Factors associated with infants’ sunlight exposure among mothers attending the EPI unit of Wolkite University Specialized Hospital

Girma Teferi Mengistu; Ayana Benti Terefe; Tolesa Gemeda Gudeta; Bizunesh Kefale Mengistu

doi:10.1371/journal.pone.0277349

. 2022 Nov 17;17(11):e0277349. doi: 10.1371/journal.pone.0277349

Factors associated with infants’ sunlight exposure among mothers attending the EPI unit of Wolkite University Specialized Hospital

Girma Teferi Mengistu ^1,^*, Ayana Benti Terefe ¹, Tolesa Gemeda Gudeta ¹, Bizunesh Kefale Mengistu ²

Editor: Mohammad Hossein Ebrahimi³

PMCID: PMC9671437 PMID: 36395250

Abstract

Background

Infant sunlight exposure in their early infancy is essential for the cutaneous synthesis of vitamin D. Vitamin D deficiency is highly prevalent due to inadequate exposure to sunlight. In Ethiopia, one in thirteen children had rickets, which could be prevented by sunlight exposure or supplementation. This study aimed to identify the practice of infants’ sunlight exposure and associated factors among mothers attending the Expanded program immunization unit of Wolkite University Specialized Hospital.

Method

This study employed an institutional-based cross-sectional study design to collect data. Data were collected from 220 mothers using an interviewer-administered questionnaire. The study employed a systematic random sampling technique to reach the study participants. The collected data were entered into a computer using the software Epidata 3.1 version and exported to SPSS version 23 for statistical analysis. Descriptive and inferential analysis was conducted. Logistic regression analysis was done, and a statistical association was declared at a p-value < 5% and a 95% confidence interval(CI). Then the results were presented using a frequency table, figures, and description.

Result

A total of 220 infant-coupled mothers who visited the Expanded program immunization unit were included in the study. According to the current study, 67.3% of mothers had good practice with infants’ sunlight exposure. Mothers’ practice of infant sunlight exposure was affected by age of mothers 30–34 years, [AOR = 3.10, 95%CI (1.13, 8.51)], and age ≥35 years, [AOR = 4.49, 95%CI (1.20, 16.86)], and living in urban, [AOR = 1.94, 95%CI (1.053, 3.57)].

Conclusion

The current study showed that two-thirds (67.3%) of mothers had good practice of sunlight exposure to their infants. Factors that affect mothers’ practice of infants’ sunlight exposure are age and place of residence. Health professionals should provide health education for mothers on the benefits of infants’ sunlight exposure.

Introduction

Infant sunlight exposure in their early infancy benefits in preventing diseases that could occur in their childhood development [1]. Sunlight exposure is essential for the cutaneous synthesis of vitamin D [2]. It is produced in the skin through a photosynthetic reaction from exposure to ultraviolet B (UVB) radiation. But clothing, excess body fat, sunscreen, and skin pigment melanin reduce the amount of the rays penetrating the skin [3]. The production of vitamin D less than body requirements can affect the health of infants [4].

Vitamin D is a fat-soluble vitamin recommended for exclusively breastfeeding infants. They can gain it through supplementation or sunlight exposure which produces it from the body [5]. The human body can generate about 80% of the vitamin D required for the body through sunlight exposure [6]. Vitamin D Supplementation for all breastfeeding infants also enables them to get the required amount [7].

Vitamin D prevents rickets in growing children and osteomalacia in adults [8]. The amount of vitamin D in the body determines the health of the bones [9]. Vitamin D can also prevent respiratory diseases such as wheezing [10].

The reasons for vitamin D deficiency are diet, atmospheric pollution, religious practices, geographical latitude and altitude, season, and time of the day [8]. Additionally, deficiency in mothers, older infants, and children with dark skin color, cultural practices, prolonged breastfeeding, and restriction of sunlight exposure are risk factors for its deficiency. In pediatrics, vitamin deficiency results in complications including hypocalcemia, seizure, rickets, limb pain, and fracture-related with poor bone formation [11,12].

Vitamin D deficiency is common among breastfeeding infants in sunny environments due to the avoidance of sunlight exposure and low supplementation [13]. Primary vitamin D deficiency is highly prevalent in countries with abundant sunshine due to inadequate sunlight exposure [14]. Mothers need awareness of the long-term effect of sunlight exposure on the growth and development of their infants [15].

Sunlight exposure initiates the body to produce vitamins due to sunlight rays. Exposure of infants starting from 6 weeks for 30 minutes per week, which lasts for 16 to 18 weeks, can achieve sufficient vitamin D at six months of age [16]. It prevents vitamin D deficiency-related bone disease, increased risk of respiratory illness, and low birth weight [17].

Adequate supplementation of vitamin D and calcium in infants can prevent nutritional rickets [18]. Calcium is supplied by the calcitriol hormone and used as a building material for bones. Sunlight exposure produces vitamin D in the skin, which in turn helps to produce calcitriol hormone [12]. In African countries, calcium intake is below the recommendations [19]. Rickets is the overt manifestation of vitamin D deficiency. If the infants are exclusively breastfed, they are prone to develop rickets [20]. Vitamin D deficiency is a public health issue in some low and middle-income countries. The risky groups in these countries are pregnant mothers, women of childbearing age, infants, and children [21].

Inadequate sunlight exposure is the cause of rickets in children [22]. In Ethiopia, the major causes of nutritional rickets in infants include lack of exposure to sunshine or inadequate intake of vitamin D. The lack of infants’ sunlight exposure is due to the traditional beliefs that prevent infants from exposure to sunlight [23].

Studies reported that children unexposed to sunlight had a deficiency of vitamin D and rickets [24]. According to a study conducted in central Ethiopia, the prevalence of vitamin D deficiency was 42% in school children [25]. On the other hand, a study conducted in eastern Ethiopia identified that one in thirteen, 7.8% of children had rickets [26]. Similarly, a study conducted at Jimma University Specialized Hospital reported that the prevalence of rickets was 10.5% in children [22]. But, sunlight exposure can treat deficiency-related rickets within weeks [27].

Previously conducted studies identified that the practice of infants’ sunlight exposure ranges from 44.6% to 58% [28–32]. Among these studies, only three of them studied associated factors where variables like maternal education, husband education, mother occupation, family size, and fear of cold were determining factors of infants’ sunlight exposure [28,30,31]. The current study included the place of residence in addition to previously studied variables. In Ethiopia, there is a cultural ceremony that prevents mothers from being outdoors during the postnatal period [33].

