Assessment Of Knowledge, Attitude And Practice Of Mothers On The Effects Of Sunlight Exposure And Its Associated Factors Among Infants Found In Debre Tabor Town, North Central Ethiopia, 2018

Background: Early morning sunlight exposure for infants was a good practice to prevent rickets and alleviate the problem of vitamin D efficiency. Rickets is a major public health problem in many countries of the world. In many rich industrialized countries, the prevalence of rickets in the general population diminished after the introduction of dietary supplementation. But the most cost-effective way of getting vitamin D is simply from sunlight exposure rather than vitamin-D supplementation and advanced treatment. The main objective of this study is to assess the knowledge, attitude and practice of mothers on the effects of sunlight exposure and its associated factors among infants found in Debre Tabor town, North central Ethiopia, 2018. Methods: community-based cross-sectional study had been conducted among 105 mothers with infants in Debre Tabor city, South Gondar Zone, Amhara, Northcentral Ethiopia, 2018 from October 30 -/2018-January 1/2019. To select study participants simple random sampling techniques was employed. Data was entered into Epi info version 7.2.0.1, and exported to SPSS window version 20 for analysis. Binary and Multivariable logistic regression was used to see the association between dependent and independent variables. Odds ratio with 95% confidence interval was computed. P-value < 0.05 was used to declare association. Results: The overall knowledge, practice and attitude of the mothers about sunlight exposure were 61.14%, 59.44%, and 61% respectively, regarding factors associated with knowledge, practice and attitude of mothers about sunlight exposure were highly influenced by good time exposure for sunlight exposure ,mother who exposed their infants to sunlight exposure sometimes were 3.2 times less for acquiring knowledge than mothers who expose their infants who warm daily [AOR: *3.2(1.02-6.4)], mothers who had an occupation of daily laborer were 3.4 times less likely attitude of the mother’s sunlight exposure was lower than knowledge and practice .Hence; Based on the result the concerned body and health care providers should create awareness about the effect of sunlight exposure through health education.


Plain English summary
Rickets is a major public health problem in many countries of the world. In many rich industrialized countries, the prevalence of rickets in the general population diminished after the introduction of dietary supplementation. But the most cost-effective way of getting vitamin D is simply from sunlight exposure rather than vitamin-D supplementation and advanced treatment.
The main objective of this study is to assess the knowledge, attitude and practice of mothers on the effects of sunlight exposure and its associated factors among infants found in Debre Tabor town, North central Ethiopia, 2018. From the total respondents of 105 mothers, the entire required sample was included and it produces the response rate of 100%, despite 5% of retested samples. The overall knowledge, practice and attitude of the mothers about sunlight exposure were 61.14%, 59.44%, and 61% respectively. mothers whose marital status of singles were 2.9 times more likely to report for inadequate knowledge about sunlight exposure than married mothers [AOR: **2.9(1.4-7.9)].Regarding good time exposure for sunlight exposure, the mother who exposed their infants to sunlight exposure sometimes were 3.2 times less for acquiring knowledge than mothers who expose their infants who warm daily [AOR: *3.2(1.02-6.4)]. In conclusion; generally mother's knowledge, practice and attitude were lower when compared with different kinds of literature. So Based on the result the concerned body and health care providers should create awareness about the effect of sunlight exposure through health education.

