Assessing General Knowledge and Nutritional Knowledge on the Role of Vitamin D, Attitudes, and Behavior Toward Sun Exposure Among Tertiary Students in Oman
Abstract
Background: Vitamin D deficiency is highly prevalent among the Omani population, driven by factors such as urbanization, technology-driven lifestyles, reduced physical activity, limited sun exposure, unhealthy eating habits, and genetic predispositions. Despite the year-round availability of sunlight, there is limited understanding of the specific causes of this deficiency and effective strategies to mitigate it.
Aim: This study aimed to develop and validate a knowledge, attitude, and practice (KAP) questionnaire on vitamin D and measure the KAP levels among students at Sultan Qaboos University (SQU) in Oman to inform preventive and educational measures.
Methodology: A cross-sectional study was conducted using a newly developed, self-administered KAP questionnaire distributed online to a random sample of 1034 Omani students enrolled in various degree programs at SQU. The questionnaire was developed following a standardized protocol, including a literature review, focus group discussions, and expert input. Validity and reliability were assessed using Cronbach’s α coefficient (α ≥ 0.70), and normality was examined with the Shapiro–Wilk test. The 54-item questionnaire was divided into three domains: general knowledge of vitamin D, nutritional knowledge, and attitudes and behavior toward sun exposure. Descriptive and variance analyses were performed, with qualitative data expressed as numbers and percentages.
Results: The questionnaire demonstrated good internal consistency (Cronbach’s α = 0.8057). Only 20.6% of the students had a good level of knowledge, 62% had an average level, and 17% had a poor level regarding vitamin D and its importance. The mean scores were 8.43 for general knowledge, 5.83 for nutritional knowledge, and 8.09 for attitudes and behavior toward sun exposure.
Conclusions: The constructed questionnaire showed satisfactory validity and reliability. The study identified a generally poor level of knowledge about vitamin D among students, highlighting the need for targeted educational strategies to improve awareness and promote better health outcomes.
1. Introduction
Vitamin D is one of the most unique vitamins, known as the sunshine vitamin due to its ability to be made in the skin from exposure to sunlight. Vitamin D plays a very important role in calcium and phosphorus metabolism, which is beneficial for musculoskeletal health and hence is referred to as a steroid hormone. Vitamin D exists in two forms: vitamin D2 and vitamin D3. Vitamin D is produced upon exposure to sun or consumed from dietary sources. It is biologically inert and requires hydroxylation first in the liver by the vitamin D 25-hydroxylase (25-OHase) to 25(OH)D. Finally, 25(OH)D requires further hydroxylation in the kidneys by the 25(OH)D-1-OHase (CYP27B1) to form the biologically active form of vitamin D, 1,25(OH)2D. The 1,25(OH)2D has a wide range of biological actions and regulates up to 200 genes in the human body through vitamin D receptors (VDRs) present in most tissues and cells in the human body [1, 2].
Vitamin D deficiency affects individuals during their different life stages and may have an influence at the population level. There is increasing evidence highlighting the impact of vitamin D deficiency as a threatening factor in various central or peripheral neurological diseases [3, 4]. Subsequent research has demonstrated that people suffering from amyotrophic lateral sclerosis (ALS), Alzheimer’s disease (AD), schizophrenia, depression, Parkinson’s disease (PD), and other neuropsychiatric disorders, such as autism, and cognitive disorders, like attention deficit hyperactivity disorder (ADHD), tend to have low serum vitamin D (25(OH)Ds less than 20 ng/mL) [5, 6]. Vitamin D is also known to affect innate and adaptive immune systems; it plays an important role in immune regulation and antibacterial response [7]. Vitamin D (1,25(OH)2D3) deficiency is highly prevalent in patients with chronic respiratory disease and infectious diseases, where it is correlated with increased disease severity [8, 9]. Vitamin D mediates its biological function when metabolized into its active steroid form 1α,25-dihydroxyvitamin D3, referred to as a hormone, affecting many genes [10]. The Middle East North Africa (MENA) region spans such latitudes that synthesizing vitamin D in the skin would be possible almost all year round (15 to 39° N) [11]. In spite of being in regions where sunshine is abundant throughout the year, the MENA region has a concentration of serum 25-hydroxyvitamin D (25(OH)D) <50 nmol/L [12, 13]. The prevalence of vitamin D deficiency is significantly high among women in populations of the United Arab Emirates (UAE), Saudi Arabia, and several Middle Eastern countries [14]. Genetic factors, namely, polymorphisms in key genes (such as VDRs and CYP27B1) involved in the vitamin D pathway, play a role in modulating vitamin D status in the Middle East and the Gulf Corporation Counsil (GCC) [15–17].
