Centers%20for%20Disease%20Control%20and%20Prevention%20Global%20Health%20Odyssey%20Museum%20Tom%20Harkin%20Global%20Communications%20Center%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20July%206-10,%202009

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Day 3
Teach Epidemiology
Professional Development Workshop
Centers for Disease Control and PreventionGlobal
Health Odyssey MuseumTom Harkin Global
Communications Center
July 6-10, 2009
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Teach Epidemiology
Teach Epidemiology
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Teach Epidemiology
Teach Epidemiology
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Teach Epidemiology In the News - Social Network
During the coming school year,

participate in an online
Teach Epidemiology In the News - Social Network
and teach epidemiology.
Teach Epidemiology
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Teach Epidemiology In the News - Social Network
Teach Epidemiology
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Teach Epidemiology In the News - Social Network

• In the News Article Selection Criteria
• Popular press article and scholarly article
• Potential to check other sources for
  information
• Non-controversial topic
• Age group / reading level appropriate
• Consider potential for inclusion of other
  disciplines
• Includes data and visuals
• Topical, but not too great a potential to
  become dated
• Background
• Identify standards that apply

Teach Epidemiology
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Teach Epidemiology
Teach Epidemiology
9
Enduring Epidemiological Understandings
Knowledge that is connected and organized, and
conditionalized to specify the context in
which it is applicable.
National Research Council , Learning and
Understanding
Teach Epidemiology
10
Making Group Comparisons and Identifying
Associations
Laboratory
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Teach Epidemiology
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Making Group Comparisons and Identifying
Associations
Laboratory
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Teach Epidemiology
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Making Group Comparisons and Identifying
Associations
Natural Experiment
Naturally occurring circumstances
in
which groups of people within a population
have been exposed to
different levels
of the hypothesized cause of an outcome.
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Teach Epidemiology
13
Making Group Comparisons and Identifying
Associations
Observational Study
An epidemiologic study of a natural experiment
in which the
investigator is not involved in the intervention
other than to record, classify,
count,
and statistically analyze results.
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Teach Epidemiology
14
Making Group Comparisons and Identifying
Associations
Controlled Trial
An epidemiologic experiment
in
which subjects are assigned into groups
to receive or not receive

a hypothesized beneficial
intervention.
14
Teach Epidemiology
15
Making Group Comparisons and Identifying
Associations
Controlled Trial
Buprenorphine
Buprenorphine will stop heroin addicts from using
heroin.
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Teach Epidemiology
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Making Group Comparisons and Identifying
Associations
Observational Study of a Natural Experiment
Naturally occurring circumstances
in
which groups of people within a population
have been exposed to
different levels
of the hypothesized cause of an outcome.
Epidemiologic studies of natural experiments
in which the investigator
is not involved in the intervention other than to
record, classify, count,
and statistically analyze results.
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Teach Epidemiology
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Making Group Comparisons and Identifying
Associations
17
Teach Epidemiology
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Making Group Comparisons and Identifying
Associations
Anecdote
A story. Often used to describe a type of
evidence used in argument, as in anecdotal
evidence. Anecdotal evidence is sometimes used
to appeal to emotion rather than logic. Those
who use anecdote in this fashion suggest that a
conclusion can be reached on the basis of one
incident, rather than a careful scientific
inquiry. Anecdotal evidence is, therefore, often
used to describe a given argument disparagingly.
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Teach Epidemiology
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Making Group Comparisons and Identifying
Associations
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Teach Epidemiology
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Making Group Comparisons and Identifying
Associations
Absolutely nothing in the available arsenal of
anti-emetics worked at all. I was miserable and
came to dread the frequent treatments with an
almost perverse intensity. I had heard that
marijuana often worked well against nausea. I
was reluctant to try it because I had never
smoked any substance habitually (and didnt even
know how to inhale). Moreover, I had tried
marijuana twice (in the 1960s) and had hated it
. Marijuana worked like a charm . The sheer
bliss of not experiencing nausea - and not having
to fear it for all the days intervening between
treatments - was the greatest boost I received in
all my year of treatment, and surely the most
important effect upon my eventual cure.
Stephen Jay Gould

