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Cross-Sectional

Studies
Studi Cross-sectional
Tujuan:
mempelajari angka kejadian suatu
penyakit/masalah kesehatan
mempelajari hubungan antara suatu faktor risiko
dengan angka kejadian suatu penyakit

Unit analisa: individual

Faktor risiko/exposure dan status


penyakit/masalah kesehatan diukur pada
saat yang sama
Disain Studi Potong-Lintang (cross-sectional study)

nama lain : studi prevalensi, survey


bersifat observasional
unit pengamatan dan unit analaisisnya adalah individu
populasi studi merupakan populasi umum
sampel diambil secara random (acak)
setiap orang di populasi mempunyai kesempatan
yang sama untuk menjadi anggota sampel
sampel representatif /mewakili populasi

pengukuran variabel independet (exposure) dan variabel dependent


(outcome) dilakukan secara simultan, sehingga :
tidak dapat terlihat sekuens mana yang terjadi lebih dulu,
variabel independent atau variabel dependent, atau sebaliknya

konsekwensinya tidak dapat melihat hubungan sebab-akibat


(exposure harus mendahului outcome )
Cross-Sectional Study
Snapshot of the health status of populations
at a certain point in time.

For each subject, exposure and disease


outcome are assessed simultaneously
(hence also called a prevalence
study/survey).

Compare prevalence of disease in persons


with and without the exposure of interest
(e.g. prevalence ratio same formula as
risk ratio).
Cross-sectional studies

An observational design that surveys


exposures and disease status at a single point in
time (a cross-section of the population)

time
Study only exists at this point in time
Cross-sectional Design
factor present
No Disease
factor absent
Study
population
factor present
Disease
factor absent

time
Study only exists at this point in time
Cross-Sectional Studies

Begin with Cross-sectional sample

Determine Exposure and Disease at


same time
Cross-Sectional Studies

or PREVALENCE
STUDY
AKA:SURVEY
Hallmark:
Risk factors (exposures) and disease
outcome are ascertained at a single
point in time in a cross-sectional
sample of subjects.
CROSS-SECTIONAL STUDIES
(PREVALENCE STUDIES)

THESE ARE SO CALLED BECAUSE A


CROSS SECTION OF A COMMUNITY
(FREQUENTLY TOTAL POPULATION
SAMPLES) IS STUDIED AT A PARTICULAR
POINT OR PERIOD OF TIME.

9
PREVALENCE STUDY
METHODOLOGY-1
IT CAN BE DONE AT A SINGLE POINT OF
CALENDAR TIME (POINT PREVALENCE)
WHEN THE MEASUREMENT OF CAUSAL
RELATIONSHIP RELATE TO THE SAME
POINT IN STUDY MEMBERS LIVES

OR
CAN BE COMPLETED IN FEW MONTHS
OR YEARS (PERIOD PREVALENCE).

10
WHEN TO CONDUCT
PREVALENCE STUDIES?

THEY ARE CONDUCTED FOR


CHRONIC DISEASES HAVING HIGH
PREVALENCE WITH VERY LOW
INCIDENCE.

11
PREVALENCE STUDY
METHODOLOGY-2
THE DESCRIPTIVE INFORMATION IS
OBTAINED BY MEANS OF DOOR TO
DOOR SURVEY.

THOUGH THEY ARE USUALLY


CARRIED OUT ON POPULATIONS OR
SAMPLES OF POPULATION, THEY ARE
INDIVIDUAL BASED i.e. THEY SEEK
THE INFORMATION OF ABOUT THE
INDIVIDUALS IN A GROUP OR
POPULATION. 12
ANALISIS YANG DILAKUKAN DAPAT BERSIFAT:

DESKRIPTIF :
distribusi frekwensi kejadian penyakit/ masalah
kesehatan
berdasarkan orang - tempat - waktu
distribusi frekwensi variabel exposure dan
outcome
(angka prevalens)

