UJIAN AKHIR SEMESTER

PROGRAM STUDI D3 FARMASI

POLITEHNIK KESEHATAN HERMINA

MATA KULIAH : METODOLOGI PENELITIAN

Dosen : dr. Rona Kartika, M.Biomed
Hari/Tanggal : Sabtu, 13 Januari 2024
Waktu : 90 menit
Sifat Ujian : Closed Book

KETENTUAN UJIAN:
1. Ujian dikerjakan sendiri dalam waktu 90 menit
2. Terdapat 20 soal ujian yang masing-masing soal benar bernilai +5, soal salah bernilai
+1, soal tidak dijawab bernilai 0
3. Saat ujian tidak boleh membuka contekan, handphone, maupun internet, translator,
dan kalkulator
4. Soal ujian di jawab di lembar jawab yang sudah disediakan, ditulis menggunakan
tulisan tangan dan rapi

Soal 1 (bobot 25 poin)

Terkait dengan artikel yang berjudul “Occurrence and types of medication error and its
associated factors in a reference teaching hospital in northeastern Iran: a retrospective
study of medical records”
Jawablah pertanyaan dibawah ini:
1. Apa tujuan dari penelitian tersebut?
2. Apa research gaps dari penelitian tersebut?
3. Apa populasi dan sampel penelitian tersebut?
4. Bagaimana mengumpulkan data pada penelitian ini?
5. Bagaimana menilai validitas dan reliabilitas ceklist pada penelitian tersebut?

Soal 2 (bobot 25 poin)

Terkait dengan artikel yang berjudul “Vitamin D Deficiency and Associated Risk Factors
in Women from Riyadh, Saudi Arabia”
Jawablah pertanyaan di bawah ini:

1
 1. Apa tujuan dari penelitian tersebut?
2. Apa research gaps dari penelitian tersebut?
3. Apa desain penelitian tersebut?
4. Bagaimana pengukur frekuensi tatapan sinar matahari pada penelitian tersebut?
5. Bagaimana klasifikasi kadar vitamin D pada penelitian tersebut?
Soal 3 (bobot 25 poin)
Seorang peneliti ingin melihat prevalensi anemia pada populasi anak sekolah di wilayah
Jakarta. Dari jurnal sebelumnya diketahui simpangan baku kadar hemoglobin adalah 2 g/dL,
presisi 10% dan Tingkat kesalahan tipe 1 adalah 5% (Za=1,96)
Jawablah pertanyaan dibawah ini:
1. Bagaimana cara sampling yang tepat pada penelitian ini?
2. Apa pertimbangan saudara menentukan cara sampling diatas?
3. Menggunakan rumus dibawah ini, tentukan sampel yang diperlukan pada penelitian
ini?

4. Bagaimana metode pengumpulan data yang tepat pada penelitian ini?

5. Apa pertimbangan saudara memilih metode pengumpulan data tersebut?
Soal 4 (Bobot 25 poin)
Jawablah secara singkat pertanyaan dibawah ini:
1. Apakah perbedaan populasi, populasi target, dan sampel penelitian?
2. Apakah yang disebut dengan kriteria inklusi dan eksklusi?
3. Apa yang disebut dengan validitas dan reliabilitas instrument penelitian?
4. Sebutnya 2 contoh instrument penelitian!
5. Sebutkan 2 metode pengumpulan data yang Anda ketahui!

2
Tabatabaee et al.
BMC Health Services Research (2022) 22:1420
https://doi.org/10.1186/s12913-022-08864-9

RESEARCH Open Access

Occurrence and types of medication error

and its associated factors in a reference teaching
hospital in northeastern Iran: a retrospective
study of medical records
Seyed Saeed Tabatabaee1,2, Vahid Ghavami3, Javad Javan‑Noughabi1,2*   and Edris Kakemam4

