Factors Affecting the Knowledge, Attitude and Practice of Vitamin D Supplement Use among adults: A Multi-Arab countries study

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Abdulrazzaq, Daniah Raad BSc, Midya Baban, and 11 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7552460/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background Vitamin D, an essential fat-soluble metabolite, plays a critical role in various physiological functions and human growth and development. This study investigates the factors influencing the knowledge, attitudes, and practices of the population regarding vitamin D supplementation. Methods A self-administered questionnaire was distributed via social media platforms. Statistical analysis involved frequency, percentages, and simple/multiple-linear regression analysis to assess study predictors. Results A total of 1340 responses were obtained from four countries: Saudi Arabia (n = 412, 30.8%), Egypt (n = 400, 29.9%), Jordan (n = 310, 23.1%), and Iraq (n = 217, 16.2%). Median knowledge scores (± IQR) in Egypt, Jordan, and Iraq indicated a moderate level of understanding regarding vitamin D supplementation (11 ± 3, 11 ± 2, and 11 ± 3, respectively), whereas Saudi Arabia exhibited lower levels of knowledge (7 ± 2). Neutral attitudes toward vitamin D were observed across all countries, while Jordan and Iraq showed good median practice scores (17 ± 5, 16 ± 5), compared to moderate levels in Saudi Arabia and Egypt (13 ± 3, 15 ± 5), respectively. Multi-linear regression analysis indicated that in Saudi Arabia, younger respondents exhibited higher knowledge, attitudes, and practice scores, while individuals working in the non-health sector displayed higher attitudes and practice scores (p-value = 0.06, 0.009, < 0.001). Similarly, in Iraq and Jordan, those working in the non-health sector demonstrated higher knowledge scores (p-value < 0.001, < 0.001, respectively). Furthermore, males attained higher attitude scores in samples from Jordan, Egypt, and Iraq (p-value < 0.001, 0.003, < 0.001). Conclusion This study highlights varying levels of knowledge, attitudes, and practices regarding vitamin D supplementation across different demographic groups and countries. Addressing misconceptions and promoting awareness, particularly among younger individuals and those working outside the health sector, is crucial for optimizing vitamin D supplementation practices and enhancing public health outcomes. Vitamin D Supplementation Knowledge Attitudes Practices Figures Figure 1 Figure 2 Figure 3 Background The Dietary Supplement (DS), Health and Education Act of 1994 (DSHEA) defines dietary supplements (DS) as a wide range of non-food, non-drug substances meant to complement the diet but not necessarily to cure illnesses or disorders of the human body [ 1 ]. DSs contain either a single nutrient or a combination of multivitamins, botanicals, amino acids, and minerals, including vitamins C, E, B-6, B-12, A, magnesium, zinc, and other substances with a nutritional or physiological effect [ 2 ]. These supplements are available in different forms like pills, tablets, capsules, and liquids with measured doses [ 3 ]. DSs are widely utilized in the United States [ 4 ], the Middle East [ 5 , 6 ], Asia [ 7 ], Canada [ 8 ], and some regions of Europe [ 9 ]. A study conducted by Archer et al. found that 52% of the study participants acknowledged using at least one vitamin supplement [ 10 ]. Also, a significant portion of the adult population in both Japan and the US have had reported using DS [ 11 , 12 ]. More than 80% of the doctors and nurses informed their patients to use a different DS product [ 13 , 14 ] to avoid and manage long-term diseases like osteoporosis, heart disease, cancer, and birth problems in the neural tube [ 15 – 18 ]. For example, getting enough calcium and vitamin D can help people with osteoporosis maintain strong bones and avoid fractures [ 19 , 20 ]. A cross-sectional survey conducted in a Jordanian university revealed that 23% of students used vitamin-mineral supplements, with the main reason being to maintain good health [ 21 ]. Supplement use in adults tends to increase with age, income, and education. Interestingly, women are more inclined to use supplements compared to men within each age group [ 22 ]. Vitamin D is a fat-soluble metabolite that is necessary for numerous physiological systems to function properly, as well as normal human growth and development [ 23 ]. There are two common forms: D-2 (ergocalciferol) and D-3 (cholecalciferol) [ 23 ]. Both kinds may be gained by diet, although the options are restricted to fortified goods and certain fish species [ 24 ]. The first recommended dietary requirements for vitamin D consumption were established in 1941 [ 25 ]. The sufficiency of vitamin D reserves is assessed by testing blood concentrations of 25-hydroxyvitamin D, where it is stated that serum concentrations in deficiency (< 20 ng/ml), sufficiency (20–40 ng/ml), and optimum (30–80 ng/ml) is debatable [ 26 ]. The recommended daily dose for adults to obtain general health benefits starts from 600IU/day, as stated by the National Institutes of Health (NIH) [ 27 ]. Vitamin D deficiency and insufficiency are very common globally and are known to exacerbate a range of chronic disease states, including diabetes [ 28 , 29 ], cancer [ 16 ], cardiovascular disease [ 30 ], dementia [ 31 ], infectious illnesses [ 32 ], and depression [ 33 , 34 ]. Despite the prevalence of vitamin D deficiency [ 35 ] and low vitamin D intakes [ 36 ], there is an absence of research on vitamin D-related knowledge, beliefs, and attitudes throughout the global population [ 37 – 42 ] and in the Middle East [ 37 ] populations. A small qualitative study conducted in Saudi Arabia [ 40 , 43 ], the United Arab Emirates [ 44 , 45 ] and other countries found limited knowledge about the health benefits of vitamin D and confusion about both dietary sources of vitamin D and the risks and benefits of sun exposure [ 38 , 46 ]. Similarly, populations in China [ 47 ], India [ 48 ], and the United Kingdom [ 49 ] had low knowledge about vitamin D. It should be also noted that supplementation, fortification, and factors affecting the use of vitamin D supplements have rarely been studied. Our objectives were therefore, to ascertain possible variables influencing the usage of vitamin D supplements in a population of Arab nations as well as to examine knowledge, attitudes, and perceptions about vitamin D supplementation. The findings of this research are anticipated to contribute to the development of successful clinical and public health initiatives to encourage and optimize the use of vitamin D supplement. Dietary supplements have been used extensively in Arabian countries/Middle Eastern populations and have proven effective in many health sides of human well-being [ 50 – 53 ]. Yet, there is no study documenting the factors that affect the use of vitamin D supplements in Arabian countries/Middle East, although there are studies highlighting the need for such investigation [ 54 , 55 ]. Thus, this study aims to explore the factors that affect the knowledge, attitude, and practice of vitamin D supplementation in the adult population in Arabian countries/Middle East. Methods 2.1. Study design and participants A self-administered questionnaire was administered using Google® Forms after reviewing similar studies in the literature [ 9 , 56 , 57 ]. The questionnaire was designed in English, then translated to Arabic before and back-translated to English by two academics fluent in both languages. Responses were collected in Arabic, the official spoken language of the participating countries (Saudi Arabia, Jordan, Egypt, and Iraq). The questionnaire was distributed using different social media platforms such as Facebook, Instagram, X, WhatsApp, and LinkedIn to collect individual responses from the target group from November 2023 to February 2024. As explicitly outlined at the beginning of the questionnaire before seeking informed consent, the inclusion criteria clearly stated that participants must be 18 years old and above. 2.2. Sample size In line with Tabachnick and Fidell's recommendations for determining sample size in analysis, it is advised to aim for 5–20 subjects per predictor [ 58 ]. Given that this study incorporates ten independent variable levels, adhering to the guideline of 20 subjects per predictor, a minimum sample size of 200 or more was deemed appropriate. To accommodate potential missing responses and unforeseen issues, the decision was made to increase the sample size in each country. 2.3. Questionnaire development, validation, and reliability The study questionnaire was crafted, employing fundamental guidelines for effective survey design [ 59 ]. A pool of questions aligned with the study's objectives was generated by integrating information from various sources [ 9 , 53 , 60 – 62 ]. The questionnaire comprised four sections featuring multiple-choice questions: sociodemographic, knowledge, attitudes, and practice toward omega 3. For content and face validity, five academics evaluated the English version of the study tool. Subsequently, it was translated into Arabic by two independent academic translators, employing translation and back-translation techniques. To enhance clarity and ensure comprehension of the questionnaire's items among the target population, consisting of individuals from diverse backgrounds (academic and professional), a pilot test was conducted with 30 participants. Linguistic refinements were implemented based on the feedback received during the pilot-testing phase. Notably, the responses gathered during the pilot were excluded from the final analyses. The reliability and internal consistency were checked, as Cronbach's α was used to evaluate the reliability of the questionnaire (= 0⋅8) for the Likert scale in the practice section and (= 0.7) for the attitude section, i.e., that the scales constructed are fit for their purpose, with values ≥ 0.7 indicating acceptable internal consistency. The questionnaire consisted of four main sections. The first section addressed the practices of the adult population in Arabian countries, and only participants who used vitamin D supplements proceeded to this section. Data collected in this section pertains to the physician and/or doctors’ consultation, blood tests made before intake of the supplement, following the label directions, and the presence of the positive effect of vitamin D supplements. Also, participants were asked about any adverse events, the dose taken, any other supplements taken concomitantly, and the reason for intake. The second section assessed participants’ knowledge of vitamin D supplements in seven main questions. Moreover, participants were asked about vitamin D supplements' possible influences on bones, brain, weight and cardiovascular. Additionally, participants were asked about the side effects of using vitamin D supplements and the source of information about vitamin D supplements (e.g., health care providers, nutritionists, social media, scientific articles, family and friends and others). The third section addressed participants’ attitudes towards the use of vitamin D supplements. Based on a five-degree Likert scale ranging from strongly agree to disagree strongly, participants were requested to provide their opinion in seven questions about the effects vitamin D supplements in terms of the importance of supplement to overall human health, the safety of supplement dose, benefit to gut microbiota, possessing possible side effects and physician and/or doctors’ consult before supplement intake. The fourth section addressed the demographics and lifestyle such as age, gender, marital status, weight, height, education level, monthly income, place of residence, being health insured, having chronic diseases or not, physical activity and smoking status. 2.4. Score calculation Scores of knowledge, attitude and practice were calculated and presented as median value ( \(\:\pm\:\text{i}\text{n}\text{t}\text{e}\text{r}\text{q}\text{u}\text{a}\text{r}\text{t}\text{i}\text{l}\text{e}\:\text{r}\text{a}\text{n}\text{g}\text{e}\:\left(\text{I}\text{Q}\text{R}\right))\:\) at end of each section in results. Knowledge statements were awarded 1 mark for each correct answer, while the attitude statements were awarded highest 5 marks for the positive attitude and practice were awarded highest 5 marks for the positive practice as a 5-degree Likert-scale. Bloom’s cutoff was used to interpret the score values [ 63 ], where 80%-100% was considered high level of knowledge/ positive attitude/ good practice, 60%-79% moderate level of knowledge/ neutral attitude/ moderate practice and < 60% low level of knowledge/ negative attitude/ poor practice . 2.5. Ethical approval The study was approved by the Institutional/Local Research Ethics Committee, Amman, Jordan (Approval number: 2023-PHA-50). All participants agreed to participate in the study by selecting “I agree” on the electronic informed consent form before filling out the questionnaire. All methods were performed in accordance with the relevant guidelines and regulations or declaration of Helsinki. 2.6. Statistical analysis Data were extracted from Google Forms into an Excel spreadsheet and were then exported and statistically analyzed using Statistical Package for Social Sciences version 24.0 (SPSS Inc., Chicago, IL, USA). Descriptive statistical analysis was used to analyze the median and interquartile range for continuous variables and normality was checked using Shapiro-Wilks test showing p -value of <0.001, not normally distributed data. Categorical variables were demonstrated as frequencies and percentages. A simple linear regression was used to figure out whether there is an association between the scores of knowledge, attitude and practice with the dichotomous variables presenting standardized Beta correlation coefficients and p -values. A p -value of <0⋅250 was set to determine if the variable is eligible for multi-linear regression analysis. In multi-linear regression analysis, a p -value of <0⋅05 was set to represent a significant difference. Graphical representation was made using MS Excel (version 16.81). Results 3.1. Demographics Our sample reached 1352 responses, with 1340 approved responses included in the final study analysis (response rate = 99.1%). The demographic and lifestyle characteristics of the participants are demonstrated in Table 1. Saudi Arabia sample represented the highest percentage ( n =412, 30.8%) of the total responses, whereas Egypt had ( n =400, 29.9%), Jordan ( n =310, 23.1%), and Iraq ( n =217, 16.2%) had lower percentages in the total sample size. There was a predominance of female participants in all four participating countries, with the highest percentage of females in Jordan ( n =252, representing 81.3% of Jordan’s sample) compared with males and other countries. The median ± IQR age of the respondents was 35± 13 years old for Saudi Arabia, 30±12.5years for Egypt, 25±10.5 years for Jordan and 28±6.75 years for Iraq respondents. Most of the study sample had bachelor's degrees, with the highest n=152 (70%) from the Iraq sample and lived in the urban area of Iraq ( n =204, 94%). More than half of respondents work in areas related to the medical field in Egypt, Jordan and Iraq, while only 19.6% work in areas not related to the medical field from the Saudi Arabia sample. Most participants were non-smokers from all countries and more than 80% of each country’s respondents had no chronic diseases, as shown in Table1. 