Health professionals' knowledge and attitudes toward vitamin D in the general population, pregnancy, and infancy : a thesis presented in partial fulfilment of the requirements for the degree of Master of Science in Nutrition and Dietetics, Massey University, Albany, New Zealand

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Background: Vitamin D is now recognised as having a role in in immune system functioning and in protection against several complications of pregnancy and common diseases of childhood. In 2012, a Consensus Statement was released by the New Zealand Ministry of Health that described the populations who are at risk of deficiency, how to manage vitamin D status whilst being conscious of the harsher ultraviolet environment in New Zealand and outlined who may benefit from vitamin D supplementation. Furthermore in 2013, a Companion Statement was released which provided additional information about vitamin D specific to the pregnant, lactating and infant populations. These documents were designed primarily for use by health professionals. There is limited literature available that explores health professionals’ knowledge of vitamin D in New Zealand. International literature is conflicting with some studies reporting good knowledge of vitamin D deficiency risk factors, sun exposure guidelines and supplement guidelines while others report limited knowledge in these areas. International studies have reported on health professionals’ knowledge of vitamin D supplement guidelines for infants with conflicting results. Identifying areas where knowledge is lacking will help to identify where New Zealand health professionals require further education. Aims: The aim of this study is to explore health professionals’ knowledge, attitudes and current practices toward vitamin D for the general population, pregnancy and infancy. Furthermore, this study aims to explore whether knowledge and attitudes have changed between 2010 and 2019. Methods: In this ecological study, an anonymous online questionnaire was used to collect data from health professionals working in a profession recognised by the Health Practitioners Competence Assurance Act. Professionals working with pregnant women, infants and their caregivers were sought after in particular. This questionnaire was conducted in 2010 and in 2019 with different sample populations. Questions were developed in 2010 and in line with available New Zealand guidelines that detailed management of vitamin D status. These were the Food and Nutrition Guidelines for Healthy Infants and Toddlers and for Healthy Pregnant and Breastfeeding Women, and the Cancer Society Position Statement on the Risks and Benefits of Sun Exposure. Question types were a combination of multiple response sets and true or false and yes or no response options. Knowledge questions were forced response to avoid missing data whereas participant characteristic questions were request response to respect privacy. Descriptive statistics were used to analyse the results. Results: A total of 283 HPCAA-recognised health professionals completed this questionnaire (2010 n=193; 2019 n=90). Health professionals have good knowledge of vitamin D sources, functions and risk factors for deficiency. There appears to be confusion surrounding the vitamin D content of breastmilk (44.4% in 2010 and 31.5% in 2019 selected breastmilk as a good dietary source of vitamin D) and exclusive breastfeeding as a risk factor for deficiency (selected by 14.6% in 2010 and 32.9% in 2019). Knowledge of sun exposure guidelines was challenging to ascertain but results indicated a lack of awareness of safe sun exposure guidelines, primarily for infants. Furthermore, participants from both years were largely unsure about vitamin D supplement availability. Majority of participants did not feel there was enough information available to health professionals regarding vitamin D (81.2% in 2010; 74.4% 2019). Conclusion: Whilst health professionals had good knowledge of deficiency risk factors, functions and sources of vitamin D, the study identified some knowledge deficits. Interventions to improve knowledge are likely to be well received as majority of participants believe there is not enough information available to health professionals about vitamin D. Areas where health professionals need further education are the vitamin D content of breastmilk, recognition of exclusive breastfeeding as a deficiency risk factor in infants, supplement availability and sun exposure guidelines. Further studies that explore where health professionals’ source their information from regarding vitamin D may provide insight as to why these gaps in knowledge have occurred and how to best rectify them. Future studies should include larger population sizes and greater population diversity.