1. DrugEpi 3-1 Associations and the 2x2 Table Module 3 Introduction Content Area: Analytical Epidemiology Essential Question (Generic): Is there an association between the hypothesized cause and the disease? Essential Question (Drug Abuse Specific): Is there an association between the hypothesized cause and drug use? Enduring Epidemiological Understanding: Causal hypotheses can be tested by observing exposures and diseases of people as they go about their daily lives. Information from these observational studies can be used to make and compare rates and identify associations. Synopsis In Module 3, students explore how hypotheses are tested epidemiologically. Students begin to uncover and develop the following epidemiological concepts and skills: the meaning of the term “association;” the need for a control group; uses of the 2x2 table in calculating risks and relative risks; experimental study design; the importance of ethics in human research; observational study designs used in epidemiology; and the strengths and limitations of each design. Lesson 3-1: Associations and the 2x2 Table Lesson 3-2: Experimental Study - Buprenorphine Example Lesson 3-3: An Actual Randomized Controlled Trial Lesson 3-4: Observational Studies of Natural Experiments - Sensation-Seeking Example Lesson 3-5: Fundamentals of Study Design Lesson 3-6: Study Design Exercises

2. DrugEpi 3-1 Associations and the 2x2 Table Module 3 - Analytical Epidemiology Lesson 3-1 Associations and the 2x2 Table Content Introduction to the concept of “association” Diagram and explanation of descriptive versus analytical epidemiology and how each relates to hypothesized associations Introduction to the 2x2 table and its use in testing hypotheses Practice in labeling and understanding the 2x2 table with examples of hypothesized associations Big Ideas An association is when two things “turn up together” Epidemiologists study associations Descriptive epidemiology generates hypotheses about associations and analytical epidemiology tests hypotheses about associations The 2x2 table is a tool used to express the numbers of people with and without the exposure and with and without the outcome. In this way it includes controls. This project is supported by a Science Education Drug Abuse Partnership Award, Grant Number 1R24DA016357-01, from the National Institute on Drug Abuse, National Institutes of Health.

3. DrugEpi 3-1 Associations and the 2x2 Table 1.How is this disease distributed? Health-related conditions and behaviors are not distributed uniformly in a population. They have unique distributions that can be described by how they are distributed in terms of person, place, and time. 2.What hypotheses might explain the distribution of disease? Clues for formulating hypotheses can be found by observing the way a health-related condition or behavior is distributed in a population. 3.Is there an association between the hypothesized cause and the disease? Causal hypotheses can be tested by observing exposures and diseases of people as they go about their daily lives. Information from these observational studies can be used to make and compare rates and identify associations. 4.Is the association causal? Causation is only one explanation for an association between an exposure and a disease. Because observational studies are complicated by factors not controlled by the observer, other explanations also must be considered. 5.What should be done when preventable causes of disease are found? Policy decisions are based on more than the scientific evidence. Because of competing values - social, economic, ethical, environmental, cultural, and political factors may also be considered. Essential QuestionsEnduring Understandings Where are we?

4. DrugEpi 3-1 Associations and the 2x2 Table Association Found Between Coffee and Pancreatic Cancer … associated with each other

5. DrugEpi 3-1 Associations and the 2x2 Table Handout Association Found Between Coffee and Pancreatic Cancer

6. DrugEpi 3-1 Associations and the 2x2 Table 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 with each other

7. DrugEpi 3-1 Associations and the 2x2 Table Things that are associated are linked in some way that makes them turn up together. Things That Turn Up Together

8. DrugEpi 3-1 Associations and the 2x2 Table 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 Things That Turn Up Together

9. DrugEpi 3-1 Associations and the 2x2 Table Review - Descriptive Epidemiology Descriptive epidemiology can generate hypotheses about associations Epidemiologic studies that are concerned with characterizing the amount and distribution of health and disease within a population

10. DrugEpi 3-1 Associations and the 2x2 Table New Topic - Module 3 is about Analytical Epidemiology Analytical epidemiology can test hypotheses about associations Epidemiologic studies that are concerned with determinants of disease and the reasons for relatively high or low frequencies of disease in specific population subgroups

11. DrugEpi 3-1 Associations and the 2x2 Table Hypothesis about associations Generate Descriptive Epidemiology Test Analytical Epidemiology An unproven idea, based on observation or reasoning, that can be supported or refuted through investigation An educated guess Hypotheses in epidemiology are statements that suggest associations between an exposure and an outcome Epidemiology and Associations (This connects everything)

12. DrugEpi 3-1 Associations and the 2x2 Table Hypothesis about associations Generate Descriptive Epidemiology Test Analytical Epidemiology Epidemiology and Associations (An example) Describes observations of kids who drink and smoke “turning up” at R- rated movies Hypothesis: Watching R-rated movies can influence teenagers to smoke and drink alcohol Scientifically studies the association between teenage drinking and smoking and going to R-rated movies to test whether the hypothesis is refuted or supported

13. DrugEpi 3-1 Associations and the 2x2 Table The 2x2 table is a tool used to express the numbers of people with and without the exposure and with and without the outcome. The 2x2 Table

14. DrugEpi 3-1 Associations and the 2x2 Table 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

15. DrugEpi 3-1 Associations and the 2x2 Table Total Smoking Not Smoking Watching R- rated movies Not watching R-rated movies ExposureExposure Outcome / Disease ab cd 2x2 Table Are there controls in this 2x2 table? If yes, where are they?

