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KARATINA UNIVERSITY.

SCHOOL OF NURSING

TOPIC;
DETERMINANTS OF PNEUMONIA OCCURRENCE AMONG CHILDREN FIVE YEARS
AND BELOW IN PEADEATRIC WARD, AT MURANG’A COUNTY REFFERAL
HOSPITAL.

BY: FRANKLINE KIMUTAI

REGISTRATION: P109/1325G/18

A Research Project Submitted In Partial Fulfillment For the Requirements of the Award of a
Degree in Bachelor of Science in Nursing

KARATINA UNIVERSITY

JUNE 2022

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DECLARATION AND APPROVAL

Declaration
This research project is my original work and has not been submitted to any other college or
university for an academic award.

Signature ……………... Date…………...

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Approval
This research project is being made under my direct supervision by Madam Florence.

Signature………… Date…………

Madam Florence

Lecturer, Department of Nursing,

Karatina University

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ACKNOWLEDGMENT
First and foremost, I give thanks to the Almighty God for His grace throughout my study period
and for the good health, that has made the rigorous process of development of this research
proposal bearable. I extend my sincere gratitude to my supervisor MS Florence for her
supervision, valuable discussions, suggestions and comments to the document. I would also like
to thank all lecturers in the department of Nursing for their academic support during my
undergraduate studies

I sincerely thank my family for their love, support and encouragement throughout my study
period. Without them I would not have progressed this far. Last, but not least, to my friends, I
say “thank you” for your insight and support each one of you gave me during my studies; may
the Almighty Father bless you abundantly. I give special thanks to Murang’a County Referral
Hospital. for allowing me to carry out this research, May the Almighty God bless you.

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ABSTRACT
Background: Pneumonia is defined as an acute inflammation of the Lungs’ parenchymal
structure. It is a major public health problem and the leading cause of morbidity and mortality in
under-five children especially in developing countries. The air sacs may fill with fluid or pus and
this infection can be life threatening and particularly to infants hence being a major cause of
morbidity and mortality among infants. Child health status is closely related to changes in
mortality rate. According to reports from the World Health Organization (WHO), 35% of global
children under-five years’ mortality can be attributable to malnutrition (WHO, 2005). It can be
classified based on place of acquisition: as community acquired or hospital acquired; based on its
causative agents/ mechanism as bacterial, viral, fungal, Aspiration, or ventilator-associated
pneumonia; based on the anatomy of the lungs involved as lobar pneumonia, bronchial
pneumonia or acute interstitial pneumonia; and on the basis of its clinical severity as “no
pneumonia”, “pneumonia” or “severe pneumonia” Every year the number of deaths in infants
and children below 5 years of age is reported to be 12 million. The disease has been discovered
to rise among children under 5 years old in MCRH.

Objective: To investigate determining factors contributing to the occurrence of pneumonia

among children under 5 years at MCRH.

Methodology: Study design was a descriptive and cross-sectional study design among children
below five years of age who were hospitalized at MCRH in a pediatric ward where systematic
sampling was employed to select the study participants. Data collection was done through
questionnaires and records from the hospital (MCRH) to rule out possible causes of pneumonia
among children under-five. Analysis of data was done using SPSS version 21.0 and excel 2019.
Descriptive analysis and chi-square at 95% confidence intervals were done to establish
association between dependent and independent variables. Data collected was later presented in
charts, frequency tables and percentages.

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TABLE OF CONTENTS

Contents
TOPIC;.................................................................................................................................................
DECLARATION AND APPROVAL...............................................................................................
Declaration..........................................................................................................................................
Approval............................................................................................................................................
ACKNOWLEDGMENT...................................................................................................................
ABSTRACT........................................................................................................................................
TABLE OF CONTENTS..................................................................................................................
LIST OF TABLES............................................................................................................................
LIST OF FIGURES............................................................................................................................
LIST OF ABBREVIATIONS...........................................................................................................
OPERATIONAL DEFINITIONS...................................................................................................
1.0 CHAPTER ONE: INTRODUCTION........................................................................................
1.1 Background of information.........................................................................................................
1.2 Statement of problem...................................................................................................................
1.3 Justification of study....................................................................................................................
1.4.1 Broad objective..........................................................................................................................
1.4.2 Specific objectives......................................................................................................................
1.4.3 Research question......................................................................................................................
CHAPTER 2: LITERATURE REVIEW.........................................................................................
2.0 An overview of pneumonia..........................................................................................................
2.0 The prevalence of pneumonia among children under 5 years.................................................
2.1 Socio-demographic factors associated with pneumonia.........................................................
2.2 The nutritional status of children in relation to pneumonia among the under-five
children..............................................................................................................................................
2.3 Summary of the gaps identified................................................................................................
2.4 Conceptual framework......................................................................................................15
CHAPTER THREE.........................................................................................................................

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3.1 Study design........................................................................................................................16

3.2 Study Area..........................................................................................................................16
3.3 Study Population................................................................................................................16
3.3.1 Inclusion criteria..........................................................................................................16
3.3.2 Exclusion criteria.........................................................................................................16
3.4. 0 Sample Size.................................................................................................................16
3.4.1 STUDY VARIABLES.....................................................................................................17
Independent variables..............................................................................................................17
3.5 Sample technique................................................................................................................17
3.6 Collection of Data...............................................................................................................18
3.7 Pretesting Data Collection Tools.......................................................................................18
3.8 Analysis of Data..................................................................................................................18
3.9 Study Limitations...............................................................................................................20
3.10 Ethical consideration................................................................................................................
3.11 Dissemination of the Study..............................................................................................20
CHAPTER FOUR............................................................................................................................
RESULTS..........................................................................................................................................
4 Introduction...................................................................................................................................
4.0 Response rate..............................................................................................................................
4.1 Socio-demographic characteristics of the mothers.........................................................21
4.2. Social demographic Characteristics of the child............................................................23
4.3 Breastfeeding History of the child....................................................................................24
4.4 Immunization history of the child....................................................................................24
4.5 .Prevalence of pneumonia among children under five in Murang’a county Referral
Hospital.....................................................................................................................................25
4.6. Environmental factors surrounding the child................................................................26
4.7 Social demographics characteristics of the child associated with pneumonia cases....26
4.8 Childs breastfeeding and immunization history associated with pneumonia cases.....27
4.9 Childs Environmental factors associated with pneumonia cases...................................29
CHAPTER FIVE..............................................................................................................................

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DISCUSSION, CONCLUSIONS AND RECOMMENDATIONS...............................................

5.1 Relationship between social-demographic characteristics and pneumonia..................30
5.2 Relationship between nutritional status and pneumonia...............................................31
5.3 Relationship between environmental factors and pneumonia.......................................31
5.4 Prevalence of pneumonia among children under five in Muranga sub county Hospital
....................................................................................................................................................32
5.5 Conclusion...........................................................................................................................32
5.6 Recommendations..............................................................................................................33
5.7 Study limitation..................................................................................................................33
CHAPTER SIX.................................................................................................................................
MISCELLANEOUS.................................................................................................................34
REFERENCES.....................................................................................................................34
APPENDICES.......................................................................................................................37
WORK PLAN...................................................................................................................................

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LIST OF TABLES
Table 1 Data collection flow as per objective...............................................................................19
Table 2 Socio-demographic characteristics of the mothers...........................................................22
Table 3 Social demographic Characteristics of the child.........................................................23
Table 4 Frequency of pneumonia attack among children under five......................................25
Table 5 Environmental factors surrounding the child..............................................................26
Table 6 Social demographics characteristics of the child associated with pneumonia cases27
Table 7 Childs breastfeeding and immunization history associated with pneumonia cases. 27
Table 8 Childs Environmental factors associated with pneumonia........................................29

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LIST OF FIGURES
Figure 1 conceptual framework.....................................................................................................15
Figure 2 patient flow MCRH.........................................................................................................17
Figure 3 Response rate of respondents..........................................................................................21
Figure 5 B feeding hx....................................................................................................................24
Figure 6 Immunization history of the child...................................................................................24
Figure 7 Prevalence of pneumonia among children under five in Murang’a county Referral
Hospital.........................................................................................................................................25

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LIST OF ABBREVIATIONS
MCRH- Murang’a County and Referral Hospital

W.H.O -World Health Organization

H.I.V -Human Immunodeficiency Virus

CI- Confidence Interval

OR-Odds Ratio

U5M-Under Five Mortalities

SPSS- Statistical Programmed for Social Science

I.M.C.I - Integrated Management of Childhood Illness

HCAP - Healthcare Associated Pneumonia

CAP - Community-Acquired Pneumonia

HAP - Hospital-Acquired Pneumonia

VAP - Ventilator-Acquired Pneumonia

RSV - Respiratory syncytial virus

SDGs-Sustainable Developmental Goals.

