Cross-Sectional Studies and Measures of

Disease Occurrence and Association

by: Dr. Dick Menzies

June 13th, 2005
 Cross-Sectional or Prevalence Studies

The basic concept of this study is that it is a

snap shot of disease and exposures at a single
moment in time in a population
In some ways it could be thought of as a form of
case control study since one looks at disease
that has already occurred and at exposures in
persons with/without disease at the same time.
The main difference is the strategy used to
identify controls
 Uses
1. Define risk factors for a disease in question
1. Personal demographic,Life style
Medical (lipids, BP, other meds)
Environmental or occupational risk factors
2. Define the prevalence of a condition in a population and
prevalence of major determinants
This can help to define the true population impact of a
determinant or exposure.
Useful for Health policy, planning health services
utilization, public health programmes
 Limitations of Prevalence Information

Not useful for

Etiologic research (cannot be sure of cause and effect)
Temporal trends increasing prevalence may reflect greater
incidence, or longer duration (better survival), or changes in
population (aging, or selective in or out-migration)
Problems of cross-sectional surveys in general
Higher prevalence may be associated with factors because:
Causes higher incidence of disease =.BAD
Or, cause longer duration (lower mortality) = GOOD
 Diseases best studied

Diseases studied should be reasonably common, ie

high prevalence
Otherwise will study too many controls without condition
this is inefficient
Chronic disease with long duration (Higher prevalence)
Or, acute disease with very high incidence
 Study Population

Population can be general - ie without specific

exposures, or selected on basis of specific
exposures
1. True general population samples
This type of sampling is difficult and so not done commonly:
One method is random digit dialing (telephone list) or random
household selection (using mapping technology such as GIS)
Also technique of staged cluster sampling
Must have a complete list of persons, and/or communities
from which to select sample
 Study Population

Proxy of General Population (easier to access)

School populations
Primary school will be more complete than high school
Requires 90-100% of children in school to be representative -
but still ignores older, younger, child-less
Certain work-forces - eg Electricians, Nurses
Are not as representative of total population (age, SES,
education, healthy worker effect)
But still can be used to study non-occupational determinants -
And useful to study specific occupational determinants (TB)
 Study Population - Exposure based
selection
Workforce Studies
Workforce studies for occupational exposures
eg Asbestos workers and Lung Ca or mesothelioma
Health care workers and TB
But healthy worker effect
And some characteristics might be quite specific to
work force
Special Populations
Prisoners, military, mental institutions
Useful for studying selected exposures in these
populations
 Study Population - Sampling
Census survey - means survey all of the population
Feasible if - you are the government
or - you have a small group
If have to sample - how will you do this?
Select sample of units or population groups (cluster
sampling)
Need a list of all units, and size of each
Take all persons in selected units
Eg., workers on certain wards in a hospitals or
floors in office buildings
Random selection of all workers - then you need a
complete list - and a method of random selection
 Study methods - Detecting the disease
In a Prevalence survey one sets out to detect/diagnose all
prevalent cases of disease
1. Need a clear case definition because:
Will often detect mild or asymptomatic cases
Impact and importance of these less clear
2. Need a method to diagnose
Questionnaire - Have you been diagnosed with ?
Will this be valid??
Direct diagnosis - sero-prevalence, diabetes, lipids, TST
Will this be practical, feasible, acceptable
What will it cost?
Is the testing method valid?
 Exposure Assessment
The major weakness in cross-sectional studies
If long latency exposure can change or be forgotten
Measuring current exposures most accurate
Or easily remembered and objective
Eg. smoking history
Pregnancies and children
Occupation
Subject to recall bias
Cases with disease remember exposures better
Or have been prompted to remember by their doctors
This can be overcome if measuring disease at time
of survey, and questionnaires about exposures are
administered before disease status known.
Measures of Disease Occurrence - 1. Prevalence

Prevalence = number of persons with condition

or disease at a given point in time
Prevalence is really a ratio
Numerator = number of persons with disease
Denominator = all persons in population
Prevalence can be expressed as:
At a given point in time - eg, January 1st, 2004
Or on entry to university or military service
Or can be for a period or time, eg., prevalence
during medical school or a five year period of time
 Specific definitions
Prevalence (P) = Persons with disease/Total
population this is a ratio (NOT A RATE)
Point Prevalence = number of persons with
disease at a specific point in time
Period Prevalence = number of persons with
disease during a specific period of time
Annual Prevalence = number of persons with
disease over one year.
Sero-Prevalence = number of persons with
serologic evidence of disease or infection or
exposure
 Measures of disease association
1. Prevalence Odds Ratio
In a prevalence survey, 60 individuals were found to
have diabetes out of 1,000 surveyed