ANALITIK : melihat korelasi/hubungan antara variabel-variabel


diteliti
Cross-Sectional Studies
How to . . .
1. Choose population and cross-sectional
sample
2. Develop a valid survey instrument
Subjective: Questionnaire
Objective: Exam, Lab Tests
3. Administer Survey
High participation is key!!
Cross-Sectional Studies
Sampling frames
Population registries
Censuses
Telephone sampling
Institutions: school, hospital, etc.
Convenience
Other haphazard approaches
Data Collection
Subjective
Objective
Kros-Seksional
(Studi prevalens, Prevalens survei)
Jumlah?
Umur?
Sex?
Pendidikan?
Pekerjaan?
Status penyakit
X?
Status variabel Y?
Measures of Disease Association
Measuring occurrence of new outcome
events can be an aim by itself, but usually
we want to look at the relationship between
an exposure (risk factor, predictor) and the
outcome
The type of measure showing an association
between an exposure and an outcome event
is linked to the study design
Measures of Association in a
Cross-Sectional Study
Simplest case is to have a dichotomous
outcome and dichotomous exposure variable
Everyone in the sample is classified as
diseased or not and having the exposure or
not, making a 2 x 2 table
The proportions with disease are compared
among those with and without the exposure
NB: Exposure=risk factor=predictor
Cross sectional design study 1

Begin with
Defined Population

Gather data on exposure and disease

Exposed, Not Exposed,


Exposed, Not Exposed,
Do not have Do not have
Have disease Have disease
disease disease
Study Design
Disease
(Outcome) _
+

+
Exposure
(Risk Factor)
_
Contoh :
dalam suatu penelitian dengan disain potong lintang

ingin melihat hubungan antara merokok dan bronchitis kronis

.
D = bronchitis kronis (data kategorikal)
E = merokok (data kategorikal)
pengukuran D dan E dilakukan secara simultan

populasi merupakan pegawai di pabrik A


sampel 1000 orang yang diambil secara random dari populasi

analisis deskriptif : menghitung distribusi frekwensi D dan E

analisis analitik :
analisis khi kuadrat dengan tabel kontingensi
alpha ditentukan 0,05
untuk melihat hubungan E dan D hitung OR atau PR
Tabel kontingensi 2x2 untuk data diatas

Outcome
D+ D- total

E+ 200 200 400


exposure
E- 100 500 600

total 300 700 1000


Populasi sampel dipilih secara random (acak)
sampel representatif untuk populasi

sampel

distribusi frekwensi variabel exposure


sampel distribusi frekwensi variabel outcome

Distribusi frekwensi berdasarkan variabel exposure pada sampel


terpapar dengan exposure E +
tidak terpapar dengan exposure E

misal sampel terdiri dari 1000 orang


terpapar dengan exposure E + = 400 orang = 40%
tidak terpapar dengan exposure E - = 600 orang = 60%

E+ 40%
prevalensi terpapar dengan exposure = 40%
E- 60% prevalensi tidak terpapar dengan exposure = 60%
Distribusi frekwensi berdasarkan variabel outcome pada sampel
outcome positif D (disease) +
outcomenegatif D (disease)

misal sampel terdiri dari 1000 orang


outcome positif D (disease) + = 300 orang = 30 %
outcomenegatif D (disease) - = 700 orang = 70%
D+ 30%

D- 70%
Prevalensi disease = 30%
prevalensi not disease = 70%
Prevalence ratio of disease in exposed and unexposed
Disease
Yes No

Yes a b a
a+b
Exposure

PR =
c
No
c d c+d

So a/a+b and c/c+d = probabilities of disease


and PR is ratio of two probabilities
Prevalence ratio of disease in exposed and unexposed

