Centers for Disease Control and Prevention Global Health Odyssey Museum Tom Harkin Global Communications Center June 7-11, 2010 Teach Epidemiology Professional Development Workshop Day 4

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3 Teach Epidemiology

4 Enduring Epidemiological Understandings

5 Teach Epidemiology Enduring Epidemiological Understandings

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7 Laboratory Teach Epidemiology Making Group Comparisons and Identifying Associations

8 Laboratory Teach Epidemiology Making Group Comparisons and Identifying Associations

9 Naturally occurring circumstances in which groups of people within a population have been exposed to different levels of the hypothesized cause of an outcome. Natural Experiment Teach Epidemiology Making Group Comparisons and Identifying Associations

10 An epidemiologic study of a natural experiment in which the investigator is not involved in the intervention other than to record, classify, count, and statistically analyze results. Observational Study Teach Epidemiology Making Group Comparisons and Identifying Associations

11 An epidemiologic experiment in which subjects are assigned into groups to receive or not receive a hypothesized beneficial intervention. Controlled Trial Teach Epidemiology Making Group Comparisons and Identifying Associations

12 Buprenorphine Buprenorphine will stop heroin addicts from using heroin. Teach Epidemiology Making Group Comparisons and Identifying Associations

13 Naturally occurring circumstances in which groups of people within a population have been exposed to different levels of the hypothesized cause of an outcome. Observational Study of a Natural Experiment Epidemiologic studies of natural experiments in which the investigator is not involved in the intervention other than to record, classify, count, and statistically analyze results. Teach Epidemiology Making Group Comparisons and Identifying Associations

14 Making Group Comparisons and Identifying Associations Teach Epidemiology

15 Making Group Comparisons and Identifying Associations Teach Epidemiology

16 Stephen Jay Gould (survivor of abdominal mesothelioma) Absolutely nothing in the available arsenal of anti-emetics worked at all. I was miserable and came to dread the frequent treatments with an almost perverse intensity. I had heard that marijuana often worked well against nausea. I was reluctant to try it because I had never smoked any substance habitually (and didn’t even know how to inhale). Moreover, I had tried marijuana twice (in the 1960s) … and had hated it …. Marijuana worked like a charm …. The sheer bliss of not experiencing nausea - and not having to fear it for all the days intervening between treatments - was the greatest boost I received in all my year of treatment, and surely the most important effect upon my eventual cure. Making Group Comparisons and Identifying Associations Teach Epidemiology

17 A particular or detached incident or fact of an interesting nature; a biographical incident or fragment; a single passage of private life. Anecdote Making Group Comparisons and Identifying Associations Teach Epidemiology

18 Science Transforming Anecdote to Science Making Group Comparisons and Identifying Associations Teach Epidemiology Anecdote

19 Time Healthy People - E Random Assignment E DZ Controlled Trial Time Healthy People - E E DZ Cohort Study Time Case-Control Study - DZ E E E E Time Cross-Sectional Study - E E DZ Making Group Comparisons and Identifying Associations Teach Epidemiology

20 Time Healthy People - E Random Assignment E DZ Controlled Trial Time Healthy People - E E DZ Cohort Study Time Case-Control Study - DZ E E E E Time Cross-Sectional Study - E E DZ d b c a Making Group Comparisons and Identifying Associations Teach Epidemiology

The goal of every epidemiological study is to harvest valid and precise information about the relationship between an exposure and a disease in a population. The various study designs merely represent different ways of harvesting this information. Essentials in Epidemiology in Public Health Ann Aschengrau and George R. Seage III Making Group Comparisons and Identifying Associations Teach Epidemiology

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25 Time Check 8:15 AM

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27 Teach Epidemiology

The Journey Detectives in the Classroom - Investigation 2-6: The Journey

Analogy Detectives in the Classroom - Investigation 2-6: The Journey

Epi Talk Study Design Epi Talk Procedures and methods, established beforehand, that are followed by the investigator conducting the study. Detectives in the Classroom - Investigation 2-6: The Journey

Timing When are the passengers identified as exposed or unexposed? E When are the passengers identified as sick or not sick? DZ Timing When does the epidemiologist start to observe the journey? - Detectives in the Classroom - Investigation 2-6: The Journey

Time E DZ Label the Train Tracks - Detectives in the Classroom - Investigation 2-6: The Journey

