VELI SUNGONO, M.S.

FACULTY OF MEDICINE
University of Pelita Harapan
Lecture 4, Monday, 13 August 2018
 Review and QUESTION

What is descriptive epidemiology?

What are the three main categories

of descriptive epidemiologic clues?

What is a hypothesis?

What is the relationship between

descriptive epidemiology and
hypotheses?

Detectives in the Classroom - Investigation 1-3: What’s My Hypothesis?

 Where are we and where are we going?
1 2
How is this disease Hypotheses Is there
distributed? an association?
What’s
Did the exposure and
my hypothesis?
the disease turn up
together?
3
Is the association
causal? Why did the exposure
and the disease turn up
together?

4
What should be done
to prevent the disease?

5
Did the prevention
strategy work?

Detectives in the Classroom – Investigation 3-1: In the News

 In the News
Is the
association
causal?

In the News
Detectives in the Classroom – Investigation 3-1: In the News
 Review

Descriptive Analytical
Hypothesis Epidemiology
Epidemiology

What is What is
What is a hypothesis? analytical
descriptive
epidemiology? epidemiology?

An Educated Guess

Detectives in the Classroom - Investigation 2-3: What's Wrong with This Picture?
 What does it mean? 1

Association Found
Between Coffee and Diabetes
Detectives in the Classroom – Investigation 3-1: In the News
 What does it mean?

Tied Related
Associated Linked
What do we mean when we say that
there is an association between two things?

Things that are associated

are linked in some way
that makes them turn up together.

Detectives in the Classroom – Investigation 3-1: In the News

The Weight of the Evidence

Guilty or Not guilty?

Detectives in the Classroom - Investigation 3-7: Weighing the Evidence
The Weight of the Evidence

Causal
Guilt or
or Not
Innocence?
Causal?
Detectives in the Classroom - Investigation 3-7: Weighing the Evidence
The Weight of the Evidence

Detectives in the Classroom - Investigation 3-7: Weighing the Evidence

 Association

Things that are associated are linked in some way

that makes them turn up together.

Happy
Birthday

Detectives in the Classroom – Investigation 3-1: In the News

 Things that Turn Up Together

Things that are associated are linked in some way

that makes them turn up together.

Detectives in the Classroom – Investigation 3-1: In the News

WHAT IS EPIDEMIOLOGY

• STUDY THE DISTRIBUTION OF

DISEASE, PATTERN?

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Basic Question in Analytic Epidemiology
• Are exposure and disease linked?

Exposure Disease
Is there an association between Exposure (E) &
Disease (D)?
Hypothesis: Do persons with exposure have higher
levels of disease than persons without exposure?
Is the association “real,” i.e. causal?
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 Review

Association

Things that are linked in

some way that makes them
turn up together.

Detectives in the Classroom – Investigation 3-1: In the News

 In the News
Suicide Higher in Smoking Linked to Youth Family Meals Are
Areas with Guns Eating Disorders Good for Mental Health

Study Links Study Concludes:

Iron Deficiency Movies Influence
to Math Scores Youth Smoking
Lack of High School Study Links
Diploma Tied to Spanking
US Death Rate to Aggression
Depressed Teens More Likely to Smoke
Snacks Key to Kids’ TV- Linked Obesity: China Study
Breakfast Each Day May Keep Colds Away
Pollution Linked with Birth Defects in US Study

Detectives in the Classroom – Investigation 3-1: In the News

 Review

Epidemiology

The study of how and why

diseases or other health-
related conditions are
distributed in a population the
way they are, in other words,
why some people get sick
and others do not.

Detectives in the Classroom – Investigation 3-1: In the News

 Association
Things that are associated are linked in some way
that makes them turn up together.

Is there an association between

the hypothesized cause and the disease?
Detectives in the Classroom – Investigation 3-1: In the News
 In the News
Suicide Higher in Smoking Linked to Youth Family Meals Are
Areas with Guns Eating Disorders Good for Mental Health

Study Links Study Concludes:

Iron Deficiency Movies Influence
to Math Scores Youth Smoking
Lack of High School Study Links
Diploma Tied to Spanking
US Death Rate to Aggression
Depressed Teens More Likely to Smoke
Snacks Key to Kids’ TV- Linked Obesity: China Study
Breakfast Each Day May Keep Colds Away
Pollution Linked with Birth Defects in US Study
Kids Who Watch R-Rated Movies More Likely to Drink, Smoke
Detectives in the Classroom – Investigation 3-1: In the News
 Always Remember
Association is not necessarily causation.

Association is not necessarily causation.

Association is not necessarily causation.

Association is not necessarily causation.

Association is not necessarily causation.

Association is not necessarily causation.

Association is not necessarily causation.

Association is not necessarily causation.

Detectives in the Classroom – Investigation 3-1: In the News

 Do Not Ever Forget
Association is not necessarily causation.

Association is not necessarily causation.

Association is not necessarily causation.

Testing a hypothesis and Finding that an

exposure and a disease turn up together is
important steps.
Interpreting study results is challenging because
several explanations for why an association is
found may be possible.
Detectives in the Classroom – Investigation 3-1: In the News
 Cause

Detectives in the Classroom – Investigation 3-1: In the News

 Epi Talk

Cause

Anything that produces an

effect.

