Exam Card 19.

1. Biases in medical research.

1) Explain bias as a systemic error in medical research
Bias is the association between exposure and outcome as a result of a
systemic error in the way the information is collected.
2) Selection bias, information bias, prevalence-incidence bias, observer
and subject bias- explain these terms.
a) Selection bias- Bias in the association between exposure and
outcome as a result of the selection of the study participants.
i) In a prospective study, this bias arises when exposed and
unexposed are selected into the study in a way that the risk of
outcome is different but for reasons other than those related to
the exposure itself
ii) In a case control study selection bias arises when the cases and
controls are selected into the study in such a way that the
likelihood of being exposed is different but for reasons other
than those related to the outcome itself.
b) Information bias may be differential or non-differential. Main
types of information bias:
i) Reporting bias- where the results of the study are changed
because of information that was given to the participants e.g.
case control study of syphilis patients may reveal a lower than
accurate number of sexual because they were told on
introduction to participation the women were told that sexual
partners must be identified and treated.
ii) Recall bias- where recollection is affected in the subject e.g.
mothers of congenitally defective children report more
exposures than control mothers
c) Prevalence incidence bias- occurs when prevalence data does not
show the same exposure- outcome relationship that would have
been detected had incidence been used e.g. if there has been a
change in exposure status since disease was diagnosed, the
prevalence data will produce a systemically different impression of
the exposure-outcome relationship than would have been obtained
from incidence data.
d)
3) Standardization to avoid biases.
a) Standardization produces indicators which eliminate the
differences in analyzed groups.

b) For example, when death rates of different places are to be

compared, crude death rate fails to give a true picture of the
situation due to differences in age and sex structure which
influences mortality. To remove this defect, deaths are corrected or
standardized by making adjustments for age and sex.
4) Randomization and matching to reduce bias.
5) Double blindness in a clinical study to minimize bias.
2.Physical inactivity as a health risk.
1) Definition and magnitude of the problem.
a. Physical activity is defined as bodily movement accomplished
by muscle power and energy expenditure and measured by the
extent to which energy expenditure exceeds the basal
metabolism.
b. Regular physical activity increases physical working capacity
or fitness.
c. Encouraging physical activity as part of preventive services in
primary care focuses on leisure time activities rather than
occupational ones.
d. Sedentary living is very common in modern affluent societies
where intensive mechanization in almost all sectors of the
economy has led to rapid decrease in energy expenditure.
e. 70% or more of men and women in all age groups are below an
acceptable minimum level of activity that would confer
significant health benefits. These people have an increase risk
of coronary heart disease and stroke.
f. The proportion of people classified as physically active in
leisure time correlates with socioeconomic status and level of
education. Better off and better educated people show more
favourable coronary risk profile with lower smoking and
obesity prevalence and healthier nutritional patterns.
g. Recent increase in leisure time physical activity popularity has
been shown but maximum 20% of population exercises at level
recommended for cardiovascular benefit.
2) Consequences (health risks) of physical inactivity.
a. Coronary heart disease
b. Stroke
c. Elevated blood pressure
d. NIDDM
e. Osteoporosis
3) Potential health benefits of psychical activity.

a.
b.
c.
d.
e.

Reduce risk of coronary heart disease

To lesser extent, prevents stroke
Lower blood pressure
Improve lipoprotein profile (increase HDL and decrease LDL)
Prevents obesity by improving balance between energy intake
and expenditure
f. Decrease serum glucose and increase glucose tolerance,
decreasing risk of NIDDM development
g. Reduce bone loss preventing osteoporosis
h. Decrease fibrinogen activity and increase fibrinolytic activity
i. Increase psychological fitness and coping with stress and
fatigue
j. Lower rates of mortality.
4) Intervention measures in primary care and recommended procedures
for physical activity.
a. Intervention measures
i. Regular, continuining, aerobic physical activity has a
protective effect against health risks attributed to physical
activity.
ii. There is a dose-response relationghip between the
intensity of physical exercise and its protective effect.
The intensity is expressed in energy required to carry out
the activity and can be estimated based on heart rate and
respiratory rate. Maximum respiratory rate is when
person is unable to speak, maximum heart rate is 220persons age.
iii. Strategies for the implementation of programmes to
increase physical activity in population are:
Creation of supportive physical, social and cultural
environments for the population
Education of the public through mass media
Direct education and counseling in primary care.
iv. Risk factor reduction is proportional to degree of exercise
intensity and exposure to and participation in the
programme.
b. Recommended procedures for physical activity.
i. Four major components:

c.

d.
e.

f.

Frequency: Three sessions per week, not done on

consecutive days to prevent soreness, fatigue and
possible injury
Duration: For cardiovascular endurance, should
exercise for 25-60minutes.
o Warm up 5-10 minutes
o Overload 15-40 minutes
o Cool down- 5-10 minutes
o The older and less fir the individual, the
more important the warm up phase.
Intensity: General population, 30-50% of optimum
oxygen consumption during warm up and cooldown and 60-80% during overload period.
Types: May include light, moderate and vigorous
activities. E.g. walking, cycling, climbing stairs,
gardening, running or jogging, swimming, rowing,
skating, skiing, teamsports dancing. The better the
activity suits the persons lifestyle, the more it is
recommended.
Frequency, duration and intensity of exercise should be
appropriate according to the initial level of fitness. Those who
are sedentary should start slowly but regularly with shorter
periods of less intense activity and build up their fitness
gradually in steps lasting a few weeks.
To assess baseline activity level, a few relevant questions
concerning current activity may be useful.
To avoid injury and adverse effects children, elderly, pregnant
women, postmenopausal women, people who experience
faintness, chest pain, dizziness, palpitation, diagnosed heart
trouble, hypertension, obesity, diabetes, chronic bronchitis,
musculoskeletal problem etc may need special advice on
physical activity.
Checklist of recommended procedures:
i. Discuss physical activity with patients and motivate them
to include physical exercise in their daily routine
ii. Ask about their leisure-time physical activities according
to intensity and frequency
iii. Identify those who need behavioral change and
encourage them to increase their physical activity to a

sufficient level for cardiovascular benefit or maintain the

level.
iv. Assist patients in choosing a personal plan for physical
activity and advise them on choosing appropriate type
and level of physical activity according to their age,
baseline activity, health and to increase this level
accordingly.
v. Follow up with patients, monitor compliance, and
encourage those who return to old pattern of inactivity.
Also refer those who have special health problems for
specialist advice.
5) Explain the reasons of difficulties in changing lifestyle.