Community-acquired pneumonia in Indonesian children: insights into diagnosis, treatment compliance, and healthcare provider challenges

Abstract

Background

Community-acquired pneumonia (CAP) remains a leading cause of morbidity and mortality in children worldwide. Inappropriate antibiotic use by healthcare workers contributes significantly to the growing problem of antibiotic resistance. This study assessed the knowledge, attitudes, and practices (KAP) of Indonesian primary healthcare workers in diagnosing and treating paediatric CAP, alongside challenges in guideline adherence.

Methods

Three studies were conducted in Indonesia. The first study reviewed medical records from Riau Islands and Central Java Provinces to assess adherence to CAP guidelines. The second evaluated KAP using pre- and post-tests, and online follow-up. The third used focus group discussions (FGDs) to explore the challenges in diagnosis and management.

Results

Out of 921 records, 37.6% of patients were misclassified as having CAP according to the World Health Organization (WHO) guideline, while 53.3% were misclassified based on the Ministry of Health of the Republic of Indonesia (MoH RI) guideline. Antibiotics were prescribed in 89.3% and 87.6% of these cases. Among correctly classified cases, 73.2% were prescribed amoxicillin in line with WHO guideline, but only 11.6% were dosed within the recommended 75–100 mg/kg/day range. Furthermore, 74.6% of patients were prescribed antibiotics more frequently, and only 28.3% received the appropriate treatment duration. The training significantly improved KAP among healthcare workers. Separately, nurses and midwives showed better practical application of the guidelines compared to physicians. Qualitative analysis identified themes highlighting diagnostic accuracy, antibiotic prescribing practices, and tailored training programs.

Conclusions

This study highlights significant inconsistencies in paediatric CAP management among healthcare providers in Indonesia and emphasises the need for targeted training to enhance guideline compliance and improve patient outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13690-025-01795-x.

Text box 1. Contributions to the literature
• Inappropriate management of paediatric pneumonia, including antibiotic misuse and inconsistent guideline adherence, remains a challenge in low- and middle-income countries.
• This study provides new evidence using a multi-method approach—combining record reviews, KAP assessments, and qualitative analysis—to identify systemic challenges in clinical practice.
• It reveals key gaps in the diagnosis and treatment of paediatric pneumonia in Indonesian primary care, including limited training and inconsistent antibiotic use.
• The study highlights the positive impact of targeted training on healthcare workers’ knowledge and compliance with WHO guidelines.
• The findings support the need for national guidelines and antibiotic stewardship in low-resource settings.

Background

Community-acquired pneumonia (CAP) is a lower respiratory tract infection acquired outside health facilities, leading to pneumonia, a severe inflammation of the lungs [1]. Globally, CAP is the leading cause of death in children under five, responsible for 18% of fatalities in this age group [2]. Based on the Indonesia Health Profile published by the Ministry of Health of the Republic of Indonesia (MoH RI) in 2017, the incidence of CAP in Indonesia reached 20.54 cases per 1000 children under five years [3]. Thus, understanding healthcare workers’ knowledge, attitudes, and practices (KAP) regarding pneumonia diagnosis and treatment is essential for enhancing patient outcomes and addressing gaps in clinical care.

The World Health Organization (WHO) recommends using amoxicillin for three to five days to treat bacterial CAP in children. For children exhibiting danger signs, first-line therapy is parenteral penicillin or ampicillin combined with gentamicin, or ceftriaxone as second-line options [4]. Similarly, the MoH RI in the Clinical Practice Guidelines for Doctors in First-Level Healthcare Facilities (MoH RI CPG) recommends amoxicillin or cotrimoxazole as first-line therapy in children under five [5].

The rational use of antibiotic therapy based on guidelines is important for improving clinical outcomes and curbing the development of antibiotic resistance [6, 7]. In Indonesia, studies have identified significant gaps in healthcare workers’ understanding and adherence to guidelines. Reports indicate that 30–80% of antibiotic use in Indonesian hospitals lacks proper indications and that antibiotic dosing is often suboptimal [8].

This study assessed the KAP and challenges faced by Indonesian primary healthcare workers in diagnosing and managing paediatric CAP. It also examined adherence to diagnostic and therapeutic guidelines, including those issued by the WHO and the MoH RI.

Methods

Three studies were conducted sequentially between April 2023 and January 2024. The first study assessed compliance with diagnostic and treatment guidelines. The second focused on healthcare providers’ KAP and the third examined challenges in diagnosing and treating paediatric CAP. Figure 1 provides an overview of the study timelines, locations, and specific objectives. A detailed description of the methods used in each study is presented below.

Fig. 1.

Summary of study designs, locations, and timelines

Study 1. Assessing compliance with diagnostic and treatment guidelines

Study design and setting

A cross-sectional study was conducted from April to October 2023 in two provinces (first-level administrative divisions) in Indonesia: Riau Islands and Central Java (Fig. 2), as a representation of Indonesia’s geographical diversity and socioeconomic variation, since Riau Islands represent the western maritime region and Central Java represents a more densely populated region in Java. As the census indicates, the 2021 population of Riau Islands and Central Java was 2,118,239 and 36,742,501 individuals, respectively. The expanse of the Riau Islands encompasses 427,608.68 square kilometres, while Central Java covers an area of 32,800 square kilometres [9, 10].

Fig. 2.

Study location in Indonesia: Tanjung Pinang City (Riau Islands Province), Semarang City and Jepara Regency (Central Java Province)

We collected medical records from Tanjung Pinang, the capital of Riau Islands province, which has seven community health centres (CHCs), the focal point of primary health care in Indonesia. From Central Java Province, we selected Semarang, the capital city, and Jepara Regency. Semarang consists of 38 CHCs, of which five were selected for this research to represent five different areas of Semarang [11]. The medical records from Semarang underwent randomised selection and screening. Simple random sampling was conducted using the online tool Research Randomizer (https://www.randomizer.org/) to select approximately 10% of eligible medical records for analysis. This proportion was chosen to ensure representativeness of the prescribing patterns while maintaining feasibility for manual data extraction and review. Jepara Regency, on the other hand, has 22 CHCs, with only two equipped with online medical records, and these two CHCs serve as representatives for rural and urban areas [12].

