PREVALENCE AND DETERMINANTS OF COMMON CHILDHOOD ILLNESSES AMONG UNDER-FIVE CHILDREN IN SOMALILAND: INSIGHTS FROM A NATIONWIDE SURVEY.

PREVALENCE AND DETERMINANTS OF COMMON CHILDHOOD ILLNESSES AMONG UNDER-FIVE CHILDREN IN SOMALILAND: INSIGHTS FROM A NATIONWIDE SURVEY. | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 16 July 2025 V1 Latest version Share on PREVALENCE AND DETERMINANTS OF COMMON CHILDHOOD ILLNESSES AMONG UNDER-FIVE CHILDREN IN SOMALILAND: INSIGHTS FROM A NATIONWIDE SURVEY. Authors : Abdilaahi Yusuf Nuh 0009-0001-9203-2557 , Mohamed Ali Adam [email protected] , and Khalid Ali Ahmed Authors Info & Affiliations https://doi.org/10.22541/au.175269460.04972698/v1 417 views 265 downloads Contents Abstract Introduction Method and Materials Result Determinants and distribution percentage of childhood illnesses Determinants of Common Childhood Illnesses Discussion Conclusion Supplementary Material References Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Background : Under-five mortality remains a significant public health challenge in Somaliland, with acute respiratory infections (ARIs), diarrhea, and fever being major contributors. This study aimed to determine the prevalence and determinants of these common childhood illnesses in Somaliland. Methods : Secondary analysis was conducted using data from the Somali Demographic and Health Survey 2020, a nationwide cross-sectional survey. The study population included 4,702 children aged 5–59 months. Data on diarrhea, fever, and ARI in the two weeks preceding the survey were analyzed using binary logistic regression to identify associated factors. Results : The prevalence rates were 6.07% for fever, 4.75% for diarrhea, and 3.66% for ARI among children aged 5-59 months. In adjusted binary logistic regression models, a maternal age of 25 years or older was associated with significantly lower odds of diarrhea (OR = 0.56, 95% CI: 0.33–0.94, p = 0.029). Children who had never been breastfed also had reduced odds of diarrhea (OR = 0.39, 95% CI: 0.15–0.98, p = 0.045) and ARI (OR = 0.34, 95% CI: 0.12–0.96, p = 0.042). Nomadic residence was a protective factor, associated with lower odds of diarrhea (OR = 0.51, 95% CI: 0.33–0.77, p = 0.001), fever (OR = 0.52, 95% CI: 0.34–0.78, p = 0.002), and Acute Respiratory Infection (OR = 0.55, 95% CI: 0.33–0.91, p = 0.020). Conclusions : This study highlights significant associations between maternal age, breastfeeding practices, place of residence, and the prevalence of common childhood illnesses in Somaliland. These findings underscore the need for targeted interventions to address modifiable risk factors and reduce the burden of childhood morbidity in Somaliland. PREVALENCE AND DETERMINANTS OF COMMON CHILDHOOD ILLNESSES AMONG UNDER-FIVE CHILDREN IN SOMALILAND: INSIGHTS FROM A NATIONWIDE SURVEY. Abdilaahi Yusuf Nuh 1, 2* Mohamed Ali Adam 1,3 Khalid Ali Ahmed 4 1 Department of Epidemiology, Faculty of Public Health, Jimma University, Jimma, Ethiopia 2 Department of Public Health, Faculty of Health Science, Alpha University, Burao, Somaliland 3 Department of medicine, faculty of medicine and nursing, Beder International University, Hargeisa, Somaliland 4 Department Ministry of Health Development of Somaliland *Corresponding author; [email protected] Background : Under-five mortality remains a significant public health challenge in Somaliland, with acute respiratory infections (ARIs), diarrhea, and fever being major contributors. This study aimed to determine the prevalence and determinants of these common childhood illnesses in Somaliland. Methods : Secondary analysis was conducted using data from the Somali Demographic and Health Survey 2020, a nationwide cross-sectional survey. The study population included 4,702 children aged 5–59 months. Data on diarrhea, fever, and ARI in the two weeks preceding the survey were analyzed using binary logistic regression to identify associated factors. Results : The prevalence rates were 6.07% for fever, 4.75% for diarrhea, and 3.66% for ARI among children aged 5-59 months. In adjusted binary logistic regression models, a maternal age of 25 years or older was associated with significantly lower odds of diarrhea (OR = 0.56, 95% CI: 0.33–0.94, p = 0.029). Children who had never been breastfed also had reduced odds of diarrhea (OR = 0.39, 95% CI: 0.15–0.98, p = 0.045) and ARI (OR = 0.34, 95% CI: 0.12–0.96, p = 0.042). Nomadic residence was a protective factor, associated with lower odds of diarrhea (OR = 0.51, 95% CI: 0.33–0.77, p = 0.001), fever (OR = 0.52, 95% CI: 0.34–0.78, p = 0.002), and Acute Respiratory Infection (OR = 0.55, 95% CI: 0.33–0.91, p = 0.020). Conclusions : This study highlights significant associations between maternal age, breastfeeding practices, place of residence, and the prevalence of common childhood illnesses in Somaliland. These findings underscore the need for targeted interventions to address modifiable risk factors and reduce the burden of childhood morbidity in Somaliland. Keywords : Childhood illnesses, diarrhea, acute respiratory