Factors related with the incidence of acute respiratory infections in toddlers in Sleman, Yogyakarta, Indonesia: Evidence from the Sleman Health and Demographic Surveillance System

Abstract

Various factors associated with Acute Respiratory Infections (ARI) in toddlers have been widely observed, but there are no studies using data from the Sleman Health and Demographic Surveillance System (HDSS). This study aimed to determine the factors associated with ARI in children under five in Sleman, Yogyakarta, Indonesia. This research was an observational analytic study with a cross-sectional design, using secondary data from the Sleman HDSS. Data of 463 children under five who met the inclusion and exclusion criteria were used in this study. Inclusion criteria were toddlers who have complete observed variable data. The variables observed were the characteristics of children under five, the attributes of the mother, the physical condition of the house, the use of mosquito coils, sanitation facilities, and sources of drinking water. The exclusion criteria were toddlers with pulmonary tuberculosis in the past year. Data analysis used chi-squared tests for bivariate analysis and multivariate logistic regression analysis. The results showed that working mothers had a greater risk of ARI under five children with OR 1.46 (95% CI = 1.01–2.11), and groundwater as a water source was a protective factor against the occurrence of ARI in toddlers with OR 0.46 (95% CI = 0.26–0.81). After a logistic regression analysis was performed, only the drinking water source variable had a statistically significant relationship with the incidence of ARI in children under five with OR = 0.47 (95% CI = 0.268–0.827). Research on the relationship between water quality and the incidence of ARI in children under five is needed to follow up on these findings.

About the Authors:

Fathmawati Fathmawati

Roles Conceptualization, Data curation, Formal analysis, Methodology, Writing – original draft, Writing – review & editing

* E-mail: [email protected], [email protected]

Affiliation: Department of Environmental Health, Politeknik Kesehatan Kemenkes Pontianak, Pontianak, Indonesia

ORCID logo https://orcid.org/0000-0002-1176-4642

Saidah Rauf

Roles Conceptualization, Data curation, Writing – review & editing

Affiliation: Masohi Nursing Study Program, Politeknik Kesehatan Kemenkes Maluku, Ambon, Indonesia

Braghmandita Widya Indraswari

Roles Conceptualization, Formal analysis, Writing – review & editing

Affiliation: Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada Yogyakarta, Yogyakarta, Indonesia

Introduction

Acute respiratory infections (ARI) are diseases caused by transmittable agents. Usually, symptoms appear quickly, ranging from a few hours to days after transmission. The spectrum of ARI symptoms can vary, usually including fever and cough. Sore throat, coryza, shortness of breath, wheezing, or difficulty breathing are common presentations. The pathogens related to this disease include pneumococcal and tubercular bacteria as well as influenza and parainfluenza virus, rhinovirus, respiratory syncytial virus (RSV) and severe acute respiratory syndrome coronavirus (SARS-CoV) [1].

ARI is one of the causes of high morbidity and mortality of children under five in the world, including Indonesia [2]. The under-five mortality rate due to ARI in Indonesia ranks first compared to other ASEAN countries. Based on the mortality survey in Indonesia, it shows that ARI is the most common cause of under-five mortality, with a percentage of 22.30% of all under-five deaths. The results of the 2018 Basic Health Research show that the under-five age group is ranked as the highest group of all ARI cases [3]. Another research showed that the highest incidence of ARI was in children aged 0–4 years, ranging from 82 to 114 per 100,000 population [4]. A study conducted one year earlier by the Sleman Health and Demographic Surveillance System (HDSS) Team of the Faculty of Medicine, Nursing and Public Health at the Universitas Gadjah Mada in Yogyakarta, Indonesia also showed the same results [5]. Currently, ARI is still a serious problem in developing counties because it can cause serious morbidity and death in children under five [6, 7].

Some researchers have found several factors that are associated with the incidence of ARI in children under five including nutritional status [8], immunization [8, 9], exclusive breastfeeding, caregivers, exposure to cigarette smoke during pregnancy [10], density occupancy, income, smoking behavior in the family, mother’s education [11], use of fuel for cooking [12, 13], and pesticides [14]. Other studies have shown that improving the quality of clean water, sanitation, hygiene, and nutrition can reduce the incidence of ARI in children under five [15]. Humid and moldy house conditions have been related with the incidence of ARI in children hospitalized in New Zealand [16], while lack of lighting and ventilation in the house have been also associated with this incidence of ARI [17].

Research that uses the Sleman HDSS data on factors associated with ARI in children under five has never been conducted. The results of the 2017 Sleman HDSS showed that ARI was ranked first in infectious diseases in Sleman and the highest ARI cases occurred in children under five [5]. If this condition continues, it will cause impaired growth and development in toddlers. This is the first report from Indonesia using the Sleman HDSS data which examined factors associated with the incidence of ARI in under-five children in Yogyakarta, Indonesia. The findings of this study will aid local governments in developing policies for the management of ARI in children under five.

Methods

Study design

This research was an analytic observational study with a cross-sectional design. The data analyzed were secondary data collected by the Sleman HDSS team from 2015 (Wave 1) to 2017 (Wave 3) to examine factors related to the incidence of ARI in children under five in the Sleman Regency in Yogyakarta, Indonesia. The Sleman HDSS is the only surveillance system in Sleman that collects data on population transitions, health status and social transitions periodically since 2015. It aims to provide valid data to measure trends, predict baseline demographics, health parameters, and to assess the effects of interventions. The Faculty of Medicine, Public Health, and Nursing UGM collaboration with the Sleman Regency Government conducted this survey. Information from the Sleman HDSS supports evidence-based policymaking [18].

