CROSS SECTIONAL STUDY IN EPIDEMIOLOGY

A. DEFINITION OF CROSS SECTIONAL STUDY

Cross-sectional survey is a study to study the dynamics of correlation
between risk factors and effects, by approach, observation or data collection at the
same time (point time approach). That is, each research subject was only observed
once and the measurements were made on the character status or subject variable at
the time of examination. This does not mean that all research subjects are observed at
the same time. This design can find out clearly which is the exposure and outcome,
and clearly the relation between causal relationships
In this cross-sectional study, researchers only observed phenomena at a
certain point in time. Research that is exploratory, descriptive, or explanatory, cross-
sectional research is able to explain the relationship of one variable with other
variables in the population studied, test the validity of a model or formulation of
hypotheses and the level of difference between sampling groups at a certain point in
time. However, cross-sectional studies do not have the ability to explain the dynamics
of changes in conditions or relationships of the populations they observe in different
time periods, as well as the dynamic variables that influence them.
cross-sectional study Like cohort studies, cross-sectional studies
conceptually begin with a population base. But unlike cohort studies, in cross-
sectional studies we do not follow individuals over time. Instead, we only look at the
prevalence of disease and/or exposure at one moment in time. These studies take a
"snapshot" of the proportion of individuals in the population that are, for example,
diseased and non-diseased at one point in time. Other health outcomes besides
diseases may also be studied. Cross-sectional studies also differ from cohort studies in
the populations that are studied. Cohort studies begin by selecting a population of
persons who are at risk of for a specific disease or health outcome; cross- sectional
studies begin by selecting a sample population and then obtaining data to classify all
individuals in the sample as either having or not having the health outcome.

cohort Cross sectional

Study group Population at risk Entire population (or a
sample)
Common measures Risks and rates Prevalence

B. FACTORS AFFECTING CROSS SECTIONAL RESEARCH

1. Risk factors originating from the organism itself (intrinsic risk factors). This
intrinsic risk factor is divided into:
  Sex and age factors
Some certain diseases are related or tend to be suffered by a person
with a certain sex or age. For example gastritis, tends to be suffered by
men rather than women. Cardiovascular tend to be suffered by people
aged 40 years.
 Anatomical factors or certain constitutions
There are certain body parts that are sensitive to an illness. For
example, the herpes virus that attacks the nerves.
 Nutritional factor
Someone who suffers from malnutrition (malnutrition) will be
vulnerable to infectious diseases, especially pulmonary tuberculosis
and diarrhea.
2. Risk factors originating from the environment (extrinsic risk factors) that
make it easier for someone to contract a certain disease.
Based on the type, these extrinsic factors can be: physical,
chemical, biological, psychological, socio-cultural, and behavioral conditions.
For example: the situation of densely populated settlements is a risk factor for
acute respiratory infections (ARI).
Risk factors are different from agents (causes of disease):
Disease agents are micro-organisms or environmental conditions that react
directly to individuals so that the individual becomes ill. Agents are a factor
that must be present for the occurrence of the disease.

