This study demonstrated insufficient knowledge, favorable attitude, and proactive practice toward M. pneumoniae infection among family members. The correlations among these dimensions suggest that educational interventions could enhance family members’ capabilities, leading to improved clinical outcomes by promoting early detection, treatment adherence, and complication prevention in pediatric patients with M. pneumoniae infection.

Our findings from baseline characteristics highlighted several demographic factors significantly associated with KAP scores. Notably, the relationship between the family member and the child emerged as a pivotal factor, with mothers scoring the highest in KAP dimensions, as supported by previous studies in pediatric conditions^19,20,21. This could be attributed to the typically more involved role mothers play in healthcare decisions and daily care²². Additionally, higher education and income levels were linked to better KAP scores, suggesting that access to information and resources can enhance understanding and management practices^23,24. The type of work also significantly influenced scores, with those in long-term stable jobs demonstrating superior KAP scores, potentially due to better access to healthcare information and a stable schedule allowing for regular healthcare visits. These observations underscore the need to tailor educational interventions to various socio-economic groups and to consider the family structure in healthcare strategies.

Upon examining the individual dimensions, specific areas of concern were identified within the knowledge dimension, where a significant number of family members were uncertain about the extrapulmonary manifestations and the necessity of hormone treatment in severe cases of M. pneumoniae infection. This lack of knowledge among family members is concerning, as it may lead to delayed recognition of serious complications and suboptimal management of severe cases. Extrapulmonary symptoms can be critical indicators of systemic involvement, necessitating prompt medical attention and specialized care^8,25. While the occurrence is rare, it is imperative for caregivers, including family members, to remain vigilant about the potential for severe and uncommon complications associated with M.coplasma pneumoniae infection, such as acute pancreatitis, mycoplasma mucositis, and rhabdomyolysis^26,27,28. These conditions, though infrequent, demand immediate medical attention and highlight the critical need for heightened awareness among healthcare providers to ensure timely and appropriate treatment interventions. Moreover, the need for hormone treatment evaluation in severe infections underscores the complexity of managing M. pneumoniae, where standard antibiotics may not be sufficient, and additional therapeutic measures are required^29,30,31. For the attitude dimension, the majority of family members exhibited a favorable attitude towards M. pneumoniae infection, demonstrating a positive and proactive stance in understanding the condition, adhering to medical prescriptions, and engaging in learning about the infection. This bodes well for the effective management of the infection but also suggests that there is substantial room for targeted educational initiatives to further bolster this positive attitude and translate it into consistently high standards of care. In terms of practices, while a majority of family members reported adhering to treatment plans and seeking timely medical attention, there is room to improve preventive practices such as handwashing and avoiding crowded places. Enhancing these practices could contribute to a reduction in infection transmission. These findings underscore the pressing necessity for targeted educational initiatives aimed at broadening the understanding of the diverse clinical manifestations of M. pneumoniae infection, thereby enhancing the overall KAP among family members.

Health literacy programs are essential in the management and control of M. pneumoniae infections, particularly because effective prevention and treatment rely heavily on individuals’ understanding of disease transmission, symptoms, and appropriate health behaviors. Health literacy programs can equip individuals and families with the knowledge needed to recognize symptoms of M. pneumoniae infections, understand routes of transmission, and adopt preventive behaviors such as handwashing, respiratory hygiene, and environmental cleaning^32,33. For effective infection management, patients and caregivers must understand the importance of completing prescribed antibiotic courses and following healthcare provider instructions. Health literacy programs improve adherence by clarifying treatment regimens and the rationale behind them³⁴. Health literacy initiatives should help bridge the communication gap between healthcare providers and patients, ensuring that families can process and act on medical advice related to the diagnosis, treatment, and prevention of M. pneumoniae³⁴. In environments like schools and childcare centers, health literacy programs can promote community-wide adoption of preventive measures, such as hand hygiene and cough etiquette, which are crucial for controlling outbreaks of M. pneumoniae³³. Therefore, such a program targeted at respiratory infections, including M. pneumoniae infection, should be designed and implemented.

The correlation analysis revealed a strong positive correlation between the KAP dimensions, emphasizing the interconnectedness of KAP in shaping family members’ responses to M. pneumoniae infection. The SEM model further substantiated these relationships, indicating that improving knowledge can have a cascading effect on attitudes and practices. Incorporating network theory into epidemiological analysis offers a robust framework, as shown by Meyers et al.., for deciphering the transmission dynamics of M. pneumoniae in confined settings and analyzing caregivers’ KAP patterns³⁵. The application of network theory in predicting the course of an epidemic from the structure of a graph supports the significance of our study’s correlation analysis³⁵. The strong positive correlations among KAP scores reflect the interconnectedness of these dimensions within the response network of caregivers, including family members, to M. pneumoniae infection. This interconnectedness is crucial for designing effective interventions that account for the complex web of interactions and potential transmission pathways within healthcare settings. Overall, a multifaceted approach is necessary for the prevention and control of M. pneumoniae.

