Data Interpretation for Public Health Professionals

Data Interpretation for Idaho Public Health

Professionals
Welcome to Data Interpretation for Idaho Public Health
Professionals. My name is Janet Baseman. I’m a faculty member
at the Northwest Center for Public Health Practice at the School
of Public Health and Community Medicine at the University of
Washington in Seattle. I also work as an epidemiologist with the
UW Center for Public Health Informatics and the Kitsap County
Health District.

Introduction to Course
This hour-long course provides public health professionals with
an introduction to data interpretation. The examples and inter-
active exercises in this module offer opportunities to increase
your skills in presenting data to co-workers, community-based
organizations, hospitals, public agencies, boards of health, and
the general public. When available, Idaho-specific examples
have been used. When not available, U.S. national examples are
used.

Objectives
By the end of this module you should be able to:
1) List at least three common data sources used to charac-
terize the health or disease status of a community
2) Define and interpret basic epidemiology measures such
as prevalence, incidence, mortality, and case-fatality
3) Define and interpret basic biostatistical measures such
as the mean, median, mode, confidence interval, and
p-value
4) Read and interpret tables and graphs, and
5) Determine the appropriate format for data presentation

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Uses of Data in Public Health

Data, and the results of data analysis, have many uses in public
health practice. These include, but are not limited to:
• Population or community health assessment
• Public health surveillance
• Disease investigation
• Prevention and control measures evaluation
• Program planning
• Future health problems and needs assessment, and
• Hypothesis generation for study design

Data Sources
Useful data for public health may come from national, state, and
local sources, and are not limited to what you might typically
identify as “public health data sources.”
Sources include, but are not limited to: surveillance data,
health related-surveys, administrative sources, vital statistics,
outbreak investigations, research, and the US Census.

Data Attributes
To be useful, data should be of good quality. When we use high
quality data, we are more likely to trust conclusions we draw
from those data and act on our results to make improvements in
whatever health condition is being studied.
The quality of data depends on several factors, including
accuracy and completeness. For example, in the case of surveil-
lance for notifiable conditions reporting, we hope that a reported
diagnosis in our data correctly classifies the true diagnosis of an
individual. This is called accuracy. As for completeness, if we get
incomplete data, we might not have a good idea of what is truly
going on specific to the health of our community. Even if our
data are not 100% accurate and complete, the data will usually still be useful if we have an idea of how
accurate and how complete the data are. Having some data is frequently better than having none at all.
When we use data to answer questions about the health of our communities, the data should be
relevant to the populations and health conditions we are interested in, and the data should arrive in
a timely enough fashion so that appropriate or necessary actions can be taken for control of a health-
related event.

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Data Limitations
But all data sets have limitations. Though we won’t discuss
them in detail, some limitations of public health data we might
encounter include: inaccurate diagnoses or coding, poorly
conducted data collection, data entry or data analysis, and issues
that result in data not being representative of the population
we’d like to draw conclusions about.
For those of us working in public health practice, it is good
to know that reliable, published public health data sources are
available at the national, state and frequently at the local level.
Understanding the strengths and limitations of the data we work
with is important. If you have questions about the quality of a
data source you’re interested in using, data experts within the state Departments of Health can often
provide additional expertise and analysis.

What Is Descriptive Epidemiology?

In public health, we frequently look at descriptive data from
sources that use the methods of descriptive epidemiology. But
what is descriptive epidemiology? Basically, it is a systematic way
to describe a health problem. And it answers the questions:
• Who is getting a disease or other health outcome of
interest? We call this the person.
• Where is the health outcome occurring? We call this
the place.
• When did the health outcome occur, and is the
frequency of the health outcome changing over time?
• When we organize or analyze data by “person” we have several categories we can
use. We may use inherent characteristics of people (for example, age, sex, or race),
their acquired characteristics (such as their marital status), their activities (such as their
occupation or leisure activities), or the conditions under which they live (such as socio-
economic status).
We describe a health event by place to gain insight into the geographical extent of the problem.
We may use place of residence, birthplace, place of employment, school district, or hospital unit. Or,
we may use geographic units such as country, state, county, census tract, street address, map coordi-
nates, or some other standard geographical designation. Sometimes, we may find it useful to analyze
data according to place categories such as urban or rural, or domestic or foreign.
To answer questions on when a health event has occurred, we use measures of time. We may
consider the date of onset, duration, or seasonal occurrence of a disease, for example. We are often
interested in how a health event changes over time, such as during an outbreak investigation when
we are interested in daily or hourly changes. We may learn about annual trends by monitoring a
health condition for expected or unexpected increases or decreases; or we may be interested in
learning how a condition has changed between two time periods: for example, before and after an
intervention.

