Knowledge, Attitude and Practice of Vitamin D Deficiency among Adults in Saudi Arabia

Insufficiency and shortage of vitamin D are now widespread illnesses [1]. Vitamin D is a family of fat-soluble prohormones that comes in various forms, including D2 (ergocalciferol) and D3 (cholecalciferol) [2]. It is an essential steroid involved in bone metabolism, cell proliferation, differentiation and mineral regulation in the body [3]. The primary function of vitamin D is to enhance calcium absorption from the small intestine [4]. Despite ample sunlight in the region, Saudi Arabia continues to experience a high prevalence of vitamin D deficiency. Approximately 76.1% of the population is affected by this deficiency, with the youngest age group (30-40 years) exhibiting the highest percentage of deficiency [5].

In 2020, research was conducted among the Saudi adult population and the result has shown a lowest score of 0 and a maximum score of 14; it has been demonstrated that the average score was 9.64±2.5 [6].

Studies have been published on the awareness of vitamin D deficiency in the general population in Jeddah, Saudi Arabia. Reported that the average score for knowledge was 5.9±1.7 (or 39.3%). Benefits knowledge was scored at 3.6±1.2 (60%). For sources, the mean knowledge score was 2.8 1.6 (35%), while for toxicity, it was 0.3±0.1 (30%) [7]. Saudi Arabian cities are characterized by average knowledge and awareness about vitamin D deficiency. In Al-Baha region, 41.7% of participants had a diagnosis of vitamin D deficiency, while 96.8% of participants were aware of vitamin D. When compared to male participants (36.3%), a startlingly high percentage of female participants (49.1%) had a diagnosis of vitamin D deficiency (p-value = 0.009) [8].

This study is essential because it addresses an important gap in the knowledge base of prior research on the subject. Numerous studies have been carried out in various areas, such as the Al-Qassim region in Saudi Arabia in 2018, where there was a significant association between overall awareness of vitamin D and consumption of at least two sources of vitamin D in men (p = 0.001) but not in women (p = 0.920). Despite having higher awareness than men, women had significantly less exposure to the sun. Additionally, Ibrahim et al. [1] study found that vitamin D deficiency and insufficiency are extremely common in Saudi Arabia's Central, Western and Eastern regions.

Similar to globally, a 2018 study in Pakistan found that university students had poor knowledge of vitamin D despite being a high-risk population. Interventions are required to raise public awareness of vitamin D's significance to health (Amina).

These studies have shed important light on the significance of adults in Saudi Arabia being aware of vitamin D deficiency, with certain areas demonstrating a severe lack of awareness across all regions. A recent and comprehensive assessment of Saudi Arabia's general population as a whole is, however, lacking. Therefore, our research proposal aims to fill this gap by conducting an updated study on a large sample size that represents all regions of Saudi Arabia. By including participants from various regions, we can ensure that our findings are representative of the entire population and provide a more accurate understanding of the Knowledge and awareness of vitamin D deficiency among adults in Saudi Arabia.

Objectives

The objective of this cross-sectional study is to assess the knowledge, attitude and practice of vitamin D deficiency among adults in Saudi Arabia.

Study Design

This is a cross-sectional descriptive study on vitamin D deficiency awareness was followed STROBE guidelines, conducted in the Kingdom of Saudi Arabia (KSA), a country in West Asia, from August 2023 to March 2025.

Study Setting

Participants, Recruitment and Sampling Procedure: The study focused on Saudi Arabian adults aged 18 and above as the target population. Participants were recruited in September 2023 from individuals who received the questionnaire.

Sample Size

The study sample was determined by the Raosoft calculator. Keeping a response distribution of 50%, a margin of error of 5% and a confidence level of 95%, the calculated sample size was 377.

Method for Data Collection and Instrument (Data Collection Technique and Tools)

A cross-sectional survey was conducted using the Knowledge, Attitude and Practice (KAP) regarding vitamin D questionnaire. The questionnaire consisted of 47 questions divided into five sections: demographic information, general knowledge, nutrition knowledge, attitude and practice. The demographic information included age, gender, nationality and residential area. D-KAP-38 included 11 general knowledge items, 5 nutrition knowledge items, 12 attitude items and 10 practice items. The possible responses are Yes/No/I don’t know options. Some questions are rated on a 5 Likert scale with the possible responses of “strongly disagree to strongly agree,” and some questions are rated on a 5 Likert scale with the possible responses of never/rarely/sometimes/often/always.

