Study Guide CBP - 2018 Final Ganesha

Study Guide Community-based Practice
Study Guide
Community-Based Practice
Department of Public Health and
Preventive Medicine
Study Program of Medicine
Faculty of Medicine
Udayana University
2018
Udayana University Faculty of Medicine, DME 1

LIST 0F CONTENT
List of Module 3
Curriculum of Community Based Practice 4
Planners Team 8
Facilitators 9
Skill Lab Facilitators 10
Time Table 11
Skill Lab Time Table 21
Assessment Method 21
Module 1 – 18 22
References 88
Annex 1 Film Summary “And the band played on” 89
Annex 2 Artikel Koran Bali Post 93
Annex 3 Artikel jurnal 98
Skill Lab (1-3) 99
Student Project: Searching, analysis, and interpreting study result 117

LIST OF MODULE
MODULE ~ 1 (Mausner & Bahn, p. 1-42) p. 22
Determinants of Morbidity and Mortality in Population
MODULE ~ 2 p.25
Demography and Epidemiology Transition of Population
MODULE ~ 3 (Mausner & Bahn, p. 1-42) p.27
Natural History of Disease and Disease Prevention: Communicable Diseases
MODULE ~ 4 (Mausner & Bahn, p. 1-42) p.30
Natural History of Disease and Disease Prevention: Non-Communicable Diseases
MODULE ~ 5 (Greenberg p. 15-28, Gordis p.37-83) p.32
Measurements of Morbidity and Mortality in a Population;
Source of Error in Measurements
MODULE ~ 6 (Greenbergp. 51-53 p.37
Crude, Specific and Adjusted Rate
MODULE ~ 7 (Kirkwood & Sterne, Chap 2) p.40
Population, Sample, Data and Variable
MODULE ~ 8 (Greenberg, p. 29-43) p.43
Analysis and Interpretation of Descriptive Data
MODULE ~ 9 (Kirkwood & Sterne, Chap 3 &4) p.47
Data Presentation and Data Description
MODULE ~ 10 (Kirkwood & Sterne, Chap. 5-8, 10, 14, 15) p.50
Inferential Analysis and Interpretation of Analysis Results
(Hypothesis Test)
MODULE ~ 11 (Kirkwood & Sterne, Chap. 7, 9, 11, 16, 18, 19) p.53
Significance Test for Categorical and Interval Data
MODULE ~ 12 (Greenberg, p. 45 – 73) p.58
Definition, Requirements, Types, and Applications of
Surveillance
MODULE ~ 13 (Greenberg p. 45-73) p. 61
Outbreak Investigation
Screening and Diagnostic Test
MODULE ~ 15 (Greenberg) p.70
Concept of Epidemiology Study to Determine Risk Factor of Disease and Cross-
sectional Study
Epidemiology Study Design: Case – Control Study
MODULE ~ 17 (Greenberg, p.113-123) p.79
Epidemiology Study Design: Cohort Study
MODULE ~ 18 (Greenberg, p.91-113, Gordis 131-163) p.82
Applications Of Clinical Trials To Determine The Effectiveness Of Intervention,
Prevention, And Treatment Of Diseases

CURRICULUM
Community Based Practice
Competency Instructional Learning Objectives Topics

Statement Goals
Use community Demonstrate ability a) Describe several Determinants of

based-practices to apply health determinants Morbidity and
to conduct prevention (models) of diseases Mortality in a
and death occurring Population,
studies that principles based on
in the population Natural History
improve diseases risks and
prevention in the determinant factors b) Explain the and Diseases
community of health problem applications of Prevention
understanding
diseases and death
determinants
(models).
c) Identify the strengths
and weaknesses of
diseases models.
d) Draw figures of the
natural history of a
certain disease.
e) Explain the
applications of the
natural history of a
disease for
prevention.
f) Explain the severity
of diseases in a
population and its
implication to
prevention.
g) Explain the Ice Berg
phenomena and its
implication in
diseases prevention.
h) Describe the level of
disease prevention
based on
determinants and
natural history.

Competency Instructional Goals Learning Objectives Topics

Statement
Demonstrate ability a) Explain Measurements

to search, organize measurements of of Morbidity and
and interpret morbidity and Mortality in a
mortality in a
information/data Population
population.
from different
sources in order to b) Describe the
assist in diagnostic, definitions of
population and
therapeutic and sample.
health
c) Explain the conditions
required for a
representative
sample.
d) Explain several
sampling methods.
e) Describe types of data
and variables.
f) Be able to prepare
software for data
entry.
g) Differentiate
proportion, ratio, rate,
prevalence and
incidence.
h) Explain four types of
incidence based on
their denominators.
i) Describe the source
of numerators and
denominators for
prevalence and
incidence.
j) Explain types of errors
in rate calculation.
k) Explain the Pattern of

differences, Morbidity and
application, Mortality Based
interpretation, and
on Person,
weaknesses of (slide)
crude, specific, and Place, and Time
adjusted rate.

l) Be able to analyze,
and interpret crude,
specific and adjusted
rate.
Statement
m) Be able to analyze,
present, and interpret
descriptive categorical
and interval data.
n) Be able to analyze and
present data using
computers. Be able to
interpret the
measurements of
morbidity and mortality
on samples
descriptively.
o) Explain the method to
determine disease
prognosis from the
population (survival
analysis).
p) Be able to manage, Surveillance

analyze and interpret and Disease
data inferentially. Outbreak
q) Describe the definition,
requirements, types,
and applications of
surveillance.
r) Be able to conduct an
epidemiologic
investigation of an
outbreak.
Demonstrate ability a. Describe Methods to

to apply methods to epidemiological determine risk
determine risk design, e.g.: cross- factors,
section, case-control,
factors of a disease effectiveness of
and cohort, to
and effectiveness of determine risk factors treatment,
diseases of diseases. prevention, and
intervention/ b. Explain the intervention of
treatment/ advantages and diseases in the
prevention disadvantages of community
cross-sectional, case-

control and cohort

design.
c. Describe the
application of clinical
trials to determine the
effectiveness of
intervention,
prevention, and
treatment of diseases.
Statement
d. Be able to describe
the differences
between descriptive,
control, and clinical
study design.
e. Describe the concept
of patient variability,
variability in medical
research, variability of
measurement, both in
individual and
population level.
f. Explain internal
validity, external
validity, selection bias,
information bias, and
confounding factors.
g. Describe sources of
bias in descriptive
research design,
control, cohort, and
clinical trials and
describe how to
minimize those biases.
Analyze and a. Be able to apply the Screening of

interpret data of concept of sensitivity, diseases in the
diseases screening specificity, and community
predictive value
in the community
b. Describe the concept
of cut off points.

~ PLANNERS TEAM ~
No Name Department Phone

Public Health and 081353380666
dr. Putu Cintya Denny Yuliyatni, MPH
1 Preventive Medicine
(Coordinator)
(PH-PM)
2 Prof. dr. D.N. Wirawan, MPH PH-PM 0811394306
3 dr. A.A.Sg. Sawitri, MPH PH-PM 0817340145
4 dr. Komang Ayu Kartika Sari, MPH PH-PM 082147092348
5 dr. Putu Aryani, MIH PH-PM 082237285856
6 dr. Ni Luh Putu Ariastuti, MPH PH-PM 0818560008
dr. Wayan Citra Wulan Sucipta Putri, PH-PM
7 087761838141
MPH
8 Dr. dr. Gde Indraguna Pinatih, M.Sc PH-PM 08123816424
10 Dr. Luh Seriani, SKM, M.Kes PH-PM 08123924326
11 dr. Dwi Ariawan, S.Ked PH-PM 081339798632
~ FACILITATORS ~
Regular Class (Class A)
No Name Department Phone Group Room
Number
dr. I Made Winarsa Ruma, S.Ked, Ph.D Biochemistry 087785356853 A-1 A.2.09
1
2 dr. Endang Sri Widiyanti, M.Biomed, Sp.OG Obgyn 081236745839 A-2 A.2.10
3 dr. IGN Bagus Artana, Sp.PD Internal Medicine 08123994203 A-3 A.2.11
4 Dr. dr. Susy Purnawati, M.KK Physiology 08123989891 A-4 A.2.12
5 Dr. dr. Cok Bagus Jaya Lesmana, Sp.KJ(K) Psychiatry 0816295779 A-5 A.2.13
6 dr. IGN Sri Wiryawan, M.Repro Histology 082341768888 A-6 A.2.14
7 dr. Ida Ayu Sri Indrayani, Sp.S Neurology 081246751536 A-7 A.2.15
8 Clinical A-8 A.2.16

Dr. dr. Sianny Herawati, Sp.PK 0818566411
Pathology
9 Anatomy A-9 A.2.20

dr. I Wayan Juli Sumadi, Sp.PA 082237407778
Pathology

10 dr. Made Satria Yudha D, M.Biomed, Sp.JP Cardiology 082163500096 A-10 A.2.21
English Class (Class B)

No Name Department Phone Group Room
Number
1 Dr. dr. I Made Muliarta, M.Kes Physiology 081338505350 B-1 B.2.09
2 Clinical B-2 B.2.10

Dr. dr. I Wayan Putu Sutirta Yasa, M.Si 08123953344
Pathology
3 Dr. dr. IBG Fajar Manuaba, Sp.OG, MARS Obgyn 081558101719 B-3 B.2.11
4 Anatomy B-4 B.2.12

dr. Ni Made Mahastuti, M.Biomed, Sp.PA 085238886457
Pathology
5 dr. I Made Putra Swi Antara, Sp.JP(K), FIHA Cardiology 08123804782 B-5 B.2.13
6 dr. Nila Wahyuni, M.Fis Physiology 087862324209 B-6 B.2.14
7 dr. I Gede Sastra Winata, M.Biomed, B-7 B.2.15

Obgyn 081338713951
Sp.OG(K)
8 Internal B-8 B.2.16

dr. Nyoman Paramita Ayu, Sp.PD 08123937372
Medicine
9 dr. I Wayan Gede Sutadarma, M.Gizi Biochemistry 082144071268 B-9 B.2.20
10 Dr. dr. Putu Eka Widyadharma, M.Sc, Sp.S(K) Neurology 081237872840 B-10 B.2.21
Skill Lab Facilitators

No Name Department Phone
Public Health and 081353380666
dr. Putu Cintya Denny Yuliyatni, MPH Preventive Medicine
1
(Coordinator)
(PH-PM)
3 dr. A.A.Sg. Sawitri, MPH PH-PM 0817340145
4 dr. Komang Ayu Kartika Sari, MPH PH-PM 082147092348
5 dr. Putu Aryani, MIH PH-PM 082237285856
6 dr. Ni Luh Putu Ariastuti, MPH PH-PM 0818560008
dr. Wayan Citra Wulan Sucipta Putri, PH-PM
7 087761838141
MPH
8 Dr. dr. Gde Indraguna Pinatih, M.Sc PH-PM 08123816424
10 Dr. Luh Seriani, SKM, M.Kes PH-PM 08123924326

11 dr. Dwi Ariawan, S.Ked PH-PM 081339798632
~ TIME TABLE ~
ENGLISH CLASS (B)
Days/date Time Activity Venue Conveyer

Class Room (CR) dr. Putu Cintya
Introductory Block 4.02 Denny Yuliyatni,
08.00 – 09.50 Watch Movie: And The Band Played MPH
On
Introductory lecture Class Room (CR) dr. Ni Luh Putu

1
10.00 – 11.50 Determinants of morbidity and 4.02 Ariastuti, MPH
Monday
mortality in a population (Topic-1)
15th of Oct
12.00 – 12.50 Break/lunch
Introductory lecture Class Room (CR)
13.00 – 14.50 Demography and Epidemiology 4.02
transition of population (Topic-2)
15.00 – 15.50 Independent Learning
08.00 – 08.50 SGD (Topic-1) Discussion Room dr. Ni Luh Putu
(DR) Ariastuti, MPH
09.00 – 09.50 SGD (Topic-2)
2 10.00 – 10.50 Independent Learning

Tuesday 11.00 – 11.50 Break/lunch
16th of Oct
12.00 – 12.50 Plenary (Topic-1) CR 4.02
13.00 – 13.50 Plenary (Topic-2) CR 4.02
14.00 – 15.50 Student Project
Introductory lecture CR 4.02
08.00 – 08.50 Natural history of diseases and dr. Putu Aryani,
Disease prevention of MIH
Communicable Disease (Topic-3)
3 Introductory lecture
Thursday Natural history of diseases and
18th of Oct 09.00 – 09.50
Disease prevention of Non
12.00 – 12.50 Break/Lunch


