Prevalence of diarrheal illness and healthcare-seeking behavior by age-group and sex among the population of Gaza strip: a community-based cross-sectional study

Diarrhea is the second worldwide most common cause of death in children below the 5syears old in particular. According to the world health organization (WHO), more than 760,000 children a year die as a consequence of diarrheal diseases [1]. Young children especially who are living in low-income states are at great risk for diarrheal consequences such as dehydration and malnutrition. Country-based investigations are highly relevant to identify diarrheal illness related-risk factors and inspect of healthcare-seeking behavior in society and recognize its implications on public health [2].

In the Gaza strip, diarrheal illness is the main cause for childhood visits to primary healthcare centers and hospitals [3]. Moreover, the United Nations relief and works agency for Palestine refugees in the Near East (UNRWA) revealed that the prevalence of diarrhea was 4017.1 case per 100,000 inhabitants in 2009, thereafter rose to 6448.2 cases per 100,000 inhabitants in 2013, resulted mainly from alter of water quality, sanitation facilities and hygiene practices (WASH) at households [4].

Factors influencing healthcare seeking behavior, include individual factors, accessibility to service, the severity of illness, the trust of healthcare providers, and prior beliefs concerning treatment of the illness [5‐7]. Moreover, the presence of considerable social, economic and information constraints would limit the use of publicly-funded healthcare and seek professional healthcare [8].

Traditional practices at houses revealed improper treatment of diarrhea in which delay seeking health care has resulted in a remarkable number of mortalities [9, 10]. Therefore, understanding the constraints are crucial especially in poverty-stricken communities like in Gaza strip to mitigate the barriers and evaluate the effectiveness of such interventions [11].

The Palestinian National Authority is the main health insurance provider and allocates 37.7% of its annual budget to the health sector. The Palestinian ministry of health is responsible for providing health services to the Gazans. The majority of MOH funding comes from foreign aid and fees for health services [12]. The Ministry of Health has about 54 primary healthcare centers (PHCCs) and 13 hospitals distributed throughout Gaza strip governorates. Furthermore, the nongovernmental organizations (NGOs) and the private health sector play a vital role in the provision of third-care services, outpatient clinics, and rehabilitation centers through 8 PHCCs and 14 hospitals [13]. The UNRWA has 22 health centers which offer primary healthcare to Palestinian 1,167,572 refugees in the Gaza strip [12]. The surveillance system for communicable diseases in the Gaza strip remains limited due to lack of logistical capacity and financial resources.

Understanding risk factors associated with the occurrence of diarrhea in all age groups of the society and the predictors of seeking non-professional healthcare for diarrhea treatment may be helpful in reducing diarrheal morbidity and mortality. To the best of our knowledge, burdens of diarrheal diseases and health care-seeking behavior among the population at risk in Gaza strip have not been assessed. Thus, the aim of this study was to identify diarrheal illness related-risk factors and predictors for seeking nonprofessional care for diarrhea treatment among the population of Gaza strip. Moreover, the trend of seeking healthcare behavior from professional and non-professional healthcare providers in the last three diarrheal episodes was explored.

In our study, we reported a high prevalence of diarrhea in the Gaza strip (3.8 per 100). Factors related to this prevalence are complex in nature including but not limited to ineffective sewage management and lack access to safe drinking water [18, 19]. The epidemiological bulletin published by the UNRWA indicated a constantly increase in trend of diarrheal incidence between 2010 and 2013 [4]. Diarrhea is more prevalent among young children. The previous finding from the same population was consistent with ours. Kanoa and his colleagues found diarrhea highly prevalent among under 5 years old [20]. Similarly, the global pattern of diarrheal is alike and it is the second leading cause of mortality and morbidity in children less than five [21‐23]. However, the burden of diarrhea remains heavy especially in industrialized countries where older ages represent a large portion of their populations [11]. A consensus between the results of our study and the final edition of the population and housing report published by the Palestinian Central Bureau of Statistics was found with respect to the average number of the Gaza’s household’s members which was around 6 members [12].