Study population

The inclusion criteria in this study were electronic medical records from children under 60 months diagnosed with pneumonia from 1 January 2018 to 31 December 2022. This period was selected because electronic medical records were first implemented in 2018 across all three sites (Semarang, Jepara, and Tanjung Pinang), and it represented the most recent complete data available before the study. We excluded medical records with incomplete date of birth, no documented history of present illness, no data on the frequency of respiratory rate and body weight, no documented prescription, and duplicate entries. The Ethical Committee of the Faculty of Medicine Universitas Diponegoro approved the study protocol (No.57/EC/KEPK/FK-UNDIP/III/2023).

Clinical data collection

We extracted age, sex, history of present illness, physical examination, laboratory results, and therapy from electronic medical records in the local healthcare information system from fourteen CHCs in three locations (Fig. 2). Children who were diagnosed and managed as severe cases at CHCs could not be included in this study, as they were referred to hospitals in accordance with national guidelines.

Case review

In this study, our comparison was based on the two guidelines that were available in CHCs during the study period: First, we used “Revised WHO Classification and Treatment of Childhood Pneumonia at Health Facilities” [4]. In Indonesia, this guideline has been adopted by the MoH RI in the “2015 Integrated Management of Childhood Illness (IMCI) Chart Book” [13]. Based on these guidelines, we classified medical records into “correct pneumonia classification” based on the symptoms of cough and/or difficult breathing and fast breathing stated in the document (0-<2 months: ≥ 60x/min, 2-<12 months: ≥ 50x/min, 12–59 months: ≥ 40x/min).

Treatment based on the recommendation of the WHO is oral amoxicillin, at least 40 mg/kg/dose twice daily (80 mg/kg/day). The 2015 Indonesian IMCI adopted amoxicillin 45 mg/kg/dose, twice daily for three days [13]. We classified medical records into “correct antibiotic choice” if healthcare providers prescribed amoxicillin, “correct daily dose” if prescribed amoxicillin was given within the range of 75–100 mg/kg/day [4], “correct frequency” if the amoxicillin was prescribed twice daily, and “correct duration” if the amoxicillin was prescribed for three days.

Second, we used the “Clinical Practice Guidelines for Doctors in First-Level Healthcare Facilities” from the MoH RI [5]. Based on this guideline, we classified medical records into “correct pneumonia classification” based on the symptoms of cough and/or difficult breathing and fast breathing stated in the document (0-<2 months: >60x/min, 2–12 months: >50x/min, 13–60 months: >40x/min). The recommended treatment is oral amoxicillin 25 mg/kg or cotrimoxazole 4 mg trimethoprim (TMP)/20 mg sulfamethoxazole (SMX)/kg twice daily. We classified medical records into “correct antibiotic choice” if healthcare providers prescribed amoxicillin or cotrimoxazole, “correct daily dose” if the prescribed amoxicillin was given within the range of 45–90 mg/kg/day [14], and 8–12 mg TMP/40–60 mg SMX/kg/day for cotrimoxazole [15]. “Correct frequency” if the amoxicillin or cotrimoxazole was prescribed twice daily. There is no explicit statement regarding the recommended duration.

Statistical analysis

All clinical data collected from the local healthcare information system were extracted to Microsoft^® Excel for Mac, Version 16.75 (Microsoft Corporation; 2023), and further analysed using SPSS^® Version 26.0 (IBM Corp.; 2019).

Study 2. Assessing the knowledge, attitudes, and practices (KAP) of healthcare providers

Study design and setting

This cross-sectional study was conducted in November 2023 and January 2024 in Semarang, Central Java, Indonesia. Primary healthcare providers from Semarang were asked to do a test before and after the workshop (pre- and post-tests) based on the Indonesian IMCI guideline [16], which is adapted from WHO recommendations and promoted as the national standard for child health management in primary care. The test results were collected to assess their KAP related to the diagnosis and treatment of pneumonia in children.

Study population

Four healthcare providers from each of the 38 CHCs in Semarang were invited to participate in this study. The group from each centre consisted of two doctors and two nurses and/or midwives, all of whom had roles closely related to pneumonia care in children. The study protocol was approved by the Ethical Committee of the Faculty of Medicine, Universitas Diponegoro (No. 458/EC/KEPK/FK-UNDIP/IX/2023).

Data collection

In November 2023, a half-day seminar and workshop about the diagnosis and treatment of pneumonia in children were held in collaboration with the Faculty of Medicine Universitas Diponegoro and the Semarang City Health Office. At the beginning of the event, the research component was explained, and written informed consent was obtained from all participants. Participants completed a pre-test using a validated paper-based questionnaire to evaluate their KAP (Supplementary File 1). Following the event, the same questionnaire, excluding attitude and practice-related questions, was distributed as a post-test. In January 2024, an online follow-up survey was sent to participants, using the same attitude and practice-related questions as in the pre-test to evaluate the attitude and practice changes in clinical practice. The participants did not have access to online or written materials while answering each test.

A panel of three paediatricians was invited to ensure the questionnaires were relevant, clear, and comprehensive. The questionnaire was then pilot-tested with healthcare personnel from different areas. The Cronbach’s alpha score for attitude and practice questions was greater than 0.8, indicating high internal consistency. VRC, HF, and ESL developed a detailed rubric for each question to assess the participants’ knowledge scores (Supplementary File 2). VRC and ESL independently evaluated each participant based on this rubric. The intraclass correlation coefficient (ICC) was greater than 0.9, indicating excellent reliability.

The questionnaires were written in Indonesian and consisted of four sections. The first section collected demographic information about the participants, including their age, sex, role in the healthcare facility, the name of the healthcare facility, employment status, and any previous training related to pneumonia in children.

The second section assessed the participants’ knowledge regarding the diagnosis and treatment of pneumonia in children. This section consisted of five short-answer questions with a maximum score of five for each question. The questions covered key areas such as the definition of pneumonia, symptoms, classifications of fast breathing, antibiotic prescriptions, and general danger signs.

