case-control ( observational )

• Used for rare out comes

• there is already an outcome so we ask about exposure ( retrospective study )

• its a design that compares two groups

◦a group with disease ( case )

TO LOOK FOR DIFFERENT RISK FACTORS
◦another group without disease ( control )

Disadvantages

• can suggest a casual relationship but cannot prove

• cannot estimate prevalence of a disease accurately as a proportion of cases and controls are studied at a time.

• Can be exposed to ‘Recall Bias’ since the subjects are providing information based on their memory.

( the subjects with disease are likely to remember the presence of risk factors compared to the subjects without disease )

Advantages

• less expensive and less time consuming than cohort studies

Matching

the process of selecting the controls so that they are similar to the cases in certain characteristics such as

◦age, race, sex,

◦socioeconomic status and occupation.

Cross-sectional study ( observational )

• it evaluate the association between an exposure and outcome AT THE SAME TIME

• It can be classi ed under either descriptive or analytic, and depends on the question being answered by the
investigator

descriptive studies — answer the question who/what/whom/where Analytic studies — answer the question why

Disadvantages

• temporal association cannot be established as the information is collected at the same point of time.

◦( but If a study involves a questionnaire, then the investigator can ask questions to onset of symptoms or risk
factors in relation to onset of disease, this would help in obtaining a temporal sequence between the exposure
and outcome )

Temporal association between two

Advantages
disorders or clinical problems

• it can measure prevalence of the exposure or the outcome. refers to their hypothesized relationship
in terms of time of onset, most often
inferring a causal or contributory
relationship.

cohort study ( observational )

• select cases based on exposure

• so they compare two groups

◦one with exposure

◦the other without exposure

• usually for a single exposure/Risk factor

• cohort studies can also be hypothesis testing studies and can infer and interpret a causal relationship between an exposure
and a proposed outcome, but cannot establish it

• Its comparing populations with and without exposure/risk factor to development of outcome/disease.

• it can be

◦Prospective
◦Retrospective

PROSPECTIVE COHORT STUDIES

Prospective cohort studies follow subjects from presence of risk factors/exposure to development of disease/outcome

• could take years

• time consuming
• expensive

RETROSPECTIVE COHORT STUDIES

identify a population with and without the risk factor/exposure based on past records and then assess if they had developed the
disease/outcome at the time of study

TB/ The choice between prospective and retrospective cohort study design would depend on the accuracy and reliability of the
past records regarding the exposure/risk factor.

Disadvantages of cohort studies

• selection bias
• informational bias
• loss of follow-up

TB/ IF the information is inaccurate when past records are used to evaluate for exposure status, then the association between the
exposure and outcome becomes di cult to interpret.

Experimental studies

• The basic concept of experimental study design is to study the e ect of an intervention.

• here the risk factor/exposure is controlled by the investigator

• composed of two groups

◦includes a group that does not receive the intervention (control group)

◦a group that receives the intervention (intervention/experiment group)

Experimental study designs can be divided into 3 broad categories:

1. clinical trial

2. community trial

3. eld trial

CLINICAL TRIALS

• also known as therapeutic trials

• involve subjects with disease and are placed in di erent treatment groups

• It is considered a gold standard approach for epidemiological research

TB/ While designing a clinical trial, it is important to select the population that is best representative of the general
population. Therefore, the results obtained from the study can be generalized to the population from which the sample
population was selected.

COMMUNITY TRIAL

• also known as cluster-randomized trials,

• involve groups of individuals with and without disease who are assigned to di erent intervention/ experiment groups.

• will not be able to account for inter- individual and intra-individual variability.

TB / groups of individuals from a certain area, such as a town or city, or a certain group such as school or college, will
undergo the same intervention/ experiment. Hence, the results will be obtained at a larger scale

FIELD TRIAL

• also known as preventive or prophylactic trials

• the subjects without the disease are placed in di erent preventive intervention groups.

• One of the hypothetical examples for a eld trial would be to randomly assign to groups of a healthy population and to
provide an intervention to a group such as a vitamin and following through to measure certain outcomes.