(survivor of abdominal mesothelioma)
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Teach Epidemiology
21
Making Group Comparisons and Identifying
Associations
Anecdote
A particular or detached incident or fact
of
an interesting nature a biographical incident or
fragment a single passage of private
life.
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Teach Epidemiology
22
Making Group Comparisons and Identifying
Associations
Transforming Anecdote to Science
Anecdote
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Teach Epidemiology
23
Making Group Comparisons and Identifying
Associations
Controlled Trial
Case-Control Study
Cohort Study
Cross-Sectional Study
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Teach Epidemiology
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Making Group Comparisons and Identifying
Associations
Controlled Trial
Case-Control Study
b
a
d
c
Cohort Study
Cross-Sectional Study
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Teach Epidemiology
25
Making Group Comparisons and Identifying
Associations
The goal of every epidemiological study
is to harvest
valid and precise information about the
relationship between an exposure and a disease in
a population. The various
study designs merely represent
different ways of harvesting
this information.
Essentials in Epidemiology in Public Health Ann
Aschengrau and George R. Seage III
Teach Epidemiology
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Making Group Comparisons and Identifying
Associations
Trial 1
Tested Negative for Heroin
Tested Positive for Heroin
Risk of Negative
Heroin Test
Total
Bupe
Nothing
What do the results tell us about the hypothesis
that Buprenorphine will stop heroin addicts from
using heroin?
Teach Epidemiology
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Making Group Comparisons and Identifying
Associations
Trial 1
Trial 2
Trial 3
Trial 4
Teach Epidemiology
29
Making Group Comparisons and Identifying
Associations
Trial 1
Trial 2
Risk of Negative
Heroin Test
Tested Negative for Heroin
Tested Positive for Heroin
Total
Bupe
Nothing
Trial 3
Trial 4
Teach Epidemiology
30
Making Group Comparisons and Identifying
Associations
Trial 1
Trial 2
Risk of Negative
Heroin Test
Tested Negative for Heroin
Tested Positive for Heroin
Risk of Negative
Heroin Test
Tested Negative for Heroin
Tested Positive for Heroin
Relative Risk
Total
Total
Bupe
Bupe
No Bupe
Nothing
Trial 3
Trial 4
Risk of Negative
Heroin Test
Tested Negative for Heroin
Tested Positive for Heroin
Risk of Negative
Heroin Test
Tested Negative for Heroin
Tested Positive for Heroin
Relative Risk
Relative Risk
Total
Total
Bupe
Bupe
No Bupe
No Bupe
Teach Epidemiology
31
Making Group Comparisons and Identifying
Associations
Trial 1
Trial 2
Risk of Negative
Heroin Test
Tested Negative for Heroin
Tested Positive for Heroin
Risk of Negative
Heroin Test
Tested Negative for Heroin
Tested Positive for Heroin
Relative Risk
Total
Total
Bupe
Bupe
No Bupe
Nothing
Trial 3
Trial 4
Risk of Negative
Heroin Test
Tested Negative for Heroin
Tested Positive for Heroin
Risk of Negative
Heroin Test
Tested Negative for Heroin
Tested Positive for Heroin
Relative Risk
Relative Risk
Total
Total
Bupe
Bupe
No Bupe
No Bupe
Teach Epidemiology
32
Making Group Comparisons and Identifying
Associations
Trial 1
Trial 2
Risk of Negative
Heroin Test
Tested Negative for Heroin
Tested Positive for Heroin
Risk of Negative
Heroin Test
Tested Negative for Heroin
Tested Positive for Heroin
Relative Risk
Total
Total
Bupe
Bupe
1
No Bupe
Bupe is not associated
with having a
negative tests for heroin.
Nothing
Trial 3
Trial 4
Risk of Negative
Heroin Test
Tested Negative for Heroin
Tested Positive for Heroin
Risk of Negative
Heroin Test
Tested Negative for Heroin
Tested Positive for Heroin
Relative Risk
Relative Risk
Total
Total
Bupe
Bupe
No Bupe
No Bupe
Teach Epidemiology
33
Making Group Comparisons and Identifying
Associations
Trial 1
Trial 2
Risk of Negative
Heroin Test
Tested Negative for Heroin
Tested Positive for Heroin
Risk of Negative
Heroin Test
Tested Negative for Heroin
Tested Positive for Heroin
Relative Risk
Total
Total
Bupe
Bupe
1
No Bupe
Bupe is not associated
with having a
negative tests for heroin.
Nothing
Trial 3
Trial 4
Risk of Negative
Heroin Test
Tested Negative for Heroin
Tested Positive for Heroin
Risk of Negative
Heroin Test
Tested Negative for Heroin
Tested Positive for Heroin
Relative Risk
Relative Risk
Total
Total
Bupe
Bupe
.34
No Bupe
No Bupe
Bupe is associated with
having a positive
test for heroin!
Teach Epidemiology
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Making Group Comparisons and Identifying
Associations
Trial 1
Trial 2
Risk of Negative
Heroin Test
Tested Negative for Heroin
Tested Positive for Heroin
Risk of Negative
Heroin Test
Tested Negative for Heroin
Tested Positive for Heroin
Relative Risk
Total
Total
Bupe
Bupe
1
No Bupe
Bupe is not associated
with having a
negative tests for heroin.
Nothing
Trial 3
Trial 4
Risk of Negative
Heroin Test
Tested Negative for Heroin
Tested Positive for Heroin
Risk of Negative
Heroin Test
Tested Negative for Heroin
Tested Positive for Heroin
Relative Risk
Relative Risk
Total
Total
Bupe
Bupe
.34
3.5
No Bupe
No Bupe
Bupe is associated with
having a positive
test for heroin!
Bupe is associated with
having a negative
test for heroin.
Teach Epidemiology
35
Making Group Comparisons and Identifying
Associations
Trial 1
Trial 2
Risk of Negative
Heroin Test
Tested Negative for Heroin
Tested Positive for Heroin
Risk of Negative
Heroin Test
Tested Negative for Heroin
Tested Positive for Heroin
Relative Risk
Total
Total
Bupe
Bupe
1
Nothing
No Bupe
Bupe is not associated
with having a
negative tests for heroin.
Nothing
Trial 3
Compared to what?
Trial 4
Risk of Negative
Heroin Test
Tested Negative for Heroin
Tested Positive for Heroin
Risk of Negative
Heroin Test
Tested Negative for Heroin
Tested Positive for Heroin
Relative Risk
Relative Risk
Total
Total
Bupe
Bupe
.34
3.5
No Bupe
No Bupe
Bupe is associated with
having a positive
test for heroin!
Bupe is associated with
having a negative
test for heroin.
Teach Epidemiology
36
Making Group Comparisons and Identifying
Associations
Teach Epidemiology