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Measures of Disease Frequency

Measuring events, such as disease or health events, is at the
heart of public health surveillance and resource allocation. One
of the simplest methods of measuring is just simply counting.
However, as you will see in a later slide, simple counts often
do not provide all of the information needed to understand the
relationship of a health event to the population in which the
event occurred. Counts alone are also insufficient for describ-
ing the characteristics of a population and for determining risk.
The key is to relate the frequency of an event to an appropriate
population. For this purpose we use ratios, proportions, and
rates.
The next series of slides will introduce you to ratios, proportions, and rates, and then we’ll provide
an overview of four measures of disease frequency or severity—prevalence, incidence, mortality, and
case-fatality – that are commonly used in public health.

Numerator and Denominator

Ratios, proportions and rates are measures frequently used to
define the health of our communities. Ratios, proportions, and
rates all include both a numerator and a denominator. Let’s start
with the numerator. The numerator is the top part of a fraction.
In the fraction ¾, 3 is the numerator. In public health, often the
numerator is the number of health events of interest.
Now let’s review the denominator. The denominator is the
bottom part of a fraction. In the fraction ¾, 4 is the denomina-
tor. In public health, the denominator is often ‘the population
at risk’. The population at risk is the group of people, healthy or
sick, who would be counted as cases if they had the health condition being studied.
Everyone in the population at risk must be eligible to be counted in the numerator if they have
the event of interest. And you only count events in the numerator that occur within the population at
risk, or the denominator. For example, in looking at the rate of colon cancer in women, we would not
include men in the population at risk, because men with colon cancer would not be included in the
number of events. Likewise, if we were interested in knowing the rate of prostate cancer in a certain
population, women would not be included in the population at risk.

Ratios and Proportions

A ratio is obtained by dividing one quantity by another. For example, to find the ratio of Idaho women
ages 65 and older to Idaho men ages 65 and older, we would divide the number of women by the
number of men. (Here we’re using the projected ratio of female to male adults ages 65 and older in
Idaho in 2010.) Notice that the number of women is the numerator, and the number of men is the
denominator [99,581 / 81,835, or 1.22].

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A proportion is a ratio in which the numerator is included in

the denominator.
The projected proportion of adults who will be 65 or older
in Idaho in 2010 is 181,416. The total population is 1,517,291,
which includes all ages of people. Notice that when you
divide the numerator by the denominator, the value you get
is 0.12. Proportions are often multiplied by 100 and reported
as percentages, so we can say that the projected proportion of
adults in Idaho who will be age 65 or older in 2010 is 12%.

Proportion and Rates

We’ll spend the next several slides talking about rates. A rate is
often a proportion, with the added dimension of time.
Rates measure the frequency at which a health event occurs
over a period of time. Later, we’ll go through examples of how
rates are calculated, but for now, let’s just say that a rate is a
numerator divided by a denominator times a standard unit
of population size (like 100 or 1000 or 100,000 people). A
rate represents the burden of disease or other health related
outcome during a specific time period.
Proportions and rates are used in public health for quantifying
morbidity and mortality
• Some measures of morbidity, or illness, include prevalence and incidence rate.
• Measures of mortality include mortality rates, and
• Measures of disease severity include case-fatality

Exercise on Proportions

Why Use Rates?

We use rates to describe the frequency of a health event or
health status relative to the size of a population
When we use rates, the number of events is adjusted for the
size of the source population in which they occurred.
Rates make it possible to compare disease frequency across
different groups of people, places, and time periods.
Clinicians often report numbers of patients they see with
certain diseases, but epidemiologists and public health agencies
use proportions and rates, which allow us to describe the
frequency of diseases relative to the size of the population in
which they occurred.

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Rates allow us to make comparisons between groups of people, such as different age groups, or
locations that have different population sizes, such as states versus cities or urban versus rural areas.
Rates also allow us to make comparisons within the same population over time.
Rates are useful in many ways. With rates, the health department can identify groups in the
community with an elevated risk of disease. With this information, risk factors can be examined and
interventions targeted to high-risk groups.

Using Rates
In using rates to make comparisons, we need to account for the
fact that the number of health events depends in part on the
number of people in the community. For instance, we expect
to find more cases in larger populations. To account for growth
in a community or to compare communities of different sizes,
we usually calculate rates to provide the number of events per
population unit.
For example, in looking at this table of surveillance data,
if you have 1000 people in your community and 20 cases
of a disease, that could be a lot more significant than if you
have 1 million people in your city and 20 cases of a disease.
Furthermore, if all 20 cases in either population occur within only one age group, race, or gender, this
might influence your decision to investigate further.
When we divide the numerator by the denominator in each city, you can see that the rate in city A
is much greater than the rate in city B – 1,000 times greater. Frequently, we will take these rates repre-
sented as decimals and multiply them by a multiple of 10 in order to convert them to whole numbers.
Here, this is done by multiplying both crude rates by 100,000, and the result is in the far right column.
As long as you multiply the rates for cities A and B by the same multiple of 10, you will still have a
valid comparison. Also, this far right column makes the most sense in terms of interpretation of a rate.
For example, in city B, we can say that the rate of disease in this population was 2/100,000, or for
every 100,000 people in the population, two cases of disease were identified during the time period
of interest.