Ethiopia has access to sunlight due to its geographical location; however, the community does not expose its infants to sunlight, and there is no nutritional supplementation of the vitamin. In Ethiopia, a cultural practice restricts mothers and infants indoors after delivery during the early weeks. In the absence of sunlight exposure with no supplementation of vitamin D, infants are risky to develop vitamin D deficiency-related complications. Therefore, this study aimed to assess the practice of sunlight exposure and associated factors among mothers attending the Expanded program on immunization (EPI) at Wolkite University Specialized Hospital.

Materials and methods

Study area, design, and period

The study was conducted at Wolkite University Specialized Hospital (WUSH) using an institutional-based cross-sectional study design from 01 June to 30 July 2021. WUSH is 158km from Addis Ababa to the south in the Gurage zone, Southern Nation, Nationalities, and Peoples Region. The hospital serves as a teaching and referral hospital. Currently, it is providing emergency services, outpatients’ services, inpatients services, major and minor surgeries, maternal care, pediatrics services, antiretroviral therapy (ART) and Tuberculosis (TB) treatment clinics, laboratory, radiography services, and EPI services for the community.

Source and study population

The source population was all mothers attending the EPI unit of WUSH for immunization service. The study population was all mothers with infants who come to WUSH to vaccinate their infants and who fulfill the inclusion criteria.

Inclusion and exclusion criteria

The study included mothers with up to a one-year baby who visited the EPI unit of WUSH. The study excluded mothers with critically ill babies and mental or physical disabilities.

Sample size determination

The sample was calculated using a 95% confidence interval level, a 5% margin of error, and a 54.5% proportion of neonatal sunlight exposure from a study conducted at Yirgalem General Hospital [30]. Based on the given information the sample was 381. On average, 420 mothers attended the EPI unit of WUSH in two months to get immunization services for their infants. We used the correction formula to get the sample needed for the study. Then the corrected sample size was 200 and adding a 10% non-response rate the final sample size was 220.

Sampling procedure

A systematic random sampling technique was employed to select study participants. On average, an estimated 420 mothers visited the EPI unit of the hospital for immunization services in two months. Then the sampling interval (k) was calculated by dividing the number of infants served within two months by the sample size. This was calculated as k = N/n, 420/220 = 1.9. Approximately the k was 2. The data was collected from every other mother. During the data collection time, the first mother was selected randomly by the lottery method.

Operational definition

Good knowledge

Respondents who scored more than the mean value of responses for knowledge-related questions. Good practice: Respondents who scored more than the mean value of responses for practice-related questions.

Data collection

Data were collected using an interviewer-administered semi-structured questionnaire. The questionnaire was adapted from other previous studies [28,29,30,32]. The questionnaire had divided into four components which include sociodemographic characteristics (nine questions), obstetric history of mothers (five questions), knowledge questions (seven questions), and practice questions (eleven questions). The questionnaire was pretested on 5% (11) of mothers attending the EPI unit of Atat Hospital. The pretest was done to check the clarity, completeness, skip pattern, and order of questions, and then we made a minor modification. Experts revised the questionnaire before data collection and the data were collected by three BSc nurses after one-day training on the objective, purpose, and confidentiality of the study. The principal investigator supervised data collection data collection precess to increase data quality.

Data analysis procedure

After data collection, the data were checked for completeness and then entered into a computer using software; Epidata 3.1 version. Then we exported the data to software; SPSS version 23. After exporting the data, we conducted descriptive and inferential analysis. The descriptive part was used to analyze the data using frequency tables with descriptions. The inferential analysis was used to analyze the relation of independent variables with dependent variables, infants’ sunlight exposure. Variables with a p-value of less than 0.2 in bivariate logistic regression analyses were selected for multivariable logistic regression analysis. We conducted multivariable logistic regression analysis at a p-value < 5%, and 95%CI and a variable with a p-value of less than 0.05 were declared statistically significant. The inferential analysis included bivariate and multivariable logistic regression analyses. The result of the logistic regression analysis was presented using the Adjusted odds ratio (AOR) at 95%CI.

Ethical consideration

The research committee of the Nursing Department of Wolkite University revised and approved the study. The department of Nursing gave us a letter of permission during data collection. We obtained informed consent from each respondent after explaining the purpose and objective of the study.

Results

Sociodemographic characteristics

Data were collected from 220 mothers attending the immunization unit, which gives a 100% response rate. Among the mothers who participated in the study, 110(50%) were in the age group of 25–29. More than three fourth, 175 (79.5%) of the infants were six weeks or less during data collection. One-third (34.3%) of mothers attended primary education. About two-thirds (67.7%) of mothers were from urban areas (Table 1).

Table 1. Sociodemographic characteristics of a mother attending the EPI unit at WUSH, 2021.

Variable	Categories	Response
Variable	Categories	Frequency	Percent
Age of mother	20–24	22	10.0
	25–29	110	50.0
	30–34	66	30.0
	≥35	22	10.0
Age of infant(in months)	0–6	175	79.5
Age of infant(in months)	7–12	45	20.5
Marital status	Single	2	0.9
	Married	216	98.2
	Widowed	2	0.9
Mother’s educational status	no formal education	38	17.3
	primary education	75	34.1
	secondary education	62	28.2
	college/diploma	45	20.5
Occupation of mother	Student	3	1.4
	Housewife	128	58.2
	Daily laborer	14	6.4
	Government employee	33	15.0
	Private employee	11	5.0
	Merchant	31	14.1
Place of residence	Urban	149	67.7
Place of residence	Rural	71	32.3
Family size	1–3	60	27.3
	4–6	156	70.9
	≥7	4	1.8
Monthly income (in ETB)	≤1800 birr	16	7.3
	1801–3800 birr	141	64.1
	3801–7500 birr	60	27.3
	>7501 birr	3	1.4
Husband educational status	No formal education	25	11.4
	Primary education	63	28.6
	Secondary education	82	37.3
	College and above	50	22.7

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WUSH = Wolkite University Specialized Hospital, EPI = Expanded program of immunization.

Obstetric characteristics of mothers

All respondents had ANC follow-ups during their last recent pregnancy, of which 130 (59.1%) had four visits. About half (51.8%) of mothers gave birth at a health center. One-third (33.6%) of mothers gave birth at less than 37 weeks. Regarding birth weight, 17(7.7%) of neonates were less than 2500 grams during delivery (Table 2).

