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EPIDEMIOLOGICAL METHODS
The main aim of an epidemiologist is to study how diseases occur in
people.

During their lives, people are exposed to many different factors, and some
of these factors play a role in causing disease.

Epidemiological methods are divided into two main types:

I. Observational Studies

A. Descriptive Studies

B. Analytical Studies

II. Experimental Studies

I. OBSERVATIONAL STUDIES
An observational study is one in which nature is allowed to take its normal
course.

The researcher only observes and measures events, but does not interfere
or take any action.

A. Descriptive Epidemiology
A descriptive study only describes how a disease occurs in a population.

It studies disease in terms of time, place, and person.

The best way to study humans is by studying humans themselves.

The main concern of an epidemiologist is to study disease in people, who
are exposed to many factors during their lives, some of which may cause
disease.

Descriptive studies are usually the first step in an epidemiological

investigation.

They are also called situational analysis.

These studies mainly answer the following questions:

 When does the disease occur? (Time distribution)

 Where does it occur? (Place distribution)
 Who gets the disease? (Person distribution)

Procedure
1. Define the population to be studied
2. Define the disease under study
3. Describe the disease by:

a. Time

b. Place

c. Person

4. Measure disease using incidence and prevalence

5. Compare with known indices
6. Formulate a hypothesis

1. Defining the Population

Descriptive studies focus on populations, not individuals.

So, the first step is to clearly define the population.

The population should be described in terms of:

 Total number
 Age
  Sex
 Occupation
 Other relevant characteristics

The population selected for study is called the population base.

This population can be:

 The whole population of a geographic area

 A representative sample from that population
 A specially selected group such as:
o Age groups
o Sex groups
o Occupational groups
o Hospital patients
o School children

The selected community should be stable and large enough.

From the beginning of the study, it must be clearly defined who is

included and who is not included in the population base.

The defined population is used as the denominator when calculating

different rates.

Finally, a health facility should be nearby so that patients can easily

access it.

2. Defining the Disease under Study

After defining the population, the next step is to clearly define the disease
or condition being studied.

The definition must be:

 Precise (clear and exact)

 Valid (correct and reliable)
 Acceptable to the population

In other words, the definition should be an operational definition.

This means the disease can be identified and measured accurately in

the population.
For example, in epidemiological studies, tonsillitis may be defined as:

“the presence of enlarged and red tonsils.”

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4. Measurement of Disease by Prevalence and Incidence

Study

It is very important to have a clear understanding of how much disease

(disease burden) exists in a population.

This information should be available in terms of death (mortality), illness

(morbidity), disability, etc.

 Measuring mortality (death rate) is simple and straightforward.

 Measuring morbidity (disease) has two parts: incidence and
prevalence.

Incidence is measured through longitudinal studies, while prevalence is

measured through cross-sectional studies.

a. Cross-Sectional Studies (Prevalence Study)

A cross-sectional study is the simplest type of observational study.

It is based on examining a group (sample) of the population at one

specific point in time.
The results can be applied to the whole population, if the sample is
chosen correctly.

This type of study is more useful for chronic (long-lasting) diseases

than for short-term diseases.

b. Longitudinal Studies (Incidence Study)

Incidence is measured by observing the same population repeatedly over

a long period of time through follow-up.

Longitudinal studies are useful for:

 Identifying risk factors of disease

 Finding out the incidence rate
 Studying the natural history of disease and its future outcomes

However, longitudinal studies are difficult to organize and take more

time, but they provide more valuable information than cross-sectional
studies.

5. Comparing with Known Indices

The main purpose of epidemiology is to make comparisons and ask

questions.

By making comparisons, we can find clues about the causes of disease

(etiology).

We can also identify groups that are at higher risk of certain diseases.

There are two types of comparisons:

 Comparison between different populations

 Comparison within the same population

6. Formulation of a Hypothesis

By studying how diseases are distributed and using descriptive

epidemiology, we can often form a hypothesis about the cause of disease.
A hypothesis is a possible explanation based on observation.

It can later be tested and either accepted or rejected using analytical

epidemiology.

An epidemiological hypothesis should clearly mention:

 The population characteristics

 The specific cause being studied
 The expected outcome of the disease
 The dose-response relationship (how much exposure affects
disease)
 The time-response relationship (how time affects disease
development)

Uses of Descriptive Epidemiology

 It gives data about the amount of disease in a population using

mortality and morbidity rates.
 It provides clues about causes of disease.
 It gives background data for planning, organizing, and
evaluating health services.
 It helps further research by showing disease patterns according to
time, place, and person.

