Background of study

The healing power of the sun and its use in medical treatment (heliotherapy) has extended back into ancient times starting from about 1400 BC [1,2]. In 1919, the first scientifically established health benefit of sun exposure was that sunlight can be used to prevent and cure rickets [3]. Recently being exposed to ultraviolet radiation has been a subject of epidemiological interest due to both its beneficial and detrimental effects. Excessive ultraviolet radiation (UVR) is associated with skin cancer, sunburn, accelerated skin aging, and cataracts and it also reduces the effectiveness of the immune system. Contrary to the adverse effect, the exposure to solar UVR is an essential step for the production of Vitamin D, and also the main source of vitamin D in human body [4-8]. Ultraviolet B (UVB) rays in the solar UVR spectrum produce vitamin D in the human body. UVB rays penetrate uncovered skin and converts cutaneous 7-dehydrocholesterol to pre-vitamin D3, which in turn becomes vitamin D3 [9,10]. Sunlight exposure also still has inadequately explored benefits, which include release of nitric oxide, production of beta endorphin, and regulation of circadian rhythms [11]. Vitamin D is used for maintaining the plasma concentration of calcium and phosphate in normal physiologic range and it interacts with parathyroid hormone to maintain bone mineralization [12]. Around 80–90% of vitamin D in humans is sunlight-derived production in the skin and the residual from dietary source and/or supplementation [13]. But, to get such amount of vitamin D there are different factors to considered. Such factors are time spent outdoors, skin pigmentation, degree of latitude, season, the amount of cloud cover, the extent of air pollution, the amount of skin exposed, and the extent of ultra-violet B (UVB) protection, including clothing and sunscreens[14-16]. For efficient production of vitamin D regular exposure of unprotected skin (without use of sunscreen and/or without clothing) to the available UVB radiation is recommended [17]. UVB (short-wave ultraviolet rays) is found maximum in the midday sun. Thus, the best time of day for vitamin D production is near to solar noon from 10 a.m. to 2 p.m [11,17,18]. Below latitudes of approximately 35° north, UVB radiation is sufficient for vitamin D3 synthesis throughout the year, however, at higher latitudes (above 35° north) vitamin D3 is not produced during the winter months and people may be predisposed to vitamin D deficiency unless taking vitamin D supplementation [19]. Vitamin D deficiency (VDD), which is serum 25- hydroxyl vitamin D (25OHD) level less than 30 nmol/l, is a worldwide major public health problem with numerous health consequences in many countries of the world [20]. Around 1 billion people worldwide, across all age groups, have a VDD. Epidemiological studies in different countries revealed that VDD is highly prevalent among infants, regardless of age, ethnicity, geographic location and climatic conditions and is believed to range from 2.7% to 45% [21,22]. Ethiopia is not an exception from this burden. A study done in Addis Ababa revealed that 41% of children below three years of age visiting an out-patient department had vitamin D deficiency rickets and the frequency was higher in infants [23]. Another study done in Jimma town also found that the prevalence of vitamin D deficiency rickets in infants was 11% [24].Studies worldwide identify lack of sun exposure as the main cause of rickets [14,25]. In many rich industrialized countries, the prevalence of rickets in the general population diminished after the introduction of dietary supplementation. However, in such countries, vitamin-D deficiency rickets has re-emerged in recent years, particularly among groups with limited exposure to UVB containing sunshine. Infants at risk of rickets are those whose mothers had poor vitamin D status during pregnancy and those exclusively breast-fed for a prolonged period with little skin exposure to UVB. Contrary to general belief, rickets is widely prevalent in many tropical and subtropical regions despite abundant sunshine. A study conducted in Kenyatta National Hospital showed 58.8% of premature infants develop rickets by the age of 6 months [26]. A recent study conducted in Kiambu District Hospital states that the prevalence of rickets in children 0–59 months to be 3.4% [27]. In Ethiopia, a review of rickets stated that the prevalence of rickets was highly as 40%, making it one of the highest in the world. Vitamin D deficiency rickets is also common in Ethiopian children [28].

