INTRODUCTION TO EPIDEMIOLOGY IN GLOBAL HEALTH

Confounding Problem Set

PROBLEM 1
The table below is adapted from an article reporting on a study that sought to assess risk factors
for hospitalized illness during pregnancy.
Table III. Obstetric and non-obstetric hospitalizations by maternal characteristics, NHDS, 1991
and 1992
Hosp. Ratio RR 95% CI
Age (year)
15-19 191,585 19.1 1.45 1.44-1.48
20-34 797,861 13.1 1 Ref
35-44 82,537 10.7 0.82 0.80-0.83
Marital Status
Married 378,490 11.4 1 Ref
Unmarried 290,194 18.8 1.65 1.63-1.67
Payment
Private 452,276 11.7 1 Ref
Medicaid 395,278 16.5 1.41 1.39-1.43
Self Pay 64,021 13.9 1.19 1.16-1.21

(Table Footnotes: Hosp., # of hospitalizations for illness during pregnancy; Ratio,

Hospitalizations per 100 pregnant women; RR, Crude relative risk). Note: Not all hospitals
reported information on marital status or payment source. You can assume this information is
missing completely at random.

1. The data presented may overstate the association between being unmarried and the risk of
hospitalization during pregnancy. What might explain this bias in the observed
relative risk?

From the age relative risk, younger age was associated with higher risk and their married
people are likely to be younger which thestudy did not take into consideration.
Also, married people can be grouped in divorced or seperated or widowed.

Introduction to Epidemiology in Global Health 1

University of Washington
PROBLEM 2
The following is inspired by a recent study of the association between exposure to welding
fumes and the risk of some forms of cancer. The actual data used in this problem are
hypothetical.

A large retrospective cohort study of occupational exposures and their associations with various
forms of cancer investigated the question of whether exposure to welding fumes is associated
with the risk of intestinal cancer. The investigators had access to employment and job-type
records for 100,000 people that included information about various workplace exposures,
including exposure to welding fumes. The investigators also had access to sociodemographic and
risk factor information collected through questionnaires completed by each participant. All
participants were determined to be free of cancer at the start of the study and were followed up
over a 20-year period. The investigators were also aware that the risk of intestinal cancer has
been reported to be associated with whether an individual smokes cigarettes and whether they eat
a diet that is higher in saturated fats compared to a diet lower in saturated fat.
Exposed to welding fumes
Smoking Status, Diet type Intestinal Person-Years
Cancer
Cases
Smoker, high fat diet 350 71,000
Smoker, lower fat diet 150 42,000
Non-smoker, high fat diet 70 21,000
Non-smoker, lower fat diet 40 16,000

Not Exposed to welding fumes

Smoking Status, Diet type Intestinal Person-Years
Cancer
Cases
Smoker, high fat diet 480 170,000
Smoker, lower fat diet 570 265,000
Non-smoker, high fat diet 575 291,000
Non-smoker, lower fat diet 907 637,000

1. Calculate the overall (crude) incidence rate (combining all possible smoking and diet
combinations) for those who were exposed to welding fumes.

ANS ; The overall incidence rate equals the sum of the various incidence rates
=(350+150+70+40)/(16000+71000+42000+21000)=3.5 per 1000 person years

Introduction to Epidemiology in Global Health 2

University of Washington
 2. Calculate the overall (crude) incidence rate (combining all possible smoking and diet
combinations) for those who were NOT exposed to welding fumes.

ANS ; The overall incidence rate equals the sum of the various incidence rates
=(480 +570+575+907)/(637000+170000+265000+291000) =1.9 per 1000 person years

3. Calculate the crude relative risk (RR) that measures the excess risk on the multiplicative
scale comparing those exposed to welding fumes to those not exposed to welding fumes.
ANS; the crude relative risk (RR) =incidence rate in exposed/ incidence rate in non-exposed
=3.5 /1.9= 1.8

4. Calculate a standardized rate of intestinal cancer among those exposed to welding fumes
using the distribution of diet and smoking observed in the population of those not
exposed to welding fumes as the standard population. Show your calculations.

Smoking Status, Observed Calculation Expected

Diet type
350 (350/71,000)*170,000 838
Smoker, high fat diet
Smoker, lower fat 150 (150/42,000)*265000 914
diet
Non-smoker, high 70 (70/21,000)*291000 970
fat diet
Non-smoker, lower 40 (40/16,000)*637000 1,593
fat diet
4,316
Total

Total person years =1,363,000 person years

Expected= 4,316

Standardized rate of intestinal cancer among those exposed= 4316/1363=3.17 per 1000
person years.

Introduction to Epidemiology in Global Health 3

University of Washington
 5. What is the relative risk of intestinal cancer among those exposed to welding fumes
compared to those not exposed to the welding fumes, accounting for differences in the
distribution of smoking and diet.
The relative risk of intestinal cancer among those exposed to welding fumes compared to
those not exposed to the welding fumes= incidence rate in exposed/incidence rate in non-
exposed = incidence rate in exposed/incidence rate in non-exposed
=3.17/1.9=1.68

6. Comment on whether or not you believe there is an indication of meaningful confounding

by smoking and diet of the association between exposure to welding fumes and intestinal
cancer. Provide a justification for your conclusions.

ANS;there is no evidence of meaningful confounding because the crude estimate of incidence

rate (3.5)is within 10% from its adjusted estimate(3.17) .

Introduction to Epidemiology in Global Health 4

University of Washington