Regional variations and determinants of acute respiratory infection in Ethiopian children under five years: a multilevel analysis

BACKGROUND: Acute respiratory infection (ARI) remains the leading cause of morbidity and mortality among children under five years worldwide. However, in Ethiopia, evidence on the distribution and determinants of ARI is limited. This study aimed to assess the geographical distribution and determinants of ARI among Ethiopian children under five years. METHODS: A nationwide community-based cross-sectional study was conducted from September to December 2022. Mothers with at least one child under five years were selected using a two-stage stratified cluster sampling approach. Data were collected through face-to-face interviews using structured questionnaires. A total of 8747 mothers were included in the analysis. Multilevel logistic regression was employed to identify determinants of ARI. Four models were fitted, and the model with the lowest Deviance Information Criterion (DIC) and Akaike Information Criterion (AIC) values was selected as the best-fitting model. RESULTS: The 2-week prevalence of ARI among children under five was 21.3% (95% CI 20.5-22.2). The highest prevalence was observed in the Tigray region (36.1%), while the lowest was reported in Oromia (9.1%). Higher odds of ARI were observed among children aged 6-12 months (AOR = 1.6; 95% CI 1.1-2.3) and those older than 12 months (AOR = 1.5; 95% CI 1.1-2.1), children not vaccinated with PCV3 (AOR = 1.5; 95% CI 1.2-1.8), and children with diarrhea (AOR = 2.9; 95% CI 2.4-3.4) or malaria (AOR = 6.8; 95% CI 5.5-8.5). Children from households in the second (AOR = 1.3; 95% CI 1.1-1.6) and fourth (AOR = 1.3; 95% CI 1.1-1.6) wealth quintiles also had increased odds of ARI. Conversely, children living at very high altitudes had lower odds of ARI (AOR = 0.6; 95% CI 0.4-0.9). Vaccination coverage was suboptimal, with only 81.1%, 71.3%, and 64.5% of eligible children receiving PCV3, measles vaccine, and vitamin A supplementation, respectively. CONCLUSION: ARI remains a major public health problem among Ethiopian children under five years, with marked regional variation in prevalence. Both individual- and household/community-level factors significantly influence ARI risk. Strengthening targeted interventions, particularly improving vaccination coverage and addressing socio-economic disparities, is essential for reducing the burden of ARI.