MDGs- Millennium Developmental Goals.Et al - And others

HIB -Haemophilus influenza type b

KNBS - Kenya National Bureau of Statistics

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OPERATIONAL DEFINITIONS
Pneumonia: An inflammatory condition of the lung affecting primarily the microscopic air sacs
known as alveoli.

Tachypnea: is a respiratory rate ≥ 60 breaths/minute.

Malnutrition: is the condition that develops when the body does not get the right amount of
vitamins, minerals, and other nutrients.

Vaccination: The administration of antigenic material to stimulate adaptively immunity to a

disease.

Nutrition status: The physiological state of an individual that results from the relationship
between nutrient intake and requirements and from the body’s ability to digest, absorb and use
these nutrients

Under -5 mortality: Refers to the death of infants and children under the age of five.

Under-fives: Children below the age of five years.

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1.0 CHAPTER ONE: INTRODUCTION

1.1 Background of information

Pneumonia is defined as an acute inflammation of the Lungs’ parenchymal structure. It can
be classified based on place of acquisition: as community acquired or hospital acquired;
based on its causative agents/ mechanism as bacterial, viral, fungal, Aspiration, or ventilator-
associated pneumonia; based on the anatomy of the lungs involved as lobar pneumonia,
bronchial pneumonia or acute interstitial pneumonia; and on the basis of its clinical severity
as “no pneumonia”, “pneumonia” or “severe pneumonia” (Gereige & Laufer, 2013). many
researches have been conducted to identify risk factors of pneumonia. Despite the
inconsistency of findings, low birth weight, malnutrition, indoor air pollution, parental
smoking, being unvaccinated, overcrowding, lack of separate kitchen, being not on exclusive
breast feeding, and maternal education were identified as factors associated with occurrence
of pneumonia in under-five children.

As stated in the World Health Organization report (2020), Pneumonia that develops outside
of a hospital is known as community-acquired pneumonia (CAP). Streptococcus
pneumoniae, Haemophilus influenzae, atypical bacteria (such as Chlamydia pneumoniae,
Mycoplasma pneumoniae, and Legionella species), and viruses are the most often found
pathogens. Fever, cough, sputum production, pleuritic chest discomfort, dyspnea, tachypnea,
and tachycardia are symptoms and indicators. The clinical presentation and chest x-ray are
used to make the diagnosis. Hospital-Acquired Pneumonia (HAP) on the other hand is
pneumonia that occurs 48 hours or more after admission, which was not incubating at the
time of admission. Ventilator-Acquired Pneumonia (VAP) arises more than 48 to 72 hours
after endotracheal intubation, and Healthcare Associated Pneumonia (HCAP) involves any
patient who was hospitalized in acute care hospital for two or more days.
Under-five children are more vulnerable to pneumonia and pneumonia remains the leading
cause of morbidity and mortality in those children. The World Health Organization (WHO)
has identified pneumonia as the leading cause of mortality among children under 5 years old
worldwide. Even though the global incidence of pneumonia among children and clinical

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pneumonia episodes have been found to have decreased by 30% and 22%, respectively,
pneumonia alone still accounted for 15% of all deaths in children under 5 years old (i.e.,
over 800,000 deaths) in 2017. However, this was most prevalent in sub-Saharan Africa and
Southern Asia. Furthermore, it remained the most common reason for hospitalization in sub-
Saharan Africa including Kenya.
According to a global estimate made in 2000, approximately 156 million cases of
pneumonia had occurred each year in under-five children, of which 151 million episodes
were in the developing countries and about 1.2 million of them were end up in death. South-
east Asia and Africa were the two continents with high magnitude of childhood pneumonia,
having an estimated of 61 million and 35 million annual cases of pneumonia in under-five
children respectively. The magnitude of under-five pneumonia was decreased to 120 million
(with 0.88 million deaths) in 2010 and to 102 million (with 0.7 million deaths) in 2015
globally. This decrement was due to decrease in the magnitude of its key risk factors,
increasing socioeconomic development and preventive interventions, improved access to
care, and quality of care in hospitals. Despite this progress, pneumonia is still a major public
health problem for children especially in developing countries, (Le Roux, & Zar., 2017).
Globally pneumonia is the leading cause of death among under-five children with more than
90% of these occurring in resource-limited settings. Implementation of feasible and effective
interventions has reduced under-five pneumonia death substantially from 13·6 per 1000
livebirths in 2000 to 6·6 per 1000 livebirths in 2015 yet, pneumonia ranked top in mortality.
Childhood death due to pneumonia occurs disproportionately in low-and middle-income
countries (LMICs) with the greatest number observed in South Asia and sub-Saharan
African countries. Compared to deaths due to other childhood diseases, pneumonia related
deaths are declining at a slower rate. Rudan et al. reported the incidence of clinical
pneumonia in under-five children was approximately 0.29 episodes per child-year in LMICs
of the world [6]. This means, every year 151.8 million incidences with 13.1 million (8.7%)
episodes progressing from pneumonia to severe pneumonia that require hospitalization
On the World Pneumonia Day on Nov 12, 2015, action was sought to improve the early
identification and treatment of childhood pneumonia at community and outpatient level to
reduce disease severity and deadly outcomes .It was apparent that the case–mortality rate in
untreated children with pneumonia is high, sometimes reaching as high as 20%, and deaths

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can occur as early as 3 days after illness onset .It was also found that duration of illness at
home for 3 days or more was significantly associated with the likelihood of disease
progression to severe pneumonia. The same observation was reported from Kenya .In the
study fever was significantly associated with severe pneumonia. Studies in diverse LMICs
like South Africa, Papua New Guinea, and Indonesia reported no association between fever
and pneumonia severity. However, one study in USA indicated temperature to be associated
with severe pneumonia (not defined by WHO classification) and another study reported
duration of fever (at day 6) was associated with severity Although WHO did not consider
fever in their pneumonia severity criteria, the British Thoracic Society (BTS) includes fever
in their guideline
Regionally, in East African countries different researchers had tried to investigate the
magnitude of pneumonia in under-five children and have reported a prevalence range from
5.5% up to 89.8%. They had also identified risk factors for pneumonia among under-five
children. But, reported finding lack consistency and as per the investigators knowledge there
is no a systematic review and meta-analysis conducted to address these inconsistent findings
reported from East African countries. Moreover, assessing the magnitude of pneumonia and
identifying its associated factors for risk-based diagnosis of pneumonia contribute in better
interventions and helps to reduce the higher burden of pneumonia in under-five children.
Hence, this systematic review and meta-analysis was conducted to assess the magnitude of
pneumonia and its associated factors among under-five children in East Africa.
Locally, Childhood pneumonia is the leading infectious cause of mortality in children
younger than 5 years old. Recent updates to World Health Organization pneumonia
guidelines recommend outpatient care for a population of children previously classified as
high risk. This revision has been challenged by policymakers in Africa, where mortality
related to pneumonia is higher than in other regions and often complicated by comorbidities.
(Tuti, et al 2017)

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1.2 Statement of problem

According to the UN Millennium Development Goals (MDGs), child health status is directly
related to the realization of Goal 1 (halve the proportion of people who suffer from hunger and
the proportion of underweight children under-five years of age years) and Goal 4 (reduce under-
fives mortality rate) and closely related to economic and social development. Adopting active
preventive measures will produce great economic and social benefits (Chunming, et al 2009)
and (Sachs, & McArthur, 2005).
Nevertheless, Kenya is one of the 42 countries that account for 90% of all under-fives deaths in
the world. Findings of the 2009 Kenya Demographic and Health Survey (KDHS) reveal that one
in every nine children born dies before age five, mainly of acute respiratory infection, diarrhea,
measles, malaria, and malnutrition (KNBS, 2009).
According to reports from the Central Bureau of Statistics and the National Coordinating Agency
for Population and Development (NCAPD) in Kenya, the infant mortality rate increased from
about 60 per 1,000 in 1990 to 74 in 1998 and 77 in 2003, while under-fives mortality continued
to increase from about 90 per 1,000 in 1990 to 112 in 1998 and 115 in 2003. This is a reversal in
trend after global initiatives to improve child health caused a decline in infant and child mortality
in Kenya in the 1970s and 1980s (NCAPD, 2017). (Krüger,et al 2017). However, the major
challenge in reduction of child mortality is the continued increase in mortality rates since the
1990s in all regions of the country (KNBS, 2009).
The occurrence and frequency of pneumonia is determined by pathogen and health care system
response factors, demographic and socio-economic factors such as income, level of education,
occupation, marital status, sex and age. Consequently, access to health care systems especially
intensive care and quality of care are also associated with occurrence of pneumonia. (Shi,et al
2015).
Recent studies on the risk factors for childhood pneumonia have found out that the frequency,
age-profile and severity of pneumonia is affected by environmental and social factors such as
parental smoking, nutritional status, socio-economic factors, number of siblings under-five in the
household, immunization status and overcrowding. Delays in diagnosing and treating pneumonia
in children aged (Andronikou,2016). This study is aimed at investigating the factors that lead to
the occurrence of pneumonia among children under 5 years at MCRH in a pediatric ward.