Despite the high prevalence of 25-OH-D deficiency globally [18], there is a paucity of evidence regarding vitamin D–related knowledge, attitude, and practice (KAP) toward sunlight exposure in different population segments worldwide. Various studies have reported limited public awareness of vitamin D in this region of the world [19]. A study conducted in the United Kingdom showed a lack of knowledge about vitamin D food sources, the benefits of sun exposure, and the health benefits of vitamin D [20]. Another qualitative study conducted in Saudi Arabia highlighted that there was a lack of knowledge on dietary sources of vitamin D [21]. Moreover, some participants had negative attitudes toward sun exposure and were avoiding sunlight to evade heat. Other contributing aspects were lifestyle issues, limited outdoor activity areas, and social and cultural factors [22]. Again, in a separate KAP survey conducted in Saudi Arabia among female students, it was reported that the students had inadequate knowledge and lacked sun exposure due to cultural and religious factors [23]. Hypovitaminosis D has been identified as a global problem in all age groups, particularly in girls and women from the Middle East [24]. For most people, exposure to solar ultraviolet B (UVB) is the primary source of vitamin D [19]. Although humans can endogenously synthesize vitamin D3 in their skin with sufficient UVB exposure (290–315 nm), the current lifestyle and clothing style in the GCC countries often make this an impediment, thus making supplementation necessary [25, 26]. Similarly, in a study conducted in Oman on medical school students, about 50% of the students did not know that vitamin D synthesis would be affected if they covered their hands and face during exposure to the sun [21]. In a 2004 health survey conducted in Oman, almost half (47%) of the 298 nonpregnant women of childbearing age had serum 25(OH)D concentrations below 37.5 nmol/L [27]. Furthermore, urbanization in GCC countries and a lifestyle ruled by technology, with less physical activity, lack of sunlight, and unhealthy eating patterns, have significantly increased the prevalence of vitamin D deficiency in the GCC [6]. Moreover, epidemiological studies related to vitamin D deficiency in the GCC are limited, and information about vitamin D status in young adult populations from the Middle East is scarce [28]. Due to the high prevalence of vitamin D deficiency in Oman, no adequate published literature focused on vitamin D–related KAP. Therefore, we conducted a survey study using an online questionnaire model to assess KAP regarding vitamin D among Sultan Qaboos University (SQU) students to assess their understanding of the current health crisis of hypovitaminosis D in Oman.
Very few instruments have been developed to assess vitamin D–related KAP in the GCC. Most of the existing questionnaires were developed in Western communities based on cultural and socioenvironmental factors with high levels of socioenvironmental disparity in Eastern countries, particularly with Muslim populations. We initiated this investigation to fill this gap in the current literature. This study is one of the first efforts aimed at developing a valid and reliable questionnaire to assess vitamin D–related knowledge, awareness of vitamin D, and attitudes toward sunlight exposure among college students at SQU, Oman. University students are at an important stage of their life development and are an effective driving force in the development of society, diverse student population, representing various demographics, backgrounds, and experiences. This diversity allows to generalize the findings to the broader population and greater willingness to participate in the current and future studies. The results of this study will help develop effective clinical and public health strategies to improve vitamin D status in the local population.
2. Study Design and Subjects
The participants selected for the study were students aged ≥ 18 years. Tertiary education students could be considered a representative sample of the population since they represent most of the governorates of Oman. The objective of this study was twofold: first, to develop and validate a KAP questionnaire on vitamin D among university students in Oman, and second, to investigate the KAP of vitamin D, by measuring and validating the KAP score of SQU students.
2.1. Study Subjects
The automated Raosoft tool [29] was used for sample size calculation: Sample size (SS) = SS/ [1 + {(SS − 1)/Population}]. At least 391 participants were needed for the study. SQU students who were ≥18 years old participated in the study. The inclusion criteria for our study were that the participant had to be a registered student at SQU. The student population at the time of the study was 18,000 students, and the online questionnaire was sent out to all students. A total of 1034 Omani students (both male and female) from nine different colleges in SQU participated in this study. The analyses were restricted to those students who completed the entire questionnaire and said they were SQU students (n = 963). The exclusion criteria were incomplete surveys, did not consent to the study, and students who said that they were not SQU students (n = 68). This workflow is summarized in the conceptual diagram (Figure 1).
2.2. Data Collection and Research Instrument
A quantitative technique with a descriptive cross-sectional research design was carried out. The study was conducted between February and June 2021 using a newly designed questionnaire. The questionnaire was distributed online through Google Forms, and the link was shared through the public relations department of SQU with all email addresses of registered university students. The questionnaire link was also distributed through social media and WhatsApp through the student council and the university Instagram page (squcoffee) to reach as many students as possible. All ethical approvals (Ref. No. SQUEC/026/2020, MREC #2134) were obtained before carrying out this study. Informed consent has been obtained from the respondent for this survey.
3. Materials and Methods
Both descriptive analysis and variance analysis were explained in the study. Qualitative data were expressed as numbers and percentages.
3.1. Questionnaire
A newly developed and piloted online questionnaire was used to assess the KAP of vitamin D sun exposure in the Omani population. This scale was developed based on previous studies investigating vitamin D knowledge [22, 23, 30–33]. The questions were modified to align with current vitamin D recommendations and are of relevance to the Omani population [20, 23, 32, 34, 35].
3.2. Instrument Development
The instrument was developed over three sequential steps captured as follows.