 Advantages
Analytical research with a cross sectional approach has the following
advantages.
a. The cross sectional study can be used to estimate the cause-effect
relationship and relative risk calculation in a fast and relatively small
way compared to prospective studies.
b. Data contained in hospitals can be used.
c. It can be used to compare the magnitude of the risk of groups exposed
by factors that are considered to be the cause of disease with groups
that are not exposed and the results are used to provide information to
the community and are useful for planning health services needed by
the community.
 Disadvantages
In addition to the aforementioned benefits, the cross sectional
study did not escape losses. The disadvantages are as follows.
a. This study cannot be used to monitor changes that occur over time
because observations on the subject of the study were only conducted
once during the study.
b. The study was a cross-sectional study with the aim of a cross-sectional
analysis to determine the comparability of the two groups compared
because it was not known whether the incidence occurred before or
after exposure.
c. It is difficult to extrapolate to a larger population.
d. Cross sectional research was not designed for analytic research.
e. The cross sectional study cannot be used to determine the causal
relationship to biochemical and physiological changes because
between causes and effects can influence each other.
 For example, in a survey it was found that people with
hypertension had high cholesterol levels so in this case it could not be
known with certainty whether high cholesterol levels were a factor
causing hypertension or after keimidian hypertension followed by high
cholesterol levels.
If high cholesterol levels precede the onset of
hypertension, it can be assumed that high cholesterol is a causative
factor for hypertension, but if it is the opposite it cannot be said that
cholesterol is a causative factor for hypertension. To distinguish these
two things is very difficult, even impossible because of the
determination of hypertension and high cholesterol levels carried out at
the same time.
Another example is the cross sectional study found
high cholesterol levels in patients with coronary heart disease. In this
case it cannot be said that high cholesterol levels are a factor that
causes coronary heart disease. To find out whether high cholesterol
levels are a risk for coronary heart disease, analytic research must be
conducted.
3. Characteristics of Cross Sectional Research
From the description above, it can be seen the following cross
sectional research characteristics.
 In accordance with the term, data collection is done at one time or one
particular period and observation of the subject of the study is only
done once during one study.
 Calculation of the estimated sample size regardless of the group
exposed or not. In hospital research, the sample size is not calculated,
but is determined based on a certain period.
 Data collection can be directed according to the criteria of the study
subject. For example, the relationship between the Cerebral blood flow
in smokers, former smokers and nonsmokers. This research was
conducted with a cross sectional approach. In this study 268 people
were voluntarily collected and divided into 3 groups, namely the
smokers, former smokers, and non-smokers. Comparability of the three
groups is divided by age. Then the cerebral blood flow was examined
and the results were compared. The method of retrieval and the size of
the sample are not disputed.
 There is no control group and there is no specific hypothesis.
 The causal relationship is only an estimate that can be used as a
hypothesis in analytical or experimental research.

 The weakness of this study lies in:

 It is difficult to hold extrapolations
 There may be too few study subjects in one group.
 Criteria for smokers, ex-smokers and nonsmokers are not explained in
detail.

Another example is research on the relationship of

anemia to the birth of premature babies. Data collection is based on
medical records in hospitals for all mothers who give birth during a 1
 year period. The data obtained were divided into anemia groups and
not anemia. And the anemia group recorded the number of preterm
births, as well as the group not anemia. Furthermore, the risk of each
group was calculated, the relative risk and compared with the chi-
quadratic statistical test. This research seems to be done prospectively.

4. Research Protocol
For planning and carrying out research, it should be done by
writing down the protocol in the form of activity steps that are used as
guidelines in research activities.
The arrangement of the protocol below is not absolute, but is
adjusted to the tastes of each institution that provides approval or funding, but
with substances that are not different. Broadly speaking, the cross sectional
research protocol is as follows.
 Formulate research questions
 Determine the purpose of the study
 Study population
 Criteria for study subjects
 How to take and estimate the sample size
 Determine the variables to be measured
 Prepare a list of questions or checks needed
 Collect data
 Analysis of data

I. Formulate research questions

Research questions should be directed according to the research
objectives. For example, if the research aims to compare the health condition of the
population of an area after the existence of a health service program to improve the
nutritional status of children, the questions asked are as follows. Is the provision of
additional food, the nutritional status of children will increase compared to children
who do not get additional food

II. Determine the purpose of the study

The purpose of the investigation must be clearly explained about what will
be sought in the research that will be carried out. For example, and questions about
the nutritional status of children can be seen that the research that will be conducted is
an analytic exploration that aims to compare the nutritional status of children who get
additional food with the nutritional status of children who do not get additional food.

III. Study Population

The study population in the cross sectional study can be in the form of a
community of a certain area with administrative boundaries or institutions such as
hospitals, schools or industries, depending on where the research was conducted. The
study population can also be in the form of certain groups of people, such as women
of childbearing age in an area. The population in the study at the hospital was
determined based on the number of patients (study subjects) recorded during a certain
period of time.