B. Analytical Epidemiology
This is the second major type of epidemiological study.

Here, the focus is on the individual within the population.

The results from descriptive epidemiology are analyzed to draw

conclusions about disease.

The goal is not to create hypotheses, but to test them.

There are two main types of analytical studies:

1. Case-control study
2. Cohort study
I. Case-Control Study
A case-control study is an analytical study where the past exposure to a
suspected risk factor is compared between:

 Cases → people who have the disease

 Controls → people who are similar but do not have the disease

It is also called a retrospective study.

Main Features

 Both exposure and disease have already occurred before the study
starts
 The study moves backward from effect to cause
 A control group is used to compare and support conclusions

Definitions

 Case: A person who has the disease

 Control: A person who does not have the disease but is similar in
other aspects

1. Selection of Cases and Controls

A. Selection of Cases

a. Definition of Cases

Before starting the study, we must clearly define what is considered a

case. This includes:

 Diagnostic criteria:

The disease definition and stage must be decided beforehand and must
not be changed during the study.
  Eligibility criteria:

Usually, only newly diagnosed cases within a specific time period

are included.

b. Sources of Cases

 Hospitals (single or multiple hospitals)

 General population

B. Selection of Controls

Controls must:

 Be free from the disease

 Be as similar as possible to cases, except for having the disease

Sources of Controls

 Hospital patients with other diseases

 Relatives
 Neighbors
 General population

Basic Steps in Case-Control Study

1. Selection of cases and controls

2. Matching
3. Measurement of exposure
4. Analysis and interpretation

2. Matching
Cases and controls may differ in factors like age, sex, occupation, and
social status.
To avoid errors, we ensure both groups are similar in these factors. This
process is called matching.

Matching means selecting controls in such a way that they are similar to
cases in important variables (like age), which could affect disease
outcome.

If not matched properly, results may become confusing or misleading

(confounded).

3. Measurement of Exposure
Just like defining cases and controls, defining exposure is also very
important.

Information about exposure can be collected through:

 Interviews
 Questionnaires
 Past records of cases and controls

4. Analysis and Interpretation

This is the final step, where we determine:

 Exposure rates among cases and controls

 Risk of disease associated with exposure (using odds ratio)

a. Exposure Rates

A case-control study helps directly estimate exposure rates in both

diseased and non-diseased groups.

Example: Smoking and Lung Cancer Study

 Cases (lung cancer patients):

Smokers = 33, Non-smokers = 2 → Total = 35

  Controls (no lung cancer):

Smokers = 55, Non-smokers = 27 → Total = 82

Exposure Rates

 Cases = 33 / 35 = 94.2%
 Controls = 55 / 82 = 67.0%

b. Estimation of Disease Risk

Even if 94.2% of cases were smokers, it does not mean that 94.2% of
smokers will get lung cancer.

Disease risk is estimated using relative risk or odds ratio.

Relative Risk (RR) / Risk Ratio

Relative risk is defined as:

RR = \frac{\text{Incidence among exposed}}{\text{Incidence among

non-exposed}}

However, case-control studies usually cannot calculate incidence, so

RR is mainly calculated in cohort studies.

Odds Ratio (Cross Product Ratio)

Odds ratio is an indirect measure of the strength of association between
exposure and disease.

It is based on three assumptions:

 The disease should be rare

 Cases should represent all diseased people
 Controls should represent healthy people

Formula:
[

\text{Odds Ratio} = \frac{ad}{bc}

Example:

 OR = (33 × 27) / (55 × 2) = 8.1

This means that smokers (less than 5 cigarettes/day) have 8.1 times
higher risk of lung cancer compared to non-smokers.

Classic Example of Case-Control Study

A famous study showed a link between mothers taking
Diethylstilbestrol (DES) during pregnancy and vaginal cancer in
young women.

 8 cancer cases were studied

 7 out of 8 mothers had taken DES
 None of the control group mothers had taken DES

This strongly suggested a relationship between DES exposure and cancer.

Advantages of Case-Control Study

 Easy to conduct
 Fast and low cost
 Requires fewer subjects
 Helps identify risk factors
 No risk to participants
 Can study multiple causes of disease

Disadvantages of Case-Control Study

 It cannot clearly separate actual causes from factors that are only associated with the
disease.
 Choosing a proper control group may be difficult.
 People may not correctly remember their past habits or exposure to risk factors,
leading to recall bias.
  Incidence of disease cannot be measured directly.
 It is not suitable for evaluating treatment or prevention (prophylaxis) of disease.

