Determinants of disease prevalence and antibiotic consumption for children under five in Nepal: analysis and modelling of Demographic Health Survey data from 2006 to 2016

Objectives Our aims were to examine the geographic, socio-economic and behavioural factors associated with disease and antibiotic consumption in Nepal between 2006 and 2016 and to explore healthcare seeking patterns and the source of antibiotics. Methods Cross-sectional data from children under five in households in Nepal was extracted from the 2006, 2011 and 2016 Demographic Health Surveys (DHS). Univariate and multivariate analyses were carried out to assess the association of disease prevalence and antibiotic use with age, sex, ecological zone, urban/rural location, wealth index, maternal smoking, use of clean fuel, sanitation, nutrition, access to healthcare and vaccinations. Results Prevalence of fever, acute respiratory infection (ARI) and diarrhoea decreased between 2006 and 2016, while the proportion using antibiotics increased. Wealth, use of clean fuel, improved toilet sanitation, nutrition and access to healthcare were associated with reduced rates of disease. Those in the highest wealth index use less antibiotics and antibiotic consumption in rural areas surpassed urban regions over time. Health-seeking from the private sector has overtaken government facilities since 2006 with antibiotics mainly originating from pharmacies and private hospitals. Adherence to WHO recommended antibiotics has reduced over time. Conclusions With rising wealth, there has been a decline in disease prevalence but an increase in antibiotic use with more access to unregulated sources. Understanding antibiotic use and identifying associated behavioural and socio-economic factors may help to inform interventions to reduce inappropriate antibiotic use whilst ensuring access to those who need them. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement No funding received for this project. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: N/A All necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable. Yes Data sources are available from the Demographic Health Survey (DHS) website.