infection, fever, Somaliland, determinants, cross-sectional study, Somali Demographic and Health Survey. Introduction The World Health Organization (WHO) describes health as a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity (1). Under-five mortality remains a critical concern for demographers, public health experts, and policymakers, serving as a vital indicator of societal development and national priorities. Globally, under-five mortality rates have declined by half, from 91 deaths per 1,000 live births in 1990 to 43 deaths per 1,000 live births in 2015(2). The World Health Organization (WHO) estimates that the annual rate of decline accelerated from 2% during 1990–2000 to approximately 4% between 2000 and 2015 (2). Despite this progress, global efforts fell short of achieving Millennium Development Goal 4 (MDG-4), which aimed to reduce under-five mortality by two-thirds by 2015(3). Although child morbidity and mortality have decreased over recent decades, their burden remains unacceptably high. In 2018, approximately 5.3 million children died before their fifth birthday, down from 6.3 million in 2013(4,5). Under-five children are disproportionately vulnerable to preventable and treatable infectious diseases such as acute respiratory infections (ARIs), diarrheal diseases, and fever(6–8). Diarrhea alone persists as a leading cause of child mortality in low- and middle-income countries (LMICs), including Somalia(9). The Sustainable Development Goals (SDGs) reinvigorated global efforts to reduce under-five mortality, targeting a rate of 25 deaths per 1,000 live births by 2030(10,11). However, sub-Saharan Africa (SSA) continues to face formidable challenges, with under-five mortality rates 20 times higher than those in high-income countries(3). In 2019, SSA recorded an average under-five mortality rate of 76 deaths per 1,000 live births, equating to 1 in 13 children dying before age five (15). Seven SSA countries—Nigeria, Somalia, Angola, Central African Republic, Mali, Sierra Leone, and Chad—account for nearly one-fifth of global under-five deaths (1.1 million of 5.9 million), underscoring regional disparities(12). Research indicates that acute respiratory infections (ARIs), including pneumonia, are prevalent and significantly contribute to morbidity and mortality rates among children under the age of five. Specifically, ARIs account for approximately 18% of total deaths within this demographic, establishing them as a leading cause of childhood mortality (13,14). Various surveys conducted in regions such as India and Ethiopia reveal that a substantial proportion of children under five exhibit symptoms of ARIs, with reported incidences ranging from 30% to 44%(14,15). Similarly, diarrhea remains a critical health issue, often resulting in severe dehydration and adverse nutritional outcomes. Some studies report that 90.7% of children experienced diarrhea within the past year(16). The prevalence of diarrhea is closely associated with factors such as water quality and hygiene practices; children from families dependent on contaminated water sources tend to exhibit higher rates of such illnesses(17,18). Consequently, the interaction of these environmental factors, nutritional status, and healthcare access exacerbates the burden of these common illnesses on vulnerable children. Moreover, fever, frequently a symptom of multiple underlying conditions, is another common concern among caregivers of children under five. On average, these children may experience between three to six febrile illnesses annually, prompting parents to seek medical advice or intervention during these episodes(19,20). Evidence suggests that understanding caregivers’ management practices and enhancing their knowledge of fever can play crucial roles in improving health outcomes for young children(21) . In Somaliland, under-five mortality stood at 42 deaths per 1,000 live births in 2020, with preventable childhood illnesses like ARIs, diarrhea, and fever driving this burden(22). Younger children are particularly susceptible to these illnesses due to underdeveloped immunity (9). While socioeconomic, maternal, and community-level determinants—such as household poverty, parental education, and healthcare access—are well-documented contributors to childhood morbidity(23–25). Method and Materials Study setting This study was conducted in Somaliland, officially known as the Republic of Somaliland, an unrecognized de facto sovereign state in the Horn of Africa. The nation is divided into six administrative regions: Awdal, Maroodi-jeeh, Sahil, Togdheer, Sanaag, and Sool. Its territory covers approximately 176,120 square kilometers and had an estimated population of 5.7 million as of 2021(26). Study design and period This study conducts a secondary analysis of data from the Somali Demographic and Health Survey 2020 (SDHS 2020), the first nationally representative demographic and health survey carried out in Somaliland. The SDHS 2020 utilized a cross-sectional design to collect extensive information on demographic, health, and social indicators, including common childhood illnesses. This