Care-seeking for diarrheal illness: A systematic review and meta-analysis

Monitoring and treating diarrheal illness often relies on individuals seeking care at hospitals or clinics. Cases that seek care through pharmacies and community health workers (CHW) are frequently excluded from disease burden estimates, which are used to allocate mitigation resources. Studies on care-seeking behavior can help identify these gaps but typically focus on children under five, even though diarrheal diseases like cholera and Enterotoxigenic E. coli affect all age groups. This study aimed to estimate the proportion of individuals seeking care for themselves or their children with diarrhea, considering different age groups, case definitions, and study settings. We conducted a systematic review of population-based primary research studies published during 2000-2024 that examined care-seeking behavior for diarrhea. We included 166 studies from 62 countries. Hospitals and clinics were the most common source of care sought outside the home, with CHW and health posts rarely reported. Using a random-effects meta-analysis, we found substantial heterogeneity in care-seeking between studies from low- and middle-income countries (I2 = 99.3) and estimated that the proportion of diarrhea cases seeking care at a hospital or clinic was 32.8% on average (95% Confidence Interval (CI) 28.1% to 37.9%; prediction interval 3.3% to 87.5%). Although there were trends toward higher care-seeking for children compared to adults, substantial variation existed between studies, and the differences were not significant. We estimated that the adjusted odds of seeking care at a hospital or clinic were significantly higher for severe diarrhea and cholera compared to general diarrhea (Odds Ratio 3.43; 95% CI 1.71 to 6.88). Our findings confirm that passive surveillance through hospitals and clinics may substantially undercount the number of people with diarrhea, particularly those with milder symptoms, although this proportion varied widely. Additionally, our findings underscore the importance of including care-seeking questions across all age groups in future studies, as we cannot assume lower care-seeking for adults across all settings. Our study was limited by fewer data on care-seeking from health posts, traditional healers, and CHW compared to hospitals and clinics, highlighting a need for further research on these sources of care.