Statement of the Problem

Decades have now elapsed since the pioneering studies on rickets in Ethiopia [23,29-31]. Showed that lack of exposure to sunshine was the single most important cause of rickets in Ethiopian children. Some pioneering studies as well as more recent work [24,32] suggested that daily exposure to sunshine remains the cheapest, safest and most effective method of preventing the disease(30). Although Ethiopia is a country with 13 months of sunshine, prevalence of Rickets remains high in Ethiopia this probably due to the poor mothers’ practice status as shown in different study.A study done in Debre Markos showed 93% of mothers exposed their infants to sunlight but only 57.9% of them exposed daily and 55.4% of them had poor practice about sunlight exposure. Mothers’ age, mothers’ educational status, mothers’ occupation, fathers’ educational status, evil eye, cold, and pneumonia had statistically significant association with sunlight exposure practice [33].A study done in Aleta Wondo Health Center, 62.2% are knowledgeable about sunlight exposure and only 32.6% of mothers had good practice of exposing their infants to sunlight [34]. A study done in Yirgalem hospital shows more than 45% and more than one-third of lactating mothers had poor practice and exposed infants to sunlight for inadequate time, respectively. Unemployed women and husbands’ education level were associated with poor practice [35], a study done in Debre Berhan, shows that 34.3% of participants have poor practice in sunlight exposure of infants. Mothers who are housewives or government employees, have a maternal age of 33 and above, perceive that sunlight strengthen infant bones, perceive that sunlight makes their infants healthier, and who got information from health-care professionals were significantly associated with good practice in sunning of their infant [36]. Although it is fairly simple to obtain vitamin D, lack of appreciation for the importance of sensible sunlight exposure to meet vitamin D requirements of children and adults has led to a worldwide VDD pandemic [16]. Furthermore social, religious norms and health practice of mothers might lead to vitamin D deficiency by preventing infants from sunlight exposure. Previous study revealed that maternal age, maternal educational status, maternal occupation, family size and fathers’ educational status were significantly associated with practice of sunlight exposure [33]. Efforts to prevent VDD with supplementation of vitamin D, fortification of milk or other foods with vitamin D and/or adequate sunlight exposure are recommended worldwide [21]. Guidelines in Ethiopia recommend sunning of neonates starting from 2 weeks old for 15–20 minutes per day. Although health education to change maternal behavior to expose infants to sunshine was adopted as the main strategy to combat rickets in the early 1960s, the implementation of this strategy is inconsistent [27]. Despite all these efforts, lack of sunlight exposure continues to be the major risk factor of VDD rickets in Ethiopian children [37,38]. It contributes to infant mortality and morbidity and carries long-term consequences. Caregivers plays a key role in prevention of rickets by exposing their infants to sunlight adequately. There is an abundance of sunlight in Ethiopia throughout the year, but studies indicating the practice of mothers on sunning of their infants and factors barring infants from getting adequate sunshine are insufficient and especially no evidence is available in the study area.

Significance of study

This study provides evidences for prevention of Rickets in infants by identifying factors affecting practices and by promoting good caregivers’ practice of infants’ sunlight exposure. Specifically, this study benefits the following:

Community - community directly benefit from this study as its finding may encourage them to have a good practice of infants’ sunlight exposure so that they can avoid Rickets.

Health professionals - this study inform health professional that how important is counselling about good practice of sunlight exposure at every encounter of caregivers including during ANC and PNC follow up.

Policy makers - this study may help policy makers to plan and deliver information about practices of sunlight exposure through various media.

Researcher - It would also be a baseline for other researcher to do prospective study in the future study to assess practice of sunlight exposure.

Methods and Materials

Study setting

The study was conducted at Arsi University, COHS, ATRH which is located in Asella town, 175 kilometers from Addis Ababa. Arsi University is one of the young universities established in 2014, whereas ATRH has been serving over 3.5 million populations in Arsi and the nearby zones since 1964 G.C. The hospital is well equipped and has 321 beds with more than 6 departments of which 102 beds for the pediatric ward (42 NICU, 54 Pediatric medical ward and 10 for emergency pediatric ward). The hospital is involved in training undergraduate and postgraduate trainees in various departments. The pediatric ward further segregated into 5 units. These are EPI clinics, regular OPD, emergency OPD, ward, NICU. In the pediatrics and child health unit there have been 8 paediatricians and 21 residents.

Study period and design

Facility based cross-sectional study was conducted among caregivers of infants attending Asella teaching and referral hospital from June 1/2022 to August 31/2022.

Source Population

All caregivers who had a child <12months of age and visited the Pediatrics and Child Health Department at Asella teaching and referral hospital.

Study population

Caregivers who had a child <12months of age and visited the Pediatrics and Child Health Department at Asella teaching and referral hospital at the time of data collection and who fulfilled the inclusion criteria.

Inclusion Criteria and Exclusion Criteria

Inclusion Criteria

·       Caregivers with infants who attended Pediatrics and Child Health Department at Asella teaching and referral hospital during the study period.

·       Those caregivers with infants and volunteer to participate in the study

Exclusion Criteria

·       Caregivers with infants, and who were not mentally and physically capable of responding during the study period.

Sample Size Determination

The sample size for the study determined by using single population formula.According to the study done in Debre Berhan in 2021, 34.3% of mothers had poor practice about sunlight exposure of infants. And the Level of significance to be 5% (?=0.05), so ?/2=1.96 by assuming 95% confidence interval, margin of error to be 5%.