Time Study Design: E DZ Label the Train Tracks - Controlled Trial Detectives in the Classroom - Investigation 2-6: The Journey

Time Healthy People Controlled Trial Flow Diagram - Healthy People E Random Assignment E DZ Detectives in the Classroom - Investigation 2-6: The Journey

Time Study Design: Label the Train Tracks Cohort Study Detectives in the Classroom - Investigation 2-6: The Journey

Cohort Study Just as in the controlled trial, the epidemiologist is also on the train during the entire journey. But there is an important difference. The epidemiologist is not telling passengers what to do. Rather, the epidemiologist is just observing them and counting. Passengers are not being told to have or not have an exposure, they are just living their normal lives. The epidemiologist, on the ride for the whole journey, just keeps observing everyone’s exposures and whether or not they develop the disease during the journey. Label the Train Tracks Detectives in the Classroom - Investigation 2-6: The Journey

Time E DZ Label the Train Tracks - Study Design: Cohort Study Detectives in the Classroom - Investigation 2-6: The Journey

Time Healthy People Cohort Study Flow Diagram - Healthy People E E DZ Detectives in the Classroom - Investigation 2-6: The Journey

Time Healthy People Cohort Study Flow Diagram - Healthy People E E DZ Controlled Trial Detectives in the Classroom - Investigation 2-6: The Journey

Time Healthy People Cohort Study Flow Diagram - Healthy People E E DZ Controlled Trial Random Assignment Detectives in the Classroom - Investigation 2-6: The Journey

Review Observational Studies Epi Talk Epidemiologic studies of natural experiments in which the investigator is not involved in the intervention other than to record, classify, count, and statistically analyze results. Detectives in the Classroom - Investigation 2-6: The Journey

Time Label the Train Tracks Study Design: Case-Control Study Detectives in the Classroom - Investigation 2-6: The Journey

The epidemiologist is not on the journey. Rather, the epidemiologist is waiting at the train station at the end of the journey. As passengers get off the train, the epidemiologist selects sick passengers for the case group and selects passengers who are similar but not sick for the control group. The epidemiologist then asks each person in the case group and control group questions about their exposures during the train ride. The epidemiologist relies on passengers’ memories of their exposures that occurred during the train ride. Label the Train Tracks Case-Control Study Detectives in the Classroom - Investigation 2-6: The Journey

Time E DZ Label the Train Tracks - Study Design: Case-Control Study Detectives in the Classroom - Investigation 2-6: The Journey

Case-Control Study Observational Study Flow Diagram Flow Diagram Time DZ - E E E E Detectives in the Classroom - Investigation 2-6: The Journey

Time Label the Train Tracks Study Design: Cross-Sectional Study Detectives in the Classroom - Investigation 2-6: The Journey

The epidemiologist, who has not been on the journey, stops the train somewhere during the trip (kind of like a train robbery) and takes a “snapshot” of all the passengers by asking them whether or not they have the exposure and whether or not they have the disease. Then the epidemiologist leaves the train and goes home to analyze the data from that particular day. The journey continues without the epidemiologist. Label the Train Tracks Cross-Sectional Study Detectives in the Classroom - Investigation 2-6: The Journey

E DZ Time Label the Train Tracks - Study Design: Cross-Sectional Study Detectives in the Classroom - Investigation 2-6: The Journey

Cross-Sectional Study Observational Study Flow Diagram Flow Diagram Time E E - DZ Detectives in the Classroom - Investigation 2-6: The Journey

Epi Talk Controlled Trial Epi Talk An epidemiologic experiment in which subjects are assigned into groups to receive or not receive a hypothesized beneficial intervention. Detectives in the Classroom - Investigation 2-6: The Journey

Epi Talk Cohort Study Epi Talk An analytical epidemiological study design in which the investigator selects a group of exposed individuals and a group of unexposed individuals and follows both groups to compare the frequency with which the disease occurs in each group. Detectives in the Classroom - Investigation 2-6: The Journey

Epi Talk Case-Control Study Epi Talk An analytical epidemiological study design in which the investigator selects a group of individuals with a disease (cases) and a group of similar individuals without the disease (controls) and compares the frequency with which an exposure occurred in the cases versus the controls. Detectives in the Classroom - Investigation 2-6: The Journey

