Factors contributing to regional inequalities in acute respiratory infections symptoms among under-five children in Nigeria: a decomposition analysis

Burden and outcome of respiratory morbidities among children and adolescents with sickle cell disease-A retrospective review of emergency presentations in some Nigerian tertiary institutions

BACKGROUND

Despite the huge burden of sickle cell disease (SCD) among Nigerian children, the burden and outcome of respiratory illnesses remain undocumented. Thus, we aimed to describe the spectrum and outcome of respiratory illnesses among SCD childrenand adolescentadmissions in ten Nigerian tertiary hospitals.

METHOD

A retrospective review of the SCD admission records of children and adolescents with a confirmed diagnosis of respiratory illnesses from 2012 to 2021 in ten tertiary health facilities across five geopolitical zones in Nigeria was conducted. The data, collectedbetween March and June 2023, included the age, sex, diagnosis, complications, duration and outcome of hospitalization.

RESULTS

Of the 72,333 paediatric admissions, 7,256 (10.0%) had SCD; the proportion of SCD from the total admission ranged from 2.1 to 16.3% in the facilities. Of the 7,256 children and adolescents with SCD, 1,213 (16.7%) had respiratory morbidities. Lower respiratory disease was the most common (70.0%) respiratory entity and the majority were pneumonia (40.1.0%), followed by acute chest syndrome (26.7%). Seventeen (1.4%) patients died; all had lower respiratory diseases [(acute chest syndrome ACS (11, 64.7%), pneumonia; 5, 29.4%, and asthma (1, 5.9%). Based on the proportion of deaths among overall SCD, the 17 death cases contributed 9.4% (95% CI 5.9 to 14.5). Factors associated with deaths included duration of hospitalization less than 72 hours and lower respiratory tract diseases.

CONCLUSION

Sickle cell disease is a major contributor to hospitalization among Nigerian children and adolescents, with high respiratory morbidity and mortality. Pneumonia and acute chest syndrome were associated with mortality, andthe highest risk of death within the first 72 hours.

Application of a count regression model to identify the risk factors of under-five child morbidity in Bangladesh

BACKGROUND

Bangladesh has seen a significant decline in child mortality in recent decades, but morbidity among children <5 y of age remains high. The aim of this analysis was to examine trends and identify risk factors related to child morbidity in Bangladesh.

METHODS

This analysis is based on data from four successive cross-sectional Bangladesh Demographic and Health Surveys for the years 2007, 2011, 2014 and 2017-18. Several count regression models were fitted and the best model was used to identify risk factors associated with morbidity in children <5 y of age.

RESULTS

According to the results of the trend analysis, the prevalence of non-symptomatic children increased and the prevalence of fever, diarrhoea and acute respiratory infections (ARIs) decreased over the years. The Vuong's non-nested test indicated that Poisson regression could be used as the best model. From the results of the Poisson regression model, child age, sex, underweight, wasted, stunting, maternal education, wealth status, religion and region were the important determinants associated with the risk of child morbidity. The risk was considerably higher among women with a primary education compared with women with a secondary or greater education in Bangladesh.

CONCLUSIONS

This analysis concluded that child morbidity is still a major public health problem for Bangladesh. Thus it is important to take the necessary measures to reduce child morbidity (particularly fever, diarrhoea and ARI) by improving significant influencing factors.

Re-examining the Nexus Between Maternal Smoking Behavior and Under-Five Children's ARI in India: A Comprehensive Study

Background

The burden of acute respiratory infections (ARIs) among children under-five is a serious concern in lower and middle-income countries (LMICs), including India, where it is positively associated with indoor smoking exposures. This study re-examines the impact of maternal smoking on ARIs among children under 5 in India, considering other indoor air pollutant factors and covariates. The aim is to establish existing findings and capture any differentials in results using comprehensive analytical approaches.

Methods

Data from the National Family Health Survey (NFHS-5), 2019 - 21, was used. Descriptive statistics, bivariate analysis, multivariable logistic regression models, and interaction analysis were applied to accomplish the study objective.

Results

The adjusted likelihood of ARI was 1.24 (95% CI: 1.04-1.48) times higher in under-five children with smoking mothers than those with non-smoking mothers. The result was also observed to be almost similar across all seasons. Moreover, the combined effect of maternal smoking with other household members smoking and using unclean cooking fuel without a separate ventilated kitchen escalated the risk (AOR: 2.01; 95% CI: 1.98-2.67). Breastfeeding was found to be a preventive measure for reducing the risk of indoor smoking exposure. The children who were never breastfed and were born large or small were more susceptible to maternal smoking.

