Time to recovery and its predictors among under-five children with severe pneumonia at Jimma town public hospitals, Southwestern Oromia, Ethiopia: a retrospective follow-up study

Abstract

Background

Severe pneumonia is a leading cause of morbidity and mortality in children under-five years of age. In Ethiopia, it is a priority disease under routine surveillance. Several factors have been identified as influencing the length of recovery time in children with severe pneumonia; however, evidence on recovery patterns and their predictors in Jimma, where severe pneumonia remains highly prevalent, is scarce. This study aimed to assess the time to recovery from severe pneumonia and its predictors among children under-five years of age admitted to Jimma town public hospitals.

Methods

A facility-based retrospective follow-up study was conducted among 272 under-five children admitted with severe pneumonia between July 1, 2021 and July 30, 2024, at public hospitals in Jimma town. A simple random sampling technique was used to select eligible medical records. A structured tool was used to extract data from medical records. The Kaplan–Meier method was used to estimate survival and group differences were assessed via the log-rank test. Variables with P < 0.25 in the bivariate analysis were entered into the multivariable Cox proportional hazards regression to identify independent predictors of recovery time, with significance set at p < 0.05.

Results

A total of 272 medical records were reviewed and retained for analysis. The median age was 10 months and 152 (55.9%) patients resided in rural areas. In total, 219 (80.5%) patients achieved clinical recovery, and the total accumulated person-days at risk were 1,913 days. The overall median recovery time from severe pneumonia was 5 days (IQR: 3–9). Children who were malnourished (AHR = 0.57, 95% CI: 0.39–0.84), not exclusively breastfed (AHR = 0.49, 95% CI: 0.31–0.80), or not fully vaccinated (AHR = 0.72, 95% CI: 0.53–0.98) had a lower hazard of recovery than children with no malnutrition, exclusively breastfed and fully vaccinated, respectively.

Conclusions

The overall median recovery time was 5 days. Recovery from severe pneumonia was delayed among under-five children who were malnourished, not exclusively breastfed or not fully vaccinated at admission. Future efforts should focus on strengthening child nutrition, promoting exclusive breastfeeding and ensuring full vaccination coverage to reduce recovery time in under-five children with severe pneumonia.

Clinical trial number

Not applicable.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12887-026-07382-5.

Introduction

Severe pneumonia is characterized by a child presenting with a cough or difficulty breathing, accompanied by any general danger sign, chest in-drawing, or stridor when the child is calm [1]. It is a critical form of lower respiratory tract infection with severe respiratory distress and remains the leading infectious cause of death among children under-five years of age [2].

Globally, the mortality rate from lower respiratory infections, in which severe pneumonia is a critical subset for children under 5 years, was 94.8 deaths per 100,000 person-years in 2023. Sub-Saharan Africa bears a substantial health burden from severe pneumonia, contributing to some of the highest child mortality rates among children under-five years of age [3]. This remains a major public health challenge in the region, particularly in Ethiopia, where limited access to timely healthcare services exacerbates the burden [4, 5].

Ethiopia, one of the five countries contributing to nearly half of these deaths, continues to face a significant public health challenge with respect to pneumonia [6, 7]. Ethiopia’s healthcare system has made significant improvements in reducing child mortality, but severe pneumonia remains a major concern, particularly in rural and underserved areas [8]. Risk factors such as malnutrition, lack of vaccination, delayed healthcare access, upper respiratory tract infections and poor sanitation exacerbate the burden of severe pneumonia in Ethiopian children [9–11]. In Ethiopia, limited data on predictors of time to recovery, particularly in the Jimma area, remain one of the gaps that may reduce the effectiveness of targeted interventions and slow progress toward global child survival goals. In Jimma, the burden of severe pneumonia is particularly concerning, with a high mortality rate of 16% reported among children admitted with this condition [12]. Despite this significant burden, the factors influencing recovery time among children hospitalized with severe pneumonia have not been well explored in this area.

Recovery time is a critical indicator of healthcare efficiency and disease management. Delayed recovery from severe pneumonia leads to prolonged hospitalization, imposing a significant financial burden on families and healthcare systems, particularly in resource-limited settings [13]. In Ethiopia, the average medical expenditure for an inpatient visit due to severe pneumonia is $64, which exceeds the median monthly wage, indicating the significant financial burden it places on families [14]. Additionally, delayed recovery can result in prolonged hospital stays, increasing the risk of hospital-acquired infections [15].

