Enhancing knowledge and practices toward Vitamin D deficiency through implementing awareness programs among medical science female students

Abstract

Objectives

Vitamin D (VD) deficiency has widespread prevalence worldwide. In Saudi Arabia, it is the most common form of public health problem with regard to malnutrition. This is because there is insufficient knowledge about negative VD practices. The current study aimed to evaluate VD deficiency knowledge and practices before and after the implementation of an awareness programme.

Methods

A quasi-experimental design was used for the study, which was conducted at the College of Applied Medical Science at Al-Baha University. A convenience sample encompassing all the female students in the Public Health Department was used (n = 83 students). Two tools were used for data collection; the first was an intervention questionnaire to assess the students’ knowledge, and the second was a questionnaire concerned with students’ practices in preventing VD deficiency.

Results

The mean age of the students was 20.75 ± 7.85 years. Of the study’s subjects, 45.8% suffered from VD deficiency and 72.3% had a family history of VD deficiency. The study showed that there had been significant progress in students’ VD knowledge and behaviours following the programme. While 59% of the students had poor knowledge and 95.2% had unsatisfactory practices pre-intervention, 86.7% and 48.2% showed exemplary knowledge and a positive attitude towards VD, respectively, post-intervention. The scores achieved by the students had significantly changed (p ≤ .01); compared to the knowledge and practice scores of 24.43 ± 7.21 out of 53 and 24.29 ± 5.23 out of 48, respectively, before the intervention, they were elevated to 46.89 ± 9.93 and 29.39 ± 14.23 following the awareness programme.

Conclusion

This type of health education programme can raise VD deficiency knowledge and improve practices. This study highlights the importance of holding public health awareness campaigns and recommends the creation of specifically designed booklets and leaflets for medical students and patients/visitors to hospital and public places.

Keywords

vitamin D deficiency among saudi female practice toward vitamin D deficiency behaviors toward vitamin D vitamin D awareness programs

Introduction

Vitamin D (VD) is a fat-soluble vitamin whose primary source is exposure to ultraviolet (UVB) sunlight. Other sources include egg yolks, salmon, mushrooms and dietary supplements.¹

VD intake recommendations, in the form of dietary reference intake (DRI), were developed by expert committees of the National Academies of Sciences, Engineering, and Medicine.² DRI is the general term used for a set of reference values used for planning and assessing nutrient intake in healthy individuals. Recommended dietary allowances (RDAs) for VD rely on various factors, such as age, gender, pregnancy and lactation.² For instance, the daily RDA for VD is 600 IU in adults aged 19 years and older and 800 IU for people over 70.² Globally, different values of 25-hydroxyVD (25(OH)D) are used to ascertain VD deficiency, with the most commonly published cut-off range between 25 and 30 nmol/L.³ Lebanese guidelines indicate that the optimal level of 25(OH)D is more than 75 nmol/L. Recommended daily doses have been suggested of 600–1000 IU for adolescents and adults aged under 50 years with low risk and 1000–2000 IU for older adults and people at high risk.⁴

VD’s classical action regulates calcium and phosphorus absorption and promotes bone health. In addition, it has several other vital functions, including immune response modulation, healthy mood maintenance and support for blood, breast, colon and prostate health.^5–8 The role of VD in health has been defined in many studies. For example, sufficient intake of this fat-soluble vitamin may decrease an individual’s risk for developing osteoporosis, hypertension, cancer and several autoimmune diseases.¹

VD deficiency has been associated with the development of certain cancers and the severity of cancer prognosis.⁹ From a cohort of 105 patients with different haematological cancers, it was found that those with insufficient or deficient VD exhibited higher malignant cell burden, worse disease and poor response to therapy.¹⁰

Moreover, low VD level has also been associated with the risk for anaemia in elderly adults and children.^10,11 VD has been reported to exhibit numerous immune-modulating and anticancer properties.^11,12 It has been found that calcitriol induces apoptosis, inhibits proliferation, sensitises cells to chemotherapy and decreases angiogenesis in multiple autoimmune diseases and cancers.^13–15