3.2. Knowledge, attitude and practice scores of countries Median knowledge score showed that Egypt, Jordan and Iraq had a moderate level of knowledge regarding vitamin D supplement use (11±3, 11±2, 11 ,respectively, while Saudi Arabia had low levels of knowledge (7 . Moreover, the median attitude scores showed neutral attitude levels for all countries as shown in Table 2. On the other hand, only Jordan and Iraq had good levels of median practice scores (17±5, 16±5), while Saudi Arabia and Egypt had moderate levels of practice (13±3, 15±5 The main source of information for the Saudi Arabia sample was seen to be friends and family (35.7%). Egypt mainly depended on the internet and social media as their main source of information regarding vitamin D supplement use, as shown in Figure 1 . Moreover, participants in Saudi Arabia had a higher concurrent use of several vitamins and minerals with vitamin D than participants in other countries. It was noticed in our study that Saudi respondents were using vitamin D with omega-3, specifically in the highest amount compared to other vitamins/minerals (84.1%). Jordan and Iraq (11.4% and 15.7% respectively) had the least use of concurrent use of vitamin E alongside vitamin D. Meanwhile, Egypt, Jordan, and Iraq had the lowest percentage of use of K2 with vitamin D (11.4%, 9.7%, 17.4% respectively as shown in Figure 2 . 3.3. Multi-linear regression of dichotomous variables for each country It was perceived through the multilinear regression analysis that the knowledge score between Saudi Arabian participants was mainly higher among non-university ( p -value = 0.035), non-insurance covered ( p -value = 0.017) and younger in age ( p -value = 0.060). While the attitude score was seen to affect the practice behavior of participants positively ( p -value <0.001). Likewise, practice score was seen to be higher among participants of younger age also (p-value <0.001), and practice scores were higher among higher attitude scores, as shown in Table 3 . It was perceived that the knowledge score between Egyptian participants was mainly higher among those who do not work in areas related to the health sector ( p -value <0.001) and are not physically active ( p -value=0.006). The attitude score was seen to be higher with a higher practice score ( p -value <0.001) and higher knowledge score (( p -value =0.018). Practice score was seen higher among higher attitude scores ( p -value <0.001). Jordanian's knowledge score was detected to be higher among males (p-value= 0.027) who are working in areas not related to the health sector ( p -value<0.001). While the knowledge score was higher with higher attitude scores ( p -value=0.019). Attitude seemed to be having higher scores with higher practice scores ( p -value =0.005) and higher knowledge score ( p -value =0.019). Meanwhile, practice was noticed to be affecting the attitude of Jordanian participants, meaning, practice score was perceived higher with higher attitude score ( p -value =0.005) between male gender ( p -value <0.001) who have no insurance coverage ( p -value =0.012). Iraqi’s knowledge score was detected to be higher among those who are working in areas not related to the health sector ( p -value <0.001) and affecting attitude scores positively ( p -value<0.001). The attitude score was higher among younger Iraqi participants ( p -value=0.035) and is higher with higher practice scores ( p -value<0.001) and knowledge scores ( p -value<0.001). Similarly, practice scores were higher among Iraqi males ( p -value=0.004) and those who do not have chronic diseases ( p -value=0.034). Meanwhile, practice score was noticed to be affecting the attitude of Iraqi participants, meaning practice score was perceived higher with higher attitude score ( p -value <0.001) as shown in Table 3 . It was comprehended in our study that the two main reasons to take vitamin D supplements were to maintain general health and for vitamin deficiency intentions. It was obvious that Saudi Arabian participants had the highest supplement intake reason for maintaining of general health reaching 90%, followed by Jordanian participants reaching 84.1%. While the vitamin deficiency reason was 89.8% for Egypt and 86.6% for Iraqi participants as seen in Figure 3 . Discussion Our study aimed to investigate factors affecting the knowledge, attitude and practice of vitamin D supplement use among Arabian adults living in Saudi Arabia, Jordan, Egypt and Iraq. Our study participants were from Saudi Arabia, with the highest response percentage (n=412, 30.8%), followed by Egypt, Jordan, and Iraq. Most of the study participants were female in all participating countries. In terms of marital status, most of the participants from Iraq (59%), Egypt (61.3%), and Jordan (68.1%) samples were single. On the other hand, a more significant part of the participants (68.5%) from Saudi Arabia were married. In the four countries in our study, most participants lived in urban areas, especially Iraqi participants (94%), did not have any chronic diseases, and were nonsmokers. More than half of the participants were covered by insurance in Saudi Arabia (63.9%), Egypt (66%), and Jordan (64.8%), while only 27.7% of the respondents from the Iraq sample had insurance coverage. The results of this study showed that participants from Egypt, Jordan, and Iraq had a moderate level of knowledge regarding vitamin D supplement use ( 3, 11 2, and 11 3, respectively), while Saudi Arabia had a low levels of knowledge (7 ). Also, there was a direct correlation between higher knowledge scores and higher attitude scores in respondents from Egypt, Jordan, and Iraq (p=0.018,0.019, <0.001, respectively). Moreover, it was noticed that participants from Egypt, Jordan, and Iraq had a higher knowledge score among those who do not work in areas related to the medical field (p<0.001, <0.001, <0.001, respectively). Likewise, a study highlighted the need for more knowledge about vitamin D deficiency among healthcare workers in Jeddah, Saudi Arabia [64]. In addition, our study showed a direct correlation of younger adults with higher knowledge scores only in participants from the Saudi Arabia sample (p=0.060). However, most studies in the literature showed that older adults were the most aware of vitamin D compared to all other age groups and had better levels of knowledge [41, 65]. Additionally, higher knowledge scores were found in male participants rather than female gender in the Jordan sample (p<0.001); this point was supported by a study that showed limited knowledge about Vitamin D among female students in Saudi Arabia [66]. This finding might result from the higher prevalence of vitamin D deficiency in men than women, as observed in Vallejo et al., 2020 study [67]. On the other hand, a study showed that women knew more than men when it came to sources of vitamin D [41]. Interestingly, in our study, non-university participants in Saudi Arabia exhibited higher knowledge scores (p=0.035); this result is similar to a result from another study that was conducted in Canada in which the knowledge of vitamin D among university students was observed to be low [39]. Similarly, another study conducted at King Saud University in Riyadh demonstrated that all university students need more knowledge regarding vitamin D [68]. Moreover, in our study, physically inactive participants from the Egypt sample had higher knowledge scores (p=0.006); a similar finding was reported in another study in which only 30% of dietary supplement users exercised regularly [69]. One explanation is that individuals with low physical activity tend to look for vitamins to compensate for their inactivity and enhance their health in intentions to be more active. Furthermore, good levels of practice were observed in Jordan (17±5) and Iraq (16 ), whereas Saudi Arabia (13 ) and Egypt (15±5) had moderate levels of practice. In our study, the main sources of information regarding vitamin D supplements use in Egypt and Jordan sample were the internet and social media, implying that these kinds of resources had become a fundamental source of health and nutrition-related knowledge [70]. Also, it is worth to mention the age of participants in the present study is between 25-35 years old, this age group is considered the millennial age (age between 27 and 42 years old), where they tend to have a behavior of seeking information with minimum efforts and expenses met by internet resources[71, 72] . At the same time, Saudi Arabia have gained information about vitamin D supplements used by friends and family. Our finding was consistent with another literature finding regarding the source of information in non-medical students, where it was stated that using friends and family as information sources was far more common among non-medical students [9]. As (80.4%) of the Saudi Arabia sample in our study were not working in the medical field, the literature supports our result. In addition, the higher interpersonal communications and family connections might be the reason for obtaining information from friends and family in the Saudi Arabia sample. Egypt, Jordan and Iraq samples were seen to use vitamin D supplements because of vitamin D deficiency. Participants in Saudi Arabia have used vitamin D supplements to maintain general good health, which aligns with a study from literature [9]. Most of the participants in our study did not use vitamin D supplements for weight loss, suggesting the insignificant role of vitamin D in weight loss, where it was mentioned in a study that found that vitamin D supplements did not enhance weight loss when compared with placebo [73]. Moreover, our study reported the highest percentage (84.1%) of the concurrent use of Omega-3 alongside vitamin D was in participants from Saudi Arabia; the expected synergistic effect of this combination could help to explain this practice, two studies revealed that the combination of vitamin D and omega-3 reduced autoimmune diseases and improved mental health in pre-diabetic women with vitamin D insufficiency [74, 75]. However, participants from Egypt and Iraq (46.9% and 43.6%, respectively) had the highest percentages of concurrent use of B-complex besides vitamin D. A literature study suggested that the use of B vitamins and/or vitamin D may be useful in alleviating symptoms of depression and anxiety [76]. Our study also showed a neutral attitude level for all four participating countries. Younger participants from Iraq sample showed higher levels of attitude, although in one study showed that older adults were found to have a considerably greater positive attitude towards dietary supplements (68%) in comparison with middle-aged adults (47.5%) [77]. Generally, this study gives an insight regarding knowledge, attitude, and practice of vitamin D supplement use among Arabian adults in the Middle East, on the other hand, limitations and obstacles were observed during the study and hence more investigation is required to elaborate and explain further factors effect on knowledge, attitude and practice of Middle Eastern population. 4.1. Limitations This study’s investigation into vitamin D supplementation among Arabian adults in Saudi Arabia, Jordan, Iraq, and Egypt has provided critical insights. Nonetheless, the research design presents several limitations that warrant consideration. The sample distribution was inconsistent across the participating nations, potentially leading to an over-representation of urban respondents, which may affect the applicability of the findings to the entire Arabian adult population. There was also a disparity in gender representation, with an uneven distribution between male and female participants. A significant proportion of the study’s respondents, particularly in Jordan, Iraq, and Egypt, were affiliated with the health sector, either through employment or education, holding at least a bachelor’s degree. This concentration of participants with a health background and higher education levels may have influenced their responses regarding vitamin D supplementation, suggesting a need for caution when extrapolating these findings to a broader audience. The study’s reliance on self-reported questionnaire data may have introduced variations in the accuracy of the responses due to factors such as social conformity and memory reliability. Additionally, the online survey format may not have reached individuals without internet access, suggesting a need for alternative data collection methods in future research. Despite these considerations, the study offers valuable preliminary data that lays the foundation for future research directions. Subsequent investigations should delve into the influence of cultural factors on supplement use and employ diverse data collection methodologies to include a broader spectrum of participants, thereby enhancing the robustness and representativeness of the findings. The outcomes of this multinational survey highlight a notable disparity in Arabian adults' knowledge, attitudes, and practices around the usage of vitamin D supplements. Despite the well-documented benefits of Vitamin D, there is a general awareness that only sometimes translates into proactive health behaviors or a positive attitude toward supplementing. This disconnect indicates a pressing need for public health initiatives to bridge the gap between awareness and action. Interestingly, the study discovered that those who did not work in the health industry had better levels of awareness regarding vitamin D in most countries evaluated. This paradoxical scenario warrants attention from health policymakers, who should strive to address and rectify this anomaly. Health policymakers should pay attention to this contradictory situation and work to address and correct this abnormality. Future research could expand on these findings by exploring the role of healthcare providers in influencing supplement choices and the impact of targeted education on supplement adherence. Such studies could pave the way for more nuanced health policies and a more health-literate populace. Policymakers should encourage healthcare professionals to engage in ongoing professional development activities, like visiting conferences and seminars that provide the latest information on supplements. Educational programs should clarify the importance