• the subjects are monitored over a period of time for occurrence of a particular disease process.

SOME METHODS USED DURING RESEARCH

Placebo

• its an inert or innocuous substance used especially in controlled experiments testing the e cacy of another
substance (such as drug)

• its typically used in a clinical research study to evaluate the safety and e cacy of a drug/intervention.

• This is especially useful if the outcome measured is subjective.

TB/ In clinical drug trials, a placebo is typically a drug that resembles the drug to be tested in certain characteristics
such as color, size, shape and taste, but without the active substance. This helps to measure e ects of just
taking the drug, such as pain relief, compared to the drug with the active substance.

• If the e ect is positive, for example, improvement in mood/pain, then it is called placebo e ect

• If the e ect is negative, for example, worsening of mood/pain, then it is called nocebo e ect

• The ethics of placebo-controlled studies is complex and remains a debate in the medical research community.

Randomization

• is a well-established methodology adopted in research to prevent bias due to subject selection, which may
impact the result of the intervention/experiment being studied.

• It is one of the fundamental principles of an experimental study designs and ensures scienti c validity.

• It provides a way to avoid predicting which subjects are assigned to a certain group and therefore, prevent
bias on the nal results due to subject selection.

TB/ This also ensures comparability between groups as most baseline characteristics are similar prior to
randomization and therefore helps to interpret the results regarding the intervention/experiment group without bias.

• There are various ways to randomize and it can be as simple as a ‘ ip of a coin’ to use of computer software
and statistical methods.

• there are three types of randomization:

◦simple randomization

◦block randomization

◦strati ed randomization

Blinding

• is a methodology adopted in a study design to intentionally not provide information related to the allocation of the
groups to the subject participants, investigators and/or data analysts.

• The purpose of blinding is to decrease in uence associated with the knowledge of being in a particular group
on the study result.

• There are 3 forms of blinding:

◦single-blinded,

◦double-blinded

◦triple-blinded.

In single-blinded studies,

• otherwise called as open-label studies,

• the subject participants are not revealed which group that they have been allocated to.

• However, the investigator and data analyst will be aware of the allocation of the groups.

In double-blinded studies,

• both the study participants and the investigator will be unaware of the group to which they were allocated to.

• Double-blinded studies are typically used in clinical trials to test the safety and e cacy of the drugs.

In triple-blinded studies,

• the subject participants, investigators and data analysts will not be aware of the group allocation.

• are more di cult and expensive to design

• but the results obtained will exclude confounding e ects from knowledge of group allocation.

• Blinding is especially important in studies where subjective response are considered as outcomes

◦( This is because certain responses can be modi ed based on the knowledge of the experiment group that they are in )

TB/ certain treatments cannot be blinded such as surgeries or if the treatment group requires an assessment
of the e ect of intervention such as quitting smoking.

Bias in research

• de ned as “any systematic error in the design conduct or analysis of a study that results in a mistaken
estimate of an exposure’s e ect on the risk of disease”.

• There are multiple types of biases such as

◦selection bias,

◦information bias and

◦observer bias.

Selection bias

• is when a systematic error is committed while selecting subjects for the study.

• will a ect the external validity of the study if the study subjects are not representative of the population being
studied and therefore, the results of the study will not be generalizable.

• will a ect the internal validity of the study if the selection of study subjects in each group is in uenced by
certain factors, such as, based on the treatment of the group assigned.

• One of the ways to decrease selection bias is

1. to select the study population that would representative of the population being studied

2. or to randomize

Information bias

• is when a systematic error is committed while obtaining data from the study subjects.

• This can be in the form of recall bias when subject is required to remember certain events from the past.

( Typically, subjects with the disease tend to remember certain events compared to subjects without the disease)

Observer bias

• is a systematic error when the study investigator is in uenced by the certain characteristics of the group that
is, an investigator may pay closer attention to the group receiving the treatment versus the group not receiving the
treatment. This may in uence the results of the study.

TB/ One of the ways to decrease observer bias is to use blinding