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1. Explain the difference between a relative risk of 2.0 and a relative risk of 0.

when the relative risk describes the risk of a disease given exposure compared to no
Since the relative of 2.0 is greater than 1 (>1) the risk in exposed group is greater
than the risk in the unexposed group there is a positive association between the
exposure and the outcome. And the 0.5 is less than 1 (<1) risk in exposed group is
less than that in unexposed group, there is a negative association between the
exposure and the outcome. Here the exposure may be a protective factor. (See pg

2. The researchers analyzed the occurrence of cancer identified between April 1991
and July 2002 for 50,000 troops who served in the first Gulf War (ended April 1991),
and that of 50,000 troops who served elsewhere during the same period. What study
design do you think they used?
Cohort Study design.
There are a few reasons for this conclusion
There are two groups of people who share common characteristic or
experience within a define time period
A retrospective cohort study because the investigator looks into what
happened to the exposed and the unexposed members over time, the
occurrence between the two is then compared
It uses the historic records of the exposure and possible outcome
[The study design would mostly likely be a Case-Control Study, because the study period is
retrospective as well as the design is restricted to a control group of population i.e soldiers
commission during the gulf war compared to the rest of the soldiers elsewhere during the
same period. The direction of the study is from outcome to exposure, meaning that the
population had already developed the disease and now the study is trying to establish the
exposure factors for the disease.]

3. What are the differences between the cohort study and case-control study?

Cohort Study

Case-Control study

From outcome to Source
Heterogenous case and control
Less reliable recalled exposure
Rate can only be estimated directly

From Cause to outcome
Homogenous healthy subject
Reliable outcome information
Rate can be calculated indirectly

4. Persons diagnosed with new-onset Lyme disease were asked how often they walk
through woods, use insect repellant, wear short sleeves and pants, etc. Twice as many
patients without Lyme disease from the same physicians practice were asked the
same questions, and the responses in the two groups were compared. What study
design do you think they used?
Case-control study design
There are a few reasons for this conclusion.
There are two distinct group of people;
One with the disease Case, and the other without the disease Control.
By comparing the similar exposure factors between the two groups to
establish the outcome.
The study direction is then Outcome to Exposure.
The study is retrospective.

5. A cross-sectional study has been carried out on etiology of lung cancer, and the
results suggest that drinking may be associated with lung cancer. How to correctly
understand this result?

In order to understand the result more correctly we first have to calculate the
prevalence rate of drinking to lung cancer and compare with the prevalence of
non-drinkers to lung cancer. Using the ratio of the two prevalence rate we can
determine if the conclusion that drinking is associated with lung cancer is
Next please use the case-control study for further analysis on etiology of lung cancer.
You can express your research by design pattern of case-control study, and list some
necessary notes.

6. A case control study of multiple sclerosis (MS) was conducted in which family
history of MS was collected on all first- and second-degree relatives. Among the
500 cases, 16 reported an affected relative. Among the 500 age- and sex-matched
controls, 8 reported an affected relative.
Please analyze the data. Do these data suggest a familial component to MS?

Table 1 The relationship between family component and Multiple sclerosis (MS)

Cases (with MS)

Controls (without MS)









Odds ratio=b/c=8/484=0.0165
X2=(b-c)2/(b+c)=(8-484)2/(8+484)=460.52, p>0.01
OR 95% CI=exp [ln (b/c)1.96 1/b+1/c]

7. Epidemiology

Epidemiology is the study of the distribution and determinants of health-related

states or events in specified populations and the application of this study to
control of health problems.
8. Secular trend
Also called long term changes. It represent the pattern of trends for a long time
such as many years, decades or even centuries

9. Exposure
Exposure is a very common used term in epidemiology, it refers to the causal
factors that may associated with the disease.
beneficial ------harmful
10. Cluster sampling
The entire population of interest is divided into groups, or
clusters, and a random sample of these clusters is selected.
Cluster sampling is typically used when the researcher can
not get complete list of the members of a population they
wish to study but can get a complete list of groups or
cluster of the population.
It is also used when a random sample would produce a list of
subjects so widely scattered that surveying them would
prove to be far too expensive.
11. Questionnaire
A questionnaire is a research instrument consisting of a
series of questions and other prompts for the purpose of
gathering information from respondents
12. What are the purposes and application of cross-sectional study?
Describes the distributing of disease or health events
within populations
To provide etiological clues
To identify high risk groups in the population

To evaluate the effect of surveillancevaccination and

disease prevention and control
13. When we want to compare two crude rates, why should we do standardization?
It is useful when comparisons are made between two populations, expecially
between countries, cities, which may vary in age distribution, proportion of men
and women.
Methods of standardization are only useful if rates are comparable and
standardization may be used only when simpler comparisons are not
Simpler comparison using age or specific rates are better than standardized rates
especially when comparisons are made between population of similar
demographic profile
14. Describe the basic methods of epidemiological study.

