A Short Introduction To Epidemiology Second Edition

A Short Introduction
to Epidemiology
Second Edition
Neil Pearce
Occasional Report Series No 2

Centre for Public Health Research
Massey University Wellington Campus
Private Box 756
Wellington, New Zealand

Private Box 756
Phone: 64-4-3800-606
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Copies of this publication can be purchased in hard copy
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2nd edition
February 2005
ISBN 0-476-01236-8
ISSN 1176-1237
To Irihapeti Ramsden
Preface
Who needs another introductory

epidemiology text? Certainly, there are
many introductory epidemiology books
currently in print, and many of them are
excellent. Nevertheless, there are four
reasons why I believe that this new text
is justified.
Firstly, it is much shorter than most
introductory texts, many of which contain
more material than is required for a short
introductory course. This is a short
introduction to epidemiology, and is not
intended to be comprehensive.
Secondly, I have endeavoured to show
clearly how the different basic
epidemiologic methods fit together in a
logical and systematic manner. For
example, I attempt to show how the
different possible study designs relate to
each other, and how they are different
approaches to a common task. Similarly,
I attempt to show how the different study
design issues (confounding and other
types of bias) relate to each other, and
how the principles and methods of data
analysis are consistent across different
study designs and data types.
Thirdly, in this context, rather than
attempt a comprehensive review of
available methods (e.g. multiple methods
for estimating confidence intervals for the
summary risk ratio), I have attempted to
select only one standard method for each
application, which is reasonably robust
and accurate, and which is consistent and
coherent with the other methods
presented in the text.
Finally, the field of epidemiology is
changing rapidly, not only with regards to
its basic methods, but also with regards
to the hypotheses which these methods
are used to investigate. In particular, in

recent years there has been a revival in
public health applications of
epidemiology, not only at the national
level, but also at the international level,
as epidemiologists tackle global problems
such as climate change. This text does
not attempt to review the more complex
measures used to consider such issues.
However, it does provide a coherent and
systematic summary of the basic
methods in the field, which can be used
as a logical base for the teaching and
development of research into these more
complex issues.
Chapter 1 gives a brief introduction to the
field, with an emphasis on the broad
range of applications and situations in
which epidemiologic methods have been
used historically, and will continue to be
used in the future.
Part 1 then addresses study design
options. Chapter 2 discusses incidence
studies (including cohort studies) and
describes the basic study design and the
basic effect measures (i.e. incidence rates
and rate ratios). It then presents
incidence case-control studies as a more
efficient means of obtaining the same
findings. Chapter 3 similarly discusses
prevalence studies, and prevalence casecontrol studies. Chapter 4 then considers
study designs incorporating other axes of
classification, continuous outcome
measures (e.g. blood pressure) such as
cross-sectional studies and longitudinal
studies, or more complex study designs
such as ecologic and multi-level studies.
Part 2 then addresses study design

issues. Chapter 5 discusses issues of
study size and precision. Chapter 6
considers general issues of validity,
namely selection bias, information bias,
and confounding. Chapter 7 discusses
effect modification.
of situations in which epidemiologic

methods can be used. However, there are
undoubtedly many other types of
epidemiologic hypotheses and
epidemiologic studies which are not
represented in this book. In particular,
my focus is on the use of epidemiology in
public health, particularly with regard to
non-communicable disease, and I include
few examples from clinical epidemiology
or from communicable disease outbreak
investigations. Nevertheless, I hope that
the book will be of interest not only to
epidemiologists, but also to others who
have other training but are involved in
epidemiologic research, including public
health professionals, policy makers, and
clinical researchers.
Part 3 then discusses the practical issues

of conducting a study. Chapter 8
addresses issues of measurement of
exposure and disease. Chapters 9-11
then discuss the conduct of cohort
studies, case-control studies and crosssectional studies respectively.
Finally, Part 4 considers what happens
after the data are collected, with chapter
12 addressing data analysis and chapter
13 the interpretation of the findings of
epidemiologic studies.
Neil Pearce
I should stress that this book provides no

more than a very preliminary introduction
to the field. In doing so I have attempted
to use a wide range of examples, which
give some indication of the broad range

Private Box 756
Acknowledgements
During the writing of this text, my salary

was funded by the Health Research
Council of New Zealand. I wish to thank
Sander Greenland and Jonny Myers for
their comments on the draft manuscript.
I also wish to thank Massey University
for support for my research programme.
A Short Introduction to Epidemiology
Contents
1.
Introduction
PART 3: CONDUCTING A STUDY
Germs and miasmas

10
Risk factor epidemiology
11
Epidemiology in the 21st century 12
8.
PART 1: STUDY DESIGN OPTIONS

2.
Incidence studies
Incidence studies
Incidence case-control studies
3.
Prevalence studies
21
22
28
9.
Precision
Basic statistics
Study size and power
6.
Validity
Confounding
Selection bias
Information bias
7.
Effect modification
Concepts of interaction
Additive and multiplicative
models
Joint effects
109
and risk period
33
10. Case-control studies
Defining the source population

and risk period
41
42
47
Selection of cases
Selection of controls
Measuring exposure
PART 2: STUDY DESIGN ISSUES

5.
Cohort studies
Measuring exposure
Follow-up
More complex study designs 41
Other axes of classification

Continuous outcome measures
Ecologic and multilevel studies
Health status
95
95
102
Prevalence studies
33
Prevalence case-control studies 38
4.
Measurement of exposure
and health status
Exposure
11. Prevalence studies

Measuring health status
Measuring exposure
59
60
61
109
112
113
117
117
118
119
122
125
125
126
128
PART 4: ANALYSIS AND

INTERPRETATION OF STUDIES
67
67
73
74
12. Data analysis
83
83
Basic principles
Basic analyses
Controlling for confounding
13. Interpretation
88
89
133
133
136
140
145
Appraisal of a single study
145
Appraisal of all of the available
evidence
148
CHAPTER 1. Introduction
(In: Pearce N. A Short Introduction to Epidemiology. 2nd ed. Wellington, CPHR, 2005)
Public health is primarily concerned with

the prevention of disease in human
population. It differs from clinical
medicine both in its emphasis on
prevention rather than treatment, and in
its focus on populations rather than
individual patients (table 1.1).
Epidemiology is the branch of public
health which attempts to discover the
causes of disease in order to make
disease prevention possible.
Epidemiological methods can be used in
other contexts (particularly in clinical
research), but this short introductory text
focuses on the use of epidemiology in
public health, i.e. on its use as part of the
wider process of discovering the causes
of disease and preventing its occurrence
in human populations.
In this context, epidemiology has been
defined as (Last, 1988):
"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"
This broad definition could in theory
include a broad range of research
methodologies including qualitative
research and quantitative randomised
controlled trials. Some epidemiologists
recognise the complementary nature of

the former (McKinlay, 1993), and some
texts include the latter in their definition
of epidemiology. However, the key
feature of epidemiological studies is that
they are quantitative (rather than
qualitative) observational (rather than
experimental) studies of the determinants
of disease in human populations (rather
than individuals). This will be my focus
here, while recognising the value, and
complementary nature, of other research
methodologies. The observational
approach is a major strength of
epidemiology as it enables a study to be
conducted in a situation where a
randomized trial would be unethical or
impractical (because of the large
numbers of subjects required). It is also
the main limitation of epidemiological
studies in that the lack of randomization
means that the groups being compared
may differ with respect to various causes
of disease (other than the main exposure
under investigation). Thus,
epidemiological studies, in general,
experience the same potential problems
as randomized controlled trials, but may
suffer additional problems of bias because
exposure has not been randomly
allocated and there may be differences in
baseline disease risk between the
populations being compared.
Table 1.1
The defining features of public health: populations and prevention
Populations
Individuals
Prevention
Treatment
---------------------------------------------------------------------Public health
Health systems research
Primary health care/
Health education
Medicine (including primary health care)
1.1 Germs and Miasmas
Epidemiology is as old as public health

itself, and it is not difficult to find
epidemiological observations made by
physicians dating back to Hippocrates
who observed that:
Whoever wishes to investigate
medicine properly should proceed thus:
in the first place to consider the
seasons of the year, and what effects
each of them produces when one
comes into a city in which he is a
stranger, he should consider its
situation, how it lies as to the winds
and the rising of the sunOne should
consider most attentively the waters
which the inhabitants useand the
ground and the mode in which the
inhabitants live, and what are their
pursuits, whether they are fond of
drinking and eating to excess, and
given to indolence, or are fond of
exercise and labor. (Hippocrates,
1938; quoted in Hennekens and Buring,
1987)
Many other examples of epidemiological
reasoning were published through the
ages. However, epidemiology was

founded as an independent discipline in a
number of Western countries in parallel
with the industrial revolution of the 19th
century. In Anglophone countries it is
considered to have been founded by the
work of Chadwick, Engels, Snow and
others who exposed the appalling social
conditions during the industrial
revolution, and the work of Farr and
others who revealed major
socioeconomic differences in disease in
the 19th century. At that time,
epidemiology was generally regarded as
a branch of public health and focused on
the causes and prevention of disease in
populations, in comparison with the
clinical sciences which were branches of
medicine and focused on disease
pathology and treatment of disease in
individuals. Thus, the emphasis was on
the prevention of disease and the health
needs of the population as a whole. In
this context, the fundamental
importance of population-level factors
(the urban environment, housing,
socioeconomic factors, etc) was clearly
acknowledged (Terris, 1987).
Table 1.2
Deaths and death rates from cholera in London 1854 in households supplied by the
Southwark and Vauxhall Water Company and by the Lambeth Water Company
Deaths
Cholera
per 10,000
Houses
deaths
houses
-----------------------------------------------------------------------------------------------Southwark and Vauxhall
40,046
1,263
315
Lambeth Company
26,107
98
37
Rest of London
256,423
1,422
59
-----------------------------------------------------------------------------------------------Source: (Snow, 1936; quoted in Winkelstein, 1995)
10
Perhaps the most commonly quoted

epidemiologic legend is that of Snow who
studied the causes of cholera in London
in the mid-19th century (Winkelstein,
1995). Snow was able to establish that
the cholera death rate was much higher
in areas supplied by the Southwark and
Vauxhall Company which took water
from the Thames downstream from
London (i.e. after it had been
contaminated with sewerage) than in
areas supplied by the Lambeth Company
which took water from upstream, with
the death rates being intermediate in
areas served by both companies.
Subsequently, Snow (1936) studied the
area supplied by both companies, and
within this area walked the streets to
determine for each house in which a
cholera death had occurred, which
company supplied the water. The death
rate was almost ten times as high in
houses supplied with water containing
sewerage (table 1.2).
Although epidemiologists and other
researchers continue to battle over
Snows legacy and its implications for
epidemiology today (Cameron and Jones,
1983; Loomis and Wing, 1991; Samet,

2000; Vandenbroucke, 1994), it is clear
that Snow was able to discover, and
establish convincing proof for, the mode
of transmission of cholera, and to take
preventive action several decades before
the biological basis of his observations
was understood. Thus, it was not until
several decades after the work of Snow
that Pasteur and others established the
role of the transmission of specific
pathogens in what became known as the
infectious diseases, and it was another
century, in most instances, before
effective vaccines or antibiotic
treatments became available.
Nevertheless, a dramatic decline in
mortality from these diseases occurred
from the mid-nineteenth century long
before the development of modern
pharmaceuticals. This has been
attributed to improvements in nutrition,
sanitation, and general living conditions
(McKeown, 1979) although it has been
argued that specific public health
interventions on factors such as urban
congestion actually played the major role
(Szreter, 1988).
1.2 Risk Factor Epidemiology
This decline in the importance of

communicable disease was accompanied
by an increase in morbidity and mortality
from non-communicable diseases such
as heart disease, cancer, diabetes, and
respiratory disease. This led to major
developments in the theory and practice
of epidemiology, particularly in the
second half of the 20th century. There
has been a particular emphasis on
aspects of individual lifestyle (diet,
exercise, etc) and in the last decade the
11
human genome project has seen an

accelerated interest in the role of genetic
factors (Beaty and Khoury, 2000).
Thus, epidemiology became widely
recognized with the establishment of the
link between tobacco smoking as a cause
of lung cancer in the early 1950's (Doll
and Hill, 1950; Wynder and Graham,
1950), although this association had
already been established in Germany in
the 1930s (Schairer and Schninger,
2001). Subsequent decades have seen

major discoveries relating to other
causes of chronic disease such as
asbestos, ionizing radiation, viruses,
diet, outdoor air pollution, indoor air
pollution, water pollution, and genetic
factors. These epidemiologic successes
have in some cases led to successful
preventive interventions without the
need for major social or political change.
For example, occupational carcinogens
can, with some difficulty, be controlled
through regulatory measures, and
exposures to known occupational
carcinogens have been reduced in
industrialized countries in recent
decades. Another example is the
successful World Health Organisation
(WHO) campaign against smallpox. More
recently, some countries have passed
legislation to restrict advertising of
tobacco and smoking in public places
and have adopted health promotion
programmes aimed at changes in
"lifestyle".
for the ethical and practical constraints,

epidemiologic theory and practice has,
quite appropriately, been based on the
theory and practice of randomised trials.
Thus, the aim of an epidemiologic study
investigating the effect of a specific risk
factor (e.g. smoking) on a particular
disease (e.g. lung cancer) is intended to
obtain the same findings that would have
been obtained from a randomised
controlled trial. Of course, an
epidemiologic study will usually
experience more problems of bias than a
randomised controlled trial, but the
randomised trial is the gold standard.
Individual lifestyle factors would ideally

be investigated using a randomised
controlled trial, but this is often unethical
or impractical (e.g. tobacco smoking).
Thus, it is necessary to do observational
studies and epidemiology has made
major contributions to the understanding
of the role of individual lifestyle factors
and health. Because such factors would
ideally be investigated in randomised
controlled trials, and in fact would be
ideally suited to such trials if it were not
This approach has led to major

developments in epidemiologic theory
(presented most elegantly and
comprehensively in Rothman and
Greenland, 1998). In particular, there
have been major developments in the
theory of cohort studies (which mimic a
randomised trial, but without the
randomisation) and case-control studies
(which attempt to obtain the same
findings as a full cohort study, but in a
more efficient manner). It is these basic
methods, which follow a randomised
controlled trial paradigm, which receive
most of the attention in this short
introductory text. However, while
presenting these basic methods, it is
important to also recognise their
limitations, and to also consider different
or more complex methods that may be
more appropriate when epidemiology is
used in the public health context.
1.3 Epidemiology in the 21st Century
In particular, in the last decade there

has been increasing concern expressed
about the limitations of the risk factor
approach, and considerable debate about
12
the future direction of epidemiology

(Saracci, 1999). In particular, it has
been argued that there has been an
overemphasis on aspects of individual
lifestyle, and little attention paid to the

population-level determinants of health
(Susser and Susser, 1996a, 1996b;
Pearce, 1996; McMichael, 1999).
Furthermore, the success of risk factor
epidemiology has been more temporary
and more limited than might have been
expected. For example, the limited
success of legislative measures in
industrialised countries has led the
tobacco industry to shift its promotional
activities to developing countries so that
more people are exposed to tobacco
smoke than ever before (Barry, 1991;
Tominaga, 1986). Similar shifts have
occurred for some occupational
carcinogens (Pearce et al, 1994). Thus,
on a global basis the "achievement" of
the public health movement has often
been to move public health problems
from rich countries to poor countries and
from rich to poor populations within the
industrialized countries.
It should be acknowledged that not all
epidemiologists share these concerns
(e.g. Savitz, 1994; Rothman et al, 1998;
Poole and Rothman, 1998), and some
have regarded these discussions as an
attack on the field itself, rather than as
an attempt to broaden its vision.
Nevertheless, the debate has progressed
and there is an increasing recognition of
the importance of taking a more global
approach to epidemiologic research and
of the importance of maintaining an
appropriate balance and interaction
between macro-level (population),
individual-level (e.g. lifestyle), and
micro-level (e.g. genetic) research
(Pearce, 2004).
There are three crucial concepts which
have received increasing attention in this
regard.
The Importance of Context
The first, and most important issue, is
the need to consider the population
context when conducting epidemiologic
13
studies. Even if one is focusing on

individual lifestyle risk factors, there is
good reason to conduct studies at the
population level (Rose, 1992). Moreover,
every population has its own history,
culture, and economic and social
divisions which influence how and why
people are exposed to specific risk
factors, and how they respond to such
exposures. For example, New Zealand
(Aotearoa) was colonised by Great
Britain more than 150 years ago,
resulting in major loss of life by the
indigenous people (the Mori). It is
commonly assumed that this loss of life
occurred primarily due to the arrival of
infectious diseases to which Mori had no
natural immunity. However, a more
careful analysis of the history of
colonisation throughout the Pacific
reveals that the indigenous people
mainly suffered major mortality from
imported infectious diseases when their
land was taken (Kunitz, 1994), thus
disrupting their economic base, food
supply and social networks. This
example is not merely of historical
interest, since it these same infectious
diseases that have returned in strength
in Eastern Europe in the last decade,
after lying dormant for nearly a century
(Bobak and Marmot, 1996). Similarly,
the effects of occupational carcinogens
may be greater in developing countries
where workers may be relatively young
or may be affected by malnutrition or
other diseases (Pearce et al, 1994).
These issues are likely to become more
important because, not only is
epidemiology changing, but the world
that epidemiologists study is also rapidly
changing. We are seeing the effects of
economic globalization, structural
adjustment (Pearce et al, 1994) and
climate change (McMichael, 1993, 1995),
and the last few decades have seen the
occurrence of the informational
revolution which is having effects as
great as the previous agricultural and
industrial revolutions (Castells, 1996).
In industrialized countries, this is likely

to prolong life expectancy for some,
but not all, sections of the population.
In developing countries, the benefits
have been even more mixed (Pearce et
al, 1994), while the countries of
Eastern Europe are experiencing the
largest sudden drop in life expectancy
that has been observed in peacetime
in recorded human history (Boback
and Marmot, 1996) with a major rise
in alcoholism and forgotten diseases
such as tuberculosis and cholera.
theories and identifies the major public

health problems which new theories
must be able to explain. A fruitful
research process can then be
generated with positive interaction
between epidemiologists and other
researchers. Studying real public
health problems in their historical and
social context does not exclude
learning about sophisticated methods
of study design and data analysis (in
fact, it necessitates it), but it may help
to ensure that the appropriate
questions are asked (Pearce, 1999).
This increased interest in populationlevel determinants of health has been

particularly marked by increased
interest in techniques such as
multilevel modelling which allow
individual lifestyle risk factors to be
considered in context and in parallel
with macro-level determinants of
health (Greenland, 2000). Such a shift
in approach is important, not only
because of the need to emphasize the
role of diversity and local knowledge
(Kunitz, 1994), but also because of the
more general moves within science to
consider macro-level systems and
processes (Cohen and Stewart, 1994)
rather than taking a solely reductionist
approach (Pearce, 1996).
Appropriate Technology
A related issue is the need to use
appropriate technology to address
the most important public health
research questions. In particular, as
attention moves upstream to the
population level (McKinlay, 1993) new
methods will need to be developed
(McMichael, 1995). One example of
this, noted above, is the recent rise in
interest in multilevel modelling
(Blakely and Woodward, 2000; Pearce,
2000), although it is important to
stress that it is an increase in
multilevel thinking in the
development of epidemiologic
hypotheses and the design of studies
that is required, rather than just the
use of new statistical techniques of
data analysis. The appropriateness of
any research methodology depends on
the phenomenon under study: its
magnitude, the setting, the current
state of theory and knowledge, the
availability of valid measurement tools,
and the proposed uses of the
information to be gathered, as well as
the community resources and skills
available and the prevailing norms and
values at the national, regional or local
level (Pearce and McKinlay, 1998).
Thus, there has been increased
interest in the interface between
epidemiology and social science
(Krieger, 2000), and in the
Problem-Based Epidemiology
A second issue is that a problem-based
approach may be particularly valuable
in encouraging epidemiologists to
focus on the major public health
problems and to take the population
context into account (Pearce, 2001;
Thacker and Buffington, 2001). A
problem-based approach to teaching
clinical medicine has been increasingly
adopted in medical schools around the
world. The value of this approach is
that theories and methods are taught
in the context of solving real-life
problems. Starting with the problem
at the population level provides a
reality check on existing etiological
14
development of theoretical and

methodological frameworks
appropriate for epidemiologic studies
in developing countries (Barreto et al,
2001; Barreto, 2004; Loewenson,
2004), and in indigenous people in
Western countries (Durie, 2004). As
noted above, this short introductory

text focuses on the most basic
epidemiologic methods, but I attempt
to refer to more complex issues, and
the potential use of more complex
methods, where this is appropriate.
Summary
Public health is primarily concerned with

the prevention of disease in human
populations, and epidemiology is the
branch of public health which attempts
to discover the causes of disease in
order to make disease prevention
possible. It thus differs from clinical
medicine both in its emphasis on
prevention (rather than treatment) and
in its focus on populations (rather than
individual patients). Thus, the
epidemiological approach to a particular
disease is intended to identify high-risk
subgroups within the population, to
determine the causes of such excess
risks, and to determine the effectiveness
of subsequent preventive measures.
Although the epidemiological approach
has been used for more than a century
for the study of communicable diseases,
epidemiology has considerably grown in
scope and sophistication in the last few
decades as it has been increasingly
applied to the study of noncommunicable diseases. At the beginning

of the 21st century, the field of
epidemiology is changing rapidly, not
only with regards to its basic methods,
but also with regards to the hypotheses
which these methods are used to
investigate. In particular, in recent years
there has been a revival in public health
applications of epidemiology, not only at
the national level, but also at the
international level, as epidemiologists
tackle global problems such as climate
change. This text does not attempt to
review the more complex methods used
to study such issues. However, it does
provide a coherent and systematic
summary of the basic methods in the
field, which can be used as a logical base
for the teaching and development of
research into these more complex
issues.
15
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Part I
Study Design Options
19
20
CHAPTER 2. Incidence Studies

In this chapter and the next one I review

the possible study designs for the simple
situation where individuals are exposed to
a particular risk factor (e.g. a particular
chemical) and when a dichotomous
outcome is under study (e.g. being alive or
dead, or having or not having a particular
disease). Thus, the aim is to estimate the
effect of a (dichotomous) exposure on the
occurrence of a (dichotomous) disease
outcome or health state.
It should first be emphasized that all
epidemiologic studies are (or should be)
based on a particular source population
(also called the study population or base
population) followed over a particular risk
period. Within this framework a
fundamental distinction is between studies
of disease incidence (i.e. the number of
new cases of disease over time) and
studies of disease prevalence (i.e. the
number of people with the disease at a
particular point in time). Studies involving
dichotomous outcomes can then be
classified according to two questions:
a. Are we studying studying incidence or
prevalence?;
b. Is there sampling on the basis of
outcome?
The responses to these two questions yield

four basic types of epidemiologic studies
(Morgenstern and Thomas, 1993; Pearce,
1998):
1.
2.
3.
4.
Incidence studies
Prevalence studies
Prevalence case-control studies
These four study types represent cells in a

two-way cross-classification (table 2.1).
Such studies may be conducted to describe
the occurrence of disease (e.g. to estimate
the burden of diabetes in the community
by conducting a prevalence survey), or to
estimate the effect of a particular exposure
on disease (e.g. to estimate whether the
incidence new cases of diabetes is greater
in people with a high fat diet than in
people with a low fat diet) in order to find
out how we can prevent the disease
occurring. In the latter situation we are
comparing the occurrence of disease in an
exposed group with that in a nonexposed group, and we are estimating the
effect of exposure on the occurrence of the
disease, while controlling for other known
causes of the disease.
Table 2.1
The four basic study types in studies involving a dichotomous health outcome
Study
outcome
Incidence
Sampling on outcome
-----------------------------------------------------------No
Yes
-----------------------------------------------------------Incidence studies
Prevalence Prevalence studies

Prevalence case-control studies
------------------------------------------------------------
21
Thus, we might conclude that lung

cancer is five times more common in
asbestos workers than in other workers,
even after we have controlled for
differences in age, gender, and
smoking. In some instances we may
have multiple categories of exposure
(high, medium, low) or individual
exposure scores, but we will start with
the simple situation in which individuals
are classified as exposed or nonexposed.
consider prevalence studies. In chapter

4, I then consider studies involving more
complex measurements of health status
(e.g. continuous lung function or blood
pressure measurements) and more
complex study designs (ecologic and
multilevel studies). As noted in chapter
1, the latter situation is perhaps the
norm, rather than the exception, when
conducting studies in the public health
context. However, for logical and
practical reasons I will first address the
simpler situation of a dichotomous
exposure (in individuals) and a
dichotomous health outcome measure.
In this chapter I discuss incidence

studies, and in the following chapter I
2.1 Incidence Studies
The most comprehensive approach

involves collecting data on the
experience of the entire source
population over the risk period in order
to estimate disease incidence (the
development of a disease for the first
time) or mortality (i.e. death which is a
particular type of incidence measure).
Figure 2.1 shows the experience of a
source population in which all persons
are followed from a particular date. For
simplicity, I will initially assume that the
source population is confined to persons
born in a particular year, i.e. a birth
cohort. In the hypothetical study shown
in figure 2.1, the outcome under study is
the "event" of developing a particular
disease. However, the concept of
incidence applies equally to studies of
other health events, such as
hospitalisation or death. The key feature
of incidence studies is that they involve
an event (e.g. developing a disease for
the first time) which occurs at a
particular point in time, rather than a
state (e.g. having a disease) which can
exist over an extended period of time.
22
In the hypothetical study shown in figure

2.1, people enter the study when they
are born, and some of them
subsequently develop disease. Of these,
some subsequently "lose" their disease
(although they may "regain" it at a later
date), and some have the condition all
their lives; some persons die from the
disease under study, but most eventually
die from another cause. However, the
information is "censored" since the study
cannot last indefinitely; i.e. follow-up
stops by a particular age, at which time
some members of the study population
have died, and some have been lost to
follow-up for other reasons (e.g.
emigration). For example, several people
in figure 2.1 were censored before
follow-up finished, either because they
died of the disease we were studying (if
we were studying the incidence of
disease, rather than deaths, they would
be censored as soon as they developed
the disease), they died of something
else, or because they were lost to
follow-up. Each person only contributes
person-time to the study until they are
censored, and after that we stop

counting them. This approach is followed
because we may not get a fair
comparison between the exposed and
the non-exposed groups if they have
been followed for different lengths of
time, e.g. if one group has many more
people lost to follow-up than the other
group.
However, the person-time approach
would be necessary even if no-one was
lost to follow up and both groups were
followed for the same length of time. For
example, consider a cohort study of
1,000 exposed and 1,000 non-exposed
people in which no-one was lost to
follow-up and everyone was followed
until they died. Assume also that the
exposure causes some deaths so the
exposed group, on the average, died at a
younger age than the non-exposed

group. If we only calculated the
percentage of people who died, then it
would be 100% in both groups, and we
would see no difference. However, if we
take into account the person-time
contributed by each group, then it
becomes clear that both groups had the
same number of deaths (1,000), but that
in the exposed group these deaths
occurred earlier and the person-time
contributed was therefore lower. Thus,
the average age at death would be lower
in the exposed group; to say the same
thing another way, the death rate
(deaths divided by person-years) would
be higher. To see this, we need to
consider not only how many people were
in each group, but how much persontime they contributed, i.e. how long they
were followed for.
Figure 2.1
Occurrence of disease in a hypothetical population followed from birth
Birth
End of Follow up
death from disease under study
at risk
other death
disease symptoms
lost to follow up
severe symptoms
23
Example 2.1
Martinez et al (1995)
studied 1246 newborns
in the Tucson, Arizona
area enrolled between
May 1980 and October
1984. Parents were
contacted shortly after
the children were born,
and completed a
questionnaire about their
history or respiratory
illness, smoking habits,
and education. Further
parental questionnaires
were completed during

the childs second year
of life and again at six
years. At the age of six
years, 51.5% of the
children had never
wheezed, 19.9% had
had at least one lower
respiratory tract illness
with wheezing during the
first three years of life
but had no wheezing at
six years, 15.0% had no
wheezing before the age
of three years but had

wheezing at six years,
and 13.7% had
wheezing both before
three years of age and
at six years. The authors
concluded that the
majority of infants with
wheezing have transient
conditions and do not
have increased risks of
asthma or allergies later
in life.
In some circumstances, a study might

be conducted to study the "natural
history" of a disease (e.g. diabetes). In
such clinical epidemiology studies,
the population (denominator) under
study comprises people who already
have a particular disease or condition,
and the goal is to ascertain which
factors affect the disease prognosis.
More typically, one might be interested
in a particular hypothesis about
developing disease, such as "a high
cholesterol diet increases the risk of
developing ischaemic heart disease".
In this situation, the population under
study comprises healthy individuals
and we are interested in factors that
determine who develops the disease
under study (and who doesnt). The
data generated by such an incidence
study involve comparing exposed
and non-exposed groups and are
similar to that generated by a
randomised controlled trial, except
that dietary exposure has not been
randomly allocated.
formally defined and enumerated (e.g.

a group of workers exposed to a
particular chemical) then the study
may be termed a cohort study or
follow-up study (Rothman and
Greenland, 1998) and the former
terminology will be used here.
Incidence studies also include studies
where the source population has been
defined but a cohort has not been
formally enumerated by the
investigator. Perhaps the most
common examples are descriptive
studies, e.g. of national death rates. In
fact, as Rothman and Greenland
(1998) note, no qualitative distinction
distinguishes descriptive variables
from the variables that are studied in
analytic studies of risk factors. Thus,
the distinction between descriptive
incidence studies and analytic
incidence studies is at best only a
distinction based on data source (e.g.
obtaining information from routine
records rather than collecting the
information specifically for the study).
Incidence studies ideally measure

exposures, confounders and outcome
times on all population members.
When the source population has been
Similarly, there is no fundamental

distinction between incidence studies
based on a broad population (e.g. all
workers at a particular factory, or all
24
0.0100 (or 1000 per 100,000 personyears).
persons living in a particular

geographical area) and incidence
studies involving sampling on the basis
of exposure, since the latter procedure
merely redefines the source population
(cohort) (Miettinen, 1985).
A second measure of disease

occurrence is the incidence proportion
or average risk which is the proportion
of people who experience the outcome
of interest at any time during the
follow-up period (the incidence
proportion is often called the
cumulative incidence, but the latter
term is also used to refer to
cumulative hazards (Breslow and Day,
1987)). Since it is a proportion it is
dimensionless, but it is necessary to
specify the time period over which it is
being measured. In this instance,
there were 952 incident cases among
the 10,000 people in the non-exposed
group, and the incidence proportion
(b/N0) was therefore 952/10,000 =
Measures of Disease Occurrence