Introductory lecture CR 4.02 dr. Komang Ayu
Measurements of Morbidity and Kartika Sari, MPH
13.00 -13.50
Mortality in A Population; Source of
Error (Topic-5)
Introductory lecture
14.00-14.50 Crude, Specific and Adjusted Rate
(Topic-6)
08.00 – 08.50 SGD (Topic-3 & 4) DR
09.00 – 09.50 SGD (Topic-5 & 6) DR
CR 4.02 dr. Putu Aryani,
4 10.00 – 10.50 Plenary (Topic-3 & 4)
MIH
Friday
19th of Oct CR 4.02 dr. Komang Ayu
11.00 – 11.50 Plenary (Topic-5 & 6)
Kartika Sari, MPH
Introductory lecture CR 4.02 DR. dr. IGN
Population, Sample, Data, and Indraguna Pinatih,
08.00 – 09.50 Msc
Variables (variability and Bias)
(Topic-7)
Monday 12.00 – 12.50 Break/Lunch
22nd of Oct
Introductory lecture CR 4.02 dr. AA Sagung
13.00 -14.50 Data Presentation and Data Sawitri, MPH
Description (Topic-8)
08.00 – 08.50 SGD (Topic-7) DR
09.00 – 09.50 SGD (Topic-8) DR
CR 4.02 DR. dr. IGN
6 10.00 – 10.50 Plenary (Topic-7) Indraguna Pinatih,
Tuesday Msc
23rd of Oct CR 4.02 dr. AA Sagung
11.00 – 11.50 Plenary (Topic-8)
Sawitri, MPH
Introductory lecture CR 4.02 DR. Luh Seri Ani,
7 Analysis and Interpretation of SKM, M.Kes
08.00 – 09.50
Wednesday Descriptive Data (Descriptive
24nd of Oct Epidemiology) (Topic-9)


Introductory lecture CR 4.02 dr. Putu Cintya
Inferential Analysis and Denny Yuliyatni,
13.00 -13.50 MPH
Interpretation of Analysis Results
(Hypothesis Test) (Topic-10)
14.00 – 14.50 Significance Test for Categorical
and Interval Data (Topic-11)
08.00 – 08.50 SGD (Topic-9) DR
09.00 – 09.50 SGD (Topic-10 & 11) DR
CR 4.02 DR. Luh Seri Ani,
10.00 – 10.50 Plenary (Topic-9)
SKM, M.Kes
8 CR 4.02 dr. Putu Cintya
Thursday 11.00 – 11.50 Plenary (Topic-10 & 11) Denny Yuliyatni,
25rd of Oct MPH
Skill Lab 1 CBT Room Skill Lab Team
13.00 – 15.50 Data Entry, Data Cleaning, and Data
Transformation
Definition, Requirements, Types, Denny Yuliyatni,
08.00 – 09.50 MPH
and Applications of Surveillance
(Topic-12)
09.00 – 09.50 Screening and Diagnostic Testing
9 (Topic-14)
Friday 10.00 – 11.50 Independent Learning
26th of Oct
Definition, Requirements, Types, Sawitri, MPH
13.00 -14.50
and Applications of Outbreaks
(Topic-13)
08.00 – 08.50 SGD (Topic-12 & 14) DR
09.00 – 09.50 SGD (Topic-13) DR
Monday 10.00 – 10.50 Plenary (Topic-12 & 14) Denny Yuliyatni,
29th of Oct MPH
CR 4.02 dr. AA Sagung
11.00 – 11.50 Plenary (Topic-13)
Sawitri, MPH


Skill Lab 2
13.00 – 15.50 Data Presentation and Data
Interpretation
Concept of Epidemiologic studies to Sawitri, MPH
08.00 – 09.50 determine risk factors of diseases
and Cross-sectional study
(Topic-15)
Tuesday 12.00 – 12.50 Break/Lunch
30th of Oct
Epidemiology Study Design: Case Indraguna Pinatih,
13.00 -14.50 MSc
Control Study
(Topic-16)
08.00 – 08.50 SGD (Topic-15) DR
09.00 – 09.50 SGD (Topic-16) DR
10.00 – 10.50 Plenary (Topic-15)
Sawitri, MPH
12 CR 4.02 DR. dr. IGN
Wednesday 11.00 – 11.50 Plenary (Topic-16) Indraguna Pinatih,
31th of Oct MSc
13.00 – 15.50 Significance Test for Categorical &
Interval Data
Introductory lecture CR 4.02 dr. Wayan Citra
08.00 – 09.50 Epidemiology Study Design: Cohort Wulan Sucipta
Study (Topic-17) Putri, MPH

13 12.00 – 12.50 Break/Lunch
Thursday
1st of Nov
Applications of Clinical Trials to
13.00 -14.50 Determine the Effectiveness of
Intervention, Prevention, and
Treatment of Diseases (Topic-18)
14 08.00 – 08.50 SGD (Topic-17) DR

Friday 09.00 – 09.50 SGD (Topic-18) DR


2nd of Nov 10.00 – 10.50 Plenary (Topic-17) CR 4.02 dr. Wayan Citra
Wulan Sucipta
11.00 – 11.50 Plenary (Topic-18) CR 4.02
Putri, MPH
15 08.00 – 11.50 Student Project Presentation CR 4.02 Team Teaching

Monday 12.00 – 12.50 Break/Lunch
5st of Nov 13.00 – 15.50 Independent Learning
16
Tuesday Break
6th of Nov
17
Wednesday Pre evaluation Break
7th of Nov
18
Thursday Evaluation
8th of Nov

~ TIME TABLE ~
REGULER CLASS (A)

1
Monday Break
15th of Oct
Class Room (CR) dr. Putu Cintya
Introductory Block 4.02 Denny Yuliyatni,
08.00 – 09.50 Watch Movie: And The Band Played MPH
On
Introductory lecture Class Room (CR) dr. Ni Luh Putu

2 10.00 – 11.50 Determinants of morbidity and 4.02 Ariastuti, MPH
Tuesday mortality in a population (Topic-1)
16th of Oct
12.00 – 12.50 Break/lunch
13.00 -13.50 Independent Learning
Introductory lecture Class Room (CR)

14.00 – 15.50 Demography and Epidemiology 4.02
transition of population (Topic-2)
08.00 – 08.50 SGD (Topic-1) Discussion Room dr. Ni Luh Putu

(DR) Ariastuti, MPH
09.00 – 09.50 SGD (Topic-2)

Thursday 11.00 – 11.50 Break/lunch
18th of Oct
12.00 – 12.50 Plenary (Topic-1) CR 4.02
13.00 – 13.50 Plenary (Topic-2) CR 4.02
08.00 – 08.50 Natural history of diseases and dr. Putu Aryani,
Disease prevention of MIH
4 Introductory lecture
Friday Natural history of diseases and
19th of Oct 09.00 – 09.50
Disease prevention of Non


Introductory lecture CR 4.02 dr. Komang Ayu
Measurements of Morbidity and Kartika Sari, MPH
13.00 -13.50
Mortality in A Population; Source of
Error (Topic-5)
14.00-14.50 Crude, Specific and Adjusted Rate
(Topic-6)
08.00 – 08.50 SGD (Topic-3 & 4) DR
09.00 – 09.50 SGD (Topic-5 & 6) DR
CR 4.02 dr. Putu Aryani,
5 10.00 – 10.50 Plenary (Topic-3 & 4)
MIH
Monday
22nd of Oct CR 4.02 dr. Komang Ayu
11.00 – 11.50 Plenary (Topic-5 & 6)
Kartika Sari, MPH
Population, Sample, Data, and Indraguna Pinatih,
08.00 – 09.50 Msc
Variables (variability and Bias)
(Topic-7)
Tuesday 12.00 – 12.50 Break/Lunch
23rd of Oct
13.00 -14.50 Data Presentation and Data Sawitri, MPH
Description (Topic-8)
08.00 – 08.50 SGD (Topic-7) DR
09.00 – 09.50 SGD (Topic-8) DR
CR 4.02 DR. dr. IGN
7 10.00 – 10.50 Plenary (Topic-7) Indraguna Pinatih,
Wednesday Msc
24nd of Oct CR 4.02 dr. AA Sagung
11.00 – 11.50 Plenary (Topic-8)
Sawitri, MPH
Introductory lecture CR 4.02 DR. Luh Seri Ani,
8 Analysis and Interpretation of SKM, M.Kes
08.00 – 09.50
Thursday Descriptive Data (Descriptive
25rd of Oct Epidemiology) (Topic-9)


Inferential Analysis and Denny Yuliyatni,
13.00 -13.50 MPH
Interpretation of Analysis Results
(Hypothesis Test) (Topic-10)
14.00 – 14.50 Significance Test for Categorical
and Interval Data (Topic-11)
08.00 – 08.50 SGD (Topic-9) DR
09.00 – 09.50 SGD (Topic-10 & 11) DR
CR 4.02 DR. Luh Seri Ani,
10.00 – 10.50 Plenary (Topic-9)
SKM, M.Kes
Friday 11.00 – 11.50 Plenary (Topic-10 & 11) Denny Yuliyatni,
26th of Oct MPH
13.00 – 15.50 Data Entry, Data Cleaning, and Data
Transformation
Definition, Requirements, Types, Denny Yuliyatni,
08.00 – 09.50 MPH
and Applications of Surveillance
(Topic-12)
09.00 – 09.50 Screening and Diagnostic Testing
10 (Topic-14)
Monday 10.00 – 11.50 Independent Learning
29th of Oct
Definition, Requirements, Types, Sawitri, MPH
13.00 -14.50
and Applications of Outbreaks
(Topic-13)
08.00 – 08.50 SGD (Topic-12 & 14) DR
09.00 – 09.50 SGD (Topic-13) DR
Tuesday 10.00 – 10.50 Plenary (Topic-12 & 14) Denny Yuliyatni,
30th of Oct MPH
11.00 – 11.50 Plenary (Topic-13)
Sawitri, MPH


Skill Lab 2
13.00 – 15.50 Data Presentation and Data
Interpretation
Concept of Epidemiologic studies to Sawitri, MPH
08.00 – 09.50 determine risk factors of diseases
and Cross-sectional study
(Topic-15)
Wednesday 12.00 – 12.50 Break/Lunch
31th of Oct
Epidemiology Study Design: Case Indraguna Pinatih,
13.00 -14.50 MSc
Control Study
(Topic-16)
08.00 – 08.50 SGD (Topic-15) DR
09.00 – 09.50 SGD (Topic-16) DR
10.00 – 10.50 Plenary (Topic-15)
Sawitri, MPH
13 CR 4.02 DR. dr. IGN
Thursday 11.00 – 11.50 Plenary (Topic-16) Indraguna Pinatih,
1st of Nov MSc
13.00 – 15.50 Significance Test for Categorical &
Interval Data
Introductory lecture CR 4.02 dr. Wayan Citra
08.00 – 09.50 Epidemiology Study Design: Cohort Wulan Sucipta
Study (Topic-17) Putri, MPH

14 12.00 – 12.50 Break/Lunch
Friday
2nd of Nov
Applications of Clinical Trials to
13.00 -14.50 Determine the Effectiveness of
Intervention, Prevention, and
Treatment of Diseases (Topic-18)
15 08.00 – 08.50 SGD (Topic-17) DR

Monday 09.00 – 09.50 SGD (Topic-18) DR


5st of Nov 10.00 – 10.50 Plenary (Topic-17) CR 4.02 dr. Wayan Citra
Wulan Sucipta
11.00 – 11.50 Plenary (Topic-18) CR 4.02
Putri, MPH
13.00 – 15.50 Student Project Presentation Team Teaching
16
Tuesday Break
6th of Nov
17
Wednesday Pre evaluation Break
7th of Nov
18
Thursday Evaluation
8th of Nov

SKILL LAB TIME TABLE (Regular and English Class)

