1. Centers for Disease Control and Prevention Global Health Odyssey Museum Tom Harkin Global Communications Center July 6-10, 2009 Teach Epidemiology Professional Development Workshop Day 2

2. 2 Teach Epidemiology

3. 3 National Research Council, Learning and Understanding Teach Epidemiology Enduring Epidemiological Understandings Knowledge that “… is connected and organized, and … ‘conditionalized’ to specify the context in which it is applicable.”

4. 4 Learners “… presented with vast amounts of content knowledge that is not organized into meaningful patterns are likely to forget what they have learned and to be unable to apply the knowledge to new problems or unfamiliar contexts.” National Research Council, Learning and Understanding Teach Epidemiology Enduring Epidemiological Understandings

6. Is there a pattern? Is there a pattern or chaos? Is there a pattern to this? Is health distributed haphazardly in a population of people or is their a pattern to its occurrence? If there is a pattern, how can I find it? Who is healthy and who is not? Is health distributed haphazardly in a population of people or is their a pattern to its occurrence? If there was a pattern, how could it be described? How could it be found? Are health and disease distributed haphazardly in a population of people or is their a pattern to their occurrence? How are health and disease distributed in a population of people? Are they distributed haphazardly or is their a pattern to their occurrence? How could the distribution be identified? 6 Teach Epidemiology Essential Questions

7. 7 Is anyone else sick? Are there differences between the sick people and healthy people? Is the sickness distributed haphazardly or is there a pattern? What would a pattern look like? Does everyone get sick, in every place, all of the time? Or do some people get sick, in some places, at some times? Who are those people? Where are those places? When are those times? How can information about the sick and healthy people be collected so that, if a pattern exists, it can be identified? If there is a pattern, if it is staring us in the face, will we see it? Teach Epidemiology Essential Questions

8. 8 Time Check 9:15 AM

9. 9 Teach Epidemiology

10. In the News Article Selection Criteria Popular press article and scholarly article Potential to check other sources for information Non-controversial topic Age group / reading level appropriate Consider potential for inclusion of other disciplines Includes data and visuals Topical, but not too great a potential to become dated Background Identify standards that apply

11. 11 Time Check 11:45 AM

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13. 13 Teach Epidemiology

14. 14 Time Check 12:15 PM

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16. 16 Teach Epidemiology

17. Enduring Epidemiological Understandings

18. Back to EU 2 and 3 Why study patterns of disease? Why is a description of the person, place, and time elements of a disease distribution important?

19. Epidemiologic Studies Descriptive epidemiology –Describes patterns of disease –Suggests hypotheses about relationships between “exposures” and “health-related conditions” Analytic epidemiology –Tests hypotheses –Evaluates relationships –Always in a search for causality –Knowing causation helps us to prevent and treat disease and promote health

20. 4. A hypothesis can be tested by comparing the frequency of disease in selected groups of people with and without an exposure to determine if the exposure and the disease are associated. 5. When an exposure is hypothesized to have a beneficial effect, studies can be designed in which a group of people is intentionally exposed to the hypothesized cause and compared to a group that is not exposed. 6. When an exposure is hypothesized to have a detrimental effect, it is not ethical to intentionally expose a group of people. In these circumstances, studies can be designed that observe groups of free-living people with and without the exposure. Making Group Comparisons and Identifying Associations

21. Heart attacks Descriptive epidemiology showed the following patterns: –Increasing incidence of heart attacks in certain Midwestern communities –More heart attacks among farmworkers than non-farmworkers in those communities –More heart attacks among males than among females What is your hypothesis/hypotheses?

22. Testing hypotheses about MI Hypothesis: Exposure to pesticides increases risk of MI. How might you go about evaluating this hypothesis?

23. Testing hypotheses about MI Hypothesis: Exposure to pesticides increases risk of MI. Evaluate the hypothesis using an: –Ecologic study

24. Ecologic study of pesticide exposure and MI Exposure is pesticide –Measured as proportion of land area devoted to wheat Outcome is MI –Measured as a rate per 100,000 Plot data on a graph What might you expect to see?

26. Ecologic Study Key element –Group-level estimates Quantify relationships –Graphical displays –Correlation coefficient Advantages –Study group-level variables, e.g. policies, laws, community socioeconomic status –Use existing data sources –Use fewer resources (time, money, subject burden) Disadvantage –Ecologic fallacy

27. Testing hypotheses about MI Hypothesis: Exposure to pesticides increases risk of MI. Evaluate the hypothesis using a: –Cross-sectional study

28. Cross-sectional study of pesticide exposure and MI Exposure is pesticide –Measured as pesticide application history Outcome is MI –Measured as yes or no Count responses What might you expect to see?

29. Pesticides and MI MI+MI- Pesticide+ Pesticide- 200

30. Pesticides and MI MI+MI- Pesticide+6090150 Pesticide-104050 70130200 So, is pesticide usage associated with MI?

31. Pesticides and MI MI+MI- Pesticide+6090150 Pesticide-104050 70130200 What is the prevalence of MI? What is the prevalence of MI among pesticide users? What is the prevalence of MI among non-users?