VD deficiency is widespread in developing and developed countries, with an incidence of up to 1 billion worldwide.¹⁶ Approximately 30%–50% of healthy middle-aged to elderly adults suffer from VD deficiency,¹⁷ which is predominant in Asia and the Middle East, where more than 50% of the population is VD deficient and about 75% insufficient.¹⁶ Saudi Arabia has also demonstrated a high prevalence of VD deficiency. The incidence of VD deficiency among healthy Saudi men ranges between 32.5% and 92.6%, while higher incidences (41.2%–100%) have been found among healthy Saudi women.¹⁸

Many studies have reported that VD deficiency is more prominent in Saudi women across different age groups.^19,20 Importantly, VD deficiency is common among female college students due to their indoor lifestyle and avoidance of sun exposure.^21,22 There is much evidence to show that there is insufficient knowledge about dietary sources of VD and negative attitudes towards sun exposure.^23,24 Recently, Al-Daghri and Alfawaz²⁵ reported inconsistent knowledge mainly about suitable sources of VD.

This study aims to evaluate VD knowledge and practices before and after the implementation of an awareness programme designed by researchers among female students in the Public Health Department at Al-Baha University.

Methodology

Research design

A quasi-experimental design was used for this study, which was conducted at the College of Applied Medical Sciences at Al-Baha University in Saudi Arabia. The purposive sampling technique was used, since we performed total population sampling. The study included all the second-, third- and fourth-year students (n = 83) in the Public Health Department who were willing to participate. Students in year 1 were excluded due to them being at the preparatory stage of their studies. After considering the legal and ethical aspects of the study and receiving the necessary official permissions, the researcher introduced herself to the students and questioned them in simple Arabic.

Data collection tool

A self-administered questionnaire was designed based on the published literature²⁶ with some modifications. The questionnaire was in Arabic, the mother language of Saudi citizens. The modified draft of the questionnaire was reviewed by an expert panel (one professor, one associate professor, two assistant professors and a lecturer) and validated using a pilot study.

Pilot study

The pilot study was conducted on 10% of the students in the sample to test the data collection tool’s clarity and applicability and to determine the time needed for the structured questionnaire. Accordingly, the necessary modifications, corrections, omissions and additions were carried out. The Cronbach’s Alpha coefficient test score was 0.80.

The final questionnaire contained three sections. The first section consisted of nine questions about the demographics of the study participants and the history of the disease. The second section consisted of fifteen questions to explore the participants’ knowledge of VD. Each correct answers receive 1 point, with possible scores for knowledge of between 0 and 53 points. Under the scoring system, scores were classified was good (100%–75%), average (74%–50%) or bad (<50%). The third section was concerned with students’ practices in preventing VD deficiency. It consisted of 43 questions, each with two responses (‘done’ or ‘not done’). ‘Done’ received 1 point, with possible scores for practice of between 0 and 48 points. Under the scoring system, scores were classified as satisfactory (80%–100%) or unsatisfactory (≤79%).

The third section included the following four sub-sections:

Sun exposure

This included seven questions with possible scores of 0–7. The participants were asked the following: if they were exposed to the sun in the early morning or before sunset; if they were exposed daily to the sun for 15–20 minutes; if they used an umbrella whenever they were under the sun; if they used a cap/hat to avoid severe sun exposure; if they used sunscreen products when staying outdoors for an extended time (more than 1 hour); if they wore sunglasses; and if they revealed their hands and feet when exposed to the sun.

Exercise outside the house

This included 13 questions with possible scores of 0–15. The participants were asked questions including the following: if they performed sports; if they performed 30 minutes of exercise outside the house; if they walked for half an hour each day; if they ran outdoors at least twice a week; if they practiced yoga; and if they cycled. They were also asked the number of times they exercised per week.