Population and data collection

A previous study has described the selection of the household as a research unit [18]. The Sleman HDSS research area covers urban, sub-urban and rural areas. The study population was all toddlers aged 13–59 months from HDSS data in 2017. This study used a population of children under five suffering from ARI with inclusion and exclusion criteria. Overall, there were 549 children under five suffering from ARI. Only 463 children under five met the inclusion criteria. The inclusion criteria were: households that had complete family data on socio-demographic conditions, use of mosquito coils, physical conditions of houses and sanitation facilities, as well as immunization status. The exclusion criteria were: households with children who had been diagnosed with pulmonary tuberculosis by health personnel such as doctors, nurses, and midwives in the last year.

Demographic data including characteristics of children under five and maternal characteristics were obtained from HDSS 2017 data. Immunization status and use of mosquito coils were obtained from HDSS 2016 data. Meanwhile, data on house characteristics including type of floor, number of people occupying the house, floor area, house walls, and ceilings, as well as sanitation facilities and water sources were obtained from the 2015 HDSS data.

Outcome measure

The ARI variable was identified as the child having been diagnosed by health workers with ARI within one month before the survey or based on reports of mothers/respondents on the child complaints of fever accompanied by a cough with phlegm/dry or runny nose within one month before the survey.

Independent variables

We categorized all variables into two categories, except immunization status. The gender groups of children were male and female. The toddler age groups were <48 months and ≥ 48 months. Immunization status consisted of not immunized, incomplete, and complete. Toddlers were classified as completed immunization if they had completed primary vaccinations by the age of 12 months. Low birth weight was classified as yes or no. We used productive age to categorize maternal age. Not attend school—Senior high school (≤ 9 years) was the boundary for the maternal education group, so mothers were grouped into primary education and higher education. Working and not working were the categories of maternal occupation.

We classified types of floors as either soil or cement/ceramic/tile. Grouping of occupancy density per person was based on SNI 03-1733-2004 [19], namely < 9 m2/person and ≥ 9 m2/person. Classification of wall types was as non-cement or cement, and ceilings as no ceiling or had ceiling. The use of mosquito coils was classified as yes or no. Ownership of the latrine and septic tank was either no or yes. Drinking water sources were either groundwater/spring or tap water/refill depot.

Statistical analysis

Bivariate analysis using the chi-square tests was conducted on independent variables that were suspected to be associated with ARI in children under five. The next step was to conduct a multivariate logistic regression analysis to obtain an appropriate model for the incidence of ARI in children under five with odds ratio (OR) and 95% confidence interval (CI). The significance of the test refers to the p-value < 0.05.

Ethical approval

This research was approved by the Medical and Health Research Ethics Committee (MHREC) Faculty of Medicine, Public Health and Nursing Universitas Gadjah Mada-Dr. Sardjito General Hospital (Ref: KE/FK/0987/EC/2020).

Results

Table 1 shows that there were 217 children under five who had complaints or were diagnosed with ARI. The results of the chi-squared tests on each variable showed no difference in the sex of children under five (OR 1.08; 95% CI = 0.75–1.57), age of toddler (OR 0.99; 95% CI = 0.69–1.46), history of low birth weight (OR 1.02; 95% CI = 0.99–1.04), immunization status (OR 0.96; 95% CI = 0.51–1.82), maternal age (OR 0.91; 95% CI = 0.63–1.31), mother’s education (OR 0.96; 95% CI = 0.62–1.49), floor type (OR 0.13; 95% CI = 0.77–1.68), space area per person (OR 1.02; 95% CI = 0.51–1.65), type of wall (OR 0.48; 95% CI = 0.12–1.87), ceiling (OR 0.82; 95% CI = 0.57–1.19), use of mosquito coils (OR 0.75; 95% CI = 0.48–1.18), ownership of latrines (OR 0.89; 95% CI = 0.47–1.67), nor ownership of septic tanks (OR 0.58; 95% CI = 0.30–1.15) between the respondent groups with ARI and those without ARI. There were only significant differences between the groups of respondents with ARI and not ARI in maternal occupation (OR 1.46; 95% CI = 1.01–2.11) and the water source used (OR 0.46; 95% CI = 0.26–0.81).

[Figure omitted. See PDF.]

Table 1. Socio-demographic, home characteristics and sanitation facilities of the study participant.

https://doi.org/10.1371/journal.pone.0257881.t001

After the variables of maternal occupation and drinking water sources were subjected to a logistic regression test, only drinking water sources had a p-value < 0.05 with an adjusted OR 0.47; 95%CI = 0.268–0.827. The results showed that the variable groundwater/spring water as a source of drinking water is a preventive factor in the occurrence of ARI in children under five after adjusted with the maternal occupation.

Discussion

Toddlers’ characteristics

Although there was no statistically significant difference, the incidence of ARI in this study was found to be slightly higher in boys than in girls. Researches conducted in Bangladesh and Iraq found that boys had higher ARIs than girls [20–22]. An immunological study showed that women are more immune to pathogens than men, but the severity of infection is higher in women [23]. Another study showed that the incidence of other ARI such as tonsillitis and sinusitis was higher in women in all age groups due to differences in the anatomy of the respiratory tract between men and women [24].

