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

2/22/2011 Cross-sectional studies 1
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/

Principles of Epidemiology for Public Health (EPID600)

2
Signs from around the world
In a Copenhagen airline ticket office:
We take your bags and send them in all
directions.
3
In a Norwegian cocktail lounge:
Ladies are requested not to have
children in the bar.
4
Rome laundry:
Ladies, leave your clothes here and
spend the afternoon having a good time.
5
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)

6
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)

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/

Principles of Epidemiology for Public Health (EPID600)

Today outline
Cross-sectional studies (and sampling)
Ecologic studies
Confidence intervals
Cross-sectional studies
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.

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/]
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.
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 follow-
up to assess.
The source of most of what we know about the
population
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
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
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
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

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

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
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)

Sample size and Precision
Sample
size
Lower
95%
Point
estimate
Upper
95% Width
100 0.17 0.25 0.33 0.16
400 0.21 0.25 0.29 0.08
900 0.22 0.25 0.28 0.06
1600 0.23 0.25 0.27 0.04
0.25 0.188 0.43301
Weighted sampling
Hypothetical Unweighted Weighted
Age group Pop (1,000's) Sample Sample
20-39 yrs 18,000 900 400
40-59 yrs 18,000 900 400
60-69 yrs 8,000 400 400
Total 44,000 2,200 1,200
stratified
Also place census blocks into categories and
sample within each
Oversample some strata

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
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]
HIV seroprevalence
seroprevalence in sexually transmitted disease clients in a low-prevalence southern
state. Ann Epidemiol 1993;3:281-288]
Group % HIV+
Homosexual men 46
Bisexual men 25
Heterosexual men 1.6
Women 0.6
Total 2.5

Characteristic Gay Hetero Women
Syphilis
(history/current)
53 9.0 3
Gonorrhea (history) 37 2.6 1
Anal intercourse 41 1.7 2
Paid for sex 5.2
Seroprevalence (% HIV+) by risk factors
seroprevalence in sexually transmitted disease clients in a low-prevalence southern state.
Ann Epidemiol 1993;3:281-288]
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)
Other points
Can choose by exposure or overall
Can choose by disease may not be
distinguishable from a case-control study with
prevalent cases
Outline
Ecologic studies
Ecologic studies
Most study designs cross-sectional, case-
control, 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
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)
Interpretation
Link between summary exposure variable and
individual-level outcome must be inferred
Inference from group to individual is not
always sound
Example: Male Circumcision and HIV
Source: Bongaarts J, et al. The relationship between male circumcision and HIV infection in African populations. AIDS 1989; 3(6): 373-7.
(Slope indicates strength of relationship;
r indicates linearity)
Outline
Ecologic studies
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.
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%
Confidence intervals interpretation
Simple interpretations are typically not
precise
Precise interpretations are typically not
simple
Simple but imprecise
There is 95% confidence that the interval
contains the true value

True, but begs the question how to
define confidence
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
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.
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%
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?
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
Suppose that this line represents the value
of the parameter we are trying to estimate
True value
Possible estimates of that parameter in N
identical studies (shows sampling variation)
o
oo
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Study estimates
True value
One possible true value and how it would
manifest, on average, in N identical studies
o
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95% of the distribution
True value
Estimate from one study of a given size
Estimate
?
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A possible true value with < 2.5% chance of
being observed at or beyond the estimate
Estimate
?
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A possible true value with > 2.5% probability
of being observed at or beyond the estimate
Estimate
?
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A possible true value with > 2.5% probability
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Estimate
?
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A possible true value with < 2.5% probability of
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Estimate
?
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What the confidence interval represents
95% confidence interval
?
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What the confidence interval represents
95% confidence interval
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1.96 x s.e. | 1.96 x s.e.
True value

Confidence intervals another take

O
One possible population

O
Another possible population

O
A 3rd possible population

O
A 4th possible population

O

O
O
O
O

O
etc.
O
O
O

O
There are 1.6 x 10
60
possible populations
(no cases all cases)
O
O
O

Suppose this is the population
(prevalence = 15%)
O
O
O
O
O
O O
O
O
O
O
O
O
O
O
O
O O O
O
O
O
O
O
O
O
O
O
O
O

Take a sample (n=10)
O
O
O
O
O
O O
O
O
O
O
O
O
O
O
O
O O O
O
O
O
O
O
O
O
O
O
O
O

The sample
O
O

Make point estimate of prevalence
O
O
Interval estimate
What are all the possible populations that
would be expected to yield this prevalence
in a sample of size 10?


O
This one is not possible

O
Possible, but VERY UNLIKELY
O

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

O
Yields just about 2.5% (3%, actually) probability of
selecting 2 (or more) cases in 10
O
O
O
O
O
o
oo
oooo
oooooo
oooooooo
oooooooooo
o
o ooooooooooo
o
oo
o ooooooooooooooooo
o o
True value

O
Just above 2.5% (actually 2.6%) probability of
selecting 2 (or fewer) cases in 10
O
O
O
O
O O O O
O
O O
O
O
O
O
O
O
O O O O
O O O
O O
O
O
O O O O O
O O O
O O
O
O
O O
O
O O
O
O
O
O O
O
O
O
O
O
O O
O
O O
O O
O
O
O O O O
O O O O O O
O
O
O
O
O O
O
O
O O O O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O O

O
Just below 2.5% (actually 2.4%) probability of
selecting 2 (or fewer) cases in 10
O
O
O
O
O O O O
O
O
O
O
O
O
O
O
O
O O O O
O O O
O O
O
O
O O O O O
O O O
O O
O
O
O O
O
O
O
O
O
O O
O
O
O
O
O
O O
O
O O
O O
O
O
O O O O
O O O O O O
O
O
O
O
O O
O
O
O O O O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O O
O
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.
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

78
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.
79
Signs from around the world Finland
On the faucet in a Finnish washroom:
To stop the drip, turn cock to right.

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

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Study designs: Cross-sectional studies,

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