1. Centers for Disease Control and Prevention David J. Sencer CDC Museum Tom Harkin Global Communications Center June 4-8, 2012 Teach Epidemiology Professional Development Workshop Day 3

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3. 3 Teach Epidemiology

4. 4 Time Check 8:15 AM

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6. 6 Teach Epidemiology

7. Teach Epidemiology Workshop—Day 2 Diane Marie M. St. George, PhD University of MD School of Medicine

8. Back to EU 2 and 3 Why study patterns of disease? Why is a description of the person, place, and time elements of a disease distribution important?

9. Epidemiologic Studies Descriptive epidemiology Describes patterns of disease Suggests hypotheses about relationships between “exposures” and “health-related conditions” Analytic epidemiology Tests hypotheses Evaluates relationships Always in a search for causality Knowing causation helps us to prevent and treat disease and promote health

10. Enduring Understandings 4. A hypothesis can be tested by comparing the frequency of disease in selected groups of people with and without an exposure to determine if the exposure and the disease are associated. 5. When an exposure is hypothesized to have a beneficial effect, studies can be designed in which a group of people is intentionally exposed to the hypothesized cause and compared to a group that is not exposed. 6. When an exposure is hypothesized to have a detrimental effect, it is not ethical to intentionally expose a group of people. In these circumstances, studies can be designed that observe groups of free- living people with and without the exposure.

11. Testing hypotheses about BrCA Hypothesis: High dietary fat intake increases risk of BrCA. Evaluate the hypothesis using a: Case-control study

12. Case-control study of dietary fat and BrCA Exposure is diet Measured as dietary fat intake (FFQ) Outcome is BrCA Measured as yes or no Want to ensure that you have enough cases to do your study, so recruit participants with BrCA Find those without BrCA Ask them about diet What might you expect to see?

13. Diet and BrCA BrCA+BrCA- High fat Low fat 100 200

14. Diet and BrCA BrCA+BrCA- High fat601070 Low fat4090130 100 200 What is the prevalence of BrCA?

15. Case-control Study Odds = probability an event will occur/probability that an event will not occur Odds of exposure in cases = (among cases) probability of being exposed/probability one was not exposed What is odds of exposure in controls? = (among controls) probability of being exposed/ probability one was not exposed What is Odds Ratio?

16. Diet and BrCA BrCA+BrCA- High fat601070 Low fat4090130 100 200 What is the odds of exposure among the cases? What is the odds of exposure among the controls? What is the OR?

17. Diet and BrCA BrCA+BrCA- High fat601070 Low fat4090130 100 200 What is the odds of exposure among the cases? (60/100)/(40/100) = 60/40 = 1.5 What is the odds of exposure among the controls? (10/90) =.11 What is the OR? ~ 13.5

18. Case-control Study Key elements Compare individuals selected on the basis of disease status Classic epidemiologic study design Quantify association Odds Ratio Advantages Can be less expensive and time-consuming than follow-up studies Efficient for rare diseases Disadvantages May be resource-intensive because of need to screen so many Difficult to assess temporality

19. Testing hypotheses about BrCA Hypothesis: High dietary fat intake increases risk of BrCA. Evaluate the hypothesis using a: Cohort study

20. Cohort study of diet and BrCA Exposure is diet Measured with food diary Outcome is BrCA Measured as yes or no Want to ensure that you have enough exposed persons to do your study, so select for those with high fat intake Find those with low fat intake Follow them up over time to ascertain BrCA status What might you expect to see?

21. Diet and BrCA BrCA+BrCA- High fat100 Low fat100 200

22. Diet and BrCA BrCA+BrCA- High fat7030100 Low fat3565100 10595200 What is the incidence of BrCA among those with high fat intake? What is the incidence of BrCA among those with low fat intake? What is the risk ratio?

23. Diet and BrCA BrCA+BrCA- High fat7030100 Low fat3565100 10595200 What is the incidence of BrCA among those with high fat intake? = 70% What is the incidence of BrCA among those with low fat intake? = 35% What is the risk ratio? = 2.0

24. Cohort Study Key element Select based on exposure status and follow-up over time Quantify association Relative risk (risk ratio) Advantages Minimizes confusion about temporality Ideal for rare exposures Disadvantages May have to screen many to get exposed group Large, time-consuming, expensive especially if disease is relatively rare and/or slow to develop Inefficient for rare diseases

25. Testing hypotheses about BrCA Hypothesis: High dietary fat intake increases risk of BrCA. Evaluate the hypothesis using a: Randomized controlled trial

26. RCT study of diet and BrCA Exposure is diet Measured as dietary fat exposure Outcome is BrCA Measured as yes or no Want to ensure maximal control over study parameters, so you decide who gets exposed and who does not Follow up over time to ascertain BrCA status What might you expect to see?

27. Diet and BrCA BrCA+BrCA- High fat Low fat 200

28. Diet and BrCA BrCA+BrCA- High fat7030100 Low fat3565100 10595200 What is the incidence of BrCA among the high fat group? What is the incidence of BrCA among the low fat group? What is the risk ratio?

29. Diet and BrCA BrCA+BrCA- High fat7030100 Low fat3565100 10595200 What is the incidence of BrCA among the high fat group? = 70% What is the incidence of BrCA among the low fat group? = 35% What is the risk ratio? = 2.0

30. Randomized Controlled Trial Key elements Assign treatments to individuals and follow up to ascertain disease status. The researcher controls primary exposure under study. Exposures can be treatments (drug, surgery) or preventive measures (water fluoridation, exercise regimens). Ethical considerations may preclude use of this design. Quantify association Relative risk (risk ratio) Advantages Random assignment serves to “equate” groups Closest to “true experiment” Disadvantages Expensive and time-consuming Subjects are often highly selected group because the requirements of participants can often be extensive

31. 31 Time Check 9:45 AM

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33. 33 Teach Epidemiology

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35. 35 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.”

