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Multilevel analysis of infant sunlight exposure practices among mothers in Mettu district Illubabor zone Oromia Ethiopia

Scientific Reports volume 15, Article number: 26819 (2025) Cite this article

Abstract

Infants can get enough vitamin D from regular sunlight exposure. It is required in infants to prevent rickets, minimize the danger of life-threatening hypocalcemic consequences, boost the immune system, and aid in the prevention of cancer, diabetes, and other chronic disorders. The aim of the study was to identify the individual and community-level factors of the practice of sunlight exposure in infants. A community-based cross-sectional study design was undertaken to collect data from March 2024 to April 2024. The multilevel mixed-effects model was used to identify significant factors associated with the practice of sunlight exposure in infants. 372 (58.13%) mothers, out of 640 participants, practiced adequate exposure of their infants to sunlight. The result of multilevel mixed-effects analysis revealed that rural mothers had lower odds of adequately exposing their infants to sunlight when compared with urban mothers [AOR = 0.34, 95% CI = 0.16–0.52]. The finding of this study revealed that 58.13% of mothers have good practices of sunlight exposure. The current study also revealed that there was variation among rural and urban women on the good practice of sunning their infants. Mothers need to be educated about the benefits of infants’ sunlight exposure. Further studies should be conducted to determine the best way to sun infants in order to maintain adequate vitamin D that helps the body to absorb calcium to strengthen bones, thereby preventing rickets and other childhood disorders.

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Introduction

Infants can get enough vitamin D from regular sunlight exposure1,2. Studies done in Australia3 and Ethiopia4 recommended to sun neonates starting from 2 weeks for 15 to 30 min twice or thrice a week before 10:00 and after 16:00. Vitamin D is required in infants to avoid rickets, reduce the risk of life-threatening complications of hypocalcemia, boost the immune system, and assist the prevention of cancer, diabetes, and other chronic diseases5. The previous study was also revealed that the main source of vitamin D, which is more than 80%, is sunlight exposure (UVB radiation)6. Excessive sunlight exposure is significantly associated with skin cancer7. Thus, it is important to limit the sun exposure of infants for approximately 15 to 30 min twice or thrice a week to maintain adequate vitamin D production and minimising the risk of skin cancer3,8,9.

Vitamin D deficiency and nutritional rickets remain major health problem around the world, particularly in developing countries. Vitamin D insufficiency affects around one billion individuals globally, including children and the elders10,11. Various epidemiological studies found that vitamin D deficiency is highly prevalent among infants in different countries, mainly in developing countries, especially in Sub-Saharan Africa, regardless of age, ethnicity, geographical location, and climatic conditions, and is thought to range from 2.7–45%10,12,13,14. Ethiopia is not exempt from this burden. A research conducted in Addis Ababa indicated that 41% of children under the age of three who visited an out-patient department had vitamin D deficiency rickets, with infants having the highest frequency15. Another study conducted in Jimma town discovered that vitamin D deficiency rickets affected 11% of infants16,17.

Most of the previous studies done in Ethiopia regarding practice of sunlight exposure of infants were limited to health facility, limited to urban areas and identified only individual level factors. Moreover, previous studies did not include birth order as a factor of mothers’ practice of sunlight exposure of infants. Therefore, the primary aim of this study was to identify the individual and community level factors of practice of sunlight exposure of infants among mothers in Mettu district, Illubabor zone, Oromia region, Ethiopia using multilevel mixed-effects analysis. Place of residence (urban, rural) is considered as a community level factor to make a comparison between rural and urban mothers regarding adequate sunning of their infants. Identifying the individual and community level factors is important to increase the practice of sunlight exposure and protect the health of infants in Ethiopia.

Methods

Study area, study design and period

The study was conducted in Mettu district, Illubabor zone, Oromia Regional State, Ethiopia. The community-based cross-sectional study design was employed in the urban and rural areas of the Mettu district from March 2024 to April 2024. According to the 2007 national census report, the district comprises 30 kebeles with an estimated resident population of 61,954 out of which 30,972 were women. The number of infants was estimated to be 2,732 in the district18.

Study population

Mothers who had infants aged less than 1 year during the data collection period were target population of the study.

Inclusion and exclusion criteria

Mothers who had infants aged less than 1 year during the data collection period, have been residing for more than six months in the study area, and who were able to speak and were not severely ill were included in the study.

