Epidemiology

and Research
Review

Dr. Galvez
PLM notes
What form of consent does the patient give when he
agrees to surgery but need not consent specifically
to the anesthetic to be used?
a. informed
b. presumed
c. surrogate
d. none of the above
Types of Consent:
A. Informed Consent: when a competent individual
makes decisions for her or himself.
Elements:
I. Information
a) the purpose of the procedure.
d) the anticipated results.
b) risks and benefits.
c) alternative procedures
II. Comprehension
a) adapted to the subjects' capacities
b) the more serious the risk, more
important full comprehension
III. Freedom
a) the subject understands the situation
b) no coercion is used
Types of Consent:
B. Presumed Consent: when a person is unable to
give consent of their own accord, but it is
reasonable to believe they would consent if able

C. Implied Consent: when a person gives consent to

something in general, then it is implied that
consent is given to the individual things involved
Types of Consent:
D. Proxy (Surrogate) Consent: when a patient is
unable to give informed consent, another person
is called on to offer a substitute informed consent.

a) the patient cannot offer true, informed consent

b) the person offering the proxy consent must
determine what the incompetent
person would have decided were he or
she able to make the ethical decision
What form of consent does the patient give when he
agrees to surgery but need not consent specifically
to the anesthetic to be used?
 a. informed
b. presumed
c. surrogate
d. none of the above
The ability of the test to pick up or label positive
those who have the disease is:
a. sensitivity
b. precision
c. specificity
d. accuracy
Validity test
 the ability to distinguish between who has a
disease and who does not
 Components
 Sensitivity is the ability of the test to
identify correctly those who have the
disease
 Specificity is the ability of the test to
identify correctly those who do not have the
disease
 Accuracy refers to
the closeness of the
measured value to
the “true” value

 Precision refers to
how closely
individual
measurements agree
with each other
The ability of the test to pick up or label positive
those who have the disease is:
 a. sensitivity
b. precision
c. specificity
d. accuracy
The following essential elements are part of the
research question format EXCEPT:
a. adequate technical expertise
b. biologic and/or theoretical rationale
c. study population
d. primary outcome of interest
 "Among young children with acute
asthma exacerbation, is a single dose
of IM dexamethasone comparable to
five days of oral prednisolone for
resolution of asthma symptoms?"

PIOM (PICO)
P – patient/study population
I – intervention/exposure
O – outcome/disease
M – method/comparison
The Research Question Format: 6 essential elements

1.Biologic and/or theoretical rationale

2.Study population
3.Maneuver, exposure or intervention to be studied
4.Primary (and secondary) outcome of interest
5.Comparative maneuver or exposure if any
6.Suggestion of study design
The following essential elements are part of the
research question format EXCEPT:
 a. adequate technical expertise
b. biologic and/or theoretical rationale
c. study population
d. primary outcome of interest
The study design that manipulate a part of the
patient’s environment is a:
a. cohort study
b. case-control study
c. clinical trial
d. cross-sectional study/survey
1. Non-intervention studies
• Exploratory study
• Descriptive study
• Analytical Study (cross-sectional,
case-control, cohort)
2. Intervention studies
• Experimental
• Quasi-experimental
• Before-After study
The study design that manipulate a part of the
patient’s environment is a:
a. cohort study
b. case-control study
 c. clinical trial
d. cross-sectional study/survey
The rate of spread of an epidemic is measured by
the:
a. incubation period
b. incidence rate
c. generation time
d. secondary attack rate
Epidemic

 disease occurs at
greater than
expected frequency
 Index Case
 Person that comes to the attention of
public health authorities
 Primary Case
 Person who acquires the disease
from an exposure
 Attack rate
 Secondary Case
 Person who acquires the disease
from an exposure to the primary case
 Secondary attack rate
Epidemiological parameters
A. Basic reproductive number, Ro
- the average number of secondary cases
generated by an index case when
an epidemic begins
B. Mean Generation Time, Tg
- the average time it takes an index case to infect
other individuals after he becomes infected.
- indicates how long it takes for an individual to
spread his infection

