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Background

In 1919, the first scientifically documented the health importance of sunlight exposure to prevent and cure rickets. Vitamin D can be synthesized in the skin by a photosynthetic reaction triggered by exposure to sunlight [1]. When the skin is stimulated with ultra-violate A (UVA) radiation, nitric oxide is released which is used to stimulate vasodilation and decrease blood pressure [2]. Additionally, human skin produces beta-endorphin in response to ultra-violate B (UVB) exposure [3]. These opioid peptides have the result of increasing a feeling of well-being, boosting the immune system, relieving pain, promoting relaxation, wound healing, and cellular differentiation [4].

The amount of sunlight exposure needed to synthesize adequate vitamin D depends upon the type of skin, [5] the time of the day, the month of the year, and the latitude [6]. The duration needed in an individual with dark skin is about ten times that in fair-skinned individuals. It has been suggested that exposure to sunlight for 5 minutes to 5 hours per day (depending upon the above-mentioned factors) may be sufficient to synthesize our daily requirement of vitamin D [6, 7].

According to studies conducted in Saudi Arabia, Sakayara, and Brazil, mothers’ poor practice of sunlight exposure to their children ranges from 66.7% to 75% [8–10]. According to a study conducted in Egypt, 27.3% of mothers had poor practices when exposing their infants (21). In Ethiopia, mothers’ poor practice of sunlight exposure to their babies ranges from 34.3% to 67.4 [5, 11–14].

Globally, lack of sun exposure has been identified as the main cause of rickets [15]. Recently, vitamin D deficiency has been reported to be a public health problem worldwide, regardless of abundant sunlight in many countries. According to the World Health Organization, approximately one billion people are vitamin D deficient, and the deficiency is most prevalent in infants regardless of topography, climatic condition, ethnicity, and age (13,25). Rickety is common in Sub-Saharan African countries, including Ethiopia, and its prevalence ranges from 4% to 41% [16–19].

Health education was adopted as the main strategy to combat rickets in Ethiopia to change maternal behaviour to appropriately expose their infants to sunlight. However, the implementation of the strategy has remained inadequate, and health messages lack focus on factors that influence maternal practice excluding infants from getting adequate sunlight. This was largely because of a lack of adequate information on the determinants of this particular risk behaviour among Ethiopian mothers [20].

Determining the pooled magnitude and associated factors of sunlight exposure practice among infants is vital to designing effective interventions to reduce inadequate sunlight exposure practice. There was no single conclusive finding regarding factors affecting sunlight exposure practice in Ethiopia. Even though the pooled prevalence of sunlight exposure practices in Ethiopia, this study includes only published studies and studies with the title of knowledge and practice of sunlight exposure. In addition, public health experts and policymakers who are working with infants need updated evidence regarding sunlight exposure practices. Therefore, this review aimed to estimate the pooled prevalence of good sunlight exposure practice and its associated factors among mother-infant pairs in Ethiopia.

Materials and methods

Registration

The preferred reporting items for systematic review and meta-analysis (PRISMA) guidelines were used to perform this systematic review and meta-analysis [21]. It has been registered in the International Prospective Registry of Systematic Reviews (PROSPERO) with a specific registration number of CRD42022382520.

Search strategy and studies identification

The studies were retrieved compressively from both published and unpublished articles. The published articles were searched by using different databases such as All articles were systematically searched by PubMed, Hinari, Global Health and CINAHL, Epistemonikos, African Journal of Online (AJOL) and unpublished literature sources like Google Scholar and Google. All relevant articles were searched and retrieved by using a combination of search terms/ keywords like; “Sunlight exposure practice”, “sunshine exposure practice”, “sunlight exposure”, “determinant”, “Predictors”, “factors”, “associated factors”, “infants, “infant-mother pair”, “Ethiopia’‘ using Boolean operators "OR" or "AND" as appropriate and the search was done by two authors independently FY, NK, YT, FD, EA, and AA).

Inclusion and exclusion criteria

All studies, irrespective of data collection and publication year until the end of May 30, 2023, were included in this review. This review included published studies with only the English language and unpublished studies that were conducted on the prevalence and factors associated with sunlight exposure practice among infants in Ethiopia. All observational studies measured sunlight exposure practice and associated factors among infants were included in this review. However, pure qualitative studies and quantitative studies not report outcomes were excluded from the review.

Outcome variable

The primary outcome of this review was the prevalence of good sunlight exposure practices among infants. The second objective was the associated factors of good sunlight exposure practices conducted in Ethiopia. The odds ratio/ 2x2 contingency was extracted for associated factors of good sunlight exposure practice.

