Knowledge, awareness and practice of vitamin D among population of Qassim Region, Saudi Arabia before and during COVID-19 pandemic

One billion people globally have been affected by vitamin D deficiency and its associated diseases; therefore, the present study was aimed to estimate the knowledge, awareness and practices of vitamin D in the Qassim region of the adult population before and during the COVID-19 pandemic. A cross-sectional survey was conducted among 195 of the general adult population in the Qassim region, Saudi Arabia from 15 September 2020 to 25 October 2020. The results revealed that a high percentage of participants are cognizant of vitamin D (93.8%). Also, it appears that there was no association between knowledge and awareness of vitamin D and age, gender, education or social status. Around 82.6% of the participants know the sources of vitamin D and the majority of participants enjoy sun exposure (79%), where the most time exposed to the sun is early in the morning and after 3 pm, reported to at 43.6% and 52.3%, respectively. In addition, about 35% of participants increased their knowledge of vitamin D after the emergence of COVID-19. A high percentage of participants thought that vitamin D raising the body immunity against viral infection or improve immunity, in general, was at 67.7%, that thought that vitamin D prevents or increase resistance to COVID-19. From the foregoing results, it could be concluded that a high level of knowledge and awareness about vitamin D in adults living in the Qassim region and increased knowledge after the emergence of COVID-19 is the most important result of the current study.


Introduction
Vitamin D is considered an immunomodulatory agent and has hormonal action related to the maintenance of mineral and skeletal homeostasis is essential for maintaining a healthy skeleton. The main function of vitamin D is to regulate the metabolism of calcium and phosphate in the body (Holick, 2007;Prietl et al., 2013).
The primary source of vitamin D in the human body is from the exposure of skin to ultraviolet light which represents more than 90% of vitamin D needed for humans. The 7-dehydrocholesterol under the skin is converted to ultraviolet light band B (UVB) to an inactive precursor vitamin D3 (cholecalciferol). The remaining need for vitamin D (10%) is gained from different food sources rich in vitamin D (Holick, 2004). However, many factors can affect the synthesis of vitamin D for UVB under the skin such as latitude, pollution, solar zenith angles, ozone layer and pigmentation (Holick, 2007).
Vitamin D deficiency is a global public health problem. Around 1 billion people worldwide suffer from vitamin D deficiency (Bjorklund, 2016). In this regard, Vitamin D deficiency is common in the Saudi Arabia population (Kelishadi, 2014;Green et al., 2015). The experts work in Prince Mutaib Chair for Biomarkers of Osteoporosis task force in Saudi Arabia have been defined the sufficient level of vitamin D as circulating serum 25(OH) D (≥50 nmol or ≥20 ng/mL) for the general population (Al-Daghri, 2018), similarly to the IOM, USA that the recommended cut-off of vitamin D status 25(OH) D is (20 ng/mL or 50 nmol/L) for normal healthy people as the main basis of bone health.
In recent years many studies have reported that vitamin D deficiency has been found to be significantly associated with common chronic diseases such as cardiovascular diseases, cancer, diabetes and immune system diseases (Wang, 2017). In addition, it has been reported that vitamin D is involved in regulating immune function, inhibiting inflammatory reactions, autoimmune diseases as well as immune cell biology system (Moreira and Hamadeh, 2010;Jeffery et al., 2015).
The lack of knowledge and practice of vitamins in addition to the wrong lifestyle, indoor activity, extensive cloths cover as well as lack of regular exposure to sunlight can be considered the major cause of Vitamin D deficiency among the Saudi population. Thus, the increase in knowledge, awareness and importance of effective practices about vitamin D is important for the general population to know. Its benefit on health especially on the prevention of diseases related to deficiency and insufficiency. Therefore, the primary goal of this study was to investigate the amount of knowledge, awareness and practices about vitamin D of adults living in the Qassim region before and during the emergence of the COVID-19 pandemic.

Questionnaire
For data collection, a cross-sectional survey was conducted among the general adult population in the Qassim region, Saudi Arabia from 15 th September 2020 to 25 th October 2020. An electronic self-administered questionnaire (Google form) consisting of five parts was used to collect data (socio-demographic characters, health and anthropometric data, knowledge and awareness of vitamin D, attitude and practices of an individual about vitamin D and sun exposure and awareness associated after COVID-19 pandemic). The questionnaire was designed by the author and validated by three arbitrators in the study area. The questionnaire was previously tested for reliability and accuracy among twenty participants.

