1. 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 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. Teachers Team-Teaching Teachers (TTTT) Authentic Assessments) (AA) - (1 Group) Team leads other workshop participants in the creation and administration of survey questions about a health-risk behavior and its distribution in terms of person, place, and time. After doing so, workshop participants count the frequency of the health-risk behavior, calculate the overall prevalence of the behavior, identify patterns of the behavior in terms of person, place, and time, and formulate hypotheses that might explain those patterns. TTTTT 10 AA

8. Teach Epidemiology Teachers Team-Teaching Teachers (TTTT) Authentic Assessments) (AA) - (1 Group) Team leads other workshop participants in the creation and administration of survey questions about a health-risk behavior and its distribution in terms of person, place, and time. After doing so, workshop participants count the frequency of the health-risk behavior, calculate the overall prevalence of the behavior, identify patterns of the behavior in terms of person, place, and time, and formulate hypotheses that might explain those patterns. Infuse Epidemiology into an Existing Lesson about Something Else (ASE) – (1 Group) Team leads other workshop participants in portions of selected existing lessons about something else into which epidemiology has been infused.

9. 9 Teach Epidemiology Enduring Epidemiological Understandings

10. 10 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 Epi – Grades 6-12

11. 11 Teach Epidemiology Enduring Epidemiological Understandings

12. 12 Time Check 10:15 AM

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14. 14 Teach Epidemiology

15. 15 Time Check 10:30 AM

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17. 17 Teach Epidemiology

18. 18 Teach Epidemiology Enduring Epidemiological Understandings Ken Bain, What the Best College Teachers Do “… they can distinguish between foundational concepts and elaborations or illustrations of those ideas.”

19. 19 Time Check 11:00 AM

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21. 21 Teach Epidemiology

22. 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?

23. 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

24. 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. Making Group Comparisons and Identifying Associations

25. Boys are more likely than girls to want to go to this field trip. –What are we comparing? Proportion of girls who will want to go on the trip to proportion of boys who will want to go on the trip. –What is the causal inference? Gender  Wanting to attend the field trip This teaching epi thing…it will work better for Ms. Smith’s kids than mine. –What are we comparing? Proportion of Smith’s students who will engage with epidemiology to proportion of my students who will engage with epidemiology. –What is the causal inference? Class  Engagement with the science of epidemiology

26. Heart attacks Descriptive epidemiology showed the following patterns: –Increasing incidence of heart attacks in certain Midwestern communities –More heart attacks among farmworkers than non- farmworkers in those communities –More heart attacks among males than among females What is your hypothesis?

27. Testing hypotheses about MI Hypothesis: Exposure to pesticides increases risk of MI. How might you go about evaluating this hypothesis?

28. Testing hypotheses about MI Hypothesis: Exposure to pesticides increases risk of MI. Evaluate the hypothesis using an: –Ecologic study

29. Ecologic study of pesticide exposure and MI Exposure is pesticide –Measured as proportion of land area devoted to wheat Outcome is MI –Measured as a rate per 100,000 Plot data on a graph What might you expect to see?

32. Ecologic Study Key element –Group-level estimates Quantify relationships –Graphical displays –Correlation coefficient Advantages –Study group-level variables, e.g. policies, laws, community socioeconomic status –Use existing data sources –Use fewer resources (time, money, subject burden) Disadvantage –Ecologic fallacy

33. Testing hypotheses about MI Hypothesis: Exposure to pesticides increases risk of MI. Evaluate the hypothesis using a: –Cross-sectional study

34. Cross-sectional study of pesticide exposure and MI Exposure is pesticide –Measured as pesticide application history Outcome is MI –Measured as yes or no Count responses What might you expect to see?

35. Pesticides and MI MI+MI- Pesticide+ Pesticide- 200

36. Pesticides and MI MI+MI- Pesticide+6090150 Pesticide-104050 70130200 So, is pesticide usage associated with MI?

37. Pesticides and MI MI+MI- Pesticide+6090150 Pesticide-104050 70130200 What is the prevalence of MI? What is the prevalence of MI among pesticide users? What is the prevalence of MI among non-users?

38. Pesticides and MI MI+MI- Pesticide+6090150 Pesticide-104050 70130200 What is the prevalence of MI? 70/200 = 35% What is the prevalence of MI among pesticide users? = 60/150 = 40% What is the prevalence of MI among non-users? = 10/50 = 20%

39. Cross-sectional Study Key element –Snapshot of one point in time Quantify association –Prevalence ratio Advantages –Individual data –Quick, cheap –Assess prevalence of a trait in the population Disadvantages –Difficult to assess temporality because measure E and D simultaneously –Inefficient for E or D that are rare –Inefficient for D that are rapidly fatal or of short duration

40. Testing hypotheses about MI Hypothesis: Exposure to pesticides increases risk of MI. Evaluate the hypothesis using a: –Case-control study

41. Case-control study of pesticide exposure and MI Exposure is pesticide –Measured as pesticide application history Outcome is MI –Measured as yes or no Want to ensure that you have enough cases to do your study, so select for those with MI Find those without MI Ask them about exposures to pesticides What might you expect to see?