Taking VD supplements and nutrition

This included 14 questions with possible scores of 0–14. The participants were asked the following: if they took VD supplements; if they took injections to raise the proportion of VD in the body; if they read nutritional information (food labels) and chose foods/drinks rich in VD; if they consumed oily fish (e.g. salmon, tuna, sardines) at least twice per week; if they ate liver; if they had mushrooms in their diet; if they consumed eggs; if they ate sufficient dairy products per week; if they had a glass of milk each day; if they consumed yogurt once a day; if they ate enough fruit per week; if they consumed oranges; if they ate foods rich in calcium; and if they avoided eating fast food.

Rest and sleep

This included nine questions with possible scores of 0–12. The participants were asked questions including the following: if they would sleep 8 hours a day; if they suffered from interrupted sleep; if they took a long time to fall asleep; if they suffered from sleepiness all day long; if they took naps during the day; if they felt exhausted; and if they felt pain in the bones and muscles.

Awareness programme

After reviewing the related literature, the researcher designed an awareness programme about VD deficiency among female students in the Public Health Department to improve their VD knowledge and practices. This programme was implemented in the following three phases.

Preparatory phase

The preparation of the study design and data collection tools relied on reviewing current, past, local and international studies on VD deficiency. Journals, magazines, books and computer searches were used to contrast the tool of the study. We also designed a small booklet containing the following comprehensive information about VD: its importance to our bodies; its sources; foods that contain VD; recommended quantities; VD deficiency disease; its signs and symptoms; its treatment; and how to protect ourselves from it.

Implementation phase

The researcher released the questionnaire for data collection in the selected settings after acquiring the necessary official permissions. She introduced herself to the female students in the Public Health Department and presented the questionnaire, which was written in simple Arabic.

We met with three levels of students (third, fifth, and seventh), and the programme was explained adequately. The students asked questions related to the subject, which we answered.

Evaluation phase

The programme was evaluated immediately after its completion using the same pre/post questionnaire.

Ethical considerations

The study was conducted following approval by the ethical committee of the Research and Studies Department, Directorate of Health Affairs, Taif, Saudi Arabia (IBR Registration number with KACST, KSA HAP-02-T-067) (approval number 428).

Statistical design

The collected data were organised, categorised, tabulated and analysed using appropriate statistical methods. Simple frequency distribution tables were used to describe the sample. Quantitative data were presented using mean and standard deviation. Qualitative data were shown as cross tabulations presenting the number and percentage of the studied subjects. Paired sample t-tests were used for the quantitative data. The chi-squared test was used for comparison between groups in the categorical data. Differences were considered significant where p < .05.

Result

The mean of students’ age was 20.75 ± 7.85. Of the participants, 62.7% were aged 20–21 years, 97.6% were single, 42.2% were at the fifth academic level and more than half (60.2%) lived in urban areas. A majority of the participants (83.1%) had siblings, whose number ranged from 1 to 7; 57.8% had checked themselves for VD deficiency; 45.8% suffered from VD deficiency; and 72.3% had a family history of VD deficiency. Regarding the source of knowledge of the participants, few (22.9%) relied on education, while more than half (56%) relied on social media (Table 1).

Table 1.

Personal characteristics and the history of female students regarding vitamin D deficiency.

Items	No. 83	Percent %
Age
18-19	19	22.9%
20-21	52	62.7%
22 -26	12	14.5%
Average	20.75 ± 7.85
Material status
Married	2	2.4%
Single	81	97.6%
Divorcee	0	0
Academic level
Third level	33	39.8%
Fifth level	35	42.2%
Seventh level	15	18.1%
Residents
Rural	33	39.8%
Urban	50	60.2%
Number of siblings
1 → 7	69	83.1%
8 → 15	14	16.8%
History of vitamin D deficiency
Checked for vitamin D
Yes	48	57.8%
No	35	42.2%
Suffer from vitamin D deficiency
Yes	38	45.8%
No	45	54.2%
Vitamin D deficient in family history
Yes	60	72.3%
No	23	27.7%
Source of knowledge
Social media	47	56.6%
Education	19	22.9%
Friends/Family	17	20.5%

