Cross-sectional study

Yuriko Suzuki, MD, MPH, PhD

National Institute of Mental Health, NCNP
yrsuzuki@ncnp.go.jp

Key issues
Why research?
Descriptive study
Hypothesis testing
Association
Sampling
An example of cross-sectional study

Why research?
To guide health practice and policy
Because local research is often needed to guide
local health practice and policy
Because carrying out research strengthens
research capacity

What is a hypothesis
A statement which describes what you expect to
find in a specific manner
Clearly stated
Testable and refutable
Not a mere research question or objective
Backed by sample size calculation, and an
appropriate design and analysis

Example
Statement of the problem: mental health
problems are said to be common in the aftermath
of a disaster, and mental health problems are
believed to be associated with physical damage
Aim: to describe the association between physical
damage and mental health problems
Question: Are mental health problems associated
with physical damage in time of disaster?
Hypothesis: elderly people with poor mental
health are more likely to have severe housing
damage in time of disaster

Advantages of hypothesisdriven research

Greater credence given to validity of findings
Less risk of type I and II errors
o Type I error: mistakenly see association while
there isnt.
o Type II error: mistakenly see no association
while there is.
Ease of replication

What do epidemiologists do?

Describe
o Distribution of health-related states in a population
o Extent, type, severity
o Who, where, when?

Explain
o Analytical epidemiology
o Hypothesis-driven etiological research
o Risk factors and causes

Evaluate
o Quasi-experimental studies
o Randomized controlled trials

Association
Risk factor

Exposure

Disease
True association?

Independent

Outcome
Dependent

Chance
Bias

Confounding

Descriptive studies
Case series
Cross-sectional study
o Multi-center (geographic variance)
o Ecological correlation
o Repeated surveys (temporal variance)

Who to study?
Population
Sample
o Advantage:
time and cost
o Disadvantages:
sampling error,
bias if sample is not representative of population

Random sampling
Simple
Systematic
Stratified
Multi-stage and cluster

How big a sample?

Sample size calculation is important to avoid
errors in interpreting findings:
Type I errors:
o The null hypothesis is rejected when it is in
fact, true (p value)
Type II errors:
o The null hypothesis is accepted when it is, in
fact, false (power)

Prevalence study

Niigata

Suzuki Y, Tsutsumi A, Fukasawa M, et al. Prevalence of mental disorders

and suicidal thoughts among community-dwelling elderly adults 3 years
after the niigata-chuetsu earthquake. J Epidemiol. 21:144-50. 2011

13

Earthquakes in Niigata
In 2004: The NiigataChuetsu earthquake
2004.10.23.5:56pm
Magnitude:6.8 in Richter scale
Seismic intensity:7 in Japanese scale
Damage:68 deaths 4805 injuries

In 2007: The Niigata

Chuetsu-oki earthquake
2007.7.16.10:13am
Magnitude:6.8 in Richter scale
Seismic intensity:6 in Japanese scale
Damage:15 deaths 2345 injuries

Prevalence of mental health disorders among community

dwelling elderly three year after the Niigata-Chuetsu
earthquake
1. Face-to-face interviews were conducted to the older people
above 65 in the severely damaged area by the NiigataChuestu earthquake
2. Diagnoses of mental disorder were confirmed using Mini
International Neuropsychiatric Interview (M.I.N.I.), and
quality of life (QOL) were measure by WHOQOL
3. The prevalence and its associated factors were described.

Methods
4. Data collection
Trained health professionals administered the
questionnaires and the following structures
interviews;
5. Measurement

A) Diagnosis of mental disorders (M.I.N.I.)

a. Major depression (current, since the earthquake)
b. Minor depression (current, since the earthquake)
c. Suicidal tendency (current, since the earthquake)
d. Posttraumatic stress disorder (current)
e. Alcohol dependence and abuse (current)
B) QOL WHO/QOL-BREF
a. Physical
b. Psychological
c. Social
d. Environmental
16

Results Flow of the study

(2007.10.1-2008.1.11)

