{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,15]],"date-time":"2026-07-15T18:08:06Z","timestamp":1784138886064,"version":"3.55.0"},"reference-count":38,"publisher":"Public Library of Science (PLoS)","issue":"7","license":[{"start":{"date-parts":[[2026,7,15]],"date-time":"2026-07-15T00:00:00Z","timestamp":1784073600000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100000865","name":"Bill and Melinda Gates Foundation","doi-asserted-by":"publisher","award":["INV-031791, INV-045988, INV-062665, INV-076498"],"award-info":[{"award-number":["INV-031791, INV-045988, INV-062665, INV-076498"]}],"id":[{"id":"10.13039\/100000865","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["www.plosglobalpublichealth.org"],"crossmark-restriction":false},"short-container-title":["PLOS Glob Public Health"],"abstract":"<jats:p>\n                    Catastrophic health expenditure (CHE) is a situation where a household\u2019s out-of-pocket medical payments are excessively high relative to its income, potentially leading to impoverishment. This study explores the risk factors associated with CHE in the management of diarrhea among children enrolled in Enterics for Global Health (EFGH) facilities in Karachi, Pakistan. We conducted a secondary analysis of data from 1,400 children presenting with diarrhea at Pakistan EFGH facilities. We estimated households\u2019 direct medical and non-medical costs per diarrheal episode. CHE was defined as healthcare expenditures exceeding 10% of total monthly household expenditure. Risk factors for CHE were assessed using univariate and multivariate regression models. CHE was observed in 9 (0.6%) households. Children experiencing severe diarrhea were 9.53 times (95%CI:1.93-46.91, p\u2009=\u20090.006) more likely to incur CHE compared to those with mild cases. Children with\n                    <jats:italic>Cryptosporidium<\/jats:italic>\n                    had a 7.08 times higher risk (95%CI:1.46-34.38, p\u2009=\u20090.015) compared to non- cryptosporidium. Children with moderate or severe wasting were 5.47 and 9.71 times more likely to experience CHE compared to those without wasting (95%CI:1.01-29.69, p\u2009=\u20090.011 and 1.64-57.6, p\u2009=\u20090.012, respectively). Similarly, moderately underweight children were 5.4 times more likely to experience CHE compared to their non-underweight counterparts (95%CI:1.01-29.69, p\u2009=\u20090.043). After adjusting for diarrhea severity, the risk of CHE among households where the father\u2019s education was limited to Quranic schooling was 8.4 times higher compared to no formal education (95%CI:1.13-62.49, p\u2009=\u20090.038). Estimates were based on a small number of CHE events and had wide confidence intervals. Although rare, CHE remains a potential risk for the vulnerable population. While limited statistical power due to small sample sizes warrants cautious interpretation of our risk ratios, our analyses suggest that severe diarrhea, malnutrition, and\n                    <jats:italic>Cryptosporidium<\/jats:italic>\n                    infection are associated with increased risk of CHE. Improving access to affordable healthcare, vaccination and nutritional programs, water, sanitation, and hygiene (WASH) practices, and financial support could reduce the impact of CHE.\n                  <\/jats:p>","DOI":"10.1371\/journal.pgph.0005391","type":"journal-article","created":{"date-parts":[[2026,7,15]],"date-time":"2026-07-15T17:28:38Z","timestamp":1784136518000},"page":"e0005391","update-policy":"https:\/\/doi.org\/10.1371\/journal.pgph.corrections_policy","source":"Crossref","is-referenced-by-count":0,"title":["Exploring risk factors associated with catastrophic health expenditure on diarrhea management in Karachi, Pakistan, 2022-2024"],"prefix":"10.1371","volume":"6","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-2768-6623","authenticated-orcid":true,"given":"Naveed","family":"Ahmed","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mohammad 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monovalent human-bovine (116E) oral rotavirus Vaccine, Rotavac, India","volume":"69","author":"I Praharaj","year":"2019","journal-title":"Clin Infect Dis"},{"key":"pgph.0005391.ref010","doi-asserted-by":"crossref","first-page":"30","DOI":"10.1186\/1475-9276-13-30","article-title":"Health care seeking patterns and out of pocket payments for children under five years of age living in Katchi Abadis (slums), in Islamabad, Pakistan","volume":"13","author":"A Rehman","year":"2014","journal-title":"Int J Equity Health"},{"issue":"1","key":"pgph.0005391.ref011","doi-asserted-by":"crossref","first-page":"356","DOI":"10.1186\/s12916-023-02957-w","article-title":"Financial hardship associated with catastrophic out-of-pocket spending tied to primary care services in low- and lower-middle-income countries: Findings from a modeling study","volume":"21","author":"S Bolongaita","year":"2023","journal-title":"BMC Med"},{"key":"pgph.0005391.ref012","article-title":"Determinants of household costs associated with childhood diarrhea in 3 South Asian settings","author":"R Rheingans","year":"2012","journal-title":"Clin Infect Dis"},{"issue":"4","key":"pgph.0005391.ref013","doi-asserted-by":"crossref","DOI":"10.1093\/ofid\/ofz150","article-title":"Household