36. 36 Association Found Between Coffee and Pancreatic Cancer Associated Teach Epidemiology

37. 37 What do we mean when we say that there is an association between two things? Associated TiedRelated Linked Things that are associated are linked in some way that makes them turn up together. Associated Teach Epidemiology

38. 38 Things that are associated are linked in some way that makes them turn up together. Associated Teach Epidemiology

39. 39 Suicide Higher in Areas with Guns Smoking Linked to Youth Eating Disorders Snacks Key to Kids’ TV- Linked Obesity: China Study Family Meals Are Good for Mental Health Lack of High School Diploma Tied to US Death Rate Study Links Spanking to Aggression Breakfast Each Day May Keep Colds Away 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 Depressed Teens More Likely to Smoke Associated Teach Epidemiology

40. 40 Epidemiologic studies that are concerned with characterizing the amount and distribution of health and disease within a population. Descriptive Epidemiology Teach Epidemiology

41. 41 Epidemiologic studies that are concerned with determinants of disease and the reasons for relatively high or low frequencies of disease in specific population subgroups. Analytical Epidemiology Teach Epidemiology

42. 42 Hypothesis Formulating Descriptive Epidemiology Testing Analytical Epidemiology An unproven idea, based on observation or reasoning, that can be supported or refuted through investigation An educated guess Hypothesis Teach Epidemiology

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44. 44 Making Group Comparisons and Identifying Associations Teach Epidemiology

45. 45 Hypothesis: Buprenorphine will stop heroin addicts from using heroin. Making Group Comparisons and Identifying Associations Teach Epidemiology

46. 46 Population Trial 1 Making Group Comparisons and Identifying Associations

47. 47 Population 500 Heroin Addicts Sample 100 Heroin Addicts 10 Weeks Trial 1 Making Group Comparisons and Identifying Associations

48. 48 Population 500 Heroin Addicts Sample 100 Heroin Addicts 10 Weeks 21 Heroin Addicts Tested Negative for Heroin Trial 1 Making Group Comparisons and Identifying Associations

49. 49 Bupe Tested Positive for Heroin Total 1002179 Tested Negative for Heroin Trial 1 Making Group Comparisons and Identifying Associations Teach Epidemiology

50. 50 When you can measure what you are speaking about, and express it in numbers, you know something about it. Lord Kelvin But when you cannot measure it, when you cannot express it in numbers, your knowledge is of a meager and unsatisfactory kind. Making Group Comparisons and Identifying Associations Teach Epidemiology

51. 51 A measure of how often an outcome occurs in a defined population in a defined period of time. It consists of a numerator and a denominator. Risk The numerator is the number of people in the population or sample who experienced the outcome and the denominator is the total number of people in the population or sample. Population / Sample Outcome Denominator Numerator Making Group Comparisons and Identifying Associations Teach Epidemiology

52. 52 … the risk of a negative heroin test was 21 / 100 in a 10-week period 21 tested negative for heroin 100 study subjects Numerator Denominator Risk Making Group Comparisons and Identifying Associations Teach Epidemiology

53. 53 A measure of how often an outcome occurs in a defined group of people in a defined period of time. The likelihood of an outcome occurring. Risk / Rate Making Group Comparisons and Identifying Associations Teach Epidemiology

54. 54 Trial 1 Bupe Tested Positive for Heroin 1002179 Tested Negative for Heroin 21 100 or 21 % Calculating Risk Risk of Negative Heroin Test Total Making Group Comparisons and Identifying Associations Teach Epidemiology

55. 55 Process of predicting from what is observed in a sample to what is true for the entire population. Inference Making Group Comparisons and Identifying Associations Teach Epidemiology

56. 56 Trial 1 What does this tell you about the hypothesis? Buprenorphine will stop heroin addicts from using heroin. Inference Probe Bupe Tested Positive for Heroin 1002179 Tested Negative for Heroin 21 100 or 21 % Risk of Negative Heroin Test Total Making Group Comparisons and Identifying Associations Teach Epidemiology

57. 57 People who participate in a trial, but do not get the treatment. People whose results are compared to the group that was treated. Control Group Making Group Comparisons and Identifying Associations Teach Epidemiology

58. 58 21 100 or 21 % 1007921 Tested Positive for Heroin Tested Negative for Heroin Bupe Control Group Extend and label the table to include a control group. Risk of Negative Heroin Test Total Making Group Comparisons and Identifying Associations Teach Epidemiology

59. 59 100 ? or ? % No Bupe Control Group Making Group Comparisons 21 100 or 21 % 1007921 Tested Positive for Heroin Tested Negative for Heroin Bupe Risk of Negative Heroin Test Total Making Group Comparisons and Identifying Associations Teach Epidemiology

60. 60 100 ? or ? % No Bupe Making Group Comparisons 21 100 or 21 % 1007921 Tested Positive for Heroin Tested Negative for Heroin Bupe ExposureExposure Outcome / Disease ab cd Risk of Negative Heroin Test Total Making Group Comparisons and Identifying Associations Teach Epidemiology

61. 61 21 100 or 21 % Total 1007921 Bupe 100 ? or ? % No Bupe Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test Making Group Comparisons and Identifying Associations Teach Epidemiology

62. 62 A cross-classification of data where categories of one variable are presented in rows and categories of another variable are presented in columns The simplest contingency table is the 2x2 table. Contingency Table Making Group Comparisons and Identifying Associations Teach Epidemiology

63. 63 Population 500 Heroin Addicts Sample 100 Heroin Addicts 10 Weeks 21 Heroin Addicts Tested Negative for Heroin Trial 1 Making Group Comparisons and Identifying Associations