Mendistribusikan variabel disease pada variabel exposure

200 D+ 100 D+
dari 400(E+) dari 600 (E-)
200 D - 500 D -

E+ 200 D+ 200 D -
E- 100 D+ 500 D -

dari 400 orang (E+) prevalens D+ pada kelompok E+ = 200/400

dari 600 orang (E-) prevalens D - pada kelompok E - = 100/600

prevalens D+ pada kelompok E+ = 200/400


Prevalens Ratio = ------------------------------------------------------------------ = 3
prevalens D + pada kelompok E- = 100/600
Odds D+ E + (kelompok orang terpapar) = 200/200
Odds D+ E - (kelompok tidaterpapar) = 100/500

Odds D+ E + (kelompok orang terpapar) 200/200

OR = ---------------------------------------------------- = ------------ = 5
Odds D+ E - (kelompok tidaterpapar) = 100/500
Tabel kontingensi 2x2 untuk data diatas

Outcome
D+ D- total

E+ 200 200 400


exposure
E- 100 500 600

total 300 700 1000


Prevalence ratio of exposure in disease and nondisease
Disease
Yes No

Yes a b a
a+c
Exposure

PR =
b
No c d b+d

So a/a+c and b/b+d = probabilities of exposure


and PR is ratio of two probabilities
Prevalence ratio of exposure in disease and non disease

Mendistribusikan variabel exposure pada variabel disease

200 E+ 200 E+
dari 300 (D+) dari 700 (D-)
100 E - 500 E -

Prevalens E+ D + (kelompok orang sakit) = 200/300


Prevalens E+ D - (kelompok tidak sakit) = 200/700

Prevalens E+ D + (kelompok orang sakit) 200/300


Prevalens Ratio = ---------------------------------------------------= ------------ = 2 1/3
Prevalens E+ D - (kelompok tidak sakit) 200/700
Odds E+ D + (kelompok orang sakit) = 200/100
Odds E+ D - (kelompok tidak sakit) = 200/500

Odds E+ D + (kelompok orang sakit) = 200/100


OR = ------------------------------------------------------------------ = 5
Odds E+ D - (kelompok tidak sakit) = 200/500

Terlihat bahwa kalkulasi nilai OR tetap = 5.


bila variabel disease didistribusikan pada variabel exposure

atau bila variabel exposure dididtribusikan pada variabel disease


Probability and Odds
Odds another way to express probability of
an event
Odds = # events
# non-events
Probability = # events
# events + # non-events
= # events
# subjects
Probability and Odds
Probability = # events
# subjects
Odds = # events
# subjects = probability
# non-events (1 probability)
# subjects
Odds = p / (1 - p)
[ratio of two probabilities]
Probability and Odds

If event occurs 1 of 5 times, probability = 0.2.

Out of the 5 times, 1 time will be the event and 4


times will be the non-event, odds = 0.25

To calculate probability given the odds:


probability = odds / 1+ odds
Odds ratio
As odds are just an alternative way of
expressing the probability of an outcome,
odds ratio (OR), is an alternative to the
ratio of two probabilities (prevalence or risk
ratios)

Odds ratio = ratio of two odds


Odds ratio of disease in exposed and unexposed
Disease
Yes No a
a+b
Yes a b a
1-
a+b
Exposure

OR =
c
No c d c+d
c
1-
c+d
Formula of p / 1-p in exposed / p / 1-p in unexposed
Odds ratio of disease in exposed and unexposed
a a
a+b a+b
b
1- a a
a+b a+b b ad
OR = c = = =
c c bc
c+d
c c+d d
1-
c+d d
c+d
Odds ratio of exposure in diseased and not diseased
Disease
Yes No a
a+c
Yes a b a
1-
a+c
Exposure

OR =
b
No c d b+d
b
1-
b+d
Important characteristic of odds ratio
a a
a+c a+c
a c a
1-
a+c a+c c ad
ORexp = = = =
b b b bc
b+d b+d
b d
1-
b+d d
b+d