42. Pesticides and MI MI+MI- Pesticide+ Pesticide- 100 200

43. Pesticides and MI MI+MI- Pesticide+601070 Pesticide-4090130 100 200 What is the prevalence of MI?

44. Case-control Study Odds = probability an event will occur/probability that event will not occur Odds of exposure in cases = probability of being exposed if one is a case/probability one was not exposed if one is a case What is odds of exposure in controls? = probability of being exposed if one is a control/probability one was not exposed if one is a control What is Odds Ratio?

45. Pesticides and MI MI+MI- Pesticide+601070 Pesticide-4090130 100 200 What is the odds of exposure among the cases? What is the odds of exposure among the controls? What is the OR?

46. Pesticides and MI MI+MI- Pesticide+601070 Pesticide-4090130 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

47. 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 –Recall bias

48. Testing hypotheses about MI Hypothesis: Exposure to pesticides increases risk of MI. Evaluate the hypothesis using a: –Cohort study

49. Cohort study of pesticide exposure and MI Exposure is pesticide –Measured as pesticide application history Outcome is MI –Measured as yes or no Want to ensure that you have enough exposed persons to do your study, so select for those with pesticide exposure Find those without pesticide exposure Follow them up over time to ascertain MI status What might you expect to see?

50. Pesticides and MI MI+MI- Pesticide+100 Pesticide-100 200

51. Pesticides and MI MI+MI- Pesticide+7030100 Pesticide-3565100 10595200 What is the incidence of MI among the pesticide users? What is the incidence of MI among the non-users? What is the risk ratio?

52. Pesticides and MI MI+MI- Pesticide+7030100 Pesticide-3565100 10595200 What is the incidence of MI among the pesticide users? = 70% What is the incidence of MI among the non-users? = 35% What is the risk ratio? = 2.0

53. Cohort Study Key element –Select based on exposure status and follow-up over time Quantify association –Relative risk (risk ratio) Advantages –Avoids the 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 –Attrition may result in selection bias –Inefficient for rare diseases

54. Testing hypotheses about MI Hypothesis: Exposure to pesticides increases risk of MI. Evaluate the hypothesis using a: –Randomized controlled trial

55. RCT study of pesticide exposure and MI Exposure is pesticide –Measured as pesticide exposure Outcome is MI –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 MI status What might you expect to see?

56. Pesticides and MI MI+MI- Pesticide+ Pesticide- 200

57. Pesticides and MI MI+MI- Pesticide+7030100 Pesticide-3565100 10595200 What is the incidence of MI among the pesticide users? What is the incidence of MI among the non-users? What is the risk ratio?

58. Pesticides and MI MI+MI- Pesticide+7030100 Pesticide-3565100 10595200 What is the incidence of MI among the pesticide users? = 70% What is the incidence of MI among the non-users? = 35% What is the risk ratio? = 2.0

59. 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.

61. Enduring Understandings Comparing Exposed and Unexposed 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.

62. Intentionally Exposing When an exposure is hypothesized to have a beneficial effect (e.g. vitamin D), 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. Enduring Understandings

63. Observing Free-Living People When an exposure is hypothesized to have a detrimental effect (HIV, pesticides, EMF), 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. Enduring Understandings

64. Reasons for associations Confounding Bias Reverse causality Sampling error (chance) Causation

65. Osteoporosis risk is higher among women who live alone than among women who live with others.

66. Confounding Confounding is an alternate explanation for an observed association of interest. Number of persons in the home Osteoporosis Age

67. Confounding Confounding is an alternate explanation for an observed association of interest. ExposureOutcome Confounder

68. Confounding in our lives MAP tests measure academic growth over time, independent of grade level or age. Age- and gender-specific growth charts Age-adjusted rates… Rates of lung cancer adjusted for smoking…

69. Controlling confounding Study design phase –Matching –Restriction –Random assignment Study analysis phase –Stratification –Statistical adjustment

70. Reasons for associations Confounding Bias Reverse causality Sampling error (chance) Causation

71. Bias Errors are mistakes that are: –randomly distributed –not expected to impact the MA –less modifiable Biases are mistakes that are: –not randomly distributed –may impact the MA –more modifiable

72. Types of bias Selection bias –The process for selecting/keeping subjects causes mistakes Information bias –The process for collecting information from the subjects causes mistakes

73. Selection bias People who are working are likely to be healthier than non-workers People who participate in a study may be different from people who do not People who drop out of a study may be different from those who stay in the study Hospital controls may not represent the source population for the cases

74. Information bias Misclassification, e.g. non-exposed as exposed or cases as controls Cases are more likely than controls to recall past exposures Interviewers probe cases more than controls (exposed more than unexposed)

75. Birth defects and diet In a study of birth defects, mothers of children with and without infantile cataracts are asked about dietary habits during pregnancy.