II. COHORT STUDY / LONGITUDINAL

STUDY / INCIDENCE STUDY
(Looking Forward Study)

A cohort study is a study design in which a specific group of people is followed over time.
The subjects are divided according to whether they were exposed or not exposed to a certain
factor, and then they are followed to see whether disease develops.

A cohort is a group of people who share a common characteristic or experience during a

specific time period, such as:

 Age
 Occupation
 Pregnancy
 Exposure to a drug

For Your Interest! A Classic Cohort Study

One famous cohort study is the Framingham Heart Study, which started in 1949.

More than 5000 people from Framingham who did not have coronary heart disease (CHD)
were included in the study.

These people were examined again every 2 years for more than 30 years.

This study successfully identified the major physical risk factors for chronic heart disease.

Distinct Features of Cohort Study

 The study moves forward from cause to effect.

Exposure → Outcome

 Cohorts are selected before the disease appears.

 The study groups are observed over time to measure how often disease develops in
them.
Annual 2007 Question

A case-control study was conducted to find the association between lung cancer and cigarette
smoking.

a. Which measure shows the strength of association between smoking and lung cancer in this
type of study?
b. How is this study different from a cohort study?

Annual 2012 Question

In an epidemiological study:

 1/3 of 90 subjects with myopia had a positive family history of disease.

 10 out of 100 subjects without myopia also had a positive family history.

a. Which study design best fits this situation?

b. Construct a 2×2 table and calculate the measure of risk.
c. Interpret the result.

Annual 2011 Question

History of Taking Coffee and Myocardial Infarction:

Coffee Intake Myocardial Infarction

Yes 60
No 90

a. Calculate the Odds Ratio.

b. Interpret the result.

Types of Cohort Study

1. Prospective Cohort Study / Current Cohort Study
In this type of study, the disease has not yet occurred when the study begins.

Example:
The long-term effects of uranium exposure were studied by selecting:
  A group of uranium miners
 A comparison group not exposed to uranium mining

Both groups were then followed to see whether lung cancer developed.

Suppose lung cancer develops 25 years after uranium exposure.

Researchers may select people who were exposed 20 years ago but still do not have lung
cancer. These people are then followed for another 5 years to observe disease development.

In this way, epidemiologists only need to follow them for 5 years instead of 25 years.

2. Retrospective Cohort Study / Historical Cohort Study

In this type, the disease has already occurred before the investigation begins.

The investigator goes back into past records to select the study groups and then traces them
forward through time.

Example:
In studies of lung cancer among miners, lung cancer had already developed. Researchers
collected information about uranium exposure and other occupational hazards and then
analyzed it to determine the cause of lung cancer.

3. Combination of Both / Ambidirectional Study

In this type, both retrospective and prospective methods are combined.

 The cohort is identified from past records.

 Their past outcomes are studied.
 Then the same cohort is followed into the future for further assessment of outcomes.

Indications for Cohort Study

Cohort studies are useful:

 When there is strong evidence of association between exposure and disease

 When exposure is rare but disease occurrence is high among exposed people
 When the cohort is stable, cooperative, and easy to follow
 When enough funds are available
Characteristics of Cohort Study
 The cohorts must be free from the disease being studied.
 Both study and control groups should have equal chances of getting the disease.
 Both groups should be comparable.
 Diagnostic and eligibility criteria must be defined before starting the study.

Steps of Cohort Study

1. Selection of study subjects
2. Obtaining information about exposure
3. Selection of comparison group
4. Follow-up
5. Analysis

1. Selection of Study Subjects

Study subjects may come from:

 General population
 Special population groups

a. General Population
When exposure or cause of death is common, cohorts may be selected from the general
population.

If the population is very large, a suitable sample is selected so the results can represent the
whole population.

b. Special Groups
These may include:

 Specific professional groups such as doctors, lawyers, and teachers

 Exposure groups, such as radiologists exposed to X-rays
2. Obtaining Data on Exposure
Information about exposure can be collected through:

Cohort Members

 Interviews
 Mailed questionnaires

Review of Records

Some information can only be obtained from medical records, such as:

 Radiation dose
 Type of surgery
 Medical treatment

Medical Examination

Certain information can only be obtained through examination, such as:

 Blood pressure (BP)

 ECG
 Serum cholesterol

Environmental Surveys

Studying the environment where the cohort lived or worked to identify suspected factors.