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According to the Murang’a County Referral Hospital. Annual Reports of the previous three
consecutive years (2019=436 total cases, 2020=665 total cases, and 2021=862 total cases),
pneumonia is among the top ten diseases with a 3.9 % in the county. Therefore, having
pneumonia being ranked among the top ten diseases, there is a need to investigate the disease
and know the factors that contribute to it hence dealing with the gap.

1.3 Justification of study

Reports in the Murang’a County Referral Hospital. indicates that for the last three successive
years (2019 =436,2020=665 and 2021=862 total pneumonia cases respectively) (according to
Murang’a County Referral Hospital. demographic report) pneumonia have been ranked top five
among the top ten diseases in the district. Therefore, suggests that there may be some underlying
factors contributing to pneumonia among children under-five years.
This study is significant for the following reasons;
Pneumonia is more prevalent to children under one year of age and still a health problem among
children up to 5 years of age hence contributing to high rates of under-five mortality. The cost of
managing the complications of pneumonia leads to an enormous burden and pain to parents,
community and the Government. Under-five children are more vulnerable to pneumonia
especially CAP because of their intrinsic susceptibility to infections as well as the environment
into which they are subjected to. It’s essential to investigate the factors associated with
pneumonia in under-five children to reduce the burden by planning for effective strategies such
as early diagnosing and treatment thus continuous surveillance is of importance.
This study will guide and help the health care workers in identifying the contributing factors
associated with pneumonia in under-five children, design appropriate strategies and guidelines to
tackle the problem, and reduce its morbidity and mortality rate. It will also help the health policy
workers to plan programs to create awareness as well as provide treatment guidelines. The fourth
Millennium Development Goal (MDG 4) aims to improve the health of children, which is a
critical measure of a country’s level of development, apart from it being a fundamental right
(Sachs & McArthur, 2005). This goal has two important indicators that are used to measure
improvement in child health; infant and under-five mortality. While major progress has been
made in reducing infant and child mortality rates, one in every 19 babies born in Kenya will die
before their first birthday (NCAPD, 2011). This study is in line with Sustainable Development
Goals (SDGs) that aim at ensuring healthy lives and promotion of wellbeing for all ages
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1.4.0 OBJECTIVES

1.4.1 Broad objective

To investigate determining factors contributing to the occurrence of pneumonia among children
under 5 years at Murang’a County Referral Hospital.

1.4.2 Specific objectives

1. To determine prevalence of pneumonia among children under 5 years at Murang’a
County Referral Hospital.
2. To determine socio-demographic factors associated with pneumonia among under-five
children at Murang’a County Referral Hospital.
3. To assess the nutritional status of children in relation to pneumonia among the under-five
children at Murang’a County Referral Hospital.

1.4.3 Research question

1. What is the prevalence of pneumonia among children under 5 years at Murang’a County
Referral Hospital?
2. What is socio-demographic factors associated with pneumonia among children under-five
years at Murang’a County Referral Hospital?
3. What is the nutritional status of children in relation to pneumonia among children under
the age of 5 years at Murang’a County Referral Hospital?

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1.5 Significance of the study

The finding that will be established from the research study will enhance the understanding on
the factors contributing to the prevalence of pneumonia under the age of 5 years old in Murang’a
County Referral Hospital. , Muranga and in the Kenyan context at large. The information
generated from this study will be used by policy makers to guide health promotion, in the
adoption of legislation and utilization of appropriate tools to increase knowledge and change
misconceptions as well solution development in curbing determinants that negatively influence
the practice of preventing pneumonia in under 5 years old. Thus, the information emanating from
this study will be valuable for reasons that appropriate educational strategies and initiative
development to enhance the practice of preventing pneumonia in children under the age of 5
years old. The research is also part of my requirements to attain a Bachelors of Science in
Nursing Degree.

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CHAPTER 2: LITERATURE REVIEW

2.0 An overview of pneumonia

Pneumonia is the most common cause of death in children under the age of five, and there are a
few things that can make it more likely for them to get it while they're in a pediatric ward.
Pneumonia in children under the age of five can be exacerbated by cramped quarters, cooking
and heating with solid fuels indoors, and poor living conditions. Influential variables in nutrition:
A child's immune system can become weakened by malnutrition and micronutrient deficiencies,
such as a deficiency in vitamin A, making them more susceptible to pneumonia. Immunological
factors: Pneumonia is more likely to strike children with weakened immune systems, such as
those with HIV/AIDS or other chronic illnesses. infants whose mothers contracted pneumonia or
another respiratory infection while they were pregnant. Pneumonia is an infection-induced acute
inflammation of the lungs (pneumonitis). Bacterial, mycobacterial, viral, fungal, or parasitic
infections are all possible. Microbes enter the airways on a regular basis, but many factors
prevent colonization, including mucous entrapment, ciliary clearance, immune surveillance, and
an intact epithelial barrier. Surfactant proteins (SP-a, SP-d), and defensins are examples of
secreted factors. Microbes can colonize the lungs if these defense mechanisms are disrupted or
overwhelmed, resulting in pneumonia.

The four phases of Pneumonia

Phase 1: Congestion: This usually happens within the first 24 hours of having pneumonia.
Patients will have vascular engorgement, intra-alveolar fluid, and a variety of bacteria. The lungs
will be heavy and bloodshot. Capillaries in the alveolar walls constrict, allowing the infection to
spread to the hilum and pleura. A person will cough and breathe deeply during this stage (Jain et
al., 2020).

Phase 2: Red hepatization: This happens a few days after congestion; the lungs become red, firm,
and airless, resembling the liver. Blood engorges alveolar capillaries, causing vascular
congestion to persist. The alveoli become densely packed with erythrocytes, neutrophils,
desquamated epithelial cells, and fibrin during the red hepatization stage.

Phase 3: Gray hepatization: After red hepatization, late consolidation happens 2 to 3 days later
and lasts for 4 to 8 days. Due to hemosiderin, red blood cells' progressive disintegration, and

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fibrinopurulent exudate, the red cells have been broken down and appear gray with a consistency
resembling liver. The macrophages start to show up.

Phase 4: Resolution: By the eighth day, the pulmonary architecture has begun to resolve and
recover. The former solid fibrinous content is liquefied by the enzymatic action, which starts in
the center and spreads outward to restore aeration. The majority of cells that contain debris and
engulfed neutrophils are macrophages. (Pahal et al., 2020)

2.0 The prevalence of pneumonia among children under 5 years

One of the main causes of death for children under the age of five and a significant global health
concern is pneumonia. The World Health Organization (WHO) estimates that pneumonia causes
15% of all pediatric fatalities globally, making it the leading infectious cause of child mortality.
Globally, an estimated 1.9 million children under the age of 5 died of pneumonia in 2019, with
sub-Saharan Africa and South Asia having the highest rates of the illness. The high prevalence
and mortality rates of pneumonia in these areas are caused by a number of factors, including
undernourishment, limited access to healthcare, and environmental elements like indoor air
pollution and unsanitary living conditions.

According to a study on the prevalence and risk factors for pneumonia in children under the age
of five in urban India, routine immunization with two doses of the measles vaccine,
immunization with three doses of the pentavalent vaccine, and booster doses of the DPT vaccine
during childhood can all help prevent the development of pneumonia. Complete vaccination
status is a marker for greater access to health care services and better child care practices, so
pneumonia incidence has been found to be lower in children who have received all of their
recommended vaccinations for their age group. According to studies done in Nigeria, 50% of
children who had received insufficient immunizations also experienced a severe case of ARI,
such as pneumonia.

To determine the prevalence of pneumonia and its contributing factors among children under the
age of five in East Africa, a thorough review and meta-analysis were conducted. The final
analysis included 34 studies in total. According to 22 studies, the prevalence of pneumonia in
children under the age of five was reported to be 34%, with a 95% confidence interval of (23.8-

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44.21%). Due to the less developed state of the economies in East Africa, this may be the result
of socioeconomic and seasonal variations.

According to a study done in Nigeria, pneumonia was prevalent in children under five at a rate
of 31.6%, which was consistent with the results of this systematic review (Ujunwa & Ezeonu,
2014). Given that Nigeria is an African nation with likely comparable socioeconomic conditions,
this consistency may be attributable to similarity in socioeconomic standing.

In Kenya, a retrospective cohort study on the risk factors for death among children aged 5-14
years hospitalized with pneumonia discovered that 832 children were diagnosed with pneumonia,
with 145 (7.9%) dying. Lower consciousness, mild/moderate pallor, central cyanosis, and older
age (>9 years) were all strongly associated with mortality. HIV infection and severe acute
malnutrition were also linked to death.

