From a total of 424 recruits 405 participated in this study resulting in a 95.5% response rate. The general characteristics of the study participants is presented in Table 1. Nearly equal proportion of study participants were recruited from the three ecologies. A little over half 228 (56.3%) of the health workers were females while the overwhelming majority 375(92.3%) were involved in clinical practice. Nurses constituted 152 (37.5%) while health extension workers were 97(24.0%) and physicians 85(21.0%).
A little less than half 186 (45.3%) of participants worked for less than 5 years in their professional carrier. More than nine in ten of the participated health care workers 367 (90.6%) indicated that they have a pre-service training on vitamin D although only 7(1.7%) of them reported an in-service training on vitamin D level measurement, diagnosis of deficiency and management and treatment of its health consequences.
Table 1
Characteristics of health care providers involved in the knowledge, attitude and practice study on adult vitamin D deficiency in three ecologic zones of Ethiopia, July 2019.
Variable response categories | Freq | Percent |
Study area: Addis Ababa Highland Lowland | 140 135 130 | 34.6 33.3 32.1 |
Age group: Less than 25 25–29 30–39 40 and over | 71 192 112 36 | 17.3 46.7 27.3 8.8 |
Sex of the respondent: Male Female | 177 228 | 43.7 56.3 |
Role in facility: Leader/Program officer Clinician | 30 375 | 7.4 92.3 |
Profession: Physician Nurse Health officer Health Extension Worker | 85 152 71 97 | 21.0 37.5 17.5 24.0 |
Service years: Less than 5 5–9 10–14 15 plus years | 186 134 56 35 | 45.3 32.6 13.6 8.5 |
Special focus on vit D in your college training? Yes No | 367 38 | 90.6 9.4 |
In-service training on Vitamin D after graduation: Yes No | 7 398 | 1.7 98.3 |
As shown in Fig. 1, the main focus areas related to vitamin D during the pre-service training were diagnosis of treatment for 59.1% of providers, treatment of deficiency related health conditions according to 55.3% of health care workers, food fortification on vitamin D for 48.5% respondents and food supplementation according to 51.8% of providers.
Knowledge of health care professional on adult vitamin D deficiency
As shown in Table 2, nearly a quarter of health care providers 95(23.5%) believe that dietary sources are sufficient to maintain vitamin D levels and only 11 (2.7%) think that mid-day is the best time to get vitamin D from sun exposure. However, a little more than half 207(51.1%) of the respondents revealed that 30 minutes is the optimal duration of sun exposure per day to get vitamin D. The proportion of health care workers who mentioned teenagers, adults and elderly people are risky population groups for vitamin D deficiency was 6 (1.5%), 6 (1.5%) and 28(6.9%), respectively. Regarding the experience of HCWs on measuring vitamin D level, identifying deficiency and management and treatment of ill health consequences only 10(2.5%), 38(9.4%), 39(9.6%) and 25(6.2%) of the health care workers felt that their competency in measuring level, diagnosing deficiency, management and treatment of ill health consequences and all of those skills mentioned above respectively was good. Overall, only 210 (51.1%) of the study health care workers had a good knowledge score in this study.
Table 2
Knowledge of health care providers on adult vitamin D level measurement, diagnosis of deficiency and its management and treatment in three ecologic zones of Ethiopia, July 2019
Variables response categories | Frequency | Percentage |
Dietary sources are sufficient to maintain Vit D levels: Yes No | 95 310 | 23.5 76.5 |
Best time of day to get vitamin D from the sun: Morning Mid-day Afternoon | 391 11 3 | 96.54 2.7 0.74 |
Optimal duration of sun exposure/day to get vit D: <30 30 > 30 | 112 207 86 | 27.7 51.1 21.2 |
Age groups at more risk of vitamin D deficiency: U5C Teenagers Adults Elderly People | 365 6 6 28 | 90.1 1.5 1.5 6.9 |
Personal assertion on competency of measuring vit D level: Poor Fair Good | 287 108 10 | 70.9 26.6 2.5 |
Personal assertion on competency of vit D deficiency diagnosis: Poor Fair Good | 173 194 38 | 42.7 47.9 9.4 |
Personal assertion on vit D management and treatment: Poor Fair Good | 193 173 39 | 47.7 42.7 9.6 |
Personal assertion on measuring vit D level, vit D deficiency diagnosis and management and treatment: Poor Fair Good | 195 185 25 | 48.2 45.7 6.2 |
Knowledge Score: Poor Good | 195 210 | 48.2 51.8 |
Figure 2 showed inadequate sun light exposure, inadequacy of nutritional intake on food items rich in vitamin D, illnesses limiting vitamin D absorption, conditions impairing vitamin D conversion and impaired bone mineralization was reported as a cause of vitamin D deficiency by 90.1%, 93.8%, 58.8%, 36.5% and 41.2% of the health workers included in this particular study.
