Open Access

Austin Journal of Public Health andEpidemiology
Research Article

Occurrence of Acute Respiratory Tract Infections among
Children Under Five Years Attending Kinango SubCounty Hospital, Kenya
Betty Muriithi1,2*, Simon Karanja1, Mohamed
Karama3, Collins Okoyo4, Morris Ndemwa2,
Yoshio Ichinose2 and Satoshi Kaneko2
1
School of Public Health, Jomo Kenyatta University ofAgriculture and Technology, Nairobi, Kenya
2
Nagasaki University Institute of Tropical MedicineKenya Medical Research Institute Project, Nairobi, Kenya
3
Umma University, Kajiado, Kenya
4
Eastern and Southern Africa Centre of International
Parasite Control, Kenya Medical Research Institute,
Nairobi, Kenya*Corresponding author: Betty Muriithi, Nagasaki
University, Institute of Tropical Medicine, Kenya Medical
Research Institute Project, Nairobi, Kenya
Received: June 08, 2021; Accepted: July 16, 2021;
Published: July 23, 2021

Abstract
Objective: To examine occurrence of Acute Respiratory tract Infections(ARIs) and determine factors associated with ARIs among children under five
years attending Kinango Sub-County Hospital.
Methods: A cross-sectional survey was conducted among mother-childaged between 0-59 month’s pairs attending outpatient care. Participants wererecruited using systematic sampling method. Data was collected using aninterviewer-administered structured questionnaire. Descriptive statistics wereused to summarize child, parental and environmental characteristics. Factors
associated with ARIs were established using binary logistic regression analysis.
Odds Ratio (OR), at 95% Confidence Interval (CI) and p <0.05 significant level
was used to describe an association between covariates and the outcome
variable. Independent factors associated with occurrence of ARIS were
determined by stepwise logistic regression.
Results: 385 children participated in this study. 228 children (59.2%)
presented with ARIs, of which 90.8% were due to acute upper respiratory tract
infections. 9.2% of the cases were due to pneumonia. Female gender aOR 3.39
[1.21-9.46], stunting aOR 3.62 [1.04-12.61], high parity aOR 11.45 [2.38-55.09],
low maternal education aOR 3.54 [1.10-11.32] and recent hospitalization aOR
8.19 [1.75-38.43] increased the odds of occurrence of an ARI while normal birthweight aOR0.06 [0.01-0.62] was protective of ARIs.
Conclusion: A high prevalence of ARIs among children aged below five
years was observed in this study, associated with gender, stunting, parity,maternal education, birth weight and recurring hospitalization. Improvements inliteracy levels, child nutrition and maternal and child health at large could help toreduce morbidity due to ARIs in this population.
Keywords: Prevalence; Children under five years; Acute respiratory tract
infections

Introduction
Acute Respiratory Tract Infections (ARIs) are infections of therespiratory tract of ranging severity that affect both upper and lower
respiratory structures, and related organs [1]. They are among themost common causes of morbidity and mortality among children
under the age of five years. They account for up to 50% of all diseases
that children under five years encounter [2] and a third of underfives deaths in developing countries [3,4]. According to GBD 2017,mortalities due to acute lower respiratory tract infections only were
118.9 per 100,000 children under five years globally, representing
15% of all under-fives deaths [5]. Over half of all diagnosis amongchildren presenting with ARI symptoms are usually due to acute
upper respiratory tract infections [6,7]. A child can experience up to
eight episodes of ARIs of varying severity in a year [8-10].
Although ARIs are common among both children and adults,
universal treatment is still lacking due to the nature of theircausative agents and diagnostic uncertainty. Symptoms of common
infections such as the common cold typically clear in one to two
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weeks but the symptoms can be quite distressing to both the childand caregiver. Moreover, the infection can spread to other parts ofthe body resulting to more serious clinical disease and even fatality.
Respiratory viruses have been shown to have neuroinvasive capacity[11] that results to various types of encephalopathy, alongside othersystemic effects due to extension of microbial toxins, inflammation
and reduced lung function [12]. ARIs are also a common reason foradministration of antibiotics. Approximately 33% of consultations fora child with an upper respiratory tract infection specifically ends up
with an antibiotic prescription [13]. Such irrational administration of
antibiotics is steadily yielding resistance to convectional antibiotics,
reducing therapeutic options for management of bacterial infections[13,14].
Given the nature of childhood ARIs, prevention and control present
more viable options for management of ARIs. Several risk factors for
ARIs have been postulated [15,16], that modulate occurrence of ARIs,
although these differ widely. Proper understanding of the drivers of
occurrence of ARIs in particular settings is therefore necessary for