survey was implemented as a national initiative to improve data systems and support evidence-based planning. Data collection began in August 2018 and concluded in December 2019, encompassing urban, rural, and nomadic populations across Somalia and Somaliland. This analysis specifically investigates the prevalence and associated factors of common childhood illnesses, drawing on the robust and high-quality data from the SDHS 2020(27), with a particular emphasis on Somaliland. Source of data The research involved a secondary analysis of data from the 2020 Somali Health and Demographic Survey (SHDS), which was executed by the Somalia National Bureau of Statistics(27). This survey covered 16 out of Somalia’s 18 regions, with the Lower Shabelle and Middle Juba regions being excluded due to security issues. The 16 pre-war geographical regions in Somalia were divided into urban, rural, and nomadic areas, except for the Banadir region, which was entirely designated as urban(28). Sampling and sample size The survey employed a multi-stage probability sampling method, dividing each region into 18 strata based on urban, rural, and nomadic residential areas. Within each stratum, 35 primary sampling units (PSUs) were randomly selected for urban and rural areas, and 10 PSUs for nomadic areas. From these enumerated PSUs, 10 secondary sampling units (SSUs) were randomly chosen in the urban and rural strata. Subsequently, 30 households were systematically sampled from each selected PSU, and all eligible women aged 15–49 years within these households were invited to participate. A three-stage stratified cluster sampling design was implemented, incorporating probability proportional to size for PSUs and SSUs, and systematic sampling at the household level. Data was collected through face-to-face interviews using a structured questionnaire designed for ever-married women. The study population included women aged 15–49 years who were either permanent residents or visitors present in selected households the night before the survey. A total of 13,210 women completed the interview. For this study, we restricted the sample to mothers of children aged 5–59 months who provided complete information on their child’s illness history (fever, acute respiratory infections [ARI], and diarrhea). After applying inclusion criteria and sampling weights to ensure nationally representative estimates, the final analytical sample comprised 4,702 children. Only complete cases with non-missing data for all variables of interest were included in the multivariable analyses. Variables Dependent variables This study seeks to quantify the prevalence of diarrhea, fever, and acute respiratory infection (ARI) among children under five years of age in Somaliland over two weeks. To evaluate the prevalence of these common childhood illnesses, mothers were asked the following question: ”Did your child suffer from diarrhea, fever, or ARI in the last two weeks?” The response to this question serves as the dependent variable, which is a dichotomous variable indicating whether a child experienced any of the aforementioned illnesses (indicated by ”Yes” and coded as ”1”) or not (indicated by ”No” and coded as ”0”). While these three diseases are infectious, they exhibit distinct characteristics concerning their sources of infection and health impacts. Each disease adversely affects children’s health in different ways. Furthermore, the SDHS survey examines these diseases separately. Consequently, this study addresses the comorbidity factors of diarrhea, fever, and ARI individually. Independent variables The independent variables comprised selected socio-demographic and environmental and health-related factors about the mother and child. The socio-demographic variables encompassed region, sex of the child, age of the mother, maternal education level (categorized as No Education, Primary, Secondary, or Higher), wealth index (classified as Lowest, Second, Middle, Fourth, and Highest), and the number of household members. The environmental and health-related variables included the classification of the place of residence as urban, rural, or nomadic, and regional variations were examined across Awdal, Maroodi-Jeeh, Saahil, Togdheer, Sool, and Sanaag. Additionally, the source of drinking water was categorized as Improved or Unimproved, and the distance to a health facility was assessed as either a significant problem or not a significant problem. Statistical methods Data analysis was conducted using STATA version 17. Descriptive statistics were used to summarize the prevalence of childhood illnesses (fever, acute respiratory infection [ARI], and diarrhea) among children aged 5–59 months. Bivariate analyses employing cross-tabulations and Pearson’s chi-square (χ²) tests were performed to assess associations between each disease (fever, ARI, diarrhea) and sociodemographic, environmental, and maternal-child health variables. Variables showing significance ( p < 0.05) in bivariate analyses were included in subsequent multivariable models. To identify determinants of the three