Sleeping in cooking room is associated with under-five pneumonia in North West Ethiopia: prospective cross-sectional study

Background Pneumonia is the one of the five-leading cause under-five morbidity and mortality in developing countries. It is the leading cause of under-five death in Ethiopia. However, data on its institutional burden and factors associated was not explored enough in the study area. Therefore, this study was aimed to asses institution-based proportion of under-five pneumonia and associated factors at Debre Tabor General Hospital. Methods Institution based cross sectional survey was conducted from January 3 to February 10/2019 on a total of 342 participants. Data was collected using structured questionnaire. Additionally, medical charts were reviewed for objective diagnosis of pneumonia. After entered by EPI info version 7 data was exported to SPSS version 20 for further analysis. The result was summarized and presented using descriptive statistics. Logistic regression was computed to assess statistical association at 95% confidence level and p-value ≤0.05.


Background
Pneumonia is inflammation of the lung parenchyma. Even though microorganism associated inflammation is common, noninfectious origins like; aspiration pneumonia, hypersensitivity reactions and drug/radiation induced inflammations might be the cause.
Since direct culture of the lung tissue is invasive, indemnification of causes in individual patient is difficult. However, molecular diagnostic tests could diagnose 40-80% of bacterial or viral causes of community acquired pneumonia. S. pneumoniae, H. influenza, and S. aureus are the major causes of hospitalization and death from bacterial pneumonia among children in developing countries (1).

According to World Health Organization (WHO) accepted Integrated Management Newborn
and Childhood Illness (IMNCI) guideline there are three severity classifications clinically for a child with cough or difficult of breathing irrespective of etiology i.e. severe pneumonia or very severe disease, pneumonia, and cough or cold (2).
Globally, pneumonia accounted for 920,000 deaths between 0-59-month age. Among 1-59month age babies, about 720,000 children who were failed to celebrate their fifth year were due to pneumonia in 2015. In the same year, Ethiopia hosted the second highest (31,000) pneumonia associated deaths among the top five under five mortality burden countries in the world (3). Ethiopia met the 2015 Millennium Development Goal-4 (MDG- 4) target (4). Under-five pneumonia is the second leading cause of morbidity, the leading cause of mortality and admission in the country (5). However, its institution-based proportion was not assessed in the study area.
Previous Ethiopian study reported, under five pneumonia was associated with maternal age less than 18 years, more than four family member in the house, parental smoking, non-exclusive breast feeding, no zinc supplementation and wasting (6). Nonetheless, data on associated factors was lacking in the study area. Therefore, this study was done to assess institution-based proportion and associated factors of under-five pneumonia among children visiting Debre Tabor general hospital under-five Outpatient Department (OPD); so as to be an input for planners, administrators and researchers.

Study area
The study was conducted at Debre Tabor General Hospital Under-five OPD which is found in Debre Tabor town 720 km far from the capital of Ethiopia in North West direction. The All under five Children 2-59 months of age with mother / care giver visiting under five OPD at Debre Tabor General Hospital during data collection period.

Exclusion Criteria
Severely sick child need life treating intervention and/or mothers or caretakers who are severely ill and less than two months age infants.
Sample size and sampling procedure Sample Size Determination The sample size was determined using single population proportion formula. Prevalence of pneumonia among under-five (28.1%) in Jima Zone Public Hospitals was taken (7). By considering 95% confidence interval (CI) and 5% marginal error the, sample size was calculated as follows; Where n = (Zα/2) 2 p (1-p) For those participants who were not volunteer to participate 10% non-response rate was added on the calculated sample size. Then, the final total sample size was 342. Interviewer administered structured questionnaire was used to collect data from sampled mother or care giver who visiting under five OPD. The questionnaire has socio-demographic characteristics, environmental factors, and Co-morbid conditions. The tool was adapted from related study and modified (7). The English version was translated into Amharic language by language professionals. Three diploma nurse data collectors and one BSc nurse supervisor were involved in the data collection. Finally, medical charts were reviewed by the data collectors to collect clinical marker of the children.

Data Quality Control
Data was collected by well-trained data collectors using pretested questionnaire. Training was given for one day (including half day of pretest). Pretest was done on 10% percent of the total sample size at Addis Zemen Primary Hospital. Using pretest result sociodemographic variables were modified. One day training was given on the objective the study, confidentiality of information, respondent's right, informed consent, techniques of interview and the elements of the questionnaires for data collectors and supervisor.

