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Knowledge, attitude and practice regarding vitamin D deficiency among

female students in Saudi Arabia: A qualitative exploration

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International Journal of Rheumatic Diseases 2011

ORIGINAL ARTICLE

Knowledge, attitude and practice regarding vitamin D

deficiency among female students in Saudi Arabia:
a qualitative exploration
Floor T. E. CHRISTIE1 and Linda MASON2
1
Prince Sultan University, General Courses Department, Riyadh, Saudi Arabia; and 2Department of Public Health, University of
Liverpool, Liverpool, UK

Abstract
Background: Vitamin D deficiency is associated with numerous chronic diseases including cancer, heart
disease and diabetes type 1 and 2. It is currently estimated that one billion people suffer from vitamin D
deficiency worldwide. A major cause is lack of sun exposure, and this is evident even in countries at mid and
low latitudes. Although a high prevalence has been found in Saudi Arabia, little is known to date about the
reasons for this and, consequently about, reduction methodologies. The study’s aim was to investigate the
knowledge, attitude and practice (KAP) towards vitamin D deficiency, sun exposure, supplementation and
fortification in a sample of female Saudi Arabian students.
Methods: A focus group and eight in depth one-to-one semi-structured interviews were conducted and analy-
sed using thematic analysis.
Results: Participants were limited in their knowledge about vitamin D and vitamin D deficiency. They
reported limited sun exposure due to intense heat, cultural reasons for covering the body, and an infrastruc-
ture that makes sun exposure difficult.
Conclusion: Important barriers for the prevention of vitamin D deficiency in Saudi Arabia were highlighted.
Recommendations for more research in specific areas including the prevalence of vitamin D deficiency and
recommended daily allowances of supplementation are made. Governmental actions including increasing
awareness of the importance of vitamin D and guidelines on how to obtain it are necessary. Creating areas
where women, particularly those of lower socio-economic status, can enjoy sun exposure as well as fortifying
more foods would go some way towards tackling this problem.
Key words: attitude and practice, cultural, qualitative, Saudi Arabia, vitamin D deficiency.

Historically vitamin D deficiency was associated

INTRODUCTION
In recent years the topic of Vitamin D has become a
highly significant subject in the medical world as Vita-
min D deficiency is largely an unrecognized worldwide
epidemic.1,2
Correspondence: Dr Floor Christie-de Jong, The University of
Calgary-Qatar, PO Box 23133, Doha, Qatar.
Email: fdejong@ucalgary.ca; floorchristie@me.com
with poor musculoskeletal health namely rickets and
osteomalacia. However, in recent years research has
indicated that vitamin D is vital to the development,
growth and protection of a healthy body throughout
the entire life span.1 Research linking Vitamin D
deficiency to other major diseases such as numerous
types of cancer,1,3,4 coronary heart disease,5 and type
1 and 2 diabetes6–8 has been extensive.9,10 Other
diseases that have been linked to vitamin D defi-
ciency are: multiple sclerosis,11 rheumatoid arthritis,