Table 2 shows levels of VD and VD deficiency awareness before and after the intervention. There was a lack of knowledge across all domains pre-intervention. More than half of the participants gave incomplete answers to the questions related to the meaning of VD (68.7%), VD normal level (66.3%), meaning of VD deficiency (78.3%), signs and symptoms of VD deficiency (73.5%), people at a high risk for VD deficiency (71.1%), health effects of VD deficiency (61.4%), complications of VD deficiency and foods that help prevent VD deficiency (72.3%). In addition, 86.7% of the subjects had weak knowledge about the sources of VD, the essential functions of VD and the causes of VD deficiency. Most participants (92.8%) were unaware of the VD deficiency risk factors. After completing the intervention, all students’ knowledge significantly improved. All domains of knowledge assessment were significantly improved post-intervention (p < 0.001), except for the general methods of preventing VD deficiency (p = .21).

Table 2.

Students’ knowledge frequency pre and post-intervention.

Knowledge (53 points)	Pre -intervention			Post-intervention			p-value
	Complete	Incomplete	Don’t know	Complete	Incomplete	Don’t know
	N (%)	N (%)	N (%)	N (%)	N (%)	N (%)
Meaning of vitamin D²	17 (20.5)	57 (68.7)	9 (10.8)	60 (72.3)	20 (24.1)	3 (3.6)	<0.001
The important functions of vitamin D³	4 (4.8)	72 (86.7)	7 (8.4)	73 (88.0)	9 (10.8)	1 (1.2)	<0.001
The normal level of vitamin D²	1 (1.2)	55 (66.3)	27 (32.5)	53 (63.9)	27 (32.5)	3 (3.6)	<0.001
Sources of vitamin D⁵	9 (10.8)	72 (86.7)	2 (2.4)	75 (90.4)	6 (7.2)	2 (2.4)	<0.001
Meaning of vitamin D deficiency³	17 (20.5)	65 (78.3)	1 (1.2)	70 (84.3)	11 (13.3)	2 (2.4)	<0.001
Causes of vitamin D deficiency³	8 (9.6)	72 (86.7)	3 (3.6)	75 (90.4)	5 (6.0)	3 (3.6)	<0.001
Signs and symptoms of vitamin D deficiency⁴	19 (22.9)	61 (73.5)	3 (3.6)	64 (77.1)	16 (19.3)	3 (3.6)	<0.001
Risk factors of vitamin D deficiency⁵	1 (1.2)	77 (92.8)	5 (6.0)	46 (55.4)	35 (42.2)	2 (2.4)	<0.001
People at a high risk of vitamin D deficiency⁵	0 (0.0)	59 (71.1)	24 (28.9)	59 (71.1)	22 (26.5)	2 (2.4)	<0.001
Health effects of vitamin D deficiency³	4 (4.8)	51 (61.4)	28 (33.7)	54 (65.1)	25 (30.1)	4 (4.8)	<0.001
Complications of vitamin D deficiency³	16 (19.3)	60 (72.3)	7 (8.4)	48 (57.8)	26 (31.3)	9 (10.8)	<0.001
Foods that help prevent vitamin D deficiency⁵	3 (3.6)	60 (72.3)	20 (24.1)	55 (66.3)	27 (32.5)	1 (1.2)	<0.001
Prevent vitamin D deficiency by exposure to sunlight⁴	5 (6.0)	72 (86.7)	6 (7.2)	58 (69.9)	23 (27.7)	2 (2.4)	<0.001
General methods for preventing vitamin D deficiency³	36 (43.4)	41 (49.4)	6 (7.2)	47 (56.6)	30 (36.1)	6 (7.2)	0.21
Treatment of vitamin D deficiency³	47 (56.6)	29 (34.9)	7 (8.4)	72 (86.7)	11 (13.3)	0 (0.0)	<0.001

An assessment of the students’ practices before and after the intervention is shown in Table 3. In terms of frequency of sun exposure practices pre-intervention, 68.7% of the students were exposed to the sun in the early morning or before sunset, 71.1% revealed their hands and feet when exposed to the sun, 78.3% used sunscreen products and 53% wore sunglasses. However, there was less frequency recorded for using an umbrella under the sun (8.4%), daily sun exposure for 15–20 minutes (45.8%) and using a cap/hat to avoid severe sun exposure (37.3%). After the implementation of the intervention, all domains of sun exposure practices were improved significantly (p < .05), except for the domains related to the use of an umbrella (p = .11) and wearing sunglasses (p = .53).

