Skip to main content
PMC home page
Global Pediatric Health logoLink to Global Pediatric Health
. 2022 Mar 21;9:2333794X221078700. doi: 10.1177/2333794X221078700

Multilevel Analysis of Lifestyle and Household Environment for Toddlers With Symptoms of Acute Respiratory Infection (ARI) in Indonesia in 2007, 2012, and 2017

Leka Lutpiatina 1,2,✉, Lilis Sulistyorini 1, Hari Basuki Notobroto 1, Reynie Purnama Raya 3,4, Ricko Darmadji Utama 2, Anny Thuraidah 2
PMCID: PMC8941706  PMID: 35342776

Abstract

Introduction. The morbidity and mortality rate of Acute Respiratory Tract Infection (ARI) in children under 5 is relatively high in Indonesia. Socio-demographic characteristic is considered one of the factors causing ARI in Indonesia. However, no study analyzed the prevalence of ARI among toddlers and the differences among the determinant factors in multiple periods. Thus, this study aimed to analyze the prevalence trends and determinant factors associated with ARI symptoms in children under 5 in Indonesia in 2007, 2012, and 2017. Methods. This study analyzed cross-sectional survey data from the Demographic and Health Survey (DHS) in Indonesia during 2007, 2012, and 2017. Bivariate and multivariate analysis with logistic regression was performed using Stata version 15. The final results were expressed in Adjusted Odds Ratio (AORs) and 95% Confidence Interval (CI). Results. The findings showed a progress in prevalence trends with a decrease in the percentage of children with ARI symptoms from 11.25% (2007), then 5.12% (2012) to 4.22% (2017). Risk factors for toddlers experiencing ARI symptoms were as follows: younger maternal age (OR: 1.13, 95% Cl 0.70-1.81 in 2007, OR: 1.72, 95% Cl 1.03-2.88 in 2012 and OR: 0.98, 95% Cl 0.48-1.97 in 2017), smoking habits of family members (OR: 1.12, 95% Cl 0.85-1.48 in 2012, OR: 1.23, 95% Cl in 2017), poor drinking water quality (OR: 1.12, 95% Cl 0.85-1.48 in 2012 and OR: 1.23, 95% Cl in 2017), unavailable toilet facilities (OR: 1.27, 95% Cl 1.04-1.56 in 2007, OR: 1.24, 95% Cl 0.95-1.63 in 2012 and OR: 1.28, 95% Cl 0.97-1.68 in 2017). Conclusion. There was a decrease in the prevalence of ARI symptoms among children in 2007, 2012, and 2017, with no prominent differences in other related factors. The lifestyle and household environmental factors such as the use of dirty fuel, the presence of smokers in the household, the poor quality of drinking water, unavailable toilet facilities in addition to the maternal age and child age were the determinant factors that must be prioritized and improved. Family self-awareness should also be enhanced for better prospects for toddler survival.

Keywords: ARI under 5 in Indonesia, lifestyle factors, household environmental factors, DHS 2007, 2012, 2017

Introduction

Acute Respiratory Infection (ARI) is considered one of the global leading causes of death among children under 5, especially in developing countries. An uncontrolled increase in population density was associated with a less organized community in terms of social, cultural, and health aspects. 1 This condition could affect toddlers especially in families with low socioeconomic status or below the poverty line due to low intake of nutritious food and the inappropriate housing environment. 2

The morbidity and mortality rate of ARI is relatively high, especially among toddlers. 3 ARI is one of the leading causes of death in children under 5 (16%). High incidence of mortality was recorded mainly in South Asia and Africa. 4 The percentage of ARI among children under 5 was 12.8% in Indonesia, with the highest distribution in 5 provinces: East Nusa Tenggara (18.6%), Banten (17.7%), East Java (17.2%), Bengkulu (16.4%), and Kalimantan Middle (15.1%). 5

ARI could be linked to the lifestyles of toddlers and their household environments. A study showed the relationship between ARI among children under 5 and other factors such as smoking habits of family members, use of mosquito coils, occupancy density, and nutritional status. 32 Furthermore, a study conducted in Nigeria stated that ARI incidence was related to population density, residential density, air pollution, and environmental sanitation. 6 Moreover, a study conducted in Eastern Indonesia showed that ARI incidence was associated with the mother’s low level of knowledge about child care, excusive breastfeeding, being exposed to cigarette smoke, and improper householding due to poverty. 7 Another study in the slums of Dibrugarh City mentioned that ARI incidence among toddlers was related to exclusive breastfeeding level, immunization, socio-economic characteristics, and air pollution level. 8

A study in Indonesia showed the 25% of children under 5 experiencing ARI symptoms did not receive the required health service and medical treatment. 9 Another study also analyzed the determinants of ARI among children under 5 in Indonesia. 10 However, neither study assessed the progress related to ARI prevalence among toddlers nor compared the influence of ARI determinant factors in 2007, 2012, and 2017 in Indonesia. That is why this study aimed to analyze the difference in both prevalence and determinant factors of ARI among children under 5 in 2007, 2012, and 2017 in Indonesia.

Method and Material

Data Source

The study analyzed cross-sectional surveys (Indonesian Demographic and Health Survey, IDHS 2007, 2012, and 2017). A large-scale study estimated fertility, mortality, family planning, maternal and child healthcare services, and other relevant indicators across Indonesia at the national level. The IDHS data were obtained from several government agencies, such as the Indonesian Ministry of Health, the National Population and Family Planning Agency, and the Central Statistics Agency.

IDHS had a stratified 2-stage sampling design for both rural and urban areas. Some census blocks were selected by systematic probability proportional to the size of the household. Then, 25 households were chosen from each census block. After that, data were collected using interview forms, including household, male, female, and village forms.