Abstract
Background: Medicationerrors are categorized among the most common medical errors that may lead to irrepara‑
ble damages to patients and impose huge costs on the health system. A correct understanding of the prevalence of
medication errors and the factors affecting their occurrence is indispensable to prevent such errors. The purpose of
this study was to investigate the prevalence and types of medication errors among nurses in a hospital in northeast‑
ern Iran.
Methods: The present descriptive-analytical research was conducted on 147 medical records of patients admitted
to the Department of Internal Medicine at a hospital in northeastern Iran in 2019, selected by systematic sampling.
The data were collected through a researcher-made checklist containing the demographic profiles of the nurses, the
number of doctor’s orders, the number of medication errors and the type of medication error, and were finally ana‑
lyzed using STATA version 11 software at a significance level of 0.05.
Results: Based on the findings of this study, the mean prevalence of medication error per each medical case was
2.42. Giving non-prescription medicine (47.8%) was the highest and using the wrong form of the drug (3.9%) was the
lowest medication error. In addition, there was no statistically significant relationship between medication error and
the age, gender and marital status of nurses (p > 0.05), while the prevalence of medication error in corporate nurses
was 1.76 times higher than that of nurses with permanent employment status (IRR = 1.76, p = 0.009). The prevalence
of medication error in the morning shift (IRR = 0.65, p = 0.001) and evening shift (IRR = 0.69, p = 0.011) was signifi‑
cantly lower than that in the night shift.
Conclusion: Estimating the prevalence and types of medication errors and identified risk factors allows for more
targeted interventions. According to the findings of the study, training nurses, adopting an evidence-based care
approach and creating interaction and coordination between nurses and pharmacists in the hospital can play an
effective role in reducing the medication error of nurses. However, further research is needed to evaluate the effec‑
tiveness of interventions to reduce the prevalence of medication errors.
Keywords: Nurses, Medication errors, Hospitals, Teaching

Introduction
*Correspondence: javadjavan.n@gmail.com Medication error is one of the basic problems of health
1
Social Determinants of Health Research Center, Mashhad University systems all over the world, which can be a serious threat
of Medical Sciences, Mashhad, Iran
Full list of author information is available at the end of the article
to the safety of patients [1, 2]. Medication errors can lead