BACKGROUND
Different kinds of literature sunshine was introduced in 1958 and sunlight was first used for neonatal jaundice, 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 and even sunlight exposure of the mother during pregnancy can prevent rickets and multiple sclerosis among newborn and infant (1). Rickets and retinopathy of the newborn and infants indirectly linked with ineffective sunlight exposure and rickets are common in children in Sub-Saharan Africa, including (2). While short exposure to solar ultraviolet radiation (UVR) can elicit increased skin pigmentation, a protective response mediated by epidermal melanocyte, chronic exposure can lead to skin cancer and photoaging, however, the molecular mechanisms that allow human skin to detect and respond to UVR remain incompletely understood (3).
Vitamin D, which is primarily obtained through exposure to sunlight (specifically ultraviolet 2 radiation B (UVR-B)), has been inversely associated with several complex diseases but despite the advantages of sunlight exposure in optimal amount, greater sunlight exposure causes skin cancer (3,4). The potential of UVR to be beneficial for some health outcomes but detrimental for others has prompted a public health debate on how to balance the positive and negative consequences of sun exposure (4). There are few modifiable risk factors for Hodgkin lymphoma (HL), the most common cancer among young adults in Western populations. Some studies have found reduced risk with exposure to ultraviolet radiation (UVR), but findings have been inconsistent and limited to HL as a group or the most common subtypes (5). Infants' risk of rickets occurs due to insufficient sunlight exposure and 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, suggested that daily exposure to sunshine remains the cheapest, safest and most effective method of preventing the disease. Generally, the scar that it late by rickets are very high and the main strategies to tackle this problem strong health education to change maternal behavior to expose infants to sunshine were adopted as the main strategy to combat rickets (6). Rickets is widely prevalent in many tropical and subtropical regions despite abundant sunshine. WHO now estimates that globally one billion people have VDD and the incidence of rickets is particularly high in children who live in crowded houses almost devoid of sunlight exposure due to poor awareness and practice of mothers about the advantages of sunlight exposure (1). Different studies showed that insufficient maternal circulating concentration of 25hydroxyvitamin D [25(OH) D] during pregnancy, also another contributing factors for the efficiency of vitamin D, in addition to poor utilization of sunlight exposure (2).besides the advantages of sunlight exposure, inappropriate and misuse of sunlight exposure in recent years, exposure to sunlight has been a subject of epidemiological interest both due to its beneficial as well as adverse effects on human health (1,2). It is an important etiological factor in the development of skin cancers and sun-related eye problems when exposure is high (3). However, the exposure to solar ultraviolet radiation (UVR) is an essential step for the production of Vitamin D, and also the main source of vitamin D in the human body (4). Studies worldwide identify a lack of sun exposure as the main cause of rickets and it is a major public health problem in many countries of the world. In many rich industrialized countries, the prevalence of rickets in the general population diminished after the introduction of dietary supplementation (6).
However, in such countries, vitamin-D deficiency rickets has re-emerged in recent years, 3 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 breastfed for a prolonged period with little skin exposure to UVB (7).
The purpose of this study would be intended primarily to assess mothers' KAP and factors affecting their practice about sunlight exposure of their infants. Therefore, this is very important to identify areas for improvement regarding sunlight exposure and to improve the health of the community. In addition to this, in our country, Ethiopia researches regarding sunlight exposure are scarce particularly in this study area. Therefore the research study may provide baseline information. So, this finding used as one input to reduce child mortality and morbidity related to rickets and the sustainable development goal would be achieved through adequate KAP of mothers about sunlight exposure. For researchers, it would be used as a reference for any high scale related study. For institutions, the research output can be used to improve infant and child health by creating awareness about the importance of sunlight exposure for parents. Since most children are at risk for rickets, and mothers had limited KAP on the effect of sunlight exposure coupled with limited research conducted on the title particularly around the study area, the research will employ primarily to assess mothers' KAP affecting their knowledge about sunlight exposure of their infants will be conducted in Debre Tabor Town. (Figure1 Conceptual framework)

Study Area and study period
This study was conducted at Debre-Tabor town. Which is far from 103 km from the capital city of Amhara National Regional State It is found 666 km away from Addis Ababa. The Town

Study design and participants characteristics
A community-based cross-sectional study had been conducted. The source populations were all mothers having children < 1year old found in Debre Tabor Town; South Gondar was the source population for this study. The study population would be mothers with infants found in Debre Tabor Town at the time of data collection and who fulfill the inclusion criteria. Each mother of having < 1years old infants found in Debre Tabor Town during the study period. Mothers with < year old infant with mentally and physically capable of being responded and who are volunteer to participate in the study was be included in the study part. Mothers with infants who are seriously ill, mentally incompetent, and unable to communicate and who are not voluntary to participate in the study were excluded from the study.
Simple size determination and sampling procedure In this study, the sample size was determined by using a single population proportion formula Since the population is less than 10,000, the reduction formula was used. So,