Table 3.

Frequency of the student's practice of sun exposure, exercise, supplements and nutrition, and rest and sleeps pre and post-program regarding vitamin D deficiency.

Sun exposure (7 points)	Pre -intervention		Post-intervention		p-value
	Done	Not done	Done	Not done
	N (%)	N (%)	N (%)	N (%)
1- Exposed to the sun in the early morning or before sunset	57 (68.7)	26 (31.3)	70 (84.3)	13 (15.7)	0.03
2- Exposed daily to the sun for 15-20 minutes	38 (45.8)	45 (54.2)	54 (65.1)	29 (34.9)	0.02
3-Use an umbrella whenever exposed to the sun	7 (8.4)	76 (91.6)	15 (18.1)	68 (81.9)	0.11
4- Use caps/hats to avoid severe sun exposure	31 (37.3)	52 (62.7)	60 (72.3)	23 (27.7)	< 0.001
5- Use sunscreen products when staying outdoors for more extended time (more than one h)	65 (78.3)	18 (21.7)	78 (94.0)	5 (6.0)	0.006
6- Like wearing sunglasses	44 (53.0)	39 (47.0)	49 (59.0)	34 (41.0)	0.53
7- Reveal hands and feet when exposed to the sun	59 (71.1)	24 (28.9)	71 (85.5)	12 (14.5)	0.04
Exercise (15 points)
1- go for a picnic once a week	53 (63.9)	30 (36.1)	73 (88.0)	10 (12.0)	< 0.001
2- prefer to go out by bike during the day	8 (9.6)	75 (90.4)	10 (12.0)	73 (88.0)	0.80
3- regularly engage in outdoor physical activities	22 (26.5)	61 (73.5)	42 (50.6)	41 (49.4)	0.002
4-Go to spend quality time with family or friends during the day at least once a week	60 (72.3)	23 (27.7)	79 (95.2)	4 (4.8)	< 0.001
5- go for a daytime walk to natural places	51 (61.4)	32 (38.6)	62 (74.7)	21 (25.3)	0.09
6- do sport	51 (61.4)	32 (38.6)	55 (66.3)	28 (33.7)	0.63
7-Do 30 minutes of exercise outside the house	24 (28.9)	59 (71.1)	30 (36.1)	53 (63.9)	0.41
8- walking	67 (80.7)	16 (19.3)	77 (92.8)	6 (7.2)	0.04
9- walk half an hour a day	57 (68.7)	26 (31.3)	75 (90.4)	8 (9.6)	0.001
10- run outdoors at least twice a week	26 (31.3)	57 (68.7)	30 (36.1)	53 (63.9)	0.62
11- do yoga	29 (34.9)	54 (65.1)	35 (42.2)	48 (57.8)	0.43
12- practice cycling	21 (25.3)	62 (74.7)	25 (30.1)	58 (69.9)	0.60
13- times for doing exercise per week 1 - 2	52 (62.7)		36 (43.4)		0.04
2 - 3	20 (24.1)		29 (34.9)
3 or more	11 (13.3)		18 (21.7)