Statistical analysis
Data were statistically analysed using descriptive statistics using IBM SPSS statistics for mac version 25.0 (SPSS Inc., Chicago, IL). Descriptive statistics were used to characterize the participants of the study population. Data were presented as a percentage in frequency tables for each part of the questionnaire to identify the participant's Socio-demographic characters information, knowledge and awareness of vitamin D, sun exposure and practices about vitamin D and after the emergence of COVID-19. A Chi-square test was conducted to identify the association between knowledge and awareness of vitamin D and each of age, gender, education and social status, at the significance level of p≤0.05.

Ethics statement
The questionnaire and data collection, a crosssectional survey was approved by the Ethics Committee of Health Research Ethics, Deanship of Scientific Research, Qassim University, 20-06-13.

Socio-demographic characters information
One hundred and ninety-five participates have completed the survey. Table 1 shows the Sociodemographic characteristics, the ages of participants where 59% were between 18-35 years, 33.8% between 36-50 years and 7.2% over 50 years. Most of the participants were male (61.5%), different education levels were found in this survey where most of them held a bachelor's degree (72.8%). In this survey, almost half of the participants were students (55.5%) and 63.1% of participants were unmarried. Regarding health, most of the participants were not diagnosed with any chronic disease (83.6%). Table 2 depicts the knowledge and awareness of vitamin D. Most of the participants (93.8%) were aware that vitamin D is essential for health. There was no significant association between knowledge and awareness of vitamin D in age, gender, education and social status. About 82.6% of the participants understood The majority of the participants were ready to analyse the concentration of vitamin D in the body and will take vitamin D as a dietary supplement (tablets/injection) if they were diagnosed with a deficiency. There was no significant association that has been found between the knowledge of vitamin D and age, gender, education and social status.

Sun exposure and practices about vitamin D
The majority of participants (79%) experienced sun exposure. About half of the participants (52%) had sun exposure after 3 pm. However, 43.6% of the volunteers were only exposed early in the morning. Data in Table 3 indicates that 68.2% of the sample population thought  have taken supplements without doing the vitamin D test, which was the main reason to raise immunity and prevent diseases, an increase in health and to treat the pain 44.3%, 39.6% and 38.7%, respectively. In this survey, doctors were the most influenced of the participants who have taken the advice of vitamin D supplementation at 65.7%, then friends and relatives at 20.1%. 61% of participants did not know the adequate level of vitamin D in the body. Milk, dairy products, and fatty fish were reported to be rich in vitamin D.

Awareness of vitamin D after COVID-19 pandemic
About 35% of participants improved their knowledge and attitude about vitamin D after the COVID-19 pandemic. A high percentage of participants thought that vitamin D raises the body immunity against viral infection or improve immunity in general. Around 67.7% thought that vitamin D prevents or may aid in the resistance of respiratory infections such as COVID-19. The COVID-19 pandemic has affected 23.6% of participants in their choice of food rich in vitamin D. Only 11.3% of participants have been diagnosed with COVID-19, 38% and 41.2% of them have been informed by doctors to take dietary supplements of vitamin D and increase their exposure to sunlight, respectively (Table  4).

