EPIDEMIOLOGICA

L STUDIES
Epidemiology CHS234
Quantitative Research:

■ These can be classified as either experimental; where the epidemiologist

have control over the circumstances from the start, or observational;
where they do not. Vaccine efficacy trials are a good example of
experimental studies because the investigators control who gets vaccine
and who does not.
■ Observational studies can be further subdivided into descriptive and
analytic studies.
1. Observational:
a) Descriptive studies
 Case report
 Case series
b) Analytic studies
 Cross sectional study
 Case control study
 Cohort study
2. Experimental studies
a) Randomized clinical trials
b) Community trials
B. Qualitative research:

■ Different data gathering techniques:

1. Focus groups
2. Participant observation
3. Interviews
4. Field Notes
5. Tape recording / transcription
Descriptive Epidemiology:

■ It is the foundation for studying population.

■ Descriptive studies (characterizing the distribution of a health
condition) usually precedes analytic studies (investigating the
determinants of a disease).
■ Three epidemiologic variables: Time, place and person.
 a) Time
Disease rates change over time.
■ Some of these changes occur regularly and can be predicted. For example,
the seasonal increase of influenza cases with the onset of cold weather is a
pattern that is familiar to everyone. By knowing when flu outbreaks will
occur, health departments can time their flu shot campaigns effectively.
■ Other disease rates make unpredictable changes. By examining events that
precede a disease rate increase or decrease, we may identify causes and
appropriate actions to control or prevent further occurrence of the disease.
• We usually show time data as a graph. We put the number or rate of cases
or deaths on the vertical, y-axis; we put the time periods along the horizontal,
x-axis.
• Depending on what event we are describing, we may be interested in a
period of years or decades, or we may limit the period to days, weeks, or
months when the number of cases reported is greater than normal (an
epidemic period).
Seasonality: By graphing the occurrence of a disease by week or month over
the course of a year or more, we can show its seasonal pattern, if any. Some
diseases are known to have characteristic seasonal distributions; for example, as
mentioned earlier, the number of reported cases of influenza typically increases
in winter.
Seasonal patterns may suggest hypotheses about how the infection is
transmitted, what behavioral factors increase risk, and other possible
contributors to the disease or condition.
Day of week and time of day: Displaying data by days of the week or time of
day may also be informative. Analysis at these shorter time periods is especially
important for conditions that are potentially related to occupational or
environmental exposures, which may occur at regularly scheduled intervals.
 b) Place:
■ We describe a health event by place to gain insight into the geographical
extent of the problem.
■ For place, we may use place of residence, birthplace, place of
employment, school district, hospital unit, etc., depending on which may
be related to the occurrence of the health event. Similarly, we may use
large or small geographic units: country, state, county, street address, map
coordinates, or some other standard geographical designation.
It may include such categories:
• Urban or rural
• Domestic or foreign
• Climate variation
• Geography
• Housing
• Pollution
 c) Person
■ In descriptive epidemiology, when we organize or analyze data by “person” there
are several person categories available to us.
■ We may use:
1. Inherent characteristics of people (for example, age, race, sex),
2. Acquired characteristics (immune or marital status),
3. Activities (occupation, leisure activities, use of medications/tobacco/drugs),
4. Conditions under which they live (socioeconomic status, access to medical care).
■ These categories determine to a large degree who is at greatest risk of
experiencing some undesirable health condition, such as becoming infected with
a particular disease organism.
■ We may show person data in either tables or graphs.
Age: is probably the single most important “person” attribute, because
almost every health-related event or state varies with age
Sex: In general, males have higher rates of illness and death than females do
for a wide range of diseases. For some diseases, this sex-related difference is
because of genetic, hormonal, anatomic, or other inherent differences
between the sexes. These inherent differences affect their susceptibility or
physiologic responses.

For example:
Premenopausal women have a lower risk of heart disease than men of the same age do. This
difference is attributed to higher estrogen levels in women.

