2Azmi Burhani Consulting, Petaling Jaya, Selangor, Malaysia
Methods: A survey was conducted between August 2012 and April 2013 in Malaysia and Vietnam. A total of 245 and 307 questionnaires were completed by respondents selected by convenience sampling in Malaysia and Vietnam, respectively. A descriptive statistical analysis was performed.
Results: Among respondents who had children below the age of 10, 89.6% of Vietnamese respondents and 98.8% of Malaysian respondents reported that their children had experienced an episode of gastroenteritis. Of these, 41.0% of Vietnamese parents and 21.1% of Malaysian respondents reported that the gastroenteritis episode required hospital admission. The most commonly reported length of hospitalization in Malaysia and Vietnam was 2 to 5 days. Overall, the most common hospitalization fees were more than USD 350 in Malaysia and between USD 1 to USD 34 in Vietnam. There were differences in the presentation of gastroenteritis and access to the health system was different in the two countries with different economic impact on families.
Conclusion: Overall, the majority of parents surveyed in both countries reported their children having experienced gastroenteritis. The episodes incurred a financial cost as well as productivity loss. There were several study limitations including the small convenience sample obtained and a lack of cost information to fully account for the economic costs. Nonetheless, the results offer some additional insight into the impact of childhood gastroenteritis on families in these two countries. Education on prevention is needed and vaccination should be considered.
Keywords: Pediatric gastroenteritis; Cost; Productivity loss; Parents
Studies in Asia have shown that rotavirus contributes 43% to 60% of the diarrheal admissions in Vietnam, 32.9% in Taiwan and 24 to 55% in Malaysia [11-13]. Young children between 6 months and 3 years old have been reported to have a higher prevalence rate of rotavirus gastroenteritis [12,14-15]. In terms of gastroenteritis in general, studies indicated that the peak incidence of gastroenteritis related hospital admissions in Malaysia occur in the rainy season , generally peaking at the beginning and end of each year  but the months may differ according to different studies.
Taking into consideration the economic burden and costs associated with gastroenteritis, studies conducted have tended to focus on rotavirus-associated gastroenteritis and this has been reported in several studies [9-10,16-17]. In Vietnam, annually, the economic burden of rotavirus gastroenteritis was estimated to be USD 3.1 million in medical costs, USD 685,000 in non-medical costs and USD 1.5 million in indirect costs . In Malaysia, such an economic study has not been performed but a study by Chai and Lee estimated that the cost incurred associated with hospitalization for rotavirus gastroenteritis was USD 194 . The direct medical costs per annum associated to rotavirus gastroenteritis was estimated at USD 10 to 16 million in Taiwan and USD 57 million in Japan [10,17]. In the larger context of developing countries, a study by Rheingans et al estimated the cost of rotavirus gastroenteritis in developing countries in general and the subsequent cost-effectiveness of rotavirus
vaccination . Within this context, Malaysia and Vietnam were classified as upper-middle-income countries respectively . According to the Rheingans study, the cost-effectiveness of rotavirus vaccine at $7.50 per dose was USD 291 and USD 329 per DALY in Vietnam and Malaysia, respectively .
Most studies on economic impact have focused on rotavirus infections. Yet, the economic impact of gastroenteritis specifically on families in South East Asia has not been reported thus far. In this study we consider South East Asia here as defined by the Association of South East Asian Nations which include Brunei, Cambodia, Indonesia, Laos, Malaysia, Myanmar, Philippines, Singapore, Thailand and Vietnam . Within the wider Asian continent, a study conducted in United Arab Emirates had explored the impact of gastroenteritis . The study was a survey among parents which found that an average of 1.4 days of work was missed by parents per episode of gastroenteritis . The study reported that 87% of parents had sought medical care for their affected children and 10% of cases required admission to hospital with an average length of stay of 2.6 days . Furthermore, the average cost of a gastroenteritis episode to parents was USD 64 . On the other hand, a study by Musawi et al. conducted in Bahrain focused on rotavirus infections reported a mean hospitalization duration of 4.1 days .
We conducted the present study to assess the impact of gastroenteritis as experienced by parents and evaluate the cost to families and productivity losses when their children have gastroenteritis. Malaysia and Vietnam were selected as two countries representing different South East Asian countries in our study. The two countries have some similarities and intercountry trade is common. However, there are also differences in terms of population size, language and economic development [23,24].