childhood illnesses, three separate binary logistic regression models were constructed. Each model examined the adjusted effects of predictors on the likelihood of a child experiencing fever, ARI, or diarrhea. The logistic regression equation was expressed as: Logit (P(Yi=1))=β0+β1X1+β2X2+⋯+βkXklogit( P ( Yi =1))= β 0+ β 1 X 1+ β 2 X 2+⋯+ βk Xk where Yi Yi is the binary outcome (1 = presence of illness; 0 = absence), X1,X2,…,Xk X 1, X 2,…, Xk represent independent variables (e.g., age, sex, maternal education, sanitation), and β β denotes regression coefficients. Adjusted odds ratios (AOR) with 95% confidence intervals (CI) were computed to quantify the strength and direction of associations, with the reference category for each variable explicitly defined. Model fit was assessed using the Hosmer-Lemeshow test, and multi-collinearity was evaluated via variance inflation factors (VIF < 10). Statistical significance was set at p < 0.05. The methodological framework for logistic regression aligns with established practices, as described by Cramer (2002)(29). Result Prevalence of Common Childhood Illnesses The study evaluated the prevalence and determinants of common childhood illnesses in Somaliland, specifically diarrhea, fever, and acute respiratory infections (ARI), among the 4,702 children under the age of five included in the analysis. The most frequently reported illness was fever, affecting 6.07% of the children, followed by diarrhea at 4.75%, and acute respiratory infection (ARI) at 3.66% (Figure 1 ). Figure 1: Estimated distribution of child illness in Somaliland, 2018–2019 (n =4,702) Determinants and distribution percentage of childhood illnesses The age of the child emerged as a significant determinant of diarrhea incidence (p<0.001). Children aged 13–24 months exhibited the highest prevalence rate, at 7.89%, followed by those under 12 months, at 6.86%. In contrast, children aged 25 months or older demonstrated the lowest prevalence, at 3.40%. The status of breastfeeding also revealed substantial variation (p<0.001); children who were still breastfeeding showed the highest prevalence of diarrhea at 7.60%, in contrast to those who had never been breastfed, who exhibited a prevalence of 2.84%. Furthermore, vaccinated children presented a higher prevalence of diarrhea at 7.94% compared to unvaccinated children, who had a prevalence of 4.63% (p=0.033). Regional disparities were apparent, with the Saahil region reporting the highest prevalence at 11.18% (p<0.001). Additionally, significant differences were observed between rural residences, with a prevalence of 6.52%, and nomadic settings, which had a prevalence of 3.01% (p<0.001). Also Maternal age (15–19 years) was linked to higher diarrhea prevalence (1.78%, p=0.009) as indicates (Table 1 ). The prevalence of fever exhibited significant variation across different age groups, reaching its highest incidence among children aged 13–24 months (8.68%, p<0.001). A correlation was observed between vaccination status and increased fever rates, with vaccinated individuals experiencing a higher prevalence (9.72%) compared to their unvaccinated counterparts (6.04%, p=0.034). Maternal education level also played a role in fever occurrence, as children of mothers with only primary education demonstrated the highest prevalence (9.28%, p=0.005). Regional disparities were evident, with the Saahil region consistently reporting elevated rates (9.15%, p=0.006). Also, urban residency (6.31%) and proximity to healthcare facilities (4.94% where distance was not a barrier, p=0.016) were associated with fever prevalence (Table 1 ). The prevalence of acute respiratory infections (ARI) was highest among children aged 13–24 months, with a rate of 4.60% (p<0.001). Notably, vaccinated children exhibited nearly double the prevalence (7.80%) compared to their unvaccinated counterparts (4.14%, p=0.013). Significant regional variations were observed, with Togdheer reporting the lowest prevalence at 1.87% (p=0.023). Furthermore, ARI rates were lower in urban (3.45%) and nomadic settings (3.00%) compared to rural areas, which had a prevalence of 4.68% (p=0.036) as indicates (Table 1 ). No Yes No Yes No Yes Sex of child Male a 5.07 94.93 0.532 6.13 93.87 0.869 4.00 96.00 0.253 Female 4.66 95.34 6.19 93.81 3.68 96.32 Age of child (in months) <12 a 6.86 93.14 0.000 9.33 90.67 0.000 5.99 94.01 0.000 13-24 7.89 92.11 8.68 91.32 4.60 95.40 25+ 3.40 96.60 4.64 95.36 2.86 97.14 Breastfeeding Status Ever breastfed but no a 4.34 95.66 0.000 5.58 94.42 0.000 3.55 96.45 0.097 . Never Breastfeed 2.84 97.16 3.33 96.67 2.46 97.54 Still breastfeeding 7.60 92.40 9.71 90.29 4.76 95.24 Vaccination Status No a 4.63 95.37 0.033 6.04 93.96 0.034 4.14 95.86 0.013 Yes 7.94 92.06 9.72 90.28 7.80 92.20 Maternal Age 15 – 19 a 1.78 98.22 0.0093 6.51 93.49 0.039 4.71 95.29 0.6551 20 - 24 5.80 94.20 7.80 92.20 3.65 96.35 25 - 29 5.92 94.08 5.10 94.90 3.30 96.70 30 - 34 4.24 95.76 5.41 94.59 3.65 96.35 35 - 39 5.16 94.84 6.46 93.54 3.47 96.53 45 - 49 1.10 98.90 12.36 87.64 6.45 93.55 Table 1: Sociodemographic, environment, and