Crude Rate
In the following slides we will introduce common rates that are
used in public health. Each serves a different purpose.
Let’s begin with crude rates: A crude rate is the rate calcu-
lated for the total population. Crude rates are recommended
when a summary measure is needed and it is not necessary or
desirable to take into account any other factors, such as the age
of the population.
A crude rate is calculated by dividing the total number of
events in a specified time period by the total number of individ-
uals in the population who are at risk for these events and
multiplying by a constant, such as 1,000 or 100,000 [in other

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words, (numerator/denominator) x constant]. We saw an example of how to calculate a crude rate on

the previous slide, when we calculated rates of disease in city A versus city B.
An example of a crude rate would be: Between 2000 and 2004, the crude rate for suicide deaths
in Idaho was 15.1 cases per 100,000 population.
The crude rate has the advantage that it is a simple, easily calculated measure that gives a broad
depiction of the extent of a health outcome in a particular area in a particular time period. The crude
rate presents the actual magnitude of an event within a population.
The problem with crude rates is that they do not account for the underlying demographic differ-
ences between communities or between time periods, and this can be a real problem when we’re
trying to compare rates of disease between two communities, for example, or between our county
and the state or between two different time periods within our own county.

Category-Specific Rates
Category-specific rates are rates measured in a specific group,
such as the rate of disease within one gender, ethnicity or age
group. When the rate applies to a specific age group, such as
those between the ages of 15–24, it is called the age-specific
rate. Category-specific rates are used for comparisons when rates
differ widely between groups. For example, if we know that the
highest injury rates from unintentional falls are for children under
14 years and for people over 65 years, we might like to calculate
injury rates in these age groups specifically instead of in the total
population.
Category specific rates are recommended when specific
causal or protective factors are different for different subgroups. They present the actual magnitude of
an event within a designated group.

Age-Adjusted Rates
Almost all diseases or health outcomes occur at different rates
in different age groups. Many chronic diseases, including
most cancers, occur more often among older people. Other
outcomes, such as many types of injuries, may occur more often
among younger people than in middle aged people. Therefore,
the age distribution of a given population often determines what
the most common health problems in a community will be.
What I mean by this is that if a certain population mostly consists
of older people, the burden of disease from cancer in that
community will likely be greater that it would be in a community
that mostly consists of younger people.
By convention, rates are frequently adjusted to the age distribution of the estimated U.S. popula-
tion of the year 2000, commonly referred to as the standard population.
To summarize, age-adjusted rates are recommended when making comparisons in the rates of
age-related health events between different populations or for comparing trends in a given popula-

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tion over time. And age-adjusted rates are essential for events that vary with age (for example, cancer
deaths), or when comparing populations with different age distributions. However, because age-
adjusted rates are often calculated using a standard population, these rates can mask important trends,
so it is also important to look at crude rates, as well as category-specific rates. Finally, age-adjustment
requires training and a knowledge of biostatistics.

Effect of Age Adjustment

When comparing rates between communities, it is useful to
calculate a rate that is not affected by differences in the age
composition of the populations. Let’s say that we have two
populations. Not knowing anything about their age distributions,
we can see that population one has a higher rate of disease than
population two. There could be many reasons for this differ-
ence. For example, there could be environmental, behavioral,
or genetic differences between the two populations that result in
different disease rates. But if you recall that many diseases occur
more often in older people, another reason for this observed
difference could be that population one has a higher proportion
of older people than population two.
An age-adjusted rate mathematically removes the effect of the age composition of the underlying
population, allowing comparisons between communities with different age distributions. By conven-
tion, rates are frequently adjusted to the age distribution of the estimated U.S. population in the year
2000, which is commonly referred to as the “standard” population.
After the rates of disease in our different populations, and within our different age categories, are
applied to the standard population, we are left with rates of disease that we can compare, having
effectively removed, or adjusted for, the differences in age distributions of the two populations.
As you can see, the disease rate in population one is still higher than the disease rate in population
two after adjusting for age. This implies that something other than age is causing the higher rate of
disease in population one.

Why Compare Rates?