Day/Date Time Topic Group SGD Venue
Thursday, 13.00 - 14.30 Skill Lab 1 English Class (SGD B1-B5) CBT Room
25th of Oct Data Entry, Data Cleaning, and 4th Floor
14.30 - 16.00 Data Transformation English Class (SGD B6 - B10)
Friday, 13.00 - 14.30 Skill Lab 1 Reguler Class (SGD A1-A5) CBT Room
26th of Oct Data Entry, Data Cleaning, and 4th Floor
14.30 - 16.00 Data Transformation Reguler Class (SGD A6 - A10)
Monday, 13.00 - 14.30 Skill Lab 2 English Class (SGD B1-B5) CBT Room
29th of Oct Data Presentation and Data 4th Floor
14.30 - 16.00 Interpretation English Class (SGD B6 - B10)
Tuesday, 13.00 - 14.30 Skill Lab 2 Reguler Class (SGD A1-A5) CBT Room
30th of Oct Data Presentation and Data 4th Floor
14.30 - 16.00 Interpretation Reguler Class (SGD A6 - A10)
Wednesday, 13.00 - 14.30 Skill Lab 3 English Class (SGD B1-B5) CBT Room
31th of Oct Significance Test for Categorical & 4th Floor
14.30 - 16.00 Interval Data English Class (SGD B6 - B10)
Thursday, 13.00 - 14.30 Skill Lab 3 Reguler Class (SGD A1-A5) CBT Room
1st of Nov Significance Test for Categorical & 4th Floor
14.30 - 16.00 Interval Data Reguler Class (SGD A6 - A10)
Guidance:
1. Each student is required to bring their own lap-top and has installed the SPSS
program in to their laptop.
2. Data for practising will be provided before the first skill lab. Each head of the SGD
have to contact coordinator Block to ask for those files.
3. Skill Lab Guide is provided on the Anexes. Remember to bring your study guide
every day.
ASSESSMENT METHOD
Student assessment of this block consists of:
1. a paper test with multiple choice questions at the end of block with proportion
80% of total score
2. a student project with proportion 15% of total score
3. evaluation of activity during the small group discussion with proportion 5% of total
score

MODULE~1
DETERMINANTS OF MORBIDITY AND MORTALITY IN
POPULATION
dr. Ni Luh Putu Ariastuti, MPH
(Reference Maussner & Bahn, p. 1-42)
AIMS:
To be able to describe determinants of morbidity and mortality in the population
LEARNING OUTCOMES:
1. Describe the difference approach of community medicine and clinical medicine
2. Describe several determinants (models) of diseases and death occurring in the
population.
3. Explain the applications of understanding diseases and death determinants (models).
4. Identify the strengths and weaknesses of diseases models.
CURRICULUM CONTENTS:
The determinants of morbidity and mortality in population.
ABSTRACTS
As a general practitioner, a medical doctor is expected to understand clinical medicine
as well as community medicine concept. Clinical medicine concept is focuses to individual
patients who are visit health providers. Meanwhile, community or population medicine
concern to whole population, either sick or healthy in certain geographical area.
Community medicine or public health focuses on prevention of diseases in the population,
whereas clinical medicine focuses on treating sick individual patients who come to health
providers.
In order to provide appropriate treatments to individual patients, the diagnosis of
her/his disease must be established. Similar approach must be established in community
medicine. In order to provide appropriate preventions, determinants of health problems
in the community must be understood.
To understand determinants or factors that influence the occurrence of diseases
in the population, some epidemiological models or theories are discussed in this lecture.
Each model has its strengths and weaknesses. There is no single model which is
appropriate to explain determinants of all diseases occurrence. Triangle model which was
first introduced, explained that the occurrence of diseases in the population is determine
by agent, host and environments. Wheel model focused on intrinsic (host factors) and
extrinsic (environments factors). Model which was introduced by Blum explained that the
occurrence of diseases in the population determine by genetic, behaviour, health
programs and environments. Web model explained that a determinant of diseases

occurrence in the population is not simple but interrelated of many factors. There are many
other models which explain determinants of diseases but not discussed in this lecture.
SELF DIRECTING LEARNING:

Basic knowledge and its application that students must know, include:
1. Clinical medicine approach vs community medicine approach
2. Disease’s model
SCENARIO& LEARNING TASKS
Guidelines:
a) During small group discussion (SGD), each group has to select a spokesperson, who
will be presenting the results of discussions at the plenary
b) Prior to the plenary, the spokesperson of each group sits in front of the class
c) Read carefully the learning tasks (1) and (2) below.
d) Each group have to discuss all learning tasks
e) Each group must present the learning tasks in the plenary.
f) Before the plenary start, every SGD has already put the file of the answer in the class’
computer/CPU
Learning Task 1
Case 1. Based on the movie “And The Band Played On”, you are required to discuss
in your group the following questions:
1. Please explain about steps to discover the cause of AIDS based on this movie.
Which one was started first, the lab investigation or epidemiology investigation
to find out the cause of AIDS?
2. How were the roles of the following fields shown in the movie
a. Statistic
b. Clinical
c. Social
d. Epidemiology
e. Virology
3. Please explain which part of the movie explained the types of social and
political threats that influenced the investigation to find out the cause of that
mysterious disease
4. Please explain which part of the movie showed ethics and professional aspects
5. Please explain which part of the movie that presented the threats/difficulties in
controlling and preventing that disease
Case 2
Please watch carefully as well:
http://www.youtube.com/watch?v=mMDUv2R6tHQ

1. What is the main topic of the conversation?

2. Please draw in a diagram about what factor influence the man’s health status!
Learning Task 2
Discuss the following in your group:
a) The high morbidity and mortality due to dengue haemorrhagic fever (DHF) is
influenced by many factors (determinants). Discuss these factors using Wheels
Model. Explain also the most dominant factor.
b) 1. The high incidence of morbidity (morbidity rate) due to traffic accidents are
influenced by many factors (determinants). Discuss in groups these factors using
Web Model. Explain the most dominant factor.
2.The high mortality rates due to traffic accidents are also influenced by many factors
(determinants). Discuss in groups these factors using Blum Model. Explain also
the most dominant factor.
c) The high morbidity and mortality due to tuberculosis (TB) are influenced by many
factors (determinants). Discuss in groups these factors using Triangle Model. Explain
also the most dominant factor.
d) The high morbidity and mortality caused by HIV-AIDS are influenced by many factors
(determinants). Discuss in groups these factors using Blum and Triangle Model.
Explain also the most dominant factor.
Self assessment
1. Why is it very important to understand the determinant of health in a population?
2. Explain the determinant factor of diseases occurrence by using the Epidemiological
Triangle, the Wheels and the Blum models!
3. A part of the Blum model is the health care factor. If you use the Wheel model, into
which factor that factor should be included?
4. The other part of the Blum model is behaviour factor. If you use the Wheel model,
that factor should be included into which factor? And if you use the Epidemiological
Triangle model, how should you place the behaviour factor?
MODULE~2

DEMOGRAPHY AND EPIDEMIOLOGY TRANSITION OF

POPULATION
dr. Ni Luh Putu Ariastuti, MPH
AIMS:
To be able to describe the concept of demography and epidemiology transition of
population
LEARNING OUTCOMES:
1. Understand the concepts of demography and epidemiological transition
2. Understand the shift from high mortality to low mortality
3. Identify the agents of change in mortality and cause of death regimes
4. Understand how health risk are changing and may change in the future
Demographic and epidemiologic transition of population
ABSTRACTS
This lecture will discuss the demography and epidemiological transition in the population.
Change in population related to change in mortality and cause of death.. Demography is
concerned with this and with understanding population dynamics. Demography refers to
study of populations, especially with reference to size and density, fertility, mortality,
growth, age, distribution, migration, vital statistics and the interaction of these with social
and economic conditions. How populations change in response to the interplay between
fertility, mortality, and migration influence health status of a state. This understanding is a
prerequisite for making the forecasts about future population size and structure, which
should underpin healthcare planning.

Basic knowledge and its application that students must know, include:
1. Demography transitional
2. Epidemiology transitional
Learning Task
Based on the article “Epidemiology of Aging”, you are required to discuss in your
group the following questions:
a. Please explain about demographic transition mentioned in the article
b. Please explain epidemiologic transition in the article
c. Please explain the correlation between demographic and epidemiologic transition of
aging population
d. Please explain the reason behind this phenomena.

e. Please discuss the impact of these transitions to healthcare system
Article can be accessed : https://www.vumc.org/psychiatry-geriatric-

fellowship/files/psychiatry-geriatric-
fellowship/public_files/Epidemiology%20of%20Aging.pdf
Self assessment
1. Why is it very important to understand demography and epidemiology transition?
2. Explain demographic data and its analysis
3. Describe recent demographic and epidemiologic transition and its impact to global
health burden.
REFERENCE
Emily and Murphy, Michael J. (2015) Demography and public health. In: Detels, Roger,
Gulliford, Martin , Karim, Quarraisha Abdool and Tan, Chorh Chuan, (eds.) Oxford
Textbook of Global Public Health. Oxford textbooks, 2. 6th ed., Oxford University Press,
Oxford, UK, pp. 718-735

MODULE~3
NATURAL HISTORY OF DISEASES AND DISEASES
PREVENTION
PART I: COMMUNICABLE DISEASES
dr. Putu Aryani, S.Ked, MIH
Reference Epidemiology “An Introductory Text” (Mausner & Bahn)
ABSTRACT
This lecture will discussed about natural history of the diseases mainly for
communicable/infectious diseases. Infectious diseases such as Tuberculosis, Influenza,
Thypoid fever, Dengue Hemorraghic fever (DHF), Malaria, Rabies, etc, has its own path
or life history. Natural history of disease is a general scheme to describe the life history of
disease started from the invasion of the agents (virus, bacteria or parasite) to the host
(human body), the process inside the body and its impact to the human body (outcome).
Naturally, every diseases will go through 4 phase. First of all, susceptibility phase/stage
where the disease has not developed, but the groundwork has been laid by the presence
of factors which favor its occurrence. For instance the availability of the infectious agent
(virus, bacteria or parasite), such as Mycobacterium tuberculosis, low economic status,
and low nutritional status of a person. Factors which is associated with an increased
likelihood that the diseases will develop are called risk factors. Secondly, the Pre-
symptomatic Disease stage. In this stage the agent has entered the body, but there is no
manifestation or symptom. For example, in the case of Tuberculosis (TB), the bacteria has
entered the body, but there is still no symptom and sign. The third stage is Symptomatic
or clinical disease stage, where the interaction between the agent and the host resulting
the manifestation of the illness. In TB patients suffers the symptom of TB infection, such
as mild fever, bloody cough, fatigue, nausea. The last stage is the outcome of the disease.
The result can be completely resolve, or causing disability or Mortality. For instance in
Tuberculosis, the results can be completely cured when the patients got appropriate
treatment at earlier stage (have completed the 6 months regiment) and have a good
nutritional status. However if the patients have low adherence towards medication, or have
low nutritional status or have low immunity, the patient could be die.
Many disease can be prevented by understanding the natural history of the disease. In
public health, there are 3 level of prevention based on the stage of the natural history of
disease. For instance in preventing tuberculosis, at the susceptibility stage, primary
prevention could be applied. Primary prevention consist of health promotion and specific
protection. However, when the agent has infected the host, in the pre-symptomatic phase,
the secondary prevention must be applied. This prevention including screening and
appropriate treatments. Lastly, tertiary prevention is the only choices when people has
develop the symptom and sign in order to limit the disability or prevent the mortality and
rehabilitation for people who has developed disability.