health characteristics of studied children aged 6–59 months and their percentage distribution by three illnesses (i.e. diarrhea, fever, and ARI) in Somaliland, 2019–2020 (n = 4,702). Primary 6.12 93.88 9.28 90.72 4.05 95.95 Secondary 7.29 92.71 6.06 93.94 1.01 98.99 Higher 2.04 97.96 2.08 97.92 4.08 95.92 Wealth index Lowest a 13.40 11.87 0.7563 11.24 12.06 0.7233 10.56 11.95 0.8096 Second 21.53 22.40 22.10 22.40 25.47 22.24 Middle 22.97 25.39 22.85 25.46 22.98 25.49 Fourth 24.88 21.88 22.85 22.00 23.60 22.05 Highest 17.22 18.45 20.97 18.07 17.39 18.27 Region Awdal a 5.62 94.38 0.000* 6.71 93.29 0.006 2.88 97.12 0.023 Maroodi-jeeh 4.29 95.71 8.13 91.87 4.71 95.29 Saahil 11.18 88.82 9.15 90.85 4.87 95.13 Togdheer 2.33 97.67 4.49 95.51 1.87 98.13 Sool 4.80 95.20 6.00 94.00 4.50 95.50 Sanaag 3.68 96.32 6.71 93.29 3.39 96.61 Place of residence Rural a 6.52 93.48 0.000* 7.99 92.01 0.0004 4.68 95.32 0.036 Urban 5.64 94.36 6.31 93.69 3.45 96.55 Nomadic 3.01 96.99 4.59 95.41 3.00 97.00 Distance to a health facility Big problem a 5.24 94.76 0.117 6.81 93.19 0.016 3.59 96.41 0.631 Not a big problem 4.14 95.86 4.94 95.06 3.88 96.12 Source of drinking water Improved a 5.07 94.93 0.50 6.03 93.97 0.90 3.56 96.44 0.86 Un improved 4.61 95.39 6.12 93.88 3.66 96.34 a Reference category in the multivariate analysis, *Significant association p < 0.05 Determinants of Common Childhood Illnesses The analysis revealed that children whose mothers are aged 25 years or older had significantly lower odds of experiencing diarrhea compared to those whose mothers are younger than 13 years (OR = 0.56, 95% CI: 0.33–0.94, p = 0.029). Additionally, children who were never breastfed also had reduced odds of diarrhea (OR = 0.39, 95% CI: 0.15–0.98, p = 0.045). Residence in nomadic settings was associated with a protective effect, as children from nomadic households had significantly lower odds of diarrhea compared to those from rural areas (OR = 0.51, 95% CI: 0.33–0.77, p = 0.001). Furthermore, when mothers perceived health problems as ”not a big problem,” their children were less likely to have diarrhea (OR = 0.47, 95% CI: 0.30–0.72, p = 0.001). Notably, children of mothers aged 45–49 years had higher odds of diarrhea (OR = 3.08, 95% CI: 1.00–9.46, p = 0.049), though this group is small and should be interpreted with caution (Table 2 ). For fever, children whose mothers were aged 25 years or older also had significantly lower odds compared to the reference group (OR = 0.56, 95% CI: 0.33–0.95, p = 0.031). Nomadic residence was again protective, with children from nomadic households having lower odds of fever (OR = 0.52, 95% CI: 0.34–0.78, p = 0.002). Similarly, a maternal perception that health problems are ”not a big problem” was associated with reduced odds of fever in children (OR = 0.47, 95% CI: 0.31–0.73, p = 0.001). Regarding ARI, children whose mothers were aged 25 years or older had significantly lower odds of ARI compared to the youngest maternal age group (OR = 0.41, 95% CI: 0.22–0.73, p = 0.003). Never having been breastfed was also associated with lower odds of ARI (OR = 0.34, 95% CI: 0.12–0.96, p = 0.042). In addition, nomadic residence was protective, with children from nomadic households having lower odds of ARI (OR = 0.55, 95% CI: 0.33–0.91, p = 0.020) (Table 2 ). Also, Hosmer and Lemeshow show that the model’s fitness was good. Table 2: Regression coefficients and odds ratios for the prevalence of diarrhea, fever and ARI by selected socio-demographic, environmental and health related factors of children in Somaliland, 2019 – 2020 Age Category >12a a 13–24 1.06 (0.25) [0.67, 1.68] 0.25 0.804 1.05 (0.25) [0.66, 1.67] 0.21 0.84 0.68 (0.19) [0.39, 1.18] -1.37 0.172 25+ 0.56 (0.15) [0.33, 0.94] -2.18 0.029 0.56 (0.15) [0.33, 0.95] -2.16 0.03 0.41 (0.12) [0.22, 0.73] -3 0.003 Vaccination Status No a Yes 1.28 (0.35) [0.75, 2.17] 0.9 0.367 1.29 (0.35) [0.76, 2.19] 0.93 0.35 1.44 (0.43) [0.80, 2.60] 1.22 0.223 Breastfeeding (V012) Ever breasfeed but not a breastfeeding no Never Breastfed 0.39 (0.18) [0.15, 0.98] -2 0.045 0.40 (0.19) [0.16, 1.02] -1.93 0.05 0.34 (0.18) [0.12, 0.96] -2.04 0.042 Still Breastfeeding 1.25 (0.27) [0.82, 1.90] 1.02 0.308 1.26 (0.27) [0.83, 1.93] 1.08 0.28 0.65 (0.18) [0.39, 1.10] -1.59 0.112 Mother’s Age (V001) 15 – 19 a 20 - 24 1.34 (0.55) [0.60, 2.97] 0.71 0.479 1.33 (0.54) [0.60, 2.96] 0.69 0.49 0.83 (0.38) [0.34, 2.01] -0.41 0.681 25 - 29 0.88 (0.36) [0.39, 1.97] -0.31 0.756 0.86 (0.35) [0.38, 1.92] -0.38 0.71 0.54 (0.25) [0.22, 1.34] -1.33 0.184 30 - 34 0.72 (0.31) [0.31, 1.67] -0.77 0.442 0.71 (0.31) [0.31, 1.67] -0.78 0.44 0.83 (0.38) [0.34, 2.03] -0.41 0.679 35 - 39 0.86 (0.38) [0.36, 2.05] -0.33 0.739 0.86 (0.38) [0.36, 2.04] -0.34 0.73 0.78 (0.37) [0.31, 1.98] -0.52 0.6 40 - 44 0.45 (0.32) [0.11, 1.80] -1.12 0.261 0.45 (0.31) [0.11, 1.78] -1.15 0.25 1.36 (0.78) [0.45, 4.17] 0.54 0.588 45 - 49 3.08 (1.76) [1.00, 9.46] 1.97 0.049 3.04 (1.74) [0.99, 9.34] 1.95 0.05 1.80 (1.21) [0.48, 6.70] 0.88 0.379 Mother’s Education (V004) No Education a Primary 1.05 (0.27) [0.63, 1.74] 0.19 0.853 1.00 (0.26) [0.60, 1.68] 