# Pneumonia Prevalence and Associated Risk Factors among under-Five Children in Goncha Siso Enesie District, Northwest Ethiopia

Authors: Bizualem Abebaw; Destaw Damtie
Journal: Advances in Public Health
 (2022)

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## Abstract

Background. Pneumonia is one of the leading causes of morbidity and mortality among under-five children in various localities of Ethiopia. This study was aimed to assess the prevalence of pneumonia and its associated factors among under-five children who were visiting Ginde Woyin health center, Goncha Siso Enesie District, Northwest Ethiopia. Methods. A health center-based cross-sectional study was conducted among 403 participants by a systematic random sampling technique. Data were collected using questionnaires and sputum diagnosis. Data were analyzed using Statistical Package for Social Science (SPSS) version 26.0. Binary and multivariable logistic regressions were used to analyze the risk variables, and P values < 0.05 were considered statistically significant. Results. The overall prevalence of pneumonia among under-five children was 24.3% (95% CI: 20.1, 28.3). The significant predictors for under-five pneumonia identified were the use of wood as a source of fuel for cooking (AOR = 2.769; P=0.049), starting complementary food before six months of age (AOR = 2.080; P = 0.033), and mixed breastfeeding conditions (AOR = 5.229; P=0.001). The highest under-five pneumonia was observed among children of age below one year (33.6%), rural dwellers (30.4%), family sizes above five (31.8%), children from families with a monthly income of less than 1000 Ethiopian Birr (<19.03 USD) (27.8%), whose mothers were students (61.5%), houses where cooking took place in the living room (37.8%), homes that lacked windows in the kitchens (28.4%), homes that lacked windows (41.5%), and mixed breastfeeders (44.1%). Conclusion. The prevalence of under-five pneumonia in the present study was relatively high. The findings in the present study will help policy makers and program officers to design pneumonia-preventive interventions.


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## Body

## 1. Background

Pneumonia is a disease of the lung or inflammation of the parenchyma of the lungs, such as the alveoli and bronchioles [1]. It results in the mortality of many under-five children in many countries. In 2018 alone, it resulted in 802,000 under-five mortalities. The annual global cases of pneumonia reach 1,400 cases per 100,000 children, or one case per seventy-one children [2]. Globally, more than 802,000 under-five children were affected by pneumonia in 2018, resulting in 2,200 mortalities per day. Also, there are over 1,400 cases of pneumonia per 100,000 Children, or one case per 71 children every year, with the highest incidence occurring in South Asia (2,500 cases per 100,000 children) and West and Central Africa (1,620 cases per 100,000 children) [3].Among African countries, this ranged from 11,000 in Sudan to 162,000 in Nigeria and 32,000 in Ethiopia [4]. Around 153,000 (19%) of the under-five children died within their first month of age (close to 2,200 under-five mortalities per day and one child every 39 seconds) [4].In Ethiopia, 44,000 under-five children encounter pneumonia annually, which contributes to 20% of all the causes of death every year and is a leading cause of death during the postnatal period [5]. The associated risk factors of pneumonia were sociodemographic status (educational status, occupation, monthly income, family size), living condition factors (housing condition, toilet facility, water facility, cooking area, and rooms in the main house), and comorbid diseases (diarrhea, upper respiratory tract infections (URTI), and asthma) [6–12].According to Ginde Woyin (Goncha Siso Enesie District) health center clinical reports, under-five pneumonia was the first of the top ten diseases in 2020. Therefore, the present study was undertaken to assess the prevalence and the associated risk factors of pneumonia among under-five children who were attending Ginde Woyin health center, Goncha Siso Enesie District, Northwest Ethiopia.


## 2. Materials and Methods

### 2.1. Study Area, Study Population, and Study Design

Goncha Siso Enesie is located 335 km northwest of Addis Ababa (the capital city of Ethiopia). The district is located at the geographical location of 10°8’00” to 11°09’00” North latitude and between 37°9’00” to 39°00’00” East longitude. The average temperature of the district is about 18.5°C, and the average annual rainfall ranges from 762 to 1825 mm. According to the Ethiopian Census 2021 current year projection, the total population of the district was 192,628 [94,613(49.12%) males and 95,015 (50.88%) females]. The rural population was 183,948 (95.49%), and the urban population was 8680 (4.51%)[13].There are eight health centers and 43 health posts in the district. Ginde Woyin health center is among the eight health centers. It gives service to 35,813 people. Under this health center, six rural and two urban health posts are assigned to implement the health extension program. We chose Ginde Woyin health center because under-five pneumonia was the first of the top 10 diseases in the 2020 clinical report (Goncha Siso Enesie Health Office Annual Report, 2020). A health center-based cross-sectional study was conducted on under-five children who attended Ginde Woyin health center from February 3, 2021, to April 10, 2021.