Toddler age < 48 months is a factor in preventing ARI. This study divided toddlers’ ages based on readiness to go to playgroups. We hypothesized that toddlers ≥ 48 months of age will be more susceptible to ARI because if they join a playgroup, the risk of transmission is not only from their home environment. However, this age did not show a statistically significant relationship with ARI. This finding is not in line with previous studies [25–27], which included toddlers at a younger age than this study. Interestingly, the odds of ARI in toddlers decreased as the age increased [28]. It was demonstrated that the immaturity of the immune system [29] in younger children (< 24 months) made them more vulnerable to suffer ARI [26, 30–32]. There is no relationship between the age of toddlers and the incidence of ARI in this study because the toddlers involved in this study were aged 25–59 months who have an immune system that is starting to mature [33], so there is no age variation that can distinguish the relationship with ARI.

This study did not find a significant relationship between low birth weight and ARI. A longitudinal study in Bangladesh also found no significant association between birth weight and ARI [22]. However, low birth weight correlates with the incidence of ARI [34]. Some researchers have shown that infants with low birth weight have organs that are not fully developed and are very susceptible to infection [35, 36]. There was no relationship between birth weight and ARI in this study due to the few cases of low birth weight found. The Sleman Regency Government seeks to reduce the low birth weight rate by minimizing the anemia rate of pregnant women for the health of mothers and babies [37].

This study found that only 11% of children under five received complete immunization. This result is different from the 2018 Basic Health Research, which showed that Yogyakarta Province is ranked second after Bali in terms of universal immunization coverage that exceeds the national coverage rate [3]. This study did not show a significant relationship between immunization status and ARI. This is in contrast to studies conducted in two other regions in Indonesia which showed a significant relationship between immunization status and ARI [8, 9]. The absence of a relationship between immunization status and ARI may be due to the low immunization coverage in this study. The issue of vaccine rejection in Sleman is undeniable [37, 38]. Local governments should prioritize increasing public understanding of vaccines so that immunization coverage can be achieved.

Mothers’ characteristics

This study found that there was no significant association between a mother’s education level with the incidence of ARI. This result was inconsistent with previous research [13, 22], which reported that higher maternal education might promote household hygiene, thus leading to the decline of developing ARI in children. The discrepancy in results could be attributed to the differences in the mother’s education categorization. The odds of ARI in children under five in Ethiopia and Turkey whose mothers had no formal education were increased compared with children whose mothers completed secondary school [26]. However, in addition to not subgrouping maternal education, our study did not classify mothers who did not attend formal schools. The education of the people of Sleman Regency is high. Sleman has a Human Development Index (HDI) higher than the national average. One of the components is the average length of schooling for residents aged 25 years and over which reaches 9.32 years. This figure is higher than the national figure of 8.17 years [39].

The unadjusted OR value of maternal occupation showed that children with working mothers have a 1.46 times higher risk of developing ARI. After adjusting for the source of drinking water, maternal occupation no longer exhibits a significant relationship, but it remains a contributing factor. Working mothers generally have higher education. A study found that women working in Sleman tend to entrust their children to daycare or leave them with family/caregivers while working [40]. The risk of transmitting ARI is greater because toddlers will interact with each other during this time away from home. Another study conducted in Sleman showed that working mothers were less likely to give exclusive breastfeeding [41]. One of the reasons is the lack of workplace support to provide space for nursing mothers [42]. Even though the Sleman Regency Government has issued a regulation requiring workplaces to provide lactation rooms for breastfeeding mothers, some companies have not fully complied with it. This is because business owners do not understand why this regulation was issued or have not received socialization regarding this matter [43]. This study did not have data on exclusive breastfeeding that could support these findings. This finding is in line with previous research which found working mothers have a positive correlation with the incidence of ARI [44].

Physical house condition

The floor type of the respondents’ house showed no correlation to ARI in children under five in Sleman. Some studies had different results. They found a significant relationship between floor type and the incidence of ARI in children under five [45, 46]. Research conducted in Cirebon, Indonesia found a weak relationship between floor types and the incidence of ARI [47]. In this research, almost all floors of the respondents’ houses are ceramic/tile/cement and watertight. We found only two toddlers with ARI whose houses have soil floors, and this variable was not related to the incidence of ARI. Even so, the floors made of the earth tend to become dry and dusty more easily and difficult to clean, which can interfere with breathing.

This study found that there was no association between occupancy density with the incidence of ARI. This result is different from the several studies [11, 45, 46, 48] that found a relationship between house density and the incidence of ARI in children under five. House conditions with an occupancy density of <9 m2/person only occurred in less than 9% of the observed houses. Most of the respondents’ dwellings have a sufficient area. Residential density measurements in this study are based on an extensive house divided by the number of residents, not including spacious bedrooms and the number of people who occupy them. This point is important considering that ARI is easily transmitted in densely populated situations [49]. A study conducted in Padang, Indonesia found that residential areas with high density were almost 22 times more likely to have ARI in children under five [50].

The type of wall was not related to the incidence of ARI in children under five in Sleman. This result is consistent with research conducted in Surabaya [17]. Types of walls made of wood or woven bamboo are difficult to clean because of their rough surface texture. In this study, only 2% of houses had non-cement wall material. Almost all the dwellings of the respondents already have walls with a solid material that is easier to clean. This condition explains that there is no relationship between the walls of the house and ARI.