76. Pesticides and cancer mortality In a study of the relationship between home pesticide use and cancer mortality, controls are asked about pesticide use and family members are asked about their loved ones’ usage patterns.

77. Minimize bias Can only be done in the planning and implementation phase Standardized processes for data collection Masking Clear, comprehensive case definitions Incentives for participation/retention

78. Reasons for associations Confounding Bias Reverse causality Sampling error (chance) Causation

79. Reverse causality Suspected disease actually precedes suspected cause Pre-clinical disease  Exposure  Disease –For example: Memory deficits  Reading cessation  Alzheimer’s Cross-sectional study –For example: Sexual activity/Marijuana

80. Minimize effect of reverse causality Done in the planning and implementation phase of a study Pick study designs in which exposure is measured before disease onset Assess disease status with as much accuracy as possible

81. Reasons for associations Confounding Bias Reverse causality Sampling error (chance) Causation

82. Sampling error/chance E and D are associated in a sample, but not in the population from which the sample was drawn.

83. Minimize sampling error (chance) Random Selection

84. 84 Time Check 11:30 AM

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86. 86 Teach Epidemiology

87. 87 Time Check 12:30 PM

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89. 89 Teach Epidemiology

90. 90 Time Check 1:45 PM

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92. 92 Teach Epidemiology

93. 93 Bupe

94. 94 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.”

95. 95 Association Found Between Coffee and Pancreatic Cancer Associated Teach Epidemiology

96. 96 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

97. 97 Things that are associated are linked in some way that makes them turn up together. Associated Teach Epidemiology

98. 98 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

99. 99 Epidemiologic studies that are concerned with characterizing the amount and distribution of health and disease within a population. Descriptive Epidemiology Teach Epidemiology

100. 100 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

101. 101 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

102. 102 Hypothesis: Buprenorphine will stop heroin addicts from using heroin. Making Group Comparisons and Identifying Associations Teach Epidemiology

103. 103 Population Trial 1 Making Group Comparisons and Identifying Associations

104. 104 Population 500 Heroin Addicts Sample 100 Heroin Addicts 10 Weeks Trial 1 Making Group Comparisons and Identifying Associations

105. 105 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

106. 106 Bupe Tested Positive for Heroin Total 1002179 Tested Negative for Heroin Trial 1 Making Group Comparisons and Identifying Associations Teach Epidemiology

107. 107 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

108. 108 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

109. 109 … 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

110. 110 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

111. 111 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

112. 112 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

113. 113 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

114. 114 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

115. 115 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

116. 116 100 ? 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

117. 117 100 ? 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

118. 118 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

119. 119 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

120. 120 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

121. 121 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

122. 122 E Assigned E O O O O Making Group Comparisons and Identifying Associations Volunteer Heroin Addicts Teach Epidemiology

123. 123 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

124. 124 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

125. 125 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

126. 126 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

127. 127 The value obtained by dividing one quantity by another Ratio Making Group Comparisons and Identifying Associations Teach Epidemiology

128. 128 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

129. 129 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

130. 130 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

131. 131 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

132. 132 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

133. 133 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

134. 134 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

135. 135 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

136. 136 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

137. 137 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

138. 138 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

139. 139 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

140. 140 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

141. 141 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

142. 142 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

143. 143 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

144. 144 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

145. 145 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

146. 146 Trial 1 Trial 2 Trial 3 Trial 4 Making Group Comparisons and Identifying Associations Teach Epidemiology

147. 147 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

148. 148 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

149. 149 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

150. 150 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

151. 151 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

152. 152 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

153. 153 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

154. 154 Buprenorphine Buprenorphine & Naloxone Placebo Making Group Comparisons and Identifying Associations Teach Epidemiology Handout

155. 155 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.”

156. 156

157. 157 By the conclusion of the course, the student will have begun to develop an understanding of the fundamental epidemiological concepts identified below: Course Objectives 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. 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. 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. 3.