### 2.2. Sample Size Determination

There was no similar study previously conducted in the area; a 50% prevalence rate of under-five pneumonia was taken, assuming that pneumonia is significantly prevalent among under-five children attending Ginde Woyin health center. Accordingly, the minimum number of sample size (n) required was determined using a single population proportion formula for cross-sectional surveys [14], i.e., n = Z2 p (1-p)/d2 = 1.962 × 0.50 × 0.50/.052 = 384 students. To compensate for the nonrespondents and to minimize errors probably arising from the likelihood of noncompliance, a 5% contingency was added, giving a final sample size of 403 study participants.


### 2.3. Variables of the Study

(i)
Dependent variable- the prevalence of under-five pneumonia(ii)
Independent variables- environmental factors (air pollution, use of firewood for cooking, tobacco smoke exposure, sanitation, lack of windows in the kitchen, lack of windows in the living room, lack of a separate kitchen, and overcrowding); health facility and child care factors (availability/distance/cost of health facility, immunization/vaccination, and comorbidity); and sociodemographic characteristics (age, sex, parental occupation, parental education level, and family size)


### 2.4. Eligibility Criteria

#### 2.4.1. Inclusion Criteria

Under-five children who did not take antipneumonia drugs and those whose parents/primary guardians were voluntary to sign consent were included.


#### 2.4.2. Exclusion Criteria

Under-five children who took antipneumonia drugs, those children and parents/guardians who have hearing impairments, and those whose parents or guardians did not sign consent were excluded.


### 2.5. Sample Collection and Processing

Structured questionnaires comprising the known risk factors were developed in English and translated into Amharic (local language). The authors interviewed the participants and the parents of younger children to obtain the sociodemographic characteristics and the related risk factors for pneumonia. The language was translated back into English. The questionnaires were pretested on a nonstudy sample population.Fresh sputum samples were collected in clean, labeled cups [15]. The authors recorded the date, name, age, and sex of each participant during the sputum collection. The sputum samples were smeared on slides, air-dried, and fixed by heating [16]. Following fixation, the slides were treated with carbon fusion and heat. Five minutes after fusion, the slides were washed with water and 3% acidic alcohol. After three minutes, they were again washed with water. Then, they were stained with methylene blue for one minute, washed with water, and dried in the air. Finally, we observed the sputum slides under a microscope for examination. A change in the color of the sputum to dark green indicates a positive for pneumonia. Generally, Ginde Woyin health center lacks an X-ray machine to confirm under-five pneumonia. Therefore, physicians in the health center used the symptoms such as cough; difficulty breathing; thick yellow, green, brown, or blood-stained mucus (phlegm); rapid heartbeat; high temperature; sweating and shivering; loss of appetite, and chest pain as confirmations of pneumonia. Consequently, the researchers of the present study confirmed pneumonia in the same way [17].


### 2.6. Data Analysis

We analyzed the data using the Statistical Package for Social Sciences (SPSS) version 26.0. We used descriptive statistics to show the prevalence of pneumonia among the different sociodemographic groups of under-five children. Associations between the risk factors and under-five pneumonia were determined using univariable logistic regression. We used multivariable logistic regression to test the strength of the associations.P values below 0.05 were considered significant.


## 2.1. Study Area, Study Population, and Study Design

Goncha Siso Enesie is located 335 km northwest of Addis Ababa (the capital city of Ethiopia). The district is located at the geographical location of 10°8’00” to 11°09’00” North latitude and between 37°9’00” to 39°00’00” East longitude. The average temperature of the district is about 18.5°C, and the average annual rainfall ranges from 762 to 1825 mm. According to the Ethiopian Census 2021 current year projection, the total population of the district was 192,628 [94,613(49.12%) males and 95,015 (50.88%) females]. The rural population was 183,948 (95.49%), and the urban population was 8680 (4.51%)[13].There are eight health centers and 43 health posts in the district. Ginde Woyin health center is among the eight health centers. It gives service to 35,813 people. Under this health center, six rural and two urban health posts are assigned to implement the health extension program. We chose Ginde Woyin health center because under-five pneumonia was the first of the top 10 diseases in the 2020 clinical report (Goncha Siso Enesie Health Office Annual Report, 2020). A health center-based cross-sectional study was conducted on under-five children who attended Ginde Woyin health center from February 3, 2021, to April 10, 2021.


## 2.2. Sample Size Determination

There was no similar study previously conducted in the area; a 50% prevalence rate of under-five pneumonia was taken, assuming that pneumonia is significantly prevalent among under-five children attending Ginde Woyin health center. Accordingly, the minimum number of sample size (n) required was determined using a single population proportion formula for cross-sectional surveys [14], i.e., n = Z2 p (1-p)/d2 = 1.962 × 0.50 × 0.50/.052 = 384 students. To compensate for the nonrespondents and to minimize errors probably arising from the likelihood of noncompliance, a 5% contingency was added, giving a final sample size of 403 study participants.


## 2.3. Variables of the Study

(i)
Dependent variable- the prevalence of under-five pneumonia(ii)
Independent variables- environmental factors (air pollution, use of firewood for cooking, tobacco smoke exposure, sanitation, lack of windows in the kitchen, lack of windows in the living room, lack of a separate kitchen, and overcrowding); health facility and child care factors (availability/distance/cost of health facility, immunization/vaccination, and comorbidity); and sociodemographic characteristics (age, sex, parental occupation, parental education level, and family size)


## 2.4. Eligibility Criteria

### 2.4.1. Inclusion Criteria

Under-five children who did not take antipneumonia drugs and those whose parents/primary guardians were voluntary to sign consent were included.