Ro indicates how many people an index case infects

but not how fast these infections happen
– Ro and Tg are interrelated:
For a given Ro, a shorter Tg  higher growth rate
 Incubation Period
• the interval between the time of contact
and/or entry of the agent and onset of
illness (latency period)
• time required for the multiplication of
microorganisms within the host up to a
threshold where the parasitic population
is large enough to produce symptoms
The rate of spread of an epidemic is measured by
the:
a. incubation period
b. incidence rate
 c. generation time
d. secondary attack rate
A research process that more or less yields the same
value when done three times is:
a. reliable
b. valid
c. precise
d. accurate
 Test Results Test
 Accuracy refers to  Validity refers to the
the closeness of the degree in which the
measured value to test actually
the “true” value measures what it is
supposed to measure

 Precision refers to  Reliability

how closely (reproducibility)
individual refers to the degree
measurements agree in which the
with each other procedure/test yields
the same result
A research process that more or less yields the same
value when done three times is:
 a. reliable
b. valid
c. precise
d. accurate
Epidemiology is defined as:
a. a study of distribution and determinants of disease
b. a study of natural history of a disease
c. a study of disease prevention in human population
d. a study of etiologies of epidemic disease in humans
Epidemiology: the study of the distribution
and determinants of health-related states or
events (including disease), and the application
of this study to the control of diseases and
other health problems

Methods in epidemiological investigations:

A. surveillance and descriptive studies
 used to study distribution
B. analytical studies
 used to study determinants.
Epidemiology is defined as:
 a. a study of distribution and determinants of disease
b. a study of natural history of a disease
c. a study of disease prevention in human population
d. a study of etiologies of epidemic disease in humans
An investigator reported three cases of carcinoma of
the lung among workers in a cement plant. This
type of study is best described as:
a. cohort
b. case series
c. case report
d. case control
 Study Designs

 Descriptive
-provides a picture of the occurrence of the
disease or condition to be able to come up
with a hypothesis regarding its causation
 Analytical
-offers to explain the reasons for the
occurrences of relationships between
disease and purported causative factors
Study Designs

 Descriptive studies
 Case Report
 Case Series
 Ecological
 Cross-sectional
Study Designs

 Analytical
 Observational
 Cross-sectional
 Case-control
 Cohort
 Experimental
Case Reports

 Studies that document unusual medical

occurrences in individual patients
 Its subjects are individual patients
Case Series

 Collections of individual case reports, which

may occur within a fairly short period of time
 Its subjects are still individual patients
Ecologic Studies

 Epidemiologic study in which the unit of

analysis is a population rather than an
individual
 Examines the health status of the
communities
Cross-sectional Studies

 Prevalence Study or Survey

 Study where exposure status and disease status
are measured at one point or over a short period
of time
An investigator reported three cases of carcinoma of
the lung among workers in a cement plant. This
type of study is best described as:
a. cohort
 b. case series
c. case report
d. case control
One of the major determinants of the degree to
which chance affects the findings in any particular
study is:
a. statistical testing
b. sample size
c. randomization
d. bias
 BIAS
• Systematic, random deviation of results

• Any trend in the collection, analysis,

interpretation, publication or review of
data that can lead to conclusions which are
systematically different from the truth.
 Randomization
• Equal chances of receiving intervention
(eliminates selection bias)
• With large sample size, the different
treatment groups tend to be more
comparable in terms of known and
unknown factors of the outcome
• It gives validity to the statistical treatment
of data
Sample size

 important because of its effect on

statistical power: the probability that a
statistical test will indicate a significant
difference when there truly is one;
 and that the difference between the
comparison groups is not due to chance

 analogous to the sensitivity of a

diagnostic test
One of the major determinants of the degree to
which chance affects the findings in any particular
study is:
a. statistical testing
 b. sample size
c. randomization
d. bias
Objectives of the research tell:
a. what variables are being considered
b. the affirmation of the hypothesis
formulated
c. when the biostatistician must come in
d. how much fund to request
 Research Process
Introduction
1. research problem
2. review of related literature
3. significance of the study
Research Objectives
Materials and Methods
1. study subjects/study design
2. description of study procedure and
outcome measurement
Data collection and Data analysis
Research Report
Research Objectives

 summarizes what is to be achieved by the

study

PIOM (PICO)
P – patient/study population
I – intervention/exposure
O – outcome/disease
M – method/comparison
Objectives of the research tell:
 a. what variables are being considered
b. the affirmation of the hypothesis
formulated
c. when the biostatistician must come in
d. how much fund to request
Controlled studies mean:
a. an experiment is being done
b. there is a comparison group
c. the characteristics of the participant are
all the same
d. a group is not to be given the experimental
procedure
 Controlled Trials

