Study Designs: Cross-Sectional Studies, Ecologic Studies (And Confidence Intervals)

Principles of Epidemiology for Public Health (EPID600)
Study designs: Cross-sectional studies,

ecologic studies (and confidence intervals)
Victor J. Schoenbach, PhD home page
Department of Epidemiology
Gillings School of Global Public Health
University of North Carolina at Chapel Hill
www.unc.edu/epid600/
2/22/2011
Cross-sectional studies
Signs from around the world

In a Copenhagen airline ticket office:
We take your bags and send them in all

directions.

In a Norwegian cocktail lounge:
Ladies are requested not to have

children in the bar.

Rome laundry:
Ladies, leave your clothes here and
spend the afternoon having a good time.
Faster keyboarding - 1
I cdnuolt blveiee taht I cluod aulaclty uesdnatnrd waht I
was rdanieg. The phaonmneal pweor of the hmuan mnid,
aoccdrnig to a rscheearch at Cmabrigde Uinervtisy. It
dn'seot mttaer in waht oredr the ltteers in a wrod are, the
olny iprmoatnt tihng is taht the frist and lsat ltteer be in
the rghit pclae. The rset can be a taotl mses and you can
sitll raed it wouthit a porbelm.
Gary C. Ramseyer's First Internet Gallery of Statistics Jokes
http://davidmlane.com/hyperstat/humorf.html (#162)
Faster keyboarding - 2
Most of my friends could read this with understanding
and rather quickly I might add. Then I had them read a
statistical bit of literature:
Miittluvraae asilyans sattes an idtenossiy ctuoonr epilsle
is the itternoiecsno of a panle pleralal to the xl-yapne and
the sruacfe of a btiiarave nmarol dbttiisruein.
Gary C. Ramseyer's First Internet Gallery of Statistics Jokes
http://davidmlane.com/hyperstat/humorf.html (#162)
Principles of Epidemiology for Public Health (EPID600)
Study designs: Cross-sectional studies,

ecologic studies (and confidence intervals)
Victor J. Schoenbach, PhD home page
Department of Epidemiology
Gillings School of Global Public Health
University of North Carolina at Chapel Hill
www.unc.edu/epid600/
2/22/2011
Today outline
Cross-sectional studies (and sampling)
Ecologic studies
Confidence intervals
10/15/2001
Cross-sectional studies include surveys
People are studied at a point in time, without
follow-up.
Can combine a cross-sectional study with follow-up
to create a cohort study.
Can conduct repeated cross-sectional studies to
measure change in a population.
2/10/2009
Number of uninsured Americans rises to 50.7 million .
(USA Today, 9/17/2010; data from Census Bureau)
In 2007-2008, almost one in five children older than 5

years was obese. (Health, United States, 2010; data from the
National Health and Nutrition Examination Survey)
35% (~7.4 million) of births to U.S. women during the

preceding 5 years were mistimed or unwanted (2002
National Survey of Family Growth, Series 23, No. 25, Table 21)
[Source: www.cdc.gov/nchs/]
2/22/2011
10
Incidence information is not available from a typical
cross-sectional study
Sometimes can reconstruct incidence from historical
information
Example: the incidence proportion of quitting smoking,
called the quit ratio:
ex-smokers / ever-smokers
is calculated from survey data.
2/10/2009
11
Measure prevalence at point in time

Snapshot of a population, a still life
Can measure attitudes, beliefs, behaviors, personal or
family history, genetic factors, existing or past health
conditions, or anything else that does not require followup to assess.
The source of most of what we know about the
population
10/15/2001
12
Population census
A cross-sectional study of an entire
population
Provides the denominator data for
many purposes (e.g., estimation of
rates, assessing generalizability,
projecting from smaller studies)
A huge effort people can be difficult to
find and to count; may not want to
provide data
Some countries maintain accurate and
current registries of the entire country
2/22/2011
13
National surveys conducted by NCHS

National Health Interview Survey (NHIS)
household interviews
National Health and Nutrition Examination

Survey (NHANES) interviews and physical
examinations
National Survey of Family Growth (NSFG)

household interviews
National Health Care Survey (NHCS)

medical records
2/22/2011
14
National surveys
Designed to be representative of the entire country
Modes: household interview, telephone, mail
Employ complex sampling designs to optimize
efficiency (tradeoff between information and cost)
Logistically challenging (answering machines, cellphones, . . .)
See presentation by Dr. Anjani Chandra at
www.minority.unc.edu/institute/2003/materials/slides/Chandra-20030522.ppt
2/22/2011
15
Example: National Health Interview Survey

