Acute Respiratory Infections (ARIs) remain a critical health concern, especially among children aged 6–59 months, ranking as a leading cause of morbidity and mortality worldwide (1). Globally, ARIs account for nearly 15% of all deaths in children under 5 years of age (2), with over 800,000 children dying annually from ARIs, primarily due to pneumonia, the most severe form (2). In Africa, ARI prevalence among children under five who received antibiotics is particularly high in Tanzania (61%), Sao Tome and Principe (60%), Rwanda and Congo (58% each), Angola (56%), Mozambique (54%), Kenya (53%), Namibia (52%), and Gabon (50%) (3). In Ghana, 2% of children under age five exhibited symptoms of an ARI, while 15% had a fever, and 13% experienced diarrhea in the 2 weeks preceding the survey (4). A study by Kolekang et al. (5) suggested that scaling up basic health interventions, including immunization, exclusive breastfeeding, and improved sanitation could significantly reduce ARI-related mortality.

ARIs encompass infections of the upper and lower respiratory tracts, from mild conditions like the common cold to severe illnesses such as pneumonia and bronchiolitis. These infections are primarily caused by viral and bacterial, including Streptococcus pneumoniae, Haemophilus influenzae type b (Hib), respiratory syncytial virus (RSV), and influenza viruses (6). ARIs are highly contagious, transmitted through airborne droplets, direct contact, and contaminated surfaces, making them highly contagious. According to Sharrow et al. (7) ARIs are the most prevalent infectious diseases globally, and their impact on children is particularly severe due to their developing immune systems.

Children with ARIs typically present with symptoms such as coughing, difficulty breathing, fever, wheezing, and nasal congestion. In severe cases, children may develop chest in-drawing, rapid breathing, and lethargy, symptoms indicative of pneumonia, a leading cause of ARI-related deaths (8). Studies have shown that early recognition and treatment of these symptoms can reduce mortality. For instance, McAllister et al. (9) found that children who received timely medical interventions for ARIs had a 30% lower risk of severe complications.

Globally, ARIs are the second leading cause of death in children under five, with the highest burden in low- and middle-income countries (2). Africa and Southeast Asia experience 70% of global deaths from pneumonia and other respiratory infections (6). In developing countries, poor healthcare infrastructure, malnutrition, and environmental factors such as air pollution exacerbate ARI risks. According to WHO estimates, two-thirds of ARI-related deaths could be prevented through simple interventions like vaccinations, adequate nutrition, and access to clean water and sanitation (10).

In many developing countries, including Ghana, ARIs remain a major cause of death among children. High prevalence is driven by overcrowded living conditions, inadequate healthcare services, and widespread biomass fuels for cooking, which increases indoor air pollution (11). In Ghana, findings from the Demographic and Health Surveys (DHS) indicate that ARI symptoms among children aged 6–59 months decreased slightly between 2000 and 2014, but the rates remain high. Approximately 2% of children under age five showed ARI symptoms, 15% exhibited fever, and 13% experienced diarrhea in the 2 weeks preceding the survey (4).

In Ghana, ARI-related morbidity and mortality continue to pose public health challenges. ARI symptoms prevalence has slightly declined in recent years due to improved healthcare access and increased vaccination coverage (4), mortality rates from respiratory infections remain a concern, especially in rural areas with limited healthcare access. The use of antibiotics for ARIs in Ghanaian children has also increased, although there is growing concerns about antibiotic resistance due to inappropriate prescription practices (12).

Key risk factors associated with ARIs in children include malnutrition, low birth weight, and exposure to indoor air pollution from biomass fuels (4, 13). In developing countries particularly Ghana, children living in households using solid fuels for cooking are twice as likely to experience ARI symptoms compared to those in households using cleaner fuels (14). Socioeconomic determinants such as maternal education, wealth status, and access to healthcare services play critical roles. For instance, Makoka (15) found that children from wealthier households and those with more educated mothers were less likely to suffer from ARIs. Additionally, boys, younger children (under 2 years) and those in rural areas face higher ARI risks due to poor healthcare access and environmental factors like indoor air pollution (11).

