BIAS AND

CONFOUNDING
Dr. B K Rakshith
1st MDS
DEPARTMENT OF PUBLIC HEALTH DENTISTRY
CONTENTS
 Definition of Bias
 Different types of bias in epidemiological study
 Introduction of confounding
 Common confounders
 Control of confounding
 References
BIAS
 Any trend in the collection, analysis, interpretation, publication or review of
data that can lead to conclusions that are systematically different from the truth
(Last 2001)

 Systematic error in design or conduct of a study (Szklo et al, 2000)

 A process at any state of inference tending to produce results that depart

systematically from the true values (Fletcher et al, 1988)
PROPERTIES OF
MEASUREMENT
 Validity (Accuracy): Validity is how much a test measures what it
is supposed to measure.

 Reliability (precision): Reliability is the consistency of test results

CLASSIFICATION OF BIAS
 Positive bias– observed effect is higher than the true value
Negative bias– observed effect is lower than the true value 
TYPES OF BIAS
1. Selection bias
 Occurs when the two groups being compared differ systematically
 That is, there are differences in the characteristics between those
who are selected for a study and those who are not selected
 Most common type of bias in health research
 Seen in observational and analytical studies
SOURCES OF SELECTION
BIAS
 Volunteer bias: when the participants select themselves for a
study, either because they are unwell or because they are
particularly worried about an exposure.
 For example, that people who respond to an invitation to
participate in a study on the effects of smoking differ in their
smoking habits from non responders, the latter are usually heavier
smoker.
 Non-response bias: occurs because individuals who do not
respond to a call or mailed questionnaire to participate in research
studies are generally from those who do not respond.
 Example smokers are less likely to return questionnaire than are
non-smoker
 Exclusion bias: occurs when in certain circumstances
epidemiologic studies exclude participants to prevent confounding
 Example when exclusion criteria is different for cases and control,
or exposed and non-exposed
 Healthy worker effect: healthy people remain workers, whereas
those who remain unemployed, retired , disabled or otherwise out
of active worker population are as a group of less healthy. i.e lower
mortality observed in employed population compared to general
population
 Information bias
 Method of gathering information is inappropriate and yields
systemic errors in the measurement of exposure or outcome

 Affects the nature of true association

SOURCES OF INFORMATION
BIAS
 Interviewer bias: An interviewer’s knowledge may influence the
structure of questions and the manner of presentation, which may
influence responses
 Recall bias: Those with a particular outcome or exposure may
remember events more clearly. For example mother of a baby born
with congenital disorder remembers every events more clearly
during pregnancy than mother with normal baby
  Reporting bias: Participants can collaborate with researchers and give
answers in the directions they perceive are of interest.

 Hawthorne effect: people act differently if they know they are being
watched

 One study was performed at a factory to discover if change in lighting would

affect productivity. Productivity did increase but only because of increased
attention due to the study. As soon as study had ended productivity decreased
again
 Loss to follow-up: those that are lost to follow up or who withdraw
from study may be different from those who are followed for the
entire study
 Surveillance bias: the group with known exposure or outcome
may be followed more closely or longer than the comparison group.
CONFOUNDING
  When another exposure exists in the study population (besides the one being
studied) and is associated both with disease and the exposure being studied.
 Confounder must be
1. Risk factor for the disease independently
2. Associated with exposure under study
3. It is not casual pathway between exposure and disease
 • E.g age , sex ,living condition
 CONTROL OF CONFOUNDING
  At design stage:
Restriction
Matching
Randomisation
 At analysis stage
Stratification
Multivariate analysis
 Restriction: Subject chosen for study are restricted to only those
 

possessing a narrow range of characteristics , to equalize important

extraneous factors. e.g. restrict study to women having a least one
child.

 Matching: for each patient in one group there is one or more

patients in comparison group with same characteristics, except for
the factor of interest. E.g. matching done for age ,sex ,race etc.
  Randomization: subjects of study are randomly selected to even
out unknown confounders.
 Stratification: The process of separating a sample into several
sub-samples according to specified criteria such as age group ,
socioeconomic status etc.
 Multivariate analysis: The statistical analysis of data collected on
more than one variable. E.g. people age ,weight, body fats . Skull
length, width and cranial capacity
REFERANCES
1. Fletcher RH et al.Clinical Epidemiology : The Essentials – 3rd ed.
2. Beaglehole R et al. Basic Epidemiology, WHO
3. Last JM. Dictionary in Epidemiology – 3rd ed.
4. Maxcy-Rosenau-Last. Public Health & Preventive Medicine – 14th ed.
5. Norell SE. Workbook of Epidemiology
6. Park K. Park’s textbook of preventive and social medicine – 24th ed.
7. Introduction to epidemiology, 4th edition, Ray M Merrill.
8. Jul 31, 1993 - Dl Sackett Bias in analytic research. J Chron Dis, 32 (1979), ... Bck Choi, Al
Noseworthy Classification, direction, and prevention of bias in epidemiologic research. J
Occup Med, 34 (1992) ... 1038-1041. 115