Pneumonia is a severe form of acute lower respiratory infection that causes high morbidity and mortality rate among children under five; it constitutes a significant danger to global public health.¹ The long-term effect of pneumonia in children under five is a decline in lung function, which will become apparent in adulthood. ² The infection causes inflammation and fluid or pus accumulation in the alveoli of the lungs. This can make it more difficult for oxygen to enter circulation. Cough, fever, chills, and difficulty breathing are moderate to severe pneumonia symptoms.^3,4 Fungi, bacteria, and viruses cause this infectious illness. In newborns, the most frequent pathogens are group B Streptococcus and gram-negative bacteria; in infants, the most frequent pathogen is typically a virus.⁵

Human metapneumovirus, respiratory syncytial virus, adenovirus, rhinovirus influenza, parainfluenza, and SARS-CoV-2 are common causes of viral pneumonia.^6,7 In contrast, Streptococcus pneumoniae (Pneumococcus) is a frequent cause of bacterial pneumonia.⁸ In addition, Coccidioidomycoses is a common cause of fungal pneumonia.^9,10 Pneumonitis is diagnosed by imaging tests like a computed tomography scan and a chest X-ray, blood tests, pulmonary function testing using an oximeter or spirometer, surgical lung biopsies, and bronchoscopy.¹¹ When pneumonia in children under the age of five years is improperly or tardily treated, the condition worsens and can result in mortality. Most pneumoniarelated fatalities occur in infants and children under the age of five.¹² In 2019, 740,180 children under the age of five worldwide died of pneumonia. Children under five made up 14% of all fatalities, whereas children ages 1 to 5 made up 22% of all fatalities.¹³ Low-income and middle-income countries have a disproportionately high mortality rate.¹⁴ Only five countries have been responsible for more than half of all pediatric pneumonia deaths: Nigeria 162,000, India 127,000, Pakistan 58,000; the Democratic Republic of the Congo 40,000; and Ethiopia 32,000.¹⁵

Every year, pneumonia kills over 800,000 children under five, including more than 153,000 newborns, especially susceptible to infection. Therefore, a kid passes away from pneumonia every 39 seconds, and most of these fatalities may be avoided.¹⁶Worldwide, there are about 1,400 cases of pneumonia per 100,000 children, or one case every 71 children per year, with South Asia having 2,500 cases per 100,000 children and West and Central Africa having the highest prevalence, 1,620 cases per 100,000 children.¹⁷

In 2021, the number of deaths from pneumonia among children under five years in Iraq, excluding the Kurdistan region, reached 758 deaths. In Wasit Governorate, in particular, the number of deaths reached 28 deaths.¹⁸ In developing countries, the risk factors for childhood pneumonia vary. Pneumonia risk factors include socio-demographic status (age, residence, educational level, occupation, monthly income, and family size).^19,20

Pneumonia may affect everyone, regardless of age.²¹ Babies and toddlers under two are more vulnerable due to their weak immune systems and immature respiratory systems, which predispose them to develop serious illnesses.²² Family income influences the risk of children experiencing pneumonia through healthy physical home quality, nutritional status, and complete immunization status.²³ Although overcrowding among family members is considered a risk factor for illness, few studies have assessed the mechanism of respiratory infection transmission in children living in overcrowded households.^24,25 Education influences mothers’ preventative, health care, and treatment behaviors. For example, mothers with limited education often misdiagnose pneumonia as a common cold.²⁶ Therefore, this study aims to identify the distribution of the proportion of pneumonia according to the severity and to determine socio-demographic factors associated with the severity of pneumonia among children under five years in Wasit Governorate.

Four hundred seventy-seven children under five were included in the study. The mean and standard deviation for the age of the children was 16.25±17.25. The highest percentage of children in the study was 55.6% in the age group 1-11 months. Children aged 36-47 months constitute the smallest percentage, 4.2%. Approximately sixty-one were 60.6% male, and 39.4% were females. More than two-thirds of the study participants, 63.7%, were urban residents. Most mothers and fathers had completed the primary graduate 50.9% and 47.4%, respectively. Most mothers interviewed were married and unemployed (housewives), 99.4% and 97.5%, respectively. More than half of the fathers, 59.5%, were self-employed. A quarter of the participants’ families, 25.6%, suffered from overcrowding. as shown in Table 1.

