Biases and Confounding

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Bias in Epidemiological Studies

While the results of an epidemiological study may reflect the true
effect of an exposure(s) on the development of the outcome under
investigation, it should always be considered that the findings may in
fact be due to an alternative explanation .
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Such alternative explanations may be due to the effects of chance

(random error), bias or confounding which may produce spurious
results, leading us to conclude the existence of a valid statistical
association when one does not exist or alternatively the absence of an
association when one is truly present .
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Observational studies are particularly susceptible to the effects of

chance, bias and confounding and these factors need to be considered
at both the design and analysis stage of an epidemiological study so
that their effects can be minimised.
Bias
Bias may be defined as any systematic error in an epidemiological
study that results in an incorrect estimate of the true effect of an
exposure on the outcome of interest. 1

 Bias results from systematic errors in the research methodology.

 The effect of bias will be an estimate either above or below the
true value, depending on the direction of the systematic error.
  The magnitude of bias is generally difficult to quantify, and
limited scope exists for the adjustment of most forms of bias at
the analysis stage. As a result, careful consideration and control
of the ways in which bias may be introduced during the design
and conduct of the study is essential in order to limit the effects
on the validity of the study results.

Common types of bias in epidemiological studies

More than 50 types of bias have been identified in epidemiological
studies, but for simplicity they can be broadly grouped into two
categories: information bias and selection bias.

1. Information bias
Information bias results from systematic differences in the way data on
exposure or outcome are obtained from the various study groups. This 1

may mean that individuals are assigned to the wrong outcome

category, leading to an incorrect estimate of the association between
exposure and outcome.
Errors in measurement are also known as misclassifications, and the
magnitude of the effect of bias depends on the type of misclassification
that has occurred. There are two types of misclassification – differential
and non-differential – and these are dealt with elsewhere (see “Sources
of variation, its measurement and control”).
Observer bias may be a result of the investigator’s prior knowledge
of the hypothesis under investigation or knowledge of an individual's
exposure or disease status. Such information may influence the way
information is collected, measured or interpretation by the investigator
for each of the study groups.
For example, in a trial of a new medication to treat hypertension, if the
investigator is aware which treatment arm participants were allocated
to, this may influence their reading of blood pressure measurements.
Observers may underestimate the blood pressure in those who have
been treated, and overestimate it in those in the control group.
Interviewer bias occurs where an interviewer asks leading questions
that may systematically influence the responses given by interviewees.
Minimising observer / interviewer bias:
  Where possible, observers should be blinded to the exposure and
disease status of the individual
 Blind observers to the hypothesis under investigation.
 In a randomised controlled trial blind investigators and
participants to treatment and control group (double-blinding).
 Development of a protocol for the collection, measurement and
interpretation of information.
 Use of standardised questionnaires or calibrated instruments,
such as sphygmomanometers.
 Training of interviewers.

Recall (or response) bias - In a case-control study data on exposure

is collected retrospectively. The quality of the data is therefore
determined to a large extent on the patient's ability to accurately
recall past exposures. Recall bias may occur when the information
provided on exposure differs between the cases and controls. For
example an individual with the outcome under investigation (case)
may report their exposure experience differently than an individual
without the outcome (control) under investigation.
Recall bias may result in either an underestimate or overestimate of
the association between exposure and outcome.
Methods to minimise recall bias include:

 Collecting exposure data from work or medical records.

 Blinding participants to the study hypothesis.

Social desirability bias occurs where respondents to surveys tend to

answer in a manner they feel will be seen as favourable by others, for
example by over-reporting positive behaviours or under-reporting
undesirable ones. In reporting bias, individuals may selectively
suppress or reveal information, for similar reasons (for example,
around smoking history). Reporting bias can also refer to selective
outcome reporting by study authors.
Performance bias refers to when study personnel or participants
modify their behaviour / responses where they are aware of group
allocations.
Detection bias occurs where the way in which outcome information is
collected differs between groups. Instrument bias refers to where an
inadequately calibrated measuring instrument systematically
over/underestimates measurement. Blinding of outcome assessors and
the use of standardised, calibrated instruments may reduce the risk of
this.

2. Selection bias
Selection bias occurs when there is a systematic difference between
either:

 Those who participate in the study and those who do not

(affecting generalisability) or
 Those in the treatment arm of a study and those in the control
group (affecting comparability between groups).

