Page et al. BMC Public Health 2011, 11:389 http://www.biomedcentral.com/1471-2458/11/389 standardized questionnaire was based on the question- naire in Annex of the WHO generic protocol for a com- munity-based survey on utilization of health care services for gastroenteritis in children [14]. It was adapted locally after field testing and the following ques- tions were removed for the purpose of simplification: socio-economical status, duration of the disease and some symptoms during illness. As our primary interest was in seeking care at formal health care structures, respondents reporting that they sought care or intended to seek care at a fixed or mobile pharmacy or drug merchant, or those intending to seek care from family, friends and traditional healers were considered as not intending to seek consultation. These results are thus presented as a reason for not consulting a health care structure. Definitions Following the WHO protocol, we defined acute watery diarrhea as more than 3 watery or liquid stools over a 24- hour period without the presence of blood. Severe watery diarrhea was defined as acute watery diarrhea with the pre- sence of at least two of the following signs: loss of con- sciousness and/or sunken eyes and/or incapable of drinking or drinking very little. Diarrhea was also considered severe if the child received intravenous rehydration treatment. Data entry and analysis An independent data entry team in Maradi, Niger, entered data using EpiData 3.1 (EpiData Association, Odense, Denmark). Coherency and consistency checks were performed on double entry. Data analysis was done using Stata 10.0 (College Station, TX, USA). Crude estimates and design effects were obtained con- sidering the survey design [22]. Sampling weights were calculated at each level to account for different house- hold compositions (more than one child eligible for inclusion), as well as for the population of each stratum when compiling results. Ethical considerations This study adhered to the principles that govern biomedi- cal research involving human subjects [23]. Ethical approval was granted by the Ethical Committee of Niger and authorization granted by the Ministry of Health, as well as from the head of each village participating in the survey. Written informed consent was obtained from par- ticipants. Children presenting with diarrhea at the moment of the survey or other pathology visibly requiring treatment were referred to the closest health structure. Results The survey took place from 21st to 28th of May 2009. A total of 3134 households were visited in all strata. Of Page 3 of 7 these, 133 (4.2%) households were absent and 61 (1.9%) refused to participate in the survey. In total, 2940 house- holds were included in the survey with 735 included in each stratum. The mean number of children aged 0 to 59 months per household was 2.4 with a male/female ratio of children included in the survey of 1.01. The interview respondent was the mother in 94.4% of house- holds and without prior education in 86.7% of respon- dents. Demographic characteristics of households included in the survey are presented in Table 1. Diarrheal episodes Of the 2940 children selected for inclusion, 1099 care- givers reported at least one episode of diarrhea during the recall period of 27 days. Of these, 33 were excluded: 4 children did not meet the definition of diarrhea (more than 3 stools per 24 h) and 29 reported blood in the stool. Therefore, the following analyses were done for 1066 reported cases. For the entire survey region, the period prevalence of watery diarrhea was 36.8% (95%CI: 33.7 - 40.0). Prevalence varied among strata (Table 2). More than half of the children aged 6 to 18 months had a diarrheal episode reported during the recall period (Table 2). Among the reported symptoms, sunken eyes were mentioned by 74.7% (n = 777/1066), unable to drink or drinking very little by 13.2% (n = 167/1066) of care- givers and loss of consciousness in 5.1% (n = 54/1066). Of the 1066 cases of acute watery diarrhea during the recall period, 9.2% (n = 98/1066) of the children with diarrhea met the criteria for severe watery diarrhea, leading to a period prevalence of 3.4% (95%CI: 2.2-4.6) (Table 2). Health care seeking behavior Of those reporting diarrhea during the recall period, 70.4% (95%CI: 66.6-74.1) reported seeking care at a health structure, and among severe cases, 83.8% (95%CI: 75.2-92.4) sought care. Proportions of consultations were consistently high in all districts, ranging from 68.7% (95%CI: 59.1-76.5) in the city of Maradi to 76.4% (95%CI: 70.4-82.5) in Madarounfa for all diarrhea cases and from 66.7% (95%CI: 36.9-96.5) in Aguie to 90.3% (95%CI: 70.8-100) in the city of Maradi for severe cases. In all sites, more than half of all diarrhea cases sought care at health centers and around one-third at health posts (Figure 1). There was no association between consultations at a health care structure and the level of education of the caretaker (Table 3). Consultations were associated with increasing number of children under 5 years of age in the household. Age was also associated to consultations at a health care structure, with a higher proportion of consultations for children aged 6 to 18 months.