Seminar 2 Questions

EPIDEMIOLOGY AND BIOSTATISTICS 1 (HSH205)

SEMINAR 2: DESCRIPTIVE STUDIES (2)

Read
• Carneiro et al (2011) Chapter 2: Measuring the frequency of outcomes.
• Oleckno (2002) available on CloudDeakin

1. San Carlos County Health Department reported 17 new cases of tuberculosis in the first half of
2001 and 18 additional cases during the second half of the year. The population of the county
was 204,500 at the beginning of the year and 215,000 at the end of the year. What was the
incidence rate of tuberculosis in San Carlos County in 2001? Also, what type of incidence rate
does this represent?

2. During the period July 1 to December 31, 2000, 76 cases of measles were reported among 12-
19 year olds in a Russian community of 32,000. Ten percent (3,200) of the residents were 12-
19 years old on April 1, and the size and age distribution of the population has remained
constant. An investigation of the cases in the 12-19-year age group revealed that 22 of the
reported cases were contracted prior to July 1. In addition, another 18 cases developed in April
and May but were clinically resolved before July 1. What was the cumulative incidence rate of
measles in 12-19 year olds in this Russian community during the period July 1-December 31,
2000?

3. An epidemiologic study of breast cancer among elderly women followed 1,400 women, 65-79
years of age, without evidence of breast cancer over several years. Every two years the
investigators examined the women for breast cancer. The results were as follows: 12 new cases
at the first evaluation, 11 new cases at the second evaluation, 23 new cases at the third
evaluation, and 28 new cases at the fourth (final) evaluation. The investigators also noted that
35 of the women had withdrawn from the study at the third evaluation. Based on this
information, calculate and interpret the person-time incidence rate of breast cancer in this
group.

4. Health authorities in Egypt reported that 22 injuries requiring hospitalisation occurred in a

community of 65,000 during a recent national holiday. Eight additional cases occurred during
the following month, and two of these died from their injuries. What was the prevalence rate of
injuries requiring hospitalisation on the holiday and for the period as a whole?

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5. For each of the following abstracts, identify the following attributes

a. Study type
b. Population of interest
c. Sampling frame
d. Sampling method
e. Response rate
f. Sample

Comment on the quality of the sample, including the sampling frame, sampling methods, and
response rate. Can you think of any ways in which the sample could have been improved?

Note: It is not expected you will have time to complete this activity for all the abstracts in the
seminar. Please aim to complete at least the first three. If you do not get through all of the
abstracts, please take the time to complete them prior to assignment 1. They will also be helpful
revision for assignment 2 and the exam.

Abstract 1
Gritz, ER., Prokhorov, AV., Hudmon, KS., Mullin, M., Rosenblum, C., Chang, CC., Chamberlain,
RM., Taylor, WC., Johnston, D. and de Moor, C. (2003) Predictors of susceptibility to smoking
and ever smoking: a longitudinal study in a triethnic sample of adolescents. Nicotine Tob Res
Aug; 5 (4), 493-506.

Aim: This report describes a longitudinal study of the natural course of smoking initiation in a
school-based, ethnically diverse (42% White, 37% African American, 20% Hispanic) sample of
adolescents in grades 5, 8, and 12 who were followed prospectively for 1 year. A cohort of 659
students was identified who were never smokers at baseline and who completed questionnaires
both at baseline and at 1-year follow-up. From this cohort, predictor variables were used to
identify ethnic-specific risk factors for (a) "susceptibility to smoking" among the 509 students who
were nonsusceptible, never smokers at baseline and (b) "ever smoking" among all 659 students
who were never smokers at baseline (both susceptible and nonsusceptible). Logistic regression
analyses revealed that parental and household influences (parental education, marital status,
household smoking) were important predictors of ever smoking, but not of susceptibility to
smoking, for African Americans. Hispanic adolescents were significantly influenced by
environmental influences, namely smoking by other household members (ever smoking) and by

