Study Designs: Cross-Sectional Studies, Ecologic Studies (And Confidence Intervals)

Principles of Epidemiology for Public Health (EPID600)
Study designs: Cross-sectional studies,

ecologic studies (and confidence intervals)
Victor J. Schoenbach, PhD home page
Department of Epidemiology
Gillings School of Global Public Health
University of North Carolina at Chapel Hill
www.unc.edu/epid600/
2/22/2011 Cross-sectional studies 1

Signs from around the world
In a Copenhagen airline ticket office:
“We take your bags and send them in all

directions.”
2
In a Norwegian cocktail lounge:
“Ladies are requested not to have

children in the bar.”
3
Rome laundry:
“Ladies, leave your clothes here and
spend the afternoon having a good time.”
4
Faster keyboarding - 1
I cdnuolt blveiee taht I cluod aulaclty uesdnatnrd waht I
was rdanieg. The phaonmneal pweor of the hmuan mnid,
aoccdrnig to a rscheearch at Cmabrigde Uinervtisy. It
dn'seot mttaer in waht oredr the ltteers in a wrod are, the
olny iprmoatnt tihng is taht the frist and lsat ltteer be in
the rghit pclae. The rset can be a taotl mses and you can
sitll raed it wouthit a porbelm.
• Gary C. Ramseyer's First Internet Gallery of Statistics
Jokes http://davidmlane.com/hyperstat/humorf.html (#162)
5
Faster keyboarding - 2
Most of my friends could read this with understanding
and rather quickly I might add. Then I had them read a
statistical bit of literature:
• Miittluvraae asilyans sattes an idtenossiy ctuoonr
epilsle is the itternoiecsno of a panle pleralal to the xl-
yapne and the sruacfe of a btiiarave nmarol
dbttiisruein.
Gary C. Ramseyer's First Internet Gallery of Statistics Jokes
http://davidmlane.com/hyperstat/humorf.html (#162)
6
Principles of Epidemiology for Public Health (EPID600)
Study designs: Cross-sectional studies,

ecologic studies (and confidence intervals)
Victor J. Schoenbach, PhD home page
Department of Epidemiology
Gillings School of Global Public Health
University of North Carolina at Chapel Hill
www.unc.edu/epid600/

Today – outline
• Cross-sectional studies (and sampling)

• Ecologic studies
• Confidence intervals

Cross-sectional studies
• Cross-sectional studies include surveys
• People are studied at a “point” in time, without
follow-up.
• Can combine a cross-sectional study with follow-up
to create a cohort study.
• Can conduct repeated cross-sectional studies to
measure change in a population.

• Number of uninsured Americans rises to 50.7
million. (USA Today, 9/17/2010; data from Census Bureau)
• In 2007-2008, almost one in five children older than
5 years was obese. (Health, United States, 2010; data from
the National Health and Nutrition Examination Survey)
• 35% (~7.4 million) of births to U.S. women during

the preceding 5 years were mistimed or unwanted
(2002 National Survey of Family Growth, Series 23, No. 25, Table 21)
[Source: www.cdc.gov/nchs/]

• Incidence information is not available from a typical
cross-sectional study
• Sometimes can reconstruct incidence from historical
information
• Example: the incidence proportion of quitting
smoking, called the “quit ratio”:
ex-smokers / ever-smokers
is calculated from survey data.

Measure prevalence at “point” in time
• “Snapshot” of a population, a “still life”
• Can measure attitudes, beliefs, behaviors, personal or
family history, genetic factors, existing or past health
conditions, or anything else that does not require follow-
up to assess.
• The source of most of what we know about the
population

Population census
• A cross-sectional study of an entire
population
• Provides the denominator data for
many purposes (e.g., estimation of
rates, assessing generalizability,
projecting from smaller studies)
• A huge effort – people can be difficult to
find and to count; may not want to
provide data
• Some countries maintain accurate and
current registries of the entire country

National surveys conducted by NCHS
National Health Interview Survey (NHIS) –
household interviews
National Health and Nutrition Examination
Survey (NHANES) – interviews and physical
examinations
National Survey of Family Growth (NSFG) –
household interviews
National Health Care Survey (NHCS) –
medical records
National surveys
• Designed to be representative of the entire country
• Modes: household interview, telephone, mail
• Employ complex sampling designs to optimize efficiency
(tradeoff between information and cost)
• Logistically challenging (answering machines, cellphones, . . .)
See presentation by Dr. Anjani Chandra at
www.minority.unc.edu/institute/2003/materials/slides/Chandra-20030522.ppt

Example: National Health Interview Survey
• Conducted every year in U.S. by National

Center for Health Statistics (CDC)
• “Stratified, multistaged, household survey
that covers the civilian noninstitutionalized
population of the United States”
• Redesigned every decade to use new
census

