Pneumonia, an acute lower respiratory tract infection caused mainly by bacteria and also viruses, is the leading cause of death in children in low-income communities. In an economically disadvantaged area, where people live in poor sanitation and have limited access to nutritious food and health care, this kind of infection is a primary cause of childhood deaths.

It is unfortunate to see that despite preventive efforts, Indonesia still sees a high prevalence of pneumonia, which has increased to 2.7 percent in 2013 from 2.1 percent in 2007, data from the 2013 Basic Health Survey (Riskesdas) reveals.

Twenty out of 34 provinces in Indonesia have a higher pneumonia prevalence than the national figure. One of them is East Nusa Tenggara (NTT), where pneumonia prevalence is more than double of the national prevalence, according to the Health Ministry’s 2013 Health Research and Development Agency data.

One important thing that many people might not know is the fact that stunting is one of the major risk factors for pneumonia mortality. Stunted children may have a weaker immune system, making them more vulnerable to death by infections, including pneumonia. This is why the government’s efforts to combat stunting in children with pneumonia should have been conducted in parallel, with nutrition intervention placed at the heart of the program.

Improving child nutrition through breastfeeding and food supplementation is among the key intervention methods of pneumonia, which are structured in the Protect, Prevent and Treat framework developed by Save the Children, a children’s rights advocate, as part of its three-year childhood pneumonia program from 2018 to 2020. The framework aims to bring about community behavioral changes that can help prevent childhood pneumonia.

The childhood pneumonia campaign strategy was launched in 2018 to commemorate the 100th anniversary of Save the Children International. A string of Protect, Prevent and Treat campaign activities are currently being conducted in West Sumba regency in NTT and Bandung regency in West Java.

“A lack of breastfeeding is among several risk factors, including low immunization coverage among under-5 children, lack of access to pneumonia vaccines and unhealthy living environment due to cultural and social factors, which all can lead to pneumonia,” Tata Sudrajat, advocacy and campaign director at Yayasan Sayangi Tunas Cilik (YSTC), a partner foundation of Save the Children International, told The Jakarta Post in Jakarta.

Infant and young child nutrition might improve through simpler interventions, namely exclusive breastfeeding, food supplementation and breastfeeding up to 2 years of age. These three methods are the components of the framework’s first pillar “to protect”, Tata said.

The YSTC reveals in its report, which was developed together with Padjadjaran University in Bandung, that parents in West Sumba and Bandung actually had a good understanding of the importance of exclusive breastfeeding. However, only 60 percent of their children received this treatment during their first 6 months of life, while the remainder got a combination of breastmilk, formula and other types of food, such as porridge and soft rice.

Many women failed to exclusively breastfeed their babies because they had to go to work, their babies refuse to breastfeed and many other reasons. In Bandung, for example, mothers claimed they were unable to produce a sufficient amount of breastmilk, thus impeding exclusive breastfeeding, which according to some research, can reduce pneumonia cases in toddlers.

Among the critical findings of the study include the fact that only around 80 percent of children in West Sumba and Bandung have received complete basic and booster immunizations, while the minimum coverage of childhood immunizations, such as BCG, Hepatitis B, DPT-HB-HiB, Polio 4 and measles/Measles Rubella (MR), should stand at 95 percent.

Mothers in the two regencies were found to have been fully aware of the benefit of immunization. Integrated health services posts (Posyandu) have become their primary choice for immunization for their children. Other places to get immunization are community health centers Puskesmas) and midwives who offer private care services.

Hana Wadoe Koedji, a physician with the YSTC advocacy and campaign team, said that in West Sumba, circulating issues related to the haram or halal status of vaccines did not affect parents’ strong belief that their children needed to be immunized.

“In Bandung regency, however, a number of families refused to immunize their children because of concerns over the haram status of vaccines,” she told the Post in a telephone interview on Nov. 4.

“By sharing the importance of vaccines to protect children from life-threatening diseases, YSTC field workers encouraged parents to vaccinate their children.”

Behavioral intervention, Hana explained, could be very effective in preventing diseases, improving people’s health and eventually reducing healthcare costs. Apart from immunization, behavioral intervention such as hand washing with soap, better sanitation and reducing pollution at home are also being pushed forward in the second pillar of the YSTC’s pneumonia prevention framework, “to prevent”.

In Bandung, poor sanitation and low awareness on the importance of washing hands with soap are reported to have likely contributed to the high rate of worm infestation in West Java. The unhygienic lifestyle was also associated to the high prevalence of stunting in Bandung regency, which stands at 40.7 percent, according to the 2013 Riskesdas.

Hana conceded that some of these habits could be difficult to change because they had been practiced for generations. Rural communities in West Sumba, for example, live in uma (traditional house) where family members gather and conduct all of their daily activities, including cooking, inside.

“Smoke released from a wood stove circulates inside the house, being constantly inhaled by family members,” said Hana.

Inhabitants are also continuously exposed to animal feces from livestock they keep in a stable installed right below their house, which also has inadequate ventilation.

Widespread smoking practices among families surveyed have shown that children and other family members are also highly exposed to air pollution. Such unhealthy living patterns have been identified by the YSTC team to “positively correspond” to a high incidence of pediatric pneumonia in West Sumba.

The YSTC pushes forward clearer roles and responsibilities between mothers and fathers in childcare, better access to healthcare facilities for sick children and a more integrated management of pediatric sickness in health facilities in the third pillar of the framework, “to treat”. This aims to ensure that children can get immediate treatment and the right medication once they show pneumonia symptoms such as shortness of breathing.

However, it is unfortunate to find out that many Indonesian health workers have little knowledge on both the symptoms and causes of pneumonia. Many of them have never heard the word “pneumonia” and others even cannot differentiate between pneumonia and upper respiratory infections, said Harimawan Latif, senior campaign manager at Save the Children.

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