LEARNING TASK
1. Please take a look this PDF file below before answering the following task:
http://www.euro.who.int/__data/assets/pdf_file/0004/129532/Ottawa_Charter.pdf
All the answers for the following task must also refer/consider to “Ottawa Charter” as
explained on the above file.
2. Discuss the natural history, primary, secondary and tertiary prevention of
Tuberculosis and Dengue Hemorraghic Fever (DHF). Please refer to the following
website:
http://www.uphs.upenn.edu/bugdrug/antibiotic_manual/iuatld_tb_manual_for_me
dical_students.pdf
INDEPENDENT LEARNING
1. Discuss the natural history and primary of DHF, HIV/AIDS, diarrheal, tuberculosis
(TBC), and avian influenza
2. The level of prevention consists of primary preventions, including health promotion
(behavior change & policy/regulation) and specific protection, secondary prevention
(early detection and prompt treatment), and tertiary prevention (disability limitation and
rehabilitation). Explain which prevention will be effective for the following
diseases/incidents: DHF, HIV/AIDS, diarrheal, tuberculosis (TBC), and avian
influenza.
3. Explain the definition of the iceberg phenomena and its consequences regarding the
communicable disease prevention in the community and regarding the accuracy of
data available at service statistic (primary health services such as private midwives/
doctor, PHC, private clinics, secondary health care service such as district hospital,
and tertiary health care service such as referral hospital).
MODULE~4

NATURAL HISTORY OF DISEASES AND DISEASES

PREVENTION
PART II: NON-COMMUNICABLE DISEASES
dr. Putu Aryani, S.Ked, MIH
Reference Book: Epidemiology “An Introductory Text” (Mausner & Bahn)
ABSTRACT
There are increasing prevalence of non-communicable disease recently including in
Indonesia, specifically in Bali. The most case that are found in the primary care
(Puskesmas) are cardiovascular and degenerative disease such as: Hypertenssion,
Diabetes, Arthritis, Gout, etc. At the referral hospital, case of heart attack, stroke and
cancer also increasing. Therefore in this lecture the focus of the discussion will be about
the natural history of the Non-communicable diseases, mainly Hypertension and Diabetes.
The life history of noncommunicalbe disease is slightly different from communicable
disease. At the Suceptibility first stage, the agents could be the excessive food component
such as sugar or fat or the other substance such as tobacco or alcoholic drink. The
duration of the process inside the body and its impact to the human body (outcome) is
usually longer (chronic) than infectious disease. Secondly, at the Pre-symptomatic
Disease stage people may have been overweight or obese but there is no manifestation
or symptom of hypertension yet, unless they underwent the laboratory examination. For
example, in the case of Hypertension, the atheroschlerosis might has been developed in
the blood vessels, but there are still no clinical sign and symptom. At the Symptomatic
stage, the people with high blood pressure may feel severe headache. For the diabetic
patients they may have a symptom of numbness on the finger and also have a longer
duration of the wound recovery. The degenerative disease usually could not be completely
cured, but it can be controlled in order to prevent the complication such as stroke or heart
or renal failure. When the disease is not treated appropriately, the complication could
leads to disability or mortality.
Non communicable disease also can be prevented by modifying the lifestyle of the
population. In this case, primary prevention such as health education about nutrition,
physical activities and other risky behavior can be done earlier. Screening of the disease
also could help in finding hypertension and diabetes at the earlier stage, so it can be
treated earlier. However if the disease has been causing symptom, the prevention effort
will be focused on curbing the complication and reducing the disability after stroke or heart
attack.
LEARNING TASK
1. Discuss the natural history, primary, secondary and tertiary prevention of
Hypertension and Type II Diabetes.

2. Discuss the example of prevention that could be taken to prevent Hypertension

and Type II Diabetes and its complication. (the three level of prevention and in
which stage of the natural history)
INDEPENDENT LEARNING
1. Discuss the natural history and prevention of Cancer, Malnutrition in under 5
Children
2. The level of prevention consists of primary preventions, including health promotion
(behavior change & policy/regulation) and specific protection, secondary
prevention (early detection and prompt treatment), and tertiary prevention
(disability limitation and rehabilitation). Explain which prevention will be effective
for the following diseases/incidents: Cervical Cancer, Lung Cancer, Stroke,
Malnutrition in under 5 Children
3. Explain the definition of the iceberg phenomena and its consequences regarding
the non-communicable disease prevention in the community and regarding the
accuracy of data available at service statistic (primary health services such as
private midwives/ doctor, PHC, private clinics, secondary health care service such
as district hospital, and tertiary health care service such as referral hospital).
MODULE~5

MEASUREMENTS OF MORBIDITY AND MORTALITY IN

A POPULATION; SOURCE OF ERROR IN
MEASUREMENTS
dr. Ayu Kartika Sari, MD., MPH
(Reference Greenberg p. 15-28 & Gordis, p. 37-83)
AIMS
To demonstrate ability to search, collect, organize and interpret information/data from
different sources in order to assist in diagnostic, therapeutic and health.
LEARNING OUTCOMES:
At the end of the module, students should be able to:
1. Explain measurements of morbidity and mortality in a population.
2. Differentiate proportion, ratio, rate, prevalence and incidence.
3. Explain four types of incidence based on their denominators.
4. Describe the source of numerators and denominators for prevalence and incidence.
5. Explain types of errors in rate calculation.
6. Explain the differences, application, interpretation, and weaknesses of (slide) crude,
specific, and adjusted rate.
7. Analyze, and interpret crude, specific and adjusted rate.
1. Measurements of Morbidity and Mortality in a Population
2. Crude, Specific and Adjusted Rate

1. Read previous lectures regarding the natural history of diseases.
2. Read Handout 1, p. 62–68, Greenberg, p. 47-53, Gordis, p. 37-83, and power point
slides.
ABSTRACTS
As a medical doctor, either in a clinic or in a public health setting, we will face many
problems in a field work which relate to rate, ratio, and proportion. A clinician will certainly
consider rate in diagnosing and predicting the fatality or prognosis of a certain disease, a
clinician will certainly use rate. Meanwhile, a public health doctor will apply rate, ratio, and
proportion to either diagnose a community problem or to evaluate a health program.
Rate, ratio, and proportion, are measurements used to describe the situation, condition,
or even a problem among population. Each measurement has specific characteristics and
applications. Ratio which is a comparison between 2 independent numbers is usually used
for management purpose. Proportion is a comparison between numerator and
denominator in which the numerator is included in the denominator. Lastly, rate is a
proportion which has population at risk as the denominator. The understanding on

measurement characteristics is needed due to giving specific interpretation based on the

situation and purpose of measurement.
SCENARIO & LEARNING TASK
Case 1.
The Jakarta Post, Jakarta | National | Tuesday, December 31 2013, 7:33 PM
http://www.thejakartapost.com/news/2013/12/31/36000-people-with-hivaids-receive-arv-
therapy-throughout-2013.html
36,000 people with HIV/AIDS receive ARV therapy throughout 2013
As many as 36,483 people living with HIV/AIDS (ODHA) have received antiretroviral
(ARV) treatment in 2013, up from 2,381 in 2005, a senior health official has said.
“The development of HIV/AIDS control in Indonesia has shown relatively good results.
This can be seen from the increase in the number of people receiving antiretroviral therapy
in 2013,” said the Health Ministry’s director general of disease control and environmental
health, T, in Jakarta on Tuesday, as quoted by Antara news agency.
However, he said, the ministry also found that the number of early detected HIV cases
had continuously increased. In 2013, 20,397 people were recorded as having been
infected with HIV, up from 895 in 2005.
Meanwhile, the number of AIDS patients reached 2,763 as of September, down from
4,987 in 2005.
“The Case Fatality Rate (CFR) has also dropped to 0.85 percent as of September from
13.65 percent in 2004,” said T.
The Health Ministry has been intensively carrying out HIV/AIDS control and prevention
programs by, among other measures, putting together a national guideline and training
modules for health workers such as Training of Trainers (ToT) on Voluntary Counseling
and Testing (VCT), which is followed up with VCT as well as Care and Support and
Treatment (CST) training sessions.
Learning Task 1
You are required to discuss the following questions, based on the study above.
1. What is the type of measurement underlined in the above case?
2. What is the weakness of that measurement when it is applied to diagnose community
health problem?
3. Do you think that measurement is still important to be used in the above case? Please
give a reason!
4. Please interpret the data of case fatality rate mentioned in the above case! What is the
importance of this rate to clinician?
5. What are the differences between Case Fatality Rate and Cause Specific Death Rate?
Case 2.
Below is the result of a survey on primary care provider’s behaviour in preventive service
provision. There are 300 primary care providers in total with 61 of them being interviewed

regarding their behaviour in preventive service provision. Table 1 shows the number and
percentage of primary care providers in each group of behaviour and demographic
characteristics.
Table 1. Number and proportion of primary care providers in each group of behavior and
demographic characteristics
Categories of behavior and Number of primary care
Percentage
characteristics providers
Preventive service
 Conducted 56 91.8
 Not conducted 5 8.2
Sex
 Male 32 52.5
 Female 29 47.5
Age
 <30 years 3 4.9
 31-60 years 51 83.6
 >60 years 7 11.5
Education
 Undergraduate 35 57.4
 Post-graduate 25 41.0
 Doctoral 1 1.6
Learning Task 2
1. What measurement is presented as percentages in the case above? Is it a ratio,
proportion or rate?
2. Give your interpretation for the behaviour in preventive service provision and
demographic characteristics of the primary care providers above.
3. When there was a total of 300 primary care providers, how many of them are
female? And how many of them have an undergraduate education?
4. What are the possibilities of biases of your estimation at number (4)? Provide your
reasons!
Case 3.
Survey of Tuberculosis in Bali, 2010

Bellow is the result of TB survey in Bali in the end of 2009 (Table 1) that was conducted
by the team of Udayana University. The survey was conducted to total available public
health centers (120 PHCs) in Bali and 3 main hospitals (RS Sanglah, RS Wangaya, and
RS Buleleng). To complete the analysis of the study, researcher took data of population
from the Bali Provincial Statistic Office (Table 2).
Table 1. Number of TB cases in Bali
No Sub-province Frequency Proportion Rate
1. Buleleng 165
2. Jembrana 73
3. Tabanan 57
4. Badung 119
5. Denpasar 312
6. Gianyar 73
7. Bangli 28
8. Klungkung 57
9. Karangasem 116
Total 1000
Source: HIV prevalence among TB patients in Bali, 2009
Table 2 Number of population in Bali, Based on District and Nationality at 2010

Regencies Indonesian Foreigners Total
China Others
Male Female Male Female Male Female
(1) (2) (3) (4) (5) (6) (7) (8)
1. Jembrana 136.063 136.757 4 1 2 1 272.828
2. Tabanan 214.260 216.884 0 0 19 9 431.172
3. Badung 197.167 195.619 0 1 161 72 393.020
4. Gianyar 199.973 199. 607 15 11 22 32 399.660
5. Klungkung 91.067 94.201 0 0 4 0 185.272
6. Bangli 107594 108.135 0 0 0 0 215.729
7. Karangasem 219.591 218.883 0 1 0 0 438.475
8. Buleleng 331.931 330.907 16 17 28 21 662.920
9. Denpasar 262.362 260.476 0 0 277 184 523.299
2010 1.760.008 1.761.469 35 31 513 319 3.522.375
Source: Bali Provincial Statistic Office, 2010
Learning Task 3

1. Fill in the proportion and the rate based on the above data. What is the
interpretation?
2. What is the difference between the proportion and rate at the above? Which one
is the appropriate to determine community health problem?
3. What is the rate you calculate: prevalence or incidence? Explain your answers!
4. What are the differences between incidence and prevalence?
5. If you want to calculate incidence of TB, draw the figure of incidence measurement
based on the above data (take one sub-district as an example)
6. With regard to the source of data, what could be biases regarding the above result?
Case 4
The occurrence of tuberculosis (TB) was measured in a study conducted in Bima Sub-
District from 1 January 2017 to 31 December 2017. On 1 January 2017, there were 15
persons diagnosed with TB and all those cases were cured before 31 December 2017.
During the study period, there were 10 cases newly diagnosed with TB. Two of the cases
were cured before 31 December 2012, while the other 8 cases were still ill on 31
December 2012. It was known that the number of mid-year population in the district was
7500 people.
Learning Task 4
1. Based on the case above, what is the point prevalence on 1 January 2012?
2. What is the period prevalence of TB from 1 January 2012 to 31 December 2012?
3. What is the cumulative incidence from 1 January 2012 to December 2012?
4. Bagaimanakah interpretasi ketiga hasil penghitungan rate di atas?
5. Apakah perbedaan kegunaan ketiga jenis rate di atas?