OR for disease = OR for exposure


Important Property of Odds Ratio #1

The odds ratio of disease in the exposed and


unexposed equals the odds ratio of exposure
in the diseased and the not diseased
Important in case-control design
Cross-Sectional Studies
DZ = Rash
(+) ()

Grape 95 88 183
(52%)

8 35 43
Tomato
(19%)

Prevalence ratio = 52%/19% = 2.6


Cross-Sectional
Instead of looking at a ratio of
prevalences, we can also look at a ratio
of odds.
Odds are not intuitively appealing: they
are the likelihood of an event occurring
divided by the likelihood of the event
not occurring.
Cross-Sectional Studies
DZ = Rash
(+) -
Grape
95 88 183 95/183
PR==2.6
8/43
43
8
Tomato 35
103 123
Oddsofgrapeworkinrashpts:
(95/103)/(8/103)=95/8=11.9
Oddsofgrapeworkinhealthy:
(88/123)/(35/123)=88/35=2.5

Cross-Sectional Studies
DZ = Rash
(+) -
Grape
95 88 183 95/183
PR==2.6
8/43
43
8
Tomato 35
Oddsofgrapeworkinrashpts:95/8=11.9
Oddsofgrapeworkinhealthy:88/35=2.5
Oddsratio=(95/8)/(88/35)=11.9/2.5=4.7
Cross-Sectional Studies
CHD No CHD
Cholesterol

High 100 400

Normal/
Low 50 450

100 / (100 + 400) 0.2


Prevalence Ratio = --------------------- = ---- = 2.0
50 / (50 + 450) 0.1
Cross-Sectional Studies
100 / (100 + 400) 0.2
Prevalence Ratio = --------------------- = ---- = 2.0
50 / (50 + 450) 0.1

Interpretation: In this study population, the


prevalence of CHD is 2 times higher among
those with high cholesterol, compared to the
prevalence in those with normal or low
cholesterol.
Cross-Sectional Study

Example:
Hypothesis:

Obesity is a risk factor for knee


osteoarthritis

Sample: 100 retirees living at University


Village
Cross-Sectional Study
Medical exam + X-rays to diagnose
osteoarthritis of the knee

Osteoarthritis
+ -
Obesity

+ 40 10 50

- 20 30 50
Cross-Sectional Study

Prevalence of osteoarthritis among


obese subjects: 40/50 = 0.8
Prevalence of osteoarthritis among
non-obese subjects: 20/50 = 0.4

Prevalence ratio = 0.8/0.4 = 2.0


Cross-Sectional Study

Obese subjects are two


times more likely to have
osteoarthritis of the knee
than non-obese subjects.
Cross-Sectional Study
Chicken or egg dilemma
What came first?
Obesity or Osteoarthritis
Study Design
TB infection, shown by a positive skin
test, usually remains dormant.
However, infected persons should be
treated with INH to prevent future TB
disease.
Q: How can you determine how big a
problem TB infection is among migrant
farm workers and if there are any high-
risk subgroups?
Cross-Sectional Studies
An example from the literature:

Tuberculin reactivity among California


migrant Hispanic farm workers.
Introduction:
Migrant farm workers at increased risk
for TB.
Cross-Sectional Studies
Methods:
Study population all residents > 1 year of
age
Brief health and work questionnaire
Tuberculin skin test (TST) for persons
not known to be TST(+)
Follow-up for TST(+) as needed
Cross-Sectional Studies
Results
Sex
Males - 204 (43.5%)
Females - 265 (56.7%)
Age
27.9 17.1 y ( Mean SD)
Place of birth
U.S. - 125 (26.7%)
Non-U.S. - 344 (73.1%)
Cross-Sectional Studies
Cross-Sectional Studies
MultivariateoddsratiosforpositiveTBskintest
Cross-Sectional Studies
Discussion
Overall prevalence 16.6%
Lower than observed in other settings
Increased prevalence for
Men (OR 1.22)
FS (OR 3.11)
15-39y (OR 2.59)
Non-US Born (OR 2.09)
Cross-Sectional Studies
Discussion
Increased risk for. . .
Men: as in other studies

15-39 yrs. not seen in other studies

FS not seen in other studies

Non-US Born as in other studies


CROSS-SECTIONAL STUDIES
E. Sample selection by exposure

Example: Workers with and without


exposure to asbestos are compared for
the simultaneous presence of lung cancer.

