Epid Lecture 8 Bias II 23 August 2018

CTB Epid Lecture 8 23 August 2018
VELI SUNGONO, M.S.

1 SELECTION BIAS
2 MEASUREMENT BIAS
3 HOW TO PREVENT/MINIMIZE BIAS
4 TAKE HOME MESSAGE

Inaccuracy
Bias
Lack of
Validity
Bias
Selection Measurement
/Information
• SAMPLE MIGHT NOT BE A
TRUE REPRESENTATION
OF THE POPULATION
• PREVENT BY RANDOM
INDEPENDENT SAMPLES
• There may be a spurious association
between diseases or between a
characteristic and a disease because of
the different probabilities of admission
to a hospital for those with the disease,
without the disease and with the
characteristic of interest
Berkson J. Limitations of the application of fourfold table analysis to hospital data. Biometrics
1946;2:47-53
Measurement Bias
(Observation Bias, Information Bias)
Error due to systematic
differences in the way data on
exposure or outcome are
obtained from various groups
leading to misclassification of
study subjects
Measurement/Information bias
•3 main types:
–Recall bias
–Interviewer bias
–Misclassification
Causes of misclassification
1. Measurement gap: gap between the measured and
the true value of a variable
- Observer / interviewer bias
- Recall bias
- Reporting bias
- Publication Bias
2. Gap b/w the theoretical and empirical definition of
exposure / disease
All FDA trials for 12 antidepressants
REALITY:
38 Positive Results vs 36 Negative Results
LITERATURE REVIEW
38 Positive Results vs 3 Negative Results
Source: Erick H. Turner et al. NEJM 358, no. 3, 2008: 252-260 in Ben Goldacre: What
doctors don't know about the drugs they prescribe, Youtube Video
https://www.youtube.com/watch?t=86&v=RKmxL8VYy0M, article Publication Bias— the
Hidden Systematic Flaw in M edicine that Can Threaten Your Life, by Dr. M ercola
Measurement bias in treatment effects
• Hawthorne effect: effect (usually positive
/ beneficial) of being under study upon the
persons being studied; their knowledge of
being studied influences their behavior
• Placebo effect: (usually, but not
necessarily beneficial) expectation that
regimen will have effect, i.e. the effect is due
to the power of suggestion.
Types of Information Bias
n Interviewer Bias – an interviewer’s
knowledge may influence the structure of
questions and the manner of presentation,
which may influence responses
n Recall Bias – those with a particular

outcome or exposure may remember events
more clearly or amplify their recollections
Epidemiology (Schneider)
Sources of measurement error
Respondent (interview, questionnaire):
n inability to understand, recall, articulate;
n unwillingness to disclose
n social desirability influences
Can be influenced by wording of questions and how
they are asked.
3/22/2011 Sources of error: Information bias 15

How not to ask questions
“Has anyone ever tried to give you the mistaken

idea that sex intercourse is necessary for the health
of the young man?
(from a survey by the NC state health officer, circa 1926,

summarized in Kinsey et al., 1948)
Can you guess the right answer?
3/22/2011 Sources of error: Information bias 16

Types of Information Bias (cont.)
n Observer Bias – observers may have
preconceived expectations of what they
should find in an examination
n Loss to follow-up – those that are lost to

follow-up or who withdraw from the study
may be different from those who are
followed for the entire study
Information Bias (cont.)
n Hawthorne effect – an effect first
documented at a Hawthorne manufacturing
plant; people act differently if they know
they are being watched
n Surveillance bias – the group with the

known exposure or outcome may be
followed more closely or longer than the
comparison group
Types of Misclassification Bias
n Differential misclassification – Errors in

measurement are one way only
n Example: Measurement bias –

instrumentation may be inaccurate, such as
using only one size blood pressure cuff to
take measurements on both adults and
children
Control of Bias
Prevent
Study
Evaluate
Sample Size
Missing Information
Increase Sample Size

Evaluation of the role of bias
Results ValidityRepeatability
Controls for Bias
n Be purposeful in the study design to minimize the
chance for bias
n Example: use more than one control group
n Define, a priori, who is a case or what constitutes

exposure so that there is no overlap
n Define categories within groups clearly (age groups,
aggregates of person years)
n Set up strict guidelines for data collection

n Train observers or interviewers to obtain data in the same
fashion
n It is preferable to use more than one observer or
interviewer, but not so many that they cannot be trained
in an identical manner
Controls for Bias (cont)
n Randomly allocate observers/interviewer
data collection assignments
n Institute a masking process if appropriate

n Single masked study – subjects are unaware of
whether they are in the experimental or control group
n Double masked study – the subject and the observer
are unaware of the subject’s group allocation
n Triple masked study – the subject, observer and data
analyst are unaware of the subject’s group allocation
n Build in methods to minimize loss to