64. 64 Trial 2 Total ? 100 ? % a b c d Bupe Tested Negative for Heroin Tested Positive for Heroin No Bupe100 ? ? % Risk of Negative Heroin Test Making Group Comparisons and Identifying Associations Teach Epidemiology

65. 65 E Assigned E O O O O Making Group Comparisons and Identifying Associations Volunteer Heroin Addicts Teach Epidemiology

66. 66 21 100 21% 2179100 or a b c d Bupe Trial 2 No Bupe Probe Total Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test Making Group Comparisons and Identifying Associations Teach Epidemiology

67. 67 21 100 21% 2179100 or a b c d Bupe Trial 2 No Bupe Total Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test 21 100 21% 2179100 or Making Group Comparisons and Identifying Associations Teach Epidemiology

68. 68 21 100 21% 2179100 or a b c d Bupe Trial 2 No Bupe Total Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test 21 100 21% 2179100 or Inference: Process of predicting from what is observed in a sample to what is occurring in the entire population Making Group Comparisons and Identifying Associations Teach Epidemiology

69. 69 When you can measure what you are speaking about, and express it in numbers, you know something about it. Lord Kelvin But when you cannot measure it, when you cannot express it in numbers, your knowledge is of a meager and unsatisfactory kind. Making Group Comparisons and Identifying Associations Teach Epidemiology

70. 70 The value obtained by dividing one quantity by another Ratio Making Group Comparisons and Identifying Associations Teach Epidemiology

71. 71 21 100 21% 2179100 or a b c d Bupe Trial 2 No Bupe Total Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test 21 100 21% 2179100 or Ratio: The value obtained by dividing one quantity by another Risk Ratio: The ratio of two risks 1 Risk Ratio Making Group Comparisons and Identifying Associations Teach Epidemiology

72. 72 21 100 21% 2179100 or a b c d Bupe Trial 2 No Bupe Total Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test 21 100 21% 2179100 or Ratio: The value obtained by dividing one quantity by another Risk Ratio: The ratio of two risks 1 Risk Ratio Create a formula a a + b c c + d Making Group Comparisons and Identifying Associations Teach Epidemiology

73. 73 21 100 21% 2179100 or a b c d Bupe Trial 2 No Bupe Total Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test 21 100 21% 2179100 or 1 Risk Ratio Relative Risk: The ratio of the risk of an outcome among the exposed to the risk of the outcome among the unexposed. Relative Risk Making Group Comparisons and Identifying Associations Teach Epidemiology

74. 74 21 100 21% 2179100 or a b c d Bupe Trial 2 No Bupe Total Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test 21 100 21% 2179100 or 1 Risk Ratio Relative Risk Inference: Process of predicting from what is observed in a sample to what is occurring in the entire population The inference here is that there is no effect of Buprenorphine Making Group Comparisons and Identifying Associations Teach Epidemiology

75. 75 Trial 3 ? 100 ? % 100 or a b c d Bupe No Bupe Total Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test ? 100 ? % 100 or Making Group Comparisons and Identifying Associations Teach Epidemiology

76. 76 21 100 21% 2179100 or a b c d Bupe No Bupe Total Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test Trial 3 Making Group Comparisons and Identifying Associations Teach Epidemiology

77. 77 21 100 21% 2179100 or a b c d Bupe No Bupe Total Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test 62 100 62% 6238100 or Trial 3 Making Group Comparisons and Identifying Associations Teach Epidemiology

78. 78 21 100 21% 2179100 or a b c d Bupe No Bupe Total Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test 62 100 62% 6238100 or Inference: Process of predicting from what is observed in a sample to what is occurring in the entire population Trial 3 Making Group Comparisons and Identifying Associations Teach Epidemiology

79. 79 21 100 21% 2179100 or a b c d Bupe No Bupe Total Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test 62 100 62% 6238100 or Relative Risk Relative Risk: The ratio of the risk of an outcome among the exposed to the risk of the outcome among the unexposed. 0.34 Trial 3 Making Group Comparisons and Identifying Associations Teach Epidemiology

80. 80 21 100 21% 2179100 or a b c d Bupe No Bupe Total Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test 62 100 62% 6238100 or Relative Risk 0.34 The heroin addicts who received Bupe were ___ times as likely to test negative for heroin as those who did not receive Bupe. 0.34 Trial 3 Making Group Comparisons and Identifying Associations Teach Epidemiology

81. 81 21 100 21% 2179100 or a b c d Bupe No Bupe Total Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test 62 100 62% 6238100 or Relative Risk 0.34 Inference: Process of predicting from what is observed in a sample to what is occurring in the entire population. Trial 3 Making Group Comparisons and Identifying Associations Teach Epidemiology

82. 82 Trial 4 ? 100 ? % 100 or a b c d Bupe No Bupe Total Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test ? 100 ? % 100 or Making Group Comparisons and Identifying Associations Teach Epidemiology

83. 83 21 100 21% 2179100 or a b c d Bupe No Bupe Total Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test Trial 4 Making Group Comparisons and Identifying Associations Teach Epidemiology

84. 84 21 100 21% 2179100 or a b c d Bupe No Bupe Total Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test 6 100 6% 694100 or Trial 4 Making Group Comparisons and Identifying Associations Teach Epidemiology

85. 85 21 100 21% 2179100 or a b c d Bupe No Bupe Total Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test 6 100 6% 694100 or Relative Risk Relative Risk: The ratio of the risk of an outcome among the exposed to the risk of the outcome among the unexposed. 3.5 Trial 4 Making Group Comparisons and Identifying Associations Teach Epidemiology