Sampling procedures

Sample size is determined with a single population proportion formula

Where,  is the sample size required.  is standard normal random variable at  level of confidence.  is margin of error.  is proportion of study population.

Accordingly, by considering the proportion of women who practiced infant sunning in the study area (p = 57.7%) from a previous study18 with margin of error of 5% and a confidence interval of 95%, which gives a calculated sample size of 376 participants. After using a design effect of 1.5 (due to multistage sampling) and adding a 15% non-response rate, the final sample size will be 649 participants.

Operational definitions

Adequate sunlight exposure

Mothers who exposed their infants to sunshine in the morning time (8:00–10:00 a.m.) for 10 min unclothed or 30 min clothed daily for the last 3 months starting before 45 days of birth.

Knowledge

Mothers responded to knowledge questions and scored above the median value 3.5 were considered to have good knowledge whereas those mothers scored the median value 3.5 or below were considered to have poor knowledge.

Practice

Mothers responded to practice questions and scored above the median value 5 were considered to have good practice whereas those mothers scored the median value 5 or below were considered to have poor practice.

Data collection instrument and sampling techniques

A multistage sampling technique was used in this study. Kebeles and households were the primary and secondary sampling units respectively. Six kebeles, out of 30 kebeles in the district, were selected using a simple random sampling method. The selected kebeles are Aba Saya, Tulube, Burusa, Tabo, Kemise and Aba Mole. The three kebeles namely Aba Saya, Aba Mole and Tabo kebeles are considered as urban areas since they found in Mettu town whereas Tulube, Burusa and Kemise are taken as rural kebeles. A total sample size was allocated to each of the selected kebeles using proportional allocation. Thereafter, a systematic random sampling method was used to select households for an interview.

The first household was selected with a lottery method and then every k-interval was included in the study. A woman who has a child aged less than 12 months from each selected household was interviewed, and if there is more than one eligible woman in the selected household the lottery method would be used to select a woman to interview. Data were collected using a structured, interviewer-administered questionnaire which was prepared from similar, previously published studies. The questionnaire is initially developed in English, and then translated to the local language Afan Oromo and then translated back to English to check its consistency.

The questionnaire included socio-demographic, economic, and obstetric characteristics of study subjects. A pilot study was conducted using 5% of the sample size which is not included in the actual study. Findings from the pilot study was used to modify the data collection tool.

Data analysis

Descriptive analysis and multilevel mixed-effects model were used to address the main objective of the study and reach valid conclusions. The two-level mixed-effects logistic regression analyses were employed using R software (R 4.5.0 Pre-release). The multilevel mixed-effects model was used because of multistage sampling technique. It includes both fixed and random effects20. Hence, four models are displayed for the data analysis. Model-I was an empty model (model containing no individual or community-level factors), Model-II (containing only individual factors), Model-III (containing only community factors) and Model-IV (both individual and community-level factors).

The fitted model was

Where;  is the probability of mothers who practice adequate sunning of their infants.  is the probability of mothers who do not practice adequate sunning of their infants.  is the log odds of the intercept.  are the amount of effect by the individual and community-level variables.  are the independent variables at individual and community level  is the random error at community(cluster) and the random error at the individual level.

Initially, bivariate two level mixed-effects logistic regression analyses were done to assess the association between the independent variables and the dependent variable of the study. The variables with a p-value < 0.25 at the bivariate two-level mixed-effects logistic regression analysis were included into the final model of multivariable two-level mixed-effects logistic regression model. In the final model, Adjusted Odd Ratio (AOR) with 95% confidence level were estimated to identify factors associated with the mothers’ practice of sunlight exposure of infants. A variable with p-value  0.05 was considered as statistically associated with the practice of sunlight exposure of infant.

To identify the degree of variability between groups, Intra-Class Correlation (ICC) was calculated as the ratio of the amount of variance due to groups relative to the total variance of dependent variable, i.e.

Where,  is variance of due to groups (cluster).  is total variance of dependent variable, .

The resulting value is theoretically falls between 0 and 1.0 because it is a proportion of variance, with higher values reflecting greater between-group variability21. Moreover, the fitness of the model was examined by AIC (Akaike Information Criterion), BIC (Bayesian Information Criterion) and Deviance.

Ethical approval

Mattu University’s College of Natural and Computational Sciences Research and Ethics Review Board granted ethical permission and human subject research approval for this study, with ethics approval number CNCS/5780/24. I confirm that all methods were performed in accordance with the relevant guidelines and regulations of the institution. Finally, I want to clarify that this research was carried out per the Helsinki Declaration.