### 2.4.2. Exclusion Criteria

Under-five children who took antipneumonia drugs, those children and parents/guardians who have hearing impairments, and those whose parents or guardians did not sign consent were excluded.


## 2.4.1. Inclusion Criteria

Under-five children who did not take antipneumonia drugs and those whose parents/primary guardians were voluntary to sign consent were included.


## 2.4.2. Exclusion Criteria

Under-five children who took antipneumonia drugs, those children and parents/guardians who have hearing impairments, and those whose parents or guardians did not sign consent were excluded.


## 2.5. Sample Collection and Processing

Structured questionnaires comprising the known risk factors were developed in English and translated into Amharic (local language). The authors interviewed the participants and the parents of younger children to obtain the sociodemographic characteristics and the related risk factors for pneumonia. The language was translated back into English. The questionnaires were pretested on a nonstudy sample population.Fresh sputum samples were collected in clean, labeled cups [15]. The authors recorded the date, name, age, and sex of each participant during the sputum collection. The sputum samples were smeared on slides, air-dried, and fixed by heating [16]. Following fixation, the slides were treated with carbon fusion and heat. Five minutes after fusion, the slides were washed with water and 3% acidic alcohol. After three minutes, they were again washed with water. Then, they were stained with methylene blue for one minute, washed with water, and dried in the air. Finally, we observed the sputum slides under a microscope for examination. A change in the color of the sputum to dark green indicates a positive for pneumonia. Generally, Ginde Woyin health center lacks an X-ray machine to confirm under-five pneumonia. Therefore, physicians in the health center used the symptoms such as cough; difficulty breathing; thick yellow, green, brown, or blood-stained mucus (phlegm); rapid heartbeat; high temperature; sweating and shivering; loss of appetite, and chest pain as confirmations of pneumonia. Consequently, the researchers of the present study confirmed pneumonia in the same way [17].


## 2.6. Data Analysis

We analyzed the data using the Statistical Package for Social Sciences (SPSS) version 26.0. We used descriptive statistics to show the prevalence of pneumonia among the different sociodemographic groups of under-five children. Associations between the risk factors and under-five pneumonia were determined using univariable logistic regression. We used multivariable logistic regression to test the strength of the associations.P values below 0.05 were considered significant.


## 3. Results

### 3.1. Sociodemographic Characteristics of the Respondents

The present study included 403 under-five children with a response rate of 100% of their parents/guardians (49.4% males and 50.6% females). Age-wise, the respondents were 1 to 3 (49.9%), less than one (36.2%), and 4 to 5 (13.9%). The majority of the study participants (60.8%) were rural dwellers. Two hundred and nine (51.9%) were from four up to five, 31% from above five, and 17.1% from below three family sizes.One hundred and seventy-one (42.4%) of the respondents came from families with monthly income ranging from 1000–2500 birr (19.03–47.57 USD), 37.5% from families with income less than 1000 birr (19.03 USD), and 20.1% from families with income greater than 2500 birr (47.57 USD). One hundred and ninety-three (47.9%) of the mothers and 44.7% of the fathers were illiterate. Sixty-two (15.4%) of the mothers and 60 (14.9%) of the fathers had an educational level of diploma or above. More than half of the mothers (63%) were housewives, while 3.2% were students. The highest proportion of the fathers (n = 227, 56.3%) were farmers, followed by daily laborers (n = 44, 10.9%), and 20 (5%) of them were civil servants (Table 1).Table 1
Sociodemographic characteristics of the respondents in Goncha Siso Enesie District, Northwest Ethiopia (n = 403).
Independent variablesCoding categoriesFrequencyPercentSexMale19949.4Female20450.6Age<1 year14636.21–3 year20149.94–5 year5613.9ResidenceUrban15839.2Rural24560.8Size of the family≤36917.14–520951.9Above 512531.0Monthly income of the family<1000 birr ($19.03)15137.51000–2500 birr ($19.03–47.57)17142.4>2500 birr ($47.57)8120.1Maternal educationIlliterate19347.9Primary (1–8)9222.8Secondary (9–12)5613.9Diploma and above6215.4Paternal educationIlliterate18044.7Primary (1–8)10927.0Secondary (9–12)5413.4Diploma and above6014.9Maternal occupationFarmer25463.0Daily laborers276.7Merchant8220.3Student133.2Civil servant276.7Paternal occupationFarmer22756.3Daily labor4410.9Merchant6315.6Student4912.2Civil servant205.0