Methodology

Both bivariate and multivariate analyses were used. Bivariate analysis showed the relationship between the study variables and children with ARI symptoms. Logistic regression was used in the multivariate analysis to show the influence of the characteristics of children, mothers, and households; besides relevant socio-economic and demographic variables on children with ARI symptoms. Data using Stata version 15 were presented in adjusted odds ratios (AORs) and 95% confidence intervals (CI).

Result Variable

In IDHS, children with ARI symptoms (dependent variable) were identified using the women’s health questionnaire by asking eligible mothers (15-49 years) about the respiratory health of their children aged 0 to 59 months. Mothers were asked if their under-5 children had a cough during the last 2 weeks. If yes, mothers were asked whether their children were suffered from shortness of breath and rapid breathing due to fever. Children who met all of the abovementioned criteria were considered having ARI symptoms and coded with a value of 1 while children who did not meet the criteria were coded with a value of 0.

Variable Explanation

The study variables included the characteristics of children, mothers, and households, besides the theoretical relevant socio-economic and demographic characteristics. The characteristics of children were sex, age category (under 1, 1-2, and 3-4 years), the birth order (1-2, 3-4, and more than 4), children who were given vitamin A in the last 6 months and children who were given deworming medicine in the last 6 months.

The characteristics of mothers included the maternal age category (15-19, 20-24, 25-29, 30-34, 35-39, 40-44, and 45-49 years), the mother’s education level (no school, not completed the first and second level of education, completed the first and second level of education and higher education), and the mother’s employment status.

The characteristics of households included wealth quintiles (from poorest to richest), residence type (urban and rural), indoor smoking behavior of family members, area of residence (west, middle and east), cooking fuel (clean, unclean, and no food cooked), quality of drinking water source, handwashing habits and the availability of toilet facilities.

Ethical Approval

The study has ethical approval from the applied country Ethics Committee and ICF Macro. Research registration was carried out on the Demographic and Health Survey (DHS) website to obtain permission to use and analyze the data set.

Results

Table 1 shows the distribution and percentage of the dependent variable (children with ARI symptoms), and independent variables (the characteristics of children, mothers, and households; area of residence; wealth quintile; and type of residence) in 2007, 2012, and 2017 in Indonesia. The percentage of children with ARI declined from 11.25% in 2007, then 5.12% in 2012 to 4.22% in 2017. Thus, the results reflect the improvement of healthcare in Indonesia. Furthermore, supporting data indicated an increase in the percentage of both children receiving vitamin A in the last 6 months (63.08% in 2007, 57.42% in 2012, and 75.14% in 2017) and children receiving deworming medicine in the last 6 months (23.49% in 2012 and 36.56% in 2017). Supporting data also presented an increase in the percentage of mothers with a higher level of education (7.61% in 2007, 12.69% in 2012, and 15.21% in 2017). They also stated an increase in the percentage of using clean cooking fuel (19.18% in 2007, 57.03% in 2012, and 77.05% in 2017), family members who did not smoke at home (19.13% in 2007, 23.7 4% in 2012 and 76.26% in 2017), availability of toilet facilities (73.95% in 2007, 82.54% in 2012, 90.38% in 2017).

Table 1.

Socio-Demographic Characteristics of Participants in 2007, 2012, and 2017.

Variables 2007 2012 2017
N % N % N %
Child characteristics
Children with ARI symptoms
 Yes 2120 11.25 950 5.12 744 4.22
 No 15 436 88.75 15 813 94.88 15 879 95.78
Sex
 Male 9156 51.89 8669 50.93 8520 50.78
 Female 8310 48.11 8094 49.07 8103 49.22
Age
 Under 1 years old 3642 21.17 3462 20.99 3205 19.12
 1-2 years old 6833 39.21 6695 40.24 6698 40.44
 3-4 years old 6991 39.62 6606 38.78 6720 40,44
Child birth order
 1st-2nd 10 515 63.66 10 913 69.69 10 635 68.69
 3rd-4th 4890 26.27 4299 22.99 4686 25.82
 More than 4th 2061 10.07 1551 7.32 1302 5.5
Child who received Vitamin A in last 6 months
 Yes 10 781 63.08 9058 57.42 12 073 75.14
 No 5949 32.97 5889 31.49 4225 23.07
 Don’t know 736 3.96 1816 11.09 325 1.8
Child who received the intestinal drug in last 6 months
 Yes N/A N/A 3899 23.49 5578 36.56
 No N/A N/A 12 727 75.77 10 879 62.48
 Don’t know N/A N/A 137 0.74 166 0.96
Mother characteristics
Age in years
 15-19 515 2.77 525 2.87 394 2.23
 20-24 3454 20.53 3138 18.9 2549 16.18
 25-29 5001 28.15 4729 27.83 4247 25.63
 30-34 4282 23.95 4116 24.48 4427 26.42
 35-39 2879 16.96 2843 17.2 3315 19.83
 40-44 1090 6.11 1192 7.19 1395 7.99
 45-49 245 1.53 220 1.51 296 1.72
Education level
 No education 739 3.43 510 2.05 240 1.08
 Incomplete primary 2343 12.21 1662 8.43 1158 6.25
 Complete primary 4513 28.87 3457 23.35 2968 19.49
 Incomplete secondary 4262 25.04 4241 26.41 4283 28.29
 Complete secondary 4263 42.63 4630 27.07 5021 29.68
 Higher 761 7.61 2263 12.69 2953 15.21
Mother’s occupation
 Not working 8874 51.44 7723 46.83 7865 49.29
 Working 8592 48.56 9040 53.17 8758 50.71
Household characteristics
Wealth quintile
 Poorest 5308 22.79 5008 21.6 4517 20.08
 Poorer 3479 19.60 3362 19.41 3266 20.17
 Middle 3044 19.62 3030 19.46 3087 20.46
 Richer 2877 19.25 2826 20.4 2929 20.18
 Richest 2758 18.74 2537 19.13 2824 19.11
Place of residence
 Rural 10 818 58.31 9086 50.24 8425 51.34
 Urban 6648 41.69 7677 49.76 8198 48.66
Region of residence
 West of Indonesia 9932 78.80 9710 80.02 9880 80.3
 Middle of Indonesia 5571 18.64 5154 16.87 5090 16.5
 East of Indonesia 1963 2.56 1899 3.11 1653 3.2
Cooking fuel
 Clean fuel 11.09 1918 7291 57.03 11 248 77.05
 Unclean fuel 88.80 15 510 9436 42.73 5355 22.85
 No Food cooked 0.11 38 36 0.24 20 0.11
Smoking pattern of house member inside the house
 Yes N/A N/A 13 778 80.87 13 029 76.26
 No N/A N/A 2985 19.13 3594 23.74
Quality of drinking water source
 Good 11 078 64.58 8669 57.73 9785 63.52
 Bad 6388 35.42 8094 42.27 6838 36.48
Handwashing habit
 Observed N/A N/A 16 235 97.76 15 573 94.47
 Not Observed N/A N/A 528 2.24 1050 5.53
Availability of toilet facilities
 Available 12 290 73.95 13 500 82.54 14 858 90.38
 Not available 5176 26.05 3263 17.46 1765 9.62
n Total 17 466 16 763 16 623
Open in a new tab