On the other hand, the sex-related differences in the occurrence of many diseases reflect
differences in opportunity or levels of exposure.
For example:
Hand/wrist disorders occur almost twice as often in females than in males.
• You may have attributed the higher level of disorders in females to their
higher level of exposure to occupational activities that require repetitive
hand/wrist motion such as typing or keyboard entry. With
occupationally related illness, we usually find that sex differences
reflect the number of workers in those occupations
Ethnic and racial groups: In examining epidemiologic data, we are
interested in any group of people who have lived together long enough to
acquire common characteristics, either biologically or socially. Several terms
are commonly used to identify such groups: race, nationality, religion, or
local reproductive or social groups, such as tribes and other geographically or
socially isolated groups.
• Clearly this graph
displays a range of suicide
death rates for the five
groups of people. These
data provide direction for
prevention programs and
for future studies to
explain the differences.
Types of observational descriptive
studies:
■ Case reports and case series
• Case reports and case series describe the experience of a single patient or a
group of patient with a similar diagnosis
• The collection of a case series rather than reliance on a single case report
can mean the difference between formulating a useful hypothesis and merely
documenting an interesting medical oddity.
Advantages include:
1. Recognition of new diseases
2. Formulation of hypotheses

Disadvantages include:
1. Based on the experience of one person, or just a few people.
2. Lack of an appropriate comparison group.
3. The presence of any risk factor may be coincidental
Analytic epidemiology:

■ Analytic epidemiology is concerned with the search for the why and the
how. We use analytic epidemiology to quantify the association
between exposures and outcomes and to test hypotheses to assess
causal relationships.
■ Analytic studies are "observational studies with comparison group"; we
simply observe the exposure and outcome status of each study
participant.
Types of observational analytic studies:

1. Cross sectional study

2. Case control study
3. Cohort studies
 1.Cross sectional studies
■ A cross-sectional study is a study of a population at a single point of time.
■ Useful determining the prevalence of risk factors and the frequency of prevalent for cases
of a disease for a defined population.
■ They are also useful for measuring current health status and planning for selected health
services.

■ Advantages include:
1. Fairly quick and easy to perform.
2. Useful for hypothesis generation.

■ Disadvantages include:
1. Do not offer evidence of temporal relationship between risk factors and disease.
2. Not good for hypothesis testing.
2.The case-control study
■ The case-control study is more common than the cohort study. In a case-
control study, we enroll a group of people with disease (cases) and a group
without disease (controls) and compare their patterns of previous exposures.
■ The key in a case-control study is to identify an appropriate control (or
comparison) group, because it provides our measure of the expected amount
of exposure.
■ Always are retrospective studies.
■ Selection of a comparison group, i.e., the controls, is an important issue
when conducting a case-control study.
■ The ideal control group should be representative of a population from
which the cases are derived, typically called the source population.
Advantages include:
1. Relatively inexpensive.
2. Providing sufficient numbers of cases for rare diseases with long
latencies.
3. Allowing several exposures to be evaluated at the same time.

Disadvantages include:
1. Susceptible to selection and information bias.
2. Not appropriate for prevalence/incidence estimates.
3. Not allowing estimation of risk.
4. Not considering more than one disease.
5. Not feasible for rare exposures.
6. Temporal relationship between exposure and disease can be
difficult/impossible to establish.
3.Cohort studies
■ The cohort study is an analytic observational study design most similar to a
clinical trial.
■ We categorize subjects on the basis of their exposure and then observe them
to see if they develop the health conditions (outcome) we are studying.
■ The difference between cohort study and experimental study is that we
observe the exposure status rather than determining it. After a period, we
compare the disease rate in the exposed group to the disease rate in the
unexposed group.
■ Always are follow-up studies with forward directionality.
■ Generally, cohort studies are prospective.
• The length of follow-up varies, ranging from a few days for acute diseases
to several decades for cancer, cardiovascular or other chronic diseases.
• I.e.; the Framingham study is a well-known cohort study which has
followed over 5,000 residents of Framingham, Massachusetts, since the early
1950's to establish the rates and risk factors for heart diseases.

Advantages include:
1. Least prone to bias when compared with other observational study designs.
2. Forward directionality; looks at cause before effect.
3. Can study several diseases (outcomes).

Disadvantages include:
1. Often quite costly and time-consuming.
2. Loss-to-follow-up may lead to bias.
3. Poor design for studying rare diseases or diseases with long latencies.
Analytic Study Designs
Hierarchy of epidemiologic study designs
Selecting study design:

■ Because some research questions can be answered by more than one

type of research designs, the choice of design depends on a variety of
considerations, including:
1. Availability of time.
2. Availability of resources.
3. Availability of data.

■ You should always aim for a design that generates the evidence to
answer the initial question as unambiguously as possible.
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