Studies from different parts of Ethiopia, including Northeast Ethiopia, Northwest Ethiopia, Southwest Ethiopia, East Wallaga, Hossana, Debre Tabor and Gondar, have reported varying median recovery times, ranging from three to eight days [16–20]. However, previous studies in the Jimma area [9, 10, 12, 21] have focused primarily on factors affecting poor treatment outcomes among children under-five years of age with severe pneumonia without exploring the recovery time and its predictors. There is a gap in evidence regarding recovery patterns and associated factors at public hospitals in Jimma town, where severe pneumonia has significantly impacted children under-five years of age. As key healthcare hubs and referral centers for southwestern Ethiopia, these hospitals serve diverse patient populations. Hence, this study aimed to assess the time to recovery and its predictors in children under-five years of age with severe pneumonia in Jimma town public hospitals, Southwestern Oromia, Ethiopia.

Methods and materials

Study setting and period

Jimma town is located 354 km southwest of Addis Ababa. Shenen Gibe General Hospital (SGGH) and Jimma University Medical Center (JUMC) were the only public hospitals in Jimma town. Both hospitals provide pediatric outpatient and inpatient services. JUMC serves as a tertiary referral hospital for the whole southwestern part of Ethiopia, for nearly 20 million people from Oromia, Gambella, southwestern Ethiopia and Benshangul, whereas SGGH is a regional hospital located at other ends of the town and serves communities in the town and surrounding areas. JUMC has a total bed capacity of approximately 970 beds, 220 of which are allocated for intensive care units and 750 for inpatient services. The pediatric department is organized into four units: the medical ward, oncology ward, surgery ward and outpatient department. The pediatric medical ward, where children with severe pneumonia are admitted, has 65 beds. Between July 1, 2021 and July 30, 2024, a total of 267 under-five children with severe pneumonia were admitted to JUMC. Similarly, SGGH provides inpatient and outpatient services to more than 500,000 people in its catchment area, with 80 inpatient beds and six delivery couches. The pediatric department at SGGH has 23 beds and a total of 447 under-five children with severe pneumonia were admitted between July 1, 2021 and July 30, 2024.

This study was conducted from January 21, 2025, to February 14, 2025, at JUMC and SGGH, which are located in Jimma town.

Study design

A health facility-based retrospective follow-up study was conducted in under-five children admitted to Shenen Gibe General Hospital and Jimma University Medical Center with severe pneumonia from July 1, 2021 to July 30, 2024.

Population

Source population

All under-five children were diagnosed with severe pneumonia and admitted to the pediatric ward of Jimma town public hospitals from July 1, 2021 to July 30, 2024.

Study population

The study population consisted of all randomly selected eligible medical records of under-five children with severe pneumonia who were admitted to Jimma University Medical Center and Shenen Gibe General Hospital between July 1, 2021 and July 30, 2024.

Study unit

The medical record of each under-five child admitted with severe pneumonia to Jimma University Medical Center and Shenen Gibe General Hospital between July 1, 2021 and July 30, 2024.

Eligibility criteria

Inclusion criteria

All children aged under-five years with severe pneumonia who were admitted to JUMC and SGGH from July 1st, 2021, to July 30th, 2024, with sufficient medical records containing key information such as baseline nutritional and clinical characteristics of the children, admission date, discharge date and discharge status were included in the study.

Exclusion criteria

Medical records of under-five children with severe pneumonia that were lost or unavailable at the time of data collection were excluded. In addition, medical record numbers with unspecified ages in the logbooks and charts lacking documented admission dates, discharge dates, or clinical outcomes were excluded. Children transferred from another health facility after initiation of treatment for severe pneumonia were also excluded.

Sample size determination, sampling technique and procedure

Sample size determination

The sample size was calculated via the log-rank test (Freedman method) in Stata version 15, which is based on predictors of recovery time from severe pneumonia among children under-five years of age identified in previous studies [16, 20, 22, 23]. These included comorbidities, delayed care seeking (> 5 days), danger signs at admission, stunting, vaccination status, nutritional status and underweight (Table 1).

Table 1.