Table 2. Obstetric characteristics of mothers attending EPI unit of WKUSH, 2021.

Variable	Characteristics	Frequency	Percentage
Number of ANC visits during pregnancy	<4	90	40.9
Number of ANC visits during pregnancy	4	130	59.1
Place of delivery	Home	1	0.5
	Health center	114	51.8
	Hospital	105	47.7
Gestational age	<37	74	33.6
	37–42	145	65.9
	>42	1	0.5
Birth weight	<2.5	17	7.7
Birth weight	≥2.5	203	92.3

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WUSH = Wolkite University Specialized Hospital, EPI = Expanded program of immunization.

Knowledge of mothers about infants’ sunlight exposure

Almost all mothers (98.2%) had information about infants’ sunlight exposure. However, about half of them (51.4%) said that infants’ sunlight exposure had harmful effects to infants if improperly exposed. More than two-thirds (99.1%) of the mothers said that morning is a good time for infants’ sunlight exposure (Table 3). The overall knowledge of sunlight exposure of infants among mothers was 51.8% (Fig 1).

Table 3. Knowledge of mothers about infants’ sunlight exposure among mothers attending EPI unit at WUSH, 2021.

Variable	Characteristics	Frequency	Percent
Heard about sunlight exposure	Yes	216	98.2
Heard about sunlight exposure	No	4	1.8
Source of information	Health professionals	155	70.5
	Media	9	4.1
	Neighbors	54	24.5
	Friends	75	34.1
Sunlight exposure is beneficial	Yes	218	99.1
Sunlight exposure is beneficial	No	2	0.9
Benefits	Strengthen bone	147	67.4
	Strengthen teeth	7	3.2
	Keep child warm	30	13.8
	Produce vitamin D	70	32.1
	Strengthen body	140	64.2
Good time to expose	Morning	218	99.1
Good time to expose	Afternoon	2	0.9
Does sunlight exposure is harmful if not exposed appropriately	Yes	114	51.4
	No	106	48.2
Harms they fear	Skin cancer	92	80.7
	Sterility	1	0.9
	Blindness	33	28.9

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WUSH = Wolkite University Specialized Hospital, EPI = Expanded program of immunization.

Practices of infants’ sunlight exposure

Out of 220 study participants, 162(73.6%) mothers exposed their infants to sunlight. Of these, 146 (90.1%) started sunlight exposure after two weeks of delivery. About 111 (68.5%) of the mothers exposed their infants to sunlight daily. Almost two-thirds (63.6%) of mothers exposed their babies to sunlight outdoors. More than ninety percent (93.2%) of the mothers exposed their infants to sunlight in the morning, 8–10 AM. Fifty percent (50.6%) of them covered their infants partially during sunlight exposure. Eighty-three percent (83.3%) of mothers exposed their infants for 15–30 minutes. More than ninety percent (92.0%) of the respondents applied lubricants during the exposure (Table 4). Two-thirds (67.3%) of mothers had good practices of infants’ sunlight exposure which is computed based on the mean value of their responses to the practice questions (Fig 2).

Table 4. Practice infants’ sunlight exposure among mothers attending the EPI unit at WUSH, 2021.

Variable	Category	Frequency	Percent
Do you expose your infant to sunlight	Yes	162	73.6
Do you expose your infant to sunlight	No	58	26.4
Age of infant to start sunlight exposure	≤ 7days	1	0.6
	8 -14days	15	9.3
	≥15days	146	90.1
How frequently do you expose	Daily	111	68.5
How frequently do you expose	Sometimes	51	31.5
Do you expose your infant to sunlight outdoors?	Yes	103	63.6
Do you expose your infant to sunlight outdoors?	No	59	36.4
At what time do you expose	Morning 8–10 am	151	93.2
	Mid-day 11 am -1pm	7	4.3
	Afternoon 2-4pm	4	2.5
Condition of clothing during exposure	Unclothed	28	17.3
	With diaper and eye protection	39	24.1
	Partially covered	82	50.6
	Completely covered	13	8.0
How many minutes do you expose your neonate	<10 minute	26	16.0
	15–30 minute	135	83.3
	>30	1	0.6
Apply lubricant during exposure	Yes	149	92.0
Apply lubricant during exposure	No	13	8.0
When do you apply	Before exposure	25	16.8
	During exposure	25	16.8
	After exposure	99	66.4
What thing do you apply	Baby Vaseline	86	57.7
	Baby lotion	31	20.8
	Butter	32	21.5
Fear to expose baby to sunlight (n = 149) (Multiple responses are possible)	Sickness	66	44.3
	Evil eye	87	58.4
	Cold	65	43.6

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WUSH = Wolkite University Specialized Hospital, EPI = Expanded program of immunization.

Factors associated with sunlight exposure of infants

Logistic regression was done to identify a statistically significant variable at a p-value of < 5% and a 95%CI. Both bivariate and multivariable logistic regression analyses were done. In bivariate logistic regression analysis, the age of mothers, place of residence, and family size were significantly associated with mothers’ practice of infants’ sunlight exposure. We used the Crude odds ratio (COR) for bivariate logistic regression analysis. Mothers in the age group of 30–34 years and ≥35 were 3.20 [COR = 3.20, 95%CI (1.18, 8.69)], and 4.08 [COR = 4.08, 95%CI (1.11, 15.02)] times more likely to expose their infants to sunlight than mothers in the age group of 20–24 respectively. Mothers from the urban area were 1.86 [COR = 1.86, 95%CI (1.03, 3.37)] times more likely to expose their infants to sunlight than mothers from rural areas. Mothers from 4–6 families were 2.08 [COR = 2.08, 95%CI (1.12, 3.86)] times more likely to expose their infants to sunlight than mothers from 1–3 families.

Multivariable logistic regression analysis was done, and two variables (age of mothers and place of residence) were statistically significant. Mothers in the age group of 30–34 years and ≥35 were 3.10 [AOR = 3.10, 95%CI (1.13, 8.51)] and 4.49 [AOR = 4.49, 95%CI (1.20, 16.86)] times more likely to expose their infants to sunlight than mothers in the age group of 20–24 respectively. Mothers from urban areas were 1.94 [AOR = 1.94, 95%CI (1.05, 3.57)] times more likely to expose their infants to sunlight than mothers from rural areas (Table 5).

