Day 3. Teach Epidemiology. Professional Development Workshop. The Health Education Center at Lankenau Hospital 100 Lancaster Avenue, Wynnewood, PA 19096 July 2024, 2009. Teach Epidemiology. Teach Epidemiology. Time Check 9:15 AM. Teach Epidemiology. Teach Epidemiology.
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3
Teach Epidemiology
Professional Development Workshop
The Health Education Center at Lankenau Hospital100 Lancaster Avenue, Wynnewood, PA 19096July 2024, 2009
Teach Epidemiology
9:15 AM
Teach Epidemiology
10:00 AM
Teach Epidemiology
10:45 AM
Teach Epidemiology
11:00 AM
Teach Epidemiology
Number of persons in the home
Osteoporosis
Age
Exposure
Outcome
Confounder
RR = (79 / 824) / (286 / 8576) = 2.9
RR = (55 / 106) / (5 / 10) = 1.0
RR = (24 / 718) / (281 / 8566) = 1.0
Bedsores
Death in the hospital
Severity of medical problems
12:15 AM
Teach Epidemiology
12:45 PM
Teach Epidemiology
Epidemiology
... the study of the distribution and determinants of healthrelated states or events in specified populations and the application of this study to the control of health problems.
Leon Gordis, Epidemiology, 3rd Edition, Elsevier Saunders, 2004.
54
X
… and you avoided or eliminated the hypothesized cause, what would happen to the outcome?
Control of Health Problems
If an association was causal, ….
?
Hypothesized Exposure
Outcome
X
55
Unobserved Exposure
X
… and you avoided or eliminated the hypothesized cause, what would happen to the outcome?
Control of Health Problems
If the association was found due to confounding, ….
?
Hypothesized Exposure
Outcome
56
found due to reversed time order, ….
X
… and you avoided or eliminated the hypothesized cause, what would happen to the outcome?
Control of Health Problems
If an association was found due to reversed timeorder, ….
?
Hypothesized Exposure
Outcome
57
… and you avoided or eliminated the hypothesized cause, what would happen to the outcome?
Control of Health Problems
If an association was found due to chance, ….
found due to chance, ….
?
Hypothesized Exposure
Outcome
58
… and you avoided or eliminated the hypothesized cause, what would happen to the outcome?
Control of Health Problems
If an association was found due to bias, ….
found due to bias, ….
?
Hypothesized Exposure
Outcome
59
If an association was causal, ….
causal, ….
Hypothesized Exposure
X
Outcome
X
… and you avoided or eliminated the hypothesized cause, what would happen to the outcome?
Control of Health Problems
... the study of the distribution and determinants of healthrelated states or events in specified populations and the application of this study to the controlof health problems.
60
... the study of the distribution and determinants of healthrelated states or events in specified populations and the application of this study to the controlof health problems.
1.
Cause
2.
Confounding
3.
Reverse Time Order
Chance
4.
5.
Bias
61
Ties, Links, Relationships, and Associations
Suicide Higher in Areas with Guns
Family Meals Are Good for Mental Health
1.
Cause
Study Links Iron Deficiency to Math Scores
Study Concludes: Movies Influence Youth Smoking
2.
Confounding
Lack of High School Diploma Tied to US Death Rate
3.
Reverse Time Order
Study Links Spanking to Aggression
Chance
4.
Depressed Teens More Likely to Smoke
Snacks Key to Kids’ TV Linked Obesity: China Study
5.
Bias
Pollution Linked with Birth Defects in US Study
Kids Who Watch RRated Movies More Likely to Drink, Smoke
62
Ties, Links, Relationships, and Associations
Suicide Higher in Areas with Guns
Family Meals Are Good for Mental Health
Study Links Iron Deficiency to Math Scores
Study Concludes: Movies Influence Youth Smoking
Lack of High School Diploma Tied to US Death Rate
Study Links Spanking to Aggression
Depressed Teens More Likely to Smoke
Snacks Key to Kids’ TV Linked Obesity: China Study
Pollution Linked with Birth Defects in US Study
Kids Who Watch RRated Movies More Likely to Drink, Smoke
Ties, Links, Relationships, and Associations
Suicide Higher in Areas with Guns
Family Meals Are Good for Mental Health
Study Links Iron Deficiency to Math Scores
Study Concludes: Movies Influence Youth Smoking
Lack of High School Diploma Tied to US Death Rate
Study Links Spanking to Aggression
Depressed Teens More Likely to Smoke
Snacks Key to Kids’ TV Linked Obesity: China Study
Pollution Linked with Birth Defects in US Study
Kids Who Watch RRated Movies More Likely to Drink, Smoke
Possible Explanations for Finding an Association
1.
Cause
2.
Confounding
3.
Reverse Time Order
Chance
4.
5.
Bias
Epidemiology
... the study of the distribution and determinants of healthrelated states or events in specified populations and the application of this study to the control of health problems.
Leon Gordis, Epidemiology, 3rd Edition, Elsevier Saunders, 2004.
Possible Explanations for Finding an Association
1.
Cause
2.
Confounding
3.
