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BMS1042 Tutorial 3 2013
BMS1042 Tutorial 3 2013
BMS1042 Tutorial 3
Exposure and Confounding
Basic Epidemiology readings:
h l d l d l
•Chapter 9: Environmental and occupational epidemiology, pp 145 – 154.
•Chapter 3: Types of studies: Potential errors in epidemiological studies,
pp 51 – 58.
Tutorial 3 Objectives
•
• Define “exposure” and list common methods of
measuring exposure.
g p
• Explain random error and systematic error in
epidemiologic studies.
• Explain the concept of confounding and describe how to
control for confounding in order to help establish
causation.
• Explain the difference between the concepts of validity
and reliability.
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What we’ll cover today
• Types of exposure, and how to measure it
• Difference between dose‐effect & dose‐response
• Risk assessment
• Potential errors in epidemiology
• Confounding
• Reliability and Validity
• Shoulder measurement exercise
Environmental factors & health
• Most diseases caused or influenced by environmental factors.
• Environmental
Environmental epidemiology
epidemiology –
relationships between the
environment and population health.
– General epi studies include:
children, elderly, sick.
• Occupational epidemiology –
specifically: environmental factors in the workplace.
p y p
– Usually: adult population, young/middle‐aged, mainly healthy.
• 25‐35% of global burden of disease caused by exposure to
environmental factors. (e.g. Water, sanitation, air pollution.)
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Figure 9.1, p. 148
Is prevention better?
• Industry exposure – cost of elimination $$
• Other times, prevention cheaper than cure for
disease. (E.g. Table 9.3, p. 148)
– Cost includes compensation, repair environmental
damage, etc.
• Future challenges for prevention include:
– Climate change, ozone layer, UV, acid rain.
Cli t h l UV id i
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Box 9.2, p. 149
How to measure exposure?
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How to measure exposure?
• Questionnaire
– Self administered or asked by researcher
• Biological (pp. 150‐1) – lab tests (blood, urine, hair)
– Blood/urine recent, hair longer term for drug use.
• Radiological – x‐rays, echo
• Physical examination – height, weight
• Evaluation of previous medical records
• Sampling of environmental factors
• Biomarkers, genetic markers
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Exposure and dose
• Can be measured quantitatively.
• Two dimensions: level and duration.
• Types of exposure:
– Cause acute effects soon after exposure starts (London smog).
– Effects only after long period of exposure (cadmium, noise).
• Can be exposure level (number of cigs/day) or
combined duration and exposure (pack‐years).
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Individual vs. Population dose
• Individual dose ‐ one person dose (pp. 151 – 2)
– Can vary over time
– Can vary in exposure
– Can vary in distribution.
• Report mean (average), median (middle) or % above threshold?
Dose effect vs. Dose response
(pp. 153 – 154)
• Dose‐effect
Relationship between
Relationship between
dose and severity of
symptoms.
Effects in one individual.
• Dose‐response
As dose increases % of
As dose increases, % of
cases with condition
increases.
Looks at population.
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More dose‐response relationship examples
British doctors study, Doll & Hill. Fig 1.1, p. 3
Table 5.2, p. 93 –
ab e 5 , p 93 Hearing loss.
ea g oss
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Ecological study
Used various data (population, deaths
from traffic crashes, air monitoring
data) all routinely collected)
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Potential errors in epidemiology studies
• Random error – due to chance alone
– Individual biological variation
– Sampling error: reduce by increase sample size
– Measurement error: reduce by strict protocol, precise
measurements (where possible)
• Systematic error – results differ from true values
– Selection bias: participants different to population.
– Measurement bias (e.g. Labs produce different results)
– Recall bias (e.g. Cases more likely to recall past exposure
than controls – “why me” thinking done!)
• Sample size
• Confounding
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Confounding
• Exposure Outcome affected by third factor.
• E.g. Age, sex, social class.
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How to control for confounding ...
• Design stage
– Randomisation: equal distribution of groups
– Restriction (e.g. Only non‐smokers, or males)
– Matching: match for age, sex, social class in case‐
control study. (Time consuming, expensive)
• Analysis stage
– Stratification: Two tables of exposure vs. Outcome –
St tifi ti T t bl f O t
one for each level of confounder.
– Statistical modelling: can adjust for multiple things
• E.g. Late antenatal care by aboriginal infant + 9 risk factors
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A more amusing example!
Source: Danny Liew, MPH tutor in 2005.
Age (yrs)
• A study found that people with blue hair were more likely to
develop bowel cancer
develop bowel cancer.
• However, elderly women are more likely to put a blue rinse
through their hair
• ... and bowel cancer increases with age.
• So age is a confounder!
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Reliability and validity
• Validity – test capable of measuring what it intended to measure.
– No systematic error, random error small.
– Internal validity: are results correct for the group being studied?
– External validity: how do results generalise/apply to those not in it?
– Internal validity ≠ external validity !!!
Internal validity ≠ external validity !!!
• Reliability – stability and reproducibility over time.
– Stability: consistent answers to questions over time?
– Reproducibility: diff interviewers = same answers from the questions? 19
Reliability and validity
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Examples of error – 1
1. Random error – Random error can occur during data collection, coding,
transfer, or analysis. For example: poorly worded questions; a
misunderstanding in interpreting an individual answer from a particular
respondent; or a typographical error during coding; a poorly functioning
respondent; or a typographical error during coding; a poorly functioning
machine measuring blood levels of some parameter like sodium. When there
is a high coefficient of variation, there will be a problem with reliability.
