Impact of climate change on diarrhoea risk in low- and middle-income countries

Diarrhoea remains a leading cause of mortality among children under five years of age, with over 99 % of deaths occurring in low- and middle-income countries. Poor water quality, inadequate sanitation, poverty, undernutrition, and limited healthcare access contribute to this lingering problem, together with emerging environmental stressors driven by climate change. We analysed long-term spatial relationships between environmental, socio-economic, and maternal/child factors using Demographic and Health Surveys and WorldClim data across eight South and Southeast Asian countries (n = 66,545 clusters; 3,143,811 child-level observations). We employed boosted regression trees to assess variable importance across five thematic phases: socio-economic, maternal, child, climate, and combined. We selected variables based on biological plausibility, collinearity checks, and completeness. We addressed uncertainty through multiple imputation and stochastic resampling, and we evaluated model performance using cross-validation. The main predictors of diarrhoea incidence included annual temperature variability, precipitation in the wettest month, maternal education, and household size. Higher annual temperature range (30-40 °C) was associated with a ∼ 39 % increase in diarrhoea probability, while lower precipitation in the wettest month (< 600 mm) increased risk by ∼ 29 %, highlighting the role of drier conditions. We found that maternal education < 8 years increased diarrhoea probability by ∼ 18 %, and household sizes exceeding six members increased it by ∼ 9 %. Our findings emphasise the need for climate-resilient public-health policies that integrate social and environmental determinants of diarrhoea. Targeted interventions - including improved maternal education, water and sanitation infrastructure, and resource management in densely populated households - are necessary to mitigate diarrhoea risk in vulnerable regions under changing climate conditions.