ProCite
RefWorks
Reference Manager
BibTeX
Zotero
EndNote
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1.
World Health Organization, 2017. Diarrhoeal Disease Fact Sheet. Available at: http://www.who.int/mediacentre/factsheets/fs330/en/. Accessed July 13, 2017.
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2.
World Health Organization, 2015. Ethiopia: WHO Statistical Profile. Available at: http://www.who.int/gho/countries/eth.pdf?ua=1. Accessed October 15, 2017.
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3.
Institute for Health Metrics and Evaluation, 2017. Global Burden of Disease. Available at: http://ghdx.healthdata.org/. Accessed October 15, 2017.
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4.
Johnston BC, Shamseer L, da Costa BR, Tsuyuki RT, Vohra S, 2010. Measurement issues in trials of pediatric acute diarrheal diseases: a systematic review. Pediatrics 126: e222–e231.
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5.
World Health Organization. Diarrhea (definition and sequelae). Geneva, Switzerland, WHO. Available at: http://www.who.int/topics/diarrhoea/en/. Accessed October 15, 2017.
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Clasen T, Schmidt WP, Rabie T, Roberts I, Cairncros S, 2007. Interventions to improve water quality for preventing diarrhoea: systematic review and meta-analysis. BMJ 334: 782.
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7.
Cairncross S, Hunt C, Boisson S, Bostoen K, Curtis V, Fung IC, Schmidt WP, 2010. Water, sanitation and hygiene for the prevention of diarrhoea. Int J Epidemiol 39 (Suppl 1): i193–i205.
-
8.
Clasen TF, Bostoen K, Schmidt WP, Boisson S, Fung IC, Jenkins MW, Scott B, Sugden S, Cairncross S, 2010. Interventions to improve disposal of human excreta for preventing diarrhoea. Cochrane Database Syst Rev CD007180.
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9.
Prüss‐Ustün A et al. 2014. Burden of disease from inadequate water, sanitation and hygiene in low‐and middle‐income settings: a retrospective analysis of data from 145 countries. Trop Med Int Health 19: 894–905.
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10.
Wolf J et al. 2014. Systematic review: assessing the impact of drinking water and sanitation on diarrhoeal disease in low‐and middle‐income settings: systematic review and meta‐regression. Trop Med Int Health 19: 928–942.
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11.
Clasen TF, Alexander KT, Sinclair D, Boisson S, Peletz R, Chang HH, Majorin F, Cairncross S, 2015. Interventions to improve water quality for preventing diarrhoea. Cochrane Database Syst Rev CD004794.
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Sinha I, Jones L, Smyth RL, Williamson PR, 2008. A systematic review of studies that aim to determine which outcomes to measure in clinical trials in children. PLoS Med 5: e96.
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Koster FT, Palmer DL, Chakraborty J, Jackson T, Curlin GC, 1987. Cellular immune competence and diarrheal morbidity in malnourished Bangladeshi children: a prospective field study. Am J Clin Nutr 46: 115–120.
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O’donnell LJD, Virjee J, Heaton K, 1988. Pseudo-diarrhea in the irritable bowel syndrome-patients records of stool form reflect transit-time while stool frequency does not. Gut 29: A1455–A1455.
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Lewis SJ, Heaton KW, 1997. Stool form scale as a useful guide to intestinal transit time. Scand J Gastroenterol 32: 920–924.
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Chumpitazi BP, Lane MM, Czyzewski DI, Weidler EM, Swank PR, Shulman RJ, 2010. Creation and initial evaluation of a stool form scale for children. J Pediatr 157: 594–597.
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Aiemjoy K et al. 2016. ‘If an eye is washed properly, it means it would see clearly’: a mixed methods study of face washing knowledge, attitudes, and behaviors in rural Ethiopia. PLoS Negl Trop Dis 10: e0005099.
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Aiemjoy K et al. 2016. Is using a latrine “a strange thing to do”? A mixed-methods study of sanitation preference and behaviors in rural Ethiopia. Am J Trop Med Hyg 96: 65–73.
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Aiemjoy K, Gebresillasie S, Stoller NE, Shiferaw A, Tadesse Z, Chanyalew M, Aragie S, Callahan K, Keenan JD, 2018. Epidemiology of soil-transmitted helminth and intestinal protozoa infections in preschool-aged children in the Amhara region of Ethiopia. Am J Trop Med Hyg 96: 866–872.
