Maternal Misconceptions Against Infant Sunlight Exposure Are Still Bottlenecks in Northwest Ethiopia, by 2022

Background : Sunlight has been used for therapeutic purposes for neonatal jaundice. Exposure to sunlight is vital for the synthesis of vitamin D. Lack of exposure to sunlight is the single most important cause of rickets. Rickets is a major public health problem in many countries of the world, especially in Sub-Saharan Africa. Vitamin D deficiency due to low exposure to sunlight, suboptimal exclusive breastfeeding, and low vitamin D intake is one of the health problems in Ethiopia. The implementation of the strategy has remained inconsistent and lacked focus on factors that influence maternal practice, excluding infants from getting adequate sunlight. Objective : To assess knowledge, practices, and factors affecting sunlight exposure of infants among women attending


Background
For years, sunlight has been used for therapeutic purposes, which dates back to ancient Rome and Greece [1] .In the second half of the 19th century, it was realized that sunshine could have a bactericidal effect as well as a therapeutic role in rickets [2][3][4] [5] .In the 1950s, sunlight was first used for neonatal jaundice [2][3][4] [5][6] [7] .Placing a child in a room where sunlight enters through window panes (not in direct sunlight) for 10 minutes twice a day was often used to help treat mild neonatal jaundice [8] .Currently, exposure to sunlight has two interests: beneficial and adverse effects on human health.
In a study conducted at Aleta Wondo Health Center, SNNPR, Ethiopia, more than half, 196 (62.8%), of the study participants were knowledgeable about sunlight exposure [9] .
Another study conducted in Debre Markos and Dejen District, Amhara Region, Northwest Ethiopia, found that 433 (50%) had poor knowledge status regarding infant sunlight exposure.The majority of mothers (852, 98.4%) knew that infant sunlight exposure was essential for the infant, and 373 (43.1%) had answered that infant sunlight exposure is for the development, growth, and strength of bones, and 779 (90%) of mothers knew relatively the safest period of infant sunlight exposure [10] [11] .
A study done in Farta District, South Gondar Zone, Northwest Ethiopia showed that nearly half (50.1%) of the respondents had knowledge of sunlight exposure for their infant.Of 183 respondents, 84 (46%) had knowledge of sunlight exposure every day, and 39 (11.4%) two times per week [12] .
In a study done at St. Paul's Hospital, Ethiopia, about 40% of the mothers had poor practice regarding sunlight exposure.
A study conducted in Debre Berhan Town, North Shewa Zone, Amhara Region, Ethiopia revealed that 65.7% of them had good practice in sunning their infants.Almost all (525; 99.1%) respondents intentionally expose their infants to direct sunlight.Four hundred and fifty (85.7%) of the mothers start to expose their infants before they are 15 days old [14] .
A study done in Debre Markos Town, Ethiopia found that 60% of mothers had poor knowledge about sunlight exposure of infants [10] .
A study in Ethiopia also found that a significant association was observed between maternal age and the knowledge of mothers; mothers in the age group of above 33 years were 8.67 times more likely to be knowledgeable than mothers in the age group of 15-20 years.The educational status of mothers was also associated with knowledge; mothers who have a diploma and above were 3.24 times more knowledgeable than mothers who were unable to read and write [11] .A family size of 4-6 was 3.88 times more knowledgeable than a family size of 1-3.Regarding sunlight exposure practice, there was a statistically significant association between maternal age and practice.A study conducted in Debre Berhan Town, North Shewa Zone, Amhara Region, Ethiopia showed that maternal age, occupational status, perceived benefits to strengthen infant bones, perceived to result in a healthier infant, and source of information from health-care professionals were found to be significantly associated with maternal practice of infant sunlight exposure [12][13][14] [15][16] [17][18] [19] .
A study carried out in Debre Markos Town, Ethiopia, found that there was a significant association between maternal age, maternal education, family size, husband's educational status, and knowledge about sunlight exposure [10] .

Methods and Materials
Study Area and Period

Study Design
A cross-sectional institutional-based study was conducted.

Source Population
The source populations were all mothers with infants attending PNC and immunization clinics at Debre Tabor Comprehensive Specialized Hospital.

Study Population
The study population were mothers with infants attending PNC and immunization clinics at Debre Tabor Comprehensive Specialized Hospital during the data collection period and who fulfilled the inclusion criteria.

Eligibility Criteria
Inclusion criteria Mothers of infants aged < 1 year attending PNC and immunization clinics at DTCSH during the study period.

Exclusion criteria
Mothers with infants who were seriously ill, mentally incompetent, and unable to communicate.
Those mothers with infants who were not willing to participate in the study.

Sample Size Determination
The sample size was calculated using the single population proportion formula by assuming p = prevalence of mothers'

Sampling Procedure
Study subjects were selected using systematic random sampling.The sampling interval (K) was obtained by dividing the total number of mothers with their infants by the sample size at the vaccinated clinic in Debre Tabor Hospital, so that K = N/n = every 3rd study subject was interviewed until we reached 375 study subjects.The first study subject was selected by the lottery method from the sampling interval (K).Each study participant was selected using a systematic sampling technique in which every third client was interviewed in the Hospital.

Operational Definitions
Knowledge -The theoretical understanding of mothers about sunlight exposure of infants.
Good knowledge -Those mothers who responded to knowledge questions and scored above the median value of 4.
Poor knowledge -Those mothers who responded to knowledge questions and scored below the median value of 4.
Practice -Mothers' activity or behavioural experience in relation to sunlight exposure of infants.
Good practice -Mothers who responded to practice questions and scored above the median value of 6.
Poor practice -Mothers who responded to practice questions and scored 6 and below the median value.