### 3.2. Prevalence of under-Five Pneumonia

The overall prevalence of pneumonia among under-five children is presented in Table2. Out of the 403 examined under-five children, pneumonia cases were 98 (24.3%). The gender distribution of under-five pneumonia was 46 (23.1%) among males and 52 (25.5%) among females. The pneumonia cases were higher in male children in the below one year age group (27%) and female children in one up to three age groups (24.8%).Table 2
Prevalence of pneumonia among under-five children by age and sex.
Sex and ageTotal examined N (%)PneumoniaPositive, N (%)Negative, N (%)Male<1 year63 (100)17 (27)46 (73)1–3 years110 (100)23 (20.9)87 (79.1)4–5 years26 (100)6 (23.1)20 (76.9)Total199 (100%)46 (23.1)153 (76.9)Female<1 year29 (100)15 (51.7)14 (48.3)1–3 years129 (100)32 (24.8)97 (75.2)4–5 years46 (100)5 (10.9)41 (89.1)Total204 (100%)52 (25.5)152 (74.5)Both sexes<1 year92 (100)32 (34.8)60 (65.2)1–3 years239 (100)55 (23)184 (77)4–5 years72 (100)11 (15.3)61 (84.7)Total403 (100)98 (24.3)305 (75.7)Overall403 (100)98 (24.3)305 (75.7)


### 3.3. Risk Factors Associated with Pneumonia

The univariate logistic regression analysis showed that children who were breastfed for less than two years were 1.75 times at higher risk of pneumonia (COR = 1.752; 95% CI: 1.009–3.041;P=0.046) compared to children who were breastfed for more than two years. Cooking in the living room was 2.5 times riskier than cooking in the kitchen (COR = 2.483; 95% CI: 1.121, 5.502; P=0.025) (Table 3).Table 3
Univariate and multivariate logistic regression analysis of potential risk factors associated with under-five pneumonia in Goncha Siso Enesie District, Northwest Ethiopia, 2020/2021.
Independent variablesCoding categoriesPneumonia statusUnivariate logistic regressionMultivariate logistic regressionPositive (percent)Negative (percent)COR (95% CI)P valueAOR (95% CI)P valueAgeBelow 1 year49 (33.6)97 (66.4)0.598 (0.295, 1.216)0.1560.897 (0.317, 2.539)0.8371–3 years old36 (17.9)165 (82.1)1.386 (0.676, 2.840)0.3731.439 (0.568, 3.845)0.4433–5 years old13 (24.1)43 (75.9)1ResidenceRural48 (30.4)110 (69.6)1.702 (1.074, 2.695)0.023∗0.538 (0.303, 0.953)0.034∗Urban50 (20.4)195 (79.6)1Size of the family>522 (31.8)47 (68.2)1.450 (0.799, 2.633)0.2220.465 (0.200, 1.081)0.0754–551 (24.4)158 (75.6)1.872 (0.958, 3.658)0.0660.651 (0.342, 1.238)0.191≤325 (20)100 (80)1Monthly income of the family (birr)<1000 birr ($19.03)42 (27.8)109 (72.2)0.590 (0.304, 1.146)0.1190.589 (0.262, 1.326)0.2011000–2500 birr ($19.03–47.57)41 (23.9)130 (76.1)0.721 (0.372, 1.396)0.3320.872(0.397, 1.919)0.734>2500 birr ($47.57)15 (18.5)66 (81.5)1Maternal occupationHouse wives51 (20.1)203 (79.9)1.393 (0.559, 3.474)0.4771.274 (0.158, 10.296)0.820Daily labor11 (40.7)16 (59.3)0.509 (0.161, 1.613)0.2610.168 (0.014, 2.061)0.163Merchant21 (25.6)61 (74.4)1.017 (0.377, 2.745)0.9740.784 (0.086, 7.114)0.829Student8 (61.5)5 (38.5)0.219 (0.053, 0.896)0.035∗1.011 (0.972, 3.643)0.061Civil servant7 (25.9)20 (74.1)1Source of fuel for cookingWood69 (28.9)170 (71.1)1.232 (0.3, 5.065)0.7732.769 (0.488, 15.727)0.049∗Charcoal26 (16.7)129 (83.3)2.481 (0.583, 10.56)0.2191.390 (0.251, 7.697)0.706Electricity3 (33.3)6 (66.7)1Cooking areaKitchen59 (24.7)180 (75.3)1Outdoor25 (19.7)102 (80.3)1.857 (0.898, 3.84)0.0950.520 (0.205, 1.319)0.169Living room14 (37.8)23 (62.2)2.483 (1.121, 5.502)0.025∗0.895 (0.481, 1.665)0.726Presence of windows in the kitchenNo61 (28.4)154 (71.6)0.619 (0.388, 0.986)0.043∗0.626 (0.361, 1.085)0.045∗Yes37 (19.7)151 (80.3)1Number of windows in the main house> three21 (23.8)67 (76.2)1Two23 (20.9)87 (79.1)1.186 (0.606, 2.321)0.6191.503 (0.689, 3.280)0.306One27 (19.3)113 (80.7)1.312 (0.688, 2.501)0.4101.252 (0.591, 2.653)0.557No window27 (41.5)38 (58.5)0.441 (0.220, 0.884)0.021∗0.598 (0.264, 1.356)0.218BF status of the childMixed BF60 (44.1)76 (55.9)0.21 (0.130, 0.340)0.001∗5.229 (3.025, 9.041)0.001∗Exclusive BF38 (14.2)229 (85.8)1Years of BFUp to 1 year12 (29.3)29 (70.7)2.240 (1.109, 4.526)0.025∗1.357 (0.509, 3.613)0.542Up to 2 years25 (19.8)101 (80.2)1.752 (1.009, 3.041)0.046∗1.699 (0.179, 16.101)0.644Up to date49 (30.2)113 (69.2)1.048 (0.494, 2.222)0.9031.599 (0.729, 3.505)0.242>2 years12 (16.2)62 (83.8)1Age when complementary feed started>6 months29 (20.7)111 (79.3)1<6 months23 (14.0)131 (86.0)1.037 (0.593, 1.814)0.8982.080 (1.061, 4.076)0.033∗Not started36 (36.7)63 (63.3)0.457 (0.256, 0.815)0.008∗1.925 (0.961, 3.855)0.065ARTI = acute respiratory tract infection; BF = breastfeeding;∗ statistically significant at P<0.05.In the multivariable logistic regression, children from families who used wood for cooking were 3.5 times more likely to be infected by pneumonia (AOR = 3.535; 95% CI: 0.829–9.724;P=0.047) than electricity users. When compared to exclusive breastfeeders, children who received mixed breastfeeding were 5.2 times at higher risk of pneumonia (AOR = 5.229; 95% CI: 3.025–9.041; P=0.001). Children who started complementary food before six months of age were 2 times at higher risk of pneumonia (AOR = 2.080; 95% CI: 1.061–4.076; P=0.033) than those who started after six months (Table 3).