The validity and reliability of the questionnaire were tested in a pilot study with 30 individuals who were not part of the main sample. The Cronbach’s alpha coefficient for the knowledge and awareness sections was 0.82 and 0.79, respectively, indicating good internal consistency.

Scoring System

About 47 questions in our survey include 38 questions about general knowledge, nutrition knowledge, attitude and practice. General knowledge. The possible responses are “Yes/No/I don’t know,” which should be scored as 2/0/1, respectively. Hence, the total raw scores of “general knowledge” ranged from 0 to 22, which proportionately transformed to 0-100. Nutrition Knowledge The possible responses are “Yes/No/I don’t know” and the scores of 0/2/1 are respectively allocated to all of them except for Q21, which should be inversely scored as 2/0/1. Total raw scores of “nutrition knowledge” ranged from 0 to 10, which proportionately transformed to 0-100. Attitude: The related questions are rated on a 5 Likert scale with the possible responses of “strongly disagree to strongly agree” and the allocated scores of 1 to 5, respectively. Total raw scores of attitudes range from 12 to 60 and proportionately transform to 0-100. Practice: The related questions are rated on a 5 Likert scale with the possible responses of “never/rarely/sometimes/often/always”. The scores of 1 to 5 allocated to the responses of questions 38, 39, 40,41, 43 and 45 and other questions should be scored inversely. The raw scores of “practices” ranged from 10 to 50 and were then proportionately transformed to 0-100.

Analysis and Entry Method

• Collected Data was entered on a computer using the Microsoft Excel program (2016)
• For Windows. Data was then transferred to the Statistical Package for Social Science
• Software (SPSS) program, version 20. To be statistically analyzed

Table 1 displays various demographic parameters of the participants with a total number of (383). The respondents' mean age was 30.1 years and the standard deviation was 12.9. The age distribution was very diverse, 21-24 years, with 33.4% of the sample. Overall, 59.3% were females and all were Saudi nationals. Most of the 68.9% were unmarried and highly educated, 79.6% with a bachelor's degree.

Makkah was geographically the leading residential region (49.1%) and most participants had a monthly income below 5000 SAR (59.3%). In terms of occupation, 30.8% of students and 24.3% were unemployed. Among participants who examined social interaction, 54.8% regarded the internet as the one most often accessed in pursuing their social impulses.

As shown in Figure 1, in our comprehensive medical research study examining the knowledge, attitude and practice regarding vitamin D deficiency among adults in Saudi Arabia, a total sample of 383 individuals was analyzed to identify key findings. Notably, the data revealed that a significant majority, comprising 336 participants, acknowledged their awareness of potential vitamin D deficiency, underscoring a heightened consciousness of this health issue among the population. Conversely, only 15 respondents reported a lack of awareness, while 32 participants expressed uncertainty about their knowledge on the subject.

Table 2 shows findings from the study of knowledge, attitudes and practice of vitamin D deficiency among adults in Saudi Arabia provides valuable insights into public awareness and misperception of a critical health issue. A large majority of participants (87.7%) were aware that individuals working indoors are at greater risk for vitamin D deficiency and 86.9% were also aware of

Table 1: Sociodemographic characteristics of participants (n = 383)

Table 2: Parameters related to general and nutritional knowledge regarding vitamin D (n = 383)

Figure 1: Illustrates whether people who work indoors have a high risk of vitamin D deficiency among participants

the same risk among the elderly. Eighty-seven point two per cent of respondents affirmed they believe vitamin D intake could be harmful if taken in excess. Significantly, 73.9% cited improper dietary intakes as contributing to deficiency and 89.0% concluded that vitamin D supplement requirements are different in each age group. In addition, 68.1% could identify pregnant and lactating women as being at risk and 71.8% understood that a high percentage of vitamin D is produced in the skin by exposure to sunlight.

As shown in Figure 2, A notable aspect of the study pertains to the impact of urbanization on sun exposure and, consequently, vitamin D synthesis. Specifically, 148 respondents agreed that urbanization hinders sun exposure

Table 3: Participants’ attitude regarding vitamin D (n = 383)

necessary for vitamin D production, while an additional 59 strongly agreed with this assertion. In contrast, 57 participants disagreed and 8 strongly disagreed; however, 111 remained uncertain.