-
22.
Lane MM, Czyzewski DI, Chumpitazi BP, Shulman RJ, 2011. Reliability and validity of a modified Bristol stool form scale for children. J Pediatr 159: 437–441.e1.
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Morton A, Dobson A, 1989. Assessing agreement. Med J Aust 150: 384–387.
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Cohen J, 1968. Weighted kappa: nominal scale agreement provision for scaled disagreement or partial credit. Psychol Bull 70: 213–220.
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Blake MR, Raker JM, Whelan K, 2016. Validity and reliability of the Bristol stool form scale in healthy adults and patients with diarrhoea-predominant irritable bowel syndrome. Aliment Pharmacol Ther 44: 693–703.
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Rogan WJ, Gladen B, 1978. Estimating prevalence from the results of a screening test. Am J Epidemiol 107: 71–76.
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Defining Diarrhea: A Population-Based Validation Study of Caregiver-Reported Stool Consistency in the Amhara Region of Ethiopia
Kristen Aiemjoy
Kristen Aiemjoy
Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, California;
Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California;
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Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California;
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Solomon Aragie
Solomon Aragie
The Carter Center Ethiopia, Addis Ababa, Ethiopia;
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Sintayehu Gebresillasie
Sintayehu Gebresillasie
The Carter Center Ethiopia, Addis Ababa, Ethiopia;
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Dionna M. Fry
Dionna M. Fry
Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, California;
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Adane Dagnew
Adane Dagnew
The Carter Center Ethiopia, Addis Ababa, Ethiopia;
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Dagnachew Hailu
Dagnachew Hailu
The Carter Center Ethiopia, Addis Ababa, Ethiopia;
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Melsew Chanyalew
Melsew Chanyalew
Amhara Regional Health Bureau, Bahir Dar, Ethiopia;
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Zerihun Tadesse
Zerihun Tadesse
The Carter Center Ethiopia, Addis Ababa, Ethiopia;
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Aisha Stewart
Aisha Stewart
The Carter Center, Atlanta, Georgia;
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Kelly Callahan
Kelly Callahan
The Carter Center, Atlanta, Georgia;
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Mathew Freeman
Mathew Freeman
Rollins School of Public Health, Emory University, Atlanta, Georgia;
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John Neuhaus
John Neuhaus
Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California;
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Benjamin F. Arnold
Benjamin F. Arnold
Division of Epidemiology, School of Public Health, University of California, Berkeley, Berkeley, California
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Jeremy D. Keenan
Jeremy D. Keenan
Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, California;
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Diarrhea is a leading cause of death among children aged less than five years globally. Most studies of pediatric diarrhea rely on caregiver-reported stool consistency and frequency to define the disease. Research on the validity of caregiver-reported diarrhea is sparse. We collected stool samples from 2,398 children participating in two clinical trials in the Amhara region of Ethiopia. The consistency of each stool sample was graded by the child’s caregiver and two trained laboratory technicians according to an illustrated stool consistency scale. We assessed the reliability of graded stool consistency among the technicians, and then compared the caregiver’s grade with the technician’s grade. We also tested if the illustrated stool consistency scale could improve the validity of caregiver’s report. The weighted kappa measuring the agreement between the two laboratory technicians reached 0.90 after 500 stool samples were graded. The sensitivity of caregiver-reported loose or watery stool was 15.5% (95% confidence interval [CI]: 9.7, 24.2) and the specificity was 98.4% (95% CI 97.1, 99.1). With the illustrated scale, the sensitivity was 68.5% (95% CI: 58.5, 77.1) and the specificity was 86.1% (95% CI: 79.3, 90.9). The results indicate that caregiver-reported stool consistency using the terms “loose or watery” does not accurately describe stool consistency as graded by trained laboratory technicians. Given the predominance of using caregiver-reported stool consistency to define diarrheal disease, the low sensitivity identified in this study suggests that the burden of diarrheal disease may be underestimated and intervention effects could be biased. The illustrated scale is a potential low-lost tool to improve the validity of caregiver-reported stool consistency.
- Supplemental Materials (PDF 109 KB)
Author Notes
Financial support: This study was supported by the National Institute of Health (NEI U10 EY016214), (NICHD F31 HD088070-01A1 [to K. A.]), and (NIAID 1K01AI119180 [to B. F. A.]); That Man May See and The Sara & Evan Williams Foundation; and Research to Prevent Blindness.