86. 86 21 100 21% 2179100 or a b c d Bupe No Bupe Total Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test 6 100 6% 694100 or Relative Risk 3.5 The heroin addicts who received Bupe were ___ times as likely to test negative for heroin as those who did not receive Bupe. 3.5 Trial 4 Making Group Comparisons and Identifying Associations Teach Epidemiology

87. 87 21 100 21% 2179100 or a b c d Bupe No Bupe Total Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test 6 100 6% 694100 or Relative Risk 3.5 Inference: Process of predicting from what is observed in a sample to what is occurring in the entire population. Trial 4 Making Group Comparisons and Identifying Associations Teach Epidemiology

88. 88 21 100 21% 2179100 or Bupe Trial 1 Total Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test What do the results tell us about the hypothesis that Buprenorphine will stop heroin addicts from using heroin? Nothing Making Group Comparisons and Identifying Associations Teach Epidemiology

89. 89 Trial 1 Trial 2 Trial 3 Trial 4 Making Group Comparisons and Identifying Associations Teach Epidemiology

90. 90 Nothing Bupe Total Trial 1 Trial 2 Trial 3 Trial 4 Risk of Negative Heroin Test Tested Negative for Heroin Tested Positive for Heroin 1002179 90 or 21% 21 100 Making Group Comparisons and Identifying Associations Teach Epidemiology

91. 91 Risk of Negative Heroin Test Nothing Bupe Total Trial 1 Trial 2 Trial 3 Trial 4 Bupe No Bupe Bupe No Bupe Bupe Total Relative Risk No Bupe Total Relative Risk Total Tested Negative for Heroin Tested Positive for Heroin Relative Risk Risk of Negative Heroin Test Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test Tested Negative for Heroin Tested Positive for Heroin 1002179 90 or 21% 21 100 Making Group Comparisons and Identifying Associations Teach Epidemiology

92. 92 Risk of Negative Heroin Test Nothing Bupe Total Trial 1 Trial 2 Trial 3 Trial 4 Bupe No Bupe Bupe No Bupe Bupe Total Relative Risk No Bupe Total Relative Risk Total Tested Negative for Heroin Tested Positive for Heroin Relative Risk Risk of Negative Heroin Test Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test Tested Negative for Heroin Tested Positive for Heroin 1002179 90 or 21% 21 100 2179 90 or 21% 21 100 2179 90 or 21% 21 100 2179 90 or 21% 21 100 Making Group Comparisons and Identifying Associations Teach Epidemiology

93. 93 Risk of Negative Heroin Test Nothing Bupe Total Trial 1 Trial 2 Trial 3 Trial 4 Bupe No Bupe Bupe No Bupe Bupe Total Relative Risk No Bupe Total Relative Risk Total Tested Negative for Heroin Tested Positive for Heroin Relative Risk Risk of Negative Heroin Test Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test Tested Negative for Heroin Tested Positive for Heroin 1002179 90 or 21% 21 100 2179 90 or 21% 21 100 2179 90 or 21% 21 100 2179 90 or 21% 21 100 2179 90 or 21% 21 100 1 Bupe is not associated with having a negative test for heroin. Making Group Comparisons and Identifying Associations Teach Epidemiology

94. 94 Risk of Negative Heroin Test Nothing Bupe Total Trial 1 Trial 2 Trial 3 Trial 4 Bupe No Bupe Bupe No Bupe Bupe Total Relative Risk No Bupe Total Relative Risk Total Tested Negative for Heroin Tested Positive for Heroin Relative Risk Risk of Negative Heroin Test Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test Tested Negative for Heroin Tested Positive for Heroin 1002179 90 or 21% 21 100 2179 90 or 21% 21 100 2179 90 or 21% 21 100 2179 90 or 21% 21 100 2179 90 or 21% 21 100 Bupe is not associated with having a negative test for heroin. 1 1006238 90 or 62% 62 100 Bupe is associated with having a positive test for heroin!.34 Making Group Comparisons and Identifying Associations Teach Epidemiology

95. 95 Risk of Negative Heroin Test Nothing Bupe Total Trial 1 Trial 2 Trial 3 Trial 4 Bupe No Bupe Bupe No Bupe Bupe Total Relative Risk No Bupe Total Relative Risk Total Tested Negative for Heroin Tested Positive for Heroin Relative Risk Risk of Negative Heroin Test Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test Tested Negative for Heroin Tested Positive for Heroin 1002179 90 or 21% 21 100 2179 90 or 21% 21 100 2179 90 or 21% 21 100 2179 90 or 21% 21 100 2179 90 or 21% 21 100 Bupe is not associated with having a negative test for heroin. 1 1006238 90 or 62% 62 100 Bupe is associated with having a positive test for heroin!.34 100694 90 or 6% 6 100 Bupe is associated with having a negative test for heroin. 3.5 Making Group Comparisons and Identifying Associations Teach Epidemiology

96. 96 Risk of Negative Heroin Test Nothing Bupe Total Trial 1 Trial 2 Trial 3 Trial 4 Bupe No Bupe Bupe No Bupe Bupe Total Relative Risk No Bupe Total Relative Risk Total Tested Negative for Heroin Tested Positive for Heroin Relative Risk Risk of Negative Heroin Test Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test Tested Negative for Heroin Tested Positive for Heroin 1002179 90 or 21% 21 100 2179 90 or 21% 21 100 2179 90 or 21% 21 100 2179 90 or 21% 21 100 2179 90 or 21% 21 100 Bupe is not associated with having a negative test for heroin. 1 1006238 90 or 62% 62 100 Bupe is associated with having a positive test for heroin!.34 100694 90 or 6% 6 100 Bupe is associated with having a negative test for heroin. 3.5 Nothing Compared to what? Making Group Comparisons and Identifying Associations Teach Epidemiology

97. 97 Buprenorphine Buprenorphine & Naloxone Placebo Making Group Comparisons and Identifying Associations Teach Epidemiology Handout

98. 98 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.”