of vitamin D for general health and the dangers of vitamin D insufficiency. Promoting a more knowledgeable mindset increases people's likelihood of healthily taking supplements. Since online platforms are the primary information source, digital outreach may successfully capture the target audience's attention. Healthcare professionals should lead these initiatives, offering tailored advice that meets the population's cultural and health-specific needs. Conclusion This study provides valuable insights into the knowledge, attitudes, and practices surrounding vitamin D supplementation across diverse Saudi Arabia, Egypt, Jordan, and Iraq populations. The findings underscore the need for targeted educational interventions, particularly in Saudi Arabia, where lower levels of knowledge were observed. Additionally, the study identifies demographic factors, such as age, gender, and occupation, influencing individuals' understanding and behaviors related to vitamin D. The implications of this research extend to public health initiatives aiming to enhance vitamin D awareness and optimize supplementation practices. Tailored educational campaigns should address specific knowledge gaps, focusing on younger individuals and those outside the health sector. Furthermore, efforts to promote positive attitudes and practices, particularly in regions with moderate to low levels of understanding, can contribute to improved overall health outcomes. Longitudinal studies could investigate the long-term impact of targeted educational interventions on knowledge retention and behavioral changes. Exploring cultural influences and regional variations in vitamin D awareness may provide additional context for designing effective public health strategies. Moreover, assessing the correlation between vitamin D supplementation practices and health outcomes could offer valuable insights into the practical implications of improved knowledge and attitudes. Abbreviations Interquartile range (IQR), Dietary Supplement (DS), Health and Education Act of 1994 (DSHEA) Declarations Ethics approval and consent to participate The study protocol was reviewed and approved by the Institutional Review Board (IRB) of the Applied Science Private University in Amman, Jordan (Approval No.: 2023-PHA-50). Participation was voluntary, and written informed consent was obtained from all participants prior to enrollment. The study was conducted in accordance with the Declaration of Helsinki and national ethical guidelines. Consent for publication Not applicable. The manuscript does not contain any individual participant data, images, or personal information requiring consent for publication. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request. Competing interests The authors declare that they have no competing interests. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Authors contribution M.B., S.B.A., and M.A.A. conceptualized the study. Data curation was performed by S.B.A., while formal analysis and investigation were carried out by M.B. and S.B.A. The methodology was developed by M.B., S.B.A., M.A.A., and A.O. Project administration was handled by M.B., S.B.A., and M.A.A. Resources and data collection were contributed by S.B.A., D.R., A.K., and M.B.B. Supervision was provided by M.B., S.B.A., and M.A.A. Validation was conducted by M.B., S.B.A., M.A.A., and A.O. Visualization was completed by M.B., A.O., and M.A.A. The original draft was written by S.B.A., D.R., A.K., and M.B.B., while review and editing were carried out by M.B., S.B.A., W.A., M.A.S., R.A and M.A.A. All authors read and approved the final manuscript. Acknowledgements The authors would like to thank all participants for their valuable time and cooperation. The authors also acknowledge the support of the Applied Science Private University in facilitating data collection and ethical oversight. References Seamon MJ, Clauson KA: Ephedra: yesterday, DSHEA, and tomorrow—a ten year perspective on the Dietary Supplement Health and Education Act of 1994 . Journal of herbal pharmacotherapy 2005, 5 (3):67-86. Shahwan M, Al Abdin SMZ: Knowledge and practice of dietary supplement and micronutrients among medical students at Ajman University . Journal of Pharmaceutical Sciences and Research 2018, 10 (1):85-90. Haines ST, Park SK: Vitamin D supplementation: what's known, what to do, and what's needed . Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy 2012, 32 (4):354-382. Bailey RL, Gahche JJ, Lentino CV, Dwyer JT, Engel JS, Thomas PR, Betz JM, Sempos CT, Picciano MF: Dietary supplement use in the United States, 2003–2006 . The Journal of nutrition 2011, 141 (2):261-266. Radwan H, Hasan HA, Ghanem L, Alnajjar G, Shabir A, Alshamsi A, Alketbi F: Prevalence of dietary supplement use and associated factors among college students in the United Arab Emirates . Journal of Community Health 2019, 44 :1135-1140. Naqvi AA, Ahmad R, Elewi AAW, AlAwa AH, Alasiri MJ: Dietary supplement use among undergraduate male students in health and non-health cluster colleges of a public-sector university in Dammam, Saudi Arabia . BMC complementary and alternative medicine 2018, 18 :1-11. Naqvi AA, Ahmad R, Zehra F, Yousuf R, Kachela B, Nehal Nadir M: Dietary supplement use among students of pharmacy colleges in the City of Karachi, Pakistan: prevalence, opinions, and attitudes . Journal of dietary supplements 2019, 16 (2):166-178. El Khoury D, Hansen J, Tabakos M, Spriet LL, Brauer P: Dietary supplement use among non-athlete students at a Canadian university: a pilot-survey . Nutrients 2020, 12 (8):2284. Žeželj SP, Tomljanović A, Jovanović GK, Krešić G, Peloza OC, Dragaš-Zubalj N, Prokurica IP: Prevalence, Knowledge and Attitudes Concerning Dietary Supplements among a Student Population in Croatia . International Journal of Environmental Research and Public Health 2018, 15 (6):1058. Archer SL, Stamler J, Moag-Stahlberg A, Van Horn L, Garside D, Chan Q, Buffington JJ, Dyer AR: Association of dietary supplement use with specific micronutrient intakes among middle-aged American men and women: the INTERMAP Study . Journal of the American Dietetic Association 2005, 105 (7):1106-1114. Imai T, Nakamura M, Ando F, Shimokata H: Dietary supplement use by community-living population in Japan: data from the National Institute for Longevity Sciences Longitudinal Study of Aging (NILS-LSA) . Journal of epidemiology 2006, 16 (6):249-260. Garcia-Cazarin ML, Wambogo EA, Regan KS, Davis CD: Dietary supplement research portfolio at the NIH, 2009–2011 . The Journal of nutrition 2014, 144 (4):414-418. Ghosn SA, Addison B, Ali MD: Community Pharmacist's Knowledge, Attitude, and Practices towards Vitamin Supplements in Al-Khobar Region, Saudi Arabia: A Descriptive Cross-Sectional Study . Journal of pharmacy & bioallied sciences 2019, 11 (4):333-340. Dickinson A, Boyon N, Shao A: Physicians and nurses use and recommend dietary supplements: report of a survey . Nutrition journal 2009, 8 :1-6. Hou Y-C, Wu C-C, Liao M-T, Shyu J-F, Hung C-F, Yen T-H, Lu C-L, Lu K-C: Role of nutritional vitamin D in osteoporosis treatment . Clinica chimica acta 2018, 484 :179-191. Carlberg C, Muñoz A: An update on vitamin D signaling and cancer . In: Seminars in cancer biology: 2022 : Elsevier; 2022: 217-230. Seraphin G, Rieger S, Hewison M, Capobianco E, Lisse TS: The impact of vitamin D on cancer: A Mini Review . The Journal of Steroid Biochemistry and Molecular Biology 2023:106308. Adrien N, Orta OR, Nestoridi E, Carmichael SL, Yazdy MM, Study NBDP: Early pregnancy vitamin D status and risk of select congenital anomalies in the National Birth Defects Prevention Study . Birth Defects Research 2023, 115 (3):290-301. Eleni A, Panagiotis P: A systematic review and meta-analysis of vitamin D and calcium in preventing osteoporotic fractures . Clinical rheumatology 2020, 39 (12):3571-3579. Mendes MM, Sahni S: Calcium and vitamin D in the management of osteoporosis . In: Marcus and Feldman's Osteoporosis. edn.: Elsevier; 2021: 1665-1678. Ibrahim MO: Research Article Nutritional Epidemiology Study: Prevalence of Vitamin and Mineral Supplement Use and Correlated Factors among University Students in Jordan . Pakistan Journal of Nutrition 2018, 17 (12):654-660. Ishihara J, Sobue T, Yamamoto S, Sasaki S, Tsugane S: Demographics, lifestyles, health characteristics, and dietary intake among dietary supplement users in Japan . International Journal of Epidemiology 2003, 32 (4):546-553. Dominguez LJ, Farruggia M, Veronese N, Barbagallo M: Vitamin D sources, metabolism, and deficiency: available compounds and guidelines for its treatment . Metabolites 2021, 11 (4):255. Health NIo: Dietary supplement fact sheet: vitamin D . See http://www dietary-supplements info nih gov/factsheets/vitamind asp 2011. Jones G: The discovery and synthesis of the nutritional factor vitamin D . International journal of paleopathology 2018, 23 :96-99. Bischoff-Ferrari H: Vitamin D: What is an adequate vitamin D level and how much supplementation is necessary? Best Practice & Research Clinical Rheumatology 2009, 23 (6):789-795. OFFERS J: Vitamin D–Fact Sheet for Health Professionals . Lips P, Eekhoff M, van Schoor N, Oosterwerff M, de Jongh R, Krul-Poel Y, Simsek S: Vitamin D and type 2 diabetes . The Journal of steroid biochemistry and molecular biology 2017, 173 :280-285. Berridge MJ: Vitamin D deficiency and diabetes . Biochemical Journal 2017, 474 (8):1321-1332. de la Guía-Galipienso F, Martínez-Ferran M, Vallecillo N, Lavie CJ, Sanchis-Gomar F, Pareja-Galeano H: Vitamin D and cardiovascular health . Clinical Nutrition 2021, 40 (5):2946-2957. Sultan S, Taimuri U, Basnan SA, Ai-Orabi WK, Awadallah A, Almowald F, Hazazi A: Low vitamin D and its association with cognitive impairment and dementia . Journal of aging research 2020, 2020 . Ao T, Kikuta J, Ishii M: The effects of vitamin D on immune system and inflammatory diseases . Biomolecules 2021, 11 (11):1624. Menon V, Kar SK, Suthar N, Nebhinani N: Vitamin D and depression: a critical appraisal of the evidence and future directions . Indian journal of psychological medicine 2020, 42 (1):11-21. Silva MRM, Barros WMA, Silva MLd, Silva JMLd, Souza APdS, Silva ABJd, Fernandes MSdS, Souza SLd, Souza VdON: Relationship between vitamin D deficiency and psychophysiological variables: a systematic review of the literature . Clinics 2021, 76 . Holick MF, Binkley NC, Bischoff-Ferrari HA, Gordon CM, Hanley DA, Heaney RP, Murad MH, Weaver CM: Evaluation, treatment, and prevention of vitamin D deficiency: an Endocrine Society clinical practice guideline . The Journal of clinical endocrinology and metabolism 2011, 96 (7):1911-1930. Cashman KD: 100 YEARS OF VITAMIN D: Global differences in vitamin D status and dietary intake: a review of the data . Endocrine Connections 2022, 11 (1). Kotta S, Gadhvi D, Jakeways N, Saeed M, Sohanpal R, Hull S, Famakin O, Martineau A, Griffiths C: “Test me and treat me”—attitudes to vitamin D deficiency and supplementation: a qualitative study . BMJ open 2015, 5 (7):e007401. Al-Mutairi N, Issa BI, Nair V: Photoprotection and vitamin D status: A study on awareness, knowledge and attitude towards sun protection in general population from Kuwait, and its relation with vitamin D levels . Indian journal of dermatology, venereology and leprology 2012, 78 :342. Boland S, Irwin JD, Johnson AM: A survey of university students’ vitamin D–related knowledge . Journal of nutrition education and behavior 2015, 47 (1):99-103. Aljefree N, Lee P, Ahmed F: Exploring knowledge and attitudes about vitamin D among adults in Saudi Arabia: A qualitative study . In: Healthcare: 2017 : MDPI; 2017: 76. Deschasaux M, Souberbielle J-C, Partula V, Lécuyer L, Gonzalez R, Srour B, Guinot C, Malvy D, Latino-Martel P, Druesne-Pecollo N: What do people know and believe about vitamin D? Nutrients 2016, 8 (11):718. Arora H, Dixit V, Srivastava N: Evaluation of knowledge, practices of vitamin D and attitude toward sunlight among Indian students . Evaluation 2016, 9 (1):308. Alamoudi LH, Almuteeri RZ, Al-Otaibi ME, Alshaer DA, Fatani SK, Alghamdi MM, Safdar OY: Awareness of vitamin D deficiency among the general population in Jeddah, Saudi Arabia . Journal of nutrition and metabolism 2019, 2019 . AlBlooshi S, Al Anouti F, Hijazi R: Knowledge about Vitamin D among Women in the United Arab Emirates . International Journal of Environmental Research and public health 2023, 20 (2):1252. Ibrahim O, Al-Tameemi N, Dawoud D: Knowledge and perceptions of vitamin D deficiency among the United Arab Emirates population . Asian J Pharmaceut Clin Res 2019, 12 :183-186. Saleh A, Shibli F, El Masri J, Mouslem H, Odeh M, Fawaz H, Almealawy YF, Bdair A, Ghazi M, Alnajjar AH: Osteoporosis and vitamin D consumption: knowledge and practice in different Arab countries . Archives of Osteoporosis 2023, 18 (1):85. Zhou M, Zhuang W, Yuan Y, Li Z, Cai Y: Investigation on vitamin D knowledge, attitude and practice of university students in Nanjing, China . Public health nutrition 2016, 19 (1):78-82. Lhamo Y, Chugh PK, Gautam SR, Tripathi C: Epidemic of Vitamin D deficiency and its management: awareness among indian medical undergraduates . Journal of environmental and public health 2017, 2017 . Clark B, Doyle J, Bull O, McClean S, Hill T: Knowledge and attitudes towards vitamin D food fortification . Nutrition & Food Science 2019, 49 (3):346-358. Covington M: Omega-3 fatty acids . American family physician 2004, 70 (1):133-140. Alshahrani A: Knowledge, attitudes, and practice of community pharmacists towards providing counseling on vitamins, and nutritional supplements in Saudi Arabia . AIMS Public Health 2020, 7 (3):697-712. Altamimi M, Hamdan M, Badrasawi M, Allahham S: Knowledge, Attitudes and Practices Related to Dietary Supplements among a Group of Palestinian Pharmacists . Sultan Qaboos Univ Med J 2021, 21 (4):613-620. Alhomoud FK, Basil M, Bondarev A: Knowledge, attitudes and practices (KAP) relating to dietary supplements among health sciences and non-health sciences students in one of the universities of United Arab Emirates (UAE) . Journal of clinical and diagnostic research: JCDR 2016, 10 (9):JC05. El-Khateeb M, Khader Y, Batieha A, Jaddou H, Hyassat D, Khawaja N, Abujbara M, Ajlouni K: Vitamin D deficiency and associated factors in Jordan . SAGE Open Med 2019, 7 :2050312119876151. Emtawel Mohamed NA, Qerem WA, Gassar ES, Hailat M, Elhamdy FA, Ling J: A Need for Improvement in the Knowledge, Attitudes and Practice Toward Vitamin D Among University Students . Bahrain Medical Bulletin 2021, 43 (2). Alowais MA, Selim MAE: Knowledge, attitude, and practices regarding dietary supplements in Saudi Arabia . J Family Med Prim Care 2019, 8 (2):365-372. Alhomoud FK, Basil M, Bondarev A: Knowledge, Attitudes and Practices (KAP) Relating to Dietary Supplements Among Health Sciences and Non-Health Sciences Students in One of The Universities of United Arab Emirates (UAE) . J Clin Diagn Res 2016, 10 (9):Jc05-jc09. Tabachnick BG, Fidell