Conducted every year in U.S. by National
Center for Health Statistics (CDC)
Stratified, multistaged, household survey
that covers the civilian noninstitutionalized
population of the United States
Redesigned every decade to use new
census
10/15/2001
16
multistaged
Improves logistical feasibility and reduces costs
(though reduces precision)
1. Divide population into primary sampling units
(PSUs)
PSU = primary sampling unit: metropolitan statistical
area, county, group of adjacent counties
2/10/2009
17
multistaged
2. Select sample of census block groups (SSUs) within
each selected PSU
3. Map each selected census block group or examine
building permits
4. Select one cluster of 4-8 housing units dispersed
evenly throughout the block
NCHS draws a new representative sample for each
weeks interviews
2/10/2009
18
stratified
US divided into 1,900 PSUs
Largest 52 PSUs are self-representing
Rest of PSUs divided into 73 categories (strata),
based on socioeconomic and demographic variables
Sampling takes place separately within each category
(stratum)
10/15/2001
19
Sample size and Precision
7/30/2010
20
Weighted sampling
Hypothetical Unweighted Weighted
Age group Pop (1,000's) Sample
Sample
20-39 yrs
40-59 yrs
60-69 yrs
Total
3/6/2006
18,000
18,000
8,000
44,000
900
900
400
2,200
400
400
400
1,200
21
stratified
Also place census blocks into categories and
sample within each
Oversample some strata
10/15/2001
22
Defined population
Studies, especially cross-sectional studies, are easiest to
interpret when they are based in a population that has some
existence apart from the study itself (defined population)
1. Political subdivision (city, county, state)
2. Institutional (HMO, employer, profession)
Probability sampling enables statistical generalizability to
the defined population
2/10/2009
23
Surveys of sentinel populations

HIV seroprevalence survey in three county STD
clinics in central NC in 1988
3,000 anonymous, unlinked, leftover sera
Anonymous questionnaire for demographics and
risk factors
[Schoenbach VJ, Landis SE, Weber DJ, Mittal M, Koch GG, Levine PH. HIV
seroprevalence in sexually transmitted disease clients in a low-prevalence southern state.
Ann Epidemiol 1993;3:281-288]
2/22/2011
24
HIV seroprevalence
seroprevalence in sexually transmitted disease clients in a low-prevalence southern
state. Ann Epidemiol 1993;3:281-288]
10/15/2001
25
Seroprevalence (% HIV+) by risk factors

Characteristic
Gay Hetero Women
Syphilis
(history/current)
Gonorrhea (history)
53
9.0
37
2.6
Anal intercourse
41
1.7
Paid for sex
5.2
seroprevalence in sexually transmitted disease clients in a low-prevalence southern state.
Ann Epidemiol 1993;3:281-288]
10/14/2003
26
Interpretation
Measures prevalence if incidence is our real
interest, prevalence is often not a good surrogate
measure
Studies only survivors and stayers
May be difficult to determine whether a cause
came before an effect (exception: genetic
factors)
10/15/2001
27
Other points
Can choose by exposure or overall
Can choose by disease may not be
distinguishable from a case-control study with
prevalent cases
10/15/2001
28
Outline
Ecologic studies
10/15/2001
29
Ecologic studies
Most study designs cross-sectional, casecontrol, cohort, intervention trials can be carried
out with individuals or with groups
Group-level studies which use routinely collected
data are easier and less costly
Group-level studies that involve interventions
may not be easier or less costly
10/15/2001
30
Types of group-level variables

Summary of individual-level variable (e.g.,
median household income, % with high
school diploma)
Property of the aggregate (e.g.,
neighborhood grocery stores, seat belt
legislation, community competence)
3/6/2006
31
Interpretation
Link between summary exposure variable and
individual-level outcome must be inferred
Inference from group to individual is not
always sound
2/22/2011
32
Example: Male Circumcision and HIV
(Slope indicates strength of relationship;

r indicates linearity)
Source: Bongaarts J, et al. The relationship between male circumcision and HIV infection in African populations. AIDS 1989; 3(6): 373-7.
2/22/2011
33
Outline
Ecologic studies
10/15/2001
34
Provide a plausible range for the quantity
being estimated
Width indicates the precision of an estimate
for a given level of confidence
Confidence intervals quantify only random
error from sampling variation, not systematic
error from nonresponse, study design, etc.
3/8/2006
35
Confidence level vs. precision