Table 5. Factors associated with sunlight exposure of infants among mothers attending EPI unit at WUSH, 2021.

Variable	Category	Practice of sunlight exposure		COR:95% CI	AOR:95% CI
Variable	Category	Good practice	Poor practice	COR:95% CI	AOR:95% CI
Age of mothers	20–24	10(45.5%)	12(54.5%)	1	1
	25–29	73(66.4%)	37(33.6%)	2.37(0.94, 5.99)	2.20(0.86, 5.65)
	30–34	48(72.7%)	18(27.3%)	3.20(1.18, 8.69)^*	3.10(1.13, 8.51)^*
	35+	17(77.3%)	5(22.7%)	4.08(1.11,15.02^*	4.49(1.12, 16.86)^*
Residence	Urban	107(71.8%)	42(28.2%)	1.86(1.03, 3.37)^*	1.94(1.05, 3.57)^*
Residence	Rural	41(57.7%)	30(42.3%)	1	1
Family size	1–3	33(55.0%)	27(45.0%)	1	1
	4–6	112(71.8%)	44(28.2%)	2.08(1.12, 3.86)^*	-
	≥7	3(75.0%)	1(25.0%)	2.46(0.24, 24.97)	-

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* = p< 0.05.

WUSH = Wolkite University Specialized Hospital, EPI = Expanded program of immunization.

Discussion

The current study identified that 98.2% of the respondents heard about infants’ sunlight exposure. Among those who heard about infants’ sunlight exposure, 70.5% of the study participants heard from health professionals. In the case of infants’ sunlight period, 99.1% of them knew that infants’ sunlight exposure is in the morning. Among the study participants, only 51.8% of them had good knowledge of infants’ sunlight exposure.

The finding of the study revealed that 73.6% of respondents have exposed their infants to sunlight. among mothers who exposed their infants to sunlight, 90.1% of them started exposure after the age of two weeks of delivery. Among those mothers who exposed their infants, two-thirds of them exposed their infants daily to the sunlight. During infants’ sunlight exposure, 50.6% of mothers exposed their infants to sunlight by partially covering their babies’ bodies with a cloth. During infants’ sunlight exposure, the mothers reported that they fear sickness, evil eyes, and cold.

Our study reveals that 67.3% of mothers had good practice in infants’ sunlight exposure. This finding was higher than the study finding from Debre Markos 44.6% [28], Ferta District 45.7% [29], Yirgalem Hospital 54.5% [30], Aleta Wendo Health Center 58% [32], and St. Paul’s Hospital 54. 6% [31]. The higher finding of the current study could be related to the time gap between the studies and study area. The mothers received advice on infants’ sunlight exposure, and the current study was conducted at a specialized hospital.

Logistic regression analysis was done to identify the factors associated with infants’ sunlight exposure among the study participants. In the bivariate analysis, there were three variables statistically significantly associated with mothers’ practice of infants’ sunlight exposure. The variables were the age of mothers, place of residence of mothers, and family size. Similarly, a study conducted in Debre Markos town showed that the age of mothers and family size were significantly associated [28].

The multivariable logistic regression analysis showed that the age of mothers and place of residence were statistically significant. Mothers in the age group of thirty to thirty-four and thirty-five and above were 3 and 4.5 times more likely to expose their infants to sunlight than mothers in the age group of twenty to twenty-four respectively. Mothers from urban areas are 1.94 times more likely to expose infants to sunlight than mothers from rural areas. Family size was significantly associated in a study conducted at Debre Markos town [28], while it was significantly associated in bivariate logistic regression analysis in the current study. Mothers at young age and mothers living in rural areas had a poor practice of infants’ sunlight exposure. These groups of mothers need attention to create awareness among them.

We addressed the place of residence of study participants, which was not studied in the previous studies. The study was based on mothers’ responses regarding their practice of infants’ sunlight exposure, and no sample was studied from infants to assess the concentration of vitamin D. Despite these limitations, this study added important information about mothers’ practice of infants’ sunlight exposure.

Conclusion

The findings of this study indicated that about two-thirds of mothers have good practice of infant sunlight exposure. Factors that affect mothers’ practice of infants’ sunlight exposure are age and place of residence. Health professionals should provide health education for mothers at young ages and mothers from rural areas on the benefits of infants’ sunlight exposure.

Supporting information

S1 File

(SAV)

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Acknowledgments

We would like to thank Wolkite University Specialized Hospital and our study participants for their participation.

Data Availability

All relevant data are within the paper and its Supporting Information files.

Funding Statement

The author(s) received no specific funding for this work.

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PLoS One. doi: 10.1371/journal.pone.0277349.r001

Decision Letter 0

Miquel Vall-llosera Camps

15 Jun 2022

PONE-D-21-36839Factors Associated With Infants’ Sunlight Exposure among Mothers Attending EPI of Wolkite University Specialized HospitalPLOS ONE

Dear Dr. Mengistu,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

I would like to sincerely apologise for the delay you have incurred with your submission. It has been exceptionally difficult to secure reviewers to evaluate your study. We have now received two completed reviews; the comments are available below. The reviewers have raised several significant scientific concerns about the study that need to be addressed in a revision.

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Comments to the Author

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Reviewer #1: Partly

Reviewer #2: Partly

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: No

**********

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Reviewer #1: Yes

Reviewer #2: Yes

**********

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Reviewer #2: Yes

**********

5. Review Comments to the Author

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Reviewer #1: Dear Authors....

This study focusing on the “ Factors Associated With Infants’ Sunlight Exposure among Mothers Attending EPI of Wolkite University Specialized Hospitals” is not uncommon, but the culture and understanding level about Infants’ Sunlight Exposure varies from location to location and culture to culture within a country and the authors used the population in Gurage , Southern-Ethiopia, which is stimulating to the readers. Authors requested to perform a major revision including language correction. I try to highlight some major and minor comments that the authors could reflect and thus confidently improving the manuscript even further.

Abstract part page-2

Q1. line-26 EPI please! change to Expanded program on immunization(EPI)

Method part page-2

*please! write the abstract part properly and clearly because it is a mirror of your manuscript including sampled number of population, study design and sampling technique

Q2. what was the study design?

Q3. what was the sampling techniques?

Result part page-2

Q4. line-32. how many infant coupled mothers were recruited in your study? please! start like A total of ........infant coupled mothers who visited EPI for vaccinating their children were included in the study.