The study did not find a relationship between the type of house ceiling and the incidence of ARI. Another study has also found the same result [51]. The ceiling functions to keep dust from entering the house through the gaps between the walls and the roof. This research found that the proportion of houses that have ceilings and do not have a ceiling was almost equal. Likewise, the proportion of children under five with ARI and not with ARI was almost evenly distributed in the groups of houses with and without ceilings. Both groups have the same opportunity for ARI. The ceiling functions to keep dust from entering the house through the gaps between the walls and the roof. Unfortunately, this study did not have data on indoor air quality. ARI in toddlers in Sleman could be caused by polluted air quality. The results of one research showed that the Sleman urban area is an area with the highest air pollution compared to other urban areas in Yogyakarta Province. The carbon monoxide (CO) content in the city of Sleman, namely Depok, Ngaglik and Kalasan, exceeds the quality standard by up to seven times the safe limit [52]. Several studies found that green open spaces in Sleman are not yet in line with public safety and city planning needs [53–55]. If adequate green open spaces are available, they can absorb pollutants from the air.

The use of mosquito coil

The use of mosquito coils in this study did not show a significant relationship. This result is different from previous studies that found a relationship between the use of mosquito coils and ARI [56, 57]. The difference between this study and previous studies is the proportion of mosquito coil users in the research subjects. In this study, mosquito coils were not popularly used by respondents, only about 20%. Meanwhile in previous studies, more than 50% of respondents used mosquito coils.

Water and sanitation facilities

Sanitation facilities in the form of toilet and septic tank ownership were not related to the incidence of ARI in children under five in Sleman. One recent study found that improved sanitation can reduce the incidence of ARI [15]. Another study found a relationship between the use of septic tanks with the incidence of ARI [20]. More than 90% of the respondents in this study already have a latrine and a septic tank. This result is in line with the results of the 2018 Basic Health Research which showed that more than 95% of households in Yogyakarta Province have disposed of their feces properly [3]. Sanitation facilities are not a factor in the occurrence of ARI in children under five in Sleman.

This study found that ground water or spring water as the source of water used by respondents for eating and drinking was a preventive factor for ARI. Sleman has a high potential for groundwater and springs, especially in rural areas [58, 59]. The Sleman Regency Government divides its territory into four sectors. Two sectors namely the Merapi Slope Area and the West Region, have abundant water resources [60], and groundwater quality is relatively better than other areas in Yogyakarta Province with low nitrate content [61, 62]. Improving water quality can reduce the incidence of ARI in children under five according to studies conducted in Rwanda [63] and Bangladesh [15].

The service coverage of the Local Water Company (LWC) in Sleman only reaches 23% of the population [64], and while a small portion uses commercially managed refill drinking water, the rest use groundwater or spring water as the main source of drinking water. The results of the 2015 Water Quality Survey in the Special Region of Yogyakarta stated that more than 60% of the people of Sleman use groundwater as a source of drinking water [65]. Therefore, in this study, it was found that there is only a small proportion of respondents whose source of drinking water was not groundwater/spring water.

The quality of water produced by LWC in Sleman has not met the requirements set by the Ministry of Health. Several parameters (including Coliform and E. coli) were found to exceed the required levels [64, 66, 67]. Likewise, the quality of refill drinking water in the Sleman area has not met the requirements. Earlier research found high content of Coliform and E. coli in samples examined in both raw water and processed water in refill drinking water depots [68, 69]. The Water Quality Survey in Yogyakarta Province in 2015 showed that only 8.5% of households could access safe drinking water according to the Sustainable Development Goals (SDGs) [65].

The presence of E. coli in drinking water can trigger lung damage in mice [70], but further exploration is still needed to explain this pathogenesis [71]. Meanwhile, research conducted in Rajasthan, India showed that consuming drinking water that contains high nitrates is significantly associated with the incidence of recurrent ARI. This study explained that consuming water containing nitrates will increase the production of methemoglobin and free radicals of nitric oxide and oxygen that will lead to alveolar damage and improper ventilation and perfusion, which may be the cause of death in children due to recurrent ARI [72]. Regrettably, research conducted recently did not include nitrates in the examined parameters [15, 63]. Accordingly, further research is needed to be able to explain the relationship between improving water quality and reducing the incidence of ARI.

Research limitations

The incidence of ARI in toddlers in this study was only based on the mother’s memory, which is prone to recall bias. Additionally, the Sleman HDSS has no data on ventilation, which functions to change the air in the house so that residents get fresh air. Increasing air circulation in the dwelling through ventilation and windows is a factor that can reduce the incidence of ARI [73]. Natural lighting in homes and bedrooms is related to temperature and humidity. Both of these are influential factors in the proliferation of the agents causing ARI [16]. Data on smokers inside the home are critical to include in the analysis because it is closely related to indoor air quality, likewise the data are limited on the use of firewood for cooking, which should be included considering some people still use it.

Conclusions

Respondents who use tap water or refilled drinking water depots are at risk of experiencing ARI. The following Sleman HDSS survey must pay attention to the quality of water consumed by respondents, especially E. coli and nitrates. It is to ensure the relationship between the use of water sources and the incidence of ARI in children under five so that the government can determine the right policy in reducing the morbidity of ARI in children under five.

Acknowledgments

The authors are grateful to Sleman HDSS Management for allowing us to use Sleman HDSS data; and Klinik Bahasa Faculty of Medicine, Public Health and Nursing UGM for proofreading this manuscript.