ª 2011 The Authors

International Journal of Rheumatic Diseases
ª 2011 Asia Pacific League of Associations for Rheumatology and Blackwell Publishing Asia Pty Ltd
F. T. E. Christie and L. Mason
hypertension, and Alzheimer’s.1,9 Mental health
has also been shown to be affected by vitamin D
deficiency.9
Studies worldwide identify lack of sun exposure as
the main cause of vitamin D deficiency.10,12 In regions
at higher latitude UV rays are less intense9 and obtain-
ing vitamin D from sun exposure becomes more diffi-
cult. Yet, even in sunny climates such as Saudi Arabia
or India, high prevalence of vitamin D deficiency has
been found.1,9,13–15 Prolonged breastfeeding without
vitamin D supplementation and lack of dietary intake
have also been identified as causes of vitamin D
deficiency.13,16
There is evidence that the prevalence of rickets and
vitamin D deficiency is greater across the Middle East
than in Western populations,13 with a large meta-
analysis concluding that 20–80% of apparently
healthy individuals suffer from vitamin D deficiency.
Two studies conducted in Saudi Arabia reported preva-
lence of 81% in an all female population,17 and 83%
in a predominantly female sample of participants with
low back pain.
Few studies have looked at socio-cultural reasons
for vitamin D deficiency. However, it has been linked
to socio-economic status, with avoidance of body
exposure to the sun being stronger in lower socio-
economic groups in Saudi Arabia17 and Muslim immi-
grant communities.18 In the Middle East an indoors
lifestyle, partly because of the heat, has been identified
as a factor for the lack of sun exposure.1 Another
factor is assumed to be lack of sun exposure due to
cultural traditions whereby Muslim communities
avoid body exposure.17,19 According to one of the
leading experts in the field, Holick (2001),20 Arab
women who cover their skin are often vitamin D defi-
cient. Unfortunately, this statement is evidenced solely
with an early study,21 although Siddiqui (2007) postu-
lates that in Saudi Arabia sun exposure is limited
because women wear a black abaya [burka] covering
them completely from head to toe.17,21 This study also
points to other potential reasons, such as, women
choosing not to expose themselves to the sun for for
cosmetic purposes, as they believe it is harmful to
their skin. In addition a lack of awareness of the
importance of vitamin D is noted by Siddiqui. How-
ever, empirical evidence is needed to confirm or refute
these opinions. Brand’s qualitative study (2008)18
among veiled women in Australia found that cultural
issues around sun exposure as well as financial con-
straints in accessing supplementation were important
contributory factors to vitamin D deficiency. However,
2 International Journal of Rheumatic Diseases 2011
it is clear that there currently is a dearth of litera-
ture looking at socio-cultural reasons for vitamin D
deficiency both, generally in the Middle East and
specifically in relation to Saudi Arabia.
The Ottawa Charter22 indicates that health promo-
tion interventions should reflect both local needs and
potential of individual countries. Significant barriers
and enablers for the reduction of vitamin D deficiency
need to be ascertained in the Saudi Arabian popula-
tion as vitamin D deficiency seems to be a significant
problem.
METHODOLOGY
This descriptive, socio-cultural study was of an explor-
atory design and produced qualitative data. The study
explored knowledge, attitudes and practice of vitamin
D deficiency, sun exposure, supplementation, and for-
tification. One in-depth focus group and 8 one-to-one
interviews were used to collect data.
Questions were developed according to the founda-
tions of KAP studies (Table 1). Aspects that were cov-
ered were knowledge or understanding of the topics:
vitamin D deficiency, supplementation, fortification,
sun exposure; attitude referring to feelings towards the
topic and practice referring to how knowledge and
attitude are demonstrated through their actions.23
Questions were adapted from those used in the Brand
and Kung & Lee studies and a study on validated
sunlight questionnaires.24
Table 1 Example questions used in the semi-structured
interviews
Have you heard of vitamin D? If you have, where did you
hear about this?
Have you ever been offered any advice about preventing
vitamin D deficiency?
What factors would you consider important when buying
vitamin supplements?
Have you heard of fortification?
Can you tell me how often you are exposed to the sun? At
what times of the day?
In the past week, how much time have you spent being
exposed to the sun?
Which parts of your body do you expose to the sun?
How do you feel about sun exposure? Do you like going
into the sun?
Where would you sunbathe, could you do that in Saudi
Arabia?
Can you tell me what things would help you, or your fam-
ily, to follow suggestions about how to prevent vitamin D
deficiency?