Citation: Muriithi B, Karanja S, Karama M, Okoyo C, Ndemwa M, Ichinose Y, et al. Occurrence of AcuteRespiratory Tract Infections among Children Under Five Years Attending Kinango Sub-County Hospital, Kenya.

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Study procedure

Figure 1: Study site.

development of appropriate prevention and control algorithms. The
aim of this study was to examine occurrence of ARIs among children
aged below five years attending Kinango Sub-County hospital anddeterminants of their occurrence.

Methods
Study site
The study was conducted in Kinango Sub-County Hospital,
located in Kinango town within Kinango Sub-County in Kwale
County, Kenya (Figure 1). The hospital is a level 4 facility with a 94bed capacity. It has a dedicated maternal and child health clinic, andan outpatient department that serves both adults and children. The
hospital’s community linkage is well developed, with the community
health volunteers actively involved in linking the community toprimary care. The hospital’s catchment area covers both ruraland semi-urban settlements, with varying levels of access by thecommunity.
Kwale County is mostly sparsely populated with a poverty index
of 41.8% [17]. It is served by one level four hospital, two level threehospitals and thirty-four level two public health facilities. The average
distance to the nearest health facility is about seven kilometers [18].
Study design and sample size calculation
A cross-sectional hospital-based study was conducted. Sample
size was calculated using Cochrane formula [19], with a sampling
error of 5% at 95% confidence interval assuming a prevalence of 50%,
yielding a minimum sample of 385.
Study population
Study subjects were children aged below five years and theirmothers. Systematic sampling was used to randomly select study
participants. About 800 children aged below five years are usuallyseen at the outpatient clinic per month. Data was collected from
November 2017 to January 2018, during which approximately
2400 children aged below five years were treated. Using a samplinginterval of six, every 6th mother-child pair was selected to participate
in the study starting from a random point until the sample size wasachieved. Children whose mothers consented for their participation
were included in the study. Children who were accompanied bycaregivers were excluded as well as children whose mothers declined
consent.
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Recruitment of study participants was conducted during routine
outpatient care. Objectives and procedure of the study were explained
to the mother-child dyads at the outpatient clinic before consultation.
Based on description by WHO [20], an ARI was defined as any acuteepisode of runny nose, cough, ear discharge, pain or itch, sore throator hoarseness of voice, difficult or fast breathing with or without
fever, or chest in drawing. Upon consultation, cases were classified
using the Integrated Management of Childhood Illness (IMCI)
criteria [21]. The diagnosis of children who were not suffering froman ARI was also clearly recorded on the health cards. Recruitmentof study participants was conducted at the records department after
going through the consultation process. Every 6th mother-child pair
was requested to participate in the study. In case a selected subject
declined consent, the next mother-child pair was requested toparticipate. The consent form was read and explained to those who
agreed to participate in the study after which they were requested tosign the consent document.
Data collection
Following consenting, data collection was conducted using
an interviewer-administered structured questionnaire. Presenceor absence of an ARI was recorded from the patient’s health card.
Birth and immunization details of the child were obtained from thematernal and child health booklet where possible or parental recall.
The child’s weight and height were then taken for computationof Z-scores. The height of infants (0-23 months) was measured inrecumbent position using a wooden height board. Heights of children
aged above two years were measured in standing position using a
vertical height board. The child was placed on board base, to stand inin upright position with head held upright, and back of the head, backand heels against the board. Children aged 0-6 months were weighedusing an electronic scale in lying position. Older children who could
not stand were weighed in sitting position while those who could
stand were weighed in standing position, all lightly dressed.
Statistical analysis
Data was entered into Microsoft access (2016) and exported to
STATA Version 14 [22] for analysis. Socioeconomic indicators weresummarized using Principal Component Analysis (PCA). Wealthquintiles were then generated and grouped into low, middle and highsocioeconomic status. Descriptive and summary statistics were used tosummarize child, parental and environmental characteristics in orderto describe the study population and calculate the prevalence of ARIs.
Factors associated with occurrence of ARIs were established using
binary logistic regression. Association was measured using odds ratio
at 0.05 significant level and 95% confidence interval. Multivariable
regression model was constructed by stepwise estimation, using
backward selection. Variables with a P-value greater than or equal
to 0.2 were removed sequentially. The model was adjusted for age ofthe children, gender, birthweight, immunization status, breastfeeding
status, underweight, stunting, parental characteristics, exposure toschool-going children, contact with an infected person in the past
two weeks, previous hospitalization, household density and socioeconomic status.