LS, Ullman JB: Using multivariate statistics , vol. 6: pearson Boston, MA; 2013. Boynton PM: Administering, analysing, and reporting your questionnaire . Bmj 2004, 328 (7452):1372-1375. Hilleman DE, Teply R, Packard KA: Knowledge, Perceptions, and Patterns of Fish Oil Use in Cardiac Patients . Journal of Pharmacy Practice 2020, 33 (5):580-585. Sharma A, Adiga S, M A: Knowledge, attitude and practices related to dietary supplements and micronutrients in health sciences students . J Clin Diagn Res 2014, 8 (8):Hc10-13. Kambal N, Abdelwahab S, Albasheer O, Taha S, Abdelrahman N, Bani I, Alsayegh A, Shammaky E, Duwayri N, Alhazmi A et al : Vitamin D knowledge, awareness and practices of female students in the Southwest of Saudi Arabia: A cross-sectional study . Medicine (Baltimore) 2023, 102 (51):e36529. Alzahrani MM, Alghamdi AA, Alghamdi SA, Alotaibi RK: Knowledge and attitude of dentists towards obstructive sleep apnea . international dental journal 2022, 72 (3):315-321. Safdar O, Baajlan O, Alamri A, Dahmash R, Alloush A, Ateeq R, Albokhari S, Zaher ZF, Alghamdi M, Jiffri H: Assessment of knowledge and awareness of vitamin D among physicians and students of healthcare in Jeddah, Saudi Arabia . Australasian Medical Journal (Online) 2019, 12 (5):143-153. Vu LH, Van Der Pols JC, Whiteman DC, Kimlin MG, Neale RE: Knowledge and attitudes about vitamin D and impact on sun protection practices among urban office workers in Brisbane, Australia . Cancer epidemiology, biomarkers & prevention 2010, 19 (7):1784-1789. Christie FT, Mason L: Knowledge, attitude and practice regarding vitamin D deficiency among female students in Saudi Arabia: a qualitative exploration . International journal of rheumatic diseases 2011, 14 (3):e22-e29. Vallejo M, Blümel J, Arteaga E, Aedo S, Tapia V, Araos A, Sciaraffia C, Castelo-Branco C: Gender differences in the prevalence of vitamin D deficiency in a southern Latin American country: a pilot study . Climacteric 2020, 23 (4):410-416. Habib S, Alhalabi H, Alharbi K, Alghamdi O, Alghamdi A, Ajarem M, Alqarni M: Knowledge attitude and practices of university students to Vitamin D and Vitamin D supplements during times of low sun exposure and post lockdown . European Review for Medical & Pharmacological Sciences 2021, 25 (23). Alowais MA, Selim MAE-H: Knowledge, attitude, and practices regarding dietary supplements in Saudi Arabia . Journal of family medicine and primary care 2019, 8 (2):365-372. Roke K, Rattner J, Brauer P, Mutch DM: Awareness of omega-3 fatty acids and possible health effects among young adults . Canadian Journal of Dietetic Practice and Research 2018, 79 (3):106-112. Dimock M: Defining generations: Where Millennials end and Generation Z begins . Pew Research Center 2019, 17 (1):1-7. Galeshi R, Sharman J, Cai J: Influence of ethnicity, gender, and immigration status on millennials’ behavior related to seeking health information: Results from a national survey . Equality, Diversity and Inclusion: An International Journal 2018, 37 (6):621-631. Mason C, Xiao L, Imayama I, Duggan C, Wang C-Y, Korde L, McTiernan A: Vitamin D3 supplementation during weight loss: a double-blind randomized controlled trial . The American journal of clinical nutrition 2014, 99 (5):1015-1025. Hahn J, Cook NR, Alexander EK, Friedman S, Walter J, Bubes V, Kotler G, Lee I-M, Manson JE, Costenbader KH: Vitamin D and marine omega 3 fatty acid supplementation and incident autoimmune disease: VITAL randomized controlled trial . Bmj 2022, 376 . Rajabi‐Naeeni M, Dolatian M, Qorbani M, Vaezi AA: Effect of omega‐3 and vitamin D co‐supplementation on psychological distress in reproductive‐aged women with pre‐diabetes and Hypovitaminosis D: a randomized controlled trial . Brain and Behavior 2021, 11 (11):e2342. Borges-Vieira JG, Cardoso CKS: Efficacy of B-vitamins and vitamin D therapy in improving depressive and anxiety disorders: a systematic review of randomized controlled trials . Nutritional neuroscience 2023, 26 (3):187-207. Alhazmi A, Kuriakose BB, Mushfiq S, Muzammil K, Hawash MM: Prevalence, attitudes, and practices of dietary supplements among middle-aged and older adults in Asir region, Saudi Arabia: A cross-sectional study . Plos one 2023, 18 (10):e0292900. Tables Tables are available in the Supplementary Files section. Additional Declarations No competing interests reported. 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1","display":"","copyAsset":false,"role":"figure","size":123134,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u0026nbsp;\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7552460/v1/60e190ec0c9dffe6953f7bcd.png"},{"id":93146780,"identity":"09577041-b40d-4e16-a394-2b4cac76a335","added_by":"auto","created_at":"2025-10-09 13:57:58","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":272458,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u0026nbsp;\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7552460/v1/0c511fc86e8fd91953af4af9.png"},{"id":93146779,"identity":"09341a1a-a36f-4c77-b7f6-d6b721579d4e","added_by":"auto","created_at":"2025-10-09 13:57:58","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":176265,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u0026nbsp;\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7552460/v1/c9c31d102ac0b558ea889ff1.png"},{"id":93148255,"identity":"51059a61-3b8c-4f6c-8bb5-3268df95a6b4","added_by":"auto","created_at":"2025-10-09 14:22:01","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4398426,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7552460/v1/fc57f6df-9836-4407-8eb3-80722e8cb75b.pdf"},{"id":93147205,"identity":"82e54ec1-4983-4638-94c9-2e32a96773b0","added_by":"auto","created_at":"2025-10-09 14:05:58","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":30525,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-7552460/v1/8788f04b48d76ae3de497df7.docx"},{"id":93146786,"identity":"8677545e-2bfd-48d9-aaf0-cb62b1df9473","added_by":"auto","created_at":"2025-10-09 13:57:58","extension":"doc","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":85504,"visible":true,"origin":"","legend":"","description":"","filename":"STROBEchecklistcrosssectionalscore.doc","url":"https://assets-eu.researchsquare.com/files/rs-7552460/v1/50b2d110327dd38b40a5af53.doc"},{"id":93147207,"identity":"d59008e0-c7af-4217-adb9-977a98f7da3d","added_by":"auto","created_at":"2025-10-09 14:05:58","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":27681,"visible":true,"origin":"","legend":"","description":"","filename":"supplementoryfileforsimplelinearregressionresults.docx","url":"https://assets-eu.researchsquare.com/files/rs-7552460/v1/0bd4815ffaf7f62587a874e9.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Factors Affecting the Knowledge, Attitude and Practice of Vitamin D Supplement Use among adults: A Multi-Arab countries study","fulltext":[{"header":"Background","content":"\u003cp\u003eThe Dietary Supplement (DS), Health and Education Act of 1994 (DSHEA) defines dietary supplements (DS) as a wide range of non-food, non-drug substances meant to complement the diet but not necessarily to cure illnesses or disorders of the human body [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. DSs contain either a single nutrient or a combination of multivitamins, botanicals, amino acids, and minerals, including vitamins C, E, B-6, B-12, A, magnesium, zinc, and other substances with a nutritional or physiological effect [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. These supplements are available in different forms like pills, tablets, capsules, and liquids with measured doses [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. DSs are widely utilized in the United States [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], the Middle East [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], Asia [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], Canada [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], and some regions of Europe [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. A study conducted by Archer et al. found that 52% of the study participants acknowledged using at least one vitamin supplement [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Also, a significant portion of the adult population in both Japan and the US have had reported using DS [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eMore than 80% of the doctors and nurses informed their patients to use a different DS product [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] to avoid and manage long-term diseases like osteoporosis, heart disease, cancer, and birth problems in the neural tube [\u003cspan additionalcitationids=\"CR16 CR17\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. For example, getting enough calcium and vitamin D can help people with osteoporosis maintain strong bones and avoid fractures [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. A cross-sectional survey conducted in a Jordanian university revealed that 23% of students used vitamin-mineral supplements, with the main reason being to maintain good health [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Supplement use in adults tends to increase with age, income, and education. Interestingly, women are more inclined to use supplements compared to men within each age group [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eVitamin D is a fat-soluble metabolite that is necessary for numerous physiological systems to function properly, as well as normal human growth and development [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. There are two common forms: D-2 (ergocalciferol) and D-3 (cholecalciferol) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Both kinds may be gained by diet, although the options are restricted to fortified goods and certain fish species [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The first recommended dietary requirements for vitamin D consumption were established in 1941 [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. The sufficiency of vitamin D reserves is assessed by testing blood concentrations of 25-hydroxyvitamin D, where it is stated that serum concentrations in deficiency (\u0026lt;\u0026thinsp;20 ng/ml), sufficiency (20\u0026ndash;40 ng/ml), and optimum (30\u0026ndash;80 ng/ml) is debatable [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. The recommended daily dose for adults to obtain general health benefits starts from 600IU/day, as stated by the National Institutes of Health (NIH) [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Vitamin D deficiency and insufficiency are very common globally and are known to exacerbate a range of chronic disease states, including diabetes [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], cancer [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], cardiovascular disease [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], dementia [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], infectious illnesses [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], and depression [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Despite the prevalence of vitamin D deficiency [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] and low vitamin D intakes [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e], there is an absence of research on vitamin D-related knowledge, beliefs, and attitudes throughout the global population [\u003cspan additionalcitationids=\"CR38 CR39 CR40 CR41\" citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e] and in the Middle East [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e] populations. A small qualitative study conducted in Saudi Arabia [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e], the United Arab Emirates [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e] and other countries found limited knowledge about the health benefits of vitamin D and confusion about both dietary sources of vitamin D and the risks and benefits of sun exposure [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Similarly, populations in China [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e], India [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e], and the United Kingdom [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e] had low knowledge about vitamin D. It should be also noted that supplementation, fortification, and factors affecting the use of vitamin D supplements have rarely been studied. Our objectives were therefore, to ascertain possible variables influencing the usage of vitamin D supplements in a population of Arab nations as well as to examine knowledge, attitudes, and perceptions about vitamin D supplementation. The findings of this research are anticipated to contribute to the development of successful clinical and public health initiatives to encourage and optimize the use of vitamin D supplement.\u003c/p\u003e\u003cp\u003eDietary supplements have been used extensively in Arabian countries/Middle Eastern populations and have proven effective in many health sides of human well-being [\u003cspan additionalcitationids=\"CR51 CR52\" citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. Yet, there is no study documenting the factors that affect the use of vitamin D supplements in Arabian countries/Middle East, although there are studies highlighting the need for such investigation [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. Thus, this study aims to explore the factors that affect the knowledge, attitude, and practice of vitamin D supplementation in the adult population in Arabian countries/Middle East.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1. Study design and participants\u003c/h2\u003e\u003cp\u003eA self-administered questionnaire was administered using Google\u0026reg; Forms after reviewing similar studies in the literature [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]. The questionnaire was designed in English, then translated to Arabic before and back-translated to English by two academics fluent in both languages. Responses were collected in Arabic, the official spoken language of the participating countries (Saudi Arabia, Jordan, Egypt, and Iraq). The questionnaire was distributed using different social media platforms such as Facebook, Instagram, X, WhatsApp, and LinkedIn to collect individual responses from the target group from November 2023 to February 2024. As explicitly outlined at the beginning of the questionnaire before seeking informed consent, the inclusion criteria clearly stated that participants must be 18 years old and above.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2. Sample size\u003c/h2\u003e\u003cp\u003eIn line with Tabachnick and Fidell's recommendations for determining sample size in analysis, it is advised to aim for 5\u0026ndash;20 subjects per predictor [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e]. Given that this study incorporates ten independent variable levels, adhering to the guideline of 20 subjects per predictor, a minimum sample size of 200 or more was deemed appropriate. To accommodate potential missing responses and unforeseen issues, the decision was made to increase the sample size in each country.