 An experiment or clinical trial in which two

groups are used for comparison purpose
 Types of control
a. standard practice (gold standard therapy)
b. placebo ("sugar pill“)
c. no intervention
Controlled studies mean:
a. an experiment is being done
 b. there is a comparison group
c. the characteristics of the participant are
all the same
d. a group is not to be given the experimental
procedure
In making a criticism journal, when one scrutinizes
the ways the sample was selected or the formation
of control group, he focuses on the:
a. design of investigation
b. statistical analysis
c. statement of conclusions
d. hypothesis of the study
 Methods of a Study
• Design
• Means of data collection
• Methods of processing
• Analysis of data
 Research Design
 Steps and mechanisms by which the research
objectives are pursued in a most valid and
objective way
 “Plan of attack”
 Includes subject selection, sample size,
control and manipulation of variables,
outcome evaluation, instrumentation,
plan of analysis
 Important to achieve internal and external
validity
INTERNAL validity
- extent to which the investigator is able
to control the different biases that may
affect the study
- valid results (close to the true result)

EXTERNAL validity
- extent to which the investigator is able
to generalize the results of the study
- results can be applied to the whole
population
 Data Analysis
 Involves quantification, description
and determination of relationships
of variables

 Statistics play an important role

Data Analysis: Two methods
1. Descriptive statistics
• Frequency distributions
• Mean, median, std deviation, range
• graphical presentations
2. Inferential statistics
a. estimation of parameters
b. hypothesis testing
• tests for means (t-test, ANOVA)
• tests for proportions (chi-square)
• tests for associations (Prevalence
ratios, Odds Ratios, Relative Risks)
• Regression (linear, logistic, Cox
survival, poisson) 5
9
In making a criticism journal, when one scrutinizes
the ways the sample was selected or the formation
of control group, he focuses on the:
 a. design of investigation
b. statistical analysis
c. statement of conclusions
d. hypothesis of the study
A study was done to prove that cotrimoxazole is
more effective than other drugs in treating
respiratory tract infections in ambulatory patients
in a community. The suitable control group will
receive:
a. another drug for respiratory infections
b. the standard drug for treating respiratory
infections
c. another experimental drug for respiratory
infection
d. a placebo
 Controlled Trials

 An experiment or clinical trial in which two

groups are used for comparison purpose
 Types of control
a. standard practice (gold standard therapy)
b. placebo ("sugar pill“)
c. no intervention
A study was done to prove that cotrimoxazole is
more effective than other drugs in treating
respiratory tract infections in ambulatory patients
in a community. The suitable control group will
receive:
a. another drug for respiratory infections
 b. the standard drug for treating respiratory
infections
c. another experimental drug for respiratory
infection
d. a placebo
Double blind determination of the exposure and
outcome is for the purpose of:
a. reducing the effects of losses to follow up
b. reducing the effects of sampling variation
c. achieving comparability of cases and
controls
d. avoiding observer and subject bias
 PURPOSE OF BLINDING
 Blinding or Masking is done to eliminate
1. Investigator bias
2. Evaluator (statistician) bias
3. Subject bias (Hawthorne effect)
Types of Blinding

• Single Blind: The patient is blind

• Double Blind: The patient and the investigator

are blind

• Triple Blind: The patient, investigator and data-

cleanup people are blind. The statistician can only
be partially blinded since he/she has to know which
patients are in the same treatment group.
Double blind determination of the exposure and
outcome is for the purpose of:
a. reducing the effects of losses to follow up
b. reducing the effects of sampling variation
c. achieving comparability of cases and
controls
 d. avoiding observer and subject bias
Descriptive studies are usually followed or
accompanied by analytic studies to discover cause
and effect relationship, the ultimate proof of which
is the:
a. cohort
b. quasi-experimental
c. case-control
d. experimental
Descriptive studies

IMPORTANCE:

 Constitute the beginning of epidemiologic

research by serving as basis in formulating
hypotheses regarding disease causation
 Analytic studies
IMPORTANCE:
 Aims to explain the reasons for the
occurrences of relationships between
disease and purported causative factors

Types:
I. Observational
a. Cross-sectional
b. Case-control
c. Cohort
II. Experimental
Cross-sectional Studies