A convenience sample of 17 female students was
recruited from Prince Sultan University (PSU). The
field researcher is female and working at PSU, where
access to male or other Saudi Arabian participants is
restricted due to cultural traditions. Therefore a small
sample of female students was recruited from PSU by
posters that were distributed on campus. Although this
small convenience sample presents a severe obstacle to
the generalizability of this study, for an exploratory,
qualitative study this should suffice to gain insight
into the underlying phenomena determining the
health behavior of these participants.25 Most partici-
pants were of Saudi Arabian origin, and three were of
Palestinian or Syrian origin but had grown up in
Saudi Arabia. All participants were Muslim, aged
between 20 and 25. All were asked to sign consent
forms prior to the interview.
The interviews were semi-structured and took place
in classrooms on campus. The 8 one-to-one interviews
lasted between 30 and 40 min; the focus group lasted
60 min. The focus group was presented with state-
ment cards containing questions in order to promote
discussion.
Each interview was fully transcribed. The data was
analysed using thematic analysis,25 themes were devel-
oped from common issues mentioned by the partici-
pants. Some themes developed from the data, others
were predetermined by the research objectives, as is
common in qualitative research.25 Ethical approval
was obtained from PSU as well as from the Ethics
Committee at University of Liverpool, UK.
RESULTS
Students displayed minimal awareness of vitamin D,
i.e. knowing that it was essential for musculoskeletal
health and that sunlight was beneficial.
I know of vitamins, and they’re good to take, that’s all I
know.
I know it’s good for the bones and we get it from the sun.
However, none were really aware of any other health
benefits, the risks of vitamin D deficiency or of a rela-
tionship between breastfeeding and vitamin D.
Participants identified the sources of their knowl-
edge as schools, parents, or television. Exceptions were
two students who had been found to be vitamin D
deficient and had been provided with some informa-
tion on the importance of sun exposure and linking
International Journal of Rheumatic Diseases 2011
A qualitative study on vitamin D in Saudi
vitamin D to musculoskeletal health by health-care
professionals.
There was some evidence of incorrect knowledge
surrounding the topic of vitamin D.
I know it’s harder for white people to get vitamin D.
You should have both, tablets and the sun
Vitamin E is the one we get from the sun
Most students were however aware that sun exposure
is beneficial yet were unclear about duration of sun
exposure, time of day affecting intensity, direct sun-
light versus shade, and the necessity of exposure of
specific body parts for the body to optimally produce
vitamin D.
I have been told that if you just expose your hands for 10
minutes it will be enough. For us [women wearing abayas]
the hands are not covered, and sometimes the face isn’t,
enough to get vitamin D from the sun.
I know that if you’re exposed to the sun much it’s not
good. It can give you cancer and stuff. But once a year it’s
good but more than that, I don’t think is good. For the
skin and even for your health.
In relation to practice many students seemed to have
some sun exposure, some even enjoying it, however, it
is likely from their accounts, that this is limited and
would not meet current recommendations. Although
some students reported sunbathing on holiday, it was
clear that most students did not spend any time in the
sun in Saudi Arabia during summer.
For many students the hot climate in Saudi Arabia
was seen as a major barrier and emerged as a key
reason for lack of sun exposure.
Here the environment doesn’t really encourage exposure
to sun. It’s either too hot or you’re in a place where you
just can’t expose.
Cultural reasons that require women to cover their
body fully, including their faces, were a significant bar-
rier for all participants. They explained that because
their bodies have to be covered in Saudi Arabia their
sun exposure is limited.
It is because you have to stay covered here in Saudi,
even if you go outside you have to stay covered. So it’s
kind of difficult to pull up your sleeves and get some
sun.
3
F. T. E. Christie and L. Mason
[Participant talking about walking in the sun every day for
half an hour]What body parts would be exposed then?
[laughs] yes, with the abaya just the face and hands.
Maybe your hands get exposed here [Saudi Arabia], only
the hands. People who don’t cover their faces get sun in
their faces but not your whole body.
On the other hand, despite limited exposure in public,
many participants expressed that there was enough
opportunity for them to uncover in private as most of
their houses have gardens, balconies, or roof gardens.
No, it’s not hard at all. Because you have roofs or gardens.
There are a lot of fitness clubs with pools [just for women].
Only a minority spontaneously expressed the lack of
opportunity for women to uncover freely to be a barrier.
It’s basically only at home, we don’t have outside space.
We don’t have places to go and just take of the hijab
[headscarf].
Several students voiced that Saudi Arabian culture
revolves around an indoor lifestyle and the infrastruc-
ture is completely geared towards transportation by
car. There are few areas to walk and no possibility to
move from one place to the other by foot, which does
not lend itself as an enabler to prevention of vitamin
D deficiency.
In Saudi Arabia we are not exposed enough by the sun,
we don’t walk anywhere; we go in the car to the place
and then back in the car.
When we travel abroad we get exposed more to the sun
than here because we’re walking. We go from place to
place by walking, here that’s not possible. It’s from place
to place by car.
If participants went abroad they tended to experience
more sun exposure. However for some this had been
several years ago and there certainly did not seem to
be a rule to travel abroad every summer. When
enquiring into more detail they would still cover most
of their body even when abroad.
On the beach I wear long t-shirts and trousers up to here
[points to mid-calf].
Long skirts for me.
Most students would use sunscreen products when
exposing themselves to the sun.
Every morning, to protect my face.
4 International Journal of Rheumatic Diseases 2011
Cosmetic reasons for avoiding sun exposure were only
mentioned by one student.
Because I’m dark skinned and most people I hang out
with also have dark complexion we don’t like the idea
of going out in the sun because we’re scared of getting
darker.
Although most students had heard of vitamin supple-
mentation, only a minority were taking supplements.
All students believed it to be essential to consult a
health-care professional before taking these and great
trust was attributed to health-care professionals in this
respect. Most students had the intention to start taking
vitamin supplements at some stage in the future
because they believed this to be beneficial.
I think we have to because sometimes we don’t have time
to eat healthy, it’s all fast food.
Maybe because we are here always in enclosed spaces, we
need it [supplementation].
Costs were not voluntarily mentioned as a reason for
not taking supplementation. When asked whether
they would consider costs, all students denied that this
would be important.
When it comes to health I don’t care about costs.
Similarly, none of the students had heard of fortifi-
cation, but most believed this to be useful when
introduced to the concept.
I think it’s a good idea, you make people take something
that is good for them without the being aware, or forcing
them.
DISCUSSION
This study explored the knowledge, attitude and prac-
tice of a female sample of students in Saudi Arabia
regarding vitamin D. Limitations of the study have to
be taken into account. Men are an under-recognised
group at risk both, through lack of awareness of vita-
min D deficiency and through failure to identify them-
selves as being at risk of vitamin D deficiency.18
Therefore it is disappointing that this study was not
able to include a male sample due to cultural reasons.
Furthermore, the sample consisted only of university
students, a group that is not representative of
the entire Saudi Arabian population. This group is