32. Pesticides and MI MI+MI- Pesticide+6090150 Pesticide-104050 70130200 What is the prevalence of MI? 70/200 = 35% What is the prevalence of MI among pesticide users? = 60/150 = 40% What is the prevalence of MI among non-users? = 10/50 = 20%

33. Cross-sectional Study Key element –Snapshot of one point in time Quantify association –Prevalence ratio Advantages –Individual data –Quick, cheap –Assess prevalence of a trait in the population –Good for estimates of D+ not routinely brought to medical attention but self-diagnosed and treated e.g. common cold, dandruff, acne Disadvantages –Difficult to assess temporality because measure E and D simultaneously –Inefficient for E or D that are rare –Inefficient for D that are rapidly fatal or of short duration

34. Testing hypotheses about MI Hypothesis: Exposure to pesticides increases risk of MI. Evaluate the hypothesis using a: –Case-control study

35. Case-control study of pesticide exposure and MI Exposure is pesticide –Measured as pesticide application history Outcome is MI –Measured as yes or no Want to ensure that you have enough cases to do your study, so select for those with MI Find those without MI Ask them about exposures to pesticides What might you expect to see?

36. Pesticides and MI MI+MI- Pesticide+ Pesticide- 200

37. Pesticides and MI MI+MI- Pesticide+601070 Pesticide-4090130 100 200 What is the prevalence of MI?

38. Case-control Study Odds = probability an event will occur/probability that event will not occur Odds of exposure in cases = probability of being exposed if one is a case/probability one was not exposed if one is a case What is odds of exposure in controls? What is Odds Ratio?

39. Pesticides and MI MI+MI- Pesticide+601070 Pesticide-4090130 100 200 What is the odds of exposure among the cases? What is the odds of exposure among the controls? What is the OR?

40. Pesticides and MI MI+MI- Pesticide+601070 Pesticide-4090130 100 200 What is the odds of exposure among the cases? (60/100)/(40/100) = 60/40 = 1.5 What is the odds of exposure among the controls? (10/90) =.11 What is the OR? ~ 13.5

41. Case-control Study Key elements –Compare individuals selected on the basis of disease status –Classic epidemiologic study design Quantify association –Odds Ratio Advantages –Can be less expensive and time-consuming than follow-up studies –Efficient for rare diseases Disadvantages –May be resource-intensive because of need to screen so many –Difficult to assess temporality –Recall bias

42. Testing hypotheses about MI Hypothesis: Exposure to pesticides increases risk of MI. Evaluate the hypothesis using a: –Cohort study

43. Cohort study of pesticide exposure and MI Exposure is pesticide –Measured as pesticide application history Outcome is MI –Measured as yes or no Want to ensure that you have enough exposed persons to do your study, so select for those with pesticide exposure Find those without pesticide exposure Follow them up over time to ascertain MI status What might you expect to see?

44. Pesticides and MI MI+MI- Pesticide+ Pesticide- 200

45. Pesticides and MI MI+MI- Pesticide+7030100 Pesticide-3565100 10595200 What is the incidence of MI among the pesticide users? What is the incidence of MI among the non-users? What is the risk ratio?

46. Pesticides and MI MI+MI- Pesticide+7030100 Pesticide-3565100 10595200 What is the incidence of MI among the pesticide users? = 70% What is the incidence of MI among the non-users? = 35% What is the risk ratio? = 2.0

47. Cohort Study Key element –Select based on exposure status and follow-up over time Quantify association –Relative risk (risk ratio) Advantages –Avoids the confusion about temporality –Ideal for rare exposures Disadvantages –May have to screen many to get exposed group –Large, time-consuming, expensive especially if disease is relatively rare and/or slow to develop –Attrition may result in selection bias –Inefficient for rare diseases

48. Testing hypotheses about MI Hypothesis: Exposure to pesticides increases risk of MI. Evaluate the hypothesis using a: –Randomized controlled trial

49. RCT study of pesticide exposure and MI Exposure is pesticide –Measured as pesticide exposure Outcome is MI –Measured as yes or no Want to ensure maximal control over study parameters, so you decide who gets exposed and who does not Follow up over time to ascertain MI status What might you expect to see?

50. Pesticides and MI MI+MI- Pesticide+ Pesticide- 200

51. Pesticides and MI MI+MI- Pesticide+7030100 Pesticide-3565100 10595200 What is the incidence of MI among the pesticide users? What is the incidence of MI among the non-users? What is the risk ratio?

52. Pesticides and MI MI+MI- Pesticide+7030100 Pesticide-3565100 10595200 What is the incidence of MI among the pesticide users? = 70% What is the incidence of MI among the non-users? = 35% What is the risk ratio? = 2.0

53. Randomized Controlled Trial Key elements –Assign treatments to individuals and follow up to ascertain disease status. –The researcher controls primary exposure under study. Exposures can be treatments (drug, surgery) or preventive measures (water fluoridation, exercise regimens). –Ethical considerations may preclude use of this design. Quantify association –Relative risk (risk ratio) Advantages –Random assignment serves to “equate” groups –Closest to “true experiment” Disadvantages –Expensive and time-consuming. –Subjects are often highly selected group because the requirements of participants can often be extensive.