3.2.1. Step 1: Design of the Questionnaire
The questionnaire was constructed following the standardized protocols consisting of a literature review and expert opinion, a focus group comprising of three academic professors, and one PhD student who are experts in the field, which worked to decipher the themes related to the theoretical framework and construction of the questionnaire items after an extensive literature review on the current topic [20, 34, 36–38]. As a culture-specific instrument, the present questionnaire was developed in English and Arabic.
After careful deliberation and extensive literature review, the themes related to a theoretical framework and construction of the questionnaire items were developed. Further, items in the questionnaire from relevant published work in this area were evaluated, modified, and classified according to the research design of this study. The created questionnaire was designed to cover three related constructs, namely, general knowledge of the role of vitamin D, nutritional knowledge of vitamin D, and attitude and behavior toward sun exposure. Additionally, the questionnaire included questions related to the sociodemographic characteristics of the participants. The questionnaire included, in the beginning, a brief description of the research, its purpose, and confidentiality limits.
3.2.1.1. The Content of the Questionnaire
The instrument used to collect data was an online questionnaire (https://forms.gle/GEjVgqNn6WoPFRyj9) and had a quantitative design approach. The items in the questionnaire were divided into four segments, each segment focusing on receiving data about the relevant constructs. This includes the following: Section A included eight questions related to the sociodemographic characteristics of the participant. Section B included 16 questions related to general knowledge of the role of vitamin D. Section C included 14 questions related to nutritional knowledge and important sources of vitamin D. Section D included 17 questions focused on the attitude and behavior toward sun exposure among the participants. All items on the questionnaire included closed-ended responses, where participants were asked to choose from the given options (i.e., multiple-choice questions).
3.2.2. Step 2: Testing the Validity of the Face and Content of the Questionnaire
The validity of the face and content was independently evaluated by the study panel team. Six items were deemed redundant and removed after discussion between the study panel and the independent panel. After the process of revision, the items were modified; based on the panel comments, lastly, a 54-item draft questionnaire was developed.
3.2.3. Step 3: Validation of the Questionnaire
This step is elaborated as follows.
3.3. Validation Method
This study was approved by the SQU College of Medicine (Ref. No. SQUEC/026/2020, MREC #2134) after reviewing the questionnaire from the pilot study. This study was initially tested online on a sample from SQU staff and students to determine the validity of the content. Initially, a cross-sectional survey of 68 respondents was carried out to validate the tool. A Cronbach’s α test (α ≥ 0.70) and Cronbach’s α coefficient of STATA v13.0 were used for the assessment of the reproducibility and internal consistency of the questionnaire [39–41]. Factor analysis was performed using Cronbach details of the α item. The Cronbach’s α (α = 0.8057) and Cronbach’s α coefficient (0.814) of the questionnaire suggested that the internal consistency of the questionnaire was adequate and that the flow of the questions was valid, indicating a good reliability of the research. The questionnaire was well accepted and can be used as a reliable KAP instrument.
The normality of the distribution was examined with the Shapiro‒Wilk normality test and showed a normal distribution (Figure 2).
3.4. Statistical Analysis
Data analysis was conducted using StataCorp Statistics version 13.0. Descriptive statistics were employed to present demographic data and evaluate KAP regarding vitamin D. Statistical analysis included descriptive measures of all variables, expressed as the mean (standard deviation [SD]) or median if the data were not normally distributed. A general knowledge score was calculated by combining the results of the 16 knowledge questions, assigning one point for each correct answer, with a maximum score of 16 indicating all questions were answered correctly. The mean and SD for the knowledge score were calculated. Responses were categorized as follows: scores of 11–16 were classified as good knowledge (mean + 2.14 SD), scores of 8–10 as average knowledge (mean + 1.6 SD), and scores below 8 (mean – 2.14 SD) as poor knowledge.
The nutritional score, attitude, and behavior scores were calculated by combining responses related to nutrition knowledge, sources of vitamin D, and attitudes and behaviors toward sun exposure. An ordinary least squares (OLS) regression model (Equation (1)) was used to assess the impact of various variables on respondents’ attitudes and behaviors (Table 1).
| KAP score | Coefficient | Standard error | t | p >|t| | 95% confidence interval |
|---|---|---|---|---|---|
| Score general knowledge | 1.13 | 0.035 | 32.05 | p ≤ 0.001 | 1.1–1.2 |
| Score nutritional knowledge | 1.12 | 0.030 | 37.53 | p ≤ 0.001 | 1.1–1.2 |
| Y-intercept | 6.33 | 0.28 | 22.59 | p ≤ 0.001 | 5.8–6.9 |
All demographic variables were included as independent variables, with sociodemographic factors presented as frequencies and percentages (Table 2). The Shapiro–Wilk normality test was used to examine the normality of the data distribution, confirming normal distribution (Figure 2), and the subscale distributions were also tested using the Shapiro–Wilk test. Means and SDs were reported. Multicollinearity and outliers were assessed using the variance inflation factor (VIF) test and added variable (AV) plot analysis, demonstrating the significance of these factors (Figure 3). A mean comparison of the KAP scores between men and women was performed (Figure 4), and the Shapiro–Wilk test for normality was also conducted in relation to the KAP scores. For significance, p-values ≤ 0.05 were considered meaningful, reflecting the socioeconomic context of the study. A two-sample t-test (p < 0.05) was used to evaluate the impact of gender on the mean KAP score (Figure 4). Pearson’s PWCORR (Pearson correlation coefficient (r)) method was used to measure the statistical association between any two continuous variables, indicating that there are correlations between variables (Figure 5). Factor analysis of the three domains was conducted to assess their correlation and avoid multicollinearity of independent variables (Figure 6).