## 3.1. Sociodemographic Characteristics of the Respondents

The present study included 403 under-five children with a response rate of 100% of their parents/guardians (49.4% males and 50.6% females). Age-wise, the respondents were 1 to 3 (49.9%), less than one (36.2%), and 4 to 5 (13.9%). The majority of the study participants (60.8%) were rural dwellers. Two hundred and nine (51.9%) were from four up to five, 31% from above five, and 17.1% from below three family sizes.One hundred and seventy-one (42.4%) of the respondents came from families with monthly income ranging from 1000–2500 birr (19.03–47.57 USD), 37.5% from families with income less than 1000 birr (19.03 USD), and 20.1% from families with income greater than 2500 birr (47.57 USD). One hundred and ninety-three (47.9%) of the mothers and 44.7% of the fathers were illiterate. Sixty-two (15.4%) of the mothers and 60 (14.9%) of the fathers had an educational level of diploma or above. More than half of the mothers (63%) were housewives, while 3.2% were students. The highest proportion of the fathers (n = 227, 56.3%) were farmers, followed by daily laborers (n = 44, 10.9%), and 20 (5%) of them were civil servants (Table 1).Table 1
Sociodemographic characteristics of the respondents in Goncha Siso Enesie District, Northwest Ethiopia (n = 403).
Independent variablesCoding categoriesFrequencyPercentSexMale19949.4Female20450.6Age<1 year14636.21–3 year20149.94–5 year5613.9ResidenceUrban15839.2Rural24560.8Size of the family≤36917.14–520951.9Above 512531.0Monthly income of the family<1000 birr ($19.03)15137.51000–2500 birr ($19.03–47.57)17142.4>2500 birr ($47.57)8120.1Maternal educationIlliterate19347.9Primary (1–8)9222.8Secondary (9–12)5613.9Diploma and above6215.4Paternal educationIlliterate18044.7Primary (1–8)10927.0Secondary (9–12)5413.4Diploma and above6014.9Maternal occupationFarmer25463.0Daily laborers276.7Merchant8220.3Student133.2Civil servant276.7Paternal occupationFarmer22756.3Daily labor4410.9Merchant6315.6Student4912.2Civil servant205.0


## 3.2. Prevalence of under-Five Pneumonia

The overall prevalence of pneumonia among under-five children is presented in Table2. Out of the 403 examined under-five children, pneumonia cases were 98 (24.3%). The gender distribution of under-five pneumonia was 46 (23.1%) among males and 52 (25.5%) among females. The pneumonia cases were higher in male children in the below one year age group (27%) and female children in one up to three age groups (24.8%).Table 2
Prevalence of pneumonia among under-five children by age and sex.
Sex and ageTotal examined N (%)PneumoniaPositive, N (%)Negative, N (%)Male<1 year63 (100)17 (27)46 (73)1–3 years110 (100)23 (20.9)87 (79.1)4–5 years26 (100)6 (23.1)20 (76.9)Total199 (100%)46 (23.1)153 (76.9)Female<1 year29 (100)15 (51.7)14 (48.3)1–3 years129 (100)32 (24.8)97 (75.2)4–5 years46 (100)5 (10.9)41 (89.1)Total204 (100%)52 (25.5)152 (74.5)Both sexes<1 year92 (100)32 (34.8)60 (65.2)1–3 years239 (100)55 (23)184 (77)4–5 years72 (100)11 (15.3)61 (84.7)Total403 (100)98 (24.3)305 (75.7)Overall403 (100)98 (24.3)305 (75.7)