55. Ecologic Study Childhood cancer and residential electric consumption Canada 1971-1986 Rank provinces by REC Rank provinces by cancer rates: surveillance data What is exposure/risk factor/agent? What is disease/health outcome?

56. Ecologic Study

57. Cross-sectional Study Literacy and misunderstanding prescription drug labels Adults in primary care clinic waiting rooms Low literacy = reading at 5 th grade level or below Example: Take one tsp by mouth 3 times daily What is exposure? Disease?

58. Cross-sectional Study Misunderstand Amoxicillin label Understand label Low literacyAB Adequate literacy CD

59. Cross-sectional Study Misunderstand Amoxicillin label Understand Amoxicillin label Low literacy 3144 Adequate literacy 36171 Please reproduce the 2X2 table on paper.

60. Cross-sectional Study What proportion of adults had low literacy? What proportion of adults misunderstood the labels? What proportion of adults who had low literacy misunderstood the labels? What proportion of adults with adequate literacy misunderstood the labels? How did the misunderstanding of the low literate adults compare with that of the adequately literate adults?

61. Case-control Study Household pesticides and Wilms tumor Early age on onset suggests in utero exposures 523 cases of Wilms tumor 517 controls—RDD to get disease free children who represent the distribution of exposure in the population from which cases arose Pesticide use in home from month before conception through date of diagnosis/date of telephone call

62. Case-control Study Wilms+Wilms- Pesticide in yard+ AB Pesticide in yard- CD

63. Case-control Study Wilms+Wilms- Pesticide in yard+ 158157 Pesticide in yard- 352344 510501

64. Cohort Study HIV status and risk of menstrual abnormalities What is exposure? disease?

65. Cohort Study AmenorrheaMenstrual period within past 6 mos HIV+1418931034 HIV-37346383 17812391417

66. Cohort study What is risk of amenorrhea among HIV+ women? What is risk of amenorrhea among HIV- women? What is the risk among HIV+ women relative to the risk among HIV- women?

67. Randomized Controlled Trial Vitamin D supplementation and risk of falls and fractures among the elderly 149 residential facilities in Australia Randomly assigned to 2 years on calcium plus Vitamin D or placebo Double-masked Study diaries maintained by caregivers What is exposure? Disease?

68. RCT Fall+Fall- Vitamin D supplement 170143 Placebo185127

69. RCT What is risk of falls among the treatment group? What is risk of falls among the comparison group? What is RR?

70. Enduring Understandings Comparing Exposed and Unexposed A hypothesis can be tested by comparing the frequency of disease in selected groups of people with and without an exposure to determine if the exposure and the disease are associated.

71. Intentionally Exposing When an exposure is hypothesized to have a beneficial effect (e.g. vitamin D), studies can be designed in which a group of people is intentionally exposed to the hypothesized cause and compared to a group that is not exposed. Enduring Understandings

72. Observing Free-Living People When an exposure is hypothesized to have a detrimental effect (HIV, pesticides, EMF), it is not ethical to intentionally expose a group of people. In these circumstances, studies can be designed that observe groups of free-living people with and without the exposure. Enduring Understandings

73. 73 Time Check 2:30 PM

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75. 75 Teach Epidemiology

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77. 77 Teach Epidemiology

78. 78 National Research Council, Learning and Understanding Teach Epidemiology Enduring Epidemiological Understandings Knowledge that “… is connected and organized, and … ‘conditionalized’ to specify the context in which it is applicable.”

79. 79 Association Found Between Coffee and Pancreatic Cancer Associated Teach Epidemiology

80. 80 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 Teach Epidemiology

81. 81 Things that are associated are linked in some way that makes them turn up together. Associated Teach Epidemiology

82. 82 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 Associated Teach Epidemiology

83. 83 Epidemiologic studies that are concerned with characterizing the amount and distribution of health and disease within a population. Descriptive Epidemiology Teach Epidemiology

84. 84 Epidemiologic studies that are concerned with determinants of disease and the reasons for relatively high or low frequencies of disease in specific population subgroups. Analytical Epidemiology Teach Epidemiology

85. 85 Hypothesis Formulating Descriptive Epidemiology Testing Analytical Epidemiology An unproven idea, based on observation or reasoning, that can be supported or refuted through investigation An educated guess Hypothesis Teach Epidemiology

86. 86 Hypothesis: Buprenorphine will stop heroin addicts from using heroin. Making Group Comparisons and Identifying Associations Teach Epidemiology

87. 87 Population Trial 1 Making Group Comparisons and Identifying Associations

88. 88 Population 500 Heroin Addicts Sample 100 Heroin Addicts 10 Weeks Trial 1 Making Group Comparisons and Identifying Associations

89. 89 Population 500 Heroin Addicts Sample 100 Heroin Addicts 10 Weeks 21 Heroin Addicts Tested Negative for Heroin Trial 1 Making Group Comparisons and Identifying Associations

90. 90 Bupe Tested Positive for Heroin Total 1002179 Tested Negative for Heroin Trial 1 Making Group Comparisons and Identifying Associations Teach Epidemiology

91. 91 When you can measure what you are speaking about, and express it in numbers, you know something about it. Lord Kelvin But when you cannot measure it, when you cannot express it in numbers, your knowledge is of a meager and unsatisfactory kind. Making Group Comparisons and Identifying Associations Teach Epidemiology