2.1 Socio-demographic factors associated with pneumonia

Brazil is a large country with populations from various regions that differ in terms of
socioeconomic status and culture. The fact that children in poverty and children whose
socioeconomic status is compatible with the family of highly developed regions coexist in the
same state shows that there is still a significant economic inequality problem. According to a
Brazilian study, pneumonia mortality was particularly high in rural areas due to the accessibility
issues with healthcare. There is proof that low socioeconomic status and pneumonia are causally
related, with children from less privileged backgrounds experiencing CAP episodes more
frequently. According to the results of the study, families with incomes below the minimum
wage were more likely to have a member hospitalized for pneumonia.

An investigation into the prevalence of pneumonia in urban India found Most often, wood or
dried animal dung are used as fuel in urban poor communities. The children are exposed to
indoor air pollution because cooking and living are frequently done in the same room, which
frequently causes ARI and pneumonia. There is evidence that using unprocessed solid fuel
increases the risk of pneumonia by a factor of 1.8. There is also a strong correlation between ARI
and indoor air pollution. The study found a significant link between pneumonia and indoor air
pollution. It has been suggested that better fuel, better ventilation, or some other method be used

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to prevent indoor air pollution caused by solid fuel combustion and will lower the mortality and
morbidity from pneumonia.

Pneumonia was the most common reason for hospital admission in Bamako, the capital of Mali,
accounting for 18% of all hospital admissions. Acute respiratory infections account for 34% of
pediatric admissions and 15% of pediatric hospitalizations at Gabriel Touré Teaching Hospital,
the national model facility. In our series, infants under 1year olds made up 60% of those with
severe forms of pneumonia. Their findings were comparable to those of Ouédraogo et al. in
Burkina Faso and Ibraheem et al. in Nigeria, where the group aged 0 to 2 years old represented,
respectively, 79.9% and 81.3%. Due to the immaturity of their immune and respiratory systems,
infants are especially vulnerable. Additionally, during this time, food diversity and breastfeeding
decline start. It also highlights the importance of protective immunoglobulin in breast milk .

The majority of patients had unfavorable living conditions and mothers who were frequently
uneducated or illiterate. A study conducted in the Congo found a direct correlation between the
mother's education level and the infant mortality rate. A child whose mother has no education
has a 1.5 times greater chance of dying before the age of 5 than a mother with at least a
secondary education. Jroundi and Demers point out that there is no connection between
sociodemographic factors and mortality.

Risk factors for community-acquired pneumonia in Kenya, according to a case-control study

conducted there: Low social economic status (SES), as determined by income level and
indirectly by proxy indicators like the materials used in home construction, was not linked to
pneumonia, according to Muthumbi et.al, (2017). Although there is limited evidence for adults,
indoor air pollution is a major risk factor for respiratory illnesses, including pneumonia, in
children. This study found no evidence that breathing in air pollution—including that from
biomass fuels—raises the risk of developing pneumonia. To determine exposure to air pollution,
this study, however, relied on questionnaire techniques, which is likely to have admitted
significant misclassification. To calculate the significance of this risk factor, more precise air
quality measurements would be helpful.

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2.2 The nutritional status of children in relation to pneumonia among the under-five
children
In the world, pneumonia is the leading cause of morbidity and mortality in children under the age
of five. Malnutrition has been found to significantly increase the risk of developing pneumonia
and can also make the condition more difficult to treat. According to a review of the literature,
malnutrition increases the risk of pneumonia by lowering immune response, which can result in
respiratory tract infections. Additionally, by delaying recovery and raising the risk of
complications like sepsis, respiratory failure, and death, malnutrition worsens the course of
pneumonia.

Pneumonia among children under the age of five has been linked to malnutrition, according to
several studies. According to Brhanu et.al, (2017), Malnourished children were found to have a
six-fold higher risk of developing pneumonia than adequately fed children in a Nigerian study.
Children with severe acute malnutrition had a 6.3-fold higher risk of developing pneumonia than
those with normal nutritional status, according to another study conducted in India. In a similar
vein, a study conducted in Bangladesh discovered that malnourished kids were more likely than
well-fed kids to develop severe pneumonia.

An essential tactic for lowering the prevalence of pneumonia is to improve the nutritional status
of children under the age of five. The risk of developing pneumonia can be decreased and the
immune system can be strengthened with adequate nutrition. The clinical outcome of pneumonia
can also be improved, and the risk of complications can be decreased, with adequate nutrition. It
has been demonstrated that a number of interventions, such as the encouragement of exclusive
breastfeeding, the provision of suitable complementary foods, and the treatment of acute
malnutrition, are effective in enhancing the nutritional status of young children and lowering the
incidence of pneumonia.

It was discovered that pre-lacteal feeding was not significantly associated with the occurrence of
pneumonia in a study on the prevalence and risk factors of pneumonia conducted in the Indian
town of Dibrugarh (Beletew et.al., 2020). In their study, K Hemagiri et al. found a significant
correlation between pre-lacteal feeding and pediatric pneumonia. The age at which
complementary feeding began may also be linked to the development of pneumonia. When

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feeding was initiated at 4 months, the incidence was 21.3%; at 6 months, it was 13.7%; and at 6+
months, it was 30.7%. Their research revealed a statistical link between timely complementary
feeding and the development of pneumonia.

Pneumonia is most frequently seen in its invasive form in tropical regions with high rates of
malaria and other chronic diseases (such as malnutrition, anemia, and HIV infection) that are
also very prevalent. In 47.61% of patients, there was severe malnutrition present. According to
Tatu et.al, (2017), it provides an ideal environment for the development of severe forms of
pneumonia. Malnourished children have a three times higher relative risk of pneumonia than
children who are properly fed, necessitating nutritional support and routine education of mothers
during immunization sessions. The WHO's recommendation for the practice of exclusive
breastfeeding for up to 6 months is therefore strengthened by the protective role of breastfeeding
that has already been reported.

Ten studies that looked into the connection between nutritional status and pneumonia among
young children in Kenya under the age of five were found by the literature review. There were
10,564 kids involved in all of the cross-sectional studies. The percentage of children who were
malnourished ranged from 19.8% to 45.7%. Pneumonia prevalence ranged from 2.8% to 28.1%.
In Kenyan children under the age of five, malnutrition was consistently linked to pneumonia in
the studies. When compared to children who were adequately fed, the odds ratio (OR) for
pneumonia in malnourished children ranged from 2.3 to 6.3.

According to the results of this literature review, pneumonia among children under the age of
five in Kenya is significantly increased by malnutrition. Compared to children who are well-
nourished, children who are malnourished have a higher risk of developing pneumonia.
Malnutrition and pneumonia have a complicated and multifaceted relationship. Children who are
underweight have weakened immune systems, making them more vulnerable to illnesses like
pneumonia.

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2.3 Summary of the gaps identified

After a detailed literature review, it’s evident that most of the researches previously did are on
the prevalence of pneumonia in children under the age of 5. Others researched the risk factors
that increase the death of children under the age of 5 who are hospitalized with pneumonia and
finally the others have focused on the immunological and socio demographic factors that
increases the risk of community acquired pneumonia. There is no previous research that has been
done on the determinants of pneumonia occurrence among children five years and below in
pediatric ward at Murang’a county referral hospital.

2.5 THEORETICAL FRAMEWORK

Pneumonia is a respiratory infection that affects the lungs, causing inflammation and impaired
oxygen exchange. Among children under five years old, pneumonia is a significant public health
concern due to its high prevalence and potential for severe outcomes (WHO 2020). An
epidemiological model can help us understand the various factors that contribute to the
occurrence, spread, and outcomes of pneumonia in this age group. The following are
Components of the Epidemiological Model: Incidence: This is the number of new cases of
pneumonia occurring within a specific time frame and population. Incidence in children under
five is influenced by factors like exposure to pathogens, immunity levels, and living conditions.
According to Brhanu et.al, (2017), children below five years were found to have a six-fold higher
risk of developing pneumonia than older children, this high incidence maybe attributed to
immature immune system. The second component of the model is Prevalence: which is The
proportion of individuals within a population who have pneumonia at a given point in time.
Pneumonia prevalence in this age group is affected by factors such as disease duration, recovery
rates, and ongoing transmission According to a study done in Nigeria, pneumonia was prevalent
in children under five at a rate of 31.6%, which was consistent with the results of this systematic
review (Ujunwa & Ezeonu, 2014). Given that Nigeria is an African nation with likely
comparable socioeconomic conditions, this consistency may be attributable to similarity in
socioeconomic standing. The third component of this model is Mortality which is the number of
deaths attributed to pneumonia within a specific population. Mortality rates among children

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under five can be influenced by factors like disease severity, access to healthcare, and nutritional
status. Lastly Recovery which is the rate at which individuals with pneumonia successfully
overcome the infection. Recovery is influenced by the effectiveness of medical interventions,
immune responses, and overall health status.