I will briefly review the basic measures
of disease occurrence that are used in
incidence studies, using the notation
depicted in table 2.2 which shows the
findings of a hypothetical incidence
study of 20,000 persons followed for
10 years (statistical analyses using
these measures are discussed further
in chapter 12).
Three measures of disease incidence
are commonly used in incidence
studies.
0.0952 over the ten year follow-up

period. When the outcome of interest
is rare over the follow-up period (e.g.
an incidence proportion of less than
10%), then the incidence proportion is
approximately equal to the incidence
rate multiplied by the length of time
that the population has been followed
(in the example, this product is 0.1000
whereas the incidence proportion is
0.0952). I have assumed, for
simplicity, that no-one or was lost to
follow-up during the study period (and
therefore stopped contributing personyears to the study). However, as noted
above when this assumption is not
valid (i.e. when a significant proportion
of people have died or have been lost
to follow-up), then the incidence
proportion cannot be estimated
directly, but must be estimated
indirectly from the incidence rate
(which takes into account that followup was not complete) or from life
tables (which stratify on follow-up
time).
Perhaps the most common measure of

disease occurrence is the person-time
incidence rate (or hazard rate, force of
mortality or incidence density
(Miettinen, 1985)) which is a measure
of the disease occurrence per unit
population time, and has the reciprocal
of time as its dimension. In this
example (table 2.2), there were 952
cases of disease diagnosed in the nonexposed group during the ten years of
follow-up, which involved a total of
95,163 person-years; this is less than
the total possible person-time of
100,000 person-years since people
who developed the disease before the
end of the ten-year period were no
longer at risk of developing it, and
stopped contributing person-years at
that time (for simplicity I have ignored
the problem of people whose disease
disappears and then reoccurs over
time, and I have assumed that we are
studying the incidence of the first
occurrence of disease). Thus, the
incidence rate in the non-exposed
group (b/Y0) was 952/95,163 =
25
A third possible measure of disease

occurrence is the incidence odds
(Greenland, 1987) which is the ratio of
the number of people who experience
the outcome (b) to the number of
people who do not experience the
outcome (d). As for the incidence
proportion, the incidence odds is
dimensionless, but it is necessary to
specify the time period over which it is
being measured. In this example, the
incidence odds (b/d) is 952/9,048 =
0.1052. When the outcome is rare
over the follow-up period then the
incidence odds is approximately equal
to the incidence proportion. Once
again, if loss to follow-up is significant,
then the incidence odds cannot be
estimated directly, but must be
estimated indirectly from the incidence

rate (via the incidence proportion, or
via life-table methods). The incidence
odds is not very interesting or useful
as a measure of disease occurrence,
but it is presented here because the
incidence odds is used to calculate the
incidence odds ratio which is estimated
in certain case-control studies (see
below).
These three measures of disease
occurrence all involve the same
numerator: the number of incident
cases of disease (b). They differ in
whether their denominators represent
person-years at risk (Y0), persons at
risk (N0), or survivors (d).
Table 2.2
Findings from a hypothetical cohort study of 20,000 persons followed for 10 years
Exposed
Non-exposed
Ratio
-----------------------------------------------------------------------------------------------Cases
1,813 (a)
952 (b)
Non-cases
8,187 (c)
9,048 (d)
-----------------------------------------------------------------------------------------------10,000 (N0)
Initial population size
10,000 (N1)
-----------------------------------------------------------------------------------------------95,163 (Y0)
Person-years
90,635 (Y1)
-----------------------------------------------------------------------------------------------0.0100 (I0)
2.00
Incidence rate
0.0200 (I1)
0.0952 (R0)
1.90
Incidence proportion
0.1813 (R1)
(average risk)
0.1052 (O0)
2.11
Incidence odds
0.2214 (O1)
26
Measures of Effect in Incidence

Studies
Corresponding to these three measures
of disease occurrence, there are three
principal ratio measures of effect which
can be used in incidence studies. The
measure of interest is often the rate
ratio (incidence density ratio), the ratio
of the incidence rate in the exposed
group (a/Y1) to that in the non-exposed
group (b/Y0). In the example in table
2.2, the incidence rates are 0.02 per
person-year in the exposed group and
0.01 per person-year in the non-exposed
group, and the rate ratio is therefore
2.00.
A second commonly used effect measure
is the risk ratio (incidence proportion
ratio or cumulative incidence ratio) which
is the ratio of the incidence proportion in
the exposed group (a/N1) to that in the
non-exposed group (b/N0). In this
example, the risk ratio is 0.1813/0.0952
= 1.90. When the outcome is rare over
the follow-up period the risk ratio is
approximately equal to the rate ratio.
A third possible effect measure is the
incidence odds ratio which is the ratio of
the incidence odds in the exposed group
(a/c) to that in the non-exposed group
(b/d). In this example the odds ratio is
0.2214/0.1052 = 2.11. When the
outcome is rare over the study period
the incidence odds ratio is approximately
equal to the incidence rate ratio.
These three multiplicative effect
measures are sometimes referred to
under the generic term of relative risk.
Each involves the ratio of a measure of
disease occurrence in the exposed group
27
to that in the non-exposed group. The

various measures of disease occurrence
all involve the same numerators
(incident cases), but differ in whether
their denominators are based on personyears, persons, or survivors (people who
do not develop the disease at any time
during the follow-up period). They are all
approximately equal when the disease is
rare during the follow-up period (e.g. an
incidence proportion of less than 10%).
However, the odds ratio has been
severely criticised as an effect measure
(Greenland, 1987; Miettinen and Cook,
1981), and has little intrinsic meaning in
incidence studies, but it is presented
here because it is the standard effect
measure in incidence case-control
studies (see below).
Finally, it should be noted that an
analogous approach can be used to
calculate measures of effect based on
differences rather than ratios, in
particular the rate difference and the risk
difference. Ratio measures are usually of
greater interest in etiologic research,
because they have more convenient
statistical properties, and it is easier to
assess the strength of effect and the
possible role of various sources of bias
when using ratio measures (Cornfield et
al, 1951). Thus, I will concentrate on the
use of ratio measures in the remainder
of this text. However, other measures
(e.g. risk difference, attributable
fraction) may be of value in certain
circumstances, such as evaluating the
public health impact of a particular
exposure, and I encourage readers to
consult standard texts for a
comprehensive review of these measures
(e.g. Rothman and Greenland, 1998).
2.2 Incidence Case-Control Studies
Incidence studies are the most

comprehensive approach to studying the
causes of disease, since they use all of
the information about the source
population over the risk period.
However, they are very expensive in
terms of time and resources. For
example, the hypothetical study
presented in table 2.2 would involve
enrolling 20,000 people and collecting
exposure information (on both past and
present exposure) for all of them. The
same findings can be obtained more
efficiently by using a case-control
design.
same population over the same period

(the possible methods of sampling
controls are described below).
Table 2.3 shows the data from a
hypothetical case-control study, which
involved studying all of the 2,765
incident cases which would have been
identified in the full incidence study, and
a sample of 2,765 controls (one for each
case). Such a case-control study would
achieve the same findings as the full
incidence study, but would be much
more efficient, since it would involve
ascertaining the exposure histories of
5,530 people (2,765 cases and 2,765
controls) rather than 20,000. When the
outcome under study is very rare, an
even more remarkable gain in efficiency
can be achieved with very little reduction
in the precision of the effect estimate.
An incidence case-control study involves

studying all (or a sample) of the incident
cases of the disease that occurred in the
source population over the risk period,
and a control group sampled from the
Table 2.3
Findings from a hypothetical incidence case-control study based on the cohort in table 2.2
Exposed
Non-exposed Odds Ratio
----------------------------------------------------------------------------------------------------Cases
1,813 (a)
952 (b)
Controls: from survivors
(cumulative sampling)
1,313 (c)
1,452 (d)
2.11
from source population
(case-cohort sampling)
1,383 (c)
1,383 (d)
1.90
from person-years
(density sampling)
1,349 (c)
1,416 (d)
2.00
28
Measures of Effect in Incidence

Case-Control Studies
In case-control studies, the relative risk
is estimated using the odds ratio.
Suppose that a case-control study is
conducted in the study population shown
in table 2.2; such a study might involve
all of the 2,765 incident cases and a
group of 2,765 controls (table 2.3). The
effect measure which the odds ratio
obtained from this case-control study will
estimate depends on the manner in
which controls are selected. Once again,
there are three main options (Miettinen,
1985; Pearce, 1993; Rothman and
Greenland, 1998).
One option, called cumulative (or
cumulative incidence) sampling, is to
select controls from those who do not
experience the outcome during the
follow-up period, i.e. the survivors
(those who did not develop the disease
at any time during the follow-up period).
In this instance, the ratio of exposed to
non-exposed controls will estimate the
exposure odds (c/d = 8178/9048 =
1313/1452) of the survivors, and the
odds ratio obtained in the case-control
study will therefore estimate the
incidence odds ratio in the source
population over the study period (2.11).
Early presentations of the case-control
approach usually assumed this context
(Cornfield, 1951), and it was emphasised
that the odds ratio was approximately
equal to the risk ratio when the disease
was rare.
It was later recognised that controls can
be sampled from the entire source
population (those at risk at the
beginning of follow-up), rather than just
from the survivors (those at risk at the
end of follow-up). This approach which
was previously used by Thomas (1972)
and Kupper et al (1975), has more
29
recently been termed case-cohort

sampling (Prentice, 1986), or case-base
sampling (Miettinen, 1982). In this
instance, the ratio of exposed to nonexposed controls will estimate the
exposure odds in the source population
of persons at risk at the start of followup (N1/N0 = 10000/10000 =
1383/1383), and the odds ratio obtained
in the case-control study will therefore
estimate the risk ratio in the source
In this instance the method of calculation
of the odds ratio is the same as for any
other case-control study, but minor
changes are needed in the standard
methods for calculating confidence
intervals and p-values to take into
account that some cases may also be
selected as controls (Greenland, 1986).
The third approach is to select controls
longitudinally throughout the course of
the study (Sheehe, 1962; Miettinen,
1976); this is sometimes described as
risk-set sampling (Robins et al, 1986),
sampling from the study base (the
person-time experience) (Miettinen,
1985), or density sampling (Kleinbaum
et al, 1982). In this instance, the ratio of
exposed to non-exposed controls will
estimate the exposure odds in the
person-time (Y1/Y0 = 90635/95613 =
1349/1416), and the odds ratio obtained
in the case-control study will therefore
estimate the rate ratio in the study
Case-control studies have traditionally
been presented in terms of cumulative
sampling (e.g. Cornfield, 1951), but
most case-control studies actually
involve density sampling (Miettinen,
1976), often with matching on a time
variable such as calendar time or age,
and therefore estimate the rate ratio
without the need for any rare disease
assumption (Sheehe, 1962; Miettinen,
1976; Greenland and Thomas, 1982).
Example 2.2
Gustavsson et al (2001)
studied the risk of
myocardial infarction
from occupational
exposure to motor
exhaust, other
combustion products,
organic solvents, lead,
and dynamite. They
identified first-time,
nonfatal myocardial
infarctions among men
and women aged 45-70
years in Stockholm
County from 1992-1994.
They selected controls
from the general
population living in the
same County during the
same period (i.e. density
matching), matched for
sex, age, year, and
hospital catchment area.
The odds ratio
(estimating the rate
ratio) of myocardial
infarction was 2.11

(95% CI 1.23-3.60)
among those highly
exposed occupationally,
and 1.42 (95% CI 1.051.92) in those
moderately exposed,
compared with persons
not occupationally
exposed to combustion
products from organic
material.
Summary
When a dichotomous outcome is under

study (e.g. being alive or dead, or
having or not having a disease) a
fundamental distinction is between
studies of incidence and studies of
prevalence. Thus, four main types of
studies can be identified: incidence
studies, incidence case-control studies,
prevalence studies, and prevalence casecontrol studies (Morgenstern and
Thomas, 1993; Pearce, 1998). These
various study types differ according to
whether they involve incidence or
prevalence data and whether or not they
involve sampling on the basis of the
outcome under study. Incidence studies
involve collecting and analysing data on
30
the exposure and disease experience of

the entire source population. They may
resemble randomized trials, but they
may involve additional problems of
confounding because exposure has not
been randomly assigned. The other
potential study designs all involve
sampling from the source population,
and therefore may include additional
biases arising from the sampling process
(chapter 6). In particular, incidence
case-control studies involve sampling on
the basis of outcome, i.e. they usually
involve all incident cases generated by
the source population and a control
group (of non-cases) sampled at random
from the source population.
References
Breslow NE, Day NE (1987). Statistical

methods in cancer research. Vol II:
The analysis of cohort studies. Lyon,
France: IARC.
useful in estimating relative risk. J Am

Stat Assoc 70:524-8.
Martinez FD, Wright AJ, Taussig LM, et al
(1995). Asthma and wheezing in the
first six years of life. New Engl J Med
332: 133-8.
Checkoway H, Pearce N, Kriebel D

(2004). Research methods in
occupational epidemiology. 2nd ed.
New York: Oxford University Press.
Miettinen OS (1976). Estimability and

estimation in case-referent studies.
Cornfield J (1951). A method of

estimating comparative rates from
clinical data: applications to cancer of
the lung, breast and cervix. JNCI 11:
1269-75.
Miettinen OS, Cook EF (1981).

Confounding: essence and detection.
Miettinen O (1982). Design options in
epidemiologic research: an update.
Scand J Work Environ Health 8(suppl
1): 7-14.
Greenland S (1986). Adjustment of risk

ratios in case-base studies (hybrid
epidemiologic designs). Stat Med 5:
579-84.
Miettinen OS (1985). Theoretical

epidemiology. New York: Wiley.
Greenland S (1987). Interpretation and

choice of effect measures in
epidemiologic analyses. Am J
Epidemiol 125: 761-8.
Morgenstern H, Thomas D (1993).

Principles of study design in
environmental epidemiology. Environ
Health Perspectives 101: S23-S38.
Greenland S, Thomas DC (1982). On the

need for the rare disease assumption
in case-control studies. Am J
Gustavsson P, Plato N, Hallqvist J, et al
(2001). A population-based casereferent study of myocardial infarction
and occupational exposure to motor
exhaust, other combustion products,
organic solvents, lead and dynamite.
Kleinbaum DG, Kupper LL, Morgenstern
H (1982). Epidemiologic research.
Principles and quantitative methods.
Belmont, CA: Lifetime Learning
Publications.
Pearce N (1993). What does the odds

ratio estimate in a case-control study?
Pearce N (1998). The four basic
epidemiologic study types. J
Epidemiol Biostat 3: 171-7.
Prentice RL (1986). A case-cohort design
for epidemiologic cohort studies and
disease prevention trials. Biometrika
73: 1-11.
Robins JM, Breslow NE, Greenland S
(1986). Estimation of the MantelHaenszel variance consistent with
both sparse-data and large-strata
limiting models. Biometrics 42: 31123.
Kupper LL, McMichael AJ, Spirtas R

(1975). A hybrid epidemiologic design
31

Sheehe PR (1962). Dynamic risk analysis
of matched pair studies of disease.
Biometrics 18: 323-41.
32
Thomas DB (1972). The relationship of

oral contraceptives to cervical
carcinogenesis. Obstet Gynecol 40:
508-18.
CHAPTER 3. Prevalence Studies

Incidence studies are ideal for studying

events such as mortality or cancer
incidence, since they involve collecting
and analysing all of the relevant
information on the source population and
we can get better information on when
exposure and disease occurred.
However, incidence studies involve
lengthy periods of follow-up and large
resources, in terms of both time and
funding, and it may be difficult to
identify incident cases of non-fatal
chronic conditions such as diabetes.
Thus, in some settings (e.g. some
developing countries) and/or for some
conditions (e.g. chronic non-fatal

disease) prevalence studies are the only
option. Furthermore, in some instances
we may be more interested in factors
which affect the current burden of
disease in the population. Consequently,
although incidence studies are usual
preferable, there is also an important
role for prevalence studies, both for
practical reasons, and because such
studies enable the assessment of the
level of morbidity and the population
disease burden for a non-fatal
condition.
3.1 Prevalence Studies
The term prevalence denotes the

number of cases of the disease under
study existing in the source population at
a particular time. This can be defined as
point prevalence estimated at one point
in time, or period prevalence which
denotes the number of cases that
existed during some time interval (e.g.
one year).
The prevalence is a proportion, and the
statistical methods for calculating a
confidence interval for the prevalence
are identical to those presented above
for calculating a confidence interval for
the incidence proportion (chapter 12).
a specific population with that in other

communities or countries. This may be
done, for example, in order to discover
differences in disease prevalence and to
thus suggest possible risk factors for the
disease. These further studies may
involve testing specific hypotheses by
comparing prevalence in subgroups of
people who have or have not been
exposed to a particular risk factor (e.g.
as passive smoking) in the past.
Prevalence studies often represent a
considerable saving in resources
compared with incidence studies, since it
is only necessary to evaluate disease
prevalence at one point in time, rather
than continually searching for incident
cases over an extended period of time.
On the other hand, this gain in efficiency
In some instances, the aim of a

prevalence study may simply be to
compare the disease prevalence among
33
is achieved at the cost of greater risk of

biased inferences, since it may be much
more difficult to understand the temporal
relationship between various exposures
and the occurrence of disease. For
example, an exposure that increases the
risk of death in people with pre-existing
chronic heart disease will be negatively

associated with the prevalence of heart
disease (in people who are alive!), and
will therefore appear to be protective
against heart disease in a prevalence
study.
Example 3.1
The International Study
of Asthma and Allergies
in Childhood (ISAAC)
(Asher et al, 1995;
Pearce et al, 1993)
involved a simple Phase
I global asthma
symptom prevalence
survey and a more indepth Phase II survey.
The emphasis was on
obtaining the maximum
possible participation
across the world in order
to obtain a global
overview of childhood
asthma prevalence, and
the Phase I
questionnaire modules
were designed to be
simple and to require
minimal resources to
administer. In addition,
a video questionnaire
involving the audiovisual presentation of
clinical signs and
symptoms of asthma
was developed in order
to minimise translation
problems. The
population of interest
was schoolchildren aged
6-7 years and 13-14
years within specified

geographical areas. The
older age-group was
chosen to reflect the
period when morbidity
from asthma is common
and to enable the use of
self-completed
questionnaires. The
younger age-group was
chosen to give a
reflection of the early
childhood years, and
involves parentcompletion of
questionnaires. The
Phase I findings,
involving more than
700,000 children,
showed striking
international differences
in asthma symptom
prevalence (ISAAC
Steering Committee,
1998a, 1998b). Figure
3.1 shows the findings
for current wheeze (i.e.
wheeze in the previous
12 months). There are a
number of interesting
features of the figure: (i)
there is a particularly
high prevalence of
reported asthma
34
symptoms in Englishspeaking countries; (ii)

centres in Latin America
also had particularly high
symptom prevalence;
(iii) there is also high
asthma prevalence in
Western Europe, with
lower prevalences in
Eastern and Southern
Europe - for example,
there is a clear
Northwest-Southeast
gradient within Europe,
with the highest
prevalence in the world
being in the United
Kingdom, and some of
the lowest prevalences
in Albania and Greece;
(iv) Africa and Asia
generally showed
relatively low asthma
prevalence. These
striking findings call into
question many of the
established theories of
asthma causation, and
have played a major role
in the development of
new theories of asthma
causation in recent years
(Douwes and Pearce,
2003).
Figure 3.1
Twelve month period prevalence of asthma symptoms in 13-14 year old children in
Phase I of the International Study of Asthma and Allergies in Childhood (ISAAC)
Source: ISAAC Steering Committee (1998b)
20%
10 to <20%
5 to <10%
<5%
35
Measures of Effect in Prevalence Studies

Figure 3.2 shows the relationship
between incidence and prevalence of
disease in a steady state population.
Assume that the population is in a
steady state (stationary) over time (in
that the numbers within each
subpopulation defined by exposure,
disease and covariates do not change
with time) this usually requires that
incidence rates and exposure and
disease status are unrelated to the
immigration and emigration rates and
population size - and that average

disease duration (D) does not change
over time. Then, if we denote the
prevalence of disease in the study
population by P, the prevalence odds is
equal to the incidence rate (I) times the
average disease duration (Alho, 1992):
P
------ = ID
(1-P)
Figure 3.2
Relationship between prevalence and incidence in a steady state population
P/(1-P) = I x D
P=prevalence
I=incidence
D=duration
N=population
N(1-p) x I
Asthma
cases
[NP]
Non-asthmatic
[N(1-P)]
NP/D
Now suppose that we compare two

populations (indexed by 1=exposed and
0=non-exposed) and that both satisfy
the above conditions. Then, the
prevalence odds is directly proportional
to the disease incidence, and the
prevalence odds ratio (POR) satisfies the
equation:
POR = [P1/(1-P1)]/[P0/(1-P0)] = I1D1/I0D0

An increased prevalence odds ratio may
thus reflect the influence of factors that
increase the duration of disease, as well
as those that increase disease incidence.
However, in the special case where the
36
average duration of disease is the same

in the exposed and non-exposed groups
(i.e. D1 = D0), then the prevalence odds
ratio satisfies the equation:
difference in prevalence between two

groups could entirely depend on
differences in disease duration (e.g.
because of factors which prolong or
exacerbate symptoms) rather than
differences in incidence. Changes in
incidence rates, disease duration and
population sizes over time can also bias
the POR away from the rate ratio, as can
migration into and out of the population
at risk or the prevalence pool.
POR = I1/I0
i.e. under the above assumptions, the
prevalence odds ratio directly estimates
the incidence rate ratio (Pearce, 2004).
However, it should be emphasised that
prevalence depends on both incidence
and average disease duration, and a
Table 3.1
Findings from a hypothetical prevalence study of 20,000 persons
Exposed
Non-exposed
Ratio
-------------------------------------------------------------------------------------Cases
909 (a)
476 (b)
Non-cases
9,091 (c)
9,524 (d)
-------------------------------------------------------------------------------------10,000 (N0)
Total population
10,000 (N1)
-------------------------------------------------------------------------------------0.0476 (P0)
1.91
Prevalence
0.0909 (P1)
0.0500 (O0)
2.00
Prevalence odds
0.1000 (O1)
Table 3.1 shows data from a

prevalence study of 20,000 people.
This is based on the incidence study
represented in table 2.2 (chapter 2),
with the assumptions that, for both
populations, the incidence rate and
population size is constant over time,
that the average duration of disease is
five years, and that there is no
migration of people with the disease
into or out of the population (such
assumptions may not be realistic, but
are made here for purposes of
illustration). In this situation, the
number of cases who "lose" the
disease each year is balanced by the
number of new cases generated from

the source population. For example, in
the non-exposed group, there are 476
prevalent cases, and 95 (20%) of
these "lose" their disease each year;
this is balanced by the 95 people who
develop the disease each year (0.0100
of the susceptible population of 9524
people). With the additional
assumption that the average duration
of disease is the same in the exposed
and non-exposed groups, then the
prevalence odds ratio (2.00) validly
estimates the incidence rate ratio (see
table 2.2).
37
3.2 Prevalence Case-Control Studies
Just as an incidence case-control study

can be used to obtain the same findings
as a full incidence study, a prevalence
case-control study can be used to obtain
the same findings as a full prevalence
study in a more efficient manner.
Measures of Effect in Prevalence

Case-Control Studies
For example, in a prevalence study,

obtaining exposure information may be
difficult or costly, e.g. if it involves
lengthy interviews, or expensive testing
of biological samples. In this situation, a
considerable gain in efficiency can be
achieved by only obtaining exposure
information on the prevalent cases and a
sample of controls selected at random
from the non-cases, rather than
collecting exposure information for
everyone in the prevalence study.
Suppose that a nested case-control

study is conducted in the study
population (table 3.1), involving all of
the 1,385 prevalent cases and a group
of 1,385 controls (table 3.2). The usual
approach is to select controls from the
non-cases. The ratio of exposed to nonexposed controls will then estimate the
exposure odds (b/d) of the non-cases,
and the odds ratio obtained in the
prevalence case-control study will
therefore estimate the prevalence odds
ratio in the source population (2.00),
which in turn estimates the incidence
rate ratio provided that the
assumptions described above are
satisfied in the exposed and nonexposed populations.
Table 3.2
Findings from a hypothetical prevalence case-control study based on the population
represented in table 3.1
Exposed
Non-exposed
Ratio
-------------------------------------------------------------------------------------Cases
909 (a)
476 (b)
Controls
676 (c)
709 (d)
-------------------------------------------------------------------------------------0.67 (O0)
2.00
Prevalence odds
1.34 (O1)
---------------------------------------------------------------------------------
38
Example 3.2
Studies of congenital
malformations usually
involve estimating the
prevalence of
malformations at birth
(i.e. this is a prevalence
rather than an incidence
measure). Garcia et al
(1999) conducted a
(prevalence) case-control
study of occupational
exposure to pesticides and

congenital malformations
in Comunidad Valenciana,
Span. A total of 261 cases
and 261 controls were
selected from those
infants born in eight
public hospitals during
1993-1994. For mothers
who were involved in
agricultural activities in
the month before

conception and the first
trimester of pregnancy,
the adjusted prevalence
odds ratio for congenital
malformations was 3.2
(95% CI 1.1-9.0). There
was no such association
with paternal agricultural
work
Summary
When a dichotomous outcome is under

study (e.g. being alive or dead, or
having or not having a disease) four
main types of studies can be identified:
incidence studies, incidence case-control
studies, prevalence studies, and
prevalence case-control studies
(Morgenstern and Thomas, 1993;
Pearce, 1998). Prevalence studies
involve measuring the prevalence of the
disease in the source population at a
particular time, rather than the incidence

of the disease over time. Prevalence
case-control studies involve sampling on
the basis of outcome, i.e. they usually
involve all prevalent cases in the source
population and a control group (of noncases) sampled from the source
population.
39
References
Alho JM (1992). On prevalence,

incidence, and duration in general
stable populations. Biometrics 48:
587-92.
prevalence of asthma symptoms:

International Study of Asthma and
Allergies in Childhood (ISAAC). Eur
Respir J 12: 315-35.
Asher I, Keil U, Anderson HR, et al

(1995). International study of asthma
and allergies in childhood (ISAAC):
rationale and methods. Eur Resp J 8:
483-91.
Morgenstern H, Thomas D (1993).

Principles of study design in
environmental epidemiology. Environ
Health Perspectives 101: S23-S38.
Pearce N (1998). The four basic
epidemiologic study types. J Epidemiol
Biostat 3: 171-7.
Douwes J, Pearce N (2003). Asthma and

the Westernization package. Int J
Epidemiol 31: 1098-1102.
Pearce N (2004). Effect measures in

prevalence studies. Environmental
Health Perspectives 2004; 112: 104750.
Garcia AM, Fletcher T, Benavides FG,

Orts E (1999). Parental agricultural
work and selected congenital
malformations. Am J Epidemiol 149:
64-74.
ISAAC Steering Committee (1998a).
Worldwide variation in prevalence of
symptoms of asthma, allergic
rhinoconjunctivitis and atopic eczema:
ISAAC. Lancet 351: 1225-32.
ISAAC Steering Committee (1998b).
Worldwide variations in the
40
Pearce NE, Weiland S, Keil U, et al

(1993). Self-reported prevalence of
asthma symptoms in children in
Australia, England, Germany and New
Zealand: an international comparison
using the ISAAC protocol. Eur Resp J
6: 1455-61.
CHAPTER 4. More Complex Study Designs

In the previous two chapters I reviewed

the possible study designs for the simple
situation where individuals are exposed
to a particular risk factor (e.g. a
particular chemical) and when a
dichotomous outcome is under study
(e.g. being alive or dead, or having or
not having a particular disease). I now

consider studies involving other axes of
classification, continuous measurements
of health status (e.g. continuous lung
function or blood pressure
measurements) and more complex study
designs (ecologic and multilevel studies).
4.1 Other Axes of Classification
The four basic study types discussed in

chapters 2 and 3 are defined in terms of:
(a) the type of outcome under study
(incidence or prevalence); and (b)
whether there is sampling on the basis of
outcome. They do not involve any
consideration of the nature of the
exposure data. This provides additional
axes of classification.
Continuous Exposure Data
Firstly, it should be noted that in
discussing the above classification we
have assumed that exposure is
dichotomous (i.e. study participants
are exposed or not exposed). In
reality, there may be multiple
exposure categories (e.g. high,
medium and low exposure), or
exposure may be measured as a
continuous variable (see chapter 8).
However, although this requires minor
changes to the data analysis (see
chapter 12), it does not alter the fourfold categorisation of study design
options presented above.
41
The Timing of Collection Of Exposure

Information
Perhaps the feature that has received
the most attention in various
classification schemes is the timing of
the collection of exposure information.
This has dominated discussions of
directionality, particularly with regard
to case-control studies. In fact, for all of
the four basic study types, exposure
information can be collected
prospectively or retrospectively. For
example, an incidence study or incidence
case-control study of occupational cancer
may collect exposure information
prospectively, or use historical
information that was collected
prospectively but abstracted
retrospectively by the investigator (e.g.
occupational hygiene monitoring
records), or use exposure information
that was collected retrospectively (e.g.
recall of duration and intensity of
pesticide use). An unfortunate aspect of
some discussions of the merits of casecontrol studies is that they have often
been labelled as retrospective studies,

when this is in fact not an inherent part
of their design. The potential problem
of bias due to exposure ascertainment
errors (e.g. recall bias) arises from the
retrospective collection of exposure
information, irrespective of whether the
study is an incidence, incidence casecontrol, prevalence, or prevalence casecontrol study.
not fundamental to the classification of

study types since, as with issues of
directionality, they do not affect the
parameterization of the exposureoutcome association.
The Level of Measurement of
Exposure
A third additional axis of classification
involves the level of measurement of
exposure. In particular, in ecologic
studies exposure information may be
collected on a group rather than on
individuals (e.g. average level of meat
consumption) although others may still
be available for individuals (e.g. age,
gender). This situation is discussed in
section 4.3.
Sources of Exposure Information

Another set of issues that occur in
practice involve the sources of exposure
information (e.g. routine records, jobexposure-matrices, questionnaires,
biological samples). However, as noted
above, these issues are important in
understanding sources of bias but are
4.2 Continuous Outcome Measures
Cross-Sectional Studies
In chapters 2 and 3, the health outcome
under study was a state (e.g. having or
not having hypertension). Studies could
involve observing the incidence of the
event of acquiring the disease state (e.g.
the incidence of being diagnosed with
hypertension), or the prevalence of the
disease state (e.g. the prevalence of
hypertension). More generally, the
health state under study may have
multiple categories (e.g. nonhypertensive, mild hypertension,
moderate hypertension, severe
hypertension) or may be represented by
a continuous measurement (e.g. blood
pressure). Since these measurements
are taken at a particular point in time,
such studies are often referred to as
cross-sectional studies. Prevalence
studies (see chapter 3) are a subgroup
42
of cross-sectional studies in which the

disease outcome is dichotomous.
Although cross-sectional studies are
sometimes described as studies in which
exposure and disease information is
collected at the same point in time (e.g.
Kramer and Boivin, 1988; Last 1988),
this is not in fact an inherent feature of
such studies. In most cross-sectional
studies (including prevalence studies),
information on exposure will be
physically collected by the investigator at
the same time that information on
disease is collected. Nonetheless,
exposure information may include
factors that do not change over time
(e.g. gender) or change in a predictable
manner (e.g. age) as well as factors that
do change over time. The latter may
have been measured at the time of data
collection (e.g. current levels of airborne
dust exposure), or at a previous time

(e.g. from historical records on past
exposure levels) or integrated over time.
The key feature of cross-sectional
studies is that they involve studying
disease at a particular point in time.
Exposure information can be collected
for current and/or historical exposures,
and a wide variety of exposure
assessment methods can be used within
this general category of study (these are
discussed further in chapter 8).
Measures of Effect in Cross-Sectional

