MASTER OF PUBLIC HEALTH

COURSEWORK ASSESSMENT SUBMISSION

Course Name Introduction of Epidemiology

Student id no. 2431112

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Question 1

The research question is to investigate and compare the health and well-being, health behaviour,
social relation between people with activity limitation (AL) and no activity limitation based on the
occurrence of 31 factors in Danish population.

The substantial background of the research is because there is inequality in health and life span of
people with activity limitation within population in general. However, according to the World Report
on Disability this challenge can be overcome by improving of health care assistance and accessible
environment for disabilities, creating a fair and health competition in world of work (1).

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Question 2

The features of the cross-sectional study that appropriate with this study, as follows (2):

 Observational, descriptive, and retrospective study

 This study make a comparison with group without activity limitation
 Gathering data from exposure which is activity limitation and 31 factors as an outcome
 There are differences in percentages and relative risk of health indicators between
individuals with AL and without AL.
 The study has specific geographical and period of time.
 The study design may not useful for establishing a causal relationship as confirmed in other
studies that within relationship between exposure and outcome might have emerged a
residual confounding (3)

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Question 3

Strengths

 The data were collected from the Danish Health and Morbidity Survey 2013 which is quite
representative for obtaining Denmark residents.
 The way for minimising the selection bias is randomly selecting the samples using particular
personal registration number and were obtained 14,265 over 25,000 which is considered as
large sample sizes.
 An effort to draw optimal participation, the questionnaire both printed and electronically
were made accessible for various disabilities and equipped with screen reader application
respectively.

Weaknesses

 Non – response bias is susceptible to be happened because probably those who do not
accept the invitation i.e family member with no activity limitation, could have filled the
questionnaire and resulting different outcome (4). However, the invitations were sent
individually, thus it is less likely to be happened.
 Even though the proportion of participants is more than 50%, there was a similar study that
showed higher overall proportion of response by 74.9%(5). This means within 25,000
individuals who were projected in this study, there is an odds that the people with severe AL
more likely did not take part of the questionnaire which is referred to survivor bias (2).

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Question 4

Exposure Measurement

Strengths

 People with activity limitation have been approached by questionnaire that convenient to
complete for those who have limitations in cognitive, visual, dyslexia.
 Activity limitation is defined on the basis of standard and internationally validated question
for measuring activity limitation (6).

Weakness

 Two categories of activity limitation have not been elaborated clearly since World Health
Organisation (WHO) has launched the International of Classification of Functioning, Disability
and Health (ICF) (7). For instance, the absence of distinction characteristics between people
with profound activity limitation and some activity limitation.
 The difficulty to reassure that whether or not people with severe activity limitation have
fulfilled the questionnaire with aid of personal assistant. Even though personal assistant has
powerful impact for those in need (8).

Outcome Measurement

Strengths

 The wide variety of health indicators that could cover the participants
 The measurement for health and well-being was using Cohen perceived stress scale.
Furthermore, to measure health behaviour validated tools such as Body Mass Index (BMI)
and Saltin-Grimsby Physical Activity Level Scale had been utilised. Validation of these
measurement is confirmed by other studies (9–11).

Weakness

 The indicators for the social relations based on empirical referent and merely discerning
subjective point of view rather than involving objective conditions in which can support
mutually (12).

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Question 5

The prevalence is performed to determine how many the event of health problems occur in each
activity limitation group compared to controls. Thus, the multiple logistic regression as a test to
determine the association between exposure and outcome could produce the relative risks of health
indicators for each AL group (13).

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Question 6

The table 2 describes the result of prevalence and relative risk each health indicator between activity
limitation groups. The prevalence of health indicators in people without activity limitation ranged
from 2.2% to 71.4% for poor self-perceived health and pain in musculoskeletal system, respectively.
Furthermore, for no activity limitation group multiple logistic regression analysis produces relative
risk (RR) values equally each health indicator which is RR (95% CI) = 1. This RR interprets that there is
no evidence of association between exposure and health condition that may happen for the
participants without activity limitation.

Table 2 also compares the results obtained from preliminary analysis of people categorised as some
activity limitation and profound activity limitation. People with several activity limitation group has
extend range of health indicator percentages from 1.2% to 92.1%. This result is slightly different
from profound activity limitation group in which prevalence of health indicator lies between 1.8% -
93.5%. Both some and profound activity limitation share a number of key features especially for
muscle pain or muscle discomfort as the highest prevalence and the usage of laxatives that
purchased directly in the counter as the lowest prevalence. The results of logistic regression analysis
for both categories are also set out in table 2 that put forward the highest RR of both some and
profound activity limitation groups was on purchasing laxative over the counter by 3.70 and 6.61,
respectively. In addition, there was difference in the lowest RR value between each AL group in
which some activity limitation group has low association with the absence of sexual contact,
whereas muscle pain and purchasing analgesics over the counter were the least value of RR in
profound activity limitation group by 1.28. Generally, the RR values of some and profound activity
limitation groups are more than 1 which means that being exposed by disability has strong
association with health problems that mentioned in the health indicators.