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.3. Questionnaire development, validation, and reliability\u003c/h2\u003e\u003cp\u003eThe study questionnaire was crafted, employing fundamental guidelines for effective survey design [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]. A pool of questions aligned with the study's objectives was generated by integrating information from various sources [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan additionalcitationids=\"CR61\" citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e]. The questionnaire comprised four sections featuring multiple-choice questions: sociodemographic, knowledge, attitudes, and practice toward omega 3.\u003c/p\u003e\u003cp\u003eFor content and face validity, five academics evaluated the English version of the study tool. Subsequently, it was translated into Arabic by two independent academic translators, employing translation and back-translation techniques. To enhance clarity and ensure comprehension of the questionnaire's items among the target population, consisting of individuals from diverse backgrounds (academic and professional), a pilot test was conducted with 30 participants. Linguistic refinements were implemented based on the feedback received during the pilot-testing phase. Notably, the responses gathered during the pilot were excluded from the final analyses. The reliability and internal consistency were checked, as Cronbach's \u003cem\u003eα\u003c/em\u003e was used to evaluate the reliability of the questionnaire (=\u0026thinsp;0\u0026sdot;8) for the Likert scale in the practice section and (=\u0026thinsp;0.7) for the attitude section, i.e., that the scales constructed are fit for their purpose, with values\u0026thinsp;\u0026ge;\u0026thinsp;0.7 indicating acceptable internal consistency.\u003c/p\u003e\u003cp\u003eThe questionnaire consisted of four main sections. The first section addressed the practices of the adult population in Arabian countries, and only participants who used vitamin D supplements proceeded to this section. Data collected in this section pertains to the physician and/or doctors\u0026rsquo; consultation, blood tests made before intake of the supplement, following the label directions, and the presence of the positive effect of vitamin D supplements. Also, participants were asked about any adverse events, the dose taken, any other supplements taken concomitantly, and the reason for intake. The second section assessed participants\u0026rsquo; knowledge of vitamin D supplements in seven main questions. Moreover, participants were asked about vitamin D supplements' possible influences on bones, brain, weight and cardiovascular.\u003c/p\u003e\u003cp\u003eAdditionally, participants were asked about the side effects of using vitamin D supplements and the source of information about vitamin D supplements (e.g., health care providers, nutritionists, social media, scientific articles, family and friends and others). The third section addressed participants\u0026rsquo; attitudes towards the use of vitamin D supplements. Based on a five-degree Likert scale ranging from strongly agree to disagree strongly, participants were requested to provide their opinion in seven questions about the effects vitamin D supplements in terms of the importance of supplement to overall human health, the safety of supplement dose, benefit to gut microbiota, possessing possible side effects and physician and/or doctors\u0026rsquo; consult before supplement intake. The fourth section addressed the demographics and lifestyle such as age, gender, marital status, weight, height, education level, monthly income, place of residence, being health insured, having chronic diseases or not, physical activity and smoking status.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e2.4. Score calculation\u003c/h2\u003e\u003cp\u003eScores of knowledge, attitude and practice were calculated and presented as median value (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\pm\\:\\text{i}\\text{n}\\text{t}\\text{e}\\text{r}\\text{q}\\text{u}\\text{a}\\text{r}\\text{t}\\text{i}\\text{l}\\text{e}\\:\\text{r}\\text{a}\\text{n}\\text{g}\\text{e}\\:\\left(\\text{I}\\text{Q}\\text{R}\\right))\\:\\)\u003c/span\u003e\u003c/span\u003eat end of each section in results. Knowledge statements were awarded 1 mark for each correct answer, while the attitude statements were awarded highest 5 marks for the positive attitude and practice were awarded highest 5 marks for the positive practice as a 5-degree Likert-scale. Bloom\u0026rsquo;s cutoff was used to interpret the score values [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e], where 80%-100% was considered high level of knowledge/ positive attitude/ good practice, 60%-79% moderate level of knowledge/ neutral attitude/ moderate practice and \u0026lt;\u0026thinsp;60% low level of knowledge/ negative attitude/ poor practice .\u003c/p\u003e\u003c/div\u003e\n\u003ch2\u003e\u003cstrong\u003e2.5.\u0026nbsp;Ethical approval\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe study was approved by the Institutional/Local Research Ethics Committee, Amman, Jordan (Approval number: 2023-PHA-50). All participants agreed to participate in the study by selecting \u0026ldquo;I agree\u0026rdquo; on the electronic informed consent form before filling out the questionnaire. All methods were performed in accordance with the relevant guidelines and regulations or declaration of Helsinki.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003e2.6.\u0026nbsp;Statistical analysis\u0026nbsp;\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eData were extracted from Google Forms into an Excel spreadsheet and were then exported and statistically analyzed using Statistical Package for Social Sciences version 24.0 (SPSS Inc., Chicago, IL, USA). Descriptive statistical analysis was used to analyze the median and interquartile range for continuous variables and normality was checked using Shapiro-Wilks test showing \u003cem\u003ep\u003c/em\u003e-value of \u0026lt;0.001, not normally distributed data. Categorical variables were demonstrated as frequencies and percentages. A simple linear regression was used to figure out whether there is an association between the scores of knowledge, attitude and practice with the dichotomous variables presenting standardized Beta correlation coefficients and \u003cem\u003ep\u003c/em\u003e-values. A \u003cem\u003ep\u003c/em\u003e-value of \u0026lt;0\u0026sdot;250 was set to determine if the variable is eligible for multi-linear regression analysis. In multi-linear regression analysis, a \u003cem\u003ep\u003c/em\u003e-value of \u0026lt;0\u0026sdot;05 was set to represent a significant difference. Graphical representation was made using MS Excel (version 16.81).\u003c/p\u003e"},{"header":"Results","content":"\u003ch2\u003e\u003cstrong\u003e3.1. Demographics\u0026nbsp;\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eOur sample reached 1352 responses, with 1340 approved responses included in the final study analysis (response rate = 99.1%). The demographic and lifestyle characteristics of the participants are demonstrated in Table 1. Saudi Arabia sample represented the highest percentage (\u003cem\u003en\u003c/em\u003e=412, 30.8%) of the total responses, whereas Egypt had (\u003cem\u003en\u003c/em\u003e=400, 29.9%), Jordan (\u003cem\u003en\u003c/em\u003e=310, 23.1%), and Iraq (\u003cem\u003en\u003c/em\u003e=217, 16.2%) had lower percentages in the total sample size. There was a predominance of female participants in all four participating countries, with the highest percentage of females in Jordan (\u003cem\u003en\u003c/em\u003e=252, representing 81.3% of Jordan\u0026rsquo;s sample) compared with males and other countries. The median \u0026plusmn; IQR age of the respondents was 35\u0026plusmn; 13 years old for Saudi Arabia, 30\u0026plusmn;12.5years for Egypt, 25\u0026plusmn;10.5 years for Jordan and 28\u0026plusmn;6.75 years for Iraq respondents. Most of the study sample had bachelor\u0026apos;s degrees, with the highest n=152 (70%) from the Iraq sample and lived in the urban area of Iraq (\u003cem\u003en\u003c/em\u003e=204, 94%). More than half of respondents work in areas related to the medical field in Egypt, Jordan and Iraq, while only 19.6% work in areas not related to the medical field from the Saudi Arabia sample. Most participants were non-smokers from all countries and more than 80% of each country\u0026rsquo;s respondents had no chronic diseases, as shown in \u003cstrong\u003eTable1.\u003c/strong\u003e\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003e3.2. Knowledge, attitude and practice scores of countries\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eMedian knowledge score showed that Egypt, Jordan and Iraq had a moderate level of knowledge regarding vitamin D supplement use (11\u0026plusmn;3, 11\u0026plusmn;2, 11 ,respectively, while Saudi Arabia had low levels of knowledge (7 . Moreover, the median attitude scores showed neutral attitude levels for all countries as shown in Table 2. On the other hand, only Jordan and Iraq had good levels of median practice scores (17\u0026plusmn;5, 16\u0026plusmn;5), while Saudi Arabia and Egypt had moderate levels of practice (13\u0026plusmn;3, 15\u0026plusmn;5\u003c/p\u003e\n\u003cp\u003eThe main source of information for the Saudi Arabia sample was seen to be friends and family (35.7%). Egypt mainly depended on the internet and social media as their main source of information regarding vitamin D supplement use, as shown in \u003cstrong\u003eFigure 1\u003c/strong\u003e. Moreover, participants in Saudi Arabia had a higher concurrent use of several vitamins and minerals with vitamin D than participants in other countries. It was noticed in our study that Saudi respondents were using vitamin D with omega-3, specifically in the highest amount compared to other vitamins/minerals (84.1%). Jordan and Iraq (11.4% and 15.7% respectively) had the least use of concurrent use of vitamin E alongside vitamin D. Meanwhile, Egypt, Jordan, and Iraq had the lowest percentage of use of K2 with vitamin D (11.4%, 9.7%, 17.4% respectively as shown in \u003cstrong\u003eFigure 2\u003c/strong\u003e.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003e3.3. Multi-linear regression of dichotomous variables for each country\u0026nbsp;\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eIt was perceived through the multilinear regression analysis that the knowledge score between Saudi Arabian participants was mainly higher among non-university (\u003cem\u003ep\u003c/em\u003e-value = 0.035), non-insurance covered (\u003cem\u003ep\u003c/em\u003e-value = 0.017) and younger in age (\u003cem\u003ep\u003c/em\u003e-value = 0.060). While the attitude score was seen to affect the practice behavior of participants positively (\u003cem\u003ep\u003c/em\u003e-value \u0026lt;0.001). Likewise, practice score was seen to be higher among participants of younger age also (p-value \u0026lt;0.001), and practice scores were higher among higher attitude scores, as shown in \u003cstrong\u003eTable 3\u003c/strong\u003e. It was perceived that the knowledge score between Egyptian participants was mainly higher among those who do not work in areas related to the health sector (\u003cem\u003ep\u003c/em\u003e-value \u0026lt;0.001) and are not physically active (\u003cem\u003ep\u003c/em\u003e-value=0.006). The attitude score was seen to be higher with a higher practice score (\u003cem\u003ep\u003c/em\u003e-value \u0026lt;0.001) and higher knowledge score ((\u003cem\u003ep\u003c/em\u003e-value =0.018). Practice score was seen higher among higher attitude scores (\u003cem\u003ep\u003c/em\u003e-value \u0026lt;0.001).\u003c/p\u003e\n\u003cp\u003eJordanian\u0026apos;s knowledge score was detected to be higher among males (p-value= 0.027) who are working in areas not related to the health sector (\u003cem\u003ep\u003c/em\u003e-value\u0026lt;0.001). While the knowledge score was higher with higher attitude scores (\u003cem\u003ep\u003c/em\u003e-value=0.019). Attitude seemed to be having higher scores with higher practice scores (\u003cem\u003ep\u003c/em\u003e-value =0.005) and higher knowledge score (\u003cem\u003ep\u003c/em\u003e-value =0.019). Meanwhile, practice was noticed to be affecting the attitude of Jordanian participants, meaning, practice score was perceived higher with higher attitude score (\u003cem\u003ep\u003c/em\u003e-value =0.005) between male gender (\u003cem\u003ep\u003c/em\u003e-value \u0026lt;0.001) who have no insurance coverage (\u003cem\u003ep\u003c/em\u003e-value =0.012). Iraqi\u0026rsquo;s knowledge score was detected to be higher among those who are working in areas not related to the health sector (\u003cem\u003ep\u003c/em\u003e-value \u0026lt;0.001) and affecting attitude scores positively (\u003cem\u003ep\u003c/em\u003e-value\u0026lt;0.001). The attitude score was higher among younger Iraqi participants (\u003cem\u003ep\u003c/em\u003e-value=0.035) and is higher with higher practice scores (\u003cem\u003ep\u003c/em\u003e-value\u0026lt;0.001) and knowledge scores (\u003cem\u003ep\u003c/em\u003e-value\u0026lt;0.001). Similarly, practice scores were higher among Iraqi males (\u003cem\u003ep\u003c/em\u003e-value=0.004) and those who do not have chronic diseases (\u003cem\u003ep\u003c/em\u003e-value=0.034). Meanwhile, practice score was noticed to be affecting the attitude of Iraqi participants, meaning practice score was perceived higher with higher attitude score (\u003cem\u003ep\u003c/em\u003e-value \u0026lt;0.001) as shown in \u003cstrong\u003eTable 3\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003eIt was comprehended in our study that the two main reasons to take vitamin D supplements were to maintain general health and for vitamin deficiency intentions. It was obvious that Saudi Arabian participants had the highest supplement intake reason for maintaining of general health reaching 90%, followed by Jordanian participants reaching 84.1%. While the vitamin deficiency reason was 89.8% for Egypt and 86.6% for Iraqi participants as seen in \u003cstrong\u003eFigure 3\u003c/strong\u003e.