Authors’ addresses: Kristen Aiemjoy, Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, CA, and Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, E-mail: kristen.aiemjoy@ucsf.edu. Solomon Aragie, Sintayehu Gebresillasie, Adane Dagnew, Dagnachew Hailu, and Zerihun Tadesse, The Carter Center Ethiopia, Addis Ababa, Ethiopia, E-mails: solomon.aragie@cartercenter.org, sintayehugs@gmail.com, adane.dagnew@cartercenter.org, dagnachew.hailu@cartercenter.org, and zerihun.tadesse@cartercenter.org. Dionna M. Fry and Jeremy D. Keenan, Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, CA, E-mails: dionna.fry@ucsf.edu and jeremy.keenan@ucsf.edu. Melsew Chanyalew, Amhara Regional Health Bureau, Bahir Dar, Ethiopia, E-mail: yeshiwork97@yahoo.com. Aisha Stewart and Kelly Callahan, The Carter Center, Atlanta, GA, E-mails: aisha.stewart@cartercenter.org and kelly.callahan@cartercenter.org. Mathew Freeman, Rollins School of Public Health, Emory University, Atlanta, GA, E-mail: matthew.freeman@emory.edu. John Neuhaus, Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, E-mail: John.Neuhaus@ucsf.edu. Benjamin F. Arnold, Division of Epidemiology, School of Public Health, University of California, Berkeley, Berkeley, CA, E-mail: benarnold@berkeley.edu.
ProCite
RefWorks
Reference Manager
BibTeX
Zotero
EndNote
-
1.
World Health Organization, 2017. Diarrhoeal Disease Fact Sheet. Available at: http://www.who.int/mediacentre/factsheets/fs330/en/. Accessed July 13, 2017.
-
2.
World Health Organization, 2015. Ethiopia: WHO Statistical Profile. Available at: http://www.who.int/gho/countries/eth.pdf?ua=1. Accessed October 15, 2017.
-
3.
Institute for Health Metrics and Evaluation, 2017. Global Burden of Disease. Available at: http://ghdx.healthdata.org/. Accessed October 15, 2017.
-
4.
Johnston BC, Shamseer L, da Costa BR, Tsuyuki RT, Vohra S, 2010. Measurement issues in trials of pediatric acute diarrheal diseases: a systematic review. Pediatrics 126: e222–e231.
-
5.
World Health Organization. Diarrhea (definition and sequelae). Geneva, Switzerland, WHO. Available at: http://www.who.int/topics/diarrhoea/en/. Accessed October 15, 2017.
-
6.
Clasen T, Schmidt WP, Rabie T, Roberts I, Cairncros S, 2007. Interventions to improve water quality for preventing diarrhoea: systematic review and meta-analysis. BMJ 334: 782.
-
7.
Cairncross S, Hunt C, Boisson S, Bostoen K, Curtis V, Fung IC, Schmidt WP, 2010. Water, sanitation and hygiene for the prevention of diarrhoea. Int J Epidemiol 39 (Suppl 1): i193–i205.
-
8.
Clasen TF, Bostoen K, Schmidt WP, Boisson S, Fung IC, Jenkins MW, Scott B, Sugden S, Cairncross S, 2010. Interventions to improve disposal of human excreta for preventing diarrhoea. Cochrane Database Syst Rev CD007180.
-
9.
Prüss‐Ustün A et al. 2014. Burden of disease from inadequate water, sanitation and hygiene in low‐and middle‐income settings: a retrospective analysis of data from 145 countries. Trop Med Int Health 19: 894–905.
-
10.
Wolf J et al. 2014. Systematic review: assessing the impact of drinking water and sanitation on diarrhoeal disease in low‐and middle‐income settings: systematic review and meta‐regression. Trop Med Int Health 19: 928–942.
-
11.
Clasen TF, Alexander KT, Sinclair D, Boisson S, Peletz R, Chang HH, Majorin F, Cairncross S, 2015. Interventions to improve water quality for preventing diarrhoea. Cochrane Database Syst Rev CD004794.
-
12.
Sinha I, Jones L, Smyth RL, Williamson PR, 2008. A systematic review of studies that aim to determine which outcomes to measure in clinical trials in children. PLoS Med 5: e96.
-
13.
