Lect 5: Cross-sectional Studies: Issues in Analysis and Design

EPHD320
AY 2019/2020

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Learning Objectives

 Discuss the basic design of cross-sectional

studies
 Recognize potential biases of cross-sectional
studies.
 Understand and calculate basic measures of
morbidity and association.
 Design a cross sectional study

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Purpose: Descriptive, Analytical, and
Experimental Epidemiology
Descriptive Analytical Experimental
Epidemiology Epidemiology Epidemiology
• Magnitude & • Determinants of disease • Control of disease (1º,
distribution of disease 2º, 3º prevention)
(Person, Place, and
Time)
• Evaluate effectiveness
• How many cases of • Why is the disease of preventive and
disease? happening? therapeutic measures.
• Who is getting the
disease?
• Where is the disease
occurring?
• When is the disease
occurring?
• Tests hypothesis related
• Generates hypothesis to disease etiology
for analytical
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epidemiology
 Overview of Epidemiologic Studies

Epidemiologic
Studies

Observational Experimental

Descriptive: Community
Analytical: Randomized interventions
Case reports clinical trials
Cohort RCT
Case-series
Case-control
Ecologic
Cross-sectional
Cross-sectional

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The Hierarchy of Research Evidence

Review
Systematic
A review in which all available evidence on a
particular subject is systematically identified,
appraised and summarised.

A group of patients/ participants are

Controlled Trials
randomly allocated to receive different
Randomised interventions. Outcomes are then
compared.
Groups of people are selected on
Cohort Study the basis of their exposure to a
particular agent and followed up.
Ecological Studies
Cross Sectional Survey/ Survey or interview of a sample of the
population of interest at one point in time.
Case control studies/

A report based on a single subject

Case Report
or patient.

Expert opinion A consensus of experience

amongst professionals.

Anecdotal an informal account of

evidence in the form of
5 an anecdote
 QUALITY IS A KEY ISSUE
The extent to which a study’s design, conduct and analysis has
minimized selection, measurement, and confounding biases (internal
validity)

 What is Bias: It is an error in design or execution of a study,

which produces results that are consistently distorted in one
direction because of nonrandom factors.

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 Internal and External Validity

 Internal Validity  External Validity

 The extent to which a study’s  Also called generalizability

design, conduct and analysis has
minimized selection,
 Extent to which the study results
measurement, and confounding
biases apply (i.e. can be generalized) to
people who were not in the
study (target population)
 Relates to factors such as proper
selection of study groups and  Relates to whether the study
lack of error in measurement
sample is representative of the
target population
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 What research design is preferable?
The Design must fit the research question!

Availability of resources

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 The research design to answer the ?

Clinical/public health Research Design

Question
Effectiveness of an Systematic review, RCT,
intervention cohort
Diagnostic, magnitude of a Cross-sectional
health problem
Prognostic (course) Cohort
Harm, causation, Case control, cohort
identification of potential
9risk factors.
 Cross sectional
 A snapshot of a problem/situation…
 A status report

SAMPLE
(assess
exposure and
outcome )

POPULATION

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 Cross-sectional Study Design
 Also called prevalence study (or survey)

 Considered both a descriptive and analytic study design

 Exposure status and outcome are assessed simultaneously at a

single point in time

 Compares prevalence of disease in persons with or without a certain

exposure

 Repeated cross-sectional studies are carried out to give a

pseudo_longitudinal study, to assess trends in specific outcome of
interest.
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 Cross-sectional Study Design
Study
population

Assess Exposure
and Outcome
(Disease)

Exposed with Exposed Non-exposed Non-exposed

disease without disease with disease without disease

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Uses: The source of most of what we know about the population

Burden of illness and risk factors

Service needs
Hypothesis generation
To measure attitudes, beliefs, behaviors,
personal or family history, genetic factors,
existing or past health conditions, or
anything else that does not require follow-
up to assess
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Baseline data for a cohort study
 Uses: Example
 Prevalence and social determinants of mental illness in a district
population in Turkey

 A study to estimate the prevalence and determinants of

undiagnosed and diagnosed type 2 diabetes in middle-aged Irish
adults

 Young adult cancer survivors' psychosocial well-being: a cross-sectional

study assessing quality of life, unmet needs, and health behaviors

 Change in smoking behavior among University students following the

implementation of the Tobacco free campus in 2018 (changes for
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population groups):a repeated cross-sectional study
Design issues in cross- sectional studies

The basic cross-sectional design is simply a single survey.