99. 99 Time Check 10:30 AM

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101. 101 Teach Epidemiology

102. 102 Time Check 10:45 AM

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104. 104 Teach Epidemiology

105. 105 Suicide Higher in Areas with Guns Smoking Linked to Youth Eating Disorders Snacks Key to Kids’ TV- Linked Obesity: China Study Family Meals Are Good for Mental Health Lack of High School Diploma Tied to US Death Rate Study Links Spanking to Aggression Breakfast Each Day May Keep Colds Away 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 Depressed Teens More Likely to Smoke In the News

106. 106 Total ab dc 2 x 2 Table Suicide Higher in Areas with Guns

107. 107 Total ab dc People who are exposed ab 2 x 2 Table Suicide Higher in Areas with Guns Areas with Guns No Suicide Suicide Areas without Guns

108. 108 ab dc 2 x 2 Table Total Kids Who Watch R-Rated Movies More Likely to Drink, Smoke

109. 109 ab dc 2 x 2 Table R-Rated Movies Total Drink & Smoke Kids Who Watch R-Rated Movies More Likely to Drink, Smoke No Drink & Smoke No R-Rated Movies

110. 110 ab dc People who are exposed and have the outcome a 2 x 2 Table R-Rated Movies Total Drink & Smoke Kids Who Watch R-Rated Movies More Likely to Drink, Smoke No Drink & Smoke No R-Rated Movies

111. 111 ab dc 2 x 2 Table Family Meals Are Good for Mental Health Total

112. 112 ab dc 2 x 2 Table Family Meals Are Good for Mental Health Family Meals Total Mental Health No Mental Health No Family Meals

113. 113 ab dc People who are not exposed and do not have the outcome d 2 x 2 Table Family Meals Are Good for Mental Health Family Meals Total Mental Health No Mental Health No Family Meals

114. 114 ab dc 2 x 2 Table Study Links Iron Deficiency to Math Scores Total

115. 115 ab dc 2 x 2 Table Study Links Iron Deficiency to Math Scores Iron Deficiency Poor Math Scores No Iron Deficiency Good Math Scores Total

116. 116 ab dc People who do not have the outcome and are not exposed d 2 x 2 Table Study Links Iron Deficiency to Math Scores Iron Deficiency Poor Math Scores No Iron Deficiency Good Math Scores Total

117. 117 ab dc 2 x 2 Table Pollution Linked with Birth Defects in US Study Total

118. 118 ab dc 2 x 2 Table Pollution Linked with Birth Defects in US Study Pollution Birth Defects No Pollution No Birth Defects Total

119. 119 ab dc People who are not exposed dc 2 x 2 Table Pollution Linked with Birth Defects in US Study Pollution Birth Defects No Pollution No Birth Defects Total

120. 120 ab dc 2 x 2 Table Depressed Teens More Likely to Smoke Total

121. 121 ab dc People who do not have the outcome d b 2 x 2 Table Depressed Teens More Likely to Smoke Depression Smoke No Depression No Smoke Total

122. 122 ab dc 2 x 2 Table Smoking Linked to Youth Eating Disorders Total

123. 123 ab dc 2 x 2 Table Smoking Linked to Youth Eating Disorders Smoke Eating Disorders No Smoke No Eating Disorders Total

124. 124 ab dc People who are exposed and do not have the outcome b 2 x 2 Table Smoking Linked to Youth Eating Disorders Smoke Eating Disorders No Smoke No Eating Disorders Total

125. 125 ab dc 2 x 2 Table Total Study Links Spanking to Aggression

126. 126 ab dc People who have the outcome a c 2 x 2 Table Study Links Spanking to Aggression Spanking Aggression No Spanking Total No Aggression

127. 127 ab dc 2 x 2 Table Total Snacks Key to Kids’ TV-Linked Obesity – China Study

128. 128 ab dc 2 x 2 Table Snacks Key to Kids’ TV-Linked Obesity – China Study Snacks Obesity No Snacks No Obesity Total People who are not exposed and have the outcome c

129. 129

130. 130 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.”

131. 131 Laboratory Teach Epidemiology Making Group Comparisons and Identifying Associations

132. 132 Laboratory Teach Epidemiology Making Group Comparisons and Identifying Associations

133. 133 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

134. 134 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

135. 135 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

136. 136 Buprenorphine Buprenorphine will stop heroin addicts from using heroin. Teach Epidemiology Making Group Comparisons and Identifying Associations

137. 137 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

138. Laboratory Teach Epidemiology Making Group Comparisons and Identifying Associations

139. 139 Making Group Comparisons and Identifying Associations Teach Epidemiology

140. 140 Making Group Comparisons and Identifying Associations Teach Epidemiology

141. 141 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

142. 142 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

143. 143 Science Transforming Anecdote to Science Making Group Comparisons and Identifying Associations Teach Epidemiology Anecdote

144. 144 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

145. 145 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

146. 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

147. 147 Time Check 11:30 AM

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149. 149 Teach Epidemiology

150. 150 Time Check 12:30 PM

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152. 152 Teach Epidemiology

153. 153

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

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

156. 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

157. 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

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

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

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

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

162. 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

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

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

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

166. 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

167. 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

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

169. 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

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

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

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

173. 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

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

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

176. 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

177. 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

178. 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

179. 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

180. 180

181. 181

182. 182 Healthy People - E E O O O O Cohort Study

183. 183 Handouts

184. 184

185. 185 http://www.nationalchildrensstudy.gov/Pages/default.aspx

186. 186

187. 187

188. 188 Science Transforming Anecdote to Science Making Group Comparisons and Identifying Associations Anecdote