Risk of diarrhea differs between gender and males showed more risky than females. Similar findings were reported Bangladesh and Sudan [11, 24, 25]. In contrast, Schlagenhauf and his colleagues assessed gender differences in travel-associated disease and found females are more likely to get diarrhea than males [26].

We explored predictors of diarrheal illness among the population of Gaza strip and were living in rural areas, having an unclean kitchen, having a non-sanitary toilet, having latrine without a flush, disposing wastewater in an open area surrounding the home, and washing hands without soap. This finding is consistent with previous studies from Ethiopia, Kenya, and Bangladesh [11, 27, 28]. Knowing the influence of sociodemographic variables on diarrheal illness is vital because it is not only related to the individual case but also societal characteristics, in general, that affect the risk of diarrhea. Previous studies concluded that houses in urban areas and adequate household income affect the ability of families to have access to improved water, sanitation, and hygiene facilities as well as to necessary healthcare that would reduce the risk of diarrhea [29‐32].

The education level of mother is seemed to be a significant predictor. Poor educated mother presented a predictor for high risk of getting diarrhea for their children. This finding is persistent with previous relevant studies [33, 34]. The systematic review of Cairncross and her colleagues concluded the importance of hand washing and having a closed sewage system to prevent the incidence and reduce the burden of diarrhea [35].

We explored predictors for seeking healthcare from non-professional provider similar to previous reports. We found low monthly income and living in rural areas were barriers to accessing professional healthcare which is consistent with ex-studies from low-income countries [2, 6, 11, 36]. This is similar to findings obtained from Chowdhury et al. 2015 [11]. We also found that the low level of education of the head of household reduces the chance of family members receiving professional healthcare. Perhaps this is due to the lack of awareness of the importance of receiving professional healthcare in the event of diarrhea illness [11, 37]. Families are unable to afford costs of professional treatments and transportations to access services at primary health centers. Moreover, low educated families are in a hurry to see their children recovered fast, so they seek non-professional healthcare.

This study drew the trend of seeking healthcare behavior from professional and non-professional healthcare providers and vice versa in the last three diarrheal episodes. We found about 47.4% initially sought care from a non-professional healthcare provider. This result could be explained by either because the symptoms of diarrhea were not serious to require professional health care or due to denial of Gaza’s households from accessing professional healthcare because of poverty and rural residency, consequently, people prefer to depend on traditional medicine and intake of medicinal herbs as self-treatment. Therefore, providing low-cost and attainable professional health care for diarrheal treatment could decrease the burden of illness [38‐40]. In this study, a transition in seeking diarrhea treatment from professional healthcare to non-professional care and vice versa was observed. This could be clearly interpreted as either because of disparities in the severity of the symptoms of diarrhea each time or due to lack of satisfaction with recovery in the previous diarrheal episode, therefore, they returned to seek another healthcare provider different from its predecessor [41, 42].

This community-based cross-sectional study has many methodological strengths, including the relatively large sample size of 1857 households, the method of interviewed questionnaire for data collection is superior to a self-administered questionnaire, using a cluster random sampling to guarantee representativeness of the sample from the five Gaza’s governorates. Therefore, generalization could possibly be applied to all of Gaza’s areas. Furthermore, the main strength of our study was it is being the first study, which identified the predictors for seeking nonprofessional care for diarrheal treatment. However, it also has some noteworthy limitations. First, many independent factors were not examined for instance: dietary habits, early weaning, seasonal patterns, lack of safe water supply, younger maternal age, and indiscriminate disposal of child feces [43‐46]. Second, recall bias and misreporting could happen when we asked about seeking healthcare behavior in the last three diarrheal episodes.

This study showed a high prevalence of diarrhea particularly among children less than 5 years old. Sociodemographic, economic, water, sanitation, and hygiene factors in the Gaza strip’s households were the predictors of the diarrheal illness and seeking non-professional healthcare for diarrhea illness treatment. Consequently, in the light of study findings, we recommend improving the status of water, sanitation, and hygiene to reduce the incidence of diarrhea and provide a low-cost and attainable professional health care for diarrheal treatment. Future studies to investigate the seasonal trend of diarrhea cases considering water, sanitation and hygiene (WASH) variables that were not included in this study are recommended.