MODULE~6
CRUDE, SPECIFIC AND ADJUSTED RATE
Ayu Kartika Sari, MD., MPH

(Greenbergp. 51-53)
__________________________________________________________________
ABSTRACTS
The other principal topic of morbidity and mortality measurements is the terms of crude,
specific, and adjustment. These measurements are often being applied to those rate, ratio,
and proportion. Crude, specific and adjustment are relative measurements. Crude means,
generally, if the numerator and the denominator use total incident in a population (ex.
CDR, CBR). While specific measurement is when the numerator and the denominator are
comes from certain sub-populations. For instances the specific mortality on delivered
women and the specific morbidity on tuberculosis. The adjustment is adjusting a certain
incident among a group of population to a standard population for comparison purpose.
Case 1
Sero prevalence of HIV among TB patients in Bali
Study of HIV-TB was conducted in 2009 by research team of Udayana University to find
out the HIV prevalence among TB patients who visit health services (puskesmas, Sub-
province and hospitals) in Bali. Each newly TB diagnosed patients were having short
counselling for examination for their HIV status in anonymously unlinked manner. One
thousand TB patients (580 male and 420 female) were visiting clinics on June to
December 2008. HIV was found to be positive among 39 TB patients (30 male and 9
female), while the distribution based on sub-provinces is presented in the following table.
(Report of Sero-Survey of HIV Co Infection among TB patients in Bali, 2009)
Distribution of TB and HIV Patients Based on Sex and Sub-province

Num Sub-province Frequency of TB patients Frequency of HIV patients
ber (male; female) (male; female)
(1) (2) (3) (4)
1. Buleleng 165 (101; 64) 19 (16; 3)
2. Jembrana 73 (45; 28) 1 (1; 0)
3. Tabanan 57 (31;26) 1 (1; 0)
4. Badung 119 (68; 51) 0
5. Denpasar 312 (171; 141) 16 (11; 5)
6. Gianyar 73 (43; 30) 0
7. Bangli 28 (18; 10) 0
8. Klungkung 57 (31; 26) 0
9. Karangasem 116 (75; 41) 2 (1; 1)
Total 1000 (580; 420) 39 (30; 9)
Learning Task 1

1. What is the crude HIV infection among TB patients in Bali? What is the
interpretation of that number?
2. What is the specific HIV infection among TB patients in Bali, based on sex? What
is the interpretation of that number? Is the number confounded by area or sub-
province?
3. What is the specific HIV infection among TB patients in Bali, based on sub-
province? What is the interpretation of that number? Is the number confounded by
sex?
4. What is the specific HIV infection among TB patients in Bali, based on sex and
sub-province? What is the interpretation of that number? Is the number
confounded by sex and sub-province?
5. Regarding the above results, explain the weaknesses of crude and specific rate.
6. If you are the Head of Bali Province, what will you do with regard to the above
result (number 1, 2, and 3)?
7. If you are the Head of Puskesmas in Buleleng area, what will you do if you
diagnose patient as a TB in Puskesmas?
Case 2
The following graphic shows data of crude birth rate and crude death rate on two countries.
Look at carefully, and discuss the following questions. Please be aware that now we are
discussing crude, specific and adjusted rate; therefore your answers should be prompted
to the concept of those measurements.
Graphic Comparison of CBR and CDR at Canada and Alberta
Learning Task 2

1. First summary: the health status at Canada is better than Alberta. Is that correct?
Explain your answer!
2. In order to make fair comparison between those states, what should you do? What
data do you need?
3. Second summary: Number of deaths at Canada is greater than Alberta. Is that correct?
Explain your answer!
4. Third summary: If adjusted death rate for Canada is 7 per 1000 persons, when the
total population of Canada is 33,476,688. The total number of death was 234,339. Is
that correct? Explain your answer!
Self Assessment
1. How do you differentiate absolute, ratio, proportion and rate?
2. Incidence and prevalence are not similar in many ways. Explain that!
3. In how many ways can you calculate incidence rate?
4. What are denominators that can be applied for calculating incidence? What is the most
ideal enumerator?
5. Which measurement can be used to predict prognosis or trend of mortality for suffering
from disease?

MODULE~7
POPULATION, SAMPLE, DATA, AND VARIABLES

Dr.dr. Gde Ngurah Indraguna Pinatih,MSc., SpGK
(Reference Kirkwood and Sterne, chapter 2)
AIM:
Demonstrate ability to search, collect, organize and interpret information/data from
LEARNING OUTCOMES:
a) Describe the definitions of population and sample.
b) Explain the conditions required for a representative sample.
c) Explain several sampling methods.
d) Describe types of data and variables.
e) Describe several method of data collection
Population, Sample, Data, and Variables
ABSTRACT
Population is a group of people or organism in whom the result of certain study shall be
applied; while sample is part of the population that should represent its population. Two
requirements for sample to be representative are concerning on samples size and sample
selection.
Sample size are determined by indicators of measurements (mean, proportion)
study design, alpha(α) and power(1-β), and tolerated deviation. Besides those above,
sample selection also takes important role. The recommended sample selection for mostly
research is random sampling (simple, systematic, stratified, multistage, etc). In clinic
setting, we frequently used consecutive sampling which is a non-random sampling and
assumed to be represented its population.
Sample allocation can be used if we need more than one group of sample. The
easiest way is block allocation. We can also use allocation of simple random sampling,
stratified allocation, and systematic allocation.

SCENARIO:
Case 1.
Study on Maternal and Child Health
The study was conducted in two phase; 1) household survey to determine the under
five years health status and 2) Quasi Experimental study to explore the effect of
food supplementation program toward the improvement of nutritional status
First Phase
A household survey was conducted to explore under five years child’s health status at
Desa Merdeka in 2011. The objective of the study was to determine several factors that
associated with anaemia and chronic malnutrition among children in the area. The area
has two different characteristics which are easy to reach area (easy) and hard to reach
area (hard). The condition of both areas was suggested to be considered since there might
be different characteristics of the family; hence, the samples were randomly selected from
both areas.
The subjects of the study were all under five years old children. Children from the family
who are no longer residing in the area were excluded from the study and those with
incomplete data were excluded during data analysis. List of the children were withdrawn
from the register at the village leader office.
Data collection was performed by interview with the mother using a structured
questionnaire and followed by measurement of the children. The characteristics that were
explored and measured include: mothers’ and children’s demographic characteristic,
haemoglobin level, height and body weight. More specifically, the variables in the study
were ID, name, area, mothers’ age, education, occupation; history of exclusive
breastfeeding, parity; and children’s weight, age, haemoglobin level, body weight and
height. The haemoglobin level measured with HemoCue, height measured with height
calliper and body weight measured with digital scale. Anaemia status was determined
when Hb level is less than 11 mg/dl and undernourished determined when BMI per-age
less than -2 SD of mean.
Second Phase
After the above data collection was completed, the second phase of the study was started.
This phase aims to evaluate the impact of food supplementation program to improve
nutritional status among undernourished children. All undernourished children were
involved in the study, expect those with severe illness. The children were allocated into
two groups; first group received food supplementation and second groups continue with
the prior daily consumption. The supplementation was provided up to 2 months and at the
end of two month the nutritional status (the body weight) were measured again.
Learning Task 1:
You are required to discuss the following questions, based on the study:
2. Explain the definition of population (target population and sampled population) and
sample!
From each study phase of the case above describe:

1. Target population of the study

2. Sampled population of the study
3. Discuss what are the different between target and sampled population
3. Discuss the reason of taking sample rather than observed all population and the
requirement of a good sample?
4. Discuss several conditions for samples to represent the population (to be
representative)!
5. Discuss the meanings and objective of inclusion criteria, exclusion criteria, and drop
out criteria?
Base on the case study above, for each phase, describe:
1. What are the inclusion criteria for the study
2. What are the exclusion criteria for the study
3. What are the drop out criteria for the study
6. Explain the indication and the technique for sampling methods below
1. Simple random, stratified random, systematic random, multi-stage random,
cluster,
2. Quota, convenience, purposive, and “snow-balling technique”
3. Based on the case study above, what is the sampling method of the study?
6. Based on the case above (phase 1), describe about sampling frame for the study. What
is the importance of constructing a sampling frame and when it is not possible to be
constructed?
7. Explain several important parts in sample size calculation including variability, design,
power (1-), level of significance (), effect size or precision or margin of error.
a. Draw the relationship between variables above
c. Classify the variables based on their function
8. a. Explain the classification of variables based on the level of measurement
b. Among the variables on the study above, classify them based on the level of
measurement
9. Describe method of data collection that have been applied on the case study above.
Self Assessments:
1. Explain the definition of population and sample!
2. What are the conditions required for a representative sample?
3. Explain several sampling methods: simple random, proportional, multistage, stratified,
systematic, cluster, quota, consecutive, incidental, purposive, and “snow-balling
technique”!
4. What is the meaning of exclusion criteria? What is the purpose of excluding some
population characteristics?
MODULE~8

ANALYSIS AND INTERPRETATION OF DESCRIPTIVE

DATA (DESCRIPTIVE EPIDEMIOLOGY)
Dr. Luh Seri Ani, SKM., M.Kes
(Reference Greenberg, p. 29-43)
AIMS:
To demonstrate ability to search, collect, organize and interpret information/data from
LEARNING OUTCOMES:
1. To analyse, present, and interpret descriptive data.
2. To interpret the measurements of morbidity and mortality on samples descriptively
1. Variable of person, place, and time
2. Rate comparison
3. Data interpretation
ABSTRACT
Descriptive in epidemiology begins with the assumption that disease do not occur in
random. Typically three standard questions are posed to characterize the non random
distribution of disease: Who get the disease? Where does the disease occur? And When
does the disease occur? These questions concern the element of person, place and
time, respectively.
At the minimum, the personal attributes examined in relation to disease
occurrence are the distribution by age, race and sex. The place of occurrence of the
disease may be studied at international, regional and local level. Temporal pattern can
be examined across year, month, or days, depending on the time course of the disease in
question.

Basic knowledge and its application that students must know include:
1. Variables of person, place and time
2. Rate comparison and interpretation
SCENARIO & LEARNING TASKS

Case 1.
Look at the following figure carefully:

Fig 1 Malnutrition Rate, by UNICEF, WHO, World Bank Group joint malnutrition
estimates, 2017
(Source: UNICEF, WHO, World Bank Group joint malnutrition estimates, 2017)
Learning Tasks 1:
After you carefully look at the figure above, please discuss the following questions:
1. What are the interpretations of the figure? How many conclusions could you drawn
from the figure?
2. What are risk factors of malnutrition?
Case 2.
Fig. 2 Percentage of stunted children under 5, by United Nations sub-region, 2016
Learning Tasks 2:
1. Which countries have high incidence of stunting?
2. Who is at risk for stunting?
3. How to diagnose stunting?

Case 3:
Figure 3. Percentage of overweight children under 5, by United Nations region, 2000 –
2016
Learning Tasks 3:
Based on the above figure, please answer the following questions:
1. What can you conclude from the obove figure ?

2. Try to compare between Asia and other countries and give review?
Case 4:
Figure 4. Percentage of stunted, overweight and wasted children under 5, by

country income classification, 2000 – 2016
Learning Tasks 4:
Based on the above figure, please answer the following questions:
1. Explain, whether economic factor contribute to the incidence of malnutrition?
Self Assessments:
1. What is the definition of specific rate?
2. What are the differences between specific and crude rate?
3. Which variables are usually used as a base for specific rate calculation?
4. What is the use/benefit of calculating specific rate?