Citation: Fathmawati F, Rauf S, Indraswari BW (2021) Factors related with the incidence of acute respiratory infections in toddlers in Sleman, Yogyakarta, Indonesia: Evidence from the Sleman Health and Demographic Surveillance System. PLoS ONE 16(9): e0257881. https://doi.org/10.1371/journal.pone.0257881

References

1. WHO. Infection Prevention and Control of Epidemic- and Pandemic-prone Acute Respiratory Infections in Health Care. Geneva: WHO Press, World Health Organization; 2014. https://www.who.int/publications/i/item/infection-prevention-and-control-of-epidemic-and-pandemic-prone-acute-respiratory-infections-in-health-care

2. WHO. World Health Statistics 2019: Monitoring Health for SDGs, Sustainable Development Goals. Geneva: World Health Organization; 2019. https://apps.who.int/iris/handle/10665/324835

3. Badan Penelitian dan Pengembangan Kesehatan. National Report of Basic Health Research 2018 [Laporan Nasional Riskesdas 2018]. Jakarta: Lembaga Penerbit Badan Penelitian dan Pengembangan Kesehatan; 2019. https://www.litbang.kemkes.go.id/laporan-riset-kesehatan-dasar-riskesdas/

4. Susilarini NK, Haryanto E, Praptiningsih CY, Mangiri A, Kipuw N, Tarya I, et al. Estimated incidence of influenza-associated severe acute respiratory infections in Indonesia, 2013–2016. Influ Other Respir Viruses. 2018;12: 81–87. pmid:29205865

5. HDSS Sleman FKKMK UGM. Hasil Survei HDSS Sleman Siklus 3 (2017). 2017 [cited 13 May 2020]. https://hdss.fk.ugm.ac.id/hdss-iii/

6. Shi T, McAllister DA, O’Brien KL, Simoes EAF, Madhi SA, Gessner BD, et al. Global, regional, and national disease burden estimates of acute lower respiratory infections due to respiratory syncytial virus in young children in 2015: a systematic review and modelling study. Lancet. 2017;390: 946–958. pmid:28689664

7. Chicaiza-Ayala W, Henríquez-Trujillo AR, Ortiz-Prado E, Douce RW, Coral-Almeida M. The burden of acute respiratory infections in Ecuador 2011–2015. PLoS One. 2018;13: 1–12. pmid:29715314

8. Atira. Nutrition status and immunization as determinant of acute respiratory infection on toddlers. Heal Notions. 2017;1: 266–272.

9. Malik I, Machfoedz I, Mahfud M. The scope of basic immunization and acute respiratory infections [ARI] in toddlers aged 1–3 years in the region of Puskesmas Wonosari 1 Gunungkidul District [Cakupan imunisasi dasar dengan kejadian ISPA pada balita usia 1–3 tahun di wilayah Puskesmas Wonosari 1 Kabupaten Gunung Kidul]. JNKI. 2015;3: 53–57.

10. Shibata T, Wilson JL, Watson LM, Leduc A, Meng C, Ansariadi , et al. Childhood acute respiratory infections and household environment in an eastern Indonesian urban setting. Int J Environ Res Public Heal. 2014;11: 12190–12203. pmid:25429685

11. Syahidi MH, Gayatri D, Bantas K. Factors that affecting acute respiratory infections (ARI) in children aged 12–59 months at the Tebet Barat Primary Health Center, Subdistrict of Tebet, South Jakarta 2013 [Faktor-faktor yang mempengaruhi kejadian infeksi saluran pernapasan akut (ISPA) pada anak usia 12–59 bulan di Puskesmas Tebet Barat, Kecamatan Tebet, Jakarta Selatan]. J Epidemiol Kesehat Indones. 2016;1: 23–27.

12. Rana J, Uddin J, Peltier R, Oulhote Y. Associations between indoor air pollution and acute respiratory infections among under-five children in Afghanistan: do SES and sex matter? Int J Environ Res Public Heal. 2019;16. pmid:31416159

13. Tazinya AA, Halle-Ekane GE, Mbuagbaw LT, Abanda M, Atashili J, Obama MT. Risk factors for acute respiratory infections in children under five years attending the Bamenda Regional Hospital in Cameroon. BMC Pulm Med. 2018;18. pmid:29338717

14. Tarmure S, Alexescu TG, Orasan O, Negrean V, Sitar-Taut AV, Coste SC, et al. Influence of pesticides on respiratory pathology—A literature review. Ann Agric Env Med. 2020;27: 194–200. pmid:32588592

15. Ashraf S, Islam M, Unicomb L, Rahman M, Winch PJ, Arnold BF, et al. Effect of improved water quality, sanitation, hygiene and nutrition interventions on respiratory illness in young children in rural Bangladesh: a multi-arm cluster-randomized controlled trial. Am J Trop Med Hyg. 2020;102: 1124–1130. pmid:32100681

16. Ingham T, Keall M, Jones B, Aldridge DRT, Dowell AC, Davies C, et al. Damp mouldy housing and early childhood hospital admissions for acute respiratory infection: a case control study. Thorax. 2019;74: 849–857. pmid:31413146

17. Mahendrayasa IGAP, Farapti F. The relationship between household physical condition with incedence of toddler’s acute respiratory infection in Surabaya. J Berk Epidemiol. 2018;6: 227–235.