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Teach Epidemiology
Randomization
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Teach Epidemiology
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Randomization
allows
everyone's differences to be similar."
42
External Data Monitoring Board
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External Data Monitoring Board
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Backpacks and Back Pain
Is there an association
between
the hypothesized cause and the disease?
Detectives in the Classroom - Investigation 2-4
Backpacks and Back Pain
46
Testing Hypotheses
Ache!
Detectives in the Classroom - Investigation 2-4
Backpacks and Back Pain
47
Trial
No Acne
Acne
Total
AcneMed
90
10
100
b
a
d
c
No AcneMed
90
10
100
Carrying heavy backpacks causes back pain.
Detectives in the Classroom - Investigation 2-4
Backpacks and Back Pain
48
Observational Study
Total
90
10
90
10
Carrying heavy backpacks causes back pain.
Detectives in the Classroom - Investigation 2-4
Backpacks and Back Pain
49
Exposure
Detectives in the Classroom - Investigation 2-4
Backpacks and Back Pain
50
Exposure
Detectives in the Classroom - Investigation 2-4
Backpacks and Back Pain
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Exposure
Check one.
Heavy Backpack
No Heavy Backpack
Detectives in the Classroom - Investigation 2-4
Backpacks and Back Pain
52
Outcome
What is back pain?
Any memorable pain in the past two weeks.
Detectives in the Classroom - Investigation 2-4
Backpacks and Back Pain
53
Outcome
Check one.
Back Pain
No Back Pain
Detectives in the Classroom - Investigation 2-4
Backpacks and Back Pain
54
2 x 2 Table
Detectives in the Classroom - Investigation 2-4
Backpacks and Back Pain
55
Observational Studies
Were you involved in assigning exposures?
Epi Talk
Observational Studies
Epidemiologic studies in which the investigator
is not involved in the subjects' exposures other
than to record, classify, count, and
statistically analyze results.
Did you observe what others had done to
themselves?
Did you record, classify, count and statistically
analyze the results?
Detectives in the Classroom - Investigation 2-4
Backpacks and Back Pain
56
Carrying Heavy Backpacks Causes Back Pain.
We are all carrying out natural experiments on
ourselves each day of our lives, as we decide
what to do, where to go, and to what to expose
ourselves.
Detectives in the Classroom - Investigation 2-4
Backpacks and Back Pain
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Investigation 2-5
Observational Studies Part 1
59
Observational Study
Selecting a Hypothesis
Step 1
Planning the Study
Steps 2-7
Collecting Data
Steps 8-13
Analyzing Data
Steps 14-17
Planning the Presentation
Step 18
Detectives in the Classroom - Investigation 2-5
Observational Studies
60
1
Epi Log Worksheet
Handout
Detectives in the Classroom - Investigation 2-5
Observational Studies
61
2-7
Planning the Study
Define the exposure.
Create a question to gather data
about the exposure.
Define the outcome in the hypothesis.
Create a question to gather data
about the outcome.
Label 2 x 2 Table Sheet.
Create an informed consent statement for
participation in the observational study.
Detectives in the Classroom - Investigation 2-5
Observational Studies
62
Review
Informed Consent
Voluntary consent given by a person for
participation in a study.
Participants must know and understand the study,
give consent without coercion, and know that
they can withdraw at any time.
Detectives in the Classroom - Investigation 2-5
Observational Studies
63
Collecting Data
Read informed consent statement and remind
class of right not to participate.
Have class label 2 x 2 Table Sheets.
Review exposure and outcome questions.
Review what cells students fit into based on
answers to exposure and outcome questions.
Instruct class to voluntarily and anonymously
place a check in the cell that identifies
their exposure and outcome for the hypothesis
being tested.
Detectives in the Classroom - Investigation 2-5
Observational Studies
64
Collecting Data
Handout
Detectives in the Classroom - Investigation 2-5
Observational Studies
65
Collecting Data
Read informed consent statement and remind
class of right not to participate.
Have class label 2x2 Table Sheets.
Review exposure and outcome questions.
Review what cells students fit into based on
answers to exposure and outcome questions.
Instruct class to voluntarily and anonymously
place a check in the cell that identifies
their exposure and outcome for the hypothesis
being tested.
Detectives in the Classroom - Investigation 2-5
Observational Studies
66
13-17
Analyzing Data
Sort 2 x 2 Table Sheets and complete the 2 x 2
table that was labeled in step 6.
Calculate the risks of the outcome for the
exposed and unexposed groups as fractions and
percents.
Calculate the relative risk.
Complete the statement.
Explain whether or not the data support the
hypothesis.
Detectives in the Classroom - Investigation 2-5
Observational Studies
67
Presentation Planning
IMRAD
Introduction Methods Results and Discussion
Detectives in the Classroom - Investigation 2-5
Observational Studies
68
Epi Talk
IMRAD
Format usually followed when epidemiological
studies are published in medical journals.
Introduction Why the authors decided to do the
study,
Methods How authors did the study,
Results What the authors found, and
Discussion What the results mean.
Detectives in the Classroom - Investigation 2-5
Observational Studies
69
18
Step 18 Presentation Planning
IMRAD
Introduction Methods Results and Discussion
Detectives in the Classroom - Investigation 2-5
Observational Studies
70
Epi Teams
Detectives in the Classroom - Investigation 2-5
Observational Studies
71
Presentation Rubric
Criteria
Got It
Getting It
Will Get It Soon
Participation
Use of Epi Talk
Data Collection Methods
Risks, Relative Risk, and Inference
IMRAD
Detectives in the Classroom - Investigation 2-5
Observational Studies
72
Observational Study
Detectives in the Classroom - Investigation 2-5
Observational Studies
73
Observational Study
Detectives in the Classroom - Investigation 2-5
Observational Studies
74
Observational Study
Detectives in the Classroom - Investigation 2-5
Observational Studies
75
Selecting a Hypothesis