Comparing rates is useful for several reasons. For example, you
might want to know whether the rate of some disease differs
between your county and the rest of the state, or whether
Idaho’s rates are different from the rest of the U.S., or whether
there have been changes in the rates of some disease between
1996 and 2006.
But it is important to remember that you should compare
rates only when the events and population are defined the same
way over time and place. Some things to consider when deter-
mining whether two rates can be compared are:
• Consistency in definition of event
• Consistency in the methods used to collect the data, and

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• Consistency over time. For example, you probably don’t want to compare the rate of
diabetes in Idaho in 2006 with the rate of diabetes in the U.S. in 1986. The exception is,
of course, when you are purposefully comparing events between two time periods within
the same population.
When comparing age-specific rates, if the age categories are relatively large, such as 15 to 29, the
rates may be distorted, because this includes such a large group of people. Looking at smaller group-
ings (such as 15-19, or 20-24) might give you a better idea of what is going on in your population of
interest. In the case of comparing age-adjusted rates, be sure to compare only rates that have been
adjusted to the same “standard” population.

Exercise on Kinds of Rates

Prevalence
We are now going to turn our attention to specific types of
measures frequently used in public health to evaluate the
burden of disease in our communities. The first is prevalence.
Prevalence measures the number of cases (including both
new and old cases) of a disease (or health-related condition or
event) at a specific time point or period in time. Note that if
prevalence is measured for a period of time, say three months,
rather than at a point in time, the population denominator
should represent the average population during that period.
Some important things to remember about prevalence are that:
• It is used to present a ‘snapshot’ view of the disease or health condition of interest.
• We frequently obtain prevalence data from surveys or surveillance databases, and that,
• Prevalence is a proportion (or percentage).
When we calculate prevalence, the numerator includes existing cases of a disease at a specified
time and the denominator includes people in the defined population at that time. Because prevalence
describes the burden of illness in a population, public health professionals use prevalence to assess
the effect of a health event or disease on the resource needs of both the public health system and the
health care delivery system.

Calculating Prevalence
Now let’s work through an example of how prevalence is
calculated.
In 2003, Idaho had a household population of 1,366,322. Of
these people, 11 percent were 65 and older.
In 2003, Idaho reported 21,000 individuals 65 and older with
diabetes.
In this example, the prevalence of diabetes among Idahoans

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ages 65 and older is calculated by dividing the number of individuals 65 years and older with diabetes
by the household population who were 65 years and older.
Here we see that calculation [21,000 / 150,295 = 0.140]. We multiply by 100, to report the preva-
lence as a percentage, and we see that in 2003, the prevalence of diabetes in Idaho residents equal to
or over 65 years of age was 14%.
We can also express the prevalence as 140 cases per 1,000 Idaho residents equal to or over 65
years of age. We arrive at this value by multiplying 0.14 by 1000.

Exercise on Prevalence

Incidence (Rate)
Another measure of burden of disease is incidence. Incidence
is defined as the number of new cases of a condition during a
defined time interval divided by the number of persons at risk of
developing the condition over that time interval.
Incidence rates provide a direct measure of the rate at which
new illness occurs in the population, and therefore incidence
rates—and the incident cases from which we derive them—can
be used to study the causes of health events. Incidence rates are
commonly expressed as the number of cases of disease or injury
per 100,000 person-years of exposure to the risk.
Now let’s look at an example of incidence.

Calculating Incidence
In 2004, 2784 new cases of chlamydia were reported in Idaho
State.
The at-risk population in Idaho in 2004 was 1,393,262.
Incidence is equal to the new cases divided by the at-risk
population [2784 / 1,393,262 = 0.001998].
In 2004, the incidence of chlamydia in Idaho State was
0.1998%.
We can also express this as 199.8 cases per 100,000
population.

Exercise on Incidence

Mortality Rates
A mortality rate is a specific type of incidence rate. Mortality rates are used to describe the incidence
of death in a population, rather than the incidence of disease. Mortality rates are frequently referred
to as death rates. Mortality rates are calculated by dividing the number of deaths in the population
during a stated time period by the number of persons at risk of dying during that period.

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Because mortality is a rate, it can be expressed as number of

deaths per 1000, per 10,000 or per 100,000, depending on the
condition being described.
• Several useful types of mortality rates are frequently
used in public health.
• The crude mortality rate for a population is the death
rate from all causes.
• A cause-specific mortality rate is the mortality rate
of a population associated with one disease or other
cause.
• And age-specific mortality rate describes the rate of
death in a certain age group.
Mortality can vary considerably by age, sex, race, and ethnicity. As a result age-specific death rates
are often presented separately for the different genders or different ethnic groups.
Now we’ll work through an example of how to calculate a
mortality rate.