189. 189

190. 190 Healthy People Flow Diagram Randomized Controlled Trial - Healthy People E Random Assignment E O O O O

191. 191 Healthy People Flow Diagram - Healthy People E E O O O O Cohort Study Observational Study

192. 192 http://abcnews.go.com/US/mystery-illness-hits-22-students-houston-texas-high/story?id=14888448#.Traba3Ltl8N Handouts

193. 193 Case-Control Study O - O E E E E

194. 194 http://www.youtube.com/watch?v=Xjgu2gYs2UQ

195. 195 http://abcnews.go.com/US/mystery-illness-hits-22-students-houston-texas-high/story?id=14888448#.Traba3Ltl8N Check Notes

196. 196

197. 197

198. Teacher Note: Enduring Epidemiological Understandings for the Epidemiology and the Energy Balance Equation Curriculum 1.Health and disease are not distributed haphazardly in a population. There are patterns to their occurrence that can be identified through surveillance. Analysis of the patterns of health and disease distribution can provide clues for formulating hypotheses about their possible causes. 2.Causal hypotheses can be tested by conducting investigations of the exposures and outcomes of selected groups of people as they go about their lives. Information from these observational studies can be used to determine if an exposure and an outcome are associated. Because observational studies are complicated by factors not controlled by the observer, other explanations also must be considered. 198

199. Teacher Note: Authentic Assessment for Module 2 of the Epidemiology and the Energy Balance Equation Curriculum 199 Students will conduct, analyze, and interpret observational, cross- sectional studies among students in their class and then among students outside their class. Working in teams, students will have the opportunity to demonstrate their abilities to select a reasonable hypothesis of interest to them, design study questions about exposure and outcome, obtain informed consent, collect and manage data, calculate and compare prevalence rates, make accurate statements about whether their data support that hypothesis, and consider alternate explanations for what they observed. Reporting of results will be required, such as a written report, an item for the school newspaper, or an oral presentation or poster for students, teachers, and/or parents. Specific performance criteria will be used to help ensure that the experiences allow a genuine, realistic, and fair assessment of students’ comprehension of the Module 2 Enduring Epidemiological Understanding.

200. 200 Teacher Note: Photos of Worksheets for Lesson 2-3 2-3b 2-3a 2-3c 2-3d

201. Start of Lesson 2-3 (estimate 2 class periods) 201

202. 202 Big Ideas in Lesson 2-2 The cross-sectional design is an observational study of a natural experiment This design is relatively quick and simple, asking individuals about exposure and outcome at one point in time After the prevalence is calculated for the group with the exposure, the next question is “compared to what?” The “compared to what” consists of prevalence for the unexposed “controls” Dividing one prevalence by the other produces the prevalence ratio; it tells us if/how the exposure and outcome are associated Because exposure and outcome are measured at the same point in time, it is usually not possible to determine the time order of the exposure and the outcome (which came first) and as such, the association may not be interpretable Review

203. Overview of Lesson 2-3 203

204. 2-3a Checklist - Study Planning Components and Expectations 2-3 Study Hypothesis - Statement of a hypothesized association between an exposure and an outcome 2-3 Study Variables - Developing questions about exposure and outcome, and additional questions about participants 2-3 Questionnaire - Preparing a one-page sheet that study participants will fill out (typed and copies made) 2-4 Draft Informed Consent Script - Preparing a script to be read to possible study participants (typed and copies made) 2-5 Plans for Study Conduct – Having assignments for study day 204 Notebook Study

205. Part of 2-3a Expectations for Successful Completion of Activities in Lesson 2-3 205 Notebook Study #Study Plan Component Met Some- what Met Not Met 2-3 Study Hypothesis - Statement of a hypothesized association between an exposure and an outcome  1) Stated clearly; 2) makes sense at face value; and 3) is feasible to study in a school setting □□ □ 2-3 Study Variables - Developing questions about exposure and outcome  1) Clear questions that will mean the same thing to anyone who reads it;  2) a good description of what you are trying to measure; 3) a good understanding of challenges in measurement; and 4) an awareness of other information about study participants that will help in understanding study results 2-3 Questionnaire - Preparing a one-page sheet that study participants will fill out (typed and copies made)  Format of the survey that is user-friendly and clear in presenting questions and answer options and instructions

206. 206 An educated guess An unproven idea, based on observation or reasoning, that can be supported or refuted through investigation A tentative explanation Hypotheses

207. Hypotheses? 207

208. Hypotheses? 208

209. 209 Tips Your hypothesis statement should state the hypothesized relationship between an exposure variable and an outcome variable, including the direction expected. Make sure that the hypothesis you choose is of genuine interest to you, because you will be spending your time and energy exploring it. Your stated hypothesis MUST NOT require the collection of any information that might be considered embarrassing, sensitive, or illegal. The hypothesis needs to be related to nutrition and/or physical activity.

210. Eat school cafeteria food Regularly watch TV Have a sedentary lifestyle Have a high-fat diet Take multivitamins Eat breakfast Have perception of overweight Have good academic performance Regularly play computer games Eat junk food every day Examples of Variables to Use in a Hypothesis Have a low-fat diet Regularly exercise Participate in a team sport Eat fruits and vegetables Drink high calorie drinks Drink diet soda Walk to school Get a good night’s rest Other ? ? ? 210

211. Some variables can be an exposure or an outcome When is “eating more fruits and vegetables” an exposure? When is “eating more fruits and vegetables” an outcome? Examples of Hypotheses: - People who eat more fruits and vegetables take more multivitamins - People who rarely watch TV are more likely to eat fruits and vegetables When is “having more physical activity” an exposure? When is “having more physical activity” an outcome? Examples of Hypotheses: - Physical activity is associated with a longer night’s sleep - People with high academic performance are more likely to also have more physical activity 211

212. 212 2-3b Notebook Study Study Hypothesis Why is your study team interested in testing this hypothesis? Discuss the reason(s) your team thinks it will be possible to test this hypothesis in your class and school. “X is associated with Y” “People with X are more likely to have Y” “People with X have higher, or more Y” How do I state a hypothesis?