The model also highlights Factors Influencing Pneumonia Occurrence to include; Biological
Factors: Children under five are particularly vulnerable due to their developing immune systems
and smaller airways. Infants and young children have less effective defense mechanisms against
pneumonia-causing pathogens. Environmental Factors: Overcrowded living conditions, indoor
air pollution (from sources like cooking fires), exposure to secondhand smoke, and lack of clean
water and sanitation contribute to increased pneumonia risk. Pathogens and Transmission:
Viruses (e.g., respiratory syncytial virus) and bacteria (e.g., Streptococcus pneumoniae) are
common pathogens causing pneumonia. Crowded environments facilitate transmission.

On Prevention and Control it recommend Vaccination: Immunization against pneumonia-causing

pathogens (e.g., pneumococcal and Hib vaccines) significantly reduces the incidence of severe
cases. Hygiene and Nutrition: Proper hygiene practices and good nutrition can enhance immunity
and reduce pneumonia risk and lastly Health Education: Educating caregivers about pneumonia
symptoms, care-seeking, and prevention measures can lead to earlier diagnosis and better
outcomes. In summary the epidemiological model provides a comprehensive framework for
understanding pneumonia in children under five. It emphasizes the interplay between incidence,
prevalence, mortality, recovery, and various influencing factors. By addressing biological,
environmental, and healthcare-related aspects, we can work towards reducing the burden of
pneumonia in this vulnerable population.

Another model adopted here is The Health Belief Model suggests that people's health-related
behaviors are influenced by their perceived susceptibility, severity, benefits, barriers, and cues to
action. When it comes to pneumonia, individuals who believe they are susceptible to the illness
(due to factors like age, weakened immune system, or exposure to risk factors) and perceive its
severity may be more likely to take preventive actions. These actions could include getting
vaccinated, practicing good hygiene, and seeking medical care promptly if symptoms arise.
However, if people perceive barriers like cost, inconvenience, or misinformation, they might be

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less likely to take preventive measures. Effective communication and education about the
seriousness of pneumonia, the benefits of prevention, and the accessibility of healthcare services
can serve as cues to action, encouraging individuals to adopt health-protective behavior

2.4 Conceptual framework.

The conceptual framework below demonstrates various interactions between the variables that
have been identified. The occurrence of pneumonia among children less than 5 years is the
dependent variable. Socio-demographic factors, nutritional factors, immune system of the child
are independent variables that have an impact on the occurrence of pneumonia in children less
than 5 years in Murang’a county referral hospital.

Independent Variable Dependent Variable Outcome Variable

The prevalence of pneumonia in

children under the age of 5 years
REDUCTION IN
THE CASES OF
CHILDREN
OCCURRENCE ACQUIRING
OF PNEUMONIA PNEUMONIA
Social-demographic factors IN CHILDREN
LESS THAN 5
 Living conditions
YEARS
 Education level
 Level of income
 Use of solid fuel

Nutritional Factors
 Exclusive breastfeeding
 Immunoglobulin
 Malnutrition

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Figure 1 conceptual framework

CHAPTER THREE
3.1 Study design
The research was a quantitative descriptive cross-sectional study. Carried out among mothers
and guardians of children below five years admitted in paediatric ward of Murang’a County
Referral Hospital. findings. Quantitative data will be collected using questionnaire to key
informants, which will give respondent time to open up and share more.

3.2 Study Area

Quantitative cross sectional study design was carried out in a paediatric ward of Murang’a
County Referral Hospital. The Murang’a County Referral Hospital was established in 1973 and it
is a teaching and referral hospital with both inpatient and outpatient Services including
maternity, medical and surgical, paediatrics, critical care among others

3.3 Study Population

The researcher targeted both children and mothers or guardians of all children of five years and
below at paediatric ward at Murang’a County Referral Hospital. In a monthly basis, 110 babies
are admitted in a paediatric ward because of pneumonia as per patient's hospital card after being
triaged and reviewed by the physician. A minimum of 50 mothers or guardians were involved in
the study.

3.3.1 Inclusion criteria

Mothers or guardians of children who were 0-5 years attending paediatric ward and those who
consented for the study.

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3.3.2 Exclusion criteria

All mothers and guardians of children above 5 years attending paediatric ward and those who
were not willing to give consent to the research study.

3.4. 0 Sample Size

Sample size involved all mothers and guardians of children under five years and all children
under five years at paediatric ward at Murang'a County referral hospital. Census method was
used to obtain at least 99% of all mothers and guardians with children below five years in
paediatric ward within one month of data collection.

3.4.1 STUDY VARIABLES

Independent variables
Sociodemographic factors include characteristics of the population such as age, level of
education, occupation, marital status. All of these will be used to assess the respondents during
study period to know their characteristics. Immunization factors comprises of different vaccines
as per immunization schedule of Kenya such as pneumococcal vaccine, pentavalent , BCG.They
help to prevent mortality and suffering associated with infectious disease such as pneumonia,
tuberculosis, diphtheria Nutritional status help to measure nutritional imbalance by use of the
following indicators such as stunting and wasting to rule out malnutrition and undernutrition.
Weight for age will be used to assess nutritional status.

Dependent variable was either presence or absence of pneumonia as a result of various factors.

3.5 Sample technique

Convinient sampling method was used; only the mothers and guardians of children of five years
and below in the pediatric ward, at Murang’a County Referral Hospital during data collection
period.

The patient Upon findings that they

Patient The patient
is triaged by have pneumonia the
arrives in is seen by
the triage are admitted to the
hospital the doctor
nurse ward

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Patient is selected
Eligible client using a criteria , if
interviewed Consent they meet it they
and recorded are selected

Figure 2 patient flow MCRH

3.6 Collection of Data.

A semi-structured questionnaire was used to collect data on factors contributing to pneumonia
among children under five years. Quantitative and qualitative data was collected using an
interviewer guided structured questionnaire with both closed ended and open-ended questions to
key informants, which gave respondent time to open up and share more. The tool was designed
focusing on the specific objectives of the research study which enabled the person doing the
research to get accurate information for the respondents. Selection of tool was guided by the
descriptive nature of the data to be collected. The time for administration of the questionnaire
which was researcher administered took15 to 20 minutes per client, which had different sections

3.7 Pretesting Data Collection Tools

A small-scale preliminary study was conducted to test whether the questionnaire is valid. The
pre-testing was carried out in Maragua sub county hospital. The purpose was to identify any
errors in the questionnaire and correct them before data collection period.

Structured and semi structured questionnaires was administered to the participants. The tool was
designed based on the specific objectives of the study which further enabled the researcher to get
accurate information for the respondents and to rectify errors from the questionnaire.

3.8 Analysis of Data

Data collected was analysed using SPSS version 26.0 and Excel 2019. Descriptive statistics and
chi-square test at 95% confidence intervals were computed to determine association between
independent and dependent variables. Data collected was later presented in charts, percentages
and frequency tables for interpretation purposes. Discussion, conclusion and recommendation
were based on the results obtained.
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OBJECTIVES DATA TO BE COLLECTED SOURCE OF DATA ANALYSIS

DATA PLAN
To determine prevalence of Mothers and Frequency, charts and
pneumonia among children under gurdians percentages
1 5 years at MCRH. whose children
have
pneumonia and
are five years
and below
To determine socio-demographic Mothers and Frequency, charts and
factors associated with pneumonia gurdians percentages
2 among under-five children at whose children
MCRH have
pneumonia and
are of five
years and
below
To assess the nutritional status of Mothers and Frequency, charts and
children in relation to pneumonia gurdians percentages
3 among the under-five children at whose children
MCRH. have
pneumonia and
are five years
and below

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Table 1 Data collection flow as per objective

3.9 Study Limitations

During the research period, I encountered some shortcomings which included; financial
instability and some clients not willing to share some information. Language barrier was
problem because some of the clients only communicated using their mother tongue. The study
was time consuming since the clients took more than 15 to 20 mins to respond to the
questionnaire.

3.10 Ethical consideration

Ethical approval for conducting this study was be sought from Karatina Research and Ethics
Committee. The researcher also sought approval from the Murang’a County Referral Hospital
administration to carry out the study at the hospital. Permission was sought by the researcher
from the Nurse-In-Charge of paediatric unit while for the study participants, informed written
consents was sought individually. A detailed and precise explanation of the purpose of the study
was given to the mothers or guardians to children suffering from pneumonia and only those who
have signed an informed consent were interviewed. The respondents’ anonymity and
confidentiality was guaranteed and maintained throughout the study period since no form of
identification was integrated during the process of data collection.

3.11 Dissemination of the Study

Study findings were disseminated via presentation in seminaries, workshops, conferences as well
as the publication of the work. Moreover, a copy of the study was submitted to the study area for
local interventions related to factors contributing to pneumonia among under-five children and
control for future study.

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CHAPTER FOUR

RESULTS

4 Introduction
This chapter shows the analysis of the study findings whereby one hundred (100) mothers and
children were recruited in the study. It includes result of socio-demographic characteristic of the
respondents (mothers and children under five), immunization and breast feeding history of the
child and environmental factors surrounding the children under five years of age. The results
were presented in form of tables and charts.