“multistaged”
• Improves logistical feasibility and reduces costs

(though reduces precision)
1. Divide population into primary sampling units
(PSU’s)
PSU = primary sampling unit: metropolitan statistical

area, county, group of adjacent counties

“multistaged”
2. Select sample of census block groups (SSU’s)
within each selected PSU
3. Map each selected census block group or
examine building permits
4. Select one cluster of 4-8 housing units
dispersed evenly throughout the block
NCHS draws a new representative sample for
each week’s interviews
“stratified”
• US divided into 1,900 PSU’s
• Largest 52 PSU’s are “self-representing”
• Rest of PSU’s divided into 73 categories (“strata”),
based on socioeconomic and demographic variables
• Sampling takes place separately within each category
(“stratum”)

Sample size and Precision
Sample Lower Point Upper

size 95% estimate 95% Width
100 0.17 0.25 0.33 0.16
400 0.21 0.25 0.29 0.08
900 0.22 0.25 0.28 0.06
1600 0.23 0.25 0.27 0.04
0.25 0.188 0.43301
Weighted sampling
Hypothetical Unweighted Weighted

Age group Pop (1,000's) Sample Sample
20-39 yrs 18,000 900 400
40-59 yrs 18,000 900 400
60-69 yrs 8,000 400 400
Total 44,000 2,200 1,200

“stratified”
• Also place census blocks into categories and

sample within each
• Oversample some strata

“Defined population”
• Studies, especially cross-sectional studies, are easiest to
interpret when they are based in a population that has some
existence apart from the study itself (“defined population”)
1. Political subdivision (city, county, state)
2. Institutional (HMO, employer, profession)
• Probability sampling enables statistical generalizability to
the defined population

Surveys of sentinel populations
• HIV seroprevalence survey in three county STD

clinics in central NC in 1988
• 3,000 anonymous, unlinked, leftover sera
• Anonymous questionnaire for demographics
and risk factors
[Schoenbach VJ, Landis SE, Weber DJ, Mittal M, Koch GG, Levine PH. HIV
seroprevalence in sexually transmitted disease clients in a low-prevalence southern
state. Ann Epidemiol 1993;3:281-288]

HIV seroprevalence
Group % HIV+
Homosexual men 46
Bisexual men 25
Heterosexual men 1.6
Women 0.6
Total 2.5
seroprevalence in sexually transmitted disease clients in a low-prevalence southern
state. Ann Epidemiol 1993;3:281-288]

Seroprevalence (% HIV+) by risk factors
Characteristic Gay Hetero Women
Syphilis 53 9.0 3
(history/current)
Gonorrhea (history) 37 2.6 1
Anal intercourse 41 1.7 2
Paid for sex 5.2
seroprevalence in sexually transmitted disease clients in a low-prevalence southern state.
Ann Epidemiol 1993;3:281-288]

Interpretation
• Measures prevalence – if incidence is our
real interest, prevalence is often not a good
surrogate measure
• Studies only “survivors” and “stayers”
• May be difficult to determine whether a
“cause” came before an “effect” (exception:
genetic factors)
Other points
• Can choose by exposure or overall

• Can choose by disease – may not be
distinguishable from a case-control study with
prevalent cases

Outline


“Ecologic” studies
• Most study designs – cross-sectional, case-
control, cohort, intervention trials – can be carried
out with individuals or with groups
• Group-level studies which use routinely collected
data are easier and less costly
• Group-level studies that involve interventions
may not be easier or less costly

Types of group-level variables
• Summary of individual-level variable (e.g.,

median household income, % with high
school diploma)
• Property of the aggregate (e.g.,
neighborhood grocery stores, seat belt
legislation, “community competence”)

Interpretation
• Link between summary exposure variable and

individual-level outcome must be inferred
• Inference from group to individual is not
always sound

Example: Male Circumcision and HIV
(Slope indicates strength of relationship;

r indicates linearity)
Source: Bongaarts J, et al. The relationship between male circumcision and HIV infection in African populations. AIDS 1989; 3(6): 373-7.

Outline


Confidence intervals
• Provide a plausible range for the quantity
being estimated
• Width indicates the precision of an estimate
for a given level of “confidence”
• Confidence intervals quantify only random
error from sampling variation, not systematic
error from nonresponse, study design, etc.

Confidence level vs. precision
• The more vague my estimate, the more
confident I can be that it includes the
population parameter: “I am 100%
confident that the prevalence of HIV is
between 0 and 100%”.
• The more specific my estimate, the lower
my confidence: “I am 0% confident that
the prevalence of HIV is 5.23%”
Confidence intervals – interpretation
• Simple interpretations are typically not

precise
• Precise interpretations are typically not
simple

Simple but imprecise
• “There is 95% confidence that the interval

contains the true value”
– True, but begs the question – how to

define “confidence”

Simple but imprecise
• “There is a 95% probability that the interval

contains the true value”
– Not quite correct: probability (as

conventionally defined) applies to a process,
not to a single instance

Probability applies to a process: example
A 95% confidence interval can be viewed as a
measurement or estimation process that will
be correct (the interval includes the true
value of the parameter) 95% of the time and
incorrect 5% of the time.
Let us make up another estimation process
that will be correct (about) 95% of the time.