© The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the
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Tabatabaee et al. BMC Health Services Research (2022) 22:1420
to unpleasant consequences such as prolonged hospitali-
zation, increased treatment costs and even death [3]. The
results of a survey conducted in 2018 in the UK found
that more than 2 million people are affected by the com-
plications of medication error every year, and give rise to
death almost 100 thousand people [4]. Medication error
is the third leading cause of death in America [5]. In addi-
tion to weakening patients’ trust in medical services and
the health care system, medication errors can impose
huge costs on the health sector [6]. The findings of a pre-
vious study reported that the cost imposed per medica-
tion error ranges from €2.58 to €111 727.08 [7].
Medication error refers to any malpractice in the
medication process (prescribing, preparing and giv-
ing medication to the patient), regardless of whether it
has side effects for the patient or not, which can occur
at any stage of the drug therapy cycle from prescription,
transcription, distribution to drug administration [7].
However, previous studies have shown that most errors
occur when the medication is delivered to the patient [8].
Doctors’ prescriptions, nurses’ implementation of drug
orders, pharmacists’ reading of prescriptions in phar-
macies, and sometimes patients themselves and their
families play a role in medication errors [9]. In addition,
medication errors are more common in hospitals when
implementing medication orders [10]. Such evidence
suggests that all health care professionals, including phy-
sicians, nurses, and pharmacists, are involved in such
errors. However, a review study in Iran documented that
the highest prevalence of medication errors was among
nurses and nursing students [11]. This is because nurses
mostly implement drug orders and drug therapy is the
most common treatment and care intervention per-
formed by nurses [12]. Many factors are implicated in
such events, including high workload and overtime [13].
Nurses themselves believe that the main causes of medi-
cation error can be the use of abbreviations instead of
the full names of drugs, similarity in the names of drugs,
carelessness of nurses, high work pressure and workload
especially in emergency situations, low drug information
and weakness in continuous education [3].
Some studies have examined the medication errors in
Iran. For instance, a recent systematic and meta-anal-
ysis study on 8 studies reported that the overall medi-
cation error’s prevalence among nursing students was
39.68% and the prevalence of lack of reporting medica-
tion errors was 48.60% [14]. Likewise, another systematic
review on 40 eligible articles about medication errors in
Iran showed that the prevalence of the medication error
ranged from 10 to 80% [11]. Karami Matin et al. in a sys-
tematic review and meta-analysis on the 22 studies with
3556 samples showed that the prevalence of medica-
tion errors among nurses in hospitals in Iran were 53%
Page 2 of 7
with a confidence interval of 95% between 41%-60% [15].
Although accurate statistics of the consequences of med-
ication errors were not found in Iran, annual costs for
prolonged hospitalization and extra care due to medica-
tion errors exceeded billions of Tomans (Iran’s currency)
[16–18].
Although medication error is a critical clinical problem
that seriously threatens the safety of patients, studies have
shown that almost half of these cases can be prevented by
implementing simple standards [18]. To achieve this goal,
the third generation of the National Accreditation Pro-
gram has paid special attention to patient safety, and one
of the eight axes of this program is dedicated to the man-
agement of drugs and equipment. Thus, the drug man-
agement consists of nine standards, including ensuring
the hospital’s access to drugs, safe storage of drugs, pre-
scription drugs, supply and distribution of drugs, man-
agement of drug consumption, continuous evaluation of
the process of prescription and drug consumption, moni-
toring of expired drugs, review of drugs prescribed and
medication error control [19, 20].
Although positive measures have been taken to pre-
vent and control medication error, it is still a big chal-
lenge in Iran. A systematic review study documented
that the prevalence of medication error in the countries
of the Middle East region, including Iran, varies between
7 and 90% [21]. Therefore, correct identification of type
of medication errors is an important step in preventing
their recurrence. According to the review of the litera-
ture, most of the studies conducted in the field of prev-
alence and types of medication errors in Iran have only
examined the opinions and experiences of nurses [22,
23]. Therefore, the current study was conducted to inves-
tigate the prevalence and type of medication errors by
nurses on the medical records of patients admitted to the
Department of Internal Medicine at a hospital in north-
eastern Iran.
Methods
Study design and setting
The present cross-sectional and descriptive-analytical
study was conducted in 2019 in a referral teaching hospi-
tal in the northeast of the country. The hospital operates
in various fields of treatment, education and research,
with 776 active beds and 46 wards. Currently, 2950 medi-
cal personnel including nurses, doctors, paraclinical, sup-
port and administrative personnel are working in this
hospital. Among the inpatient departments, the Depart-
ment of Internal Medicine with 61 active beds with an
occupancy rate of 83% and due to the large volume of
medication orders compared to other wards was selected
as the study setting.
Tabatabaee et al. BMC Health Services Research (2022) 22:1420
Study population and sample
The research population included all the medical records
of patients admitted to the Department of Internal Medi-
cine at the mentioned hospital (n = 6995), among which
147 cases were selected by systematic sampling method
and based on the following equation, taking into account
the error level (α) of 0.05, accuracy (d) of 0.08 and limited
population size (N).
Data collection tool
The data were collected through a researcher-made
checklist containing the demographic profiles of the
nurses (age, gender, marital status, type of employment,
shift work and work experience), the number of doctor’s
orders, the number of medication errors and the type
of medication error (giving the wrong medicine, wrong
medicine dose, giving medicine at the wrong time, not
giving medicine, drug interaction, etc.). Employment
type is included permanent, contract, corporative, and
bonded. Corporate forces are forces that are hired by
intermediary companies (human resources supply com-
panies) for government organizations. The intermediary
company receives the salaries and benefits of the indi-
viduals from the relevant main organization and pays
to its corporate forces. Therefore, corporate forces do
not have a direct financial relationship with government
institutions.
A number of nursing experts and quality improvement
officers confirmed validity of the checklist. The reliability
of the checklist was supported by the findings of an inter-
nal consistency reliability. The Cronbach’s alpha coeffi-
cient for all items was greater than 0.7.
Data collection
To do this, first, the necessary permits were obtained
from the deputy of research of the university and the hos-
pital directorate in cooperation with the nursing man-
agement of the hospital. Then, two trained nurses went
to the medical records unit, studied the nursing reports
and matched the report with the doctor’s order report.
Medication error was identified and recorded through
non-compliance of nursing report and doctor’s orders.
In order to increase the accuracy in identifying medica-
tion errors, each medical file was reviewed by two nurses
separately and any contradictions in the collected infor-
mation were resolved on the spot and by mutual consul-
tation and third person judgment. The hospital matron
and two nurse managers with a history of membership
in the medication errors committee were selected to col-
lect data. Despite the familiarity of the selected nurses
with medication errors, three two-hour sessions were
held for the training of nurses about types of medication
Page 3 of 7
errors. The inclusion criteria were the existence of a file
in the sector of medical records and also the sector of
hospitalization process at the time of discharge from the
Department of Internal Medicine. The exclusion criteria
included lack of access to files. It should be noted that the
patient file information was kept confidential.
Data analysis
After completing the checklist, the demographic char-
acteristics of the nurses noted in the checklist were
extracted through the personnel system. Descriptive
statistics were used to analyze the data, the mean and
standard deviation for quantitative variables as well as
frequency and percentage for qualitative variables. Since
the nurses’ performance was error-free in many cases,
Poisson and classical negative binomial regression mod-
els were not suitable, and so Zero Inflated Poisson (ZIP)
and Zero Inflated Negative Binomial (ZINB) regression
models were fitted to these zero inflated data [24, 25]. On
the other hand, if there is over-dispersion in the data, the
ZINB model will be preferred to the ZIP model, there-
fore, Likelihood-Ratio Test (LRT) was used to check
over-dispersion in the data [26]. Because there was more
than one data record for each nurse, robust standard
errors were estimated for the regression coefficients. All
data were finally analyzed using STATA version 11 soft-
ware at a significance level of 0.05.
Results
This study investigated the performance of 57 nurses who
had implemented 955 doctors’ orders. The distribution
of the number of medication errors is shown in Fig. 1.
One of the important features of the number of errors in
this study was the zero-medication error in 754 doctor’s
orders (76%).
Regarding the type of errors, giving non-prescription
medicine (47.8%) was the highest and using the wrong
form of the drug (3.9%) was the lowest medication error
(Table 1).
The average age of the nurses was 34 ± 7 years, the
average work experience was 7 ± 2.5 years, and the
majority of nurses were female (70%). The majority of
nurses (66%) were married. Other demographic informa-
tion of nurses is shown in Table 2.
Due to the high number of cases without errors in
medication orders (Fig. 1), ZIP and ZINB regression
models were fitted to the data. LRT results showed over-
dispersion in the data (χ2 = 6.2 and p = 0.01), so ZINB
was determined as the final model. The fitting results of
the ZINB model are reported in Table 3.
Based on the results of ZNIB model, the prevalence
of medication error in corporate nurses was 1.76 times
higher than that of nurses with permanent employment
 www.nature.com/scientificreports