18. Dewi FST, Choiriyyah I, Indriyani C, Wahab A, Lazuardi L, Nugroho A, et al. Designing and collecting data for a longitudinal study: the Sleman Health and Demographic Surveillance System (HDSS). Scand J Public Heal. 2018;46: 704–710. pmid:28752803

19. Badan Standardisasi Nasional. SNI 03-1733-2004 Planning Procedures for Housing Environment in Urban Areas [Tata Cara Perencanaan Lingkungan Perumahan di Perkotaan]. Badan Standardisasi Nasional. Jakarta; 2004. http://sni.litbang.pu.go.id/index.php?r=/sni/new/sni/detail/id/694

20. Siziya S, Muula AS, Rudatsikira E. Diarrhoea and acute respiratory infections prevalence and risk factors among under-five children in Iraq in 2000. Ital J Pediatr. 2009;35: 1–9.

21. Gurley ES, Homaira N, Salje H, Ram PK, Haque R, Petri W, et al. Indoor exposure to particulate matter and the incidence of acute lower respiratory infections among children: A birth cohort study in urban Bangladesh. Indoor Air. 2013;23: 379–386. pmid:23906055

22. Ullah MB, Mridha MK, Arnold CD, Matias SL, Khan MSA, Siddiqui Z, et al. Factors associated with diarrhea and acute respiratory infection in children under two years of age in rural Bangladesh. BMC Pediatr. 2019;19: 1–11.

23. Klein SL, Flanagan KL. Sex differences in immune responses. Nat Rev Immunol. 2016;16: 626–638. pmid:27546235

24. Falagas ME, Mourtzoukou EG, Vardakas KZ. Sex differences in the incidence and severity of respiratory tract infections. Respir Med. 2007;101: 1845–1863. pmid:17544265

25. Krishnan D, Omprakash A, Ramaswamy P, G T, S S, Balakrishnan K. Prevalence of acute respiratory infection in children less than 2 years in rural and urban population in and around Chennai, Tamil Nadu. Nat J Physiol Pharm Pharmacol. 2019;9: 1.

26. Amsalu ET, Akalu TY, Gelaye KA. Spatial distribution and determinants of acute respiratory infection among under-five children in Ethiopia: Ethiopian Demographic Health Survey 2016. PLoS One. 2019;14: e0215572. pmid:31009506

27. Islam F, Sarma R, Debroy A, Kar S, Pal R. Profiling acute respiratory tract infections in children from Assam, India. J Glob Infect Dis. 2013;5: 8–14. pmid:23599611

28. Gebertsadik A, Worku A, Birhane Y. Factors associated with acute respiratory infection in children under the age of 5 years: evidence from the 2011 Ethiopian Demographic and Health Survey [Corrigendum]. Pediatr Heal Med Ther. 2015;6: 9–13. pmid:29388590

29. Amugsi DA, Aborigo RA, Oduro AR, Asoala V, Awine T, Amenga-Etego L. Socio-demographic and environmental determinants of infectious disease morbidity in children under 5 years in Ghana. Glob Heal Action. 2015;8. pmid:26455493

30. Dagne H, Andualem Z, Dagnew B, Taddese AA. Acute respiratory infection and its associated factors among children under-five years attending pediatrics ward at University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia: Institution-based cross-sectional study. BMC Pediatr. 2020;20: 1–7.

31. Fatmi Z, White F. A comparison of “cough and cold” and pneumonia: risk factors for pneumonia in children under 5 years revisited. Int J Infect Dis. 2002;6: 294–301. pmid:12718824

32. Dadi AF, Kebede Y, Birhanu Z. Determinants of pneumonia in children aged two months to five years in urban areas of Oromia Zone, Amhara Region, Ethiopia. OALib. 2014;01: 1–10.

33. Ygberg S, Nilsson A. The developing immune system—From foetus to toddler. Acta Paediatr. 2012;101: 120–127. pmid:22003882

34. Etiler N, Velipasaoglu S, Aktekin M. Incidence of acute respiratory infections and the relationship with some factors in infancy in Antalya, Turkey. Pediatr Int. 2002;44: 64–69. pmid:11982874

35. de Mello RR, Dutra MVP, Ramos JR, Daltro P, Boechat M, Lopes JM de A. Neonatal risk factors for respiratory morbidity during the first year of life among premature infants. Sao Paulo Med J. 2006;124: 77–84. pmid:16878190

36. Kirk CM, Uwamungu JC, Wilson K, Hedt-Gauthier BL, Tapela N, Niyigena P, et al. Health, nutrition, and development of children born preterm and low birth weight in rural Rwanda: a cross-sectional study. BMC Pediatr. 2017;17: 1–9.

37. Dinas Kesehatan Kabupaten Sleman. Sleman District Health Profile 2020 [Profil Kesehatan Kabupaten Sleman Tahun 2020]. Sleman; 2020. https://dinkes.slemankab.go.id/download

38. Ningsih DPS, Sahayati S, Dharmawidjaja I. Analysis of priority of health problems in Sleman District Yogyakarta [Analisis prioritas masalah kesehatan di Kabupaten Sleman Yogyakarta]. J Sains Kesehat. 2018;25: 1–13.