That is, there are differences in the characteristics between study

groups, and those characteristics are related to either the exposure or
outcome under investigation. Selection bias can occur for a number of
reasons.
Sampling bias describes the scenario in which some individuals
within a target population are more likely to be selected for inclusion
than others. For example, if participants are asked to volunteer for a
study, it is likely that those who volunteer will not be representative of
the general population, threatening the generalisability of the study
results. Volunteers tend to be more health conscious than the general
population.
Allocation bias occurs in controlled trials when there is a systematic
difference between participants in study groups (other than the
intervention being studied). This can be avoided by randomisation.
Loss to follow-up is a particular problem associated with cohort
studies. Bias may be introduced if the individuals lost to follow-up differ
with respect to the exposure and outcome from those persons who
remain in the study. The differential loss of participants from groups of
a randomised control trial is known as attrition bias.
• Selection bias in case-control studies
Selection bias is a particular problem inherent in case-control studies,
where it gives rise to non-comparability between cases and controls. In
case-control studies, controls should be drawn from the same
population as the cases, so they are representative of the population
which produced the cases. Controls are used to provide an estimate of
the exposure rate in the population. Therefore, selection bias may
occur when those individuals selected as controls are unrepresentative
of the population that produced the cases.
The potential for selection bias in case-control studies is a particular
problem when cases and controls are recruited exclusively from
hospital or clinics. Such controls may be preferable for logistic reasons.
However, hospital patients tend to have different characteristics to the
wider population, for example they may have higher levels of alcohol
consumption or cigarette smoking. Their admission to hospital may
even be related to their exposure status, so measurements of the
exposure among controls may be different from that in the reference
population. This may result in a biased estimate of the association
between exposure and disease.
For example, in a case-control study exploring the effects of smoking
on lung cancer, the strength of the association would be
underestimated if the controls were patients with other conditions on
the respiratory ward, because admission to hospital for other lung
diseases may also be related to smoking status. More subtly, the effect
of alcohol on liver disease could potentially be underestimated if
controls are taken from other wards: higher than average alcohol
consumption may result in admission for a variety of other conditions,
such as trauma.
As the potential for selection bias is likely to be less of a problem in
population-based case-control studies, neighbourhood controls may be
a preferable choice when using cases from a hospital or clinic setting.
Alternatively, the potential for selection bias may be minimised by
selecting controls from more than one source. For example, the use of
both hospital and neighbourhood controls.
• Selection bias in cohort studies
Selection bias can be less of problem in cohort studies compared with
case-control studies, because exposed and unexposed individuals are
enrolled before they develop the outcome of interest.
However, selection bias may be introduced when the completeness of
follow-up or case ascertainment differs between exposure categories.
For example, it may be easier to follow up exposed individuals who all
work in the same factory, than unexposed controls selected from the
community (loss to follow-up bias). This can be minimised by ensuring
that a high level of follow-up is maintained among all study groups.
The healthy worker effect is a potential form of selection bias specific
to occupational cohort studies. For example, an occupational cohort
study might seek to compare disease rates amongst individuals from a
particular occupational group with individuals in an external standard
population. There is a risk of bias here because individuals who are
employed generally have to be healthy in order to work. In contrast,
the general population will also include those who are unfit to work.
Therefore, mortality or morbidity rates in the occupation group cohort
may be lower than in the population as a whole.
In order to minimise the potential for this form of bias, a comparison
group should be selected from a group of workers with different jobs
performed at different locations within a single facility ; for example, a
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group of non-exposed office workers. Alternatively, the comparison

group may be selected from an external population of employed
individuals.
• Selection bias in randomised trials
Randomised trials are theoretically less likely to be affected by
selection bias, because individuals are randomly allocated to the
groups being compared, and steps should be taken to minimise the
ability of investigators or participants to influence this allocation
process. However, refusals to participate in a study, or subsequent
withdrawals, may affect the results if the reasons are related to both
exposure and outcome.

Confounding
Confounding, interaction and effect modification
Confounding provides an alternative explanation for an association
between an exposure (X) and an outcome. It occurs when an observed
association is in fact distorted because the exposure is also correlated
with another risk factor (Y). This risk factor Y is also associated with the
outcome, but independently of the exposure under investigation, X. As
a consequence, the estimated association is not that same as the true
effect of exposure X on the outcome.
An unequal distribution of the additional risk factor, Y, between the
study groups will result in confounding. The observed association may
be due totally, or in part, to the effects of differences between the
study groups rather than the exposure under investigation. 1

A potential confounder is any factor that might have an effect on the

risk of disease under study. This may include factors with a direct
causal link to the disease, as well as factors that are proxy measures
for other unknown causes, such as age and socioeconomic status. 2

In order for a variable to be considered as a confounder:

1. The variable must be independently associated with the outcome

(i.e. be a risk factor).
2. The variable must also be associated with the exposure under
study in the source population.
3. The variable should not lie on the causal pathway between
exposure and disease.