Socioeconomic factors such as household wealth, maternal smoking, and vaccination status significantly affect ARI risk. In Ghana, children from poorer households are more likely to suffer from ARIs, especially where sanitation and access to clean water are inadequate (12). Poor sanitation, particularly in rural areas with limited access to improved toilet facilities, exacerbates the risk of respiratory infections (15). Despite extensive research on ARIs, there remains a gap in understanding the specific determinants of ARI severity and how various factors interact to influence health outcomes among children in Ghana. Previous studies have often focused on isolated risk factors without fully exploring the combined effects of environmental, socioeconomic, and behavioral determinants on ARI prevalence. This study uses multinomial regression analysis on 2022 Demographic and Health Survey data to assess the risk factors associated with ARIs among children aged 6–59 months in Ghana. By identifying the key determinants of ARI severity, this study seeks to inform targeted interventions to reduce child mortality and improve health outcomes in Ghana. Specifically, this study aligned with Sustainable Development Goal (SDG) target 3.2, which seeks to end preventable deaths of newborns and children under 5 years of age by 2,030.

Our study observed a decline in chest problems from 25.7% in 2014 to 17.1% in 2022, comparing this result with the 2014 GDHS findings, it shows that 25.7% of children had chest problems only which means that there has been an 8.6% decrease in this prevalence. Furthermore, the 2014 GDHS findings indicated that 46.4% of children had nose breathing problems, which shows that the prevalence has increased by 19.7%. Again, there has also been a decrease in the proportion of children with both chest and nose breathing problems from 27.9% in 2014 to 16.8% in 2022 in Ghana. It is also important to note that the number of children with ARI has increased from 372 in 2014 to 541 in 2022. This outcome is likely due to expanded preventive health measures, particularly vaccination programs, improvements in environmental and sanitation and improved healthcare access and utilization. Similar trends were found in studies by Brooks et al. (18) in Bangladesh and Hammitt et al. (19) in Kenya, which reported reductions in childhood pneumonia and ARIs, following the introduction of pneumococcal conjugate vaccines (PCV) and improved healthcare systems. In agreement with our findings, Fujita et al. (20) noted that access to antibiotics and healthcare advancements in countries like Ethiopia have helped lower ARI complications. Additionally, the decline in children experiencing both chest and nasal breathing problems aligns with results from Weary et al. (21) in Uganda, where integrated health programs effectively reduced respiratory infections. Conversely, the significant rise in nasal breathing problems (46.4% to 66.1%) is consistent with findings from Ohemeng et al. (22) in Ghana and Raju et al. (23) which emphasize the impact worsening air quality and indoor pollution on upper respiratory tract infections (URTIs). Similarly, Fan et al. (24) in China linked an increase in URTIs to urbanization and air pollution. Moreover, the growing number of children with ARI reflects an ongoing public health challenge, underscoring that ARIs remain a major cause of child morbidity and mortality globally due to factors like population growth, limited healthcare access, and antimicrobial resistance (25–29).

Maternal factors, such as the ecological location of residence, significantly influence the likelihood of children developing respiratory infections. Children in coastal areas were also at greater risk, possibly due to increased humidity and the presence of allergens such as mold and sea salt aerosols, which aggravate respiratory conditions. Existing studies have confirmed that these environmental factors in coastal zones contribute to higher incidences of respiratory infections (30–32). Maternal literacy also emerged as a critical determinant. Although illiteracy was paradoxically associated with lower odds of respiratory infections, this might be explained by lower health-seeking behavior or underreporting of symptoms in populations with lower education levels. Daffe et al. (32) highlight the general trend that maternal literacy is protective for child health, as educated mothers are more likely to recognize symptoms and seek medical care. However, this paradox may be attributed the potential underreporting or reporting biases of respiratory symptoms by less literate mothers or reduced access to health facilities, as suggested by Naz and Ghimire (33). Thus, the relationship between maternal literacy and respiratory infections may be complex, with cultural and reporting behaviors influencing the results. We suggest further studies and in-depth qualitative research into the relationship between mothers' literacy level and ARI infections among their children to either confirm or refute this study's findings. Moreover, ethnic differences were observed, with children from the Akan ethnic groups experiencing lower odds of respiratory difficulties. This finding may reflect cultural health practices or variations in environmental exposures, as previous studies have shown that certain ethnic groups tend to have better health outcomes due to specific cultural practices or healthcare-seeking behaviors (34–36).

The Akan ethnic group predominately resides in the southern regions of Ghana, such as Ashanti, Greater Accra Eastern and Central regions. These areas are generally more urbanized and economically developed compared to other parts of the country. Urban settings often offer better access to healthcare facilities which encourages Akan mothers to be more inclined toward biomedical practices leading to better health outcomes for their children (37, 38).

However, Ganle (39) contradicts these findings, arguing that ethnic disparities in healthcare access often put minority groups at a disadvantage, increasing their vulnerability to childhood infections. This indicates that ethnicity can interact with various social and environmental factors to influence child health outcomes in different ways.