Epi Talk Cross-Sectional Study Epi Talk An analytical epidemiological study design in which the investigator selects a group of individuals and determines the presence or absence of a disease and the presence or absence of an exposure at the same time. Detectives in the Classroom - Investigation 2-6: The Journey

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Epi Team Challenge Detectives in the Classroom - Investigation 2-7: Epi Team Challenge

Time Healthy People - E Random Assignment E DZ Controlled Trial Time Healthy People - E E DZ Cohort Study Time DZ E E E E Case-Control Study Time E E DZ Cross-Sectional Study DZ What’s My Design? Detectives in the Classroom - Investigation 2-7: Epi Team Challenge

Epidemiologist is involved during the entire time from exposure to disease. Assign treatment and control groups. Follow through time and compare risk of disease in treatment group with risk of disease in control group. Give exposure to treatment group, but not control group. What’s My Design? Practice Clue Trial Detectives in the Classroom - Investigation 2-7: Epi Team Challenge

Assign treatment and control groups. What’s My Design? Clue 1 Begin Epi Team Challenge Trial Detectives in the Classroom - Investigation 2-7: Epi Team Challenge

Observational Study Flow Diagram DZ - E E E E Clue 2 Case-Control Study What’s My Design? Detectives in the Classroom - Investigation 2-7: Epi Team Challenge

Observational Study Clue 3 What’s My Design? Cohort, Case-Control, and Cross-Sectional Studies Detectives in the Classroom - Investigation 2-7: Epi Team Challenge

Follow through time and compare risk of disease in exposed group with risk of disease in the unexposed group. Clue 4 Trial and Cohort Study What’s My Design? Detectives in the Classroom - Investigation 2-7: Epi Team Challenge

Follow through time and compare risk of disease in treatment group with risk of disease in control group. Give exposure to treatment group, but not control group. Clue 5 Trial What’s My Design? Detectives in the Classroom - Investigation 2-7: Epi Team Challenge

Epidemiologist is involved during the entire time from exposure to disease. Clue 6 Trial and Cohort Study What’s My Design? Detectives in the Classroom - Investigation 2-7: Epi Team Challenge

Select a group of people with disease and a similar group of people without disease. Clue 7 Case-Control Study What’s My Design? Detectives in the Classroom - Investigation 2-7: Epi Team Challenge

Healthy People Flow Diagram - Healthy People E E Random Assignment Non-Observational Study Clue 8 Trial What’s My Design? Detectives in the Classroom - Investigation 2-7: Epi Team Challenge

Observational Study Flow Diagram E E - DZ Clue 9 Cross Sectional Study What’s My Design? Detectives in the Classroom - Investigation 2-7: Epi Team Challenge

Compare odds of exposure in the two groups. Clue 10 Case-Control Study What’s My Design? Detectives in the Classroom - Investigation 2-7: Epi Team Challenge

Healthy People Flow Diagram - Healthy People E E DZ Random Assignment Clue 11 Trial What’s My Design? Detectives in the Classroom - Investigation 2-7: Epi Team Challenge

Flow Diagram Clue 12 Cross Sectional Study What’s My Design? Detectives in the Classroom - Investigation 2-7: Epi Team Challenge

Flow Diagram DZ Observational Study Clue 13 Cohort Study What’s My Design? Detectives in the Classroom - Investigation 2-7: Epi Team Challenge

Ask each person about both exposure and disease at that point in time. What’s My Design? Clue 14 Cross Sectional Study Detectives in the Classroom - Investigation 2-7: Epi Team Challenge

Ask both groups about their exposures in the past. What’s My Design? Clue 15 Case-Control Study Detectives in the Classroom - Investigation 2-7: Epi Team Challenge

Healthy People Flow Diagram - Healthy People Random Assignment Clue 16 Trial What’s My Design? Detectives in the Classroom - Investigation 2-7: Epi Team Challenge

Disease risk in exposed group is compared to disease risk in unexposed group. Clue 17 Trial, Cohort Study, and Cross Sectional Study What’s My Design? Detectives in the Classroom - Investigation 2-7: Epi Team Challenge

Flow Diagram E E - DZ Clue 18 Cross Sectional Study What’s My Design? Detectives in the Classroom - Investigation 2-7: Epi Team Challenge

Select a healthy study sample. Clue 19 Trial (?) and Cohort Study What’s My Design? Detectives in the Classroom - Investigation 2-7: Epi Team Challenge