So, =95
By adding 10% none response rate the total sample size was 95+9.5=105, The total sample size was 105. Where: n= the desired sample size, P= practice of mothers on sunlight exposure on 5 similar studies during the assessment was 93 %, (15). Zα/2 = standard normal variation value at a confidence interval of 95% (1.96), d= the margin error between the sample and the population.
Simple random sampling technique was employed to select the study participants. (Figure 1: Schematic presentation of the sampling procedure of the Study)

Independent variables
Socio-demographic factors (age, religion, ethnicity, marital status, educational status, occupation, family size), source of information (physician, nurse/midwife, TV/Radio, neighbors/elder people), time of sunlight exposure (morning, afternoon, evening), opinion about sunlight exposure (good, bad), the belief of mothers on sunlight exposure (good, bad), place of exposure (indoor, outdoor).

Dependent variables
Knowledge, Attitude and practice of sunlight exposure

Operational definition
Knowledge -The theoretical understanding of mothers' about sunlight exposure of infants.
Practice -Mothers' activity or behavioral experience in relation to sunlight exposure of infants. 6 Good knowledge -Those mothers that were responded to knowledge questions and scored above the mean Poor knowledge -Those mothers that were responded to knowledge questions and scored 4 and below the mean Good practice-Those mothers that were responded to practice questions and scored above the mean Poor practice-Those mothers that were responded to practice questions and scored 6 and below the mean Good attitude -Those mothers that were responded to practice questions and scored above the mean Poor attitude -Those mothers that were responded to practice questions and scored 6 and below the mean

Data collection procedure and instrument
Data was collected through face to face interview method after preparing a structured pre-tested questionnaire, prepared via reviewing of literature and had been used. The questionnaire initially prepared in English and translated into Amharic (local language) and again retranslated back to English to check for any inconsistencies or distortions in the meaning of words and concepts.
Three data collectors (two BSc-nurses and two diploma midwifery) and one supervisor and data were collected by face to face interview techniques. That would not work in that unit were being recruited as data collectors, one BSc nurse was recruited as a supervisor. All data collectors and supervisors were trained for two days on their responsibilities for describing the purpose of the study, how to collect the data and telling clients the importance of honest and genuine reply on responding to questions. Mothers were interviewed after they got the services. The principal investigator and the supervisor would strictly follow the overall activities of the data collection on a daily base to ensure the completeness of the questionnaire and to give further clarification.
To select participants' simple ransom or lottery sampling method was used.

Data processing and analysis
After checking the completeness of the data, it was entered into Epi info version 7.2.0.1, and then; it was exported to SPSS Version 20 for analysis. Descriptive analysis was done by 7 computing proportions and summary statistics. The association between each independent variable and the outcome variable was assessed by using binary logistic regression. All variables with P ≤ 0.2 in the bivariate analysis were included in the final model of multivariable analysis in order to control all possible confounders.
Adjusted odds ratio along with 95% CI were computed and P-value < 0.05 was considered to declare factors that have statistically significant association with Sunlight Exposure by using multivariable analysis in the binary logistic regression. The goodness of fit was tested by Hosmer-Lemeshow statistic test. Finally; the result is presented in the form of texts, tables and graphs.

Data quality assurance
The quality of data was ensured by doing the questioner was pre-tested on 5% of the total sample size at Nefas Mewucha town that is assumed to have Similar Characteristics of the targeted population. Based on their feedback the necessary amendment had been done and the questioner was assessed for its clarity; the completeness and evaluate the validity and content of the questionnaire and modified accordingly close supervision had been made during the data collection and appropriate feedback was provided. Was provided to the data collectors for one day by the principal investigator the Training was focused on the objective, how to obtain consent, keeping confidentiality of the information they gathered. The collected data was cheeked for its completeness every day before the following day of data collection by supervisors and the principal investigator and Corrective measures had been taken according to the finding during supervision.