Sample size calculation for recovery time and its predictors in under-five severe pneumonia, Jimma, 2025

Predictors	References	Hazard ratio	Significance level	Power	Proportion of recovery	Number of events	Sample size
Comorbidities	[16]	0.49	0.05	90	0.76	90	120
Delayed presentation	[22]	0.64	0.05	90	0.89	219	246
Danger sign	[22]	0.61	0.05	90	0.89	180	202
Stunting	[22]	0.62	0.05	90	0.89	191	216
Vaccination status	[16]	0.35	0.05	90	0.76	46	60
Underweight	[20]	0.56	0.05	90	0.93	133	144
Nutritional status	[23]	0.65	0.05	90	0.92	234	254

A hazard ratio of 0.65 for nutritional status [23] yielded the largest required sample size of 254, with 234 events. Accordingly, by taking a recovery probability of 0.92 [23], a 5% significance level, a 95% confidence interval and 90% power, the total sample size required to achieve the estimated number of events was calculated via the following formula.

n =

• n = total sample size needed

• E = the number of events to be observed, which is 234, was calculated by Stata by taking nutritional status as the predictor, resulting in the largest sample size of 254.

• Pr (E) = the probability that recovery will occur, which is 0.92.

Finally, after adding 10% to the sample size to account for incomplete records, the final sample size of this study was 279.

Sampling technique and procedure

A simple random sampling technique was used to select study participants from the pediatric ward registration books. The sampling frame comprised all medical records of under-five children admitted with severe pneumonia at JUMC and SGGH between July 1, 2021 and July 30, 2024. During this period, 267 and 447 under-five children with severe pneumonia were admitted to JUMC and SGGH, respectively (see Supplementary Material 1). Using proportional allocation, 104 children were selected from JUMC and 175 from SGGH, yielding a total sample of 279. Eligible records were identified through a detailed review of pediatric ward documents, including admission and discharge registers, therapeutic feeding program registers and patient cards, using medical record numbers (MRNs). All eligible MRNs were first listed in a single column in Excel. Random numbers were then generated for each record and the list was sorted accordingly. Finally, the top 279 medical records were selected. For cases with incomplete medical records, a cross-check was conducted using multiple data sources, such as medical charts, nurse notes, or discharge summaries, to fill any gaps. If the missing information remained inaccessible, the records were excluded from the analysis.

Data collection technique and procedure

The structured English version of the data extraction tool was adopted from a peer-reviewed study conducted in Addis Ababa, as detailed in online supplemental file 3 [24]. Using this tool, sociodemographic and clinical data were extracted from medical records. The data collection was carried out by trained pediatric nurses working in the pediatric ward. Four pediatric nurses (two from each hospital) were recruited as data collectors. These nurses and two supervisors received a one-day training session covering the objectives of the study, the contents of the data extraction tool, the data collection procedures, the importance of maintaining data quality and strategies for minimizing errors during the process.

Study variables

The outcome variable for this study was recovery from severe pneumonia, which was dichotomized into event (recovered = 1) and censored = 0 if children were referred to another facility, died, absconded, left against medical advice or discharged for any reason without achieving recovery during the study period.

Dependent variable

Time to recover from severe pneumonia.

Independent variables

The independent variables included sociodemographic characteristics such as age, sex and residence; the presence of comorbidities, including severe acute malnutrition, congenital heart disease, rickets, pertussis, Down syndrome and other conditions;

Nutritional status indicators such as stunting, wasting, underweight, exclusive breastfeeding and clinical factors were assessed at admission, including the presence of danger signs (head nodding, impaired consciousness, hypoxia, vomiting and abnormal body movements), baseline oxygen saturation and baseline body temperature.

The immunization status (fully vaccinated, partially vaccinated, unvaccinated, or unknown), sunlight exposure and drug regimen received (crystalline penicillin, ceftriaxone, ampicillin and gentamycin, or other treatments) were also considered. Additionally, treatment outcomes of severe pneumonia were included as independent variables.

Operational and term definitions

Recovery

Children who recovered from severe pneumonia and were discharged from the hospital on the basis of the Integrated Management of Childhood Illness (IMCI) criteria. This included resolution of respiratory distress, absence of hypoxemia (oxygen saturation ≥ 90%), ability to feed well, tolerance of oral medication and parents’ understanding of warning signs of pneumonia [25].

Time to recovery

Refers to the time from the date of admission to recovery from severe pneumonia, which was determined for each participant.

Event

This refers to recovery from severe pneumonia during the follow-up period. This outcome was recorded for each participant in the admission and discharge register and determined on the basis of the IMCI criteria [25]. It was coded as 1 if recovery occurred and 0 if it did not.

Censored

This refers to children who were referred to another facility, died, absconded, left against medical advice, or discharged for any reason without achieving recovery during the study period.

Danger signs

If the child is unable to drink or breastfeed, vomits everything, convulsions, lethargy, or unconsciousness [1].