On the other hand, Fig. 3 revealed that promotion of healthy bone growth, prevention of rickets, osteoporosis and absorption of dietary calcium and prosperous were reported as the uses of vitamin D by 97.8%, 93.6%, 88.9%, 63.2% and 54.1% of health care workers participated in this study respectively.
The proportion of HWs who described ill health consequences of vitamin such as osteoporosis, osteomalacia, hypocalcemia, hypophosphatemia and chronic illnesses were 95.6%, 65.3%, 64.7%, 56.1% and 54.8% ,respectively (Fig. 4).
When health care workers were asked on factors affecting synthesis of vitamin D from sun light exposure, they indicated time of day (83.2%), clothing styles (80.0%), season (75.6%), sunscreen use (69.4%), illnesses (64.9%) and pollution (61.2%) as main ones influencing syntheses ( Fig. 5).
According to health workers, people who spent most of their time indoor (96.5%), cover their skin when going out (82.0%), old age persons (78.3%) and white skin people (29.4%) were the main population groups at more risk of vitamin D deficiency (Fig. 6).
The attitude of health care workers on adult vitamin D deficiency
Table 3 shows that 174(43.0%) of HCWs thought vitamin D deficiency is a public health problem and 183(45.2%) recommended universal screening to identify deficiency. However, only 16(4.0%) believe that there is an adequate laboratory investigation to diagnose vitamin D deficiency in the study area. Besides, only 45(11.1%) of study participants mentioned that vitamin D supplementation is adequate in Ethiopia. Moreover, few 66(16.3%) thought that they are adequately aware of prevention of vitamin D deficiency and treatment of associated diseases. On the other hand, the majority 394(97.3%) of them reported that there is a need for community sensitization on deficiency of vitamin D. However, only 13(3.2%) of them indicated that ministry of health or regional health bureaus has given adequate attention to the issue under caption. Though 289(70.6%) of respondents believed that vitamin D deficiency needs an easy and less costly intervention only few 7(1.7%) of them believed that health care providers are adequately trained on measurement of vitamin D level, diagnosis of its deficiency, and management and treatment of its ill health consequences. The overall positive attitude score in this study was estimated to be 216 (63.5%).
Table 3
Attitude of health care providers towards adult vitamin D level measurement, diagnosis of deficiency and its management and treatment in three ecologic zones of Ethiopia, July 2019
Vit D Deficiency is a public health problem: Yes No | 174 231 | 43.0 57.0 |
There should be a universal screening for vitamin D deficiency: Yes No | 183 222 | 45.2 54.8 |
There is an adequate laboratory investigation to diagnose vit D def: Yes No DK | 16 342 47 | 4.0 8.4 11.6 |
There is an adequate Vitamin D supplementation in Ethiopia? Yes No DK | 45 303 57 | 11.1 74.8 14.1 |
Healthcare practitioners adequately aware of prevention and Rx: Yes No | 66 339 | 16.3 83.7 |
There is a need for community sensitization on deficiency of vitamin D: Yes No | 394 11 | 97.3 2.7 |
MOH/RHB gave adequate attention to Vitamin D deficiency: Yes No DK | 13 371 21 | 3.2 91.6 5.2 |
Vitamin D deficiency needs an easy and less costly intervention: Yes No | 289 119 | 70.6 29.4 |
Health care providers are adequately trained on vitamin D: Yes No DK | 7 385 13 | 1.7 95.1 3.2 |
Attitude Score: Poor Good | 150 261 | 36.5 63.5 |
DK = do not know |
Practice of health care providers on adult vitamin D deficiency
Only 46(11.4%) of health care workers reported that they have diagnosed adult patients for vitamin D deficiency in their professional carrier, of those 26(56.5%) of them diagnosed 1–3 patients of any age on an average working month. When asked on mechanisms of diagnosis 41(89.1%), did it by making clinical examination, 26(56.5%) measured serum vitamin D and 21(45.7%) used a combination of them. Moreover, 26(56.5%) revealed that they measured concentration of 25 OH to assess vitamin D status.
