Table 2 presents the results of a chi-square test assessing the association between respiratory infections among children under five years of age and various socioeconomic variables. The analysis identifies several significant relationships at different levels of significance. Regional disparities in respiratory health outcomes are evident, as the region variable is significantly associated with respiratory infections (p = 0.0187). Household wealth status exhibits a strong association (p < 0.001), indicating that children from wealthier households are more likely to have better respiratory health conditions. Cooking fuel (p = 0.0056) and place of cooking (p = 0.0016) are also highly significant, underscoring the importance of clean fuel usage and proper cooking environments in reducing respiratory health risks. Additionally, cooking practices, which combine fuel type and kitchen setup, show a significant association with respiratory issues (p = 0.018), emphasizing the compounded effect of these factors. Antenatal care during pregnancy (p = 0.0002) and maternal education level (p < 0.001) highlight the crucial role of maternal healthcare and education in mitigating respiratory health conditions in children. Lastly, maternal tobacco use is a strong predictor (p < 0.001), reflecting the adverse health impacts of tobacco exposure.
After checking the association between respiratory infections and the independent variables, in the next step a regression analysis was performed to check the direction of causality. The results of logistic regression analysis are reported in Table 3.
The first independent variable considered was the type of cooking fuel used by households. According to an odds ratio of 0.667, compared to the base category (use of unclean cooking fuel), children in households using clean cooking fuel are 1.43 times less likely to suffer from respiratory infections. This can be interpreted as: “Compared to households using unclean cooking fuel, the odds of respiratory infections in children from households using clean cooking fuel are 0.667.” Alternatively, this can be converted into how many times it is less likely by dividing 1 by the given odds ratio (1/0.667 = 1.43 times). A similar interpretation is applied when odds ratios are less than 1. This interpretation of the odds ratio has been adopted from (Nadeem et al., 2024). Access to clean cooking fuel is critical to reducing the negative impact of household air pollution on respiratory health. The use of traditional cooking fuels, such as solid biomass (wood, charcoal, crop waste, and dung) and kerosene, results in high levels of indoor air pollution. Exposure to such pollutants is particularly harmful to children’s respiratory health, as their lungs are still developing and they breathe more rapidly than adults. The findings of the current study are consistent with a study in Nigeria, which also found that households using Liquefied Petroleum Gas (LPG) (which is a clean cooking fuel) had significantly lower rates of respiratory symptoms and illnesses than those using solid fuels (Oluwole et al., 2019). Another study conducted in rural India also found that switching from traditional solid fuels to LPG resulted in a 35% reduction in the incidence of acute lower respiratory infections among children under 5 years old (Balakrishnan et al., 2013). Another study found that pregnant women exposed to secondhand smoke at home have a higher likelihood of delivering low birth weight infants (Andriani et al., 2023).
The second variable was the place of cooking. The base category was, “there was no separate kitchen available in the house for cooking”. The odds ratio associated with cooking place, where a separate kitchen is available for cooking, was 0.797, which indicates that if cooking takes place in separate kitchens in the house, then the child of that household is 1.25 times less likely to suffer from respiratory infections. Cooking practices are the next variable that can significantly impact the respiratory health of children. The odds ratio associated with cooking practices (use of clean fuel for cooking in a separate kitchen) was 0.804, which indicates that if households use clean fuel for cooking in a separate kitchen, then the child of such a household is 1.25 times less likely to suffer from respiratory infections. Using cleaner fuels, proper ventilation, and adopting safe cooking practices can help reduce exposure to air pollutants and lower the risk of respiratory symptoms and diseases. In many homes, cooking is performed in the same space in which people spend their time, which can increase the risk of exposure. However, having a separate kitchen where cooking is performed away from the rest of the living space can potentially reduce exposure to cooking-related air pollutants. Similar findings were reached by a study conducted in China, which found that children living in homes with separate kitchens had a lower prevalence of respiratory symptoms such as coughing and wheezing than those living in homes without separate kitchens (Chen et al., 2014). Another study conducted in the United States found that children living in homes with gas stoves and no-range hoods, which can contribute to higher levels of cooking-related air pollutants, had a higher risk of asthma if they did not have a separate kitchen (Belanger et al., 2014). The use of solid fuels like wood and charcoal, coupled with cooking indoors without proper ventilation, significantly increases the risk of respiratory and other health issues among household members, especially women and children (Ahamad et al., 2021).
Antenatal care is another important determinant of child health. The base category has been antenatal care received. The odds ratio associated with antenatal care not received was 1.08. This finding indicates that if antenatal care is not sought by the mother during pregnancy, the child is slightly more prone to respiratory infections. Antenatal care can provide opportunities for health education and counseling on topics such as breastfeeding, nutrition, and maternal smoking cessation, which can reduce the risk of respiratory problems in children. A study conducted in India found that antenatal care is associated with a reduced risk of childhood respiratory infections. Children born to mothers who received adequate antenatal care had a lower incidence of respiratory infections than did those whose mothers did not receive antenatal care (Thakur et al., 2016).