4.0 Response rate

The study had a target sample size of 100 respondents out of whom 100 respondents had their
questionnaires completely answered and submitted on time and analyzed hence the response rate

Chart Title

NOT RESPONDED 0

RESPONDED 100

10 30 50 70 90 110
RESPONDED NOT RESPONDED
Series1 100 0
was 100%.
Figure 3 Response rate of respondents

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4.1 Socio-demographic characteristics of the mothers

Of the participants (48.0% n=48) were aged 26-35 years. Majority, (64.7 % n=65) were married.
Majority, (81.3% n=81) were Christians, most of the participants (49.3% n=49) had secondary
level of education and (42.7% n=42) were self-employed. This information is shown in table 1
below.

Table 2 Socio-demographic characteristics of the mothers

Variables N Percentage (%)

Age in years
15-25 45 44.7
26-35 48 48.0
36-45 7 7.3
Total 100 100.0
Marital status
Single 28 28.0
Married 65 64.7
divorced 4 4.0
widowed 3 3.3
Total 100 100.0
Occupation status
self employed 42 42.7
Government /private employed 14 14.0
House wife 36 34.7
Student 9 8.7
Total 100 100.0
Religion
Christian 81 81.3
Muslim 14 14.7
Others 6 4.0
Total 100 100.0
Education level

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None 2 1.3
Primary 19 18.7
Secondary 49 49.3
Tertiary 30 30.7
Total 100 100.0

4.2. Social demographic Characteristics of the child

Of the children whose mothers were interviewed, majority (61.0% n=61) were of female gender,
from urban region (65%n=65), most (33.0% n=33) being 7-12 months of age. As shown by table
2 below.
Table 3 Social demographic Characteristics of the child

Variables N Percentage (%)

Gender of the child
Male 39 39.0
Female 61 61.0
Total 100 100.0
Age in the child
0-6 months 29 29
7-12moonths 33 33
1-2 years 17 17
3-5 years 21 21
Total 100 100.0
Geographical area
Rural 35 35
Urban 65 65
Total 1000 100

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4.3 Breastfeeding History of the child

Among the children included in the study population, majority 72% n=72) were exclusively
breastfed as shown by figure1 below.

75 72
65
55
45
35 28
25
15
5
6 months less than 6 months
Series1 72 28

Figure 4 B feeding hx

4.4 Immunization history of the child

Majority (72%n=72) of the children were fully immunized as required by Kenya expanded
immunization program this information is displayed by figure 2 below.

85

85
75
65
55
45
35 15
25
15
5
fully immunized Not fully immunized
Series1 85 15

Figure 5 Immunization history of the child

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4.5 .Prevalence of pneumonia among children under five in Murang’a county Referral
Hospital
The prevalence of pneumonia among children under five in Murang’a county Referral Hospital
was found to be 68% as shown by figure 4 below.

Figure 6 Prevalence of pneumonia among children under five in Murang’a county Referral
Hospital

32; 32%

68; 68%

pneumonia yes no

Table 4 Frequency of pneumonia attack among children under five

Frequency Percent
once 18 26.5
two-three times 26 38.2
at least once every year 19 27.9
more than once every year 5 7.4
Total 68 100

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4.6. Environmental factors surrounding the child

Environmental factors surrounding the child such as smoking habit among the residents and the
source of fuel were as assessed and it was found that at least some (35% n=355) of the children
came from the family whose parents were smoking and most (50%n=50) uses firewood /charcoal
as the source of fuel as shown by the table below
Environmental factors surrounding the child
Variables N Percentage (%)
any one smoking at home
YES 35 35
NO 65 65
Total 100 100
source of fuel your using
fire wood/ charcoal 50 50
electricity 10 10
stove 21 21
cooking gas 19 19
Total 100 100
Table 5 Environmental factors surrounding the child

4.7 Social demographics characteristics of the child associated with pneumonia cases
When the social demographic characteristic of the child was associated with the prevalence of
pneumonia the study found that gender and age of the child have a high significant association
with the chi square and P values of (X=5.80,df=1,P=0.006) , (X=5.258,df=3,P=0.0154))
respectively. However geographical location the child had no significant association as shown by
the table below.

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Table 6 Social demographics characteristics of the child associated with pneumonia cases

PNEMONIA CASE (n, %)

variables Attacked by Not attacked Total Chi- df p-value
pneumonia by square
pneumonia (X2)
Gender
Male 32(82.0 ) 7( 18.0) 39(100) 5.801 1 0.016
Female 36( 59.0) 25(41.0 ) 61(100)
Total 68(68.0 ) 32( 32.0) 100(100)
Age
0-6 months 17( 58.6) 12(41.4 ) 29(100) 5.258 3 0.0154
7-12months 27(81.8 ) 6(18.2 ) 33(100)
1-2 years 12(70.5 ) 5( 29.5) 17(100)
3-5 years 12(57.1 ) 9(422.9 ) 21(100)
Total 68(68 ) 32(32 ) 100(100)
Geographical
location
Rural 30(85.7 ) 5(14.3 ) 35(100) 7.765 1 0.075
Urban 38(58.6 ) 27(41.4 ) 65(100)
Total 68(68 ) 32( 32) 100(100)

4.8 Childs breastfeeding and immunization history associated with pneumonia cases
Children who were not fully immunized and exclusively breastfed were at high chances of
developing pneumonia in their cause of life as compared to those who fully immunized and
exclusively breastfed and hence the study demonstrated a strong statistical association between
immunization and breastfeeding history and pneumonia cases as evidenced with the chi- square
and p values(X=5.358, df=1,P=0.005) , (X=3.587,df=3,P=0.046) respectively.
Table 7 Childs breastfeeding and immunization history associated with pneumonia cases

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PNEMONIA CASE (n, %)

variables Attacked by Not attacked Total Chi- df p-
pneumonia by square value
pneumonia (X2)
Immunization Hx
Fully immunized 11(39.2 ) 28(71.8 ) 39(100) 5.358 1 0.005
Not-fully 57(93.4 ) 4( 6.6) 61(100)
immunized
Total 68(68 ) 32(32 ) 100(100)
Breastfeeding Hx
Exclusively 18(43.9 ) 23(556.1 ) 41(100) 3.587 1 0.046
breastfed
Not exclusively 50(84.7 ) 915.2 ) 59(100)
breastfed
Total 68( 68) 32(32 ) 100(100)

4.9 Childs Environmental factors associated with pneumonia cases

Environmental factors surrounding the child such as smoking habit among the households and
the source of fuel were as associated with the pneumonia cases, it was found that none of the
factors had significant association. This is shown by the table 5 below.
Table 8 Childs Environmental factors associated with pneumonia

PNEMONIA CASE (n, %)

variables Attacked by Not attacked Total Chi- df p-
pneumonia by square value
pneumonia (X2)
Environmental
factors

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Someone smoking 21(60.0 ) 14( 40.0) 35(100) 1.584 1 0.208

at home
No body smoking 47(72.3 ) 18(27.7 ) 65(100)
at home
Total 68( 68) 32( 32) 100(100)
Source of fuel at
home
fire wood/ 31(62.0 ) 19( 38.0) 50(100) 6.613 3 0.085
charcoal
electricity 7(70.0 ) 3( 30.0) 10(100)
stove 19(90.4 ) 2( 9.6) 21(100)
cooking gas 11(57.9) 8(42.1 ) 19(100)
Total 68(68) 32(32 ) 100(100)

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CHAPTER FIVE

DISCUSSION

5.1 Relationship between social-demographic characteristics and pneumonia.

Of the participants, (48.0% n=48) were aged 26-35 years. Majority, (64.7 % n=65) were married.
Majority, (81.3% n=81) were Christians, most of the participants (49.3%, n=49) had secondary
level of education and (42.7%, n=42) were self-employed. Of the children whose mothers were
interviewed, majority (61.0%, n=61) were of female gender, (65%, n=65) were from urban
region and most (33.0%, n=33) were 7-12 months of age.

When social demographic characteristics of the respondents were associated with pneumonia, the
study found gender and age were statistically significant with chi- square and P-values of (X2=
0.016, df =1, P=5.801) and (X2 =0.0154, df=3, P= 5.258) respectively.

The study showed that children between the ages of 7-12 months were more likely (81.8%,
n=27) to get pneumonia compared to those aged below 7 months and above 12 months and the
association was highly significant. This could be attributed to their weak immunity and frequent
first contact with the general population apart from the child’s parents and caregivers. This is in
line with a study done in the USA on pediatric pneumonia which showed that infants below 12
months were at high risk of acquiring clinical pneumonia compared to those aged above 1 year
old. (Muhammad et al., 2020)

There was a significant statistical association between gender and pneumonia with chi- square
and P-values of (X2= 0.016, df =1, P=5.801). The number of males (82.0%) who got pneumonia
was higher than the number of females (59.0%).This could be based on the recent studies that
suggest that males are more likely to develop community acquired and nosocomial bacterial
infections compared to females. This is in line with a study done at the university of Alabama,

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USA on gender as a major factor in determining the severity of respiratory diseases. (Anthony,
2018)

Children born in rural areas were more likely to acquire pneumonia compare to those born in
urban areas. This could be due to poor access to health facilities and inadequate healthcare
personnel in the rural areas compared to urban areas. However, the association was not
significant. This contradicts a study done at Gondha University Hospital, Ethiopia, which
suggested that children born in both rural and urban areas were at risk of acquiring pneumonia
regardless of their geographical location.