 Prevalence Study or Survey

 Study where exposure status and disease status
are measured at one point or over a short period
of time
 Uses Prevalence Ratio as effect measure
Cross-sectional Design

Description
ED
ED
N n
ED
ED
 Case-control Studies
• Studies where persons with a particular
disease (the cases) and persons without the
disease (the controls) are selected and
exposure of interest are then determined
and compared
• Identify possible causes of disease
• Uses Odds Ratio as an effect measure
 Case-Control Design
Description

E
D
E
E
D
E

Direction of Inquiry
 Cohort Studies
 Studies wherein a group or groups of individuals
who are free of the outcome of interest are
classified according to their exposure to a
suspected risk factor and followed-up over a
period of time for the development of the
outcome of interest
 Identify risk factors, protective factors and
prognostic factors for disease
 Describe the natural history of disease
 Uses Risk Ratio as an effect measure
 Cohort Design
Description

D
E
D

D
E
D

Direction of Inquiry
 Cohort Studies
• Prospective – begins at the present and
proceeds forward to the future
• Retrospective – begins in the past and
proceeds forward to a more recent past
• Ambispective – begins in the past and
proceeds forward to the future
 Feature Cohort Case-Control
Starting Exposed group Diseased group
population
Control Unexposed group Non-diseased group
population
Information Disease rate (incidence Proportion with past
sought or mortality) exposure to suspected
factor
Principal bias Knowledge of Knowledge of disease
exposure may may influence report of
influence diagnosis exposure
Time required to Usually long (except Short period
collect data for retrospective
cohort)
Measure of Risk of disease for Odds ratio
association individuals
 Experimental Studies

• Studies wherein the investigator assigns

subjects to exposure or treatment groups
usually utilizing random allocation, and
follows them up to determine the outcome
of interest.
 Experimental Studies
Description
Reference Population

Random Sample

Randomization

Treatment Grp Control Grp

 Experimental Studies
Advantages:

1. Treatment and control groups are likely to be

comparable due to randomization

2. Provides best chance of obtaining strong

evidence of ‘cause and effect’
 Basic ‘Experimental’ Designs
• One-shot case study design
• One-group pre-test-post-test design
• Nonrandomized control-group post-test only
design
• Nonrandomized control-group pre-test-post-test
design
• Randomized control group post-test only design
• Randomized control group pre-test-post-test
design
Descriptive studies are usually followed or
accompanied by analytic studies to discover cause
and effect relationship, the ultimate proof of which
is the:
a. cohort
b. quasi-experimental
c. case-control
 d. experimental
A study comparing the prevalence of hepatitis B
infection among government and private hospitals
falls under:

a. descriptive study
b. cohort study
c. case-control
 d. cross-sectional
A study is planned to determine if there are more
users of oral contraceptives among patients with
thrombophlebitis than among well persons. To
achieve the objective, which of the following type of
studies is most appropriate:

a. clinical
b. descriptive
c. concurrent cohort
 d. case control
In a cohort study of the association of leukemia
with x-ray exposure, the relative risk was found to
be 3. What does this mean?
a. Those with x-ray exposure have threefold
probability of developing leukemia.
b. X-ray exposure protects the person from
developing leukemia.
c. There is no association between x-ray
exposure and leukemia.
d. None of the above.
 Cohort Studies
Analysis of Results:
Null value of 1 = no association between
exposure and outcome
RR > 1 <= harmful effect
RR < 1 <= protective or beneficial effect
In a cohort study of the association of leukemia
with x-ray exposure, the relative risk was found to
be 3. What does this mean?
 a. Those with x-ray exposure have threefold
probability of developing leukemia.
b. X-ray exposure protects the person from
developing leukemia.
c. There is no association between x-ray
exposure and leukemia.
d. None of the above.
It is important to formulate a research hypothesis
particularly when doing analytic studies because it
helps the researcher in:
a. identifying the most appropriate study
design to use.
b. determining the best approach to how
subjects are to be selected
c. anticipating the appropriate statistical
analysis to use
d. estimating the sample size for the study
Research Objectives
General objective
• identifies in general terms what is to
be accomplished by the study

Specific objective
• identifies in specific details on how to
accomplish the research by using
measurable parameters
90
Research Design

 “Plan of attack”
 Includes subject selection, sample size,
control and manipulation of variables,
outcome evaluation, instrumentation,
plan of analysis
 Important to achieve internal and
external validity