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peers (susceptibility and ever smoking), although peer pro-tobacco influences (friends who smoke
or friends' approval of smoking) were important predictors of susceptibility to smoking or ever
smoking for all three ethnic groups. Exposure to tobacco-related advertising was a risk factor for
White (susceptibility and ever smoking) and African American (susceptibility only) adolescents
but not for Hispanic adolescents. Inclusion of the susceptibility to smoking variable in the model
predicting ever smoking substantially reduced the importance of other predictors in the model,
suggesting that susceptibility to smoking was not an independent risk factor for ever smoking but
rather a potential mediating variable. The results of this study offer important insights for
designing ethnic-specific strategies for preventing smoking during adolescence.
Methods: We conducted a mixed cross-sectional, longitudinal study with a multiethnic focus.
Schools were recruited from six school districts in the greater Houston– Galveston area in Texas.
Permission to participate was obtained using written, active consent procedures. A signed
informed consent, which described the purpose of the study and the methods to be used, was
obtained from parents or guardians of students under age 18 years; students aged 18 years or older
signed their own forms. Student materials were written in English; however, both English and
Spanish versions of the parental informed consent forms were available. Because of the stringent
active consent procedures, obtaining signed parental consent forms represented a formidable
barrier to recruitment. Thus, our cohorts constituted a volunteer sample. At the school site,
students completed study surveys, and provided height and weight measures and a saliva sample.
Students received an incentive for participation, usually a voucher for use at a local restaurant or
videotape rental store. Surveys were mailed to the homes of a small number of students who were
absent on the survey date; saliva samples and anthropometric measures were not collected from
these participants. Fifth graders who were absent were not mailed surveys because we believed
that staff supervision was needed. More details regarding our procedures for sampling,
recruitment, and data collection are described in our earlier publication documenting our baseline
results (Gritz et al., 1998). As described in Gritz et al. (1998), 1,441 students in fifth, eighth, and
12th grades completed a baseline survey; of these students, 1,223 were of African American,
Hispanic, or White ethnicity. This group was followed prospectively for 1 year. Of this total
baseline sample, 1,004 students (82.1%) were retained for the follow-up assessment. Here we
present and discuss results of the 1-year predictions of susceptibility to smoking and ever
smoking. We attempted to conduct follow-up on as many students as possible, even if they had
moved out of the school district and were not able to complete the assessments on-site (at the
school). Postgraduates completed surveys that were sent and returned by mail.

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Results: Table 1 presents the characteristics of the participants who were never smokers at
baseline (n~659); this is the sample under consideration in this report. The mean (standard
deviation) age at baseline was 12.9 (2.1) years; 63% were female. Effects of attrition: Despite
efforts to retain our sample, we experienced some attrition, particularly among postgraduates, with
1,004 of the 1,223 participants (82.1%) completing the 1-year follow-up assessment. Among 760
baseline never smokers (the subgroup used in the regression analyses, presented below), 659
(86.7%) completed the 1-year assessment. To determine the extent to which Table 1.attrition
biased our cohort of baseline never smokers, we assessed differences between baseline never
smokers who completed the follow-up assessment and those who did not. Students who were lost
to follow-up were more likely to be African American, older (in the 12th grade or a postgraduate),
have parents who were divorced, and exhibit poorer academic performance (pv.05).

Abstract 2
James, S., Reddy, SP., Taylor, M. and Jinabhai, CC. (2004) Young people, HIV/AIDS/STIs and
sexuality in South Africa: the gap between awareness and behaviour. Acta Pædiatr; 93: 264–269.

