2.1. Study area

Cross River State is situated in the south geopolitical zone of Nigeria and has a total population of 2,892,988 people (2006 census) of which 372,909 are below the age of 5 years. Spread out over its 18 local government areas (Fig. 1), the State is ethnically diverse. The health services in the State provide care at three levels; primary, secondary, and tertiary care. The primary level of care is the first point of contact at the community level and the different local government councils in the state are responsible for primary health care in their areas.

Fig. 1

Map of Cross River State, Nigeria showing local government areas.

2.2. Study design

A cross-sectional study was carried out in randomly selected communities in five local government areas in Cross River State, Nigeria. The local government areas chosen were the mainly urban Calabar South and Calabar Municipal areas in the southern part of the State, the mainly rural Abi area in the central part of the State, and Obanliku and Yala areas in the northern part of the State (Fig. 1).

Using a two-stage cluster design, communities were selected from these local government areas. With a relatively high proportion of riverine communities, especially in the creeks, some of the selected communities were situated in the riverine areas while others were in nonriverine areas.

2.3. Participants

A total of 1240 caregivers of children aged <5 years (adults with primary responsibility for the index child at the time of the study) were surveyed from 13 communities in five local government areas. All of the caregivers (100% response rate) aged between 18 years and 50 years in selected communities agreed to participate in the study, and only the youngest child was selected for the study if a family had more than one child in this age category who had presented symptoms of diarrhea in the 2-week period preceding the study. Informed consent was obtained from mothers or caregivers after they had received an explanation about the study’s objective and method. The study protocol was reviewed and approved by the Ethical Committee of the Cross River State Ministry of Health, Calabar, Nigeria.

2.4. Data collection

In this study, diarrhea was defined as the passage of three or more loose stools or defecation frequency of three or more loose/liquid stools in a day.

Data collection was done in three phases: (1) informal interviews: information on the protocol of management of childhood diarrhea was collected from care providers in the health care units at the local government areas selected; (2) training of interviewers: volunteers selected for their local experience in carrying out house to house visits for community child health were trained and supervised using a training guide and the data collection tools (questionnaire and flash cards); and (3) interview of caregivers: information was collected on sociodemographic factors of the family, knowledge of causes and symptoms of diarrhea, description of care provided during illness, and risk factors of diarrheal illness including breastfeeding, immunization, water sources and treatment of water, household hand washing arrangements, mother’s knowledge of hand washing techniques, toilet facilities, and stool disposal methods.

Information collected using a semistructured questionnaire was validated using flashcards and interviewer’s observation of household hand washing arrangements and techniques, toilet facilities, and child’s immunization records.

2.5. Recommended management of childhood diarrhea

Informal interviews with primary health-care coordinators supervising health care at the district level indicated the care information given to caregivers of young children. For children younger than 2 months presenting with diarrhea, mothers were advised to seek care at the health care facility. However, the care to be given to older children was based on the classification of the illness or the presenting symptoms (see Table A1). Caregivers received training on recognition of symptoms in order to be able to provide appropriate care during the diarrheal illness.

2.6. Statistical analysis

To show that at least 50% of caregivers adopted appropriate care seeking for diarrhea in their children, a study sample size of 1140 caregivers assuming a confidence interval (CI) of ±5% and a confidence level of 95% was estimated.

Study data was coded and entered into Windows Microsoft Access 2013, Washington, United States of America IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp., which was then imported into SPSS version 20 where analysis was done.

Variables like maternal age, education, occupation, child’s age, sex of child, area of living, and breastfeeding and immunization practices that had a p value <0.05 based on bivariate analysis by logistic regression testing, were considered as potential confounders. Adjusted odds ratios with 95% CI were used to assess factors that determined the care seeking choices of caregivers.

3.1. Summary of participants

In summarizing the characteristics of caregivers in this study by local areas (Table 1 ), most caregivers who participated in this study were aged between 25 years and 50 years (59%, n = 124 in Calabar South area to 83.9%, n = 120 in Calabar Municipality area) with a higher proportion between 25 years and 34 years (44.7%, n = 102 in Obanliku area to 74.1%, n = 106 in Calabar Municipality area). All eligible caregivers participated in the study with a response rate of 100%.

Most caregivers had received some education, with the highest proportion of educated caregivers in the mainly urban Calabar Municipality area (97.9%, n = 140) and the lowest proportion in the mainly rural Yala area (87.3%, n = 145). Of the caregivers employed in the private and public sector jobs, there was a high proportion of farmers in the mainly rural Obanliku (34.8%, n = 80) and Yala (34.9%, n = 58) areas. Unemployed caregivers were either students or housewives and made up a higher proportion (41.8%, n = 197) of respondents in the riverine mainly rural Abi area.

There was an almost equal male to female ratio amongst the index children (51.8%, n = 632 to 48.2%, n = 588). Although almost all of the children were breastfed, (70.9%, n = 163 in the Obanliku area and 100%, n = 166 in the Yala area), a higher proportion of children had incomplete immunization records (56.5%, n = 130 in the Obanliku area to 95.1%, n = 136 in the Calabar Municipal area) as was demonstrated by either having lost the child’s immunization card or the observation of incomplete immunizations on cards sighted by the interviewers (see Table 2).

3.2. Burden of childhood diarrhea illness

There were 294 children who received care for diarrhea in the 2 weeks preceding the study and these children were mostly in the mainly rural areas of Abi (137), Obanliku (50), and Yala (40) areas.