Source: Indonesia Demographic and Health Survey; IDHS 2007, 2012 and 2017.

Table 2 presents that age had a significant effect on the susceptibility of ARI symptoms among children aged (1-2 years) as follows: 13.6% in 2007, 5.87 % in 2012, and 4.89 % in 2017. Furthermore, data showed that mothers with low education had higher susceptibility to having children with ARI symptoms. For mothers who did not complete their first level of education, the percentage of children with ARI symptoms was as follows: 14.19 % in 2007, 7.53% in 2012, and 5.67 % in 2017. The better the maternal education, the less the possibility of experiencing ARI symptoms among their children. The percentage of mothers with higher education who had children with ARI symptoms was as follows: 9.16 % in 2007, 3.33% in 2012, and 3.73% in 2017. Moreover, the results presented that the wealth quintile was a significant variable. The children had better facilities in the richer families reducing the risk of experiencing ARI symptoms. The percentage of children with ARI symptoms among the richest families was as follows: 8.68% in 2007, 3.59% in 2012, and 2.99% in 2017. Data also showed that the central part of Indonesia had the highest percentage of children with ARI symptoms as follows: 13.00 % in 2007, 6.63% in 2012, and 5.09% in 2017. Cooking fuel was also a significant factor as data showed that the percentage of children with ARI symptoms in families who cooked with dirty fuel was high: 11.62% in 2007, 6.2% in 2012, and 5.08% in 2017. The unavailability of toilet facilities was also associated with a higher percentage of children with ARI as follows:14.37 % in 2007, 7.13% in 2012, and 6.73% in 2017.

Table 2.

The Relationship Between the Characteristics of Children and Mothers, Geographical Location, and Household Characteristics With the Status of Children With ARI Symptoms in 2007, 2012, and 2017 in Indonesia.