Mothers’ tobacco use was another important variable. The base category used for this variable was that the mother of the child did not use tobacco. The odds ratio associated with the mother’s tobacco use was 1.656, which indicates that if the mother of the child smoked tobacco, the child was 1.656 times more likely to suffer from respiratory infections. Maternal tobacco use during pregnancy and the postpartum period is associated with respiratory issues in children. Nicotine and other harmful chemicals in tobacco can cross the placenta and affect fetal lung development, leading to a higher risk of respiratory problems in children. Findings of this study are consistent with a study conducted in Iran, which found that children born to mothers who smoked during pregnancy were more likely to develop respiratory problems, such as wheezing and asthma, than children born to non-smoking mothers (Hosseini et al., 2018).
Geographical region is also an indicator; each province of the country has been taken as a region. The base category was Sindh Province. The odds ratio associated with Punjab province is 1.321, which indicates that compared to Sindh province, children in Punjab province are 1.321 times more likely to suffer from respiratory infections. The odds ratio associated with KPK province was 1.249, which indicates that children in KPK are 1.249 times more likely to suffer from respiratory infections. The odds ratio associated with Baluchistan province was 0.92, indicating that the children in Baluchistan province were 1.086 times less likely to suffer from respiratory infections. The odds ratio associated with ICT was 1.253, indicating that children of ICT are 1.253 times more likely to suffer from respiratory infections. Geographical regions have also been found to be strong predictors; they are higher in Punjab, KPK, and Sindh and lower in Baluchistan. This may be because the houses have smaller areas in Punjab, KPK, and ICT, and small areas, there will be dense smoke, and the smoke of the cooking fuel can be more dangerous to the respiratory system of children. In Baluchistan, the area of the houses may be larger, due to which smoke may disperse in the air, and it may be less dense and less dangerous for the respiratory system of the children.
Place of residence can also be an important factor in determining the child’s health. In the current study, the place of residence has been divided into rural and urban areas, and the base category was the urban area; the odds ratio associated with the rural area was 0.779, which indicates that the children of the rural area are 1.28 times less likely to suffer from respiratory infections. Respiratory problems were found to be lower in rural areas. This may be due to the fact that in rural areas, the houses are not as congested and a lot of open spaces are available in the houses, so smoke can disperse and is less injurious to the health of the young ones as compared to urban areas. Children living in urban areas are more likely to suffer from respiratory problems than those living in rural areas because of their increased exposure to air pollution and other environmental factors. A study conducted in India found that children living in urban areas were more likely to suffer from respiratory problems such as wheezing and coughing than those living in rural areas (Padhi et al., 2020). Overcrowding, poor housing conditions and a lack of access to basic amenities such as clean water and sanitation are more common in urban areas and have also been found to be associated with respiratory problems among children (Osimani et al., 2020).
A mother’s educational level can play a very important role; the base category is that the mother has no education. The odds ratio associated with the primary level of the mother’s education was 1.282, which indicates that the child of a mother with a primary level of education is 1.28 times more likely to suffer from respiratory infections. However, the value of the odds ratio decreases as the level of mother’s education increases This indicates that the respiratory issue of the children is less likely for the children of more educated mothers which may be due to the reason that a more educated mother is more likely to adopt various precautionary measures to avoid the children being exposed to smoke. Mothers with higher education levels are more likely to have better knowledge and awareness of health-related issues, including respiratory problems, and are more likely to adopt healthier behaviors for their children. Our findings are consistent with a study conducted in Bangladesh, which found that the children of mothers with higher education levels were less likely to suffer from respiratory problems than those of mothers with lower education levels (Tiwari et al., 2020). Similarly, a study in Nigeria also found that maternal education level was a significant predictor of respiratory problems among children, with children of mothers with higher education levels being less likely to suffer from respiratory problems (Ojo et al., 2020).
Household wealth status has the poorest households as the base category. The odds ratio associated with poorer households is 0.943, indicating that, compared to the poorest households, the children of poorer households are less likely to suffer from respiratory infections. The odds ratio value decreases as the household moves to the next level of wealth status. The odds ratio for the richest households is 0.541, which indicates that the children of the richest households are 1.84 times less likely to suffer from respiratory infections. This may be because the richest households are more likely to use clean cooking fuel, and they are also more likely to have separate kitchens in the house. Therefore, the children of such households may be less likely to suffer from respiratory issues. Children from households with lower wealth status are more likely to suffer from respiratory problems than those from wealthier households. This is because households with a lower wealth status are more likely to be exposed to environmental hazards, such as indoor air pollution, inadequate ventilation, and poor housing conditions. This is consistent with a study conducted in India, which found that children from poorer households were more likely to suffer from respiratory problems than those from wealthier households (Sreeramareddy et al., 2015). Similarly, a study in Ethiopia also found that household wealth status was a significant predictor of respiratory problems among children, with those from poorer households being more likely to suffer from respiratory infections (Getachew et al., 2018).
The results of logistic regression are summarized in Fig. 1, which is a bar chart of odds ratios of key independent variables affecting respiratory infections in children. Variables with odds ratios less than 1 (green bars) indicate protective effects, while those greater than 1 (red bars) indicate increased risk. It shows that children of households that use clean cooking fuel, households having a separate kitchen, residing in rural areas, being residents of Baluchistan and belonging to well-off wealth status are less likely to be affected by respiratory health infections. In addition, it is evident from Fig. 1 that the children whose mother has no antenatal care, the mothers smoke tobacco and a low level of the mother’s education are more likely to be affected by respiratory infections.
Logistic regression results—odds ratios of respiratory infections.
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