16. DrugEpi 3-1 Associations and the 2x2 Table People who participate in a study and do not have the exposure of interest People whose results are compared to the group that was exposed. Control Group

17. DrugEpi 3-1 Associations and the 2x2 Table Exposed Not Exposed Outcome No Outcome Total Tests hypotheses Analytic Epidemiology What is Important to Understand So Far... Analytical Epidemiology / Study Design Need for an unexposed comparison group 2x2 table can express relationships between exposure and outcome

18. DrugEpi 3-1 Associations and the 2x2 Table 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

19. DrugEpi 3-1 Associations and the 2x2 Table Total ab dc 2 x 2 Table Suicide Higher in Areas with Guns

20. DrugEpi 3-1 Associations and the 2x2 Table Total ab dc 2 x 2 Table Suicide Higher in Areas with Guns Areas with Guns No Suicide Suicide Areas without Guns

21. DrugEpi 3-1 Associations and the 2x2 Table 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

22. DrugEpi 3-1 Associations and the 2x2 Table ab dc 2 x 2 Table Total Kids Who Watch R-Rated Movies More Likely to Drink, Smoke

23. DrugEpi 3-1 Associations and the 2x2 Table ab dc 2 x 2 Table R-Rated Movies Total Drink & Smoke Kids Who Watch R-Rated Movies More Likely to Drink, Smoke Do Not Drink & Smoke No R-Rated Movies

24. DrugEpi 3-1 Associations and the 2x2 Table 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 Do Not Drink & Smoke No R-Rated Movies

25. DrugEpi 3-1 Associations and the 2x2 Table ab dc 2 x 2 Table Family Meals Are Good for Mental Health Total

26. DrugEpi 3-1 Associations and the 2x2 Table ab dc 2 x 2 Table Family Meals Are Good for Mental Health Family Meals Total Good Mental Health Poor Mental Health No Family Meals

27. DrugEpi 3-1 Associations and the 2x2 Table 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 Good Mental Health Poor Mental Health No Family Meals

28. DrugEpi 3-1 Associations and the 2x2 Table ab dc 2 x 2 Table Study Links Iron Deficiency to Math Scores Total

29. DrugEpi 3-1 Associations and the 2x2 Table 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

30. DrugEpi 3-1 Associations and the 2x2 Table 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

31. DrugEpi 3-1 Associations and the 2x2 Table ab dc 2 x 2 Table Pollution Linked with Birth Defects in US Study Total

32. DrugEpi 3-1 Associations and the 2x2 Table ab dc 2 x 2 Table Pollution Linked with Birth Defects in US Study Pollution Birth Defects No Pollution No Birth Defects Total

33. DrugEpi 3-1 Associations and the 2x2 Table 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

34. DrugEpi 3-1 Associations and the 2x2 Table ab dc 2 x 2 Table Depressed Teens More Likely to Smoke Total

35. DrugEpi 3-1 Associations and the 2x2 Table ab dc 2 x 2 Table Depressed Teens More Likely to Smoke Depression Smoke No Depression Do Not Smoke Total

36. DrugEpi 3-1 Associations and the 2x2 Table 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 Do Not Smoke Total

37. DrugEpi 3-1 Associations and the 2x2 Table ab dc 2 x 2 Table Smoking Linked to Youth Eating Disorders Total

38. DrugEpi 3-1 Associations and the 2x2 Table ab dc 2 x 2 Table Smoking Linked to Youth Eating Disorders Smoke Eating Disorders Do Not Smoke No Eating Disorders Total

39. DrugEpi 3-1 Associations and the 2x2 Table 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 Do Not Smoke No Eating Disorders Total

40. DrugEpi 3-1 Associations and the 2x2 Table ab dc 2 x 2 Table Total Study Links Spanking to Aggression

41. DrugEpi 3-1 Associations and the 2x2 Table ab dc 2 x 2 Table Study Links Spanking to Aggression Spanking Aggression No Spanking Total No Aggression

42. DrugEpi 3-1 Associations and the 2x2 Table 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

43. DrugEpi 3-1 Associations and the 2x2 Table ab dc 2 x 2 Table Total Snacks Key to Kids’ TV-Linked Obesity

44. DrugEpi 3-1 Associations and the 2x2 Table ab dc 2 x 2 Table Snacks Key to Kids’ TV-Linked Obesity Snacks Obesity No Snacks No Obesity Total

45. DrugEpi 3-1 Associations and the 2x2 Table 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

46. DrugEpi 3-1 Associations and the 2x2 Table Big Ideas in this Lesson (3-1) An association is when two things “turn up together” Epidemiologists study associations Descriptive epidemiology generates hypotheses about associations and analytical epidemiology tests hypotheses about associations The 2x2 table is a tool used to express the numbers of people with and without the exposure and with and without the outcome. In this way it includes controls. This project is supported by a Science Education Drug Abuse Partnership Award, Grant Number 1R24DA016357-01, from the National Institute on Drug Abuse, National Institutes of Health. Re-Cap

47. DrugEpi 3-1 Associations and the 2x2 Table 6. Where are we?Next Lesson Hypothesis: Buprenorphine will stop heroin addicts from using heroin. In the next Lesson, 3-2, students will learn about how an experimental study can test hypotheses between an exposure and a beneficial health-related effect