The prevalence of ARI was 2.41%, indicating improvements in child health compared to SouthAsian counterparts but highlighting the continued vulnerability of certain subpopulations to preventable respiratory illnesses. However, the 2022 NDHS reported a further decline in ARI prevalence to 1%, suggesting continued progress in reducing the burden of respiratory infections among children under five.¹⁹

Healthcare-seeking behavior among caregivers was encouraging in this study, with 84.92% of children with ARI symptoms receiving medical advice or treatment (Table 2). However, the 2022 NDHS reported a slightly lower rate of care-seeking at 75%, indicating a potential decline in healthcare utilization for ARI cases.¹⁹ This study found that private medical facilities (32.30%) and pharmacies (27.92%) were the most utilized healthcare providers for ARI treatment. The NDHS 2022 reported an even greater reliance on private sector healthcare, with 60% of ARI cases managed in private clinics and pharmacies. A study done in Bangladesh showed that most caregivers sought medical care for children with ARI symptoms, but the reliance on private facilities may lead to financial challenges and concerns about care quality.²⁰ Public healthcare systems must be strengthened to provide accessible, affordable, and standardized care for ARI to reduce inequities in health outcomes.

A significant association was observed between household wealth quintile and ARI prevalence (Table 3). Children from the poorest households had the highest prevalence (3.32%), while those from the richest households had the lowest prevalence (0.59%). Global evidence supports the link between poverty and increased respiratory illness risk, driven by factors such as reliance on biomass fuels, poor housing, and limited access to healthcare.²¹ Interventions like promoting clean cooking technologies, improving housing conditions, and poverty alleviation programs are essential to mitigating ARI risk among socioeconomically disadvantaged populations.

Even after adjusting for confounders, children from poorer households exhibited higher odds of ARI compared to their wealthier counterparts (AOR: 1.60; 95% CI: 0.063–40.836) (Table 4). These findings align with global and regional evidence linking poverty to increased susceptibility to respiratory illnesses due to factors such as reliance on biomass fuels, poor housing conditions, and limited access to healthcare services. Targeted interventions, such as clean cooking technologies, housing improvements, and poverty alleviation programs, are essential to mitigating ARI risk among the most vulnerable populations.

Geographic disparities in ARI prevalence were also observed (Table 3), with the highest rates in Province 6 (now Karnali Province) (3.37%) and Province 1 (now Koshi Province) (3.31%). Although these differences were not statistically significant in the multivariate model, they highlight important structural inequities. The NDHS 2022 findings confirm that Karnali Province still experiences the highest ARI burden with 4% prevalence.¹⁹ This persistent geographic disparity suggests structural inequities in healthcare access, environmental risk factors, and socioeconomic conditions. Provinces with higher rates of poverty, greater reliance on biomass fuels, and limited healthcare infrastructure are likely to experience higher ARI prevalence. The relationship between poverty, biomass fuel use, and ARI is well-established, though more research with improved exposure assessment is needed to validate findings and inform interventions. ^{17 21}

Contrary to expectations, maternal education was not significantly associated with ARI prevalence (Table 3). Maternal education often influences child health outcomes through improved caregiving and health-seeking behaviors.^{22 23} This effect may be attenuated in Nepal due to broader systemic barriers, such as limited healthcare access and environmental risk factors. Community-based interventions, including health education programs can improve parental knowledge and awareness of ARI prevention and management, are crucial.²⁴ Similarly, no significant differences in ARI prevalence were observed between urban and rural settings. This lack of association may be explained by urban areas facing unique challenges, including overcrowding, inadequate ventilation, and exposure to ambient air pollution, which offset the benefits of urbanization.

This study is strengthened by its use of a nationally representative dataset and rigorous statistical methods, including adjustments for the survey’s complex sampling design. However, certain limitations must be acknowledged. First, ARI status was based on caregiver-reported symptoms, which may introduce recall bias or misclassification. Second, the cross-sectional design precludes causal inferences. Third, the absence of data on critical risk factors, such as direct measures of household air pollution exposure and nutritional status, limited the scope of the analysis.

Despite these limitations, the findings underscore the critical role of socioeconomic and geographic disparities in shaping ARI risk among children in Nepal. Targeted public health interventions that address poverty, promote clean energy adoption, and enhance access to affordable healthcare are essential to mitigating the ARI burden. Improving access to quality healthcare services, including timely diagnosis, appropriate treatment, and effective case management, is essential.^{2 25} This involves strengthening health systems, training healthcare providers, and promoting appropriate healthcare-seeking behavior among parents.

Future research should focus on longitudinal studies to establish causal pathways and incorporate additional contextual factors, such as environmental exposures, healthcare quality, and cultural practices. Policy makers should consider these variables when taking steps to improve the health of children under 5 years of age who are affected by ARI. It is also important to keep regional variations in mind.