Results

Socio-demographic, socio-economic and obstetric characteristics

Out of 649 recruited participants, 640 (98.6%) provided complete information during data collection. However, data collected from 9 (1.4%) of the participants were excluded from the analysis due to their incompleteness and inconsistency. Out of 640 participants, 372 (58.13%) mothers practiced adequate exposure of their infants to sunlight. The majority of study participants were between the ages of 26 and 35. Furthermore, 471 (73.59%) of the mothers who participated in this study were housewives (Table 1).Table 1 Distribution of socio-demographic, economic and obstetric characteristics of study participants in Mettu district, illubabor zone, oromia region, ethiopia, 2024 (n = 640).

Full size table

More than half (52.27%) of the study participants had an education status of grade 1–8 (Fig. 1).

figure 1
Fig. 1

Knowledge of study participants about infants’ sunlight exposure

Among 640 mothers, majority of them (67.27%) had good knowledge about sunning their infants and 635 (99.2%) of them knew the perfect sunning time to be in the morning, 8:00 am-10:00 am. From all respondents, only 59 (9.2%) believed that sunlight exposure had a harmful effect on the infant, and the most commonly mentioned harmful effect of sunlight exposure was blackness (30 (4.69%)) (Table 2).Table 2 Knowledge level of mothers about sunlight exposure of their infants in Mettu district, illubabor zone, oromia region, ethiopia, 2024 (n = 640).

Full size table

Level of practice of mothers about infants’ sunlight exposure

Among the 577 (90.1%) mothers who were informed about infant sunlight exposure, 532 (83.1%) of them exposed their infants to sunlight properly, and the majority of mothers, 591 (92.3%), exposed their infants to sunlight daily. However, 98.9% of mothers who exposed their infants to sunlight appear to have applied various types of lubricants. The majority of participants, 636 (99.4%), exposed their infants outdoors (outside the house), with 551 (86.1%) of the participants starting to expose their infants to sunlight before 45 days of birth (Table 3).Table 3 Practice of mothers on sunlight exposure of their infants in Mettu district, illubabor zone, oromia region, ethiopia, 2024 (n = 640).

Full size table

figure 2
Fig. 2

Description of the models

Four models were considered for multilevel analysis: Model-I was an empty model, which had no individual or community-level variables; Model-II included individual-level variables only; Model-III considered community-level variables only; and Model-IV considered both the individual and community-level variables.

Comparison of the models

The model comparison result revealed that Model-IV is a better fit for the data as compared to other models since it has the smallest AIC and BIC values. At a 5% level of significance, the result of the combined model revealed that the predictors such as age of mother, occupation of mother, educational status of mother, place of delivery, marital status, family size, birth order, source of information, knowledge of infant’s sunlight exposure, fear of sunlight exposure due to evil eye, mass media, and place of residence were significantly associated with the practice of sunlight exposure of infants. Factors such as the educational status of the husband, monthly income, and number of ANC visits during pregnancy were not statistically significant at the 95% level of confidence.

Interpretation of parameters

Mothers aged 26–35 years were 2.36 times (AOR = 2.36, 95% CI: 1.71, 3.00) more likely to have good practice in sunlight exposure of infants compared with mothers of age 16–25 years. Those mothers whose age was 36 and above were 1.6 times (AOR = 1.6, 95% CI: 1.30, 1.89) more likely to have good practice in sunlight exposure of infants compared with mothers of age 16–25 years. Married mothers had good practice of infants’ exposure to sunlight. They were found to be 1.27 times more likely to have good practices than single mothers. Mothers whose occupation was farmer (AOR = 0.40, 95% CI: 0.28, 0.52), merchant (AOR = 0.38, 95% CI: 0.16, 0.60), and government employee (AOR = 0.12, 95% CI: 0.10, 0.14) had lower odds of practicing adequate sunning of their infants compared with housewives. Furthermore, mothers who took information about sunning their infants from health-care professionals (AOR = 2.27, 95% CI: 1.52, 3.01) showed a statistically significant association with the practice of sunlight exposure of infants. Mothers who had educational status of diploma and above were 2.68 times more likely to practice sunlight exposure than mothers who were unable to read and write (AOR = 2.68, 95%CI = 1.99, 3.37). Mothers who had family sizes of 4–6 (AOR = 0.78, 95% CI: 0.58, 0.98) and above 6 (AOR = 0.59, 95% CI: 0.41, 0.77) had lower odds of adequately sunning their infants than those mothers with family sizes of 3 or less. Compared with mothers with birth orders of 1–3, mothers who had birth orders of 4 or above had lower odds for good practice of infant sunlight exposure (AOR = 0.86, 95% CI: 0.84, 0.88). Regarding fear of sunlight exposure, mothers who had no fear of the evil eye were 3.30 times more likely to practice sunlight exposure than mothers who feared the evil eye (AOR = 3.30, 95% CI: 1.54, 5.06).