Characteristic 2007 2012 2017
Children with ARI symptoms Children without ARI Symptoms P-value Children with ARI symptoms Children without ARI symptoms P-value Children with ARI symptoms Children without ARI symptoms P-value
n %¥ n %¥ n %¥ n %¥ n %¥ n %¥
Child characteristic
Sex of child
 Male 1168 11.79 7988 88.21 .151 545 5.69 8124 94.31 .0146* 397 4.46 8123 95.54 .1854
 Female 952 10.67 7358 89.33 405 4.53 7689 95.47 347 3.96 7756 96.04
Age of child
 Under 1 years old 385 9.2 3257 90.8 .000* 157 4.11 3305 95.89 .0191* 105 3.12 3100 96.88 .0036*
 1-2 years old 972 13.6 5861 86.4 441 5.87 6254 94.13 349 4.89 6349 95.11
 3-4 years old 763 10.02 6228 89.98 352 4.89 6254 95.11 290 4.06 6430 95.94
Child birth order
 1st-2nd 1265 11.4 9250 88.6 .475 588 4.66 10 325 95.34 .0025* 473 4.17 10 302 95.83 .7087
 3rd-4th 608 11.38 4282 88.62 277 6.54 4022 93.46 205 4.21 4481 95.79
 More than 4th 247 9.94 1814 90.06 85 5.05 1466 94.95 66 4.85 1236 95.15
Child who received Vitamin A in last 6 months
 Yes 1332 11.55 9449 88.45 .6497 552 5.67 8506 94.33 .0133* 566 4.23 11 647 95.77 .0666
 No 726 10.81 5223 89.19 299 4.39 5590 95.61 171 4.42 4054 95.58
 Don’t know 62 10.19 674 89.81 99 4.34 1717 95.66 7 1.2 318 98.8
Child who received an intestinal drug in last 6 months
 Yes N/A N/A N/A N/A N/A 231 5.93 3688 94.07 .2906 275 4.45 5303 95.55 .4422
 No N/A N/A N/A N/A 715 4.87 11 992 95.13 467 4.11 10 552 95.89
 Don’t know N/A N/A N/A N/A 4 5.15 133 94.85 2 2.23 164 97.77
Mother characteristic
Age of mother in years
 15-19 75 12.20 440 87.80 .169 49 7.12 476 92.88 .1245 17 4.47 377 95.53 .2761
 20-24 501 12.67 2953 87.33 178 4.92 2960 95.08 136 4.68 2413 95.32
 25-29 599 11.74 4402 88.26 285 5.85 4444 94.15 200 4.34 4047 95.66
 30-34 487 10.52 3795 89.48 225 4.58 3891 95.42 201 4.59 4226 95.41
 35-39 321 10.86 2558 89.14 141 4.81 2702 95.19 124 3.46 3191 96.54
 40-44 113 8.78 977 91.22 63 5.32 1129 94.68 58 3.95 1337 96.05
 45-49 24 7.25 221 92.75 9 1.74 211 98.26 8 2.02 288 97.98
Mother’s level of education
 No education 97 15.5 642 84.50 .021* 28 5.62 482 94.38 .0006* 15 5.7 225 94.3 .0147*
 Incomplete primary 372 14.19 1971 85.81 121 7.53 1541 92.47 62 5.67 1096 94.33
 Complete primary 582 11.47 3931 88.53 216 5.19 3241 94.81 162 5.11 2806 94.89
 Incomplete secondary 524 10.34 3738 89.66 274 5.86 3967 94.14 201 4.3 4082 95.7
 Complete secondary 430 10.46 3833 89.54 218 4.39 4412 95.61 183 3.44 4838 96.56
 Higher 115 9.16 1229 90.84 93 3.33 2170 96.67 121 3.73 2832 96.27
Mother’s occupation
 Not working 1023 10.53 7851 89.47 .059 404 4.73 7319 95.27 .141 318 3.88 7547 96.12 .106
 Working 1097 12.01 7495 87.99 546 5.47 8494 94.53 426 4.54 8332 95.46
Household characteristic
Wealth quintile
 Poorest 787 13.86 4521 86.14 .001* 343 6.79 4665 93.21 .0002* 279 6.21 4238 93.79 .0000*
 Poorer 470 12.66 3009 87.34 223 6.04 3139 93.96 156 4.94 3110 95.06
 Middle 338 10.56 2706 89.44 155 4.89 2875 95.11 113 3.39 2974 96.61
 Richer 297 9.92 2580 90.08 131 4.13 2695 95.87 107 3.51 2822 96.49
 Richest 228 8.68 2530 91.32 98 3.59 2439 96.41 89 2.99 2735 97.01
Place of residence
 Rural 1414 11.93 9404 88.07 .088 566 5.88 8520 94.12 .0038* 428 4.6 7997 95.4 .0619
 Urban 706 10.30 5942 89.70 384 4.36 7293 95.64 316 3.81 7882 96.19
Region of residence
 West of Indonesia 1169 10.93 8763 89.07 .005* 532 4.88 9178 95.12 .0001* 402 4.1 9478 95.9 .0038*
 Middle of Indonesia 794 13.00 4777 87.00 357 6.63 4797 93.37 283 5.09 4807 94.91
 East of Indonesia 157 8.46 1806 91.54 61 3.04 1838 96.96 59 2.57 1594 97.43
Cooking fuel
 Clean fuel 162 8.38 1756 91.62 .008* 356 4.28 6935 95.72 .0018* 469 3.97 10 919 96.03 .0171*
 Unclean fuel 1958 11.62 13 572 88.38 592 6.2 8844 93.8 274 5.08 5081 94.92
 No food cooked 0 0 18 100 2 12.67 34 87.33 1 1.1 19 98.9
Smoking pattern of House member inside the house
 Yes N/A N/A N/A N/A N/A 810 5.33 12 968 94.67 .0864 625 4.52 12 544 95.48 .081
 No N/A N/A N/A N/A 140 4.24 2845 95.76 119 3.26 3475 96.74
Quality of drinking water source
 Good 1268 10.57 9810 89.43 .037* 463 4.5 8206 95.5 .0032* 406 4.01 9379 95.99 .2030
 Bad 852 13.31 5536 86.69 487 5.96 7607 94.04 338 4.57 6500 95.43
Handwashing habit
 Observed N/A N/A N/A N/A N/A 923 5.12 15 312 94.88 .9560 697 4.17 15 016 95.83 .3157
 Not observed N/A N/A N/A N/A 27 5.19 501 94.81 47 5.05 1003 94.95
Availability of toilet facilities
 Available 1367 10.15 10 923 89.85 .000* 704 4.7 12 796 95.3 .0001* 628 3.95 14 370 96.05 .0000*
 Not available 753 14.37 4423 85.63 246 7.13 3017 92.87 116 6.73 1649 93.27
Open in a new tab

Source: Indonesia Demographic and Health Survey; IDHS 2007, 2012, and 2017.

¥Proportions are weighted.

*

P-value <.05.