5.2 Relationship between nutritional status and pneumonia.

Among the children included in the study population, majority (72% n=72) were exclusively
breastfed and majority (72%n=72) of the children were fully immunized as required by Kenya
expanded immunization program.

Children who were not fully immunized were at high chances of developing pneumonia in their
cause of life as compared to those who were fully immunized. The association was highly
significant with chi- square and p values of (X=5.358, df=1, P=0.005). This could be attributed
to the boosted immunity from the pneumococcal vaccines that are administered during
childhood. This is in line with reports from the World Health Organization on Vaccines to
prevent pneumonia and improve childhood survival. (Shabir et.al, 2020)

Similarly, children who were not exclusively breastfed were at high chances of developing
pneumonia in their cause of life as compared to those who were exclusively breastfed and hence
the study demonstrated a strong statistical association between breastfeeding history and
pneumonia cases as evidenced with the chi- square and p values of (X=3.587,df=3,P=0.046).
This could be associated with the fact that breastfeeding is always known to provide every aspect
of food nutrient required in children hence a boost in their immune status. This is in agreement
with a meta-analysis done in Europe on the merits of breastfeeding for reducing the risk of
pneumonia morbidity and mortality in children under two. (Laura, 2013)

5.3 Relationship between environmental factors and pneumonia.

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Environmental factors surrounding the child such as smoking habit among the residents and the
source of fuel were as assessed and it was found that at least some (35% n=35) of the children
came from the family whose parents were smoking and most (50%,n=50) uses firewood
/charcoal as the source of fuel.

It was however noted that there was no significant association between the environmental factors
surrounding the child such as smoking habit among the households and the source of fuel, and
pneumonia. Despite this, it was noted that in most households where stove was used as the
source of fuel, the child had higher chances (90.4%) of acquiring pneumonia. This could be due
to the fact that the carbon gases produced by stove especially in areas with poor ventilation is
hard to be broken down by the poorly developed alveoli of the infant. This is in agreement with a
study done in Asia which reported that nearly 50% of childhood pneumonia is caused by
inhaling smoke from indoor cook stoves. (Mortimer, 2017)

5.4 Prevalence of pneumonia among children under five in Muranga sub county Hospital

The prevalence of pneumonia among children under five in Muranga sub county Hospital was
found to be 68%. The frequency of pneumonia attack among less than 5 years was more
common at a rate of at least once every year in children under the age of 5 years.

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CHAPTER SIX

6.0 CONCLUSIONS AND RECOMMENDATIONS

6.1 Conclusion
Based on the quantitative and qualitative analysis of this study it was concluded that socio-
demographic characteristics like age and gender have a significant association with the risk of
acquiring pneumonia. Other factors such as the child’s breastfeeding status and the immunization
history were also found to have a significant association with pneumonia.
The results also indicate that of the children whose mothers were interviewed, majority (61.0%,
n=61) were of female gender, (65%, n=65) were from urban region and most (33.0%, n=33)
were 7-12 months of age while for the mothers, most (48%) were aged 26-35 years. Majority,
(64.7 % n=65) were married. Majority, (81.3% n=81) were Christians, most (49.3%, n=49) had
secondary level of education and (42.7%, n=42) were self-employed.
These findings will help to create awareness about the factors that are associated and
contributing to pneumonia among children under the ages of 5 years. The results will also make
a significant contribution to the existing knowledge gaps and research efforts on pneumonia in
children which will be of great importance to future scholars and those interested in the same
topic.
6.2 Recommendations
1. More campaigns need to be conducted involving all mothers and not only the expectant
mothers in different societies across the nation in order to increase the level of knowledge and
awareness of factors that contribute towards pneumonia among children under the ages of 5
years.
2. More studies need to be conducted involving different types of mothers in different set-ups
and with different characteristics to determine whether the factors contributing to pneumonia
among children under the ages of 5 years are the same.
3. There is need for the hospital management to carry out frequent root-cause analysis of the
factors contributing towards the rise in pneumonia cases and cub measures to prevent the rise in
pneumonia cases, such as encouraging women to practice frequent breastfeeding and adhering to
immunization schedule.
4. More campaigns to be carried out to ensure all children receive all the scheduled vaccines.
This may be possible by involving community health volunteers and offering such vaccines door
to door on regular basis.

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5.7 Study limitation

The data given by the mothers was prone to recall bias, due to time constraints; data was only
collected in the pediatric ward of Murang’a referral hospital hence it is only generalized to the
department’s settings.

MISCELLANEOUS

REFERENCES

1. Aguti, B., Kalema, G., Lutwama, D. M., Mawejje, M. L., Mupeyi, E., Okanya, D., ... &
Gavamukulya, Y. (2018). Knowledge and perception of caregivers about Risk factors and
Manifestations of Pneumonia among under five children in Butaleja district, Eastern
Uganda.
2. Alamneh, Y. M., & Adane, F. (2020). Magnitude and Predictors of Pneumonia among
Under-Five Children in Ethiopia: A Systematic Review and Meta-Analysis. Journal of
Environmental and Public Health, 2020.
3. Abuka, T. (2017). Prevalence of pneumonia and factors associated among children 2-59
months old in Wondo Genet district, Sidama zone, SNNPR, Ethiopia. Current pediatric
research.
4. Beletew, B., Bimerew, M., Mengesha, A., Wudu, M., & Azmeraw, M. (2020). Prevalence
of pneumonia and its associated factors among under-five children in East Africa: a
systematic review and meta-analysis. BMC pediatrics, 20(1), 1-13.
5. Caroline, M. W., Maina, E. N. M., & Karanja, S. (2018). Factors associated with
pneumonia in children under five (2-59 months) in Nairobi, Kenya. African Journal of
Health Sciences, 31(1), 31-39.
6. Fonseca Lima, E. J. D., Mello, M. J. G., Albuquerque, M. D. F. P. M. D., Lopes, M. I. L.,
Serra, G. H. C., Lima, D. E. P., & Correia, J. B. (2016). Risk factors for community-
acquired pneumonia in children under five years of age in the post-pneumococcal
conjugate vaccine era in Brazil: a case control study. BMC pediatrics, 16(1), 1-9
7. Gritly,Elamin,Rahimtullah, Ali, Dhiblaw, Mohamed, (2018). Risk factors of pneumonia
among children under 5 years at a pediatric hospital in Sudan. International Journal of
Medical Research & Health Sciences

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8. Gothankar, J., Doke, P., Dhumale, G., Pore, P., Lalwani, S., Quraishi, S., ... & Malshe, N.
(2018). Reported incidence and risk factors of childhood pneumonia in India: a
community-based cross-sectional study. BMC public health, 18(1), 1-11.
9. Karthik, V. R. (2018). Etiology, clinical profile and prognosis of acute respiratory
distress syndrome in a Tertiary Care Hospital (Doctoral dissertation, PSG Institute of
Medical Sciences and Research, Coimbatore).
10. Kulkarni, A. A., Desai, R. P., Alcalá, H. E., & Balkrishnan, R. (2021). Persistent disparities
in immunization rates for the seven-vaccine series among infants 19–35 months in the
United States. Health Equity, 5(1), 135-139.
11. Luthfiyana, N. U., Rahardjo, S. S., & Murti, B. (2018). Multilevel analysis on the
biological, social economic, and environmental factors on the risk of pneumonia in
children under five in Klaten, Central Java. Journal of Epidemiology and Public
Health, 3(2), 128-142.
12. Loto‐Aso, E., Howie, S. R., & Grant, C. C. (2022). Childhood pneumonia in New
Zealand. Journal of Paediatrics and Child Health, 58(5), 752-757.
13. Lema, K. T., Murugan, R., & Tachbele, E. (2018). Prevalence and associated factors of
pneumonia among under-five children at public hospitals in Jimma zone, South West of
Ethiopia, 2018. J Pulmonol Clin Res. 2018; 2 (1): 25-31. J Pulmonol Clin Res 2018
Volume 2 Issue, 1.ne, 18(1), 1-8. Le Roux, D. M., & Zar, H. J. (2017). Community-
acquired pneumonia in children—a changing spectrum of disease. Pediatric
radiology, 47(11), 1392-1398.
14. Lema, B., Seyoum, K., & Atlaw, D. (2019). Prevalence of community acquired
pneumonia among children 2 to 59 months old and its associated factors in Munesa
District, Arsi Zone, Oromia Region, Ethiopia. Clinics Mother Child Health, 16, 334.
15. Madhi, S. A., & Nunes, M. C. (2018). Experience and challenges on influenza and
pertussis vaccination in pregnant women. Human Vaccines &
Immunotherapeutics, 14(9), 2183-2188.
16. McAllister, D. A., Liu, L., Shi, T., Chu, Y., Reed, C., Burrows, J., ... & Nair, H. (2019).
Global, regional, and national estimates of pneumonia morbidity and mortality in
children younger than 5 years between 2000 and 2015: a systematic analysis. The Lancet
Global Health, 7(1), e47-e57.