 Choose population and cross-sectional sample

 Develop a valid survey instrument

 Valid and reliable indicators

 Administer Survey
 High participation is key!!
 The level of nonresponse is one concern, but a greater one still is that of
biased response, where a person is more likely to respond when they
have a particular characteristic or set of characteristics!!
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 Design

 Population and sample

 Defining the population (inclusion, exclusion criteria, accessibility)

 Sampling frames: list and non list:

 Registered voters in a town, residents listed in a local telephone directory, or a
roster of students enrolled in a course

 Selection of sample
Probability sampling: random sample …. External
validity

16The sampling frame used to select a sample and the response

Characteristics of a good sampling frame
 An Inadequate sampling frame can result in bias in your
result : and therefore the frame/list should be evaluated for
its:

 Comprehensiveness: are all units in the population listed?

 Telephone directories do not include residents with unlisted telephone
numbers or those who have only recently begun telephone service
  Missing elements that cannot be identified and recovered have no chance
of being selected into the sample. Consequently any sample selected
from frames with missing elements often do not adequately represent the
population

 Accuracy: check sampling frame for data entry errors,

17 outdated information, and other problems.
 List of doctors from doctor’s syndicate
 Sampling Designs
Non
Probabilit
probabilit
y
y
Simple convenie HUMAN
CHANCE
Random nt JUDGEMENT

Systemat
More rigorous snowball More suited to
ic
statistical qualitative or
analysis and purposiv inductive
generalization stratified research
e

Cluster quota

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multistag
e
 Types of Probability Sample
 Simple random sample
 Selection by equal probability of inclusion

 Systematic sample
 Selection from sample frame at a constant interval

 Stratified sample
 Proportional representation of population characteristics

 Multi-stage cluster sample

 Selection from groupings of population units

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 The final sample
There are multiple reasons why the final sample you draw may not
exactly reflect the population. These include:

 The use of stratification and/or cluster sampling causes certain elements to have a higher
probability of selection into the sample than others.
 Some respondents are systematically less likely to respond to an invitation to participate in a
survey.
 Even after correcting for the first two issues, the weighted sample distribution may still often fail
to correspond to a known population distribution (obtained from, for example, Census data).

Survey specialist create sampling weights to correct for these

systematic differences in selection probabilities.
It is important to utilize sampling weights when analyzing survey
data, especially when calculating univariate statistics such means or
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 Sampling weights?
I want to have a representative sample of 300 AUB graduate
and undergraduate students to measure support of a certain
policy
The population distribution of students:
Undergraduate: 88 %
Graduate :12 %
If I want a perfectly representative sample then my sample
should have
 Undergraduate :266
 Graduate:39

I might get 100 graduate and 300 undergraduates / or I might

decide to oversample Graduate to have a large enough sample
from this category
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 Cross Sectional National
Surveys

 A large set of national epidemiological surveys are conducted by

the National Center for Health Statistics (NCHS) --- the Federal
Government’s 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.
 http://www.cdc.gov/nchs/

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Examples of National Surveys, USA
Behavioral Risk Factor Surveillance System (BRFSS)
Ongoing survey of US residents aged 18 years and older
Since 1984
Collects data on behavioral risk factors that are associated
with chronic diseases
Through monthly telephone interviews
World’s largest survey; more than 350,000 adults are
interviewed each year
BRFSS data used by states to identify emerging health
problems, establish and track health objectives, and develop
and evaluate public health policies and programs.
http://www.cdc.gov/brfss/
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Example of Data Collected through the BRFSS:
Obesity Trends Among U.S. Adults By State, 2006

• Twenty two states

had a prevalence of
obesity ≥ 25%
• MS and WV had a
prevalence ≥30%

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Source: Behavioral Risk Factor Surveillance System, CDC 25

 Examples of National Surveys, USA

• National Health Interview Survey

• Conducted every year in U.S. by National Center for Health
Statistics (CDC)
• “Stratified, multistaged, household survey that covers the
civilian noninstitutionalized population of the United States”
• Redesigned every decade to use new census

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“multistaged”

 Improves logistical feasibility and reduces costs (though

reduces precision)
 Divide population into primary sampling units (PSU’s)
PSU = primary sampling unit: metropolitan statistical area,
county, group of adjacent counties
 Select sample of census block groups (SSU’s) within each
selected PSU
 Map each selected census block group or examine building
permits
 Select one cluster of 4-8 housing units dispersed evenly
throughout the block
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 Global Youth Tobacco Survey (CDC and
WHO)