• Acne
• Auto injuries
• Bad mood
• Cavities
• Cell phones
• Class disruption
• Chewing gum
• Colds
• Drinking soda
• Eating breakfast
• Eating candy
• Eating high fat food
• Eating school cafeteria food
• Exercise
• Foul language
• Getting a good nights sleep
• Good quiz scores
• Good grades
• Having a quiet place to study

• Improves performance
• Indigestion
• Lack of regular exercise
• Listening to music while studying
• Listening to rap music
• Multi-vitamins
• Nightmares
• Overweight
• Poor grades
• Poor quiz scores
• Practicing a sport
• Seat belts
• Skipping breakfast
• Studying
• Too much talking on the telephone
• Violent behavior
• Watching the evening news on TV
• Watching too much TV
• Watching violent movies

Detectives in the Classroom - Investigation 2-5
Observational Studies
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Teach Epidemiology
Dots
77
Teach Epidemiology
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What do you mean - Teach Epidemiology?
Leverage the Science Olympiad Competition
http//soinc.org/
Teach Epidemiology
80
 Think Like an Epidemiologist Challenge New
Jersey Science Olympiad High School Finals March
17, 2009
81
Handout
Test the hypothesis People who watch more TV
eat more junk food.
82
Getting Ready
1
83
Asking Questions / Gathering Data
2
84
Asking Questions / Gathering Data
2
85
Asking Questions / Gathering Data
2
86
Analyzing Data / Testing Hypotheses
3
87
Analyzing Data / Testing Hypotheses
3
88
Reporting Out
4
89
Reporting Out
4
Handouts
90
(No Transcript)
91
Enduring Epidemiological Understandings
Knowledge that is connected and organized, and
conditionalized to specify the context in
which it is applicable.
National Research Council , Learning and
Understanding
Teach Epidemiology
92
Epi Grades 6-12
Authentic Assessment

• Are realistic simulate the way a persons
  understanding is tested in the real world
• Require judgment and innovation to address an
  unstructured problem, rather than following a set
  routine
• Ask students to do the subject rather than
  simply recall what was taught
• Replicate the context in which a person would
  be tested at work, in the community, or at home
• Are messy and murky
• Require a repertoire of knowledge and skill to
  be used efficiently and effectively
• Allow opportunities for rehearsal, practice,
  consultation, feedback, and refinement

Teach Epidemiology
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Epi Team Challenge
Epi Team Challenge
Detectives in the Classroom - Investigation 2-7
Epi Team Challenge
95
Whats My Design?
Detectives in the Classroom - Investigation 2-7
Epi Team Challenge
96
Whats My Design?
Practice Clue
Trial
Detectives in the Classroom - Investigation 2-7
Epi Team Challenge
97
Whats My Design?
Begin Epi Team Challenge
Clue 1
Assign treatment and control groups.
Trial
Detectives in the Classroom - Investigation 2-7
Epi Team Challenge
98
Whats My Design?
Clue 2
Case-Control Study
Detectives in the Classroom - Investigation 2-7
Epi Team Challenge
99
Whats My Design?
Clue 3
Cohort, Case-Control, and Cross-Sectional Studies
Detectives in the Classroom - Investigation 2-7
Epi Team Challenge
100
Whats My Design?
Clue 4
Follow through time and compare risk of disease
in exposed group with risk of
disease in the unexposed group.
Trial and Cohort Study
Detectives in the Classroom - Investigation 2-7
Epi Team Challenge
101
Whats My Design?
Clue 5
Trial
Detectives in the Classroom - Investigation 2-7
Epi Team Challenge
102
Whats My Design?
Clue 6
Epidemiologist is involved during
the entire time from
exposure to disease.
Trial and Cohort Study
Detectives in the Classroom - Investigation 2-7
Epi Team Challenge
103
Whats My Design?
Clue 7
Select a group of people with disease
and a similar group of
people without disease.
Case-Control Study
Detectives in the Classroom - Investigation 2-7
Epi Team Challenge
104
Whats My Design?
Clue 8
Trial
Detectives in the Classroom - Investigation 2-7
Epi Team Challenge
105
Whats My Design?
Clue 9
Cross Sectional Study
Detectives in the Classroom - Investigation 2-7
Epi Team Challenge
106
Whats My Design?
Clue 10
Compare percent of exposed people in the two
groups.
Case-Control Study
Detectives in the Classroom - Investigation 2-7
Epi Team Challenge
107
Whats My Design?
Clue 11
Trial
Detectives in the Classroom - Investigation 2-7
Epi Team Challenge
108
Whats My Design?
Clue 12
Flow Diagram
Cross Sectional Study
Detectives in the Classroom - Investigation 2-7
Epi Team Challenge
109
Whats My Design?
Clue 13
Flow Diagram
Observational Study
Cohort Study
Detectives in the Classroom - Investigation 2-7
Epi Team Challenge
110
Whats My Design?
Clue 14
Ask each person about both exposure and disease
at that point in time.
Cross Sectional Study
Detectives in the Classroom - Investigation 2-7
Epi Team Challenge
111
Whats My Design?
Clue 15
Ask both groups about their exposures in the past.
Case-Control Study
Detectives in the Classroom - Investigation 2-7
Epi Team Challenge
112
Whats My Design?
Clue 16
Trial
Detectives in the Classroom - Investigation 2-7
Epi Team Challenge
113
Whats My Design?
Clue 17
Disease risk in exposed group
is compared
to disease risk in unexposed group.
Trial, Cohort Study, and Cross Sectional Study
Detectives in the Classroom - Investigation 2-7
Epi Team Challenge
114
Whats My Design?
Clue 18
Cross Sectional Study
Detectives in the Classroom - Investigation 2-7
Epi Team Challenge
115
Whats My Design?
Clue 19
Select a healthy study sample.
Trial (?) and Cohort Study
Detectives in the Classroom - Investigation 2-7
Epi Team Challenge
116
Whats My Design?
Clue 20
Observe who has and has not been exposed.
Cohort and Cross-Sectional Studies
Detectives in the Classroom - Investigation 2-7
Epi Team Challenge
117
Whats My Design?
Clue 21
Give exposure to treatment group, but not control
group.
Trial
Detectives in the Classroom - Investigation 2-7
Epi Team Challenge
118
Whats My Design?
Clue 22
Cohort Study
Detectives in the Classroom - Investigation 2-7
Epi Team Challenge
119
Whats My Design?
Clue 23
Epidemiologist is involved after disease has
occurred and relies on subjects memories