Vaccination status

Full vaccination status was defined as the following: children who had completed all forms of vaccinations; partially vaccinated (children who had taken at least one dose of PCV); and non-vaccinated (children who had never been vaccinated with PCV or other vaccines) [24].

Late presentation

Refers to seeking medical care after 5 days of illness [22].

Early presentation

Refers to seeking medical care within the first 5 days of illness [22].

Severe acute malnutrition

Children with a MUAC less than 11.5 cm and/or children with bilateral edema regardless of their MUAC [1].

Moderate acute malnutrition

Children under-five years of age who are underweight (indicator: weight for age<-2 Z score) [1].

Incomplete records

A medical record was considered incomplete if critical data required for analysis, including treatment initiation date, drug regimen received, baseline nutritional and comorbidity status, or treatment outcome date, were missing.

Data processing and analysis

Data were collected via KoboCollect version 2024.2.4 and analyzed using Stata version 15 after data cleaning and coding. The time to recovery from severe pneumonia was dichotomized (recovered/censored) and described using medians and percentages. Kaplan-Meier curves were used to compare survival functions and estimated recovery times, while log-rank tests revealed significant differences between predictor groups (p < 0.05).

To identify factors associated with recovery time after severe pneumonia, bivariate analysis was conducted using Cox proportional hazards regression. Before the Cox proportional hazards regression model was fitted, multicollinearity among independent variables was assessed via the variance inflation factor (VIF). The mean VIF was 1.55 and all the variables had VIF values less than 5. The proportional hazards assumption was evaluated statistically via the Schoenfeld residuals test for individual covariates and the global test (p > 0.05) (see Supplementary Material 2), and the model’s goodness-of-fit was evaluated via the likelihood ratio test. The likelihood ratio chi-square value was 71.02 with 12 degrees of freedom (p < 0.001). Factors showing an association with the outcome variable at a p-value of less than 0.25 in the bivariate analysis were included in the multivariable model. The independent effects of variables on recovery time were examined using a multivariate Cox proportional hazards model. A significant association between recovery time and covariates was determined with a p-value of less than 0.05 and adjusted hazard ratios with 95% confidence intervals (CI).

Data quality management

Before data collection, training was given to the data collectors. The data extraction tool was pretested on 5% of the total sample size (14 records in total, with 7 records selected from each hospital) using a simple random sampling technique. The pretest was conducted using patient records dated before 2021, which were used exclusively for pretesting and excluded from the study analysis. On the basis of the findings from the pretest, necessary modifications were made to improve the clarity and functionality of the tool before the actual data collection began.

During data collection, the investigator followed the entire process, whereas supervisors monitored the data collectors daily to ensure strict adherence to the protocol and provide immediate guidance when necessary. The investigator reviewed the collected data at the end of each day and any discrepancies identified were resolved promptly by revisiting the medical records. Continuous communication between the data collectors, supervisors and investigator ensured that any issues encountered were addressed immediately.

After data collection, the investigator and supervisors reviewed the extracted data to verify its completeness and accuracy. The collected data were subsequently cleaned and entered into KoboCollect version 2024.2.4 to minimize entry errors.

Results

Sociodemographic characteristics of the participants

A total of 714 under-five children were admitted with severe pneumonia between July 1, 2021 and July 30, 2024, in public hospitals in Jimma town. A total of 279 medical records were randomly selected and screened for eligibility. Seven records were excluded due to missing charts or incomplete baseline information. Finally, 272 eligible records were included in the final dataset, resulting in a completeness rate of 97.5%. The median age of the participants was 10 months (IQR: 6–24) and 158 (58.1%) were male. More than half of the children, 152 (55.9%), resided in rural areas (Table 2).

Table 2.

Socio-demographic, vaccination and nutritional characteristics of under-five severe pneumonia cases, Jimma town public hospitals, 2021–2024