The third section focused on the participants’ attitudes, utilising a 5-point Likert scale ranging from “strongly disagree, disagree, neutral, agree, and strongly agree”. This section consisted of twenty-four questions with a maximum score of five for each question. The statements addressed participants’ beliefs about the importance of educating parents regarding follow-up visits when symptoms of pneumonia persist, as well as their suspicions of danger signs in patients who cannot drink. The participants’ perspectives on the necessity of knowing a patient’s weight for medication dosage, the importance of inquiring about the duration of cough symptoms, and the significance of measuring the respiratory rate for a full 60 s were also explored.

Additionally, the section assessed their recognition of stridor and the need for further physical examination for general danger signs. Participants reflected on whether they believed educating parents about general danger signs was essential to ensure timely medical attention for children. Other statements explored their opinions on the relevance of the patient’s age in pneumonia diagnosis, the importance of examining the chest area, and the appropriate method for counting respiratory rates. Furthermore, participants considered their management of patients who appeared lethargic, as well as their views on whether a patient experienced seizures. The section also examined their beliefs about accurately calculating antibiotic doses according to the MoH RI’s recommendations and the necessity of educating parents about general danger signs after examinations.

In the fourth section, participants’ clinical practices were examined again using a 5-point Likert scale, but this time with the options “never, rarely, sometimes, often, and always.” This section consisted of fifteen questions with a maximum score of five for each question. Questions in this section included ensuring that the patient’s age and weight were recorded in the medical record, asking whether the patient could drink or breastfeed, and checking for symptoms such as vomiting, lethargy, and difficulty breathing. Other questions focused on important practices, such as allocating time to measure the respiratory rate, looking for chest indrawing and stridor, writing antibiotic prescriptions according to the Indonesian IMCI, relieving coughs with safe remedies, and educating caretakers on when to return to the healthcare facility and on general danger signs.

Statistical analysis

Descriptive statistics were employed to summarise participant characteristics. Categorical variables, including sex, role in healthcare, employment status, and previous training in pneumonia, were presented as frequencies and percentages. Continuous variables, such as age and scores from the questionnaires (knowledge, attitude, and practice), were reported as mean and standard deviation or median and interquartile range (IQR), depending on the distribution. The normality of continuous data was assessed using the Kolmogorov-Smirnov test. To compare pre-and post-test scores of KAP across all participants, either the paired t-test or the Wilcoxon signed-rank test was utilised as appropriate. For subgroup analysis based on roles in healthcare facilities, either the independent t-test or the Mann-Whitney U test was applied to assess differences in pre-test and post-test scores between physicians and nurses/midwives for KAP variables. Delta (post-test – pre-test) comparisons for specific indicators of knowledge and practice were also analysed using the independent t-test or the Mann-Whitney U test to evaluate any significant changes in scores. A p value of less than 0.05 was considered statistically significant. Data were analysed using SPSS^® Version 26.0 (IBM Corp.; 2019).

Study 3. Assessing challenges in diagnosing and treating pediatric pneumonia

Study design and setting

A qualitative study was conducted in Semarang, Central Java, Indonesia, in January 2024. The reporting of data followed the COnsolidated criteria for REporting Qualitative (COREQ) research guidelines [17] (Supplementary File 3). This study used focus group discussions (FGDs) to explore and gather insights into the challenges faced by healthcare providers at CHCs in diagnosing and managing pneumonia in children.

Study population

The study population consisted of healthcare providers, doctors, nurses, and midwives from CHCs who previously attended a half-day seminar and workshop about diagnosing and treating pneumonia in children held in collaboration with the Faculty of Medicine Universitas Diponegoro and the Semarang City Health Office in November 2024. This study received approval from the Ethical Committee of the Faculty of Medicine, Universitas Diponegoro (No. 548/EC/KEPK/FK-UNDIP/XI/2023). Written informed consent was obtained from all respondents before the FGDs. Participants were informed of their right to withdraw from the study at any time. Personal data were pseudonymised in the transcripts to ensure confidentiality.

Data collection

In collaboration with the Semarang City Health Office, we invited groups of doctors, nurses, and midwives from CHCs who had previously attended our seminars to participate in FGDs held at the Faculty of Medicine, Universitas Diponegoro. Three separate FGDs were conducted, each consisting of one professional group: doctors, nurses, and midwives. Purposeful sampling was used to select participants based on their roles in healthcare. Twelve doctors and twelve midwives were randomly selected from the participant list, while all ten nurses who came to the previous seminar were invited. Participants were selected to ensure representation from different CHCs. All selected participants were formally invited through an official letter issued by the Semarang City Health Office.

VRC (female, lecturer, medical doctor, clinical microbiologist), TAS (female, lecturer, medical doctor, board-certified psychiatrist), and AM (female, PhD in public health and medical anthropology) developed an open-ended, semi-structured discussion guide to encourage in-depth discussion. The discussion guide consisted of opening, transition questions, and key questions. The discussion opened with an introduction from the research team, who explained the study objectives, procedures, and confidentiality principles. Participants were informed about the FGD format, consented to audio and video recording, and provided written informed consent before the session began, followed by participants’ self-introductions and a description of their experience in managing paediatric pneumonia. Transition questions explored participants’ perceptions of pneumonia in children, its severity, associated risks, and the treatment required. Participants also discussed the prevalence rate of pneumonia in their CHCs, their current roles in the pneumonia program, the adherence to MoH RI or WHO guidelines, and the internal coordination among healthcare workers. Key questions focused on the challenges faced in diagnosing pneumonia, mainly related to respiratory rate count, antibiotic prescribing practices, and training provided to healthcare staff. The FGDs also addressed the quality of care provided under high patient loads, the process for evaluating pneumonia management, and antibiotic resistance. Participants were asked to share suggestions for improving pneumonia diagnosis and the appropriate dosing of the prescribed antibiotics. Follow-up prompts were provided to explore participants’ responses further. The guide was not pilot-tested, but further evaluated and improved during the FGD sessions.

During FGDs, AM acted as the moderator, VRC served as the observer, and TAS and LPF (female, lecturer, medical doctor) were the field notes writers. All FGDs were conducted in colloquial Indonesian. Data triangulation was performed by VRC and LPF through interviews with pneumonia program managers at the Semarang City Health Office.