Household factors, such as the age of the household head, were significantly associated with the likelihood of children experiencing respiratory infections. Younger household heads, particularly those between 20 and 39 years, were more likely to have children with respiratory difficulties. This could be attributed to their generally lower socioeconomic status and less experience in managing household health risks. Existing studies have affirmed that younger heads of households often have fewer resources and may live in environments with poor ventilation or substandard housing (29, 38–40). In addition, improved sanitation was found to be protective against respiratory infections in children. Households with improved toilet facilities had lower odds of respiratory difficulties, which align with existing evidence that better sanitation reduces exposure to pathogens and indoor air pollution, contributing to a healthier environment (41, 42). Furthermore, the type of cooking fuel used was an important determinant. While solid fuels like wood have long been known to increase respiratory infection risks due to indoor air pollution, this study surprisingly found that households using charcoal had lower odds of respiratory difficulties. Woolley et al. (43) reported that both wood and charcoal increase respiratory risks due to the smoke produced. However, this study's results may reflect local practices, as households using charcoal may have better ventilation or use outdoor cooking areas, which reduce children's exposure to harmful smoke. Furthermore, charcoal combustion typically produces less smoke and fewer pollutants than wood. This is because charcoal undergoes a carbonization process that removes moisture and volatile compounds, resulting in a cleaner-burning fuel. In contrast, wood combustion releases higher levels of particulate matter and other harmful pollutants, increasing the risk of respiratory issues.

Child-related factors such as boys were found to be more vulnerable to respiratory infections compared to girls. This observation is consistent with existing studies that suggest boys have a higher biological susceptibility to respiratory infections, likely due to differences in immune system function and lung development (44–46). The age of the child also significantly influenced the likelihood of respiratory difficulties. Infants under 12 months were especially prone to respiratory infections, reflecting their underdeveloped immune systems and smaller airways, which make them more susceptible to such conditions. This finding is supported by existing studies which noted that infants, particularly those under 1 year of age, are more likely to suffer from acute respiratory infections due to these physiological vulnerabilities (13, 46–48). These child-related factors highlight the importance of targeted interventions for vulnerable age groups and the need to consider gender differences in respiratory health. These findings underscore the need for designing strategies, policies, and programme to prevent ARIs among children under five through a holistic and integrated approach. Addressing maternal, household, and child-related socio-demographic factors collectively is important for develop effective interventions. Key policy actions should include investments in female literacy programs and maternal health education, the promotion and the adoption of clean cooking technologies, scaling up nutrition programmes targeting children under five and culturally sensitive health education campaigns that dispel misconceptions about ARIs.

The study has the following limitations. First, it relies on existing (secondary) data that is cross-sectional in nature. Consequently, it cannot be used to infer causality but only establish associations between the variables of interest. Second, the data were collected 3 years ago. Although there has been a general decline in ARI among children since then, the proximate determinants may have changed over time. Third, the occurrence of ARI among children is self-reported and not clinically verified, which may introduce social desirability bias. Additionally, the study is limited in its inclusion of some maternal, household and child related predictors of ARI among children, which may not be exhaustive due to the constraints of secondary data.

Finally, there were some very wide confidence intervals in the regression results which indicate potential issues related to sparse data, overlifting or instability in the model. On the sparse data issue, if the number of observations in a subgroup (for example household heads aged 20–29) is small, especially with few events (disease cases), the model may struggle to estimate the effect precisely. This may lead to high uncertainty, which inflates the confidence interval. Again, there is potential overfitting occurs when the model is too complex for the amount of available data such as having too many predictors or interaction terms relative to the number of events. This makes the estimates unstable and overly sensitive to small changes in the data, resulting in exaggerated odds ratios and very wide confidence intervals. However, these limitations, did not significantly affect the accuracy and robustness of the result obtained.

Findings from the 2022 GDHS indicate that a considerable proportion of children aged 6–59 months in Ghana experienced ARIs. Key determinants significantly associated with ARI prevalence included maternal literacy level, household sanitation, ecological location of residence, and the child's demographics, nutritional and health status. These findings highlight the need for targeted public health interventions that prioritize improving maternal literacy, improving household living conditions, and raising caregiver awareness on ARI prevention. Such focused efforts are essential to reducing the burden of ARIs among this vulnerable age group. A comprehensive, cross-sectoral response is critical to reducing ARI prevalence and improving respiratory health outcome for vulnerable children across diverse communities.