generally of higher socio-economic status, especially at
a private university. It is possible that an awareness of
vitamin D benefits might be higher in this group. Sun
exposure could also be different for this group as edu-
cational levels have been linked to sun exposure.13
This group comes into greater contact with Western
societies where it is more accepted for Muslims to
expose more body parts and where a more outdoor-
orientated lifestyle lends itself further to sun exposure.
Many have the means to travel and some students
reported to be somewhat more exposed to the sun
abroad. Therefore the generalizability of the study is
limited, however, as a qualitative exploration some
interesting issues are raised.
The background of the researcher as a Westerner and
non-Muslim should also be highlighted. These differ-
ences can be an obstacle in research and limit rapport
building. However, some studies have found that dis-
tance can also facilitate a level of trust and rapport.25
This seemed to occur in the present study where partic-
ipants were very open in sharing their experiences.
Gaps in basic knowledge around vitamin D and its
benefits became apparent in this study. The need for
more health education is highlighted by the conclu-
sion that participants were unaware of any health ben-
efits of vitamin D other than musculoskeletal health.
This is also urged for in the literature.2,13,15 Although
the multiple findings that vitamin D is related to
many aspects of health other than musculoskeletal
health are still very recent, the research evidence is
very convincing and shows its vast importance to
public health.2,9,10 However, there may be a need to
inform health-care professionals as well of these new
findings. According to Khalsa9 many health-care pro-
fessionals are not fully aware of the benefits of vitamin
D to public health. Brand’s18 study also evidenced the
need for actively increasing awareness amongst health-
care professionals.
Awareness of the benefits of sunlight needs to be
increased by provision of specific guidelines about
how often sun exposure is required, the duration, and
how much of the body should be exposed for optimal
vitamin D uptake. All of these aspects were deficient
in the knowledge of our participants, in contrast to
Brand et al.18 who found extremely high levels of
awareness amongst females in Australia. An explana-
tion for this may be that Brand’s study was done as a
response to a health promotion campaign. This may
well be an encouraging sign for health promotion
campaigns to be able to achieve the desired effect of
informing the population.
International Journal of Rheumatic Diseases 2011
A qualitative study on vitamin D in Saudi
Lack of awareness about the amount of exposure
needed was demonstrated in our sample through the
high number who believed they were getting enough
sun exposure, unaware that having just their face, and
sometimes only hands, exposed would probably not
suffice. Covering skin with clothing prevents skin from
coming into contact with UV-B rays essential for pro-
duction of vitamin D.9,20 Most students seemed to
think that exposing face and hands to the sun a few
times a week for 10 min in the early or late sun would
suffice. For a white woman 12 min of summer midday
sun with bare arms and legs would produce approxi-
mately 3000 IU of vitamin D.9 In contrast, a similarly
dressed woman with black skin would need 2 hours
of sun exposure to produce the same. Many partici-
pants had slightly darker skin complexion, as numer-
ous inhabitants of Saudi Arabia do. Therefore, it is
essential that more parts of the body are exposed,
ideally for longer and at different times of day, and
that women are made aware of this.
Women in Muslim communities are affected by the
tradition of avoiding body exposure.19 This can limit
the opportunities women have to uncover and experi-
ence sun exposure. Only a minority of participants
spontaneously expressed a need for more areas to
uncover. Therefore, this may not be a priority for this
group. However, it has to be remembered that not all
groups of women have the opportunity to uncover.
Many women from lower socio-economic status do
not live in houses that have outside areas where one
can uncover. Siddiqui17 found that many of the girls
in his Saudi Arabian study who were found to be vita-
min D deficient lived in smaller, crowded houses
where sunlight does not penetrate. Indeed, socio-
economic status has been linked to vitamin D defi-
ciency in the Middle East.13 For Middle Eastern and
Muslim women generally there are very few opportu-
nities to uncover their faces or their bodies and to
expose themselves to sun. Creating more areas where
women can uncover freely may have to be part of the
strategy of preventing vitamin D deficiency.
The lack of knowledge regarding vitamin D was fur-
ther demonstrated in the use of sun protection by our
participants. Of course for years many health cam-
paigns have quite successfully promoted the use of
sun protection with high skin protection factor (SPF)
to prevent skin cancer.12,20 However, the use of sun
protection products prevents UV-B rays from being
absorbed by the body and therefore vitamin D cannot
be produced.9 Research has shown that sun exposure
is beneficial to the human body, whereas excessive
5