Discussion
Vitamin D deficiency is a public health issue around the world (Wahl et al., 2012) even in a country with sunshine most of the year (Green et al., 2015;Santos et al., 2019). Knowledge, awareness and practices about vitamin D may differ between communities and populations. The present study is one of the first studies to examine these factors before and after the emergence of COVID-19 among adults living in the Qassim region.
The finding of this study showed that most of the participants were well-versed about vitamin D. While majority knew the right sources of vitamin D and its benefits for their general health and bones. About half of the participants in this study thought that vitamin D deficiency was related to health conditions such as heart diseases, diabetes, depression, high blood cholesterol, cancer, multiple sclerosis and asthma. Previously, published studies related to vitamin D deficiency and   Reflecting on the results, high knowledge and awareness about vitamin D, affected their readiness to analyse the vitamin D concentrations and treat vitamin D deficiency if they were diagnosed. Thus, this attitude can help the community to increase their health status and prevent any related health issues in the future. As the main source of vitamin D is sunlight (Holick, 2016), 80% of participants liked being exposed to the sun, few have reported to usually protect themselves from the sun, while others were exposed without sunscreen. The usual amount of time participants were exposed to sunlight was in the early morning from 6 to 8 am and after 3 pm, which is an efficient time to receive vitamin D from sunlight as it has been reported the perfect time to get vitamin D from sunlight in the summer and winter was after 9:00 am to 10:30 am, 2:00 pm to 3:00 pm and 10:00 am to 2:00 pm, respectively (Al-Daghri et al., 2017).
The face, neck and hands were the body parts most exposed to sunlight in this survey which reflects the traditional clothes of this population in Qassim city. However, most participants thought the time exposure about 3 to 4 times a week was not enough to receive vitamin D and tended to expose 20% of their body (Al-Daghri et al., 2017).
About half of the participants have undergone a test to check the vitamin D level in their bodies, which was a personal decision that reflects how educated the participants in this survey were about the importance of vitamin D. Their results of vitamin D level were classified as a deficiency (~64%), insufficiency (~12%), sufficiency (~7%) and unavailable results (~17%). The majority have taken vitamin D supplements after the analysis to increase its potency in the body (Institute of Medicine, 2011). However, around 42% of the participants taking the vitamin D supplement or group of nutritional supplements that contain vitamin D without having analyzed vitamin D were mostly interested in raising their immunity and prevent diseases and treating any ailments they suffer from. Most took the advice of doctors (~65%), friends and relatives (~20%) and after reading health and medical awareness (~17%). Whereas, the impact of social media was the lowest (~6%).
In this study, most of the participants do not know the adequate level of vitamin D in the body and around half of the participants selected (> 100 ng/mL or 250  FULL PAPER nmol/L) as the adequate level of vitamin D. The recommended cut-off level of vitamin D by IOM, USA is (20 ng/mL or 50 nmol/L) for normal healthy people as the main basis of bone health whereas the range below (30 ng/mL or 75nmol/L) of 25(OH) D concentration is considered vitamin D deficiency by Holick et al. (2011).
At the end of the year 2019, with the prominence of COVID-19 around the world, people are more worried about protecting themselves from the disease. As the awareness of vitamin D after the emergence of COVID-19 was examined in this study, the results showed in the second part of this survey the majority of participants have been reading up about vitamin D (93.8%) and a small percentage (~3%) of the participants were not as knowledgable about vitamin D after the emergence of COVID-19. However, (~35%) of participants reported that the emergence of COVID-19 affected their needing to boost their immune systems.
The association between vitamin D and body immunity have been reported previously (Charoenngam and Holick, 2020) and in this study, the majority of participants (85.6%) thought there is a relationship between vitamin D and rising the body immunity against viral infection or for improving immunity in general. This is due to reports published in this relation (Zemb, 2020). In this study, some participants around 39 and 23% ensured their intake of an adequate level of vitamin D throughout the emergence of COVID-19 and affected their choices of food rich in vitamin D, which is a good practice among themselves A few participants in this study have been diagnosed with COVID-19. It was interesting to note that some of the participants, after being infected with COVID-19 have been informed by doctors to take dietary supplements of vitamin D and to increase their exposure to sunlight to raise their immunity. This supports the importance of an adequate level of vitamin D (Charoenngam and Holick, 2020;Zemb, 2020).

Conclusion
A high level of knowledge and awareness about vitamin D in general adults living in the Qassim region were reported. There was no association between knowledge and awareness of vitamin D in age, gender, education or social status. The majority of participants under the current study were knowledgeable of the sources of vitamin D and were akin to the exposure of sunlight. The most effective time of exposure was found to be in the early morning and after 3 pm. The increasing awareness about vitamin D and its importance was collected from different sources where social media ranked the highest, before friends and relatives, and doctors on the internet and social sites. Participants increased their knowledge of vitamin D after the emergence of COVID-19, majority of participants thought that vitamin D raises the body immunity against viral infection and increases their resistance to COVID-19.