Detectives in the Classroom – Investigation 3-1: In the News

 Epi Talk

Risk Factor

An exposure that increases

the likelihood of a specific
outcome.

Detectives in the Classroom – Investigation 3-1: In the News

 Essential Question 3
Is the
association
causal?

In the News
Detectives in the Classroom – Investigation 3-1: In the News
 Epi Talk

Interpret

To give the meaning of,

explain, or make clear.

Detectives in the Classroom – Investigation 3-1: In the News

Possible Explanations for Finding an Association

Investigations Explanations

3-2 Cause

3-3 Chance

3-4 Confounding

3-5 Reverse Time Order

3-6 Bias

Detectives in the Classroom – Investigation 3-1: In the News

VALIDITY VS RELIABILITY

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Epi Talk

Chance

To occur accidentally.

To occur without design.

A coincidence.

Detectives in the Classroom – Investigation 3-3: Chance

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Epi Talk

Confound

To confuse.
Confounder

A third factor that can make it

appear that an observed exposure
causes an outcome.

An unobserved exposure that is

both associated with an observed
exposure and is an actual cause of
an outcome.

Investigation 3-4
Detectives in the Classroom – Investigation 3-4: Confounding
Scenario 1

Vinnie

Sophia
X Broken
Window

Investigation 3-4
Detectives in the Classroom – Investigation 3-4: Confounding
 Confounding 2

Playing
Volleyball
X Skin
Cancer

Investigation 3-4
Detectives in the Classroom – Investigation 3-4: Confounding
 Confounding 3

Drinking Alcohol
during
X Low
Birth Weight
Pregnancy Babies

Investigation 3-4
Detectives in the Classroom – Investigation 3-4: Confounding
 Confounding 5

Watching TV X Acne

Investigation 3-4
Detectives in the Classroom – Investigation 3-4: Confounding
Which came first?

Egg Chicken

Detectives in the Classroom – Investigation 3-5: Reversed Time Order

Scenario 2

Detectives in the Classroom – Investigation 3-5: Reversed Time Order

Scenario 3

Detectives in the Classroom – Investigation 3-5: Reversed Time Order

Epi Talk
Reversed Time Order

When the
hypothesized time
order of an exposure
and an outcome is
actually reversed and
the outcome really
comes before the
exposure.

Detectives in the Classroom – Investigation 3-5: Reversed Time Order

Exercise Fat or Fat Exercise
Reversed Time Order 2

It is possible that
people who __________ watch TV
are more likely to ____________. be overweight

But it is also possible that

people who are __________ overweight
are more likely to __________.
watch TV

Detectives in the Classroom – Investigation 3-5: Reversed Time Order

 HYPOTHESIS
Tea intake reduces
the risk of colon
cancer in African-
American and
Whites
Explanations for Finding an Association

Could the
association have
been found because
of reversed time
order?

Detectives in the Classroom – Investigation 3-5: Reversed Time Order

Epi Talk

Bias

A faulty assumption in a
study that makes things
appear differently from
how they really are.

Detectives in the Classroom - Investigation 3-6: Selection Bias

Inaccuracy

Bias

Lack of
Validity
 Bias

Selection Information
BIAS
Epi Talk

Selection Bias

A faulty assumption in a
study because of a
systematic difference in
how subjects were chosen
to be in the study.

Detectives in the Classroom - Investigation 3-6: Selection Bias

Selection Bias

Selection Bias
A faulty assumption that occurs because
there are systematic differences
in characteristics between those who
are selected for study and those who are
not.
Detectives in the Classroom - Investigation 3-6: Selection Bias
 Always Remember
Association is not necessarily causation.

Association is not necessarily causation.

Association is not necessarily causation.

Association is not necessarily causation.

Association is not necessarily causation.

Association is not necessarily causation.

Association is not necessarily causation.

Association is not necessarily causation.

Detectives in the Classroom – Investigation 3-1: In the News

Possible Explanations for Finding an Association

Investigations Explanations

3-2 Cause

3-3 Chance

3-4 Confounding

3-5 Reverse Time Order

3-6 Bias

Detectives in the Classroom – Investigation 3-1: In the News

NEXT LECTURE : TUESDAY, 15 AUGUST 2017

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Grey hair stroke

Source: Kostas Danis, EPIET Introductory course, Menorca 2012

56
 TAKE HOME MESSAGE
• Association is not always causal:
The Association may be happen because
• Chance
• Reverse time Order
• Confounding
• Bias
• Causal
1 Leon Gordis, Epidemiology 5th edition, 2013, Saunders Elsevier
https://books.google.co.id/books?id=7YX6AQAAQBAJ&printsec=fr
ontcover&dq=leon+gordis+epidemiology+5th&hl=en&sa=X&redir_
esc=y#v=onepage&q&f=true
2 Detective in Classroom Source
http://www.epiedmovement.org/detectives.html
3. Kostas Danis, EPIET Introductory course, Menorca 2012