1. Lesson 2-7: Cross-Sectional Study – In School Teacher Note: Module 2 Overview Content Area: Hypothesis-Testing: Cross-Sectional Study Essential Questions: How can I select groups of people and collect data/evidence from them that will test my hypothesis? If my causal hypothesis is correct, how would the exposure and outcome be distributed in these groups? Enduring Understanding: 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, when an association is found, other explanations in addition to causality also must be considered. Core Concepts: Testing hypotheses Association Exposure/outcome Control group 2x2 table Observational studies Study design/study plan Study samples Prevalence rate Prevalence ratio Statement of effect Lessons: 2-1 Looking for Associations 2-2 Cross-sectional Studies 2-3 Developing Hypothesis and Study Questions 2-4 Respect – Part II 2-5 Planning Study Conduct 2-6 Cross-Sectional Study - In Class 2-7 Cross-Sectional Study – In School 1 Revised Sept 14, 2011

2. Lesson 2-7: Cross-Sectional Study – In School 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. 2

3. Lesson 2-7: Cross-Sectional Study – In School Teacher Note: Authentic Assessment for Module 2 of the Epidemiology and the Energy Balance Equation Curriculum 3 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.

4. Lesson 2-7: Cross-Sectional Study – In School 4 Teacher Note: Photos of Worksheets for Lesson 2-7 2-5a 2-3a 2-3d 2-7a 2-7b 2-7c

5. Lesson 2-7: Cross-Sectional Study – In School Teacher Note: Cross-Sectional Study - In School 5

6. Lesson 2-7: Cross-Sectional Study – In School Start of Lesson 2-7 (estimate 4 class periods) 6

7. Lesson 2-7: Cross-Sectional Study – In School 7 Big Ideas in Lesson 2-6 The in-class studies are final practice for conducting the in-school studies. This is simulated research, not actual research, because the results are not generalizable. Steps and materials should all be ready prior to starting. In all aspects of the study, every effort should be made to protect the privacy of participants and their information. The study allows us to test a hypothesis: it yields counts, that can be turned into prevalence rates, that can be compared as a prevalence ratio, that provides information about an association versus no association. Review

8. Lesson 2-7: Cross-Sectional Study – In School Rubric for Evaluating In-School Study and Poster 8 CriteriaGot ItGetting ItWill Get It Soon ParticipationAll study team members participate Most study team members participate Some study team members participate Use of Epidemiology Terminology such as Prevalence, Prevalence Ratio, and others All are appropriate and accurate Most are appropriate and accurate Some are appropriate and accurate Understanding of Importance of Informed Consent Full understanding of importance Some understanding of importance Limited understanding of importance Thoughtful discussion of challenges in data collection and management At least 2 challenges well discussed One challenge well discussed Little discussion of challenges Accurate calculation of prevalence and prevalence ratio All prevalence rates and ratios correctly calculated Some correctly calculated Mostly or completely incorrectly calculated Thoughtful discussion of whether the data support or do not support the hypothesis A thorough and reasonable discussion of whether the data support the hypothesis Some reasonable thoughts about whether the data support the hypothesis Little thoughtful discussion of whether the data support the hypothesis Understanding of limitations of their study Identified at least 2 reasonable and logical limitations Identified 1 reasonable and logical limitation Did not identify any reasonable or logical limitations

9. Lesson 2-7: Cross-Sectional Study – In School Lesson 2-7: Cross-Sectional Study - In School 9

10. Lesson 2-7: Cross-Sectional Study – In School Preparation for In-School Cross-Sectional Studies Who is going to be in your study population among all the students in your school? 10

11. Lesson 2-7: Cross-Sectional Study – In School Preparation for In-School Cross-Sectional Studies Any other tweaks or adjustments based on experience from your in-class study? 11

12. Lesson 2-7: Cross-Sectional Study – In School 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 Notebook Study 2-3a Checklist - Study Planning Components and Expectations Consider adjustments to improve the quality of your study.

