Page et al. BMC Public Health 2011, 11:389 http://www.biomedcentral.com/1471-2458/11/389 Table 3 Proportions of consultations in a health care structure for diarrhea according to demographic characteristics Table 4 Reasons for not consulting in a health structure for diarrhea cases in children under 5 years of age (N = 335) Proportion 95% CI p Proportion ratio Education 0 years 1 to 6 years more than 6 years Number of children 1 to 2 3 to 5 more than 5 Sex male female Age (months) 24-59 18-23 12-17 6-11 3-5 0-2 68.3 76.4 63.4 64.5 74.9 86.0 66.3 70.8 60.9 70.0 77.8 75.7 73.5 47.4 67.0 66.3 73.1 Vaccination No Oral history Card confirmed Maradi Region, April 24th-May 21st 2009 leading to a proportion of 44.0% (95%CI: 28.8-59.2) of severe diarrhea cases who were hospitalized. Hypothetical health seeking behavior All respondents whose child did not have diarrhea dur- ing the recall period were asked what they would do in case their child had diarrhea. Almost all respondents (98.1%; n = 1806/1841) stated that they would seek medical attention for a future episode of diarrhea whether simple or severe. The health structures where people would seek care were the health centers, followed by health posts (Figure 1). The answers were very simi- lar whether the putative diarrhea was simple or severe. Discussion This survey in four health districts in the region of Mar- adi, Niger, confirms the high burden of diarrhea in Niger while showing an adequate use of the decentra- lized health system, and provides essential information for the establishment of a surveillance system for diar- rheal diseases. The 36.8% period prevalence of acute watery diarrhea found here is similar to the results of the 2006 DHS sur- vey, when adjusted by the duration of the recall period Ref 1.12 [0.98-1.27] 0.93 [0.79-1.09] 0.098 0.359 Ref 1.16 [1.07-0.27] 0.001 1.33 [1.18-1.50] < 0.001 Ref 1.07 [0.98-1.17] 0.151 Ref 1.15 [1.02-1.30] 0.025 1.27 [1.15-1.41] < 0.001 1.24 [1.11-1.39] < 0.001 1.21 [1.02-1.42] 0.031 0.78 [0.48-1.25] 0.294 Ref 0.99 [0.89-1.10] 1.09 [0.99-1.21] 0.86 0.091 Page 5 of 7 95% CI [34.2-52.6] [10.7-22.7] [4.6-21.6] [4.1-10.6] [3.0-12.1] [1.6-9.7] [1.2-5.0] [0.4-3.2] [0.3-2.1] Spontaneous recovery Pharmacy Financial problems Self-medication Distance Inability* “Teething” or “newborn” diarrhea Traditional healer Traditional medicine Maradi Region, April 24th - May 21st 2009 * Children at home, pregnant, too old ** Weighted proportions (see methods) n 120 64 34 33 19 13 12 10 11 %** 43.4 15.8 13.1 6.6 6.2 5.6 3.1 1.8 1.2 [19]. In contrast, the percentage of reported health sys- tem consultations in case of diarrhea was remarkably higher; 70% overall compared to 17.2% reported consul- tations at the national level and only 13.7% in the region of Maradi in the 2006 DHS survey. In addition, the pro- portions were consistently high throughout districts, with no significant differences between the urban dis- trict (Maradi CU) and the three rural districts, which is remarkable in a region where reaching a health struc- ture can take up to several hours of walking due to the long distances and lack of public transportation. The interpretation of the increase since 2006 is not straight- forward due to potential methodological differences between this and the DHS surveys, in particular in the Figure 1 Distribution of consultations by type of health structure for diarrhea and severe diarrhea cases in children under 5 years of age. Maradi Region, April 24th - May 21st 2009. The bars show the proportion of consultations by type of health structure among all diarrhea cases and severe cases who consulted during the recall period (Retrospective use) and hypothetical consultation location in case of diarrhea or severe diarrhea for children who did not have diarrhea during the recall period (Hypothetical use).