to gather information about exposure.
Case-Control Study
Detectives in the Classroom - Investigation 2-7
Epi Team Challenge
120
Whats My Design?
Clue 24
Select a study sample.
Trial, Cohort, Case-Control, and Cross Sectional
Studies
Detectives in the Classroom - Investigation 2-7
Epi Team Challenge
121
Whats My Design?
Clue 25
Cohort Study
Detectives in the Classroom - Investigation 2-7
Epi Team Challenge
122
Whats My Design?
Clue 26
Epidemiologist gathers data only at that one
point in time.
Cross Sectional Study
Detectives in the Classroom - Investigation 2-7
Epi Team Challenge
123
Whats My Design?
Clue 27
Trial and Cohort Study
Detectives in the Classroom - Investigation 2-7
Epi Team Challenge
124
Whats My Design?
Clue 28
Follow through time and compare risk of disease
in exposed group to risk of disease in unexposed
group.
Trial and Cohort Study
Detectives in the Classroom - Investigation 2-7
Epi Team Challenge
125
Whats My Design?
Clue 29
Epidemiologist is involved
during the entire
time from exposure to disease.
Trial and Cohort Study
Detectives in the Classroom - Investigation 2-7
Epi Team Challenge
126
Whats My Design?
Clue 30
Cross Sectional Study
Detectives in the Classroom - Investigation 2-7
Epi Team Challenge
127
Whats My Design?
Clue 31
Case-Control Study
Detectives in the Classroom - Investigation 2-7
Epi Team Challenge
128
Whats My Design?
Clue 32
Cross Sectional Study
Detectives in the Classroom - Investigation 2-7
Epi Team Challenge
129
Whats My Design?
Clue 33
Case-Control Study
Detectives in the Classroom - Investigation 2-7
Epi Team Challenge
130
Whats My Design?
Clue 34
Cohort Study
Detectives in the Classroom - Investigation 2-7
Epi Team Challenge
131
Whats My Design?
Clue 35
Trial
Detectives in the Classroom - Investigation 2-7
Epi Team Challenge
132
Whats My Design?
End Epi Team Challenge
Detectives in the Classroom - Investigation 2-7
Epi Team Challenge
133
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134
Which Design Is Best?
Which Design Is Best?
Detectives in the Classroom - Investigation 2-8
Which Design Is Best?
135
Epi Team Challenge
Detectives in the Classroom - Investigation 2-8
Which Design Is Best?
136
Epi Team Challenge
Detectives in the Classroom - Investigation 2-8
Which Design Is Best?
137
Epi Team Challenge
Fastest
Which study design is the fastest?
Detectives in the Classroom - Investigation 2-8
Which Design Is Best?
138
Fastest
Which study designs are the most time consuming?
Detectives in the Classroom - Investigation 2-8
Which Design Is Best?
139
Most Scientifically Sound
Time Consuming
Time Consuming
Fastest
Which study design is the most scientifically
sound?
Detectives in the Classroom - Investigation 2-8
Which Design Is Best?
140
Most Scientifically Sound
Time Consuming
Time Consuming
Can Study Rare Diseases
Fastest
Which study design is best for studying rare
diseases?
Detectives in the Classroom - Investigation 2-8
Which Design Is Best?
141
Most Scientifically Sound
Time Consuming
Time Consuming
Can Study Rare Diseases
Fastest
Which study designs do not identify
the time order of exposure and disease?
Detectives in the Classroom - Investigation 2-8
Which Design Is Best?
142
Time Consuming
Most Scientifically Sound
Time Consuming
Possible Time-Order Confusion
Can Study Rare Diseases
Possible Time-Order Confusion
Fastest
Least Confidence in Findings
Which study design gives the least confidence
in findings?
Detectives in the Classroom - Investigation 2-8
Which Design Is Best?
143
Time Consuming
Most Scientifically Sound
Best Measure of Exposure
Time Consuming
Possible Time-Order Confusion
Can Study Rare Diseases
Possible Time-Order Confusion
Fastest
Least Confidence in Findings
Which study design provides the best measure of
exposure?
Detectives in the Classroom - Investigation 2-8
Which Design Is Best?
144
Time Consuming
Most Scientifically Sound
Best Measure of Exposure
Most Accurate Observational Study
Time Consuming
Possible Time-Order Confusion
Can Study Rare Diseases
Possible Time-Order Confusion
Fastest
Least Confidence in Findings
Which study design is the most accurate
observational study?
Detectives in the Classroom - Investigation 2-8
Which Design Is Best?
145
Time Consuming
Most Scientifically Sound
Best Measure of Exposure
Most Accurate Observational Study
Time Consuming
Possible Time-Order Confusion
Can Study Rare Diseases
Possible Time-Order Confusion
Fastest
Least Confidence in Findings
Least Expensive
Which study design is the least expensive?
Detectives in the Classroom - Investigation 2-8
Which Design Is Best?
146
Time Consuming
Most Scientifically Sound
Unethical for Harmful Exposures
Best Measure of Exposure
Time Consuming
Most Accurate Observational Study
Possible Time-Order Confusion
Can Study Rare Diseases
Fastest
Possible Time-Order Confusion
Least Confidence in Findings
Least Expensive
Which study design
would be unethical for harmful
exposures?
Detectives in the Classroom - Investigation 2-8
Which Design Is Best?
147
Time Consuming
Most Scientifically Sound
Unethical for Harmful exposures
Best Measure of Exposure
Time Consuming
Most Accurate Observational Study
Good Measure of Exposure
Possible Time-Order Confusion
Can Study Rare Diseases
Fastest
Possible Time-Order Confusion
Least Confidence in Findings
Least Expensive
Which study design
provides a good measure of exposure?
Detectives in the Classroom - Investigation 2-8
Which Design Is Best?
148
Most Scientifically Sound
Time Consuming
Unethical for Harmful exposures
Best Measure of Exposure
Time Consuming
Most Accurate Observational Study
Good Measure of Exposure
Possible Time-Order Confusion
Can Study Rare Diseases
Fastest
Possible Time-Order Confusion
Least Expensive
Least Confidence in Findings
Which study designs are the most expensive?
Detectives in the Classroom - Investigation 2-8
Which Design Is Best?
149
Most Scientifically Sound
Time Consuming
Unethical for Harmful exposures
Best Measure of Exposure
Time Consuming
Most Accurate Observational Study
Good Measure of Exposure
Can Study Rare Diseases
Possible Time-Order Confusion
Relatively Less Expensive and Relatively Fast
Possible Time-Order Confusion
Fastest
Least Confidence in Findings
Least Expensive
Which study design is
relatively less expensive and
relatively fast?
Detectives in the Classroom - Investigation 2-8
Which Design Is Best?
150
Time Consuming
Most Scientifically Sound
Unethical for Harmful exposures
Best Measure of Exposure
Time Consuming
Most Accurate Observational Study
Good Measure of Exposure
Possible Time-Order Confusion
Can Study Rare Diseases
Possible Error in Recalling Past
Exposures
Relatively Less Expensive and Relatively Fast
Possible Time-Order Confusion
Fastest
Least Confidence in Findings
Least Expensive
Which study design creates the possibility of
error in recalling
past exposures?
Detectives in the Classroom - Investigation 2-8
Which Design Is Best?
151
Which Design Is Best?
Time Consuming
Most Scientifically Sound
Unethical for Harmful exposures
Best Measure of Exposure
Time Consuming
Most Accurate Observational Study
Good Measure of Exposure
It depends .
Possible Time-Order Confusion
Can Study Rare Diseases
Relatively Less Expensive and Relatively Fast
Possible Error in Recalling Exposures
Fastest
Possible Time-Order Confusion
Least Expensive
Least Confidence in Findings
Which Design Is Best?
Detectives in the Classroom - Investigation 2-8
Which Design Is Best?
152
It depends on .