Age of respondents
51 and over
Parents of children below age of 10
Number of children
5 or more children
Monthly household income
Less than USD 350
USD 3500 and above
In addition to that, our study also found a percentage of gastroenteritis reported among children aged from 0 to 5 years old in both countries surveyed (Figure 2). In Malaysia, 63.3% of the respondents reported that their child who had gastroenteritis was between 0 to 1 year followed by 33.2% reporting that their child had gastroenteritis between the ages of 1 to 2 years old and only a minority of respondents reported gastroenteritis episode between age group of 2 to 5 years or above (Figure 2). In contrast, in Vietnam, the proportion of reported gastroenteritis was more commonly reported in children aged between 2 to 5 years old (38.5%) and less than 1 year of age (36.3%) (Figure 2).
On the other hand, we also noted some differences in the access to the health system in the two countries surveyed. From the data collected, we observed that public hospital admissions were more common in Vietnam compared to Malaysia. This is an interesting finding considering that public hospitals are widespread throughout Malaysia providing highly subsidized care. This could be due to a lack of representativeness of our sample. And yet, it may also raise the possibility that when it comes to care of their children, parents are willing to pay for what is perceived as higher quality or greater comfort and hence opt for the private care despite the higher cost to them. The length of hospitalization was similar in both countries with the greatest proportion of respondents reporting that their child was hospitalized for 1 to 5 days. A recent study by Goh et al performed in a tertiary hospital in Sabah, Malaysia also reported similar common range of hospitalization duration, between 1 to 6 days . This length of time is significant considering that in many cases both parents may be working. As well, due the large number of people working in the informal sector or working for daily wages in these two countries, the loss of a week's work could be a significant burden on a family's income. In Malaysia, the percentage of people working in the informal sector varies from less than 10% in some states up to approximately 15% . In Vietnam, this is estimated to be as high as 82% . Therefore, the impact of the number of days spent not working may have worse impact on families in Vietnam if there are more parents earning daily wages.
We found a significant variation in the hospitalization fee charges for gastroenteritis-associated hospital admission in children in Malaysia and Vietnam. The current study observed that the cost of hospitalization per episode was significantly lower in Vietnam compared to Malaysia. Related to this, it was observed that the majority of the parents or caregivers in Malaysia paid more than USD 350 in hospitalization fees per episode whereas the average hospitalization fee in Vietnam was only between USD 1 to USD 34. For Vietnam, our findings are similar to a study by Fischer et al in 2004 which reported that the estimated costs of diarrheal disease in Vietnam was USD 36 . For Malaysia, the cost reported is slightly higher than prospective study by Chai in 2007 in a single academic center which showed that the estimated outof- pocket expenditure incurred by caregivers for an admission to hospital due to rotavirus caused gastroenteritis was USD 194 . This is likely due to the large number of survey respondents reporting their child was admitted to a private hospital. On the other hand, we note that Malaysian respondents receiving public hospital care reported hospitalization fees less than USD 34 only which is similar to that reported by Vietnamese parents in our survey and lower than that reported by Chai. This point can be explained since academic centre fees are generally slightly higher than that charged by Ministry of Health hospitals and lower than that of private hospitals. It is important to reiterate here that our study is intended to report the fees paid by parents as users of the healthcare system. The fees charged by government run hospitals, including academic settings, are greatly subsidized by the governments of both countries [30,31].
There were some recognized limitations in our study. Firstly, this was an exploratory survey and respondents were recruited using a convenience sampling method. Furthermore, the total number of respondents recruited was small. Hence, our survey participants cannot be considered representative of all parents of the two countries. Besides that, our survey data was based on the respondent's recall of their child's most recent gastroenteritis episode. We collected categorical data to ease recall but this has its inherent limitations. In addition, there would have been disruption to other family activities and care of other children in the family particularly with the occurrence of a hospital admission. Additional family helpers may have had to be called to assist with family responsibilities while parents accompanied their child during admission. This cost was not taken into account in our survey. Aside from methodological issues, there were also important differences in the income level, healthcare system variation and possibly cultural differences between the two countries which may explain our findings.
Despite these limitations, findings from our study may provide useful insights into the experience of gastroenteritis from the parental perspective. Out-of-pocket costs incurred, time away from work and the related potential loss of income are important factors to consider. Our study may also have indicated that parents are willing to pay the higher private hospitals fees, at least in Malaysia, to obtain treatment for their child despite its cost. This study highlights that despite economic development in these two countries, gastroenteritis still has significant impact on families. We hope that the findings from our study help to add impetus to a commitment to better educate parents on improving hygiene and preventing childhood gastroenteritis. Simple steps like maintenance of oral hydration through consumption of liquids during an episode of gastroenteritis should be stressed to parents. For instance, breastfeeding infants should continue to breastfeed and older children should be coaxed to drink sips of water more frequently . As rotavirus is one of the most common pathogens causing acute gastroenteritis, vaccination should be considered as a means to reduce the impact on families if the vaccination costs are within affordable reach .
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