OPEN Vitamin D Deficiency and

Associated Risk Factors in Women
from Riyadh, Saudi Arabia
Nora A. AlFaris 1*, Nora M. AlKehayez1, Fatema I. AlMushawah2, AbdulRhman N. AlNaeem2,
Nadia D. AlAmri3 & Ebtisam S. AlMudawah3
Vitamin D deficiency is an epidemic public health problem worldwide. It is common in the Middle East
and is more severe in women. This cross-sectional study was conducted to assess vitamin D deficiency
and associated risk factors in women living in Riyadh, Saudi Arabia. Serum 25-hydroxyvitamin D
(25(OH)D) was measured in 166 women aged 30–65 years. Socio-demographic, lifestyle and health
status characteristics, as well as intake of selected dietary supplements, were collected. Weight
and height were measured. Vitamin D deficiency (25(OH)D < 20 ng/mL) was reported in 60.2% of
participants. Mean of serum 25(OH)D was 20.7 ng/mL. Older age and taking the supplements of
vitamin D, multi-vitamins or calcium were identified as factors that associated with a lower risk of
hypovitaminosis D. A national strategy is needed to control a hypovitaminosis D crisis in Saudi Arabia.
This could be accomplished by raising public awareness regarding vitamin D, regulating and enhancing
vitamin D fortification and supplementation and screening vitamin D status among women at high risk.