Logistic regression analysis showed that factors that influenced diarrheal illness in the 2 weeks before the study were mother’s age and education, the age of the child, and the sources of water supply with the treatment of water (Table 3). Unexpectedly, the child’s immunization status was found to be positively associated with the odds of childhood diarrhea. These findings will be discussed in the next section.

3.3. Care for childhood diarrhea

Unlike the local recommended management (see Table A1), at the beginning of the illness most children (73%) received care outside the home, at the health-care facility (50.4%), at the local drug store (19.1%), and at the traditional healers (3.5%). Only 27% of the ill children received initial care at home as advised in the care protocol (see Table A1).

When care was received at home, the most common form of rehydration given was the government recommended salt sugar solution (43.6%) prepared at home using readily available salt, sugar, clean water, and oral rehydration solution (36.6%) purchased at the local drug stores or health care centers (see Tables 4–6).

Maternal characteristics of age, education, and knowledge of diarrhea causes and symptoms were not significantly associated with the choices of care for diarrheal illness. However, living in Abi (95% CI = 1.34–2.97) and Calabar South (95% CI = 1.97–6.73) was associated with increased odds of using the health facility, while living in Calabar Municipality (95% CI = 1.63–6.25) and Obanliku areas (95% CI = 1.74–5.14) was associated with giving care for childhood diarrhea at home.

4.1. Determinants of diarrheal illness

In this study, children of educated older mothers aged between 25 years and 50 years were less likely to present with diarrhea. Similar to the Vietnamese study in rural communities [24] and the Saudi Arabian study in an urban city [25], the younger caregivers had a lower level of understanding of the causes and symptoms of diarrhea and so their children are at a higher risk of illness. These observations were also usually linked with low educational levels.

Educational status is a determinant of the socioeconomic influences on the health status of the child through the economic potential of the mother. This is a good indicator of the available health care that can be used for childcare as demonstrated by the effect of education irrespective of level—primary or secondary—being protective for childhood diarrhea. The enlightenment received by the mother influences all care decisions including health-care decisions that are made by the mother [26]. A more literate mother is likely to be more receptive of health education messages, translating them to enhance the health of household members including the young child. Unlike other similar studies [27,28] that have not been able to show a significant association between maternal education and the risk of childhood diarrhea, this study demonstrated the importance of maternal education in determining the risk of disease in this population subgroup.

The significantly increased risk of diarrheal illness in children between the ages of 2 months and 36 months is due to the protective effect of breastfeeding in younger infants. Breastfeeding has been shown to be protective against infectious disease more so when the children are exclusively breastfed [29]. Older children are more readily influenced by negative environmental influences compared to younger children (<2 months of age). In this study, the different types of toilet facilities for eight out of 10 households were either open defecation or pit latrines, which are propagators of diarrheal illnesses (Table 3). This is an important finding because it reinforces the need for environmental modification in the health awareness intervention that is a major part of diarrhea control at the primary level of health care. Pit latrines and open defecation methods of fecal disposal are associated with environmental contamination and this in addition to the increased mobility of children at this age, who are either crawling or walking, increases the risk of infection and thus diarrheal illness. This finding, like the Lagos study by Ekanem et al. [9] and the Ibadan study by Oloruntoba et al. [30], which also showed a significant association between the use of unimproved toilet facilities and the occurrence of childhood diarrhea in younger children, illustrates the importance of improving sanitation in the prevention of diarrheal illness.

Unexpectedly, children who had completed immunization for their ages were at a higher risk of illness. Information on completeness of immunization was collected using the sighting of immunization cards, which was not always present even when caregivers reported that children had completed immunizations for age. This may have underestimated the number of children who had completed their immunizations for age.

4.2. Gaps in care provisions for diarrhea

At the primary level, recommended care for children who presented with diarrheal illness was variable depending on the presenting symptoms and signs as outlined in the protocol of management, however, the majority of caregivers accessed care outside the home mainly because of their perception of the health education messages they had received. The ability of caregivers to recognize symptoms and signs of disease has been highlighted in timely care seeking, however in this study, caregivers were not able to recognize danger symptoms of dehydration that would encourage treatment to be given appropriately.

Although other studies [14,31,32] have argued that the caregiver’s perception of the cause of illness is a major determinant of the choice of care sought, in this study, the knowledge of causes or symptoms of diarrhea was not significantly associated with care seeking avenues used. The observed difference from one area to another may be due to local variations in the delivery of health care interventions at the local level; however, the delivery of interventions (health education and awareness drive) was outside the scope of this investigation. The examination of determinants of care is an important consideration because it underscores the fact that recommended care will have to be modified to local factors influencing the choice of care for childhood diarrhea. These factors include, but are not limited to cultural interactions, differential income generation, and the relative availability of alternative health care providers like local drug store, traditional healers and the religious organizations. Integrating care at the local level to include these alternative care providers requires the recognition and standardization of the care offered for child health and this can be done at the local level. This will strengthen the health care system for the provision of child health care services to improve the delivery of care for childhood diarrhea.

Unlike the investigation of health care seeking in a hospital based cohort in Shagamu, Nigeria [33], maternal factors of age and education were not found to significantly influence the care seeking pattern of caregivers. This is observed even though the majority (73%) of the respondents sought care outside the home at the onset of the illness, mainly because the health education messages they perceived directed them to do this.

Appendix A.

See Table A1.