With the sixth largest population on earth, Bangladesh has the eighth largest population in poverty [1
], and the highest percentage of the population below the national poverty line among all South Asian countries [2
]. Since its independence in 1971, the country has made remarkable strides in reducing extreme poverty and promoting key population health indicators such as maternal and child mortality, and providing access to basic public health services [3
]. Bangladesh continues to face overwhelming challenges in meeting the basic healthcare needs of the population. The situation is particularly challenging among vulnerable groups of the population, such as women and children [5
]. According to the United Nations International Children’s Emergency Fund (UNICEF), about half of all Bangladeshi children (~33 million) are living in poverty, with one-quarter being deprived of basic needs including food, education, health, and sanitation [9
]. The impact of economic poverty on child health is further aggravated by chronic water and sanitation insecurity among the disadvantaged populations [10
]. The World Health Organization (WHO) has estimated that 60% of the population in Bangladesh lacks access to improved sources of water and sanitation [14
]. The persisting water and sanitation poverty represent a serious challenge for promoting child health in Bangladesh [10
The entrenched economic, water, and sanitation poverty is reflected in the high burden of infectious diseases of poverty such as acute respiratory infections (ARIs), which represent the largest share of disease burden in Bangladesh [18
]. ARIs, as a group of diseases, are classified as upper or lower respiratory tract infections whose negative effects can include infection, inflammation, and reduced lung function [19
]. ARIs are the most common causes of morbidity and mortality among under-five children (except for neonates) [19
]. Evidence from studies in India and sub-Saharan African countries suggests that poverty influences child health and disease outcomes, including ARIs, through various direct and indirect pathways [22
]. For many poor households in Bangladesh, especially in rural areas, lack of electricity and clean fuel are common concerns that are circumvented by the use of biomass fuel such as coal, solid domestic waste, dried leaves and wood, and often kerosene [26
]. Biomass fuel burning is known to be a major cause of indoor air pollution because of the organic material emissions, such as nitrogen oxides, carbon monoxide, and hazardous air pollutants (HAPs), which thereby contribute to the higher burden of ARIs [27
]. However, no research evidence has been published on these associations among under-five children in Bangladesh. To address this research gap, in the present study, we analysed several nationally-representative datasets from the Bangladesh Demographic and Health Survey. The main objective was to measure the prevalence of ARIs among under-five children during the last two decades. We examined sociodemographic patterns in the prevalence of ARIs, with special focus on household wealth status and lack of improved water and sanitation facilities.
Acute respiratory infections (ARIs) are a leading cause of morbidity and mortality among under-five children in low-income countries like Bangladesh. Evidence suggests that in 1997–2001, ARIs including pneumonia were major contributors to hospitalization (40%) among under-five children at primary public care facilities in rural Bangladesh [35
]. The findings of the present study are in line with the existing evidence that a remarkable proportion of the under-five children in Bangladesh continue to suffer from ARIs. As the findings indicate, the prevalence of fever and dyspnea has increased over the last 15 years, especially among children aged three to five years old. During 1997–2014, the overall prevalence has slowly but steadily risen, despite a net decline in the prevalence among infants (<12 months). Although previous studies reported significant sex differentials in childhood morbidity and mortality in Bangladesh [34
], the present study suggests that the male-female disparity is not significant for ARIs.
A high ARI burden was reported in several sub-national studies among South Asian children including Bangladesh (72% in 2001, urban slums of Dhaka) [37
] and India (59.1% in 2013–2014, Puducherry) [38
]. ARI-attributed mortality rates were found to be high in Nepal (20–30%) [39
] and Pakistan (20–30%) [40
]; however, corresponding estimates are currently not available for Bangladesh. Existing studies suggest that the health impacts of the high disease burden among South Asian children are further exacerbated by sub-optimal care seeking behavior, especially among the poorest households [41
]. In light of the past and current findings, ARIs remain a common health issue among under-five children in Bangladesh, which requires urgent attention from public health stakeholders.
Apart from the high prevalence, the findings also highlight the significant demographic and socioeconomic pattern in the occurrence of ARIs. The odds of fever or dyspnea did not differ noticeably across maternal age groups; however, being an older child appeared to be a protective factor against both fever and dyspnea. Maternal community level factors, such as rural residency and certain regional disparities, were observed in the odds of fever. For instance, compared to those based in Barishal district, the odds of fever were lower in Khulna but higher in Rajshahi, whereas the odds of dyspnea were lower in Rajshahi only. However, the association between region and ARIs was not consistent across the districts. Regarding maternal socioeconomic characteristics, having higher education and living in higher wealth quintile households were inversely associated with fever and dyspnea, indicating a protective effect of better maternal socioeconomic status (SES) on child’s experience of ARIs.
The beneficial effect of higher SES on child’s health outcomes is generally attributed to better living conditions, better nutritional status, and access to healthcare services. Parental material hardship can affect child health and exposure to illness through various pathways. For instance, financial stress is strongly correlated with child undernutrition, poor cognitive development, and weakened immune system, so can increase the vulnerability to infectious diseases. Children in financially well-off families are more likely to enjoy healthy and secure living facilities with greater access to health-promoting conditions in comparison to those from impoverished families [43
]. Several other environmental aspects of poverty, such as inability to afford improved water, sanitation, and hygiene facilities (WASH) and clean cooking fuel, are also strong predictors of acute illnesses due to their link with important risk factors such as of fecal contamination of food, drinking water, utensils, and child’s toys [44
This study reported the prevalence of ARIs among under-five children in Bangladesh, and their association with maternal and household socioeconomic indicators using nationally representative samples. Th information generated from this study should increase the awareness about this ever-growing health issue and help policy makers to implement appropriate policy measures. Our findings have the potential to inspire national WASH and poverty reduction policies in an effort to improve child poverty-reduction and health-promotion strategies. Bangladesh is also a highly disaster-prone country and is vulnerable to climate change, which are important risk factors for ARIs [45
]. Growing evidence in this area of public health can help with the development of effective planning, coping, and intervention mechanisms. Apart from our important contributions, our study has several limitations. First, the symptoms of ARIs were reported by mothers and were not the result of objective measurement. The variables were self-reported, and are hence subject to reporting bias. Second, there were no data available on household hygiene practices, which is a key predictor of infectious diseases among populations of all ages. There were no data on whether the children were suffering from any specific illness; therefore, it is possible that the symptoms of fever and dyspnea resulted from conditions other than ARIs. However, this gap is expected to be overcome, to a great extent, by the inclusion of water and sanitation variables. Lastly, the data were secondary, and thus no causal inferences can be made about the associations.
Since 1997, there has been a slow but steady increase in the prevalence of ARI symptoms, such as fever and dyspnea, among under-five children in Bangladesh. Apart from the high prevalence, our study provides several important findings regarding the socioeconomic predictors of these conditions that might be of interest for child health- and WASH-related stakeholders in the country. Higher maternal educational status and employment status showed protective effects against suffering from fever. As expected, lack of improved WASH facilities was significantly associated higher odds of ARI. Of particular concern was the higher burden of ARIs in households in the lower wealth quintiles. Given these findings, we suggest that child-health-related sustainable development programs in Bangladesh should try to emphasize maternal socioeconomic status and ensuring better environmental conditions, such as optimum WASH coverage and use of clean fuel, especially among the most marginalised communities. More studies are required to investigate the broader macroeconomic and sociocultural factors that may underlie the constantly high prevalence of ARIs among under-five children.