MVUMI INSTITUTE OF HEALTH SCIENCES

DIOCESE OF CENTRAL TANGANYIKA

 Tutor: Samson Lazaro

email: samson134@gmail.com
Epidemiology and Biostatistics
Session 4: Analytical Observational studies– Case-
Control
Learning Objectives
By the end of this session, students are
expected to be able to:
 Describe General Overview of analytical
methods/studies
 Describe Designing and Conduction of Case-
control studies
 Describe Measures of Risk/association
 Describe Measures of Effect from a Case-control
study
What is analysis?

• What is the meaning of analytical study

Descriptive epidemiology describes occurrence of disease (or of its determinants)
within a population, the analytical epidemiology aims to gain knowledge on the
quality and the amount of influence that determinants have on the occurrence of
disease.
• The usual way to gain this knowledge is by group comparisons. Such a comparison
starts from one or more hypotheses about how the determinant may influence
occurrence of disease.
• Analytical studies are observational studies used to test specific aetiological
hypothesis
•  They try to explain a disease in context and are aimed at establishing the cause of
a disease by looking for associations between exposure to a risk factor and its
associated occurrence of a disease.
• n general the outcome of an analytical study is the conclusion that – a disease and
its suspected cause are or are not associated.
 These studies answer the following questions:

• Why does the disease occur in the persons

experiencing it, and not in the persons not
experiencing it?
• Why do certain persons fail to make use of health
services?
• Can the decreased incidence of the disease be
attributed to the introduction of preventive measures?
• To answer these questions, hypotheses are formulated
and tested that may help to explain the situation.
Examples of analytical studies include:

• Case-Control Studies –Retrospective studies

• Cohort Studies – Prospective studies and retrospective
Case-Control Studies
A case control-study
• A case control-study is an epidemiologic
investigation which involves comparing the
characteristics of diseased persons (the cases) with
those of non-diseased person (the controls).
• The purpose of this comparison is to identify
factors which occur more (or less) frequently in the
cases as compared to the controls
• A case-control study provides clues regarding the
role of the factors in elevating or reducing the risk
of the disease under investigation.
 Case-Control Studies
• It is a study that compares patients who have a disease
or outcome of interest (cases) with patients who do not
have the disease or outcome (controls), and looks back
retrospectively to compare how frequently the exposure
to a risk factor is present in each group to determine the
relationship between the risk factor and the disease.
• A case-control study involves comparing the
characteristics of diseased persons (the cases)
with those of non-diseased persons (the
controls).
• Also called case-referent studies case
comparisons or case history studies.
• Case control studies are also known as "retrospective
studies" and "case-referent studies."
• The purpose of this comparison is to identify factors
which occur more (or less) frequently in the cases as
compared to the controls, and hence provide clues
regarding the role of these factors in elevating (or
reducing) the risk of the disease under investigation.
• Case-control studies are by far the simplest in
determining cause and effect relationships.
• These studies are designed to estimate odds.
 Case-Control Studies are designed to
estimate odds.
Advantages of Case-Control Studies

• Efficient in time and cost as less time needed to conduct the

study because the condition or disease has already occurred
• Efficient for the study of rare diseases.
• Efficient for the study of chronic diseases
Disadvantages of Case-Control Studies

• Retrospective studies have more problems with data

quality because they rely on memory and people with
a condition will be more motivated to recall risk
factors (also called recall bias).
• Both the exposure and disease have already occurred
at the time the participants are recruited into the
study.
Therefore; The design is susceptible to bias arising from
differential selection of cases or controls into the study
 Disadvantages cont.……
• Inefficient in ascertainment of rare exposures.
• Rates cannot be computed directly unless a modified design is adopted.
• Temporal relationships between exposure and disease are usually
difficult to ascertain
• Important disadvantages of case-control studies are that they are more
susceptible to selection bias and that information on exposure is less
accurately ascertained than in cohort studies.
• Not good for evaluating diagnostic tests because it‘s already clear that
the cases have the condition and the controls do not
• It can be difficult to find a suitable control group
Designing and Conducting of Case-Control
Studies
Selecting Cases
• A case control study begins with the selection of cases
• Cases should represent as far as possible a homogenous disease entity
to ensure that the cases selected represent a homogenous disease
entity.
• Establish strict diagnostic criteria for the disease.
• Selection of cases should be done from a well-defined
population called source population.
Selecting Controls
• The controls should represent people who would
have been designated study cases if they had
developed the disease i.e. A control is as much like
a case as possible except that they do not have the
disease (outcome) in question.
• They must have the same opportunity for exposure
as a case and must be subject to the same inclusion
and exclusion criteria.
• No one control group is optimal for all situations.
• Scientific, economic and practical considerations
should be sought before selecting controls.
Measures of Risk/Association
• A measure of association is a statistical quantity
used to indicate the strength of the relationship
between two variables. Measures of association
take on values ranging from -1.0 to +1.0, with the
positive and negative signs indicating the direction
of the relationship, not the strength of the
relationship.
• It is a measure used to determine the association
between risk factor and disease as well as methods
to assess the effect, i.e. the importance of the risk
factor to the study population
• Association is a statistical relationship between two
or more variables
Three measure of association which are most frequently used are