Ethical consideration
Ethical clearance was obtained from Research Ethics Committee of Debre Tabor university department of Nursing. Then, the participants of the study were informed about the purpose of the study, the importance of their participation, and their right to withdraw at any time. Verbal informed consent was obtained prior to data collection, written informed consent was obtained from a parent or guardian for participants under 16 years old. Then data collects from volunteer mothers. Mothers who are not practice Sunlight Exposure during the data collection period were advised regarding to use of Sunlight Exposure. 8

Socio-demographic characteristics of the respondents
From the total respondents of 105 mothers, the entire required sample was included and it produces the response rate of 100%, despite 5% of retested samples. The mean age and standard deviation of the baby were 0.58 ±0.3 years respectively with the mean age and standard deviation of the mother 24.5±6.21 years respectively. Regarding the religion of the respondents, On the other way studies mothers whose marital status of singles were 2.9 times more likely to report for inadequate knowledge about sunlight exposure than married mothers [AOR: **2.9(1.4-7.9)].Regarding good time exposure for sunlight exposure, the mother who exposed their infants to sunlight exposure sometimes were 3.2 times less for acquiring knowledge than mothers who expose their infants who warm daily [AOR: *3.2(1.02-6.4)]. (Table 5).

Factors associated with the practice of mothers about sunlight exposure
The Bivariate and logistic regression multivariate model was used to determine the significant t factors of the practice of mothers about sunlight exposure by using SPSS version 20 through coding the interested outcome variables. As it shows in table 5. Regarding the selected sociodemographic and practice related variables marital status of the mother, educational level of mothers ,,occupation of the mother ,frequency of exposure husbands educational status, and place of exposure of the respondents were showed that statically significant association with practice of the mother about sunlight exposure in Bivariate analysis, but age of the mother, mothers about sunlight exposure was 61.14% but a study done in Sakarya, Turkey, to determine the extent of intentional sun exposure in infancy and the prevalence of maternal belief that potentially increases the children's harm risk from ultraviolet radiation showed that 79.7% of mothers named one benefit of intentional baby sunning, in this case, the result of in this study is lower than done in Sakarya, Turkey and the difference is due to health education of the community and information from mass media (2, 7). The cross-sectional study conducted in Debre Markos with regard to the assessment of KP of the mothers on sunlight exposure and its associated factors revealed that the overall knowledge score of the respondents were 60% but in this study the overall result of knowledge of mothers about sunlight exposure was 61.14 %, which is almost the same and in line with the study conducted in Debre Markos (15).
In this study from the total respondents 61% of mothers had positive attitude towards sunlight exposure and 39% had negative attitude towards sunlight exposure but the study conducted to assess behavioral intention and factors influencing intention of Ethiopian mothers to expose infants to sunshine revealed that 48.5% of the respondents had good attitude towards sunshine and the study also showed that 52.3% of them also said that sunshine has bad effect on health, in this regard on this study more study participants had positive attitude than the study conducted in Ethiopia but less than of mothers who were in bad attitude and the difference may be due to familial and environmental influences (10). In this study Age of the mothers >35 years -49 years were 1.96 time had bad attitude for sunlight exposure than age of mothers <35 years but the study conducted in Ethiopia revealed that showed that age <=19 years times, educational status and information1.633 trims significant predictors of poor attitude for sunlight exposure (10). The cross-sectional study conducted in Ghana, the results showed that 46.3% of them had positive attitude towards sunlight exposures and the majority of the respondents or 53.7% of the parents had poor attitude on the effect of sunlight exposure among their infants and from this study 61% and 39% of mothers had good and negative attitude towards sunlight exposure (17).
From this study, the overall practice of mothers on the effect of sunlight exposure on their infants was 59.44%. Regarding exposure of infants on sunlight exposure, 61.9 %( 65) of mothers expose their infants on sunlight exposure but similar cross-sectional studies done in Sakarya on the assessment of sunlight exposure in infancy 87.5% of mothers exposed their infants on sunlight, in this case, this study revealed that lower number of study participants practice sunlight exposure than the study in Turkey, which difference may be due to socioeconomically 14 and educational status of the individual (7) . Another study conducted in Townsville, Australia reveal that 20% of mothers only warm their babies to sun lights due to the hot climatic environmental condition, 34.5% of the mothers do not expose their infants in sun in Australia in case of fear of skin cancer but in this study more of patents practice sunlight exposure than the study conducted in Australia and the difference may be due to climatic condition (12). A research is done in Jimma town on the assessment of rickets and the knowledge and practice of exposure to sunlight shows, 92.16% of mothers expose their children on sunlight daily but in this study d 61.5% of the mother expose their infants to sunlight exposure daily and the difference may be due to information and community awareness (11). The cross-sectional study conducted by Debre Markos with regard of the assessment of KP of the mothers on sunlight exposure and its associated factors revealed that practice of sunlight exposure was 93% of mothers exposed which was very higher when compared with this study(15). Generally mother's knowledge, practice and attitude were lower when compared with different kinds of literature.'  The information was self-reported and no behavior of the mother was observed.