Supplements and nutrition (14 points)	Pre -intervention		Post-intervention		p-value
	Done	Not done	Done	Not done
	N (%)	N (%)	N (%)	N (%)
1- Take vitamin D supplements	30 (36.1)	53 (63.9)	50 (60.2)	33 (39.8)	0.003
2- Take injections to raise the proportion of vitamin D	4 (4.8)	79 (95.2)	6 (7.2)	77 (92.8)	0.75
3- Read nutrition information (food labels) and choose foods/drinks rich in vitamin D	39 (47.0)	44 (53.0)	49 (59.0)	34 (41.0)	0.16
4- Take oily fish (e.g., salmon, tuna, sardines) at least two times per week	36 (43.4)	47 (56.6)	40 (48.2)	43 (51.8)	0.64
5- Eat liver	41 (49.4)	42 (50.6)	48 (57.8)	35 (42.2)	0.35
6- Include mushrooms in the diet	20 (24.1)	63 (75.9)	25 (30.1)	58 (69.9)	0.49
7-Eat eggs eat eggs (85.5) eat enough dairy products per week (74.7)	71 (85.5)	12 (14.5)	79 (95.2)	4 (4.8)	0.06
8- Eat enough dairy products per week	62 (74.7)	21 (25.3)	70 (84.3)	13 (15.7)	0.18
9- Have a glass of milk every day	35 (42.2)	48 (57.8)	38 (45.8)	45 (54.2)	0.76
10-Eat yogurt once a day	31 (37.3)	52 (62.7)	38 (45.8)	45 (54.2)	0.35
11- Eat enough fruit per week	41 (49.4)	42 (50.6)	66 (79.5)	17 (20.5)	< 0.001
12- Eat oranges	57 (68.7)	26 (31.3)	60 (72.3)	23 (27.7)	0.73
13- Diet poor in calcium sources	40 (48.2)	43 (51.8)	28 (33.7)	55 (66.3)	0.08
14- Eat fast food a lot	43 (51.8)	40 (48.2)	35 (42.2)	48 (57.8)	0.28
Rest and sleep (12 points)
1- sleep 8 hours a day	49 (59.0)	34 (41.0)	65 (78.3)	18 (21.7)	0.01
2- suffer from interrupted sleep	44 (53.0)	39 (47.0)	52 (62.7)	31 (37.3)	0.27
3- take a long time to fall asleep	55 (66.3)	28 (33.7)	40 (48.2)	43 (51.8)	0.03
4- suffer from sleepiness all day long	50 (60.2)	33 (39.8)	47 (56.6)	36 (43.4)	0.75
5- suffer from insomnia	56 (67.5)	27 (32.5)	64 (77.1)	19 (22.9)	0.23
6- take naps during the day	41 (49.4)	42 (50.6)	61 (73.5)	22 (26.5)	0.002
7- feel exhausted	60 (72.3)	23 (27.7)	45 (54.2)	38 (45.8)	0.02
8-Feel pain in the bones and muscles	51 (61.4)	32 (38.6)	42 (50.6)	41 (49.4)	0.21
9- sleep hours per day 5 – 6	32 (38.6)		5 (6.0)		< 0.001
6 – 7	19 (22.9)		19 (22.9)
7 – 8	17 (20.5)		41 (49.4)
9 or more	15 (18.1)		18 (21.7)

Regarding exercise practices, the most frequent was walking (80.7%), followed by spending quality time with family or friends during the day at least once a week (72.3%), before the intervention. Nevertheless, some practices were less frequent among the participants pre-intervention and did not show improvement after the intervention (p > .05). These included riding a bike outside during the day (9.6% pre-intervention, 12.0% post-intervention), doing 30 minutes of exercise outside the house (28.9%, 36.1%), running outdoors at least twice a week (31.3%, 36.1%) and cycling (25.3%, 30.1%).

Nutrition and supplement practices pre-intervention showed that few students took VD supplements (36.1%), had injections to raise VD levels (4.8%), read nutrition information (food labels) or choose foods/drinks rich in VD (47%). Following the intervention programme, there was a significant improvement in the students’ practices in terms of using VD supplements (p = .003) and eating sufficient fruit per week (p < 0.001).

In terms of rest and sleep, the awareness programme was shown to significantly improve some of the students’ practices, such as sleeping 8 hours a day, taking a long time to fall asleep and taking naps during the day (p ≤ .03). Additionally, the largest proportion of students (38.5%) would sleep 5–6 hours per day before the intervention, whereas after it, the largest group consisted of those who would sleep 7–8 hours per day (49.4%; p < .001).