92. 92 A measure of how often an outcome occurs in a defined population in a defined period of time. It consists of a numerator and a denominator. Risk The numerator is the number of people in the population or sample who experienced the outcome and the denominator is the total number of people in the population or sample. Population / Sample Outcome Denominator Numerator Making Group Comparisons and Identifying Associations Teach Epidemiology

93. 93 … the risk of a negative heroin test was 21 / 100 in a 10-week period 21 tested negative for heroin 100 study subjects Numerator Denominator Risk Making Group Comparisons and Identifying Associations Teach Epidemiology

94. 94 A measure of how often an outcome occurs in a defined group of people in a defined period of time. The likelihood of an outcome occurring. Risk / Rate Making Group Comparisons and Identifying Associations Teach Epidemiology

95. 95 Trial 1 Bupe Tested Positive for Heroin 1002179 Tested Negative for Heroin 21 100 or 21 % Calculating Risk Risk of Negative Heroin Test Total Making Group Comparisons and Identifying Associations Teach Epidemiology

96. 96 Process of predicting from what is observed in a sample to what is true for the entire population. Inference Making Group Comparisons and Identifying Associations Teach Epidemiology

97. 97 Trial 1 What does this tell you about the hypothesis? Buprenorphine will stop heroin addicts from using heroin. Inference Probe Bupe Tested Positive for Heroin 1002179 Tested Negative for Heroin 21 100 or 21 % Risk of Negative Heroin Test Total Making Group Comparisons and Identifying Associations Teach Epidemiology

98. 98 People who participate in a trial, but do not get the treatment. People whose results are compared to the group that was treated. Control Group Making Group Comparisons and Identifying Associations Teach Epidemiology

99. 99 21 100 or 21 % 1007921 Tested Positive for Heroin Tested Negative for Heroin Bupe Control Group Extend and label the table to include a control group. Risk of Negative Heroin Test Total Making Group Comparisons and Identifying Associations Teach Epidemiology

100. 100 ? or ? % No Bupe Control Group Making Group Comparisons 21 100 or 21 % 1007921 Tested Positive for Heroin Tested Negative for Heroin Bupe Risk of Negative Heroin Test Total Making Group Comparisons and Identifying Associations Teach Epidemiology

101. 101 100 ? or ? % No Bupe Making Group Comparisons 21 100 or 21 % 1007921 Tested Positive for Heroin Tested Negative for Heroin Bupe ExposureExposure Outcome / Disease ab cd Risk of Negative Heroin Test Total Making Group Comparisons and Identifying Associations Teach Epidemiology

102. 102 21 100 or 21 % Total 1007921 Bupe 100 ? or ? % No Bupe Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test Making Group Comparisons and Identifying Associations Teach Epidemiology

103. 103 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 Making Group Comparisons and Identifying Associations Teach Epidemiology

104. 104 Population 500 Heroin Addicts Sample 100 Heroin Addicts 10 Weeks 21 Heroin Addicts Tested Negative for Heroin Trial 1 Making Group Comparisons and Identifying Associations

105. 105 Trial 2 Total ? 100 ? % a b c d Bupe Tested Negative for Heroin Tested Positive for Heroin No Bupe100 ? ? % Risk of Negative Heroin Test Making Group Comparisons and Identifying Associations Teach Epidemiology

106. 106 E Assigned E O O O O Making Group Comparisons and Identifying Associations Volunteer Heroin Addicts Teach Epidemiology

107. 107 21 100 21% 2179100 or a b c d Bupe Trial 2 No Bupe Probe Total Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test Making Group Comparisons and Identifying Associations Teach Epidemiology

108. 108 21 100 21% 2179100 or a b c d Bupe Trial 2 No Bupe Total Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test 21 100 21% 2179100 or Making Group Comparisons and Identifying Associations Teach Epidemiology

109. 109 21 100 21% 2179100 or a b c d Bupe Trial 2 No Bupe Total Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test 21 100 21% 2179100 or Inference: Process of predicting from what is observed in a sample to what is occurring in the entire population Making Group Comparisons and Identifying Associations Teach Epidemiology

110. 110 When you can measure what you are speaking about, and express it in numbers, you know something about it. Lord Kelvin But when you cannot measure it, when you cannot express it in numbers, your knowledge is of a meager and unsatisfactory kind. Making Group Comparisons and Identifying Associations Teach Epidemiology

111. 111 The value obtained by dividing one quantity by another Ratio Making Group Comparisons and Identifying Associations Teach Epidemiology

112. 112 21 100 21% 2179100 or a b c d Bupe Trial 2 No Bupe Total Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test 21 100 21% 2179100 or Ratio: The value obtained by dividing one quantity by another Risk Ratio: The ratio of two risks 1 Risk Ratio Making Group Comparisons and Identifying Associations Teach Epidemiology

113. 113 21 100 21% 2179100 or a b c d Bupe Trial 2 No Bupe Total Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test 21 100 21% 2179100 or Ratio: The value obtained by dividing one quantity by another Risk Ratio: The ratio of two risks 1 Risk Ratio Create a formula a a + b c c + d Making Group Comparisons and Identifying Associations Teach Epidemiology