Why probability applies to a process
• Estimate your gender by flipping a coin 5 times -
if the result is 5 heads estimate your gender to
be its opposite; otherwise estimate your gender
to be what you think it is now.
• Probability that estimate will be correct is
(1 – Probability of 5 heads) = 0.97 = 97%
• Probability that estimate will be incorrect is 3%
Why probability applies to a process
So we now have a measurement process that
will be correct 97% of the time. We will use it
to measure your gender.
Flip the coin 5 times, and suppose you get 5
heads
– Is there a 97% probability that you are of the
opposite sex?
Precise but not simple
A 95% confidence interval is:
1. obtained by using a procedure that will include
the population parameter being estimated 95%
of the time
2. the set of all population values which are “likely”
to yield a sample like the one we obtained

Suppose that this line represents the value
of the parameter we are trying to estimate
True value

Possible estimates of that parameter in N
identical studies (shows sampling variation)
o
Study estimates oo
oooo
True value
oooooo
oooooooo
oooooooooo
o o ooooooooooo o
oo o ooooooooooooooooo o o

One possible “true” value and how it would
manifest, on average, in N identical studies
o
oo
oooo True value
oooooo
oooooooo
oooooooooo
o o ooooooooooo o
95% of the distribution
Estimate from one study of a given size
?
Estimate

A possible “true” value with < 2.5% chance of
being observed at or beyond the estimate
?
o
oo Estimate
oooo
oooooo
oooooooo
oooooooooo
o ooooooooooo o
ooooooooooooooo o o
A possible true value with > 2.5% probability
of being observed at or beyond the estimate
?
o
oo Estimate
oooo
oooooo
oooooooo
oooooooooo
o o ooooooooooo o
oooooooooooooooo o o
A possible true value with > 2.5% probability
of being observed at or beyond the estimate
?
o
Estimate oo
oooo
oooooo
oooooooo
oooooooooo
o o ooooooooooo o
oo o ooooooooooooooo
A possible true value with < 2.5% probability of
being observed at or beyond the estimate
?
o
Estimate oo
oooo
oooooo
oooooooo
oooooooooo
o o ooooooooooo
oo o oooooooooooooo
What the confidence interval represents
o
o ? oo
o
oo ooo o o
oo
oooo oooooo o o
oooo
oooooo oo
oo oooooo o o
oooooo
oooooooo oooo
oooooooooo o o
oooooooo
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o oo oo
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o ooooooooooo o oo
oooo
oooooooooooo
oo o
o ooooooooooo o oo o ooo
ooooooooooooooo o o o o ooooooooooo o
oooooooooooooooo o o
oo o ooooooooooooooo
95% confidence interval
What the confidence interval represents
o o o
ooo o o o
oo oo oo
oooo o o oo
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ooo ooo o o o o o o oo o o o o o o o oo ooooo
ooo oooooooo o o o o o o o o o o o o o oo o ooooooooo
ooo oo oooooooo ooo o o o o o o o o o o oo o ooooooooo o
o oo
ooo o o o o o o o o o oooooooooo
o o oo o o o oo o
ooo o oo o o o o o o oo o o o o oo oo o o
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ooo ooo o o o o
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o ooo oo oo o o o o o oo oo ooo o
oo o o o o o o o o o o o o o
o o o o o o o o o o o o o o ooo o o ooo o o o o o o o o o
o o o o o o o o o o o o o o o o o o o o o o o o o o oooo oo oo oo oo
95% confidence interval
o
oo
oooo True value
oooooo
oooooooo
oooooooooo
o o ooooooooooo o
1.96 x s.e. | 1.96 x s.e.
Confidence intervals – another take

One possible population
O

Another possible population
O

A 3rd possible population
O

A 4th possible population
O

O

O
O

O

O

etc.

O

O

O

O

There are 1.6 x 1060 possible populations
(no cases all cases)

O

O

O

O
Suppose this is the population
(prevalence = 15%)
O
O O
O O OO

O O O

O O O O

O O O O

O O O O

O O O O O

O O O

Take a sample (n=10)
O
O O
OO OO

O O O

O O O O

O O O O

O O O O

O O O O O

O O O

The sample

O

O

Make point estimate of prevalence

O

O

Interval estimate
• What are all the possible populations that

would be expected to yield this prevalence
in a sample of size 10?