Where, n?=initial sample size

p= proportion of poor practice; 34.3%=0.343

a= confidence interval (95%)

d= is the margin of sampling error tolerated (5%) = 0.05

????????= (1.96)2 (0.343) (1-0.343)/ (0.05)2 =3.8416(0.343) (0.657)/.0025 =346

For possible dropout rate 10% (34) is added to sample size.

Sample size = 346 + 34 =380

Sampling procedure

Systematic random sampling technique was used to select among caregivers of infants attending at ATRH during the study period. Using a formula K= N/n where N is the total numbers infants visited ATRH over 3 months and n is the sample size. There are 740 infants visited ATRH over the past 3 months. (Between January 01/2022 to March 31/ 2022.). So, K=740/380 = 1.9 ~ 2

Every 2^nd Caregiver of infants visiting ATRH was selected until the required sample achieved.

Study Variables

Independent Variables

·       Socio-demographic factors (Caregiver age group, Infant’s age group, Caregiver religion, Marital status, Caregiver’ educational status, Occupational status, Family size, Husband’s educational level)

·       Perception of Caregivers (benefit or harms)

·       Caregiver’s Source of Information ((physician, nurse/midwife, TV/Radio, neighbors/elders)

·       Health service utilization of mother during ANC, Delivery and PNC

Dependent Variables

·       The practice of exposing infants to sunlight

Key Words and Operational Definitions

Good practice: Caregivers that responded to practice questions and scored above median values

Poor practice: Caregivers responded to practice questions and scored below median values

Completely covered: Infant wearing clothes that cover the whole body except the face [33,36] (Figure 1).

Unclothed: Infant wearing no clothes except pants

Partly covered: Infant wearing minimal clothing (pants and vest) and not long shorts such that legs, arms and face are not covered.

Got antenatal care: Caregivers who had at least one visit in health facility prior to onset of labor.

Got postnatal care: Caregivers who had at least one return visit of health facility for postnatal care within six weeks of postpartum period.

Data Collection Instrument

A structured interviewer administered questionnaire were adopted from a study done in Jimma [24], Debre Berhan [36] and Turkey [47] and it was modified. The questionnaire included ten questions related to socio-demographic characteristics; seven questions to evaluate practice of mother on sunning of infants; one question about sources of information; and four questions related to perceived consequence of sunlight exposure and six questions linked to health service utilization.

Data Quality Assurance

The questionnaire was prepared in English and then translated in to Amharic and Afan Oromo and back translated. The supervisor checked the collected data on daily bases for completeness and the principal investigator monitored the overall quality of data collection.

Data processing and analysis

The completed questionnaires were checked for their completeness and consistency, then data were coded and entered to Epi-Data version 4.6 software and exported to SPSS statistical software version 21 for analysis. Categorical and continuous variables was summarized as proportions and means respectively. Cross-tabulations comparing cases versus controls was performed. Chi-square (Fischer’s exact test was used to see the association between groups where statistical significance defined as alpha less than 0.05 (two-sided). The crude regression model was adjusted for known confounders, and then variables whose p-value is < 0.25 in bivariate analysis and a prior selected key variable were fitted into a multivariate logistic regression model. The Hosmer-Lemeshow test was used to check model fitness. Then, a p-value < 0.05 in multivariate logistic regression was considered as statistically significant and the strength of associations was determined using the adjusted odds ratio (AOR) with the corresponding 95% confidence interval

Ethical considerations

Ethical clearance was obtained from the research unit of Arsi University. Letter of permission was obtained from college of medicine and health science. Prior to administering the questionnaire, the objectives of the study was clearly explained to the participants and oral informed consent was obtained. Participants was informed that their participation is voluntary and they have the right not to participate and this will not affect any service or benefit that they will get from the institution.

Results of Study

Socio-Demographic characteristics of the respondent

A total of 380 caregivers were interviewed. 185(48.7%) infants are aged below 6 months while 195 (51.3%) infants are above 6 months. 213(56.1%) infants were male while 167(43.9%) were female infants. Those caregivers aged 27-32 years and above 33 years are equally contributed about 31.8% of all. 37.1% of caregivers were housewife, whereas 1.6% was daily laborer. Those caregivers who have no any formal education were 31.3% of all caregiver. 338(88.9%) of caregivers were married, 4.5% were single, 3.4% were divorced and 3.2% were widowed. Regarding ethnicity the majority70.3% and 22.9% were Oromo and Amhara, respectively. In terms of religion 50.3% and 41.3% were Muslim and Orthodox respectively. Concerning husbands’ educational status of 363, 35.8% of them had at least a Diploma (Table 1).