Results
Out of the 385 children who participated in the study, 228
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Acute respiratory infection

216

56.1

on Table 1. According to IMCI guidelines, 207 (90.8%) children had
ARIs and 21 (9.2%) had pneumonia. No cases of severe pneumonia
were observed.

Acute respiratory tract infection with co-infection

12

3.1

Demographic characteristics of study children

Acute febrile illness

53

13.8

Dermatological conditions

40

10.4

Gastrointestinal infection

19

4.9

Malaria4

1

Of the study sample, 192 (49.9%) were male. Mean age was 22.14± 14.7 months. Majority of the participants; 237 (61.6%) were aged
below two years of whom 58 (15.1%) were aged below six months.
Only 95 (24.7%) children were born at home. Average breastfeeding
duration was 20.1±5.1 months. Children who were fully immunized
as per schedule were 277 (72%) as shown in Table 1. Prevalence ofunderweight, stunting and wasting was 15.8%, 26.3% and 11.4%
respectively.

Table 1: Diagnosis observed among study children.
Diagnosis

Number of Children%(59.2%) presented with ARIs. 5% were co-infected mostly withgastrointestinal and dermatological conditions. Acute febrile illness
and dermatological conditions were frequently reported as shown

Table 2: Demographic characteristics of study children and association between ARIs and children’s demographic characteristics.
Characteristic

No. of Participants (%)

No. of Cases (%)

OR (95% CI)

P-value

0-6

58 (15.1)

33 (56.9)

1.06 (0.57-1.96)

0.846

7-12

67 (17.4)

42 (62.9)

1.35 (0.74-2.44)

0.318

13-24

112 (29.1)

71 (63.4)

1.39 (0.84-2.30)

0.196

25-59

148 (38.4)

82 (55.4)

ReferenceMale

192 (49.9)

103 (53.6)

Reference

Female193 (50.1)

125 (64.8)

1.59 (1.05-2.39)

Adjusted OR (95% CI)

P-valueAge (Months)

Gender
Reference
0.027

3.39 (1.21-9.46)

0.02

0.921

0.06 (0.01-0.61)

0.018

0.06 (0.00-1.28)

0.071

3.63 (1.04-12.61)

0.043

Birth WeightLow

25 (8.9)

15 (60.0)

Reference

Normal256 (91.1)

151 (59.0)

0.96 (0.41-2.22)

ReferenceHome

95 (24.7)

54 (56.8)

Reference

Hospital

290 (75.3)

174 (60.0)

1.14 (0.71-1.82)

Supplemented

61 (18.3)