Conclusion part page-2

Q5. Your conclusion is more than your result and please! revise it properly

Introduction part page-3

Q6. line 49 UVB please! change to ultra violet B (UVB)

Q7. pge-5 line 107 EPI please! change to Expanded program on immunization(EPI)

Materials and methods part page 6

Q8. inclusion and exclusion part line 128: what was the age infants which were included in the study? please! mention properly in the inclusion part.

Q9. There was no any information on how authors selected 220 infant coupled mothers for this study? no sample size estimation information? is it single/two population proportion formula? purposive?

Q10. ......knowledge, and practice questions. Every day, the filled questionnaire was

checked for completeness by the principal investigator to increase data quality. How authors categorized the knowledge level practice level of of mothers? or nothing was defined about level of knowledge and practice? nothing was mentioned in the manuscript. How many Likert scaled questions were applied? Have you use principal component analysis? or threshold formula or mean/median score?

Q11. result part page 9; Please! remove ANC visit rows from table two because it doesn't give any meaning

Mothers’ knowledge about sunlight exposure of neonates part page-9

Q12. line 183-184. The overall knowledge of sunlight exposure of infants among mothers was 51.8%. How did you get this proportions? what was your analytic approach to calculate this proportion?

The practice of Sunlight Exposure part page 11.

Q13. line 197-198 The overall practice of sunlight exposure among them were 67.3% during the study period. Similar to Q12.

Discussion part page-15.

In general the conclusion part was written poorly and the authors' requested to re-write this part by reviewing different literatures which were conducted in different parts with similar topic. please! the following literatures

1. https://www.dovepress.com/getfile.php?fileID=75617

2. https://bmcresnotes.biomedcentral.com/track/pdf/10.1186/s13104-019-4221-4.pdf

3. https://journals.sagepub.com/doi/pdf/10.1177/11795565211041348

4. https://www.hindawi.com/journals/ijrmed/2019/2638190/

Reviewer #2: The authors described the sunlight exposure among infants and the factors associated with it.

The authors could improve the manuscripts in the following sections:

Introduction:

1. The Introduction section needs to be summed up concisely.

2. The author may want to provide the prevalence of vitamin D deficiency among infants in the study area to show that sunlight exposure is very important, since “vD deficiency in order of magnitude was found in 62%, 28%, and 6% of Mexican, Cincinnati and Shanghai infants, respectively (p<0.001)”.

3. The logic flow of the introduction needs to be improved. For example, you need to provide the association between vitamin D and calcium before talking about “In African countries, calcium intake is below recommendations”.

4. The authors need to describe the importance/innovation of this study. Is there a knowledge gap in the research question? Is this study better than prior studies?

Method:

1. A comprehensive literature review is expected in the method section to identify the potential factors associated with sunlight exposure among infants from prior publications.

2. The authors may want to emphasize the representative of the study population when describing the study hospital.

3. The audience would like to read about sample size and power calculation in the method section.

4. Please provide more information about the design of the questionnaire and the validation of the questionnaire.

5. Please describe the training of interviewers before the study to improve the quality of the data collection.

Results:

1. The authors may want to add the “outdoor” to the sunlight in the questionnaire since indoor sunlight exposure may not lead to vitamin D synthesis.

2. The distribution of “sunlight is beneficial” and “sunlight is harmful” were conflict with each other in Table 3.

3. Please add the unit of monthly income in table 1.

4. The percentages mentioned in the Tables 3-4 were not consistent with the percentages mentioned in the result section.

5.“162(73.6%) of mothers exposed their infants to sunlight. Of these,146(66.4%) started sunlight exposure from 3weeks” (row 189) was not provided in table 4.

6. Please keep two decimal places for ORs.

7. Please describe the definition of the dependent variable for the regression model. The sample size for good practice is 148 in table 5, which is not consistent with any prior tables. The 148 is consistent with figure 2, but the audience still could not find the definition of “good practice” in the manuscript.

Discussion:

1. In the first paragraph of the discussion, please just emphasize the most important findings.

2. Please add strengths, limitations, biological mechanisms, and public health implications in the discussion section. For example, please discuss the potential selection bias and limited generalizability due to the use of “specialized” hospitals and the description of the sampling method.

Conclusion:

It is too early to provide public health policy recommendations based on one cross-sectional study among participants from one specialized hospital “Government should prepare a guideline on time of exposure and duration including starting age.”, “Each health institution has to work in providing health education for mothers during ANC visits, during discharge after delivery. Health education that could be given home to home by health extension workers for rural mothers. Government should prepare a guideline on time of exposure and duration including starting age.”

Grammar:

1. The following sentences need to be improved for readability:

1) “The practice was determined by the age of mothers and their residence. ”

2) “Compared with other previous studies used in discussion, there is progress from time to time even though the

study area was not the same.”

3) “Being in the age category of 30–34, 3.095 [AOR= 3.095, 95%CI (1.126, 8.506)], being in the age category of

35+ were 4.491 [AOR= 4.491, 95%CI (1.196, 16.863)], Living in urban 1.938 [AOR= 1.938, 95%CI (1.053,

3.566)] more likely to expose infants to sunlight than living in rural”

4) “Health education that could be given home to home by health extension workers for rural mothers.”

2. There are inconsistent capitalization, inappropriate use of abbreviations, and inconsistent fonts.

3. No reference for the sentence for rows 48,53, 57, and 77

4. There is repetitive “of clothing” in Table 4

**********

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Reviewer #1: Yes: Agete Tadewos Hirigo (MSc, Assistant professor of Clinical chemistry and Ph.D. fellow)

Reviewer #2: No

**********

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PLoS One. 2022 Nov 17;17(11):e0277349. doi: 10.1371/journal.pone.0277349.r002

Author response to Decision Letter 0

1 Aug 2022

Responses to Editor(s) and Reviewers

Manuscript Id: PONE-D-21-36839

Title: Factors Associated with Infants’ Sunlight Exposure among Mothers Attending EPI of Wolkite University Specialized Hospital

Dear editor(s) and Reviewers I would like to say thank for your comments and recommendations. I have included the concerns raised by reviewers in the documents, and if there is untouched points I am ready to amend. Thank you again.

Reviewer #1

Section Comments Responses

Abstract part page-2

Q1. line-26 EPI please! change to Expanded program on immunization(EPI) Changed

Method part page-2

*please! write the abstract part properly and clearly because it is a mirror of your manuscript including sampled number of population, study design and sampling technique Revised and the raised concerns are incorporated.