39. BPS Provinsi Daerah Istmewa Yogyakarta. Yogyakarta Human Development Index (HDI) 2018 [Indeks Pembangunan Manusia (IPM) D.I. Yogyakarta 2018]. Ber Resmi Stat. 2019. https://yogyakarta.bps.go.id/pressrelease/2019/05/06/951/indeks-pembangunan-manusia-d-i—yogyakarta-2018.html

40. Puspitasari E. The dual role of women in working mothers in Pakembinangun, Pakem, Sleman, Yogyakarta [Peran ganda perempuan pada ibu bekerja di desa Pakembinangun, Pakem, Sleman, Yogyakarta]. Universitas Negeri Yogyakarta. 2016. http://eprints.uny.ac.id/37957/

41. Okawary O. Relationship between mother’s work status and exclusive breastfeeding in the work area of Puskesmas Sayegan Sleman Yogyakarta [Hubungan status pekerjaan ibu dengan pemberian ASI eksklusif di wilayah kerja Puskesmas Seyegan Sleman Yogyakarta]. Sekolah Tinggi Ilmu Kesehatan ‘Aisyiyah Yogyakarta. 2015. http://digilib.unisayogya.ac.id/199/

42. Sutrisno AH. Breastfeeding room availability of exclusive breastfeeding among working women in Sleman Yogyakarta [Ketersediaan ruang menyusui terhadap ASI eksklusif pada ibu bekerja di Sleman Yogyakarta]. Sekolah Tinggi Ilmu Kesehatan ‘Aisyiyah Yogyakarta. 2015. http://digilib.unisayogya.ac.id/338/

43. Kaulika D, Werdati S, Hardianti A, Anwar C. Implementation of regulation policy of Sleman Regency number 38 of 2015 concerning of giving exclusive breastfeeding of working mother. J Gizi dan Diet Indones (Indonesian J Nutr Diet. 2019;7: 89–96.

44. Pinzón-Rondón ÁM, Aguilera-Otalvaro P, Zárate-Ardila C, Hoyos-Martínez A. Acute respiratory infection in children from developing nations: a multi-level study. Paediatr Int Child Heal. 2016;36: 84–90. pmid:25936959

45. Barros SD, Yudhana A. Physical conditions of house and community behavior analysis of acute respiratory tract infection in working Region Central Public Health Soe City South East Central District. J Glob Res Public Heal. 2019;4: 175–182. https://www.jgrph.org/index.php/JGRPH/article/view/49

46. Fera D, Sriwahyuni S. The relationship between home environmental conditions and the occurrence of acute respiratory infection (ARI) in toddlers in Nagan Raya Regency. J-Kesmas. 2020;7: 38–43.

47. Wulandari DE, Widayani P. Effect of physical environmental condition of the settlement on ARI disease in toddlers based on high resolution remote sensing imagery and GIS in Lemahwungkuk Sub-District, Cirebon City. In: Wibowo SB, Ananda IN, Pramesti AI, Putri AFS, editors. Shifting Paradigm in Geospatial Data Management. Yogyakarta: Faculty of Geography Universitas Gadjah Mada; 2019. pp. 58–65.

48. Hidayah N, Rahman RTA, Dwi Salmarini D. Household environment factors associated with Acute Respiratory Infection (ARI) among under-five children. Adv Heal Sci Res. Atlantis Press; 2017. pp. 595–603.

49. Ferkol T, Schraufnagel D. The global burden of respiratory disease. Ann Am Thorac Soc. 2014;11: 404–406. pmid:24673696

50. Hidayanti R, Yetti H, Putra AE. Risk factors for acute respiratory infection in children under five in Padang, Indonesia. Matern Child Heal J. 2019;4: 62–69.

51. Ahmad H, Arminsih Wulandari R, Zakianis, Nur Azizah F, Khairina Ashar Y. The determinant factors of acute respiratory infections (ARI) among housewives in Allakuang Village, South Sulawesi, Indonesia. The 2nd International Meeting of Public Health 2016 with theme “Public Health Perspective of Sustainable Development Goals: The Challenges and Opportunities in Asia-Pacific Region. KnE Life Sciences; 2018. pp. 502–512.

52. Basuki AT, Saptutyningsih E. Mapping of urban air pollution in Yogyakarta Special Province [Pemetaan polusi udara perkotaan di Propinsi Daerah Istimewa Yogyakarta]. Unisia. 2012;34: 3–27.

53. Islami CP. Analysis of the availability of green open space on oxygen demand in Depok District, Sleman Regency [Analisis ketersediaan ruang terbuka hijau terhadap kebutuhan oksigen di Kecamatan Depok Kabupaten Sleman]. Universitas Muhammadiyah Surakarta. 2020. http://eprints.ums.ac.id/86266/

54. Nugroho VC. Evaluation of green open space in Sleman District, Sleman Regency. Planta Trop J Agro Sci. 2015;3: 114–121.

55. Widowati SP. Implementation of policies for providing residential green open space in urban areas of Sleman Regency. J Sains dan Teknol Lingkung. 2013;5: 102–116.

56. Wulandari VO, Susumaningrum LA, Susanto T, Kholis A. The relationship between smoke exposure and the incidence of acute respiratory infection (ARI) in children aged 0–5 years in the agricultural area of Panti District, Jember Regency [Hubungan paparan asap dengan kejadian infeksi saluran pernapasan akut (ISPA) pada anak usia 0–5 tahun di wilayah pertanian Kecamatan Panti, Kabupaten Jember]. JEKK. 2020;5: 88–95.

57. Koirala R. Risk factors of acute respiratory infections in children under five years attending the Fishtail Hospital, Pokhara, Nepal. J Gandaki Med Coll. 2019;12: 74–79.