Black RE, Brown KH, Becker S, Yunus M, 1982. Longitudinal studies of infectious diseases and physical growth of children in rural Bangladesh. I. Patterns of morbidity. Am J Epidemiol 115: 305–314.
-
14.
Koster FT, Palmer DL, Chakraborty J, Jackson T, Curlin GC, 1987. Cellular immune competence and diarrheal morbidity in malnourished Bangladeshi children: a prospective field study. Am J Clin Nutr 46: 115–120.
-
15.
Blum D, Feachem RG, 1983. Measuring the impact of water supply and sanitation investments on diarrhoeal diseases: problems of methodology. Int J Epidemiol 12: 357–365.
-
16.
O’donnell LJD, Virjee J, Heaton K, 1988. Pseudo-diarrhea in the irritable bowel syndrome-patients records of stool form reflect transit-time while stool frequency does not. Gut 29: A1455–A1455.
-
17.
Lewis SJ, Heaton KW, 1997. Stool form scale as a useful guide to intestinal transit time. Scand J Gastroenterol 32: 920–924.
-
18.
Chumpitazi BP, Lane MM, Czyzewski DI, Weidler EM, Swank PR, Shulman RJ, 2010. Creation and initial evaluation of a stool form scale for children. J Pediatr 157: 594–597.
-
19.
Aiemjoy K et al. 2016. ‘If an eye is washed properly, it means it would see clearly’: a mixed methods study of face washing knowledge, attitudes, and behaviors in rural Ethiopia. PLoS Negl Trop Dis 10: e0005099.
-
20.
Aiemjoy K et al. 2016. Is using a latrine “a strange thing to do”? A mixed-methods study of sanitation preference and behaviors in rural Ethiopia. Am J Trop Med Hyg 96: 65–73.
-
21.
Aiemjoy K, Gebresillasie S, Stoller NE, Shiferaw A, Tadesse Z, Chanyalew M, Aragie S, Callahan K, Keenan JD, 2018. Epidemiology of soil-transmitted helminth and intestinal protozoa infections in preschool-aged children in the Amhara region of Ethiopia. Am J Trop Med Hyg 96: 866–872.
-
22.
Lane MM, Czyzewski DI, Chumpitazi BP, Shulman RJ, 2011. Reliability and validity of a modified Bristol stool form scale for children. J Pediatr 159: 437–441.e1.
-
23.
Morton A, Dobson A, 1989. Assessing agreement. Med J Aust 150: 384–387.
-
24.
Cohen J, 1968. Weighted kappa: nominal scale agreement provision for scaled disagreement or partial credit. Psychol Bull 70: 213–220.
-
25.
Rogers W, 1994. Regression standard errors in clustered samples. Stata Tech Bull 3: 19–23.
-
26.
Genders TSS, Spronk S, Stijnen T, Steyerberg EW, Lesaffre E, Myriam Hunink MG, 2012. Methods for calculating sensitivity and specificity of clustered data: a tutorial. Radiology 265: 910–916.
-
27.
Coughlin SS, Trock B, Criqui MH, Pickle LW, Browner D, Tefft MC, 1992. The logistic modeling of sensitivity, specificity, and predictive value of a diagnostic test. J Clin Epidemiol 45: 1–7.
-
28.
Janssens ACJW, Deng Y, Borsboom GJJM, Eijkemans MJC, Habbema JDF, Steyerberg EW, 2005. A new logistic regression approach for the evaluation of diagnostic test results. Med Decis Making 25: 168–177.
-
29.
Baqui AH, Black RE, Yunus MD, Hoque ARA, Chowdhury HR, Sack RB, 1991. Methodological issues in diarrhoeal diseases epidemiology: definition of diarrhoeal episodes. Int J Epidemiol 20: 1057–1063.
-
30.
Blake MR, Raker JM, Whelan K, 2016. Validity and reliability of the Bristol stool form scale in healthy adults and patients with diarrhoea-predominant irritable bowel syndrome. Aliment Pharmacol Ther 44: 693–703.
-
31.
Rogan WJ, Gladen B, 1978. Estimating prevalence from the results of a screening test. Am J Epidemiol 107: 71–76.
| Past two years | Past Year | Past 30 Days | |
|---|---|---|---|
| Abstract Views | 518 | 390 | 39 |
| Full Text Views | 1553 | 10 | 1 |
| PDF Downloads | 492 | 9 | 1 |