Variables	Category	Status		Total (N = 272) N (%)
		Censored (N = 53) N (%)	Recovered (N = 219) N (%)
Age	0–5 months	14 (5.15)	46 (16.91)	60 (22.06)
	6–11 months	17 (6.25)	71 (26.10)	88 (32.35)
	12–23 months	11 (4.04)	40 (14.71)	51 (18.75)
	24–35 months	3 (1.10)	21 (7.72)	24 (8.82)
	36–47 months	2 (0.74)	16 (5.88)	18 (6.62)
	48–59 months	6 (2.21)	25 (9.19)	31 (11.40)
Sex	Female	16 (5.88)	98 (36.03)	114 (41.91)
	Male	37 (13.60)	121 (44.49)	158 (58.09)
Residence	Urban	21 (7.72)	99 (36.40)	120 (44.12)
	Rural	32 (11.76)	120 (44.12)	152 (55.88)
Hospital	SGGH	36 (13.24)	134 (49.26)	170 (62.50)
	JUMC	17 (6.25)	85 (31.25)	102 (37.50)
Exclusive breast feeding	Yes	30 (11.03)	149 (54.78)	179 (65.81)
	No	10 (3.68)	29 (10.66)	39 (14.34)
	< 6 month of age a	13 (4.78)	41 (15.07)	54 (19.85)
Sun light exposure	Yes	48 (17.65)	188 (69.12)	236 (86.76)
	No	5 (1.84)	31 (11.40)	36 (13.24)
Vaccination status	Fully vaccinated	36 (13.24)	127 (46.69)	163 (59.93)
	Not fully vaccinated	17 (6.25)	92 (33.82)	109 (40.07)
Nutritional status	No malnutrition	37 (13.60)	158 (58.09)	195 (71.69)
	Malnutrition	16 (5.88)	61 (22.43)	77 (28.31)

SGGH Shenen Gibe General Hospital, JUMC Jimma University Medical Center

^aChildren whose age was less than six months and not fulfilling the definition of exclusive breast feeding

Baseline vaccination and nutritional characteristics of the participants

With respect to baseline nutritional characteristics, 179 (65.8%) had been exclusively breastfed during the first six months of life, while 54 (19.9%) were younger than six months at admission. Overall, 77 (28.3%) children were malnourished. Regarding vaccination status, 163 (59.9%) children were fully vaccinated according to national guidelines. In addition, most participants, 236 (86.8%), had regular exposure to sunlight (Table 2).

Baseline clinical characteristics and drug regimens received by the study participants

At admission, 56 (20.6%) children presented with one or more clinical danger signs. The median respiratory rate was 56 breaths per minute (IQR: 48–60) and the median pulse rate was 139 beats per minute (IQR: 132–153). Children received a range of empirical antibiotic regimens, including ceftriaxone monotherapy and combination therapies. Among all the inpatients, the most commonly prescribed regimen was ceftriaxone monotherapy, which was administered to 134 (49.3%) children (Table 3).

Table 3.

Clinical characteristics and drug regimens of under-five severe pneumonia cases, Jimma town public hospitals, 2021–2024

Variables	Category	Status		Total (N = 272) N (%)
		Censored (N = 53) N (%)	Recovered (N = 219) N (%)
Duration before seeking care (days)	Early presentation (≤ 5days)	50 (18.38)	170 (62.50)	220 (80.88)
	Late presentation (> 5days)	3 (1.10)	49 (18.01)	52 (19.12)
Past history of URTI	No	33 (12.13)	158 (58.09)	191 (70.22)
	Yes	20 (7.35)	61 (22.43)	81 (29.78)
Oxygen saturation	≥ 90%	34 (12.50)	126 (46.32)	160 (58.82)
	< 90%	19 (6.99)	93 (34.19)	112 (41.18)
Was on Oxygen	No	18 (6.62)	82 (30.15)	100 (36.76)
	Yes	35 (12.87)	137 (50.37)	172 (63.24)
Inability to drink/eat/ breastfeed	No	44 (16.18)	170 (62.50)	214 (78.68)
	Yes	9 (3.31)	49 (18.01)	58 (21.32)
Severe respiratory distress	No	25 (9.19)	93 (34.19)	118 (43.38)
	Yes	28 (10.29)	126 (46.32)	154 (56.62)
Comorbidity	No	31 (11.40)	162 (59.56)	193 (70.96)
	Yes	22 (8.09)	57 (20.96)	79 (29.04)
Presence of danger sign	No	43 (15.81)	173 (63.60)	216 (79.41)
	Yes	10 (3.68)	46 (16.91)	56 (20.59)
Antibiotics given	Ceftriaxone	32 (11.76)	102 (37.50)	134 (49.26)
	Ceftriaxone plus Vancomycin	6 (2.21)	44 (16.18)	50 (18.38)
	Ceftriaxone plus Gentamicin	5 (1.84)	33 (12.13)	38 (13.97)
	Ceftriaxone plus Crystalline penicillin	3 (1.10)	13 (4.78)	16 (5.88)
	Ampicillin plus Gentamicin	4 (1.47)	20 (7.35)	24 (8.82)
	Amoxicillin	3 (1.10)	7 (2.57)	10 (3.68)

URTI Upper Respiratory Tract Infection

Among the children admitted with severe pneumonia, 79 (29.0%) out of 272 had at least one comorbid condition. Severe acute malnutrition was the most common comorbidity, identified in 26 (32.9%) of the 79 patients, followed by acute gastroenteritis, which was reported in 8 (10.1%) patients (see Supplementary Material 2).