5. Describe the method to diagnose an undernourish problem among under-five- year

old children in one area?
6. A clinician needs to understand the variation (pattern) of diseases based on Who,
Where, and When. Why?
MODULE ~9
DATA PRESENTATION AND DATA DESCRIPTION
dr. Anak Agung Sagung Sawitri, MPH

(Reference Kirkwood & Sterne, Chap 3 &4)

AIM:
LEARNING OUTCOME:
Be able to perform data presentation and data description.
Data presentation and data description
ABSTRACT
Presenting and describing data are closely related with data classification based on their
function, which are: interval (numeric or quantitative), discrete, continue, categorical
(qualitative), and ordinal data.
Qualitative data is divided into two categories (dichotomies) and more than two categories
(multi-chotomies). Important aspect of qualitative data is the number for each category.
The analysis can be made is, either frequency distribution or cross-tab frequency
distribution. In the table of frequency distribution, we can calculate incidence, prevalence,
and ratio, both for crude and specific measurements based on place, time and person. To
summarize the data we can use highest and lowest frequencies and or mode. While for
cross-tab frequency distribution, we can make percentage based on column, row, dan
total percentages. For specific cross-tab 2x2 (four-fold table), we can calculate some
important indicators such as Odds Ratio (OR), Risk Ratio (RR), Specificity (Sp), and
Sensitivity (Se). Besides table, we can present this data by graphic, which is most
appropriate, is bar chart
Presenting numeric/quantitative data looks more simple than presenting
categorical/nominal data. The important aspect to be understood is how to determine
appropriate data presentation, either as a single variable or in relation with other variable.
Measurements which are used is central tendency (Average) and dispersion. Including in
average are mean, mode, median, strength and weakness of average. While including in
dispersion are range, variance, SD; strength and weakness of dispersion. This data can
be displayed in graphic such as line chart, hystogram, and box plot.
SCENARIO:
Case 1. Data Presentation of Categorical Data
Look at the skill lab Data (appendix) Data which have been collected, include several
variables: area, age, education level, occupation, exclusive breastfeeding, parity, children
age, Hb level , body weight and height. In the previous session, we’ve discuss variables
based on their scale of measurement. Understanding the measurement scale of data is
important for selecting the way to present the data. .
For categorical data, the presentation mainly using three different mode which are table,
graph/chart and statistics. Table for categorical data are single frequency table, and cross
table. Presentation of categorical data in graph can used either bar or pie chart; and
statistics that is used are percentage or ratio.
Learning Task 1
Discuss the following:

1. Discuss data presentation in a table and/or chart; and explain the components of table
and chart.
2. Discuss the appropriate chart for categorical data based on the variable available in
skill lab data
3. Discuss about absolute, relative ad cumulative frequency
4. Below is draft of single frequency distribution table
Table-1. The frequency distribution of parity among mothers at Ds. Merdeka, 2011
Parity Frequency Cumulative Relative Cumulative relative
frequency frequency frequency
0 15
1 25
2 30
3 15
4 10
5 or more 5
Total 100
- Please fill the blank cells and Interpret the information on the table above!
5. Discuss the presentation of data in a cross tabs frequency distribution table and when
we use this type of table. Give example based on the skill lab data
6. Below is cross tabulation between area and type of school and nutritional status
among teenager in Province Sentosa
Table 2. Distribution of teenage nutritional status based on type of school in Province

Sentosa in 2012
Type of school Undernourished Normal Obese Total
Public 20 (a) 50 (b) 15 (c) 85
Private 10 (d) 50 (e) 5 (f) 65

Total 30 100 20 150
Based on table 2 above,

- calculate, the row and column percentages for each cells
- Interpret the meaning of row percentage in cell a
- Interpret the meaning of column percentage in cell d
- Discuss about chart for presenting data in table 2, please provide an illustration.
7. Specific for 2 by 2 cross tabulation (four-fold table), we can calculate several numbers
that useful for describing another method for presenting categorical data, which is
ratio. The ratio such as: OR (Odds Ratio), PR (Prevalence Ratio), RR (Relative
Risk/risk ratio). Discuss and give example (based on the skill lab data if possible, or
your own example)
- The Indication of each ratio
- How to calculate each ratio
- How to interpret the meaning of each ratio
8. There was a cohort study that observed the impact of physical inactivity toward
obesity among people age above 40 years old in Province Asri. Underneath is the
result after 2 years follow up
Table 3. Cross table between physical activity level and the obesity among people
age above 40 years old
Physical activity Obese Normal Total

Less active 30 25 55
Active 10 35 45
Total 40 60 100
From table 3,
- Determine the type of ratio that appropriate for comparing the risk of obesity based
on degree of physical activity?
- Calculate the ratio
- Interpret the meaning of the ratio
Case 2.
Data Description/Interpretation of Continuous data
Re-open the Skill lab data (appendix). Previously, you have discussed about data
presentation of categorical data.
Similar to categorical data, the mode of presentation for continuous data divides into three
ways namely; 1) Table, 2) Graphs and 3) Statistics. The tables that can be used are single
frequency tables when the range of the data is narrow; on the other hand, using grouped
frequency table when the range of data is wide. Several types of graph can be used for
presenting continuous data include histogram, box plot, steam and Leaf plot, polygon and
scatter plot. Meanwhile, statistics for continuous data comprise measure of central
tendency and Measure of dispersion.
The measure of central tendency is the value where the data are concentrated. It includes
mean, median and modus. Meanwhile, measure of dispersion show the spread of the data
includes range, variance, standard deviation, and inter quartile range. It is also important
to understand the distribution of data which can be seen by plotting them on a histogram.
The distribution will guide us to select the appropriate statistics to represent the data.
Learning Task 2
Discuss the following
1. Discuss and explain the definition, of central tendency (mean, modus, median).
2. Discuss the distribution of data which can be determine by the value of mean, median
and modus of the data
3. Case 1;If from 100 samples, we found mean Hb level is 12.8 mg/dl, the median is
11.0 mg/dl and the mode is 11.0 mg/dl.
- Is the data tend to distribute normally or skewed?
- Which measure of central tendency is appropriate for describing the data?
4. Discuss and explain the definition of measure of dispersion/spread (range, variance,
SD, percentile, quartile and inter quartile range)
- Based on case 1 above, what measure of spread is appropriate for describe the
data?
5. Based on continuous variables on skill lab data, discuss the appropriate chart that
can be used for data presentation and provide illustration
6. In the skill lab data, we have data on children’s age and body weight. Suppose we
wish to show both data in a graphto show the relationship between both variables,
what type of graph can be used and make an illustration
Self Assessments:

1. Explain the components of a one-way frequency distribution table!

2. How can you conclude the content of a frequency distribution table?
3. Explain the application of cumulative percentage!
4. Cumulative percentage is applied to which kind of data? What is it for?
5. Explain how to conclude the content of a cross tabulation table!
6. Explain briefly the definition of: column, row, and total percentages!
7. Explain some indicators to show the relationship regarding to various categories of
variables!
8. Explain the understanding and application of central tendency (average): mean,
median, and mode.
9. Explain the understanding and application of dispersion (spread): range, variance, and
SD.
10. Explain the advantages and disadvantages of central tendency (average): mean,
median, and mode.
11. Explain the advantages and disadvantages of dispersion: range, variance, SD.
12. Explain the differences of data presentation and data description of age and formal
education, before and after the categorization.
13. Explain the differences of data presentation and data description of body height, body
weight, and Body Mass Index (BMI).
M O D U L E ~ 10
INFERENTIAL ANALYSIS AND INTERPRETATION OF
ANALYSIS RESULTS (HYPOTHESIS TEST)


(Reference Kirkwood & Sterne, Chap. 5-8, 10, 14, 15)
AIM:
LEARNING OUTCOME:
Be able to interpret inferential and interpretation of result analysis
Inferential Analysis and Interpretation of Analysis Results (Hypothesis Test)
ABSTRACT
THEORETICAL DISTRIBUTIONS, CONFIDENCE INTERVAL, AREA UNDER

NORMAL DISTRIBUTION, AND HYPOTESIS TEST
For statistical test purpose, we must have basic understanding on theoritical
distribution, confidence interval (CI), one-tail and two-tail test.
In a theoritical distribution there are several topics need to be understood, are the
probability distribution, characteristics of normal distribution, area under normal
distribution curve, definition of Standard Normal Deviate, and also definition and the
application of Confidence Interval. The important point is the understanding on whether
a certain data is normally distributed or not. Parametric test require normal data
distribution.
Related with normality of data, extreme value outliers may influence data normality. By
deleting those values (if the sample size is sufficient), we may produce data with normal
distribution. We also can replace those values with the median to gain normal
distribution data. If those efforts are not succeed, we may use transformation methods
based on power of transformation in the Explore. If the data still not normally
distributed, we may choose non parametric test.
In a hypothetic test, we must know the asumptions used, definition of nul and alternative
hyphotesis, relation between hyphotesis test with probability (p), confidence interval
(CI), the errors in hyphotetis test, and the application of one and two tail tests.
SCENARIO:
Case 1.
Theoretical Distributions, Confidence Interval, Area under Normal Distribution
For statistical tests, it is important to understand probability theory, theoretical
distributions, confidence intervals (CI), one-tail and two-tail statistical tests, and error in
interpreting hypothesis tests.

Learning Task 1
Discuss the following
1. Explain the definition of probability, marginal probability, conditional probability and
joint probability
2. Explain the definition of “the addition rule and multiplication rule”
3. Table 1. Cross tabulation between Low back pain among Industrial Worker
Low Back Pain Total
Industrial Worker
Yes No
Managers 1 19 20
Office workers 2 28 30
Professional workers 7 43 50
Non-professional 14 86 100
workers
Total 24 176 200
Based on table above, calculate the probability:

a. What is the probability if we selected one employee randomly, will be low back
pain? What type of probability it is?
b. What is the probability of non-low back pain, if office worker? What type of
probability it is?
c. Probability of LBP from managers or office manager?
d. Probability of LBP from professional and non-professional workers?
4. Describe the type of probability distribution of a random variable. Give examples!

5. Describe the characteristic of normal distribution and the use of normal distribution?
6. Distinguish the difference between “normal distribution/Gaussian distribution” and
“standard normal distribution”
7. Describe about z score and its use?
8. If from a study we found the mean of work hours from 200 samples of employee is 8.6
hours, and the standard deviation is 0.6 hours. It is assumed that data was normally
distributed.
Based on the used of normal distribution and the area under normal curve (z score)
a. What is the probability of employees in the population has work hours > 9 hours
b. What is the probability of employees in the population has work hours < 11 hours
9. Based on case 2 above:
- Calculate the standard error of the mean
- Calculate the 95% CI of the mean
- Interpret the 95% CI of the mean
Case 2
Hypothesis Testing and Linear Correlation
Re-open skill lab data (appendix).
Recall that the type of data presentation is based on scale measurement and also the type
of hypothesis testing will be based on the scale of measurement and purpose of the
analysis. Basically, there are two types of hypothesis testing; namely: testing the
difference and testing the association. The basic concept of hypothesis testing should be

understood before performing the test. In hypothesis testing we are testing the possibility
of the difference or the association is likely to be true in the population. There two type of
hypothesis, null hypothesis (Ho) and alternative hypothesis (Ha)
For testing the association between two continuous variables we can use correlation test
with correlation coefficient from Pearson (r). In the correlation test, we can determine the
strength and direction of the association.
Correlation may be a linear and non-linear, symmetric and non-symmetric, straight and
reverse correlation, and relational and causal. In this case, we will only discuss linear
correlation.
Learning Task 2
1. Discuss the indication of linear correlation analysis.
2. From the variables in skill lab data, discuss example of possible correlation analysis
3. Discuss the two ways that we can use for determining correlation between two
variables?
4. Discuss the use of coefficient correlation?
5. Discuss the meaning of negative and positive correlation, provide example!
6. Discuss the strength of the association, when it is considered low, moderate, high and
perfect, describe with example!
Self Assessments:
1. Draw figure of t-distribution, chi-square (2) distribution, F-distribution, Poisson
distribution, Log normal distribution, Binomial distribution. What are the differences of
those six distributions?
2. Explain the probability distribution of a random variable!
3. Explain the definition of Normal distribution (Gaussian distribution).
4. Explain the characteristics of Normal distribution.
5. What is the total area under the normal curve between: (-) and (+), (-1.96)
and (+1.96), (-2.58) and (+2.58).
6. Describe the definition of SND (Standard Normal Deviate).
7. Explain one-tail and two-tail statistical tests and when they can be applied.
8. Describe the strength and direction of quantitative variables correlation.
9. What does it mean if two quantitative variables have correlation coefficients (r) which
are negative or positive?
10. What does it mean if two quantitative variables have correlation coefficients (r) of (0)
or (1)?
M O D U L E ~ 11
SIGNIFICANCE TEST FOR CATEGORICAL AND
INTERVAL DATA

(Reference Kirkwood & Sterne, Chap. 7, 9, 11, 16, 18, 19)

AIM:
LEARNING OUTCOME:
Understand the significance test for categorical and interval data
Significance Test for Categorical and Interval Data
ABSTRACT
1. CATEGORICAL DATA
For analytical test, we must remind classification of variables based on their function to
determine which variable act as dependent or independent variable.
In a sample taken from certain population, we can calculate proportion, rate, or ratio.
Those numbers are used to estimate the parameters in a population. To know whether
those numbers are accurate to estimate population parameters, we need to conduct
hypothesis test. When conducting the hypothesis test, we need to state statistic
hypothesis. There are two types of statistic hypothesis, are null hypothesis (H0) which
shows no difference (similar) in a population, and alternative hypothesis (Ha) which
shows there is/are difference(s) (not similar) in a population. The way to write those
hypothesis are depending on the study direction and indicator to be measured.
Statistical tests for categorical data include test for 1 proportion (binomial test), two
proportions (Chi-square, Mc Nemar, Fisher exact), and three proportions or more (Chi-
square). Each of those has requirements to be fulfilled before the test being conducted.
In some tests, if the requirement is failed to be fulfilled, there are available the
alternative test.
2. INTERVAL DATA
For interval data, the indicators to be calculated in statistical test are mean or median.
Statistical hypothesis also stated in H0 andHa in a ways depend study direction and
the indicator measured. Requirements for statistical test on interval data are data must
be normally distributed and the variance between the groups tested are similar.
Statistical tests for interval data include test for mean of 1 sample (One-sample T-test),
Independent-Sample T Test for unmatched 2 samples and Paired-Sample T Test for
matched 2 samples if the analysis is conducted for one dependent interval variable
with one dichotomous categorical variable. If the data is not normally distributed, we
may choose parametric test such as Mann Whitney U Test, Wilcoxon (Wilcoxon Sign
Rank)
While for analysis of one dependent interval variable with one multicotomous (more
than 2 categories) variable, the choice are One-Way ANOVA (if normally distributed),
comparative group test Bonferroni, LSD, Scheffe etc (if variance is similar), Tamhane’s
T2/T3 etc (if variance is not similar), and non parametric test Kruskal-Wallis if the data
is not normally distributed.