Study selection, risk of bias assessment, and data extraction

Those studies searched from selected databases were transferred to End Note, and duplicate files were excluded. The rest articles and abstracts were separately screened by two groups (FY, YT, NK, FD, AA, HY, AM, AH, AE, FB and EA) for inclusion in the full-text appraisal. The differences between reviewers were managed by discussion, and disagreement was handled by the third party (CB, NC, TB, ZA, MM, AMM, DM, FB and BW). The quality of articles was evaluated using the Joanna Briggs Institute (JBI) critical appraisal checklist [22]. Two reviewers have separately assessed articles before inclusion for review.

Nineteen authors (FY, YT, NK, FD, AA, HY, AM, AH, AE, EA, CB, NC, TB, ZA, MM, AMM, DM, FB and BW) independently retrieved all the necessary data using Microsoft Excel 2010 sheet. The data extraction tool contains information on the Author’s name, year of publication, study area, response rate, sample size, study quality score, and prevalence.

Statistical methods and analysis

The statistical analysis was conducted using STATA 17 software. A Forest plot was used to display the magnitude of sunlight exposure practice among infants in Ethiopia. Due to the significant presence of heterogeneity among studies, the random effect model of analysis was applied. The pooled prevalence of sunlight exposure practice among adolescents was presented with a 95% CI. The heterogeneity test of involved studies was measured by using the inverse variance (I²) statistics. The value of I ² was interpreted as 25% as low, 50% as medium, and 75% as high heterogeneity [23]. Subgroup and sensitivity analysis was also conducted by different study characteristics such as sub-region of Ethiopia (Amara or other), sample size (small or large), and residence (urban or rural). The presence of publication bias was assessed using Begg’s test and the Egger regression asymmetry test [24]. When the p-value was less than 0.05, it declared the presence of a publication bias.

Results

Study selection

This systematic review and meta-analysis identify 1145 published and unpublished studies conducted on sunlight exposure practice and associated factors among infant-coupled mothers in Ethiopia. Then 435 were excluded due to duplication, and the remaining 691 studies were excluded due to their titles and abstracts. Nineteen full-text articles were assessed for eligibility. From these, five full-text articles were removed for prior criteria, and a total of 14 studies were included in the review (Fig 1).

[Figure omitted. See PDF.]

Characteristics of included studies

A total of 14 studies [5, 11, 13, 14, 25–34] with 6,121 study participants were included to estimate the pooled prevalence of sunlight exposure practice and associated factors among infant mothers pair in Ethiopia. The sample size of the studies ranged from 105 study participants in a study conducted in the Debre Tabor [14] to 866 participants in a study conducted in Dejen Woreda [29]. In this meta-analysis, four regions from nine regions of the country were represented; two studies from Addis Ababa [25, 26], eight studies from Amhara [5, 11, 14, 28–32], four studies from SNNP [13, 27, 34, 35] one from Oromo [33]. The studies were conducted from 2015 to 2021 in different regions of the country (Table 1).

[Figure omitted. See PDF.]

Prevalence of good sunlight exposure practice

The overall pooled lifetime prevalence of good sunlight exposure practice among infants in Ethiopia was 53.75% (95%CI: 46.84, 60.66). The highest lifetime prevalence of good sunlight exposure practice was reported in a study done in Bahir Dar City. The study showed that 75.12% of infants had experienced good sunlight exposure practice [28]. The lowest prevalence of good sunlight exposure practice was 27.14% among infants in Addis Ababa [26]. Significant heterogeneity was observed among included studies in the meta-analysis, I ² = 97.2%, p < 0.001 (Fig 2). The funnel plot showed a symmetrical appearance (Fig 3).

[Figure omitted. See PDF.]

The Egger’s regression asymmetry test also showed non-significant publication bias, p-value = 0.287. Sensitivity analysis was conducted to identify the possible source’s source of bias, but no outlier study potentially shifted the primary pooled estimates (Fig 4).

[Figure omitted. See PDF.]

Subgroup analysis

The subgroup analysis was conducted by region, sample size, and study design to identify the discrepancy across the studies. Even though heterogeneity still existed in the subgroup analysis of all the above-mentioned factors, the prevalence of good practice of sunlight exposure was significantly higher among studies conducted in the SNNP region [56.57, 95% CI: (48.28., 64.86)] as compared to studies conducted in another region. Also, the prevalence of good sunlight exposure practice was a significant difference between community-based study design [58.60, 95% CI: (46.52, 70.68)] and institutional study design [51.37 95%CI: (41.44, 61.30)] (Table 2).

[Figure omitted. See PDF.]

Associated factors of sunlight exposure practice among infants

In this study, we assessed factors associated with good sunlight exposure practice. A separate analysis was conducted for each factor which was considered in this meta-analysis. Variables assessed with the sunlight exposure practice were: PNC follow-up, maternal educational status, maternal occupational status, residence, and fear of sunlight exposure.