Table 3 showed the multivariate analysis for the dependent variable (children with ARI symptoms) with independent variable. Female children had a lower probability of experiencing ARI symptoms than male ones (OR: 0.89, 95% Cl 0.77-1.04 in 2007, OR: 0.79, 95% Cl 0.65-0.96 in 2012 and OR: 0.87 95% Cl 0.72-1.05 in 2017). Children in the 3rd and 4th born order had a higher risk of experiencing ARI symptoms (OR: 1.02, 95% Cl 0.84-1.25 in 2007, OR: 1.59, 95% Cl 1.25-2.02 in 2012 and OR: 1.12, 95% Cl 0.86-1.47 in 2017). Younger maternal age (15-19 years) was significantly associated with a higher risk of having children experiencing ARI symptoms (OR: 1.13, 95% Cl 0.70-1.81 in 2007, OR: 1.72, 95% Cl 1.03-2.88 in 2012 and OR: 0.98, 95% Cl 0.48-1.97 in 2017). On the other hand, the oldest maternal age group (45-49 years) was accompanied by a lower risk of having children with ARI symptoms (OR: 0.59, 95% Cl 0.27-1.30 in 2007, OR: 0.28, 95% Cl 0.12-0.65 in 2012 and OR: 0.35, 95% Cl 0.15-0.84 in 2017). Moreover, children of non-working mothers had lower risk of ARI symptoms (OR: 0.87, 95% Cl 0.74-1.02 in 2007, OR: 0.83, 95% Cl 0.67-1.02 in 2012 and OR: 0.80, 95% Cl 0.65-0.99 in 2017). Children in the richest families had low risk of experiencing ARI symptoms (OR: 0.77, 95% Cl 0.54-1.09 in 2007, OR: 0.83, 95% Cl 0.54-1.29 in 2012 and OR: 0.61, 95% Cl 0.42-0.89 in 2017). In Eastern Indonesia, children had low possibility of experiencing ARI symptoms (OR: 0.65, 95% Cl 0.49-0.86 in 2007, OR: 0.46, 95% Cl 0.29-0.73 in 2012 and OR: 0.48, 95% Cl 0.31-0.75 in 2017). Using of unclean cooking fuel was associated with a higher risk of experiencing ARI symptoms among children (OR: 1.15, 95% Cl 0.82-1.63 in 2007, OR: 0.89, 95% Cl 0.70-1.11 in 2012 and OR: 1.09, 95% Cl 0.85-1.40 in 2017). Children of smoker family members were more prone to experience ARI symptoms (OR: 1.12, 95% Cl 0.85-1.48 in 2012 and OR: 1.23, 95% Cl in 2017). Drinking water with bad quality was associated with higher vulnerability to ARI symptoms among children (OR: 1.02, 95% Cl 0.85-1.24 in 2007, OR: 1.21, 95% Cl 0.99-1.48 in 2012 and OR: 1.06, 95% Cl 0.85-1.32 in 2017). Unavailable toilet facilities were also related to a higher risk of children experiencing ARI symptoms (OR: 1.27, 95% Cl 1.04-1.56 in 2007, OR: 1.24, 95% Cl 0.95-1.63 in 2012 and OR: 1.28, 95% Cl 0.97-1.68 in 2017).

Table 3.

Prediction of Children With ARI Symptoms in 2007, 2012, and 2017 in Indonesia.

Variable 2007 2012 2017
OR 95% CI OR 95% CI OR 95% CI
Lower Upper Lower Upper Lower Upper
Child characteristic
Sex
 Male 1.00 1.00 1.00
 Female 0.89 0.77 1.04 0.79* 0.65 0.96 0.87 0.72 1.05
Age
 Under 1 year old 0.66*** 0.54 0.82 0.78 0.58 1.05 0.61*** 0.45 0.82
 1-2 years old 1.00 1.00 1.00
 3-4 years old 0.071*** 0.59 0.85 0.83 0.67 1.02 0.82 0.66 1.01
Child birth order
 1st-2nd 1.00 1.00 1.00
 3rd-4th 1.02 0.84 1.25 1.59*** 1.25 2.02 1.12 0.86 1.47
 More than 4th 0.84 0.61 1.16 1.28 0.85 1.94 1.29 0.86 1.94
Child who received Vitamin A in last 6 months
 Yes 1.00 1.00 1.00
 No 0.94 0.76 1.16 0.76** 0.61 0.94 1.15 0.89 1.48
 Don’t know 0.86 0.55 1.35 0.76 0.57 1.03 0.29 0.78 1.13
Child who received the intestinal drug in last 6 months
 Yes N/A N/A N/A 1.19 0.92 1.53 1.08 0.87 1.33
 No N/A N/A N/A 1.00 1.00
 Don’t know N/A N/A N/A 1.19 0.27 5.26 0.96 0.18 5.19
Mother characteristic
Age in years
 15-19 1.13 0.70 1.81 1.72* 1.03 2.88 0.98 0.48 1.97
 20-24 1.21 0.94 1.55 1.17 0.83 1.63 1.04 0.78 1.39
 25-29 1.13 0.91 1.41 1.39* 1.08 1.80 0.97 0.74 1.27
 30-34 1.00 1.00 1.00
 35-39 1.04 0.81 1.34 0.92 0.67 1.27 0.69* 0.51 0.95
 40-44 0.82 0.56 1.19 0.98 0.61 1.57 0.76 0.51 1.14
 45-49 0.59 0.27 1.30 0.28** 0.12 0.65 0.35* 0.15 0.84
Education Level
 No education 1.61 0.96 2.62 1.00 0.52 1.94 1.11 0.56 2.20
 Incomplete primary 1.36* 1.04 1.79 1.17 0.81 1.68 1.12 0.73 1.71
 Complete primary 1.09 0.86 1.37 0.83 0.64 1.09 1.10 0.82 1.48
 Incomplete secondary 1.00 1.00 1.00
 Complete secondary 1.13 0.90 1.42 0.86 0.64 1.14 0.92 0.71 1.19
 Higher 1.09 0.72 1.64 0.70 0.47 1.05 1.08 0.77 1.51
Mother’s occupation
 Not working 0.87 0.74 1.02 0.83 0.67 1.02 0.80* 0.65 0.99
 Working 1.00 1.00 1.00
Household characteristic
Wealth quintile
 Poorest 1.01 0.79 1.29 0.95 0.71 1.28 1.26 0.94 1.68
 Poorer 1.00 1.00 1.00
 Middle 0.86 0.64 1.17 0.89 0.64 1.23 0.69* 0.49 0.95
 Richer 0.85 0.65 1.11 0.82 0.58 1.17 0.71 0.51 1.01
 Richest 0.77 0.54 1.09 0.83 0.54 1.29 0.61** 0.42 0.89
Place of residence
 Rural 1.00 1.00 1.00
 Urban 1.08 0.86 1.35 0.94 0.74 1.21 1.11 0.89 1.38
Region of residence
 West of Indonesia 1.00 1.00 1.00
 Middle of Indonesia 1.09 0.94 1.29 1.16 0.95 1.41 1.07 0.87 1.32
 East of Indonesia 0.65 0.49 0.86 0.46*** 0.29 0.73 0.48*** 0.31 0.75
Cooking fuel
 Clean fuel 1.00 0.89 0.70 1.11 1.09 0.85 1.40
 Unclean fuel 1.15 0.82 1.63 1.00 1.00
 No food cooked 1.00 N/A N/A 2.40 0.43 13.58 0.28 0.03 2.33
Smoking pattern of House member inside house
 Yes N/A N/A N/A 1.12 0.85 1.48 1.23 0.95 1.59
 No N/A N/A N/A 1.00 1.00
Drinking water source quality
 Good 1.00 1.00 1.00
 Bad 1.02 0.85 1.24 1.21 0.99 1.48 1.06 0.85 1.32
Handwashing habit
 Observed N/A N/A N/A 1.00 1.00
 Not observed N/A N/A N/A 0.83 0.48 1.44 0.89 0.59 1.32
Toilet facility
 Available 1.00 1.00 1.00
 Not available 1.27* 1.04 1.56 1.24 0.95 1.63 1.28 0.97 1.68
Open in a new tab