Observe who has and has not been exposed. Clue 20 Cohort and Cross-Sectional Studies What’s My Design? Detectives in the Classroom - Investigation 2-7: Epi Team Challenge

Clue 21 Give exposure to treatment group, but not control group. Trial What’s My Design? Detectives in the Classroom - Investigation 2-7: Epi Team Challenge

Healthy People Flow Diagram - Healthy People E E Observational Study Clue 22 Cohort Study What’s My Design? Detectives in the Classroom - Investigation 2-7: Epi Team Challenge

Epidemiologist is involved after disease has occurred and relies on subjects’ memories to gather information about exposure. Clue 23 Case-Control Study What’s My Design? Detectives in the Classroom - Investigation 2-7: Epi Team Challenge

Select a study sample. Clue 24 Trial, Cohort, Case-Control, and Cross Sectional Studies What’s My Design? Detectives in the Classroom - Investigation 2-7: Epi Team Challenge

Healthy People Flow Diagram - Healthy People E E DZ Observational Study Clue 25 Cohort Study What’s My Design? Detectives in the Classroom - Investigation 2-7: Epi Team Challenge

Epidemiologist gathers data only at that one point in time. Clue 26 Cross Sectional Study What’s My Design? Detectives in the Classroom - Investigation 2-7: Epi Team Challenge

Flow Diagram DZ Clue 27 Trial and Cohort Study What’s My Design? Detectives in the Classroom - Investigation 2-7: Epi Team Challenge

Follow through time and compare risk of disease in exposed group to risk of disease in unexposed group. Clue 28 Trial and Cohort Study What’s My Design? Detectives in the Classroom - Investigation 2-7: Epi Team Challenge

Epidemiologist is involved during the entire time from exposure to disease. Clue 29 Trial and Cohort Study What’s My Design? Detectives in the Classroom - Investigation 2-7: Epi Team Challenge

Flow Diagram E E DZ Clue 30 Cross Sectional Study What’s My Design? Detectives in the Classroom - Investigation 2-7: Epi Team Challenge

Flow Diagram DZ - Clue 31 Case-Control Study What’s My Design? Detectives in the Classroom - Investigation 2-7: Epi Team Challenge

Ask each person about both exposure and disease at that point in time. Epidemiologist gathers data only at that one point in time. Disease risk in exposed group is compared to disease risk in unexposed group. Select a study sample. Clue 32 Cross Sectional Study What’s My Design? Detectives in the Classroom - Investigation 2-7: Epi Team Challenge

Epidemiologist is involved after disease has occurred and relies on subjects’ memories to gather information about exposure. Select a group of people with disease and a similar group of people without disease. Compare percent of exposed people in the two groups. Ask both groups about their exposures in the past. Case-Control Study Clue 33 What’s My Design? Detectives in the Classroom - Investigation 2-7: Epi Team Challenge

Epidemiologist is involved during the entire time from exposure to disease. Select a healthy study sample. Follow through time and compare risk of disease in exposed group to risk of disease in unexposed group. Observe who has and has not been exposed. Cohort Study Clue 34 What’s My Design? Detectives in the Classroom - Investigation 2-7: Epi Team Challenge

Epidemiologist is involved during the entire time from exposure to disease. Assign treatment and control groups. Follow through time and compare risk of disease in treatment group with risk of disease in control group. Give exposure to treatment group, but not control group. Trial Clue 35 What’s My Design? Detectives in the Classroom - Investigation 2-7: Epi Team Challenge

End Epi Team Challenge What’s My Design? Detectives in the Classroom - Investigation 2-7: Epi Team Challenge

Detectives in the Classroom - Investigation 2-8: Which Design Is Best? Which Design Is Best?

Cross-Sectional Study Case-Control Study Cohort Study Trial Main WeaknessesMain StrengthsStudy Designs Epi Team Challenge Detectives in the Classroom - Investigation 2-8: Which Design Is Best?

Cross-Sectional Study Case-Control Study Cohort Study Trial Main WeaknessesMain StrengthsStudy Designs Cross- Sectional Cohort Case- Control Controlled Trial Epi Team Challenge Detectives in the Classroom - Investigation 2-8: Which Design Is Best?

Cross-Sectional Study Case-Control Study Cohort Study Trial Main WeaknessesMain StrengthsStudy Designs Fastest Which study design is the fastest? Epi Team Challenge Detectives in the Classroom - Investigation 2-8: Which Design Is Best?