In terms of age, the results indicate more than half of the 265 (55.6%) participating children were within the age group 1-11 months, 213 (80.4%) of them had pneumonia, 13 (4.9%) had severe pneumonia, and 39 (14.7%) had very severe pneumonia as showed in Table 2. However, there was no statistically significant relationship 0.855 P-value. In this study, pneumonia was more common among the 1-11-month age group. This result is in line with the study conducted by Fadl et al. in Alexandria, Egypt, which mentioned that children under 12 months of age are one factor independently associated with pneumonia.³¹ This is due to the immature immune system: Infants and young children have less developed immune systems than adults, which makes them more vulnerable to infections like pneumonia. In addition, infants’ symptoms may be more subtle and difficult to notice at an early stage, which could cause the appropriate therapy to be delayed and result in the development of a severe illness.²²

Regarding sex, the results showed that nearly two-thirds of the children included in the study were boys: 289 (60.6%), 242 (83.7%) were diagnosed with pneumonia, 12 (4.2%) with severe pneumonia, and 35 (12.1%) with very severe pneumonia. Of these children, 188 (39.4%) were girls, 144 (76.6%) had pneumonia, 11 (5.9%) had severe pneumonia, and 39 (12.8%) had very severe pneumonia. With this, there was no statistically significant relationship P-value 0.149. There were more males diagnosed with pneumonia than females. This result agrees with the study conducted by Seramo et al. in Worabe Town, Ethiopia, in which it was mentioned that males had more pneumonia than females.³² This could be owing to the family’s preference for boy children.³³ Another explanation is that boys are more exposed to the outside environment, albeit under the age of five. Boys and girls are usually equally exposed.³⁴

As for residence, the results showed that nearly two-thirds of the participants were urban residents, 304 (63.7%), because hospitals are located in urban areas, and most of the participants in the study were from those areas. 250 (82.2%) had pneumonia, 15 (4.9%) had severe pneumonia, and 39 (12.8%) had very severe pneumonia. However, there was no significant relationship P-value 0.521. Pneumonia was more common in urban areas in this study. Findings are consistent with the study conducted in Egypt, which reported that the majority of children in urban areas suffer from pneumonia.³¹ This is because houses are typically close together in urban regions, with numerous occupants and less air ventilation. In contrast to rural regions, rural areas offer better housing conditions and cleaner air. However, there are still some homes with dirt floors. Pneumonia can result from these circumstances in everyone. ³⁵ Regarding the mother’s educational level, this study’s results indicate that more than half of the participating mothers, 243 (50.9%), obtained a primary education. Thus, 200 (82.3%) of the children whose mothers obtained a primary education had pneumonia, 15 (4.9%) had severe pneumonia, and 39 (12.8%) had very severe pneumonia. However, no significant association was found P-value 0.782. In this study, pneumonia was more common in children whose mothers had primary education as showed in the Table 2. The result of this study is consistent with the study conducted by Abuka in Wondo Genet district, Sidama zone, SNNPR, Ethiopia, that more than half of the mothers who attended primary education had children with pneumonia.¹⁹ Regarding the father’s educational level, the results of this study indicate that about half of the participating fathers, 226 (47.4%), obtained a primary education. Thus, 180 (79.6%) of the children whose parents had primary education had pneumonia, 14 (6.2%) had severe pneumonia, and 32 (14.2%) had very severe pneumonia. However, no significant association was found P-value of 0.873. Our study found pneumonia most common in children whose parents had primary education. The result of this study is consistent with the study conducted in the town of Warabi in Ethiopia showed that half of the parents who completed primary education had children with pneumonia. ³² Parents with lower education levels may have limited knowledge about maintaining good hygiene, inadequate nutrition, financial barriers to accessing healthcare, and lack of awareness about preventive measures such as vaccination are some factors that increase the risk of pneumonia in children.