Aim: To determine the baseline data of secondary school students in the Midlands district of Kwa-
Zulu, Natal, South Africa. The data provide details of students’ knowledge about sexually
transmitted infections (STIs) including HIV and AIDS, spread, prevention, how they can protect
themselves from contracting an STI, their general awareness and sources of information, their
perceptions of their vulnerability and their sexual practices. Methods: A cross-sectional study was
carried out among 1113 grade 11 students in 19 randomly allocated secondary schools. Data were
collected through structured questionnaires and analysed using the SPSS software package.
Results: The results confirm that knowledge levels were high for causes and spread of STIs and
the participants were well informed about issues relating to protection against STIs and seeking
treatment. However, there was significant deviation in reported behaviours. Conclusion: This
discrepancy between awareness and behaviour calls for a reorientation of sexuality education to
include those elements critical for behavioural change, such as addressing gender discrepancies
and promoting skills for communication through planned intervention programmes.
Method: This cross-sectional descriptive study was carried out among grade 11 students in the
Midlands district of the province of Kwa-Zulu–Natal (KZN), South Africa. The Midlands is a
district in one of the eight regions of KZN. It has both rural and urban dwellers and a largely
Zuluspeaking population. According to Bot et al. (4), most children, both boys and girls, in South
Africa attend school. However, before 1996 when compulsory education was introduced for
children under 16 y of age (7), children started school at varying ages depending on their social

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circumstances. Furthermore, those children whose education had been disrupted because of the
effect of the political climate at the time were allowed to go back to school. Hence the small
percentages of older people in schools. For the purposes of analysis, students over 22 y of age
were excluded from this study, resulting in a sample size of 1113 students out of the original 1168.
There are 27 secondary schools in this district with a total of 24276 students. Initially, 20 schools
were randomly allocated to participate in the study; however, 4 schools refused because of having
to write year-end examinations. These schools were replaced by a random selection of 4 schools
from the 7 schools that were originally left out but only 3 schools accepted, resulting in a total of
19 schools in the final sample. The schools comprised a mixture of rural and urban students. Two
classes were randomly selected from all the grade 11 classes at the sampled schools. All the
students from those two classes were included in the study. The schools had adequate
infrastructures in terms of buildings, classrooms and ablution facilities, but there was a scarcity of
recreational facilities at the schools and the surrounding areas. Since 1994 the South African
government has been making an effort to integrate schools in terms of “race”, as well as to redress
inequities owing to historical lack of resources among certain schools. The questionnaires were
completed individually by the students and were supervised by a fieldworker and researcher,
during a normal class lesson. The survey was conducted in English, the language used for
instruction at schools. Grade 11 students were selected as they had already had four years of high
school education in English and this ensured an adequate level of readability and understanding of
the questionnaire. Students were given as much time as they needed to complete the questionnaire
to allow for individual abilities. Time taken to complete the questionnaire varied between 30 and
50 min. To respect anonymity, students were requested not to write their names on the
questionnaires. They were only identifiable by numbers for the purposes of gathering data. Written
consent was obtained from the parents and the Department of Education. The students were also
given the opportunity to decide whether they were comfortable with participating in the study.
There were no refusals from the parents and only one learner refused to participate. The Faculty of
Medicine, Nelson R. Mandela Medical School, granted approval of the ethics for the study.

Abstract 3
Davies, HD., Adair, CE., Schuchat, A., Low, DE., Sauve, RS. and McGeer, A. (2001) Physicians'
prevention practices and incidence of neonatal group B streptococcal disease in 2 Canadian
regions. CMAJ 164 (4), 479-85.

Aim: The impact of expert guidelines on the prevention of neonatal group B streptococcal (GBS)
disease has not been studied in Canada. Our aim was to determine physician practices with regard