Conclusion

The study highlights the association between maternal smoking and ARIs in Indian under-five children. Interventions include reducing maternal smoking, promoting breastfeeding, and improving respiratory health in fuel-exposed households.

Acute lower respiratory infections among children under five in Sub-Saharan Africa: a scoping review of prevalence and risk factors

BACKGROUND

Acute lower respiratory tract infections (ALRTIs) among children under five are still the leading cause of mortality among this group of children in low and middle-income countries (LMICs), especially countries in sub-Saharan Africa (SSA). This scoping review aims to map evidence on prevalence and risk factors associated with ALRTIs among children under 5 years to inform interventions, policies and future studies.

METHODS

A thorough search was conducted via four main databases (PubMed, JSTOR, Web of Science and Central). In all, 3,329 records were identified, and 107 full-text studies were considered for evaluation after vigorous screening and removing duplicates, of which 43 were included in this scoping review.

FINDINGS

Findings indicate a high prevalence (between 1.9% to 60.2%) of ALRTIs among children under five in SSA. Poor education, poverty, malnutrition, exposure to second-hand smoke, poor ventilation, HIV, traditional cooking stoves, unclean fuel usage, poor sanitation facilities and unclean drinking water make children under five more vulnerable to ALRTIs in SSA. Also, health promotion strategies like health education have doubled the health-seeking behaviours of mothers of children under 5 years against ALRTIs.

CONCLUSION

ALRTIs among children under five still present a significant disease burden in SSA. Therefore, there is a need for intersectoral collaboration to reduce the burden of ALRTIs among children under five by strengthening poverty alleviation strategies, improving living conditions, optimising child nutrition, and ensuring that all children have access to clean water. There is also the need for high-quality studies where confounding variables in ALRTIs are controlled.

Associations Between Indoor Air Pollutants and Risk Factors for Acute Respiratory Infection Symptoms in Children Under 5: An Analysis of Data From the Indonesia Demographic Health Survey

OBJECTIVES

The study investigated the association between indoor air pollution (IAP) and risk factors for acute respiratory infection (ARI) symptoms in children under 5 years of age.

METHODS

A cross-sectional study was conducted using data derived from Indonesia Demographic and Health Survey in 2017. Binary logistic regression modeling was employed to examine each predictor variable associated with ARI among children under 5 years of age in Indonesia.

RESULTS

The study included a total of 4936 households with children. Among children under 5 years old, 7.2% reported ARI symptoms. The presence of ARI symptoms was significantly associated with the type of residence, wealth index, and father's smoking frequency, which were considered the sample's socio-demographic characteristics. In the final model, living in rural areas, having a high wealth index, the father's smoking frequency, and a low education level were all linked to ARI symptoms.

CONCLUSIONS

The results revealed that households in rural areas had a substantially higher level of reported ARI symptoms among children under 5 years old. Furthermore, the father's smoking frequency and low education level were associated with ARI symptoms.

Multivariate Assessment of Vaccine Equity in Nigeria: A VERSE Tool Case Study using Demographic and Health Survey 2018

Nigeria experiences wide heterogeneity in vaccination rates by vaccine and region. However, inequities in vaccination status extend beyond just geographic covariates. Traditionally, inequity is represented by a single metric pertaining to socioeconomic status. A growing body of literature suggests that this view is limiting, and a multi-factor approach is necessary to comprehensively evaluate relative disadvantage between individuals. The Vaccine Economics Research for Sustainability and Equity (VERSE) tool produces a composite equity metric, which accounts for multiple factors influencing inequity in vaccination coverage. We apply the VERSE tool to Nigeria's 2018 Demographic and Health Survey (DHS) to cross-sectionally evaluate equity in vaccination status for national immunization program (NIP) vaccines over the following contributing covariates: age of child, sex of child, maternal education level, socioeconomic status, health insurance status, state of residence, and urban or rural designation. We also assess equity for zero-dose, fully immunized for age, and completion of NIP. Results show that socioeconomic status contributes substantially to variation vaccination coverage, but it is not the most substantial factor. For all vaccination statuses, except for NIP completion, maternal education level is the greatest contributor towards a child's immunization status among model variables. We highlight the outputs for zero-dose, fully immunized at infancy, MCV1 and PENTA1. The percentage point gap in vaccination status between the top and bottom quintiles of disadvantage, as ranked by the composite indicator is 31.1 (29.5-32.7) for zero-dose status, 53.1 (51.3-54.9) for full immunization status, 48.9 (46.9-50.9) for MCV1, and 67.6 (66.0-69.2) for PENTA1. Though concentration indices indicate inequity for all statuses, full immunization coverage is very low at 31.5% suggesting significant gaps in reaching children after initial doses for routine immunizations. Applying the VERSE tool to future Nigeria DHS surveys can allow decisionmakers to track changes in vaccination coverage equity, in a standardized manner, over time.