213. Eat school cafeteria food Regularly watch TV Have a sedentary lifestyle Have a high-fat diet Take multivitamins Eat breakfast Have perception of overweight Have good academic performance Regularly play computer games Eat junk food every day Have a low-fat diet Regularly exercise Participate in a team sport Eat fruits and vegetables Drink high calorie drinks Drink diet soda Walk to school Get a good night’s rest Other ? ? ? 213 2-3b Notebook Study Study Hypothesis

214. A few examples of hypotheses to test Students who drink caffeinated drinks do more homework after school. Students who drink caffeinated drinks get less sleep. Healthy eating (at least 2 servings of fruit and vegetables a day) results in better grades (“doing well in school. Students that regularly eat vegetables have fewer periods of illness (24 hours or more of flu/cold symptoms). Students who eat breakfast have fewer colds and therefore have fewer absences from school. A healthy breakfast is associated with playing in an organized sport. Students who eat dinner with their family more often get better grades. Students who skip lunch will eat more snacks. People who eat more fruits and vegetables take more multivitamins. Drinking more water is associated with eating more fruits and vegetables. Students who drink more sweetened drinks are more likely to eat unhealthy snacks. Drinking at least 2 cans or a 20 ounce bottle of non-diet soda per day leads to a crash (feeling tired). 214 OPTIONAL SLIDE TO SHOW STUDENTS

215. Students who have one or more cats or dogs are more physically active. Students who have one or more cats or dogs have more school absences due to colds. Receiving a daily, weekly, or monthly allowance is related to eating junk food/unhealthy food more than twice a day. Students who chew gum eat fewer snacks. Students who listen to an IPOD are more likely to participate in physical activity. Students who text more are less physically active. Watching more TV is associated with having lower stress levels. Students who watch TV eat more snacks. Students who regularly play video games eat more snacks. Students who play regular video games (not active) eat more junk food. Playing active video games is related to getting better grades. Student athletes, on average, get more sleep than students who do not participate in a sport. 215 OPTIONAL SLIDE TO SHOW STUDENTS A few examples of hypotheses to test

216. Students who participate in sports are more satisfied with their lives Physical activity is associated with eating less junk food. People who participate in a team sport are more likely to eat fruits and vegetables. Physically active students place greater weight on the importance of a healthy lifestyle. Regular exercise is related to higher academic performance. Students who get 8 or more hours of sleep on average have higher academic performance. Students who sleep <8 hours a night eat more often than those who get at least 8 hours of sleep. Students who have less parental supervision are more likely to watch TV. Students who have less parental supervision eat more junk food for after school snacks. High academic performance is associated with more physical activity. High academic performance is associated with a healthy diet. 216 OPTIONAL SLIDE TO SHOW STUDENTS A few examples of hypotheses to test

217. 217 Possible break point between class periods

218. More Information about CHIS Study Theresa A. Hastert, Susan H. Babey. School lunch source and adolescent dietary behavior. Prevention of Chronic Diseases 2009, Vol 6 (4). http://www.cdc.gov/pcd/issues/2009/oct/08_0182.htm 218

219. Review: “Criteria for a Good Question” It should be clear and unambiguous, written so that its intended audience understands it. It should mean the same thing to everyone who reads it. The answer options must categorize and cover the entire range of possible behavior (from complete absence of the behavior to a maximum amount of the behavior). The time period to consider when answering a particular question must be appropriate (long or short enough) to capture the frequency of behavior desired (depending on the information desired and the type of behavior). 219

220. 220 Exposure Question During the school year, about how many times a week do you usually bring your own lunch to school from home? 0 1 2 3 4 5

221. 221 Outcome Questions TOPICQUESTION Fruit? Vegetables? Fast food? Soda? Fried potatoes? High-sugar foods?

222. 222 TOPICQUESTION FruitYesterday, how many servings of fruit, such as an apple or a banana, did you eat? Vegetables? Fast food? Soda? Fried potatoes? High-sugar foods? Outcome Questions

223. 223 TOPICQUESTION FruitYesterday, how many servings of fruit, such as an apple or a banana, did you eat? VegetablesYesterday, how many servings of vegetables, like corn, green beans, green salad or other vegetables did you eat? Fast food? Soda? Fried potatoes? High-sugar foods? Outcome Questions

224. 224 TOPICQUESTION FruitYesterday, how many servings of fruit, such as an apple or a banana, did you eat? VegetablesYesterday, how many servings of vegetables, like corn, green beans, green salad or other vegetables did you eat? Fast foodYesterday, how many times did you eat fast food? Soda? Fried potatoes? High-sugar foods? Outcome Questions

225. 225 TOPICQUESTION FruitYesterday, how many servings of fruit, such as an apple or a banana, did you eat? VegetablesYesterday, how many servings of vegetables, like corn, green beans, green salad or other vegetables did you eat? Fast foodYesterday, how many times did you eat fast food? SodaYesterday, how many glasses or cans of soda, such as Coke, or other sweetened drinks, such as fruit punch or Sunny Delight did you drink? Do not count diet drinks. Fried potatoes? High-sugar foods? Outcome Questions