Besides, only 50(12.4%) of study HCWs prescribed vitamin D supplementation for adults recently. Vitamin D supplementation for pregnant women was prescribed by only 3(0.3%) of the health care workers. Besides, 13(3.2%) of health care workers used guidelines to recommend vitamin D supplementation. This study also revealed that 77(19.0%) of health care workers have given calcium supplement for adults to prevent the ill consequences of vitamin D deficiency in their full-service years. In addition to this, 64(15.8%) of health care providers usually counseled their adult patients about the importance of vitamin D deficiency. Meanwhile, 89(22.0%) of health care workers have advised adult patients about the source of vitamin D and 53(13.1%) of them asked their patients on the adequacy of sun light exposure for vitamin D. Moreover, 86(21.2%) of health care workers counseled their adult patients on the need of sunlight exposure to get vitamin D. However, only 26 (6.4%) of health care providers received an on job training or workshop on diagnosis of deficiency and treatment of vitamin D.
Table 4
Practice of health care providers on adult vitamin D level measurement, diagnosis of deficiency and its management and treatment in three ecologic zones of Ethiopia, July 2019
Variables | Freq | Per |
Have you ever diagnosed adult patients for vitamin D deficiency? Yes No | 46 359 | 11.4 88.6 |
How many patients of any age do you diagnose in an average month? 1–3 4 plus | 26 20 | 56.5 43.5 |
Clinically: Yes No | 41 5 | 89.1 10.9 |
Measuring serum VD: Yes No | 26 20 | 56.5 43.5 |
Both: Yes No | 21 25 | 45.7 54.4 |
Did you measure concentration of 25 OH vitamin D to assess vitamin D status: Yes No | 26 20 | 56.5 43.5 |
Did you prescribe vitamin D supplement for adults recently? Yes No | 50 355 | 12.4 87.6 |
Do you prescribe vitamin D supplement for pregnant women recently? Yes No | 3 402 | 0.7 99.3 |
Is there any guideline to recommend for vitamin D supplementation? Yes No | 13 392 | 3.2 96.8 |
Have you ever given calcium supplement for adults to prevent the ill consequences: Yes No | 77 328 | 19.0 81.0 |
Do you usually counsel your adult patients about the importance of vit D: Yes No | 64 341 | 15.8 84.2 |
Do you advise adult patients about the source of vitamin D? Yes No | 89 316 | 22.0 78.0 |
Do you ask your adult patients about adequate sunlight exposure? Yes No | 53 352 | 13.1 86.9 |
Do you counsel your adult patients on the need of sunlight exposure for vit D: Yes No | 86 319 | 21.2 78.8 |
Do you ever attend any on job training/workshop on vit D deficiency: Yes No | 26 379 | 6.4 93.6 |
Practice Score: No Yes | 216 195 | 52.6 47.4 |
The practice in measuring vitamin D status, diagnosis of deficiency and management and treatment of ill health conditions is significantly different among providers deployed in the three ecologies, which is higher among health workers working in Addis Ababa followed by those working in the rural highland district (Table 5). Females providers had a significantly better practice compared with males and as the age of the provider increases the practice level is improving. Obviously, clinicians have a better practice compared with those assigned in leadership and health promotion positions though the difference is not statistically significant. The practice level was significantly better among physicians and health officers, whose trainings have more emphasis on clinical orientation. Moreover, those workers worked for several years had a significantly better practice level compared with the junior ones. In addition to this, health workers who have good knowledge and attitude had a better practice in measuring vitamin D level, diagnosis of deficiency and management of ill health consequences.