114. 114 21 100 21% 2179100 or a b c d Bupe Trial 2 No Bupe Total Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test 21 100 21% 2179100 or 1 Risk Ratio Relative Risk: The ratio of the risk of an outcome among the exposed to the risk of the outcome among the unexposed. Relative Risk Making Group Comparisons and Identifying Associations Teach Epidemiology

115. 115 21 100 21% 2179100 or a b c d Bupe Trial 2 No Bupe Total Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test 21 100 21% 2179100 or 1 Risk Ratio Relative Risk Inference: Process of predicting from what is observed in a sample to what is occurring in the entire population The inference here is that there is no effect of Buprenorphine Making Group Comparisons and Identifying Associations Teach Epidemiology

116. 116 Trial 3 ? 100 ? % 100 or a b c d Bupe No Bupe Total Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test ? 100 ? % 100 or Making Group Comparisons and Identifying Associations Teach Epidemiology

117. 117 21 100 21% 2179100 or a b c d Bupe No Bupe Total Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test Trial 3 Making Group Comparisons and Identifying Associations Teach Epidemiology

118. 118 21 100 21% 2179100 or a b c d Bupe No Bupe Total Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test 62 100 62% 6238100 or Trial 3 Making Group Comparisons and Identifying Associations Teach Epidemiology

119. 119 21 100 21% 2179100 or a b c d Bupe No Bupe Total Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test 62 100 62% 6238100 or Inference: Process of predicting from what is observed in a sample to what is occurring in the entire population Trial 3 Making Group Comparisons and Identifying Associations Teach Epidemiology

120. 120 21 100 21% 2179100 or a b c d Bupe No Bupe Total Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test 62 100 62% 6238100 or Relative Risk Relative Risk: The ratio of the risk of an outcome among the exposed to the risk of the outcome among the unexposed. 0.34 Trial 3 Making Group Comparisons and Identifying Associations Teach Epidemiology

121. 121 21 100 21% 2179100 or a b c d Bupe No Bupe Total Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test 62 100 62% 6238100 or Relative Risk 0.34 The heroin addicts who received Bupe were ___ times as likely to test negative for heroin as those who did not receive Bupe. 0.34 Trial 3 Making Group Comparisons and Identifying Associations Teach Epidemiology

122. 122 21 100 21% 2179100 or a b c d Bupe No Bupe Total Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test 62 100 62% 6238100 or Relative Risk 0.34 Inference: Process of predicting from what is observed in a sample to what is occurring in the entire population. Trial 3 Making Group Comparisons and Identifying Associations Teach Epidemiology

123. 123 Trial 4 ? 100 ? % 100 or a b c d Bupe No Bupe Total Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test ? 100 ? % 100 or Making Group Comparisons and Identifying Associations Teach Epidemiology

124. 124 21 100 21% 2179100 or a b c d Bupe No Bupe Total Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test Trial 4 Making Group Comparisons and Identifying Associations Teach Epidemiology

125. 125 21 100 21% 2179100 or a b c d Bupe No Bupe Total Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test 6 100 6% 694100 or Trial 4 Making Group Comparisons and Identifying Associations Teach Epidemiology

126. 126 21 100 21% 2179100 or a b c d Bupe No Bupe Total Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test 6 100 6% 694100 or Relative Risk Relative Risk: The ratio of the risk of an outcome among the exposed to the risk of the outcome among the unexposed. 3.5 Trial 4 Making Group Comparisons and Identifying Associations Teach Epidemiology

127. 127 21 100 21% 2179100 or a b c d Bupe No Bupe Total Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test 6 100 6% 694100 or Relative Risk 3.5 The heroin addicts who received Bupe were ___ times as likely to test negative for heroin as those who did not receive Bupe. 3.5 Trial 4 Making Group Comparisons and Identifying Associations Teach Epidemiology

128. 128 21 100 21% 2179100 or a b c d Bupe No Bupe Total Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test 6 100 6% 694100 or Relative Risk 3.5 Inference: Process of predicting from what is observed in a sample to what is occurring in the entire population. Trial 4 Making Group Comparisons and Identifying Associations Teach Epidemiology

129. 129 21 100 21% 2179100 or Bupe Trial 1 Total Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test What do the results tell us about the hypothesis that Buprenorphine will stop heroin addicts from using heroin? Nothing Making Group Comparisons and Identifying Associations Teach Epidemiology

130. 130 Trial 1 Trial 2 Trial 3 Trial 4 Making Group Comparisons and Identifying Associations Teach Epidemiology

131. 131 Nothing Bupe Total Trial 1 Trial 2 Trial 3 Trial 4 Risk of Negative Heroin Test Tested Negative for Heroin Tested Positive for Heroin 1002179 90 or 21% 21 100 Making Group Comparisons and Identifying Associations Teach Epidemiology

132. 132 Risk of Negative Heroin Test Nothing Bupe Total Trial 1 Trial 2 Trial 3 Trial 4 Bupe No Bupe Bupe No Bupe Bupe Total Relative Risk No Bupe Total Relative Risk Total Tested Negative for Heroin Tested Positive for Heroin Relative Risk Risk of Negative Heroin Test Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test Tested Negative for Heroin Tested Positive for Heroin 1002179 90 or 21% 21 100 Making Group Comparisons and Identifying Associations Teach Epidemiology