Cross-Sectional Study Case-Control Study Cohort Study Trial Main WeaknessesMain StrengthsStudy Designs Fastest Time Consuming Which study designs are the most time consuming? Epi Team Challenge Detectives in the Classroom - Investigation 2-8: Which Design Is Best?

Cross-Sectional Study Case-Control Study Cohort Study Trial Main WeaknessesMain StrengthsStudy Designs Fastest Time Consuming Most Scientifically Sound Which study design is the most scientifically sound? Time Consuming Epi Team Challenge Detectives in the Classroom - Investigation 2-8: Which Design Is Best?

Cross-Sectional Study Case-Control Study Cohort Study Trial Main WeaknessesMain StrengthsStudy Designs Fastest Time Consuming Most Scientifically Sound Can Study Rare Diseases Which study design is best for studying rare diseases? Time Consuming Epi Team Challenge Detectives in the Classroom - Investigation 2-8: Which Design Is Best?

Cross-Sectional Study Case-Control Study Cohort Study Trial Main WeaknessesMain StrengthsStudy Designs Fastest Time Consuming Most Scientifically Sound Possible Time-Order Confusion Can Study Rare Diseases Which study designs do not identify the time order of exposure and disease? Time Consuming Epi Team Challenge Detectives in the Classroom - Investigation 2-8: Which Design Is Best?

Cross-Sectional Study Case-Control Study Cohort Study Trial Main WeaknessesMain StrengthsStudy Designs Fastest Time Consuming Least Confidence in Findings Most Scientifically Sound Possible Time-Order Confusion Can Study Rare Diseases Which study design gives the least confidence in findings? Time Consuming Epi Team Challenge Detectives in the Classroom - Investigation 2-8: Which Design Is Best?

Cross-Sectional Study Case-Control Study Cohort Study Trial Main WeaknessesMain StrengthsStudy Designs Fastest Time Consuming Least Confidence in Findings Most Scientifically Sound Best Measure of Exposure Possible Time-Order Confusion Can Study Rare Diseases Which study design provides the best measure of exposure? Time Consuming Epi Team Challenge Detectives in the Classroom - Investigation 2-8: Which Design Is Best?

Cross-Sectional Study Case-Control Study Cohort Study Trial Main WeaknessesMain StrengthsStudy Designs Fastest Time Consuming Least Confidence in Findings Most Scientifically Sound Best Measure of Exposure Possible Time-Order Confusion Can Study Rare Diseases Most Accurate Observational Study Which study design is the most accurate observational study? Time Consuming Epi Team Challenge Detectives in the Classroom - Investigation 2-8: Which Design Is Best?

Cross-Sectional Study Case-Control Study Cohort Study Trial Main WeaknessesMain StrengthsStudy Designs Fastest Time Consuming Least Confidence in Findings Most Scientifically Sound Best Measure of Exposure Possible Time-Order Confusion Can Study Rare Diseases Least Expensive Most Accurate Observational Study Which study design is the least expensive? Time Consuming Epi Team Challenge Detectives in the Classroom - Investigation 2-8: Which Design Is Best?

Cross-Sectional Study Case-Control Study Cohort Study Trial Main WeaknessesMain StrengthsStudy Designs Fastest Time Consuming Least Confidence in Findings Most Scientifically Sound Best Measure of Exposure Possible Time-Order Confusion Can Study Rare Diseases Least Expensive Unethical for Harmful Exposures Most Accurate Observational Study Which study design would be unethical for harmful exposures? Time Consuming Epi Team Challenge Detectives in the Classroom - Investigation 2-8: Which Design Is Best?

Cross-Sectional Study Case-Control Study Cohort Study Trial Main WeaknessesMain StrengthsStudy Designs Fastest Time Consuming Least Confidence in Findings Most Scientifically Sound Best Measure of Exposure Possible Time-Order Confusion Can Study Rare Diseases Least Expensive Good Measure of Exposure Which study design provides a good measure of exposure? Most Accurate Observational Study Time Consuming Unethical for Harmful exposures Epi Team Challenge Detectives in the Classroom - Investigation 2-8: Which Design Is Best?