F. T. E. Christie and L. Mason
sun exposure is known to cause erythema, skin aging,
skin cancer and sun-related eye disorders.26 In order
to reach a balance between the harmful effects and
benefits of sun exposure, public education about the
beneficial effects of some limited sun exposure should
be implemented.1 Although more research is needed,
the current advice seems to be to spend about 10–
15 min in the sun before applying sunscreen prod-
ucts.9 Our study participants were unaware of this.
Considering the barriers identified in this study,
supplementation might be an important enabler for
this population to prevent vitamin D deficiency12,13
and with this, knowledge of vitamin supplementation
should also be increased. Little research has been
undertaken regarding individuals’ knowledge of sup-
plementation.9 Again, our results would indicate the
importance of the role of health-care professionals, as
none of the participants were comfortable taking sup-
plements without consulting their physician. It is cru-
cial that physicians are informed of the evidence that
current recommended daily allowance (RDA) for vita-
min D intake seems too low.4,27 It would be helpful if
clarity could be reached on what the specific RDA
should be.12,13 Thus, more research into this is
urgently needed.
Interestingly, one of Brand’s (2008) findings was
that cost of vitamin supplements was a barrier to par-
ticipants’ use. Although none of the participants in
our study expressed concern about cost, it is quite pos-
sible that this was due to the high socio-economic sta-
tus of our participants. This may well prove to be a
barrier for individuals of lower socio-economic status.
Considering that there is a strong link between mater-
nal vitamin D levels and breastfeeding,13,16 it is vital
that women are properly informed about this. Rates of
women starting to breastfeed in Saudi Arabia are high
(96%) and cultural importance of breastfeeding is sig-
nificant as it is encouraged by their religion.28 Therefore
it is disappointing that none of the participants, not
even the two mothers amongst the participants, had
been informed about this aspect of vitamin D.
Although cosmetic reasons have been cited as a bar-
rier to sun exposure in other studies, Siddiqui’s,17,29
this was not viewed as a barrier amongst our partici-
pants, with only one mentioning this as her reason for
keeping out of the sun. The difference may be a result
of different study groups but suggests that cosmetic
reasons may not be specifically important to women
living in Saudi Arabia.
The other major barrier for the prevention of vita-
min D deficiency found in the present study was the
6 International Journal of Rheumatic Diseases 2011
Saudi Arabian climate. Although also reported by Al
Faraj and Al Mutairi19 this is not usually cited as a
barrier in the wider literature. More emphasis is put
on the cultural tradition of covering skin with clothes.
Considering that the summer months can range from
March until November, climate may be an important
barrier, too. The combination of the two barriers
together seems to have an unfortunate effect on pre-
vention of vitamin D deficiency. It seems essential to
establish how much vitamin D the skin can produce
both, in summer months and in winter, at what times
of day, in the shade or in the sun, and how much of
the body should be exposed. Research into this area
has been carried out in some locations,30,31 for exam-
ple in Boston, but these observations are very different
at higher latitude. Therefore research would have to be
done in the Middle East to determine exact recom-
mendations for the population here.
Furthermore the Saudi Arabian indoors lifestyle,
whether influenced by climate or culture, also became
apparent as a barrier. Several students mentioned that
because of the infrastructure, the lifestyle is generally
restricted to indoor activities. There is virtually no
movement outside. People move from their homes to
the car to another building, it is impossible to walk.
There are no pavements and if one wanted to spend
any time outside one would have to be driven to a
designated area, of which there are very few, especially
for women. This has severe implications for public
health, not only in terms of sun exposure but also
decreased physical exercise. This barrier has not been
described in the literature to date, but does need
consideration.
Considering the limited sun exposure fortifying
more foods might have to be deemed as part of a pub-
lic health strategy in preventing vitamin D deficiency.
Fortification is urged for in the literature.2,13 Currently
bread and milk are fortified in Saudi Arabia;17 rice
would qualify as a staple food in Saudi Arabia and
may need to be fortified in addition. Encouragingly,
our participants displayed a positive attitude to this
suggestion, although more research into this is also
urgently needed.
The prevalence of vitamin D deficiency in the Mid-
dle East has been described as alarming,13 and world-
wide as epidemic.1,9 The major cause of this epidemic
is lack of sun exposure.10,12 The threat to public
health has been demonstrated by highlighting the vast
amount of literature linking vitamin D to chronic dis-
eases. This study has emphasised cultural, gender
and socio-economic health inequalities in relation to