Data analysis

Data were analysed using thematic analysis, following the six-step framework outlined by Braun and Clarke [23]. The analysis involved familiarising with the data, generating initial codes, and identifying themes that emerged from the discussions. The researchers constantly compared the FGDs to identify patterns, similarities, and differences in participants’ experiences and perspectives. All FGDs were audio- and video-recorded with participants’ consent and transcribed verbatim. Field notes were also taken to capture non-verbal cues and interactions among participants. VRC translated excerpts into English. Codes and themes were compared and corroborated by VRC and LPF. Data management and analysis were facilitated using ATLAS.ti for Mac Version 23.3.0 (ATLAS.ti Scientific Software Development GmbH; 2023), a software designed for coding and retrieving qualitative data. Transcripts were not returned to participants for comment or verification. An example of the thematic analysis process as part of the code tree is presented in Supplementary File 4.

Results

Study 1. Assessment of compliance with diagnostic and treatment guidelines among healthcare providers

Diagnostic compliance

This study retrospectively reviewed 921 medical records of paediatric patients to assess healthcare providers’ compliance with pneumonia diagnostic and treatment guidelines based on both WHO and MoH RI CPG standards. The majority of patients were male (56.9%), with a median age of 21 months (IQR 11–37 months) (Table 1).

Table 1.

Demographic characteristics of patients

Characteristics	Tanjung Pinang n (%) (N = 242)	Semarang n (%) (N = 483)	Jepara n (%) (N = 196)	Total n (%) (N = 921)
Sex
Male	139 (57.4)	285 (59.0)	100 (51.0)	524 (56.9)
Female	103 (42.6)	198 (41.0)	96 (49.0)	397 (43.1)
Age in months —Median (IQR)	20 (12–37)	22 (11–37)	21 (10–39)	21 (11–37)
Age groups (months)
0–1	0 (0.0)	2 (0.4)	0 (0.0)	2 (0.2)
2–11	58 (24.0)	119 (24.6)	58 (29.6)	235 (25.5)
12–59	184 (76.0)	362 (75.0)	138 (70.4)	684 (74.3)

Due to the differences in parameters between the WHO guideline and MoH RI CPG (Table 2), we conducted a comparative analysis based on both guidelines. According to the WHO guideline [4], 575 out of 921 (62.4%) patients were correctly classified as pneumonia. All 575 reportedly exhibited fast breathing, 558 (97.0%) had a cough, 63 (10.9%) experienced difficulty breathing, and 14 (2.4%) showed chest indrawing. Among the 346 patients (37.6%) who were misclassified, 309 (89.3%) still received antibiotics. Conversely, 54 out of 575 (9.4%) patients correctly classified as pneumonia did not receive antibiotic treatment (Fig. 3).

Table 2.

Parameter differences between the World Health Organization (WHO) guideline and the Clinical Practice Guidelines for Doctors in First-Level Healthcare Facilities (CPG) from the Ministry of Health of the Republic of Indonesia (MoH RI)

Parameter differences	WHO Guideline	MoH RI CPG
Respiratory rate threshold for pneumonia diagnosis	0-<2 months: ≥60x/min 2-<12 months: ≥50x/min 12–59 months: ≥40x/min	0-<2 months: >60x/min 2–12 months: >50x/min 13-60 months: >40x/min
Recommended treatment and dosage	oral amoxicillin 40 mg/kg	oral amoxicillin 25 mg/kg or oral cotrimoxazole 4 mg trimethoprim (TMP)/ 20 mg sulfamethoxazole (SMX)/kg
Dosing frequency	twice daily	twice daily
Treatment duration	three days	not explicitly stated

Fig. 3.

Case review flow based on the revised WHO guideline for the classification and treatment of childhood pneumonia at health facilities. Abbreviation: BW (body weight), DoB (date of birth), HPI (history of present illness), PE (physical examination), Tx (therapy)

According to the MoH RI CPG [5], 491 out of 921 (53.3%) patients with lower respiratory tract infections were misclassified as having pneumonia, and among these, 430 (87.6%) received antibiotics. Conversely, among the 430 patients correctly classified as pneumonia, 41 (9.5%) did not receive antibiotics (Supplementary File 5).

Choice of antibiotic, dosage, and treatment duration

According to WHO guideline [4], among the 575 patients correctly classified as having pneumonia, 421 (73.2%) received the recommended antibiotic, amoxicillin, while others were treated with cotrimoxazole, cefadroxil, or chloramphenicol (Fig. 3). In alignment with the MoH RI CPG [5], among the 430 patients correctly classified as having pneumonia, 321 (74.7%) received amoxicillin, 48 (11.2%) received cotrimoxazole, and the remainder were prescribed non-recommended antibiotics, such as cefadroxil and chloramphenicol (Supplementary File 5).

The prescribed daily doses of amoxicillin varied widely, ranging from 10.4 to 173.1 mg/kg, with a median dose of 41.7 mg/kg (IQR 33.3–55.4 mg/kg) (Fig. 4). Out of 421 patients correctly received amoxicillin, only 49 (11.6%) of correctly classified cases received the correct dosage, whereas 361 (85.7%) of children were prescribed an underdose (below the WHO-adapted range of 75–100 mg/kg/day) (Fig. 3). In comparison, under the MoH RI CPG, which recommends a dose 37.5% lower than the WHO guideline, out of 321 patients correctly received amoxicillin, 200 (62.3%) were still underdosed (below the MoH RI CPG-adapted range of 45–90 mg/kg/day) (Supplementary File 5).

Fig. 4.

Scatter plot of individual amoxicillin dosages compared to the WHO recommended dose (80 mg/kg/day) and acceptable range (75–100 mg/kg/day)

WHO and MoH-RI recommend twice daily (BID) amoxicillin for non-severe pediatric pneumonia primarily to support adherence. In our cohort, amoxicillin was prescribed thrice daily (TID) in 314 out of 421 children (74.6%). Among BID recipients (n = 104), the median per-dose amount was 25.2 mg/kg (IQR 17.8–34.5), with only 11 (4%) receiving ≥ 40 mg/kg/dose. For TID prescriptions, the median daily dose was 40 mg/kg/day (IQR 33.3–50.0), which is markedly lower than the BID-based daily target. Because β-lactam efficacy depends on the duration for which drug concentrations remain above the minimum inhibitory concentration (MIC), dosing frequency (BID vs. TID) directly affects pharmacodynamic adequacy, and the total daily dose alone may therefore misrepresent actual exposure.