37 (60.7)

Reference

Exclusive

272 (81.7)

161 (59.2)

0.94 (0.53-1.66)

0.833

0-12 months

18 (9.6)

11 (61.1)

2.36 (0.31-17.85)

0.407

13-24 months

165 (87.8)

93 (56.4)

1.94 (0.31-11.90)

0.475

25-36 months

5 (2.7)

2 (40.0)

Reference

Place of Birth

0.59

Breast Feeding Status

Breast Feeding Duration

Immunization Status
Complete

277 (72.0)

169 (61.0)

Reference

In progress

87 (22.6)

48 (55.2)

0.79 (0.48-1.27)

0.333

Incomplete

21 (5.4)

11 (52.4)

0.70 (0.29-1.71)

0.438

Normal324 (84.2)

194 (59.9)

Reference

Underweight

61 (15.8)

34 (55.7)

0.84 (0.48-1.46)

Normal284 (73.8)

166 (58.4)

Reference

Stunted101 (26.3)

62 (61.4)

1.13 (0.71-1.80)

Normal341 (88.6)

209 (61.3)

Reference

Wasted44 (11.4)

19 (43.2)

0.48 (0.25-0.91)

Weight for Age

0.547

Height for Age

0.606

Height for Weight

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0.024

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Table 3: Environmental characteristics of study participants and association between ARIs and children’s environmental characteristics.
No participantsUnivariable analysis OR
Multivariable analysis aOR
Characteristic
Prevalence
P-value(%)(95% CI)(95% CI)

P-valueHousehold density
2-4

171 (44.4)

98 (57.3)

Reference

5-7

156 (40.5)

95 (60.9)

1.16 (0.75-1.80)

0.51

≥8

58 (15.1)

35 (60.3)

1.14 (0.62-2.08)

0.686

Number of rooms
1

23 (6.0)

13 (56.5)

Reference2

193 (50.1)

113 (58.5)

1.09 (0.45-2.60)

0.852

≥3

169 (43.9)

102 (60.4)

1.17 (0.48-2.82)

0.725

2.34 (0.76-7.20)

0.139

8.19 (1.74-38.43)

0.008

History of contact with an infected
personHad contact

166 (43.1)

99 (59.6)

Reference

No contact

219 (56.9)

129 (58.9)

0.97 (0.64-1.46)

Yes

260 (67.5)

164 (63.1)

ReferenceNo

125 (32.5)

64 (51.2)

0.61 (0.40-0.95)

No

306 (79.5)

180 (58.8)

ReferenceYes

79 (20.5)

48 (60.8)

1.08 (0.65-1.79)

0.755

Respiratory infection related

41 (51.9)

26 (63.4)

1.26 (0.51-3.11)

0.616

Not respiratory infection related

38 (48.1)

22 (57.9)

ReferenceNo

238 (61.8)

138 (58.0)

0.87 (0.57-1.33)

Yes

147 (38.2)

90 (61.2)

Reference

0.885

School-going sibling

0.027

Hospitalization within the past 3
months

Cause of hospitalization

Exposure to cigarette smoke
0.53

Socioeconomic statusLow

132 (35.9)

79 (59.8)

Reference

Middle116 (31.5)

69 (59.5)

0.98 (0.59-1.63)

0.953

4.23 (0.90-19.96)

0.068

High

120 (32.6)

69 (57.5)

0.91 (0.54-1.50)

0.705

3.01 (0.68-13.23)

