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 are presented in Table 1. A 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 career. 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
|
Frequency
|
Percent
|
Study area: Addis Ababa
Highland
Lowland
|
140
135
130
|
34.6
33.3
32.1
|
Age group: 19- 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 the 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 Figure 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 sunlight exposure, the 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, Figure 3 revealed that promotion of healthy bone growth, prevention of rickets, osteoporosis, and absorption of dietary calcium and phosphorous 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 D such as osteoporosis, osteomalacia, hypocalcemia, hypophosphatemia and chronic illnesses was 95.6%, 65.3%, 64.7%, 56.1%, and 54.8%, respectively (Figure 4).
When health care workers were asked about factors affecting the synthesis of vitamin D from sunlight 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 (Figure 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 (figure 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 a 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, a few 66(16.3%) thought that they are adequately aware of the 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 the deficiency of vitamin D. However, only 13(3.2%) of them indicated that the ministry of health or regional health bureaus has given adequate attention to the issue under the caption. Though 289(70.6%) of respondents believed that vitamin D deficiency needs an easy and less costly intervention only a 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
Vitamin D Deficiency is a public health problem: Yes
No
|
174
231
|
43.0
57.0
|
There should be 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 career, 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 a 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. Also, 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 about the adequacy of sunlight exposure for vitamin D. Moreover, 86(21.2%) of health care workers counseled their adult patients on the need for 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 Vitamin D: 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 a vitamin D supplement for adults recently? Yes
No
|
50
355
|
12.4
87.6
|
Do you prescribe vitamin D supplements 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 for sunlight exposure for Vit D: Yes
No
|
86
319
|
21.2
78.8
|
Do you ever attend any on the 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 who 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 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
Variables
|
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 the 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 the 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 a 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 Ababa
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: 19-25
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
|
*Adjusted for study area, sex, age group, role, profession, service year, knowledge and attitude
HEW=Health Extension Worker