133. 133 Risk of Negative Heroin Test Nothing Bupe Total Trial 1 Trial 2 Trial 3 Trial 4 Bupe No Bupe Bupe No Bupe Bupe Total Relative Risk No Bupe Total Relative Risk Total Tested Negative for Heroin Tested Positive for Heroin Relative Risk Risk of Negative Heroin Test Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test Tested Negative for Heroin Tested Positive for Heroin 1002179 90 or 21% 21 100 2179 90 or 21% 21 100 2179 90 or 21% 21 100 2179 90 or 21% 21 100 Making Group Comparisons and Identifying Associations Teach Epidemiology

134. 134 Risk of Negative Heroin Test Nothing Bupe Total Trial 1 Trial 2 Trial 3 Trial 4 Bupe No Bupe Bupe No Bupe Bupe Total Relative Risk No Bupe Total Relative Risk Total Tested Negative for Heroin Tested Positive for Heroin Relative Risk Risk of Negative Heroin Test Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test Tested Negative for Heroin Tested Positive for Heroin 1002179 90 or 21% 21 100 2179 90 or 21% 21 100 2179 90 or 21% 21 100 2179 90 or 21% 21 100 2179 90 or 21% 21 100 1 Bupe is not associated with having a negative tests for heroin. Making Group Comparisons and Identifying Associations Teach Epidemiology

135. 135 Risk of Negative Heroin Test Nothing Bupe Total Trial 1 Trial 2 Trial 3 Trial 4 Bupe No Bupe Bupe No Bupe Bupe Total Relative Risk No Bupe Total Relative Risk Total Tested Negative for Heroin Tested Positive for Heroin Relative Risk Risk of Negative Heroin Test Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test Tested Negative for Heroin Tested Positive for Heroin 1002179 90 or 21% 21 100 2179 90 or 21% 21 100 2179 90 or 21% 21 100 2179 90 or 21% 21 100 2179 90 or 21% 21 100 Bupe is not associated with having a negative tests for heroin. 1 1006238 90 or 62% 62 100 Bupe is associated with having a positive test for heroin!.34 Making Group Comparisons and Identifying Associations Teach Epidemiology

136. 136 Risk of Negative Heroin Test Nothing Bupe Total Trial 1 Trial 2 Trial 3 Trial 4 Bupe No Bupe Bupe No Bupe Bupe Total Relative Risk No Bupe Total Relative Risk Total Tested Negative for Heroin Tested Positive for Heroin Relative Risk Risk of Negative Heroin Test Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test Tested Negative for Heroin Tested Positive for Heroin 1002179 90 or 21% 21 100 2179 90 or 21% 21 100 2179 90 or 21% 21 100 2179 90 or 21% 21 100 2179 90 or 21% 21 100 Bupe is not associated with having a negative tests for heroin. 1 1006238 90 or 62% 62 100 Bupe is associated with having a positive test for heroin!.34 100694 90 or 6% 6 100 Bupe is associated with having a negative test for heroin. 3.5 Making Group Comparisons and Identifying Associations Teach Epidemiology

137. 137 Risk of Negative Heroin Test Nothing Bupe Total Trial 1 Trial 2 Trial 3 Trial 4 Bupe No Bupe Bupe No Bupe Bupe Total Relative Risk No Bupe Total Relative Risk Total Tested Negative for Heroin Tested Positive for Heroin Relative Risk Risk of Negative Heroin Test Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test Tested Negative for Heroin Tested Positive for Heroin Risk of Negative Heroin Test Tested Negative for Heroin Tested Positive for Heroin 1002179 90 or 21% 21 100 2179 90 or 21% 21 100 2179 90 or 21% 21 100 2179 90 or 21% 21 100 2179 90 or 21% 21 100 Bupe is not associated with having a negative tests for heroin. 1 1006238 90 or 62% 62 100 Bupe is associated with having a positive test for heroin!.34 100694 90 or 6% 6 100 Bupe is associated with having a negative test for heroin. 3.5 Nothing Compared to what? Making Group Comparisons and Identifying Associations Teach Epidemiology

138. 138 Buprenorphine Buprenorphine & Naloxone Placebo Making Group Comparisons and Identifying Associations Teach Epidemiology Handout

139. 139 National Research Council, Learning and Understanding Teach Epidemiology Enduring Epidemiological Understandings Knowledge that “… is connected and organized, and … ‘conditionalized’ to specify the context in which it is applicable.”

140. 140

141. 141

142. Backpacks and Back Pain Detectives in the Classroom - Investigation 2-4: Backpacks and Back Pain Is there an association between the hypothesized cause and the disease?