The WHO guideline recommends a three-day antibiotic course. Amoxicillin in this study was prescribed for three days in 119 out of 421 cases (28.3%) (Fig. 3). While the MoH RI CPG does not explicitly specify the recommended antibiotic treatment duration, based on the available data, 89 of 321 (27.7%) patients were prescribed antibiotics for three days. The remaining prescriptions varied, with durations ranging from four to six days (Supplementary File 5). We were not able to assess the duration of treatment for oral suspension antibiotics due to insufficient data on prescribed quantities, which could result in misinterpretation of leftover medication as extended use.

Study 2. Knowledge, attitudes, and practices (KAP) of healthcare providers

Demographic characteristics

This cross-sectional study was conducted in November 2023 and January 2024 in Semarang, Central Java, Indonesia. One hundred ten healthcare workers participated in the seminar and workshop and completed pre- and post-test questionnaires to assess KAP with a completion rate of 100%. The median (IQR) age was 34 years (30–39 years), and 93.6% were female. Among the participants, 45 (40.9%) were physicians, 10 (9.1%) were nurses, and 55 (50.0%) were midwives. Only 14.5% had prior training in pneumonia management. A comparison of pre- and post-test scores revealed a significant overall improvement in KAP (p < 0.001) (Table 3).

Table 3.

Comparison of pre-test and post-test results from all participants

Variable (Maximum score)	Pre-test score Median (IQR)	Post-test score Median (IQR)	p
Knowledge (25)	13 (11–15)	20 (18–22)	< 0.001*
Attitude (120)	110 (104–116)	115 (110–119)	< 0.001*
Practice (75)	72 (69–75)	74 (71–75)	< 0.001*

IQR Interquartile range

*Variables analysed using the Wilcoxon signed-ranks test, p < 0.05

Knowledge

When comparing knowledge scores by professional role (Table 4), physicians scored significantly higher than nurses and midwives in both the pre-test (p = 0.045) and post-test (p = 0.020). Key knowledge indicators were further analysed (Table 5), including the definition of pneumonia, symptoms, fast breathing categories, antibiotic prescribing, and recognition of danger signs. Physicians had a significantly higher pre-test score than nurses and midwives (p = 0.003) in pneumonia definition, while no significant differences were observed in the remaining indicators.

Table 4.

Comparison of pre-test and post-test total score based on role in healthcare facility

Variable (Maximum score)	Physician score (n = 45) Median (IQR)	Nurse and midwife score (n = 65) Median (IQR)	p
Pre-test
Knowledge (25)	14 (12–15)	12 (11–15)	0.045*
Attitude (120)	112 (104–116)	109 (103–115)	0.276
Practice (75)	70 (67–74)	72 (69–75)	0.135
Post-test
Knowledge (25)	21 (19–22)	19 (18–21)	0.020*
Attitude (120)	115 (110–118)	115 (109–119)	0.653
Practice (75)	73 (69–75)	75 (72–75)	0.038*

IQR Interquartile range

*Variables analysed using the Mann-Whitney U test, p < 0.05

Table 5.

Pre-test, post-test, and delta (post-test – pre-test) comparison score of knowledge indicators based on role in healthcare facility

Knowledge indicators (Maximum score)		Physician score (n = 45)		Nurse and midwife score (n = 65)		p
		Median (IQR)	Mean rank	Median (IQR)	Mean rank
1. Pneumonia definition (5)	Pre-test	3 (3–4)	65.80	3 (2–3)	48.37	0.003*
	Post-test	4 (4–4)	59.63	4 (3–4)	52.64	0.171
	Delta	0 (0–1)	50.14	1 (0–1)	59.21	0.121
2. Pneumonia symptoms (5)	Pre-test	3 (3–4)	52.83	4 (3–4)	57.35	0.431
	Post-test	4 (4–5)	57.21	4 (4–5)	54.32	0.614
	Delta	1 (0–2)	57.60	1 (0–1)	54.05	0.552
3. Fast breathing categories (5)	Pre-test	1 (1–3)	56.81	1 (1–3)	54.59	0.670
	Post-test	5 (3–5)	55.01	5 (3–5)	55.84	0.866
	Delta	2 (2–4)	53.99	2 (2–4)	56.55	0.655
4. Antibiotic prescription for pneumonia (5)	Pre-test	2 (2–2)	58.24	2 (1–2)	53.60	0.338
	Post-test	4 (2–5)	62.30	4 (2–4)	50.79	0.051
	Delta	2 (0–3)	59.64	2 (0–3)	52.63	0.242
5. General danger sign (5)	Pre-test	3 (2–4)	61.18	3 (2–4)	51.57	0.111
	Post-test	4 (4–5)	58.04	4 (4–5)	53.74	0.452
	Delta	1 (0–2)	51.96	1 (0–2)	57.95	0.316

IQR Interquartile range

*Variables analysed using the Mann-Whitney U test, p < 0.05

Attitude

Attitude scores towards pneumonia diagnosis and treatment improved across all participant groups (Table 3). Median post-test attitude scores significantly increased compared to the pre-test scores (p < 0.001), indicating a positive change in attitude following intervention. No significant differences in pre- and post-test attitude scores were found among physicians, nurses, and midwives (Table 4).

Practice

Practice scores also improved significantly across all participant groups (p < 0.001, Table 3), demonstrating that the seminar and workshop enhanced practical skills. While pre-test scores did not significantly differ between groups (Table 4), nurses and midwives had significantly higher post-test scores than physicians (p = 0.038).

Table 6 depicts the pre- and post-test scores for various practice indicators by professional role. Nurses and midwives performed significantly better than physicians in measuring respiratory rate in both pre-test (p = 0.012) and post-test (p < 0.001). They also showed superior post-test performance in detecting chest indrawing (p = 0.028) and pre-test performance in managing cough with safe remedies (p = 0.027).

Table 6.