Calculating Mortality Rates

Between the years 2000 and 2004, 1039 suicide deaths were
reported among Idaho residents. If we are interested in knowing
the annual suicide mortality rate during this time period, how
would we calculate it?
Number of suicide deaths should go in the numerator. The
number of suicide deaths we are given 1039, is for a 5 year time
interval, so we can divide that by 5 to get the numerator for an
average annual rate.
The mid-year, or 2002, population of Idaho was 1,341,131.
This will be our denominator.
Dividing the average number of deaths per year by the 2002
Idaho population gives us the following value: 0.000155. This is the suicide mortality rate. Multiplying
our rate by 100,000, we can say that the suicide mortality rate in Idaho between 2000 and 2004 was
15.5 per 100,000 people.

Age-Specific Mortality Rate

Here’s an age-specific mortality rate example. For annual rates,
the age-specific rate is the number of new cases or deaths in
given age group and year divided by the population in that age
group.
The breast cancer mortality rate in 2003 among women
between the ages of 20 and 44 in Idaho State was 4.2 per
100,000 women. This rate was calculated by dividing the
number of breast cancer deaths in 2003 among women in this

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age group by the total number of women in Idaho in that age group in 2003 and then multiplying
that value by 100,000. The breast cancer mortality rate for women ages 45-64 was 34 per 100,000.
Among women ages 65 and older, the breast cancer mortality rate was 108 per 100,000.

Case Fatality
Another type of measure we sometimes use in public health
is the case-fatality. Case-fatality is calculated by dividing the
number of deaths from a condition during a stated time period
by the number of persons with the condition of interest. We call
this case-fatality because in the denominator we’re referring to
those with the condition as cases.
The case-fatality provides us with a measure of the severity of
the condition of interest. For example, among people older than
age 70 with West Nile Virus meningoencephalitis, the case-fatal-
ity was 21% in the U.S. in the year 2002.
Now let’s work through an example.

Case Fatality Example

The National Highway Traffic Safety Administration reported
that in the year 2000, 4,739 deaths occurred in the U.S. when a
pedestrian was hit by a motor vehicle.
For calculation of case-fatality, these are the fatalities.
Additionally, the report estimated that there were a total of
78,000 pedestrians injured after being struck by motor vehicles
in the year 2000.
For calculation of case-fatality, these are the cases. Dividing
the number of fatalities by the total number of cases of injury
(including deaths) gives us a case-fatality of 6.1%, and we can
say that in 2000, 6.1% of pedestrians injured by motor vehicles
died as a result of their injuries.

Comparing Mortality & Case-Fatality

Now let’s compare mortality and case-fatality using an example.
Assume you have a population of 150,000 people of whom 20
are sick with a certain disease X, and in one year, 18 people die
from disease X. The mortality rate in that year from disease X is
equal to 18/150,000.
Converting this to a mortality rate per 100,000 people, we
can say that the mortality rate is 12 per 100,000 population.
Note that this is a cause-specific mortality rate because we’re
only reporting the death rate due to disease X.
The case-fatality rate from disease X is equal to 18/20, or
90%.

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Exercise on Incidence and Prevalence

Descriptive Statistics and Tools

In public health, we frequently use statistics to gain a better
understanding of our data. The next few slides will introduce
you to several statistical techniques, often applied to public
health data. We will discuss techniques used to summarize or
describe a set of data, which allows us to simplify large amounts
of data and to prepare those data for presentation. This process
allows us to draw conclusions about the health of populations.
The goal of using these statistical tools is ultimately to
describe health conditions, events or behaviors in our commu-
nities in order to address key public health questions and
ultimately improve health and reduce disease. So we use
“descriptive statistics” to draw conclusions about large amounts of data. Some of these tools are
referred to as summary measures.
Summary measures not only include the average, or mean, but also the median and the mode. It is
important to look at summary measures along with the entire data set in order to understand our data,
because the same summary measures may be used to describe very different data sets.
In addition to summary measures, we will also discuss two other commonly used statistical tools in
public health practice: the confidence interval and p-value. Let’s begin with summary measures.

Mean
The mean is the average value of a set of data. We calculate
it by adding two or more quantities together and dividing by
the number of quantities. For example, if we wanted to know
the mean of two numbers, 6 and 7, we would add these two
numbers and then divide by 2 (which is the number of quanti-
ties we have).
The mean is a popular statistical measure because: it is
familiar to most people; it provides useful summary informa-
tion about our data, and it is easily used with other statistical
measurements. The major disadvantage to the use of the statisti-
cal mean is that it can be affected by extreme values in the data
set and therefore can be biased.

