Lack of Sun Exposure Among Saudi Women Living in Canada

1) Lack of awareness about vitamin D

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The lack of information and awareness about vitamin D was apparent in young Saudi women living in Canada after the assessment of knowledge concerning numerous essential concepts, such as sources of vitamin D-food fortification, supplementation, sun exposure-, other health benefits of vitamin D, and factors that might decrease the amount of vitamin D. Gaps in basic knowledge around vitamin D and its benefits became apparent in this study. The need for more health education, and increase awareness is highlighted by the conclusion that participants were unaware of any health benefits of vitamin D other than musculoskeletal health, and the sun is beneficial for vitamin D. Although the multiple findings that vitamin D is related to many aspects of health other than musculoskeletal health are still very recent, the research evidence is very convincing and shows its vast importance to public health (Sadat-Ali et al, 2009; MORE references). Regarding that, none of Saudi women participants mentioned any prior knowledge about breast cancer for example or other relationship to other health issues. Also, health professionals who participated in this study indicated that they do not really expected young Saudi woman to know that, as it is new. However, for (Pharmacist #1) and (Pharmacist #2) they assumed that Saudi women recognize there is an association between vitamin D levels in conjunction with pregnancy and breastfeeding.

Interestingly, this study had one participant, who had been found to be vitamin D deficient previously, and this participant stated a level of knowledge about several aspects related to this matter, and she stated that her knowledgeable came from her experience of being deficient of vitamin D. When we asked her about vitamin D food sources, she offered varied vitamin D food sources more than what the other participants said. She also identified the word food fortification, and recognized several fortified foods available in Canada. She also tells about knee pain and back pain, and the association with vitamin D deficiency, and considering vitamin Ds link to depression. Regarding the use of supplementation she said she has to take vitamin D drops, or supplement daily due to her illness, even sometimes she forgets.

Sun exposure

Our results showed that the hijab wearing, the busy lifestyle, and Saskatoons weather are barriers for Saudi women to exposure to sunlight. Living in Canada between two to four years, did not appear as something that increased participants level of sun exposure. Our results stated that exposure to sunlight in Canada, Saskatoon is difficult for Saudi women living in Canada. There are several barriers for this group- Saudi women living in Canada- to get enough sun exposure.

First of all, most of Saudi women living in Canada, or anywhere else regarding Islam Religion are wearing - style of clothes that cover most of body- called - a hijab - that is limit the sun exposure. This style is depend on women's preferences and there is no one style. Some women wear long clothes with fail that cover every thing except the hands, others wear a hijab that cover the full body except hand and face. In common, most of Muslim women wear a style of clothes that cover most of the body. However, not all Muslim women do so, but most of them do. This style of clothes can limit the opportunities women have to uncover and experience sun exposure in public (Al Faraj & Al Mutairi, 2003; REFRENCES).

The second barrier for the prevention of vitamin D deficiency found in this study was the climate. Although reported by (Al Faraj & Al Mutairi, 2003) this is not usually cited as a barrier in the wider literature. More emphasis is put on the cultural tradition of covering skin with clothes. Considering that the winter months can range from late October, to March, climate may be an important barrier, too.

The combination of the two barriers together seems to have an unfortunate effect on prevention of vitamin D deficiency. It seems essential to establish how much vitamin D the skin can produce both, in summer months, fall, spring and in winter, at what times of day, in the shade or in the sun, and how much of the body should be exposed. Researches into this area have been carried out in some locations for example in Saudi Arabia by (Alamri et all, 2015), and in other locations (Holick, 2007) but these observations are very different at different latitude. Therefore recommendations, and guidelines would have to be done to determine exact recommendations for the population in different part of the world, and especially in the North such as Saskatoon, Canada.

Our participants - Saudi women living in Canada - are living in a country that is different from Saudi Arabia (where exposure to the sun is really harsh), this group living in Canada acted the same way and stated that exposure to sun for Saudi women anywhere is quit challenging, in public places especially. Despite wearing their hijabs all the time in public places, many participants said that they do not expose themselves to the sun simply because they do not like it. This could be explained by: cultural reasons for covering skin with clothing,, and that Saudi women in Saudi Arabia get used to the indoor lifestyle due to the hot climate and for cultural reasons. The hot climate does not allow people to stay outside or even to do activities during sunny days. Consequently, women in Saudi Arabia are rarely having a chance for sun exposure before they come to Canada. After they came to Canada, they acted the same way, because they simply did not get used to it before and because they have layers of clothes, even in summer, so it is understandable they would get hot easily. Avoiding the sun is the solution from their perspective. Further explaining for that, air conditioners that are everywhere in Saudi Arabia in cars, houses, and malls accustomed them to staying in the cold, comfortable air. However, Several of our participants spend time in the sun with pleasant relaxation, nearly all were concerned about being too hot under the sun, something they indicated they do not really like. They care more about being comfortable and not sweating.

