MPH 604:

EPIDEMIOLOGY

CHAPTER 6
ECOLOGICAL, CROSS-SECTIONAL
AND CASE-CONTROL STUDY DESIGNS
Learning Objectives

Define the basic differences between observational and

experimental epidemiology
Identify an epidemiologic study design by its description
List the main characteristics, advantages, and
disadvantages of ecologic, cross-sectional, and case-
control studies
Calculate and interpret an odds ratio
Attributes of Study Design

Person

Study
Design

Place Time
Study Design: Person, Place, & Time

Good study design considers:

PERSON: disease, transmission, course of disease,

intrinsic risk factors, behavior, demographics

PLACE: environment, mapping, clustering, proximity

TIME: temporal sequence, trends, seasonal, cycles,

clustering, incubation, time at risk
Study Design: Goals

Test Hypothesis/Find Associations

Address Potential Biases
Indentify and Control Confounding
Evaluate interventions
Study Design: Two Main Types

Ecological
Observational Cross sectional
Retrospective/Case-
Control
Prospective/Cohort

Community trials
Experimental
Clinical Trials
Study Design: Two Main Types

Collect Exposure
Observational Variables
Collect Outcome
Variables
Collect Covariates

Exposure Variable is
Experimental Manipulated
e.g. drug, intervention
Randomization of
Subjects
Study Design: Two Types of Data

vs.
Descriptive Analytical

Routinely
Hypothesis
Collected
Testing
Data

Lists Intervention

Examine
Limited
Cause -
Statistics
Effect

E.g. Life E.g. Clinical

Tables Trials
Study Design: Types of Variables

Past Current Day Future

Exposure
Aka Risk Factor

e.g. smoking, diet,

sun exposure,
Outcome
BRCA1, injection
drug use, etc.
e.g. cancer,
diabetes,
osteoporosis,
HIV/AIDS, etc.
CoVariates

e.g. gender,
age,
ethnicity/race,
SES, BMI, etc.
Example: Framingham Heart Study

Variables: Which set of varibles is the

outcome variable?

Atrial Fibrillation
Which set of variables contain
the exposure variables?
Diabetes, Hypertension,
Congestive Heart Failure,
Valve Disease Which set of variable contain
the covariates?

Gender, Age, Ethnicity

Observational Study Design: Time

Observational Studies
Past Current Day Future

Cross sectional
(Prevalence)

Retrospective
(Case Control)

Prospective
(Cohort,
longitudinal,
Incidence)

Historical Prospective
Observational Study Designs: Advantages

Cross Case-
Cohort
Sectional Control
Quick Quick Gold Standard
Less Expensive
Risk Factors
Less Expensive
Rare Disease
Intervention
Risk Factors
Large Sample
Quality Data
Review Records
Attributes Small Samples Natural History
Study Design: Ecological Studies
Unit of Meaure = Group
School, city, neighborhood, clinic, etc.

Ecologic Comparison Study

Compares exposure and outcome rates
2(+) groups, same time period

Ecologic Trend Study

Compares exposure and outcome changes over time
Same group (school, community, clinic) over time
Study Design: Ecological Studies
Examples of Ecologic Studies

The association between breast cancer and dietary fat for 39

countries.

High intakes of dietary fats associated with high rates of breast cancer
mortality.

Childhood lead poisoning in communities in Massachusetts.

Mean systolic blood pressure levels and stroke mortality rates in the
Seven Countries Study.
Study Design: Ecological Studies
Advantages:
Inexpensive and Quick
Interested in ecological effects
Simple presentation and information

Disadvantages:
Ecological fallacy
Lack of complete/adequate data
Temporal confusion
Migration across groups

Ecologic Fallacy
Observations at group level may not represent exposure-outcome
relationship at individual level
Study Design: Cross Sectional Study
Unit of Measure = individual participants

Time Period = one point in time

1 questionnaire, 1 visit, 1 hospital/medical record, death certificates
Prevalence study, can NOT measure incidence

Exposure and Outcome both collected simultaneously

Study Design: Cross Sectional Study
Uses for Cross-Sectional Studies

Hypothesis generation

Intervention planning

Estimation of magnitude and distribution of health problem

Study Design: Cross Sectional Study

Examples of Cross-Sectional Study

Surveys of smokeless tobacco use among high school

students

Prevalence surveys of number of vasectomies performed

Prevalence of congenital malformations across maternal

age groups
Study Design: Cross Sectional Study

Advantages
Larger, Generalizable Samples
Relatively Quick Study
Less Expensive
Describe Attributes of Disease (or outcome)
Disadvantages
Difficult to Examine Cause and Effect (temporality)
Diseases with a Long Duration are confusing
No Incidence Data (only prevalence)
Not appropriate for rare diseases
Not appropriate for cycling diseases
Study Design: Case-Control Study
Unit of Measure individuals, case vs. control

Time Period retrospective, today -> into the past

Measure outcome TODAY

Measure exposure from the PAST (retrospectively)
Study Design: Case-Control Study

Odds Ratio (OR)

Probability that a case was exposed compared to a control being
exposed

2 x 2 Contingency Tables
OR = (a/c)/(b/d) = ad/bc

Outcome
Exposure Case Control
Exposed a b
Unexposed c d
Study Design: Case-Control Study
Odds Ratio (OR) - Interpretation
OR = 1 implies no association
Null Value = 1

OR > 1 implies positive association (risk factor)

E.g. use of tanning beds can be a risk factor for skin cancer

OR < 1 implies protective factor

E.g. physical activity can be protective against obesity or diabetes

E.g. The probability that someone with lung cancer was a smoker is 3.5
times more likely than that someone without lung cancer was a
smoker. OR Those with lung cancer are 3.5 times more likely to have
been a smoker than someone without lung cancer.
Study Design: Case-Control Study
Advantages
Relatively Quick and Inexpensive
Smaller Sample Size Required (vs. Prospective Study)
Can Utilize Existing Records/Data
Can Examine Multiple Exposures
Good for Rare Diseases
Outbreak Investigations Null Value = 1

Disadvantages
Potential Bias based on Case Definition
Information Bias for Exposure Data
Selection Bias in Choosing a Control Group