SCENARIO:
Case 1.
Significancy Test for Categorical Data
Re-open skill lab data (annex).
Data available in the data set include: area, age, education level, occupation, exclusive
breastfeeding, parity, children age, Hb level, and body weight. Let’s recall that
understanding the measurement scale of data is important for selecting the way to present
the data. Beside for purpose of data presentation, measurement scale of data is important
on determining the appropriate type of statistical testing (hypothesis testing). Moreover,
the classification of data based on the function in the relationship is also important issue
to be considered.
We have discussed that there are mainly two type of hypothesis testing which are testing
the association and testing the difference (comparison). In the previous section, we
learned about correlation test which is one type of test for testing association between
variables. In this section, we will discuss hypothesis test for the difference (comparison).
The testing will be differentiating based on the type of data (categorical or continuous
data).
From a sample taken from a population, we can calculate proportion, rate, and ratio. These
numbers are parameter estimations of a population. Whether a number gained from
sample may or may not represent its population, it needs to be verified by statistical
methods towards the hypothetical test. There are two kinds of hypothetical statistic
statements: Null Hypothesis (H0) and Alternative Hypothesis (Ha). The Null
Hypothesis (H0) assumes that there is no difference (similarity) in a population, while the
Alternative Hypothesis (Ha) assumes the opposite.
Learning Task 1
1. Discuss about null hypothesis and alternate hypothesis, and provide example of
hypothetical testing based on the skill lab data
2. Discuss two type of error in making decision on statistical analysis
3. Discuss about the p value and its use in statistical testing?
4. Discuss
a. If the p value of a test is 0.01, what does it means?
b. if the p value of a test is 0.1, what does it means?
5. If from the study, we found that the incidence of Measles in Ayodya Province is
3%. Can we conclude that the proportion is different from national data which is at
2%? (α=0.05)
Discuss:
a. The statistical hypothesis of the case
b. The statistical test should we apply for the analysis of the case
c. How we determine the statistical decision
d. If the p value for the study is 0.1, what is your decision and interpretation

6. We want to compare the incidence of Measles in under five children (1) and kinder
garden children (2). with α=0.05. The incidence of Measles of under five years old
children and kinder garden children is 5% and 1%, respectively.
Discuss:
a. The statistical hypothesis for testing there is a different between both of
age group!
b. The statistical hypothesis for testing that the incidence of Measles is higher
in the under five y.o children compare to kinder garden children
c. The test should we apply for the analysis!
d. Create the 2x2 table for this case
e. If p value from the study is 0.005, what is the statistical decision and
conclusion of the analysis
7. We want to determine wether eradication of mosquito breeding place behavior
(perilaku pemberantasan sarang nyamuk-PSN) is a predictor of Chikungunya
among people in Ayodya Province. A cross-sectional study was conducted; among
100 families; 60 of them have bad habit of PSN. Among those 60 with bad habit of
PSN, 10 of them have Chik history; meanwhile among the remaining 40 of families
who have good habit in PSN, 4 of them had history of Chik.
Discuss:
a. The statistical hypothesis for testing for determining that PSN is predictor
of Chik
b. The test should we apply for the analysis!
c. Create the 2x2 table for this case
d. Calculate the ratio of risk/odd that appropriate based on the study design
e. If the 95% CI of the above ratio is between 0.8-3.5, what is the statistical
decision and conclusion of the analysis
Case 2
Significancy Test for Interval Data
Open again “skill lab data” file (annex). Classification of variables has been discussed in
previous lesson. Remember about interval variables! For statistical analysis, we also need
to remember variable classification based on its function. Variables may act as dependent
or independent variables.
The statistical analysis is classify into two group which a parametric test and non
parametric test. Parametric test based on the assumption of the distribution of the data.
For continuous data that are normally distributed, the statistical analysis includes t test
and ANOVA. The tests principally based on comparison of mean between groups.
Learning task 2
Discuss the following:
1. Discuss the statistical method to be applied for testing of a sample mean.

We want to compare the mean Hb level of pregnant women in the study, with the
normal Hb level for pregnant women which is 11mg/dl. Can we conclude that the
mean of Hb level of samples is higher than 11 mg/dl?
a. Write down the statistical hypothesis!
b. Discuss, the test that should be applied for the analysis!
c. How we determine the statistical decision
2. Discuss about when two groups of samples/ data considered as two independent
or two dependent samples?
3. Discuss about homogeneity of variance and when we should determine it?
4. What type of test is used for testing homogeneity of variance, provide an
illustration!
5. We want to compare the mean body mass index (BMI) among children from hard
area and children from easy area. We wish to conclude that the mean BMI of
children in hard are is higher than the children in easy area. Let α=0.05
a. Write down the statistical hypothesis for case 2!
b. Explain what test should be applied for the analysis of case 2!
c. If the p value from the study is 0.09, what is the statistical decision and
conclusion of the analysis?
6. We want to evaluate the impact of nutrition program on the body weight among the
children in the study. Can we conclude that the intervention is effective to increase
the children’s body weight? Let α=0.05
a. Write down the statistical hypothesis for case 3!
b. Discuss the test should be applied for the analysis for case 3!
d. If the 95% confidence interval of body weight mean difference is 1.2 to
2.8 kg, what is the statistical decision and conclusion of the analysis?
7. We want to compare the mean Hb level pre intervention (Hbpre) of children based
on the nutritional status pre intervention (stgizi_pre). Can we conclude that the
mean body weight differ based on nutritional status?
Discuss:
a. What test should we apply for the analysis?
b. Is the analysis one tail or two tails?
c. Write down the statistical hypothesis!
d. If the p value from the test is 0.2, discuss about the statistical decision
and the conclusion.
8. Explain the conditions for applying those statistical tests above (no. 5,6,7) !
If the conditions cannot be met, what statistical method should be applied for
testing the hypothesis?
Self Assessments:
Significance Test for Categorical Data
1. Explain the statistical method for 2x2 tables and its requirements.
2. Explain the statistical methods if those requirements are not fulfilled!
3. Explain the statistical method for pair 2x2 tables.

4. Describe the statistics that can be calculated in 2x2 tables for cross-sectional, case-
control, and cohort study.
5. Write down the statistical hypothesis statement!
6. Explain the statistics for correlation of two variables: interval-interval, ordinal-ordinal,
nominal-interval, nominal-nominal, and similar number of categories.
7. Explain the condition for 2 test of the 2x3 tables or more. Explain how to deal with that
if those conditions are not provided.
8. Write down the statistical hypothesis statement for proportion, prevalence, RR, PR,
and OR for one-way and two-way tests.
9. What is the meaning of type 1 and type 2 sampling error?
Significance Test for Interval Data

1. Explain the application and requirements for one sample T-test!
2. Which T-test should be applied for independent and pair samples?
3. Write down the statistical hypothesis statement used above!
4. Regarding the tests above, which tests should be used if the condition required for T-
test is not met?
5. Explain the non-parametric test to be applied if the condition required for the
independent One-Way ANOVA is not met.
6. Write down the statistical hypothesis statement for the above question!
M O D U L E ~ 12
DEFINITION, REQUIREMENTS, TYPES, AND
APPLICATIONS OF SURVEILLANCE

(Reference Greenberg, p. 45 – 73)
AIM:
LEARNING OUTCOMES:
a) Manage, analyze and interpret data inferentially.
b) Describe the definition, requirements, types, and applications of surveillance.
Surveillance
ABSTRACT
Surveillance was defined as the detection of the occurrence of health-related events or
exposures in a target population. Successful surveillance activities require continuity over
time; standardize methodology, and timelines of data collection and dissemination.
Surveillance data can be used in different ways, depending on the type of
information collected. Persons newly diagnosed with a disease can yield information on
incidence rate, death from a disease can be used to describe mortality rate, indices of
premature death can be used to assess the impact of a disease of longevity, and
prevalence of risk factors can be used to predict future disease occurrence or to assess
the status of prevention initiatives.
Self Directing Learning

1. Read previous lectures
2. Read Greenberg pp. 45-73and power point slides

Case 1 & Learning Task 1
Interpretation of Surveillance Results
The following chart contains results of surveillance of dengue haemorrhagic fever in Bali
Province, provided by the Bali Provincial Health Department.
Discuss the following questions:

1. The surveillance is conducted to assess morbidity, mortality, or risk factor of dengue?
Explain your answer.
2. What is the interpretation of the figure?
3. What is the benefit of conducting surveillance of dengue cases?
4. Think of the natural history and the determinant of DHF and also consider the types of
surveillance. What other surveillance might be needed for the success of the dengue
prevention program?

KASUS DBD PERBULAN SELAMA 5 TAHUN DI BALI
1600
1400
1200
1000
800
600
400
200
0
Agustus
Agustus
Agustus
Agustus
Agustus
Oktober
Desember
Oktober
Desember
Oktober
Desember
Oktober
Desember
Oktober
Desember
Maret
Maret
Maret
Maret
Maret
Januari
Februari
Mei
Juni
Januari
Februari
Mei
Juni
Januari
Februari
Mei
Juni
Januari
Februari
Mei
Juni
Januari
Februari
Mei
Juni
September
Nopember
September
Nopember
September
Nopember
September
Nopember
September
Nopember
April
Juli
April
Juli
April
Juli
April
Juli
April
Juli
2003 2004 2005 2006 2007
Case 2 & Learning Task 2

In this chart, we see the top 10 of death causes in Indonesia, 2014.
1. Can you compare and find the similarity of death causes among men and women?
2. Discuss what is the surveillance will you build for the Non Communicable disease
above?
Self Assessment
Interpretation of Surveillance Results

1. The government continuously collects data for smoking behavior among men and
patterns of meat consumption among both men and women. In this case, what the
government does is:
A. New infections surveillance
B. Outbreaks surveillance
C. Death surveillance
D. Risk factors surveillance
E. Epidemiologic surveillance
2. A group of Lung Cancer patients who died were identified for their age of death. The
difference between the age of death and their average life expectancy was then
accumulated. That will produce:
A. B. PYL (Person-years of Life lost).
B. MR (Mortality rate).
C. YPLL (years of potential life lost).
D. YPM (Years of mortality)
3. 60% of lung Cancer patients in stage 2 have the possibility of survival for five years
following diagnosis of the cancer. The measurement of 60% follows the criteria as
below:
A. It is a case fatality rate of Lung Cancer patients
B. Can be used to predict the prognosis of Lung cancer patients in a similar stage.
C. It was measured from the lung cancer patients in one periode of time into Lung
cancer patients’ stage 1 – 3.
D. One person with Lung cancer stage 2 having possibility to live in the first five
years as of 0.06.
E. All Lung cancer patients’ stage 2 may live five years after diagnosed.
4. When compared to the corresponding rate for non-migrants in a low risk country, the
incidence rate for a genetically determined disease among offspring in a high-risk
country is:
A. Greater
B. Smaller
C. About the same
D. Cannot be determined from the information provided
E. All possible
M O D U L E ~ 13
OUTBREAKS INVESTIGATION
Anak Agung Sagung Sawitri, MD., MPH

