p<0.001) and rural (p<0.05) residence. Consult fees and indirect costs made up a large proportion of total costs. Forty-five percent of patients' families paid ≥1% of their annual household income for this single diarrheal episode. The perception that cost was affecting family finances was more frequent among those with higher actual cost burden.
  
  
  CONCLUSIONS
  This study demonstrated that indirect costs due to acute pediatric diarrhea were a large component of total incurred familial costs. Additionally, familial costs associated with a single diarrheal episode affected the actual and perceived financial situation of a large number of caregivers. These data serve as a baseline for societal diarrheal costs before and immediately following the implementation of the rotavirus vaccine and highlight the serious economic importance of a diarrheal episode to Bolivian caregivers.
authors.affiliation: Hubert Department of Global Health, Emory University, Rollins School of Public Health, Mailstop 1518-002-7BB, 1518 Clifton Road NE, Claudia N Rollins Bldg, 6050, Atlanta, GA 30322, USA.
authors.forename: Rachel M
authors.initials: RM
authors.lastname: Burke
authors.forename: Paulina A
authors.initials: PA
authors.lastname: Rebolledo
authors.forename: Sally R
authors.initials: SR
authors.lastname: Embrey
authors.forename: Laura Danielle
authors.initials: LD
authors.lastname: Wagner
authors.forename: Carter L
authors.initials: CL
authors.lastname: Cowden
authors.forename: Fiona M
authors.initials: FM
authors.lastname: Kelly
authors.forename: Emily R
authors.initials: ER
authors.lastname: Smith
authors.forename: Volga
authors.initials: V
authors.lastname: Iñiguez
authors.forename: Juan S
authors.initials: JS
authors.lastname: Leon
mesh_terms: D001291:Attitude of Health Personnel; D001838:Bolivia; D017028:Caregivers / Q000523:psychology*; D016009:Chi-Square Distribution; D017281:Cost of Illness; D003365:Costs and Cost Analysis; D003430:Cross-Sectional Studies; D003968:Diarrhea, Infantile / Q000191:economics* / Q000523:psychology / Q000628:therapy; D017050:Episode of Care; D005191:Family Characteristics; D005260:Female; D017144:Focus Groups; D006776:Hospitals, Pediatric / Q000191:economics* / Q000706:statistics & numerical data; D006801:Humans; D007182:Income / Q000706:statistics & numerical data; D007223:Infant; D008297:Male; D010465:Perception; D012424:Rural Population / Q000706:statistics & numerical data; D014505:Urban Population / Q000706:statistics & numerical data
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