Treatment outcomes and recovery rates among under-five children with severe pneumonia

Among the 272 children included in the study, 219 (80.5%) achieved clinical recovery, 15 (5.5%) died, 25 (9.2%) were referred to higher-level care facilities, 8 (2.9%) were left against medical advice and 5 (1.8%) were absconded. The length of recovery time ranged from 1 to 58 days, with a total accumulated person-days at risk of 1,913 days. The overall recovery rate was 11.45 per 100 person-days (95% CI: 10.03–13.07).

Kaplan–Meier survival estimates of recovery time among under-five children with severe pneumonia

The overall median time to recovery from severe pneumonia among the study participants was 5 days (IQR: 3–9). Recovery time varies significantly across several factors, including exclusive breastfeeding, vaccination status and nutritional status. The Kaplan–Meier survival analysis revealed a rapid decline in the probability of remaining unable to recover over time among children under-five years of age admitted with severe pneumonia. As shown in Table 4, the survival probability of not being recovered remained high on the first day of admission but decreased markedly within the first 5 to 10 days, indicating that most recoveries (74%) occurred during this early period. Beyond 20 days, very few children remained unrecovered (< 5%), with survival probabilities approaching zero. These findings highlight that the majority (85%) of children experienced recovery within the first two weeks of hospitalization.

Table 4.

Kaplan–Meier survival probabilities at selected time points in under-five severe pneumonia cases, Jimma town public hospitals, 2021–2024

Time in days	Beginning total	Fail	Survivor function	Standard error	95% Confidence interval
1	272	10	0.9632	0.0114	0.9327 0.9800
5	157	94	0.5853	0.0313	0.5213 0.6438
10	60	69	0.2633	0.0298	0.2068 0.3231
15	27	26	0.1259	0.0236	0.0843 0.1763
20	10	12	0.0519	0.0169	0.0254 0.0923
25	7	2	0.0389	0.0150	0.0166 0.0763
30	5	2	0.0260	0.0125	0.0088 0.0596
35	3	2	0.0130	0.0090	0.0026 0.0417
40	2	1	0.0065	0.0064	0.0006 0.0325

A Kaplan–Meier survival curve was used to estimate the probability of recovery among children under-five years of age with severe pneumonia. Children with malnutrition experienced slower recovery than did those without malnutrition. The survival curve for children with malnutrition declined more gradually, indicating prolonged recovery. Conversely, children with a normal nutritional status recovered more quickly. The log-rank test confirmed a significant difference between the two groups (χ² = 34.47, P < 0.001) (Fig. 1).

Fig. 1.

Recovery time from severe pneumonia by nutritional status among under-five children in Jimma town public hospitals, 2021–2024

Compared with fully vaccinated children, not fully vaccinated children experienced slower recovery. The survival curve of not fully vaccinated children declined more gradually, indicating prolonged recovery duration. The log-rank test confirmed a significant difference between the two groups (χ² = 23.86, P < 0.001) (Fig. 2).

Fig. 2.

Recovery time from severe pneumonia by vaccination status among under-five children in Jimma town public hospitals, 2021–2024

Children who were not exclusively breastfed experienced slower recovery than those who were exclusively breastfed. The survival curve of not exclusive breastfed children declined more gradually, indicating prolonged recovery. The log-rank test confirmed a significant difference between the two groups (χ² = 30.07, P < 0.001) (Fig. 3).

Fig. 3.

Recovery time from severe pneumonia by exclusive breastfeeding status among under-five children in Jimma town public hospitals, 2021–2024

Predictors of recovery time from severe pneumonia

According to the findings of multivariate Cox proportional hazard regression analysis, nutritional status, exclusive breastfeeding status and vaccination status were statistically significant predictors. Compared with non-malnourished children, malnourished children had a 43% lower hazard of recovery, indicating a longer recovery time (AHR = 0.57, 95% CI: 0.39–0.84; p = 0.005). Similarly, children who were not exclusively breastfed had a 51% lower hazard of recovery than those who were exclusively breastfed (AHR = 0.49, 95% CI: 0.31–0.80; p = 0.004). In addition, children who were not fully vaccinated had a 28% lower hazard of recovery from severe pneumonia than fully vaccinated children did (AHR = 0.72, 95% CI: 0.53–0.98; p = 0.042) (Table 5).