143. Ache! Testing Hypotheses Detectives in the Classroom - Investigation 2-4: Backpacks and Back Pain

144. Acne No Acne Total 9010 9010 b d a c AcneMed No AcneMed 100 Trial Carrying heavy backpacks causes back pain. Detectives in the Classroom - Investigation 2-4: Backpacks and Back Pain

145. Back Pain No Back Pain Total 9010 9010 b d a c Heavy Backpacks No Heavy Backpacks Observational Study Carrying heavy backpacks causes back pain. Detectives in the Classroom - Investigation 2-4: Backpacks and Back Pain

146. Exposure Detectives in the Classroom - Investigation 2-4: Backpacks and Back Pain

147. Exposure Detectives in the Classroom - Investigation 2-4: Backpacks and Back Pain

148. Exposure Check one. Heavy Backpack No Heavy Backpack Detectives in the Classroom - Investigation 2-4: Backpacks and Back Pain

149. Outcome Any memorable pain in the past two weeks. What is back pain? Detectives in the Classroom - Investigation 2-4: Backpacks and Back Pain

150. Outcome Check one. Back Pain No Back Pain Detectives in the Classroom - Investigation 2-4: Backpacks and Back Pain

151. 2 x 2 Table Detectives in the Classroom - Investigation 2-4: Backpacks and Back Pain

152. Epi Talk Observational Studies Were you involved in assigning exposures? Did you observe what others had done to themselves? Did you record, classify, count and statistically analyze the results? Epidemiologic studies in which the investigator is not involved in the subjects' exposures other than to record, classify, count, and statistically analyze results. Detectives in the Classroom - Investigation 2-4: Backpacks and Back Pain

153. Carrying Heavy Backpacks Causes Back Pain. We are all carrying out “natural experiments” on ourselves each day of our lives, as we decide what to do, where to go, and to what to expose ourselves. Detectives in the Classroom - Investigation 2-4: Backpacks and Back Pain

154. 154

155. Investigation 2-5 Observational Studies Part 1

156. Observational Study Selecting a HypothesisStep 1 Planning the StudySteps 2-7 Collecting DataSteps 8-13 Analyzing DataSteps 14-17 Planning the PresentationStep 18 Detectives in the Classroom - Investigation 2-5: Observational Studies

157. Epi Log Worksheet Detectives in the Classroom - Investigation 2-5: Observational Studies 1 Handout

158. CDC Planning the Study Define the exposure. Create a question to gather data about the exposure. Create a question to gather data about the outcome. Create an informed consent statement for participation in the observational study. Label 2 x 2 Table Sheet. Step 2: Step 3: Step 4: Step 5: Step 7: Step 6: Define the outcome in the hypothesis. 2-7 Detectives in the Classroom - Investigation 2-5: Observational Studies

159. Review Epi Talk Voluntary consent given by a person for participation in a study. Informed Consent Participants must know and understand the study, give consent without coercion, and know that they can withdraw at any time. Detectives in the Classroom - Investigation 2-5: Observational Studies

160. Collecting Data Read informed consent statement and remind class of right not to participate. Have class label 2 x 2 Table Sheets. Review what cells students “fit” into based on answers to exposure and outcome questions. Instruct class to voluntarily and anonymously place a check in the cell that identifies their exposure and outcome for the hypothesis being tested. Step 8: Step 9: Step 10: Step 11: Step 12: CDC Review exposure and outcome questions. Detectives in the Classroom - Investigation 2-5: Observational Studies

161. Collecting Data Detectives in the Classroom - Investigation 2-5: Observational Studies Handout

162. Collecting Data Read informed consent statement and remind class of right not to participate. Have class label 2x2 Table Sheets. Review what cells students “fit” into based on answers to exposure and outcome questions. Instruct class to voluntarily and anonymously place a check in the cell that identifies their exposure and outcome for the hypothesis being tested. Step 8: Step 9: Step 10: Step 11: Step 12: CDC Review exposure and outcome questions. Detectives in the Classroom - Investigation 2-5: Observational Studies

163. Analyzing Data Calculate the risks of the outcome for the exposed and unexposed groups as fractions and percents. Calculate the relative risk. Complete the statement. CDC 13-17 Explain whether or not the data support the hypothesis. Step 13: Step 14: Step 15: Step 16: Step 17: Sort 2 x 2 Table Sheets and complete the 2 x 2 table that was labeled in step 6. Detectives in the Classroom - Investigation 2-5: Observational Studies

164. IMRAD IMRADIMRAD ========== Introduction Methods Results and Discussion Presentation Planning Detectives in the Classroom - Investigation 2-5: Observational Studies

165. Epi Talk IMRAD Epi Talk Format usually followed when epidemiological studies are published in medical journals. Introduction: Why the authors decided to do the study, Methods: How authors did the study, Results: What the authors found, and Discussion: What the results mean. Detectives in the Classroom - Investigation 2-5: Observational Studies

166. IMRAD IMRADIMRAD ========== Introduction Methods Results and Discussion Step 18: Presentation Planning 18 Detectives in the Classroom - Investigation 2-5: Observational Studies

167. Epi Teams Detectives in the Classroom - Investigation 2-5: Observational Studies

168. Presentation Rubric CriteriaGot ItGetting ItWill Get It Soon Participation All participateMost participateSome participate Use of Epi Talk All are appropriate and accurate Most are appropriate and accurate Some are appropriate and accurate Data Collection Methods All are thorough and accurate Most are accurateSome are accurate Risks, Relative Risk, and Inference All are identified and accurate Most are identified and accurate Some are identified and accurate IMRAD All are presented and accurate Most are presented and accurate Some are presented and accurate Detectives in the Classroom - Investigation 2-5: Observational Studies