226. 226 TOPICQUESTION FruitYesterday, how many servings of fruit, such as an apple or a banana, did you eat? VegetablesYesterday, how many servings of vegetables, like corn, green beans, green salad or other vegetables did you eat? Fast foodYesterday, how many times did you eat fast food? SodaYesterday, how many glasses or cans of soda, such as Coke, or other sweetened drinks, such as fruit punch or Sunny Delight did you drink? Do not count diet drinks. Fried potatoesYesterday, how many servings of French fries, home fries, or hash browns did you eat? High-sugar foods? Outcome Questions

227. 227 TOPICQUESTION FruitYesterday, how many servings of fruit, such as an apple or a banana, did you eat? VegetablesYesterday, how many servings of vegetables, like corn, green beans, green salad or other vegetables did you eat? Fast foodYesterday, how many times did you eat fast food? SodaYesterday, how many glasses or cans of soda, such as Coke, or other sweetened drinks, such as fruit punch or Sunny Delight did you drink? Do not count diet drinks. Fried potatoesYesterday, how many servings of French fries, home fries, or hash browns did you eat? High-sugar foodsYesterday, how many servings of high-sugar foods, such as cookies, candy, doughnuts, pastries, cake or popsicles did you eat? Outcome Questions

228. Questions for your Cross-Sectional Studies One question must obtain information about the exposure in your hypothesis and the other question must obtain information about the outcome in your hypothesis. The study information on exposure and outcome must fit into a 2x2 table. A “yes/no” question will fit and is recommended. If using a multiple choice question, you will need a predetermined “cut point” so there is a “higher/lower” range to fit into the 2x2 table. 228

229. Yes Exposure Total No Exposure ab cd Yes Outcome No Outcome The 2x2 table Exposure and Outcome Distributions Among Individuals in a Study Population Optional: Use as needed for review of 2x2 tables and necessity for a question about exposure and a question about outcome 229

230. 2-3c Study Variables: Questions About Exposure and Outcome and Additional Questions 230 Notebook Study How should we ask about eating a healthy breakfast?

231. “Criteria for a Good Question” It should be clear and unambiguous, written so that its intended audience understands it. It should mean the same thing to everyone who reads it. The answer options must categorize and cover the entire range of possible behavior (from complete absence of the behavior to a maximum amount of the behavior). The time period to consider when answering a particular question must be appropriate (long or short enough) to capture the frequency of behavior desired (depending on the information desired and the type of behavior). 231

232. 2-3c Item 5 - Labeling a 2x2 Table 232 Notebook Study 2x2 Table Fill in the two boxes in the table below, to show how your exposure and outcome variables will be analyzed in a contingency table in order to test your hypothesis. (Note: if you plan to use multiple choice questions for your exposure and/or outcome, determine cut points for the data so that you can fill in the contingency table below.)

233. 233 2-3c Item 6 – Additional Questions Notebook Study Think about what other information about students in your study would be interesting to know, in terms of your hypothesis. (Hint: perhaps gender would be one of these) In the space below, write any additional questions for your questionnaire that will gather information about these other characteristics of your study subjects.. Should we ask about gender? Questions to Gather Additional Information on Participants

234. Break Between Classes 234

235. 235 2-3d Sample Questionnaire for for Cross-Sectional Study Notebook Study Thank you for your participation in this survey. Please answer the questions below by circling one choice for each question. When you are finished, fold this paper in half and follow instructions for handing in your questionnaire. Remember: Do not write your name anywhere on this paper. Study Questions: (Circle one answer for each question) 1. During the past month, did you usually eat 2 or more servings of fruits/vegetables per day? Yes No 2. In the last semester that you have completed, did you have a grade average of A or B? Yes No 3. What is your gender? Male Female 4. What grade are you in? 6th grade 7th grade 8th grade

236. 236 Type your questionnaire Make enough copies for all potential study participants

237. 237 Big Ideas in Lesson 2-3 A good study plan includes careful thought about choice of exposure and outcome variables and high-quality questions to measure them Additional questions about other characteristics of participants can be asked in order to better understand study results A well-planned study has a user-friendly questionnaire to administer to participants Re-Cap

238. 238 Time Check 2:15 PM

239. 239

240. 240 Teach Epidemiology

241. Teachers Team-Teaching Teachers (TTTT) News Item Team leads other workshop participants in the analysis of a news item from an epidemiological perspective. 1

242. Teach Epidemiology Teachers Team-Teaching Teachers (TTTT) News Item Team leads other workshop participants in the analysis of a news item from an epidemiological perspective. 2

243. Teach Epidemiology Teachers Team-Teaching Teachers (TTTT) Existing Lesson Team leads other workshop participants in a portion of a selected existing epidemiological lesson. 3

244. Teach Epidemiology Teachers Team-Teaching Teachers (TTTT) Existing Lesson Team leads other workshop participants in a portion of a selected existing epidemiological lesson. 4

245. TTTT Rules 245 1.Teach epidemiology 2.As a group, create a 30-minute lesson during which we will develop a deeper understanding of an enduring epidemiological understanding. 3.Focus on the portion of the unit that is assigned. Use that portion of the unit as the starting point for creating your 30-minute lesson. 4.When teaching assume the foundational epidemiological knowledge from the preceding days of the workshop. 5.Try to get us to uncover the enduring epidemiological understanding. Try to only tell us something when absolutely necessary. 6.End each lesson by placing it in the context of the appropriate enduring epidemiological understanding. 7.Teach epidemiology. 8.After the lesson, metacognitate about your preparation for and teaching of the lesson. Teach Epidemiology

246. 246 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 Metacognition Teach Epidemiology Teachers Team-Teaching Teachers (TTTT)

247. 247 Time Check 2:45 PM

248. 248

249. 249 Teach Epidemiology

250. 250 Time Check 3:00 PM

251. 251

252. 252 Teach Epidemiology

253. 253 Broadcast Studios Teach Epidemiology Tours

254. 254 Time Check 4:00 PM