13. Lesson 2-7: Cross-Sectional Study – In School 13 Consider re-assignments as appropriate, based on experience during the in-class study. 2-5a Assignments for Day of Study Notebook Study

14. Lesson 2-7: Cross-Sectional Study – In School 14 Next Class Conducting In-School Surveys

15. Lesson 2-7: Cross-Sectional Study – In School Putting It All Together on Study Day 15

16. Lesson 2-7: Cross-Sectional Study – In School Conduct Steps for Study Held in Each Class CD C 16 Introduce team Read informed consent statement and remind class of their right to not participate. Review questionnaire with the entire class + Read over all the questions + Remind them to NOT write their name on the paper Instruct participants to voluntarily and anonymously fill out the questionnaire. When they are finished, instruct students to fold their paper in half and to put the paper into the large envelope that will be passed around (participants and non-participants should do this) Thank participants.

17. Lesson 2-7: Cross-Sectional Study – In School 17 Next Class Data Analysis

18. Lesson 2-7: Cross-Sectional Study – In School 18 Data Management and Calculations for the In-School Cross-Sectional Study 2-7a Notebook Study

19. Lesson 2-7: Cross-Sectional Study – In School 19 In-School Cross-Sectional Study: Analysis by Gender OPTIONAL - 2-7b Notebook Study

20. Lesson 2-7: Cross-Sectional Study – In School 20 Honor Roll Total 1207050 No Honor Roll 120 No Healthy Breakfast 7050 Healthy Breakfast Prevalence Rates Total Study Population

21. Lesson 2-7: Cross-Sectional Study – In School 21 Honor Roll Total 1207050 No Honor Roll 70 120 or 58% 120 No Healthy Breakfast 7050 Healthy Breakfast Prevalence Rates Total Study Population

22. Lesson 2-7: Cross-Sectional Study – In School 22 Honor Roll Total 1207050 No Honor Roll 70 120 or 58% 120 No Healthy Breakfast 7050 or Healthy Breakfast Prevalence Rates 50 120 42% Total Study Population

23. Lesson 2-7: Cross-Sectional Study – In School 23 Honor Roll Total 1207050 No Honor Roll 70 120 or 58% 120 No Healthy Breakfast 7050 Prevalence Ratio or Healthy Breakfast Prevalence Rates 50 120 42% 1.4 Total Study Population Students who eat a healthy breakfast are 1.4 times as likely to make the honor role compared to students who do not eat a healthy breakfast.

24. Lesson 2-7: Cross-Sectional Study – In School 24 Honor Roll Total 604020 No Honor Roll 40 No Healthy Breakfast 3010 Healthy Breakfast Prevalence Rates Males Only

25. Lesson 2-7: Cross-Sectional Study – In School 25 Honor Roll Total 604020 No Honor Roll 40 60 or 67% 40 No Healthy Breakfast 3010 Healthy Breakfast Prevalence Rates Males Only

26. Lesson 2-7: Cross-Sectional Study – In School 26 Honor Roll Total 604020 No Honor Roll 40 60 or 67% 40 No Healthy Breakfast 3010 or Healthy Breakfast Prevalence Rates 10 40 25% Males Only

27. Lesson 2-7: Cross-Sectional Study – In School 27 Honor Roll Total 604020 No Honor Roll 40 60 or 67% 40 No Healthy Breakfast 3010 Prevalence Ratio or Healthy Breakfast Prevalence Rates 10 40 25% 2.7 Males Only Boys who eat a healthy breakfast are 2.7 times as likely to make the honor role compared to boys who do not eat a healthy breakfast.

28. Lesson 2-7: Cross-Sectional Study – In School 28 Honor Roll Total 6030 No Honor Roll 80 No Healthy Breakfast 40 Healthy Breakfast Prevalence Rates Females Only

29. Lesson 2-7: Cross-Sectional Study – In School 29 Honor Roll Total 6030 No Honor Roll 30 60 or 50% 80 No Healthy Breakfast 40 Healthy Breakfast Prevalence Rates Females Only

30. Lesson 2-7: Cross-Sectional Study – In School 30 Honor Roll Total 6030 No Honor Roll 30 60 or 50% 80 No Healthy Breakfast 40 or Healthy Breakfast Prevalence Rates 40 80 50% Females Only

31. Lesson 2-7: Cross-Sectional Study – In School 31 Honor Roll Total 6030 No Honor Roll 30 60 or 50% 80 No Healthy Breakfast 40 Prevalence Ratio or Healthy Breakfast Prevalence Rates 40 80 50% 1.0 Females Only Girls who eat a healthy breakfast are 1.0 times as likely to make the honor role compared to girls who do not eat a healthy breakfast.