Vitamin D has a crucial role in calcium homeostasis and metabolism in the human body and consequently is
considered important to maintain bone health1. Furthermore, vitamin D plays an essential role in the modula-
tion of the immune system and the regulation of body cells’ differentiation and proliferation. Therefore, vitamin
D deficiency is believed to be associated with the risk of several serious non-skeletal chronic diseases such as
autoimmune diseases, cardiovascular disease and certain cancers2. Unfortunately, dietary sources of vitamin D
are rare and found mainly in few foods such as fatty fish and fortified dairy products3. However, vitamin D
can be obtained through synthesis in the human skin when the human body is exposed directly to ultravio-
let B radiation of sunlight3. Vitamin D is produced in the human skin through photochemical conversion of
7-dehydrocholesterol to cholecalciferol (vitamin D3)3. Vitamin D3 is then metabolized to 25-hydroxyvitamin
D (25(OH)D), the main storage and circulating form of the vitamin, and then to 1, 25-dihydroxyvitamin D, the
hormonal form of the vitamin, by the hepatic and the renal enzymes4. In addition, there are alternative pathways
of vitamin D activation by CYP11A15–8. However, these products were not measured in this study.
Currently, the global prevalence of vitamin D deficiency is an epidemic and considered as a public health
concern in many regions around the world9. The Middle East is a sunny region, but still suffering from a high
prevalence of hypovitaminosis D10. In Saudi Arabia, widespread prevalence of vitamin D deficiency were reported
in the different age and gender groups of this population, despite the plentiful sunshine that available throughout
the year in this Middle Eastern country11. Furthermore, vitamin D deficiency is more prominent in women of
varying ages in Saudi Arabia12,13. Several factors could contribute to vitamin D deficiency. Therefore, it is impor-
tant to determine the risk factors that are associated with vitamin D deficiency among those women in order to
establish relevant strategies to prevent and manage this serious health problem.
The objective of this study was to assess vitamin D deficiency among a sample of women living in Riyadh,
Saudi Arabia and identified the major risk factors which might be associated with vitamin D deficiency by evalu-
ating selected variables related to socio-demographic, lifestyle and health status characteristics, as well as, dietary
supplements intake.

1
Nutrition and Food Science (PhD), Department of Physical Sport Science, Princess Nourah bint Abdulrahman University,
Riyadh, P.O. Box 84428, Riyadh, 11671, Saudi Arabia. 2King Fahad Medical City, P.O. Box 59046, Riyadh, 11525, Saudi
Arabia. 3King Saud Medical City, P.O. Box 3897, Riyadh, 11196, Saudi Arabia. *email: naalfaris@pnu.edu.sa

Scientific Reports | (2019) 9:20371 | https://doi.org/10.1038/s41598-019-56830-z 1

www.nature.com/scientificreports/ www.nature.com/scientificreports

Methods
Study design and subjects. This study is a cross-sectional study. One hundred and sixty-eight women were
recruited to participate from the King Saud Medical City in Riyadh, Saudi Arabia during the period from May
2015 to June 2016. The inclusion criteria were: women aged 30–65 years, living in Riyadh; Saudi Arabia (latitude
24.7°N) who had not been diagnosed with any medical disorder or taking any medications that interfere with
vitamin D status. The systematic random sampling method was used to recruit the study sample from women
who came for a follow-up examination at the gynecology clinic at the King Saud Medical City. In fact, two sub-
jects were excluded as they didn’t meet the inclusion criteria, and therefore 166 women participated in the current
study.

Data collection. Data were collected from the participants directly by trained nutritionists. Collected data
include socio-demographic characteristics such as age groups, lifestyle characteristics such as sun exposure dura-
tion, health status characteristics such as obesity, selected dietary supplements intake, as well as, measuring height
and weight. The sun exposure frequency was defined as frequent when subjects were exposed to sunlight at least
three times weekly, occasional when they were exposed to sunlight at least once per week, rare when they were
exposed to sunlight at least once a month, and never when their sun exposure was lower than once per month.
Sun exposure meant that subjects had to expose at least 20% of their bodies including the face, arms and hands to
sunshine directly. Body height was measured to the closest 0.1 cm and body weight was measured to the closest
0.1 kg using standardized methods. Body mass index (BMI) was calculated by dividing weight (in kg) over height
squared (in meter). Obesity was defined as a BMI equal to or higher than 30. Data regarding diagnoses of type 2
diabetes and/or hypertension were collected from the medical files of the patients.