Pre-test, post-test, and delta (post-test – pre-test) comparison score of practice indicators based on role in healthcare facility

Practice indicators (Maximum score)		Physician score (n = 45)		Nurse and midwife score (n = 65)		p
		Median (IQR)	Mean rank	Median (IQR)	Mean rank
1. Ensure that the patient’s age is recorded in the medical record (5)	Pre-test	5 (5–5)	51.88	5 (5–5)	58.01	0.096
	Post-test	5 (5–5)	54.61	5 (5–5)	56.12	0.589
	Delta	0 (0–0)	58.69	0 (0–0)	53.29	0.194
2. Ensure the patient’s weight is recorded in the medical record (5)	Pre-test	5 (5–5)	55.08	5 (5–5)	55.79	0.842
	Post-test	5 (5–5)	54.66	5 (5–5)	56.08	0.608
	Delta	0 (0–0)	54.13	0 (0–0)	56.45	0.530
3. Ask whether the patient is able to drink or breastfeed (5)	Pre-test	5 (5–5)	53.28	5 (5–5)	57.04	0.443
	Post-test	5 (5–5)	52.60	5 (5–5)	57.51	0.194
	Delta	0 (0–0)	54.39	0 (0–0)	56.27	0.678
4. Ask whether the patient vomits everything (5)	Pre-test	5 (4–5)	56.43	5 (4–5)	54.85	0.758
	Post-test	5 (5–5)	50.08	5 (5–5)	59.25	0.051
	Delta	0 (0–1)	55.92	0 (0–0)	55.21	0.886
5. Ask whether the patient had convulsions (5)	Pre-test	5 (4–5)	53.14	5 (4–5)	57.13	0.455
	Post-test	5 (4–5)	54.06	5 (5–5)	56.50	0.589
	Delta	0 (0–0)	50.01	0 (0–0)	59.30	0.080
6. See if the patient is lethargic or unconscious (5)	Pre-test	5 (4–5)	54.28	5 (4–5)	56.35	0.629
	Post-test	5 (5–5)	54.02	5 (5–5)	56.52	0.484
	Delta	0 (0–1)	53.58	0 (0–1)	56.83	0.554
7. Ask whether the patient has a cough (5)	Pre-test	5 (5–5)	55.61	5 (5–5)	55.42	0.951
	Post-test	5 (5–5)	54.11	5 (5–5)	56.46	0.369
	Delta	0 (0–0)	55.12	0 (0–0)	55.76	0.872
8. Ask whether the patient has difficulty in breathing (5)	Pre-test	5 (3–5)	55.72	5 (4–5)	55.35	0.927
	Post-test	5 (4–5)	54.02	5 (5–5)	56.52	0.484
	Delta	0 (0–1)	54.61	0 (0–1)	56.12	0.782
9. Allocate a full minute to meticulously measure the respiratory rate (5)	Pre-test	4 (5–5)	47.27	5 (5–5)	61.20	0.012 *
	Post-test	5 (5–5)	44.58	5 (5–5)	63.06	< 0.001*
	Delta	0 (0–0)	53.40	0 (0–0)	56.95	0.382
10. Look for chest indrawing (5)	Pre-test	5 (4–5)	52.08	5 (5–5)	57.87	0.162
	Post-test	5 (5–5)	50.72	5 (5–5)	58.81	0.028*
	Delta	0 (0–1)	59.72	0 (0–0)	52.58	0.143
11. Look and listen for stridor (5)	Pre-test	5 (5–5)	50.40	5 (5–5)	59.03	0.080
	Post-test	5 (5–5)	55.58	5 (5–5)	55.45	0.973
	Delta	0 (0–0)	55.11	0 (0–0)	55.77	0.886
12. Write antibiotic prescriptions correctly according to the Indonesian Integrated Management of Childhood Illness (5)	Pre-test	5 (4–5)	52.96	5 (4–5)	57.26	0.415
	Post-test	5 (5–5)	51.82	5 (5–5)	58.05	0.109
	Delta	0 (0–1)	55.52	0 (0–1)	55.48	0.994
13. Relieve the cough with a safe remedy (5)	Pre-test	4 (4–5)	48.27	5 (4–5)	60.51	0.027*
	Post-test	5 (4–5)	52.09	5 (5–5)	57.86	0.245
	Delta	0 (0–1)	59.71	0 (0–0)	52.58	0.187
14. Educate the caretaker when to return to healthcare facility (5)	Pre-test	5 (5–5)	53.94	5 (5–5)	56.58	0.461
	Post-test	5 (5–5)	52.89	5 (5–5)	57.31	0.091
	Delta	0 (0–0)	54.62	0 (0–0)	56.11	0.715
15. Educate the caretaker on the general danger signs (5)	Pre-test	5 (5–5)	53.94	5 (5–5)	56.58	0.461
	Post-test	5 (5–5)	55.61	5 (5–5)	55.42	0.951
	Delta	0 (0–0)	57.10	0 (0–0)	54.39	0.475

IQR Interquartile range

*Variables analysed using the Mann-Whitney U test, p < 0.05

Study 3. Challenges in diagnosis and treatment of paediatric pneumonia

Demographic characteristic

This qualitative study explored healthcare providers’ perceptions and practices regarding diagnosing and treating paediatric pneumonia. Out of the 34 healthcare providers invited to participate in the study, one midwife missed the FGDs due to personal reasons. The FGDs were conducted over three consecutive days in a closed room attended only by the research team and participants. Most participants were female (97.0%), with only one male nurse. The median age of participants was 35 years (IQR 28.5–43.5). Midwives were generally older than doctors. Most participants (75.8%), including all nurses, were civil servants. The median duration of experience in pneumonia program management was 24 months (IQR 12–60), with doctors and midwives having longer experience (median 60 months; IQR 18–60 for physicians and 12–108 months for midwives).

Data saturation

Data saturation was achieved after conducting one 90–120–minute FGD with each professional group. Each group was homogeneous in terms of professional roles, work environments, and experience with pneumonia program management, which enabled the emergence of clear and consistent themes during each FGD session.

The FGDs explored key topics, such as the participants’ roles, challenges, and suggestions for improving pneumonia program management. An experienced moderator facilitated the discussions, encouraging open dialogue and ensuring that all participants contributed. The recurrence of themes, consistent responses, and the absence of new information indicated data saturation, and no additional FGDs were deemed necessary.

Qualitative data analysis

Qualitative data analysis revealed five overarching themes: perceptions and understanding of pneumonia, diagnosis and management practices, antibiotic prescribing and resistance, challenges in clinical practice, and recommendations for improvement.