Studies
In a simple cross-sectional study
involving continuous outcome data, the
basic methods of statistical analysis
involve comparing the mean level of the
outcome in exposed and nonexposed groups, e.g. the mean levels of
blood pressure in exposed and nonexposed people. Standard statistical
methods of analysis for comparing
means (perhaps after a suitable
transformation to normalise the data),
and calculating confidence intervals (and
associated p-values) for differences
between means, can be used to analyse
such studies (see chapter 12). More
generally, regression methods can be
used to model the relationship between
the level of exposure (measured as a
continuous variable) and the level of the
outcome measure (also measured as a
continuous variable) (e.g. Armitage et al,
2002).
Just as a prevalence case-control study

can be based on a prevalence survey, a
cross-sectional study can also involve
sampling on the basis of the disease
outcome. For example, a cross-sectional
study of bronchial hyperresponsiveness
(BHR) could involve testing all study
participants for BHR and then
categorising the test results into severe
BHR, mild BHR, and no BHR, and then
obtaining exposure information on all
severe BHR cases and from random
samples of the other two groups.
Example 4.1
Nersesyan et al (2001)
studied chromosome
aberrations in
lymphocytes of persons
exposed to an
earthquake in Armenia.
They collected blood
samples from 41 victims
of the 1988 earthquake
and from 47 reference
blood donors. Those
exposed to the
earthquake had a higher
proportion of cells with
chromosome aberrations
(3.1% (SD 2.1)) than
the referents (1.7% (SD
1.3)). The differences
persisted when the data
were adjusted for age
and gender. The authors
suggested that the
43
findings could be due

either to environmental
exposures related to the
earthquake or to severe
psychogenic stress.
They noted that studies
in wild rodents living in
seismic regions have
shown similar findings.
Longitudinal Studies
Longitudinal studies (cohort studies)
involve repeated observation of study
participants over time (Pearce et al,
1998). Incidence studies (chapter 2) are
a subgroup of longitudinal study in which
the outcome measure is dichotomous.
More generally, longitudinal studies may
involve repeated assessment of
categorical or continuous outcome
measures over time (e.g. a series of
linked cross-sectional studies in the
same population). They thus can involve
incidence data, a series of prevalence
surveys, or a series of cross-sectional
continuous outcome measures.
General longitudinal studies
A simple longitudinal study may involve
comparing the disease outcome
measure, or more usually changes in the
measure over time, between exposed
and non-exposed groups. For example,
rather than comparing the incidence of
hypertension (as in an incidence study),
or the prevalence at a particular time (as

in a prevalence study), or the mean
blood pressure at a particular point in
time (as in a cross-sectional study), a
longitudinal study might involve
measuring baseline blood pressure in
exposed and non-exposed persons and
then comparing changes in mean blood
pressure (i.e. the change from the
baseline measure) over time in the two
groups. Such a comparison of means can
be made using standard statistical
methods for comparing means and
calculating confidence intervals and
associated p-values for the difference
between the means (Armitage et al,
2002; Beaglehole et al, 1993). More
generally, regression methods (Diggle et
al, 1994) might be used to model the
relationship between the level of
exposure (measured as a continuous
variable) and the level of the outcome
measure (also measured as a continuous
variable, in this instance the change in
FEV1).
Example 4.2
The Tokelau Island
Migrant Study (Wessen
et al, 1992) examined
the effects of migration
on development of
Western diseases within
a population which
initially had a low
incidence of these
conditions. Round I
surveys were conducted
in the Tokelau Islands in
1968/1971, and these
were repeated (Round

II) in both the Tokelau
Islands (1976) and in
New Zealand (1975-7).
A regression analysis of
changes in blood
pressure between Round
I and Round II (adjusted
for age) found that the
mean annual increase in
blood pressure was
greater in those who had
migrated than in those
44
who had not: the mean

differences were 1.43 for
systolic and 1.15 for
diastolic in men, and
0.66 and 0.46
respectively in women.
These differences in
rates of annual increase
in blood pressure were
maintained in
subsequent surveys in
men, but not in women.
Time series
One special type of longitudinal study is
that of time series comparisons in
which variations in exposure levels and
symptom levels are assessed over time
with each individual serving as their own
control. Thus, the comparison of
exposed and non-exposed involves
the same persons evaluated at different
times, rather than different groups of
persons being compared (often at the
same time) as in other longitudinal
studies. The advantage of the time series
approach is that it reduces or eliminates
confounding (see chapter 6) by factors
which vary among subjects but not over
time (e.g. genetic factors), or whose day
to day variation is unrelated to the main
exposure (Pope and Schwartz, 1996). On
the other hand, time series data often
require special statistical techniques
because any two factors that show a
time trend will be correlated (Diggle et
al, 1994). For example, even a threemonth study of lung function in children
will generally show an upward trend due
to growth, as well as learning effects
(Pope and Schwartz, 1996). A further
problem is that the change in a measure
over time may depend on the baseline
value, e.g. changes in lung function over
time may depend on the baseline level
(Schouten and Tager, 1996).
Time series can involve dichotomous
(binary) data, continuous data, or
counts of events (e.g. hospital
admissions) (Pope and Schwartz, 1996),
and the changes in these values may be
45
measured over minutes, hours, days,

weeks, months or years (Dockery and
Brunekreef, 1996). In many instances,
such data can be analysed using the
standard statistical techniques outlined
above. For example, a study of daily
levels of air pollution and asthma
hospital admission rates can be
conceptualised as a study of the
incidence of hospital admission in a
population exposed to air pollution
compared with that in a population not
exposed to air pollution. The key
difference is that only a single population
is involved, and it is regarded as
exposed on high pollution days and as
non-exposed on low pollution days.
Provided that the person-time of
exposure is appropriately defined and
assessed, then the basic methods of
analysis are not markedly different from
other studies involving comparisons of
exposed and non-exposed groups.
However, the analysis of time series may
be complicated because the data for an
individual are not independent and serial
data are often correlated (Sherrill and
Viegi, 1996), i.e. the value of a
continuous outcome measure on a
particular day may be correlated with the
value for the previous day.
Furthermore, previous exposure may be
as relevant as, or more relevant than,
current exposure. For example, the
effects of air pollution may depend on
exposure on preceding days as well as
on the current day (Pope and Schwartz,
1996).
Example 4.3
Hoek et al (2001)
studied associations
between daily variations
in air pollution and
mortality in The
Netherlands during
1986-1994. The authors
found (table 4.1) that
heart disease deaths
were increased during
periods with high levels
of ozone, black smoke,
particulate matter 10
microns in diameter
(PM10), carbon monoxide
(CO), sulfur dioxide
(SO2) and nitrogen

dioxide (NO2). As with
previously published
studies, the effects
depended on exposures
on the previous few
days, and were weaker
when the analysis only
considered exposures on
a particular day without
using any lag period
(Schwartz, 2000). The
authors reported that
deaths due to heart
failure, arrhythmia,
cerebrovascular causes
and thrombocytic causes

were more strongly
associated with air
pollution than were
cardiovascular deaths in
general. In particular,
heart failure deaths,
which made up 10% of
all cardiovascular
deaths, were responsible
for about 30% of the
excess cardiovascular
deaths related to air
pollution from particular
matter, SO2, CO, and
NO2.
Table 4.1
Relative risks* (and 95% CIs) of cardiovascular disease mortality associated with air
pollution concentrations in the Netherlands
Pollutant
Total CVD mortality
Heart failure mortality
-----------------------------------------------------------------------------------------------Ozone (1 day lag)
1.055 (1.032-1.079)
1.079 (1.009-1.154)
Black smoke (7 day mean)
1.029 (1.013-1.046)
1.081 (1.031-1.134)
PM10 (7 day mean)
1.012 (0.984-1.041)
1.036 (0.960-1.118)
CO (7 day mean)
1.026 (0.993-1.060)
1.109 (1.012-1.216)
SO2 (7 day mean)
1.029 (1.012-1.046)
1.098 (1.043-1.156)
NO2(7 day mean)
1.023 (1.009-1.036)
1.064 (1.024-1.106)
-----------------------------------------------------------------------------------------------*Relative risks per 1 to 99th percentile pollution difference

Relative risks per 150 g/m3 for ozone (8-hour maximum of the previous
Day), per 120 g/m3 for CO, per 80 g/m3 for PM10, per 30 g/m3
for NO2, and per 40 /m3 for black smoke and SO2, all as 7-day moving averages
Source: Hoek et al (2001)
46
4.3 Ecologic and Multilevel Studies
The basic study designs described in

chapters 2 and 3 involved the
measurement of exposure and disease
in individuals. In this section, I
consider more complex study designs
in which exposures are measured in
populations instead of, or in addition
to, individuals.
ecologic fallacy (see below) can occur

in that factors that are associated with
national disease rates may not be
associated with disease in individuals
(Greenland and Robins, 1994). Thus,
ecologic studies have recently been
regarded as a relic of the premodern phase of epidemiology before
it became firmly established with a
methodologic paradigm based on the
theory of randomized controlled trials
of individuals.
Ecologic Studies
In ecologic studies exposure
information may be collected on a
group rather than on individuals. In
the past, ecologic studies have been
regarded as an inexpensive but
unreliable method for studying
individual-level risk factors for disease.
For example, rather than go to the
time and expense to establish a cohort
study or case-control study of fat
intake and breast cancer, one could
simply use national dietary and cancer
incidence data and, with minimal time
and expense, show a strong
correlation internationally between fat
intake and breast cancer. In this
situation, an ecologic study does not
represent a fundamentally different
study design, but merely a particular
variant of the four basic study designs
described in chapter 2 in which
information on average levels of
exposure in populations is used as a
surrogate measure of exposure in
individuals.
However, population-level studies are

now experiencing a revival for two
important reasons (Pearce, 2000).
Firstly, it is increasingly recognised
that, even when studying individuallevel risk factors, population-level
studies play an essential role in
defining the most important public
health problems to be addressed, and
in generating hypotheses as to their
potential causes. Many important
individual-level risk factors for disease
simply do not vary enough within
populations to enable their effects to
be identified or studied (Rose, 1992).
More importantly, such studies are a
key component of the continual cycle
of theory and hypothesis generation
and testing (Pearce, 2000).
Historically, the key area in which
epidemiologists have been able to add
value has been through this
population focus (Pearce, 1996, 1999).
For example, many of the recent
discoveries on the causes of cancer
(including dietary factors and colon
cancer, hepatitis B and liver cancer,
aflatoxins and liver cancer, human
papilloma virus and cervical cancer)
have their origins, directly or
indirectly, in the systematic
international comparisons of cancer
This approach has been quite rightly

regarded as inadequate and unreliable
because of the many additional forms
of bias that can occur in such studies
compared with studies of individuals
within a population. In particular, not
only will measures of exposure in
populations often be poor surrogates
for exposures in individuals, but the
47
incidence conducted in the 1950s and

1960s (Doll et al, 1966). These
suggested hypotheses concerning the
possible causes of the international
patterns, which were investigated in
more depth in further studies. In some
instances these hypotheses were
consistent with biological knowledge at

the time, but in other instances they
were new and striking, and might not
have been proposed, or investigated
further, if the population level analyses
had not been done.
Example 4.4
The International Study
of Asthma and Allergies
in Childhood (ISAAC)
(Asher et al, 1995;
Pearce et al, 1993) was
described in example
3.1. Figure 4.1 shows
the findings for current
wheeze (i.e. wheeze in
the previous 12 months)
and its association with
tuberculosis notification
rates (von Mutius et al,
2000). It shows a
negative association
between tuberculosis
rates and asthma
prevalence. This is not
compelling evidence in
itself (because of the
major shortcoming of
ecologic analyses that
A second reason that ecologic studies

are experiencing a revival is that it is
increasingly being recognised that some
risk factors for disease genuinely
operate at the population level (Pearce,
2000). In some instances they may
directly cause disease, but perhaps
more commonly they may cause disease
as effect modifiers or determinants of
exposure to individual-level risk factors.
For example, being poor in a rich
country or neighbourhood may be worse
than having the same income level in a
poor country or neighbourhood, because
of problems of social exclusion and lack
of access to services and resources (Yen
are described below),

but it is generally
consistent with the
hygiene hypothesis
that suggests that
asthma prevalence is
increasing in Western
countries because of the
loss of a protective effect
from infections such as
tuberculosis in early life.
et al, 1999). The failure to take account

of the importance of population context,
as an effect modifier and determinant of
individual-level exposures could be
termed the individualistic fallacy
(Diez-Rouz, 1998) in which the major
population determinants of health are
ignored and undue attention is focussed
on individual characteristics. In this
situation, the associations between
these individual characteristics and
health can be validly estimated, but
their importance relative to other
potential interventions, and the
importance of the context of such
interventions, may be ignored.
48
Figure 4.1
Association of tuberculosis notification rates for the period 1980-1982 (in countries with
valid tuberculosis notification data) and the prevalence of asthma symptoms in 13-14
year old children in the International Study of Asthma and Allergies in Childhood (ISAAC)
Wet
heeze
last
Source: von Mutius
al (2000)
12 months (written questionnaire) vs tuberculosis

notification rate for the period 1980-1982 in countries with valid
tuberculosis notification data
40
Wheeze last 12 months %
35
30
25
20
15
10
0
0
10
20
30
40
50
60
70
80
Tuberculosis notification rate per 100,000
Example 4.5
Wilkinson (1992) has
analysed measures of
income inequality and
found them to be
positively associated
with national mortality
rates in a number of
Western countries. This
is a true ecologic
exposure since the level
of income inequality is a
characteristic of a
country, and not of an
individual. If this
evidence is correct, this
is clearly of crucial
importance since it
implies that
development in itself
may not automatically
be good for health, and
that the way in which
the Gross National
Product (GNP) is 'shared'
may be as important as
its absolute level. It
should be noted,
however, that this
evidence has been
disputed by other
49
researchers (e.g. Lynch

et al, 2000; Pearce and
Davey Smith, 2003) who
have argued that the
level of income
inequality in a country,
or in a state, is a
surrogate measure for
other socioeconomic
factors, including the
provision of public
education and health
services, as well as
social welfare services.
Ecologic Fallacies
While stressing the potential value of
ecologic analyses, it is also important to
recognise their limitations. In particular,
ecologic studies are a very poor means
of assessing the effects of individual
exposures (e.g. diet or tobacco
smoking) since confounding (and effect
modification) can occur at the individual
level, the country (population) level, or
both (Morgenstern, 1998). For example,
almost any disease that is associated
with affluence and westernisation has in
the past been associated at the national
level with sales of television sets, and
nowadays is probably associated at the
national level with rates of internet
usage. This does not mean that

watching television causes every type of
disease, but rather than in many
instances the association between sales
of television sets and disease at the
national level is confounded by other
exposures (at both the national and
individual level). A hypothetical example
is given in example 4.6. Another
problem is that individual level effects
can confound ecologic estimates of
population-level effects (Greenland,
2001).These problems of cross-level
inference are avoided (or reduced) in
multilevel analyses (see below).
Example 4.6
Table 4.2 shows the data
for a hypothetical
ecological analysis. The
numbers of cases and
population numbers (and
hence disease rates), as
well as the percentage of
the population exposed,
are known for each
country. Thus, the
numbers of people
exposed and nonexposed within each
country are known, but
it is not known how
many cases were
exposed and how many
were not; thus it is not
possible to estimate the
rates in the exposed and
non-exposed groups
within each country. The
country-level data
indicate a negative
association between
exposure and disease at
the country level: if a

regression is performed
on the country-level data
it indicates (comparing
100% exposure with 0%
exposure) a relative risk
of 0.5. However, it is not
known whether this
association applies to
individuals, since the
data are not available.
Tables 4.3-4.5 give three
different scenarios, each
of which could generate
the data in table 4.2. In
table 4.3, there is no
confounding at the
country level (because
the rate in the nonexposed is the same 200 per 1,000 - in each
country), although there
could of course still be
uncontrolled confounding
at the individual level.
50
Thus, the ecologic

analysis correctly
estimates the individuallevel relative risk of 0.5.
In table 4.4, there is
confounding at the
country level (because
the rate in the nonexposed differs by
country) and there is in
fact no association at the
individual level. In table
4.5, there is effect
modification at the
country level, and the
relative risk is positive,
but of differing
magnitude, in all three
countries. These three
very different situations
(a protective effect, no
effect, a positive effect
which is different in each
country) all yield the
same country-level data
shown in table 4.2.
Table 4.2
Hypothetical example of an ecologic analysis
Country 1
(35% exposed)
Cases
Rate
Country 2
(50% exposed)
Cases
Rate
Country 3
(65% exposed)
Cases
Rate
----------------------------------------------------------------------------------------Exposed
?/
7000
Non-exposed
?/
10000
?/
13000
?/
13000
?/
10000
?/
7000
----------------------------------------------------------------------------------------------Total
33/
165
20000
30/
150
20000
27/
135
20000
Source: Adapted from Morgenstern (1998)
Table 4.3
Hypothetical example of an ecologic analysis:
No confounding by country
Country 1
Country 2
Country 3
(35% exposed)
(50% exposed)
(65% exposed)
Cases
Rate
Cases
Rate
Cases
Rate
---------------------------------------------------------------------------------------------Exposed
7/
100
7000
Non-exposed
10/
100
10000
26/
200
13000
13/
100
13000
20/
200
10000
14/
200
7000
---------------------------------------------------------------------------------------------Total
33/
165
20000
30/
150
20000
27/
135
20000
---------------------------------------------------------------------------------------------Ratio
0.5
0.5
51
0.5
Table 4.4
Confounding by country
Country 1
Country 2
Country 3
(35% exposed)
(50% exposed)
(65% exposed)
Cases
Rate
Cases
Rate
Cases
Rate
---------------------------------------------------------------------------------------------Exposed
12/
171
15/
150
18/
139
7000
Non-exposed
10000
21/
162
13000
13000
15/
150
10000
9/
129
7000
---------------------------------------------------------------------------------------------Total
33/
165
20000
30/
150
20000
27/
135
20000
---------------------------------------------------------------------------------------------Ratio
1.1
1.0
1.1
Table 4.5
Effect modification by country
Country 1
Country 2
Country 3
(35% exposed)
(50% exposed)
(65% exposed)
Cases
Rate
Cases
Rate
Cases
Rate
---------------------------------------------------------------------------------------------Exposed
20/
286
20/
200
20/
154
7000
Non-exposed
10000
13/
100
13000
13000
10/
100
10000
7/
100
7000
---------------------------------------------------------------------------------------------Total
33/
165
20000
30/
150
20000
27/
135
20000
---------------------------------------------------------------------------------------------Ratio
2.9
2.0
52
1.5
Multilevel Studies
If individual as well as population-level
data are available, then the problems
of cross-level confounding and effect
modification (illustrated in example
4.6) are avoided by using multilevel
modelling (Greenland, 2000, 2002).
This enables the simultaneous
consideration of individual level effects
(e.g. individual income) and
population-level effects (e.g. per capita
national income, or income inequality).
This approach therefore combines the
best features of individual level

analyses and population-level analyses.
In particular, it enables us to take the
population context of exposure into
account (Pearce, 2000). However, it
should be stressed that multilevel
modelling is complex, and requires
intensive consideration of possible
biases at the population level, as well
as at the individual level (Blakely and
Woodward, 2000).
Example 4.7
Yen and Kaplan (1999)
conducted a multi-level
analysis of
neighbourhood social
environment and risk of
death in the Alameda
County Study,
comprising 6,928 noninstitutionalised adult
residents of the County
recruited in 1965.
Mortality risks were
significantly higher in
neighbourhoods with a
low social
environment, even
after account was
taken of individual
income level,
education, ethnicity,
perceived health
status, smoking status,
body mass index, and
alcohol consumption.
The authors concluded
that the findings
demonstrate the
importance of area
characteristics as a
health risk factor.
Summary
The basic study designs presented in

chapters 2 and 3 can be extended in
two ways: by the inclusion of continuous
outcome measures; and by the use of
exposure information on populations
rather than individuals.
Prevalence studies are a subgroup of

cross-sectional studies in which the
outcome measure is dichotomous.
Similarly, longitudinal studies can
involve incidence data, but may also
involve a series of cross-sectional
measurements. Incidence studies are a
subgroup of longitudinal studies in
which the outcome measure is
dichotomous. Time series studies are a
particular type of longitudinal study in
Cross-sectional studies can include a

variety of measurements of the health
outcome under study (e.g. lung function
or blood pressure measurements).
53
which each subject serves as his or her

own control.
estimate the effects of exposures in

individuals. These problems are avoided
(or reduced) in multilevel analyses,
which permit us to take the population
context of exposure into account.
Ecologic studies play an important role

in the process of hypothesis generation
and testing, but they pose additional
problems of bias when attempting to
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55
56
Part II
Study Design Issues
57
58
CHAPTER 5. Precision
Random error will occur in any

epidemiologic study, just as it occurs in
experimental studies. It is often referred
to as chance, although it can perhaps
more reasonably be regarded as
"ignorance" (although it is not the only
thing that we may be ignorant about as
our study may be biased by unknown
confounders, measurement error, etc).
For example, if we toss a coin 50 times,
then ideally we might be able to predict
the outcome of each toss based on the
speed, spin, and trajectory of the coin.
In practice, we do not have all of the
necessary information (because of
ignorance), or the computing power to
use it (because of chaotic behaviour),
and we therefore regard the outcome of
each toss as a chance phenomenon.
However, we may note that, on the
average, 50% of the tosses are heads
and therefore we may say that a
particular toss has a 50% chance of
producing a head.
12). However, there will always be other

unknown or unmeasurable risk factors
operating, and hence the disease rates in
particular subgroups will fluctuate about
the average. This will occur even if each
subgroup has exactly the same exposure
history.
Even in an experimental study, in which
participants are randomised into
"exposed" and "non-exposed" groups,
there will be "random" differences in
background risk between the compared
groups, but these will diminish in
importance (i.e. the random differences
will tend to even out) as the study size
grows. In epidemiological studies,
because of the lack of randomisation,
there is no guarantee that differences in
baseline (background) risk will "even
out" between the exposure groups as the
study size grows.
Similarly, suppose that 50 lung cancer

deaths occurred among 10,000 people
aged 35-39 exposed to a particular
factor during one year. Then, if each
person had exactly the same cumulative
exposure, we might expect two
subgroups of 5,000 people each to
experience 25 deaths during the oneyear period. However, just as 50 tosses
of a coin will not usually produce exactly
25 heads and 25 tails, neither will there
be exactly 25 deaths in each group. This
occurs because of differences in
exposure to other risk factors for lung
cancer, and differences in individual
susceptibility between the two groups.
Ideally, we should attempt to gather
information on all known risk factors
(potential confounders), and to adjust
for these in the analysis (see chapter
59
The basic principles of analysis of

epidemiologic data are discussed in
chapter 12. However, at this stage it is
important to discuss some basic
statistical principles and methods since
they are relevant to the calculation of
the appropriate study size.
5.1 Basic Statistics
Basic Concepts
Data can be summarized in various
forms, including frequency tables,
histograms, bar charts, cross-tabulations
and pie charts. However, it is usually
also useful to give a summary measure
of central tendency. The mean (or
average) is the most commonly used
measure of central tendency, because of
its convenient statistical properties. The
next step is data smoothing which
involves the combination of the data with
a statistical model. In the simplest case,
this involves assuming a particular
statistical distribution in order to obtain a
summary measure of variability of the
data. The most common measure of
variability is the standard deviation
(Armitage et al, 2002). The standard
deviation is especially useful when the
underlying data distribution is
approximately normal (i.e. symmetric
with a special type of bell-shape). If data
is not normally distributed, then it can
often be made approximately normally
distributed by an appropriate
transformation (e.g. a log
transformation), but these
transformations may distort the scientific
meaning of the findings, and make them
difficult to interpret.
Usually it is not possible to study the
entire population in which one is
interested (theoretically, this is almost
always infinite since we usually wish to
generalise our findings not only to the
population we are studying, but also to
other populations). It is therefore
necessary to consider a random sample
and to relate its characteristics to the
total population. If repeated samples are
taken from the same population, then
the mean will vary between samples.
Even if the underlying population is not
normally distributed, the means of the

samples will be approximately normally
distributed provided that the samples are
sufficiently large (how "large" depends
on how non-normally distributed the
population is). The standard deviation of
the sample means is termed the
standard error of the mean. Since the
means are approximately normally
distributed, about 95% of sample means
will lie within 1.96 standard errors of the
overall population mean. Usually, a
study only involves one sample, but the
standard error can be estimated by
dividing the standard deviation of the
sample by the square root of the number
of people in the sample.
Most epidemiological studies involve
categorical rather than continuous
outcome data. For example, in a
particular area one might estimate the
proportion of births involving congenital
malformations over a particular time
period (this is actually the prevalence at
birth - it is very difficult to calculate the
incidence of congenital malformations
because this requires information on
abortions and stillbirths as well as live
births). This involves the calculation of a
proportion (p). Under the binomial
distribution, if the sample is sufficiently
large, the sampling distribution will
approximate to the normal distribution
with mean (p) and standard deviation:
s=
(p(1-p)/n)0.5
where the 0.5 indicates the square root

of the expression in parentheses. Thus,
one can calculate the proportion with
malformations (i.e. the mean score for a
population in which a malformation
scores 1 and a completely healthy baby
scores 0), and the standard deviation of
this proportion (i.e. the standard error of
60
the mean score), and if the sample is

sufficiently large one can analyze these
estimates based on the normal
distribution.
also whether an association as large as

this is likely to have arisen by chance, if
in fact there is no causal association
between exposure and disease. The pvalue is the probability that differences
as large or larger as those observed
could have arisen by chance if the null
hypothesis (of no association between
exposure and disease) is correct. In the
past, it is been common to test the
statistical significance of the study
findings by seeing whether the p-value is
less than an arbitrary value (e.g.
p<0.05). The limitations of statistical
significance testing are discussed in
chapter 12. However, even if we do not
intend to use p-values when reporting
the findings of a study, the statistical
principles involved are nevertheless
relevant to determining the appropriate
study size.
Testing and Estimation

Usually, in epidemiologic studies, we
wish to measure the difference in
disease occurrence between groups
exposed and not exposed to a particular
factor. For example, if we have
estimated the proportion of pregnancies
involving congenital malformations in an
area with high nitrate levels in drinking
water, then we would wish to compare
this to the corresponding proportion in
an area with low nitrate levels (or with
the proportion in all births nationally. In
doing so, we not only wish to estimate
the size of the observed association, but
5.2 Study Size and Power
The most effective means of reducing

random error is by increasing the study
size, so that the precision of the
measure of association (the effect
estimate) will be increased, i.e. the
confidence intervals will be narrower.
Random error thus differs from
systematic error (see chapter 6) which
cannot be reduced simply by increasing
the study size.
size. When exposure increases the risk

of the outcome, or referents are
cheaper to include in the study than
index subjects, then a larger ratio may
be more efficient. The optimal
reference: index ratio is rarely greater
than 2:1 for a simple unstratified
analysis (Walter, 1977) with equal index
and referent costs, but a larger average
ratio may be desirable in order to
assure an adequate ratio in each
stratum for stratified analyses.
A second factor that can affect

precision, given a fixed total study size,
is the relative size of the reference
group (the unexposed group in a cohort
study, or the controls in a case-control
study). When exposure is not associated
with disease (i.e. the true relative risk is
1.0), and the costs (of recruitment, data
collection, etc) of index and reference
subjects are the same, then a 1:1 ratio
is most efficient for a given total study
The ideal study would be infinitely large,

but practical considerations set limits on
the number of participants that can be
included. Given these limits, it is
desirable to find out, before
commencing the study, whether it is
large enough to be informative. One
61
method is to calculate the "power" of the

study. This depends on five factors:
the cutoff value (i.e. alpha level)

below which the p-value from the
study would be considered
statistically significant. This value
is usually set at 0.05 or 5%;
the disease rate in the non-exposed

group in a cohort study or the
exposure prevalence of the controls
in a case-control study;
the expected relative risk (i.e. the

specified value of the relative risk
under the alternative (non-null)
hypothesis));
the ratio of the sizes of the two

groups being studied;
Once these quantities have been

determined, standard formulas are then
available to calculate the statistical
power of a proposed study (Walter,
the total number of study participants.
1977; Schlesselman, 1982). The

standard normal deviate corresponding
to the power of the study (derived from
Rothman and Boice, 1982) is then:
Z = N00.5|P1 P0|B0.5 ZB
K0.5
where:
Z
= standard normal deviate corresponding to a given statistical power
= standard normal deviate corresponding to an alpha level (the largest

p-value that would be considered "statistically significant")
N0 = number of persons in the reference group (i.e. the non-exposed

group in a cohort study, or the controls in a case-control study)
P1
= outcome proportion in study group
P0
= outcome proportion in the reference group
= allocation ratio of referent to study group (i.e., the relative size of the
two groups)
= (1-P0) (P1+ (A-1) P0) + P0 (1-P1)
= (1-P0) (AP1 - (A-1) P0) + AP0 (1-P1)
= BC - A (P1-P0)2
Standard calculator and

microcomputer programmes
incorporating procedures for power
calculations are widely available. In
particular, EPI-INFO (Dean et al, 1990)
can be downloaded for free from
http://www.cdc.gov/epiinfo/, and
Rothmans Episheet programme
(Rothman, 2002) can be downloaded
for free from
http://www.oup-usa.org/epi/rothman/
62
Example 5.1
Consider a proposed study
of 5,000 exposed persons
and 5,000 non-exposed
persons. Suppose that on
the basis of mortality
rates in a comparable
Then:
Z
N0 =
group of workers, the

expected number of cases
of the disease of interest
is 25 in the non-exposed
group. However, we
expect that exposure will
1.96 (if a two-tailed significance test, for an alpha-level of 0.05, is to

be used)
5,000
P1
0.010 (= 50/5000)
P0
0.005 (= 25/5000)
Using the equation above, the standard

normal deviate corresponding to the
power of the study to detect a
Z =
double the risk of disease,

so the number of cases
observed will be 50 in the
exposed group.
statistically significant lung cancer

excess in the exposed group is:
50000.5 (0.010-0.005) (0.0149)0.5 - 1.96 x 0.0149 = 0.994

0.0001970.5
From tables for the

(one-sided) standard
normal distribution, it
can be seen that this
corresponds to a power
of 83%. This means that
if 100 similar studies of
this size were
performed, then we
would expect 83 of them
to show a statistically
significant (p<0.05)
excess of cases in the
exposed group.
An alternative approach
is to carry out a
standard analysis of the
hypothesized results. If
we make the
assumptions given
above, then the relative
risk would be 2.0, with a
90% confidence interval
of 1.4-3.0. This
approach only has an
indirect relationship to
the power calculations.
For example, if the
63
lower 95% confidence

limit is 1.0, then the
power for a two-tailed
test (of p<0.05) would
be only 50%. This
simulated confidence
interval gives the
additional information
that the observed
relative risk could be as
large as 3.0 or as low as
1.4 if the observed
relative risk is 2.0.
Related approaches are to estimate

the minimum sample sizes required to
detect an association (e.g., relative
risk) of specified magnitudes
(Beaumont and Breslow, 1981), and to
estimate the minimum detectable
association for a given alpha level,
power and study size (Armstrong,
1987).
1982; Greenland, 1983), and the size

of the expected association is often
just a guess. Nevertheless, power
calculations are an essential aspect of
planning a study since, despite all their
assumptions and uncertainties, they
nevertheless provide a useful general
indication as to whether a proposed
study will be large enough to satisfy
the objectives of the study.
Occasionally, the outcome is measured

as a continuous rather than a
dichotomous variable (e.g. blood
pressure). In this situation the
standard normal deviate corresponding
to the study power is:
Z =
Estimating the expected precision can

also be useful (Rothman and
Greenland, 1998). This can be done by
"inventing" the results, based on the
same assumptions used in power
calculations, and carrying out an
analysis involving calculations of effect
estimates and confidence limits. This
approach has particular advantages
when the exposure is expected to have
no association with disease, since the
concept of power is not applicable but
precision is still of concern. However,
this approach should be used with
considerable caution, as the results
may be misleading unless interpreted
carefully. In particular, a study with an
expected lower limit equal to a
particular value (e.g. 1.0) will have
only a 50% chance of yielding an
observed lower confidence limit above
that value.
N00.5(1-0) Z
s(A + 1)0.5
where:
1
= mean outcome measure in

exposed group
= mean outcome measure in

reference group
= estimated standard
deviation of outcome measure
The power is not the probability that

the study will estimate the size of the
association correctly. Rather, it is the
probability that the study will yield a
"statistically significant" finding when
an association of the postulated size
exists. The observed association could
be greater or less than expected, but
still be "statistically significant". The
overemphasis on statistical
significance is the source of many of
the limitations of power calculations.
Many features such as the significance
level are completely arbitrary, issues
of confounding, misclassification and
effect modification are generally
ignored (although appropriate methods
are available - see Schlesselman,
In practice, the study size depends on

the number of available participants
and the available resources. Within
these limitations it is desirable to make
the study as large as possible, taking
into account the trade-off between
including more participants and
gathering more detailed information
about a smaller number of participants
(Greenland, 1988). Hence, power
calculations can only serve as a rough
guide as to whether a feasible study is
large enough to be worthwhile. Even if
such calculations suggest that a
particular study would have very low
power, the study may still be
worthwhile if exposure information is
64
collected in a form which will permit

the study to contribute to the broader
pool of information concerning a
particular issue. For example, the
International Agency for Research on
Cancer (IARC) has organised several
international collaborative studies such
as those of occupational exposure to
man-made mineral fibers (Simonato et
al, 1986) and phenoxy herbicides and
contaminants (Saracci et al, 1991).
The man-made mineral fiber study
involved pooling the findings from
individual cohort studies of 13
European factories. Most of the
individual cohorts were too small to be

informative in themselves, but each
contributed to the overall pool of data.
Once a study has been completed,
there is little value in retrospectively
performing power calculations since
the confidence limits of the observed
measure of effect provide the best
indication of the range of likely values
for the true association (Smith and
Bates, 1992; Goodman and Berlin,
1994). In the next chapter, random
error will be ignored, and the
discussion will concentrate on issues of
systematic error.
Summary
Random error will occur in any

epidemiologic study, just as it occurs
in experimental studies. The most
effective means of reducing random
error is by increasing the study size,
so that the precision of the effect
estimate will be increased. Random
error thus differs from systematic error
which cannot be reduced simply by
increasing the study size. The ideal
study would be infinitely large, but
practical considerations set limits on
the number of participants that can be
included. Given these limits, it is
desirable to find out, before
commencing the study, whether it is
large enough to be informative. One

method is to calculate the "power" of
the study. In practice, the study size
depends on the number of available
participants and the available
resources. Within these limitations it is
desirable to make the study as large
as possible, taking into account the
trade-off between including more
participants and gathering more
detailed information about a smaller
number of participants. Hence, power
calculations can only serve as a rough
guide as to whether a feasible study is
large enough to be worthwhile.
65
References
Armitage P, Berry G, Matthews JNS

(2002). Statistical methods in medical
research. 4th ed. Oxford: Blackwell.

