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Nyoman Sutarsa, MD., MPH
Community and Preventive (Public Health)
Faculty of Medicine, Udayana University
Ph. +62878 6038 0028

Learning Outcomes
1. To describe prospective and
retrospective cohort studies
2. To explain advantages and
disadvantages of cohort studies
3. To explain risk(s) interpretation
in cohort studies

Chapter 8. Cohort Studies
(Greenberg et al., 2001; pp. 113
– 125)
1. Bonita et al., 2006. Basic
Epidemiology (WHO) (pp. 4649)
2. Webb and Bain, 2011.
Essential Epidemiology (pp.

Please write it down on a paper and submit them morning! tomorrow .Correction(s) Case 1. Tobacco smoking as a risk factor for depression: A 26year population-based follow up study Please skip this during SGD and do it as a homework instead.

Case-Control.Do the researcher assign a particular intervention? Yes No Experimental Study Observational Study Random Allocation Comparison Groups Yes RCTs No Yes NonRCTs Analitik: Crossectional. Cohort No Descriptive: Crossectional and Longitudinal .

a cardiologist. Please explain your comment about his conclusion! . 80 were found to have CHD. He explained that from 100 patients who didn’t regularly exercise visiting his clinic. He then concluded that lack of physical activities is the major risk factor for CHD.ILLUSTRATION: Parikesit. delivered a community health education related to coronary heart disease (CHD).

WHAT IS COHORT ? A group of people who have certain similar characteristics Example(s): Birth Cohort Marital Cohort Medical Faculty Admission Cohort Smoker Cohort IUD Users Cohort .

then inquiring the disease incidence To study the relationship between a risk factor and a disease outcome “CAUSE TO EFFECT” .COHORT STUDY Comparing the exposed and the un-exposed groups.

Time of Study Onset of study Eligible Subjects (Free of disease) Disease (+) Exposed Disease (-) “CAUSE TO EFFECT” Unexpos ed Direction of Inquiry Disease (+) Disease (-) .

TYPES Cohort Prospective Cohort Retrospective (Historical Cohort) .

Prospective Onset of study Eligible Subjects Disease (+) Exposed Disease (-) “CAUSE TO EFFECT” Unexpos ed Direction of Inquiry Disease (+) Disease (-) .

Onset of study (2013) 2012 Secondary Data Eligible Subjects Disease (+) Exposed Disease (-) “CAUSE TO EFFECT” Unexpos ed Retrospective Direction of Inquiry Disease (+) Disease (-) .

When cohort studies can be used  INDICATION (s) To explore the relationship between CAUSE (s) or RISK FACTOR(s) and EFFECT (s) or DISEASES The incidence of disease (under investigation) is quite common (not considered as a rare disease) To gather information on the incidence of diseases .

Select the study group (exposed) and control group (un-exposed) 3.Define the study population (cohort population) 2.Collect the exposure data 4.Observe the outcome(s) 5.STUDY PROCEDURES 1.Conduct data analysis .

Farmers using pesticides 3.Radiologist 2.People who live in area with high level of CO or other chemical hazards .Smokers 4.Determining Study Group: Study Group (s) are an exposed population (with a particular risk factor) and can be evaluated Examples: 1.

A group of “volunteer” “Cohort” from certain geographic area .Insurance clients 3.Industrial workers 2.Determining Study Group: A group who are possible to “follow-up” Examples: 1.Patients in Ante Natal Care clinics 4.

Other Cohort as a control group Control selected from a different population .Determining Control Group: 1. Internal Control: Control selected from the same population with the study group 2.

Examining Environmental factors (e. CO level. Medical Record 2. Interviewing Cohort Member 3. because some exposures are one-time episode (asphyxia at birth) and some are long term exposure (cigarette smoking. Examining the health status 4.It is essential the exposure Collecting to define the data exposure clearly. use of oral 1.g. Lead level) .

Periodic examination by the investigators.Observing the outcome(s) Information on outcome may come from various sources and it must have standard criteria 1. 3. The record of physicians and hospitals 2. Combination of the two .

Analysis Relative Risk (RR) Attributable Risk (AR) Attributable Risk % (AR%) .

Relative Risk (RR) The ratio of incidence rate among the “exposed” group with the “unexposed” group Risk Ratio Rate Ratio .

RR Calculation Disease Exposed Group Unexposed Group Total Yes A B A+B No C D C+D A+C B+D A+B+C+D Total RR = [A/(A+C)]/[B/ (B+D)] .

RR Interpretation Example: RR = 1. Statistic Test Ho: RR = 1 Ha: RR ≠ 1 or Ha: RR > 1 . Statistically significant? 1. Calculate the Confidence Interval 2.8 times higher to suffer from a disease compared to the unexposed group.8 The risk of the exposed group is 1.

Calculating CI of RR Where: .

95% CI: 0.5 – 3.6 * 1 inside the CI  not significant .5.How to interpret CI of RR? If 1 inside the CI. Example: * RR = 1. then the risk between exposed and un-exposed groups is not significantly different.

Analysis atributable Risk (AR) Relative Risk (RR) Attributable Risk (AR) Attributable Risk % (AR%) .

40 (incidence among exposure group) • AR =P(D|E) – P(D|C) = ..30 (incidence attributed to exposure) .The incidence of “exposed” group minus the incidence of “unexposed” group • Example: • P(D|C)= .10 (incidence among control group) • P(D|E)= .10 = .40 .

[B/ (B+D)] A/(A+C) – B/ ARP = A/ (B+D) x 100% .Calculating AR and AR%: Outcome Exposed Unexpose Total Yes A d B A+B No C D C+D Total A+C B+D A+B+C+D AR = [A/(A+C)] .

How to interpret AR and AR %? Interpretation “Attributable risk” incidence of the disease attributable to the “exposed” factor or number of incidence will reduce when the risk is not existed Interpretation “Attributable risk %” • Proportion of all cases (disease) in the population caused by the ‘exposure’ (indicator for public health impact) .

Confounding in Cohort Studies Hypertens ion CHD Confoundin g • Smoking Control by • Drinking Control by • Age design? analysis? • Sex (multivariate (matched or analysis) elimination) .

particularly those with short duration and frequent Ideal to explain the relationship between risk factors and disease/outcomes (temporal relationship) Good to study fatal and progressive cases or diseases Limitations Require long time and high cost Often really complex May not applicable or not efficient to rare cases Drop out or lost to follow up Can be used to study several effects threat and the exposure intensity (at one point) from the risk factor might change over time  disturb data analysis Generally are more accurate because long and continuous observation Ethical consideration for a particular cases if we let the harmful exposure to be continued .COHORT STUDIES: Advantages Ideal to study incidence and natural history of disease.