•Odds ratio;
•Relative risk
•Attributable risk (or risk difference)
Odds ratio;
• Odds are simply a ratio of the probability that an
event will occur versus the probability that the event
will not occur, or probability / (1-probability).
• The odds ratio is one of a range of statistics used to
assess the risk of a particular outcome (or disease) if
a certain factor (or exposure) is present.
•  The odds ratio is a relative measure of risk, telling
us how much more likely it is that someone who is
exposed to the factor under study will develop the
outcome as compared to someone who is not
exposed.
• This is used when you want to compare the odds of something
occurring to two different groups.
• The formula is p/(1- p)
q//(1-q)
• Where p is the probability for the first group, and q is
the probability for the second.
OR = P (disease/exposed) / (1 - P (disease/exposed))
P (disease/unexposed) / (1 - P (disease/unexposed))

• In statistics, the odds of an event occurring is the

probability of the event divided by the
probability of an event not occurring.
Relative Risk (RR)
The relative risk (RR) is the probability that a member of an
exposed group will develop a disease relative to the probability
that a member of an unexposed group will develop that same
disease.
• The relative risk is the ratio of the probabilities of two events; if
p is the probability of the first
• event, and q is the probability of the second, then the relative
risk is p/q.
RR = p (disease/exposed)
q (disease/unexposed)
 Attributable risk (or risk difference)
• Attributable risk (AR) or risk difference is the difference
between the incidence rates in exposed and non-exposed groups.
In a cohort study, AR is calculated as the difference in
cumulative incidences (risk difference) or incidence densities
(rate difference).
• This reflects the absolute risk of the exposure or the excess risk
of the outcome (e.g. Disease) in the exposed group compared
with the non-exposed group.
• AR is sometimes referred to as attributable risk in the exposed
because it is used to quantify risk in the exposed group that is
attributable to the exposure
• AR = Incidence in the exposed (E+) - Incidence in the non-exposed (E-)
CALCULATION

Exposure
Status
Cases
(diseased)
Controls
(healthy) Total
Exposed a b a+b
Not exposed c d c+d
Total a +c b +d (a + b + c + d)
•Odds Ratio = a/c = axd
b/d bxc
CALCULATION

Exposure
Status
Cases
(diseased)
Controls
(healthy) Total
Exposed a b a+b
Not exposed c d c+d
Total a +c b +d (a + b + c + d)
QNS
1. What are the advantages of case control studies?
2. What are the disadvantages of case control
studies?
3. What are the advantages of selecting controls
from hospital or health facility?
4. What are the disadvantages of selecting controls
from hospital or health facility?
5. What are the advantages of using special groups
for controls?
6. How is the Odds Ratio interpreted?
interpretation

INTERPRETATION
• When the above are taken care of, the odds ratio may
be interpreted as follows:
• OR = 1
An odds ratio of one means lack of association between
exposure and disease.
• OR ≠ 1
Odds ratios different from one indicate the possibility of
an association between exposure and disease.
• OR > 1
If the odds ratio is greater the one exposure to the factors
will lead to an increased risk of disease
• o OR < 1
• If the odds ratio is less than one it shows a protective
effect of the exposure under investigation
Problem 1
 Calculate Odds Ratio using the following data.
 Interpret the result (strength of association)
The distribution of bottled water consumption and the occurrence of
diarrhea diseases in case control S
Exposure Cases Controls Total
Status
Exposed 20 5 25
Not exposed 5 20 25
Total 25 25 50
• Odds of exposed cases = 20/5

• Odds of exposed controls = 5/20

• OR = 20/5 DIVIDE BY 5/20 = 16

• Odds Ratio is 16. It is greater than 1, therefore there is

association between exposure and occurrence of disease
• BUT IF Odds Ratio is 1. Therefore there is no
association between exposure and occurrence of
disease.
Problem 1
 Calculate Odds Ratio using the following data.
 Interpret the result (strength of association)
The distribution of bottled water consumption and the occurrence of
diarrhea diseases in case control S

Exposure Cases Controls Total

Status
Exposed 10 20 30
Not exposed 5 10 15
Total 15 30 45
Problem 1
 Calculate Odds Ratio using the following data.
 Interpret the result (strength of association)
The distribution of bottled water consumption and the occurrence of
diarrhea diseases in case control S

Exposure Cases Controls Total

Status
Exposed 15 20 35
Not exposed 20 15 35
Total 35 35 70
• Odds Ratio is 0.56. It is less than 1, which suggests that the exposure
(drinking bottled water) is protective against the disease (diarrhoea).