Armstrong B (1987). A simple estimator

of minimum detectable relative risk,
sample size, or power in cohort
studies. Am J Epidemiol 125: 356358.
Saracci R, Kogevinas M, Bertazzi P, et al

(1991). Cancer mortality in an
international cohort of workers
exposed to chlorophenoxy herbicides
and chlorophenols. Lancet 338: 102732.
Beaumont JJ, Breslow NE (1981). Power

considerations in epidemiologic
studies of vinyl chloride workers. Am J
Epidemiol 114: 725-734
Dean J, Dean A, Burton A, Dicker R
(1990). Epi Info. Version 5.01.
Atlanta, GA: CDC.
Goodman SN, Berlin JA (1994). The use
of predicted confidence intervals when
planning experiments and the misuse
of power when interpreting results.
Ann Intern Med 121: 200-6.
Greenland S (1983). Tests for interaction
in epidemiologic studies: a review and
a study of power. Statist Med 2: 24351.
Greenland S (1988). Statistical
uncertainty due to misclassification:
implications for validation substudies.
J Clin Epidemiol 41: 1167-74.
Rothman KJ, Boice JD (1983).
Epidemiologic Analysis with a
Programmable Calculator.
Epidemiology Resources, Inc.: Boston,
MA.
Rothman KJ (2002). Epidemiology: an
introduction. New York, Oxford
University Press.
66
Schlesselman JJ (1982). Case-control

studies: design, conduct, analysis.
Simonato L, Fletcher AC, Cherrie J, et al.
(1986). Scandinavian Journal of Work,
Environment and Health 12: (suppl 1)
34-47.
Smith AH, Bates M (1992). Confidence
limit analyses should replace power
calculations in the interpretation of
epidemiologic studies. Epidemiol 3:
449-52.
Walter SD (1977). Determination of
significant relative risks and optimal
sampling procedures in prospective
and retrospective studies of various
sizes. Am J Epidemiol 105: 387-97.
CHAPTER 6. Validity
Systematic error (lack of validity) is

distinguished from random error (lack
of precision) in that it would be
present even with an infinitely large
study, whereas random error can be
reduced by increasing the study size.
Thus, systematic error, or bias, occurs
if there is a systematic difference
between what the study is actually
estimating and what it is intended to
estimate.
categories (Rothman and Greenland,

1998): confounding; selection bias;
and information bias. In general
terms, these refer to biases arising
from differences in baseline disease
risk between the exposed and nonexposed subpopulations of the source
population (confounding), biases
resulting from the manner in which
study participants are selected from
the source population (selection bias),
and biases resulting from the
misclassification of these study
participants with respect to exposure
or disease (information bias).
There are many different types of bias,

but in studies of cause and effect most
biases fall into one of three major
6.1 Confounding
Confounding occurs when the exposed

and non-exposed groups (in the source
population) are not comparable due to
inherent differences in background
disease risk (Greenland and Robins,
1986) because of differences in the
distribution of other risk factors between
the exposed and non-exposed groups.
For example, this could occur if we were
studying the risk of heart disease in
people who exercise frequently and
those who do not, and if the people who
exercised frequently smoked less than
those who did not exercise; thus they
might have a lower risk of heart disease
because they smoked less, and not
because they exercised more. Similar
problems can occur in randomised trials
because randomisation may fail, leaving
the treatment groups with different
characteristics (and different baseline

disease risk) at the time that they enter
the study, and because of differential
loss and non-compliance across
treatment groups. However, there is
more concern about non-comparability
in epidemiological studies because of
the absence of randomisation. The
concept of confounding thus generally
refers to the source population,
although confounding can also be
introduced (or removed) by the manner
in which study participants are selected
from the source population (Pearce and
Greenland, 2004).
If no other biases are present, three
conditions are necessary for a factor to
be a confounder (Rothman and
Greenland, 1998).
67
First, a confounder is a factor which is

predictive of disease in the absence of
the exposure under study. Note that a
confounder need not be a genuine
cause of disease, but merely
"predictive". Hence, surrogates for
causal factors (e.g. age) may be
regarded as potential confounders,
even though they are rarely directly
causal factors.
symptom of disease) should not be

treated as a confounder because to do
so could introduce serious bias into the
results (Greenland and Neutra, 1981;
Robins, 1987; Weinberg, 1993). For
example, in a study of high fat diet
and colon cancer, it would be
inappropriate to control for serum
cholesterol levels if it was considered
that high serum cholesterol levels were
a consequence of a high fat diet, and
hence a part of the causal chain
leading from diet to colon cancer. On
the other hand, if serum cholesterol
itself was of primary interest, then this
should be studied directly, and high fat
diet would be regarded as a potential
confounder if it also involved exposure
to other risk factors for colon cancer.
Evaluating this type of possibility
requires information external to the
study to determine whether a factor is
likely to be a part of the causal chain.
Intermediate variables can sometimes
be used in the analysis, but special
techniques are then require
d to avoid adding bias (Robins, 1989;
Robins et al, 1992; Robins et al,
2000).
Second, a confounder is associated

with exposure in the source population
at the start of follow-up (i.e. at
baseline). In case-control studies this
implies that a confounder will tend to
be associated with exposure among
the controls. An association can occur
among the cases simply because the
study factor and a potential
confounder are both risk factors for
the disease, but this does not cause
confounding in itself unless the
association also exists in the source
population.
Thirdly, a variable which is affected by
the exposure or the disease (e.g. an
intermediate in the causal pathway
between exposure and disease, or a
Example 6.1
Table 6.1 presents a
hypothetical example of
confounding by tobacco
smoking in a prevalence
case-control study. Onehalf of the study
participants are
"exposed to the risk
factor of interest and
one-half are not.
However, two-thirds of
the exposed people are
smokers compared with
one-third of the non-
exposed people. Thus,

although exposure is
not associated with
disease either within the
subgroup of smokers
(POR=1.0) or within the
subgroup of nonsmokers (POR=1.0), it is
associated with disease
overall (POR=1.38)
when the two subgroups
are combined. This
occurs because smoking
is associated with the
68
exposure (as noted

above) and is an
independent risk factor
for the disease (40% of
non-exposed smokers
have the disease
compared with 20% of
non-exposed nonsmokers). Thus, smoking
is a confounder and the
crude prevalence odds
ratio of 1.38 is invalid
because it is not
adjusted for smoking.
Table 6.1
Hypothetical example of confounding by tobacco smoking in a prevalence
case-control study
Smokers
NonExposed exposed
Cases
800
400
Non-cases
1,200
600
Total
2,000
1,000
Prevalence (%)
40
40
Prevalence odds ratio
1.0
Control of Confounding
Non-smokers
NonExposed exposed
200
400
800
1,600
1,000
2,000
20
20
1.0
Total
NonExposed exposed
1,000
8,00
2,000
2,200
3,000
3,000
33.3
26.7
1.38
epidemiology or whether they constitute

a separate methodology).
Misclassification of a confounder leads to

a loss of ability to control confounding,
although control may still be useful
provided that misclassification of the
confounder is non-differential
(Greenland, 1980). Misclassification of
exposure poses a greater problem
because factors which influence
misclassification may appear to be
confounders, but control of these factors
may increase the net bias (Greenland
and Robins, 1985). In general, control of
confounding requires careful use of a
priori knowledge, as well as inference
from the observed data.
A second method of control at the design

stage is to restrict the study to narrow
ranges of values of the potential
confounders, e.g., by restricting the
study to white males aged 35-54. This
approach has a number of conceptual
and computational advantages, but may
severely restrict the number of potential
study subjects and the generalizability of
the study, as effects in younger or older
people will not be observable.
A third method of control involves
matching study subjects on potential
confounders. For example, in a cohort
study one would match a white male
non-exposed subject aged 35-39 with
an exposed white male aged 35-39. This
will prevent age-sex-race confounding
in a cohort study, but is seldom done
because it may be very expensive.
Matching can also be expensive in casecontrol studies, and does not prevent
confounding in such studies, but does
facilitate its control in the analysis.
Matching may actually reduce precision
in a case-control study if it is done on a
factor which is associated with
exposure, but is not a risk factor for the
Control in the study design

Confounding can be controlled in the
study design, or in the analysis, or both.
Control at the design stage involves
three main methods (Rothman and
Greenland, 1998).
The first method is randomization, i.e.,
random allocation to exposure
categories, but this is rarely an option in
epidemiology which generally involves
observational studies (it is debatable
whether randomised studies are part of
69
disease of interest. However, matching

on a strong risk factor will usually
increase the precision of effect
estimates.
confounder(s) and calculating an effect

estimate which summarizes the
association across strata of the
confounders. It is usually not possible to
control simultaneously for more than 2
or 3 confounders in a stratified analysis.
For example, in a cohort study, finer
stratification will often lead to many
strata containing no exposed or no nonexposed persons. Such strata are
uninformative, thus fine stratification is
wasteful of information. This problem
can be mitigated to some extent, by the
use of multiple regression which allows
for simultaneous control of more
confounders by "smoothing" the data
across confounder strata.
Control in the Analysis

Confounding can also be controlled in
the analysis, although it may be
desirable to match on potential
confounders in the design to optimize
the efficiency of the analysis. The
analysis ideally should control
simultaneously for all confounding
factors. Control of confounding in the
analysis involves stratifying the data
according to the levels of the
Example 6.2
If the data presented in
example 6.1 (table 6.1)
is analysed separately in
smokers and nonsmokers, then the
prevalence odds ratio is
1.0 in each of the two

subgroups (i.e. 1.0 in
smokers and 1.0 in nonsmokers). Taking a
weighted average of
these two stratum-
In general, control of confounding

requires careful use of a priori
knowledge, together with assessment
of the extent to which the effect
estimate changes when the factor is
controlled in the analysis. Most
epidemiologists prefer to make a
decision based on the latter criterion,
although it can be misleading,
particularly if misclassification is
present (Greenland and Robins, 1985).
The decision to control for a presumed
confounder can certainly be made with
more confidence if there is supporting
prior knowledge that the factor is
predictive of disease.
specific estimates (see

chapter 12) then yields
an overall smokingadjusted prevalence
odds ratio of 1.0.
Misclassification of a confounder leads

to a loss of ability to control
confounding, although control may still
be useful provided that
misclassification of the confounder was
nondifferential (unbiased) (Greenland,
1980). Misclassification of exposure is
more problematic, since factors which
influence misclassification may appear
to be confounders, but control of these
factors may increase the net bias
(Greenland and Robins, 1985).
70
Example 6.3
Suppose that a cohort
study of lung cancer
involves a comparison
with national mortality
rates in a country where
50% of the population
are non-smokers, 40%
are moderate smokers
with a 10-fold risk of
lung cancer (compared
to non-smokers), and
10% are heavy smokers
with a 20-fold risk of
lung cancer. Then, it
can be calculated that
the national lung cancer
incidence rate will be 6.5

(= 0.50 x 1.0 + 0.40 x
10 + 0.10 x 20) times
the rate in non-smokers.
Suppose that it was
considered most unlikely
that the cohort under
study contained more
than 50% moderate
smokers and 20% heavy
smokers. Then, the
incidence rate in the
study cohort would be
9.4 times the rate in
non-smokers. Hence, the
observed incidence rate
would be biased upwards

by a factor of 9.4/6.5 =
1.4, i.e. it would be 1.4
times higher than the
national rate due to
confounding by smoking.
Table 7.2 gives a range
of such calculations
presented by Axelson
(1978) using data from
Sweden. The last column
indicates the likely bias
in the observed rate
ratio due to confounding
by smoking (a value of
1.00 indicates no bias).
Table 6.2
Estimated crude rate ratios in relation to fraction of smokers in various hypothetical
populations
Population fraction (%)
Nonsmokers
Moderate Smokersa
Heavy Smokersa
100
80
70
60
50
40
30
20
10
----
-20
30
35
40
45
50
55
60
65
25
--
--5
10
15
20
25
30
35
75
100
Bias in
relative risk
0.15
0.43
0.57
0.78
1.00b
1.22
1.43
1.65
1.86
2.08
2.69
3.08
Source: Axelson (1978)

aTwo different risk levels are assumed for smokers: 10 times for moderate smokers; and 20 times for heavy
smokers.
bReference population with rates similar to those in general population in countries such as Sweden.
71
Assessment of Confounding
exposed and non-exposed groups in

order to check that the average level
of humidity in the home is similar in
the two groups. Such limited
information, if taken in all exposuredisease subgroups, can also be used to
directly control confounding (White,
1982; Walker, 1982; Rothman and
Greenland, 1998).
When one lacks data on a suspected

confounder (and thus cannot control
confounding directly) it is still desirable
to assess the likely direction and
magnitude of the confounding it
produces. It may be possible to obtain
information on a surrogate for the
confounder of interest (for example,
social class is associated with many
lifestyle factors such as smoking, and
may therefore be a useful surrogate
for some lifestyle-related
confounders). Even though confounder
control will be imperfect in this
situation, it is still possible to examine
whether the exposure effect estimate
changes when the surrogate is
controlled in the analysis, and to
assess the strength and direction of
the change. For example, if the
relative risk actually increases (e.g.
from 2.0 to 2.5), or remains stable
(e.g. at 2.0) when social class is
controlled for, then this is evidence
that the observed excess risk is not
due to confounding by smoking, since
social class is correlated with smoking
(Kogevinas et al, 1997), and control
for social class involves partial control
for smoking.
Finally, even if it is not possible to

obtain confounder information for any
study participants, it may still be
possible to estimate how strong the
confounding is likely to be from
particular risk factors. For example,
this is often done in occupational
studies, where tobacco smoking is a
potential confounder, but smoking
information is rarely available; in fact,
although smoking is one of the
strongest risk factors for lung cancer,
with relative risks of 10 or 20, it
appears that smoking rarely exerts a
confounding effect of greater than 1.5
times in studies of occupational
disease (Axelson, 1978; Siemiatycki,
1988), because few occupations are
strongly associated with smoking,
although this degree of confounding
may still be important in some
contexts.
Alternatively, it may be possible to

obtain accurate confounder
information for a subgroup of
participants in the study, and to assess
the effects of confounder control in this
subgroup. A related approach, known
as two-stage sampling, involves
obtaining confounder information for a
sample of the source population (or a
sample of the controls in a casecontrol study). For example, in a study
of asthma in children, it may not be
possible to obtain information on
humidity levels in the home in all
children. However, it may still be
possible to obtain humidity
measurements for a sample of the
72
6.2 Selection Bias
Whereas confounding generally

involves biases that are inherent in the
source population, and therefore would
occur even if everyone in the source
population took part in the study,
selection bias involves biases arising
from the procedures by which the
study participants are selected from
the source population. Thus, selection
bias is not an issue in a cohort study
involving complete follow-up, since in
this case the study cohort composes
the entire source population. However,
selection bias can occur if participation
in the study or follow-up is incomplete.

For example, in a cohort mortality
study, if a national population registry
(or some surrogate for this such as the
United States Social Security system)
were not available, then it might be
necessary to attempt to contact each
worker or his next-of-kin to verify vital
status (i.e. whether the worker was
still alive). Bias could occur if the
response rate was higher in the most
heavily exposed persons who had been
diagnosed with disease than in other
persons.
Example 6.4
Wrensch et al (2000)
conducted a case-control
study of 476 adults
newly diagnosed with
glioma in the San
Francisco Bay Area
between August 1991
and April 1994, and 462
age- gender- and
ethnicity-matched
controls. In addition,
limited information was
obtained during a brief

telephone interview with
101 controls who
declined participation in
the lengthy in-person
interview. Controls who
participated in the full
interview were more
likely than controls who
only completed the
telephone interview to
report head injury. Thus
Although we should recognize the

possible biases arising from subject
selection, it is important to note that
epidemiologic studies need not be based
on representative samples to avoid bias.
For example, in a cohort study persons
who develop disease might be more
likely to be lost to follow-up than
persons who did not develop disease;
however, this would not affect the
there was evidence of a

selection bias in the
recruitment of controls.
The odds ratio for cases
versus controls who
completed the full
interview was 0.9,
whereas when both
control groups were
combined the odds ratio
was 1.3.
relative risk estimate provided that loss

to follow-up applied equally to the
exposed and non-exposed populations
(Criqui, 1979). Analogously, casecontrol studies have differing selection
probabilities as an integral part of their
design, in that the selection probability
of diseased persons is usually close to
1.0 provided that most persons with
disease are identified, whereas that for
73
non-diseased persons is substantially

less; however, this does not affect the
relative risk estimate provided that
these selection probabilities apply
equally within each exposure group.
restricted to union members (because

the records are available), then the nonexposed comparison group could be
other workers in the same geographical
area who are members of the same
union, and/or a similar union.
Additional forms of selection bias can

occur in case-control studies because
these involve sampling from the source
population. In particular, selection bias
can occur in a case-control study
(involving either incident or prevalent
cases) if controls are chosen in a nonrepresentative manner, e.g. if exposed
people were more likely to be selected
as controls than non-exposed people.
Control of Selection Bias

Selection bias can sometimes be
controlled in the analysis by identifying
factors which are related to subject
selection and controlling for them as
confounders (provided that these
factors are not affected by the study
exposure or disease). For example, if
white-collar workers are more likely to
be selected for (or participate in) a
study than manual workers (and white
collar work is negatively or positively
related to the exposure of interest),
then this bias can be partially controlled
by collecting information on social class
and controlling for social class in the
analysis as a confounder.
Minimizing Selection Bias

If selection bias has occurred in the
enumeration of the exposed group, it
may still be possible to avoid bias by
choosing an appropriate non-exposed
comparison group. For example, if the
exposed group does not include all
workers in a particular industry, but is
6.3 Information Bias
Information bias involves

misclassification of the study
participants with respect to disease or
exposure status. Thus, the concept of
information bias refers to those people
actually included in the study, whereas
selection bias refers to the selection of
the study participants from the source
population, and confounding generally
refers to non comparability of
subgroups within the source
population. Information bias involves
misclassification of the study subjects
with respect to exposure, confounders,
or disease.
It is customary to consider two types

of misclassification: non-differential
and differential misclassification.
Non-Differential Misclassification
Non-differential misclassification
occurs when the probability of
misclassification of exposure is the
same for cases and non-cases (or
when the probability of
misclassification of disease is the
same for exposed and non-exposed
persons). This can occur if exposed
and non-exposed persons are equally
74
likely to be misclassified according to

disease outcome, or if diseased and
non-diseased persons are equally
likely to be misclassified according to
exposure. Non-differential
misclassification of exposure usually
(but not always) biases the relative
risk estimate towards the null value

of 1.0 (Copeland et al, 1977;
Dosemeci et al, 1990). Hence, nondifferential misclassification tends to
produce "false negative" findings and
is of particular concern in studies
which find a negligible association
Example 6.5
In many cohort studies
some exposed persons
will be classified as nonexposed, and vice versa.
Table 6.3 illustrates this
situation with
hypothetical data from a
study of lung cancer
incidence in asbestos
workers. Suppose the
true incidence rates are
100 per 100,000 personyears in the high
exposure group, and 10
per 100,000 personyears in the low exposure
group, and the relative
risk is thus 10. If 15% of

high exposed persons are
incorrectly classified,
then 15 of every 100
deaths and 15,000 of
every 100,000 personyears will be incorrectly
allocated to the low
exposure group. Similarly
if 10% of high exposed
persons are incorrectly
classified, then 1 of every
10 deaths and 10,000 of
every 100,000 personyears will be incorrectly
allocated to the low
exposure group. As a
result, the observed

incidence rates per
100,000 person-years
will be 91 and 23
respectively, and the
observed relative risk will
be 4.0 instead of 10.0.
Due to non-differential
misclassification,
incidence rates in the
high exposed group have
been biased downwards,
and incidence rates in
the low exposure group
have been biased
upwards.
Table 6.3
Hypothetical data from a cohort study in which 15% of highly exposed persons and
10% of low exposed persons are incorrectly classified.
Actual
Observed
--------------------------------------------------------------------------------------High
Low
High Exposure
Low Exposure
Exposure Exposure
----------------------------------------------------------------------------------------------------------------Deaths
100
10
85 +
1=
86
9+
15 =
24
Person-years
100,000
100,000
85,000 + 10,000 = 95,000 90,000 +15,000 = 105,000
----------------------------------------------------------------------------------------------------------------Incidence rate 100
10
91
23
per 100,000
person years
---------------------------------------------------------------------------------------------------------------Rate ratio
10.0
4.0
75
between exposure and disease. One

important condition is needed to ensure
that exposure misclassification produces
bias towards the null however: the
exposure classification errors must be
independent of other errors. Without
this condition, non-differential exposure
misclassification can produce bias in any
direction (Chavance et al, 1992;
Kristensen, 1992).
by the misclassification. For example if

only 80% of the deaths are identified in
a study, but this under-ascertainment
applies equally to the exposed and nonexposed groups, then this will not affect
the relative risk estimate.
Secondly, the effect estimate may be
biased away from the null for some
exposure categories when there are
multiple exposure categories (see
example 6.6).
Furthermore, there are several other

situations in which non-differential
misclassification will not produce a bias
towards the null.
Finally, when there is positive

confounding, and there is nondifferential misclassification of the
confounder, then confounding control
will be incomplete and the adjusted
effect estimate will consequently be
biased away from the null.
Firstly, when the specificity of the

method of identifying the disease under
study is 100%, but the sensitivity is less
than 100%, then the risk difference will
be biased towards the null, but the risk
ratio (or rate ratio) will be not be biased
Example 6.6
Table 6.4 gives
cohort study in which the
findings for the high and
low exposure groups are
the same as in example
6.5, but there is also a
non-exposed group for

which there is no
misclassification. In this
instance, the nondifferential
misclassification between
the high and low exposure
groups produces a bias

away from the null when
the low exposure group is
compared to the nonexposed group: the
relative risk is 4.6 instead
of 2.0.
Table 6.4
Hypothetical data from a cohort study in which 15% of highly exposed persons and 10% of
low exposed persons are incorrectly classified, but the non-exposed are correctly classified
Actual
Observed
----------------------------------------------------------------------------High
Low
Non-Exposed
High
Low
Non-Exposed
-----------------------------------------------------------------------------------------------------------Deaths
100
10
5
86
24
5
Person-years
100,000
100,000
100,000
95,000
105,000
100,000
-----------------------------------------------------------------------------------------------------------Rate
100
10
5
91
23
5
-----------------------------------------------------------------------------------------------------------Rate ratio
20.0
2.0
1.0
18.1
4.6
1.0
76
One special type of non-differential

misclassification occurs when the study
outcome is not well-defined and
includes a wide range of etiologically
unrelated outcomes (e.g., all deaths).
This may obscure the effect of exposure
on one specific disease since a large
increase in risk for this disease may
only produce a small increase in risk for
the overall group of diseases under
study. A similar bias can occur when the
exposure measure is not well defined
and includes a wide range of
etiologically unrelated exposures,
possibly due to a non-specific exposure
definition or due to the inclusion of
exposures which could not have caused
the disease of interest because they
occurred after, or shortly before,
diagnosis. It could be argued that these
phenomena do not represent

misclassification because these are not
errors in measurement. However, they
do involve misclassification in the sense
that the etiologically relevant exposure
(or disease) has not been measured
appropriately.
Differential Misclassification
Differential misclassification occurs when
the probability of misclassification of
exposure is different in diseased and nondiseased persons, or the probability of
misclassification of disease is different in
exposed and non-exposed persons. This
can bias the observed effect estimate
either toward or away from the null
value. For example, in a nested casecontrol study of lung cancer, with a
Example 6.7
Table 6.5 shows data from
a hypothetical casecontrol study in which 70
of the 100 cases and 50 of
the 100 controls have
actually been exposed to
some chemical. The true

odds ratio is thus (70/30)
(50/50) = 2.3. If 90%
(63) of the 70 exposed
cases, but only 60% (30)
of the 50 exposed controls
are classified correctly,

then the observed odds
ratio would be (63/37) /
(30/70) = 4.0.
Table 6.5
Hypothetical data from a case-control study in which 90% of exposed cases and 60% of
exposed controls are correctly classified
Actual
Observed
Exposed
Non-exposed
Exposed
Non-exposed
Cases
70
30
63
37
Controls
50
50
30
70
Odds ratio
2.3
4.0
77
control group selected from among nondiseased members of the cohort, the
recall of occupational exposures in
controls might be different from that of
the cases. In this situation, differential
misclassification would occur, and it
could bias the odds ratio towards or
away from the null, depending on
whether members of the cohort who did
not develop lung cancer were more or
less likely to recall such exposure than
the cases.
the validity of a study. Given limited

resources, it will often be more
desirable to reduce information bias by
obtaining more detailed information on
a limited number of subjects than to
reduce random error by including more
subjects. However, a certain amount of
misclassification is unavoidable, and it is
usually desirable to ensure that it is
towards the null value (as usually
occurs with nondifferential exposure
misclassification) to minimize the
chance of false positive results.
As can be noted from example 6.7,

misclassification can drastically affect
Example 6.8
In the case-control
study of lung cancer in
Example 6.7, the
misclassification could
be made non-differential
by selecting controls
from cohort members
with other types of
cancer, or other
diseases, in order that
their recall of exposure
would be more similar to
that of the cases. As
before, 63 (90%) of the
exposed cases would

recall exposure, but now
45 (90%) of the 50
exposed controls would
recall their exposure.
The observed odds ratio
would be
(63/37)/(45/55) = 2.1
This estimate is still
biased in comparison
with the correct value of
2.3. However, the bias is
non-differential, is much
smaller than before, and
is in a predictable
direction, towards the
null. However, it should
be noted that making a
bias non-differential will
not always make it
smaller, and that the
direction of bias from
non-differential
misclassification is
sometimes predictable
in advance.
Minimizing Information Bias

Misclassification can drastically affect
the validity of a study. It is often helpful
to ensure that the misclassification is
non-differential, by ensuring that
exposure information is collected in an
identical manner in cases and non-cases
(or that disease information is collected
in an identical manner in the exposed
and non-exposed groups). In this
situation, if it is independent of other
errors, exposure misclassification tends
to produce false negative findings and is

thus of greatest concern in studies
which have not found an important
effect of exposure. Thus, in general it is
important to ensure that information
bias is non-differential and, within this
constraint, to keep it as small as
possible. Thus, can be argued that the
aim of data collection is not to collect
perfect information, but to collect
information in a similar manner from
78
the groups being compared, even if this

means ignoring more detailed exposure
information if this is not available for
both groups. However, this is not
always the case (Greenland and Robins,
1985).
Relationship of Selection and

Information Bias to Confounding
Selection bias and confounding are not
always clearly demarcated. In
particular, selection bias can sometimes
be viewed as a type of confounding,
since both can be reduced by controlling
for surrogates for the determinants of
the bias (e.g. social class).
Unfortunately, selection affected by
exposure and disease generates a bias
that cannot be reduced in this fashion.
Some consider any bias that can be
controlled in the analysis as
confounding. Other biases are then
categorized according to whether they
arise from the selection of study
subjects (selection bias), or their
classification (information bias).
Assessment of information bias

Information bias is usually of most
concern in historical cohort studies or
case-control studies when information is
obtained by personal interview. Despite
these concerns, relatively little
information is generally available on the
accuracy of recall of exposures. When
possible, it is important to attempt to
validate the classification of exposure or
disease, e.g., by comparing interview
results with other data sources such as
employer records, and to assess the
potential magnitude of bias due to
misclassification of exposure.
Summary
The greatest concern in

epidemiological studies usually relates
to confounding, because exposure has
not been randomly allocated, and the
groups under study may therefore be
noncomparable with respect to their
baseline disease risk. However, to be a
significant confounder, a factor must
be strongly predictive of disease and
strongly associated with exposure.
Thus, although confounding is
constantly a source of concern, the
strength of confounding is often
considerably less than might be
expected (it should be appreciated
however, that this appearance may be
illusory, for non-differential
misclassification of a confounder which
is common will usually make the
confounding appear smaller than it

really is).
Provided that information has been
collected in a standardized manner
(and its accuracy is unrelated to other
errors), then misclassification will be
non-differential, and any bias it
produces will usually be towards the
null value. In this situation,
misclassification tends to produce false
negative findings and is thus of
greatest concern in studies which have
not found an important effect of
exposure; it is of much less concern in
studies with positive findings, since
these findings are likely to have been
even more strongly positive if
misclassification had not occurred.
79
Again, one should appreciate the

limitations of these observations: it
may be difficult to be sure that the
exposure and disease misclassification
is non-differential, and non-differential
misclassification of a confounder can

lead to bias away from the null if the
confounder produces confounding
away from the null.
References
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confounding in occupational health
epidemiology. Scand J Work Environ
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Greenland S, Robins JM (1985).
Confounding and misclassification. Am
Chavance M, Dellatolas G, Lellouch J

(1992). Correlated nondifferential
misclassifications of disease and
exposure: application to a crosssectional study of the relationship
between handedness and immune
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Greenland S, Robins JM (1986).