follow-up
2. INFORMATION BIAS
Any aspect of the way information is collected in
the study that creates a systematic difference
between the compared populations that is not due
to the association under study. (some call this
measurement bias). The incomplete chart
recording in the baby feeding example would be a
form of information bias.
Other examples -
n Diagnostic suspicion bias
n Recall bias
n publication bias (tendency to publish papers
which show positive results).
Source: http://www.google.co.id/imgres?imgurl=https://soulsconverge.files.wordpress.com/2011/05/truth.jpg&imgrefurl=https://soulsconverge.wordpress.com/tag/truth/&h=291&w=320&tbnid=EYd-fm9U427iwM:&docid=YNOHLa49egIywM&ei=JwHlVZPmIMacugTqpL7wCg&tbm=isch&ved=0CFIQMygtMC1qFQoTCNOV9qbZ1McCFUaOjgodapIPrg,
http://www.google.co.id/imgres?imgurl=https://uturntograce.files.wordpress.com/2012/05/truth_set_free.jpg&imgrefurl=https://uturntograce.wordpress.com/tag/foundation/&h=416&w=600&tbnid=KRGyrCSVg8w95M:&docid=xw7ZLTODNHYY1M&itg=1&ei=JwHlVZPmIMacugTqpL7wCg&tbm=isch&ved=0CIIBEDMoXTBdahUKEwjTlfam2dTHAhVGjo4KHWqSD64
I. PENDAHULUAN III. KERANGKA TEORI
A. Latar Belakang KERANGKA KONSEP
DEFINISI OPERASIONAL
B. Rumusan Masalah
C. Tujuan Penelitian IV. METODOLOGI
C.1. Tujuan Umum A. Design Studi
C.2. Tujuan Khusus B. Populasi dan Sampel
C. Inklusi Ekslusi
D. Manfaat Penelitian
D. Perhitungan Sampel
II. TINJAUAN PUSTAKA E. Teknik Sampling
F. Analisa Statistik
Review: IV. Metodologi Penelitian
C. Teknik Pengambilan Sampel
n P value
n Confidence Interval
n Question
n Understand the basic logic and procedures
involved in common statistical analysis
n Know what the RESULTS Mean
Standard Deviation and Probability
n For a set of data with a
normal distribution, a value X
Frequency
will fall within a range of:
n +/- 1 SD 68.2% of the time
n +/- 2 SD 95.5% of the time 68.2%
n +/- 3 SD 99.7% of the time
95.5%
99.7%
-3s- 2s -1s Mean +1s +2s +3s
Interval estimation Confidence interval (CI)
provide us with a range of values that we belive, with a

given level of confidence, containes a true value
CI for the population means
95%CI = x ± 1.96 SEM

99%CI = x ± 2.58 SEM
SD
SEM =
n
Interval estimation
Confidence interval (CI)
34% 34%
14% 14%
2% 2%
z
-3.0 -2.0 -1.0 0.0 1.0 2.0 3.0
-2.58 -1.96 1.96 2.58
Interval estimation
Confidence interval (CI), interpretation and example
50
40
Frequency
30
20
10
0
22.5 27.5 32.5 37.5 42.5 47.5 52.5 57.5
25.0 30.0 35.0 40.0 45.0 50.0 55.0 60.0
Age in years
`x= 41.0, SD= 8.7, SEM=0.46, 95% CI (40.0, 42), 99%CI (39.7, 42.1)
Source: http://4.bp.blogspot.com/-LaGAgcbaKIM/Tz--W5aIpRI/AAAAAAAAA-k/ysFZyzXTP0w/s400/Estatistica2.png
Source: http://sphweb.bumc.bu.edu/otlt/MPH-Modules/EP/EP713_Association/Giardia%20OR-2.jpg
SOURCE
• Madhukar Pai, Selection Bias in
Epidemiological Studies, Assistant Professor
Department of Epidemiology & Biostatistics
McGill University, Montreal, Canada
• Neil Pearce, et. all, Bias in Occupational
Epidemiology Studies, Occup Environ Med
2007; 64:562-568
• Leon Gordis, Epidemiology Fourth Edition

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CTB Epid Lecture 8 23 August 2018

VELI SUNGONO, M.S.

3 HOW TO PREVENT/MINIMIZE BIAS

4 TAKE HOME MESSAGE

n Recall Bias – those with a particular

3/22/2011 Sources of error: Information bias 15

“Has anyone ever tried to give you the mistaken

(from a survey by the NC state health officer, circa 1926,

Can you guess the right answer?

3/22/2011 Sources of error: Information bias 16

n Loss to follow-up – those that are lost to

n Surveillance bias – the group with the

n Differential misclassification – Errors in

n Example: Measurement bias –

Increase Sample Size

n Define, a priori, who is a case or what constitutes

n Set up strict guidelines for data collection

n Institute a masking process if appropriate

n Build in methods to minimize loss to

provide us with a range of values that we belive, with a

CI for the population means

95%CI = x ± 1.96 SEM

-2.58 -1.96 1.96 2.58

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