Socio-ecological determinants of under-five mortality in Nigeria: exploring the roles of neighbourhood poverty and use of solid cooking fuel

Globally, despite the decline in under-five mortality rate from 213 per 1000 live births in 1990 to 132 per 1000 live births in 2018, the pace of decline has been slow, and this can be attributed to poor progress in child survival interventions, including those aimed at reducing children's exposure to household pollution. This study examined the influence of neighbourhood poverty and the use of solid cooking fuels on under-five mortality in Nigeria. Data for the study comprised a weighted sample of 124,442 birth histories of childbearing women who reported using cooking fuels in the kitchens located within their house drawn from the 2018 Nigeria Demographic and Health Survey. Descriptive and analytical analyses were carried out, including frequency tables, Pearson's chi-squared test and multivariate analysis using a Cox proportional regression model. The results showed that the risk of under-five mortality was significantly associated with mothers residing in areas of high neighbourhood poverty (HR: 1.44, CI: 1.34-1.54) and the use of solid cooking fuels within the house (HR: 2.26, CI: 2.06-2.49). Government and non-governmental organizations in Nigeria should initiate strategic support and campaigns aimed at empowering and enlightening mothers on the need to reduce their use of solid cooking fuels within the house to reduce harmful emissions and their child health consequences.

Understanding the rural-urban disparity in acute respiratory infection symptoms among under-five children in Sub-Saharan Africa: a multivariate decomposition analysis

Background

Acute Respiratory Infections (ARIs) account for more than 6% of the worldwide disease burden in children under the age of five, with the majority occurring in Sub-Saharan Africa. Rural children are more vulnerable to and disproportionately affected by ARIs. As a result, we examined the rural–urban disparity in the prevalence of ARI symptoms and associated factors among children under the age of five in Sub-Saharan Africa.

Methods

We used the most recent Demographic and Health Survey (DHS) data from 36 countries in Sub-Saharan Africa. The study included 199,130 weighted samples in total. To identify variables associated with ARIs symptoms, a multilevel binary logistic regression model was fitted. The Adjusted Odds Ratio (AOR) with a 95% CI was used to determine the statistical significance and strength of the association. To explain the rural–urban disparity in ARI prevalence, a logit-based multivariate decomposition analysis was used.

Results

Being female, ever breastfeeding, belonging to a poorer, better wealth status, and having better maternal educational status were significantly associated with lower odds of ARIs among under-five children. Whereas, small size or large size at birth, not taking vitamin A supplementation, being severely underweight, having diarrhea, didn’t have media exposure, never had the vaccination, being aged 36–47 months, and being aged 48–59 months were significantly associated with higher odds of ARIs among under-five children. The multivariate decomposition analysis revealed that the difference in characteristics (endowment) across residences explained 64.7% of the overall rural–urban difference in the prevalence of ARIs, while the difference in the effect of characteristics (change in coefficient) explained 35.3%.

Conclusion

This study found that rural children were highly affected by ARIs in SSA. To reduce the excess ARIs in rural children, public health interventions aimed at impoverished households, home births, and unvaccinated and malnourished children are crucial.

Spatial Co-Morbidity of Childhood Acute Respiratory Infection, Diarrhoea and Stunting in Nigeria

In low- and middle-income countries, children aged below 5 years frequently suffer from disease co-occurrence. This study assessed whether the co-occurrence of acute respiratory infection (ARI), diarrhoea and stunting observed at the child level could also be reflected ecologically. We considered disease data on 69,579 children (0–59 months) from the 2008, 2013, and 2018 Nigeria Demographic and Health Surveys using a hierarchical Bayesian spatial shared component model to separate the state-specific risk of each disease into an underlying disease-overall spatial pattern, common to the three diseases and a disease-specific spatial pattern. We found that ARI and stunting were more concentrated in the north-eastern and southern parts of the country, while diarrhoea was much higher in the northern parts. The disease-general spatial component was greater in the north-eastern and southern parts of the country. Identifying and reducing common risk factors to the three conditions could result in improved child health, particularly in the northeast and south of Nigeria.