Table 3 shows a great part of respondents admitted that urbanization (54%; combined agree/strongly agree) as well as the lack of public outdoor spaces (70.8%; combined agree/strongly agree) made the sun exposure needed to produce vitamin D impossible to obtain. In fact, almost all participants (91.2%) understood that the lack of sun is inherent to full time indoor occupations. Education was a key factor whereby 70.2% of patients agreed that poor awareness of the benefits of sun exposure is part of the causal chain of vitamin D deficiency. Most

Table 4: Practice level regarding vitamin D (n = 383)

Figure 2: Illustrates whether urbanization prevents sun exposure and production of vitamin D among participants

participants held the belief that supplement intake is better than dietary sources, with 69.5% in agreement that supplement intake is preferable to nutritional status, yet this group included a notable (79.9%) opinion that supplement intake without physician recommendation is inappropriate.

Table 4 shows results of this study on the knowledge and practice and attitude on vitamin D deficiency among adults in Saudi Arabia provided some insights on the practices toward vitamin D sufficiency. Further, a large proportion of participants reported infrequent outdoor physical activity, i.e. having participated in outdoor physical activity at least once a month among 39.7% and never among 15.1%. Additionally, dietary practices

Table 5: Shows general knowledge of vitamin D score results

Table 6: Shows nutrition knowledge about vitamin D score results

Table 7: Shows attitude of vitamin D score results

Table 8: Shows practice of vitamin D score results

followed a troubling track, as 33.2% of respondents consumed fortified milk rarely, half of whom (16.3%) claimed not to consume any dairy products, while 39.2% of respondents said they do not eat fish at least twice a week, both of which are important to have enough vitamin D. Vitamin D supplements were used by 37.1% of participants sometimes and 20.6% said they always used them. Furthermore, the data revealed that many people keep their hands and faces out of direct sun, with 25.6% never applying sunscreen to their hands ever and 19.8% never putting sunscreen on their faces.

Table 5 shows the findings of my research on the knowledge, attitude and practice regarding vitamin D deficiency among adults in Saudi Arabia reveal that a significant majority exhibits a high level of general knowledge about vitamin D, with 63.7% of participants scoring highly in this area, encompassing a total of 244 individuals. Meanwhile, 33.2% of the respondents demonstrated a moderate level of knowledge, amounting to 127 individuals, while a small minority, consisting of only 3.1% or 12 participants, displayed a low level of general knowledge.

Table 6 shows findings from my medical research article, which investigates the knowledge, attitude and practices related to vitamin D deficiency among adults in Saudi Arabia, reveal concerning trends in nutritional awareness. As demonstrated in Table 6, the results indicate that only 8.9% of participants exhibited a high level of nutrition knowledge regarding vitamin D, while 21.1% displayed moderate knowledge. Alarmingly, the majority-70.0%-of respondents reported low levels of nutritional knowledge in this area.

Table 7 shows findings from the medical research article examining the knowledge, attitudes and practices regarding vitamin D deficiency among adults in Saudi Arabia illuminate significant trends in public perception. As illustrated in Table 7, the results reveal that a predominant 66.8% of participants exhibited a moderate attitude towards vitamin D, while only 28.7% demonstrated a high level of awareness, suggesting a substantial gap in optimal understanding. Notably, a minimal 4.4% of respondents reflected a low attitude level, indicating that most individuals have at least some recognition of the importance of vitamin D.

Table 8 shows findings of this study, which aimed to assess the knowledge, attitudes and practices concerning vitamin D deficiency among adults in Saudi Arabia, revealing significant insights into the practices related to vitamin D intake. As indicated in Table 8, the categorization of practice levels among the 383 participants illustrates that only 30.5% exhibited a high level of practice regarding vitamin D supplementation and lifestyle choices aligned with sufficient vitamin D levels. In contrast, a substantial majority, 58.7%, demonstrated a moderate practice level, suggesting that while some awareness and actions are present, they may not be sufficient to prevent deficiency. Alarmingly, 10.7% of respondents reported low practice levels.