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Median
The median is the midpoint, or “middle value,” in a series of
numbers arranged in order from small to large. Half the data
values are above the median, and half are below. For example,
in 2005 the median age of death in the U.S. was 75, meaning
that half the people who died were older than 75 and half were
younger.
If the list has an odd number of entries, the median is the
middle entry in the list. If the list has an even number of entries,
the median is equal to the sum of the two middle numbers
divided by two.
The median, unlike the mean, is not affected by extreme data
values.

Mode
The final summary measure we will discuss is the mode.
In a list of numbers, the mode is the number that occurs most
often, assuming at least one number, or data point, occurs more
than once.
For example, in the following set of data [1, 3, 5, 5, 7, 9], 5 is
the mode because it is the most frequently occurring value.
Some data are Unimodal, meaning they have only one
mode; some data are bimodal meaning they have two modes.
In this set of data [1, 3, 3, 5, 5, 7, 9], both 3 and 5 are the
modes.

Mean and Median Example

Let’s compare the mean and median using the number of
firearm-related deaths in Idaho in 2004. In the left column we
see that there were a total of 177 deaths. We can also see that
the range of ages of the firearm-related deaths was 6 to 93. The
mean age of those who died was 46.7. The mean is the sum of
all ages, divided by 177.
The median age of firearm-related deaths in Idaho in 2004
was 46. Therefore, half the cases were higher in age and half the
cases were lower in age than the median of 46. In this example,
the mean and median are very similar, but this is not always the
case.

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Exercises on Mean, Median, and Mode

95% Confidence Interval (CI)

Now let’s look at two other statistical tools public health
commonly uses. The first one is the 95% confidence interval.
A 95% confidence interval is a range of values that is used to
describe how confident we are that a rate or proportion calcu-
lated from a sample of data represents the true underlying rate
or proportion in the population from which the sample was
drawn.
For each estimated rate, one would expect the rate to fluctu-
ate somewhat, depending on several factors, but to remain
within the confidence interval 95% of the time. So if we were to
repeatedly calculate new rates from samples of our population
using the same procedures each time, 95 times out of 100, we would expect the sample rates to fall
within the 95% confidence interval.
The width of the confidence interval gives us some idea about how precise we are about the rate
or proportion around which we’ve calculated the CI. A narrow confidence interval around a rate
indicates that the population rate is probably quite close to the rate we observed in our sample. A
wider CI indicates that our estimated rate might be further from the true population rate.
By convention, 95% confidence intervals are routinely calculated in public health, though you
might also come across 99% or 90% confidence intervals.

95% CI Example
Let’s take a look at an example of the 95% CI. In this example,
we can look at the confidence interval and get a feel for how
precise our estimates are of the annual rate of death in Idaho
and in the different districts in Idaho. The annual rate of death
per 100,000 people in the state is 7.2/100,000. The narrow
confidence interval of 7.0 to 7.3 suggests that we can be 95%
confident that the true death rate lies within this range.
We can also use confidence intervals to compare 2 rates
to determine whether they are statistically different from each
other. When comparing two rates, if the confidence intervals
do not overlap, the difference in the rates is considered unlikely
to be the result of chance. (We use the term “statistically significant” to say that something is unlikely
to be the result of chance.) For example, when comparing the confidence intervals around the death
rates for districts 2 and 3, we can see that they do not overlap. This suggests that the difference
between the death rate of 9.0 per 100,000 for district 2 and 7.3 per 100,000 for district 3 is statisti-
cally significant.
It is worth noting that when comparing 2 rates, although non-overlapping CIs indicate a statistically
significant difference between the 2 rates, the opposite is not true. In other words overlapping CIs do

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not necessarily suggest that the 2 rates are statistically similar. In order to be sure, you would have to
perform a statistical test to compare the 2 rates.

Exercise on Confidence Intervals

P-Value
Now let’s take a look at the other useful statistical tool I
mentioned at the beginning of the section: P-value. The p-
value is frequently used in public health to determine whether
observed differences between groups are ‘real’ differences.
(Another way to say this is that the p-value is a measure of
the statistical significance of a difference between rates or
proportions.)
The p-value is a measure of how likely it is that the differences
between two observed rates or proportions occurred by chance
alone. We’ll look at examples of p-values on the next slide, but
for now let me just say that a very small p-value means that observed differences were very unlikely to
have occurred by chance. For example, a p-value of 0.05 indicates that there was only a 5% chance
that the observed differences between the two estimates you are comparing occurred by chance
alone. This means that conversely, there was a 95% chance that the difference between the two
estimates you observed resulted from something other than chance.
A p-value of less than .05 suggests that there was less than a 5% chance that the observed
differences between the two estimates you are comparing occurred by chance alone.
It is common practice in publi health to use a cutoff of p less than .05 to establish that an oberved
difference was unlikely to have occurred by chance alone.