Q2. what was the study design? Included

Q3. what was the sampling techniques? Included

Result part page-2

Conclusion part page-2

Q5. Your conclusion is more than your result and please! revise it properly Revised and updated

Introduction part page-3

Q6. line 49 UVB please! change to ultra violet B (UVB) Changed

Q7. pge-5 line 107 EPI please! change to Expanded program on immunization(EPI) Changed

Materials and methods part page 6

Q8. inclusion and exclusion part line 128: what was the age infants which were included in the study? please! mention properly in the inclusion part. Included

Q9. There was no any information on how authors selected 220 infant coupled mothers for this study? no sample size estimation information? is it single/two population proportion formula? purposive? Sample size determination is included in the document.

Q10. ......knowledge, and practice questions. Every day, the filled questionnaire was checked for completeness by the principal investigator to increase data quality. How authors categorized the knowledge level practice level of of mothers? or nothing was defined about level of knowledge and practice? nothing was mentioned in the manuscript. How many Likert scaled questions were applied? Have you use principal component analysis? or threshold formula or mean/median score? An operational definition is added in the document for both knowledge and practice questions.

Result Q11. result part page 9; Please! remove ANC visit rows from table two because it doesn't give any meaning Removed

Mothers’ knowledge about sunlight exposure of neonates part page-9

Q12. line 183-184. The overall knowledge of sunlight exposure of infants among mothers was 51.8%. How did you get this proportions? what was your analytic approach to calculate this proportion? This is explained under the operational definition.

The practice of Sunlight Exposure part page 11.

Q13. line 197-198 The overall practice of sunlight exposure among them were 67.3% during the study period. Similar to Q12. This is explained under operational definition.

Discussion part page-15.

Reviewer #2

Introduction: 1. The Introduction section needs to be summed up concisely. Rearranged

4. The authors need to describe the importance/innovation of this study. Is there a knowledge gap in the research question? Is this study better than prior studies? Included in the document, in the colored part of the literature review

Method: 1. A comprehensive literature review is expected in the method section to identify the potential factors associated with sunlight exposure among infants from prior publications. In reviewing the submission guideline, I found that a comprehensive literature review is under the introduction part. I added it at the end of the introduction part which is highlighted.

2. The authors may want to emphasize the representative of the study population when describing the study hospital. Even though the Hospital is a specialized hospital, it is surrounded by rural villages where it serves them in addition to referral cases.

3. The audience would like to read about sample size and power calculation in the method section. Included

4. Please provide more information about the design of the questionnaire and the validation of the questionnaire. Included

5. Please describe the training of interviewers before the study to improve the quality of the data collection. Included

Results: 1. The authors may want to add the “outdoor” to the sunlight in the questionnaire since indoor sunlight exposure may not lead to vitamin D synthesis. Added

2. The distribution of “sunlight is beneficial” and “sunlight is harmful” were conflict with each other in Table 3. Revised

3. Please add the unit of monthly income in table 1. Added

4. The percentages mentioned in the Tables 3-4 were not consistent with the percentages mentioned in the result section. Sorry, it was a mistake done during descriptive analysis. Rather than using Valid percent, we used the normal percent. Now the table and the descriptions are revised and updated.

5.“162(73.6%) of mothers exposed their infants to sunlight. Of these,146(66.4%) started sunlight exposure from 3weeks” (row 189) was not provided in table 4.

6. Please keep two decimal places for ORs. Changed

Discussion:

1. In the first paragraph of the discussion, please just emphasize the most important findings. Addressed

Conclusion It is too early to provide public health policy recommendations based on one cross-sectional study among participants from one specialized hospital “Government should prepare a guideline on time of exposure and duration including starting age.”, “Each health institution has to work in providing health education for mothers during ANC visits, during discharge after delivery. Health education that could be given home to home by health extension workers for rural mothers. Government should prepare a guideline on time of exposure and duration including starting age.” Revised and updated

Grammar:

1. The following sentences need to be improved for readability:

1) “The practice was determined by the age of mothers and their residence.”

2) “Compared with other previous studies used in discussion, there is progress from time to time even though the study area was not the same.”

3) 3) “Being in the age category of 30–34, 3.095 [AOR= 3.095, 95%CI (1.126, 8.506)], being in the age category of 35+ were 4.491 [AOR= 4.491, 95%CI (1.196, 16.863)], Living in urban 1.938 [AOR= 1.938, 95%CI (1.053, 3.566)] more likely to expose infants to sunlight than living in rural”

4) “Health education that could be given home to home by health extension workers for rural mothers.” Revised and updated

2. There are inconsistent capitalization, inappropriate use of abbreviations, and inconsistent fonts. Revised

3. No reference for the sentence for rows 48,53, 57, and 77 Revised

4. There is repetitive “of clothing” in Table 4 Revised

Attachment

Submitted filename: Responses to Reviewer #1.docx

Click here for additional data file.^{(19.4KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0277349.r003

Decision Letter 1

Mohammad Hossein Ebrahimi

2 Oct 2022

PONE-D-21-36839R1Factors associated with infants’ sunlight exposure among mothers attending the EPI unit of Wolkite University Specialized HospitalPLOS ONE

Dear Dr. Mengistu,

Please submit your revised manuscript by Nov 16 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Mohammad Hossein Ebrahimi

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Review Comments to the Author

Reviewer #1: Dear, Authors thank you for your response and I hope you will take actions to correct some parts in your manuscript as much as possible. And some comments are attached here

Abstract part

Line-26: This study aims to…. Please! Modify to “This study aimed to….” Or “The aim of this study was….”

Line 31-35: please! Modify to: The collected data were entered into a computer using the software Epidata 3.1 version and exported to SPSS version 23 for statistical analysis. Descriptive and inferential analysis was conducted. Logistic regression analysis was done, and a

statistical association was declared at p-value < 5% and 95% confidence interval(CI).Then the results were presented using a frequency table, figures, and description.

Line 38-39: please! Modify to: Mothers practice of infant sunlight exposure was affected

39 by age of mothers 30–34 years, [AOR= 3.095, 95%CI (1.126, 8.506)], and age ≥35 years, [AOR= 4.491, 95%CI (1.196, 16.863)], and living in urban, [AOR= 1.938, 95%CI (1.053, 3.566)].