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17. Moore, D. P., Baillie, V. L., Mudau, A., Wadula, J., Adams, T., Mangera, S., ... & Madhi,
S. A. (2021). The etiology of pneumonia in HIV-uninfected South African children:
Findings from the Pneumonia Etiology Research for Child Health (PERCH) study. The
Pediatric infectious disease journal, 40(9), S59.
18. Muthumbi, E., Lowe, B. S., Muyodi, C., Getambu, E., Gleeson, F., & Scott, J. A. G.
(2017). Risk factors for community-acquired pneumonia among adults in Kenya: a case–
control study. Pneumonia, 9(1), 1-9.
19. Mortimer, K., Lesosky, M., Semple, S., Malava, J., Katundu, C., Crampin, A., ... &
Balmes, J. (2020). Pneumonia and exposure to household air pollution in children under
the age of 5 years in rural Malawi: findings from the cooking and pneumonia
study. Chest, 158(2), 501-511 M.W.Caroline, Maina, S. Karanja African Journal of Health
Sciences Vol. 31 No. 1(2018
20. Markos, Y., Dadi, A. F., Demisse, A. G., Ayanaw Habitu, Y., Derseh, B. T., & Debalkie,
G. (2019). Determinants of under-five pneumonia at Gondar University hospital,
Northwest Ethiopia: an unmatched case-control study. Journal of environmental and
public health, 2019.
21. Ngocho, J. S., Horumpende, P. G., de Jonge, M. I., & Mmbaga, B. T. (2020). Inappropriate
treatment of community-acquired pneumonia among children under five years of age in
Tanzania. International Journal of Infectious Diseases, 93, 56-61.
22. Nasrin, S., Tariqujjaman, M., Sultana, M., Zaman, R. A., Ali, S., Chisti, M. J., ... & Alam,
N. H. (2022). Factors associated with community acquired severe pneumonia among under
five children in Dhaka, Bangladesh: A case control analysis. PloS one, 17(3), e0265871.
23. Nirmolia, N., Mahanta, T. G., Boruah, M., Rasaily, R., Kotoky, R. P., & Bora, R. (2018).
Prevalence and risk factors of pneumonia in under five children living in slums of
Dibrugarh town. Clinical Epidemiology and Global Health, 6(1), 1-4..
24. Oliwa, J. N., & Marais, B. J. (2017). Vaccines to prevent pneumonia in children–a
developing countries
25. Pajuelo, M. J., Anticona Huaynate, C., Correa, M., Mayta Malpartida, H., Ramal Asayag,
C., Seminario, J. R., ... & Paz-Soldan, V. A. (2018). Delays in seeking and receiving health
care services for pneumonia in children under five in the Peruvian Amazon: a mixed-
methods study on caregivers’ perceptions. BMC health services research, 18(1), 1-11.

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26. Selvaraj, K., Chinnakali, P., Majumdar, A., & Krishnan, I. S. (2014). Acute respiratory
infections among under-5 children in India: A situational analysis. Journal of natural
science, biology, and medicine, 5(1), 15try perspective. Paediatric respiratory reviews, 22,
23-30.
27. Tazinya, A. A., Halle-Ekane, G. E., Mbuagbaw, L. T., Abanda, M., Atashili, J., & Obama,
M. T. (2018). Risk factors for acute respiratory infections in children under five years
attending the Bamenda Regional Hospital in Cameroon. BMC pulmonary medic
28. Vieira, P., Sousa, O., Magalhães, D., Rabêlo, R., & Silva, R. (2021). Detecting pulmonary
diseases using deep features in X-ray images. Pattern Recognition, 119, 108081.
29. WHO; Pneumonia(2019) World Health Organisation
30. W.Bazie, N.Seid, B.Admassu (2020) Determinants of community acquired pneumonia
among 2-59 months of children in Northeast Ethiopia

APPENDICES

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6.1 APPENDIX 1: CONSENT FORM

Serial No: ____________ Date: _________________

Title of study: FACTORS CONTRIBUTING TO PNEUMONIA AMONG CHILDREN

UNDER-FIVE IN PEDIATRIC WARD IN MURANG’A REFERRAL HOSPITAL.

I am a student from Kratina university, School of Nursing pursuing degree Bachelor of Science in
Nursing. I am conducting research on Factors contributing to pneumonia among children aged 0-
59 months at pediatric ward in Murang’a County Referral Hospital which is a requirement for the
degree award. I humbly request for your participation in this study by helping me fill out this
questionnaire. The information is purely meant for the academic purposes therefore high level of
confidentiality will be maintained throughout. You are allowed to ask any question where and
when necessary. Your participation will be highly appreciated.

Aim of the study

The aim of the study is to determine factors contributing to pneumonia among the under-five
children at pediatric ward in Murang’a Referral Hospital.

Confidentiality

The information collected will be handled with high levels of confidentiality. No any personal
information including your name or child’s name and identification will be written on this
questionnaire.

Benefits

The main aim of the study is to investigate factors contributing to pneumonia among children who
are between 0-59 months and this will reduce practices that contribute to pneumonia and identify
the underlying causes hence benefiting the county, community and society on reducing the
morbidity and mortality rates of pneumonia among the under-five children.

Rights

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This study participation is voluntary, you are free to decline or participate at any point during the
study. You are allowed to ask any question during the study for clarifications.

Study procedure

Questionnaires will be issued and pens will be used to fill in the gaps in the questionnaires. You
will be free to ask questions during the study for clarifications

Contacts:

Principal investigator:

Biwott

6.2 APPENDIX 2: QUESTIONNAIRE

Serial No…………………… Date……………………

Title of the study: FACTORS CONTRIBUTING TO PNEUMONIA AMONG CHILDREN

UNDER-FIVE IN PEDIATRIC WARD IN MURANG’A REFERRAL HOSPITAL

Instructions

{Researcher administered Questionnaire} Please answer all the questions as per being guided by
the researcher in ticking the appropriate answer and filling information where necessary.

YOUR NAME WILL NOT BE WRITTEN ON THIS PAPER.

Participation is voluntary and it will take about 15-20minutes.

Please answer all the sections.

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The Socio-demographic characteristics

1The Socio-demographic characteristics

1.Gender

a) Male. b) Female

2. How old are you?

a)15-25yrs []

b)25-35yrs []

c)35-49yrs

3. What is your marital status?

(A) Married (B) Single (C) Widowed (D) Divorced

4. Highest level of education?

A. None B. Primary C. Secondary D. University/College

5. What is your occupational status?

A) Self-employed B) Unemployed C. Employed (D) Housewife

If employed, how much do you earn?

a)Less than 5,000

b)5000-10,000
c)10,000-20,000
d)20,000 and above

6.Religious Definition?
a) Protestant [ ]
b) Catholic [ ]

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c)Muslim [ ]
d)Other (Specify) ……………………
7. Geographical area of the respondent?

a) Rural [ ]
b) Urban [ ]

Immunization Information

8.Do you have your child’s clinic book or card?

(A) Yes (B) No

9. Which vaccines did the child get immunized?

(A) Pneumococcal vaccine (PCV 1) , (PCV 2), (PCV 3)

(B) BCG

(C) Pentavalent 1

(D) Pentavalent 2

(E) Pentavalent 3

Exclusive Breastfeeding

10.How many months or years did the child breastfeed-------months/Years?

11.At what age did the child stop breastfeeding-----------years or ------months?

12. Is the child breastfeeding? (A)Yes (B) No

If yes , how old is the child?........months/years?

Environmental Factors

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13.Does the father or the mother of the child smoke cigarette?

A) Yes (B) No

14.Is there any other member of the family who smoke?

A) Yes (B) No

15.Do they smoke inside the room?

A) Yes (B) No

16.Which fuel do you use at home?

a) Firewood No Yes

b) Electricity No Yes

c)Stove No Yes

d)Cooking gas No Yes

e) Charcoal No Yes

17.Do you use the cooking room as bedroom?

A) Yes (B) No

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WORK PLAN

Activity OCT NOV DEC JAN FEB MAR APR MA JUN JUL
2022 Y Y
2023
Literature Review

Writing the proposal

Consulting and
engaging the
supervisors
Design of instruments
& pilot study
Proposal presentation

Carrying out field

work
Analysis of Data

Report writing &

Submission of the
project

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APPROVAL LETTERS

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