Population modifiable risk factors associated with under-5 acute respiratory tract infections and diarrhoea in 25 countries in sub-Saharan Africa (2014-2021): an analysis of data from demographic and health surveys

Kedir Y Ahmed; Abel F Dadi; Getiye Dejenu Kibret; Habtamu Mellie Bizuayehu; Tahir A Hassen; Erkihun Amsalu; Daniel Bekele Ketema; Zemenu Yohannes Kassa; Meless G Bore; Animut Alebel; Addisu Alehegn Alemu; Jemal E Shifa; Cheru Tesema Leshargie; Subash Thapa; Syed Haris Omar; Allen G Ross

doi:10.1016/j.eclinm.2024.102444

Population modifiable risk factors associated with under-5 acute respiratory tract infections and diarrhoea in 25 countries in sub-Saharan Africa (2014-2021): an analysis of data from demographic and health surveys

EClinicalMedicine. 2024 Feb 3:68:102444. doi: 10.1016/j.eclinm.2024.102444. eCollection 2024 Feb.

Authors

Kedir Y Ahmed¹, Abel F Dadi^{2

3}, Getiye Dejenu Kibret^{4

5}, Habtamu Mellie Bizuayehu⁶, Tahir A Hassen⁷, Erkihun Amsalu^{8

9}, Daniel Bekele Ketema^{10

11}, Zemenu Yohannes Kassa^{12

13}, Meless G Bore^{13

14}, Animut Alebel⁴, Addisu Alehegn Alemu^{15

16}, Jemal E Shifa¹³, Cheru Tesema Leshargie^{4

11}, Subash Thapa¹, Syed Haris Omar¹⁷, Allen G Ross¹

Affiliations

¹ Rural Health Research Institute, Charles Sturt University, Orange, NSW 2800, Australia.
² Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia.
³ Addis Continental Institute of Public Health, Addis Ababa, Ethiopia.
⁴ Faculty of Health, School of Public Health, University of Technology Sydney, Ultimo, NSW, Australia.
⁵ Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Australia.
⁶ First Nations Cancer and Wellbeing (FNCW) Research Program, School of Public Health, The University of Queensland, Australia.
⁷ Center for Women's Health Research, College of Health, Medicine and Wellbeing, The University of Newcastle, NSW, Australia.
⁸ Faculty of Medicine and Health, Sydney Medical School, University of Sydney, Australia.
⁹ St. Paul Hospital Millennium Medical College, Addis Ababa, Ethiopia.
¹⁰ The George Institute for Global Health, University of New South Wales (UNSW), Sydney, Australia.
¹¹ School of Public Health, College of Medicine and Health Science, Debre Markos University, Ethiopia.
¹² College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia.
¹³ School of Nursing and Midwifery, University of Technology Sydney, Sydney, Australia.
¹⁴ School of Nursing, College of Medicine and Health Science, Hawassa University, Hawassa, Ethiopia.
¹⁵ School of Women's and Children's Health, University of New South Wales Sydney, Kensington, Australia.
¹⁶ College of Medicine and Health Science, Debre Markos University, Ethiopia.
¹⁷ School of Dentistry and Medical Sciences, Charles Sturt University, Orange, NSW 2800, Australia.

Abstract

Background: Identifying the critical modifiable risk factors for acute respiratory tract infections (ARIs) and diarrhoea is crucial to reduce the burden of disease and mortality among children under 5 years of age in sub-Saharan Africa (SSA) and ultimately achieving the Sustainable Development Goals (SDGs). We investigated the modifiable risk factors of ARI and diarrhoea among children under five using nationally representative surveys.

Methods: We used the most recent demographic and health survey (DHS) data (2014-2021) from 25 SSA countries, encompassing a total of 253,167 children. Countries were selected based on the availability of recent datasets (e.g., DHS-VII or DHS-VIII) that represent the current socioeconomic situations. Generalised linear latent mixed models were used to compute odds ratios (ORs). Population attributable fractions (PAFs) were calculated using adjusted ORs and prevalence estimates for key modifiable risk factors among ARI and diarrhoeal cases.

Findings: This study involved 253,167 children, with a mean age of 28.7 (±17.3) months, and 50.5% were male. The highest PAFs for ARI were attributed to unclean cooking fuel (PAF = 15.7%; 95% CI: 8.1, 23.1), poor maternal education (PAF = 13.4%; 95% CI: 8.7, 18.5), delayed initiation of breastfeeding (PAF = 12.4%; 95% CI: 9.0, 15.3), and poor toilets (PAF = 8.5%; 95% CI: 4.7, 11.9). These four modifiable risk factors contributed to 41.5% (95% CI: 27.2, 52.9) of ARI cases in SSA. The largest PAFs of diarrhoea were observed for unclean cooking fuel (PAF = 17.3%; 95% CI: 13.5, 22.3), delayed initiation of breastfeeding (PAF = 9.2%; 95% CI: 7.5, 10.5), household poverty (PAF = 7.0%; 95% CI: 5.0, 9.1) and poor maternal education (PAF = 5.6%; 95% CI: 2.9, 8.8). These four modifiable risk factors contributed to 34.0% (95% CI: 26.2, 42.3) of cases of diarrhoea in SSA.

Interpretation: This cross-sectional study identified four modifiable risk factors for ARI and diarrhoea that should be a priority for policymakers in SSA. Enhancing home-based care and leveraging female community health workers is crucial for accelerating the reduction in under-5 mortality linked to ARI and diarrhoea in SSA.

Funding: None.

Keywords: Acute respiratory tract infections; Children; Diarrhoea; Modifiable risk factors; Population attributable fractions; Sub-Saharan Africa.