Table 5
The cross-tabulation of different characteristics of health care providers with the practice of them on measuring level, diagnosing deficiency and its management and treatment in three ecologic zones of Ethiopia, July 2019
Variable | Practice: #(%) | p-value |
No | Yes |
Study area: Addis Ababa Highland Lowland | 40(28.6) 82(60.7) 94(72.3) | 100(71.4) 53(39.3) 36(27.7) | 0.000 |
Sex: Male Female | 78(44.1) 138(60.5) | 99(55.9) 90(39.5) | 0.001 |
Age group: Less than 25 25–29 30–39 40 and over | 48(67.6) 112(58.3) 44(39.3) 12(33.3) | 23(32.4) 80(41.7) 68(60.7) 24(66.7) | 0.000 |
Role: Clinician Program officer | 197(52.5) 19(63.3) | 178(47.5) 11(36.7) | 0.254 |
Profession: Physician Nurse Health officer Health Extension Worker | 17(20.0) 99(65.1) 38(53.5) 62(63.9) | 68(80.0) 34(34.9) 33(46.5) 35(36.1) | 0.000 |
Service year: Less than 5 years 5–9 years 10–14 years 15 plus years | 104(55.9) 70(52.2) 31(55.4) 11(31.4) | 82(44.1) 64(47.8) 25(44.6) 24(68.6) | 0.063 |
Knowledge: Poor Good | 125(64.1) 91(43.3) | 70(35.9) 119(56.7) | 0.000 |
Attitude: Poor Good | 93(62.0) 123(47.1) | 57(38.0) 138(52.9) | 0.004 |
Table 6 showed the binary logistic analysis to identify health care workers’ characteristics associated with their practice in measuring vitamin D level, diagnosing deficiency, and management and treatment of ill health consequences. The odds of vitamin D service provision practice was AOR = 6.87: 95% CI (3.57, 13.21) times statistically significantly higher among health care workers deployed in Addis Ababa and AOR = 2.20: 95% CI (1.23, 3.92) times statistically significantly higher in the rural highland compared with those health care workers deployed in the rural lowland area. The likelihood of female health care workers’ practice in provision of vitamin D related service was AOR = 1.26: 95% CI (0.71, 2.22) times statistically significantly higher compared with males. However, the difference in the odds of practice in vitamin D service provision vanished when it is adjusted for other socio-demographic factors.
Besides, the likelihood of clinicians’ practice in the provision of vitamin D service was AOR = 4.26: 95% CI (1.48, 12.25) times statistically significantly higher compared with those working in leadership and health program positions. The difference in the odds of competency in vitamin D service provision among different professional groups vanished when it is controlled for other socio-demographic factors. The same is true for service year of health care workers.
On the other hand, the adjusted odds of practice in vitamin D service provision was AOR = 1.96: 95% CI (1.19, 3.23) times statistically significantly higher among those health care workers who have a good knowledge on vitamin D related service compared with those with poor knowledge. Besides, the likelihood of better practice in vitamin D service provision was AOR = 2.30: 95% CI (1.40, 3.78) times statistically significantly higher among those health care workers with positive attitude in vitamin D service provision compared with those who did have a negative attitude.
Table 6
The binary logistic regression of different characteristics of health care providers with the practice of them on measuring level, diagnosing deficiency and its management and treatment in three ecologic zones of Ethiopia, July 2019
Variables | Crude OR (95% CI) | p-value | Adjusted OR (95% CI) | p-value |
Study area: Addis A. Highland Lowland | 6.53(3.84, 11.10) 1.69(1.01, 2.83) 1.00 | 0.00 0.04 | 6.87(3.57, 13.21) 2.20(1.23, 3.92) 1.00 | 0.00 0.00 |
Sex: Male Female | 1.95(1.31, 2.90) 1.00 | 0.01 | 1.26(0.71, 2.22) 1.00 | 0.43 |
Age group: < 25 25–29 30–39 40 and over | 1.00 1.49(0.84, 2.65) 3.23(1.73, 6.03) 4.17(1.78, 9.79) | 0.17 0.00 0.00 | 1.00 1.03(0.51, 2.08) 1.98(0.82, 4.80) 1.23(0.20, 7.52) | 0.93 0.13 0.82 |
Role: Clinician Programmer | 1.56(0.72, 3.37) 1.00 | 0.26 | 4.26(1.48, 12.25) 1.00 | 0.00 |
Profession: Physician Nurse Health officer HEW | 7.09(3.61, 13.90) 0.95(0.56, 1.61) 1.54(0.82, 2.87) 1.00 | 0.00 0.85 0.18 | 1.53(0.53, 4.45) 0.42(0.20, 0.91) 0.50(0.20, 1.25) 1.00 | 0.43 0.03 0.14 |
Service year: < 5 years 5–9 years 10–14 years 15 plus years | 1.00 1.16(0.74, 1.81) 1.02(0.56, 1.87) 2.77(1.28, 5.98) | 0.52 0.94 0.01 | 1.00 1.06(0.59, 1.92) 0.91(0.39, 2.13) 1.80(0.33, 9.72) | 0.85 0.83 0.49 |
Knowledge: Poor Good | 1.00 2.34(1.57, 3.48) | 0.00 | 1.00 1.96(1.19, 3.23) | 0.00 |
Attitude: Negative Positive | 1.00 1.83(1.22, 2.76) | 0.00 | 1.00 2.30(1.40, 3.78) | 0.00 |