Theme 1: perceptions and understanding of pneumonia

Participants generally viewed pneumonia as an important health concern, particularly in children, often describing it as “a dangerous disease if not handled properly” (Nurse 7 (N7)). However, compared to pneumonia, primary healthcare programs prioritised non-communicable diseases (NCDs) ”because the focus [of NCD] is on the productive age group, which tends to consume more healthcare funding” (Doctor 2 (D2)), often leaving pneumonia marginalised within the system.

Information on pneumonia was primarily assessed through professional organisations, seminars, or updates shared by the Semarang City Health Office, often disseminated via meetings or WhatsApp groups. One participant shared, “It’s mostly just from this [meeting], the internet, or from the previous program holder” (N5).

Theme 2: diagnosis and management practices

“When diagnosing pneumonia, we usually refer to the IMCI” (Midwife 2 (M2)). However, some doctors rely on older medical training, sometimes leading to disagreement among staff. Another nurse recounted, “Even though, according to the IMCI chart, it is already considered pneumonia, but they (doctors) still refuse” (N8). Furthermore, “Not all community health centres have the necessary facilities for all IMCI examinations” (D9).

In addition, physical examination can be challenging, particularly in counting respiratory rates in non-cooperative children. Healthcare staff described various workaround strategies, like having mothers breastfeed the ill baby or observing from a distance. However, counting inconsistencies remained, for example, “our midwives counting for less than one full minute or 30 seconds and then doubling the result” (N5), and errors in data recording into the system.

Theme 3: antibiotic prescribing and resistance

Antibiotic use was mostly aligned with the IMCI guideline, with amoxicillin as the first-line treatment. However, some staff used alternative regimens or different dosages. One doctor remarked, “I also provided the pharmacy with the guideline book [IMCI] to show that this [amoxicillin] is already established, along with the dosage and administration method” (D9). Regarding prescribing antibiotics, some CHCs ensure that “antibiotic prescriptions should only be issued by doctors” (D11). If a doctor is unavailable to examine the patient, other healthcare providers will prescribe the medication, but must first confirm it with the doctor.

Additional concerns included treatment non-completion: “the antibiotics weren’t taken until finished as prescribed” (D9), poor parental understanding regarding treatment history, and inappropriate self-medication.

Theme 4: challenges in clinical practice

Participants highlighted heavy patient loads and overlapping responsibilities as significant challenges, particularly due to human resources issues: “lack of doctors” (D2) and “because the tasks overlap, it feels like one doctor has to do it all” (D11).

There was consensus on the need for better training regarding pneumonia management: “there hasn’t been any specific training on pneumonia yet” (M7). Participants from the FGDs expressed concerns about inconsistent training, corroborated by the triangulation interview, which highlighted that training sessions were not conducted frequently enough due to “no budget for that [training]” (N8).

Theme 5: recommendations for improvement

Participants emphasised the need for more focused training, especially on respiratory rate: “focus on the correct way to count breaths” (M8) and pneumonia diagnosis. They recommended that training sessions be conducted in “a smaller forum” (M8), formally coordinated by the health department. These sessions should include speakers from various health professions, involve all staff working with paediatric pneumonia, at least be held annually, and focus on improving skills as well as knowledge.

Both FGDs and triangulation interviews emphasised the need to improve antibiotic prescribing practices and raise awareness about antimicrobial resistance: “I have also reminded my colleagues in the network multiple times to supervise and emphasise that antibiotics should not always be given” (D9).

Discussion

This study provides a comprehensive analysis of paediatric pneumonia management using three interrelated approaches: (1) assessing compliance with WHO and MoH RI guidelines (2), evaluating healthcare providers’ knowledge, attitudes, and practices, and (3) exploring challenges in diagnosis and treatment, emphasising guidelines adherence, the importance of practical training, and management barriers.

The first component revealed marked noncompliance with WHO and MoH RI guidelines for paediatric pneumonia. During the study period, two national guidelines for pneumonia management were concurrently available in CHCs: the WHO guideline adopted by the MoH RI in the 2015 IMCI Chart Book and the MoH RI CPG. These guidelines showed some discrepancies in respiratory rate cut-offs and recommended antibiotic dosing, which may have contributed to variations in healthcare workers’ adherence observed in this study. Over 37.6% and 53.3% of cases were incorrectly classified as pneumonia according to the WHO and MoH RI CPG criteria, respectively, leading to unnecessary antibiotic prescriptions. This underscores the need for improved clinical training in paediatric pneumonia to support accurate diagnosis and guideline-based treatment. Previous studies have shown that clinical training improves diagnostic accuracy and treatment outcomes and can equip healthcare providers with the necessary skills to manage pneumonia effectively [18, 19]. Interestingly, although being diagnosed with pneumonia, a substantial proportion of children in our study did not receive antibiotics. Such under-treatment, stemming primarily from non-adherence to guidelines, is particularly concerning because it may allow the disease to progress and increase the likelihood of complications. Data from an outpatient cohort showed that around 20% of children diagnosed with pneumonia were not treated with antibiotics. This group had a higher number of treatment failures compared with those who received antibiotic therapy [20]. Moreover, retrospective analyses among hospitalised children have indicated that not receiving antibiotic treatment was linked with a longer duration of hospitalisation and a higher chance of readmission [21]. In community settings, non-adherence to antibiotic regimens has been implicated in treatment failure among children with fast-breathing pneumonia [22].

Issues such as antibiotic underdosing and incorrect frequency, as observed in this study, may result from clinical habits and limited access to current information. Lau et al. [23] also reported frequent antimicrobial underdosing of common antibiotics like amoxicillin for pneumonia in paediatric emergency departments. In addition, Roumeliotis et al. [24] highlighted that dosing errors are the most common type of medication error in paediatric practice, often due to the complexities of weight-based dosing. When antibiotics are given at subtherapeutic doses, they may fail to fully treat the infection, prolong recovery, and at the same time create conditions that favour bacterial mutations and the development of resistance [25]. As a time-dependent antibiotic, amoxicillin requires maintaining concentrations above the minimum inhibitory threshold to effectively combat infections. Previous studies have shown that inadequate dosing contributes to the emergence of resistant bacterial strains, and that ensuring the antibiotic dose remains above the MIC is crucial to preventing resistance [26]. These findings highlight the need for targeted interventions to improve antibiotic prescribing. For example, Sarraf et al. [27] showed improved antibiotic prescription practices among continuous medical education participants, while integrating antibiotic stewardship into medical curricula can improve responsible antibiotic prescription among medical students [28]. In addition to formal education, implementing audit and feedback mechanisms can reinforce the importance of adhering to guidelines. Walsh et al. [29] suggested that simply providing education may not be sufficient; instead, combining educational initiatives with audits of prescribing practices can lead to substantial changes in clinician behaviour.