Identifiability, exchangeability and
epidemiological confounding. Int J
Copeland KT, Checkoway H, McMichael

AJ, et al (1977). Bias due to
misclassification in the estimation of
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Kogevinas M, Pearce N, Susser M,

Boffetta P (1997). Social inequalities
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N, Susser M, Boffetta P (eds). Social
inequalities and cancer. Lyon: IARC,
pp 1-15.
Criqui MH (1979). Response bias and risk

ratios in epidemiologic studies.
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Kristensen P (1992). Bias from

nondifferential but dependent
misclassification of exposure and
outcome. Epidemiol 3: 210-5.
Dosemeci M, Wacholder S, Lubin JH

(1990). Does nondifferential
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bias a true effect toward the null
value? Am J Epidemiol 132: 746-8.
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Confounding and interaction. In:
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(eds). Handbook of epidemiology.
Heidelberg: Springer-Verlag, 2004, pp
375-401.
Greenland S (1980). The effect of

misclassification in the presence of
covariates. Am J Epidemiol 112: 5649.
Robins J (1987). A graphical approach to

the identification and estimation of
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Greenland S, Neutra R (1981). An

analysis of detection bias and
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Robins J (1989). The control of

confounding by intermediate variables.
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Robins JM, Blevins D, Ritter G, et al
(1992). G-estimation of the effect of
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Walker AM (1982). Anamorphic analysis:

sampling and estimation for covariate
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Weinberg CR (1993). Toward a clearer
definition of confounding. Am J
Epidemiol 137: 1-8.
Robins JM, Hernn MA, Brumback B

(2000). Marginal structural models and
causal inference in epidemiology.
Epidemiol 11; 550-62.
White JE (1982). A two-stage design for

the study of the relationship between a
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Rothman KJ, Greenland S (1998). Modern

epidemiology. 2nd ed. Philadelphia:
Lippincott-Raven.
Wrensch M, Miike R, Neuhaus J

(2000). Are prior head injuries of
diagnostic X-rays associated with
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control selection bias.
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al (1988). Smoking and degree of
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81
82
CHAPTER 7. Effect Modification

In the previous chapter I discussed the

problem of confounding which occurs
when the exposed and non-exposed
subpopulations of the source population
are inherently different in background
disease risk. This should not be confused
with effect modification which occurs
when the measure of the effect of the
study factor depends on the level of
another factor in the study population
(Miettinen, 1974). The term statistical

interaction denotes a similar phenomenon
in the observed data. However, the terms
interaction and effect modification are
also used in a variety of other contexts,
with a variety of meanings. In particular,
the term interaction has different
meanings for biostatisticians, lawyers,
clinicians, public health professionals,
epidemiologists and biologists.
Example 7.1
Katsouyanni et al (1993)
studied the effects of air
pollution and high
temperature in the
causation of excess
mortality during a major
heat wave in Greece in
July 1987. They found
that the effects of the
heat wave were modified

by the presence (or
absence) or high air
pollution levels. In Athens
(where air pollution levels
are high) the increase in
deaths on extremely hot
days was 97% in Athens,
but was 33% in other
urban areas and 27% in

non-urban areas. Further
analyses suggested that
the threshold of effect of
various air pollutants
appeared to be lower on
extremely hot days.
7.1 Concepts of Interaction
The different concepts of interaction will

be illustrated with data from a
hypothetical study of the risk of lung
cancer per 1,000 population (e.g. over a
five year period) in relation to exposure
to cigarette smoke and asbestos (Table
7.1). The risk difference due to smoking
is 30 per 1,000 in asbestos workers and 9
83
per 1,000 person-years in smokers. On

the other hand, the rate ratio for smoking
is 7.0 in asbestos workers and 10.0 in
other people. I will now consider how this
data might be interpreted by a different
researchers and policy makers. In each
instance, it is recognized that it is
important to prevent or reduce both
asbestos exposure and smoking.

However, in this case the asbestos
exposure has already occurred and the
factory has now closed, so our focus is on
smoking. We want to know whether the
effect of smoking is modified by
asbestos exposure, i.e. do smoking and
asbestos exposure interact?
Two Biostatisticians
Suppose that we first consult a
biostatistician about how to interpret this
data. The first biostatistician we talk to
uses relative risk measures of effect.
They note that the relative risk for
smoking and lung cancer is 7.0 (35/5) in
asbestos workers and 10.0 (10/1) in
other people. Thus, the effect of smoking
on lung cancer is less in asbestos workers
and there is therefore a negative
statistical interaction between the effects
of smoking and asbestos (table 7.2).
They may even fit a multiplicative model
with an interaction term and show that
the interaction term is negative.
We can see the logic of this argument,
but are somewhat surprised by the
conclusion, since we can see the very
high rates in people who both smoke and
are exposed to asbestos. We therefore
consult a second biostatistician. This
alternative biostatistician uses the risk
difference as the effect measure. They

note that the risk difference for smoking
and lung cancer is 30 per 1,000 (35 - 5)
in asbestos workers and 9 per 1,000 (10
- 1) in other people. Thus, the effect of
smoking is greater in asbestos workers
and there is a positive statistical
interaction between the effects of
smoking and asbestos (table 7.2). They
may even fit an additive model with an
interaction term and show that the
interaction term is positive.
We eventually get our two biostatistical
consultants together and they argue that
there is no contradiction in the advice
they have given us. Effect modification
and statistical interaction are merely
statistical concepts which depend on the
methods used. In fact, all secondary risk
factors modify either the rate ratio or the
rate difference, and uniformity over one
measure implies non-uniformity over the
other (Koopman, 1981; Steenland and
Thun, 1986), e.g. an apparent additive
joint effect implies a departure from a
multiplicative model. Several authors
(e.g. Kupper and Hogan, 1978; Walter
and Holford, 1978) have demonstrated
the dependence of statistical interaction
on the underlying statistical measure of
effect, and have therefore argued that
the assessment of interaction is "modeldependent".
Table 7.1
Lung cancer risk per 1,000 people (and RR) in relation to exposure to cigarette smoke
and asbestos
Asbestos
Yes
No
-----------------------------------------------------Smoking
Yes
35/1000 (35.0)
10/1000 (10.0)
No
5/1000 (5.0)
1/1000 (1.0)
-----------------------------------------------------Rate difference
30/1000
9/1000
------------------------------------------------------------------------------------Rate ratio
7.0
10.0
84
A Lawyer
Next we consult a lawyer (I do not
advise this as a real course of action;
this is just a hypothetical consultation!).
She/he is also concerned about the
effect of smoking, but the effect they are
interested in is what is the probability
that my clients lung cancer was caused
by their smoking? If we look at the
asbestos workers, we find that if they
smoked their risk of lung cancer was 35
per 1,000 whereas it was 7 per 1,000 if
they didnt smoke. Thus, assuming there
is no confounding by other factors, then
of every 35 lung cancer occurring in the
smokers, 5 would have happened
anyway, and 30 are additional cases due
to smoking. Thus, for an individual lung
cancer case, the probability that smoking
caused the cancer is 100*30/35 which is
86% (this is just 100*(R-1)/R where R is

the relative risk of 1.9). The
corresponding estimate for other people
(not exposed to asbestos) is 100*9/10
which is 90%. Thus, the probability of
causation by smoking is slightly less in
asbestos workers and there is therefore
a negative interaction between the
effects of smoking and asbestos (table
7.2). It should be noted that this
lawyers approach is a little simplistic
(Greenland, 1999), but the key issue
here is that the effect that is being
measured, and the inference about
interaction, is different from that of the
two biostatisticians, although it is more
consistent with that of the biostatistician
who uses the relative risk as the
measure of effect.
Table 7.2
The approaches of different consultants to interpreting the data in table 8.1
Consultant
Effect
measure
Size of effect
---------------------------- Inherent
Asbestos
Statistical
workers
Others
model
Biostatistician 1
Relative risk
7.0
10.0
Relative risk
Yes
-ve
Biostatistician 2
Risk difference
30/1000
9/1000
Risk difference
Yes
+ve
Lawyer
Probability of
causation
86%
90%
Relative risk
Yes
-ve
Clinician
Individual risk
30 per
1,000
9 per
1,000
Risk difference
Yes
+ve
Public health
worker
Deaths
prevented
30 per
1,000
9 per
1,000
Risk difference
Risk difference
Yes
Yes
+ve
+ve
Epidemiologist
Combination of
factors to cause
disease
21 cases
out of 35
(60%) are
due to the
combination
of exposures
Not
applicable
Risk difference
Yes
+ve
Is there an
Interaction? Direction?
----------------------------------------------------------------------------------------------------------
85
A Clinician
except that they are concerned about

the population rather than about
individual patients. They say I want to
conduct population smoking prevention
campaigns and persuade people to give
up smoking and that if they do then
they will reduce their risk of lung
cancer. I only have a limited amount of
resources so I want to know if I can
prevent more cases of lung cancer by
focusing on asbestos workers, or by
doing my campaigns in the same
number of people in the general
population. If they prevent 1,000
asbestos workers smoking, then (once
there has been time for the reduction in
risk to start occurring) they will have
prevented 30 lung cancer cases each
year. If they prevent 1,000 other people
from smoking then each year they will
have prevented 9 cases of lung cancer.
Thus, the effect of smoking is greater in
asbestos workers and there is therefore
a positive statistical interaction between
the effects of smoking and asbestos
(table 7.2).
Next we consult with a clinician. She/he

says I advise my patients to give up
smoking, and I tell them that if they do
manage to stop then they will reduce
their risk of lung cancer. They ask by
how much? So I want to know what the
reduction in their individual risk will be if
they give up smoking. Well, if their
patient is an asbestos worker then they
will reduce their risk by 30 per 1,000
(over five years) by giving up smoking;
other people will reduce their risk by 9
per 1,000 (once again, this is a little
simplistic since it this does not tell us
exactly how many years of life they will
gain). Thus, the effect of smoking is
greater in asbestos workers and there is
therefore a positive statistical
interaction between the effects of
smoking and asbestos (table 8.2).
A Public Health Worker
The public health worker that we consult
has a similar approach to the clinician,
Figure 7.1
Numbers of cases occurring through background factors, asbestos alone,

smoking alone, and their combination in people exposed to both factors
Background
Asbestos
Smoking
Asbestos &
Smoking
S
U
Cases
1/35 (3%)
4/35 (11%)
86
9/35 (26%)
21/35 (60%)
An Epidemiologist
asbestos) together with unknown

background exposures (U), and 21
cases (60%) occurred through
mechanisms involving both factors
together with unknown background
exposures (U). This means that 86%
of the cases (26% + 60%) could have
been prevented by preventing smoking,
whereas 71% (11% + 60%) could have
been prevented by preventing asbestos
exposure. Thus, the attributable risks
for the individual factors of smoking
(86%) and asbestos (71%) sum to
more than 100% because of the cases
that occur through mechanisms
involving both exposures and which
consequently could be prevented by
preventing either exposure.
I have argued in chapter 1 that

epidemiology is part of public health,
and therefore I might be quite content
to accept the public health workers
approach. However, as an
epidemiologist I do want to know more
about the causation of disease, since
what I learn may be relevant to other
exposures or other diseases. Thus, I
may be particularly interested in the
combination of smoking and asbestos to
produce cases of lung cancer. Rothman
and Greenland (1998) have thus
adopted an unambiguous
epidemiological definition of interaction
in which two factors are not
"independent" if they are component
causes in the same sufficient cause. This
concept of independence of effects leads
to the adoption of additivity of incidence
rates as the state of "no interaction".
Thus, the fact that the lung cancer rate
in the group exposed to both factors
(35/1000) is greater than the sum of
the baseline risk (1/1000) plus the
effect of asbestos alone (5/1000
1/1000) plus the effect of smoking
alone (10/1000 - 1) indicates that there
are some cases of disease that are
occurring due to the combination of
exposures and which would not have
occurred if either of the exposures had
been eliminated. We can do the same
calculations using the relative risks
(relative to the group with exposure to
neither factor) rather than incidence
rates: the joint effect is 35.0 times,
whereas it would be 1+(5.0-1)+(10.01)=14.0 if it were additive. This
situation is summarized in figure 7.1. It
shows that in the group exposed to both
factors, 1 case (3%) occurred through
unknown background exposures (U), 4
cases (11%) through mechanisms
involving asbestos exposure alone (and
not smoking) together with unknown
background exposures (U), 9 cases
(26%) occurred through mechanisms
involving smoking alone (and not
One apparent exception should be noted

(Koopman, 1977). If two factors (A and
B) belong to different sufficient causes,
but a third factor (C) belongs to both
sufficient causes, then A and B are
competing for a single pool of
susceptible individuals (those who have
C). Consequently the joint effect of A
and B will be less than additive
(Miettinen (1982) reaches a similar
conclusion based on a model of
individual outcomes). However, this
phenomenon can be incorporated
directly into the causal constellation
model by clarifying a previous ambiguity
in the description of antagonism in the
model's terms. Specifically, the absence
of B can be included in the causal
constellation involving A, and vice
versa. Then, two factors would not be
"independent" if the presence or
absence of the factors (or particular
levels of both factors) were component
causes in the same sufficient cause
(Greenland and Poole, 1988; Rothman
and Greenland, 1998).
A Biologist
Finally, it should be stressed that this
epidemiological concept of
independence of effects is distinct from
87
some biological concepts of

independence. For example, Siemiatycki
and Thomas (1981) give a definition in
which two factors are considered to be
biologically independent "if the
qualitative nature of the mechanism of
action of each is not affected by the
presence of absence of the other".
However, this concept does not lead to
an unambiguous definition of
independence of effects, and thus does
not produce clear analytic implications.
Rothman's concept of independence is
at a more abstract conceptual level in
which a particular biologic model, rather

than being accepted as the "baseline", is
itself evaluated in terms of the coparticipation of factors in a sufficient
cause. For example, two factors which
act at different stages of a multistage
process are not independent since they
are joint components of at least one
sufficient cause. This occurs irrespective
of whether they affect each other's
qualitative mechanism of action (the
ambiguity in Siemiatycki and Thomas'
formulation stems from the ambiguity of
this concept).
7.2 Multiplicative and Additive Models
Rothman's approach is attractive

because it is based on epidemiological
concepts which have a clear biologic
interpretation, and because it leads to
an unambiguous definition of
independence of effects which is
identical to that obtained through
public health considerations (Rothman
et al, 1980). However, the analytic
implications of these concepts are not
straightforward, since assessing
independence of effects is usually only
one of the analytic goals of an
epidemiological study. Rather, there
are several other considerations which
often favour the use of multiplicative
models.
Second, it has been argued that

multiplicative models facilitate the
assessment of the extent of unknown
confounding or bias (Cornfield et al,
1959), although this is not always the
case.
Third, if it is desired to keep statistical
interaction (effect modification) to a
minimum, then a multiplicative model
may be more appropriate. It is not
uncommon for risk factors to have
approximately multiplicative effects
(Saracci, 1987). This presumably
occurs because they are a part of
common causal processes, although
other sufficient causes usually also
operate, and exact multiplicativity may
not occur. Nevertheless, in this
situation there may be less masking of
heterogeneity in calculating an overall
rate ratio than in calculating an overall
rate difference; there are also many
instances of non-multiplicative
departures from additivity, however
(Selikoff et al, 1980; Saracci, 1987).
First, multiplicative models have

convenient statistical properties.
Estimation in non-multiplicative
models may have problems of
convergence, and inference based on
the asymptotic standard errors may be
flawed unless the study size is very
large (Moolgavkar and Venzon, 1987).
88
7.3 Joint Effects
These considerations imply an apparent

dilemma. How can an analysis be
conducted which combines the
advantages of ratio measures of effect
with the assessment of independence in
terms of a departure from additivity?
These apparently contradictory goals
can be reconciled in analyses which
concentrate on the estimation of
separate and joint effects (Pearce,
1989).
analysis strategies are based on the

principle that it is not appropriate to
calculate an overall effect estimate if
interaction is present. However, this
principle is commonly ignored if the
difference in stratum-specific effect
estimates is not too great. In fact
standardized rate ratios (see chapter
12) have been developed for precisely
this situation, and will consistently
estimate meaningful epidemiological
parameters even under heterogeneity
(Greenland, 1982). Nevertheless, some
authors have proposed modeling
strategies in which the first step in the
analysis involves testing for statistical
interaction. A related approach has been
the development of generalized families
of models which include the additive
and multiplicative models as special
cases. An alternative general strategy
can be based on epidemiological
considerations (Pearce, 1989). The key
difference is that interaction is assessed
(rather than tested) in terms of a
departure from additivity in order to
elaborate an observed effect, rather
than being tested for departure from an
arbitrary effect measure as an essential
initial analytic step. This procedure can
be achieved within the confines of
statistically convenient multiplicative
models through the analysis of separate
and joint effects.
Thus, when studying asbestos, smoking

and lung cancer, relative risks might be
presented for smoking (in non-asbestos
workers), asbestos exposure (in nonsmokers) and exposure to both factors,
relative to persons exposed to neither
factor. These relative risks would be
adjusted for all other factors (e.g. age)
which are potential confounders, but not
of immediate interest as effect
modifiers.
The estimation of separate and joint
effects may be difficult when the factors
of interest are closely correlated, and
there are therefore only small numbers
of people who are exposed to either
factor alone. However, when it is
feasible, this approach combines the
best features of multiplicative models
and additive independence assessment,
but also permits readers with other
concepts of independence to draw their
own conclusions (as in table 7.1).
When the assessment of joint effects is
a fundamental goal of the study, it can
be accomplished by calculating stratumspecific effect estimates, as in Example
7.1 above. On the other hand, it is less
clear how to proceed when effect
modification is occurring, but
assessment of joint effects is not an
analytical goal. Conventional statistical
89
Summary
The terms interaction and effect

modification are used in a variety of
contexts, with a variety of meanings. In
particular, the term interaction has
different meanings for biostatisticians,
lawyers, clinicians, public health
professionals, epidemiologists and
biologists. In each instance, they are
interested in the same question, namely
does the effect of exposure A depend on
whether exposure B is also present (or
absent)? However, the word effect has
different meanings in different contexts.
In contrast to definitions based on
statistical concepts, Rothman has
adopted an unambiguous
epidemiological definition of interaction
in which two factors are not

"independent" if they are component
causes in the same sufficient cause. This
leads to the adoption of additivity of
incidence rates as the state of "no
interaction". However, there are other
considerations which generally favor the
use of multiplicative models. This
implies an apparent dilemma as to how
an analysis can be conducted which
combines the advantages of ratio
measures of effect with the assessment
of independence in terms of a departure
from additivity. These apparently
contradictory goals can be reconciled
through the analysis of separate and
joint effects.
References
Cornfield J, Haenszel W, Hammond EC,

et al (1959). Smoking and lung
cancer: recent evidence and a
discussion of some questions. JNCI
22: 173-203.
Katsouyanni K, Pantazopoulou A,
Touloumi G, et al. Evidence for
interaction between air pollution and
high temperature in the causation of
excess mortality. Arch Environ Health
1993; 48: 235-42.
Greenland S (1982). Interpretation and

estimation of summary ratios under
heterogeneity. Statist Med 1: 21727.
Koopman JS (1977). Causal models and

sources of interaction. Am J
Greenland S, Poole C (1988). Invariants

and noninvariants in the concept of
interdependent effects. Scand J Work
Environ Health 14; 125-9.
Koopman JS (1981). Interaction

between discrete causes. American
Journal of Epidemiology 13:716-724.
Kupper LL, Hogan MD (1978).
Interaction in epidemiologic studies.
Greenland S (1999). Relation of

probability of causation to relative
risk and doubling dose: a
methodologic error that has become
a social problem. AJPH 89: 1166-9.
Miettinen OS (1974). Confounding and

effect modification. Am J Epidemiol
100: 350-3.
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Miettinen OS (1982). Causal and

preventive interdependence:
elementary principles. Scand J Work
Environ Health 8: 159-68.
cancer etiology. Epidemiologic

Reviews 9: 175-93.
Selikoff I, Sedman H, Hammond E
(1980). Mortality effects of cigarette
smoking among amosite asbestos
factory workers. JNCI 65: 507-13
Moolgavkar SH, Venzon DJ (1987).

General relative risk models for
epidemiologic studies. Am J
Siemiatycki J, Thomas DC (1981).

Biological models and statistical
interactions: an example from
multistage carcinogenesis. Int J
Pearce NE (1989). Analytic implications

of epidemiological concepts of
interaction. Int J Epidemiol 18: 97680.
Steenland K, Thun M (1986). Interaction

between tobacco smoking and
occupational exposures in the
causation of lung cancer. Journal of
Occupational Medicine 28:110-118.
Rothman KJ, Greenland S, Walker AM

(1980). Concepts of interaction. Am J
Walter SD, Holford TR (1978). Additive,

multiplicative and other models for
disease risks. Am J Epidemiol 108:
341-6.
Saracci R (1987). The interactions of

tobacco smoking and other agents in
91
92
Part III
Conducting a study
93
94
CHAPTER 8. Measurement of Exposure and

Health Status
In this chapter I briefly review the

various options for measuring exposure
and disease status. In the following
chapters I then discuss the practicalities

of conducting cohort, case-control and
cross-sectional studies.
8.1 Exposure
As discussed in chapter 1, epidemiological

studies involve a wide variety of
exposures ranging from the population
level to the individual and micro-levels.
The term exposure is thus used
generically to refer to any factor that is
under study, and exposures may include
population factors (e.g. income
inequality), individual-level socioeconomic factors (e.g. income), physical
environmental factors (e.g. air pollution),
aspects of individual lifestyle (e.g. diet),
as well as exposures measured at the
level of the body, (e.g. total body burden
of dioxin), organ (e.g. the concentration
of asbestos in the lung), cell, or molecule
(e.g. DNA adducts). These various
situations are discussed here briefly; a
more detailed discussion can be found in
Armstrong et al (1992).
Exposure and Dose
Strictly speaking, the term exposure
refers to the presence of a substance
(e.g. fine particulate matter) in the
external environment, whereas the term
dose refers to the amount of substance
that reaches susceptible targets within
the body, such as the airways. In some
situations (e.g. in a coal mine)
measurements of external exposures
95
may be strongly correlated with internal

dose, whereas in other situations (e.g.
environmental lead exposure) the dose
may depend on individual lifestyle and
activities and may therefore be only
weakly correlated with the
environmental exposure levels.
Exposure levels can be assessed with
regard to the intensity of the substance
in the environment (e.g. dust
concentration in the air) and the
duration of time for which exposure
occurs. The risk of developing disease
may be much greater if the duration of
exposure is long and/or the exposure is
intense, and the total cumulative
exposure may therefore be important.
For protracted etiologic processes, the
time-pattern of exposure may be
important and it is possible to assess
this by examining the separate effects of
exposures in various time windows prior
to the occurrence and recognition of
clinical disease (Pearce, 1992). For
example, in cancer studies recent
exposures may not be relevant since the
cancer may have first become
established some years previously
(Pearce, 1988). Similarly, recent work
suggests that occupational asthma is
most likely to occur after about 1-3
years of exposure to a sensitising agent

(Ant et al, 1996).
Methods of exposure measurement

include personal interviews or selfadministered questionnaires (completed
either by the study participant or by a
proxy respondent), diaries, observation,
routine records, physical or chemical
measurements on the environment, or
physical or chemical measurements on
the person (Armstrong et al, 1992). For
example, table 8.1 summarizes the types
of exposures data most commonly used
in occupational epidemiology studies
(Checkoway et al, 2004). Measurements
on the person can relate either to
exogenous exposure (e.g. airborne dust)
or internal dose (e.g. plasma cotinine);
the other measurement options (e.g.
questionnaires) all relate to exogenous
exposures.
Socio-economic status poses more

significant measurement problems. It
can be measured in a variety of ways,
including occupation, income, and
education (Liberatos et al, 1988;
Berkman and MacIntyre, 1997). These
measures may pose problems in some
demographic groups; for example,
occupation and income may be poor
measures of socio-economic status in
women, for whom the total family
situation may reflect their socioeconomic status better than their
individual situation, and measures of
socio-economic status in children must
be based on the situation of the parents
or the total family situation.
Nevertheless, the various measures of
socio-economic status are strongly
correlated with each other, and asthma
epidemiology studies are usually based
on whichever measures are available,
unless socio-economic status is the main
focus of the research and it is necessary
to obtain more detailed information.
Demographic Factors
Questionnaires
In most instances, information on

demographic factors such as age,
gender and ethnicity can be obtained in
a straightforward manner from routine
health care records or with
questionnaires. In studies focusing on
ethnicity, the etiologically relevant
definition will depend on the extent to
which an ethnic difference is considered
to be due to genetic and/or cultural and
environmental factors, but the available
information will vary from country to
country depending on historical and
cultural considerations. For example, in
New Zealand, Mori ethnicity is defined
as a person who has Mori ethnicity and
chooses to identify as Mori (Pomare et
al, 1992), whereas some other countries
use solely biologically-based definitions
of race or ethnicity (Polednak, 1989).
Traditionally, exposure to most nonbiological risk factors (e.g. tobacco

smoking) has been measured with
questionnaires, and this approach has a
long history of successful use in
epidemiology (Armstrong et al, 1992).
Questionnaires may be self-administered
(e.g. postal questionnaires) or
interviewer-administered (e.g. in
telephone or face-to-face interviews)
and may be completed by the study
subject or by a proxy (e.g. parental
completion of questionnaires in a study
of children, or completion by the spouse
of deceased cases). The validity of
questionnaire data also depends on the
structure, format, content and wording
of questionnaires, as well as methods of
administration and selection and training
of interviewers (Armstrong et al, 1992).
General Approaches to Exposure

Assessment
96
Table 8.1
Types of exposure data commonly used in occupational epidemiology studies
(Source: Adapted from Checkoway et al, 2004)
Ever employed in the industry

Duration of employment in the industry
Ordinally ranked jobs or tasks
Job-exposure matrices
Quantified personal measurements
Example 8.1
Raum et al (2001)
studied the impact of
maternal socio-economic
status on intrauterine
growth in the former
west and East Germany.
Information on sociodemographic or lifestyle
factors and pregnancy
outcome was available
for 3,374 live-born
singletons from West
Germany (1987/88) and
3070 from East Germany
(1990/91). Women were
recruited during
pregnancy and given a

self-administered 30page questionnaire
covering sociodemographic,
psychosocial, nutritional,
environmental and
occupational factors. The
two school systems were
not identical, but in each
system maternal
educational level was
grouped into five
categories. Women with
the lowest education had
a significantly elevated
risk of small-forgestational-age (SGA)

newborns compared to
women with the highest
education in both the
west (OR = 2.58, 95%
CI 1.17-5.67) and the
east (OR = 2.77, 95% CI
1.54-5.00). The authors
concluded that social
inequalities existed and
caused health
inequalities in both the
West, and in the former
socialist country of East
Germany.
Example 8.2
Vartia (2001) studied
the consequences of
workplace bullying in the
municipal sector in
Helsinki, Finland. Every
35th member of the
Municipal Officials Union
was selected and 1037
(65.5%) responded to a
postal questionnaire. A
definition of bullying was
provided and study
participants were asked

if they felt themselves
subjected to such
behaviour, or if they had
observed someone else
at their workplace being
bullied. They were also
asked about the
frequency and duration
of such acts. Both the
targets of bullying and
the observers reported
97
more general stress and

mental stress reactions
than did respondents
from workplaces with no
bullying. The targets
of bullying used sleepinducing drugs and
sedatives more often
than did the
respondents who were
not bullied.
Environmental Measurements and

Job-Exposure Matrices
In many studies, e.g. community-based
case-control studies, questionnaires are
the only source of exposure information.
However, in some instances, particularly
in occupational studies, questionnaires
may be combined with environmental
exposure measurements (e.g. industrial
hygiene surveys) to obtain a quantitative
estimate of individual exposures. Table
8.2 shows environmental measurements
in an asbestos textile plant in South
Carolina (Dement et al, 1983;
Checkoway et al, 2004). It shows that
for each job title, exposure levels

decreased over time, but increased again
during the 1966-75 time period. Within
each time period, the highest exposures
were in raw fiber handling and the
lowest were in general area workers.
This historical exposure information can
be combined with information from
employment records to obtain exposure
estimates for individual workers. For
example, table 5.3 shows the cumulative
exposure for a worker who worked as a
card operator during 1933-1938 and
then worked in clean-up during 19391948.
Example 8.3
Saracci et al (1984a)
conducted a historical
cohort study of mortality
and cancer incidence of
workers exposed to
made-made vitreous
fibres at 13 European
plants. At 12 of the
plants an environmental
survey was conducted to
measure present
concentrations of fibres
in air samples. This was
used to create a jobexposure matrix. Within
each plant, job/plant

areas were grouped into
six main occupational
categories: not
specified, office,
preproduction,
production, secondary
processes and
maintenance. For each
worker a cumulative
exposure index was
created by multiplying
the time spent in each
job category by the
mean concentration of
respirable fibres in the

job category. The
relative risk of lung
cancer was elevated,
particularly in the group
with 30 years or more
since first employment
(RR=1.92, 95% CI 1.173.07). There was a
tendency for the risk to
increase with cumulative
exposure, but the
pattern was not
consistent.
Table 8.2
Asbestos concentrations (fibers/cc) in job categories in an asbestos textile plant
(Source: Adapted from Checkoway et al, 2004)
Job category
General area
Card operators
Clean-up
Raw fiber handling
1930-35
10.8
13.3
18.1
22.8
1936-45
5.3
6.5
8.8
11.0
98
1946-65
2.4
2.9
4.0
5.0
1966-75
4.3
5.3
7.2
9.0
Table 8.3
Example of an exposure history of an individual worker
Job
Card operator
Card operator
Clean-up
Clean-up
Years
1933-35
1936-1938
1939-45
1946-48
Mean exposure
10.8
6.5
8.8
4.0
Cumulative exposure
32.4
41.9
103.5
115.5
Quantified Personal Measurements

In some instances, quantified personal
exposure measurements may be
available, e.g. in radiation workers
wearing radiation dosimeters
(Checkoway et al, 2004). This
information is invaluable when it is
available, but it is rarely available for
historical exposures with the exception
of some industries such as the nuclear
power industry. Such information can
of course be collected prospectively.
This is rarely practical for cohort
studies of rare diseases with long
latency periods (e.g. cancer), but is
more appropriate for cohort studies of
relatively common conditions. For
example, infant cohort studies of
respiratory disease frequently
prospectively collect information on
individual levels of allergen exposure
(e.g. Lau et al, 2001).
Quantified personal exposure

measurements can also be used in
case-control studies to estimate
historical exposures. However, a
potential problem in this situation is
that exposure may have changed over
time, or study participants may change
their behaviour as a result of having
been diagnosed with disease. This has
been a particular issue in case-control
studies of electromagnetic field
exposure and childhood leukemia
where it has been argued that current
personal exposure measurements may
be inferior to wire code information
(i.e. whether the wiring to the house is
underground, or by overhead wires,
etc) in estimating historical exposures
(Neutra and del Pizzo, 1996).
99
Example 8.4
Wing et al (1991)
conducted a historical
cohort mortality study
among workers at Oak
Ridge National
Laboratory, Tennessee.
Individual exposures to
external penetrating
radiation, primarily
gamma rays, were
measured using pocket
ionising chambers from
1943 until June 1944,
film badges from then

until 1975, and
thermoluminescent
dosimeters since 1975.
This information was
used to estimate
individual exposures
over time. After
accounting for age, birth
cohort, socio-economic
status, and active
worker status, external
radiation with a 20-year
exposure lag (i.e.

