Discussion:
To our knowledge, this is the first study in Jordan to assess the maternal awareness, perception regarding VDD in children, and the practices undertaken by mothers toward this problem. Evaluating the parent’s knowledge level is important in developing plans and making decisions that help solving this issue.
The findings of the current study reported that half of participants were knowledgeable about vitamin D including its sources, benefits, risk factors and complications of deficiency.
Sunlight is the main source of vitamin D 14 which is well known to most of participants in the recent study. The results were similar to that found in a French study 15. Only 0.5% didn’t know that sunlight is the main source of vitamin D, this finding was lower than what found in previous study in which 13.7% of parents did not know that sunlight is a major source of vitamin D.16
Not all respondents indicated all dietary sources of vitamin D. More than 60% of our participants recognized fish and egg as main dietary sources and 35%-60% quoted incorrect sources of vitamin D such as meat, poultry, fruits, and vegetables. These findings were compared to a previous Malaysian study in which 20%-30% of participants indicated fish and egg as main dietary sources and 4%-27% recognized incorrect sources of vitamin D. 17
In a Chinese study, woman incorrectly stated vegetables as one of vitamin D sources.18 In a Canadian study, only 26% of participants identified the sources of vitamin D 19, and only 17% recognized sources of vitamin D other than sun in a study conducted on a group of New Zealand athletes. 20 Age had an impact on participant’s knowledge score about vitamin D sources.
Almost all participants (93.9%) in the current study knew the importance of vitamin D in calcium absorption, bone and teeth health. These findings were high compared to results of a French study (78%) (15), Chinese study (12%-18%) 18, and Pakistanian study (33%).21 Age, nature of housing, educational level, family income had impact on benefit score.
Vitamin D production can be affected by factors which cause change in sun exposure such as season of the year, clothing, use of sunscreen, skin color. 22
Our participants were knowledgeable about low sun exposure and low dietary intake of vitamin D as risk factors of VDD, but they lacked knowledge about sunscreen use as a risk factor. The last finding was lower than that reported in a previous study.17
The darker skin color, the more need for sun exposure to produce vitamin D. 23 In our study, the minority of participants knew that vitamin D synthesis through skin is affected by its color.
More than 50% of mothers answered incorrectly that breast milk contains large amount of vitamin D, although only 29% believed that it is enough to provide their babies with the required amount of vitamin D. The results of the recent study demonstrated the need for improvement of knowledge regarding vitamin D sources, and risk factors of deficiency.
Comparison of knowledge level among demographic groups showed significant difference for age groups. Similar findings were found in a previous study conducted in United Kingdom study 24and supported by findings of study carried out among population in Hong Kong. 18 The level of education is not associated with knowledge level in our study. Different findings were found in a previous study. 25
Vitamin D during pregnancy is important for calcium absorption, transport through placenta, for immunity, and for inflammation inhibition26 VDD in pregnancy may increase the risk of pre-eclampsia, gestational diabetes Mellitus (GDM), low birth weight, respiratory and allergic diseases, skeletal deformities. So, it is recommended in a daily dose of 600 IU for all pregnant women.27
In the recent study, 71.4% of mothers received vitamin D supplements during pregnancy, this may reflect the high level of knowledge about vitamin D benefit in pregnancy. The rate of positive response to this question was significantly different among educational level groups in which most of mothers who received vitamin D supplements during pregnancy had baccalaureate degree compared to the lowest percentage who had secondary education or less (X2 =19.318, P value=0.000). In contrast, lower percentage of mothers (45.7%) received vitamin D during breast feeding.
Only about 20% of mothers in the current study tested vitamin D for their babies/children. Vitamin D screening is not necessary in the following groups: children, adolescents, pregnant women, and patients who receive bone active medications. 28 On the other hand, 40%-50% of mothers gave vitamin D supplements for their babies/children, and 50% had gotten the supplements through private’s children clinic. Only 7.4% of them got supplements through governmental hospitals, this reflects the need for vitamin D supplementation to be included as a health protocol given to all children free of charge.
In our study, a small proportion knew the best time of sun exposure. Similar findings found in previous study. 10
By looking to practices undertaken by mothers, the need appears for improvement of knowledge level of mothers regarding duration of giving vitamin D supplements for their babies/children, the number of times of sun exposure, and the best time of sunning. This can be achieved through conducting an awareness and education campaign for mothers regarding VDD.