Table 9 shows that general knowledge about vitamin D has statistically significant relation to age (p-value = 0.038), marital status (p-value = 0.0001), educational level (p-value = 0.0001), residential region (p-value = 0.0001), monthly income (p-value = 0.004), occupation (p-value = 0.0001) and sources of socialising (p-value = 0.0001). It also shows a statistically insignificant relation to gender.

Table 10 shows attitude level regarding vitamin D has statistically significant relation to educational level (p-value = 0.0001), residential region (p-value = 0.001),

Table 9: Relation between general knowledge about vitamin D and sociodemographic characteristics

*p-value was considered significant if ≤0.05

Table 10: Attitude level regarding vitamin D in association with sociodemographic characteristics

*p-value was considered significant if ≤0.05

occupation (p-value = 0.0001) and sources of socialising (p-value = 0.043). It also shows statistically insignificant relation to gender, age, marital status and monthly income.

The purpose of the present study was to assess adults’ knowledge, attitudes and practices regarding vitamin D deficiency in Saudi Arabia. Since the vast majority of the population reportedly suffers from vitamin D deficiency in this region, this investigation is particularly important. The results of this study show a great deal of general knowledge about vitamin D, as evidenced by participant responses but as well a disconcertingly low nutritional awareness regarding the dietary sources of vitamin D. In this discussion we shall compare these findings to the results of previous studies and discuss their similarities and discrepancies, as well as the limitations of this study.

Our observation of a very high level of general knowledge of vitamin D, as well as the knowledge mentioned in this study among the populations is above 63.7% that indicates high level of awareness similar with findings by Aljefree et al. [9], who reported widely different knowledge on vitamin D between populations in Saudi Arabia, some of which know relatively well. Nevertheless, poor levels of nutritional knowledge were found about vitamin D; only 8.9% of participants had a high level of knowledge of nutrition. Findings from Al-Faris et al. [10], that traditional foods of Saudi Arabia are poor sources of vitamin D, as also noted here, support this. A big problem with this lack of awareness about dietary sources of vitamin D is that even if they know how vital vitamin D is, it means that they don’t know how to make dietary decisions that could help prevent a deficiency.

In addition, the study found that although the majority of the participants have understood the risks of vitamin D deficiency, such as the vulnerability of the indoor working population and the elderly, there is no correlation between knowledge and practice. For example, only 39.7% of participants said they engaged in outdoor physical activity at least once a month, key to vitamin D synthesis through sunlight exposure. As in the work of Al-Othman et al. [11], this finding is echoed in work showing that physical activity and sun exposure significantly contribute to levels of vitamin D status in children and adolescents in Saudi Arabia. Our finding of the low levels of outdoor activity among adults may reflect findings that broader societal trends, such as urbanization and lifestyle changes that prioritize indoor activities, may be barriers to the levels of sun exposure necessary for optimum vitamin D synthesis.

Furthermore, attitudes toward vitamin D supplementation were divided: A large number of participants felt that supplements are better than dietary sources. This view is in accordance with Hariri [12] who reported how the Saudi population relies on supplements for vitamin D, despite dietary sources that may supply sufficient vitamin D. It's a positive aspect of the overall attitude toward supplementation that 79.9% of participants were concerned that supplementation should be along recommended by a physician, indicating a recognition of the need of professional guidance in managing vitamin D intake.

Demographically we found that there was a strong relation of education with the awareness and attitude towards vitamin D deficiency. The vast majority was highly educated-79.6% had a bachelor's degree. Consistent with Alfaris et al. [13] observations, it is found that education increases awareness about vitamin D deficiency and its diseases. However, despite high educational levels, the many gaps in nutritional knowledge suggest that educational interventions need to be tailored for specific knowledge deficits about dietary sources and the significance of sun exposure.

However, limitations of the present study are its cross-sectional design, which prohibits the making of any inference of causality between knowledge, attitudes and practices around vitamin D deficiency. Furthermore, applying it is reliant on self-reported data that may involve bias as such as participants reporting more information than they truly possess on vitamin D. Additionally, the sample used for the study was mostly young and educated and may not fully reflect the broader Saudi public. Future studies should aim to include a more diverse demographic to better understand vitamin D awareness across different age groups, educational backgrounds and socioeconomic statuses.