A multilevel analysis of the social determinants associated with symptoms of acute respiratory infection among preschool age children in Pakistan: A population-based survey

BACKGROUND

As advocated by WHO in "Closing the Health Gap in a Generation", dramatic differences in child health are closely linked to degrees of social disadvantage, both within and between communities. Nevertheless, research has not examined whether child health inequalities include, but are not confined to, worse acute respiratory infection (ARI) symptoms among the socioeconomic disadvantaged in Pakistan. In addition to such disadvantages as the child's gender, maternal education, and household poverty, the present study also examined the linkages between the community environment and ARI symptoms among Pakistan children under five. Furthermore, we have assessed gender contingencies related to the aforementioned associations.

METHODS

Using data from the nationally representative 2017-2018 Pakistan Demographic and Health Survey, a total of 11,908 surviving preschool age children (0-59 months old) living in 561 communities were analyzed. We employed two-level multilevel logistic regressions to model the relationship between ARI symptoms and individual-level and community-level social factors.

RESULTS

The social factors at individual and community levels were found to be significantly associated with an increased risk of the child suffering from ARI symptoms. A particularly higher risk was observed among girls who resided in urban areas (AOR = 1.42; p<0.01) and who had a birth order of three or greater.

DISCUSSIONS

Our results underscore the need for socioeconomic interventions in Pakistan that are targeted at densely populated households and communities within urban areas, with a particular emphasis on out-migration, in order to improve unequal economic underdevelopment. This could be done by targeting improvements in socio-economic structures, including maternal education.

Determinants of Acute Respiratory Infection Among Children Under-Five Years in Indonesia

BACKGROUND

Acute respiratory infection (ARI) among children under five years has been identified as a risk factor for child morbidity, leading to child mortality in Indonesia. Many factors may cause ARI; however, determinants associated with ARI remain unclear in Indonesia.

OBJECTIVES

This study sought to analyze the determinants of ARI among children aged under five years in Indonesia.

METHODS

This study was cross-sectional and utilized secondary data from the 2017 Indonesian Demographic and Health Survey (IDHS). A total of 15,993 children under five years old were selected as respondents. Chi-squared test and binary logistic regression were used to examine the determinants of ARI among children under five years in Indonesia.

RESULTS

Children aged 1 year [Odds Ratio (OR) = 1.43, 95% CI = 1.04-1.97], children aged 2 years [OR = 1.54, 95% CI = 1.12-2.11], mother's occupation [OR = 1.24, 95% CI = 1.01-2.154], poorest wealth index [OR = 1.91, 95% CI = 1.26-2.89], poor [OR = 1.50, 95% CI = 1.01-2.21], region of residence: Western Indonesia [OR = 1.96, 95% CI = 1.28-2.00], Middle of Indonesia [OR = 2.19, 95% CI = 1.44-3.33] were significantly associated with ARI among children under five years in Indonesia.

CONCLUSIONS

This study revealed that the determinants of ARI among children under five years in Indonesia remain related to the socio-demographic aspect. This research highlighted that the family's and the living area's wealth index remains essential in improving children's health outcomes.

PRACTICE IMPLICATIONS

Our findings support increasing awareness of the low-income family through adequate information and health promotion. Advancing the feasibility, accessibility, and affordability of health information and health services across all Indonesian regions should be strengthened.

Childhood morbidity and its determinants: evidence from 31 countries in sub-Saharan Africa

Background

Although under-five mortality reduced globally from 93 per 1000 live births in 1990 to 39 in 2018, sub-Saharan Africa witnessed an increase from 31% in 1990 to 54% in 2018. Morbidity has been reported to contribute largely to these deaths. This study examined the factors that are associated with childhood morbidity in sub-Saharan Africa.

Methods

Demographic and Health Surveys of 31 countries in sub-Saharan Africa were used in this study. The study involved 189 069 children who had or did not have fever, cough or diarrhoea in the 2 weeks preceding the surveys. Descriptive statistics and binary logistic regression were applied in the analysis.

Results

About 22% of the children suffered from fever, 23% suffered from cough and 16% suffered from diarrhoea. While the odds of experiencing fever increased by 37% and 18%, respectively, for children from poorest and poorer households, children of women aged 15–24 and 25–34 years are 47% and 23%, respectively, more likely to experience diarrhoea. The probability of suffering from morbidity increased for children who are 12–23 months, of higher order birth, small in size at birth and from households with non-improved toilet facility.