| Background variables | N | % |
|---|---|---|
| Age (in years) | ||
| 16–25 | 925 | 96 |
| 26–35 | 29 | 3 |
| 36–45 | 8 | 0.8 |
| >46 | 1 | 0.1 |
| Gender | ||
| Male | 331 | 34 |
| Female | 632 | 66 |
| Marital status | ||
| Single | 920 | 95.5 |
| Married | 41 | 4.2 |
| Divorced | 2 | 0.20 |
| Education | ||
| Diploma/higher diploma | 406 | 42.1 |
| Bachelor’s degree | 364 | 37.7 |
| Masters | 190 | 19.7 |
| PhD | 3 | 0.31 |
| Are you a student at SQU | ||
| Yes | 963 | 93.1 |
| No | 68 | 6.9 |
| Which year are you in your studies at SQU (in years) | ||
| 1–2 | 518 | 53.7 |
| 2–3 | 279 | 28.9 |
| >4 | 166 | 17.2 |
| Body mass index (BMI) | ||
| Under weight (<18.5) | 199 | 20.6 |
| Normal (18.5–24.9) | 546 | 56.6 |
| Overweight (25–29.9) | 158 | 16.4 |
| Obese (>30) | 60 | 6.2 |
- Abbreviation: SQU, Sultan Qaboos University.
4. Results
Our study is one of the first to develop a validated KAP questionnaire that aims to understand knowledge, attitudes, and behavior toward vitamin D among tertiary students in Oman.
4.1. Sociodemographic Profile of the Respondents
The 1034 tertiary student sample, both male and female, participated in the study from all nine different colleges at SQU through an online Google questionnaire (https://forms.gle/GEjVgqNn6WoPFRyj9). Only 963 participants (n = 331 males [34%] and n = 632 females [66%] with a mean [±SD] age of 20.4 [±3.4]) had completed the questionnaire and met the inclusion criteria (Figure 1). The mean ± SD of the age of the study participants was 20.424 ± 3.427 years (range between 16 and 48 years). About 96% of the students belonged to the age group of 16–25 years (n = 925). Regarding marital status, 95.5% were single (n = 920). All participants had a secondary level of education (n = 963). Of the 93.1% of the students who studied at SQU (n = 963), 53.7% of the students were 1–2 years of age at their study level (n = 518). More than 50% of the students (52.6%) were in the normal weight range and had a normal body mass index (BMI) (n = 507), 20.6% of the students were underweight (n = 199), 16.4% were overweight (n = 158), and only 6.2% (n = 60) were obese. The profile of the respondents with their sociodemographic characteristics is summarized in Table 2.
4.2. Statistical Analysis Results
Various statistical analyses were calculated to assess the correlation between variables and their impact on the KAP score. The diagnostic tools used were VIF, AV plots for independent variables in KAP analysis, difference in fit(s) (DFFITS), and Cook’s values to check for any outliers; the dots represent the participants. The test suggested that there was no indicated outlier participant in our study (Figure 3). To check for normality and that the distribution of the respondents is normal, a normality histogram was produced (Figure 4), and it showed a good representation of the results of the participants. The VIF test was conducted to check for the presence of multicollinearity among age, marital status, level of education, and gender (Figure 5). A value of VIF > 10 indicates the multicollinearity of the variables and shows all independent variables with VIF < 2.5 with a mean of VIF = 1.58. The results found an absence of multicollinearity between variables (VIF < 10), indicating the lack of impact between given variables.
To correlate with the KAP score, the Shapiro–Wilk test for normality of data was also performed. Shapiro–Wilk and normal distribution for the KAP score mean ± SD, p ≤ 0.05, will be considered significant, as this is a socioeconomic study. The most significant of them was the correlation score of attitudes, which showed a normal distribution (0.01214). The score for gender and nutrition was closely distributed, with a score of 0.067, and the requirement was 0.05 (Table 3).
| Variables | Obs | W | V | Z | Prob > Z |
|---|---|---|---|---|---|
| Score gender | 963 | 0.99 | 1.83 | 1.49 | 0.067 |
| Score nutrition | 963 | 0.99 | 1.83 | 1.49 | 0.067 |
| Score attitude | 963 | 0.99 | 2.49 | 2.25 | 0.012 |
| KAP score | 963 | 0.99 | 1.85 | 1.53 | 0.063 |
- Abbreviations: Obs, observation mean data collected from participants; Prob > Z, probability of the Z-score or hypothesis testing; V, Cramer’s V; W, weighted sum; Z, Z-score which is standard deviation from the mean.