Materials and methods part page 6

Line 113-115: please! Modify to: Currently, it is providing emergency services, outpatients’ services, inpatients services, major and minor surgeries, maternal care, pediatrics services, antiretroviral therapy (ART) and Tuberculosis (TB) treatment clinics, laboratory, radiography services, and EPI services for the community.

Sample size Determination part page 6

Line 124-128. The sample was calculated using a 95% confidence interval level, 5% margin of error, and 54.5%: based on this the calculated sample size is

(1.96)2x0.545x (1-0.545)/0.052=381

Factors associated with sunlight exposure of infant’s page 13

Line 213-214: Mothers in the age group of 30–34 years and ≥35 were 3.20 [COR= 3.20, 95%CI (1.18, 8.69)],

Also please! Correct sentence of line 220-221 in similar manner

Reviewer #2: The authors may improve the manuscript using the following suggestions:

Abstracts:

1 The authors just need to keep two decimal points for the odds ratio

2 It is too early to suggest “Health professionals should provide health education for mothers at young ages and mothers from rural areas on the benefits of infants' sunlight exposure.” based on one cross-sectional study.

Introduction:

1. Thank you for working on the introduction. If the authors would like to sum up the introduction section concisely, you can use the following detailed information to improve the re-submitted draft.

The authors can

1)start with the outcome (prevalence of rickets in the study area) (The authors can use rows 90-92), and add information about the significance of rickets (mortality, disability, medical cost, et al)

2)state the association between rickets and vitamin D deficiency (The authors can use rows 58-61, 66-67, 78-81, 86)

3)provide the prevalence of vitamin D deficiency in study area (The authors can use rows 89-90)

4)state the sources of vitamin D in infant and the role of sunlight in vitamin D level (The authors can use rows 49-50, 62-65)

5)state sunlight would be the best solution due to the sufficient sunlight in study area, the lack of vitamin D supplements, and the common use of breastfeeding in study area (The authors can use rows 53-57, 68-76, 82, 88, 93, 103)

6)provide the prevalence of sunlight exposure in study area and factors affect the sunlight exposure in study area (The authors can use rows 51, 87, 94-97, 99-102)

7)add articles that indicate the lack of published study on practice of infant sunlight exposure and associated factors among study population

8)the aim of the study to address the knowledge gap (The authors can use rows 104-105).

Please also remove repeated information if the authors choose to rearrange the introduction section using this format.

2. If the authors added rows 94-98 as the knowledge gap to address previous comment #4 (there were no highlights in the introduction), then the authors need to provide why “The current study included the place of residence in addition to previously studied variables.” is the innovation/importance of the current study. Are there any articles indicating that place of residence is an important factor for sunlight exposure? The authors may need to add one sentence here.

3. Other suggestions about the introduction that might improve the introduction:

1) Reference 10 may not support the statement

2) The authors can use “children unexposed to sunlight “ to replace “unexposed children to sunlight”

3) Lack of reference in row 92

Methods:

1 The “10% non-response rate” is not consistent with the “which gives a 100% response rate”

2 Please add the year to the “from 01 June to 30 July.”.

3 The power calculation needs to be improved. 1) The authors can use a fixed number of participants to calculate power, or the authors can calculate the number of participants required to reach the 80% statistical power at the significance level of 0.05. The authors can also calculate the minimal detectable odds ratios using the fixed number of participants and the 80% statistical power. 2) The information provided in the sample size determination section is not sufficient to calculate sample size or power using the Epiinfor 7 software.

Results:

1 “More than two-thirds (69.1%) of the mothers said that morning is a good time for infants’ sunlight exposure (Table 3).” is not consistent with the “99.1% “ reported in table 3.

2 The percentages for “Fear to expose baby on sunlight” in Table 4 are not consistent with the frequency.

Discussion:

1 For the first two paragraphs, please just mention the important findings. Please try not to repeat what you had in the result section.

2 Please revise the “The study could not support the cause and effect relationship between independent and dependent variables.” We usually would not use the terms “cause” and “effect” in the cross-sectional study.

Reviewer #3: Data analysis procedure: Please describe the variables included in the logistic regression analyses and define AOR.

Results: the factors associated with sunlight exposure of infants, which were found in logistic regression, are unclear. The reader needs to know the coefficients, and you must define what COR is in the first mention.

Include in all tables notes defining all the acronyms used.

**********

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PLoS One. 2022 Nov 17;17(11):e0277349. doi: 10.1371/journal.pone.0277349.r004

Author response to Decision Letter 1

4 Oct 2022

Responses to Editor(s) and Reviewers’ comments

Manuscript Id: PONE-D-21-36839R1

Title: Factors Associated with Infants’ Sunlight Exposure among Mothers Attending EPI of Wolkite University Specialized Hospital

Thank you for reviewing the paper.

Section Comments Responses

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. Upon reviewing the references, three of them were found incorrectely written and modified.

Reviewer #1

Abstract part Line-26: This study aims to…. Please! Modify to “This study aimed to….” Or “The aim of this study was….” Modified

statistical association was declared at p-value < 5% and 95% confidence interval(CI).Then the results were presented using a frequency table, figures, and description. Modified

Line 38-39: please! Modify to: Mothers practice of infant sunlight exposure was affected by age of mothers 30–34 years, [AOR= 3.095, 95%CI (1.126, 8.506)], and age ≥35 years, [AOR= 4.491, 95%CI (1.196, 16.863)], and living in urban, [AOR= 1.938, 95%CI (1.053, 3.566)]. Modified

Materials and methods part page 6 Line 113-115: please! Modify to: Currently, it is providing emergency services, outpatients’ services, inpatients services, major and minor surgeries, maternal care, pediatrics services, antiretroviral therapy (ART) and Tuberculosis (TB) treatment clinics, laboratory, radiography services, and EPI services for the community. Modified

Sample size Determination part page 6

Line 124-128. The sample was calculated using a 95% confidence interval level, 5% margin of error, and 54.5%: based on this the calculated sample size is

(1.96)2x0.545x (1-0.545)/0.052=381

Please! Correct your sample size calculation. The sample size could be more than 380 as shown above based on your explanation. So how it could be reduced to 220? Please! Write clear explanation about it. We changed the methods sample size calculations based on your concern first we used epi info, and due to error in metnod of calculation we used correction formula.