58. Kristanto WAD, Nugroho NE, Anom TN, Muhaimin A. Identification of groundwater potential in volcanic sedimentary rocks by geoelectric measurements of the Prambanan District, Sleman, Yogyakarta [Identifikasi potensi airtanah pada batuan sedimen vulkanik dengan pengukuran geolistrik daerah kecamatan Prambanan, Sleman, Yogyakarta]. Kurvatek. 2020;5: 89–95.

59. Wardani AEP, Purnama ILS. Evaluation of potential springs for domestic water needs in Cangkringan District, Sleman Regency after the 2010 Merapi eruption [Evaluasi potensi mataair untuk kebutuhan air domestik di Kecamatan Cangkringan Kabupaten Sleman pasca erupsi Merapi 2010]. J Bumi Indones. 2012;1: 299–309. http://lib.geo.ugm.ac.id/ojs/index.php/jbi/article/view/97/0

60. Pemkab Sleman. Sleman Regency Profile [Profil Kabupaten Sleman]. 2020 [cited 15 Nov 2020]. http://www.slemankab.go.id/profil-kabupaten-sleman/geografi/karakteristik-wilayah

61. Wijayanti Y, Yuniasih B, Verma N, Krisdiarto AW, Safitri L. Groundwater quality mapping of Yogyakarta City, Sleman, Kulonprogo and Bantul regency area of Yogyakarta Province. IOP Conf Ser Earth Environ Sci. IOP Publishing; 2018. pp. 1–10.

62. Fathmawati F, Fachiroh J, Sutomo AH, Putra DPE. Origin and distribution of nitrate in water well of settlement areas in Yogyakarta, Indonesia. Environ Monit Assess. 2018;190: 628. pmid:30280272

63. Kirby MA, Nagel CL, Rosa G, Zambrano LD, Musafiri S, Ngirabega J de D, et al. Effects of a large-scale distribution of water filters and natural draft rocket-style cookstoves on diarrhea and acute respiratory infection: a cluster-randomized controlled trial in Western Province, Rwanda. PLoS Med. 2019;16: 1–24. pmid:31158266

64. Ardyansyah F. Evaluation of the performance of LCW Sleman in the field of operations and services in the Capital District of Prambanan, Kalasan, Ngemplak, Bimomartani, Condong Catur, Depok [Evaluasi kinerja PDAM Sleman di bidang operasi dan pelayanan pada ibukota Kecamatan Prambanan, Kalasan, Ngemplak, Bimomartani, Condong Catur, Depok]. Universitas Islam Indonesia. 2019. https://dspace.uii.ac.id/handle/123456789/16317

65. Subdirektorat Statistik Kesehatan dan Perumahan. Results of the 2015 Water Quality Survey in Yogyakarta Special Region [Hasil Survei Kualitas Air di Daerah Istimewa Yogyakarta 2015]. Jakarta-Indonesia: Badan Pusat Statistik; 2016. https://www.bps.go.id/publication/2016/11/03/26dd424f1c7391a6c62adf33/hasil-survei-kualitas-air-di-daerah-istimewa-yogyakarta-tahun-2015.html

66. Marsha A. Evaluation of the disinfection system at LCW Sleman Tridadi Unit [Evaluasi sistem disinfeksi pada PDAM Sleman Unit Tridadi]. Universitas Islam Indonesia. 2020. https://dspace.uii.ac.id/handle/123456789/24046

67. Damayanti. Evaluation of the disinfection system at LCW Sleman Nogotirto Unit [Evaluasi sistem disinfeksi pada PDAM Sleman Unit Nogotirto]. Universitas Islam Indonesia. 2020. https://dspace.uii.ac.id/handle/123456789/24045

68. Darmawan BA. Evaluation of drinking water quality control at refill drinking water depot in Sleman Regency, Yogyakarta [Evaluasi pengendalian kinerja kualitas air minum pada depot air minum isi ulang di Kabupaten Sleman, Yogyakarta]. Khazanah. 2011;4: 33–54.

69. Sekarwati N, Subagiyono , Wulandari H. Analysis of Total Coliform in clean water and Escherichia coli in drinking water at refill drinking water depots in the working area of Puskesmas Kalasan, Sleman. Kesmas. 2016;10: 1–12.

70. Shalaby SM, El-Shal AS, Abd-Allah SH, Selim AO, Selim SA, Gouda ZA, et al. Mesenchymal stromal cell injection protects against oxidative stress in Escherichia coli-induced acute lung injury in mice. Cytotherapy. 2014;16: 764–775. pmid:24525173

71. Promite S, Saha SK. Escherichia coli in respiratory tract infections: evaluating antimicrobial resistance and prevalence of fimA, neuC and iutA virulence genes. Gene Reports. 2020;18: 100576.

72. Gupta SK, Gupta RC, Gupta AB, Seth AK, Bassin JK, Gupta A. Recurrent acute respiratory tract infections in areas with high nitrate concentrations in drinking water. Env Heal Perspet. 2000;108: 363–366. pmid:10753096

73. Murray EL, Brondi L, Kleinbaum D, McGowan JE, Van Mels C, Brooks WA, et al. Cooking fuel type, household ventilation, and the risk of acute lower respiratory illness in urban Bangladeshi children: a longitudinal study. Indoor Air. 2012;22: 132–139. pmid:22007670