Data Processing and Analysis
After visually checking for completeness and cleaning, data was entered into Epi info version 7 and exported into SPSS version 22 for coding and analysis. All variables were used in the bivariable logistic regression, then variables with p-value ≤0.2 were further considered for multivariable logistic regression to incorporate more candidate variables.
The result was summarized and presented using descriptive statistics. Multivariable logistic regression was done to minimize confounders. Variables in the final model predict 57.4% of the outcome with Hosmer and Lemishow test result of 0.574. Finally, statistical association was declared using Adjusted Odds Ratio (AOR) at 95% confidence level and p-value≤0.

Results
Socio demographic characteristics of the respondents Total of three hundred forty-two (342) mothers/care givers and children pair were included in the study with a response rate of 100%. The mean age of children was 20.44 +15.224 months old. The majority of 241 (70.5%) children were urban resident. Male accounts more than half 201 (58.8%) of the participated children. Children aged 24-59 months accounts largest proportion of surveyed children 128 (37.4%), but from the total pneumonia cases in this study children between 2-11 months accounted 37 (31.6%) ( Table   1).

Environmental and housing characteristics of the respondents
In this study more than half children live in cooking rooms. Besides, more than 2/3 of children who had pneumonia were sleeping in the same house used for cooking (Table 2).

Nutritional, past co-morbidities and vaccination status of children
The majority of children 260 (76%) completed according to the EPI schedule of our country. More than 2/3 (77.3%) of children who had pneumonia were not feeding breast milk exclusively for six months ( Table 3).

Proportion of under-five pneumonia
The overall proportion of under-five pneumonia during the five weeks institution-based survey was estimated to be more than 1/4 th of under-five children visiting Debre Tabor Hospital under-five outpatient department with 95% uncertainty range of 23.2%-31.8% (Fig 1).

Factors associated with under-five pneumonia
In this study, multivariable analysis result revealed those participants who were not  (Table 4).

Discussion
This study was done to estimate institution-based proportion of under-five pneumonia and associated factors at Debre Tabor General Hospital during 2019.
Keeping in mind the limitations of cross sectional and institution-based study, the proportion of under-five pneumonia among children visiting outpatient department at the hospital was 27.5%. This finding was above a community based done on slum residents of Nigerian study (8). Variation might be explained by difference in study setting, vaccine coverage, socio economic status, and health care accessibility.
This study found a proportion higher than a community-based study endorsed at Este districts in Amhara region, Ethiopia (9). In contrast, the result was lower than a proportion reported at Ilu Aba bora zone health centers in Ethiopia (10). The possible explanation for higher proportion in this study could be setting difference due to the fact that children visiting health institution are more likely to be diagnosed for pneumonia. While, the reason for lower proportion might be due to time variation, diagnostic sensitivity of currently applied IMNCI (Integrated Management of Newborn and Childhood Illness) protocol and wider implementation of PCV (Pneumococcal Conjugate Vaccine) in Ethiopia.
Sleeping in cooking room, malnutrition and breast-feeding status were associated with under-five pneumonia at our study setting. About 94% of children could be protected from pneumonia in this study. An Indian study support this finding (11). As sleeping in the same house increase indoor air pollution, indoor smoke exposure (8,(12)(13)(14), and lack of ventilation (11, 15). As a result, all these increase the development of pneumonia.
The likely hood of under-five pneumonia was as high as 8 times among malnourished babies in this study. Malnutrition ranging from under-weight to wasting were mentioned as factor for under-five pneumonia (6,9,11,(16)(17)(18). Under nutrition decreases immunity due to decrease in secretary IgA, IgM, IgG concentration in blood as well as cell mediated immunity with concomitant important micronutrient deficiency (19). Pneumonia might be consequently portrayed to those derangements.
Inappropriate breast-feeding expressed as either lack of exclusive breast feeding or mixed feeding before six months of age increase the odds of under-five pneumonia with six and four folds respectively in this study. Breast feeding was previously identified as a factor for worsening of severity as well as contributing factor for initiation of the pneumonia disease process (12,18,20,21). This result was in line with previous studies done at and regulatory T cells, innate and acquired immunity will not be produced enough/produced at all. Similarly, a wide range of pro-and anti-inflammatory cytokines and chemokines will not be produce adequately (23). Therefore, observed association of increased proportion in under-five pneumonia and mixed or not exclusively breast feed children in this study might be linked to those qualities of human milk.

Conclusions
This study showed that the proportion of pneumonia was high in the study area. The study also identified that malnutrition, sleeping in cooking room, and inappropriate breast feeding were independently associated with increased proportion of under-five pneumonia. Therefore, sleep in separate room, educate mothers about exclusive breast feeding and improve nutrition would worth better to prevent under five pneumonia.