Factors associated with sunlight exposure of infant’s page 13 Line 213-214: Mothers in the age group of 30–34 years and ≥35 were 3.20 [COR= 3.20, 95%CI (1.18, 8.69)],

Also please! Correct sentence of line 220-221 in similar manner Modified

Reviewer #2:

Abstracts:

1 The authors just need to keep two decimal points for the odds ratio Corrected to two decimal place

Introduction: 1. Thank you for working on the introduction. If the authors would like to sum up the introduction section concisely, you can use the following detailed information to improve the re-submitted draft.

The authors can

1)start with the outcome (prevalence of rickets in the study area) (The authors can use rows 90-92), and add information about the significance of rickets (mortality, disability, medical cost, et al)

2)state the association between rickets and vitamin D deficiency (The authors can use rows 58-61, 66-67, 78-81, 86)

3)provide the prevalence of vitamin D deficiency in study area (The authors can use rows 89-90)

4)state the sources of vitamin D in infant and the role of sunlight in vitamin D level (The authors can use rows 49-50, 62-65)

6)provide the prevalence of sunlight exposure in study area and factors affect the sunlight exposure in study area (The authors can use rows 51, 87, 94-97, 99-102)

7)add articles that indicate the lack of published study on practice of infant sunlight exposure and associated factors among study population

8)the aim of the study to address the knowledge gap (The authors can use rows 104-105). We leave the introduction part as it is. The flow of ideas were started from benefits of sunlight exposure, vitamin D and sunlight exposure, deficiency of vit D, its epidemiology, relation to exposure, …

This is the reason for no rearranging the introduction.

But, we appreciate your suggestions.

Please also remove repeated information if the authors choose to rearrange the introduction section using this format. We decided no to rearrange the part.

3. Other suggestions about the introduction that might improve the introduction: 1) Reference 10 may not support the statement Removed

2) The authors can use “children unexposed to sunlight “ to replace “unexposed children to sunlight” Replaced

3) Lack of reference in row 92 Revised and added.

Method: :1 The “10% non-response rate” is not consistent with the “which gives a 100% response rate” you are right, but all distributed paper was returned from data collectors. When we check the questionnaire all were complete and decicded to include all.

2 Please add the year to the “from 01 June to 30 July.”. Added

Results: 1 “More than two-thirds (69.1%) of the mothers said that morning is a good time for infants’ sunlight exposure (Table 3).” is not consistent with the “99.1% “ reported in table 3. Corrected

2 The percentages for “Fear to expose baby on sunlight” in Table 4 are not consistent with the frequency. Multiple resposnes are possible.

Discussion:

1 For the first two paragraphs, please just mention the important findings. Please try not to repeat what you had in the result section. Reviewed and modified

Reviewer #3

Data analysis procedure Please describe the variables included in the logistic regression analyses and define AOR. Described, and defined

Results the factors associated with sunlight exposure of infants, which were found in logistic regression, are unclear. The reader needs to know the coefficients, and you must define what COR is in the first mention. Included

Include in all tables notes defining all the acronyms used. Included

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PLoS One. doi: 10.1371/journal.pone.0277349.r005

Decision Letter 2

Mohammad Hossein Ebrahimi

10 Oct 2022

PONE-D-21-36839R2Factors associated with infants’ sunlight exposure among mothers attending the EPI unit of Wolkite University Specialized HospitalPLOS ONE

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Reviewers' comments:

PLoS One. 2022 Nov 17;17(11):e0277349. doi: 10.1371/journal.pone.0277349.r006

Author response to Decision Letter 2

23 Oct 2022

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. We reviewed and checked the references, all are correct and available online.

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PLoS One. doi: 10.1371/journal.pone.0277349.r007

Decision Letter 3

Mohammad Hossein Ebrahimi

26 Oct 2022

Factors associated with infants’ sunlight exposure among mothers attending the EPI unit of Wolkite University Specialized Hospital

PONE-D-21-36839R3

Dear Dr. Mengistu,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Reviewers' comments:

PLoS One. doi: 10.1371/journal.pone.0277349.r008

Acceptance letter

Mohammad Hossein Ebrahimi

9 Nov 2022

PONE-D-21-36839R3

Factors associated with infants’ sunlight exposure among mothers attending the EPI unit of Wolkite University Specialized Hospital

Dear Dr. Mengistu:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

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Data Availability Statement

All relevant data are within the paper and its Supporting Information files.

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PERMALINK

Factors associated with infants’ sunlight exposure among mothers attending the EPI unit of Wolkite University Specialized Hospital

Girma Teferi Mengistu

Ayana Benti Terefe

Tolesa Gemeda Gudeta

Bizunesh Kefale Mengistu

Roles

Abstract

Background

Method

Result

Conclusion

Introduction

Materials and methods

Study area, design, and period

Source and study population

Inclusion and exclusion criteria

Sample size determination

Sampling procedure

Operational definition

Good knowledge

Data collection

Data analysis procedure

Ethical consideration

Results

Sociodemographic characteristics

Table 1. Sociodemographic characteristics of a mother attending the EPI unit at WUSH, 2021.

Obstetric characteristics of mothers

Table 2. Obstetric characteristics of mothers attending EPI unit of WKUSH, 2021.

Knowledge of mothers about infants’ sunlight exposure

Table 3. Knowledge of mothers about infants’ sunlight exposure among mothers attending EPI unit at WUSH, 2021.

Fig 1. Knowledge of infants’ sunlight exposure among mothers attending EPI unit at WUSH, 2021.

Practices of infants’ sunlight exposure

Table 4. Practice infants’ sunlight exposure among mothers attending the EPI unit at WUSH, 2021.

Fig 2. Practice of infants’ sunlight exposure among mothers attending EPI unit at WUSH, 2021.

Factors associated with sunlight exposure of infants

Table 5. Factors associated with sunlight exposure of infants among mothers attending EPI unit at WUSH, 2021.

Discussion

Conclusion

Supporting information

Acknowledgments

Data Availability

Funding Statement

References

Decision Letter 0

Miquel Vall-llosera Camps

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Author response to Decision Letter 0

Decision Letter 1

Mohammad Hossein Ebrahimi

Roles

Author response to Decision Letter 1

Decision Letter 2

Mohammad Hossein Ebrahimi

Roles

Author response to Decision Letter 2

Decision Letter 3

Mohammad Hossein Ebrahimi

Roles

Acceptance letter

Mohammad Hossein Ebrahimi

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

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