0.145

Demographic characteristics of parents of study children
Average maternal age was 26±6.1 years. Age ranged from 17 to 47
years. Mothers who had primary level of education were 182 (47.3%).
Only 47 (12.2%) of the mothers had attended secondary education
and above. Most mothers; 252 (65.5%) were unemployed while 310(86.4%) fathers were in various forms of employment as shown on
Table 2.
Environmental characteristics of study participants
Majority of the children, 288 (74.8%) lived in mud walled
houses. Most of the houses; 254 (66.0%) had iron sheet roofing and
298 (77.4%) houses had earthen floor material. Firewood (80%) andcharcoal (13%) were the most common sources of cooking energy
while kerosene (57.7%) and solar (32.0%) were the most common
sources of lighting energy.
Univariable analysis of factors associated with ARIs
As shown in Table 1, female children were significantly more likely(OR 1.59; 95% CI: 1.05-2.39) to be infected with an ARI compared tomale children. Odds of infection increased with increase in age, withchildren aged between 13 to 24 months presenting the highest odds ofSubmit your Manuscript | www.austinpublishinggroup.com

infection (OR 1.39; 95% CI: 0.84-2.30). Breastfeeding was protectiveof ARIs by 6% (OR 0.94; 95% CI: 0.53-1.66), as well as normal birthweight (OR 0.95; 95% CI: 0.41-2.22) although not significantly.
Odds of infection decreased with increasing breastfeeding duration.
Immunization was generally protective of ARIs, with children who
were up-to-date on the immunization schedule presenting up to 30%
reduced odds of infection (OR 0.70; 95% CI: 0.29-1.71).
The risk of getting an ARI decreased by 43% among children
whose fathers were educated up to primary school (OR 0.57; 95% CI:
0.34-0.96). Age, marital status, level of education and employment
status of mothers were not statistically significant determinantsof occurrence of ARIs. However, odds of infection decreased withincrease in mothers’ age and with increasing level of education asshown on Table 2.
Not having school going siblings was a significant protective
factor too (OR 0.61; 95% CI: 0.40-0.95). Odds of infection increased
with increase in household density and number of rooms although
not significantly. Absence of contact with an infected person
marginally reduced the odds of infection by 3% (OR 0.97; 95% CI:
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Table 4: Parental socio-demographic characteristics and association between ARIs and Parental socio-demographic characteristics.
Characteristic

No of participants (%)

ARI Prevalence %OR (95% CI)

P-value<20

52 (13.5)

27 (51.9)

Reference

21-30

249 (64.7)

152 (61.0)

1.45 (0.79-2.64)

0.225

>31

84 (21.8)

49 (58.3)

1.30 (0.65-2.60)

0.465

Married359 (93.3)

209 (58.2)

0.51 (0.21-1.25)

0.143

Single26 (6.7)

19 (73.1)

Reference

Adjusted OR (95% CI)

P-value

3.54 (1.10-11.32)

0.033

0.37 (0.13-1.09)

0.07

Maternal age

Marital status of mother

Education level of motherNo formal education

156 (40.5)

90 (57.7)

ReferencePrimary education

182 (47.3)

110 (60.4)

1.12 (0.73-1.73)

0.609

Secondary education and above

47 (12.2)

28 (59.6)

1.08 (0.56-2.10)

0.819

No formal education

90 (25.1)

58 (64.4)

ReferencePrimary education

177 (49.3)

90 (50.8)

0.57 (0.34-0.96)

0.035

Secondary education and above

92 (25.6)

61 (66.3)

1.09 (0.59-2.00)

0.792

Housewife

52 (13.5)

27 (51.9)

Reference

Unemployed

252 (65.5)

155 (61.5)

1.48 (0.81-2.70)

0.201

5.14 (0.90-29.36)

0.065

Employed81 (21.0)

46 (56.8)

1.21 (0.60-2.45)

0.582

7.21 (0.84-61.58)

0.071

Unemployed49 (13.7)

33 (67.3)

Reference

Employed

310 (86.4)

176 (56.8)

0.64 (0.33-1.21)

1-2

182 (47.3)

106 (58.2)

Reference

3-4

106 (27.5)

62 (58.5)

1.01 (0.62-1.64)

0.967

4.69 (1.20-18.28)

0.026

≥5

97 (25.2)

60 (61.9)

1.16 (0.70-1.92)

0.558

11.46 (2.38-55.09)