While the study of the present study indicates a good level of general knowledge about vitamin D among Saudi adults, it also points out a significant lack of nutritional awareness and actual use of such knowledge. Our findings underscore the urgent need for targeted educational interventions aimed not only at raising awareness of vitamin D but also atfacilitating easy measures to boost dietary intake and sun exposure. Ultimately, closing these gaps is necessary to reduce the prevalence of vitamin D deficiency, which is extremely high in Saudi Arabia and improve public health.

Acknowledgement

We acknowledge all of the volunteers who provided samples for this research.

Conflicts of Interest

The authors declare no conflict of interest.

Ethical Approval

After fully explaining the study and emphasizing that participation is optional, each participant gave their informed consent. The information gathered was safely stored and utilized exclusively for study.

1. Ibrahim, Osama Mohamed et al. “Knowledge and perceptions of vitamin D deficiency among the United Arab Emirates population.” Asian Journal of Pharmaceutical and clinical research, 12, no. 8, 2019, pp. 183-186.

2. Safdar, Osama et al. “Assessment of knowledge and awareness of vitamin D among physicians and students of healthcare in Jeddah, Saudi Arabia.” Australasian Med. J., 12, no. 5, 2019, pp. 143-153.

3. Smitha, P. M. and Katari Kantha. “Assessing the Knowledge on Vitamin ‘D’Deficiency among Adults in Nellore (Andhra Pradesh).” Nursing Journal of India, 110, no. 5, 2019, pp. 230-234.

4. Ali, Suad Mohamed et al. “Awareness of medical students about vitamin D deficiency at Ahfad University for women, Sudan.” Sudanese Journal of Paediatrics, 19, no. 2, 2019, pp. 117-125. https://pmc.ncbi.nlm.nih.gov/articles/ PMC6962265/.

5. Farhat, Karim H. et al. “Vitamin D status and its correlates in Saudi male population.” BMC Public Health, 19, February 2019. https://link.springer.com/article/10.1186/ s12889-019-6527-5.

6. Goweda, Reda Abdelmoaty et al. “Awareness of vitamin D deficiency among the adult population in Makkah, Saudi Arabia: a cross-sectional study.” International Journal of Medicine in Developing Countries, 4, no. 11, September 2020, pp. 1818-1822. https://www.bibliomed.org/mnsfulltext/ 51/51-1600516858.pdf?1740226109.

7. Alamoudi, Lujain H. et al. “Awareness of vitamin D deficiency among the general population in Jeddah, Saudi Arabia.” Journal of Nutrition and Metabolism, 1, March 2019. https://onlinelibrary.wiley.com/doi/full/10.1155/2019/ 4138187.

8. Abukhelaif, Abuobaida E. et al. “Assessment level of awareness of vitamin d deficiency among the public residents of Al-baha region; Saudi Arabia.” Medical Science, 25, no. 116, October 2021, pp. 2728-2736. https://www. discoveryjournals.org/medicalscience/current_issue/v25/n116/A32.pdf.

9. Aljefree, Najlaa M. et al. “Knowledge and attitudes about vitamin D and behaviors related to vitamin D in adults with and without coronary heart disease in Saudi Arabia.” BMC Public Health, 17, March 2017. https://link.springer. com/article/10.1186/s12889-017-4183-1.

10. Al-Faris, Nora Abdullah. “Nutritional evaluation of selected traditional foods commonly consumed in Saudi Arabia.” Journal of Food and Nutrition Research, 5, no. 3, March 2017, pp. 168-175.

11. Al-Othman, Abdulaziz et al. “Effect of physical activity and sun exposure on vitamin D status of Saudi children and adolescents.” BMC Pediatrics, 12, July 2012. https://link. springer.com/article/10.1186/1471-2431-12-92.

12. Hariri, Al. “Vitamin D deficiency/insufficiency and anxiety among Saudis: degree and differences.” European Scientific Journal, 12, no. 27, 2016, pp. 93-108. https://core.ac.uk/ download/pdf/328025594.pdf.

13. AlFaris, Nora A. et al. “Vitamin D deficiency and associated risk factors in women from Riyadh, Saudi Arabia.” Scientific Reports, 9, no. 1, December 2019. https://www.nature. com/articles/s41598-019-56830-z.