These RR findings for muscle pain stated above are contrary to prevalence which has suggested that
the disorder has gotten the highest prevalence in both some and profound activity limitation groups.
These results may be explained that people without activity limitation also suffering muscle pain in
their daily life resulting the high prevalence by 71.4%. It is underpinned by a recent cross-sectional
study that investigated the factors related to musculoskeletal pain in undergraduate student (14). In
contrast with RR of pain in musculoskeletal, RR in laxative apparently is significant for 2 last
categories. A possible explanation for this might be that those who unexposed with disability rarely
have the constipation problem whilst those in activity limitation do (15). Moreover, there is a large
proportion of participant age ≥ 75 years, particularly in people with activity limitation groups which

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lead to high RR. A significant analysis and discussion on the elderly related to laxative use was
presented in other study (16).

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Question 7

The research question of this study is whether or not activity limitation is affecting health profile in
Danish adult population. In order to answer the question analytical – prospective cohort study may
be the alternative study design to determine the relationship between disability as exposure factor
and health indicators as the outcome. The sample selection could be opted likely as cross-sectional
study by collecting from Danish Health and Morbidity Survey 2013 and sending the invitation which
comprises the measurement of activity limitation using criterion in ICF to distinguish study group and
control group. The baseline data for age should be narrowed to 16 – 44 years as it is a prospective
cohort study, study population requires to follow over period of time to perceive the outcome that
may happen. This would minimises a number of people who loss to follow – up regarding death
event and migration. In addition, having a clear cut of the measurement of exposure would
decreases selection bias and misclassification bias. Then, the analysis is based on results of data
outcome using hypothesis test which leads to obtaining the odds ratio for each health indicator.
Thus, it could be interpreted whether or not the activity limitation gives protective relationship to
the health profile in Danish population.

Word Count = 1315

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References

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2. Bhopal RS. Epidemiology study design and principles of data analysis. In: Concepts of
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Oxford: Oxford University Press; 2008. p. 286–333.

3. Sallis JF, Cerin E, Conway TL, Adams MA, Frank LD, Pratt M, et al. Physical activity in relation
to urban environments in 14 cities worldwide: A cross-sectional study. Lancet. 2016;1–13.

4. Sedgwick P. Bias in observational study designs : cross sectional. Br Med J [Internet].

2015;350:1–2.

5. Goodridge D, Lawson J, Marciniuk D, Rennie D. A population-based profile of adult Canadians

living with participation and activity limitations. Can Med Assoc J. 2011;183(13):1017–24.

6. Cox B, van Oyen H, Cambois E, Jagger C, Roy S Le, Robine JM, et al. The reliability of the
Minimum European Health Module. Int J Public Health. 2009;54(2):55–60.

7. World Health Organisation (WHO). International Classification of Functioning, Disability and

Health. World Health Organisation. Geneva; 2001.

8. Boren T, Granlund M, Wilder J, Axelsson AK. Sweden ’ s LSS and Social Integration : An
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9. Eskildsen A, Dalgaard VL, Nielsen KJ, Hviid J, Zachariae R, Olsen LR, et al. Cross-cultural
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12. Land KC. Social Indicator Models: An Overview. In: Land KC, Spilerman S, editors. Social
Indicator Models [Internet]. New York: Russell Sage Foundation; 1975 [cited 2020 Jan 16]. p.

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 5–36. Available from: https://books.google.co.uk/books?
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SmAi&sig=U85RP8H1WmkYBySjVNe4qfJKt0Q#v=onepage&q=indicator of social
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14. Morais BX, Dalmolin G de L, Andolhe R, Dullius AI dos S, Rocha LP. Musculoskeletal pain in
undergraduate health students: prevalence and associated factors. J Sch Nurs. 2019;53:1–8.

15. Koch T, Hudson S. Older people and laxative use: Literature review and pilot study report. J
Clin Nurs. 2000;9(4):516–25.

16. AlMutairi H, O’Dwyer M, Burke E, McCarron M, McCallion P, Henman MC. Laxative use
among older adults with intellectual disability: a cross-sectional observational study. Int J Clin
Pharm [Internet]. 2019;1–11.

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