IV. Criteria for Study Subjects

 Determination of criteria for study subjects in cross sectional studies is
very important to clearly determine who this research was conducted especially if the
cross-sectional study is used as an analytical study to estimate the cause-effect
relationship or measurement of risk factors.
These criteria can be in the form of age, education level, matrial status,
employment or other conditions related to the estimated risk factors for the onset of
an illness.
For example, in a study of the use of IUD contraceptives with
thrombophlebitis should be explained the criteria for couples of childbearing age and
users of contraceptive criteria, whether those who have ever used are also included
in the study subject or not and also determine the diagnosis of
thrombophlebitis used, and others. After determining the subject subject criteria
should be explained about the operational definition so that the research variables that
are abstract can be measured, for example to measure knowledge about the use of
ORS for diarrhea because knowledge cannot be measured directly, then
measurements are taken by asking a number of questions, for example, do you know
the meaning diarrhea ?, do you know about ORS ?, do you know the benefits of
ORS?, where can you get ORS ?, as many as 10 questions, then each answer is given
number 1 for the correct answer and 0 for the wrong answer until all will be obtained
supply and 0 to 10.
And the results are then determined for example 8-10 questions answered
correctly said good knowledge, grades 6-8 including moderate categories and under
value 6 categorized as lack of knowledge.

V. How to Take and Amount of Samples

How to take

The method of sampling can be done by random sampling if the research

is carried out in the field or samples are taken based on medical records in a certain
period if the research conducted is hospital-based.

Sample Size

Determination of the estimated sample size in a cross-sectional study that

is analytically based on a hospital basis can be explained by the 2 x 2 table as an
order.

SICK TOTAL
YES NO
+ ? ? ?
- ? ? ?
TOTAL ? ? n

And the table above is clear that the determination of the size of the
sample is carried out without regard to the presence or absence of disease or exposure.
After the sample size was obtained, it was divided into two groups, namely groups
 exposed to risk factors and other groups that were not exposed. The two groups were
identified as whether or not the investigator was studied.
The disadvantage of this method is the possibility of a value that is too
small in one cell to be difficult to analyze.

Example:

The study of the relationship between anemia and hospital-based LBW

then all pregnant women who gave birth in hospital to certain sites were taken as
samples based on their current medical records, then divided into two groups, namely
anemic mothers as audi groups and not anemia as a control group Furthermore, it was
noted that the number of infants with Rada, Rendab Weight (LBW) were rheumatoid
in the audi and control groups.
And for this reason the magnitude of the risk of each group and the risk of
risk calculated is carried out by the static test with chi-square, and the conclusion is
the conclusion of whether or not there is a relationship between anemia and LBW.
In this way, the sample size is determined first and then the barre is
divided into exposed groups and the unexposed group and an observation of the
occurrence of LBW in both groups. The sample size can be calculated by runzus as in
analytic research (see prospective or retrospective study design).

VI. Determine the Voriabel to be Measured

Because it is not possible to collect all variables, important variables must
be chosen that are related to the research objectives and can be used as indicators.
For example in the example of the pattern of contraceptive use, the
variables studied were the variables of age, parity, duration of use, education. work,
type of contraception, place of service, service provider, and others.

VII. Prepare a list of questions and checklists

For the preparation of a list of questions the same as in the descriptive
research and measuring instruments to be used, for example to measure the nutritional
status of children who use LLA measurements, then the meter will be used.
The study, whose data was taken and medical records at the hospital, was
not done. this is one of the weaknesses of secondary data, for example, research on
anemia cannot be known how to measure or who measures Hb.