Obesity Not Obesity Totals

Diabetes 27 33 60
No Diabetes 200 740 940

Prevalence of diabetes total = 6%

Prevalence of diabetes among obese persons =
27/200 = 13.5%
Prevalence of diabetes in non obese persons =
33/773 = 4.3%
 Prevalence Odds Ratio, contd
Obesity Not Obesity Totals
Diabetes 27 33 60
No Diabetes 200 740 940

Express the findings as prevalence odds

i.e., odds of exposure if disease
or, odds of obesity if diabetes = 27/33 = 0.81
Odds of obesity if not diabetes = 200/740 = 0.27
Prevalence odds ratio (POR) = 0.81/0.27 = 3.0
For cross-sectional or prevalence studies the
prevalence odds ratio is the same as the ratio of the
prevalence of disease in persons with and without the
risk factor
Measures of Disease Occurrence - 2. Incidence
The incidence is the number of persons who develop a
given disease in a population initially free of disease in a
defined amount of time.
Numerator = persons with newly developed disease
Denominator = persons who did not have the disease at the
beginning of the period of study
There must be a unit of time
Per week, per month, per year
This gives you a rate.
Births and deaths are a form of incidence
Birth rate, mortality rate
 Relationship between Incidence and
Prevalence
Prevalence = incidence x duration
This holds ONLY when:
Incidence is stable
Duration is also stable
These conditions are often not true
Eg., HIV incidence is changing
Duration is also changing with new effective
therapy
 Types of Incidence and Prevalence
Measures
Rate Type Numerator Denominator

Mortality rate Incidence Number of deaths from Person-years at risk in

a disease (or all causes) the population

Infant mortality rate Incidence Number of deaths in a N. Live births in the

year of children less same period, usually
than 1 year of age per 1,000 annually
Case-fatality rate Incidence Number of deaths from Number of cases with
a disease that disease
Attack rate Incidence Number of new cases of Total population at risk,
a disease for a limited period of
observation

Period prevalence Prevalence Number of existing plus Total population (at

all new cases during risk)
given time period
 Measures of Disease Association
2. Odds Ratios

Summary measure of disease association in

case control studies
General formula:
odds of exposure given disease
odds of exposure given no disease

This format is used because case control

studies identify subjects on the basis of
disease status, and then measure exposures
 Calculation of Odds Ratio - example

60 females with lung cancer = cases

60 females selected without lung cancer = controls
Exposure in question is current smoking

Smokers Non Smokers Totals

Lung Cancer (cases) 41 19 60

No lung cancer (controls) 28 32 60

 Calculation of Odds Ratio - example

Smokers Non Smokers Totals

Lung Cancer (cases) 41 19 60

No lung cancer (controls) 28 32 60

Odds of smoking if cancer = 41/19 = 2.16

Odds of smoking if no cancer = 28/32 = 0.875
ODDS RATIO of smoking if lung cancer
= 2.16 / 0.875 = 2.5
 Measures of Association:
2. Risk Ratios

Summary measure of association in Cohort Studies

Formula:
risk of disease in persons with exposure
risk of disease in persons without exposure

Fundamental concept in cohort studies:

1. classify persons on the basis of exposure
2. follow to measure the incidence (or risk) of
disease during follow-up.
 Calculation of Risk Ratio - example

Cohort at inception: 1,000 people without diabetes

Prevalence of obesity at inception = 22.7%
Outcome: Incidence of diabetes in a population
Exposure - obesity at inception of cohort
Follow-up - six years
Overall incidence of diabetes = 1% per year
Cumulative Incidence = 6%
 Risk Ratio Calculation in Cohort Study
Example

Number with Developed Cumulative

exposure Diabetes Incidence rate

Obese 227 27 27/227

Non Obese 773 33 33/773
Total 1,000 60

Ratio of Incidence = risk ratio = 27/227 / 33/773

= 12 / 4
= 3.0