SEM is widely used in KAP studies to analyze complex relationships among latent and observed variables. However, its application in this context comes with several notable limitations. If important variables are omitted or relationships are incorrectly specified, the results may be biased or misleading^36,37. KAP studies with small or convenience samples may yield unreliable or non-generalizable results due to insufficient statistical power³⁷. SEM often assumes multivariate normality and linear relationships among variables³⁷. Goodness-of-fit indices may suggest a model fits well, but this does not guarantee the model is correct or meaningful^36,37. Models that fit one dataset well may not generalize to other samples, especially if they capitalize on the chance characteristics of the data³⁷. SEM results can be complex and require careful interpretation. Misinterpretation of path coefficients, latent variables, or model fit is possible, especially for researchers less familiar with the method^36,37. Finally, high correlations among observed variables (multicollinearity) can cause estimation problems, such as unstable parameter estimates and difficulties in identifying unique effects³⁷.

Cultural norms and values in China can significantly influence the KAP of families regarding infectious diseases like M. pneumoniae infection in children, potentially contributing to notable deficiencies in understanding the complexities of this illness. Chinese health beliefs are deeply influenced by traditional philosophies such as Confucianism, Taoism, and the theory of Yin and Yang, which emphasize balance and harmony between the body and the environment^38,39. These beliefs often shape how illness is perceived and managed, sometimes prioritizing traditional Chinese medicine (TCM) or holistic approaches over biomedical explanations and treatments. While this can foster trust in certain health practices, it may also lead to gaps in understanding the specific etiology, transmission, and modern treatment options for infections like M. pneumoniae^38,39,40. The Chinese culture is collectivist, valuing family cohesion and group decision-making over individual autonomy^39,40. In healthcare, this often means that decisions about seeking treatment or following medical advice are made collaboratively within the family, sometimes influenced by elders or those perceived as having more authority. While collaborative decision-making can be beneficial, it may also mean that if one member has limited or incorrect knowledge about the disease, this can spread throughout the family, especially if there is a lack of formal education on the topic³⁹. Trust in scientists, healthcare personnel, and government policies is a strong predictor of health attitudes and behaviors in China⁴⁰. When public health messages are not clearly communicated or are overshadowed by traditional beliefs, families may not prioritize or fully understand the complexities of M. pneumoniae infection, such as its symptoms, transmission, and the importance of appropriate antibiotic use. This trust, while generally positive, can also lead to overreliance on authoritative sources without critical questioning or independent verification⁴⁰. Despite increasing health literacy in urban areas, rural populations and those with lower education levels may have less access to accurate information about infectious diseases³⁹. Knowledge deficiencies about antimicrobial resistance and the specifics of M. pneumoniae infection, such as its atypical presentation and the rise of macrolide-resistant strains, are well-documented in both the general public and even among some healthcare professionals^41,42. These gaps can be exacerbated by cultural norms that prioritize traditional knowledge or defer to authority figures without seeking further clarification. Therefore, cultural norms and values in China (such as traditional health beliefs, collectivism, trust in authorities, and educational disparities) can lead to notable deficiencies in family members’ knowledge about the complexities of M. pneumoniae infection in children.

While providing valuable insights, this study on KAP regarding M. pneumoniae infections has several limitations that warrant acknowledgment. Firstly, the cross-sectional design of our study restricts the ability to infer causality or the directionality of the relationships observed among knowledge, attitudes, and practices. Secondly, the participants were enrolled through convenience sampling. Convenience sampling, while popular for its simplicity and speed, comes with several significant limitations that can affect the findings, including limited representativeness, sampling bias, low external validity, difficulty assessing error margins, researcher and response bias, lack of diversity, unknown errors, difficulty replicating the results, and generalization only to the sampled group. Thirdly, although questionnaires were distributed on-site and most invited participants appeared to complete them, we did not formally record the total number of individuals invited; therefore, the response rate could not be accurately calculated, which further limits the ability to assess potential non-response bias. Fourthly, this study’s findings are based on self-reported data from family members, which may be subject to social desirability bias or recall inaccuracies. Moreover, this study’s generalizability may be limited due to the specific demographic and geographic focus on family members of children with M. pneumoniae infection at a single hospital. Additionally, while our study aimed to explore the KAP comprehensively, the questionnaire items may not cover the entire scope of family members’ understanding or practices related to M. pneumoniae infection, potentially missing out on other significant aspects that could influence infection control and management. Lastly, this study’s reliance on quantitative data collection methods may not fully capture the qualitative nuances of family members’ experiences and perceptions, which could offer a deeper understanding of their behaviors and decision-making processes.