Table 5.

Predictors of recovery time among under-five severe pneumonia cases, Jimma town public hospitals, 2021–2024

Variables	Category	CHR (95% CI)	P-value	AHR (95% CI)	P-value
Sex	Female	Ref.
	Male	0.772 (0.589–1.011)	0.060#	0.78 (0.59–1.02)	0.074
Residence	Urban	Ref.
	Rural	0.826 (0.631–1.081)	0.164#	0.87 (0.66–1.15)	0.337
Comorbidity	No	Ref.
	Yes	0.564 (0.415–0.766)	0.000#	0.93 (0.65–1.33)	0.700
Nutritional status	No malnutrition	Ref.
	Malnutrition	0.415 (0.30–0.572)	0.000#	0.57 (0.39–0.84)	0.005*
Exclusive breastfeeding	Yes	Ref.
	No	0.339 (0.221–0.520)	0.000#	0.49 (0.31–0.80)	0.004*
	EBF < 6 month	0.873 (0 616–1.237)	0.445	0.86 (0.59–1.23)	0.404
Vaccination status	Fully vaccinated	Ref.
	Not fully vaccinated	0.515 (0.386–0.688)	0.000#	0.72 (0.53–0.98)	0.042*
Sun light exposure	Yes	Ref.
	No	0.878 (0.598–1.288)	0.506
Duration before seeking care	Early presentation (≤ 5 days)	Ref.
	Late presentation (> 5days)	0.666 (0.505–0.878)	0.004#	0.83 (0.61–1.11)	0.208
Past history of URTI	No	Ref.
	Yes	0.918 (0.683–1.234)	0.570
Inability to drink/eat/ breastfeed	No	Ref.
	Yes	0.958 (0.696–1.318)	0.791
Severe respiratory distress	No	Ref.
	Yes	0.555 (0.421–0.732)	0.000#	0.87 (0.58–1.31)	0.516
Presence of danger sign	No	Ref.
	Yes	1.026 (0.740–1.422)	0.878
Oxygen saturation	≥ 90%	Ref.
	< 90%	0.548 (0.414–0.725)	0.000#	0.72 (0.47–1.09)	0.120
Hospital	SGGH	Ref.
	JUMC	0.585 (0.442–0.772)	0.000#	1.12 (0.71–1.72)	0.652
Antibiotics given	Ceftriaxone	Ref.
	Ceftriaxone plus Vancomycin	1.072 (0.751–1.533)	0.699
	Ceftriaxone plus Gentamicin	0.967 (0.649–1.443)	0.871
	Ceftriaxone plus Crystalline penicillin	1.167 (0.652–2.088)	0.602
	Ampicillin plus Gentamicin	1.150 (0.709–1.864)	0.571
	Amoxicillin	1.036 (0.479–2.239)	0.928
Age in months		0.999 (0.992–1.008)	0.938
Body temperature		0.871 (0.732–1.036)	0.119#	0.890 (0.74–1.07)	0.208
Respiratory rate		0.997 (0.986–1.008)	0.626
Pulse rate		1.003 (0.996–1.010)	0.356

URTI Upper Respiratory Tract Infection, CHR Crude hazard ratio, AHR Adjusted hazard ratio, CI Confidence interval, Ref Reference category

^#Statistically significant at P value < 0.25, ^*Statistically significant at P value < 0.05

Discussion

This study aimed to assess the time to recovery and its predictors among children under-five years of age admitted with severe pneumonia in Jimma town public hospitals. This study revealed that the overall median time to recovery from severe pneumonia was 5 days. Moreover, the predictors of time to recovery among under-five children admitted with severe pneumonia were nutritional status, exclusive breastfeeding status and vaccination status.

The median recovery time of 5 days indicates that half of the children admitted with severe pneumonia recovered within five days of initiating treatment. This observed median recovery time is comparable to findings from studies in East Wallaga [17], Southwest Region of Ethiopia [26] and the South Wollo Zone [16], which reported similar recovery durations. However, our estimate was shorter than that reported in Addis Ababa hospitals [24], where children with complex or referred cases are often treated and are likely to prolong their recovery time. In contrast, the recovery time was longer than that documented at Gondar Comprehensive Specialized Hospital [18], a difference that may be related to variations in the case mix, hospital capacity and sociodemographic characteristics of the study populations. These comparisons highlight how the local context, referral pathways and health-care infrastructure may influence the time to recovery from severe pneumonia.