Source: Indonesia Demographic and Health Survey,2007, 2012 and 2017.

Proportions are weighted.

*

P-value < .05. **P-value < .01. ***P-value < .001.

The study showed a remarkable decline in the prevalence of ARI symptoms in children under 5 between 2012 and 2017 in Indonesia. The prevalence of children with ARI symptoms was significantly reduced from 5.12% in 2012 to 4.22% in 2017 (Table 1). This success was a result of the substantial progress of the Sustainable Development Goals (SDGs). The SDGs were created by the United Nations (UN) and promoted as a global goal for sustainable development. The SDGs declaration, among others, aims to reduce child mortality and improves maternal health. 11

The results in Table 1 approved the improvement in maternal and child healthcare from 2012 to 2017 in Indonesia, including the increase of the percentage of children receiving vitamin A in the last 6 months, children receiving deworming medicine in the previous 6 months, the rate of the education level of both college-level mothers and mothers who completed the secondary education level. Supporting data also showed the increase in the percentage of clean cooking fuel, family members who do not smoke at home, and drinking water of good quality.

Socio-demographic factors had a significant influence on the prevalence of ARI symptoms in toddlers in Indonesia. The results showed that ARI symptoms were most among children aged (1-2 years) in 2012 and 2017 (Table 2). This finding aligns with another research 12 in addition to basic health research showing that the highest ARI symptoms were among children aged 1 to 2 years (14.4%). 5 Children under 1 year had a low risk of infection as the parents usually keep them away from pollution. Moreover, babies are less vulnerable to ARI symptoms due to mothers’ compliance with exclusive breastfeeding along with complementary foods. Breastfeeding enhanced immunoglobulins of babies protecting them from ARI. 13 However, other studies opposed these results showing that children under 1 year had a higher risk of ARI symptoms. 14

The study showed that girls were less exposed to ARI symptoms compared to boys (Table 3). The data in 2012 and 2017 aligned with the results of previous research. 15 Similarly, basic health research in Indonesia showed that the percentage of girls under 5 experiencing ARI symptoms (12.4%) was less compared to boys (13.2%). 5 Boys like to move more outside and inside their homes exposing themselves to air pollution and increasing the risk of having lung infections.

The study revealed that younger maternal age (15-19 years) was significantly associated with a higher risk of having children experiencing ARI symptoms; similar results were approved in previous studies.14,16 Compared to older mothers, younger mothers may have less experience in caring for their children. Similarly, this study presented that children of the most senior maternal age group (45-49 years) had a lower risk of ARI symptoms in 2012 and 2017 (Table 3).

The results, mainly in 2017, showed that children of rich families were less vulnerable to ARI symptoms (Table 3). This is confirmed by other studies mentioning that the frequency and severity of ARI symptoms elevated along with poverty. 17 In addition, data showed that poverty was associated with improper toilet facilities, crowding, and chronic malnutrition. 17 In addition, poverty was linked to using both improper water sources 18 and unclean fuel. 19 Thus, the abovementioned factors could be considered as risk factors for experiencing ARI symptoms in children. This aligns with this study showing that dirty cooking fuel, inadequate drinking water quality, unavailable toilet facilities were associated with a higher risk of ARI symptoms in children (Table 3).

The study showed that children in families who use dirty cooking fuel had a high risk of developing ARI symptoms, although this relationship was not statistically significant (Table 3). However, the percentage of children with ARI symptoms was significantly higher in families using unclean cooking fuel in 2012 and 2017 as follows: 6.2% in 2012 and 5.08% in 2017 (Table 2). According to some literature, children who were exposed to smoke and lived in households that use dirty cooking fuel were more vulnerable to developing ARI symptoms compare to others who were not exposed to smoke and live in households using clean fuels.15,20 These results are consistent with previous research in Nigeria showing that dirty cooking fuel was a significant risk factor for experiencing ARI symptoms in children.6,21

In Indonesia, most households (72%) use clean fuel (liquefied petroleum gas or LPG). LPG is used more in urban areas (86%) than in rural areas (59%). While fewer households (23%) use dirty fuel (wood): 38% in rural areas, and 8% in urban areas. 31 This goes along with a study in Bangladesh showing that the risk of ARI symptoms in children is higher in households using solid fuels by 18%. 22 Similarly, in Afghanistan, children in families who cook with solid fuels were 1.19 times at risk of experiencing ARI than children from families that use cleaner fuels. 23 In Zimbabwe, the likelihood of developing ARI symptoms was more than double among children in households using solid fuels (ie, wood, dung, or straw) than others using cleaner fuels. 24 In Ethiopia, the children in households using high-polluting fuels were at a higher risk of experiencing ARI symptoms 3 times than others in families using low-polluting fuels. 25 Exposure to dirty fuels increases the risk of viral and bacterial infections caused by bronchial reactivity.

