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Lecture 2
Increasing
Hierarchy of
Epidemiologic
Study Design
NO
Experimental studies
Observational studies
Random allocation?
Comparison group?
NO
YES
Randomized
controlled trial
YES
Non-randomized
controlled trial
NO
Analytical
Descriptive
Direction?
Exposure
Cohort
study
Outcome
Exposure
Outcome
Case-control
study
Cross-sectional study
Observation at one particular point in time/ over a period:
snapshot of the situation of population at a point of time
POPULATION
SAMPLE
Exposed
Disease
Not exposed
No Disease
Disadvantages
Case-control study
Onset of study
TIME
EXPOSED
CASES
NOT EXPOSED
EXPOSED
CONTROL
NOT EXPOSED
Direction of inquiry
(Backward directionality)
Compares a case group (with disease) with a control group (not diseased) with
reference to past exposure to possible risk factors.
Example
Onset of study
TIME
SMOKE
LUNG
CANCER
DO NOT SMOKE
SMOKE
NO LUNG
CANCER
DO NOT SMOKE
Direction of inquiry
(Backward directionality)
Disadvantages
Cohort study
Onset of study
TIME
DISEASE
EXPOSED
NO
DISEASE
DISEASE
NOT EXPOSED
NO
DISEASE
Direction of inquiry
(Forward directionality)
Subjects are defined based on the exposure status and followed over time to
determine disease development.
Experimental study
Involves deliberate application of intervention or
treatment in the experimental group while no
expected changes in the control group and
comparing the outcomes for a duration of time.
RANDOM ERROR
SELECTION BIAS
SYSTEMATIC ERROR
OR BIAS
INFORMATION BIAS
CONFOUNDING
Error
Random error
Occurs by chance and usually cannot be predicted unless
from sampling error.
As random error increases, the precision of study
decreases.
Solution: Increasing sample size or by making the sample
representative of the population (study design).
Systematic error or bias
Occurs when there is a tendency to produce results that
are different in a systematic manner from the true value.
As systematic error increases, the validity of study
decreases.
Solution: Good study design
Bias
Selection Bias occur at the start of a
study due to method of selection is biased.
Berksons bias
Self selection bias
Lead time bias
Detection bias
Bias
Information Bias occurs because the data that
are collected or observed are incomplete or
incorrect.
Interviewer or observer bias
Loss to follow-up bias
Misclassification
Recall bias
Inter- interviewer bias
Hawthorne effect
Confounding
Definition distortion or the masking of an association
between exposure and a outcome because of third
extraneous factor.
Effects of confounding decrease, increase, or even
change the direction of the estimated association
between an exposure and outcome (conclusion is
biased)
Can be controlled by:
Randomization
Restriction
Matching
Stratification
Measurement of Risk
Relative Risk
group
If RR < 1, there is a decreased risk for the exposed
group
If RR = 1, there is an equal risk
Relative Risk
No Lung
Cancer
Total
Incidenc
e
10 (a)
990 (b)
1000 (a + b)
1%
3980(d)
4000 (c + d)
0.5%
Total
4970 (b + d) 5000
(a+b+c+d)
Smoker
30 (a + c)
Odds Ratio
Odd ratio
If 100 out of 1000 men with lung cancer had smoked and
200 of the 4000 without lung cancer had smoked. The odds
of developing lung cancer in those who smoke is:
Lung
Cancer
No Lung
Cancer
Total
Smoked
100 (a)
200 (b)
300 (a + b)
Did not
smoke
900 (c)
3800 (d)
4700 (c + d)
Total
1000 (a +
c)
4000 (b + d) 5000
(a+b+c+d)
2
Interpretation: There is two fold greater odds of getting
Attributable Risk
60
40
20
0
Risk Factor
Attributable risk
No Lung
Cancer
Total
10 (a)
990 (b)
1000 (a + b)
3980(d)
4000 (c + d)
Total
4970 (b + d) 5000
(a+b+c+d)
Smoker
30 (a + c)
Reading Materials
1. Abdul Rashid Khan and N.A Narayan. Lecture Notes
Thank you