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur study aimed to investigate factors affecting the knowledge, attitude and practice of vitamin D supplement use among Arabian adults living in Saudi Arabia, Jordan, Egypt and Iraq. Our study participants were from Saudi Arabia, with the highest response percentage (n=412, 30.8%), followed by Egypt, Jordan, and Iraq. Most of the study participants were female in all participating countries. In terms of marital status, most of the participants from Iraq (59%), Egypt (61.3%), and Jordan (68.1%) samples were single. On the other hand, a more significant part of the participants (68.5%) from Saudi Arabia were married. In the four countries in our study, most participants lived in urban areas, especially Iraqi participants (94%), did not have any chronic diseases, and were nonsmokers. More than half of the participants were covered by insurance in Saudi Arabia (63.9%), Egypt (66%), and Jordan (64.8%), while only 27.7% of the respondents from the Iraq sample had insurance coverage. \u003c/p\u003e\n\u003cp\u003eThe results of this study showed that participants from Egypt, Jordan, and Iraq had a moderate level of knowledge regarding vitamin D supplement use ( 3, 11 2, and 11 3, respectively), while Saudi Arabia had a low levels of knowledge (7 ). Also, there was a direct correlation between higher knowledge scores and higher attitude scores in respondents from Egypt, Jordan, and Iraq (p=0.018,0.019, \u0026lt;0.001, respectively). Moreover, it was noticed that participants from Egypt, Jordan, and Iraq had a higher knowledge score among those who do not work in areas related to the medical field (p\u0026lt;0.001, \u0026lt;0.001, \u0026lt;0.001, respectively). Likewise, a study highlighted the need for more knowledge about vitamin D deficiency among healthcare workers in Jeddah, Saudi Arabia [64]. In addition, our study showed a direct correlation of younger adults with higher knowledge scores only in participants from the Saudi Arabia sample (p=0.060). However, most studies in the literature showed that older adults were the most aware of vitamin D compared to all other age groups and had better levels of knowledge [41, 65]. Additionally, higher knowledge scores were found in male participants rather than female gender in the Jordan sample (p\u0026lt;0.001); this point was supported by a study that showed limited knowledge about Vitamin D among female students in Saudi Arabia [66]. This finding might result from the higher prevalence of vitamin D deficiency in men than women, as observed in Vallejo et al., 2020 study [67]. On the other hand, a study showed that women knew more than men when it came to sources of vitamin D [41]. Interestingly, in our study, non-university participants in Saudi Arabia exhibited higher knowledge scores (p=0.035); this result is similar to a result from another study that was conducted in Canada in which the knowledge of vitamin D among university students was observed to be low [39]. Similarly, another study conducted at King Saud University in Riyadh demonstrated that all university students need more knowledge regarding vitamin D [68]. Moreover, in our study, physically inactive participants from the Egypt sample had higher knowledge scores (p=0.006); a similar finding was reported in another study in which only 30% of dietary supplement users exercised regularly [69]. One explanation is that individuals with low physical activity tend to look for vitamins to compensate for their inactivity and enhance their health in intentions to be more active.\u003c/p\u003e\n\u003cp\u003eFurthermore, good levels of practice were observed in Jordan (17\u0026plusmn;5) and Iraq (16 ), whereas Saudi Arabia (13 ) and Egypt (15\u0026plusmn;5) had moderate levels of practice. In our study, the main sources of information regarding vitamin D supplements use in Egypt and Jordan sample were the internet and social media, implying that these kinds of resources had become a fundamental source of health and nutrition-related knowledge [70]. Also, it is worth to mention the age of participants in the present study is between 25-35 years old, this age group is considered the millennial age (age between 27 and 42 years old), where they tend to have a behavior of seeking information with minimum efforts and expenses met by internet resources[71, 72] . At the same time, Saudi Arabia have gained information about vitamin D supplements used by friends and family. Our finding was consistent with another literature finding regarding the source of information in non-medical students, where it was stated that using friends and family as information sources was far more common among non-medical students [9]. As (80.4%) of the Saudi Arabia sample in our study were not working in the medical field, the literature supports our result. In addition, the higher interpersonal communications and family connections might be the reason for obtaining information from friends and family in the Saudi Arabia sample.\u003c/p\u003e\n\u003cp\u003eEgypt, Jordan and Iraq samples were seen to use vitamin D supplements because of vitamin D deficiency. Participants in Saudi Arabia have used vitamin D supplements to maintain general good health, which aligns with a study from literature [9]. Most of the participants in our study did not use vitamin D supplements for weight loss, suggesting the insignificant role of vitamin D in weight loss, where it was mentioned in a study that found that vitamin D supplements did not enhance weight loss when compared with placebo [73]. Moreover, our study reported the highest percentage (84.1%) of the concurrent use of Omega-3 alongside vitamin D was in participants from Saudi Arabia; the expected synergistic effect of this combination could help to explain this practice, two studies revealed that the combination of vitamin D and omega-3 reduced autoimmune diseases and improved mental health in pre-diabetic women with vitamin D insufficiency [74, 75]. However, participants from Egypt and Iraq (46.9% and 43.6%, respectively) had the highest percentages of concurrent use of B-complex besides vitamin D. A literature study suggested that the use of B vitamins and/or vitamin D may be useful in alleviating symptoms of depression and anxiety [76]. Our study also showed a neutral attitude level for all four participating countries. Younger participants from Iraq sample showed higher levels of attitude, although in one study showed that older adults were found to have a considerably greater positive attitude towards dietary supplements (68%) in comparison with middle-aged adults (47.5%) [77]. Generally, this study gives an insight regarding knowledge, attitude, and practice of vitamin D supplement use among Arabian adults in the Middle East, on the other hand, limitations and obstacles were observed during the study and hence more investigation is required to elaborate and explain further factors effect on knowledge, attitude and practice of Middle Eastern population.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.1. Limitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study\u0026rsquo;s investigation into vitamin D supplementation among Arabian adults in Saudi Arabia, Jordan, Iraq, and Egypt has provided critical insights. Nonetheless, the research design presents several limitations that warrant consideration. The sample distribution was inconsistent across the participating nations, potentially leading to an over-representation of urban respondents, which may affect the applicability of the findings to the entire Arabian adult population. There was also a disparity in gender representation, with an uneven distribution between male and female participants. A significant proportion of the study\u0026rsquo;s respondents, particularly in Jordan, Iraq, and Egypt, were affiliated with the health sector, either through employment or education, holding at least a bachelor\u0026rsquo;s degree. This concentration of participants with a health background and higher education levels may have influenced their responses regarding vitamin D supplementation, suggesting a need for caution when extrapolating these findings to a broader audience.\u003c/p\u003e\n\u003cp\u003eThe study\u0026rsquo;s reliance on self-reported questionnaire data may have introduced variations in the accuracy of the responses due to factors such as social conformity and memory reliability. Additionally, the online survey format may not have reached individuals without internet access, suggesting a need for alternative data collection methods in future research. Despite these considerations, the study offers valuable preliminary data that lays the foundation for future research directions. Subsequent investigations should delve into the influence of cultural factors on supplement use and employ diverse data collection methodologies to include a broader spectrum of participants, thereby enhancing the robustness and representativeness of the findings.\u003c/p\u003e\n\u003cp\u003eThe outcomes of this multinational survey highlight a notable disparity in Arabian adults\u0026apos; knowledge, attitudes, and practices around the usage of vitamin D supplements. Despite the well-documented benefits of Vitamin D, there is a general awareness that only sometimes translates into proactive health behaviors or a positive attitude toward supplementing. This disconnect indicates a pressing need for public health initiatives to bridge the gap between awareness and action. Interestingly, the study discovered that those who did not work in the health industry had better levels of awareness regarding vitamin D in most countries evaluated. This paradoxical scenario warrants attention from health policymakers, who should strive to address and rectify this anomaly. Health policymakers should pay attention to this contradictory situation and work to address and correct this abnormality. Future research could expand on these findings by exploring the role of healthcare providers in influencing supplement choices and the impact of targeted education on supplement adherence. Such studies could pave the way for more nuanced health policies and a more health-literate populace.\u003c/p\u003e\n\u003cp\u003ePolicymakers should encourage healthcare professionals to engage in ongoing professional development activities, like visiting conferences and seminars that provide the latest information on supplements. Educational programs should clarify the importance of vitamin D for general health and the dangers of vitamin D insufficiency. Promoting a more knowledgeable mindset increases people\u0026apos;s likelihood of healthily taking supplements. Since online platforms are the primary information source, digital outreach may successfully capture the target audience\u0026apos;s attention. Healthcare professionals should lead these initiatives, offering tailored advice that meets the population\u0026apos;s cultural and health-specific needs.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study provides valuable insights into the knowledge, attitudes, and practices surrounding vitamin D supplementation across diverse Saudi Arabia, Egypt, Jordan, and Iraq populations. The findings underscore the need for targeted educational interventions, particularly in Saudi Arabia, where lower levels of knowledge were observed. Additionally, the study identifies demographic factors, such as age, gender, and occupation, influencing individuals\u0026apos; understanding and behaviors related to vitamin D.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe implications of this research extend to public health initiatives aiming to enhance vitamin D awareness and optimize supplementation practices. Tailored educational campaigns should address specific knowledge gaps, focusing on younger individuals and those outside the health sector. Furthermore, efforts to promote positive attitudes and practices, particularly in regions with moderate to low levels of understanding, can contribute to improved overall health outcomes. Longitudinal studies could investigate the long-term impact of targeted educational interventions on knowledge retention and behavioral changes. Exploring cultural influences and regional variations in vitamin D awareness may provide additional context for designing effective public health strategies. Moreover, assessing the correlation between vitamin D supplementation practices and health outcomes could offer valuable insights into the practical implications of improved knowledge and attitudes.\u003c/p\u003e\n"},{"header":"Abbreviations","content":"\u003cp\u003eInterquartile range (IQR), Dietary Supplement (DS), Health and Education Act of 1994 (DSHEA)\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u003cbr\u003eThe study protocol was reviewed and approved by the Institutional Review Board (IRB) of the Applied Science Private University in Amman, Jordan (Approval No.: 2023-PHA-50). Participation was voluntary, and written informed consent was obtained from all participants prior to enrollment. The study was conducted in accordance with the Declaration of Helsinki and national ethical guidelines.\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003cbr\u003e\u0026nbsp;Not applicable. The manuscript does not contain any individual participant data, images, or personal information requiring consent for publication.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003cbr\u003e\u0026nbsp;The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003cbr\u003e\u0026nbsp;The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors contribution\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eM.B., S.B.A., and M.A.A. conceptualized the study. Data curation was performed by S.B.A., while formal analysis and investigation were carried out by M.B. and S.B.A. The methodology was developed by M.B., S.B.A., M.A.A., and A.O. Project administration was handled by M.B., S.B.A., and M.A.A. Resources and data collection were contributed by S.B.A., D.R., A.K., and M.B.B. Supervision was provided by M.B., S.B.A., and M.A.A. Validation was conducted by M.B., S.B.A., M.A.A., and A.O. Visualization was completed by M.B., A.O., and M.A.A. The original draft was written by S.B.A., D.R., A.K., and M.B.B., while review and editing were carried out by M.B., S.B.A., W.A., M.A.S., R.A and M.A.A. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003eThe authors would like to thank all participants for their valuable time and cooperation. The authors also acknowledge the support of the Applied Science Private University in facilitating data collection and ethical oversight.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSeamon MJ, Clauson KA: \u003cstrong\u003eEphedra: yesterday, DSHEA, and tomorrow\u0026mdash;a ten year perspective on the Dietary Supplement Health and Education Act of 1994\u003c/strong\u003e. \u003cem\u003eJournal of herbal pharmacotherapy \u003c/em\u003e2005, \u003cstrong\u003e5\u003c/strong\u003e(3):67-86.\u003c/li\u003e\n\u003cli\u003eShahwan M, Al Abdin SMZ: \u003cstrong\u003eKnowledge and practice of dietary supplement and micronutrients among medical students at Ajman University\u003c/strong\u003e. \u003cem\u003eJournal of Pharmaceutical Sciences and Research \u003c/em\u003e2018, \u003cstrong\u003e10\u003c/strong\u003e(1):85-90.