• Regulations
• Time urgency
• How much is known about the association
• Money
• Whether the exposure is believed to be
  beneficial

Detectives in the Classroom - Investigation 2-8
Which Design Is Best?
153
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154
Designs, Diagrams, and Tables

Detectives in the Classroom Investigation 2-9
Designs, Diagrams, and Tables
155
Controlled Trial
Where do these people fit in the 2x2 table?
DZ
DZ
E
a
E
2x2 Table
Flow Diagram
Detectives in the Classroom Investigation 2-9
Designs, Diagrams, and Tables
156
Controlled Trial
Where do these people fit in the 2x2 table?
DZ
DZ
E
b
E
2x2 Table
Flow Diagram
Detectives in the Classroom Investigation 2-9
Designs, Diagrams, and Tables
157
Controlled Trial
Where do these people fit in the 2x2 table?
DZ
DZ
E
E
c
2x2 Table
Flow Diagram
Flow Diagram
Detectives in the Classroom Investigation 2-9
Designs, Diagrams, and Tables
158
Controlled Trial
Where do these people fit in the 2x2 table?
DZ
DZ
E
E
d
2x2 Table
Detectives in the Classroom Investigation 2-9
Designs, Diagrams, and Tables
159
Cohort Study
Where are these people in the flow diagram?
DZ
DZ
E
Healthy People
Healthy People
E
c
2x2 Table
Flow Diagram
Detectives in the Classroom Investigation 2-9
Designs, Diagrams, and Tables
160
Cohort Study
Where are these people in the flow diagram?
DZ
DZ
E
Healthy People
Healthy People
a
E
2x2 Table
Flow Diagram
Detectives in the Classroom Investigation 2-9
Designs, Diagrams, and Tables
161
Cohort Study
Where are these people in the flow diagram?
DZ
DZ
E
Healthy People
Healthy People
E
d
2x2 Table
Flow Diagram
Detectives in the Classroom Investigation 2-9
Designs, Diagrams, and Tables
162
Cohort Study
Where are these people in the flow diagram?
DZ
DZ
E
Healthy People
Healthy People
b
E
2x2 Table
Flow Diagram
Detectives in the Classroom Investigation 2-9
Designs, Diagrams, and Tables
163
Case-Control Study
Where do these people go in the 2x2 table?
DZ
DZ
E
a
E
Flow Diagram
2x2 Table
Detectives in the Classroom Investigation 2-9
Designs, Diagrams, and Tables
164
Case-Control Study
Where do these people go in the 2x2 table?
DZ
DZ
E
E
c
Flow Diagram
2x2 Table
Detectives in the Classroom Investigation 2-9
Designs, Diagrams, and Tables
165
Case-Control Study
Where do these people go in the 2x2 table?
DZ
DZ
E
b
E
Flow Diagram
2x2 Table
Detectives in the Classroom Investigation 2-9
Designs, Diagrams, and Tables
166
Case-Control Study
Where do these people go in the 2x2 table?
DZ
DZ
E
E
d
Flow Diagram
2x2 Table
Detectives in the Classroom Investigation 2-9
Designs, Diagrams, and Tables
167
Cross-Sectional Study
Where do these people go in the 2x2 table?
DZ
DZ
Flow Diagram
E
a
E
2x2 Table
Detectives in the Classroom Investigation 2-9
Designs, Diagrams, and Tables
168
Cross-Sectional Study
Where do these people go in the 2x2 table?
DZ
DZ
Flow Diagram
E
E
c
2x2 Table
Detectives in the Classroom Investigation 2-9
Designs, Diagrams, and Tables
169
Cross-Sectional Study
Where do these people go in the 2x2 table?
DZ
DZ
Flow Diagram
E
E
d
2x2 Table
Detectives in the Classroom Investigation 2-9
Designs, Diagrams, and Tables
170
Cross-Sectional Study
Where do these people go in the 2x2 table?
DZ
DZ
Flow Diagram
E
b
E
2x2 Table
Detectives in the Classroom Investigation 2-9
Designs, Diagrams, and Tables
171
Enduring Epidemiological Understandings
Knowledge that is connected and organized, and
conditionalized to specify the context in
which it is applicable.
National Research Council , Learning and
Understanding
Teach Epidemiology
172
Making Group Comparisons and Identifying
Associations
The goal of every epidemiological study
is to harvest
valid and precise information about the
relationship between an exposure and a disease in
a population. The various
study designs merely represent
different ways of harvesting
this information.
Essentials in Epidemiology in Public Health Ann
Aschengrau and George R. Seage III
Teach Epidemiology
173
173
174
Teach Epidemiology
Teach Epidemiology
175
175
176
Teach Epidemiology
Teach Epidemiology
177
Enduring Understandings 7-9