P-Value Example
Here is an example of how to interpret p-values. In this slide,
we are looking at a table of annual death rates per 100,000
people in Idaho by district. The far right column shows the
p-values for the death rates for each district compared with the
rest of the state.
A p-value that is less than .05 indicates that there is a statisti-
cally significant difference between the annual death rate in a
certain district and the rest of the state. We can see that 5 of the
p-values are less than .05. By looking at the rates themselves,
we can see that in districts 1, 2 and 5, the annual death rates
were statistically significantly higher than the rest of Idaho, and
in districts 4 and 7, the death rates were statistically significantly lower than the rest of Idaho. Because
the p-values were not less than .05 for the comparisons between district 3 and the rest of the state
and district 6 and the rest of the state, we cannot say that there is a statistically significant difference
between these death rates.

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Data Presentation
In the previous slides, we discussed ways to use data to measure
the burden of disease in populations using disease frequency
measures such as prevalence and incidence. Then we discussed
ways to summarize data (such as with the mean or median) and
we discussed ways to measure the precision of our estimates and
make comparisons between groups (using confidence intervals
and p-values). But once you have summarized your data, how
do you know how to present those data in a clear and meaning-
ful fashion?
In the following slides we will discuss ways to present data
and the strengths and limitations of each presentation format,
and we will describe how to chose between different presentation options.
Often it is difficult to determine the most appropriate way to visually display data. Although we
may be comfortable with using one of these formats, the choice of graphic depends on what we want
to emphasize, rather than simply trying to fit the data into a familiar framework. The next series of
slides will review some common ways that data can be presented, and the strengths and limitations of
each method.
Examples of data presentation options that we will discuss are:
• Tables
• Line graphs
• Bar graphs
• Pie charts

Why Care About Data Presentation?

Why is data presentation so important?
Data may be presented in several different ways but each
presentation format has a similar goal: to organize and summa-
rize data in a clear and accurate manner. Visual displays of
data are often simpler and more understandable than standard
writing, and as a result, they can make the interpretation of data
easier, allowing the reader to identify and explore:
• Disease frequencies,
• Various comparisons between groups,
• Trends over time, and
• Other relationships in the data.

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Tables
A table is a visual display of data arranged into rows and
columns. One benefit of using tables is that they allow us to
demonstrate a number of patterns or differences between
groups, depending on what data are included in the table.
Almost any quantitative information can be organized into a
table.
Tables may take longer to read and understand than some
other visual comparisons, such as graphs. A table should be as
simple as possible. Because large complicated tables can be
overwhelming for the reader, for clarity, sometimes it is better to
create two or three small tables rather than one large table.
Although tables can be useful for presenting time trend data, sometimes other data presentation
options might be preferable.

Table Example
This table illustrates the leading causes of death among Idaho
residents below the age of 1 year in 2004. In the first column,
causes of death are presented. In the second column, the
number of deaths that occurred in each category is shown, and
in the third column, the frequency of those cause-specific deaths
is represented. In the bottom row of the table, total number of
deaths is reported, and you can see that the frequencies of the
cause-specific deaths add to 100%.
This table is simple and clear in its presentation. The fact that
the causes of death are listed in order of how frequently they
occurred makes it easy for the reader to identify the leading
causes of death in this age group and perhaps to begin thinking
about prevention strategies.

Line Graphs
A line graph is a useful data presentation tool for showing a long
series of data (such as disease trends over time). Line graphs are
also useful for comparing several different series of data in the
same graph. Line graphs display data in two dimensions. We call
the dimensions the x-axis and the y-axis.
By convention the dependent or y variable is on the vertical
axis and the x, or independent variable is on the horizontal axis.
When reading a line graph, you’ll notice that rises and falls in the
line show how one variable is affected by another. Let’s look at
an example.

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Line Graph Example

Here’s an example of a line graph that represents the prevalence
of tobacco use during pregnancy among women in Idaho and
in the U.S. between 1998 and 2002. Along the y-axis, we have
the percent (or prevalence) of women who reported having
used tobacco during pregnancy, and along the x-axis, we have
the year. Two trends are represented here: one is the change
in prevalence of tobacco use during pregnancy in Idaho, and
the second is the change in prevalence of tobacco use during
pregnancy in the U.S. This allows us to evaluate the changes in
prevalence separately for the U.S. and Idaho but also allows us
to visually compare the two trends with each other.
For example, we can see that in 2002, the prevalence of tobacco use during pregnancy was lower
for Idaho than it was for the U.S. Note that if we wanted to determine whether this difference of
11.4% in the U.S. versus 10.5% in Idaho was statistically significant, we would have to see a p-value
comparing the two.