vitamin D deficiency that should be prevented to ben-
efit public health. Some characteristics of the Saudi
Arabian culture seem to encourage the lack of sun
exposure. This is experienced more by Muslim women
and those of lower socio-economic status, therefore
these characteristics could be said to be at the roots of
these health inequalities. This has to be tackled on
multiple levels. Strengthening individuals and commu-
nities with knowledge and the opportunity to make
healthier choices, improving access to facilities and
encouraging healthy public policy are all fundamental
elements of this process.32 In every culture strategies
to do this will be different. The potential and needs of
each country differ regarding social and cultural sys-
tems and this should be reflected in health promotion
interventions, as stated in the Ottawa Charter.22 Vita-
min D deficiency is a preventable and unnecessary
public health threat.1,17 Developing an understanding
of the socio-cultural barriers is essential before a pub-
lic health intervention can be developed.
In summary, due to a severe scarcity of research into
the field of qualitative and socio-cultural studies on
KAP regarding vitamin D deficiency, a qualitative KAP
study was carried out. Although there were limitations
to this study, it was found that gaps in knowledge both
in the population and in health care professionals may
be a barrier to the prevention of vitamin D deficiency.
It is recommended that this is addressed by health pro-
motion campaigns with specific guidelines. Support
from health-care professionals is needed to change
health behaviour. Furthermore, from their accounts we
believe that participants were unlikely to experience
sufficient sun exposure to prevent vitamin D deficiency.
This could be explained by: cultural reasons for cover-
ing skin with clothing and the Saudi Arabian climate
which is very hot and geared towards an indoors life-
style. Recommendations for more research both, quali-
tative and quantitative, have repeatedly been made in
this study. Supplementation might be an important
enabler and therefore more research into the optimal
levels of RDA is urgently needed. Governmental
actions such as creating more areas for women to
uncover freely and fortifying more foods may be
needed in the battle to prevent the epidemic of vitamin
D deficiency as a threat to public health.
ACKNOWLEDGMENTS
We would like to thank the participants who so kindly
volunteered and Prince Sultan University for their
cooperation.
International Journal of Rheumatic Diseases 2011
A qualitative study on vitamin D in Saudi
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