Mothers who had good knowledge regarding infant sunlight exposure were 1.65 times more likely to have a good practice of infant sunlight exposure than those mothers who had poor knowledge. Regarding place of delivery, mothers who had delivered babies at health facilities were 1.8 times more likely to practice sunlight exposure than mothers who had delivered at home (AOR = 1.85, 95% CI: 1.63, 2.06). Mothers who had exposure to mass media had higher odds of good practice of infant sunlight exposure. Compared with urban mothers, the rural mothers had lower odds [AOR = 0.34, 95% CI = 0.16–0.52] for good practice of infant sunlight exposure (Table 4).Table 4 Results of multilevel logistic regression analysis for factors associated with practice of mothers on sunlight exposure of their infants in Mettu district, illubabor zone, oromia, ethiopia, 2024 (n = 640).

Full size table

Random effect measures of variation

A two-level mixed-effects logistic regression was used to analyze the effect of individual factors and community-level factors in determining the practice of sunlight exposure of infants. The ICC (%) in the empty model indicates that 23% of the total variance in the odds of practice of sunlight exposure of infants was accounted for by between-cluster variations of characteristics. The between-cluster variability declined over successive models from 23% in Model-I to 19% in Model-II, 14% in Model-III, and 13% in Model-IV. Also, as we have seen, the variance of a constant was declined over successive models from 0.45 in Model-I, 0.36 in Model-II, 0.30 in Model-III, and 0.28 in Model-IV (Table 5). The AIC and BIC values were also small for Model-IV as compared to the other models. Thus, Model-IV, the model considered both individual-level and community-level factors, was preferred for predicting the practice of sunlight exposure of infants.Table 5 Measure of variation and goodness of fit statistics.

Full size table

Discussion

The current study aimed to identify the individual and community-level factors of the practice of sunlight exposure of infants among mothers in Mettu district using multilevel mixed-effects analysis. Four models were employed for multilevel analysis, namely Model-I (empty model), Model-II (model containing individual-level variables only), Model-III (model containing community-level variables only) and Model-IV (model of individual and community-level variables). Based on model fit statistics, Model-IV was preferred for predicting the practice of sunlight exposure of infants. The descriptive summary of the study revealed that the prevalence of mothers’ good practice of sunlight exposure of their infants was found to be 58.13%. This finding is lower than the same study done in Sakarya, which was 87.5% of mothers who exposed their infants to sunlight22. It was also greater than the study done in Mettu rural areas (57.7%)18 Debre Markos town (44.6%)23 and Farta district (51.98%)24. The reasons for the differences might be the difference in socio-cultural factors like fear of evil eyes, level of appropriate information concerning sunning the baby, weather conditions due to geographical differences, and limiting the study area to urban or rural areas only rather than taking both.

Occupational status of mothers was significantly associated with their practice of sunlight exposure of infants. Mothers whose occupational status was farmer, merchant, and government employee had lower odds of practicing adequate sunning of their infants compared with housewives. This might be attributed to mothers who had occupations not having sufficient time to expose their infants to sunlight when compared to those mothers who had no occupation (housewives). Similarly, the studies done in Debre Birhan town revealed that mothers who were government employees were 5 times [AOR = 5.10, 95% CI: (1.54, 16.92)] more likely to practice good sunlight exposure of their infants than the unemployed4. This finding is also in line with studies at Debre Markos23 and Australia25. The finding is also contradictory to the report of Mettu rural areas; the odds of having good practice among government-employed mothers were 4 times more likely than those of mothers who were housewives18.

The finding of this study also revealed that mothers whose age group was 36 and above years were more likely to have good practice in sunlight exposure of infants compared with mothers of age group 16–25 years. This is in line with the study at Dessie town26. This may be due to being young in age, which may make an individual careless.