Table 4 shows the overall coding and scoring of the knowledge and practice domains. It shows that there was significant progress in terms of knowledge and practices after the intervention (p < 0.001). Before the intervention, 59% of the students had poor knowledge and 95.2% applied unsatisfactory practices, whereas the majority of the students (86.7%) had good knowledge and 48.2% applied satisfactory practices after the intervention.

Table 4.

Overall code and score of knowledge and practices pre and post-intervention.

Coding		Pre –Intervention	Post-intervention	p-value
Coding		N (%)	N (%)	p-value
Knowledge code	Good (≥75)	1 (1.2)	72 (86.7)	<0.001
	Average (50:74)	33 (39.8)	7 (8.4)
	Poor (0:49)	49 (59.0)	4 (4.8)
Practice code	Satisfactory (≥70)	4 (4.8)	40 (48.2)	<0.001
Practice code	Unsatisfactory (<70)	79 (95.2)	43 (51.8)	<0.001

Scoring	Maximum obtainable scores	Scores received by students		p-value
		Pre –Intervention	Post-intervention
		Mean ± SD	Mean ± SD
Knowledge score	53	24.43 ± 7.21	46.89 ± 9.93	<0.001
Practice score	48	24.29 ± 5.23	29.39 ± 14.23	0.002
Sun exposure sub-score	7	3.61 ± 1.29	4.78 ± 2.16	<0.001
Exercise sub-score	15	7.16 ± 2.83	8.93 ± 3.88	0.002
Supplements and nutrition sub-score	14	6.63 ± 2.37	7.61 ± 4.91	0.09
Rest and sleep sub-score	12	6.89 ± 2.08	8.06 ± 3.84	0.01

The overall knowledge score was higher post-intervention (46.89 ± 9.93 vs 24.43 ± 7.21; p < 0.001), and the score for practices showed a significant elevation (p = .002) post-intervention (29.39 ± 14.23 vs 24.29 ± 5.23) (Table 4). The sub-scores of the students’ behaviours demonstrated a greater improvement in scoring in terms of sun exposure (4.78 ± 2.16 vs 3.61 ± 1.29), exercise (8.93 ± 3.88 vs 7.16 ± 2.83) and rest and sleep (8.06 ± 3.84 vs 6.89 ± 2.08). There was a change in the students’ overall scores of supplements and nutrition behaviour before and after the intervention (7.61 ± 4.91 vs 6.63 ± 2.37 respectively), but this was not statistically significant (p = .09) (Table 4).

Discussion

This study aimed to evaluate VD knowledge and practices before and after the implementation of an awareness programme designed by researchers among female students in the Public Health Department of Al-Baha University.

The study found that most of the students’ families (72.3%) had a history of VD deficiency, and nearly half of the students (45.8%) currently suffered from the condition.

According to the student’s knowledge assessment, they had higher knowledge about VD after the intervention than before it. The overall VD knowledge score was significantly higher after the intervention, including for understanding the important function of VD, knowledge of VD sources and the signs and symptoms of VD deficiency as well as for awareness of the methods that contribute to its prevention, such as consuming certain foods and sun exposure. This difference in knowledge before and after the intervention highlights the importance of using reliable sources to gain knowledge. Before the awareness programme, more than half of the participants relied on social media to source their information, and thus, they needed to gain a better understanding.

A high rate of VD deficiency has been reported among Saudi across different age groups.^18–20 Consistent with our findings, it has been shown that VD deficiency is frequent among female students at the college level.^21,22 Moreover, a recent study conducted in Al-Qunfudhah Governorate, Saudi Arabia, reported a high percentage of hypovitaminosis D among the participant’s family members.²⁶ It also showed a poor level of knowledge that negatively impacted the participants’ willingness to be exposed to sunlight and use VD supplementation when required. The study reported good attitude of female to preventing VD deficiency and this could encourage them to change their behaviour.²⁶ A low level of knowledge and awareness regarding VD deficiency has been reported worldwide, and this is likely to be a factor contributing to global VD deficiency.^27–29 Female gender, receiving medical information from physicians and being unmarried, young and highly educated were recently reported as determinants for good VD knowledge.²⁶