## 3.3. Risk Factors Associated with Pneumonia

The univariate logistic regression analysis showed that children who were breastfed for less than two years were 1.75 times at higher risk of pneumonia (COR = 1.752; 95% CI: 1.009–3.041;P=0.046) compared to children who were breastfed for more than two years. Cooking in the living room was 2.5 times riskier than cooking in the kitchen (COR = 2.483; 95% CI: 1.121, 5.502; P=0.025) (Table 3).Table 3
Univariate and multivariate logistic regression analysis of potential risk factors associated with under-five pneumonia in Goncha Siso Enesie District, Northwest Ethiopia, 2020/2021.
Independent variablesCoding categoriesPneumonia statusUnivariate logistic regressionMultivariate logistic regressionPositive (percent)Negative (percent)COR (95% CI)P valueAOR (95% CI)P valueAgeBelow 1 year49 (33.6)97 (66.4)0.598 (0.295, 1.216)0.1560.897 (0.317, 2.539)0.8371–3 years old36 (17.9)165 (82.1)1.386 (0.676, 2.840)0.3731.439 (0.568, 3.845)0.4433–5 years old13 (24.1)43 (75.9)1ResidenceRural48 (30.4)110 (69.6)1.702 (1.074, 2.695)0.023∗0.538 (0.303, 0.953)0.034∗Urban50 (20.4)195 (79.6)1Size of the family>522 (31.8)47 (68.2)1.450 (0.799, 2.633)0.2220.465 (0.200, 1.081)0.0754–551 (24.4)158 (75.6)1.872 (0.958, 3.658)0.0660.651 (0.342, 1.238)0.191≤325 (20)100 (80)1Monthly income of the family (birr)<1000 birr ($19.03)42 (27.8)109 (72.2)0.590 (0.304, 1.146)0.1190.589 (0.262, 1.326)0.2011000–2500 birr ($19.03–47.57)41 (23.9)130 (76.1)0.721 (0.372, 1.396)0.3320.872(0.397, 1.919)0.734>2500 birr ($47.57)15 (18.5)66 (81.5)1Maternal occupationHouse wives51 (20.1)203 (79.9)1.393 (0.559, 3.474)0.4771.274 (0.158, 10.296)0.820Daily labor11 (40.7)16 (59.3)0.509 (0.161, 1.613)0.2610.168 (0.014, 2.061)0.163Merchant21 (25.6)61 (74.4)1.017 (0.377, 2.745)0.9740.784 (0.086, 7.114)0.829Student8 (61.5)5 (38.5)0.219 (0.053, 0.896)0.035∗1.011 (0.972, 3.643)0.061Civil servant7 (25.9)20 (74.1)1Source of fuel for cookingWood69 (28.9)170 (71.1)1.232 (0.3, 5.065)0.7732.769 (0.488, 15.727)0.049∗Charcoal26 (16.7)129 (83.3)2.481 (0.583, 10.56)0.2191.390 (0.251, 7.697)0.706Electricity3 (33.3)6 (66.7)1Cooking areaKitchen59 (24.7)180 (75.3)1Outdoor25 (19.7)102 (80.3)1.857 (0.898, 3.84)0.0950.520 (0.205, 1.319)0.169Living room14 (37.8)23 (62.2)2.483 (1.121, 5.502)0.025∗0.895 (0.481, 1.665)0.726Presence of windows in the kitchenNo61 (28.4)154 (71.6)0.619 (0.388, 0.986)0.043∗0.626 (0.361, 1.085)0.045∗Yes37 (19.7)151 (80.3)1Number of windows in the main house> three21 (23.8)67 (76.2)1Two23 (20.9)87 (79.1)1.186 (0.606, 2.321)0.6191.503 (0.689, 3.280)0.306One27 (19.3)113 (80.7)1.312 (0.688, 2.501)0.4101.252 (0.591, 2.653)0.557No window27 (41.5)38 (58.5)0.441 (0.220, 0.884)0.021∗0.598 (0.264, 1.356)0.218BF status of the childMixed BF60 (44.1)76 (55.9)0.21 (0.130, 0.340)0.001∗5.229 (3.025, 9.041)0.001∗Exclusive BF38 (14.2)229 (85.8)1Years of BFUp to 1 year12 (29.3)29 (70.7)2.240 (1.109, 4.526)0.025∗1.357 (0.509, 3.613)0.542Up to 2 years25 (19.8)101 (80.2)1.752 (1.009, 3.041)0.046∗1.699 (0.179, 16.101)0.644Up to date49 (30.2)113 (69.2)1.048 (0.494, 2.222)0.9031.599 (0.729, 3.505)0.242>2 years12 (16.2)62 (83.8)1Age when complementary feed started>6 months29 (20.7)111 (79.3)1<6 months23 (14.0)131 (86.0)1.037 (0.593, 1.814)0.8982.080 (1.061, 4.076)0.033∗Not started36 (36.7)63 (63.3)0.457 (0.256, 0.815)0.008∗1.925 (0.961, 3.855)0.065ARTI = acute respiratory tract infection; BF = breastfeeding;∗ statistically significant at P<0.05.In the multivariable logistic regression, children from families who used wood for cooking were 3.5 times more likely to be infected by pneumonia (AOR = 3.535; 95% CI: 0.829–9.724;P=0.047) than electricity users. When compared to exclusive breastfeeders, children who received mixed breastfeeding were 5.2 times at higher risk of pneumonia (AOR = 5.229; 95% CI: 3.025–9.041; P=0.001). Children who started complementary food before six months of age were 2 times at higher risk of pneumonia (AOR = 2.080; 95% CI: 1.061–4.076; P=0.033) than those who started after six months (Table 3).