\u003c/li\u003e\n\u003cli\u003eHaines ST, Park SK: \u003cstrong\u003eVitamin D supplementation: what\u0026apos;s known, what to do, and what\u0026apos;s needed\u003c/strong\u003e. \u003cem\u003ePharmacotherapy: The Journal of Human Pharmacology and Drug Therapy \u003c/em\u003e2012, \u003cstrong\u003e32\u003c/strong\u003e(4):354-382.\u003c/li\u003e\n\u003cli\u003eBailey RL, Gahche JJ, Lentino CV, Dwyer JT, Engel JS, Thomas PR, Betz JM, Sempos CT, Picciano MF: \u003cstrong\u003eDietary supplement use in the United States, 2003\u0026ndash;2006\u003c/strong\u003e. \u003cem\u003eThe Journal of nutrition \u003c/em\u003e2011, \u003cstrong\u003e141\u003c/strong\u003e(2):261-266.\u003c/li\u003e\n\u003cli\u003eRadwan H, Hasan HA, Ghanem L, Alnajjar G, Shabir A, Alshamsi A, Alketbi F: \u003cstrong\u003ePrevalence of dietary supplement use and associated factors among college students in the United Arab Emirates\u003c/strong\u003e. \u003cem\u003eJournal of Community Health \u003c/em\u003e2019, \u003cstrong\u003e44\u003c/strong\u003e:1135-1140.\u003c/li\u003e\n\u003cli\u003eNaqvi AA, Ahmad R, Elewi AAW, AlAwa AH, Alasiri MJ: \u003cstrong\u003eDietary supplement use among undergraduate male students in health and non-health cluster colleges of a public-sector university in Dammam, Saudi Arabia\u003c/strong\u003e. \u003cem\u003eBMC complementary and alternative medicine \u003c/em\u003e2018, \u003cstrong\u003e18\u003c/strong\u003e:1-11.\u003c/li\u003e\n\u003cli\u003eNaqvi AA, Ahmad R, Zehra F, Yousuf R, Kachela B, Nehal Nadir M: \u003cstrong\u003eDietary supplement use among students of pharmacy colleges in the City of Karachi, Pakistan: prevalence, opinions, and attitudes\u003c/strong\u003e. \u003cem\u003eJournal of dietary supplements \u003c/em\u003e2019, \u003cstrong\u003e16\u003c/strong\u003e(2):166-178.\u003c/li\u003e\n\u003cli\u003eEl Khoury D, Hansen J, Tabakos M, Spriet LL, Brauer P: \u003cstrong\u003eDietary supplement use among non-athlete students at a Canadian university: a pilot-survey\u003c/strong\u003e. \u003cem\u003eNutrients \u003c/em\u003e2020, \u003cstrong\u003e12\u003c/strong\u003e(8):2284.\u003c/li\u003e\n\u003cli\u003eŽeželj SP, Tomljanović A, Jovanović GK, Kre\u0026scaron;ić G, Peloza OC, Draga\u0026scaron;-Zubalj N, Prokurica IP: \u003cstrong\u003ePrevalence, Knowledge and Attitudes Concerning Dietary Supplements among a Student Population in Croatia\u003c/strong\u003e. \u003cem\u003eInternational Journal of Environmental Research and Public Health \u003c/em\u003e2018, \u003cstrong\u003e15\u003c/strong\u003e(6):1058.\u003c/li\u003e\n\u003cli\u003eArcher SL, Stamler J, Moag-Stahlberg A, Van Horn L, Garside D, Chan Q, Buffington JJ, Dyer AR: \u003cstrong\u003eAssociation of dietary supplement use with specific micronutrient intakes among middle-aged American men and women: the INTERMAP Study\u003c/strong\u003e. \u003cem\u003eJournal of the American Dietetic Association \u003c/em\u003e2005, \u003cstrong\u003e105\u003c/strong\u003e(7):1106-1114.\u003c/li\u003e\n\u003cli\u003eImai T, Nakamura M, Ando F, Shimokata H: \u003cstrong\u003eDietary supplement use by community-living population in Japan: data from the National Institute for Longevity Sciences Longitudinal Study of Aging (NILS-LSA)\u003c/strong\u003e. \u003cem\u003eJournal of epidemiology \u003c/em\u003e2006, \u003cstrong\u003e16\u003c/strong\u003e(6):249-260.\u003c/li\u003e\n\u003cli\u003eGarcia-Cazarin ML, Wambogo EA, Regan KS, Davis CD: \u003cstrong\u003eDietary supplement research portfolio at the NIH, 2009\u0026ndash;2011\u003c/strong\u003e. \u003cem\u003eThe Journal of nutrition \u003c/em\u003e2014, \u003cstrong\u003e144\u003c/strong\u003e(4):414-418.\u003c/li\u003e\n\u003cli\u003eGhosn SA, Addison B, Ali MD: \u003cstrong\u003eCommunity Pharmacist\u0026apos;s Knowledge, Attitude, and Practices towards Vitamin Supplements in Al-Khobar Region, Saudi Arabia: A Descriptive Cross-Sectional Study\u003c/strong\u003e. \u003cem\u003eJournal of pharmacy \u0026amp; bioallied sciences \u003c/em\u003e2019, \u003cstrong\u003e11\u003c/strong\u003e(4):333-340.\u003c/li\u003e\n\u003cli\u003eDickinson A, Boyon N, Shao A: \u003cstrong\u003ePhysicians and nurses use and recommend dietary supplements: report of a survey\u003c/strong\u003e. \u003cem\u003eNutrition journal \u003c/em\u003e2009, \u003cstrong\u003e8\u003c/strong\u003e:1-6.\u003c/li\u003e\n\u003cli\u003eHou Y-C, Wu C-C, Liao M-T, Shyu J-F, Hung C-F, Yen T-H, Lu C-L, Lu K-C: \u003cstrong\u003eRole of nutritional vitamin D in osteoporosis treatment\u003c/strong\u003e. \u003cem\u003eClinica chimica acta \u003c/em\u003e2018, \u003cstrong\u003e484\u003c/strong\u003e:179-191.\u003c/li\u003e\n\u003cli\u003eCarlberg C, Mu\u0026ntilde;oz A: \u003cstrong\u003eAn update on vitamin D signaling and cancer\u003c/strong\u003e. In: \u003cem\u003eSeminars in cancer biology: 2022\u003c/em\u003e: Elsevier; 2022: 217-230.\u003c/li\u003e\n\u003cli\u003eSeraphin G, Rieger S, Hewison M, Capobianco E, Lisse TS: \u003cstrong\u003eThe impact of vitamin D on cancer: A Mini Review\u003c/strong\u003e. \u003cem\u003eThe Journal of Steroid Biochemistry and Molecular Biology \u003c/em\u003e2023:106308.\u003c/li\u003e\n\u003cli\u003eAdrien N, Orta OR, Nestoridi E, Carmichael SL, Yazdy MM, Study NBDP: \u003cstrong\u003eEarly pregnancy vitamin D status and risk of select congenital anomalies in the National Birth Defects Prevention Study\u003c/strong\u003e. \u003cem\u003eBirth Defects Research \u003c/em\u003e2023, \u003cstrong\u003e115\u003c/strong\u003e(3):290-301.\u003c/li\u003e\n\u003cli\u003eEleni A, Panagiotis P: \u003cstrong\u003eA systematic review and meta-analysis of vitamin D and calcium in preventing osteoporotic fractures\u003c/strong\u003e. \u003cem\u003eClinical rheumatology \u003c/em\u003e2020, \u003cstrong\u003e39\u003c/strong\u003e(12):3571-3579.\u003c/li\u003e\n\u003cli\u003eMendes MM, Sahni S: \u003cstrong\u003eCalcium and vitamin D in the management of osteoporosis\u003c/strong\u003e. In: \u003cem\u003eMarcus and Feldman\u0026apos;s Osteoporosis.\u003c/em\u003e edn.: Elsevier; 2021: 1665-1678.\u003c/li\u003e\n\u003cli\u003eIbrahim MO: \u003cstrong\u003eResearch Article Nutritional Epidemiology Study: Prevalence of Vitamin and Mineral Supplement Use and Correlated Factors among University Students in Jordan\u003c/strong\u003e. \u003cem\u003ePakistan Journal of Nutrition \u003c/em\u003e2018, \u003cstrong\u003e17\u003c/strong\u003e(12):654-660.\u003c/li\u003e\n\u003cli\u003eIshihara J, Sobue T, Yamamoto S, Sasaki S, Tsugane S: \u003cstrong\u003eDemographics, lifestyles, health characteristics, and dietary intake among dietary supplement users in Japan\u003c/strong\u003e. \u003cem\u003eInternational Journal of Epidemiology \u003c/em\u003e2003, \u003cstrong\u003e32\u003c/strong\u003e(4):546-553.\u003c/li\u003e\n\u003cli\u003eDominguez LJ, Farruggia M, Veronese N, Barbagallo M: \u003cstrong\u003eVitamin D sources, metabolism, and deficiency: available compounds and guidelines for its treatment\u003c/strong\u003e. \u003cem\u003eMetabolites \u003c/em\u003e2021, \u003cstrong\u003e11\u003c/strong\u003e(4):255.\u003c/li\u003e\n\u003cli\u003eHealth NIo: \u003cstrong\u003eDietary supplement fact sheet: vitamin D\u003c/strong\u003e. \u003cem\u003eSee \u003c/em\u003e\u003cem\u003ehttp://www\u003c/em\u003e\u003cem\u003e dietary-supplements info nih gov/factsheets/vitamind asp \u003c/em\u003e2011.\u003c/li\u003e\n\u003cli\u003eJones G: \u003cstrong\u003eThe discovery and synthesis of the nutritional factor vitamin D\u003c/strong\u003e. \u003cem\u003eInternational journal of paleopathology \u003c/em\u003e2018, \u003cstrong\u003e23\u003c/strong\u003e:96-99.\u003c/li\u003e\n\u003cli\u003eBischoff-Ferrari H: \u003cstrong\u003eVitamin D: What is an adequate vitamin D level and how much supplementation is necessary?\u003c/strong\u003e \u003cem\u003eBest Practice \u0026amp; Research Clinical Rheumatology \u003c/em\u003e2009, \u003cstrong\u003e23\u003c/strong\u003e(6):789-795.\u003c/li\u003e\n\u003cli\u003eOFFERS J: \u003cstrong\u003eVitamin D\u0026ndash;Fact Sheet for Health Professionals\u003c/strong\u003e.\u003c/li\u003e\n\u003cli\u003eLips P, Eekhoff M, van Schoor N, Oosterwerff M, de Jongh R, Krul-Poel Y, Simsek S: \u003cstrong\u003eVitamin D and type 2 diabetes\u003c/strong\u003e. \u003cem\u003eThe Journal of steroid biochemistry and molecular biology \u003c/em\u003e2017, \u003cstrong\u003e173\u003c/strong\u003e:280-285.\u003c/li\u003e\n\u003cli\u003eBerridge MJ: \u003cstrong\u003eVitamin D deficiency and diabetes\u003c/strong\u003e. \u003cem\u003eBiochemical Journal \u003c/em\u003e2017, \u003cstrong\u003e474\u003c/strong\u003e(8):1321-1332.\u003c/li\u003e\n\u003cli\u003ede la Gu\u0026iacute;a-Galipienso F, Mart\u0026iacute;nez-Ferran M, Vallecillo N, Lavie CJ, Sanchis-Gomar F, Pareja-Galeano H: \u003cstrong\u003eVitamin D and cardiovascular health\u003c/strong\u003e. \u003cem\u003eClinical Nutrition \u003c/em\u003e2021, \u003cstrong\u003e40\u003c/strong\u003e(5):2946-2957.\u003c/li\u003e\n\u003cli\u003eSultan S, Taimuri U, Basnan SA, Ai-Orabi WK, Awadallah A, Almowald F, Hazazi A: \u003cstrong\u003eLow vitamin D and its association with cognitive impairment and dementia\u003c/strong\u003e. \u003cem\u003eJournal of aging research \u003c/em\u003e2020, \u003cstrong\u003e2020\u003c/strong\u003e.\u003c/li\u003e\n\u003cli\u003eAo T, Kikuta J, Ishii M: \u003cstrong\u003eThe effects of vitamin D on immune system and inflammatory diseases\u003c/strong\u003e. \u003cem\u003eBiomolecules \u003c/em\u003e2021, \u003cstrong\u003e11\u003c/strong\u003e(11):1624.\u003c/li\u003e\n\u003cli\u003eMenon V, Kar SK, Suthar N, Nebhinani N: \u003cstrong\u003eVitamin D and depression: a critical appraisal of the evidence and future directions\u003c/strong\u003e. \u003cem\u003eIndian journal of psychological medicine \u003c/em\u003e2020, \u003cstrong\u003e42\u003c/strong\u003e(1):11-21.\u003c/li\u003e\n\u003cli\u003eSilva MRM, Barros WMA, Silva MLd, Silva JMLd, Souza APdS, Silva ABJd, Fernandes MSdS, Souza SLd, Souza VdON: \u003cstrong\u003eRelationship between vitamin D deficiency and psychophysiological variables: a systematic review of the literature\u003c/strong\u003e. \u003cem\u003eClinics \u003c/em\u003e2021, \u003cstrong\u003e76\u003c/strong\u003e.\u003c/li\u003e\n\u003cli\u003eHolick MF, Binkley NC, Bischoff-Ferrari HA, Gordon CM, Hanley DA, Heaney RP, Murad MH, Weaver CM: \u003cstrong\u003eEvaluation, treatment, and prevention of vitamin D deficiency: an Endocrine Society clinical practice guideline\u003c/strong\u003e. \u003cem\u003eThe Journal of clinical endocrinology and metabolism \u003c/em\u003e2011, \u003cstrong\u003e96\u003c/strong\u003e(7):1911-1930.\u003c/li\u003e\n\u003cli\u003eCashman KD: \u003cstrong\u003e100 YEARS OF VITAMIN D: Global differences in vitamin D status and dietary intake: a review of the data\u003c/strong\u003e. \u003cem\u003eEndocrine Connections \u003c/em\u003e2022, \u003cstrong\u003e11\u003c/strong\u003e(1).\u003c/li\u003e\n\u003cli\u003eKotta S, Gadhvi D, Jakeways N, Saeed M, Sohanpal R, Hull S, Famakin O, Martineau A, Griffiths C: \u003cstrong\u003e\u0026ldquo;Test me and treat me\u0026rdquo;\u0026mdash;attitudes to vitamin D deficiency and supplementation: a qualitative study\u003c/strong\u003e. \u003cem\u003eBMJ open \u003c/em\u003e2015, \u003cstrong\u003e5\u003c/strong\u003e(7):e007401.\u003c/li\u003e\n\u003cli\u003eAl-Mutairi N, Issa BI, Nair V: \u003cstrong\u003ePhotoprotection and vitamin D status: A study on awareness, knowledge and attitude towards sun protection in general population from Kuwait, and its relation with vitamin D levels\u003c/strong\u003e. \u003cem\u003eIndian journal of dermatology, venereology and leprology \u003c/em\u003e2012, \u003cstrong\u003e78\u003c/strong\u003e:342.\u003c/li\u003e\n\u003cli\u003eBoland S, Irwin JD, Johnson AM: \u003cstrong\u003eA survey of university students\u0026rsquo; vitamin D\u0026ndash;related knowledge\u003c/strong\u003e. \u003cem\u003eJournal of nutrition education and behavior \u003c/em\u003e2015, \u003cstrong\u003e47\u003c/strong\u003e(1):99-103.\u003c/li\u003e\n\u003cli\u003eAljefree N, Lee P, Ahmed F: \u003cstrong\u003eExploring knowledge and attitudes about vitamin D among adults in Saudi Arabia: A qualitative study\u003c/strong\u003e. In: \u003cem\u003eHealthcare: 2017\u003c/em\u003e: MDPI; 2017: 76.\u003c/li\u003e\n\u003cli\u003eDeschasaux M, Souberbielle J-C, Partula V, L\u0026eacute;cuyer L, Gonzalez R, Srour B, Guinot C, Malvy D, Latino-Martel P, Druesne-Pecollo N: \u003cstrong\u003eWhat do people know and believe about vitamin D?\u003c/strong\u003e \u003cem\u003eNutrients \u003c/em\u003e2016, \u003cstrong\u003e8\u003c/strong\u003e(11):718.\u003c/li\u003e\n\u003cli\u003eArora H, Dixit V, Srivastava N: \u003cstrong\u003eEvaluation of knowledge, practices of vitamin D and attitude toward sunlight among Indian students\u003c/strong\u003e. \u003cem\u003eEvaluation \u003c/em\u003e2016, \u003cstrong\u003e9\u003c/strong\u003e(1):308.\u003c/li\u003e\n\u003cli\u003eAlamoudi LH, Almuteeri RZ, Al-Otaibi ME, Alshaer DA, Fatani SK, Alghamdi MM, Safdar OY: \u003cstrong\u003eAwareness of vitamin D deficiency among the general population in Jeddah, Saudi Arabia\u003c/strong\u003e. \u003cem\u003eJournal of nutrition and metabolism \u003c/em\u003e2019, \u003cstrong\u003e2019\u003c/strong\u003e.\u003c/li\u003e\n\u003cli\u003eAlBlooshi S, Al Anouti F, Hijazi R: \u003cstrong\u003eKnowledge about Vitamin D among Women in the United Arab Emirates\u003c/strong\u003e. \u003cem\u003eInternational Journal of Environmental Research and public health \u003c/em\u003e2023, \u003cstrong\u003e20\u003c/strong\u003e(2):1252.\u003c/li\u003e\n\u003cli\u003eIbrahim O, Al-Tameemi N, Dawoud D: \u003cstrong\u003eKnowledge and perceptions of vitamin D deficiency among the United Arab Emirates population\u003c/strong\u003e. \u003cem\u003eAsian J Pharmaceut Clin Res \u003c/em\u003e2019, \u003cstrong\u003e12\u003c/strong\u003e:183-186.\u003c/li\u003e\n\u003cli\u003eSaleh A, Shibli F, El Masri J, Mouslem H, Odeh M, Fawaz H, Almealawy YF, Bdair A, Ghazi M, Alnajjar AH: \u003cstrong\u003eOsteoporosis and vitamin D consumption: knowledge and practice in different Arab countries\u003c/strong\u003e. \u003cem\u003eArchives of Osteoporosis \u003c/em\u003e2023, \u003cstrong\u003e18\u003c/strong\u003e(1):85.\u003c/li\u003e\n\u003cli\u003eZhou M, Zhuang W, Yuan Y, Li Z, Cai Y: \u003cstrong\u003eInvestigation on vitamin D knowledge, attitude and practice of university students in Nanjing, China\u003c/strong\u003e. \u003cem\u003ePublic health nutrition \u003c/em\u003e2016, \u003cstrong\u003e19\u003c/strong\u003e(1):78-82.\u003c/li\u003e\n\u003cli\u003eLhamo Y, Chugh PK, Gautam SR, Tripathi C: \u003cstrong\u003eEpidemic of Vitamin D deficiency and its management: awareness among indian medical undergraduates\u003c/strong\u003e. \u003cem\u003eJournal of environmental and public health \u003c/em\u003e2017, \u003cstrong\u003e2017\u003c/strong\u003e.\u003c/li\u003e\n\u003cli\u003eClark B, Doyle J, Bull O, McClean S, Hill T: \u003cstrong\u003eKnowledge and attitudes towards vitamin D food fortification\u003c/strong\u003e. \u003cem\u003eNutrition \u0026amp; Food Science \u003c/em\u003e2019, \u003cstrong\u003e49\u003c/strong\u003e(3):346-358.