Biochemical analysis. After a 12- hour of overnight fasting, blood samples were collected from all partic-
ipants at the midday at the clinical laboratory. Plasma was separated by centrifugation at 2000 g for 20 minutes
within an hour after the samples were drawn and stored at −70 °C for further analysis. Vitamin D levels, 25(OH)
D were determined by a radioimmunoassay technique (Roche Diagnostics, Mannheim, Germany). Subjects
were classified based on vitamin D level into vitamin D sufficient (25(OH)D ≥ 30 ng/mL), insufficient (25(OH)
D = 20–29.9 ng/mL), and deficient (25(OH)D < 20 ng/mL). Moreover, severe vitamin D deficiency was defined
as 25(OH)D < 10 ng/mL14.

Statistical analysis. SPSS version 20 was used for data analysis. Categorical variables were expressed as
frequencies and percentages. Continuous variables were expressed as both mean ± standard deviation (SD) and
median ± interquartile range (IQR). Univariate logistic regression analysis was conducted to identify risk factors
which might be associated with vitamin D deficiency. Differences were considered statistically significant at p
values < 0.05.

Ethics approval and consent to participate. All participants were given informed consent in their
native language to sign prior to enrolling in this study. All human protocols were approved by the King Saud
Medical City Institutional Review Board in accordance with the declaration of Helsinki.

Results
Overall, 166 women living in Riyadh; Saudi Arabia were involved in this study. The socio-demographic and life-
style characteristics of the study subjects are presented in Table 1. Most of the study subjects (85.5%) are Saudis.
Younger women aged 30–49 years formed 57.2% of subjects, while the older women aged 50–65 years formed the
rest of the sample. Most of the participants (77.7%) live in houses that afford them with an easy access to sunshine,
while the remaining subjects live in apartments which are characterized by limited sunshine access. Monthly fam-
ily income was 1000 USD or less for about half of the study subjects (48.8%) and more than 1000 USD for the rest
of them. Regarding education, about one-fifth of participants (19.9%) had a college degree. However, education
level did not exceed high school for 80.1% of the sample. In addition, about two-thirds of the participants (65.1%)
were married, while unmarried women; including single, divorced and widowed women, composed 34.9% of the
sample. Actually, 40.9% of the participating women were rarely or never exposed to the sunlight. Only 15.1% of
them had frequent sun exposure. The morning was the usual daytime of sun exposure for about half of the study
sample (50.3%) and the duration of sun exposure for 72.8% of the participants was less than 15 minutes per day.
Finally, most of the subjects (72.9%) had no daily practice of exercise.
Health status characteristics and dietary supplements intake of the study subjects are shown in Table 2. Obesity
was reported in 62.0% of the study sample. In addition, 24.1% of the participants had been diagnosed with type
2 diabetes, while hypertension was diagnosed among 15.7% of subjects. Vitamin D supplement was taken by
29.5% of the participants as a single nutrient supplement (at least 400 IU/day). Moreover, 18.1% of the subjects
were taking the multi-vitamins supplement which contains variable amounts of vitamin D (at least 400 IU/day).
The other supplementation that reported by subjects were calcium supplement (21.1%), and the multi-minerals
supplement (7.8%) that provides at least 400 mg/day of calcium.
Vitamin D deficiency (25(OH)D < 20 ng/mL) was reported in 60.2% of the participants; about half of them
(28.9% of study sample) had severe vitamin D deficiency (25(OH)D < 10 ng/mL). Furthermore, 19.9% of sub-
jects were found with vitamin D insufficiency (25(OH)D = 20–29.9 ng/mL) and another 19.9% of subjects were
found with vitamin D sufficiency (25(OH)D ≥ 30 ng/mL) (Fig. 1). The mean of serum 25(OH)D concentrations
of all subjects was 20.7 ng/mL (SD = 13.2), whereas the median was 16.9 ng/mL (IQR = 17.2) (Table 3). The only
variable from the selected socio- demographic characteristics that significantly associated with vitamin D defi-
ciency was age groups (Table 4). Younger women aged 30–49 years had a significantly higher risk of vitamin D
deficiency than older women aged 50–65 years (odds ratio [OR] = 2.01, p = 0.03). Furthermore, one of selected
lifestyle variables was associated with a higher risk of vitamin D deficiency but not significantly. Participants with

Scientific Reports | (2019) 9:20371 | https://doi.org/10.1038/s41598-019-56830-z 2