The OLS regression equation was used to show the impact of different variables on the attitude and behavior of the respondent. The KAP score is significantly affected by both general knowledge and nutrition knowledge of vitamin D. The impact coefficiency for them was p = 1.127; the gender and age of the students had a positive effect on the KAP score (Figure 5). However, the level of education of the students does not significantly affect the KAP score (p = 0.995), as it is greater than ≥0.5. Marital status has a negative impact on the KAP score, the impact coefficient was (p = −1.800), and it is significant based on the study respondents as displayed in Figure 5. The observed values are real values, and the scores are not due to randomness, which gives a good indication that the values are still congruent.
4.3. General Knowledge KAP Score
The maximum score for general knowledge of vitamin D was 14.5. The mean score was 8.43, and the SD was ±2.14, with a range of 2.28–14.5, as noted in Table 4. The impact of gender on the general knowledge of vitamin D, suggesting good knowledge with a coefficient (p = 1.777) coefficient, is also visible and shows a positive slope, suggesting that both male and female students had a positive impact on the KAP score. Approximately 50% of the students scored average in the KAP analysis, about 31% of the student population scored well, and only 19% of the students showed very poor knowledge of the role of vitamin D (Figure 3) which shows the age, level of education, and marital status, indicating that the older the age, the better is general knowledge and nutritional knowledge of vitamin D, indicating that age had a positive and significant impact on the KAP score.
| Variables | Mean | Standard deviation | Mean ± standard deviation (min) | Mean ± standard deviation (max) |
|---|---|---|---|---|
| Gender | 1.66 | 0.48 | 1 | 2 |
| Age (years) | 20.43 | 3.25 | 16 | 48 |
| Weight (kg) | 59.43 | 15.02 | 31 | 153 |
| Height (cm) | 162.88 | 9.85 | 100 | 200 |
| Score general knowledge | 8.43 | 2.14 | 2.29 | 14.53 |
| Score nutrition knowledge | 5.84 | 2.52 | 0 | 13 |
| Score attitude | 8.09 | 2.16 | 2.33 | 14.66 |
| KAP score | 22.37 | 4.91 | 7.09 | 37.88 |
- Abbreviation: KAP, knowledge, attitude, and practice.
4.4. General Knowledge Score
The current study revealed that most of the students were aware of vitamin D. Of the 78.3% of the students (n = 963), approximately 46% had heard or learned about vitamin D from educational institutions, schools, colleges, and universities. Almost 33.4% of them had heard from health professionals; around 13.3% had heard from the media, including newspapers, magazines, and television; and 7.2% had heard from parents, friends, and relatives. However, only 15.1% of the students had done a vitamin D test, while 71.9% had never done a vitamin D test, and 12.8% of the students did not know about the vitamin D test. In evaluating the knowledge of vitamin D on health, for most students, 76.1% chose healthy bone as the benefit of vitamin D, 59% chose prevention of osteoporosis, 54.6% chose prevention of general weakness, 39.3% of the students chose prevention of osteomalacia, 33% chose prevention of chronic illness, 29.5% chose prevention of rickets, and 22.3% chose healthy pregnancy as the benefit of vitamin D.
Regarding the factors influencing vitamin D synthesis from sunlight, only 7.99% of students identified fewer than six correct factors. Additionally, 19.5% of students were unaware of the factors affecting vitamin D synthesis from sunlight. Conversely, 72.4% of students were able to identify five or fewer correct factors related to the synthesis of vitamin D from sunlight.
Regarding the role of sunscreen in preventing sun exposure, 79.9% of the students were unaware that using sunscreen on the face, neck, and hands reduces the sun exposure needed for vitamin D production. Only 20.1% of the students understood that sunscreen use on these areas can prevent the necessary sun exposure for vitamin D synthesis.
4.5. Nutritional Knowledge KAP Score
The highest score achieved by the respondents for nutritional knowledge and sources of vitamin D was 13. The mean score was 5.83, and the SD was ±2.52, with a range of 0–13 (Table 4). The KAP score assessing the nutritional knowledge of vitamin D showed that most students (44%) scored an average, 38% of students scored good, and only 18% of students showed a poor score on the KAP score of nutritional knowledge. The impact of gender on nutritional knowledge suggests good knowledge with an impact coefficient for them (p = 1.777), and the line shows a positive slope, suggesting that the impact of gender was positive on the KAP score. The impact of age was also positive (Figure 5), indicating a positive slope. Older individuals have better nutritional knowledge. The highest nutritional knowledge score achieved by the respondents regarding vitamin D sources was 13, with a mean score of 5.83 and a SD of ± 2.52, ranging from 0 to 13 (Table 4). The KAP assessment revealed that 44% of students scored average, 38% scored good, and 18% scored poorly in nutritional knowledge of vitamin D. Gender showed a positive impact on the KAP score, with an impact coefficient of p = 1.777, and the line indicated a positive slope, suggesting that gender positively influenced nutritional knowledge. Similarly, the impact of age was positive (Figure 5), indicating that older individuals had better nutritional knowledge.