Population of the older adults (65 and over) in the

severely affected areas in Ojiya city (n=902)
Exclusion
Dead (n=42)
Hospitalized (n=20)
Institutionalized( n=15
)
Moved out (n=24)

Community-dwelling older adults (n=799)

Unable to interview
Absents (n=27)
Due to disability (hearing, seeing, etc) (n=71)

Refusal to interview (n=215)

Completed interviews (n=496), Completion rate
62.1%

Results
2
Table 1. Characteristics of participants of the study of three year after the
Niigata-Chuetsu earthquake in 2004 (n=473)

n
Gender
Male
190
Age
65-74
209
75+
264
Average age
Marital status
Married
328
Divorced
3
Bereaved
140
Never married
2
Education
Elementary school
128
Koutouka
112
Chugakko
167
Koukou
20
Others
Numbers of year in education
Number of cohabitant
Previous psychiatric visit
19
Digit spam (3 digits)

Incorrect

29

Mean

95% CI

40.2
44.2
55.8
76.0

75.4-76.6

8.2
3.9

8.1-8.4
3.7-4.1

69.3
0.6
29.6
0.4
27.5
24.0
35.8
4.3

4.3

11.2

18

Results 3

Severity of disaster damage

I. Prevalence
study

Results Prevalence
4 of mental disorders in 2 weeks and past 3 years
Prevalence rate (%)

among the older people living in community by gender (n=444)

**:p<0.05
**
**
**
**

2w 3y
Major
depression

2w 3y
Major and Minor
depression

Current PTSD

Earthquake
Other events

Current
alcoholdependence, abuse

2w 3y
Suicidal
tendency

Results 5
The percentage of those who met criterion A and B of
PTSD in DSM-IV-TR by exposure of the earthquake and
the other events

(n=446) (n=443) (n=245)

(n=445) (n=88) (n=51)

Results 7
QOL mean
: male 3.54 (95%CI:3.47-3.60)
female 3.48 (95%CI:3.43-3.53)

Results Results
8 of regression analysis for quality of life and interviewees basic
characteristics (n=439)
Variables

Psychologica
l

Coef.

Social

-0.05

-0.07

0.07

-0.10

-0.01

0.00

0.00

0.00

0.00

0.03

0.01

-0.08

-0.04

0.00

0.02

0.03

Years in education

-0.03

0.00

0.00

-0.01

-0.01

Previous psychiatric visit

-0.13

-0.03

-0.06

0.04

-0.03

-0.03

-0.04

-0.03

-0.04

-0.01

0.00

-0.15

**

3.6
0.015

3.9
0.034

Gender
(male=0, female=1)
Age
year
Marital status

Physical
Coef.

Coef.

Environmental Mean QOL score

Coef.

Coef.
*

-0.05

(not married=0, married=1)

Number of cohabitants

0.02

0.03 **

0.03

(never=0, yes=1)
Severity of disaster damage -0.05
in 2004

Physical illness

-0.29 **

-0.17 **

Intercept
Adjusted R2

4.9
0.060

3.6
4.1
0.022 0.003

*:p<0.05, **:p<0.01

Discussion 1

Prevalence of major depression and PTSD was lower than

previous researches in disaster settings in other countries
6.4-11%, 4.4-25% respectively in literature .

The prevalence of major depression since the earthquake

was 4.4%, within the range of the prevalence in nondisaster community studies (0.9-9.4% in literature).

Among males, the alcohol related problems were reported in

6.0% and among females, major or minor depression were
reported in 10.0%, and suicidal tendency were seen in 8.0%
of the interviewees.

Pathological levelabout same level as usual

Subclinical level require further attention to promote
their mental health

Discussion 2

In general, having fewer cohabitants, and greater degree of

disaster damage, and any physical illness were attributing to the
worse quality of life.

The risk factors for poor QOL were severity of disaster damage,
and physical illness in physical domain, fewer cohabitants and
physical illness in psychological domain, being female, and
fewer cohabitants in environmental domain.

Mental health and physical health care would be better if

provided hand in hand, and social support persistently had
favorable effects on QOL among disaster affected elderly people.