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to this condition before and after publication of Canadian guidelines and to monitor concurrent
trends in the incidence of neonatal GBS disease.
Methods: We used repeat cross-sectional surveys, distributed by mail to all family practitioners
and obstetricians attending deliveries in Alberta and in the Metropolitan Toronto and Peel region,
Ontario, in 1994, 1995 and 1997, to document prevention practices. Audits were conducted for a
subset of respondents to confirm reported practices. Population-based surveillance involving all
microbiology laboratories in both regions for 1995-1998 was used to document rates of neonatal
disease. All physicians providing obstetric care in Alberta (population 2 688 100, with 39 654 live
births in 1994) and the Metropolitan Toronto and Peel region, Ontario (population 3 124 554, with
49 054 live births), were identified by contacting all hospitals serving residents of these 2 areas in
1994. The lists of physicians were updated in 1995 and 1997. Surveys were conducted in 1994,
1995 and 1997. The surveys were distributed by means of 2 mailings and a reminder card.
Toronto physicians preferring anonymity could tear off an identifying number. All microbiology
laboratories serving residents of Alberta (n = 38) and the Metropolitan Toronto and Peel region (n
= 32) participated in active surveillance for invasive early-onset GBS disease, defined as isolation
of GBS from a normally sterile site in infants younger than 7 days of age. Monthly telephone calls
and annual audits were used to ensure that no cases were missed. A subset of 400 deliveries was
randomly selected from all births to mothers resident in Metropolitan Toronto and Peel region in
1995-1996. For each delivery, maternal and neonatal charts were reviewed, and abstracted data
were compared with reported practice of the care provider who had most responsibility for
prenatal care. All study elements were approved by the ethics boards of the Universities of
Calgary and Toronto. For Alberta data, generalized estimating equations were used to model
correlates of conformity to practice patterns, while adjusting for the correlations in data resulting
from the same individuals responding up to 3 times. This analysis could not be performed for the
Toronto data, because 25% of the surveys were returned anonymously. .
Results: The overall survey response rates were as follows: for 1994, 1128/1458 (77%); for 1995,
1054/1450 (73%); and for 1997, 1030/1421 (72%). The overall survey response rates were 77% in
1994 (675/884 [76%] for Alberta and 453/574 [79%] for Toronto), 73% in 1995 (651/888 [73%]
for Alberta and 403/562 [72%] for Toronto) and 72% in 1997 (655/855 [77%] for Alberta and
375/566 [66%] for Toronto). During 1995 and 1997, significantly more obstetric care providers
were screening at least 75% of pregnant women in their practices than had been the case in 1994
(747/916 [82%] and 693/812 [85%] v. 754/981 [77%]; p < 0.001). The percentage of obstetric care
providers who reported practice that conformed completely with any of 3 consensus prevention
strategies increased from 10% in 1994 to 29% in 1997 (p < 0.001). There was a concurrent overall
significant decrease in incidence of neonatal GBS disease during the same period. The adoption by

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Canadian obstetric care providers of neonatal GBS prevention practices recommended by expert
groups was slow but improved significantly over time. These findings highlight the difficulties
associated with achieving compliance with diverse and frequently changing recommendations.
However, the associated incidence of neonatal GBS disease, which was low or declining, suggests
that efforts to disseminate current GBS prevention guidelines have been moderately successful.
Family practitioners accounted for 89% of obstetric providers in Alberta and 64% in Toronto.
Most family practitioners (more than 94%) attended fewer than 100 deliveries annually, whereas
most obstetricians (more than 80%) attended more than 100 deliveries per year

Abstract 4
Brown, DR., Shew, ML., Qadadri, B., Neptune, N., Vargas, M., Tu, W., Juliar, BE., Breen, TE.
and Fortenberry, JD. (2005) A Longitudinal Study of Genital Human Papillomavirus Infection in a
Cohort of Closely Followed Adolescent Women. J Infect Dis.;191(2):182-92.