• Explaining associations
• and
• judging causation

178

• EU7 One possible explanation for finding an
  association is that the exposure causes the
  outcome. Because studies are complicated by
  factors not controlled by the observer, other
  explanations also must be considered, including
  confounding, chance, and bias.

179

• EU8 Judgments about whether an exposure causes a
  disease are developed by examining a body of
  epidemiologic evidence, as well as evidence from
  other scientific disciplines.

180

• EU9 While a given exposure may be necessary to
  cause an outcome, the presence of a single factor
  is seldom sufficient. Most outcomes are caused
  by a combination of exposures that may include
  genetic make-up, behaviors, social, economic, and
  cultural factors and the environment.

181
Reasons for associations

• Confounding
• Bias
• Reverse causality
• Sampling error (chance)
• Causation

182

• Osteoporosis risk is higher among women who live
  alone.

183
Confounding

• Confounding is an alternate explanation for an
  observed association of interest.

Number of persons in the home
Osteoporosis
Age
184
Confounding

• Confounding is an alternate explanation for an
  observed association of interest.

Exposure
Outcome
Confounder
185
Confounding

• YES confounding module example
• Cohort study
• 9,400 elderly in the hospital
• RQ Are bedsores related to mortality among
  elderly patients with hip fractures?

186
Bedsores and Mortality
D D-
E 79 745 824
E- 286 8290 8576
365 9035 9400
RR (79 / 824) / (286 / 8576) 2.9
187
Bedsores and Mortality

• Avoid bedsoresLive forever!!
• Could there be some other explanation for the
  observed association?

188
Bedsores and mortality

• If severity of medical problems had been the
  reason for the association between bedsores and
  mortality, what might the RR be if all study
  participants had very severe medical problems?
• What about if the participants all had problems
  of very low severity?

189
Bedsores and Mortality
Died Did not die
Bedsores 55 severe 24 not 51 severe 694 not 824
No bedsores 5 severe 281 not 5 severe 8285 not 8576
365 9035 9400
190
Bedsores and Mortality (Severe)
Died Did not die
Bedsores 55 51 106
No bedsores 5 5 10
60 56 116
RR (55 / 106) / (5 / 10) 1.0
191
Bedsores and Mortality (Not severe)
Died Did not die
Bedsores 24 694 718
No bedsores 281 8285 8566
305 8979 9284
RR (24 / 718) / (281 / 8566) 1.0
192
Bedsores and Mortality stratified by Medical
Severity
SEVERE Died Didnt die
Bedsores a b
No sores c d
RR 1.0
SEVERE- Died Didnt die
Bedsores a b
No sores c d
RR 1.0
SEVERE Died Didnt die
Bedsores a b
No sores c d
RR 2.9
SEVERE- Died Didnt die
Bedsores a b
No sores c d
RR 2.9
193
Bedsores

• Bedsores are unrelated to mortality among those
  with severe problems.
• Bedsores are unrelated to mortality among those
  with problems of less severity.
• Adjusted RR 1, and the unadjusted RR 2.9

194
Confounding

• Confounding is an alternate explanation for an
  observed association of interest.

Bedsores
Death
Severity of medical problems
195
Reasons for associations

• Confounding
• Bias
• Reverse causality
• Sampling error (chance)
• Causation

196
Bias

• Errors are mistakes that are
• randomly distributed
• not expected to impact the MA
• less modifiable
• Biases are mistakes that are
• not randomly distributed
• may impact the MA
• more modifiable

197
Types of bias

• Selection bias
• The process for selecting/keeping subjects causes
  mistakes
• Information bias
• The process for collecting information from the
  subjects causes mistakes

198
Selection bias

• Healthy worker effect
• People who are working are more likely to be
  healthier than non-workers
• Non-response
• People who participate in a study may be
  different from people who do not
• Attrition
• People who drop out of a study may be different
  from those who stay in the study
• Berksons
• Hospital controls in a case-control study

199
Information bias

• Misclassification, e.g. non-exposed as exposed or
  cases as controls
• Recall bias
• Cases are more likely than controls to recall
  past exposures
• Interviewer bias
• Interviewers probe cases more than controls
  (exposed more than unexposed)

200
Birth defects and diet

• In a study of birth defects, mothers of children
  with and without infantile cataracts are asked
  about dietary habits during pregnancy.