0.01 0.99 0.69 (0.23) [0.35, 1.34] -1.11 0.268 Secondary 0.67 (0.50) [0.15, 2.91] -0.53 0.593 0.67 (0.50) [0.15, 2.89] -0.54 0.59 0.37 (0.39) [0.05, 2.83] -0.95 0.341 Higher 1.00 (empty) 1.00 (empty) 1.79 (1.94) [0.21, 14.91] 0.54 0.591 Residence (V003) Rural a Urban 0.67 (0.17) [0.41, 1.10] -1.6 0.111 0.68 (0.17) [0.41, 1.11] -1.53 0.13 0.96 (0.26) [0.56, 1.65] -0.15 0.878 Nomadic 0.51 (0.11) [0.33, 0.77] -3.19 0.001 0.52 (0.11) [0.34, 0.78] -3.1 0 0.55 (0.14) [0.33, 0.91] -2.33 0.02 Perceived Problem (V008) Big problem a Not a big problem 0.47 (0.10) [0.30, 0.72] -3.42 0.001 0.47 (0.11) [0.31, 0.73] -3.35 0 0.88 (0.20) [0.56, 1.37] -0.58 0.563 Constant 0.16 (0.07) [0.07, 0.37] -4.26 0 0.16 (0.07) [0.07, 0.37] -4.25 0 0.17 (0.08) [0.07, 0.43] -3.73 0 LR chi2(16) = 65.20 LR chi2(16) = 63.29 LR chi2(17) = 33.96 Prob > chi2 = 0.000* Prob > chi2 = 0.000* Prob > chi2 = 0.0085 Pseudo R2 = 0.0597 Pseudo R2 = 0.0584 Pseudo R2 = 0.0400 Hosmer and Lemenshow test = 5.98 ** 6.32 ** 8.82 * a Reference category of each independent variable b Reference category of each dependent variable is ‘no’ i.e. children had not suffered diarrhea, fever or ARI * p < 0.05, **p < 0.01, ***p < 0.001 Discussion This study provides nationally representative estimates on the prevalence and determinants of common childhood illnesses—namely diarrhea, fever, and acute respiratory infections (ARI) among under-five children in Somaliland. Utilizing data from the Somali Demographic and Health Survey (SDHS) 2020, our analysis reveals important insights into the health challenges faced by children under five and highlights several modifiable and contextual risk factors. The overall prevalence rates of fever (6.07%), diarrhea (4.75%), and ARI (3.66%) were lower than figures reported in earlier regional studies, such as those from Ethiopia and Bangladesh, where prevalence estimates exceeded 20% for some conditions(8,13,17). These discrepancies may reflect differences in environmental exposures, healthcare access, and seasonal variation during data collection, or underreporting due to caregiver recall bias. Nonetheless, the findings affirm that infectious diseases remain a persistent threat to child survival in Somaliland. Child age emerged as a consistent predictor across all three illnesses, with the 13–24 months age group exhibiting the highest vulnerability. This is likely due to increased mobility, exposure to pathogens, and waning maternal antibodies during this developmental stage(6,14). This aligns with previous research indicating that children transitioning from exclusive breastfeeding to complementary feeding face increased susceptibility to infections(8,18). Breastfeeding status was significantly associated with illness occurrence. Paradoxically, children who were still breastfeeding had a higher prevalence of diarrhea, while those who were never breastfed exhibited lower odds of diarrhea and ARI. This finding contrasts with global evidence that supports breastfeeding as protective against infections(24). However, the apparent contradiction may be influenced by reverse causality—children with recent illnesses may continue to breastfeed more frequently—or by inadequate maternal hygiene practices during breastfeeding. Further qualitative investigations are needed to disentangle these dynamics within the Somaliland context. Maternal age was also an influential determinant. Children of mothers aged 25 years and above were significantly less likely to experience diarrhea, fever, or ARI compared to those of younger mothers. This finding supports literature suggesting that older mothers may possess greater health literacy, experience, and caregiving efficacy(23,24). Conversely, children of mothers aged 45–49 exhibited increased odds of diarrhea, which may reflect age-related caregiving challenges, although the small sample size within this age bracket warrants cautious interpretation. Geographic disparities were prominent. Children residing in nomadic households consistently demonstrated lower odds of all three illnesses compared to their rural counterparts. This may reflect differences in exposure patterns, household structures, or mobility-associated health-seeking behaviors. In contrast to the expected challenges of healthcare access among nomadic populations, the protective association may also be linked to underreporting or limited healthcare contact(9). Perceived ease of accessing health facilities significantly influenced illness outcomes. When mothers did not perceive distance to a healthcare facility as a major problem, their children had reduced odds of both diarrhea and fever. This finding underscores the critical role of perceived and actual healthcare accessibility in shaping child health outcomes, consistent with prior studies in similar low-resource settings(14,19,21). Interestingly, vaccination status showed no significant association with the likelihood of fever, ARI, or diarrhea in multivariable analysis, despite crude associations suggesting higher prevalence among vaccinated children. This might reflect confounding by indication—where