Health care seeking behavior for diarrhea in children under 5 in rural Niger: results of a cross-sectional survey

Although better sanitation, hygiene and access to care have successfully alleviated the burden of diarrheal diseases in developed countries [1, 2], diarrhea remains the second leading cause of death in children under 5 years of age in the world, representing nearly one in five child deaths - about 1.5 million each year [3, 4]. In sub-Saharan Africa, the etiology of diarrhea is seldom known due to the lack of infrastructure for diagnosis. Further, improved hygiene has not had a major impact on some causes of diarrheal diseases, such as rotavirus, for which vaccination is now the recommended prevention strategy [5‐7]. As rotavirus vaccines have become available, considerable efforts have been made to document the burden of severe rotavirus diarrhea with recent focus on Asia and Africa through the Asian and African Rotavirus Networks [8‐11]. Despite these efforts, knowledge about the disease burden as well as the circulating strains is still lacking in many countries, such as Niger [8, 12, 13]. The World Health Organization (WHO) developed a generic protocol for the hospital-based surveillance of severe diarrhea due to rotavirus in children under 5 years of age to inform decision making prior to vaccine introduction [14]. The recommended first step of this protocol is a survey among caretakers of children under 5 years of age to establish their hospital-use pattern in case of diarrhea. A first field-test of the survey protocol in Ghana showed that a hospital-based surveillance of rotavirus would miss the vast majority of children with severe diarrhea [15], emphasizing the need for investigating local specificities before implementing a surveillance system.

The organization of the health system in Niger is based on several international initiatives launched in 1995-1996 [16]. This period was marked by the creation of health districts for decentralization of care, the gradual introduction of the Integrated Management of Childhood Illness (IMCI) algorithms [17] in all districts, and the implementation of cost recovery following the Bamako Initiative [18]. Despite these efforts, the most recent national Demographic and Health Survey (DHS) in Niger in 2006 showed that only 17% of caretakers of children under 5 years of age had sought advice or treatment for childhood diarrhea [19]. With the aim of reducing child mortality in line with the UN Millennium Development Goals, free care for children under 5 years of age was introduced in April 2007. The health system in Niger is pyramidal based on health structures with increasing levels of service: health posts (cases de santé), health centers (centres de santé intégrés), district and regional hospitals [20]. Health posts provide basic care and preventive services and are staffed mainly by community health workers aided by community representatives. Health centers are staffed by nurses and ensure the provision of all services not requiring hospitalization. Diarrhea with severe dehydration is the only severe condition that does not automatically lead to referral to a hospital. In the absence of other severity signs, diarrhea with severe dehydration is managed by injection of intravenous fluids at the health center level.

The objective of this study was to determine the proportion of children under 5 years of age suffering from severe diarrhea, who were treated in the health care system of Maradi region, Niger. This was an initial step to determine the suitable sites to implement a rotavirus and diarrheal disease surveillance system in order to provide essential information for guidance on vaccine introduction.

The survey took place from 21^st to 28^th of May 2009. A total of 3134 households were visited in all strata. Of these, 133 (4.2%) households were absent and 61 (1.9%) refused to participate in the survey. In total, 2940 households 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 households and without prior education in 86.7% of respondents. Demographic characteristics of households included in the survey are presented in Table 1.

This survey in four health districts in the region of Maradi, Niger, confirms the high burden of diarrhea in Niger while showing an adequate use of the decentralized health system, and provides essential information for the establishment of a surveillance system for diarrheal diseases.

The 36.8% period prevalence of acute watery diarrhea found here is similar to the results of the 2006 DHS survey, when adjusted by the duration of the recall period [19]. In contrast, the percentage of reported health system consultations in case of diarrhea was remarkably higher; 70% overall compared to 17.2% reported consultations at the national level and only 13.7% in the region of Maradi in the 2006 DHS survey. In addition, the proportions were consistently high throughout districts, with no significant differences between the urban district (Maradi CU) and the three rural districts, which is remarkable in a region where reaching a health structure 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 straightforward due to potential methodological differences between this and the DHS surveys, in particular in the length of the questionnaire and the recall period. It is interesting to note that the data parallel an approximately 3.5 × increase in the number of consultations for diarrhea in children under 5 years of age reported from the health centers in Niger between 2006 and 2009 [24]. Abolition of user fees for children under 5 years old in April 2007 may be one of the major reasons for this increase. User fees have been shown to have an impact on patient behavior, and in particular on the delay before consultation and in the most vulnerable groups [25, 26].

The proportion of patients having received oral rehydration solution shows good compliance with national and international recommendations for the treatment of simple diarrhea [4, 27]. However, only half of the cases retrospectively classified as severe received intravenous rehydration therapy. Interestingly, the type of health structure visited did not vary much according to severity, both in the retrospective and hypothetical questionnaire, with health centers as the most frequently visited structures, followed by health posts. Referrals were not precisely documented here, but hospitalizations for at least one night were recorded and reported in only 44% of severe cases. As this also includes patients who stayed overnight at a health center, it is an over-estimate of the proportion of severe cases who were admitted to hospital. This, together with the decentralized healthcare organization and recommendations for treatment of severe dehydration at the health centre level, suggests that the majority of children with severe diarrhea would be missed by a hospital-based surveillance system.

Data from other African settings also show the limits of hospital-based surveillance. Similar low coverage of hospital-based surveillance was also concluded from a survey in Ghana [15]. In a hospital-based study in Kenya, the reported incidence of rotavirus-associated diarrhea was at least 70% higher in the areas close to the hospital than in the district overall [28]. Relying only on hospital based surveillance may have an impact on the estimated incidence of rotavirus-associated diarrhea, but also on the characterization of circulating genotypes, as well as on the estimation of expected health and economic impacts of vaccination, which are essential indicators to guide vaccine introduction [11, 29, 30].

The principal limitations of this study are related to its retrospective design. The survey was meant to focus primarily on severe diarrhea but retrospective classification of the severity of the disease was made difficult by the subjective assessment of dehydration signs, as shown even among clinicians [31]. Recall bias for diarrhea has been shown to be high after 7 days, with under-reporting up to 45% after this time [32, 33]. Positive behavior (here consultation at a health structure) could have been over-reported, although it was mentioned by surveyors that many caregivers showed the health passport of the child to prove the visit at the health structure. Finally, the questionnaire focused on health-seeking behavior of the care provider and was not optimal for documenting subsequent referrals within the healthcare system. Some of these limitations could be addressed in the future by slightly modifying the survey methodology. First and most importantly, severity scales such as the Clark or Vesikari scores might be more appropriate to evaluate severity than dehydration signs. These scores are widely used, in particular as the main outcome to assess rotavirus vaccine efficacy [34]. A modified Vesikari score was proposed and validated for use in outpatient settings, which excludes dehydration signs, considered subjective, in favor of objective signs such as number of stools or vomiting or duration of illness [35]. We suggest that this score be adapted and used for retrospective assessment of diarrhea in the future. Other suggested modifications include recording travel time from the house to nearest health care structure, clarifying questions on different steps in health care seeking behavior (first and subsequent visits, referrals), and, when possible, asking for the health passport to confirm the visit.

The results of this survey show an increase in health care seeking behavior in case of diarrhea of children under 5 years of age in the Maradi region since the 2006 DHS survey, suggesting the efficacy of recent health policies for children in Niger. In addition, the data suggest that hospital-based surveillance of severe diarrheal diseases might not be appropriate in this type of decentralized health system. Health centers and posts are the cornerstone of the health system, in particular in rural areas, and should not be overlooked for the establishment of surveillance systems.