## 4. Discussion

The overall prevalence of pneumonia (24.3%) was in line with the findings from Tanzania (22%) [18], in the Sheka zone of SNNPR (Ethiopia) (23.8%) [19], and in Gondar city (Ethiopia) (26.3%) [20]. It was higher than that of studies in Debre Birhan (Ethiopia) (5.5%) [7], Mali (6.7%) [21], Uganda (6.9%) [22], and Kenya (6.9%) [23]. However, it was lower than the findings in Nigeria (31.6%) [24], Sudan (65%) [11], Kenya (74%) [25], Uganda (56%) [26], and the Sidama Zone, Wondo Genet district (Ethiopia) (33.5%) [10]. The difference in the prevalence could be due to sociodemographic differences, seasonal variation, socioeconomic differences, environmental change [8], and immunization inaccessibility or provision [27]. It is because Africa is a continent characterized by marked ethnic, sociodemographic, and economic diversity [28]. Sociodemographic factors such as age, gender, socioeconomic status (SES), race/ethnicity, and immigration status may in turn affect the status of vaccination [29]. Furthermore, geographical inequality contributes to child mortalities and morbidities [30].Children who were from families that used wood for cooking were 2.77 times more likely to be infected by pneumonia (AOR = 2.769; 95% CI: 0.488, 15.727;P=0.049) than electricity users. This result was in line with studies in Gondar city (Northwest Ethiopia) [20], the Sheka Zone (Southwest Ethiopia) [19], and the Jimma zone (Southwest Ethiopia) [31]. The possible reason behind this might be that firewood smoke contains indoor air pollutants, which adversely affect the defenses of the respiratory tract against pathogens [32]. Wood smoke can irritate the lungs, cause inflammation, suppress the immune system, and make the lungs more susceptible to infections [33]. Reports also show that reducing exposure to smoke from open fires and wood-burning cook stoves significantly reduces the incidence of pneumonia, the leading cause of death for children five and under in developing countries [34].Children who started complementary food before six months of age were 2 times (AOR = 2.08; 95% CI: 1.061–4.076;P=0.033) more infected by pneumonia than those who started complementary food after six months of age. This finding agreed with studies conducted in Ethiopia [35]. The possible reason might be that starting complementary food early in childhood may reduce breast milk intake and make the children susceptible to different infections [36]. Similarly, being partially breastfed or not breastfed at all increases the risk of mortality due to various infections [37], as does pneumonia.Children who used mixed breastfeeding were 5.2 times at higher risk of pneumonia (AOR = 5.229; 95% CI: 3.025–9.041;P=0.001) than exclusive breastfeeders. This finding agreed with the studies conducted in India (AOR = 1.92; 95%CI: 0.79, 4.68) [38] and in the Jimma zone, Ethiopia (AOR = 3.3; 95%CI: 1.266, 8.3) [31]. The reason might be that breast milk contains nutrients, antioxidants, hormones, lymphocytes, and antibodies that prevent infection [38]. Exclusive Breast Feeding (EBF) for the first six months of life prevents child mortality and morbidity [39].Several studies reported that factors such as maternal and parental educational status, gender of the child, child age, history of past morbidity, the condition of the child’s vaccination, housing, and environmental factors are significantly associated with under-five pneumonia [7, 31, 40], but in the present finding, these factors were not associated with under-five pneumonia. It agrees with the report saying that in Africa, a one-year increase in maternal education is not associated with a significant change in pneumonia rates [41], the exposure rate of under-five males and females may not be different in rural Ethiopia, the routine immunization in Ethiopia only includes preventable diseases such as measles, diphtheria, pertussis, tetanus, polio, and tuberculosis [42], and most houses and other environmental factors in rural Ethiopia may be of close status.


## 5. Conclusion

The prevalence of under-five pneumonia in the present study was relatively high. The significant predictors for under-five pneumonia identified were the use of wood as a source of fuel for cooking; starting complementary food before six months of age; and mixed breastfeeding conditions.


### 5.1. Recommendations

The authors recommend awareness-creation programs on the importance of breastfeeding in the study area, the need for kitchen windows, and using healthy fuel alternatives to firewood.


### 5.2. Significance of the Study

The findings of the present study provide information for health offices, parents, policy makers, and program officers to design pneumonia-preventive interventions.