Conclusion
The overall knowledge, practice, and attitude of mothers about the effect of sunlight exposure were 61.14%, 59.44% and 61% respectively which was very lower when operand with the study conducted in the same is true for practice and attitude of mothers about sunlight exposure.
Mothers gave different reasons for sunlight exposure like the sun can cause disease of cancers in newborns and infants. Another mother gave reasons like the environment is cold so, infants not get sunlight more than warming with closes but the fact is to prevent rickets not the purpose of warming. Generally, mothers practice is lower rates than knowledge and practice of mothers about sunlight exposure.

Recommendations
Based on the results of this study the following recommendations are forwarded: The policy makers, Ministry of health, Amhara regional health bureau, South Gondar ᴢone health department and Woreda health office of Debre Tabor should create awareness about the benefit of sunlight exposure to the community.
Nongovernmental organizations should give involve to give training for mother to mother groups about the advantages of sunlight exposure.
Health professionals should provide appropriate information about the good effects of sunlight exposure at infancy.
Mass Media should create awareness about the health effect of sunlight exposure.     Figure 4 Practice of mothers on sunlight exposure of their infants on the assessment of the knowledge, attitude and practice of mothers on the effects of sunlight exposure and its associated factors among infants found in Debre Tabor Town, south Gondar administrative zone, Amhara   Figure 5 Attitude of mothers about sunlight exposure infants on the assessment of the knowledge, attitude and practice of mothers on the effects of sunlight exposure and its associated factors among infants found in Debre Tabor Town, south Gondar administrative zone, Amhara   NB:@=variables whose p-value <0.2in Bivariate *significant at p<0.05, ** significant at p<0.01, ***significant at p<0.00    Knowledge of mothers about sunlight exposure on the assessment of the knowledge, attitude and practice of mothers on the effects of sunlight exposure and its associated factors among infants found in Debre Tabor Town, south Gondar administrative zone, Amhara regional state, north-central Ethiopia, 2019 (n=105) Figure 4 Practice of mothers on sunlight exposure of their infants on the assessment of the knowledge, attitude and practice of mothers on the effects of sunlight exposure and its associated factors among infants found in Debre Tabor Town, south Gondar administrative zone, Amhara regional state, north-central Ethiopia, 2019 (n=105) Figure 5 Attitude of mothers about sunlight exposure infants on the assessment of the knowledge, attitude and practice of mothers on the effects of sunlight exposure and its associated factors among infants found in Debre Tabor Town, south Gondar administrative zone, Amhara regional state, north-central Ethiopia, 2019 (n=105)