Acute respiratory infections and associated factors among under-five children in sub-Saharan Africa: a multilevel modified Poisson regression analysis of the latest DHS data

Background: Acute respiratory infections (ARIs) are the leading cause of morbidity and mortality among children under 5 years of age, particularly in sub-Saharan Africa. Although several individual- and household-level factors have been associated with ARI, previous studies in the region have largely been limited to single-country analyses, older datasets, or conventional regression approaches that did not account for the hierarchical structure of Demographic and Health Surveys (DHS) data. Furthermore, evidence based on recent multicountry data collected after COVID-19 pandemic remains limited. Objectives: To assess the prevalence of ARI and associated factors among children under 5 years of age in sub-Saharan Africa Design: A cross-sectional study was conducted using nationally representative DHS data collected between 2021 and 2024 from 11 sub-Saharan African countries. Methods: A weighted sample of 67,134 children aged 0–59 months with complete information on ARI was included in the analysis. Missing data were handled using multiple imputation. Given the hierarchical structure of DHS data, a multilevel modified Poisson regression model with robust variance estimation was employed to identify individual- and community-level factors associated with ARI. Adjusted prevalence ratios (APRs) with 95% confidence intervals (CIs) were reported. Results: The prevalence of ARI among under-five children in sub-Saharan Africa was 31.0% (95% CI: 30.6–31.5). ARI prevalence was higher among children of mothers aged 35–49 years (APR = 1.13; 95% CI: 1.02–1.25) and wasted children (APR = 1.23; 95% CI: 1.05–1.50), and in households using polluted cooking fuels (APR = 1.22; 95% CI: 1.05–1.42). Lower prevalence was observed among children from rich households (APR = 0.86; 95% CI: 0.75–0.98), with household media exposure (APR = 0.85; 95% CI: 0.78–0.93), delivered in health institutions (APR = 0.89; 95% CI: 0.79–0.99), and residing in communities with high media exposure (APR = 0.90; 95% CI: 0.83–0.98). Conclusion: ARI remains highly prevalent among children under five in sub-Saharan Africa. Individual and household factors, including maternal age, child nutritional status, household wealth, type of cooking fuel, place of delivery, and media exposure, are significantly associated with ARI, highlighting the need for targeted interventions to reduce its burden. Trail registration: Not applicable.