91
Research Hypothesis

Hypothesis – a proposition or statement

about the relationship of variables being
investigated

92
Research Hypothesis

Hypothesis – a proposition or statement

about the relationship of variables being
investigated

Example:
obesity hypertension

age

93
It is important to formulate a research hypothesis
particularly when doing analytic studies because it
helps the researcher in:
a. identifying the most appropriate study
design to use.
b. determining the best approach to how
subjects are to be selected
 c. anticipating the appropriate statistical
analysis to use
d. estimating the sample size for the study
The peculiar feature of a cross-sectional study that
distinguishes it from other study designs is:
a. Information on both the independent and
dependent variable are collected simultaneously
at the time of the survey
b. Information on the independent variable is
collected first, after which the subjects are
followed up later for assessment of the dependent
variable
c. Information on the dependent variable is
obtained, after which assessment of the
independent variable is made
d. Information on both the independent and
dependent variable are obtained by doing either
queries or actual observation
The peculiar feature of a cross-sectional study that
distinguishes it from other study designs is:
a. Information on both the independent and

dependent variable are collected simultaneously
at the time of the survey
b. Information on the independent variable is
collected first, after which the subjects are
followed up later for assessment of the dependent
variable
c. Information on the dependent variable is
obtained, after which assessment of the
independent variable is made
d. Information on both the independent and
dependent variable are obtained by doing either
queries or actual observation
The effect of an inadequate sample size for a study
is:
a. Subjects may not be a random representative
of the base population
b. there may not be enough subjects that will
develop the outcome, in order to detect a
difference.
c. the researcher will not be able to apply the
appropriate statistical test for the kind of
data available.
d. the researcher might find an association
between independent and dependent
variables, even if there is actually none.
Sample size

 important because of its effect on

statistical power: the probability that a
statistical test will indicate a significant
difference when there truly is one;
 and that the difference between the
comparison groups is not due to chance

 analogous to the sensitivity of a

diagnostic test
If no statistically significant difference:
1. Results correct, there is truly no statistically significant
difference, a true-negative result
2. Results erroneous, there is actually an underlying
difference but study not powerful enough to find the
difference, a false-negative result (type II error)
 inadequate sample size
 The effect of an inadequate sample size for a study
is:
a. Subjects may not be a random representative
of the base population
 b. there may not be enough subjects that will
develop the outcome, in order to detect a
difference.
c. the researcher will not be able to apply the
appropriate statistical test for the kind of
data available.
d. the researcher might find an association
between independent and dependent
variables, even if there is actually none.
The following method of data analysis is most
relevant for the cohort study design:
a. prevalence odds ratio
b. prevalence rate
c. odds ratio
 d. relative risk
This is sampling method wherein every subject
falling within a fixed sampling interval is obtain
from a population N which is arranged in some
definite way:
a. simple random sampling
b. systematic sampling
c. stratified sampling
d. cluster sampling
 Probability Sampling Designs

● Simple Random Sampling

● Systematic Sampling
● Cluster Sampling
● Stratified Random Sampling
Simple Random Sampling
● Most basic type of sampling design
● Every element in the population has an equal
chance of being included in the sample ( p =
1/n)
Systematic Sampling
● Samples are chosen at regular intervals
from the sampling frame
● Sampling interval computed as k= N/n
● Random start is done by randomly picking a
number between 1 to k
 Stratified Random Sampling
● Population divided into non-overlapping
groups called strata
● Simple random sampling then performed
in each stratum
Cluster Sampling
● Divide population into non-overlapping
groups called clusters
● Randomly select a number of clusters
● Include all individuals in the selected
clusters
 Multistage Sampling
● sampling procedure is carried out in phases
● Involves more than one sampling method
● The population is divided into sets of primary or
first stage sampling units and then a random
sample of secondary stage units is obtained from
each of the selected clusters in the first stage.
This is sampling method wherein every subject
falling within a fixed sampling interval is obtain
from a population N which is arranged in some
definite way:
a. simple random sampling
 b. systematic sampling
c. stratified sampling
d. cluster sampling
Which method of collecting data results to
accumulation of “secondary data”;
a. self-administered questionnaire
b. observation
c. measurement
d. review of documents
Primary Data
● collected by the investigator of research
through survey, interview, direct observation
● expensive and difficult to acquire but
trustworthy