\u003c/li\u003e\n\u003cli\u003eCovington M: \u003cstrong\u003eOmega-3 fatty acids\u003c/strong\u003e. \u003cem\u003eAmerican family physician \u003c/em\u003e2004, \u003cstrong\u003e70\u003c/strong\u003e(1):133-140.\u003c/li\u003e\n\u003cli\u003eAlshahrani A: \u003cstrong\u003eKnowledge, attitudes, and practice of community pharmacists towards providing counseling on vitamins, and nutritional supplements in Saudi Arabia\u003c/strong\u003e. \u003cem\u003eAIMS Public Health \u003c/em\u003e2020, \u003cstrong\u003e7\u003c/strong\u003e(3):697-712.\u003c/li\u003e\n\u003cli\u003eAltamimi M, Hamdan M, Badrasawi M, Allahham S: \u003cstrong\u003eKnowledge, Attitudes and Practices Related to Dietary Supplements among a Group of Palestinian Pharmacists\u003c/strong\u003e. \u003cem\u003eSultan Qaboos Univ Med J \u003c/em\u003e2021, \u003cstrong\u003e21\u003c/strong\u003e(4):613-620.\u003c/li\u003e\n\u003cli\u003eAlhomoud FK, Basil M, Bondarev A: \u003cstrong\u003eKnowledge, attitudes and practices (KAP) relating to dietary supplements among health sciences and non-health sciences students in one of the universities of United Arab Emirates (UAE)\u003c/strong\u003e. \u003cem\u003eJournal of clinical and diagnostic research: JCDR \u003c/em\u003e2016, \u003cstrong\u003e10\u003c/strong\u003e(9):JC05.\u003c/li\u003e\n\u003cli\u003eEl-Khateeb M, Khader Y, Batieha A, Jaddou H, Hyassat D, Khawaja N, Abujbara M, Ajlouni K: \u003cstrong\u003eVitamin D deficiency and associated factors in Jordan\u003c/strong\u003e. \u003cem\u003eSAGE Open Med \u003c/em\u003e2019, \u003cstrong\u003e7\u003c/strong\u003e:2050312119876151.\u003c/li\u003e\n\u003cli\u003eEmtawel Mohamed NA, Qerem WA, Gassar ES, Hailat M, Elhamdy FA, Ling J: \u003cstrong\u003eA Need for Improvement in the Knowledge, Attitudes and Practice Toward Vitamin D Among University Students\u003c/strong\u003e. \u003cem\u003eBahrain Medical Bulletin \u003c/em\u003e2021, \u003cstrong\u003e43\u003c/strong\u003e(2).\u003c/li\u003e\n\u003cli\u003eAlowais MA, Selim MAE: \u003cstrong\u003eKnowledge, attitude, and practices regarding dietary supplements in Saudi Arabia\u003c/strong\u003e. \u003cem\u003eJ Family Med Prim Care \u003c/em\u003e2019, \u003cstrong\u003e8\u003c/strong\u003e(2):365-372.\u003c/li\u003e\n\u003cli\u003eAlhomoud FK, Basil M, Bondarev A: \u003cstrong\u003eKnowledge, Attitudes and Practices (KAP) Relating to Dietary Supplements Among Health Sciences and Non-Health Sciences Students in One of The Universities of United Arab Emirates (UAE)\u003c/strong\u003e. \u003cem\u003eJ Clin Diagn Res \u003c/em\u003e2016, \u003cstrong\u003e10\u003c/strong\u003e(9):Jc05-jc09.\u003c/li\u003e\n\u003cli\u003eTabachnick BG, Fidell LS, Ullman JB: \u003cstrong\u003eUsing multivariate statistics\u003c/strong\u003e, vol. 6: pearson Boston, MA; 2013.\u003c/li\u003e\n\u003cli\u003eBoynton PM: \u003cstrong\u003eAdministering, analysing, and reporting your questionnaire\u003c/strong\u003e. \u003cem\u003eBmj \u003c/em\u003e2004, \u003cstrong\u003e328\u003c/strong\u003e(7452):1372-1375.\u003c/li\u003e\n\u003cli\u003eHilleman DE, Teply R, Packard KA: \u003cstrong\u003eKnowledge, Perceptions, and Patterns of Fish Oil Use in Cardiac Patients\u003c/strong\u003e. \u003cem\u003eJournal of Pharmacy Practice \u003c/em\u003e2020, \u003cstrong\u003e33\u003c/strong\u003e(5):580-585.\u003c/li\u003e\n\u003cli\u003eSharma A, Adiga S, M A: \u003cstrong\u003eKnowledge, attitude and practices related to dietary supplements and micronutrients in health sciences students\u003c/strong\u003e. \u003cem\u003eJ Clin Diagn Res \u003c/em\u003e2014, \u003cstrong\u003e8\u003c/strong\u003e(8):Hc10-13.\u003c/li\u003e\n\u003cli\u003eKambal N, Abdelwahab S, Albasheer O, Taha S, Abdelrahman N, Bani I, Alsayegh A, Shammaky E, Duwayri N, Alhazmi A\u003cem\u003e et al\u003c/em\u003e: \u003cstrong\u003eVitamin D knowledge, awareness and practices of female students in the Southwest of Saudi Arabia: A cross-sectional study\u003c/strong\u003e. \u003cem\u003eMedicine (Baltimore) \u003c/em\u003e2023, \u003cstrong\u003e102\u003c/strong\u003e(51):e36529.\u003c/li\u003e\n\u003cli\u003eAlzahrani MM, Alghamdi AA, Alghamdi SA, Alotaibi RK: \u003cstrong\u003eKnowledge and attitude of dentists towards obstructive sleep apnea\u003c/strong\u003e. \u003cem\u003einternational dental journal \u003c/em\u003e2022, \u003cstrong\u003e72\u003c/strong\u003e(3):315-321.\u003c/li\u003e\n\u003cli\u003eSafdar O, Baajlan O, Alamri A, Dahmash R, Alloush A, Ateeq R, Albokhari S, Zaher ZF, Alghamdi M, Jiffri H: \u003cstrong\u003eAssessment of knowledge and awareness of vitamin D among physicians and students of healthcare in Jeddah, Saudi Arabia\u003c/strong\u003e. \u003cem\u003eAustralasian Medical Journal (Online) \u003c/em\u003e2019, \u003cstrong\u003e12\u003c/strong\u003e(5):143-153.\u003c/li\u003e\n\u003cli\u003eVu LH, Van Der Pols JC, Whiteman DC, Kimlin MG, Neale RE: \u003cstrong\u003eKnowledge and attitudes about vitamin D and impact on sun protection practices among urban office workers in Brisbane, Australia\u003c/strong\u003e. \u003cem\u003eCancer epidemiology, biomarkers \u0026amp; prevention \u003c/em\u003e2010, \u003cstrong\u003e19\u003c/strong\u003e(7):1784-1789.\u003c/li\u003e\n\u003cli\u003eChristie FT, Mason L: \u003cstrong\u003eKnowledge, attitude and practice regarding vitamin D deficiency among female students in Saudi Arabia: a qualitative exploration\u003c/strong\u003e. \u003cem\u003eInternational journal of rheumatic diseases \u003c/em\u003e2011, \u003cstrong\u003e14\u003c/strong\u003e(3):e22-e29.\u003c/li\u003e\n\u003cli\u003eVallejo M, Bl\u0026uuml;mel J, Arteaga E, Aedo S, Tapia V, Araos A, Sciaraffia C, Castelo-Branco C: \u003cstrong\u003eGender differences in the prevalence of vitamin D deficiency in a southern Latin American country: a pilot study\u003c/strong\u003e. \u003cem\u003eClimacteric \u003c/em\u003e2020, \u003cstrong\u003e23\u003c/strong\u003e(4):410-416.\u003c/li\u003e\n\u003cli\u003eHabib S, Alhalabi H, Alharbi K, Alghamdi O, Alghamdi A, Ajarem M, Alqarni M: \u003cstrong\u003eKnowledge attitude and practices of university students to Vitamin D and Vitamin D supplements during times of low sun exposure and post lockdown\u003c/strong\u003e. \u003cem\u003eEuropean Review for Medical \u0026amp; Pharmacological Sciences \u003c/em\u003e2021, \u003cstrong\u003e25\u003c/strong\u003e(23).\u003c/li\u003e\n\u003cli\u003eAlowais MA, Selim MAE-H: \u003cstrong\u003eKnowledge, attitude, and practices regarding dietary supplements in Saudi Arabia\u003c/strong\u003e. \u003cem\u003eJournal of family medicine and primary care \u003c/em\u003e2019, \u003cstrong\u003e8\u003c/strong\u003e(2):365-372.\u003c/li\u003e\n\u003cli\u003eRoke K, Rattner J, Brauer P, Mutch DM: \u003cstrong\u003eAwareness of omega-3 fatty acids and possible health effects among young adults\u003c/strong\u003e. \u003cem\u003eCanadian Journal of Dietetic Practice and Research \u003c/em\u003e2018, \u003cstrong\u003e79\u003c/strong\u003e(3):106-112.\u003c/li\u003e\n\u003cli\u003eDimock M: \u003cstrong\u003eDefining generations: Where Millennials end and Generation Z begins\u003c/strong\u003e. \u003cem\u003ePew Research Center \u003c/em\u003e2019, \u003cstrong\u003e17\u003c/strong\u003e(1):1-7.\u003c/li\u003e\n\u003cli\u003eGaleshi R, Sharman J, Cai J: \u003cstrong\u003eInfluence of ethnicity, gender, and immigration status on millennials\u0026rsquo; behavior related to seeking health information: Results from a national survey\u003c/strong\u003e. \u003cem\u003eEquality, Diversity and Inclusion: An International Journal \u003c/em\u003e2018, \u003cstrong\u003e37\u003c/strong\u003e(6):621-631.\u003c/li\u003e\n\u003cli\u003eMason C, Xiao L, Imayama I, Duggan C, Wang C-Y, Korde L, McTiernan A: \u003cstrong\u003eVitamin D3 supplementation during weight loss: a double-blind randomized controlled trial\u003c/strong\u003e. \u003cem\u003eThe American journal of clinical nutrition \u003c/em\u003e2014, \u003cstrong\u003e99\u003c/strong\u003e(5):1015-1025.\u003c/li\u003e\n\u003cli\u003eHahn J, Cook NR, Alexander EK, Friedman S, Walter J, Bubes V, Kotler G, Lee I-M, Manson JE, Costenbader KH: \u003cstrong\u003eVitamin D and marine omega 3 fatty acid supplementation and incident autoimmune disease: VITAL randomized controlled trial\u003c/strong\u003e. \u003cem\u003eBmj \u003c/em\u003e2022, \u003cstrong\u003e376\u003c/strong\u003e.\u003c/li\u003e\n\u003cli\u003eRajabi‐Naeeni M, Dolatian M, Qorbani M, Vaezi AA: \u003cstrong\u003eEffect of omega‐3 and vitamin D co‐supplementation on psychological distress in reproductive‐aged women with pre‐diabetes and Hypovitaminosis D: a randomized controlled trial\u003c/strong\u003e. \u003cem\u003eBrain and Behavior \u003c/em\u003e2021, \u003cstrong\u003e11\u003c/strong\u003e(11):e2342.\u003c/li\u003e\n\u003cli\u003eBorges-Vieira JG, Cardoso CKS: \u003cstrong\u003eEfficacy of B-vitamins and vitamin D therapy in improving depressive and anxiety disorders: a systematic review of randomized controlled trials\u003c/strong\u003e. \u003cem\u003eNutritional neuroscience \u003c/em\u003e2023, \u003cstrong\u003e26\u003c/strong\u003e(3):187-207.\u003c/li\u003e\n\u003cli\u003eAlhazmi A, Kuriakose BB, Mushfiq S, Muzammil K, Hawash MM: \u003cstrong\u003ePrevalence, attitudes, and practices of dietary supplements among middle-aged and older adults in Asir region, Saudi Arabia: A cross-sectional study\u003c/strong\u003e. \u003cem\u003ePlos one \u003c/em\u003e2023, \u003cstrong\u003e18\u003c/strong\u003e(10):e0292900.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-epidemiology-and-global-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Journal of Epidemiology and Global Health](https://www.springer.com/journal/44197)","snPcode":"44197","submissionUrl":"https://submission.nature.com/new-submission/44197/3","title":"Journal of Epidemiology and Global Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Vitamin D, Supplementation, Knowledge, Attitudes, Practices","lastPublishedDoi":"10.21203/rs.3.rs-7552460/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7552460/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eVitamin D, an essential fat-soluble metabolite, plays a critical role in various physiological functions and human growth and development. This study investigates the factors influencing the knowledge, attitudes, and practices of the population regarding vitamin D supplementation.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA self-administered questionnaire was distributed via social media platforms. Statistical analysis involved frequency, percentages, and simple/multiple-linear regression analysis to assess study predictors.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eA total of 1340 responses were obtained from four countries: Saudi Arabia (n\u0026thinsp;=\u0026thinsp;412, 30.8%), Egypt (n\u0026thinsp;=\u0026thinsp;400, 29.9%), Jordan (n\u0026thinsp;=\u0026thinsp;310, 23.1%), and Iraq (n\u0026thinsp;=\u0026thinsp;217, 16.2%). Median knowledge scores (\u0026plusmn;\u0026thinsp;IQR) in Egypt, Jordan, and Iraq indicated a moderate level of understanding regarding vitamin D supplementation (11\u0026thinsp;\u0026plusmn;\u0026thinsp;3, 11\u0026thinsp;\u0026plusmn;\u0026thinsp;2, and 11\u0026thinsp;\u0026plusmn;\u0026thinsp;3, respectively), whereas Saudi Arabia exhibited lower levels of knowledge (7\u0026thinsp;\u0026plusmn;\u0026thinsp;2). Neutral attitudes toward vitamin D were observed across all countries, while Jordan and Iraq showed good median practice scores (17\u0026thinsp;\u0026plusmn;\u0026thinsp;5, 16\u0026thinsp;\u0026plusmn;\u0026thinsp;5), compared to moderate levels in Saudi Arabia and Egypt (13\u0026thinsp;\u0026plusmn;\u0026thinsp;3, 15\u0026thinsp;\u0026plusmn;\u0026thinsp;5), respectively. Multi-linear regression analysis indicated that in Saudi Arabia, younger respondents exhibited higher knowledge, attitudes, and practice scores, while individuals working in the non-health sector displayed higher attitudes and practice scores (p-value\u0026thinsp;=\u0026thinsp;0.06, 0.009, \u0026lt;\u0026thinsp;0.001). Similarly, in Iraq and Jordan, those working in the non-health sector demonstrated higher knowledge scores (p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.001, \u0026lt;\u0026thinsp;0.001, respectively). Furthermore, males attained higher attitude scores in samples from Jordan, Egypt, and Iraq (p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.001, 0.003, \u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eThis study highlights varying levels of knowledge, attitudes, and practices regarding vitamin D supplementation across different demographic groups and countries. Addressing misconceptions and promoting awareness, particularly among younger individuals and those working outside the health sector, is crucial for optimizing vitamin D supplementation practices and enhancing public health outcomes.\u003c/p\u003e","manuscriptTitle":"Factors Affecting the Knowledge, Attitude and Practice of Vitamin D Supplement Use among adults: A Multi-Arab countries study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-09 13:57:53","doi":"10.21203/rs.3.rs-7552460/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-13T11:34:40+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-05T19:27:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"203477767396065096375983313511893847745","date":"2025-10-03T08:31:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"213676052739410569407168159805404677624","date":"2025-10-03T08:28:39+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-01T03:11:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"88102567578352261464987252173352528798","date":"2025-09-28T08:05:38+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-28T07:41:47+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-11T04:52:45+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-09T06:02:10+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Epidemiology and Global Health","date":"2025-09-06T17:40:59+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-epidemiology-and-global-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Journal of Epidemiology and Global Health](https://www.springer.com/journal/44197)","snPcode":"44197","submissionUrl":"https://submission.nature.com/new-submission/44197/3","title":"Journal of Epidemiology and Global Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d51d0668-2f48-4771-af3d-ed737833c2c1","owner":[],"postedDate":"October 9th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-10-20T08:38:59+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-09 13:57:53","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7552460","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7552460","identity":"rs-7552460","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}