Reverse Time Order
Chance
4.
5.
Bias
Possible Explanations for Finding an Association
Cause
A factor that produces a change in another factor.
William A. Oleckno, Essential Epidemiology: Principles and Applications, Waveland Press, 2002.
X1
X1
X1
X1
X1
X1
DZ
X1
X1
X1
X1
X1
X1
X1
X1
X1
X1
X1
X1
X1
X1
X1
X1
X1
X1
X1
Necessary and Sufficient
Diagram
2X12 Table
DZ
DZ
X1
a
b
c
d
X1
X1
X1
X1
X1
X1
X1
X1
X1
+
X2
+
X3
DZ
X1
X1
X1
X1
X1
X1
X1
X1
X1
X1
X1
X1
X1
X1
X1
X1
X1
X1
X1
X1
X1
X1
X1
X1
X1
X1
X1
Necessary but Not Sufficient
Diagram
2X12 Table
DZ
DZ
X1
a
b
c
d
X1
X1
X1
X1
+
X2
+
X3
X1
X1
X1
X4
+
X5
+
X6
DZ
X1
X1
X1
X7
+
X8
+
X9
X1
X1
X1
X1
X1
X1
X1
X1
X1
X1
X1
X1
X1
X1
X1
X1
X1
X1
X1
X1
X1
Not Necessary and Not Sufficient
Diagram
2X12 Table
DZ
DZ
X1
a
b
c
d
X1
X
X
X
+
X
+
X
X
X
X
X
+
X
+
X
DZ
X
X
X
X
+
X
+
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Not Necessary and Not Sufficient
Diagram
2x2 Table
DZ
DZ
X
X
a
b
c
d
X
Heart Attack
Lack of Fitness
No Lack of Fitness
Lack of fitness and physical activity causes heart attacks.
a bc d
Lead Poisoning
Lack of Supervision
No Lack of Supervision
Lack of supervision of small children causes lead poisoning.
a bc d
Ties, Links, Relationships, and Associations
Suicide Higher in Areas with Guns
Family Meals Are Good for Mental Health
1.
Cause
Study Links Iron Deficiency to Math Scores
Study Concludes: Movies Influence Youth Smoking
2.
Confounding
Lack of High School Diploma Tied to US Death Rate
3.
Reverse Time Order
Study Links Spanking to Aggression
Chance
4.
Depressed Teens More Likely to Smoke
Snacks Key to Kids’ TV Linked Obesity: China Study
5.
Bias
Pollution Linked with Birth Defects in US Study
Kids Who Watch RRated Movies More Likely to Drink, Smoke
Possible Explanations for Finding an Association
1.
Cause
2.
Confounding
3.
Reverse Time Order
Chance
4.
5.
Bias
Possible Explanations for Finding an Association
Inference
Process of predicting from what is observed in a sample to what is not observed in a population.
To generalize back to the source population.
Not Observed
Inference
Population
Sample
Process of predicting from what is observed
to what is not observed.
Deck of 100 cards
a
b
c
d
No Marijuana
No Marijuana
Odd #
25 cards
25 cards
25 cards
Even #
25 cards
Population
Total
a
b
=
=
c
d
b
c
d
No Marijuana
No Marijuana
50
25
25
Odd #
25 cards
25 cards
50
25
25
25 cards
Even #
25 cards
Population
Population
Total
=
=
a
b
c
d
No Marijuana
No Marijuana
No Flu
Flu
50
50
25
25
25
25
Odd #
M&M’s
25 cards
25 cards
50
50
25
25
25
25
No M&M’s
25 cards
Even #
25 cards
Population
Total
=
=
=
Total
a
b
c
d
No Marijuana
No Marijuana
50
25
25
Odd #
25 cards
25 cards
50
25
25
25 cards
Even #
25 cards
Population
=
=
Total
Risk
25 / 50 or 50%
25 / 50 or 50%
a
b
c
d
No Marijuana
No Marijuana
50
25
25
Odd #
25 cards
25 cards
50
25
25
25 cards
Even #
25 cards
Risk
= 1
50 % / 50% =
Population
=
=
Total
Relative Risk
25 / 50 or 50 %
50 %
____
25 / 50 or 50 %
50 %
Possible Explanations for Finding an Association
Chance
To occur accidentally.
To occur without design.
A coincidence.
b
Sample
No Marijuana
No Marijuana
10
5
5
Odd #
10
5
5
Even #
25 cards
25 cards
25 cards
25 cards
Sample
Sample of 20 cards
Total
b
Sample
No Marijuana
No Marijuana
10
5
5
Odd #
10
5
5
Even #
Risk
25 cards
25 cards
25 cards
25 cards
Sample
Sample of 20 cards
Total
5 / 10 or 50 %
5 / 10 or 50 %
b
Sample
No Marijuana
No Marijuana
10
5
5
Odd #
10
5
5
Even #
Relative Risk
= 1
50 % / 50% =
25 cards
25 cards
25 cards
25 cards
Sample
Sample of 20 cards
Total
Risk
5 / 10 or 50 %
50 %
____
5 / 10 or 50 %
50 %
No Marijuana
No Marijuana
Sample of 20 cards
Odd #
Even #
Risk
Relative Risk
5 / 10 = 50 %
50 1
5 / 10 = 50 %
Sample
CDC
By Chance
Total
%
___
%
=
Chance
How many students picked a sample with 5 people in each cell?