Secondary Data
● data gathered from other sources
● cheap and easy to collect but must be
treated with caution
Which method of collecting data results to
accumulation of “secondary data”;
a. self-administered questionnaire
b. observation
c. measurement
 d. review of documents
The following statements are true regarding bias:
a. it may result both from biologic as well as
measurement variations
b. it is a systematic deviation from the true
underlying value
c. it may result from sampling error
d. all of the above
 BIAS
• Systematic, random deviation of results

• Any trend in the collection, analysis,

interpretation, publication or review of
data that can lead to conclusions which are
systematically different from the truth.
TYPES OF BIASES
• Selection Bias

• Information Bias
 recall bias
 interviewer bias

• Confounding

• Publication
The following statements are true regarding bias:
a. it may result both from biologic as well as
measurement variations
b. it is a systematic deviation from the true
underlying value
c. it may result from sampling error
 d. all of the above
A disease that occurs at an unusual or unexpected
number is said to be:
a. epidemic
b. endemic
c. sporadic
d. any of the above
Temporal patterns of disease
1. Endemic
 disease occurs at expected frequency
2. Epidemic
 disease occurs at greater than expected
frequency
3. Pandemic
 huge epidemic (international)
4. Sporadic
 single case or small cluster of cases
A disease that occurs at an unusual or unexpected
number is said to be:
 a. epidemic
b. endemic
c. sporadic
d. any of the above
An epidemiologic study provides clues for disease
etiology and hypothesis for further study is called:
a. cross-sectional study
b. cohort study
c. descriptive study
d. case-control study
 Study Designs

 Descriptive
-provides a picture of the occurrence of the
disease or condition to be able to come up
with a hypothesis regarding its causation
 Analytical
-offers to explain the reasons for the
occurrences of relationships between
disease and purported causative factors
An epidemiologic study provides clues for disease
etiology and hypothesis for further study is called:
a. cross-sectional study
b. cohort study
 c. descriptive study
d. case-control study
Prevalence is defined as the rate at which disease
occurs in a population over time. It is composed of:
a. old cases
b. new cases
c. old and new cases
d. old and selected new cases
 Prevalence
• Measures the proportion of individuals in a
population with the disease/condition at a given
time

• With disease = old and new cases

• Gives the magnitude of the problem at a given

time

• Used to measure chronic diseases

• Provides an estimate of the probability that an

individual will be ill at a given time

122
 Prevalence
• Two types
– Point Prevalence
– Period Prevalence

No. of existing cases of a dse at a pt/pd in time

Total population

123
 Incidence
• Unlike the prevalence, the incidence
measure deals with new cases only

• Has two types depending on the nature

of the data or cohort

1. Cumulative Incidence or
Incidence Proportion (fixed
cohort)
124
2. Incidence Density (dynamic cohort)
 Incidence
Conduct of a Cohort Study
Fixed Cohort
 All members of the cohort are gathered at
the beginning of the study and there are no
additional members after the study starts
 All members of the cohort are followed up for
the specified period of time

Dynamic Cohort
• Membership is not fixed at the start of the study
• Recruitment process goes on even after some
members are already being followed-up

125
 Incidence
1. Cumulative Incidence or Incidence Proportion
No. of new cases of a dse at the given time pd
No. of dse-free indvs at the start of the period

Total population at risk

2. Incidence Density
 Provides an estimate of the average rate of
disease occurrence in a population
 follow-up times are not uniform for all individuals

No. of new cases of a dse at the given time pd

Total Person-Time
Prevalence is defined as the rate at which disease
occurs in a population over time. It is composed of:
a. old cases
b. new cases
 c. old and new cases
d. old and selected new cases
If you are a Municipal Health Officer and
investigation an epidemic of pneumonia in an
evacuation center, the rate than you are going to
use to determine number of beds to be used,
medicines to bring, number of manpower to deploy
is:
a. prevalence rate
b. incidence rate
c. secondary attack rate
d. specific death rate by cause
 Incidence Rate

Cause-Specific = deaths occurring during a given time period

x 10ⁿ
Mortality Rate size of the population in which the deaths occurred
If you are a Municipal Health Officer and
investigation an epidemic of pneumonia in an
evacuation center, the rate than you are going to
use to determine number of beds to be used,
medicines to bring, number of manpower to deploy
is:
 a. prevalence rate
b. incidence rate
c. secondary attack rate
d. specific death rate by cause
To determine how many times more likely are
exposed persons to become diseased relative to non-
exposed, you will calculate for:
a. population attributable risk
b. relative risk
c. attributable risk
d. population attributable fraction
 Disease No Total
disease
Exposed a b