This one is not possible
O

Possible, but VERY UNLIKELY
O

O

Not quite 2.5% probability (2.1%, in fact)
O
O

O

O
O

Yields just about 2.5% (3%, actually) probability of
selecting 2 (or more) cases in 10
O
O

O

O O
O

o
oo
oooo True value
oooooo
oooooooo
oooooooooo
o o ooooooooooo o
Just above 2.5% (actually 2.6%) probability of
selecting 2 (or fewer) cases in 10
O OO OO O O OOO O O

O O OO OO OOOOO O OO OO

O O O OO OO O O OO OO O

OO O OO O O O O OO

O O O O O O O OO O OO O

OO OO O OO O OO O O O

O O OO OOO O OO O OO

O O O O OOO OO OOO O

Just below 2.5% (actually 2.4%) probability of
selecting 2 (or fewer) cases in 10
O OO OO OO O OOO O O

O O OO OO O OOO O OO O OO

O O O OO OO O O OO OO O

OO O OO O O OO O O

O O O O O O O OO O OO O

OO OO OO OO O OO O O O

O O OO O O O OO O OO

OO O OO O OOO OO OOO O

Interval estimate for 2/10
• Lower bound: 2.5% (5 cases)
• Upper bound: 55% (110 cases)
Meaning: Our sample of 10 with 2 cases provides
evidence to exclude, at conventional error
tolerance, populations with fewer than 5 cases or
more than 110 cases. Populations with 5-110
cannot be excluded as likely sources for this
sample.
Interval estimate for 2/10
• Actual population prevalence was 15%,

which in fact is between 2.5% and 55%.
• 2.5% to 55% is a very wide interval, i.e.,
a very imprecise estimate
• To make it more precise, we need a
larger sample

Signs from around the world – Germany
“A sign posted in Germany's Black Forest:

It is strictly forbidden on our black forest
camping site that people of different sex, for
instance, men and women, live together in
one tent unless they are married with each
other for that purpose.”
78
Signs from around the world – Finland
On the faucet in a Finnish washroom:
“To stop the drip, turn cock to right.”
79

Study Designs: Cross-Sectional Studies, Ecologic Studies (And Confidence Intervals)

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Principles of Epidemiology for Public Health (EPID600)

Study designs: Cross-sectional studies,

Victor J. Schoenbach, PhD home page

2/22/2011 Cross-sectional studies 1

In a Copenhagen airline ticket office:

“We take your bags and send them in all

In a Norwegian cocktail lounge:

“Ladies are requested not to have

Study designs: Cross-sectional studies,

Victor J. Schoenbach, PhD home page

2/22/2011 Cross-sectional studies 7

• Cross-sectional studies (and sampling)

10/15/2001 Cross-sectional studies 8

2/10/2009 Cross-sectional studies 9

• 35% (~7.4 million) of births to U.S. women during

2/22/2011 Cross-sectional studies 10

2/10/2009 Cross-sectional studies 11

10/15/2001 Cross-sectional studies 12

2/22/2011 Cross-sectional studies 13

2/22/2011 Cross-sectional studies 15

• Conducted every year in U.S. by National

10/15/2001 Cross-sectional studies 16

• Improves logistical feasibility and reduces costs

PSU = primary sampling unit: metropolitan statistical

2/10/2009 Cross-sectional studies 17

10/15/2001 Cross-sectional studies 19

Sample Lower Point Upper

Hypothetical Unweighted Weighted

3/6/2006 Cross-sectional studies 21

• Also place census blocks into categories and

10/15/2001 Cross-sectional studies 22

2/10/2009 Cross-sectional studies 23

• HIV seroprevalence survey in three county STD

2/22/2011 Cross-sectional studies 24

10/15/2001 Cross-sectional studies 25

10/14/2003 Cross-sectional studies 26

• Can choose by exposure or overall

10/15/2001 Cross-sectional studies 28

• Cross-sectional studies (and sampling)

10/15/2001 Cross-sectional studies 29

10/15/2001 Cross-sectional studies 30

• Summary of individual-level variable (e.g.,

3/6/2006 Cross-sectional studies 31

• Link between summary exposure variable and

2/22/2011 Cross-sectional studies 32

(Slope indicates strength of relationship;

2/22/2011 Cross-sectional studies 33

• Cross-sectional studies (and sampling)

10/15/2001 Cross-sectional studies 34

3/8/2006 Cross-sectional studies 35

• Simple interpretations are typically not

10/12/2004 Cross-sectional studies 37

• “There is 95% confidence that the interval

– True, but begs the question – how to

10/15/2001 Cross-sectional studies 38

• “There is a 95% probability that the interval

– Not quite correct: probability (as

10/15/2001 Cross-sectional studies 39

3/7/2006 Cross-sectional studies 40

2/22/2011 Cross-sectional studies 43

10/15/2001 Cross-sectional studies 44

10/15/2001 Cross-sectional studies 45

10/15/2001 Cross-sectional studies 47