GYTS is a nationally representative school-based survey of

students in grades associated with 13 to 15 years of age and
is designed to produce cross-sectional estimates for each
country. It uses a global standardized methodology that
includes a two-stage sample design with schools selected
with a probability proportional to enrollment size. The
classes within selected schools are chosen randomly and all
students in selected classes are eligible to participate in the
survey

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 Measurements
 Source of data:
 Subjective using structured questionnaires
 Face to face interview
 Self administered questionnaire
 Computer assisted interview
 Telephone interview
 Objective using lab tests and actual measurement

 A key issue is: Validity and reliability of measures and

indicators

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 Illustration
Cross sectional Studies
from Lebanon
 Large scale
 National study of rheumatic diseases
 National study on NCD behavioral risk factors
 National study of mental disorders

 Small-scale
 Smoking prevalence among pregnant women
 Determinants of depression among elderly males living in
underprivileged areas
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 Biases
 Selection Bias
 Was the study population clearly defined?
 What were the inclusion and exclusion criteria?
 Were refusals kept to a minimum?
 Non-response. This is a particular problem when the
characteristics of non-responders differ from responders
 Information bias
 Were the main variables of interest clearly defined?
 Were the measurements as objective as possible?
 Were measurements valid?
 Confounding : did the investigators collect data on
confounders?
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 Selection Bias
 The selection bias classic for cross-sectional studies is “the
healthy worker effect.” I.e., only “healthy workers” are
available for study, distorting your findings.
 Example: Low asthma rates in animal handlers (because
persons contracting asthma quit and are not available for study).
 Non-response. This is a particular problem when the
characteristics of non-responders differ from responders.

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 Types of measure

1. Prevalence
2. Incidence?
3. Measures of association

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 Reminder
 Incidence measures the rate at which people
without the disease gets the disease during a
specified period of time. It is a measure of
risk of occurrence of new cases.

 Prevalence measures the number of people in

a population who have the disease (new and
pre-existing) at or during a given point in
time.
 Cross sectional study= Prevalence study
34 But could in rare instances measure
 Measures of association
Prevalence Rate Ratio
It is the ratio of the prevalence of people having the
disease and exposed / prevalence of people having disease
and non-exposed
Odds Ratio
An odds ratio is calculated by dividing the odds in group a
by the odds in group b
It can calculate the odds of an event happening given a
particular exposure or treatment
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 Cross-Sectional Studies
Disease No Disease

Exposed a b

Not
Exposed c d

a / (a + b)
Prevalence Ratio (PR) = ------------
c / (c + d)
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 Mansour M. Al-Nozha et al. A national Cross sectional study of Diabetes Mellitus
risk factors.Saudi Med J 2004; Vol. 25 (11): 1603-1610

Prevalence of impaired fasting glucose and diabetes mellitus categorized by place of residence

impaired fasting glucose

Normal Impaired Diabetic
<6 mmol (%) 6.1-6.9 (%) >7 mmol (%) Total

Urban 6971 1701 2975 11647

Rural 3554 687 1029 5270
Total 10525 2388 4004 16917

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What measures can we generate?
 Evaluating association?
 Is the association real or is it due to chance?
Statistical tests

 Calculate confidence Intervals and P-Value

 if it is, how strong is the relationship?
 Is it dues to selection or information bias?
 Is it due to Confounding? What are possible confounders?
 How to control for confounding?

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 Strengths of 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

 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
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 Limitations of Cross-Sectional Studies
 Prevalent rather than incident (new) cases are identified - exposure
could be associated with survival after disease occurrence, rather than
development of the disease

 Temporal sequence between exposure and disease cannot be

established

 Not suitable for studying rare diseases or diseases with a short duration
 Susceptible to bias due to low response and misclassification due to
recall bias
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Illustration Article ( Karam et al, 2006)
Prevalence and treatment of mental disorders in Lebanon:
a national epidemiological survey; Elie G Karam, Zeina N
Mneimneh, Aimee N Karam, John A Fayyad, Soumana C Nasser,
Somnath Chatterji, Ronald C Kessler. Lancet 2006

 The purpose of the activity is to recognize/ identify the various

aspects of cross sectional study design and analysis
 Discuss appropriateness and clarity of presentation of analysis
and results

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