VIII. Data Collection

The cross sectional research data collection is analytical conducted by a
survey or medical record in the hospital in accordance with predetermined criteria.
For example, research on the relationship between nutritional status of children 1-5
years with intestinal worms.
Data collection was carried out by collecting all 1 5-year-old children in
the study location and then separated into two groups. There is children with good
nutrition and children with malnutrition. In all children a stool examination was
performed to detect worms and then the frequency of intestinal worms in children
with good nutrition and nutrition was less than that.
For research in hospitals with medical records as data sources. For
example, research on the relationship between primiparas and preekiamsia. Data
collection was carried out by collecting all mothers who gave birth during a certain
 period and then divided it into two groups, namely the primitive and multivariate
groups.
Furthermore, in the primipara group the amount of preekiamsia was
recorded, as well as in the multiparous group then compared. The comparability of the
two groups is based on age, education level. and social economy.
Presentation of data in the form of characteristics of study subjects in the
study group and the control group. Characteristics can be in the form of age, type of
kelainin, education, work or things related to the purpose of the study, the types of
contraception used.

IX. Data Analysis

Data analysis was performed by calculating the risk of each group relative
risk, attribute risk, and statistical tests according to the data obtained.
The report on the results of the study should be published so that other researchers can
conduct evaluations or conduct similar research to compare or compare the results of
research that has been done elsewhere.

C. Ways to use cross-sectional studies

Cross-sectional studies are used both descriptively and analytically.

Descriptive cross-sectional studies simply characterize the prevalence of a health
outcome in a specified population. Prevalence can be assessed at either one point in
time (point prevalence) or over a defined period of time ( period prevalence). Period
prevalence is required when it takes time to accumulate sufficient information on a
disease in a population, e.g. what proportion of persons served by a public health
clinic over a year have hypertension. These prevalence measures are commonly used
in public health; often the point or period aspect is not specified.

In analytical cross-sectional studies, data on the prevalence of both exposure

and a health outcome are obtained for the purpose of comparing health outcome
differences between exposed and unexposed.

Analytical studies attempt to describe the prevalence of, for example, disease
or non-disease by first beginning with a population base. These studies differ from
solely descriptive cross-sectional studies in that they compare the proportion of
exposed persons who are diseased (a/(a+b)) with the proportion of non-exposed
persons who are diseased (c/ (c+d)).

D. Calculating prevalence

The prevalence of a health outcome is simply the proportion of individuals

with the health outcome in a population.

Prevalence = cases / total population

 For the following example, two different sub-measures of prevalence can be
calculated: the prevalence of coronary heart disease (CHD) among the exposed
(people who are not active) and the prevalence of CHD among the unexposed.

Present CHD Absent CHD Total

Not active 50 a b 200 250
Active 50 c d 700 750
total 100 900 1000

P1= a/a+b= 50/250 = 20.0% prevalence of CHD among people who are not active.

P0= c/c+d = 50/750 = 6.7% prevalence of CHD among people who are active.

E. The prevalence odds ratio

The prevalence odds ratio (POR) is calculated in the same manner as the odds ratio.

POR = ad / bc

F. The prevalence ratio

The prevalence ratio (PR) is analogous to the risk ratio (RR) of cohort studies.
The denominators for both ratios are fixed populations – fixed at the start of the study
in the case of a cohort study, and fixed at the point or period of

time for the case-control study. The PR is similar to a RR when the outcome
occurs over a short period of time. For example, one would calculate a prevalence
ratio for an acute outbreak of tuberculosis in a prison population. This is in contrast to
calculating the overall prevalence of positive tuberculin skin tests among the
prisoners.

The prevalence ratio can also be calculated from the information on CHD and
physical activity. It is preferable to calculate the prevalence odds ratio when the
period for being at risk of developing the outcome extends over a considerable time
(months to years) as it does in this example:

PR = (a/N1) / (c/N0)

PR= (50/250) / (50/750) = 3.0

In this case, a prevalence ratio of 3.0 can be interpreted to mean that the
proportion of people with CHD is 3-fold greater if a person is not physically active.