Married mothers had a good practice of exposing their infants to sunlight. This finding is supported by a study done in Mettu rural areas18. However, the finding is incomparable with the report of Debre Markos23 and Yirgalem27 in which married women were not significantly associated (p > 0.05) with the practice of sunlight exposure.

Regarding the source of information, 75.63% of mothers who took part in the present study got information about sunning their infants from health-care professionals. The finding is higher than the reports from Mettu rural areas (51.4%)18. The inconsistency could be explained by the fact that the setting of past study in Mettu was rural only, and the mothers could not have exposure to mass media such as TV, radio, and others.

Mothers who had educational status of diploma and above were 2.68 times more likely to practice sunlight exposure than mothers who were unable to read and write. This was supported by the study report from Debre Markos and Dejen district23,28. 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 educated29,30.

Mothers who had family sizes of 4–6 and above 6 had lower odds of adequately sunning their infants than those mothers with family sizes of 3 or less. This is in line with study18 and revealed that mothers who had family sizes of 4–6 and above 6 had 0.51 and 0.40 times lower odds of adequately sunning their infants than those mothers with family sizes of 3 or less.

Fear of sunlight exposure had a significant association with the practice of infant sunlight exposure. Mothers who had no fear of the evil eye were 3.30 times more likely to practice sunlight exposure than mothers who feared the evil eye. This finding is consistent with studies done by29,31,32. 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 the evil eye are not exposed to sunlight.

Mothers who had good knowledge regarding infant sunlight exposure were 1.65 times more likely to have a good practice of infant sunlight exposure than those mothers who had poor knowledge. This was supported by the study report from Dejen district28. Regarding place of delivery, mothers who had delivered babies at health facilities were 1.8 times more likely to practice sunlight exposure than mothers who had delivered at home. This was supported by the study report from Dejen district28.

The study addressed the place of residence of study participants, which was not studied in the previous studies as a community-level factor. At the community level, the rural mothers had lower odds for good practice of infant sunlight exposure than urban mothers. 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%29,33.

Strength and Limitation of the study

The study used primary data and also applied a strong statistical model to ensure statistical estimates. Despite possessing the aforementioned strengths, the study also presents certain limitations. Since the study design was cross-sectional, it could not show the cause-and-effect relationship between the outcome variable and the identified factors. Moreover, the respondents might respond with what they did not experience, which could lead to bias.

Conclusion

The finding of this study revealed that about 58% of mothers have good practice in sunlight exposure of their infant. Age of mother, occupation of mother, educational status of mother, place of delivery, marital status, family size, birth order, source of information, knowledge of sunlight exposure, fear of sunlight exposure due to evil eye, mass media and place of residence were significantly associated with practice of infant sunning. Moreover, the rural mothers had lower odds for good practice of infant sunlight exposure than urban mothers.

Implications

The ministry of health of the Federal Democratic Republic of Ethiopia should work with concerned bodies to prepare detailed counselling on the good practice of sunning of infants, which should be incorporated into other health service guidelines/ policies. Mass media and health-care professionals should give more attention to the importance of sunlight exposure, how to practice it, and provide better information to mothers, particularly for those mothers who are at young ages and live in rural areas. Further studies should be conducted to determine the best way to sun infants in order to maintain adequate vitamin D that helps the body to absorb calcium to strengthen bones, thereby preventing rickets and other childhood disorders.

Data availability

The data used in this study are available from corresponding author upon a reasonable request.

Abbreviations

AIC:

Akakie information criterionBIC:

Bayesian information criterionICC:

Intra-class correlationAOR:

Adjusted odds rationCI:

Confidence intervalUVR:

Ultra-violet radiationSNNPR:

Sothern Nation Nationalities and People Region

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Acknowledgements

The author gratefully acknowledge all households included in this study for giving data of their infants. The authors also would like to thank College of Natural Sciences of Mattu University for providing letter of ethics approval documentation.

Funding

The author received no financial support for the research, authorship, and/or publication of this article.

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  1. Department of Statistics, Mattu University, Mettu, EthiopiaWoldemariam Erkalo Gobena

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WEG conceived the idea, contributed to the design analyses, completed all statistical analyses and interpretations, drafted the manuscript, read it, and approved it.

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Correspondence to Woldemariam Erkalo Gobena.

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Gobena, W. Multilevel analysis of infant sunlight exposure practices among mothers in Mettu district Illubabor zone Oromia Ethiopia. Sci Rep 15, 26819 (2025). https://doi.org/10.1038/s41598-025-12680-6

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