Conclusions

This study has shown that childhood morbidity remains a major health challenge in sub-Saharan Africa with socioeconomic, maternal, child’s and environmental factors playing significant roles. Efforts at addressing this problem should consider these factors.

The burden and risks of pediatric pneumonia in Nigeria: A desk-based review of existing literature and data

BACKGROUND

Pneumonia is a leading killer of children under-5 years, with a high burden in Nigeria. We aimed to quantify the regional burden and risks of pediatric pneumonia in Nigeria, and specifically the states of Lagos and Jigawa.

METHODS

We conducted a scoping literature search for studies of pneumonia morbidity and mortality in under-5 children in Nigeria from 10th December 2018 to 26th April 2019, searching: Cochrane, PubMed, and Web of Science. We included grey literature from stakeholders' websites and information shared by organizations working in Nigeria. We conducted multivariable logistic regression using the 2016 to 2017 Multiple Cluster Indicators Survey data set to explore factors associated with pneumonia. Descriptive analyses of datasets from 2010 to 2019 was done to estimate trends in mortality, morbidity, and vaccination coverage.

RESULTS

We identified 25 relevant papers (10 from Jigawa, 8 from Lagos, and 14 national data). None included data on pneumonia or acute respiratory tract infection burden in the health system, inpatient case-fatality rates, severity, or age-specific pneumonia mortality rates at state level. Secondary data analysis found that no household or caregiver socioeconomic indicators were consistently associated with self-reported symptoms of cough and/or difficulty breathing, and seasonality was inconsistently associated, dependant on region.

CONCLUSION

There is a clear evidence gap around the burden of pediatric pneumonia in Nigeria, and challenges with the interpretation of existing household survey data. Improved survey approaches are needed to understand the risks of pediatric pneumonia in Nigeria, alongside the need for investment in reliable routine data systems to provide data on the clinical pneumonia burden in Nigeria.

Social inequality and pneumonia hospitalization in children under five years of age in Maranhão, Brazil

Abstract Objectives: to describe the characteristics of pneumonia hospitalizations in children under five years of age across the State of Maranhão, Brazil, and explore patterns of spatial distribution of admissions. Methods: ecological study using data on occurrences (age, gender, skin color/race, month of occurrence, and municipality of residence) between 2012 and 2017 taken from the Unified Health System’s Hospital Information System and municipal level socioeconomic indicators for 2010. Each respiratory disease, including pneumonia, was presented as a percentage of overall admissions for respiratory tract diseases, together with the monthly distribution of admissions as a percentage of total annual cases, and annual rate of admissions by gender. The General G* statistic was calculated to identify significant clustering of municipalities with similar proportions of hospital admissions for pneumonia relative to overall hospital admissions. Results: pneumonia was the leading cause of admissions for respiratory disease, accounting for 57% of all cases and occurring with greater frequency in the rainy season (February to June) and in cities with lower socioeconomic indicator values. The rate of admissions decreased over the study period. Significant clusters (p<0.05) of municipalities with high proportions of hospital admissions for pneumonia relative to overall hospital admissions occurred predominantly in the south of the state, while clusters with low propor-tions were located mainly in and around the metropolitan region of the state capital São Luís. Conclusions: pneumonia was shown to be a key cause of hospitalization in children and its distribution was associated with contextual socioeconomic factors, reflecting the quality of life and health status of children in Maranhão.

Respiratory symptoms and associated risk factors among under-five children in Northwest, Ethiopia: community based cross-sectional study

Introduction

Acute respiratory infections are still a major public health problem resulting in morbidity and mortality among under-five children. This study aims to assess the extent of respiratory symptoms and associated risk factors among under-five children in Gondar city, Northwest Ethiopia.

Methods

A community-based cross-sectional study was carried out from February to June 2019. From 792 study participants, data were collected via face to face interviews by using a semi-structured pre-tested questionnaire. Data were entered in Epi Info version 7, then exported to Stata 14.00 for analysis. Binary (Bivariable and Multivariable) logistic regression analysis was used to test the association of explanatory and outcome variables. Variables with p<0.05 were considered as significantly associated with the outcome variable.