201
Pesticides and cancer mortality

• In a study of the relationship between home
  pesticide use and cancer mortality, controls are
  asked about pesticide use and family members are
  asked about their loved ones usage patterns.

202
Induced abortion breast CA

• Positive association found in 5 studies
• No association found in 6 studies
• Negative association found in 1 study

203
Minimize bias

• Can only be done in the planning and
  implementation phase
• Standardized processes for data collection
• Masking
• Clear, comprehensive case definitions
• Incentives for participation/retention

204
Reasons for associations

• Confounding
• Bias
• Reverse causality
• Sampling error (chance)
• Causation

205
Reverse causality

• Suspected disease actually precedes suspected
  cause
• Pre-clinical disease ? Exposure ? Disease
• For example Memory deficits ? Reading cessation
  ? Alzheimers
• Cross-sectional study
• For example Sexual activity/Marijuana

206
Minimize effect of reverse causality

• Done in the planning and implementation phase of
  a study
• Pick study designs in which exposure is measured
  before disease onset
• Assess disease status with as much accuracy as
  possible

207
Reasons for associations

• Confounding
• Bias
• Reverse causality
• Sampling error (chance)
• Causation

208
Sampling error/chance

• E and D are associated in a sample, but not in
  the population from which the sample was drawn.

209
RR in the population
D D-
E 50 50 100
E- 50 50 100
100 100 200
210
RR in sample1
D D-
E 25 25 50
E- 25 25 50
50 50 100
211
RR in sample2
D D-
E 20 30 50
E- 30 20 50
50 50 100
212
RR in sample3
D D-
E 30 20 50
E- 15 35 50
45 55 100
213
Reasons for associations

• Confounding
• Bias
• Reverse causality
• Sampling error (chance)
• Causation

214
The process of assessing causality

• Observe patterns
• Generate hypothesis
• Design study to test hypothesis
• Conduct study
• Interpret the resultsthe big question is did the
  exposure cause the disease?
• Are there alternate non-causal explanations for
  the results we found?
• If not, then is this the whole story?

215
Causal pathways

• Necessary, sufficientrare, if at all
• Necessary, not sufficientTB, HIV
• Not necessary, sufficientinjury
• Not necessary, not sufficient--Most causes fall
  into this category--heart disease, obesity

216
So, what should we do?

• Goal is to understand causality
• Use guidelines to help us make sense of the
  evidence

217
Key Guidelines

• Temporality a necessary condition
• Consistency
• Dose-response
• Consideration of alternate explanations
• Coherence

218
Enduring Understandings

• 7, 8, and 9

219

• EU7 One possible explanation for finding an
  association is that the exposure causes the
  outcome. Because studies are complicated by
  factors not controlled by the observer, other
  explanations also must be considered, including
  confounding, chance, and bias.

220

• EU8 Judgments about whether an exposure causes a
  disease are developed by examining a body of
  epidemiologic evidence, as well as evidence from
  other scientific disciplines.

221

• EU9 While a given exposure may be necessary to
  cause an outcome, the presence of a single factor
  is seldom sufficient. Most outcomes are caused
  by a combination of exposures that may include
  genetic make-up, behaviors, social, economic, and
  cultural factors and the environment.

222
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223
Teach Epidemiology
Teach Epidemiology
224
Teach Epidemiology
Teach Epidemiology
225
Teach Epidemiology
Teach Epidemiology
226
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227
Teach Epidemiology
Teach Epidemiology
228
Teaching Epidemiology

• Rules
• Teach epidemiology
• As a group, create a 20-minute lesson during
  which we will develop a deeper understanding of
  an enduring epidemiological understanding.
• Focus on the portion of the unit that is
  assigned. Use that portion of the unit as the
  starting point for creating your 20-minute
  lesson.
• When teaching assume the foundational
  epidemiological knowledge from the preceding days
  of the workshop.
• Try to get us to uncover the enduring
  epidemiological understanding. Try to only tell
  us something when absolutely necessary.
• End each lesson by placing it in the context of
  the appropriate enduring epidemiological
  understanding.
• Be certain that the lesson is taught in 20
  minutes or less.
• Teach epidemiology.

Teach Epidemiology
229
Teaching Epidemiology
Metacognition
They can then use that ability to think about
their own thinking to grasp
how other people might learn.
They know what
has to come first,
and they can
distinguish between foundational concepts
and elaborations or
illustrations of those ideas. They realize
where people are likely to face
difficulties developing
their own comprehension,
and
they can use that understanding
to
simplify and clarify complex topics for others,
tell the right story, or raise a powerfully
provocative question. Ken Bain, What the Best
College Teachers Do
Teach Epidemiology
230
Teaching Epidemiology
To create a professional community

that discusses new teacher materials and
strategies and
that supports the risk taking and struggle
entailed in
transforming practice.
Teach Epidemiology
231
Teaching Epidemiology
Class 1 Pages 6-12
Group 1
Teach Epidemiology
232
Teaching Epidemiology
Group 2
Pages 35-39
Teach Epidemiology
233
Teaching Epidemiology
Class 1 Pages 16-21)
Group 3
Teach Epidemiology
234
Teaching Epidemiology
Group 4
Pages 32-36
Teach Epidemiology
235
Teaching Epidemiology
Pages 25-29 and 30-32
Group 5
Teach Epidemiology
236
Teaching Epidemiology
Procedures 2, 4, and 5
Group 6
Teach Epidemiology