Prevalence and determinants of diarrhea and acute respiratory infections among children under five in Somalia: A nationally representative study

Abstract

Diarrhea and acute respiratory infections (ARI) remain the leading infectious causes of morbidity and mortality among children under five globally, particularly in fragile and conflict-affected states like Somalia. Despite this high burden, nationally representative epidemiological data remain scarce. The objective of this study was to determine the prevalence and overlapping socio-demographic, maternal, and environmental determinants of diarrhea and ARI among children under five in Somalia. We conducted a secondary analysis of the 2020 Somali Demographic and Health Survey (SDHS), a nationally representative cross-sectional survey. The study included a weighted sample of 13,802 children under five years of age. The primary outcomes were maternal-reported diarrhea and ARI symptoms in the two weeks preceding the survey. Bivariate analyses and multivariable binary logistic regression models, adjusted for the complex survey design, were utilized to identify independent predictors. Results were reported as adjusted odds ratios (aOR) with 95% confidence intervals (CI). The two-week prevalence of diarrhea and ARI symptoms was 5.3% (95% CI: 4.7–6.0) and 2.9% (95% CI: 2.4–3.4), respectively. Multivariable analysis revealed that older maternal age (30–44 years) was protective against diarrhea compared to adolescent mothers (15–19 years). For ARI, children in urban (aOR = 2.13; 95% CI: 1.26–3.60) and nomadic (aOR = 1.65; 95% CI: 1.13–2.41) settings, as well as those in wealthier household quintiles, had higher odds of symptoms compared to those in rural and the poorest households. Unimproved sanitation facilities also increased ARI risk (aOR = 1.46; 95% CI: 1.00–2.14). Counterintuitively, home delivery was associated with lower odds of both diarrhea (aOR = 0.50; 95% CI: 0.38–0.66) and ARI (aOR = 0.51; 95% CI: 0.35–0.74) compared to health facility delivery. The determinants of childhood diarrhea and ARI in Somalia are complex and challenge conventional public health assumptions. The observed "urban penalty" and increased risk among wealthier households highlight the adverse health impacts of rapid, unplanned urbanization and inadequate sanitation infrastructure. Targeted interventions focusing on adolescent mothers, urban water, sanitation, and hygiene (WASH) infrastructure, and infection prevention and control within health facilities are strongly recommended to reduce preventable child morbidity.