0.002

Education level of father

Employment status of mother

Employment status of father

0.166

Parity0.64-1.46), as well as not having been previously hospitalized in thelast three months (OR 0.86; 95% CI: 0.50-1.46). Absence of a smoker
in a household lowered the odds of infection by 13% (95% CI: 0.571.33) as shown on Table 3.

with having five and above children increasing odds of infection by
11 times (aOR 11.45; 95% CI: 2.38-55.09) as shown on Table 4. Recent
hospitalization significantly increased odds of getting an ARI by 8times (aOR 8.19; 95% CI: 1.75-38.43).

Housing characteristics, source of cooking and lighting energy
and overall exposure of a child to wood smoke were not significantly
associated with occurrence of an ARI. These factors were used to
calculate socioeconomic status of participants using PCA. Computed
scores were categorized onto low, middle and high socioeconomic
status, which too were not significantly associated with occurrenceof ARIs.

Discussion

Multivariable analysis
Female children were three times more likely (aOR 3.39; 95% CI:
1.21-9.46) to be infected with an ARI compared to male children.
Normal birth weight was significantly protective of ARIs, with up to94% (aOR 0.06; 95% CI: 0.01-0.62) reduced odds of infection whilestunting posed a three-folds increase in odds (aOR 3.62; 95% CI: 1.0412.61) of getting and ARI as shown on Table 1. Among the parental
characteristics, primary level of education among mothers increaseda child’s odds of getting an ARI by three times (aOR 3.54; 95% CI:
1.10-11.32). High parity also significantly increased odds of infection,
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ARIs remain an important public health problem, causing
significant morbidity and mortality, and children continue to bear thehighest burden of these infections. This study reported a prevalenceof 59.2%. In agreement with this finding, Muthoni & Ngesa [9],reported an estimated ARI prevalence of 55-60 % for Kwale County
from models based on national health and demographic survey data.
Additionally, a high individual risk of infection by various respiratory
viruses, up to 93.4% was reported in a large household survey in rural
North Coast with similar settings [23], suggesting a high likelihoodof occurrence of ARIs along the larger coastal region. The highprevalence observed could also be as a result of timing of the study,
since the study was conducted during a peak season for transmissionof respiratory diseases. Equally high prevalence rates were observedin related studies [16,24,25], highlighting a substantial burden of
ARIs among children under five years in various settings.
ARI infections peaked at two years. This age group has been shown
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to be highly vulnerable to ARIs mostly due to underdevelopment of
their immune system [26], coupled with incomplete development of
their lungs and relatively short bronchial tree that causes an infection
to spread faster [27]. Additionally, increasing contact between thechild and other household members as the child grows older anddecreasing protective effects of passive maternal immunity, coupledwith increased contact with fomites makes them more exposed to
ARIs.
This study identified female gender as a significant determinant
for occurrence of ARIs. Although previous studies [1,28,29] haveconsistently reported a higher risk among males. Involvement ofgender in development of ARIs remains relatively non-conclusive.
For instance, no consistent sex differences in the burden of ARIs wasobserved over a period of twenty-four years, even after controllingfor possible confounding factors while examining sex-specific trendof childhood ARIs in Nigeria [30]. Since perception of gender as apotential modulator of response to infection persists, it is necessary
to elucidate its mechanisms and establish whether it is applicable tochildhood ARIs in order to understand ARIs development in eachgender.
Normal birth weight was significantly protective against ARIs in
this study. Birthweight is an important modulator of child survival,
growth and development [31]. Children born with low birth weight
are more susceptible to respiratory infections [6] especially of thelower respiratory tract [32]. Protective effect of normal birth weightobserved in this study was tentatively due to immune system sufficiency
and optimal lung function conferred by normal birthweight, despite
potential confounding by factors such as malnutrition and continued
exposure to environmental triggers.
Childhood stunting increased the odds of getting an ARI in
this study. The high prevalence of malnutrition that has been
extensively reported in this population [33-35] tentatively explains
this observation. Although the relationship between infections andmalnutrition is mostly bidirectional [36,37], a child with underlying
malnutrition lacks nutrients needed for immune activation,
increasing their susceptibility to acute infections [38]. Further, theprocess of linear growth catch-up that could reverse stunting and its
effects on immunity may be slow or impossible in this setting due
to food insecurity and high burden of infectious diseases resulting
in sustained stunting with sustained susceptibility to ARIs [39]. In
concurrence, an association between stunting and occurrence of
ARIs among children was similarly observed in a study conducted in
Bangladesh [40].
Maternal education status was significantly associated withoccurrence of ARIs too. Children whose mothers were educatedup to primary level had significantly increased odds of getting
an ARI. Moreover, odds of infection decreased with increasinglevel of maternal education in the unadjusted model although notsignificantly. Generally, a higher level of education among mothers
promotes adoption of good childcare practices that reduce exposureof children to ARIs and other infections. It is also likely to improvesocial and environmental conditions of a household resulting
in improvements in child health by modifying factors such as
employment and household income. In agreement with the findingsof this study, a meta-analysis of observational studies from low andSubmit your Manuscript | www.austinpublishinggroup.com