As for the mother’s occupation, our study showed that the vast majority of unemployed mothers (housewives), 465 (97.5%) of the children whose mothers are unemployed had pneumonia, and 23 (4.9%) had severe pneumonia. And 67 (14.4%) had very severe pneumonia. However, there was no significant correlation P-value 1,000. Our results showed that pneumonia was more common in children whose mothers were unemployed (housewives). The result of this study is consistent with the study conducted by Andualem et al. in Northwest Ethiopia, who stated that 68.3% of the respondents’ occupation was a housewife.³⁶ As for the father’s occupation, our results indicate that more than half of the fathers were self-employed, 284 (59.5%). Of the children whose parents were self-employed, 231 (81.3%) had pneumonia, 12 (4.2%) had severe pneumonia, and 41 (14.4%) had very severe pneumonia. However, a statistically significant association P-value 0.002 was found. Results indicate that pneumonia was more common in children whose parents were self-employed. Contradictory results were obtained in a case-control study in Adama, Ethiopia, which reported children with pneumonia whose fathers were farmers.³⁷ Another study in Este town and the surrounding rural kebeles in northwest Ethiopia showed that nearly three-quarters of parents were farmers who had children with pneumonia.³⁸ Certain occupations, such as housewives or self-employed, may be associated with lower socioeconomic status; besides, self-employed and housewives’ parents may not have access to paid sick leave or health insurance, which may lead to a delay in seeking healthcare and receiving proper treatment, poor housing conditions, and limited access to adequate nutrition.

The study showed that most mothers were married, 474 (99.4%). And 383 (80.2%) of the children whose mothers were married had pneumonia, 23 (4.9%) had severe pneumonia, and 68 (14.3%) had very severe pneumonia. However, there was no statistically significant relationship P-value 1.000. Our study indicates that pneumonia is more common in children whose mothers were married. This result is consistent with a study conducted in northeast Ethiopia, which showed that nearly three-quarters of married mothers had children with pneumonia.³⁹ In addition, a mother’s marital status may indirectly affect the risk of pneumonia. For example, married mothers may face more socioeconomic challenges, making it difficult to afford healthcare or access healthcare services. As for the overcrowding index, our results indicate that a quarter of the participants’ families, 122 (25.6%), do suffer from overcrowding. Of the participants’ families who suffered from crowding, 98 (80.3%) had children with pneumonia, 8 (6.6%) with severe pneumonia, and 16 (13.1%) with very severe pneumonia. However, there is no statistically significant relationship P-value 0.554, where pneumonia was more common in children whose families did not suffer from crowding as shown in Table 2. The result of this study was opposite to the study conducted by Keleb et al. in peri-urban areas of north-eastern Ethiopia, who stated that 42.9% of household overcrowding was a predictor of childhood pneumonia.⁴⁰ Population density influences illness spread because the transfer of germs and viruses that cause pneumonia is more easily and swiftly transmitted by breathing. The greater the population density, the more likely to come into contact with pneumonia patients.⁴¹

Regarding the pneumonia severity. The majority of children included in the study suffered from pneumonia, 81%. And 14% of children suffer from very severe pneumonia, and the lowest percentage of children suffering from severe pneumonia was 5%, as shown in Figure 1.

Regarding the socioeconomic situation, the results showed that more than two-thirds of the participants in the study, 65%, were from low monthly income, 31% were from middle income, and 4% were from high income, as shown in Figure 2.

The results of this study indicate that about two-thirds of the participants, 311 (65.2%), were of low income, 248 (64.2%) had pneumonia, 16 (69.6%) had severe pneumonia, and 47 (69.1%) had very severe pneumonia. A statistically significant correlation was found P. Value 0.049. The results of this study indicate that pneumonia is more common among participants with low incomes, and this indicates that participants with a low economic level are at greater risk of developing pneumonia as appeared in Table 3. This finding agreed with Sriram and Satyanarayana, who stated that low socioeconomic status was a significant risk factor for pneumonia.³³ Also, another study in Sudan showed that pneumonia was higher among families with a lower income 26 (65%), and there was a relation between family income and pneumonia.²⁰ Low income may result in inadequate housing, poor nutrition, and little to no preventive medical care, such as immunization, all of which can dramatically increase the risk of contracting infectious diseases.

Based on the results, it can be concluded that pneumonia is a significant health issue among children, with a vast majority (81%) suffering from the condition. The findings also indicate that children within the age group of 1-11 months, males, and those residing in urban areas, whose parents had completed primary education are more susceptible to pneumonia. Furthermore, children whose fathers were self-employed, and those from low socioeconomic status and overcrowded houses, were also more likely to develop pneumonia. Therefore, the father’s occupation and socioeconomic status significantly determine pneumonia severity in children.