The study showed that toddlers of family members who smoke indoors had a higher risk of experiencing ARI symptoms, although this relationship was not statistically significant (Table 3); however, a study in Padang in Indonesia stated that this relation was significant among children under 5 . 26 Furthermore, the smoking patterns of family members were related to the incidence of ARI symptoms among toddlers in Surabaya, Indonesia. 27 Similarly, Tazinya et al 28 showed that families who smoke were at greater risk of experiencing ARI than non-smokers in a hospital in Cameroon. Choube et al 29 also stated that the incidence of ARI increased among toddlers whose family members smoke inside the home. Children as passive smokers are at high risk since their immune system is still weak.

Data in Eastern Indonesia, prominently, showed a low percentage of children with ARI symptoms in 2 years (Table 3). Geographically, Eastern Indonesia has a high distribution of islands and consists of Sulawesi, Maluku, Irian/Papua, West Nusa Tenggara, and East Nusa Tenggara. According to the Indonesian Statistical Agency, the population of Eastern Indonesia was less than other regions which may play a role in the low number of children with ARI symptoms. IDHS data collection took place from 24th July to 30th September 2017 (IDHS, 2017). However, according to the Indonesian Meteorology, Climatology, and Geophysics Agency, the dry season reached its peak in July to September 2017. This could be linked to the high number of ARI cases in Indonesia in 2017 since pathogenic microbes survive longer in the air in dry weather. In turn, pathogenic microbes can cause respiratory problems in children. 30

The main limitation of this study was the use of secondary data. Moreover, possible bias, related to the prevalence of ARI symptoms, could happen during data collection of mothers’ self-reported information. The data were cross-sectional, therefore a causal relationship between factors was not assessed. Moreover, the study did not assess the children who received intestinal drugs last 6 months, smoke patterns of family members, and handwashing habits from IDHS 2007.

The strength of this study was the ability to show the trend and progress in prevalence and factors associated with ARI symptoms among children under 5 in 2007, 2012, and 2017 in Indonesia. Demographic Health Survey (DHS) data has been validated, thus the results can be generalized. The DHS survey variables were defined in the same way in different countries to compare the results across countries.

Conclusion

This study approved the success of Indonesia in decreasing the prevalence of ARI symptoms among toddlers in 2007, 2012, and 2017 respectively with little differences in other related factors. Lifestyle and household environmental factors such as the use of dirty fuel, the presence of smokers in the household, the poor quality of drinking water, low availability of toilet facilities in addition to the maternal age and child age were all determinant factors that should be prioritized and improved. Health workers must immediately implement interventions especially for families with inadequate lifestyles and poor household environments. Moreover, family self-awareness should be enhanced for better prospects for toddler survival.

Acknowledgments

The authors thank the MEASURE DHS project for its support and for providing free access to the original data.

Footnotes

Author Contributions: Leka Lutpiatina: Conceptualization, Methodology, Data curation, Formal analysis, Writing - original draft, Writing - review & editing.

Lilis Sulistyorini: Conceptualization, Methodology, Data curation, Formal analysis, Writing - original draft, Writing - review & editing.

Hari Basuki Notobroto: Conceptualization, Methodology, Data curation, Formal analysis, Writing - original draft, Writing - review & editing.

Reynie Purnama Raya: Conceptualization, Methodology, Data curation, Formal analysis, Writing - review & editing.

Ricko Darmadji Utama: Conceptualization, Methodology, Data curation, Formal analysis, Writing - original draft, Writing - review & editing.

Anny Thuraidah: Methodology, Data curation, Formal analysis, Writing - review & editing.

Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD: Leka Lutpiatina Inline graphic https://orcid.org/0000-0003-3349-4978