Aim: We performed a study to better characterize the natural history of genital human
papillomavirus (HPV) infection in a cohort of closely followed adolescent women.
Methods: A longitudinal study of sexual behaviour and STIs in 250 adolescent women is currently
under way. The current analysis was performed using data collected from the first 60 subjects who
have completed at least 2 full years of testing. All patients were evaluated under the main protocol,
which was approved by the local institutional review board. Adolescent women, aged 14–17 years
and attending 1 of 3 primary-care clinics in Indianapolis, were enrolled in a 27-month longitudinal
study. Inclusion criteria for the larger study, which were not modified for this analysis, included
that the adolescent be between the ages of 14 and 17 years, be able to understand English and give
written consent, not have any serious psychiatric disturbances or mental handicaps, and have a
parent who was able to give permission for their participation in the study. The adolescent did not
have to be sexually active to participate but could not be recruited if she were pregnant. As each
subject was enrolled, informed consent and parental consent were obtained. All participants
received financial remuneration for their time and efforts. Human-experimentation guidelines of
Indiana University School of Medicine were followed in the conduct of this research. All subjects
participated in quarterly visits (every 3 months) at their clinic site and in as many as 5 diary
collection periods of 3 months during the study. At the quarterly visits, subjects participated in
face-to-face interviews and underwent a pelvic examination for STI screening, including a cervical
cotton swab for HPV testing. Cervical cytological results were obtained at intervals of 6– 12
months and were determined by standard cytologic methods. Cervical cytological testing was not
performed on 3 subjects who did not report engaging in sexual intercourse. A cohort of 60

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adolescent women was followed over a 2.2-year period, on average. A median of 41.5 self-
collected vaginal and clinician-obtained cervical swabs were obtained from each subject.
Results: HPV was detected in 45.3% of all adequate specimens, by use of a polymerase chain
reaction/reverse blot strip assay. Oncogenic--or high-risk (HR)--HPV types were detected in
38.6% of specimens, and nononcogenic--or low-risk (LR)--types were detected in 19.6% of
specimens. During the entire study period, 49 of 60 subjects tested positive for HPV (cumulative
prevalence, 81.7%). The most frequently detected HR types were HPV types 52, 16, and 59.
Infections with multiple HPV types were common. The median duration of persistence of a
specific HPV type was 168 days, and HR types were more persistent than LR types. Abnormal
cervical cytological results occurred in 37% of the adolescent women and were significantly
associated with HR HPV infection. The cumulative prevalence of HPV infection in sexually active
adolescent women is extremely high, involves numerous HPV types, and frequently results in
cervical dysplasia.

Abstract 5
Mitchell, R. and Haddrill, K. (2004) From the bush to the beach: water safety in rural and remote
New South Wales. The Australian Journal of Rural Health 12 (6), 246-50.

Aim: To describe the types of aquatic locations attended by residents of rural and remote New
South Wales (NSW), to record self-reported water safety-related behaviour, and identify preferred
communication mediums for water safety messages.
Methods: A stratified random telephone survey was conducted of 500 NSW residents aged greater
than 15 years residing in moderately accessible, remote and very remote locations in NSW. A
stratified random sample of 500 NSW residents residing in moderately accessible (300
interviews), remote (100 interviews) and very remote (100 interviews) locations based on scores
higher than 3.51 on the Accessibility /Remoteness Index of Australia (ARIA)9 were selected from
the NSW white pages telephone directory during 26 March to 22 April 2002 and a further
selection was made of persons aged over 15 years within each household, based upon the most
recent birthday. The survey asked respondents to identify the type of water-related locations they
attended (e.g. dam, lake or beach) in the last 6 months, how often they attended these locations,
and for what length of time. Preferred communication mediums for the receipt of water safety
information were also canvassed, along with access to the Internet and Internet usage.
Demographic details collected included sex, age group, number of people and number of children
less than 5 years living in the household, postcode and highest level of education completed.
Visitation to property by children less than 5 years of age in the past 3 months was also recorded.

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The survey was administered through a Computer Aided Telephone Interviewing (CATI) system.
It took around 10 min to complete and was piloted before use. Up to six call-backs were conducted
for each telephone number. If an answering machine was reached interviewers left a scripted
message asking respondents to call a 1800 free-call telephone number.
Results: Results indicate that around two-thirds of respondents had been in or on the water at a
pool, beach, lake, river or dam in the past 6 months. The most common type of aquatic facilities
used were rivers, creeks or streams (53.5%), beaches (45.7%), public pools (45.5%), private pools
(40.7%), dams (40.6%) and lakes (27.0%). Time spent at each of these locations and time of day
each location was visited varied. Overall, the majority of respondents reported practicing water-
related safe behaviour. Preferred communication mediums for water safety messages included
television, schools and newspapers. Water safety education, especially in relation to beach
conditions, remains just as important a topic for public health authorities and key water safety
agencies in regional and remote NSW as it is in coastal suburbs. Responses from the survey, along
with key stakeholder advice, will be used to inform the development of appropriate strategies
aimed to reduce drowning deaths in rural and remote locations in NSW.