The extremely busy lifestyle of most Saudi women living in Canada also is a challenge, as they are working or studying and, as a result, probably don't pay attention to the importance of exposure to sun, this results similar to what (Billie et all, 2013), in Australia found in their study the ability to go outside, the weather and work, was a barriers to Receiving Sun Exposure for Adequate vitamin D.

Linking that the amount of sun exposure with the level of education as (Fuleihan, 2009) stated, the level of awareness of the benefits of sunlight needs to be increased by provision of specific guidelines about how often sun exposure is required, the duration, and how much of the body should be exposed for optimal vitamin D uptake. All of these aspects were deficient in the knowledge of our participants; our results are similar to (Christie & Mason, 2011) the qualitative study that done in Saudi Arabia, which indicated the Saudi female students, was limited in their knowledge about vitamin D and vitamin D deficiency, and also to (Billie et all, 2013; Janda et all, 2010; Youl, Janda, & Kimlin, 2008) that was showing low levels of vitamin D knowledge in Australia. However, in contrast to (Brand, 2008) who found extremely high levels of awareness amongst females in Australia. An explanation for this may be that Brands study was done as a response to a health promotion campaign. This may well be an encouraging sign for health promotion campaigns to be able to achieve the desired effect of informing the population. However, it is likely that all Saudi women living in Canada, who participated in this study, at high level of education especially all of them living in Canada as students, or wives of students, however, they stated limited sun exposure, So linking the level of education with the amount of sun exposure was not showing in our participants, which is different than other studies such as (Fuleihan, 2009), Even though one of the inclusion criteria for participating in this research was to be out of health professional area, and to not have a close family member who is health professionals, it is possible that Saudi women living in Canada, who participated in this study's level of awareness, and knowledge regarding vitamin D, and vitamin D deficiency might be better than other groups.

Lack of awareness about sun exposure needed was demonstrated in our sample through the participants who were not sure about the best time for sun exposure, the optimal length of time for sun exposure, or which parts of the body should be exposed. Participants believed they were getting enough sun exposure, unaware that having just their face, and sometimes only hands, exposed would probably not suffice. Covering skin with clothing prevents skin from coming into contact with UV-B rays essential for production of vitamin D. some participants seemed to think that exposing face and hands to the sun in the early or late sun would suffice, or opening the windows to let the sun come inside for a few mints in enough. Also, some of our participants had slightly darker skin complexion, as numerous populations of Saudi Arabia do. However in fact, several studeies stated that there is some factors that affect production of vitamin D include latitude, season, time of day, air pollution, cloud cover, glass shielding, melanin content of the skin, use of sun-blockers, age and the extent of clothing covering the body (Holick, 1987; Holick, 2001). Therefore, it is essential that more parts of the body be exposed, ideally for longer and at different times of day. 19 Wearing a hijab all of the time that they stayed outside can limit the opportunities women have to experience more sun exposure. Participants expressed a need for more areas to uncover.

Further, a lack of knowledge also appeared when we asked the participant regarding the duration of exposure, there was different responses; the most important factor governing the duration of exposure was the need to finish tasks outside. For example, they may walk from the house to the bus, so they are exposed to the sun, but it is tangential to their primary purpose. If they go outside purely for enjoyment, such as to have picnics, they will stay as long as there is a nice breeze and shade, but if there is full sun and the temperature is high, they will leave directly.

Incidental exposure during the day while walking to the bus, or to do some shopping sometimes, and sitting under a shade place was the most common type of sun exposure reported. This type of sun exposure may not be sufficient for vitamin D, given that the recommendation of up to 10 min outside of peak UV time is based on estimates from ideal conditions of sun exposure (clear, open sky and an unshaded, horizontal surface) and may not correspond to typical outdoor behaviours (Diffey, 2010).

Even thought, socioeconomic status has been linked to vitamin D deficiency in the Middle East, and for Middle Eastern and Muslim women generally there are very few opportunities to uncover their faces or their bodies and to expose themselves to sun such as in (Fuleihan, 2009) study, and (Siddiqui, 2007) study- who found that many of the girls in his Saudi Arabian study who were found to be vitamin D deficient lived in smaller, crowded houses where sunlight does not penetrate, our results are different than that. Our Saudi participants living in Saskatoon, Canada are living in a large, big townhouses, with private backyards -outside areas where they can uncover privately, however some participants stated that even they can exposure to sun in their own backyard, but they do not do it, simply because they do no...