Data Collection Tools and Procedure
A structured questionnaire was designed by reviewing different literature to include all the relevant variables to meet the objectives.
After the informed consent was obtained, data were collected through face-to-face interviews using a prepared standard checklist and structured questionnaire.Three nurses and two midwives who were working at the immunization center were considered as data collectors.

Data Quality Assurance
The questionnaire was sent to two senior staff who are academicians and researchers for face validity; approval was obtained, and modifications were made.The questionnaire was prepared in the English version and translated into Amharic and back to English to check its consistency.A 5% pretest was done at Hidar 11 health center outside the study area.The collected data were checked for completeness and the overall quality of data collection was monitored by the principal investigators.
Data Analysis Procedure Data were entered into EpiData version 4.6.2 and exported to SPSS Software version 25 for further analysis.Mean, standard deviation, frequencies, percent, and odds ratio were calculated.Binary and multiple logistic regression analyses were conducted to assess the association between independent and dependent variables.The strength of the statistical association was measured by odds ratio and 95% confidence intervals, and statistical significance was considered at P<0.05.

Socio-Demographic Characteristics of Mothers
A total of 375 mothers with a response rate of 100% were involved.Of these, 176 (46.9%) of them were in the age range of 21-26 years and 361 (96.3%) of them were married (Table 1).

Knowledge of Mothers About Sunlight Exposure of Their Infants
About 253 (67.5%) of the mothers had good knowledge about sunlight exposure.The overall knowledge of mothers about the effect of sunlight exposure was 77.8% (Table 2).

Practice of Mothers About Sunlight Exposure of Their Infants
Regarding the practice of mothers about the exposure of infants to sunlight, 233 (62.1%) of them exposed their babies to sunlight and 36.9% of the mothers started exposing their infants at the age of 45 days and above (Table 3).4).

Variables Frequency Percentage
Table

Discussion
This study revealed that about 67.5% of the mothers had good knowledge about sunlight exposure.The result of this study is higher when compared with the results of the studies conducted in Aleta Wondo Health Center, Dejen District, Farta District, and Debre Markos Town where 62.8%, 50%, 50.1%, and 60% of the respondents had good knowledge of sunlight exposure for their infants, respectively [9][10] [11][12] .Such discrepancies might have resulted either from cultural influences or poor awareness.However, this finding is lower when compared with the result found in a study conducted at St. Paul's Hospital, Ethiopia, which showed that 86.1% of the mothers had good knowledge towards sunlight exposure of their infants [20] .The possible reason may be differences in study period, study area, and cultural differences.In addition to this possible justification for the variation, it might be due to differences in the awareness level of mothers concerning the importance of infants' sunlight exposure.
The current study found that the majority (91.7%) of the mothers had information about the need for sunlight exposure.
This result is similar to the finding of the study done at Aleta Wondo Health Center, SNNPR, Ethiopia, where 92.3% of the mothers had information about the need for sunlight exposure for their infants [9] .
Regarding the practice of mothers, 62.1% of the mothers had good practice regarding adequate sunlight exposure.This finding is comparable with the results of studies conducted at Aleta Wondo Health Center (58%) and St. Paul's Hospital (60%) [11][12][13] [14][15] .This finding is higher than the results obtained from the studies conducted in Dejen District, Amhara Region, and Farta District, South Gondar Zone, where 44% and 46% of the mothers had good practice towards sunlight exposure of infants, respectively [10][11] [12] .The possible reason for this variation could be differences in the awareness level of mothers concerning the importance of infants' sunlight exposure.
Concerning the factors associated with sunlight exposure of mothers, mother's age, mother's educational status, marital status, and family size were the factors associated with sunlight exposure.Mother's age is significantly associated with sunlight exposure.Mothers in the age group above 33 years were 1.43 times more likely to be knowledgeable than mothers in the age group of 15-20 years.This finding is supported by the study conducted at St. Paul's Hospital, which showed that mothers in the age group above 33 years were 8.67 times more likely to be knowledgeable than mothers in the age group of 15-20 years [20] .This finding is also supported by the studies conducted in Debre Berhan Town and Debre Markos Town, which found that mother's age is significantly associated with sunlight exposure [10][14] .
The educational status of mothers and family size are also associated with the knowledge of mothers towards sunlight exposure.This result is supported by the studies conducted at St. Paul's Hospital [20] , Debre Berhan Town [14] , Debre Markos Town [10] , and Dejen District, Amhara Region [11] .

Conclusion and Recommendation
According to our study, participants did not have good knowledge and practice regarding sunlight exposure of infants.
Mother's age, mother's educational status, marital status, and family size were the factors associated with sunlight exposure.
Therefore, health education focusing on the importance of sunlight exposure is important to improve the knowledge and practice of mothers towards sunlight exposure of their infants.
knowledge and practice on sunlight exposure in Debre Markos town = 44.6%(37),Z = 1.96, and D = precision (marginal error) = 5%.The sample size was calculated as follows: n = sample size The total number of infants in Debre Tabor Town is 2,277.Since this figure is below 10,000, we use the following adjustment formula for the sample size: n = n / (1 + n/N) Where, n = sample size for a population of size above 10,000 N = number of infants in Debre Tabor Town Therefore, n = 380 / (1 + 380/2,277) n ≈ 341 Taking a 10% (34) non-response rate, the final sample size was 375.

Table 4 .
Associated factors with sunlight exposure among mothers in