The second part of this study examined KAP among healthcare workers. Significant improvements in post-test scores suggest the value of targeted training. However, long-term changes in attitudes and practices should also be evaluated next to immediate knowledge gains [30]. Compared to the physicians’ group, the nurses’ and midwives’ groups demonstrated significantly better practice in measuring respiratory rates. Bruyneel et al. [31] explained how power distance and collegial relations could affect the collaboration between nurses and physicians, implying that nurses often take on more hands-on roles in patient care. Similarly, Peltonen et al. [32] indicated that nurses often have more direct patient interaction and are responsible for ongoing patient monitoring. These findings suggest that comprehensive training, not only on knowledge but also held together with workshops on specific practical tasks, such as respiratory count in training, may result in better compliance with pneumonia guidelines across diverse healthcare roles.

The qualitative analysis from the third part of this study further emphasises the challenges healthcare providers encounter in diagnosing and managing paediatric pneumonia. Key barriers included inadequate formal and regular training, limited resources, and high patient loads. Participants highlighted the value of targeted, practical skills training, including respiratory rate counting, preferably in small-group formats. As noted by Pervaiz et al. [19], training programs that include hands-on practice and direct observation by trainers lead to better skill acquisition and retention. Similarly, Sun et al. [33] demonstrated that targeted training increases healthcare workers’ confidence in their knowledge and skills related to specific clinical practices. Regarding the central theme of antimicrobial stewardship, participants expressed concerns about inappropriate antibiotic use and emphasised the importance of responsible prescribing practices to prevent antimicrobial resistance. Katwyk et al. [34] underscored the need for healthcare workers to be able to distinguish between bacterial and viral infections to make informed prescribing decisions.

While this study provides insight into critical aspects of paediatric pneumonia management, certain limitations must be acknowledged. The limited sample size and regional focus may limit the generalizability of the findings. Future studies should aim to expand the geographical scope, incorporating a wider variety of healthcare settings, and assess the long-term effects of targeted training programs on diagnostic accuracy and antibiotic adherence. Another limitation is that dosing adequacy was assessed solely based on numerical comparison of the daily dose of two guidelines used in this study, without considering the pharmacokinetic and pharmacodynamic properties of amoxicillin, such as time above the MIC (T > MIC). At the end, despite significant improvements in KAP in healthcare providers, these findings do not ensure consistent or sustained implementation of the guidelines in daily clinical practice. Additional longitudinal or implementation studies are necessary to ascertain whether better KAP correlates with enhanced real-world performance.

Conclusions

This study highlights areas for improvement in paediatric pneumonia management, particularly regarding training and adherence to treatment guidelines. As this research focused on KAP rather than clinical outcomes, the findings should be interpreted as reflective of potential areas for improvement rather than direct measures of clinical performance. At the time of the study, the use of two different pneumonia guidelines suggested that Indonesia was in a transition period in its pneumonia management policy. The release of the 2022 Indonesian IMCI guideline helped to bridge the differences between the existing protocols and brought national practice closer to WHO standards. This change is expected to improve consistency and the overall quality of paediatric pneumonia care in CHCs. Based on the results, the following recommendations are proposed:

1. Promotion and implementation of the national paediatric pneumonia guideline

The government should promote and strengthen a unified, comprehensive, and regularly updated national guideline to standardise the diagnosis and treatment of paediatric pneumonia across different healthcare settings.

• 2. Implementation of an enhanced training program

Healthcare workers should regularly participate in a training program on the management of paediatric pneumonia and other common childhood infections, with a strong emphasis on practical skills and appropriate antibiotic prescribing.

• 3. Strengthening antibiotic stewardship

Educating healthcare providers, particularly physician prescribers, on the risks associated with inappropriate antibiotic use to increase awareness of antibiotic resistance and adherence to antibiotic guidelines.

Abbreviations

CAP

Community-acquired pneumonia

CHC

Community health centre

CPG

Clinical Practice Guidelines for Doctors in First-Level Healthcare Facilities

COREQ

COnsolidated criteria for REporting Qualitative research

FGD

Focus group discussion

IMCI

Integrated Management of Childhood Illness

IQR

Interquartile range

KAP

Knowledge, attitudes, practices

MoH RI

Ministry of Health of the Republic of Indonesia

SMX

Sulfamethoxazole

TMP

Trimethoprim

WHO

World Health Organization

Authors’ contributions

VRC, ESL, HF, QdM, MIdJ conceived the study. All authors contributed to the study design. VRC, ESL, HF, TAS, LPF, AM contributed to data collection and data analysis. All authors contributed to data interpretation. VRC drafted the manuscript. All authors critically revised the manuscript. All authors approved the submitted version and have agreed to both to be personally accountable for the author’s contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.

Funding

This research was supported by an institutional fee from Universitas Diponegoro, Semarang, Indonesia, and the Radboud university medical center, Nijmegen, The Netherlands. The funders of the study had no role in the study design, data collection, data analysis, data interpretation, or writing of the manuscript.

Data availability

The dataset supporting the conclusions of this article is included within the article and its additional files.

Declarations

Ethics approval and consent to participate

The research was performed in accordance with the Declaration of Helsinki. The dataset used for this research was de-identified to ensure participant confidentiality. The Ethical Committee of the Faculty of Medicine Universitas Diponegoro approved the study protocols: No.57/EC/KEPK/FK-UNDIP/III/2023, No. 458/EC/KEPK/FK-UNDIP/IX/2023, No. 548/EC/KEPK/FK-UNDIP/XI/2023. Study participants were informed about the study’s objectives, purposes, privacy measures, and confidentiality protocols. They were assured of their right to withdraw from the study at any time without consequence. Written informed consent was obtained from all participants prior data collection.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.