G. POR vs. PR

For chronic disease studies or studies of long-lasting risk factors, POR is the
preferred measure of association in cross-sectional studies. For acute disease studies,
PR is the preferred measure of association. If the prevalence of disease is low, i.e.
10% or less in exposed and unexposed populations, POR = PR. Since cross-sectional
studies are particularly useful for investigating chronic diseases (e.g. prevalence of
 AIDS) where the onset of disease is difficult to determine, or for studying long lasting
risk factors (such as smoking, hypertension, and high fat diets), the prevalence odds
ratio will generally be the preferred measure of association.

H. Limitations of cross-sectional studies to evaluate risk

Recall that, under steady conditions, the prevalence of disease is influenced

both by incidence and duration of disease (or survival with disease).

Prevalence = Rate x Average Duration of Disease

Persons who survive longer with a disease will have a higher probability of
being counted in the numerator of a prevalence proportion. Short-term survivors will
be less likely to be counted as a case. Incidence is influenced only by exposure,
whereas prevalence is influenced both by exposure and duration of disease.

If exposure influences survival time, then the POR or PR will not provide a
valid estimate of the risk ratio or rate ratio. Thus, the interpretation of the POR or PR
is subject to survival bias.

Even if incidence remains constant, either an improvement in disease

treatment (that results in higher cure rates) or increased lethality (resulting in a higher
case fatality rate) will result in decreased prevalence. The disease itself or the threat of
developing the disease may cause outmigration of cases from an environment
perceived as causing disease, e.g. workers affected by toxic exposures in a plant may
quit, while more resistant workers will stay. This selective migration can bias
measures of prevalence.

I. Other problems with interpretation of cross-sectional studies

Cross-sectional studies as well as case-control studies are affected by the

antecedent-consequent bias, similar to the chicken and egg question (i.e. “which came
first?”). This bias occurs when it cannot be determined that exposure preceded
disease, since both are ascertained at the same time (unlike cohort studies or clinical
trials). Antecedent- consequent bias does not affect cohort studies because subjects in
cohort studies are selected for study because they are disease-free. Exposure is
actually observed to precede disease only in a cohort design, including randomized
trials.

J. Uses of cross-sectional studies

Descriptive studies are an important method to evaluate the proportion of a

population with disease or with risk factors for disease, such as the prevalence of
asthma in children or the prevalence of elevated blood lead in
 Descriptive cross-sectional studies are widely used to estimate the occurrence
of risk factors in segments of the population characterized by age, sex, race or
socioeconomic status (SES). National examples of cross- sectional studies of great
importance are the decennial census and the National Health and Nutrition Surveys
(NHANES). Opinion polls and political polls are basically cross-sectional studies.
Surveillance of changes in smoking habits or of other behavioral risk factors are
sequential cross-sectional studies. The US National Health and Nutrition Examination
Survey (NHANES) is one such example Similarly, surveillance of long lasting
diseases such as AIDS is cross-sectional. Descriptive cross-sectional studies are
useful for planning or administering preventive or health care services, surveillance
programs, and surveys and polls.

Descriptive/analytical cross-sectional studies are useful for establishing

preliminary evidence for a causal relationship. These studies are also useful for
examining the association between exposure and disease onset for chronic diseases
where researchers lack information on time of onset. Examples might include diet and
arthritis, smoking and chronic bronchitis, and asthma and exposure to air pollution.
Interpretation requires caution regarding potential association of duration of disease
with exposure status (survival bias).

Survival bias may be minimized if information can be obtained on exposures

that clearly preceded the first symptoms of a chronic disease such as arthritis,
diabetes, or chronic bronchitis. This depends on access to medical records before the
onset of a chronic disease. In addition, it may be necessary to have historical records
on an individual’s exposure status prior to these first medical visits, e.g. where the
person lived or where the person was employed.

K. CONCLUSION

Cross sectional (Cut Latitude)

The design of this study aims to get a sample of the population at a time. After that,
check the exposure status and disease status at the same time point of each individual
in the sample. That is, each research subject was only observed once and the
measurements were made on the character status or subject variable at the time of
examination.