The more vague my estimate, the more
confident I can be that it includes the
population parameter: I am 100% confident
that the prevalence of HIV is between 0 and
100%.
The more specific my estimate, the lower my
confidence: I am 0% confident that the
prevalence of HIV is 5.23%
10/15/2001
36
Confidence intervals interpretation

Simple interpretations are typically not
precise
Precise interpretations are typically not
simple
10/12/2004
37
Simple but imprecise

There is 95% confidence that the interval
contains the true value
True, but begs the question how to
define confidence
10/15/2001
38
Simple but imprecise

There is a 95% probability that the interval
contains the true value
Not quite correct: probability (as
conventionally defined) applies to a process,
not to a single instance
10/15/2001
39
Probability applies to a process: example

A 95% confidence interval can be viewed as a
measurement or estimation process that will
be correct (the interval includes the true
value of the parameter) 95% of the time and
incorrect 5% of the time.
Let us make up another estimation process
that will be correct (about) 95% of the time.
3/7/2006
40
Why probability applies to a process

Estimate your gender by flipping a coin 5 times if the result is 5 heads estimate your gender to
be its opposite; otherwise estimate your gender to be
what you think it is now.
Probability that estimate will be correct is
(1 Probability of 5 heads) = 0.97 = 97%
Probability that estimate will be incorrect is 3%
6/29/2002
41
Why probability applies to a process

So we now have a measurement process that will
be correct 97% of the time. We will use it to
measure your gender.
Flip the coin 5 times, and suppose you get 5 heads
Is there a 97% probability that you are of the
opposite sex?
6/29/2002
42
Precise but not simple

A 95% confidence interval is:
1. obtained by using a procedure that will include
the population parameter being estimated 95%
of the time
2. the set of all population values which are likely
to yield a sample like the one we obtained
2/22/2011
43
Suppose that this line represents the value

of the parameter we are trying to estimate
True value
10/15/2001
44
Possible estimates of that parameter in N

identical studies (shows sampling variation)
o
Study estimates
oo
oooo
True
value
oooooo
oooooooo
oooooooooo
o o ooooooooooo o
oo o ooooooooooooooooo o o
10/15/2001
45
One possible true value and how it would

manifest, on average, in N identical studies
o
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True value
oooooo
oooooooo
oooooooooo
o o ooooooooooo o
95% of the distribution
10/15/2001
46
Estimate from one study of a given size

?
Estimate
10/15/2001
47
A possible true value with < 2.5% chance of

being observed at or beyond the estimate
?
o
oo
oooo
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oooooooo
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o ooooooooooo o
ooooooooooooooo o o
Estimate

10/14/2003
48
A possible true value with > 2.5% probability

of being observed at or beyond the estimate
?
o
oo
oooo
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oooooooo
oooooooooo
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oooooooooooooooo o o
Estimate

10/15/2001
49
A possible true value with > 2.5% probability

of being observed at or beyond the estimate
?
Estimate
o
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10/15/2001
50
A possible true value with < 2.5% probability of

being observed at or beyond the estimate
?
Estimate
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10/15/2001
51
What the confidence interval represents

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95% confidence interval
10/14/2003
52
What the confidence interval represents
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95% confidence interval
10/15/2001
53

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True value
oooooo
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1.96 x s.e. | 1.96 x s.e.
3/8/2006
54
Confidence intervals another take
10/15/2001
55
One possible population
10/15/2001
56
Another possible population

O
10/15/2001
57
A 3rd possible population

O
10/15/2001
58
A 4th possible population

O
10/15/2001
59

O
10/15/2001
60

O
10/15/2001
61
etc.
10/15/2001
62
There are 1.6 x 1060 possible populations

(no cases all cases)
10/15/2001
63
Suppose this is the population

(prevalence = 15%)
O
O O
OO
O
O
O
O
O
O
O
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O
O O O
O
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O O
O
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O O
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10/15/2001
64
Take a sample (n=10)