children receiving vaccines may already be at higher risk or were unwell during the recall period. Moreover, timing and completeness of vaccination were not assessed, which could further clarify this relationship(13,20). The model diagnostics, including the Hosmer-Lemeshow goodness-of-fit test, confirmed the robustness of all three logistic regression models. This supports the reliability of the identified predictors and the validity of our analytical framework in identifying key factors associated with common childhood illnesses in Somaliland. Conclusion This study underscores the ongoing burden of prevalent childhood illnesses, namely diarrhea, fever, and acute respiratory infections (ARI) among children under the age of five in Somaliland, despite relatively low prevalence estimates when compared to similar contexts. The primary determinants identified include the child’s age, maternal age, breastfeeding practices, type of residence, and perceived access to healthcare services. It was observed that children of older mothers, those residing in nomadic households, and those with improved access to healthcare were less likely to experience illness. These findings underscore the need for targeted, context-specific interventions that aim to enhance maternal health education, promote safe child-feeding practices, and improve healthcare accessibility. Strengthening community-based health services and addressing social determinants can significantly contribute to reducing child morbidity and advancing progress toward the Sustainable Development Goals related to child health in Somaliland. Declarations Ethical Approval Declaration The Somali Demographic and Health Survey 2020 (SDHS 2020) was approved by the Somali National Bureau of Statistics (SNBS) and the Ministry of Health, Somalia. The study adhered to the SNBS’s ethical data collection and participant protection guidelines. Human Ethics and consent to participate declarations This study utilized secondary data from the Somali Demographic and Health Survey 2020 (SDHS 2020), which adheres to ethical guidelines for data collection and participant protection. Informed consent was obtained from all participants by the Somali National Bureau of Statistics before data collection. No additional ethical approval was required for this secondary data analysis, as the dataset was anonymized and did not contain personally identifiable information. Source of funding There is no funding. Grant No N/A Consent for publication The authors declared this manuscript have not been published elsewhere. Availability of data and materials The data for the study was freely available: https://microdata.nbs.gov.so/index.php/catalog/50/get-microdata Competing Interests Authors declare no competing interests Authors’ contributions A.Y. conceptualized the study, designed the methodology, and conducted the data analysis. A.Y. drafted the initial manuscript and prepared all visualizations, including figures and tables. M.A. and K.A. contributed to refining the study design, provided critical feedback on the analytical approach, and revised the manuscript for intellectual clarity and coherence. Both authors collaborated on interpreting the results, reviewed successive drafts of the manuscript, and approved the final version for submission and publication. A.Y. and M.A. are jointly accountable for the integrity and validity of the research. Acknowledgments I acknowledge the Somaliland Central Statistics Department (SLCSD) program for approving the use of the 2020 SDHS in my study. Supplementary Material File (table 1.docx) Download 22.25 KB File (table 2.docx) Download 21.19 KB References 1. 1. Organization WH. Constitution of the world health organization. World Heal Organ Handb basic Doc. 1952;3–20. 2. WHO. WHO Child mortality. WHO Child Mortal. 2023; 3. WHO. Child mortality and causes of death. WHO; 2023. (ClinicalKey 2014). 4. UNICEF, WHO WBG and UN. Child mortality. Unicef. 5. Alkema L, New JR, Pedersen J, You D, Group all members of the UNI agency G for CME, its Technical Advisory. Child Mortality Estimation 2013: An Overview of Updates in Estimation Methods by the United Nations Inter-Agency Group for Child Mortality Estimation. PLoS One [Internet]. 2014 Jul;9(7):e101112. Available from: https://doi.org/10.1371/journal.pone.01011126. Krishnan A, Amarchand R, Gupta V, Lafond KE, Suliankatchi RA, Saha S, et al. Epidemiology of acute respiratory infections in children - preliminary results of a cohort in a rural north Indian community. BMC Infect Dis. 2015;15(1):1–10. 7. Novignon J, Nonvignon J. Socioeconomic status and the prevalence of fever in children under age five: evidence from four sub-Saharan African countries. BMC Res Notes. 2012 Jul;5:380. 8. Alebel A, Tesema C, Temesgen B, Gebrie A, Petrucka P, Kibret GD. Prevalence and determinants of diarrhea among under-five children in Ethiopia: A systematic review and meta-analysis. PLoS One. 2018;13(6):e0199684. 9. Ali HA, Nuh AM, Abdi HA, Muse AH. Multilevel analysis of prevalence and determinants of diarrhea among under-five children in Somalia: insights from the Somalia demographic and health survey 2020. BMC Public Health. 