4.6. Nutrition Knowledge of Vitamin D
The majority of students 72.1% said they knew about the sources of vitamin D, but when asked about the dietary sources of vitamin D, only 39.9% chose milk and dairy products, 30.3% chose eggs, 20.9% selected meat and products, 36.1% chose fruits, 89.9% selected sunlight, 15.2% chose mushrooms, 36.7% chose cod liver oil, and 62% of the students chose fatty fish as a good source of vitamin D, as seen in Table 5.
| Questions on nutrition knowledge | Yes (%) | No (%) | Do not know (%) |
|---|---|---|---|
|
598 (62%) | 50 (5%) | 315 (33%) |
| Milk and dairy products are one of the sources of vitamin D | 385 (40%) | 205 (21%) | 375 (39%) |
| Eggs are one of the Sources of vitamin D | 292 (30%) | 212 (22%) | 460 (47.7%) |
| Meat and poultry are one of the sources of vitamin D | 202 (21%) | 291 (30.2%) | 471 (48.9%) |
| Fruits are one of the sources of vitamin D | 348 (36.1%) | 218 (22.6%) | 397 (41.2%) |
| Sunlight is one of the sources of vitamin D | 866 (89.9%) | 47 (4.8%) | 50 (5.1%) |
| Mushroom is one of the sources of vitamin D | 147 (15.2%) | 110 (11.4%) | 706 (73.3%) |
| Cod liver oil is one of the sources of vitamin D | 354 (36.7%) | 63 (6.54%) | 548 (56.9%) |
Approximately 76.8% of the students did not know the correct recommended amount of vitamin D for adults. However, 56.9% of the students were aware that vitamin D can be obtained from other sources, such as fortified foods. However, when asked if they ate food fortified with vitamin D, only 19.3% of the students said they ate food fortified with vitamin D. Most of the students had not heard about vitamin D fortification in food. Only 31.7% of the students knew that there were foods available that were fortified with vitamin D.
The majority of students (72.1%) reported knowing about the sources of vitamin D, but when asked specifically about dietary sources, only 39.9% selected milk and dairy products, 30.3% chose eggs, 20.9% picked meat and related products, 36.1% selected fruits, 89.9% identified sunlight, 15.2% chose mushrooms, 36.7% selected cod liver oil, and 62% identified fatty fish as a good source of vitamin D (Table 5).
Approximately 76.8% of students were unaware of the correct recommended amount of vitamin D for adults. However, 56.9% were aware that vitamin D could be obtained from other sources, such as fortified foods. Despite this, only 19.3% of students reported consuming foods fortified with vitamin D, indicating that most students were not familiar with vitamin D fortification in food. Only 31.7% knew that fortified foods were available as a source of vitamin D.
4.7. Attitude and Behavior KAP Score
The maximum score for attitude and behavior toward exposure to sunlight was 14.66. The mean score was 8.09, and the SD was±2.15, with a range of 2.33–14.66, as shown in Table 4. General knowledge of vitamin D and nutritional knowledge of vitamin D reflect positively on attitude and behavior scores. The KAP analysis assessing the attitude and behavior toward sun exposure showed that 25% of the students scored well, indicating that these students have a positive attitude toward sun exposure, and 25% of the students scored average. Only 24% of the students scored poorly, indicating that these students have a negative attitude toward sun exposure.
The impact coefficient for them was p = 1.127, and the line is visibly positive. Mann‒Whitney (Wilcoxon rank-sum test) suggests that there is no comparative difference between the attitudes of males (n = 332) and females (n = 631) toward sunlight exposure. There is no significant association between gender and attitudes toward sunlight exposure.
4.8. Attitude and Behavior Score
Assessment of attitude and behavior toward sun exposure indicated that most of the students 57.2% said they avoided sun exposure, and only 42.8% of the students said they preferred sun exposure as shown in Table 6. When asked how much time students spend in direct sunlight, 49.3% said 30 min, and only 3.3% spent >2 h in sunlight as shown in Table 7. Regarding knowledge of traditional clothing style (Omani black clothing covering the entire body [e.g., abaya, dishdasha, hijab, or kumah] preventing sun exposure), 48.8% of the students agreed that wearing traditional Omani clothing keeps their skin away from the sun, 28.4% did not feel that traditional clothing was a barrier to sun exposure, and 22.7% did not know if traditional clothing kept their skin away from sun exposure.