In the present study, nutritional status was associated with the time to recovery from severe pneumonia. Compared with well-nourished children, malnourished children require a longer time to recover, which is consistent with studies from Debre Markos [22] and Gondar [18]. Malnutrition impairs both innate and adaptive immune responses [27], reduces resistance to respiratory infections and delays tissue repair, which may explain the prolonged recovery among malnourished children. This finding reinforces the importance of integrating nutritional interventions into severe pneumonia case management.

In the current study, a lack of exclusive breastfeeding during the first six months of life was associated with a slower recovery from severe pneumonia. Compared with their exclusively breastfed counterparts, children who were not exclusively breastfed were 51% less likely to recover earlier. This finding is consistent with evidence from other studies showing that exclusive breastfeeding reduces both the incidence and severity of pneumonia in early childhood [28, 29]. Similarly, a study conducted in a similar area [21] reported that children who received mixed feeding during the first six months of life had a higher risk of developing pneumonia than those who were exclusively breastfed. In addition to reducing infection risk, exclusive breastfeeding may also facilitate faster clinical recovery among hospitalized children through its immunological and nutritional benefits.

In this study, vaccination status was significantly associated with the time to recovery from severe pneumonia. Children who were not fully vaccinated were less likely to recover earlier than those who had received all recommended vaccines. This finding aligns with global evidence showing that immunization, particularly with pneumococcal conjugates and Haemophilus influenzae type b vaccines, reduces the severity of pneumonia and improves clinical outcomes [30, 31]. Additionally, a study from South Wollo Zone public hospitals revealed that not being fully immunized was significantly associated with longer periods of recovery from severe pneumonia [16]. The protective effect of vaccination is biologically plausible, as these vaccines reduce pathogen-specific infections that often complicate pneumonia and delay recovery.

Strengths and limitations of the study

This study evaluated the time to recovery and its predictors among under-five children admitted with severe pneumonia using three years of data from two public hospitals in Jimma town. Each patient was followed throughout the hospital stay, and predictors of recovery time were assessed by recruiting participants from multiple health-care institutions. In addition, the use of a three-year recording period helped minimize the influence of short-term fluctuations. These aspects were key strengths of the study.

However, some limitations warrant cautious interpretation of the findings. Owing to the retrospective study design and the inherent limitations of routine programmatic records, important predictors, such as maternal demographic characteristics, family socioeconomic status and environmental factors, could not be assessed. This may have limited our ability to comprehensively evaluate the effects of these potential predictors.

Conclusions

The current study revealed that the median time it took under-five children to recover from severe pneumonia was 5 days. Moreover, this study revealed that malnutrition, not-exclusive breastfeeding and incomplete vaccination were significant predictors of delayed recovery from severe pneumonia among children under-five years of age. These highlight that strengthening nutritional support, promoting exclusive breastfeeding and improving childhood vaccination could be important components of strategies to reduce recovery time among children with severe pneumonia. Accordingly, children with these factors should be closely monitored during their treatment to reduce the duration of recovery.

Abbreviations

AHR

Adjusted hazard ratio

CI

Confidence interval

IQR

Interquartile range

IMCI

Integrated Management of Childhood Illness

JUMC

Jimma University Medical Center

MUAC

Mid-upper arm circumference

PCV

Pneumococcal conjugate vaccine

PHEM

Public health emergency management

SAM

Severe acute malnutrition

SGGH

Shenen Gibe General Hospital

WHO

World Health Organization

Authors’ contributions

GB: Conception and design of the study, acquisition of clinical data, analysis of the data, writing-original draft and critical revision of the manuscript. YZ: drafted the manuscript and critical revision. MG: supervision and drafting of the manuscript. All the authors read and approved the final manuscript.

Funding

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

This study was conducted in accordance with the ethical principles of the Declaration of Helsinki and adhered to international guidelines for research involving human participants. Ethical clearance was obtained from the Jimma University Institutional Review Board with Ref. No. JUIH/IRB/246/25. The official letters were obtained from the Department of Epidemiology and Biostatistics. A permission letter was obtained from the management of JUMC and SGGH for data collection. Since the study was retrospective and did not involve any personally identifiable information, the ethical committee waived the requirement for informed consent. The information obtained from the patient records was kept anonymous, and confidentiality was maintained. Any information from patients’ records was used only for the purpose of the study, as clearly described to the ethical review board.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.