costs of diarrhea by etiology in 7 countries, the global enterics mulitcenter study (GEMS)","volume":"6","author":"M Zimmermann","year":"2019","journal-title":"Open Forum Infect Dis"},{"key":"pgph.0005391.ref014","doi-asserted-by":"crossref","first-page":"100440","DOI":"10.1016\/j.lansea.2024.100440","article-title":"Universal health coverage in Pakistan: Exploring the landscape of the health system, health seeking behaviours, and utilization of health services","volume":"27","author":"BT Shaikh","year":"2024","journal-title":"Lancet Reg Health Southeast Asia"},{"issue":"1","key":"pgph.0005391.ref015","doi-asserted-by":"crossref","first-page":"4","DOI":"10.1186\/s12992-023-00904-1","article-title":"Universal health coverage in 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Ngcamphalala","year":"2018","journal-title":"Glob Health Action"},{"key":"pgph.0005391.ref024","volume-title":"Diarrhea case surveillance in the enterics for global health Shigella surveillance study: epidemiologic methods","author":"HE Atlas","year":"2024"},{"key":"pgph.0005391.ref025","doi-asserted-by":"crossref","DOI":"10.1093\/ofid\/ofad651","volume-title":"The enterics for global health (EFGH) Shigella surveillance study in Pakistan","author":"N Ahmed","year":"2024"},{"key":"pgph.0005391.ref026","doi-asserted-by":"crossref","DOI":"10.1093\/ofid\/ofad575","article-title":"Quantifying the Cost of Shigella Diarrhea in the Enterics for Global Health (EFGH) shigella surveillance study","volume":"11","author":"C Morozoff","year":"2024","journal-title":"Open Forum Infect Dis"},{"issue":"11","key":"pgph.0005391.ref027","doi-asserted-by":"crossref","first-page":"921","DOI":"10.1002\/hec.776","article-title":"Catastrophe and impoverishment in paying for health care: With applications to Vietnam 1993-1998","volume":"12","author":"A Wagstaff","year":"2003","journal-title":"Health Econ"},{"issue":"1","key":"pgph.0005391.ref028","first-page":"124","article-title":"Catastrophic health expenditure in an urban city: Seven years after universal coverage policy in Thailand","volume":"44","author":"J Weraphong","year":"2013","journal-title":"Southeast Asian J Trop Med Public Health"},{"issue":"1","key":"pgph.0005391.ref029","doi-asserted-by":"crossref","first-page":"141","DOI":"10.9745\/GHSP-D-15-00384","article-title":"Simplified asset indices to measure wealth and equity in health programs: A reliability and validity analysis using survey data from 16 countries","volume":"4","author":"NM Chakraborty","year":"2016","journal-title":"Glob Health Sci Pract"},{"key":"pgph.0005391.ref030","year":"2019"},{"key":"pgph.0005391.ref031","year":"2024"},{"issue":"9","key":"pgph.0005391.ref032","article-title":"Examining comorbidities in children with diarrhea across four provinces of Mozambique: A cross-sectional study (2015 to 2019)","volume":"18","author":"AFL Bauhofer","year":"2023","journal-title":"PLoS One"},{"issue":"6","key":"pgph.0005391.ref033","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pntd.0009439","article-title":"Cost of illness for severe and non-severe diarrhea borne by households in a low-income urban community of Bangladesh: A cross-sectional study","volume":"15","author":"R Sultana","year":"2021","journal-title":"PLoS Negl Trop Dis"},{"issue":"1","key":"pgph.0005391.ref034","doi-asserted-by":"crossref","DOI":"10.1136\/bmjgh-2016-000166","article-title":"Household expenditures on pneumonia and diarrhoea treatment in Ethiopia: A facility-based study","volume":"2","author":"ST Memirie","year":"2017","journal-title":"BMJ Glob Health"},{"issue":"8","key":"pgph.0005391.ref035","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0182820","article-title":"Pediatric cryptosporidiosis: An evaluation of health care and societal costs in Peru, 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Costs and Cost Drivers Of Shigella Medically Attended Diarrhoea: Results from the Enterics for Global Health (EFGH) Study. 2025."},{"key":"pgph.0005391.ref037","doi-asserted-by":"crossref","first-page":"42","DOI":"10.1016\/j.puhe.2021.06.006","article-title":"Incidence and determinants of catastrophic health expenditures and impoverishment in Pakistan","volume":"197","author":"S Bashir","year":"2021","journal-title":"Public Health"},{"key":"pgph.0005391.ref038","doi-asserted-by":"crossref","first-page":"1607313","DOI":"10.3389\/ijph.2024.1607313","article-title":"Socioeconomic inequalities in out-of-pocket and catastrophic health expenditures in Pakistan","volume":"69","author":"S Bashir","year":"2024","journal-title":"Int J Public Health"}],"container-title":["PLOS Global Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pgph.0005391","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,15]],"date-time":"2026-07-15T17:28:44Z","timestamp":1784136524000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pgph.0005391"}},"subtitle":[],"editor":[{"given":"Md Sabbir","family":"Hossain","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2026,7,15]]},"references-count":38,"journal-issue":{"issue":"7","published-online":{"date-parts":[[2026,7,15]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pgph.0005391","relation":{},"ISSN":["2767-3375"],"issn-type":[{"value":"2767-3375","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,7,15]]}}}