32. Lesson 2-7: Cross-Sectional Study – In School 32 Interpretation of Analysis by Gender Boys who eat a healthy breakfast are 2.7 times as likely to make the honor role compared to boys who do not eat a healthy breakfast. Girls who eat a healthy breakfast are 1.0 times as likely to make the honor role compared to girls who do not eat a healthy breakfast. What do these findings suggest?

33. Lesson 2-7: Cross-Sectional Study – In School Next Class Reporting Out 33

34. Lesson 2-7: Cross-Sectional Study – In School 34 2-7a – Basis for Report Out and Discussion Notebook Study

35. Lesson 2-7: Cross-Sectional Study – In School 1.2x2 tables and calculations 2.Accurate statements about results 3.Do the results support the hypothesis? 4.What limitations exist? Report Out and Discussion of Results In Class 35

36. Lesson 2-7: Cross-Sectional Study – In School Interpretation of Prevalence Ratios 36 ResultsInterpretation Prevalence Ratio At or Near 1.0 NO ASSOCIATION – the prevalence rate among the exposed group is similar or the same as the prevalence rate among the unexposed group Prevalence Ratio Above 1.0 POSITIVE ASSOCIATION - the prevalence rate among the exposed group is greater than the prevalence rate among the unexposed group Prevalence Ratio Below 1.0 NEGATIVE ASSOCIATION the prevalence rate among the exposed group is lower than the prevalence rate among the unexposed group A prevalence ratio of 1.1 is a weak positive association, while a prevalence ratio of 3.1 is a strong positive association A prevalence ratio of 0.95 is a weak negative association, while a ratio of 0.45 is a strong negative association

37. Lesson 2-7: Cross-Sectional Study – In School 37 “ This study has several limitations.” “The dietary intake data are self-reported, making them subject to errors.” “A single question was used to address each dietary behavior, and questions ask about diet on the previous day, which might not be representative of the respondents’ overall diet patterns.” “Additionally, we did not assess or control for the social desirability of bringing lunch.” An important limitation of the cross-sectional study design is that exposure and outcome are measured at the same point in time - - can we tell the time order?

38. Lesson 2-7: Cross-Sectional Study – In School 2-7c 38 Notebook Study Rubric for Poster of In-School Study Results

39. Lesson 2-7: Cross-Sectional Study – In School 39 Assessment of Simulated Research Experience Study Planning Teamwork Report Out Respect for Participants Study Conduct Understanding of Study Strengths and Limitations Data Analysis Interpretation of Study Data Management Study Communications

40. Lesson 2-7: Cross-Sectional Study – In School 40 Big Ideas in Lesson 2-7 Same big ideas as in Lesson 2-7. The independent (to the extent possible) conduct of an in-school study by the study team constitutes an authentic assessment of their knowledge and skills related to the second enduring understanding. 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. Re-Cap

41. Lesson 2-7: Cross-Sectional Study – In School Optional - A Little History 41

42. Lesson 2-7: Cross-Sectional Study – In School 42 Examples from Pioneer Epi Club Members 8 th Graders at Charles J. Riley School 9 Paterson, New Jersey – Spring 2010 1.Epi Stars - Drinking at least 2 cans or a 20 ounce bottle of non-diet soda every day leads to a crash (feeling tired) - Prevalence ratio = 2.5 2.Pop Science – A healthy breakfast is associated with playing in an organized sport - Prevalence ratio = 0.96 3.Hypertensions – Receiving a daily, weekly, or monthly allowance is related to eating junk food/unhealthy food more than twice a day - Prevalence ratio = 1.6 4.Dr. Observation – Healthy eating (at least 2 servings of fruit and vegetables a day) results in better grades (“doing well in school”) - Prevalence ratio = 1.0

43. Lesson 2-7: Cross-Sectional Study – In School Making a Poster to Display Survey Results Examples on next slides from Epi Club Members 8 th Graders at Charles J. Riley School 9 Paterson, New Jersey – Spring 2011 43

44. Lesson 2-7: Cross-Sectional Study – In School Making a Poster to Display Survey Results 44

45. Lesson 2-7: Cross-Sectional Study – In School Making a Poster to Display Survey Results 45

46. Lesson 2-7: Cross-Sectional Study – In School Making a Poster to Display Survey Results 46

47. Lesson 2-7: Cross-Sectional Study – In School Making a Poster to Display Survey Results 47

48. Lesson 2-7: Cross-Sectional Study – In School 48