Cross-Sectional Study Case-Control Study Cohort Study Trial Main WeaknessesMain StrengthsStudy Designs Fastest Time Consuming Least Confidence in Findings Most Scientifically Sound Best Measure of Exposure Possible Time-Order Confusion Can Study Rare Diseases Least Expensive Most Expensive Most Accurate Observational Study Which study designs are the most expensive? Good Measure of Exposure Time Consuming Unethical for Harmful exposures Epi Team Challenge Detectives in the Classroom - Investigation 2-8: Which Design Is Best?

Cross-Sectional Study Case-Control Study Cohort Study Trial Main WeaknessesMain StrengthsStudy Designs Fastest Time Consuming Least Confidence in Findings Most Scientifically Sound Best Measure of Exposure Possible Time-Order Confusion Can Study Rare Diseases Least Expensive Relatively Less Expensive and Relatively Fast Most Accurate Observational Study Which study design is relatively less expensive and relatively fast? Time Consuming Unethical for Harmful exposures Most Expensive Good Measure of Exposure Epi Team Challenge Detectives in the Classroom - Investigation 2-8: Which Design Is Best?

Cross-Sectional Study Case-Control Study Cohort Study Trial Main WeaknessesMain StrengthsStudy Designs Fastest Time Consuming Least Confidence in Findings Most Scientifically Sound Best Measure of Exposure Possible Time-Order Confusion Can Study Rare Diseases Least Expensive Relatively Less Expensive and Relatively Fast Possible Error in Recalling Past Exposures Most Accurate Observational Study Which study design creates the possibility of error in recalling past exposures? Time Consuming Unethical for Harmful exposures Most Expensive Good Measure of Exposure Epi Team Challenge Detectives in the Classroom - Investigation 2-8: Which Design Is Best?

Cross-Sectional Study Case-Control Study Cohort Study Trial Main WeaknessesMain StrengthsStudy Designs Fastest Time Consuming Most Scientifically Sound Best Measure of Exposure Can Study Rare Diseases Least Expensive Relatively Less Expensive and Relatively Fast Possible Error in Recalling Exposures Most Accurate Observational Study Which Design Is Best? Time Consuming Unethical for Harmful exposures Most Expensive Possible Time-Order Confusion Least Confidence in Findings Good Measure of Exposure It depends …. Detectives in the Classroom - Investigation 2-8: Which Design Is Best?

It depends on …. Regulations Time urgency How much is known about the association Money Whether the exposure is believed to be beneficial Detectives in the Classroom - Investigation 2-8: Which Design Is Best?

DZ E E d b c a Flow Diagram 2x2 Table Detectives in the Classroom – Investigation 2-9: Designs, Diagrams, and Tables & “fit” Designs, Diagrams, and Tables Healthy People - E E DZ

E E a 2x2 Table Where do these people “fit” in the 2x2 table? Flow Diagram Controlled Trial Healthy People E E DZ Random Assignment Detectives in the Classroom – Investigation 2-9: Designs, Diagrams, and Tables

DZ E E b Flow Diagram 2x2 Table Healthy People E E DZ Random Assignment Where do these people “fit” in the 2x2 table? Controlled Trial Detectives in the Classroom – Investigation 2-9: Designs, Diagrams, and Tables

DZ E E c Flow Diagram 2x2 Table Flow Diagram Healthy People E E DZ Random Assignment Where do these people “fit” in the 2x2 table? Controlled Trial Detectives in the Classroom – Investigation 2-9: Designs, Diagrams, and Tables

DZ E E d 2x2 Table Flow Diagram Healthy People E E DZ Random Assignment Where do these people “fit” in the 2x2 table? Controlled Trial Detectives in the Classroom – Investigation 2-9: Designs, Diagrams, and Tables

DZ E E c Flow Diagram 2x2 Table Where are these people in the flow diagram? Cohort Study Healthy People E E DZ Detectives in the Classroom – Investigation 2-9: Designs, Diagrams, and Tables

DZ E E a 2x2 Table Where are these people in the flow diagram? Flow Diagram Cohort Study Healthy People E E DZ Healthy People Detectives in the Classroom – Investigation 2-9: Designs, Diagrams, and Tables

DZ E E d Flow Diagram 2x2 Table Where are these people in the flow diagram? Cohort Study Healthy People E E DZ Healthy People Detectives in the Classroom – Investigation 2-9: Designs, Diagrams, and Tables