3. Selection of Comparison Groups

Different methods can be used to create comparison groups.

Internal Comparisons
In some studies, no outside control group is needed.

The same cohort is divided into groups based on exposure information.

External Comparisons
When degree of exposure is not known, an external control group is needed.

Examples:

 Smokers vs non-smokers
 Alcoholics vs non-alcoholics

Comparison with General Population Rates

If no comparison group is available, mortality rates of the exposed group are compared with
mortality rates of the general population.

4. Follow-Up
One major problem in cohort studies is regular follow-up of all participants.

Follow-up procedures include:

 Regular medical examinations

 Reviewing hospital and physician records
 Monitoring death records

Loss of participants during follow-up is called attrition.

5. Analysis
Data is analyzed in terms of:

a. Incidence rates
b. Estimation of risk

a. Incidence Rates
In cohort studies, incidence rates can be directly measured among exposed and non-exposed
groups.

Example
Cigarette Smoking Developed Lung Cancer Did Not Develop Lung Cancer Total
Yes 70 (a) 6930 (b) 7000
No 3 (c) 2997 (d) 3000

Incidence Rates

Among smokers:

\frac{70}{7000}=10\text{ per 1000}

Among non-smokers:

\frac{3}{3000}=1\text{ per 1000}

b. Estimation of Risk / Measures of Risk

Risk can be measured by:

1. Relative Risk (RR)

2. Attributable Risk (AR)

I. Relative Risk (RR) / Risk Ratio

Relative risk is the ratio of disease incidence among exposed people to disease incidence
among non-exposed people.

RR=\frac{\text{Incidence among exposed}}{\text{Incidence among non-exposed}}

In the above example:

RR=\frac{10}{1}=10

This means smokers are 10 times more likely to develop lung cancer than non-smokers.

The larger the RR value, the stronger the association between the risk factor and disease.

Interpretation of RR
RR Value Interpretation
RR = 1 No association
RR Value Interpretation
RR > 1 Positive association
RR < 1 Negative association

II. Attributable Risk (AR) / Risk Difference

Attributable risk is the difference in disease incidence between exposed and non-exposed
groups.

It is also called risk difference.

AR=\text{Incidence among exposed}-\text{Incidence among non-exposed}

Attributable Fraction (AF)

AF=\frac{\text{Incidence among exposed}-\text{Incidence among non-exposed}}{\
text{Incidence among exposed}}\times100

Using the previous example:

AF=\frac{10-1}{10}\times100=90%

This means:

 90% of lung cancer cases among smokers were due to smoking.

 The remaining 10% were due to other causes.

It also shows how much disease could be prevented if smoking were eliminated.

Interpretation of AR
AR Value Interpretation
AR = 0 No risk
AR > 0 Positive association
AR < 0 Negative association

III. Population Attributable Risk

This is the disease incidence in the total population minus the disease incidence among non-
exposed people.
It estimates how much disease in the population could be reduced if the suspected risk factor
were removed.

Advantages of Cohort Study

 Incidence can be measured directly
 Provides direct estimation of relative risk
 Dose-response relationship can be studied
 Bias can be minimized
 Best study type when true experiments cannot be done
 Can establish absolute risk of disease
 Can also identify protective factors like exercise and healthy diet

Disadvantages of Cohort Study

 Requires a large number of people
 Takes a long time to complete
 Difficult to maintain follow-up
 Administrative problems may occur, such as:
o Lack of experienced staff
o Lack of funding
o Extensive record keeping
 Expensive
 Ethical problems may arise
 Not practical for rare diseases

For example, if only 1 disease case occurs in every 10,000 people, then 100,000 people must
be followed to obtain 10 cases.

Annual 2008 Question

A researcher studied the risk of Perinatal Mortality (PNM per 100,000 births) caused by
maternal anemia during pregnancy.

Anemia Incidence of PNM / 100,000 births

Present 4000
Absent 200

a. Calculate:

 Attributable Risk (AR)

  Attributable Fraction (AF %)

b. Interpret the result.

Annual 2014 Question

In a cohort study on smoking and coronary heart disease (CHD):

 Out of 3000 smokers, 84 developed CHD

 Out of 5000 non-smokers, 87 developed CHD

a. Make a 2×2 table and calculate the measure of risk.

b. Interpret the results.