Exercise on Line Graphs

Bar Graphs
Bar graphs are also used to compare data and show relationships
between two or more variables (or groups or items).
Each independent variable is discrete, such as race or gender
(which only has two categories: male and female). If you
wanted to display data comparing, for example, the prevalence
of smoking in people of different ages, using a bar graph, you
would group the age variable into categories (such as ages 15-19
or 20-24) for clarity of presentation.
Bar graphs are a quick and intuitive way to show big differ-
ences in data.

Vertical Bar Graph

Here we see a simple bar graph representing the proportion (or
percent) of Idaho adults who had ever been told by a health
care professional that they have diabetes. This is a measure of
prevalence. We can see that the data have been presented for
the state and also separately for each health district. What can
we say about these data?
One thing we can say is that the prevalence was higher in
District 6 than in all the other districts and that the prevalence
was lowest in District 4. But keep in mind that we don’t know
whether any observed differences are real resulting from true

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differences in the people who live in district 6 vs. district 4 for example, or whether differences in
prevalence results from random error or bias in our sample of respondents.
Again, in order to determine whether differences in prevalence between two or more districts
are statistically significant, we would have to see a p-value. Recall that the p-value is obtained from
performing a statistical test.

Horizontal Bar Graph

Bar graphs can be displayed either vertically or horizontally.
Here we see an example of a horizontal bar graph, displaying
infant deaths in Idaho in 2004. Along the y axis infant deaths are
displayed. Along the x axis, the percent of total infant deaths is
displayed. Thus, the bars represent the percent of total deaths
attributable to each cause of death.
These data could also be displayed using a vertical bar graph.
Your choice of which to use can depend on personal preference,
but it might be useful to construct a bar graph both vertically and
horizontally to determine which presentation format is clearest
given the data you are presenting.

Pie Charts
Pie charts are frequently used to show how part of something
relates to the whole. Pie charts are useful for showing the
component parts of a single group or variable. The basic design
is a circle, the shape of a pie, and the components, or slices of
the pie, are usually percentages of the different categories of the
variable.
Pie charts are a way to effectively present percentages in
which the “slices” of the pie add up to 100%.

Pie Chart Example

Let’s look at a pie chart. The whole pie represents the total
number of deaths from unintentional injuries among children in
Idaho between the ages of 1 and 4 for the times period 2000 to
2002. From this pie chart we can see that drowning or submer-
sion- related injuries were the leading cause of unintentional
injury deaths among 1–4 year olds in Idaho during that time
period.
Although these data could certainly be presented in a table
or using a bar graph, note how easy it is to make comparisons
between the causes of death using the pie chart in this example.
When a single variable is being presented (such as deaths due

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Data Interpretation for Public Health Professionals

to unintentional injuries), and the information you want to convey is how parts relate to the whole
(like how the causes of deaths due to unintentional injuries relate to the total number of injuries), you
should consider using a pie chart to display your data.

Exercise on Display of Data

Summary
In this course, we covered some basic concepts you will need to
understand and talk about public health data. These concepts
include:
• Measures of disease frequency, such as prevalence,
incidence, mortality, and case-fatality
• Biostatistical tools, such as the mean, median, mode,
confidence interval, and p-value
• Graphical forms of displaying data, such as tables, line
graphs, bar graphs and pie charts
Remember, knowing how to read understand, and interpret data specific to your community will
help you better understand your community’s health needs.

Resources
Here is a list of useful resources that provide further information
about this topic. You can also print out the list of these resources
by clicking the resources link in the attachments drop-down box
located at the top of the screen.
Online Resources
CDC WONDER, http://wonder.cdc.gov/. Provides a single
point of access to a wide variety of reports and numeric
public health data.
E is for EPI, North Carolina Center for Public Health
Preparedness. http://www.sph.unc.edu/nccphp/training/
training_list/t_e_epi.htm.
Principles of Epidemiology, CDC, Second Edition, 1992. http://www.phppo.cdc.
gov/phtn/catalog/pdf.
Books
Basic and Clinical Biostatistics, Beth Dawson and Robert G. Trapp. McGraw Hill, 2004.
A Cartoon Guide to Statistics, Larry Gonick and Woollcott Smith, Harper Collins, 1994.
Epidemiology, Leon Gordis, W.B. Saunders Company, 2000.
Epidemiologic Methods, Thomas Koepsell and Noel White, Oxford University Press, 2003.
Epidemiology for Public Health Practice. Robert H. Friis and Thomas A Sellers. Jones and Parlett
Publishers, 2004.
Intuitive Biostatistics, Harvey Motulsky, Oxford University Press, 1995.

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