The odds of good sunlight exposure practice were 2.22 times higher among mothers who had PNC follow-up compared with mothers who had no PNC follow-up [OR = 2.22 (95% CI: 1.31, 3.47)]. Overall and within the study design, the value of I ² was 65.7 (Fig 5). The odds of good sunlight exposure practice were 4.17 times higher among mothers with secondary and above educational status compared with mothers with can’t read and write [OR = 4.17, (95% CI: 1.73, 10.06)]. Overall and within the study design, the value of I ² was high (Fig 6). The odds of good sunlight exposure practice were 3.72 times higher among employed mothers compared to those unemployed mothers [OR = 372, (95% CI: 2.71, 5.11)]. Overall and within the study design, the value of I ² was low (Fig 7).

[Figure omitted. See PDF.]

The odds of good sunlight exposure were 2.67 times higher among urban residence mother-infant pairs compared with mother-infant pairs who reside in rural areas [OR = 2.67, (95% CI: 1.17, 6.08)] (Fig 8). The odds of good sunlight exposure were 4.80 times higher among mothers with no fear of sunlight exposure compared with mothers with fear of sunlight exposure [OR = 4.08, (95% CI: 1.44, 16.00)] (Fig 9). However, we found that a woman who had ANC follow-up was not associated with good sunlight exposure practice compared to mothers who had no ANC follow-up.

[Figure omitted. See PDF.]

Discussion

Good sunlight exposure practice has a significant role for infants because, with sufficient exposure to ultraviolet B (UVB) from sunlight, a healthy person should be able to synthesize all of their vitamin D requirements in their skin. Therefore, the objective of this review was to estimate the pooled prevalence of good sunlight exposure practice and its associated factors among infants in Ethiopia.

According to this meta-analysis, the overall pooled prevalence of good sunlight exposure practices among infants in Ethiopia was 53.75% (95%CI: 46.84, 60.66). The finding of this study reveals that more than half of the infants were adequately exposed to sunlight in Ethiopia. This finding was consistent with other studies conducted in the UK (56%), and New Zealand (55.9%) [36, 37]. Vitamin D insufficiency continues to be a significant public health issue worldwide, regardless of the presence of sunlight [38]. Above 50% of healthy individuals were vitamin D sufficient, whereas not meeting the recommended dietary goal [39]. Exposure to sunlight is the most reasonable way to address the widespread issue of vitamin D deficiency. Furthermore, fortification or supplementation cannot fully substitute for sun exposure [40]. As per the Practical Cooking and Feeding Guide for Ethiopian Children 6–23 Months Old, it is recommended to have your baby spend 20 to 30 minutes in the sun each day to promote healthy bone growth and overall well-being by ensuring adequate vitamin D intake [41].

According to this study finding, the odds of good sunlight exposure practice were 2.22 times higher among mothers who had PNC follow-up compared with mothers who had no PNC follow-up. This might be because, during postnatal care follow-up, mothers receive guidance on the significance of sunlight exposure for their babies. It is essential to communicate the need for behaviour change to increase exposure to ultraviolet light in order to prevent vitamin D deficiency in countries with tropical climates, such as Ethiopia [42]. Mothers who lack adequate knowledge about new-born care and rely on traditional childcare methods may inadvertently harm or impair their new-borns [43].

The pooled odds of good sunlight exposure practice were 4.17 times higher among mothers with secondary and above educational status compared with mothers with couldn’t read and write. This could be attributed to the fact that in the Ethiopian context, mothers who have received education are more likely to comprehend and implement nutritional knowledge, as they are typically responsible for caring for infants and managing household activities, including ensuring exposure to sunlight. Educated mothers tend to be well-informed, have greater access to health-related information, and experience fewer challenges in understanding guidance from healthcare providers compared to those who are not educated [44].

The pooled odds of good sunlight exposure practice were 3.72 times higher among employed mothers compared to unemployed mothers. Most of the time, the employed mother is educated, being the main component that affects development and economic growth. Maternal education influences child health, which is an important factor in predicting well-being and productivity in adult life. Also, greater maternal education translates into greater healthcare utilization, including formal prenatal visits [45].

Urban residence mother-infant pairs had 2.67 times higher odds of good sunlight exposure compared to mother-infant pairs living in rural areas. This could be due to easier access to health facilities and nutrition information through various media in urban areas. Surprisingly, even rural agricultural labourers, who spend a significant amount of time outdoors with a large body surface area exposed, have reported a high prevalence of vitamin D deficiency ranging from 44–70% [46].

The pooled odds of good sunlight exposure were 4.80 times higher among mothers with no fear of sunlight exposure compared with mothers who fear sunlight exposure. This might be due to the mother not fearing the risk of sunlight exposure; the mother can adequately expose the child to sunlight. This is supported by the evidence when the mothers affected by cultural practices and beliefs to prevent evil eye not exposure to sunlight [47, 48].