158. 158 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

159. 159 Total ab dc 2 x 2 Table Suicide Higher in Areas with Guns

160. 160 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

161. 161 ab dc 2 x 2 Table Total Kids Who Watch R-Rated Movies More Likely to Drink, Smoke

162. 162 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

163. 163 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

164. 164 ab dc 2 x 2 Table Family Meals Are Good for Mental Health Total

165. 165 ab dc 2 x 2 Table Family Meals Are Good for Mental Health Family Meals Total Mental Health No Mental Health No Family Meals

166. 166 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

167. 167 ab dc 2 x 2 Table Study Links Iron Deficiency to Math Scores Total

168. 168 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

169. 169 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

170. 170 ab dc 2 x 2 Table Pollution Linked with Birth Defects in US Study Total

171. 171 ab dc 2 x 2 Table Pollution Linked with Birth Defects in US Study Pollution Birth Defects No Pollution No Birth Defects Total

172. 172 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

173. 173 ab dc 2 x 2 Table Depressed Teens More Likely to Smoke Total

174. 174 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

175. 175 ab dc 2 x 2 Table Smoking Linked to Youth Eating Disorders Total

176. 176 ab dc 2 x 2 Table Smoking Linked to Youth Eating Disorders Smoke Eating Disorders No Smoke No Eating Disorders Total

177. 177 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

178. 178 ab dc 2 x 2 Table Total Study Links Spanking to Aggression

179. 179 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

180. 180 ab dc 2 x 2 Table Total Snacks Key to Kids’ TV-Linked Obesity – China Study

181. 181 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

182. 182 Time Check 2:15 PM

183. 183

184. 184 Teach Epidemiology

185. Teachers Team-Teaching Teachers (TTTT)

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

187. 187 Teach Epidemiology

188. 188 Teach Epidemiology Teachers Team-Teaching Teachers (TTTT) TTTT 11 EL

189. 189 Teach Epidemiology Teachers Team-Teaching Teachers (TTTT) TTTT 12 EL

190. 190 Teach Epidemiology Teachers Team-Teaching Teachers (TTTT) TTTT 13 EL

191. 191 Teach Epidemiology Teachers Team-Teaching Teachers (TTTT) TTTT 14 EL

192. Teach Epidemiology Teachers Team-Teaching Teachers (TTTT) 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.

193. 193 Teach Epidemiology

194. 194 Teach Epidemiology Teachers Team-Teaching Teachers (TTTT) TTTT 15 NI

195. 195 Teach Epidemiology Teachers Team-Teaching Teachers (TTTT) TTTT 16 NI

196. 196 Teach Epidemiology Teachers Team-Teaching Teachers (TTTT) TTTT 17 NI

197. 197 Teach Epidemiology Teachers Team-Teaching Teachers (TTTT) TTTT 18 NI

198. 198 Teach Epidemiology

199. Teachers Team-Teaching Teachers (TTTT) Infuse Epidemiology into an Existing Lesson about Something Else (ASE) – (1 Group) Team leads other workshop participants in portions of selected existing lessons about something else into which epidemiology has been infused. TTTTT 19 ASE

200. 200 Teach Epidemiology

201. Teachers Team-Teaching Teachers (TTTT) Authentic Assessments) (AA) - (1 Group) Team leads other workshop participants, in teams of 5, in carrying out cross-sectional studies among workshop participants. Workshop participants will create and ask questions that will allow them to test a hypothesis about a health-related exposure and outcome, request informed consent, tabulate data in a 2x2 table, calculate prevalence rates of the outcome for those with and those without the exposure, calculate a prevalence ratio, explain whether or not the prevalence ratio supports the hypothesis (shows or does not show an association), and identify possible explanations for why the association was or was not found. TTTTT 20 AA

202. 202 TTTT Rules 1.Teach epidemiology. 2.As a team, create a 20-minute lesson during which you model a way to teach epidemiology for your workshop colleagues. 3.Make sure your lesson develops a deeper understanding of an enduring epidemiological understanding. 4.Assume the foundational epidemiological knowledge from the workshop. 5.Try to get us to uncover the enduring epidemiological understanding. 6.End each lesson by placing it in the context of the appropriate enduring epidemiological understanding. 7.Contribute to creating “… a professional community that discusses new teacher materials and strategies and that supports the risk taking and struggle entailed in transforming practice.” 8.Teach epidemiology. Teach Epidemiology Teachers Team-Teaching Teachers (TTTT)

203. 203 Time Check 2:45 PM

204. 204

205. 205 Teach Epidemiology

206. 206 Time Check 3:00 PM

207. 207

208. 208 Teach Epidemiology

209. 209 Teach Epidemiology Tours

210. 210 Broadcast Studios Teach Epidemiology Tours

211. 211 Emergency Operation Center Teach Epidemiology Tours

212. 212 Time Check 4:00 PM