The present study has identified a relatively low prevalence of pneumonia among 2 -59 months old children and also pointed out certain modifiable risk factors. This figure of 2 -59 months old children pneumonia prevalence (7.5%) is almost equivalent to the national prevalence of pneumonia (7%), according to EDHS 2011(6). This similarity might be due to following the same assessment method to ascertain the diseases based on mothers or care takers' report. On the other hand, this finding is not in line with the findings from a cross sectional survey in Este town (7) which found the prevalence of under-five pneumonia to be significantly higher, 16.1%.The possible reason for this difference could be due to the seasonal variation and topographic dissimilarity of the two study areas. Similarly, this finding is not comparable to the findings from the retrospective study in UNHCR refugee camps (8) where pneumonia accounted 17 % of child morbidity. Besides the difference in methodology, the study setting, i.e. the refugee camps are the area where there is overcrowding and hence higher chance of transmission of the disease, may have accounted for the difference in the prevalence of pneumonia in children. Also, efforts to improve access to maternal and childcare services in this study area could have contributed to this low level of childhood pneumonia morbidity. The prevalence of pneumonia in children in this study setting is not consistent with the findings from a cross sectional survey in Uganda (9) where pneumonia prevalence was found to be significantly higher (53.7%). The discrepancy in the difference in the prevalence of pneumonia could be due to the difference in the setting in which these two studies were conducted, the latter being done in the National referral hospital of Uganda. The cross sectional survey in Kuwaiti, Bangladesh (10) showed the prevalence of under-five pneumonia was estimated to be 53%.
In this study, the occurrence of pneumonia was not affected by the residence. This is comparable to the findings from the cross sectional survey in Este town (7) where pneumonia prevalence was not different between urban and rural dwellers. The presence of pneumonia among under five-year children did not show statistically significant association with the educational status and occupation of parents. This finding is consistent with the findings from a case control study in Pakistan (11) where there was no a statistically significant difference in the prevalence of pneumonia between educated and none educated parents. This case control study, however, reported that maternal occupation had been found to be significantly associated with pneumonia, which is in contrary to the finding in this study. This difference could be explained by the difference in the methodology. Similarly, this finding is supported by the report from the cross sectional survey in Este town (7) where educational status and occupation of the parent did not illustrate significant association with pneumonia in children. Another case control study from India (12) reported that the literacy status of the father did not show any association with pneumonia in under-fives. Also, we did not find any significant difference in the occurrence of pneumonia with sex of the child. This finding is not consistent with the findings from the report of lancet 2013 (13) which showed higher occurrence of pneumonia in boys than in girls (median OR=1.3). The difference in the methodology could be the reason for this discrepancy.
In this study, there was a difference in the occurrence of pneumonia with the age of child. This finding is in line with the report from lancet 2013 (13) which revealed higher occurrence of pneumonia in children younger than 2 years of age. Similarly, the result is similar to studies conducted in Urban Areas of Oromiya Zone, Amhara Region (3) where children at age rang 2-11months were 85% higher chance to have pneumonia as compared to older age. Though this study showed that use of charcoal and wood for cooking was higher in the study area, there was no significant statistical association with pneumonia in under-fives. This is just the opposite findings to the cross sectional survey report in Este town (7) where there was a statistically significant association of the occurrence of pneumonia with charcoal use for cooking. On the other hand, place of cooking and place of the child during cooking were associated with pneumonia in this study. This is consistent with the Este town cross sectional survey (7) findings, where cooking in the living room and carrying the child during cooking were a significant risk factor for pneumonia.
In addition, types of latrines households use were not associated with pneumonia in 2 -59 months old children in this study. This is not consistent with the WHO/UNICEF report (13) which revealed that improved latrine can for most part prevent pneumonia in children. This study could not find a significant association between pneumonia in children and current smoking habits of any household resident. This is not in line with the reports from WHO training package on health sector (14), where children whose parents smoke were 60% more affected by pneumonia. Also, this finding is not supported by the scientific articles published in Miami (15) and Poland (16) and case control study in West Africa (17) where cigarette smoke was demonstrated to be the risk factor for pneumonia in children.
The finding of this study revealed that the number of windows of the living house has a significant association with the prevalence of pneumonia in the study area; this finding is similar to the study conducted in Este town, where the finding of the study showed that indoor air pollution resulting from the use of biomass fuel for cooking has statistical association with pneumonia. Air pollutants associated with biomass fuel use may adversely affect specific and non-specific host defenses of the respiratory tract against pathogens.
Exclusive breast-feeding status of the child during the first 6 months of child's life was not found to factor pneumonia in children in the study area. This is not consistent with findings from a systematic review and meta-analysis (18) done in USA, 2013, 2011 UNICEF report (19) and the integrated action plan for prevention and control of pneumonia and diarrhea report 2013 of the WHO and UNICEF (20) where exclusive breast feeding was one of the factors that could determine the incidence and prevalence of pneumonia and mortality from pneumonia in children. This difference could be explained by the fact that mothers who might know that breast feeding children exclusively to the first 6 months of children's life is socially acceptable may falsely reported that their children had been breastfed exclusively during their first 6 months of age.
The presence of malnutrition among children2-59 months of age was not statically associated with the prevalence of pneumonia in the study area, this finding is not in line to studies conducted in Costa Rica and Philippines (21) which revealed a significantly higher proportion of sever pneumonic infant with first, second and third degree of malnutrition compared with normal nutritional status. A similar study conducted in Ethiopia demonstrates the fact that children with malnutrition tend to have low immunity and are vulnerable to a number of infections, including Pneumonia (22). Finally, the finding of our study revealed that vaccination status of the child has a significant association with the prevalence of pneumonia. It was least in children who were fully immunized (12.5%) as compared to unimmunized children. Similarly an Indian study reported that non immunized infants were more prone to develop sever pneumonia (23).
Limitations
The cross-sectional survey could not help establishing temporal relationship between the possible determinants 2 -59 months old children pneumonia and the outcome of interest, pneumonia among 2 -59 months old children. The study selectively addressed certain factors of under-five pneumonia while various factors are found to cause the diseases.
The WHO's IMNCI is not a confirmatory gold standard diagnostic tool to surely settle pneumonia diagnosis. It was difficult to measure indoor air pollution.
Conclusion
The study identified a comparatively similar result with the national prevalence of pneumonia among children 2-59 months of age. It also came up with some modifiable risk factors of pneumonia in the study area. Risk factors associated with community acquired pneumonia in Gumay district were Age of the child, cooking foods regularly in the main house, number of windows the house is constructed with, carrying the child on the back during cooking and lack of chance to be vaccinated at least once in the child’s life time.
Recommendations
Based on the findings in this study, the following recommendation were forwarded
The district Health Office should: -
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Raise awareness of the community about the adverse health effect of indoor air pollution, resulting from cooking in living house without adequate ventilation.
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The district health office in collaboration with different sectors needs to encourage contracting kitchens separately from the living house.
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District health office should establish a strong awareness raising strategies in the community to improve proper childcares and to promote the acceptability of vaccines.
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Mothers/caregivers should keep children away from smoke during cooking.
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Households should ventilate living rooms by opening doors and windows.