F. Sample selection by outcome

Example: Workers determined to have or


not have lung cancer at a point in time are
compared for simultaneous exposure to
asbestos 62
G. Sample selection neither by
outcome nor by exposure

Example: All workers in a plant are


simultaneously assessed both for
asbestos exposure and lung cancer
status.
(Sampling schemes D, E and G are
likely to be inefficient)

63
Beware!
The fact that past exposure and health data are collected
does not make it a retrospective cohort study

The distinction is that in the cross-sectional study you


start with people where they are now

In the retrospective cohort study you start identifying


people in the past before the outcomes occurred

If you start with people where they are now, some are
missing from the cohort that might have been defined
years ago
Bias You got the wrong answer

Selection bias: always consider it


in cross-sectional studies
Selection bias in cross-sectional studies

How did the people who are participating in your study get
to be where they are? Was it related to exposure? Was it
related to disease?

Are those who ended up in your study representative of the


source population? Could their participation relate to
exposure? Could it relate to disease?

You should not do a cross-sectional study without


pondering about the answers to these questions
SamplingBiasinCrossSectional
Studies
Isstudypopulationrepresentativeoftarget
population?
Oftenuseanonprobabilitysample:Convenience
samplewithnonconsecutiveenrollment
Istheresystematicincreaseordecreaseofcases?
Lengthbiasedsampling.Casesareoverrepresentedif
illnesshaslongdurationandareunderrepresentedif
shortduration(P=kxincxt)
Istheresystematicincreaseordecreaseofexposure?
Prevalenceincidencebias.Exposuredoesnotalter
diseaserisk,butaltersdiseaseduration.
exposureincasesifmilddiseaseeg,HLAA2
exposureincasesifrapidlyfatal
DesignStrategiestoMinimize
SamplingBias

Populationbasedsample
Probabilitysample
Nonprobabilitysample
Useconsecutiveenrollmentifconveniencesample
Adjustforseasonalorothertimedependenttrends
MeasurementBiasinCross
SectionalStudies
Outcome
Misclassified(dead,misdiagnosed,undiagnosed)
Exposure
Differentialmisclassificationduetorecallbias
Timefromexposureimportantindicatorofaccuracy
Needetiologicallyrelevantexposure.Usecurrentexposure
if:
Exposureisfixedeg,bloodtype
Recentexposurecorrelateswellwithpriorexposure
Recallofpriorexposureunlikelytobereliableeg,diet
StrategiestoMinimize
MeasurementBias
Standardizemeasurementmethods
Trainandcertifyassessors
Refinetheinstruments
Calibratetheinstruments
Automatetheinstruments
Makeunobtrusivemeasures
Forkeyvariables,usedatafrom>1source
Blindingofsubjectandobserver
Implementationofthesestrategiesdependsonimportance
ofvariable,potentialeffectofinaccuracy,feasibilityand
cost.
Occupational Lead Neurotoxicity: a
behavioral and electrophysiological
evaluation

To evaluate the effects of chronic lead exposure on


the nervous system in adults, a set of tests was
administered to 99 lead exposed foundry
employees and 61 unexposed workers.

This is a cross-sectional study


Those workers with the highest blood lead concentrations were
more tense
more angry
more depressed
more fatigued
more confused
and had less vigor
than those with low blood lead

Selection bias?
Who choose (or are chosen for) dirty jobs?
Who stay there?
Who get dirtiest on the job?