No Marijuana
No Marijuana
Total
Risk
Relative Risk
5
5
10
5 / 10 or 50 %
Odd #
50 %
____
5
5
10
5 / 10 or 50 %
50 %
Even #
By Chance
Ties, Links, Relationships, and Associations
Study Links Having an Odd Address to Marijuana Use
Ties, Links, Relationships, and Associations
Study Links Having an Even Address to Marijuana Use
No Marijuana
Odd #
Even #
Risk
Relative Risk
5 / 10 = 50 %
50
5 / 10 = 50 %
Different Sample Sizes
b
Sample of 20 cards
50
Total
%
___
%
=
By Chance
By Chance
25 cards
25 cards
25 cards
25 cards
Chance
50 cards
Relative Risks
Greater than 1
Less than 1
No Marijuana
Odd #
Even #
Risk
Relative Risk
5 / 10 = 50 %
50
5 / 10 = 50 %
Different Sample Sizes
b
Sample of 20 cards
75
Total
%
___
%
=
By Chance
By Chance
25 cards
25 cards
25 cards
25 cards
Chance
75 cards
Relative Risks
Greater than 1
Less than 1
No Marijuana
Odd #
Even #
Risk
Relative Risk
5 / 10 = 50 %
50 1
5 / 10 = 50 %
Different Sample Sizes
b
Sample of 20 cards
99
Total
%
___
%
=
By Chance
By Chance
25 cards
25 cards
25 cards
25 cards
Chance
99 cards
Relative Risks
Greater than 1
Less than 1
Ties, Links, Relationships, and Associations
Association is not necessarily causation.
Suicide Higher in Areas with Guns
Family Meals Are Good for Mental Health
1.
Cause
Study Links Iron Deficiency to Math Scores
Study Concludes: Movies Influence Youth Smoking
2.
Confounding
Lack of High School Diploma Tied to US Death Rate
Study Links Spanking to Aggression
3.
Reverse Time Order
Chance
4.
Depressed Teens More Likely to Smoke
Snacks Key to Kids’ TV Linked Obesity: China Study
5.
Bias
Kids Who Watch RRated Movies More Likely to Drink, Smoke
E
%
Hypothesis
or
DZ
%
or
Healthy People
Healthy People
DZ
E

?
DZ
Risk
Relative Risk
Total
Exposure
Outcome
a b
c d
Turned Up Together
Where are we?
126
Explaining Associations and Judging Causation
Teach Epidemiology
Explaining Associations and Judging Causation
Coffee and Cancer of the Pancreas
1.
Cause
2.
Confounding
3.
Reverse Time Order
Chance
4.
5.
Bias
Teach Epidemiology
Explaining Associations and Judging Causation
Does evidence from an aggregate of studies support a causeeffect relationship?
Causal or Not Causal?
Guilt or Innocence?
131
Teach Epidemiology
Explaining Associations and Judging Causation
Handout
Sir Austin Bradford Hill “The Environment and Disease: Association or Causation?” Proceedings of the Royal Society of Medicine January 14, 1965
Teach Epidemiology
Explaining Associations and Judging Causation
“In what circumstances can we pass from this observed association to a verdict of causation?”
133
Teach Epidemiology
Explaining Associations and Judging Causation
“Here then are nine different viewpoints from all of which we should study association before we cry causation.”
134
Teach Epidemiology
Explaining Associations and Judging Causation
Does evidence from an aggregate of studies support a causeeffect relationship?
Teach Epidemiology
O
E
O
E
Healthy People
Healthy People
O
E
O
O
Random Assignment
O
O
E
E
O
E
O
Healthy People
Healthy People
O
O
E
E
E
E
Timeline
Timeline
Timeline
Timeline
Explaining Associations and Judging Causation
CaseControl Study
Randomized Controlled Trial
Cohort Study
CrossSectional Study
Teach Epidemiology
Explaining Associations and Judging Causation
Stress causes ulcers.
Helicobacter pylori causes ulcers.
Teach Epidemiology
Explaining Associations and Judging Causation
Teach Epidemiology
Explaining Associations and Judging Causation
Handout
“Does Playing Video Games Cause Asthma?”
Teach Epidemiology
3:30 PM
Teach Epidemiology
Teach Epidemiology
Metacognition
They can then use that ability to think about their own thinking … to grasp how other people might learn. They know what has to come first, and they can distinguish between foundational concepts and elaborations or illustrations of those ideas.
They realize where people are likely to face difficulties developing their own comprehension, and they can use that understanding to simplify and clarify complex topics for others,
tell the right story, or raise a powerfully provocative question.
Ken Bain, What the Best College Teachers Do
Teach Epidemiology
To create “… a professional community that discusses new teacher materials and strategies and that supports the risk taking and struggle entailed in transforming practice.”
Teach Epidemiology