No t c d
exposed
Total

Relative Risk = risk of disease in exposed group (a/a+b) Ie

(Risk Ratio) risk of disease in unexposed group (c/c+d) Iu

Population Attributable Risk

= incidence in population It – incidence in unexposed Iu
*incidence of a disease in the population that would be eliminated if exposure were eliminated

Population Attributable Fraction

= incidence in population It – incidence in unexposed Iu
incidence in population It
 Disease No Total
disease
Exposed a 20 b 80 100

No t c 10 d 90 100
exposed
Total 30 170 200

Relative Risk = risk of disease in exposed group (a/a+b) Ie 0.2 = 2

(Risk Ratio) risk of disease in unexposed group (c/c+d) Iu 0.1

Population Attributable Risk

= I in population It – I in unexposed Iu 0.15 – 0.1 =
0.05
*incidence of a disease in the population that would be eliminated if exposure were eliminated

Population Attributable Fraction

0.15 – 0.1 = 0.33
= I in population It – I in unexposed Iu
0.15
I in population It
To determine how many times more likely are
exposed persons to become diseased relative to non-
exposed, you will calculate for:
a. population attributable risk
 b. relative risk
c. attributable risk
d. population attributable fraction
Characteristic/s of confounder:
a. associated with exposure
b. associated with outcome
c. does not lie between exposure and outcome
d. a and b only
 CONFOUNDING
• Refers to the mixing of the effects of the
exposure under study on the disease with
that of a third factor

• Characteristics of a confounders
– Is a risk factor to the disease /outcome
– Must be associated with the exposure
– Not an intermediate variable
 CONTROLLING FOR BIASES
• Control of Confounding
1. At the design stage
• Randomization (for exp designs)
• Restriction of the inclusion criteria
• Matching

2. At the analysis stage

• Stratified analysis
• Multivariate analysis
Characteristic/s of counfounder:
a. associated with exposure
b. associated with outcome
c. does not lie between exposure and outcome
 d. a and b only
Evidences that an association is cause and effect
EXCEPT:
a. Cause should always precede effect
 b. Large exposure to cause associated with
lower rates of disease
c. Reduction in exposure associated with
lower rates of disease
d. One cause leads to one effect
The best study design to show evidence for cause
and effect relationship:
a. case series
b. cohort
c. case control
d. case report
 Case-control Studies
ADVANTAGES
• Appropriate for studying diseases with long latency
periods
• Provides opportunity to investigate rare diseases
• Less time-consuming/expensive than cohort study
• Smaller sample size than cohort study
• Allows evaluation of wide range of potential etiologic
exposures
 Case-control Studies
DISADVANTAGES
• Cannot provide actual incidence rates
• Disease status of subject most likely to influence
ascertainment of exposure
• Temporal relationship may be difficult to establish
• Potential problem of difference in reporting of
exposure status of the cases and controls
• Info on potential risk factors and confounders may not
be available
 Cohort Studies
ADVANTAGES
• More clearly established temporal sequence
• Direct calculation of exposure-specific incidence
rates
• Can look at multiple effects of a single exposure
• Suitable for studies of rare exposures
• Certain biases are minimized especially regarding
ascertainment of exposure
 Cohort Studies
DISADVANTAGES
• Generally more expensive
• May require long follow-up periods
• Requires large sample sizes
• Susceptible to follow-up bias
The best study design to show evidence for cause
and effect relationship:
a. case series
 b. cohort
c. case control
d. case report
The commonly cited basis for early termination of
multicenter studies does not include:
a. severe adverse events
b. better than expected p-value differences
c. skewed reults
 d. too many drop-outs
Which elements is not considered a gold standard in
clinical trials?
a. randomization
b. double-blind
c. triple-blind
d. informed consent
 Clinical Trials
• Selection of experimental population
• Informed consent
• Random allocation of subjects
• Blinding to minimize bias
Which elements is not considered a gold standard in
clinical trials?
a. randomization
b. double-blind
 c. triple-blind
d. informed consent
What is the gold standard metric in measuring
hygiene?
a. knowledge
b. attitude
c. behavior
d. skills
KAP Studies
 Measures the KAP of a community including their
response to a specific intervention such as outreach,
demonstration or education
 Serves as educational diagnosis of the community
 widely used in public health, water supply and
sanitation, family planning, education and other
programs
Knowledge that is possessed by a community refers to their
understanding of that topic.
Attitude refers to their feelings toward this subject, as well as
any preconceived ideas they may have towards it.
Practice refers to the ways in which they demonstrate their
knowledge and attitudes through their actions
What is the gold standard metric in measuring
hygiene?
a. knowledge
b. attitude
 c. behavior
d. skills
This describes true treatment of intervention under
ideal conditions:
a. efficacy
b. effectiveness
c. reliability
d. validity
Efficacy
• intervention works and produces the expected result
under ideal circumstances
• traditional controlled outcome studies, e.g. RCTs
• good control over confounding variables, reliable
inference of causation (high internal validity)