exposures were only
considered up until 20
years previously) was
associated with an
increased risk of death
(2.68% increase per 10
mSv cumulative
exposure), particularly
from cancer (4.94%
increase per 10 mSv).
Biomarkers
More recently, there has been increasing
emphasis on the use of molecular
markers of internal dose (Schulte,
1993). In fact, there are a number of
major limitations of currently available
biomarkers of exposure (Armstrong et
al, 1992), particularly with regard to
historical exposures (Pearce et al, 1995).
For example, serum levels of
micronutrients reflect recent rather than
historical dietary intake (Willett, 1990).
Some biomarkers are better than others
in this respect (particularly markers of
exposure to biological agents), but even
the best markers of chemical exposures
usually reflect only the last few weeks or
months of exposure. On the other hand,
with some biomarkers it may be possible
to estimate historical levels provided that
certain assumptions are met. For
example, it may be possible to estimate
historical levels of exposure to pesticides
(or contaminants) from current serum
levels provided that the exposure period
is known, and the half-life is known.
Similarly, information on recent
exposures can be used if it is reasonable
to assume that exposure levels (or at
least relative exposure levels) have
100
remained stable over time (this may be

particularly relevant in occupational
studies), and have not been affected by
lifestyle changes, or by the occurrence of
the disease. However, if the aim is to
measure historical exposures, then
historical information on exposure
surrogates may be more valid than direct
measurements of current exposure or
dose levels. This situation has long been
recognised in occupational epidemiology,
where the use of work history records in
combination with a job-exposure matrix
(based on historical exposure
measurements of work areas rather than
individuals) is usually considered to be
more valid than current exposure
measurements (whether based on
environmental measurements or
biomarkers) if the aim is to estimate
historical exposure levels (Checkoway et
al, 2004). On the other hand, some
biomarkers have potential value in
validation of questionnaires which can
then be used to estimate historical
exposures. Furthermore, biomarkers of
internal dose may have relatively good
validity in studies involving an acute
effect of exposure.
A more fundamental problem of

measuring internal dose with a
biomarker is that it is not always clear
whether one is measuring the exposure,
the biological effect, or some stage of
the disease process itself (Saracci,
1984b). Thus the findings may be
uninterpretable in terms of the causal
association between exposure and
disease. When it is known that the
biologically effective dose is the most
appropriate measure, then the use of
appropriate biomarkers clearly has some
scientific advantages. However, choosing
the appropriate biomarker is a major
dilemma, and biomarkers are frequently
chosen on the basis of an incomplete or
erroneous understanding of the etiologic
process (or simply because a particular
marker can be measured). An
environmental exposure (e.g. tobacco
smoke) may involve hundreds of
different chemicals, each of which may
produce hundreds of measurable

biological responses (there are
exceptions to this, of course, such as
environmental lead exposure, but most
environmental exposure involves
complex mixtures). A biomarker typically
measures one of the biological responses
to one of the chemicals. If the chosen
biomarker measures the key etiological
factor, then it may yield relatively good
exposure data; however, if a biomarker
is chosen which has little relationship to
the etiological component of the complex
exposure mixture then the biomarker will
yield relatively poor exposure data.
A further major problem with the use of
biomarkers is that the resulting expense
and complexity may drastically reduce
the study size, even in a case-control
study, and therefore greatly reduce the
statistical power for detecting an
disease.
Example 8.5
Ross et al (1992) studied
urinary aflatoxin
biomarkers and risk of
hepatocellular carcinoma
as part of an ongoing
prospective study of
18,244 middle-aged men
in Shanghai. After
35,299 person-years of
follow-up, a nested casecontrol study was

conducted based on the
22 identified cases of
liver cancer, and 140
density-matched
controls (matched for
age and neighbourhood
or residence). The cases
101
of liver cancer were

more likely than controls
to have detectable
concentrations of
aflatoxin metabolites
(OR = 2.4, 95% CI 1.05.9).
Thus, questionnaires and environmental

measurements will continue to play a
major role in exposure assessment in
epidemiology, but biomarkers may be
expected to become increasingly useful
over time, as new techniques are
developed. The emphasis should be on
using appropriate technology to obtain
the most practical and valid estimate of
the etiologically relevant exposure. The

appropriate approach (questionnaires,
environmental measurements or
biological measurements) will vary from
study to study, and from exposure to
exposure within the same study, or
within the same complex chemical
mixture (e.g. in tobacco smoke).
8.2 Health Status
The type of information required for

measuring health status in
epidemiological studies may be different
from that which is required in clinical
practice. As with exposure data, the key
issue is that information should be of
similar quality for the various groups
being compared. For example, suppose
that the bladder cancer incidence in a
particular geographical area is being
compared with national incidence rates;
then it would be inappropriate to
conduct a pathological review and
reclassification of the cases of the cancer
identified in the area, since such a
reclassification had not been made for
the national data and the information
would not be comparable. Rather, the
cancer cases in the area should be
classified exactly as they had been
classified in routine national cancer
statistics. Thus, the emphasis should be
on the comparability of information
across the various groups being
compared.
The types of health outcome data used
in epidemiological studies include:
mortality; disease registers; health
service records; and morbidity surveys.
These can be grouped into data based
on routinely collected records, and
morbidity data that is collected for a
specific epidemiologic study.
102
Routine Records
Most countries maintain comprehensive
death registration systems at the
national or regional levels, and cause of
death information for identified deaths
can be obtained by requesting copies of
death certificates from national, state, or
municipal vital statistics offices. In most
instances the causes of death are coded
by a nosologist trained in the rules
specified in the International
Classification of Diseases (ICD) volumes
compiled by the World Health
Organisation. Revisions to the ICD
coding are made about every ten years,
and in some instances the ICD code for a
particular cause of death may change
(Checkoway et al, 2004).
Some countries or states also maintain
incidence registers for conditions such as
cancer, congenital malformations or
epilepsy. These have most commonly
been established for cancer registration
and the International Agency for
Research on Cancer (IARC) has been
attempting to encourage the
establishment of cancer registries and to
standardize methods of cancer
registration throughout the world
(Jensen et al, 1991). Provided that
registration is relatively complete, then
cancer registrations can provide valuable
additional health status information (and

increase the number of identified cases)
in a cohort study. Furthermore, cancer
registries are invaluable for identifying
newly diagnosed cases who can be
interviewed (while they are still alive) for
population-based case-control studies.
Many Western countries have notification
systems for occupational diseases. For
example, in the United Kingdom the
Surveillance of Work Related and
Occupational Respiratory Disease
(SWORD) project was established in
1989 as a national surveillance scheme

for occupational respiratory disease
(Meredith et al, 1991).
As discussed in chapter 9, other
routinely collected records can be used
for determining health status in cohort
studies, or to create informal registers
for identifying cases for case-control
studies; these include hospital admission
records, health insurance claims, health
maintenance organisation (HMO)
records, and family doctor (general
practitioner records).
Example 8.6
Jones et al (1998)
performed a record
linkage study of prenatal and early life risk
factors for childhood
onset diabetes mellitus.
They identified 160 boys
and 155 girls born
during 1965-1986 who
had been admitted to
hospital in Oxfordshire,
England with a diagnosis
of diabetes during 19651987. For each case, up
to eight controls were
chosen from records for
live births in the same
area, matched on sex,
year of birth and hospital
or place of birth. They
then linked the hospital

record for each child to
all of that childs hospital
records and to his or her
mothers maternity
record. There were no
significant associations
between subsequent
diabetes and
birthweight, gestational
age, birthweight for
gestational age,
maternal age and parity.
There were nonsignificantly increased
risks with not
breastfeeding (OR=1.33,
95% CI 0.76-2.34) and
with diabetes recorded
in the mother during
pregnancy (OR=5.87,
95% CI 0.90-38.3), and

a significantly raised risk
with pre-eclampsia or
eclampsia during
pregnancy (OR=1.48,
95% CI 1.05-2.10).
They hypothesized that
pre-eclampsia may be
the result of an
immunogenetic
incompatibility between
mother and fetus, and
that this early
immunological
disturbance may be
related to the incidence
of diabetes later in life.
Morbidity Surveys
In some circumstances, routine records
may not be available for the health
outcome under study, or may not be
sufficiently complete or accurate or use
in epidemiological studies. Although this
could in theory apply to mortality

records, more commonly this is an issue
for non-fatal conditions, particularly
chronic diseases such as respiratory
disease and diabetes. Such morbidity
103
surveys may involve clinical

examinations (e.g. a clinical history and
peak flow measurements for asthma),
more invasive testing (e.g. blood tests
for diabetes), questionnaires, or a
combination of these methods.
To take the example of asthma, the
essential feature of the condition (at
least in clinical and epidemiological
terms) is variable airflow obstruction
which can be reversed by treatment or is
self-limiting (Pearce et al, 1998). This
poses several problems with the use of
"diagnosed asthma" in asthma
prevalence studies, since the diagnosis
of "variable airflow obstruction" usually
requires several medical consultations
over an extended period. It is therefore
not surprising that several studies have
found the prevalence of physiciandiagnosed asthma to be substantially
lower than the prevalence of asthma

symptoms. Such problems of differences
in diagnostic practice could be minimised
by using a standardized protocol for
asthma diagnosis in prevalence studies.
However, this is rarely a realistic option
since it requires repeated contacts
between the study participants and
physicians, and this is not possible or
affordable in large-scale epidemiological
studies. Thus, most epidemiological
studies must, by necessity, focus on
factors which are related to, or
symptomatic of, asthma but which can
be readily assessed on a particular day.
The main options in this regard are
symptoms and physiological
measurements (Pearce et al, 1998). In
particular, standardized symptoms
questionnaires have been developed for
use in adults (Burney et al, 1994) and
children (Asher et al, 1995).
Example 8.7
Dowse et al (1990)
studied the prevalence
of non-insulin dependent
diabetes mellitus
(NIDDM) in adults aged
25-74 years in Mauritius.
A random sample of
5,892 individuals was
chosen and 5,080
(83.4%) participated.
They used a 75g oral
glucose tolerance test
with fasting and 2-h post
load blood collection.
Glucose tolerance was
classified according to
the World Health
Organisation (WHO)
criteria (World Health
Organisation, 1985). The
prevalence of NIDDM
was similar in men
(12.1%) and women
(11.7%). Age and sexstandardized prevalence
was similar in Hindu
Indians (12.4%), Muslim
Indians (13.3%), Creoles
(10.4%) and Chinese
(11.9%). The authors
104
commented that the

findings in Indians were
similar to those in other
studies of Indian migrant
communities, but the
findings in Creoles and
Chinese were
unexpected. Potent
environmental factors
shared between ethnic
groups in Mauritius may
be responsible for the
epidemic of glucose
intolerance.
Health status can also be measured by

more general morbidity and quality of
life questionnaires. Perhaps the most
widely used questionnaire has been the
Medical Outcomes Study Short Form
(SF-36) (Ware, 1993). This includes
scales to measure physical functioning,
role functioning, bodily pain, mental

health, and general health perceptions.
The SF-36 scales have been widely used
in clinical research in a wide variety of
populations to assess overall health
status.
Summary
Methods of exposure measurement

include personal interviews or selfadministered questionnaires (completed
either by the study participant or by a
proxy respondent), diaries, observation,
routine records, physical or chemical
measurements on the environment, or
physical or chemical measurements on
the person. Measurements on the person
can relate either to exogenous exposure
(e.g. airborne dust) or internal dose
(e.g. plasma cotinine); the other
measurement options (e.g.
questionnaires) all relate to exogenous
exposures. Traditionally, exposure to
most non-biological risk factors (e.g.
cigarette smoking) has been measured
with questionnaires (either selfadministered or intervieweradministered), and this approach has a
long history of successful use in
epidemiology. Questionnaires may be
combined with environmental exposure
measurements (e.g. pollen counts,
industrial hygiene surveys) to obtain a
quantitative estimate of individual
exposures. More recently, there has
been increasing emphasis on the use of
molecular markers of internal dose
105
(Schulte, 1993). However,

questionnaires and environmental
measurements have good validity and
reproducibility with regard to current
exposures and are likely to be superior
to biological markers with respect to
historical exposures. The emphasis
should be on using appropriate
technology to obtain the most practical
and valid estimate of the etiologically
relevant exposure.
Similar considerations apply to the
collection of information on health
status. Once again, it is important that
the information obtained should be of
comparable quality in the exposed and
non-exposed populations. With this
proviso, the specific methods used will
differ according to the hypothesis and
population under study, but the main
options include use of routine records
(mortality, incidence, hospital admission,
health insurance, general practitioner,
etc) and the mounting of a special
morbidity survey (using clinical
examinations, biological testing or
questionnaires).
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(1996). Comparison of soybean
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Jones ME, Swerdlow AJ, Gill LE, Goldacre

MJ (1998). Pre-natal and early life risk
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Armstrong BK, White E, Saracci R

(1992). Principles of exposure
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al (1990). High prevalence of NIDDM
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107
108
CHAPTER 9. Cohort Studies

As discussed in chapter 2, an incidence

study is a subtype of longitudinal study
in which the outcome measure is
dichotomous (e.g. death or disease
incidence). Perhaps the simplest type of
incidence study involves descriptive
analyses using routine mortality or
incidence records for a defined
geographic population. For example,
most countries have comprehensive
death registration schemes, as well as
regular national censuses, a population
register, or other methods of estimating
population numbers. These can then be
used, as the numerator and denominator
respectively, to calculate overall national
death rates, as well as the death rates
by age-group and gender. In some
countries, information may also be
available to calculate death rates by
other demographic variables such as
ethnicity, socio-economic status,
employment status, occupation or
geographical area. However, the validity

of such analyses may be questionable,
because in most countries death
certificates (or other routine records
such as cancer registration records) are
not linked directly to the corresponding
population records. Thus, problems may
occur if factors such as ethnicity are
coded differently on the death records
and on the population records.
Nevertheless, such descriptive
analyses, have played a major role in
identifying public health problems and
suggesting priorities for public health
research.
However, the limitations of analyses
based on routine records usually mean
that a specific cohort must be
constructed for many epidemiologic
studies. In this chapter I discuss the
practicalities of conducting a cohort
study.
9.1 Defining the source population and risk period
Community-based cohort studies
further surveys being conducted at

regular intervals.
For studies investigating

environmental factors, or general
lifestyle (diet, exercise, etc) a cohort
study may be based on a particular
community which is followed (usually
prospectively) over time. For example,
a cohort may be based on all persons
aged 20 years or more living in a
particular city or county in a particular
year. This would usually require a
special survey to be conducted at the
start of the follow-up period, with
More specific cohorts

Cohorts may also be constructed not
only on the basis of more specific
exposures. Perhaps the most common
example of this approach involves
studies that are based on workers in a
particular factory or industry
(Checkoway et al, 2004). Such studies
may be based on historical records,
enabling follow-up to be conducted
retrospectively.
109
Typically, such a historical cohort study

might involve all workers who worked
for at least one month in the factory at
any time during 1970-1999. The list of
such workers can be enumerated using
personnel records which also provide
information on their job titles and
departments (which can be used to
estimate their historical exposures).
the country who did not work in the

factory). However, this is rarely feasible
in practice, and is usually a trivial
problem if the exposure is rare. Thus,
the comparison is usually made between
the exposed group and the national
population as a whole.
Comparison populations
Once the source population has been

defined, then the risk period must also
be specified. It is important that the risk
period is the same for the two or more
groups being compared. For example, it
would be inappropriate to compare
deaths from ischaemic heart disease in
two different communities at two
different time periods, since there is a
continuing decline in IHD mortality, and
spurious differences between the
communities may be observed if they
are not studied over the same risk
period.
The risk period
In community-based cohorts,
comparisons are usually made internally
between study participants exposed and
those not exposed to a particular risk
factor (e.g. low dietary beta carotene
intake compared with high dietary beta
carotene intake).
In studies of specific populations, an
internal comparison may still be
possible, e.g. by comparing workers
with high benzene exposure to those
with low benzene exposure. However, in
some instances this may not be possible
because good individual exposure
information is not available (apart from
the fact that workers in the factory
received high exposure on the average)
or because there is not sufficient
variation in exposure within the
population (e.g. because everyone who
worked in the factory had high
exposure). In this situation, an external
comparison may be made, e.g. with
national death rates or cancer
registration rates. In this situation, the
source population for the study is
effectively the national population, and a
comparison is being made between the
subgroup in the source population that
worked in a particular factory (for
example) and the entire source
population. Ideally the comparison
should be made between the exposed
group and the source population minus
the exposed group (i.e. everyone else in
In a historical cohort study, participants

may be followed from some date in the
past (e.g. the date the factory opened)
up until the present (or some recent date
for which death records or cancer
registration records are complete). In a
prospective cohort study, participants
may be followed from the present until
some specified future date (e.g. a tenyear follow-up of participants in a recent
survey). In both instances, not all study
participants will be followed for the
entire risk period. For example, someone
who moved into the community during
the risk period and was recruited
during a later survey would only be
followed from the time of that survey.
Similarly, someone who emigrated
during the risk period would only be
followed until their date of emigration.
110
Example 9.1
The Renfrew/Paisley
study was based on two
adjacent urban burghs
considered to be typical
of the West of Scotland.
During 1972-1976, men
and women aged
between 45 and 64 and
identified by door-todoor census as living in
Renfrew and Paisley
were invited to take
part. The response rate
was 80% (7,052 men
and 8,354 women).
Participants completed a
questionnaire which
included self-reported
smoking history,
occupation, address,
age, gender, and
respiratory symptoms.
Study participants were
flagged at the National
Health Service Central
Register in Edinburgh
and followed for 20
years. Hart et al (2001)
reported that high lung
cancer mortality risks
were seen for manual
compared with nonmanual workers. The
risk reduced when
adjusted for smoking,

and reduced further
when adjusted for lung
function, phlegm and
(area) deprivation
category. They
concluded that the social
class difference in lung
cancer mortality was
explained by poor lung
health, deprivation and
poor socio-economic
conditions throughout
life, in addition to
smoking.
Example 9.2
Rafnsson et al (2001)
studied cancer incidence
in a cohort of 1690 flight
attendants working with
two airline companies in
Iceland. The total
number of person-years
of follow-up was 27,148.
Among the 1,532
women flight
attendants, there were

64 cases of cancer,
whereas 51.6 were
expected on the basis of
national cancer
incidence rates
(RR=1.2). There was a
particularly elevated risk
for breast cancer in
those who had been
111
hired in 1971 or later

and therefore had had
the heaviest exposure to
cosmic radiation at a
young age (RR=4.1).
The authors concluded
that the association may
be due to cosmic
radiation or disturbance
of circadian rhythm.
9.2 Measuring exposure

As discussed in chapter 8, there are a
variety of possible methods for
measuring exposure in cohort studies.
These include routine records,
questionnaires, environmental
measurements, Job-Exposure-Matrices
(JEM), quantified personal
measurements, and biomarkers of
exposure.
Ideally, exposures should be measured
continuously, or at least at regular
intervals, through the risk period (i.e.
the period of follow-up). For some risk
factors (e.g. for demographic factors
such as age, gender and ethnicity), the
risk factor status is unlikely to change
during the risk period, and can simply be
ascertained at baseline. For other
exposures that do change over time
(e.g. smoking, diet, occupational
exposures) regular surveys, or regular

examination of routine records, may be
desirable to update the exposure
information. However, in many studies
this is not feasible and information is
only collected in a baseline survey; it is
then necessary to assume that the
exposure level (e.g. serum cholesterol
level) has not changed meaningfully
during the subsequent follow-up.
In occupational studies, more detailed
exposure information may be available
through the combination of personnel
records (which include changes of job
title and department) and Job-ExposureMatrices (JEMs) based on workplace
exposure surveys and/or personal
measurements in a subgroup of the
workforce (see chapter 8).
Example 9.3
Prescott et al (2004)
studied vital exhaustion
(fatigue, hopelessness
and depression) as a
risk factor for
ischaemic heart disease
(IHD) in 4084 men and
5479 women in
Copenhagen. The study
was based on
participants in the
Copenhagen City Heart
Study, and the
analyses were based on
10,135 people who
attended the third
follow-up examination
in 1991-1993.
Cardiovascular risk
factors were assessed
by a self-administered
questionnaire checked
with the participant by
trained staff, and by
various laboratory
tests. Vital exhaustion
was assessed using a
17-item questionnaire.
Participants were
followed until 31
December 1997 for
fatal and non-fatal IHD,
with the information
being obtained from
the National Board of
Health and National
Hospital Discharge
Register respectively.
Subjects with selfreported and verified
IHD prior to enrolment
were excluded. During
112
follow-up, 483
experienced an IHD
event, of which 25%
were fatal, and 1559
subjects died from all
causes. All but 4 of the
17 items were
significantly associated
with IHD with
significant relative risks
ranging from 1.36 to
2.10. The RR for IHD in
those with a vital
exhaustion score of 10
or more was 2.57
(95% CI 1.65-4.00)
and this altered little
after adjustment for
biological, behavioural
and socioeconomic risk
factors.
9.3 Follow-up
Vital status ascertainment
to search multiple registers. Since 1979

a National Death Index for the United
States has been compiled and
computerized and is available for vital
status tracing (Wentworth et al, 1983).
In some instances, particularly in

community based studies, follow-up
may involve regular contact with the
study participants, including repeated
surveys of health status. Perhaps more
commonly, follow-up may not involve
further contact with the study
participants, but may be done by
routine record linkage.
Just because someone has been not

been identified in death records, this
does not mean that they are still alive
and at risk since they may have
emigrated or may not have been
identified in death registrations for some
other reason. It is therefore desirable to
confirm that they are alive using other
record sources such as drivers license
records, voter registrations, social
security records, etc. In the United
States, the Social Security
Administration (SSA) records have been
frequently used in the past, and in Great
Britain the Central Record Office of the
Ministry of Pensions and National
Insurance is the analogous tracing
source (Checkoway et al, 2004).
For example, study participants may be

followed over time by linking the study
information with national death records,
or incidence records (e.g. a national
cancer registry) as well as with other
record systems (e.g. social security
records, drivers license records) to
confirm vital status in those who are not
found to have died during the follow-up
period.
Although most developed countries have
complete systems of death registration,
and it is easy in theory to identify all
deaths in a particular cohort, this may
not be so straightforward in practice. For
example, many countries do not have
national identification numbers and
record linkage may have to be done on
the basis of name and date of birth. This
may not be infallible because of
differences in spelling of names, or
inaccuracies in date of birth, but various
record linkage programmes are available
to identify near matches (Jones and
Sujansky, 2004). These will be
ineffective, however, for people who
have changed their name, e.g. because
of marriage.
Coding of the disease outcome

It is not only necessary to determine if
and when an event such as a death or
hospital admission occurred. It is also
necessary to verify, for example, the
cause of death, or the cause of a hospital
admission. Coding of causes of death
should be performed by a nosologist
trained in the rules specified by the
International Classification of Diseases
(ICD) volumes compiled by the World
Health Organisation. In many countries
this is done routinely for national death
registration records, and it is not
necessary (or desirable) to recode death
registrations for a specific study.
However, the ICD codes have changed
over time, and when using routine death
registration records it is necessary to be
A further problem is that some countries

do not have national death registrations,
and these may be done on a regional or
state basis instead, making it necessary
113
aware of which ICD revision was in effect

at the time of death.
Person-time
In a study of a specific population, e.g.
workers in a particular factory,
participants may enter the study on
the date that the study starts
(1/1/70), or the date that they first
meet the eligibility criteria (i.e.
employment for one month),
whichever is the latest date. If they
started working in the factory after the

start of the study, then they would
only start being followed on the date
they started work (or a subsequent
date when they met the eligibility
criteria).
They stop contributing person-time
when they die (or are diagnosed with
the disease in an incidence study),
emigrate, they are lost to follow-up, or
the study finishes (31/12/99)
whichever is the earliest.
Example 9.4
Munk Nielsen et al
(2003) studied longterm mortality after
poliomyelitis by
identifying a group of
5,977 patients diagnosed
with poliomyelitis in
Copenhagen between
1919 and 1954. This
involved a review of
more than 80,000
consecutive hospital
records for
Blegdamshospitalet
which served as the
primary centre for
diagnosing and treating
patients with acute
poliomyelitis in the area
of greater Copenhagen.
Information extracted
from the records
included name, sex, date
and place of birth, date
of admission and
discharge, and details of
the acute severity of the
case.
Since 1 April 1968, all

Danish citizens have
been given a unique
identification number,
which is recorded in the
Danish Civil Registration
System (CRS). The
cohort was linked to the
CRS to identity individual
CRS numbers which
were then used to
identify deaths in the
Danish Cause-of-Death
Register. Patients not
identified in the CRS
were believed to have
died or emigrated before
1 April 1968 and for
these patients the
Cause-of-Death Register
was searched for their
name and date of birth.
Patients were followed
from the initiation of the
Cause-of-Death Register
in 1943 or the month
after the hospital
114
discharge (whichever
came later) until the
date of death,
emigration or 1 May
1997 (whichever came
earlier).
There were 1295 deaths
compared with an
expected number of
1141 (SMR 1.14, 95% CI
1.07-1.20). Excess
mortality was restricted
to polio patients with a
history of severe
paralysis of the
extremities (SMR =
1.69, 95% CI 1.32-2.15)
or patients who had
been treated for
respiratory failure during
the epidemics (SMR =
2.71; 95% CI 2.183.37).
Summary
Cohort studies provide the most

comprehensive approach for evaluating
patterns of exposure and disease, since
they involve studying the entire source
population (assuming that there is a
100% response rate) over the entire risk
period.
exposed and those participants not

exposed to a particular risk factor.
However, in some instances, all of the
study participants may be exposed, or
valid individual exposure information
may not be available, and it may be
necessary to make an external
comparison, e.g. with national mortality
rates (in which case the national
population comprises the source
population for the study). It is important
that any comparisons are made over the
same risk period, and that follow-up is
as complete as possible. The basic effect
measures in a cohort study are the rate
ratio and risk ratio. Methods of data
analysis for these effect measures are
described in chapter 12.
Thus, the cohort design ideally includes

all of the relevant person-time
experience of the source population over
the risk period. A cohort study may be
based on a particular community (e.g. a
geographical community), or on a more
specific population defined by a
particular exposure (e.g. workers in a
particular factory). In both instances, an
internal comparison would ideally be
made between those participants
References

factor for ischaemic heart disesae and

all-cause mortality in a community
sample: a prospective study of 4084
men and 5479 women in the
Copenhagen City Heart Study. Int J
Hart CL, Hole DJ, Gillis CR, et al (2001).