2025;25(1):202. 10. You D, Hug L, Ejdemyr S, Idele P, Hogan D, Mathers C, et al. Global, regional, and national levels and trends in under-5 mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the UN Inter-agency Group for Child Mortality Estimation. Lancet (London, England). 2015 Dec;386(10010):2275–86. 11. Walsh PP, Banerjee A, Murphy E. The UN 2030 Agenda for Sustainable Development. Sustain Dev Goals Ser. 2022;Part F2740:1–12. 12. Group UNI agency. Levels & Trends in. 2024. 13. Sultana M, Sarker AR, Sheikh N, Akram R, Ali N, Mahumud RA, et al. Prevalence, determinants and health care-seeking behavior of childhood acute respiratory tract infections in Bangladesh. PLoS One. 2019;14(1):e0210433. 14. Ayalneh AA, Fetene DM, Lee TJ. Inequalities in health care utilization for common childhood illnesses in Ethiopia: evidence from the 2011 Ethiopian Demographic and Health Survey. Int J Equity Health. 2017;16:1–9. 15. Sethy G, Jena D, Biswas T, Nayak M. Assessment Of Morbidity Profile Among Under-Five Children In Urban Slum Area Of Berhampur, A Southern City Of Odisha-A Cross-Sectional Study. J Evid Based Med Healthc. 2017; 16. Saeedi P, Petersohn I, Salpea P, … BMD research and, 2019 undefined. Global and regional diabetes prevalence estimates for 2019 and projections for 2030 and 2045: Results from the International Diabetes Federation Diabetes Atlas. ElsevierP Saeedi, I Petersohn, P Salpea, B Malanda, S Karuranga, N Unwin, S ColagiuriDiabetes Res Clin Pract 2019•Elsevier [Internet]. [cited 2025 Mar 17]; Available from: https://www.sciencedirect.com/science/article/pii/S016882271931230617. Islam KN, Sultana S, Rahman F, Rahman A. Exploring the impact of child underweight status on common childhood illnesses among children under five years in Bangladesh along with spatial analysis. PLoS One. 2024;19(9):e0311183. 18. Bizuneh H, Getnet F, Meressa B, Tegene Y, Worku G. Factors associated with diarrheal morbidity among under-five children in Jigjiga town, Somali Regional State, eastern Ethiopia: a cross-sectional study. BMC Pediatr. 2017;17:1–7. 19. Hassona MMA, Atlam SAE, Shalaby SE. Knowledge, Attitude and Practice of Mothers towards Fever and its Home Management among under five Children in Kom Hamada city, Behira Governorate, Egypt. J Adv Med Res. 2021;33(19):173–85. 20. Craig JC, Williams GJ, Jones M, Codarini M, Macaskill P, Hayen A, et al. The accuracy of clinical symptoms and signs for the diagnosis of serious bacterial infection in young febrile children: prospective cohort study of 15 781 febrile illnesses. Bmj. 2010;340. 21. Yildam FJ, Adanchin FH, Igboechesi GP. Review on the Reflection of National Health Financing Policy and Strategy on Nigerians towards Achieving Universal Health Coverage by 2030. Univers Heal Cover Int J Public Heal Pharm Pharmacol. 2023;8(5):10–25. 22. World bank. UN Inter-agency Group for Child Mortality Estimation. WORLD BANK. 2022;315(8168):606. 23. Franz JS, FitzRoy F. Child mortality and environment in developing countries. Popul Environ. 2006;27(3):263–84. 24. Amy L. Rice, 1 Lisa Sacco, 2 Adnan Hyder 3 & Robert E Black. Bulletin of the World Health Organization - Malnutrition as an underlying cause of childhood deaths associated with infectious diseases in developing countries. 2000;78(10):1207–21. Available from: https://www.who.int/bulletin/archives/78%2810%291207.pdf25. Fuchs R, Pamuk E, Lutz W. Education or wealth: which matters more for reducing child mortality in developing countries? Vienna Yearb Popul Res [Internet]. 2010 Apr;8:175–99. Available from: http://www.jstor.org/stable/2302551426. Somaliland M of HDR of. National Health Policy III. 2022. 27. Statistics. SNB of. The Somali Health and Demographic Survey; 2020. 2020. 28. Ali DA, Mohamed NA, Ismail AI, Hassan GD. The risk factors of infant mortality in Somalia: evidence from the 2018/2019 Somali health & demographic survey. BMC Pediatr. 2024;24(1):486. 29. Cramer JS. The origins of logistic regression. Tinbergen Institute discussion paper; 2002. Crossref Google Scholar Information & Authors Information Version history V1 Version 1 16 July 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords acute respiratory infection childhood illnesses cross-sectional study determinants diarrhea fever somali demographic and health survey somaliland Authors Affiliations Abdilaahi Yusuf Nuh 0009-0001-9203-2557 Jimma University Faculty of Public Health View all articles by this author Mohamed Ali Adam [email protected] Jimma University Faculty of Public Health View all articles by this author Khalid Ali Ahmed Bahagian Perkembangan Perubatan View all articles by this author Metrics & Citations Metrics Article Usage 417 views 265 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Abdilaahi Yusuf Nuh, Mohamed Ali Adam, Khalid Ali Ahmed. PREVALENCE AND DETERMINANTS OF COMMON CHILDHOOD ILLNESSES AMONG UNDER-FIVE CHILDREN IN SOMALILAND: INSIGHTS FROM A NATIONWIDE SURVEY.. Authorea . 16 July 2025. 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