Examples of confounding
A study found alcohol consumption to be associated with the risk of
coronary heart disease (CHD). However, smoking may have
confounded the association between alcohol and CHD.
Smoking is a risk factor in its own right for CHD, so is independently
associated with the outcome, and smoking is also associated with
alcohol consumption because smokers tend to drink more than non-
smokers.
Controlling for the potential confounding effect of smoking may in fact
show no association between alcohol consumption and CHD.
Effects of confounding
Confounding factors, if not controlled for, cause bias in the estimate of
the impact of the exposure being studied. The effects of confounding
may result in:

 An observed association when no real association exists.

 No observed association when a true association does exist.
 An underestimate of the association (negative confounding).
 An overestimate of the association (positive confounding).

Controlling for confounding

Confounding can be addressed either at the study design stage, or
adjusted for at the analysis stage providing sufficient relevant data
have been collected. A number of methods can be applied to control
for potential confounding factors and the aim of all of them is to make
the groups as similar as possible with respect to the confounder(s).

Controlling for confounding at the design stage

Potential confounding factors may be identified at the design stage
based on previous studies or because a link between the factor and
outcome may be considered as biologically plausible. Methods to limit
confounding at the design stage include randomisation, restriction and
matching.
• Randomisation
This is the ideal method of controlling for confounding because all
potential confounding variables, both known and unknown, should be
equally distributed between the study groups. It involves the random
allocation (e.g. using a table of random numbers) of individuals to
study groups. However, this method can only be used in experimental
clinical trials.
• Restriction
Restriction limits participation in the study to individuals who are
similar in relation to the confounder. For example, if participation in a
study is restricted to non-smokers only, any potential confounding
effect of smoking will be eliminated. However, a disadvantage of
restriction is that it may be difficult to generalise the results of the
study to the wider population if the study group is homogenous. 1

• Matching
Matching involves selecting controls so that the distribution of
potential confounders (e.g. age or smoking status) is as similar as
possible to that amongst the cases. In practice this is only utilised in
case-control studies, but it can be done in two ways:

1. Pair matching - selecting for each case one or more controls with
similar characteristics (e.g. same age and smoking habits)
2. Frequency matching - ensuring that as a group the cases have
similar characteristics to the controls

Detecting and controlling for confounding at the analysis stage

The presence or magnitude of confounding in epidemiological studies
is evaluated by observing the degree of discrepancy between the
crude estimate (without controlling for confounding) and the adjusted
estimate after accounting for the potential confounder(s). If the
estimate has changed and there is little variation between the stratum
specific ratios (see below), then there is evidence of confounding.
It is inappropriate to use statistical tests to assess the presence of
confounding, but the following methods may be used to minimise its
effect.
• Stratification
Stratification allows the association between exposure and outcome to
be examined within different strata of the confounding variable, for
example by age or sex. The strength of the association is initially
measured separately within each stratum of the confounding variable.
Assuming the stratum specific rates are relatively uniform, they may
then be pooled to give a summary estimate as adjusted or controlled
for the potential confounder. An example is the Mantel-Haenszel
method. One drawback of this method is that the more the original
sample is stratified, the smaller each stratum will become, and the
power to detect associations is reduced.
• Multivariable analysis
Statistical modelling (e.g. multivariable regression analysis) is used to
control for more than one confounder at the same time, and allows for
the interpretation of the effect of each confounder individually. It is the
most commonly used method for dealing with confounding at the
analysis stage.
• Standardisation
Standardisation accounts for confounders (generally age and sex) by
using a standard reference population to negate the effect of
differences in the distribution of confounding factors between study
populations. See “Numerators, denominators and populations at risk”
for more details.

Residual confounding
It is only possible to control for confounders at the analysis stage if
data on confounders were accurately collected. Residual confounding
occurs when all confounders have not been adequately adjusted for,
either because they have been inaccurately measured, or because
they have not been measured (for example, unknown confounders). An
example would be socioeconomic status, because it influences multiple
health outcomes but is difficult to measure accurately. 3

Interaction (effect modification)

Interaction occurs when the direction or magnitude of an association
between two variables varies according to the level of a third variable
(the effect modifier). For example, aspirin can be used to manage the
symptoms of viral illnesses, such as influenza. However, whilst it may
be effective in adults, aspirin use in children with viral illnesses is
associated with liver dysfunction and brain damage (Reye’s
syndrome). In this case, the effect of aspirin on managing viral
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illnesses is modified by age.

Where interaction exists, calculating an overall estimate of an
association may be misleading. Unlike confounding, interaction is a
biological phenomenon and should not be statistically adjusted for. A
common method of dealing with interaction is to analyse and present
the associations for each level of the third variable. In the example
above, the odds of developing Reye’s syndrome following aspirin use in
viral illnesses would be far greater in children compared to adults, and
this would highlight the role of age as an effect modifier. Interaction
can be confirmed statistically, for example using a chi-squared test to
assess for heterogeneity in the stratum-specific estimates. However,
such tests are known to have a low power for detecting interaction and
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a visual inspection of stratum-specific estimates is also recommended.