DZ E E b Flow Diagram 2x2 Table Where are these people in the flow diagram? Cohort Study Healthy People E E DZ Healthy People Detectives in the Classroom – Investigation 2-9: Designs, Diagrams, and Tables

DZ E E a Where do these people go in the 2x2 table? 2x2 Table Flow Diagram Case-Control Study DZ E E E E Detectives in the Classroom – Investigation 2-9: Designs, Diagrams, and Tables

DZ E E c Where do these people go in the 2x2 table? Flow Diagram 2x2 Table Case-Control Study DZ E E E E Detectives in the Classroom – Investigation 2-9: Designs, Diagrams, and Tables

Flow Diagram DZ E E b 2x2 Table Where do these people go in the 2x2 table? Case-Control Study DZ E E E E Detectives in the Classroom – Investigation 2-9: Designs, Diagrams, and Tables

Flow Diagram DZ E E d 2x2 Table Where do these people go in the 2x2 table? Case-Control Study DZ E E E E Detectives in the Classroom – Investigation 2-9: Designs, Diagrams, and Tables

DZ E E a Flow Diagram 2x2 Table Where do these people go in the 2x2 table? Cross-Sectional Study E E DZ Detectives in the Classroom – Investigation 2-9: Designs, Diagrams, and Tables

DZ E E c Flow Diagram 2x2 Table Where do these people go in the 2x2 table? Cross-Sectional Study E E DZ Detectives in the Classroom – Investigation 2-9: Designs, Diagrams, and Tables

DZ E E d Flow Diagram 2x2 Table Where do these people go in the 2x2 table? Cross-Sectional Study E E DZ Detectives in the Classroom – Investigation 2-9: Designs, Diagrams, and Tables

DZ E E b Flow Diagram 2x2 Table Where do these people go in the 2x2 table? Cross-Sectional Study E E DZ Detectives in the Classroom – Investigation 2-9: Designs, Diagrams, and Tables

132 National Research Council, Learning and Understanding Teach Epidemiology Enduring Epidemiological Understandings Knowledge that “… is connected and organized, and … ‘conditionalized’ to specify the context in which it is applicable.”

The goal of every epidemiological study is to harvest valid and precise information about the relationship between an exposure and a disease in a population. The various study designs merely represent different ways of harvesting this information. Essentials in Epidemiology in Public Health Ann Aschengrau and George R. Seage III Making Group Comparisons and Identifying Associations Teach Epidemiology

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135 Hypothesis Total RiskRelative Risk a b c d or % % ExposureOutcome ? Turned Up Together Healthy People - E E DZ Teach Epidemiology Where are we?

136 Teach Epidemiology Enduring Epidemiological Understandings

Teach Epidemiology Explaining Associations and Judging Causation

1.Cause 2.Confounding 3.Reverse Time Order 4. Chance 5.Bias Teach Epidemiology Explaining Associations and Judging Causation Coffee and Cancer of the Pancreas

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140 Guilt or Innocence?Causal or Not Causal? Does evidence from an aggregate of studies support a cause-effect relationship? Teach Epidemiology Explaining Associations and Judging Causation

141 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 Handout

142 “In what circumstances can we pass from this observed association to a verdict of causation?” Teach Epidemiology Explaining Associations and Judging Causation

143 “Here then are nine different viewpoints from all of which we should study association before we cry causation.” Teach Epidemiology Explaining Associations and Judging Causation

Does evidence from an aggregate of studies support a cause-effect relationship? 1. What is the strength of the association between the risk factor and the disease? 2. Can a biological gradient be demonstrated? 3. Is the finding consistent? Has it been replicated by others in other places? 4. Have studies established that the risk factor precedes the disease? 5. Is the risk factor associated with one disease or many different diseases? 6. Is the new finding coherent with earlier knowledge about the risk factor and the m disease? 7. Are the implications of the observed findings biologically sensible? 8. Is there experimental evidence, in humans or animals, in which the disease has m been produced by controlled administration of the risk factor? Teach Epidemiology Explaining Associations and Judging Causation

Handout Teach Epidemiology Explaining Associations and Judging Causation

Timeline Cohort Study Randomized Controlled Trial Timeline Case-Control Study Timeline Cross-Sectional Study Timeline E E O O O O E E E E Healthy People E Random Assignment E O O O O Healthy People E E O O O O Teach Epidemiology Explaining Associations and Judging Causation

Teach Epidemiology Explaining Associations and Judging Causation Handout

148 Stress causes ulcers. Helicobacter pylori causes ulcers. Teach Epidemiology Explaining Associations and Judging Causation

149 * * * * * * * * * Teach Epidemiology Explaining Associations and Judging Causation

150 Teach Epidemiology Explaining Associations and Judging Causation

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152 Epidemiology... the study of the distribution and determinants of health- related states or events in specified populations and the application of this study to the control of health problems. Leon Gordis, Epidemiology, 3 rd Edition, Elsevier Saunders, 2004.