15. Describe one disease and provide examples of prevention strategies by levels of
Three levels of prevention include; Primary, Secondary and Tertiary levels.
Hypertension is an abnormal increase in systolic blood pressure and is one of the
common cause of cardiovascular disease.
Primary prevention- is to prevent the development of the disease, restricting salt
intake to prevent hyperstension
Secondary prevention- screening programs for the early detection of the disease
before the clinical stages. Periodic blood pressure measurement to detect
elevated bp in time to prevent the progression of the disease.
Tertiary prevention- treatment and rehabilitation of the disease after is has
occurred by improve the duration or the outcome of illness or improve quality of

life for chronic disease. E.g. Hypertension medication and concsulting for
lifestyle and diet are necessary to control bp and also prevent some complication
of cardiovascular disease such as coronary heart disease. (See pg 13-14)

16. What are some of the limitations of a cross-sectional study?

Do not establish the true temporal sequence of events.
Does not yield incidence or true relative risk.
They are not feasible for the cases of death, recovery and short course.
Not effective if the disease is rare.
17. What is the Application of epidemiology?
Determine great public health Problems
Describe the distribution of the disease and the health related states in the
Response and deal with emergency event
Disease related surveillance
Risk factor and disease
Study the natural history of disease
Evaluate the effect of prevent and treatment
18. RCT
An epidemiological experiment in which subjects in a population are randomly
allocated into groups, usually called study and control groups to receive and not
receive an experimental preventive or therapetuic procedure, maneuver, or
19. Bias
Bias is a systematic error in the design, conduct or analysis of a study that results
in a mistaken estimate of an exposures effect on the risk of disease.
Types of bias
Selection bias
Measurement / (mis)classification bias
Confounding bias

20. Confounding
A situation in which the effects of two processes are not separated. The distortion
of the apparent effect of an exposure on risk brought about by the association
with other factors that can influence the outcome

21. Berkson bias

Berkson bias is a special type of selection bias that occurs in hospital based casecontrol studies. It is used to describe the bias caused by the systematic
differences between hospital controls and the general population.
22. Blinding
Blinding refers to hiding information about treatment assignment from the key
participants in a trial.
23. Double blinding
Double blind: neither participants nor investigators know allocation
24. Screening
Screening is the early detection and presumptive identification of an
unrecognized disease or deficit by application of examinations or tests which can
be applied rapidly and cheaply to large populations.
25. Positive predictive value

26. What kinds of experimental studies can you name? And what are the
characteristics of experimental studies?
Experimental studies include
Clinical trial,
Field trial and
Community trial.
General characteristics
Assigning one or more intervention to the subjects

Having parallel experimental group and control group

Randomization of study subjects

27. What are the advantages and disadvantages of experimental studies?

Advantages of experimental studies
Experimental studies can balance the study groups with respect to both
known and unknown prognostic factors.
Detailed information can be collected on baseline and subsequent
characteristics of participants, and some procedures can be put in place to
enable the researchers to collect data in a fairly complete and accurate
Dose levels of medicine taken by patients can be predetermined by the
investigator rather than relying on physician or patient preferences.
When blinding, the assessment of clinical outcome is less likely to be
influenced by knowing which treatment was used, thereby reducing
distortion in assessment of outcomes.
Disadvantages of experimental studies
Subject exclusions may restrict the ability to generalize findings to
patients with other characteristics.
A long period of time is often required to reach a conclusion in clinical
trials, particularly in those trials involving chronic processes.
A prolonged observational period leads to higher costs, increases the
likelihood that patients would be lost to follow-up, and delays the time to
make a treatment recommendation.

28. Can you list biases related with different kinds of studies?

Type of studies

Related biases

Case control study

Recall bias
Interviewer bias
Berkson bias
Prevalence and incidence bias

Cohort study

Participant selection bias

Follow-up cohort
Observation bias

Screening study

Lead time bias

Length time bias
Overdiagnosis bias
Selection bias

29. Can you list commonly used methods to control for confounding factors?
During Study Design
During analysis

Often used in RCT
All types of studies
Mainly used in case control studies
Used in all studies and often performed
before multivariate adjustment
Commonly used to control for age and

Multivariate adjustment
Used in all studies
30. What are the advantages and disadvantages of screening?
Early detection is secondary prevention
Simpler testing procedures can be used
Tests can be applied to a large population
Screening can be relatively inexpensive (cost effective)
Issues of false positives and negatives must be considered

Screening must be provided to everyone in the target group

There will be an increased demand for health services
Care must be taken to avoid biases in designing the screening procedures
31. For what type of diseases would it be appropriate to set up screening programs?
Important health problem
High prevalence
Natural history understood
Long latent period
Early detection improves prognosis
Please list characteristics. Please see pg 136 table 10.1
1. The disease or condition being screened for should be a major medical
2. Acceptable treatment should be available for individuals when the
disease is discovered in the screening process.
3. Access to health care facilities and services for follow-up diagnosis
and treatment should be available for the disease discovered by the
screening process.
4. The disease should have a recognizable course, with early and latent
states of disease.
5. A suitable or effective test or examination for the disease should be
6. The test and the testing process should be acceptable to the general
7. The natural history of the disease or condition should be adequately
understood, including the regular phases and course of the disease,
with an early period identifiable through testing.
8. Policies, procedures and levels on tests should be determined in order
to establish who would be referred for further testing, diagnostic and
possible treatment.
9. The process should be simple enough to encourage large groups of
persons to participate.
10. Screening should not be an occasional activity but should be done as a
regular and on-going process.