| Reason to avoid/prefer sun exposure | Preferred (%) | Avoided (%) |
|---|---|---|
| Enjoys sun exposure | 42.8 | 57.2 |
| Due to heat | — | 33.5 |
| Due to aesthetic reason | — | 17 |
| Due to medical reason | — | 4.4 |
| Not applicable | — | 2.3 |
| What are the students most likely to do when they are outdoors | Preferred (%) | Avoided (%) |
|---|---|---|
| Seek shade | 98.1 | 1.9 |
| Covering up | 98.1 | 1.9 |
| Use an umbrella | 1.9 | 98.1 |
| Stay indoors | 9.2 | 90.9 |
| Sought direct sunlight | 6 | 94 |
| Regular exposure to sunlight | 20.3 | 79.7 |
| Walking under direct sunlight | 32.8 | 67.1 |
Regarding indirect exposure to sunlight (through glass) during the day, 76.1% said yes, and 23.9% said that they were not indirectly exposed to sunlight. When asked the students if they knew about sunscreen, 91.5% knew about sunscreen products. However, only 32% of the students used sunscreen, 37.6% did not like to use sunscreen, and 30.4% said they used it sometimes
5. Discussion
The current study was conducted to validate the KAP questionnaire on vitamin D among tertiary students from SQU in Oman and to assess the KAP of the students using a questionnaire method. The results of the KAP study were reviewed and interpreted. Virtually all students in the study group (99.3%) had heard of vitamin D. Similar studies conducted by Sannathimmappa, Nambiar, and Gowda [42] and O’Connor et al. [1] found that 97.6% and 99.5% of the participants were aware of vitamin D, respectively [20, 21].
Concerning the requirement for vitamin D supplement intake for different age groups, a higher number of students (53.25%) did not know or were unaware of the supplement requirements for different age groups. When asked if they took supplements, 77% of the students said that they did not take vitamin D supplements. With this, the knowledge of vitamin D supplementation should also be increased. Very little research has been undertaken with respect to an individual’s knowledge of supplementation. The National Institute of Nutrition recommends a daily dietary intake of 1000 IU for healthy individuals and adult women.
Regarding the dietary sources of vitamin D in the present study, we observed that the knowledge of the students on the dietary sources of vitamin D and food fortification was insufficient in many of the students, as described in many other studies [37, 43]. Approximately 72.1% said they knew about the sources of vitamin D. However, 68.4% of the students had not heard about the fortification of food with vitamin D, and 43% of the students did not know that vitamin D can be obtained from other sources, such as fortified foods. Approximately 80.6% of the students said they did not consume foods fortified with vitamin D, 36.1% chose fruits, and 20.9% chose meat and products as a source of vitamin D. Approximately 70%–85% of the students lacked nutritional knowledge of the dietary source of vitamin D. Among food products, oily fish such as salmon, cod liver oil, eggs, milk, and milk products have been shown to be rich in vitamin D. However, 37.8% of them did not know or were unaware of fatty fish, 60.1% milk and dairy products, 69.7% eggs, 79.1% meat and poultry, 84.7% mushrooms, and 63.4% cod liver oil as one of the sources of vitamin D. Overall knowledge of sunlight as a source of vitamin D was good and was consistent with similar studies from the GCC [37].
Approximately 76.8% were unaware of the recommended daily amount of vitamin D for adults. And, almost 50% of the students were not aware of the correct amount of time they needed to spend in the sun to obtain enough vitamin D. Overall, participants had suboptimal knowledge of the various factors that affect vitamin D synthesis from sunlight, as 70% of the students reported poorly on barriers to vitamin D synthesis, such as skin complexion, sunscreen use, cloud cover, latitude, time of day, and cloud cover. In a similar study conducted in the United States, they suggested that individualized patient education based on individual factors such as color of the skin, BMI, age, usage of sunscreen or clothing use, and cultural and lifestyle practices also affects the adequate amount of sun exposure needed to generate the required vitamin D [42]. Similar results were delineated in a cross-sectional study carried out among the population in Al Qunfudhah governorate, Saudi Arabia, through a self-administrated online questionnaire result which showed poor level of knowledge about vitamin D deficiency. The study highlighted mass media as the main source of information about vitamin D [44]. Another study conducted in Oman reported similar results from Sharqiyah University [35].
The KAP study findings showed that only 20.6% of the students had an optimal level of general knowledge, nutritional knowledge on vitamin D, and attitudes and behaviors toward sun exposure, while 62% of them had an average level of general knowledge, nutritional knowledge on vitamin D, and attitudes and behavior toward sun exposure, and 17% of them had poor general knowledge, nutritional knowledge on vitamin D, and attitude and behavior toward sun exposure. The mean score for general knowledge about vitamin D was 8.43, nutritional knowledge was 5.83, and attitude and behavior toward sun exposure was 8.09. The results of the survey revealed a lack of knowledge and awareness of the importance of vitamin D within the study group. The general knowledge of the cohorts was limited to bone health, while the important role of vitamin D in the immune system, neuronal maturation and function, and intestinal physiology was suboptimal. Students showed an average awareness of vitamin D and poor knowledge of the sources of vitamin D. Very few students incorporated vitamin D–rich foods into their diet. The majority of the students had never performed a vitamin D test to check their levels of vitamin D. However, most of the respondents were unaware of any other health benefits, other than healthy bones and prevention of osteoporosis, and very few knew of the benefits of vitamin D in the prevention of chronic diseases, prevention of rickets, and its benefits during pregnancy. In a similar cross-sectional study performed in Lebanon, Syria, Egypt, Palestine, Iraq, Jordan, and Saudi Arabia, less than 50% of the study participants had moderate vitamin D–related practices. Despite the high prevalence of vitamin D deficiency, the knowledge about osteoporosis and vitamin D–related practices were moderate in some countries in the MENA region [45].