References

  • 1. Adesanya OA, Chiao C. Environmental risks associated with symptoms of acute respiratory infection among preschool children in north-western and south-southern Nigeria communities. Int J Environ Res Public Health. 2017;14(11):1396. doi: 10.3390/ijerph14111396 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2. Kolawole O, Oguntoye M, Dam T, Chunara R. Etiology of respiratory tract infections in the community and clinic in Ilorin, Nigeria. BMC Res Notes. 2017;10(1):712. doi: 10.1186/s13104-017-3063-1 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3. Solomon OO, Odu OO, Amu EO, et al. Prevalence and risk factors of acute respiratory infection among under fives in rural communities of Ekiti state, Nigeria. Glob J Med Public Health. 2018;7(1):1-12. [Google Scholar]
  • 4. WHO. Pneumonia. World Health Organization. 2016. https://www.who.int/news-room/fact-sheets/detail/pneumonia [Google Scholar]
  • 5. Riskesdas. Laporan Nasional Riset Kesehatan Dasar 2018. Badan Penelitian dan Pengembangan Kesehatan Kementerian Kesehatan RI; 2018. [Google Scholar]
  • 6. Akinyemi JO, Morakinyo OM. Household environment and symptoms of childhood acute respiratory tract infections in Nigeria, 2003-2013: a decade of progress and stagnation. BMC Infect Dis. 2018;18(1):296. doi: 10.1186/s12879-018-3207-5 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7. Shibata T, Wilson J, Watson L, et al. Childhood acute respiratory infections and household environment in an eastern Indonesian urban setting. Int J Environ Res Public Health. 2014;11(12):12190-12203. doi: 10.3390/ijerph111212190 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 8. Nirmolia N, Mahanta TG, Boruah M, Rasaily R, Kotoky RP, Bora R. Prevalence and risk factors of pneumonia in under five children living in slums of Dibrugarh town. Clin Epidemiol Glob Health. 2018;6(1):1-4. doi: 10.1016/j.cegh.2017.07.004 [DOI] [Google Scholar]
  • 9. Titaley CR, Que BJ, de Lima FVI, et al. Health care-seeking behavior of children with acute respiratory infections symptoms: analysis of the 2012 and 2017 Indonesia demographic and health surveys. Asia Pac J Public Health. 2020;32(6-7):310-319. [DOI] [PubMed] [Google Scholar]
  • 10. Windi R, Efendi F, Qona’ah A, Adnani QES, Ramadhan K, Almutairi WM. Determinants of acute respiratory infection among children under-five years in Indonesia. J Pediatr Nurs. 2021;60:e54-e59. doi: 10.1016/j.pedn.2021.03.010 [DOI] [PubMed] [Google Scholar]
  • 11. United Nations. Transforming Our World: The 2030 Agenda for Sustainable Development. United Nations; 2015. [Google Scholar]
  • 12. Acharya P, Mishra SR, Berg-Beckhoff G. Solid fuel in kitchen and acute respiratory tract infection among under five children: evidence from Nepal demographic and health survey 2011. J Community Health. 2015;40(3):515-521. [DOI] [PubMed] [Google Scholar]
  • 13. Ujunwa F, Ezeonu C. Risk factors for acute respiratory tract infections in under-five children in Enugu southeast Nigeria. Ann Med Health Sci Res. 2014;4(1):95-99. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14. Dagne H, Andualem Z, Dagnew B, Taddese AA. Acute respiratory infection and its associated factors among children under five years attending pediatrics ward at University of Gondar Comprehensive Specialized Hospital, northwest Ethiopia: institution-based cross-sectional study. BMC Pediatr. 2020;20(1):1-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 15. Mondal D, Paul P. Effects of indoor pollution on acute respiratory infections among under-five children in India: evidence from a nationally representative population-based study. PLoS One. 2020;15(8):e0237611. doi: 10.1371/journal.pone.0237611 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 16. Cardoso AM, Coimbra CEA, Werneck GL. Risk factors for hospital admission due to acute lower respiratory tract infection in Guarani indigenous children in southern Brazil: a population-based case-control study. Trop Med Int Health. 2013;18(5):596-607. [DOI] [PubMed] [Google Scholar]
  • 17. Douglas RM. Acute respiratory infections in children in the developing world. Sermin Resp Infect. 1991;6:217-224. [PubMed] [Google Scholar]
  • 18. Morakinyo OM, Adebowale SA, Oloruntoba EO. Wealth status and sex differential of household head: implication for source of drinking water in Nigeria. Arch Public Health. 2015;73:58. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 19. Larrea C, Kawachi I. Does economic inequality affect child malnutrition? The case of Ecuador. Soc Sci Med. 2005;60:165-178. [DOI] [PubMed] [Google Scholar]
  • 20. Pandey S, Lin Y. Adjusted effects of domestic violence, tobacco use, and indoor air pollution from use of solid fuel on child mortality. Matern Child Health J. 2013;17:1499-1507. [DOI] [PubMed] [Google Scholar]
  • 21. Adesanya OA, Chiao C. A multilevel analysis of lifestyle variations in symptoms of acute respiratory infection among young children under five in Nigeria. BMC Public Health. 2016;16(880):880. doi: 10.1186/s12889-016-3565-0 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 22. Hasan M, Tasfina S, Haque SMR, et al. Association of biomass fuel smoke with respiratory symptoms among children under 5 years of age in urban areas: results from Bangladesh urban health survey, 2013. Environ Health Prev Med. 2019;24(1):65. doi: 10.1186/s12199-019-0827-3 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 23. Rana J, Uddin J, Peltier R, Oulhote Y. Associations between indoor air pollution and acute respiratory infections among under-five children in Afghanistan: do SES and sex matter? Int J Environ Res Public Health. 2019;16(16):2910. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 24. Mishra V. Indoor air pollution from biomass combustion and acute respiratory illness in preschool age children in Zimbabwe. Int J Epidemiol. 2003;32(5):847-853. doi: 10.1093/ije/dyg240 [DOI] [PubMed] [Google Scholar]
  • 25. Sanbata H, Asfaw A, Kumie A. Association of biomass fuel use with acute respiratory infections among under-five children in a slum urban of Addis Ababa, Ethiopia. BMC Public Health. 2014;14(1):1122. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 26. Hidayanti R, Yetti H, Putra AE. Risk factors for acute respiratory infection in children under five in Padang, Indonesia. Matern Child Health J. 2019;4(2):62-69. doi: 10.26911/thejmch.2019.04.02.01 [DOI] [Google Scholar]
  • 27. Mahendrayasa IGAP. Hubungan antara kondisi fisik rumah dengan kejadian infeksi saluran pernafasan atas pada Balita di Surabaya. Jurnal Berkala Epidemiologi. 2018;6(3):227-235. doi: 10.20473/jbe.v6i32018.227-235 [DOI] [Google Scholar]
  • 28. Tazinya AA, Halle-Ekane GE, Mbuagbaw LT, Abanda M, Atashili J, Obama MT. Risk factors for acute respiratory infections in children under five years attending the Bamenda Regional Hospital in Cameroon. BMC Pulm Med. 2018;18(1):7. doi: 10.1186/s12890-018-0579-7 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 29. Choube A, Kumar B, Mahmood S, Srivastava A. Potential risk factors contributing to acute respiratory infections in under five age group children. Int J Med Sci Public Health. 2014;3(11):1385-1389. doi: 10.5455/ijmsph.2014.200820141 [DOI] [Google Scholar]
  • 30. Darrow LA, Klein M, Flanders WD, Mulholland JA, Tolbert PE, Strickland MJ. Air pollution and acute respiratory infections among children 0–4 years of age: an 18-year time-series study. Am J Epidemiol. 2014;180(10):968-977. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 31. Indonesian Demographic and Health Survey (IDHS). (2017). https://dhsprogram.com/pubs/pdf/FR342/FR342.pdf
  • 32. Taksande AM, Yeole M. Risk factors of acute respiratory infection (ARI) in underfives in a rural hospital of central India. J Pediatr Neonat Individual Med. 2015;5(1):e050105. doi: 10.7363/050105 [DOI] [Google Scholar]

Articles from Global Pediatric Health are provided here courtesy of SAGE Publications

RESOURCES