Right: Those who are tense, angry, depressed, fatigued,


confused, and have lest vigor
Kelebihan Studi Potong Lintang :

dapat untuk melihat distribusi frekwensi penyakit di


populasi

dapat untuk melihat hubungan variabel exposure


dan variabel outcome

hasil analisisnya dapat dipakai untuk membangun


hipotesis baru

Kelemahan Studi Potong Lintang


tidak dapat untuk melihat hubungan sebab akibat,
karena variabel exposure dan variabel outcome
diukur secara simultan
Cross-Sectional Studies
Strengths:
Provides prevalence estimates of
exposure and disease for a well-defined
population

Easier to perform than studies that


require follow-up (hence relatively
inexpensive)

Can evaluate multiple risk (and


protective) factors and health outcomes
at the same point in time
Cross-Sectional Studies

Strengths:
May identify groups of persons at
high or low risk of disease

Can be used to generate hypotheses


about associations between
predictive factors and disease
outcomes
Cross-Sectional Studies
Limitations:
Prevalent rather than incident (new)
cases are used the exposure could be
associated with survival after disease
occurrence, rather than development
of the disease

Temporal sequence between exposure


and disease cannot be established
* i.e. Which came first, chicken or the egg?
Cross-Sectional Study
Disadvantages:

Chicken or egg dilemma do not


know whether the exposure preceded
disease, or was a consequence of
disease development.
Cross-Sectional Study
Advantages:

Quick, easy, and cheap.

Can study multiple exposures and


disease outcomes simultaneously.

Good for describing the magnitude and


distribution of health problems.
Cross-sectional Studies
Often used to study conditions that are relatively
frequent with long duration of expression (nonfatal,
chronic conditions)
It measures prevalence, not incidence of disease
Example: community surveys
Not suitable for studying rare or highly fatal diseases
or a disease with short duration of expression
Cross-sectional studies
Disadvantages
Weakest observational design, (it
measures prevalence, not incidence of disease).
Prevalent cases are survivors
The temporal sequence of exposure and effect may be
difficult or impossible to determine
Usually dont know when disease occurred
Rare events a problem. Quickly emerging diseases a
problem
National Surveys
A large set of national epidemiological
surveys are conducted by the National
Center for Health Statistics (NCHS) ---
the Federal Governments principal
vital and health statistics agency.

The NCHS is part of the Center for


Disease Control and Prevention (CDC)
under the U.S. Dept. of Health and
Human Services.
National Surveys
National Health Interview Survey (NHIS)
Principal source of information on the
health of the civilian, non-
institutionalized household population
of the U.S.

National Health and Nutrition


Examination Survey (NHANES)
Collects information about the health
and diet of people in the U.S.
National Surveys
National Health Care Survey (NHCS)
Collects a wide range of data on
health care use, impact of medical
technology, and quality of care
provided.

National Immunization Survey (NIS)


Collects information on the
immunization coverage and health
care of children across the U.S.
National Surveys

National Survey of Family Growth (NSFG)


Collects data on factors affecting
pregnancy and womens health in the U.S.

National Mortality Followback Survey


(NMFS)
Aggregate sample of death certificates
across the U.S. for targeted research
purposes.
National Surveys
National Maternal and Infant Health
Survey (NMIHS)
Collects data on study factors related
to low birthweight, stillbirth, infant
illness, and infant death.
Behavioral Risk Factor Surveillance
System
Collects data on prevalence of
personal health behaviors among
adults associated with premature
morbidity and mortality.
National Surveys/Programs
Youth Risk Behavior Surveillance
System
Collects data to monitor prevalence of
behaviors in youths that results in
significant mortality, morbidity,
disability, and social problems.
National Program of Cancer Registries
(NPCR)
Surveillance, Epidemiology, and End
Results (SEER) Program
Other Sources of National Data

National Vital Statistics System


--- Birth data
--- Mortality data
--- Fetal death data
--- Marriages and divorces
--- Linked births/infant deaths
--- National death index

U.S. Census Bureau

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