Results

The prevalence of respiratory symptoms among under-five children was 37.5% at [95% (CI: 34.3-41)]. Uterine irritability during pregnancy [AOR = 1.89 at 95% CI: (1.11-3.23)], physical exercise during pregnancy [AOR = 0.60 at 95% CI: (0.41-0.89)], using wood and coal for heating [AOR = 2.42 at 95% CI: (1.65-3.53)], cockroaches infestation [AOR = 1.95 at 95% CI: (1.36 – 2.90)], presence of new carpets [AOR = 2.38 at 95% CI: (1.33-4.29)], damp stain [AOR = 2.45 at 95% CI: (1.02-2.69)], opening windows during cooking [AOR = 0.58 at 95% CI: (0.36-0 .93)], living less than 100 m heavy traffic [AOR = 1.94 at 95% CI: (1.16-3.27)], and living less than 100 m (unpaved roads/streets) [AOR= 2.89 at 95% CI: (1.89-4.55)] were significantly associated with respiratory symptoms.

Conclusion

The prevalence of respiratory symptoms among under-five children was relatively high in the study area. Personal and environmental characteristics influencing symptom occurrence were identified. Respiratory symptoms will be minimized by reducing exposure to indoor and outdoor air pollution and enhancing housing quality.

Associations between Indoor Air Pollution and Acute Respiratory Infections among Under-Five Children in Afghanistan: Do SES and Sex Matter?

Background: Low-income families often depend on fuels such as wood, coal, and animal dung for cooking. Such solid fuels are highly polluting and are a primary source of indoor air pollutants (IAP). We examined the association between solid fuel use (SFU) and acute respiratory infection (ARI) among under-five children in Afghanistan and the extent to which this association varies by socioeconomic status (SES) and gender. Materials and Methods: This is a cross-sectional study based on de-identified data from Afghanistan’s first standard Demographic and Health Survey (DHS) conducted in 2015. The sample consists of ever-married mothers with under-five children in the household (n = 27,565). We used mixed-effect Poisson regression models with robust error variance accounting for clustering to examine the associations between SFU and ARI among under-five children after adjusting for potential confounders. We also investigated potential effect modification by SES and sex. Additional analyses were conducted using an augmented measure of the exposure to IAP accounting for both SFU and the location of cooking/kitchen (High Exposure, Moderate, and No Exposure). Results: Around 70.2% of households reported SFU, whereas the prevalence of ARI was 17.6%. The prevalence of ARI was higher in children living in households with SFU compared to children living in households with no SFU (adjusted prevalence ratio (aPR) = 1.10; 95% CI: (0.98, 1.23)). We did not observe any effect modification by SES or child sex. When using the augmented measure of exposure incorporating the kitchen’s location, children highly exposed to IAP had a higher prevalence of ARI compared to unexposed children (aPR = 1.17; 95% CI: (1.03, 1.32)). SES modified this association with the strongest associations observed among children from the middle wealth quintile. Conclusion: The findings have significant policy implications and suggest that ARI risk in children may be reduced by ensuring there are clean cookstoves as well as clean fuels and acting on the socio-environmental pathways.

Do fuel type and place of cooking matter for acute respiratory infection among Afghan children? Evidence from the Afghanistan DHS 2015

In Afghanistan, acute respiratory infection (ARI) is a leading cause of under-five mortality. Previous studies on the effects of cooking fuel on ARI have only looked at the types of cooking fuel, and not the effects of the location of the cooking place. The present study aimed to assess the effects of fuel type and place of cooking on the prevalence of ARI among under-five children in Afghanistan. Descriptive statistics and multilevel logistic regression analysis were performed for 31,063 children using data from the first round of the Afghanistan Demographic and Health Survey conducted in 2015. Overall, 13% of the children suffered from ARI symptoms in the 2 weeks before the survey, but this varied widely across the country. The multilevel analysis showed that, compared with households using clean cooking fuel in a separate building or outside, households using clean cooking fuel within the house and without a separate kitchen had a 32% lower risk [95% confidence interval (CI)=0.51-0.91] of having under-five children with ARI, and those using clean fuel in a separate kitchen in the house had a 17% lower risk (95% CI=0.67-1.03). On the other hand, households using polluting cooking fuel in the house without a kitchen had a 14% (95% CI=0.91-1.44) higher risk of having under-five children with ARI, and those using polluting cooking fuel in the house with a separate kitchen had a 5% (95% CI=0.85-1.30) higher risk, after adjusting for other covariates. The findings indicate that type of cooking fuel is not the only issue affecting ARI in children. Place of cooking (in a house with or without a separate kitchen versus outside) also affects the risk of ARI among under-five children. The study also found that mother's education and occupational status, community poverty and ethnicity are other important factors affecting the prevalence of ARI in under-five children in Afghanistan.