The current study reported a significant improvement in the students’ practices following the intervention (p < 0.001). The percentage of students who applied satisfactory practices had been only 4.8% before the awareness programme but increased to 48.2% after it. Although there were some good practices among the students regarding sun exposure, including exposure time and revealing hands and feet when exposed to the sun, there were unsatisfactory practices in terms of the duration of exposure and the methods to avoid severe sun exposure effects. Mohamed and Qerem³⁰ reported that a high percentage of females avoid sun exposure, compared to males. A previous study found there to be good knowledge regarding the benefit of VD sourced from sunlight and dietary intake; however, insufficient knowledge was found regarding the time required for exposure to sunlight.³¹

The current study also demonstrates that significant progress was made in terms of exercise, rest and sleep practices. For instance, the students showed improved exercise time per week and sleep hours after the programme, compared to before it.

On the other hand, the awareness programme failed to improve the students’ supplement and nutrition practices, and the overall analysis showed insignificant scores after the intervention (p = .09). Similar to another study,³² there was shown to be a poor attitude towards the consumption of VD-rich food sources. No significant change was recorded in all the supplement and nutrition practice domains except for the one related to VD supplements. However, the frequency of students taking VD supplements was higher post-intervention (60.2%) compared to pre-intervention (36.1%). VD is a common form of malnutrition in the Saudi community.²⁹ VD supplements significantly affect the serum levels of VD and thus can be used as an alternative source, especially for those with unhealthy eating habits.³³

Inconsistent with our finding, Alemu and Varnam³⁴ reported that most at-risk patients had a better attitude to consuming VD-rich foods than they did to sun exposure. VD-rich food consumption and exposure to sunlight are essential in maintaining the expected level of VD. However, sun exposure practice is the primary source of VD. Many studies have shown the link between 25(OH)D levels in the serum and sunlight exposure to be more significant than dietary intake because VD from the diet lasts less time in the blood than it does from sunlight.^35,36

There are a number of limitations in this study that need to be addressed. First, this study was conducted only with female students, and the findings therefore cannot be generalised across the Saudi population. Also, it assessed the progress of knowledge and practice at a group level, and so multivariate analysis cannot be performed to identify the determinants. However, despite these shortcomings, the study obtained information on how VD knowledge and practices can be improved and recommends the creation of specifically designed booklets and leaflets for medical students and patients/visitors to hospital and public places.

Conclusions

Overall, this study found that the students’ VD knowledge and practices improved after the implementation of a health education programme. This result indicates the programme’s effectiveness in influencing students’ VD knowledge and practices.

University students are highly educated members of the community, compared to the general population. Since they initially showed poor knowledge of VD, the general population is more likely to have an even greater deficit. Thus, based on the study’s findings, it is recommended that public health awareness campaigns be conducted, and health education programmes provided to encourage healthy lifestyles and eating habits.

Supplemental Material

Supplemental Material - Enhancing knowledge and practices toward Vitamin D deficiency through implementing awareness programs among medical science female students

Supplemental Material - Enhancing knowledge and practices toward Vitamin D deficiency through implementing awareness programs among medical science female students by Hayaa M. Alhuthali, Hind A. Alzahrani, Eman F. Ataya, Mazen Almehmadi, Ahad Amer Alsaiari, Amani A. Alrehaili, Maha M. Bakhuraysah, Fouzeyyah A. Alsaeedi, Ohud Alsalmi, Wafaa Altalhi, Amal F. Gharib and Eman N. Ramadan in European Journal of Inflammation.

Footnotes

Acknowledgments

The authors would like to sincerely thank the participants for completing the study questionnaire. In addition, the researcher would like to acknowledge the deanship of scientific research, Taif University, for funding this work.

Authors’ notes

We believe that this manuscript is appropriate for publication by European journal of inflammation.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

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

ORCID iDs

Hayaa M. Alhuthali

Mazen Almehmadi

Supplemental Material

Supplemental material for this article is available online.

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