2. Biologic variation – Background variation due to behavioural factors between
individuals will result in studies showing relatively low correlations. For
example: biologic variation of the interval from the first day of the last
menstrual period to start of pregnancy; and the biologic variation of
menstrual period to start of pregnancy; and the biologic variation of
gestational length to delivery. In human pregnancies, the day of the onset of
pregnancy is usually unknown hence the first day of the last menstrual period
is used as a surrogate variable. Pregnancy duration is therefore counted from
the last menstrual period. This introduces a random component to the length
of a human pregnancy which is the biologic variation of the interval from last
menstrual period to the start of pregnancy.
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Examples of error – 2
3. Systematic error – The machine used to measure oxygen saturation of a
patient's blood is calibrated incorrectly so you get consistently high
measures. Since the error happens in every instance, it is systematic and
conclusions made will be incorrect. The measuring device could be
precise but not accurate. There is therefore a problem with the validity
of the measurements.
4. Selection bias – healthy worker effect
5. Recall bias – In a study of women with premature babies, questions were
asked about stress during their pregnancy. Controls mothers who had a
healthy baby born at term were also asked about stress during their
pregnancies. Cases were more likely to report stress than controls.
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Ethical considerations
• Informed consent – free, voluntary informed
consent, free to withdraw at any time.
• Confidentiality
• Respect for human rights – especially
HIV/AIDS (see example in the textbook)
• Scientific integrity (fabricated data)
• More information on pp. 58‐9.
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EXERCISE TIME !!
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Exercise 1 – bias, confounding or random error?
• In a study of risk factors for infant mortality, it is found that infant
mortality is significantly lower in households where the father wears a
silk tie. The investigators therefore conclude that if silk ties were given
to fathers infant mortality will fall
to fathers, infant mortality will fall.
• Four people want to give up smoking. Two of them take garlic pills to
two them stop and two do not. The two who take garlic pills succeed
in giving up smoking. The other two do not. The investigators
conclude that garlic pills help people give up smoking. However a
significance test shows that P = 0.3.
• In a case‐control study to examine risk factors for lung cancer, cases
are people admitted to hospital with lung cancer, and controls are
people admitted to the same hospital with emphysema (a chronic
lung disease for which smoking is a risk factor). The study finds no
association between smoking and lung cancer.
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Exercise 1 – bias, confounding or random error?
• In a study of risk factors for infant mortality, it is found that infant
mortality is significantly lower in households where the father wears a
silk tie. The investigators therefore conclude that if silk ties were given
to fathers, infant mortality will fall.
CONFOUNDING silk tie ≈ socioeconomic status
CONFOUNDING – silk tie socioeconomic status
• Four people want to give up smoking. Two of them take garlic pills to
two them stop and two do not. The two who take garlic pills succeed
in giving up smoking. The other two do not. The investigators
conclude that garlic pills help people give up smoking. However a
significance test shows that P = 0.3.
RANDOM ERROR (small sample size)
• In a case‐control study to examine risk factors for lung cancer, cases
are people admitted to hospital with lung cancer, and controls are
people admitted to the same hospital with emphysema (a chronic
lung disease for which smoking is a risk factor). The study finds no
association between smoking and lung cancer.
BIAS – smoking can cause lung cancer & emphysema! 26
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Exercise 2 – variable a confounder?
1. A study of the relationship between contact lens use and the risk of eye
ulcers. The crude relative risk is 3.0 and the age‐adjusted risk is 1.5. Is
age a confounder in this study?
2. A case‐control
A case control study of the relationship between cigarette smoking and
study of the relationship between cigarette smoking and
pancreatic cancer. In this study, coffee drinking is associated with
smoking and is a risk factor for pancreatic cancer among both smokers
and non‐smokers. Is coffee drinking a confounder in this study?
3. A study of the relationship between exercise and heart attacks that is
conducted among men who do not smoke. Is gender a confounder in this
study?
4. A cohort study of the risk of liver cirrhosis among female alcoholics.
y g
Incidence rates of cirrhosis among alcoholic women are compared to
those among non‐alcoholic women. Non‐alcoholics are individually
matched to alcoholics on month and year of birth. Is age a confounder in
this study?
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Exercise 2 – variable a confounder?
1. A study of the relationship between contact lens use and the risk of eye
ulcers. The crude relative risk is 3.0 and the age‐adjusted risk is 1.5. Is
age a confounder in this study? YES
2. A case‐control
A case control study of the relationship between cigarette smoking and
study of the relationship between cigarette smoking and
pancreatic cancer. In this study, coffee drinking is associated with
smoking and is a risk factor for pancreatic cancer among both smokers
and non‐smokers. Is coffee drinking a confounder in this study?
YES
3. A study of the relationship between exercise and heart attacks that is
conducted among men who do not smoke. Is gender a confounder in this
study? NO
4. A cohort study of the risk of liver cirrhosis among female alcoholics.
Incidence rates of cirrhosis among alcoholic women are compared to
those among non‐alcoholic women. Non‐alcoholics are individually
matched to alcoholics on month and year of birth. Is age a confounder in
this study? NO
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Activity 3: Measuring & Describing Extension of
the Shoulder
• MOTIVATION FOR THIS EXCERCISE
• ETHICAL CONSIDERATIONS
ETHICAL CONSIDERATIONS
– Identification of information
– Consent to participate
• METHOD OF MEASUREMENT
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Discussion
The following questions are designed to help you think about and discuss among the
group some of the issues that arise when taking measurements of this kind.
QUESTION: Discuss any strategies that you can think of to improve the accuracy of the
measurement?
QUESTION: Discuss the issue of measurement accuracy. To what degree of accuracy
will you record range of movement and height?
DESCRIBING DATA
What proportion of tutorial group members consented to participate?
%
What proportion of participants were female? %
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Shoulder Measurement
Identification number Consented to Gender Shoulder extension: Height
participate (M/F) Range of movement (cm)
(Yes/No) (degrees)
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