Effectiveness
• intervention works and produces the expected result
under “real world” clinical settings
• “real world” studies of therapy as performed outside
research studies (techniques, populations)
• good generalization to real life patient populations and
real-life treatment methods (high external validity)
This describes true treatment of intervention under
ideal conditions:
 a. efficacy
b. effectiveness
c. reliability
d. validity
Metaanalysis may be used for the following reasons
EXCEPT:
a. decide on the best clinical approach to a
problem based on a several related studies
b. scrutinize studies to explain why research
differ
c. to report unusual event or unexpected
events
d. identify new directions for research
Metaanalysis
the statistical technique for combining results from
individual studies for the purpose of integrating the
findings
used to assess the clinical effectiveness of health care
interventions
provides a precise estimate of treatment effect, giving
due weight to the size of different studies included
good meta-analyses aim for complete coverage of all
relevant studies, look for the presence of heterogeneity,
and explore the robustness of the main findings using
sensitivity analysis.
Metaanalysis may be used for the following reasons
EXCEPT:
a. decide on the best clinical approach to a
problem based on a several related studies
b. scrutinize studies to explain why research
differ
 c. to report unusual event or unexpected
events
d. identify new directions for research
Who among the following is the reference
population in a research study to test the
effectiveness of a vaccine against tetanus
neonatorum?
a. all neonates without tetanus
b. mother who has tetanus
c. all patients with tetanus
d. All neonates with tetanus
 Experimental Studies
REFERENCE VS. EXPERIMENTAL POPULATIONS
• Reference population - the population to
which one would like to generalize the
results of the experimental study
• Experimental population – the population
that is actually studied
Who among the following is the reference
population in a research study to test the
effectiveness of a vaccine against tetanus
neonatorum?
 a. all neonates without tetanus
b. mother who has tetanus
c. all patients with tetanus
d. All neonates with tetanus
Prevalence rate is generally used to measure:
a. chronic diseases
b. accidents
c. socio-economic status
d. disabilities
 Prevalence
• Measures the proportion of individuals in a
population with the disease/condition at a given
time

• With disease = old and new cases

• Gives the magnitude of the problem at a given

time

• Used to measure chronic diseases

163
Prevalence rate is generally used to measure:
 a. chronic diseases
b. accidents
c. socio-economic status
d. disabilities
Cohort perspective has the following disadvantages:
a. time-consuming and expensive
b. can readily establish a cause-effect
relationship
c. the risks are accurate
d. occurrence of the illness is readily observed
 Cohort Studies
ADVANTAGES
• More clearly established temporal sequence
• Direct calculation of exposure-specific incidence
rates
• Can look at multiple effects of a single exposure
• Suitable for studies of rare exposures
• Certain biases are minimized especially regarding
ascertainment of exposure
 Cohort Studies
DISADVANTAGES
• Generally more expensive
• May require long follow-up periods
• Requires large sample sizes
• Susceptible to follow-up bias
Cohort perspective has the following disadvantages:
 a. time-consuming and expensive
b. can readily establish a cause-effect
relationship
c. the risks are accurate
d. occurrence of the illness is readily observed
This describes the population of true abnormal or
test-positives correctly identified:
a. Sensitivity
b. Specificity
c. Bias
d. Reliability
 9 5

1 95

aa da
Sn = a/a+c a+c b+d
This describes the population of true abnormal or
test-positives correctly identified:
 a. Sensitivity
b. Specificity
c. Bias
d. Reliability