Knowledge of the consequences of vitamin D deficiency on overall health has also been very limited. The awareness of vitamin D–rich food sources, the recommended daily intake in adults and children, vitamin D supplementation, and vitamin D fortification of food products were found to be significantly poor. Many students reported negative attitudes toward sun exposure and a lack of knowledge about the importance of optimal sun exposure for general health and optimal functioning.
The results of the KAP study highlight the importance of developing strategies to educate students and the general population about the importance of sun exposure and the importance of vitamin D in maintaining health, promoting growth, and preventing chronic diseases and its therapeutic uses due to its anti-inflammatory and antioxidative effects in the body. We believe that public participation, government (such as legislation, rules, or the formulation of public health policies), media, and primary healthcare centers should conduct education campaigns and health activities to increase awareness and knowledge regarding vitamin D. For example, modest exposure to sunlight on the face and hands for 30 min three times a week in adults along with a diet supplemented with vitamin D may be sufficient to produce adequate vitamin D stores, while exposure to the sun for 2 h per week by promoting outdoor activities may be beneficial in preventing hypovitaminosis D in infants and children.
Using new effective educational methods aimed at improving general and nutritional knowledge of vitamin D in the general population, creating awareness of the fortification of food products with vitamin D and supplementation, and changing their attitude toward sun exposure can enhance public health outcomes. In general, these effects can improve vitamin D health in the overall Omani population.
6. Limitations and Future Research
KAP studies often have limitations. First, the study included only students from a single university, which may limit the generalizability of the findings to the broader community. Cross-sectional studies conducted among students may not fully represent the general population, as students tend to be younger and may have different educational backgrounds and socioeconomic statuses compared to the wider community. As a specific subgroup, students may not capture the full diversity and characteristics of the general population. Additionally, the study faced some gender disparity, a common issue within the GCC region. Also, the percentage proportion could adjust the imbalance of gender representation. Therefore, community surveys are warranted. The conduct of a KAP study during the COVID-19 pandemic on the role of vitamin D, nutritional knowledge, and awareness of sun exposure presents a challenge, due to nationwide lockdowns in the country. Findings from this exploratory study could inform the development of a larger and more complex study with support from local governments, healthcare centers, and voluntary organizations to reach the wider Omani population. Including the survey questions translated in other languages would also help widen access.
7. Conclusions
A KAP survey was developed and used to identify vitamin D knowledge and awareness levels among SQU students to bridge knowledge gaps, cultural beliefs, and behavioral patterns that can identify deficiencies, needs, problems, and barriers to help plan and implement interventions.
The present study identified a lack of knowledge and awareness of the importance of vitamin D among the study group. This study also highlights the importance of developing strategies to improve awareness about vitamin D fortification and supplementation, along with education strategies on behavior toward sun exposure, which may be an effective means of improving Oman’s vitamin D health. The findings suggest students have poor knowledge about the consequences of vitamin D deficiency and vitamin D–rich dietary sources (70%–85%), unaware of the recommended daily intake (76.8%) and supplementation (53.25%) requirements, and 77% of them did not take vitamin D supplements, and unaware of the fortification of foods with vitamin D (68%) and the importance of optimal sunlight exposure (50%). The findings also indicate that education strategies (46%) can be an effective tool to improve and impart knowledge on vitamin D and its benefits on health; therefore, different approaches are needed to impart knowledge about adequate sun exposure, encouraging intake of foods containing vitamin D and foods fortified with vitamin D and vitamin D supplements, as the findings show average knowledge and attitude and poor practice.
Although the results of the current study reflect the knowledge and awareness of one university in Oman, they may not be typical for all subpopulations in Oman. Yet, the current questionnaire is potentially well accepted and can be used as a reliable instrument to assess vitamin D knowledge, attitudes, and perceptions within research since SQU is a representative of Oman’s governorates. The instrument has shown satisfactory validity and good internal consistency.
Disclosure
Sultan Qaboos University had no role in the study design, data collection, analysis, publication decision, or manuscript preparation.
Conflicts of Interest
The authors declare no conflicts of interest.
Funding
This research was completed through academic scholarship support and bench fees to carry out this study (Ref. No. SQU-EC/026/2020 MREC #2134) from Sultan Qaboos University Postgraduate Studies for PhD.
Acknowledgments
The researchers express their gratitude to the Student Council of Sultan Qaboos University for their kind assistance in sharing the survey link on their social media platforms. The authors express their special appreciation to all participants who willingly dedicated their time and actively participated in the study with great patience. The author (N.A.S.) acknowledges Sultan Qaboos University for granting her a PhD fee waiver scholarship to pursue her doctoral studies.
Open Research
Data Availability Statement
The authors confirm that the data supporting the findings of this study are available within the article. Raw data that supports the finding of this study are available from the corresponding author, upon reasonable request.
