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Background: Early morning sunlight exposure for infants is a good practice to prevent rickets and alleviate the problem of vitamin D deficiency. Rickets is a major public health problem in many countries especially in developing country including Ethiopia. As mothers are frontline person for their children who should know and practice about sunlight exposure, this systematic review and meta-analysis aimed to assess the pooled level of knowledge and practice towards sunlight exposure of their children among mothers in Ethiopia. Methods: PubMed, Google Scholar, Excerpta Medica database (EMBASE), Cochrane Library, Web of Science, and African Journal of Online (AJOL) were searched. The data were extracted using Microsoft Excel and analyzed using STATA version 14. Publication bias was checked by funnel plot and more objectively through Egger’s regression test, with P < 0.05 considered to indicate potential publication bias. The heterogeneity of studies was checked using I2 statistics. Pooled analysis was conducted using a weighted inverse variance random-effects model. Subgroup analysis was done related to geographic region and time. A leave-one-out sensitivity analysis was also employed. Result: A total of 8 studies with 2974 study participants for knowledge, nine studies with 3475 study participants for practice were used to estimate the pooled level of good knowledge and good practice of sunshine exposure among Ethiopian mothers. The overall estimated good level of knowledge and good practice towards sunshine exposure of their children among mothers was found to be 56.08% ((95% CI: 46.26 – 65.89%; I2 = 96.8%) and 55.632% (95%CI: 44.091 – 67.174%; I2 = 98.2%). Regional subgroup analysis showed that the pooled level of good practice in Amhara and Sidama regions found to be 54.41 and 58.32% respectively. Conclusion: Study findings showed mothers knowledge and practice towards sunshine exposure of children was quite low in Ethiopia. This study therefore recommends that interventions are needed to increase knowledge and practice of sunlight exposure. This study provides much needed significant evidence for making health-policy recommendations for this vulnerable population group.
This study was conducted to estimate the pooled level of KP of mothers towards sunshine exposure of their children in Ethiopia. We checked the DARE database (http://www.library.UCSF.edu) and the Cochrane library to ensure this had not been done before and to avoid duplication. We also checked whether there was any similar ongoing systematic review and meta-analysis in the PROSPERO database ((PROSPERO 2017:CRD42017074407); Available from http://www.Crd.york.ac.uk/PROSPERO_REBRANDING/displayrecord.asp?ID = CRD42017074407. These checks reassured us that there had been no previous similar studies undertaken. All relevant and published researches in the following databases; PubMed, Google Scholar, Excerpta Medica database (EMBASE), Cochrane Library, Web of Science, and African Journal of Online (AJOL) were searched. We reviewed grey literature using Google. Unpublished studies were sought from the official website of an international and/or local organization or university. The following core search terms or phrases were used; knowledge, awareness, practice, sunshine, rickets, vitamin D deficiency, children and mother. Search terms were pre-defined to allow a complete search strategy that included all-important studies. All fields within records and MeSH (Medical Subject Headings) and Boolean operators were used to search in the advanced PubMed search engine. Notably, to fit with the advanced PubMed database the following search strategy was developed using different Boolean operators; ((((((((Knowledge[tw] OR Awareness[tw] OR Practice[tw])) OR (“Health Knowledge, Attitudes, Practice”[Mesh] OR “Practice Management, Veterinary”[Mesh] OR “Patient Medication Knowledge”[Mesh] OR “Knowledge Discovery”[Mesh] OR “Intraoperative Awareness”[Mesh] OR “Knowledge Management”[Mesh] OR “General Practice”[Mesh] OR “Practice Patterns, Nurses’“[Mesh] OR “Knowledge Bases”[Mesh] OR “Advanced Practice Nursing”[Mesh]))) AND (((Sunshine [tw] OR Sun light [tw])) OR “Sunlight”[Mesh])) AND ((Exposure [tw]) OR (“Pre-Exposure Prophylaxis”[Mesh] OR “Virtual Reality Exposure Therapy”[Mesh] OR “Post-Exposure Prophylaxis”[Mesh] OR “Inhalation Exposure”[Mesh] OR “Paternal Exposure”[Mesh] OR “Maternal Exposure”[Mesh] OR “Occupational Exposure”[Mesh] OR “Prenatal Exposure Delayed Effects”[Mesh] OR “Environmental Exposure”[Mesh] OR “Atmosphere Exposure Chambers”[Mesh] OR “Dental Pulp Exposure”[Mesh] OR “Exposure to Violence”[Mesh] OR “Dietary Exposure”[Mesh] OR “Radiation Exposure”[Mesh] OR “War Exposure”[Mesh] OR “Implosive Therapy”[Mesh] OR “Disease Notification”[Mesh]))) AND (((Newborn [tw] OR Infant [tw] OR children [tw])) OR (“Infant, Newborn, Diseases”[Mesh] OR “Infant, Newborn”[Mesh] OR “Infant Welfare”[Mesh] OR “Infant Health”[Mesh] OR “Respiratory Distress Syndrome, Newborn”[Mesh] OR “Infant Death”[Mesh] OR “Infant, Extremely Premature”[Mesh] OR “Transient Tachypnea of the Newborn”[Mesh] OR “Infant, Extremely Low Birth Weight”[Mesh] OR “Infant Formula”[Mesh] OR “Diapers, Infant”[Mesh] OR “Adult Children”[Mesh] OR “Disabled Children”[Mesh] OR “Dental Care for Children”[Mesh] OR “Infant, Very Low Birth Weight”[Mesh] OR “Infant Behavior”[Mesh] OR “Infant Equipment”[Mesh]))) AND (((Mother[tw] OR Women [tw])) OR (“Pregnant Women”[Mesh] OR “Kangaroo-Mother Care Method”[Mesh] OR “Women, Working”[Mesh] OR “Women”[Mesh] OR “Physicians, Women”[Mesh] OR “Battered Women”[Mesh] OR “Mother-Child Relations”[Mesh] OR “Dentists, Women”[Mesh] OR “Maternal-Fetal Relations”[Mesh] OR “Infectious Disease Transmission, Vertical”[Mesh] OR “Women’s Health Services”[Mesh] OR “Mothers”[Mesh] OR “Postpartum Period”[Mesh] OR “Achard-Thiers syndrome” [Supplementary Concept]))) AND ((Ethiopia [tw]) OR (“Ethiopia”[Mesh] OR “hemoglobin Ethiopia” [Supplementary Concept])). We reviewed studies that assessed KP on sunshine exposure through face to face interviews, self-administered questionnaires or checklist among mothers. Knowledge: knowledge was assessed based on 10 questions about sunshine exposure that included the benefit, timing, duration and its drawback. Knowledge was defined as good if the respondents scored above the mean level. Practice: practice was assessed by using 7 questions about the timing, frequency, duration and the condition of sunshine exposure and the respondent was categorized as showing good practice if she scored above the mean level. The results of this review were reported in line with the Preferred Reporting Items for Systematic Review and Meta-Analysis statement (PRISMA) guideline [16]. All observational studies, including cross-sectional, case-control and cohort studies on KP of mothers towards sunshine exposure of their children were considered for this study. Those studies about KP of sunshine exposure among mothers which were published in English were included and there was no restriction on study period. The level of good knowledge and good practice was calculated using the data presented in the studies. Papers were excluded if they were: review articles, studies reporting confused data or with probable errors, studies without any information on the country and studies which were not able to fully access. An attempt was made to contact the corresponding authors using the email address or phone number as provided in the published articles. Retrieved articles were exported to the reference manager software, Mendeley Desktop, and this was used to remove duplicate studies. Two independent reviewers screened the title and abstract. Any disagreement was handled based on established article selection criteria. Data were extracted using a standardized data extraction format prepared in Microsoft Excel by two independent reviewers. Any discrepancy during extraction was solved through discussion. The name of the first author, study area and region, the study year, study design, year of publication, study population, sample size, response rate and level of good knowledge and good practice were collected. Three independent authors appraised the quality of the studies. The Joanna Briggs Institute (JBI) quality appraisal checklist was used [17]. When there was disagreement, all authors discussed and resolved the issue. The critical appraisal checklist had 8 parameters with options of “yes, no, unclear and not applicable.” The quality parameters included the following questions: (1) Were the criteria for inclusion in the sample clearly defined?, (2) Were the study subjects and the setting described in detail?, (3) Was the exposure measured in a valid and reliable way?, (4) Were objective, standard criteria used for measurement of the condition?, (5) Were confounding factors identified?, (6) Were strategies to deal with confounding factors stated?, (7) Were the outcomes measured in a valid and reliable way?, and (8) Was an appropriate statistical analysis used?. Studies were considered low risk if there was a score of 50% and above of the quality assessment indicators. The data were extracted using Microsoft Excel and analyzed by using STATA version 14 statistical software (stataCorp LP, 4905 Lakeway Drive, College Station, TX 77845, USA). Publication bias was checked by funnel plot and more objectively through Begg and Egger’s regression tests, with P < 0.05 considered to indicate potential publication bias [18, 19]. The presence of significant between-study heterogeneity was assessed using the Cochrane Q statistic. I2 was used to quantify between-study heterogeneity, in which a value of 0, 25, 50, and 75% indicated no, low, medium, and increased heterogeneity, respectively [20]. A forest plot was used to visualize the presence of heterogeneity. Since we found a high level of heterogeneity, we used a random-effect model for analysis to estimate Der Simonian and Laird’s pooled effect. Subgroup analysis was done by stud region. A leave-one-out sensitivity analysis was employed to see the effect of a single study on the overall meta-analysis estimate. The results were presented in the form of text, tables and figures.
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