Abstract 6
Parslow, RA., Jorm, AF., Christensen, H., Rodgers, B. and Jacomb, P. (2005) Pet ownership and
health in older adults: findings from a survey of 2,551 community-based Australians aged 60-64.
Gerontology. 51 (1); 40-7.

Aim: It is commonly assumed that owning a pet provides older residents in the community with
health benefits including improved physical health and psychological well-being. It has also been
reported that pet owners are lower on neuroticism and higher on extraversion compared with those
without pets. However, findings of research on this topic have been mixed with a number of
researchers reporting that, for older people, there is little or no health benefit associated with pet
ownership. To identify health benefits associated with pet ownership and pet caring
responsibilities in a large sample of older community-based residents.
Methods: Using survey information provided by 2,551 individuals aged between 60 and 64 years,
we compared the sociodemographic attributes, mental and physical health measures, and
personality traits of pet owners and non-owners. For 78.8% of these participants, we were also
able to compare the health services used, based on information obtained from the national insurer
on the number of general practitioner (GP) visits they made over a 12-month period. The PATH
Through Life Project is a longitudinal study of 3 age groups of residents living independently in
the community in the Australian Capital Territory and the neighbouring town of Queanbeyan,

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New South Wales. The present study focuses on the oldest age group of participants who were
aged between 60 and 64 years on January 1, 2001. Potential participants were drawn from the
Australian Electoral Rolls for Canberra and Queanbeyan. Enrolment on these rolls is compulsory
for Australian citizens aged 18 and over. All potential respondents were initially sent a letter
explaining the purpose of the research, and, if willing to participate, were then interviewed by
professionally trained interviewers. Answers to most questions, including those being considered
for this study, were self-entered by the participants into a hand-held computer under the
supervision of the interviewer who provided assistance in use of the computer when required. The
number of potential participants found and confirmed to be in the required age group was 4,378, of
whom 2,551 participated, giving a response rate of 58.3%. Information on participants’ visits to
GPs was also obtained. In Australia, the costs of all health care visits made to medical
practitioners by Australians with citizenship or residency status are subsidized, either partly or
totally, through the government funded universal health insurance scheme, Medicare. Information
on the number of visits made is collected by the Health Insurance Commission. These data are
used for administrative purposes and identify the type of medical practitioner providing the
service, but not the health problems addressed during a visit. All participants were asked if they
would consent to the researchers being provided information on the number of visits they made to
GPs for specified periods before and after their interview. For the 2,010 (78.8%) who consented,
information was then obtained from the Health Insurance Commission on the number of GP visits
they had made in the 6 months preceding and the 6 months following their being surveyed.
Results: Compared with non- owners, those with pets reported more depressive symptoms while
female pet owners who were married also had poorer physical health. We found that caring for a
pet was associated with negative health outcomes including more symptoms of depression, poorer
physical health and higher rates of use of pain relief medication. No relationship was found
between pet ownership and use of GP services. When we examined the personality traits of pet
owners and carers, we found that men who cared for pets had higher extraversion scores. Our
principal and unexpected finding, however, was that pet owners and carers reported higher levels
of psychoticism as measured by the Revised Eysenck Personality Questionnaire. We conclude that
pet ownership confers no health benefits for this age group. Instead, those with pets have poorer
mental and physical health and use more pain relief medication. Further, our study suggests that
those with pets are less conforming to social norms as indicated by their higher levels of
psychoticism.

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