169. Observational Study Detectives in the Classroom - Investigation 2-5: Observational Studies

170. Observational Study Detectives in the Classroom - Investigation 2-5: Observational Studies

171. Observational Study Detectives in the Classroom - Investigation 2-5: Observational Studies

172. Acne Auto injuries Bad mood Cavities Cell phones Class disruption Chewing gum Colds Drinking soda Eating breakfast Eating candy Eating high fat food Eating school cafeteria food Exercise Foul language Getting a good night’s sleep Good quiz scores Good grades Having a quiet place to study Head aches Selecting a Hypothesis Improves performance Indigestion Lack of regular exercise Listening to music while studying Listening to rap music Multi-vitamins Nightmares Overweight Poor grades Poor quiz scores Practicing a sport Seat belts Skipping breakfast Studying Too much talking on the telephone Violent behavior Watching the evening news on TV Watching too much TV Watching violent movies Wearing hats Detectives in the Classroom - Investigation 2-5: Observational Studies

173. 173 National Research Council, Learning and Understanding Teach Epidemiology Enduring Epidemiological Understandings Knowledge that “… is connected and organized, and … ‘conditionalized’ to specify the context in which it is applicable.”

174. 174

175. 175 Leverage the Science Olympiad Competition http://soinc.org/ Teach Epidemiology What do you mean - Teach Epidemiology?

176. Think Like an Epidemiologist Challenge New Jersey Science Olympiad High School Finals March 17, 2009

177. Test the hypothesis: People who watch more TV eat more junk food. Handout

178. Getting Ready 1

179. Asking Questions / Gathering Data 2

180. 2

181. 2

182. Analyzing Data / Testing Hypotheses 3

183. 3

184. Reporting Out 4

185. 4 Handouts

187. 187 National Research Council, Learning and Understanding Teach Epidemiology Enduring Epidemiological Understandings Knowledge that “… is connected and organized, and … ‘conditionalized’ to specify the context in which it is applicable.”

188. Authentic Assessment Teach Epidemiology Epi – Grades 6-12 Are realistic; simulate the way a person’s understanding is tested in the real world Require judgment and innovation to address an unstructured problem, rather than following a set routine Ask students to “do” the subject rather than simply recall what was taught Replicate the context in which a person would be tested at work, in the community, or at home Are messy and murky Require a repertoire of knowledge and skill to be used efficiently and effectively Allow opportunities for rehearsal, practice, consultation, feedback, and refinement

189. 189

190. 190 Teach Epidemiology

191. 191 National Research Council, Learning and Understanding Teach Epidemiology Enduring Epidemiological Understandings Knowledge that “… is connected and organized, and … ‘conditionalized’ to specify the context in which it is applicable.”

192. Teach Epidemiology Essential Questions

193. 193 Teach Epidemiology Essential Questions

194. 194 Teach Epidemiology Essential Questions If my causal hypothesis is correct, how would health be distributed in a group of people? How could I collect evidence from these people? How can I test my hypothesis in a population of people? How could evidence be collected from people to determine if the explanation is correct? What would the evidence look like?

195. 195 Teach Epidemiology Teaching Epidemiology

196. 196 Scholarship Creativity Teaching Epidemiology Interpret Teach Epidemiology

197. 197 YES Teaching Units Teach Epidemiology Handout

198. 198 Stand Alone / Pick One Off the Shelf Teaching Epidemiology Teach Epidemiology

199. 199 1 Teaching Epidemiology Teach Epidemiology 32 465

200. 200 Teach Epidemiology Teaching Epidemiology Handout Group 1

201. 201 Teach Epidemiology Teaching Epidemiology Handout Group 2

202. 202 Teach Epidemiology Teaching Epidemiology Handout Group 3

203. 203 Teach Epidemiology Teaching Epidemiology Handout Group 4

204. 204 Teach Epidemiology Teaching Epidemiology Handout Group 5

205. 205 Teach Epidemiology Teaching Epidemiology Handout Group 6

206. 206 1.Teach epidemiology 2.As a group, create a 30-minute lesson during which we will develop a deeper understanding of an enduring epidemiological understanding. 3.Focus on the portion of the unit that is assigned. Use that portion of the unit as the starting point for creating your 30-minute lesson. 4.When teaching assume the foundational epidemiological knowledge from the preceding days of the workshop. 5.Try to get us to uncover the enduring epidemiological understanding. Try to only tell us something when absolutely necessary. 6.End each lesson by placing it in the context of the appropriate enduring epidemiological understanding. 7.Teach epidemiology. 8.After the lesson, metacognitate about your preparation for and teaching of the lesson. Teach Epidemiology Teaching Epidemiology Rules Handout

207. 207 They can then use that ability to think about their own thinking … to grasp how other people might learn. They know what has to come first, and they can distinguish between foundational concepts and elaborations or illustrations of those ideas. They realize where people are likely to face difficulties developing their own comprehension, and they can use that understanding to simplify and clarify complex topics for others, tell the right story, or raise a powerfully provocative question. Ken Bain, What the Best College Teachers Do Teach Epidemiology Teaching Epidemiology Metacognition Handout

208. 208 Time Check 3:30 PM