Social class differences in lung cancer
mortality: risk factor explanations
using two Scottish cohort studies. Int
Rafnsson V, Tulinius H, Jnasson JG,

Hrafnkelsson J (2001). Risk of breast
cancer in female flight attendants: a
population-based study (Iceland).
Cancer Causes and Control 12: 95101.
Jones L, Sujansky W (2004). Patient

data matching software: a buyers
guide for the health conscious.
Okaland, CA: California HealthCare
Foundation (www.chcf.org).
Wentworth DN, Neaton JD, Rasmussen

WL (1983). An evaluation of the
Social Security Administration Master
Beneficiary Record file and the
National Death Index in the
ascertainment of vital status. Am J
Public Health 73; 127-1274.
Munk Nielsen N, Rostgaard K, Juel K, et

al (2003). Long-term mortality after
poliomyelitis. Epidemiol 14: 355-60.
Prescott E, Holst C, Gronbaek M, et al
(2004). Vital exhaustion as a risk
115
116
CHAPTER 10. Case-control Studies

As discussed in chapter 2, the only

conceptual difference between a full
cohort study based on a specified source
population and risk period, and an
(incidence) case-control study based on
the same source population and risk
period, is that the latter involves
outcome-specific samples of the source
population, rather than an analysis of
the entire source population. There is
usually little loss of precision compared

to a full cohort study, and there may be
considerable savings in terms of time
and expense, particularly if the study
disease is rare or has a long induction
time.
In this chapter I discuss the practicalities
of conducting an (incidence) case-control
study.
10.1 Defining the source population and risk period
An incidence case-control study should

be based on a specified source
population and risk period. The task in
such a population-based case-control
study is then to identify all cases of
the outcome under study that are
generated by the source population
over the risk period. Controls are then
sampled at random from the source
population.
defined geographical area. This may

be a formal register (such as a Cancer
Register) or a similar data source (e.g.
admission records for a particular
hospital). In such a registry-based
study the task is to identify the source
population for the register (e.g. all
persons who would have been
admitted to the hospital if they had
developed the disease under study).
This obviously poses more problems in
the appropriate selection of controls
than is the case for a population-based
study; these issues are discussed in
more depth below.
In some instances, cases may be

identified from a particular disease
register which is not comprehensive
with respect to the population of any
117
Example 10.1
Bigert et al (2001)
studied myocardial
infarction (MI) among
professional drivers. The
source population
comprised all men aged
45-70 years free of
previous MI and living in
Stockholm County
during 1992-1993.
Cases of first MI
generated by this source
population and risk
period were identified
from three sources: the
medical care units at the
10 emergency hospitals
within the Stockholm
County (87% of the
cases), other hospital
units (1% of the cases,

obtained from a
computerized hospital
discharge register), or
death certificates from
the Causes of death
Register at Statistics
Sweden (12% of the
cases). Controls were
selected at random from
a computerized
population register,
stratified for sex, 5-year
age-group, hospital
catchment area and year
of enrolment in the
study (1992 or 1993).
The 1,067 cases and
1,482 controls
completed a postal
questionnaire (for fatal

cases the questionnaires
were completed by nextof-kin). Of the cases, 45
(4.2%) had worked as a
bus driver, compared
with 31 (2.1%) of the
controls, yielding an
odds ratio of 2.14 (95%
CI 1.34-3.41). The
corresponding odds
ratios for taxi drivers
and truck drivers were
1.88 (95% CI 1.19-2.98)
and 1.66 (95% CI 1.221.26) respectively.
Adjustment for potential
confounders gave lower
odds ratios: 1.49, 1.34
and 1.10 respectively.
10.2 Selection of cases
In a population-based study the first

step in the selection of cases is to
attempt to ascertain all cases generated
by the source population over the risk
period (Checkoway et al, 2004). If
complete case ascertainment is not
achieved, then the relative risk estimate
(odds ratio) will not necessarily be
biased unless case ascertainment is
associated with exposure history, e.g. if
people who are prescribed a particular
drug receive more intensive medical
screening and are therefore more likely

to be diagnosed with a non-fatal
myocardial infarction.
In a registry-based study the case-group
usually consists of all incident cases
occurring in the registry during the risk
period. The registry could consist of a
formal population-based registry (e.g. a
cancer registry or birth defects registry),
or could involve an ad hoc registry,
e.g. based on admission records for the
major hospitals in a city.
118
Example 10.2
Mian et al (2001) studied homicide in
Orangi, the largest squatter settlement
in Karachi with an estimated population
of 1.2 million. They defined the cases as
individuals who lived in Orangi and were
killed in Orangi between January 1994
and January 1997, due to intentional
violence, by firearms, sharp or blunt
trauma. Cases were identified in the 15
neighbourhoods (out of 103 in total in
Orangi) which field workers identified as
the highest violence neighbourhoods.
Field workers identified households
where they knew someone had been
killed; in a few neighbourhoods they also
contacted other social organisations in
the community to identify further cases.
Controls were selected from a random
sample of households enrolled in a
related study conducted at the same
time in the same 15 neighbourhoods. For
both cases and controls, the interviews

were conducted with their wife, or if she
was inaccessible or unwilling it was
conducted with the wife of the head of
the household. People who were killed
were 34 times more likely to have
attended all political processions (29%
versus 1%, odds ratio (OR) = 34, 95%
CI 4-749), 19 times more likely to have
attended political meetings (31% versus
2%, OR = 19, 95% CI 4-136), and 17
times more likely to have held an
important position in a political party
(29% versus 2%, OR = 17, 95% CI 3120). The authors concluded that
homicide in Orangi was political and that
efforts to build trust between ethnic
groups and to build legitimacy for nonviolent forms of conflict resolution are
important steps to limit future violence.
10.3 Selection of controls
Control sampling options
the rate ratio is usually the effect

measure of interest. Fortunately,
although case-control studies have
traditionally been presented in terms
of cumulative sampling (e.g. Cornfield,
1951), most case-control studies
actually involve density sampling
(Miettinen, 1976), often with matching
on a time variable (such as calendar
time and/or age), and therefore
estimate the rate ratio without the
need for any rare disease assumption
(Pearce, 1993). In particular, the
standard population-based casecontrol design in which all cases
occurring in a country (or state or city)
in a particular year are compared with
a control sample of all other people
As discussed in chapter 2, there are

three main options for selection of
controls: (i) cumulative sampling
involves selecting controls from those
who do not experience the outcome
during the risk period (i.e. the
survivors) and will estimate the
incidence odds; (ii) case-cohort
sampling involves selecting controls
from the entire source population and
will estimate the risk ratio; (iii) density
sampling involves selecting controls
longitudinally throughout the course of
the study and will estimate the rate
ratio. Density sampling is therefore
usually the preferred approach since
119
living in the same country during the

same year, actually involves density
sampling with calendar year as the
time matching variable (possibly with
additional matching on the additional
time variable of age).
admissions from all major hospitals in

the city and excluding cases who do not
live in the city; controls can then be
sampled from that defined source
population.
If it proves impossible to define and
enumerate the source population, then
one possibility is to select controls
from people appearing in the same
register for other health conditions
(e.g. admissions to the hospital for
other causes). This may not only
produce a valid sample of the source
population, but may also have
advantages in making the case and
control recall more comparable (Smith
et al, 1988). However, it may result in
bias if the other health conditions are
also caused (or prevented) by the
exposure under study (Pearce and
Checkoway, 1988). For this reason,
the population-based approach is
preferable, although registry-based
studies may still be valuable when
population-based studies are not
practicable, provided that careful
consideration is given to possible
sources of bias.
Sources of controls
In a population-based case-control
study, controls are usually sampled at
random from the entire source
population (perhaps with matching on
factors such as age and gender). In
some instances, it may be necessary
to restrict the source population in
order to achieve valid control
sampling. For example, if controls are
to be selected from voter registration
rolls, and these are known to be less
than 100% complete for the
geographical area under study, then
the source population might be
restricted to persons appearing on the
voter registration roll, and cases that
were not registered to vote would be
excluded; controls would then be
sampled from this redefined source
population by taking a random sample
of the roll.
In registry-based studies, selection of
controls may not be so straightforward
because the source population may not
be so easy to define and enumerate. For
example, if there are two major hospitals
in a city, and a study is based on lung
cancer admissions in one of them during
a defined risk period, then the source
population is all those who would have
come to this hospital for treatment if
they had developed lung cancer during
this risk period. This population may be
difficult to define and enumerate,
particularly if cases may also be referred
from smaller regional hospitals. The best
solution is usually to define a more
specific source population (e.g. all people
living in the city) and to attempt to
identify all cases generated by that
source population, e.g. by including
120
Matching
In some instances it may be appropriate
to match cases and controls on potential
confounders (e.g. age and gender). This
can be done by 1:1 matching (e.g. for
each case, choose a control of the same
age and gender) or by frequency
matching (e.g. if there are 25 male cases
in the 30-34 age-group then choose the
same number of male controls for this
age-group). It is important to
emphasize, however, that this will not
remove confounding in a case-control
study, but will merely facilitate its
control in the analysis. For example, in a
case-control study of lung cancer, the
cases will generally be relatively old
whereas a random general population
control sample will be relatively young.
This may lead to inefficiencies when age
is controlled in the analysis since the

older age-groups will contain many cases
and few controls, whereas the younger
age-groups will contain many controls
and few cases. Matching on age will
ensure that there are approximately
equal numbers of cases and controls in
each age-strata and will thereby improve
the precision of the effect estimates
(given a fixed number of cases and
controls). However, it will not remove
confounding by age it merely makes it
easier to control in the analysis
(Checkoway et al, 2004).
It is also important to emphasize that if
pair matching (i.e. 1:1 matching) has
been done, then it is important to control
for the matching factors in the analysis,
but that this need not involve a
matched analysis. For example, if pair
matching has been done on age and
gender, then it is important to control for
age and gender in the analysis, but this
can be done with simple stratification on

age (e.g. by five-year age-groups) and
gender and it is not necessary to retain
the 1:1 matched pairs in the analysis
(Rothman and Greenland, 1998).
There are also potential disadvantages of
matching. In particular, matching may
actually reduce precision in a casecontrol study if it is done on a factor that
is associated with exposure but is not a
risk factor for the disease under study
and hence is not a true confounder
Furthermore, matching is often
expensive and/or time consuming. For
these reasons, it is usually sufficient, and
preferable, to only match on basic
demographic factors such as age and
gender, and to then control for other
potential confounders (along with age
and gender) in the analysis (Checkoway
et al, 2004).
Example 10.3
Cole et al (2000)
studied time urgency
and risk of non-fatal
myocardial infarction
(MI) in a study of 340
cases and an equal
number of age, sex and
community-matched
controls. Cases were
identified from
admissions to the
coronary or intensive
care units of six
suburban Boston
hospitals between 1
January 1982 and 31
December 1983. Those
eligible for inclusion
were white men and
women under 76 years

old living in the Boston
area with no previous
history of MI. For each
case, a control subject
of the same sex and
age (+ 5 years) was
selected at random
from the residents list
of the town in which
the patient resided.
Each subject was
interviewed in his or
her home by one of two
trained nurse
interviewers
approximately 8 weeks
after discharge from
the hospital. A sense of
121
time urgency/
impatience was
ascertained using four
items from the 10-item
Framingham Type A
scale. A dose-response
relation was apparent
among subjects who
rated themselves
higher on the four-item
urgency/impatience
scale with a matched
odds ratio for non-fatal
MI of 4.45 (95% CI
2.20-8.99) comparing
those with the highest
rating to those with the
lowest.
Once the cases and controls have been

selected, information on previous
exposures is then obtained for both
groups. As discussed in chapter 8, there
are a variety of possible methods for
measuring exposure in case-control
studies. In some instances this may be
from historical records, e.g. personnel
records that contain work history
information.
open to criticism as being particularly

prone to bias, e.g. because the recall of
past exposures (e.g. eating meat,
drinking alcohol, spraying pesticides)
may be different between cases of
disease and healthy controls. However,
collecting exposure information from
questionnaires is not an inherent feature
of case-control studies, and is sometimes
also a feature of cohort studies. Thus,
there is nothing inherently biased in the
case-control design; rather what is
important is the validity of the exposure
information that is collected, whatever
study design is employed.
Perhaps more commonly, exposure

information may be obtained from
questionnaires. It is this latter feature of
case-control studies which has left them
Summary
The only conceptual difference between

a full cohort study based on a specified
source population and risk period, and
an (incidence) case-control study based
on the same source population and risk
period, is that the latter involves
outcome-specific samples of the source
population, rather than an analysis of
the entire source population. There is
usually little loss of precision compared
to a full cohort study, and there may be
considerable savings in terms of time
and expense, particularly if the study
disease is rare or has a long induction
time.
and risk period. The tasks are then to:

(i) identify all cases generated by the
source population over the risk period;
(ii) select a random sample of controls
from the source population over the risk
period (ideally by density matching); (iii)
obtain exposure information from cases
and controls in a standardized and
unbiased manner.
The standard effect estimate in a casecontrol study is the odds ratio. If controls
are selected by density matching, then
the odds ratio will estimate the incidence
rate ratio (in the source population and
risk period) in an unbiased manner
without the need for any rare disease
assumption. Methods of data analysis for
odds ratios are described in chapter 12.
The key feature of good case-control

study design is that the study should be
based on a specified source population
122
References
Bigert C, Gustavsson P, Hallqvist J, et al

(2003). Myocardial infarction among
professional drivers. Epidemiol 14:
333-9.
Miettinen OS (1976). Estimability and

estimation in case-referent studies.
Pearce N (1993). What does the odds
ratio estimate in a case-control study?

occupational epidemiology. New York:
Pearce N, Checkoway H (1988). Casecontrol studies using other diseases

as controls: problems of excluding
exposure-related diseases. Am J
Cornfield J (1951). A method of

estimating comparative rates from
clinical data: applications to cancer of
the lung, breast and cervix. JNCI 11:
1269-75.

Mian A, Mahmood SF, Chotani H, Luby S

(2001). Vulnerability to homicide in
Karachi: political activity as a risk
factor. Int J Epidemiol 31: 581-5.
Smith AH, Pearce N, Callas PW (1988).

Cancer case-control studies with other
cancers as controls. Int J Epidemiol
17; 298-306.
123
124
CHAPTER 11. Prevalence Studies

As discussed in chapter 3, incidence

studies are usually the preferred
approach, but may be time consuming
and expensive, and it may be difficult to
identify incidence cases of non-fatal
chronic conditions such as diabetes. In
particular, some degenerative diseases
(e.g. chronic bronchitis) may have no
clear point of onset.
Examples of prevalence surveys include

general households surveys conducted
by government agencies (e.g. Ministry of
Health, 1999), more focussed general
population surveys (e.g. Australian
Bureau of Statistics, 1998) such as the
National Health and Nutrition
Examination Survey (NHANES)
(Kuczmarski et al, 1994), international
surveys of the prevalence of conditions
such as asthma (Burney et al, 1994;
Asher et al, 1995), and surveys in
populations with specific exposures (e.g.
surveys of asthma in children living on
farms (Braun-Fahrlnder et al, 1999)).
Thus, in some settings (e.g. developing

countries) and for some conditions (e.g.
chronic non-fatal disease) prevalence
studies may be the only realistic option.
Furthermore, in some instances we may
be more interested in factors that affect
the current burden of disease in the
population (i.e. prevalence) rather than
disease incidence.
In this chapter I discuss the practicalities

of conducting a prevalence study.
11.1 Defining the source population
Prevalence studies usually involve

surveys in a source population defined
by a geographic region or a particular
exposure (e.g. an industry or factory).
As with an incidence study, it is
important that this source population
is well-defined and that a high
response rate is obtained.
point in time may not necessarily be

the same date for each study
participant. For example, studies of
congenital malformations usually
involve measuring the prevalence of
congenital malformations at birth.
Thus the source population may be all
babies born in this city during 2004
and the time at which prevalence is
measured may be birth which will be
a different date and time for each
member of the source population.
In a prevalence study, disease

prevalence is measured at a specific
point in time, rather than over a
specified risk period. However, this
125
Example 11.1
Wilks et al (1999)
conducted a survey of
the prevalence of
diabetes in the
population of Spanish
Town, Jamaica. A
random population
sample was recruited by
door-to-door canvassing
(n=1,303) and oral
glucose tolerance testing

was conducted after an
overnight fast (response
rate = 60%). The
prevalence of Type 2
diabetes mellitus was
15.7% among women
and 9.8% among men.
The sex patterns were
consistent with the
fourfold excess of
diabetes in women
compared to men, but
obesity could not
entirely account for the
high prevalences
observed which exceed
those previously
reported among
European populations.
11.2 Measuring health status
Prevalence studies differ from

incidence studies in that the
measurement of health status most
commonly involves a morbidity survey,
rather than identifying incident cases
through routine records (e.g. hospital
admissions or cancer registration
records). Methods that can be used for
such surveys have already been
discussed in chapter 8 and will only be
considered briefly here.
In fact, if we are using a particular

method to measure the prevalence of a
disease, and:
Sn = sensitivity
Sp = specificity
P is the true prevalence of the
disease in the source population
then the observed prevalence that will
be obtained in the survey is:
Sn P + (1 - Sp) (1 - P)
As discussed in chapter 8, methods of

measuring disease status, that are
most appropriate in clinical practice
may not be appropriate or applicable
in epidemiologic surveys. Furthermore,
the criteria for deciding the most valid
method to use may differ between
clinical practice and epidemiological
surveys. In the clinical setting the
emphasis is often on the positive
predictive value of a test, which
depends in turn on the sensitivity,
specificity, and the underlying
population prevalence of the disease.
= P (Sn + Sp - 1) + (1 - Sp)
therefore if two populations are being
compared, and their true prevalences
(according to the gold standard) are P1
and P0 respectively, then the observed
difference in prevalence between the two
centres is:
(P1 P0)(Sn + Sp - 1)
The expression (Sn + Sp -1) is
Youden's Index. When this is equal to
1 (which only occurs when the
126
sensitivity and specificity are both 1)

then the observed difference in
prevalence will be exactly equal to the
true difference in prevalence. More
commonly, Youden's Index will be less
than 1 and the observed prevalence
difference will be reduced accordingly,
e.g. if Youdens Index is 0.75 then the
observed prevalence difference will be
0.75 times the true prevalence
difference. Youden's Index therefore
provides the most appropriate

measure of the validity of a particular
question or technique in prevalence
comparisons (Pekkanen and Pearce,
1999).
In this respect, basic symptom
questionnaires may often perform
better than supposedly more
objective measures such as bronchial
responsiveness testing (Pearce et al,
1998).
Example 11.2
Table 11.1 shows
study of asthma
prevalence in childhood.
The true prevalence
rates were 40% in the
exposed group, and 20%
in the non-exposed
group; the true
prevalence difference
was thus 20%. If 20% of
asthmatics are
incorrectly classified as
non-asthmatics (i.e. a
sensitivity of 0.80), and
10% of non-asthmatics
are incorrectly classified
as asthmatics (i.e. a
specificity of 0.90), then
the observed
prevalences will be 38%

and 24% respectively
(table 11.1); the
observed prevalence
difference will then be
14% (instead of the true
value of 20%). The net
effect is to bias the
towards the null value of
zero. The extent of the
bias is related to
Youdens index: this is
0.80+0.90-1.0=0.7, and
the observed prevalence
difference of 14% is 0.7
times the true value of
20%. If the sensitivity
and specificity had been
perfect (1.0) then
127
Youdens Index would

have been 1.0 and there
would have been no
diminishment in the
observed prevalence
difference; on the other
hand, if the sensitivity
and specificity had been
no better than chance
(e.g. both equal to 0.5)
then Youdens Index
would have been zero,
and the expected value
of the observed
also have been zero
(although the observed
value might be different
from zero due to chance
variation).
Table 11.1
Hypothetical data from a prevalence study in which 20% of asthmatics
and 10% of non-asthmatics are incorrectly classified
Actual
Observed
----------------------------- --------------------------------------------------NonExposed
exposed
Exposed
Non-exposed
----------------------------------------------- ----------------------- --------------------------Asthmatics
40
20
32 + 6 = 38
16 + 8 = 24
Non-asthmatics 60
80
54 + 8 = 62
72 + 4 = 76
-------------------------------------------------------------------------------------------------Total
100
100
100
100
-------------------------------------------------------------------------------------------------Prevalence
40%
20%
38%
24%
As discussed in chapter 8, there are a

variety of possible methods for
measuring exposure in prevalence
studies. These include questionnaires,
biological measurements, and
examination of historical records (e.g.
personnel and work history records).
of selecting controls, in a prevalence

case-control study there is only one
valid option, i.e. controls should be
selected at random from the noncases. For both groups, information on
historical and current exposures may
be obtained, as well as information on
potential confounders.
In a full prevalence study, exposure is

measured in all members of the source
population. In a prevalence casecontrol study, exposure information is
obtained for the cases and for a
control sample of non-cases (chapter
3). Thus, a prevalence case-control
study can be based on routine records
(see example 3.2) or as a second
phase of a specific prevalence survey.
It is important to emphasize that

although a prevalence study involves
measuring disease status at one point
in time, information can be collected
on historical exposures. For example, a
prevalence survey of bronchitis might
involving assessing whether a person
has current bronchitis on a particular
day, but exposure information could be
collected for both current smoking as
well as smoking history.
Whereas incidence case-control studies

involve at least three possible methods
128
Example 11.3
Guha Mazumder et al
(2000) studied arsenic
in drinking water and
the prevalence of
respiratory effects in
West Bengal, India. A
cross-sectional survey
involving 7,683
participants of all ages
was conducted in an
arsenic-affected region
between April 1995 and
March 1996. The
source population was
based on two areas of
the arsenic-affected
districts south of
Calcutta. A
convenience sampling
strategy was used in
which the field team
went to the centre of
each village and
selected the most
convenient hamlet to
begin sampling; all
household members
were invited to
participate and
sampling continued
from house to house
until sufficient numbers
had been recruited.
Participants were
clinically examined and
interviewed, and the
arsenic content of their
current primary
drinking water source
was measured. There
were few smokers and
analyses were confined
to non-smokers (6,864
participants). Among
both males and
females, the
prevalence of cough,
shortness of breath,
and chest sounds
(crepitations and/or
rhonchi) in the lungs
rose with increasing
arsenic concentrations
in drinking water. In
participants with
arsenic-related skin
lesions, the ageadjusted prevalence
odds ratios for cough
were 7.8 for females
(95% CI 3.1-19.5), and
5.0 for males (95% CI
2.6-9.9); the
corresponding findings
for chest sounds were
9.6 (95% CI 4.0-22.9)
and 6.9 (95% CI 5.892.8), and those for
shortness of breath
were 23.3 (95% CI
5.8-92.8) and 3.7
(95% CI 1.3-10.6). The
authors concluded that
these results add to
evidence that longterm ingestion of
arsenic can cause
respiratory effects.
Summary
Incidence studies are usually the

preferred approach, but in some settings
and for some conditions prevalence
studies are the only option. Furthermore,
in some instances we may be more
interested in factors that affect the
current burden of disease in the
population rather than disease incidence.
The conduct of a prevalence study is (at
least in theory) relatively
straightforward. A source population is
defined, and at one point in time the
129
prevalence of disease is measured in the

population. Exposure information is then
obtained for all members of the source
population (a prevalence study), or for
all cases of the disease under study and
a control sample of the non-cases (a
prevalence case-control study). The
standard effect estimate in a prevalence
study is the odds ratio. Methods of data
analysis for odds ratios are described in
chapter 12.
References
(1995). International study of asthma
and allergies in childhood (ISAAC):
483-91.
in Wert Bengal, India (2000). Int J

Kuczmarski RJ, Flegal KM, Campbell SM,
Johnson CL (1994). Increasing
Prevalence of Overweight Among US
Adults. The National Health and
Nutrition Examination Surveys, 1960
to 1991. JAMA 1994; 272: 205-211
Australian Bureau of Statistics (1998).

National Nutrition Survey: Nutrient
Intakes and Physical Measurements,
Australia, 1995. Canberra: Australian
Bureau of Statistics.
Ministry of Health (1999). Taking the

pulse: the 1996/1997 New Zealand
Health Survey. Wellington: Ministry of
Health.
Braun-Fahrlnder CH, Gassner M, Grize

L, et al (1999). Prevalence of hay
fever and allergic sensitization in
farmers children and their peers
living in the same rural community.
Clin Exp Allergy 29: 28-34.
Burney PGJ, Luczynska C, Chinn S, Jarvis
D (1994). The European Community
Respiratory Health Survey. Eur Resp J
7: 954-60.

Pekkanen J, Pearce N. Defining asthma
in epidemiological studies. Eur Respir
J 1999; 14: 951-7.
Wilks R, Rotimi C, Bennett F, et al
(1999). Diabetes in the Caribbean:
results of a population survey from
Spanish Town, Jamaica. Diabetic
Medicine 1999; 16: 875-83.

Guha Mazumder DN, Haque R, Ghosh N,
et al. Arsenic in drinking water and
the prevalence of respiratory effects
130
Part IV
Analysis and Interpretation of Studies
131
132
CHAPTER 12. Data Analysis

In this chapter I describe the basic

principles of data analysis in
epidemiologic studies including the
estimation of effects and calculation of
confidence intervals while controlling for
potential confounders. I only cover the
basic methods for dichotomous
exposures and dichotomous health
outcomes (chapters 2 and 3) and I do

not consider more complex study
designs (chapter 4). Readers requiring a
more formal and detailed statistical
presentation are referred to standard
texts (particularly Rothman and
Greenland, 1998).
12.1 Basic Principles
Data Management
epidemiological resources, including

epidemiological software which is
available free of charge, or at
minimal cost, has been produced by
the Epidemiology Monitor, and this
publication also has a regular feature
reviewing such software (see the
Epidemiology Monitor Website at
http://www.epimonitor.net/). There
is also an excellent epidemiology
Excel spreadsheet (Episheet)
available, which can be used to do
most of the analyses described in this
chapter (Rothman, 2002). It can be
downloaded from http://www.oupusa.org/epi/rothman/.
With the rapid advances in computer

technology in recent years, almost
any epidemiological study can be
analysed on a personal computer
(PC). In addition, a wide variety of
software is available for data entry,
data analysis and graphical
presentation of data on PCs (much of
which is not available for mainframe
computers). One particularly useful
package is EPI-INFO (Dean et al,
1990), which is available through
WHO (Geneva) and CDC (Atlanta)
and can be downloaded from
http://www.cdc.gov/epiinfo. This
package is particularly useful for data
entry and editing, and can be used
on small laptop computers in the field
as well as on desktop computers.
However, the same facilities are
available in many other packages,
some of which are more sophisticated
both statistically and in terms of data
management (e.g. Stata (Hills and
De Stavola, 2002)). A catalogue of
Given the huge amount of work usually

involved in collecting data for
epidemiologic studies, it is essential to
examine the raw data very carefully for
errors and to make every attempt to
avoid errors in the transfer of data from
questionnaires onto the computer. In
most cases, the first step is to translate
some of the information into numerical
(or alphabetical) codes, following a set
133
of coding instructions that should have

been prepared prior to data collection.
For instance, a detailed occupational
history may have been taken in a seminarrative form, and must be
subsequently coded. It is usually
preferable to do this when entering the
data directly onto a PC, since this
minimizes transcription errors.
done, both to avoid confusion, and also

to avoid any possibility of the data
coding and checking being influenced by
the results of preliminary analyses.
Once the data have been entered and
edited, there is usually a major task of
data management. This typically
involves the use of a computer package
to transform the data, compute new
variables, and prepare new files suitable
for statistical analysis.
Once the data are coded and entered,

programmes should be run that seek
strange data, contradictions, and
impossible data (e.g. a systolic blood
pressure of 40 mm Hg). These
programmes should not be restricted to
a search for logic errors or
impermissible symbols. They should
include also procedures that identify
values that lie outside plausible limits.
The values being queried should be
listed, and decisions on how the "errors"
are dealt with should be documented.
With many packages, this process can
be conducted during the actual data
entry since the range of permissible
values (for numeric variables) or legal
codes (for alphanumeric variables) can
be specified, as well as variables which
must not be left blank, conditional
jumps (e.g. if the answer is "NO" the
computer skips to the next relevant
question), repeat fields (so that the
value of a variable is set by default to
that of the last record entered or
displayed), and logical links between
variables. The best method of data
checking is to enter all of the data
twice, and to compare the two files for
discrepancies. This approach, combined
with extensive edit checks at the time of
data entry, should minimize errors.
Data Analysis
The basic aim of the analysis of a single
study is to estimate the effect of
exposure on the outcome under study
while controlling for confounding and
minimizing other possible sources of
bias. In addition, when confounding and
other sources of bias cannot be
removed, then it is important to assess
their likely strength and direction. This
latter task was discussed in chapter 7.
In this chapter I focus on the control of
confounding.
Effect estimation
The basic effect measures, and methods
of controlling confounding are described
below. Usually, in epidemiology studies,
we wish to measure the difference in
disease occurrence between groups
exposed and not exposed to a particular
factor.
The analysis ideally should control
simultaneously for all confounding
factors. Control of confounding in the
analysis involves stratifying the data
according to the levels of the
confounder(s) and calculating an effect
estimate which summarizes the
information across strata of the
confounder(s). For example, controlling
for age (grouped into 5 categories) and
gender (with 2 categories) might involve
grouping the data into the 10 (= 5 x 2)
confounder strata and calculating a
Even with double data entry and

sophisticated checking procedures,
errors may occur, and it is therefore
important to run further edit checks
before data analysis begins. It is
particularly important to finish all edit
checks and to have a final version of the
data file before any data analysis is
134
summary effect estimate which is a

weighted average of the stratumspecific effect estimates.
In most instances, epidemiologic data

involves binomial (i.e. with persons in
the denominator) or Poisson (i.e. with
person-years in the denominator)
outcome variables and ratio measures
of effect. The estimated relative risk
(rate ratio, risk ratio, odds ratio) has an
approximate log normal distribution,
and the ln(RR) can be written as the
difference of the two compared risks:
Confidence intervals
As well as estimating the effect of an
exposure, it is also important to
estimate the statistical precision of the
effect estimate. The confidence interval
(usually the 95% confidence interval)
provides a range of values in which it is
plausible (provided that there is no
uncontrolled confounding or other bias)
that the true effect estimate may lie. If
the statistical model is correct, and
there is no bias, then the confidence
intervals derived from an infinite series
of study repetitions would contain the
true effect estimate with a frequency no
less than its confidence level (Rothman
ln(RR) = ln(R1/R0) = ln(R1) ln(R0)

Thus (assuming no bias) the 95%
confidence interval for the natural log
(ln) of the relative risk is:
ln(RR) + 1.96 SE
Thus the confidence interval for the
relative risk itself is:
The usual practice is to use 90% or

95% confidence intervals, but these
values are completely arbitrary. Given a
large enough sample, an approximate
95% confidence interval for the true
population mean is:
RR e + 1.96 SE
P-Values
As discussed in chapter 5, the p-value is
the probability that a test statistic as
large or larger as that observed could
have arisen by chance if there is no bias
and if the null hypothesis (of no
disease) is correct. The test statistic
defines the p-value and usually has the
form:
m + 1.96 SE
where m is the observed mean of the
sample, and SE is its standard error,
estimated from the standard deviation
of the sample divided by the square root
of the sample size.
This confidence interval depends on two
quantities (m and SE) which are
estimated from the sample itself, and
different results will be obtained from
different samples. Provided that the
samples are sufficiently large, then 95%
of the time, the confidence interval
estimated from the sample would
contain the true population mean. One
should note, however, that this is no
guarantee that the interval from ones
data contains the true value.
z = D/SE
where D is the observed difference and
SE is the standard error of the
difference.
This provides a test statistic (z) which
can be used to calculate the probability
(p-value) that a difference as large as
that observed would have occurred by
135
chance if the null hypothesis (that there

is no difference in reality) were true.
studies, as well as non-statistical

considerations such as the plausibility
and coherence of the effect in the light
of current theoretical and empirical
knowledge (see chapter 13).
In the past, p-values have often been

used to describe the results of a study
as "significant" or "not significant" on
the basis of decision rules involving an
arbitrary alpha level as a cutoff for
significance (e.g. alpha=0.05).
However, it is now recognised that there
are major problems with this approach
The problems of significance testing can

be avoided by recognizing that the
principal aim of an individual study
should be to estimate the size of the
effect rather than just to decide whether
or not an effect is present. The point
estimate should be accompanied by a
confidence interval (the interval
estimate) which indicates the precision
of the point estimate by providing a
range of values within which it is most
plausible that the true treatment effect
may lie if no bias were present (Gardner
and Altman, 1986; Rothman and
Greenland, 1998). The point estimate
reflects the size of the effect, whereas
the confidence interval reflects the
study size on which this effect estimate
is based. This approach also facilitates
the comparison of the study findings
with those of previous studies. Note that
all conventional statistical methods
assume no bias is present. Because
this assumption is rarely if ever correct,
further considerations beyond the
statistics presented here are always
needed (see chapter 13).
First, the p-value associated with a

difference in outcome between two
groups depends on two factors: the size
of the difference; and the size of the
study. A very small difference may be
statistically significant if the study is
very large, whereas a very large
difference may not be significant if the
study is very small. p-values thus
combine two phenomena which should
be kept separate: the size of the effect;
and the size of the study used to
measure it.
A second problem with significance
testing is more fundamental. The
purpose of significance testing is to
reach a decision. However, in
environmental research, decisions
should ideally not be based on the
results of a single study, but should be
based on information from all available
12.2 Basic Analyses
Measures of Disease Occurrence

The basic measures of disease occurrence
and association have been introduced in
chapter 2. In this section I consider them
in more depth and show how to calculate
confidence intervals for the commonly
136
used measures. In the next section I

extend these methods to adjust for
potential confounders. I will only present
large sample methods of analysis which
have sample size requirements for valid
use. To avoid statistical bias, more

complex techniques are required for
analyses of studies involving very small
numbers or sparse stratifications
(Greenland et al, 2000). Once again,
readers are referred to standard texts
(particularly Rothman and Greenland,
1998) for a more comprehensive review
of these methods. I will emphasise
confidence intervals, but will also present
methods for calculating p-values.
Table 12.1 shows the findings of a

hypothetical incidence study of 20,000
persons followed for 10 years. As noted
in chapter 2, three measures of disease
incidence are commonly used in incidence
studies.
The observed incidence rate in the nonexposed group (table 9.1) has the form:
I0 =
cases
-------------person-time
b
---Y0
Table 12.1
Findings from a hypothetical cohort study of 20,000 persons followed for 10 years
Cases
Non-cases
Exposed
1,813 (a)
8,187 (c)
Non-exposed
952 (b)
9,048 (d)
Initial population size
10,000 (N1)
10,000 (N0)
Person-years
Incidence rate
Incidence proportion (average risk)
Incidence odds
90,635
0.0200
0.1813
0.2214
95,163
0.0100
0.0952
0.1052
(Y1)
(I1)
(R1)
(O1)
(Y0)
(I0)
(R0)
(O0)
Ratio
2.00
1.90
2.11
I0 e+ 1.96 SE
The natural logarithm of I0 has an

approximate standard error (under the
Poisson model for random variation in
b) of:
The observed incidence proportion in

the non-exposed group has the form:
SE [ln(I0)] = (1/b)0.5
R0 =
and an approximate 95% confidence

interval for the incidence rate is thus:
137
cases
b
---------- = -----persons
N0
The observed incidence proportion in

the non-exposed group has the form:
R0 =
person-years at risk (Y0), persons at

risk (N0), or survivors (d).
Measures of Effect
cases
b
---------- = -----persons
N0
Corresponding to these three

measures of disease occurrence, there
are three principal ratio measures of
effect which can be used in incidence
studies: the rate ratio, the risk ratio,
and the odds ratio. In incidence casecontrol studies, the measure of effect
is always the odds ratio (though what
this is estimating depends on how the
controls were chosen). In prevalence
studies, the effect measure is usually
the prevalence odds ratio, and the
statistical methods are identical to
those used in incidence case-control
studies.
Its logarithm has an approximate

standard error (under the binomial
model for random variation in b) of:
SE[ln(R0)]
(1/b - 1/N0)0.5
and an approximate 95% confidence

interval for the incidence proportion is
thus:
R0e+ 1.96 SE
The observed incidence rate ratio has

the form (table 12.1):
The observed incidence odds in the

non-exposed group has the form:
O0 =
a/Y1
I1
RR = ----- = -----b/Y0
I0
cases
b
----------- = ---non-cases
d
An approximate p-value for the null

hypothesis that the rate ratio equals
the null value of 1.0 can be obtained
using the person-time version of the
Mantel-Haenszel chi-square (Breslow
and Day, 1987). This test statistic
compares the observed number of
exposed cases with the number
expected under the null hypothesis
that I1 = I0:
The natural log of the incidence odds