Strengths and limitations of the study

We try to use different search engines to address all data sets including unpublished studies to estimate the pooled prevalence of sunlight exposure practice and its determinants. Even though the analysis had strengths, it has certain limitations: The heterogeneity was not completely fixed in the final random effect model. These findings will have vital implications for program planners, policymakers, and healthcare providers to design nutrition intervention programs accordingly. Measurements for the level of practice were taken from each primary study with different operational definitions.

Conclusion

The pooled prevalence of good sunlight exposure practice among infants is low. Being urban residents, PNC follow-up, mothers’ educational status and fear of sunlight exposure status were found to be associated with good sunlight exposure practices among infants. The governments and relevant stakeholders should develop and implement effective interventions to increase the prevalence of good sunlight exposure practices. Therefore health professionals create awareness for mothers about the importance of sunlight exposure and to increase follow postnatal care, especially for rural residence mothers.

Supporting information

S1 Table. PRISMA checklist.

https://doi.org/10.1371/journal.pone.0300598.s001

(DOCX)

S2 Table. The datasets used/analysed in this systematic review and meta-analysis.

https://doi.org/10.1371/journal.pone.0300598.s002

(XLSX)

Acknowledgments

The authors would like to recognize Wollo University for organizing an office and free internet access to conduct this study.

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Citation: Ayele FY, Kebede N, Mekonen AM, Mihiretu MM, Tsega Y, Addisu E, et al. (2024) Sunlight exposure practice and its associated factors among infants in Ethiopia, systematic review and meta-analysis. PLoS ONE 19(11): e0300598. https://doi.org/10.1371/journal.pone.0300598

About the Authors:

Fanos Yeshanew Ayele

Roles: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing

E-mail: [email protected]

Affiliation: Department of Public Health Nutrition, College of Medicine and Health Sciences, Wollo University, Dessie City, Ethiopia

ORICD: https://orcid.org/0000-0003-0646-9742

Natnael Kebede

Roles: Conceptualization, Data curation, Investigation, Methodology, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing

Affiliation: Department of Health Promotion, School of Public Health, College of Medicine and Health Sciences, Wollo University, Dessie City, Ethiopia

Asnakew Molla Mekonen

Roles: Conceptualization, Data curation, Formal analysis, Methodology, Validation, Visualization, Writing – review & editing

Affiliation: Department of Health System and Management, School of Public Health, College of Medicine and Health Sciences, Wollo University, Dessie City, Ethiopia

Mengistu Mera Mihiretu

Roles: Conceptualization, Data curation, Formal analysis, Methodology, Validation, Visualization, Writing – review & editing

Affiliation: Department of Health System and Management, School of Public Health, College of Medicine and Health Sciences, Wollo University, Dessie City, Ethiopia

Yawkal Tsega

Roles: Conceptualization, Data curation, Methodology, Software, Validation, Writing – review & editing

Affiliation: Department of Health System and Management, School of Public Health, College of Medicine and Health Sciences, Wollo University, Dessie City, Ethiopia

Elsabeth Addisu

Roles: Conceptualization, Data curation, Formal analysis, Methodology, Validation, Writing – review & editing

Affiliation: Department of Reproductive and Family Health, School of Public Health, College of Medicine and Health Sciences, Wollo University, Dessie City, Ethiopia

Niguss Cherie

Roles: Conceptualization, Data curation, Methodology, Validation, Visualization, Writing – review & editing

Affiliation: Department of Reproductive and Family Health, School of Public Health, College of Medicine and Health Sciences, Wollo University, Dessie City, Ethiopia

Tesfaye Birhane

Roles: Conceptualization, Data curation, Methodology, Software, Validation, Visualization, Writing – review & editing

Affiliation: Department of Reproductive and Family Health, School of Public Health, College of Medicine and Health Sciences, Wollo University, Dessie City, Ethiopia

Chala Daba

Roles: Conceptualization, Data curation, Formal analysis, Methodology, Validation, Visualization, Writing – review & editing

Affiliation: Department of Environmental Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia

Ahmed Hussien Asfaw

Roles: Conceptualization, Data curation, Investigation, Methodology, Validation, Visualization, Writing – review & editing

Affiliation: Department of Public Health Nutrition, College of Medicine and Health Sciences, Wollo University, Dessie City, Ethiopia

Zinet Abegaz

Roles: Conceptualization, Data curation, Methodology, Software, Validation, Visualization, Writing – review & editing

Affiliation: Department of Reproductive and Family Health, School of Public Health, College of Medicine and Health Sciences, Wollo University, Dessie City, Ethiopia

Abel Endawekie

Roles: Formal analysis, Methodology, Validation, Visualization, Writing – review & editing