153 Outcome If an association was causal, …. Hypothesized Exposure X X … and you avoided or eliminated the hypothesized cause, what would happen to the outcome? causal, …. ? Control of Health Problems

154 Outcome If the association was found due to confounding, …. Hypothesized Exposure Unobserved Exposure X … and you avoided or eliminated the hypothesized cause, what would happen to the outcome? ? found due to confounding, …. Control of Health Problems

155 Hypothesized Exposure Outcome If an association was found due to reversed time-order, …. 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

156 Outcome If an association was found due to chance, …. Hypothesized Exposure found due to chance, …. X … and you avoided or eliminated the hypothesized cause, what would happen to the outcome? ? Control of Health Problems

157 Outcome If an association was found due to bias, …. Hypothesized Exposure ? found due to bias, …. X … and you avoided or eliminated the hypothesized cause, what would happen to the outcome? Control of Health Problems

158 Outcome If an association was causal, …. Hypothesized Exposure X X … and you avoided or eliminated the hypothesized cause, what would happen to the outcome? causal, ….... the study of the distribution and determinants of health-related states or events in specified populations and the application of this study to the control of health problems. Control of Health Problems

159 1.Cause 2.Confounding 3.Reverse Time Order 4. Chance 5.Bias... the study of the distribution and determinants of health-related states or events in specified populations and the application of this study to the control of health problems. Control of Health Problems

160 Suicide Higher in Areas with Guns Family Meals Are Good for Mental Health Lack of High School Diploma Tied to US Death Rate Study Links Spanking to Aggression Study Concludes: Movies Influence Youth Smoking Study Links Iron Deficiency to Math Scores Kids Who Watch R-Rated Movies More Likely to Drink, Smoke Pollution Linked with Birth Defects in US Study 1.Cause 2.Confounding 3.Reverse Time Order 4. Chance 5.Bias Snacks Key to Kids’ TV- Linked Obesity: China Study Depressed Teens More Likely to Smoke Ties, Links, Relationships, and Associations

161 Teach Epidemiology Enduring Epidemiological Understandings

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181 Teach Epidemiology Teachers Team-Teaching Teachers (TTT) Teach Existing Epidemiological Lessons (EL) (4 Groups) Team leads other workshop participants in a portion of a selected existing epidemiological lesson. TTTT 12 EL

182 Teach Epidemiology Enduring Epidemiological Understandings

183 Time Check 1:00 PM

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185 Teach Epidemiology

Teachers Team-Teaching Teachers (TTT) Teach Existing Epidemiological Lessons (EL) (4 Groups) Team leads other workshop participants in a portion of a selected existing epidemiological lesson. TTTT 13 EL

187 Teach Epidemiology Enduring Epidemiological Understandings

188 Time Check 1:30 PM

189

190 Teach Epidemiology

Teachers Team-Teaching Teachers (TTT) Teach Existing Epidemiological Lessons (EL) (4 Groups) Team leads other workshop participants in a portion of a selected existing epidemiological lesson. TTTT 14 EL

192 Teach Epidemiology Enduring Epidemiological Understandings

193 Time Check 2:00 PM

194

195 Teach Epidemiology

View a News Item from an Epidemiological Perspective (NI) (4 Groups) Team leads other workshop participants in the analysis of a news item from an epidemiological perspective. Teach Epidemiology Teachers Team-Teaching Teachers (TTT) TTTT 15 NI

197 Teach Epidemiology Enduring Epidemiological Understandings

198 Time Check 2:45 PM

199

200 Teach Epidemiology

201 Time Check 3:00 PM

202

203 Teach Epidemiology

204 Teach Epidemiology Tours

205 Broadcast Studios Teach Epidemiology Tours

206 Emergency Operation Center Teach Epidemiology Tours

207 Time Check 4:00 PM