O
O O
OO
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O
O O O
O
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10/15/2001
65
The sample
10/15/2001
66
Make point estimate of prevalence
10/15/2001
67
Interval estimate
What are all the possible populations that
would be expected to yield this prevalence in
a sample of size 10?
6/29/2005
68
This one is not possible

O
10/15/2001
69
Possible, but VERY UNLIKELY

O
3/8/2006
70
Not quite 2.5% probability (2.1%, in fact)

O
3/8/2006
71
Yields just about 2.5% (3%, actually) probability of

selecting 2 (or more) cases in 10
O
3/8/2006
72

o
oo
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True value
oooooo
oooooooo
oooooooooo
o o ooooooooooo o
3/8/2006
73
Just above 2.5% (actually 2.6%) probability of

selecting 2 (or fewer) cases in 10
O OO OO O O OOO
O O
O OO OO OOOOO O OO
OO
O
O O O OO OO O O OO OO O
OO O OO O O O O
OO
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O O OO OOO O OO O OO
O O O O OOO OO OOO O
3/8/2006
74
Just below 2.5% (actually 2.4%) probability of

selecting 2 (or fewer) cases in 10
O OO OO OO O OOO
O O
O OO OO O OOO O OO O OO
O
O O O OO OO O O OO OO O
OO O OO O O OO O
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O O OO O O O OO O OO
OO O OO O OOO OO OOO O
3/8/2006
75
Interval estimate for 2/10

Lower bound: 2.5% (5 cases)
Upper bound: 55% (110 cases)
Meaning: Our sample of 10 with 2 cases provides
evidence to exclude, at conventional error
tolerance, populations with fewer than 5 cases or
more than 110 cases. Populations with 5-110
cannot be excluded as likely sources for this
sample.
3/8/2006
76
Interval estimate for 2/10

Actual population prevalence was 15%,
which in fact is between 2.5% and 55%.
2.5% to 55% is a very wide interval, i.e.,
a very imprecise estimate
To make it more precise, we need a
larger sample
3/8/2006
77
Signs from around the world Germany

A sign posted in Germany's Black Forest:
It is strictly forbidden on our black forest camping

site that people of different sex, for instance, men
and women, live together in one tent unless they
are married with each other for that purpose.
78
Signs from around the world Finland

On the faucet in a Finnish washroom:
To stop the drip, turn cock to right.
79

Study Designs: Cross-Sectional Studies, Ecologic Studies (And Confidence Intervals)

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Principles of Epidemiology for Public Health (EPID600)

Study designs: Cross-sectional studies,

Signs from around the world

We take your bags and send them in all

Signs from around the world

Ladies are requested not to have

Signs from around the world

Principles of Epidemiology for Public Health (EPID600)

Study designs: Cross-sectional studies,

In 2007-2008, almost one in five children older than 5

35% (~7.4 million) of births to U.S. women during the

Measure prevalence at point in time

National surveys conducted by NCHS

National Health and Nutrition Examination

National Survey of Family Growth (NSFG)

National Health Care Survey (NHCS)

Example: National Health Interview Survey

Sample size and Precision

Surveys of sentinel populations

Seroprevalence (% HIV+) by risk factors

Gay Hetero Women

Paid for sex

Types of group-level variables

Example: Male Circumcision and HIV

(Slope indicates strength of relationship;

Confidence level vs. precision

Confidence intervals interpretation

Simple but imprecise

Simple but imprecise

Probability applies to a process: example

Why probability applies to a process

Why probability applies to a process

Precise but not simple

Suppose that this line represents the value

Possible estimates of that parameter in N

One possible true value and how it would

Estimate from one study of a given size

A possible true value with < 2.5% chance of

95% of the distribution

A possible true value with > 2.5% probability

95% of the distribution

A possible true value with > 2.5% probability

A possible true value with < 2.5% probability of

What the confidence interval represents

What the confidence interval represents

One possible true value and how it would

Confidence intervals another take

One possible population

Another possible population

A 3rd possible population

A 4th possible population

A 5th possible population

A 6th possible population

There are 1.6 x 1060 possible populations

Suppose this is the population

Take a sample (n=10)

Make point estimate of prevalence

This one is not possible

Possible, but VERY UNLIKELY

Not quite 2.5% probability (2.1%, in fact)

Yields just about 2.5% (3%, actually) probability of

One possible true value and how it would