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middle-income countries identified low maternal education as a risk
factor for mortality due to acute infections of the lower respiratory
tract [41], confirming the impact of maternal education.
Hospitalization in the preceding three months significantly
increased the odds of getting an ARI. Recurrent hospitalization inearly childhood increases the risk of morbidity with acute respiratory
infections and even asthma in a dose response manner [42]. Recurrent
ARIs particularly increase the risk of subsequent respiratory infections[43]. Of the children who had been previously hospitalized in thisstudy, 51.9% had been hospitalized for respiratory related infections
especially pneumonia and asthma, suggesting that recurrent ARIs
potentially increase the risk of getting an ARI in future.
Parity was shown to affect occurrence of ARIS, with odds ofgetting an ARI increasing with increasing parity. High parity could
have increased household density and person-to-person contact,
facilitating transmission of respiratory pathogens. Moreover,this study observed an association between school-going siblings
and occurrence of ARIs, who have been shown to be important
introducers of respiratory pathogens in households [44], suggesting
a potential risk posed by multiple siblings. High parity compromises
quality of care accorded to each child too, due to increased financial
and social requirements. This affects not only living conditions but
also nutritional care of children especially since this population has
been shown to be relatively food insecure [33], generally increasing
susceptibility to infectious diseases.
An important limitation of this study is that prevalence of ARIs
was captured at the hospital level hence it may not be a true reflectionof the activity of ARIs in the community. A longitudinal study
will illustrate the epidemiology of ARIs among under-fives better.
Additionally, diagnosis was made based on clinical symptoms using
IMCI guidelines. Over diagnosis or under diagnosis is possible given
the limitations surrounding its application.

Conclusion
This study highlights a high burden of ARIs among children
under five years. Female gender, stunting, low maternal educationand high parity were significantly associated with occurrence of
ARIs. Normal birth weight and absence of hospitalization in theprevious three months were protective factors. This study suggeststhat improvements in maternal education, with increased awarenesson maternal and child health could minimize morbidity due to ARIs
in this population. Prevention and management of other infectious
diseases is also likely to reduce the burden of ARIs and improveoverall health of children. Since no intervention can singly reducemorbidity and mortality due to ARISs, modulation of core risk factors
could substantially help to reduce preventable deaths.

Acknowledgement
We acknowledge the Kwale County Government for allowing us
to conduct this study. We also acknowledge and appreciate Kinango
sub-County hospital for supporting implementation of this study.
We thank Nagasaki University Institute of Tropical Medicine, Kenya
research station for supporting the study and appreciate the caregivers
who participated in this survey for voluntarily participating in thisstudy and for the time they freely put into the study.
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