(ln(O0)) has (under a binomial model)
an approximate standard error of:
SE(ln(O0))
(1/b + 1/d)0.5
and a 95% confidence interval for O0

is:
[Obs(a) - Exp(a)]2
[a - Y1M1/T]2
2 = ---------------------- = ---------------Var(Exp(a))
O0 e+1.96 SE
[M1Y1Y0/T2]
where M1, Y1, Y0 and T are as depicted

in table 12.1.
These three measures of disease

occurrence all involve the same
numerator: the number of incident
cases of disease (b). They differ in
whether their denominators represent
138
The natural logarithm of the rate ratio

has (under a Poisson model for a and
b) an approximate standard error of:
An approximate 95% confidence

interval for the risk ratio is then given
by:
RR e+1.96 SE
SE[ln(RR)] = (1/a + 1/b)0.5
The incidence odds ratio has the form:

interval for the rate ratio is then given
by (Rothman and Greenland, 1998):
O1
OR = --- =
O0
a/c
----- =
b/d
ad
bc
+1.96 SE
RR e
An approximate p-value for the

hypothesis that the odds ratio equals
from the Mantel-Haenszel chi-square
(Mantel and Haenszel, 1959):
The risk ratio has the form:

a/N1
R1
RR = ------ = -------b/N0
R0
[Obs(a) - Exp(a)]2 [a - N1M1/T]2

2 = ------------------- = ----------------Var(Exp(a))
[M1M0N1N0/T2(T-1)]

hypothesis that the risk ratio equals
using the Mantel-Haenszel chi-square
(Mantel and Haenszel, 1959):
where M1, M0, N1, N0 and T are as

depicted in table 9.1.
[Obs(a) - Exp(a)]2 [a - N1M1/T]2

2
= ------------------ = -----------------Var(Exp(a))
[M1M0N1N0/T2(T-1)]
The natural logarithm of the odds ratio

has (under a binomial model) an
approximate standard error of:
SE[ln(OR)] = (1/a +1/b+ 1/c +1/d)0.5
where M1, M0, N1, N0 and T are as


interval for the odds ratio is then given
by:
The natural logarithm of the risk ratio

has (under a binomial model for a and
b) an approximate standard error of:
OR e+1.96 SE
SE[ln(RR)] = (1/a - 1/N1 + 1/b - 1/N0)0.5
139
12.3 Control of Confounding
In general, control of confounding

requires careful use of a priori
knowledge, together with assessment
of the extent to which the effect
estimate changes when the factor is
controlled in the analysis. Most
epidemiologists prefer to make a
decision based on the latter criterion,
although it can be misleading,
particularly if misclassification is
present (Greenland and Robins,
1985a). The decision to control for a
presumed confounder can certainly
be made with more confidence if
there is supporting prior knowledge
that the factor is predictive of
disease.
where Ti = Y1i + Y0i

hypothesis that the summary rate ratio
is 1.0 can be obtained from the persontime version of the one degree-offreedom Mantel-Haenszel summary chisquare (Shore et al, 1976):
[Obs(a) - Exp(a)]2
[ai - Y1iM1i/Ti]2
2 = ------------------------- = -------------------Var(Exp(a))
[M1iY1iT0i/Ti2]
where M1i, Y1i, Y0i and Ti are as depicted

in table 12.1.
There are two methods of calculating

a summary effect estimate to control
confounding: pooling and
standardization (Rothman and
Greenland, 1998).
An approximate standard error for the

natural log of the rate ratio is
(Greenland and Robins, 1985b):
[ M1iY1iY0i/Ti2]0.5
SE = -----------------------------[(aiY0i/Ti)(biY1i/Ti)]0.5
Pooling
Pooling involves calculating a
summary effect estimate assuming
stratum-specific effects are equal.
There are a number of different
methods of obtaining pooled effect
estimates, but a commonly used
method which is both simple and
close to being statistically optimal
(even when there are small numbers
in all strata) is the method of Mantel
and Haenszel (1959).
Thus, an approximate 95% confidence

interval for the summary rate ratio is
then given by:
RR e+1.96 SE
The Mantel-Haenszel summary risk ratio

has the form:
The Mantel-Haenszel summary rate

ratio has the form:
aiY0i/Ti
RR = ------------- biY1i/Ti
aiN0i/Ti
RR = ------------biN1i/Ti
140

hypothesis that the summary risk ratio is
1.0 can be obtained from the one degreeof-freedom Mantel-Haenszel summary
chi-square (Mantel and Haenszel, 1959):
[Obs(a) - Exp(a)]2 [ai - M1iM1i/Ti]2
= ----------------------- = ------------------
where M1i, M0i, N1i, N0i and Ti are as

natural log of the odds ratio (under a
binomial or hypergeometric model) is
(Robins et al, 1986):
Var(Exp(a))
[M1iM0iM1iN0i/Ti2(Ti-1)]
where M1i, M0i, N1i, N0i and Ti are as

PR

natural log of the risk ratio is
(Greenland and Robins, 1985b):
OR e+1.96 SE
Standardization
RR e+1.96 SE
The Mantel-Haenszel summary odds
ratio has the form:
aidi/Ti
OR = ---------- bici/Ti
hypothesis that the summary odds ratio
is 1.0 can be obtained from the one
degree-of-freedom Mantel-Haenszel
summary chi-square (Mantel and
Haenszel, 1959):
[Obs(a) -
P = (ai + di)/Ti
Q = (bi + ci)/Ti
R = aidi/Ti
S = bici/Ti
R+ = R
S+ = S

interval for the summary odds ratio is
then given by:

interval for the summary risk ratio is
then given by:
QS
SE = ----- + -------------- + -----2R+S+

2S+2
2R+2
where:
[ M1iN1iN0i/Ti2 - aibi/Ti]0.5
SE = --------------------------------[(aiN0i/Ti)(biN1i/Ti)]0.5
(PS + QR)
Exp(a)]2
[ai -
N1iM1i/Ti]2
= ------------------------ = ----------------------
Var(Exp(a))
[ M1iM0iN1iN0i/Ti2(Ti-1)]
141
Standardization is an alternative
approach to obtaining a summary
effect estimate (Miettinen, 1974;
Rothman and Greenland, 1998).
Pooling involves calculating the effect
estimate under the assumption that
the measure (e.g. The rate ratio)
would be the same (uniform) across
strata if random error were absent. In
contrast, standardization involves
taking a weighted average of the
disease occurrence across strata (e.g.
the standardized rate) and then
comparing the standardized
occurrence measure between exposed
and non-exposed (e.g. the
standardized rate ratio) with no
assumptions of uniformity of effect.
Standardization is more prone than
pooling to suffer from statistical
instability due to small numbers in
specific strata; by comparison, pooling

with Mantel-Haenzsel estimators is
robust and in general its statistical
stability depends on the overall
numbers rather than the numbers in
specific strata. However, direct
standardization has practical
advantages when more than two
groups are being compared, e.g. when
comparing multiple exposure groups or
making comparisons between multiple
countries or regions, and does not
require the assumption of constant
effects across strata.
(under the binomial model for random

error) of:
0.5
[ wi2Ri(1-Ri)/Ni]
SE = ----------------------R wi
where Ni is the number of persons in
stratum i. An approximate 95%
confidence interval for the
standardized rate is thus:
R e+ 1.96 SE
The standardized rate has the form:

Standardization is not usually used for
odds, since the odds is only used in
the context of a case-control study,
where the odds ratio is the effect
measure of interest, but standardized
odds ratios can be computed from
case-control data (Miettinen, 1985;
Rothman and Greenland, 1998).
wiRi
R = -------- wi
The natural log of the standardized rate
has an approximate standard error
(under the Poisson model for random
error) of:
2
A common choice of weights in

international comparisons is Segi's
World Population (Segi, 1960) shown
in table 12.2, although it does reflect a
developed countries bias in its age
structure. In etiologic studies a better
approach is to use the structure of the
overall source population as the
weights when calculating standardized
rates or risks in subgroups of the
source population. When one is
specifically interested in the effects
that exposure had, or would have, on
a particular subpopulation, then
weights should be taken from that
subpopulation.
0.5
[ wi Ri/Yi]
SE = ---------------R wi
where Yi is the person-time in stratum i.
An approximate 95% confidence interval
for the standardized rate is thus:
R e+ 1.96 SE
The standardized risk has the form:
Multiple Regression
wiRi
Multiple regression allows for the

simultaneous control of more
confounders by "smoothing" the data
across confounder strata. In particular,
rate ratios (based on person-time
data) can be modelled using Poisson
R = --------- wi
The natural log of the standardized risk
has an approximate standard error
142
log-linear rate regression, risk ratios can

be modelled using binomial log-linear risk
regression, and odds ratios can be
modelled using binomial logistic
regression (Pearce et al, 1988; Rothman
Similarly, continuous outcome variables
(e.g. in a cross-sectional study) can be
modelled with standard multiple linear
regression methods. These models all
have similar forms, with minor variations
to take into account the different data
types. They provide powerful tools when
used appropriately, but are often used
inappropriately, and should always be
used in combination with the more
straightforward methods presented here
Mathematical modelling methods and
issues are reviewed in depth in a number
of standard texts (e.g. Breslow and Day,
1980, 1987; Checkoway et al, 2004;
Clayton and Hills, 1993; Rothman and
Greenland, 1998), and will not be
discussed in detail here.
Table 12.2
Segis World population
Age-group
Population
----------------------------0-4 years
12,000
5-9 years
10,000
10-14 years
9,000
15-19 years
9,000
20-24 years
8,000
25-29 years
8,000
30-34 years
6,000
35-39 years
6,000
40-44 years
6,000
45-49 years
6,000
50-54 years
5,000
55-59 years
4,000
60-64 years
4,000
65-69 years
3,000
70-74 years
2,000
75-59 years
1,000
80-84 years
500
85+ years
500
----------------------------Total
100,000
----------------------------Source: Segi (1960)
Summary
The basic aim of the analysis of a single

study is to estimate the effect of
exposure on the outcome under study
while controlling for confounding and
minimizing other possible sources of
bias. In addition, when confounding and
other sources of bias cannot be
removed, then it is important to assess
their likely strength and direction.
Control of confounding in the analysis
involves stratifying the data according
to the levels of the confounder(s) and
calculating an effect estimate which
summarizes the information across
strata of the confounder(s). In general,
control of confounding requires careful
use of a priori knowledge, together with
assessment of the extent to which the

effect estimate changes when the factor
is controlled in the analysis. There are
two basic methods of calculating a
summary effect estimate to control
confounding: pooling and
standardization. Multiple regression
allows for the simultaneous control of
more confounders by "smoothing" the
data across confounder strata. It
provides a powerful tool when used
appropriately, but are often used
inappropriately, and should always be
used in combination with the more
straightforward methods presented
here.
143
References

methods in cancer research. Vol I:
The analysis of case-control studies.
Lyon, France: IARC.
Mantel N, Haenszel W (1959). Statistical

aspects of the analysis of data from
retrospective studies of disease. J
Natl Cancer Inst 22: 719-48.

methods in cancer research. Vol II:
The analysis of cohort studies.
Lyon, France: IARC.
Miettinen OS (1974). Standardization of

risk ratios. Am J Epidemiol 96: 3838.
Miettinen OS (1985). Theoretical
epidemiology. New York: Wiley and
Sons.

Pearce NE, Checkoway HA, Dement JM

(1988). Exponential models for
analyses of time-related factors:
illustrated with asbestos textile
worker mortality data. J Occ Med
30: 517-22.
Clayton D, Hills M (1993). Statistical

models in epidemiology. Oxford:
Oxford Scientific Publications.
Dean J, Dean A, Burton A, Dicker R
(1990). Epi Info. Version 5.01.
Atlanta, GA: CDC.
Robins JM, Breslow NE, Greenland S

(1986). Estimation of the MantelHaenszel variance consistent with
both sparse-data and large-strata
limiting models. Biometrics 42:
311-23.
Gardner MJ, Altman DG (1986).

Confidence intervals rather than p
values: estimation rather than
hypothesis testing. Br Med J 292:
746-50.
Rothman KJ (2002). Epidemiology: an

introduction. New York: Oxford
University Press.
Greenland S, Robins JM (1985a).

Confounding and misclassification.

Greenland S, Robins JM (1985b).

Estimation of a common effect
parameter from sparse follow-up
data. Biometrics 41: 55-68.
Segi M (1960). Cancer mortality for

selected sites in 24 countries (19501957). Sendai, Japan: Department
of Public Health, Tohoku University
School of Medicine.
Greenland S, Schwartsbaum JA, Finkle

WD (2000). Problems due to small
samples and sparse data in
conditional logistic regression
analysis. Am J Epidemiol 2000;
191; 530-9.
Shore RE, Pasternak BS, Curnen MG

(1976). Relating influenza epidemics
to childhood leukaemia in tumor
registries without a defined
population base. Am J Epidemiol 103:
527-35.
Hills M, De Stavola BL (2002). A short

introduction to Stata for
biostatistics. London: Timberlake,
2002.
144
CHAPTER 13. Interpretation

[In: Pearce N. A Short Introduction to Epidemiology. 2nd ed. Wellington, CPHR, 2005]
In this chapter I first consider the issues

involved in interpreting the findings of a
single epidemiological study. I then
consider problems of interpretation of all
of the available evidence. Interpreting
the findings of a single study includes
considering the strength and precision
of the effect estimate and the possibility
that it may have been affected by
various possible biases (confounding,
selection bias, information bias). If it is
concluded that the observed
associations are likely to be valid, then

attention shifts to more general causal
inference, which should be based on all
available information. In both situations,
it should be stressed that
epidemiological studies almost always
contain potential biases, and the focus
should be on assessing the likely
direction and magnitude of the biases,
and whether they could explain the
observed associations.
13.1 Appraisal of a Single Study
It is easy to criticize an epidemiological

study. Populations do not usually
randomize themselves by exposure
status, do not always respond to
requests to participate in
epidemiological studies, may supply
incomplete or inaccurate exposure
histories for known or possible risk
factors, and cannot be asked about
unknown risk factors. Thus, although
some studies are clearly better than
others, it is important to emphasize that
perfect epidemiological studies do not
exist. Furthermore, it is usually not
possible, nor desirable, to reach
conclusions on the basis of the findings
of a single study, and it is essential to
consider all of the available evidence.
possible explanations for the

associations found (or a lack of
association) in the study, before
proceeding to consider other evidence.
However, the emphasis should not be
on simply preparing a list of possible
biases (e.g. Feinstein, 1988). Rather, it
is essential to attempt to assess the
likely strength and direction of each
possible bias, and to assess whether
these biases (and their possible
interactions) could explain the observed
associations.
What is the magnitude and
precision of the effect estimate?
As discussed in chapter 5, random error
(lack of precision) will occur in any
epidemiologic study, just as it occurs in
experimental studies. The possible role
of random error is often addressed
Nevertheless, when confronted with a

new study, perhaps with unexpected
findings, it is valuable to first consider
145
through the question could the

observed association be due to chance
alone? and this issue is usually
assessed by calculating the p-value.
This is the probability (assuming that
there are no biases) that a test statistic
as large as that actually observed would
be found in a study if the null
hypothesis were true, i.e. that there
was in reality no causal effect of
exposure. However, recent reviews have
stressed the limitations of p-values and
significance testing (Rothman, 1978;
Gardner and Altman, 1986; Poole,
1987; Pearce and Jackson, 1988).
Foremost among these is that
significance testing attempts to reach a
decision on the basis of the data from a
single study, whereas what is more
important is the strength and precision
of the effect estimate and whether the
findings of a particular study are
consistent with those of previous
studies. These issues are better
addressed by calculating confidence
intervals rather than p-values (Gardner
and Altman, 1986; Rothman and
Greenland, 1998). Similarly, the
possibility that the lack of a statistically
significant association could be due to
lack of precision (lack of study power) is
more appropriately addressed by
considering the confidence interval of
the effect estimate rather than by
making post hoc power calculations
(Smith and Bates, 1992).
been discussed in chapter 6. In the

current context the key issue is that any
epidemiologic study will involve biases.
The problem is not to identify possible
biases (these will almost always exist),
but rather to ascertain what direction
they are likely to be in, and how strong
they are likely to be.
Confounding
In assessing whether an observed
association could be due to confounding,
the first consideration is whether all
potential confounders have been
appropriately controlled for or
appropriately assessed (e.g. by
collecting and using confounder
information in a sample of study
participants). If not, it is essential to
assess the potential strength and
direction of uncontrolled confounding.
In some areas of epidemiologic
research, e.g. occupational and
environmental studies, the strength of
uncontrolled confounding is often less
than might be expected. For example,
Axelson (1978) has shown that for
plausible estimates of the smoking
prevalence in occupational populations,
confounding by smoking can rarely
account for a relative risk of lung cancer
of greater than 1.5. Similarly,
Siemiatycki et al (1988) have found that
confounding by smoking is generally
even weaker for internal comparisons in
which exposed workers are compared
with non-exposed workers in the same
factory or industry. On the other hand,
the potential for confounding can be
severe in studies of lifestyle and related
factors (e.g. diet, nutrition, exercise).
What are the likely strengths and

directions of possible biases?
Systematic error is distinguished from
random error in that it would be present
even with an infinitely large study,
whereas random error can be reduced
by increasing the study size. Thus,
systematic error, or "bias", occurs if
there is a systematic difference between
what the study is actually estimating
and what it is intended to estimate. The
types of bias (confounding, selection
bias, information bias) have already
It is unreasonable to simply assume

that a strong association could be due
to confounding by unknown risk factors,
since to be a strong confounder a factor
must be a very strong risk factor as well
as being strongly associated with
exposure. For example, if an
146
occupational study found a relative risk

of 2.0 for lung cancer in exposed
workers, it is highly unlikely that this
could be due to confounding by
smoking, and it would be unreasonable
to dismiss the study findings merely
because smoking information had not
been available. On the other hand,
small relative risks (e.g. those in the
range of 0.7-1.5, as frequently occur in
dietary studies) are not so difficult to
explain by lack of measurement, or poor
measurement and control, of
confounders.
assess what direction the bias is likely

to have been in. The important issue is
not whether information bias could
have occurred (this is almost always
the case since there are almost always
problems of misclassification of
exposure and/or disease) but rather
the likely direction and strength of
such bias. In particular, if a study has
yielded a positive finding (i.e. an effect
estimate markedly different from the
null value) then it is not valid to
dismiss it because of the possibility of
non-differential misclassification, or
differential misclassification that is
likely (although not guaranteed) to
produce a bias towards the null.
Selection bias
Whereas confounding generally
involves biases inherent in the source
population, selection bias involves
biases arising from the procedures by
which the study subjects are chosen
from the source population. As with
confounding, if it is not possible to
directly control for selection bias, it
still may be possible to assess its likely
strength and direction. It is
unreasonable to dismiss the findings of
a particular study because of possible
selection bias, without at least
attempting to assess which direction
the possible selection bias would have
been in, and how strong it might have
been.
Summary of Issues of Systematic

Error
In summary, when assessing whether
the findings of a particular study could
be due to such biases, the important
issue is not whether such biases are
likely to have occurred (since they will
almost always be present to some
extent), but rather what their direction
and strength is likely to be, and
whether they taken together could
explain the observed association. In
particular, epidemiological studies are
often criticized on the grounds that
observed associations could be due to
uncontrolled confounding or errors in
the classification of exposure or
disease. However, the likely strength
of uncontrolled confounding is
sometimes less than might be
expected, and non-differential
misclassification of exposure will
usually (though not always) produce a
tendency for false negative findings
rather than false positive findings.
Information bias
With regards to information bias, the
key issue is whether misclassification
is likely to have been differential or
non-differential. In the latter case, the
bias will usually be in a know direction,
i.e. towards the null. If
misclassification has been differential,
then it is important to attempt to
147
13.2 Appraisal of All of the Available Evidence
If it is concluded that the association in

a particular study is unlikely to be
primarily due to bias and chance,
attention then shifts to assessing
whether this association exists more
generally, and whether the association
is likely to be causal. This should involve
a review of all of the available evidence
including non-epidemiological studies. A
systematic quantitative review of the
epidemiological evidence may involve a
formal meta-analysis with statistical
pooling of information from the various
studies (e.g. Dickerson and Berlin,
1992; Rothman and Greenland is,
1998). However, such a summary of the
various study findings is just one step in
the process of causal inference. A
systematic approach to causal inference
was elaborated by Hill (1965) and has
since been widely used and adapted
(e.g. Beaglehole et al (1993)). I will
divide these considerations into those
that involve systematic review of the
epidemiological evidence (including
meta-analyses) and those that also
involve consideration of evidence from
animal or mechanistic studies.
same time (e.g. by questionnaire, is

blood tests, etc).
The criterion of specificity has been
criticised (e.g. Rothman and Greenland,
1998), on the grounds that there are
many instances of exposures that have
multiple (i.e. non-specific) effects.
These include tobacco smoke and
ionizing radiation, both of which cause
many different types of cancer.
Nevertheless, the specificity of the
effect may be relevant in assessing the
possibility of various biases. For
example, if an exposure is associated
with esophageal cancer but is not
associated with lung cancer, then the
association is unlikely to be due to
confounding by smoking.
Consistency is demonstrated by several
studies giving similar results, and
corresponds to the statistical concept of
homogeneity across studies (Rothman
and Greenland, 1998). This is
particularly important when a variety of
designs are used in different settings,
since the likelihood that all studies are
all suffering from the same biases may
thereby be reduced. On the other hand,
a lack of consistency does not exclude a
causal association, because different
exposure levels and other conditions
may alter the effect of exposure in
certain studies.
Evidence From Epidemiological

Studies
Considerations for assessing the
epidemiological evidence include
temporality, specificity, consistency,
strength of association and whether
there is evidence of a dose-response
relationship (Hill, 1965).
The strength of association is important

in that a relative risk than is far from
the null value of 1.0 is more likely to be
causal than a weak association, which
could be more easily explained by
confounding or other biases. However,
the fact that an association is weak does
not preclude it from being causal; rather
it means that it is more difficult to
Temporality is crucial; the cause must

precede the effect. This is usually selfevident, but difficulties may arise in
studies (particularly case-control
studies) when measurements of
exposure and effect are made at the
148
exclude alternative explanations for the

observed association.
power, it is more appropriate to

examine the magnitude of variation
instead of relying on formal statistical
tests (Rothman and Greenland, 1998).
A dose-response relationship occurs

when changes in the level of exposure
are associated with changes in the
prevalence or incidence of the effect
than one would expect from biologic
considerations. The absence of an
expected dose-response relationship
provides evidence against a causal
relationship, while the presence of an
expected relationship narrows the scope
of biases that could explain the
relationship.
The limitations of meta-analyses should

also be emphasized (Greenland, 1994;
Egger and Davey-Smith, 1997; Egger et
al, 1997). Strikingly different results can
be obtained depending on which studies
are included in a meta-analysis.
Publication bias is of particular concern,
given the tendency of journals to
publish positive findings and for the
publication of negative findings to be
delayed (Egger and Davey-Smith,
1998), but naive graphical approaches
to its assessment can be misleading
(Greenland, 1994).
Experimental evidence provides strong

evidence of causality, but this is rarely
available for occupational exposures.
Meta-Analysis
Even when an unbiased and

comprehensive list of studies is included
in a meta-analysis, there still remain the
same problems of selection bias,
information bias, and confounding, that
need to be addressed in assessing
individual studies. Thus, a systematic
quantitative review (i.e. meta-analysis)
is like a report of a single study in that
both quantitative and narrative
elements are required to produce a
balanced picture (Rothman and
Greenland, 1998). Essentially the same
issues need to be a addressed as in a
report of a single study: what is the
overall magnitude and precision of the
effect estimate (if it is considered
appropriate to calculate a summary
effect estimate), and what are likely
strengths and directions of possible
biases?
In the past, epidemiological evidence

has been assessed in literature reviews,
but in recent years there has been an
increasing emphasis on formal metaanalysis, i.e. systematic quantitative
reviews. One benefit of a meta-analysis
is that it can reduce the probability of
false negative results because of small
numbers in specific studies (Egger and
Davey-Smith, 1997), and may enable
the effect of an exposure to be
estimated with greater precision than is
possible in a single study. Furthermore,
although a meta-analysis should ideally
be based on individual data, relatively
simple methods are available for metaanalyses of published studies in which
the study (rather than the individual) is
the unit of statistical analysis (Rothman
and Greenland, 1998). Such methods
can be used to address the causal
considerations outlined above, in
particular the overall strength of
association and the shape and strength
of the dose-response curve. Just as
importantly, statistical methods can also
be used to assess consistency between
studies, but because statistical tests for
homogeneity often have relatively low
An advantage of meta-analysis is that

these issues can often be better
addressed by contrasting the findings of
studies based on different populations,
or using different study designs. Thus,
possible systematic biases can be
addressed with actual data from specific
studies rather than by hypothetical
examples. For example, in a study of an
149
occupational exposure and lung cancer,

there might be concern that an
observed association was due to
confounding by smoking. If smoking
data had not been available, then the
best that could be done would be to
attempt to assess the likely extent of
confounding by smoking (see chapter
6), for example by sensitivity analysis
However, in a meta-analysis, if smoking
information were available for some
(but not all) studies then these studies
could be examined to assess the likely
strength and direction of confounding by
smoking (if any).
reduce random error. However, it will

not necessarily reduce systematic error,
and may even increase it (because of
publication bias). Nevertheless, a
careful meta-analysis will enable various
possible biases to be addressed, using
actual data from specific studies, rather
than hypothetical examples. Such a
meta-analysis will therefore facilitate
the consideration of the causal
considerations listed above, and in some
instances will provide a valid summary
estimate of the overall strength of
association and the shape and strength
of the dose-response curve (Greenland,
2003).
Similarly, studies of exposure to

phenoxy herbicides and the
development of soft tissue sarcoma and
non-Hodgkins lymphoma have
produced widely differing findings, and
it has been suggested that the high
relative risks obtained in the Swedish
studies could be due to recall bias (a
particular type of information bias) in
that cases or cancer (soft tissue
sarcoma or non-Hodgkins lymphoma)
were compared with healthy general
population controls, and that patients
with cancer may be more likely to recall
previous chemical exposures. This
hypothesis was tested in specific studies
(e.g. Hardell et al, 1979, 1981), but can
also be tested more generally by
considering the findings of studies that
used general population controls with
those that used other cancer controls.
In particular, one New Zealand study
(Pearce et al, 1986) used both types of
controls and found similar results with
each, indicating that recall bias was not
an important problem in this study.
Combination of Epidemiological
Evidence With Evidence From Other
Sources
Epidemiological evidence should be
considered together with all other
available evidence, including animal
experiments. An association is plausible
if it is consistent with other knowledge,
whereas the epidemiological evidence is
coherent if it is not inconsistent with
other knowledge. For instance,
laboratory experiments may have
shown that a particular environmental
exposure can cause cancer in laboratory
animals, and this would make more
plausible the hypothesis that this
exposure could cause cancer in humans.
However, biological plausibility is a
relative concept; many epidemiological
associations were considered
implausible when they were first
discovered but were subsequently
confirmed by other evidence, e.g. the
relation of lice to typhus. Lack of
plausibility may simply reflect lack of
knowledge (medical, biological, or
social) which is continually changing and
evolving.
In summary, a key advantage of metaanalysis is that pooling findings from

studies will increase the numbers
available for analysis and will therefore
150
Summary
The task of interpreting the findings of

a single epidemiological study should
be differentiated from that of
interpreting all of the available
evidence. Interpreting the findings of a
single study includes considering the
strength and precision of the effect
estimate and the possibility that it may
have been affected by various possible
biases (confounding, selection bias,
information bias). The important issue
is not whether such biases are likely to
have occurred (since they will almost
always be present to some extent),
but rather what their direction and
strength is likely to be, and whether
together they could explain the
observed association. If the observed
associations seem likely to be valid,
then attention shifts to more general
causal inference, which should be
based on all available information. This
includes assessing the specificity,
strength and consistency of the
association and the dose-response
across all epidemiological studies. This
may include the use of meta-analysis,
but it is often not appropriate to derive
a single summary effect estimate
across all studies. Rather, a metaanalysis can be used to examine
hypotheses about reasons for
differences between study findings and

the likely magnitude of possible biases.
Furthermore, causal inference also
necessitates considering nonepidemiological evidence from other
sources (animal studies, mechanistic
studies) in the consideration of more
general causal criteria including the
plausibility and coherence of the
overall evidence.
Despite the continual need to assess
possible biases, and to consider
possible imperfections in the
epidemiological data, it is also
important to ensure that preventive
action occurs when this is warranted,
albeit on the basis of imperfect data.
As Hill (1965) writes:
"All scientific work is incomplete whether it be observational or
experimental. All scientific work
is liable to be upset or modified
by advancing knowledge. That
does not confer upon us a
freedom to ignore the knowledge
that we already have, or to
postpone the action that it
appears to demand at a given
time."
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152

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A Short Introduction

Occasional Report Series No 2

Centre for Public Health Research

Who needs another introductory

are used to investigate. In particular, in

Part 2 then addresses study design

of situations in which epidemiologic

Part 3 then discusses the practical issues

I should stress that this book provides no

Centre for Public Health Research

During the writing of this text, my salary

A Short Introduction to Epidemiology

PART 3: CONDUCTING A STUDY

Germs and miasmas

PART 1: STUDY DESIGN OPTIONS

and risk period

10. Case-control studies

Defining the source population

PART 2: STUDY DESIGN ISSUES

More complex study designs 41

Other axes of classification

Defining the source population

11. Prevalence studies

PART 4: ANALYSIS AND

12. Data analysis

Public health is primarily concerned with

recognise the complementary nature of

Medicine (including primary health care)

1.1 Germs and Miasmas

Epidemiology is as old as public health

ages. However, epidemiology was

-----------------------------------------------------------------------------------------------Source: (Snow, 1936; quoted in Winkelstein, 1995)

Perhaps the most commonly quoted

1983; Loomis and Wing, 1991; Samet,

1.2 Risk Factor Epidemiology

This decline in the importance of

human genome project has seen an

2001). Subsequent decades have seen

for the ethical and practical constraints,

Individual lifestyle factors would ideally

This approach has led to major

1.3 Epidemiology in the 21st Century

In particular, in the last decade there

the future direction of epidemiology

lifestyle, and little attention paid to the

studies. Even if one is focusing on

In industrialized countries, this is likely

theories and identifies the major public

This increased interest in populationlevel determinants of health has been

development of theoretical and

noted above, this short introductory

Public health is primarily concerned with

applied to the study of noncommunicable diseases. At the beginning

Barreto ML (2004). The globalization of

between science and indigenous

Barreto ML, Almeida-Filho N, Breihl J

Hennekens CH, Buring JE (1987).

Barry M (1991). The influence of the