### 5.3. Limitation of the Study

This study was limited to sputum (mucus) and blood tests with pulse oximetry. But, these tests cannot strictly identify pneumonia. In addition, the use of the chest X-ray test helps to look at the extent of the infection (prevalence) of pneumonia. However, failure to use this method in the present study may underestimate the prevalence of pneumonia among the study subjects.


### 5.4. Operational Definition of Variables

(i)
Age refers to the participants’ age measured in years between the time from birth and the date of data collection (February 3, 2021, to April 10, 2021)(ii)
Associated risk factors- sociodemographic, behavioral, and environmental factors that caused or contributed to the development of pneumonia among under-five children visiting Ginde Woyin health center (February 3, 2021, to April 10, 2021)(iii)
Family size refers to the number of persons in the family of under-five children visiting Ginde Woyin health center (February 3, 2021, to April 10, 2021)(iv)
Maternal/paternal education- the level of the “formal” education of the mothers/fathers of under-five children visiting Ginde Woyin health center (February 3, 2021, to April 10, 2021)(v)
Maternal/paternal occupation- the main sectors of employment of the mothers/fathers of under-five children visiting Ginde Woyin health center (February 3, 2021, to April 10, 2021)(vi)
Monthly income of the family- the combined monthly incomes (Ethiopian Birr) of all members of the households (18 years and above) of under-five children visiting Ginde Woyin health center (February 3, 2021, to April 10, 2021)(vii)
Prevalence of pneumonia- the calculated value of pneumonia cases among under-five children visiting Ginde Woyin health center (February 3, 2021, to April 10, 2021) divided by the total number in a study of under-five children multiplied by 100(viii)
Residence- defined based on the dwelling of under-five children visiting Ginde Woyin health center (February 3, 2021, to April 10, 2021) by relating to the countryside or the town, the former as rural and the latter as urban residents(ix)
Sex was the physical condition of being a male or female of under-five children visiting Ginde Woyin health center, Goncha Siso Enesie District, Northwest Ethiopia, February 3, 2021, to April 10, 2021(x)
Sputum- a mixture of saliva and mucus coughed up from the respiratory tracts of under-five children visiting Ginde Woyin health center (February 3, 2021, to April 10, 2021)(xi)
Under-five pneumonia is an infection of the lungs caused by fungi, bacteria, or viruses with symptoms including chest pain, fever, cough, and trouble breathing


## 5.1. Recommendations

The authors recommend awareness-creation programs on the importance of breastfeeding in the study area, the need for kitchen windows, and using healthy fuel alternatives to firewood.


## 5.2. Significance of the Study

The findings of the present study provide information for health offices, parents, policy makers, and program officers to design pneumonia-preventive interventions.


## 5.3. Limitation of the Study

This study was limited to sputum (mucus) and blood tests with pulse oximetry. But, these tests cannot strictly identify pneumonia. In addition, the use of the chest X-ray test helps to look at the extent of the infection (prevalence) of pneumonia. However, failure to use this method in the present study may underestimate the prevalence of pneumonia among the study subjects.


## 5.4. Operational Definition of Variables

(i)
Age refers to the participants’ age measured in years between the time from birth and the date of data collection (February 3, 2021, to April 10, 2021)(ii)
Associated risk factors- sociodemographic, behavioral, and environmental factors that caused or contributed to the development of pneumonia among under-five children visiting Ginde Woyin health center (February 3, 2021, to April 10, 2021)(iii)
Family size refers to the number of persons in the family of under-five children visiting Ginde Woyin health center (February 3, 2021, to April 10, 2021)(iv)
Maternal/paternal education- the level of the “formal” education of the mothers/fathers of under-five children visiting Ginde Woyin health center (February 3, 2021, to April 10, 2021)(v)
Maternal/paternal occupation- the main sectors of employment of the mothers/fathers of under-five children visiting Ginde Woyin health center (February 3, 2021, to April 10, 2021)(vi)
Monthly income of the family- the combined monthly incomes (Ethiopian Birr) of all members of the households (18 years and above) of under-five children visiting Ginde Woyin health center (February 3, 2021, to April 10, 2021)(vii)
Prevalence of pneumonia- the calculated value of pneumonia cases among under-five children visiting Ginde Woyin health center (February 3, 2021, to April 10, 2021) divided by the total number in a study of under-five children multiplied by 100(viii)
Residence- defined based on the dwelling of under-five children visiting Ginde Woyin health center (February 3, 2021, to April 10, 2021) by relating to the countryside or the town, the former as rural and the latter as urban residents(ix)
Sex was the physical condition of being a male or female of under-five children visiting Ginde Woyin health center, Goncha Siso Enesie District, Northwest Ethiopia, February 3, 2021, to April 10, 2021(x)
Sputum- a mixture of saliva and mucus coughed up from the respiratory tracts of under-five children visiting Ginde Woyin health center (February 3, 2021, to April 10, 2021)(xi)
Under-five pneumonia is an infection of the lungs caused by fungi, bacteria, or viruses with symptoms including chest pain, fever, cough, and trouble breathing



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*Source: 6497895-2022-08-04.xml*