(Reference Greenberg, p. 45 – 73)
AIM:
LEARNING OUTCOMES:
a) Describe the mode of transmission in disease outbreak
b) Describe the type of disease outbreak
c) Define attack rate and use it to identify a mode of transmission in a common-source
disease outbreak
d) Describe how to conduct an epidemiologic investigation of an outbreak
e) Describe alternate prevention activities for possible future similar outbreak
Investigation of Disease Outbreak
ABSTRACT
OUTBREAKS
An epidemic is define if there is sudden significant increase of cases of the similar disease.
Significant increase of the disease means it is over the past experience would have
predicted in term of time, person, and place. The Ministry of Health (MOH) of Indonesia
defined specific term of outbreak for particular diseases. In the MOH decree no 82 year
2014 about the Control of infectious disease, there are 24 + 13 diseases that considered
potential to develop in to an outbreak in Indonesia, and they need specific management if
they are found in the health services.
The investigation of disease outbreaks is an essential role epidemiology. The primary
goals of an outbreak investigation are the identification of the causal agent (the pathogen)
and prevention for further cases. The propagation of a disease outbreak requires a
pathogen, a viable mode of transmission, and an adequate poll of susceptible persons.
Elimination of one or more of these three components will terminate the outbreak. Two
basic modes of transmission are person-to-person spread and common-source exposure.
Infection illnesses can be transmitted by either mode, whereas non-infectious
environmental pathogens usually produce disease outbreaks through a common-source
transmission.
Not all disease outbreaks warrant investigation. The decision to investigate an
outbreak typically is based on the severity of illness, the number of affected persons,
uncertainty about the pathogen, and the perceived need to control further spread of the
disease. Investigations usually are conducted by local, state or federal public health
officials.
A measure of the risk of developing an illness over specified period of time is the
attack rate (AR). The traditional epidemiology of food-borne outbreaks-high attack rates,
short incubation periods, and clustering of affected individuals in time and place-is

changing for a number of reasons. The composition of the topical diet has shifted, with
decreased consumption of red meat and increased consumption of poultry, fresh fruits,
and vegetables.
Emerging infections can be defined as infections that are appearing in a population
for the first time or that have existed in a population but rapidly increasing in incidence or
geographic range. A number of factors contribute to the emergence of certain infections:
1) Man-made or natural changes in the environment
2) Demographic shift in population
3) Increased international travel and commerce
4) Technologic and industrial changes.
5) Adaptation of microbes
6) Lapses of the public health system.
Self-Directing Learning
3. Read previous lectures
4. Read Greenberg pp. 45-73and power point slides
5. Watch the “Contagion” movie

Case 1. Watch the movie “Contagion” and read the synopsis below
Synopsis of the movie: “Contagion”
1. This movie is a fiction which inspired by the incidence of SARS in several
countries around the world.
2. The story is about an outbreak of an unknown disease occurred initially in China
and spread to other places including the USA, Japan and England.
3. The movie shows how a disease can be transmitted very fast to cause an outbreak
all over the world, how the mode of transmission and the causing agent can be
identified, and how the transmission can be finally prevented.
4. The story is started with a woman named Beth Emhoff (Gwyneth Paltrow)
departing to Minnesota from her Chicago layover. She had a short term visit to
Macao (near Hong Kong) beforehand. She seemed to cough several times at the
airport when she talked to her old boyfriend on the phone.
5. The story was continued with the occurrence of a severe flu-like disease in a
young man in Hong Kong who then died because of a traffic accident, in a young
model in London who then found dead in her bathroom and in a man in Tokyo
who had a seizure and died on a bus.
6. The same symptoms that happened to Beth got worsened once she arrived in
Minnesota and met her husband and son. She died in a hospital 2 dayslater with
severe seizures and the doctor decided to make an autopsy to her body. Soon
after her death, her son died after having the same symptoms.
7. Beth’s husband, Mitch (Matt Damon), was then put in isolation but turned out to
be immune to the disease.
8. In Switzerland, a briefing led by Dr. Leonora Orantes (Marion Cotillard) was
conducted at the WHO office. She emphasized the need to investigate the cases

of infection thoroughly and thought that Beth is the potential start of the infection.
She then went to Hong Kong to investigate the movements Beth made while
there.
9. Dr. Ellis Cheever (Laurence Fishburne), who works at the Atlanta-based Centers
for Disease Control and Prevention (CDC), asked Dr. Erin Mears (Kate Winslet)
to do an investigation in Minnesota. She gave a briefing at the nearby CDC office
about the potential mode of transmission of the disease. She said that the virus is
a contagion of touch and the problem is the number of people will be potentially
infected (R-naught number), which is very high for this novel disease. She was
then unfortunately infected and died during the investigation.
10. There was an issue released by a blogger journalist, Allen (Jude Law), that the
virus is being manufactured by drug companies to get profit. Another issue said
by Homeland Security agents was that the virus might be a terrorist action to kill
people.
11. Two doctors, Ally Hextal (Jennifer Ehle) and David Eisenberg (Demetri Martin)
looked at the samples taken from Beth’s body in a secure CDC bio laboratory.
They found a virus that taking over the host cell completely, and noticed there
were traces of bat and pig in the virus DNA code.
12. Dr. Sussman (Eliott Gould) ran some further tests on the virus samples and he
was able to make a stable cultured version of the virus using a particular bat cell
line. This finding made them able to develop and test vaccines. The news reported
on the virus, now called MEV-1 (Meningoencephalitis virus type 1), and credited
Sussman for the discovery.
13. The story continues with the situation of the quarantine and vaccines delivery
process to prevent the transmission of the disease. Finally the movie shows the
process of how Beth was initially infected by the virus.
Learning Task 1
Based on the story of the movie, please answer the following questions:
1. What is the type of the disease outbreak in the movie? Is it a “person to person
outbreak” or a “common source outbreak”? Please explain your answer.
2. Why is it important to find the first person being infected? Describe how the
process of identifying the mode of transmission was conducted in the movie.
3. What efforts need to be taken to prevent the disease transmission before the
vaccines are available?
4. Describe how the process of finding the virus was conducted in the movie.
5. What is the importance of many stakeholders involvement (WHO, CDC,
government, military staff and journalists) in the outbreak investigation and
transmission prevention process?
Case 2. Carefully read the following case

Since the middle of August 1991, the Head of public health center (PHC) of
Abiansemal I received report from the satellite PHC of Mambal due to a lot of cases with
fever, nausea, and vomit. The health staff reported to see some of cases with icteric on

eye and the palm of the hand. Village cadre reported persons have died and they were
being issued to have that complaints. Following the report, the head of PHC undergo
coordination meeting at the PHC (22 August 1991). During the meeting, two satellite PHC
staff (Anggabaya and Taman) also reported the same things.
To ensure, the head of PHC ask the satellite PHC staff to look at again those cases
and to follow up further similar cases in the next 1-2 weeks. The head of PHC determine
complaints and signs need to be recorded are: fever, icteric on eye and skin, abdominal
pain, nausea/vomit, diarrhea, dark color of urine, and skin rash. At least 117 cases were
detected.
The head of PHC assume that there is an outbreak of hepatitis. Investigation is set
up by distributing questionnaire to the head of households. There are at least 1694 cases
to fulfil criteria as determined. Based on history, cases had been existed since May 1991
and continuing until Oktober 1991. [DATA SPSS KLB_2018]. Many issues have been
developed since then, suspicion at food stalls in the area, poor hygiene and sanitation in
the area, food at the traditional village ceremony, things associated with the Mystic, and
particularly because deaths have been reported.
The head of PHC, in coordination with the district health office start to investigate
the outbreak. Of 117 early detected cases were determined as cases and their healthy
neighbors were determined as control [DATA SPSS KLB_CASE CONTROL_2018].
Some questions have been asked to cases and control related to habits of drinking raw
water, history of eating in the stalls in the area, habit of defecating in the fields/yards,
history to attend the traditional village ceremony, and source of and habits to boil water to
be consumed.
Learning Task 2
Do comprehensive investigation by discuss and answering the below questions
1. Is the above case an outbreak? Explain the rationale of your answer.
2. What exactly is the disease that became an outbreak? Explain the rationale of
your answer
3. How you determine the definition of the above case?
a. What is the clinical criteria and the laboratory criteria?
b. Use File SPSS KLB_2018 to analyze the distribution frequency of CASE
when the definition of CASE is as follows:
i. Cases = dark urine + fever
ii. Cases = dark urine + fever + icteric
iii. Cases = dark urine + fever + abdominal pain + icteric
c. What is your conclusion in term of the definition of case? How it is implied
to your investigation?
4. How is the distribution of cases based on person, place, and time variable?
Complete the attack rate in the following table and provide interpretation for each
variables
5. Assumed that you have conducted the case control study (use the SPSS file
KLB_CASE CONTROL_2018). You examine risk factors of habits of drinking raw
water, history of eating in the stalls in the area, habit of defecating in the

fields/yards, history to attend the traditional village ceremony, and source of and
habits to boil water to be consumed. Conduct analysis using chi-square test to the
illness status.
a. Interpret the result of chi-square test and the OR
b. What is you final conclusion for the cause of this outbreak?
6. What is the role of laboratory in term of this investigation?
7. What is your recommendations following the result of this investigation?
Table 1. Attack rate based on person and place

Attack
Number of Cases Attack Rate Number of Cases
Characteristics Populaton Rate per
by criteria (ii) per 1000 by criteria (iii)
1000
Sex
Male 9,795
Female 9,438
Age category (years)
0-4 2,544
5-14 5,027
15-44 8,354
>45 3,308
Village
Mambal 7,340
Anggabaya 4,610
Sedang 1,820
Mekar Buana 2,020
Taman 3,443
Total Population 19,233
Self-Assessment
1. Which steps of those above are parts of descriptive methods? Which are parts of
analytic methods?
2. Not all outbreaks need epidemiologic investigation. Several factors to be considered for
an investigation are:
1. Number of apparent cases prevalent
2. Public concern
3. Aetiology of the outbreak is obviously unclear
4. Need for intervention to be stopped
3. The following are parts of the outbreak investigation steps:
1. Distribute cases based on person, place and time
2. Calculate prevalence rate based on person, place and time
3. Assume temporary hypothesis on transmission’s source
4. Analyse aetiology by cross sectional study
4. Due to the outbreak investigation, the analysis of cases based on person, place, and
time is done. Its main purpose is:
1. Find out the most common group affected by the disease

2. Find out the area which was mostly affected by the disease
3. Determine the time of outbreak
4. Predict the possibility of exposure
5. A result of outbreak investigation is as follows:

95% Confidence Interval
Risk Estimate Value
Lower Upper
Odds Ratio for Stall B (Yes / No) 0.048 0.016 0.145
For cohort Sick/healthy = Yes 0.231 0.130 0.410
For cohort Sick/healthy = No 4.846 2.307 10.181
Its interpretation is:

a. Risk of diarrhea if having meals at B stall is a half lower than not having meals at
the other stall.
b. Risk of diarrhea if having meals at B stall is higher than not having meals at B stall.
c. The OR only affects sample, but not a population.
d. The B stall is proven not to be source of transmission.
6. If an OR of eating “es campur” at the B stall is 1.3 with the CI from 0.6–1.9, what is the
significance of the data? What conclusions can you draw about the “es campur” eating
within the whole population? Give an example of a more significant OR and CI.
7. A doctor at puskesmas was function as program coordinator for transmitted disease
at district with the total population was 500.000 persons. The result of surveillance for
several infectious diseases for 5 years was as follows: (source UKDI)
Diseases Year I (%) Year II (%) Year III (%) Year IV (%) Year V (%)
Malaria 30 35 32 34 31
DHF 0,6 0,5 0,4 0,9 2,1
Typhoid 5,1 5,4 4,8 6,2 5,8
Hepatitis C 2,1 2,2 1,8 1,7 1,6
Influenza 50 45 52 53 53
Which one of the above has become an outbreak?
a. Malaria
b. DHF
c. Typhoid
d. Hepatitis C
e. Influenza
M O D U L E ~ 14
SCREENING AND DIAGNOSTIC TESTING
(Reference Greenberg, p. 127-136)
AIMS:

To be able to describe validity and reliability of certain test to apply in the individual and
or community context
LEARNING OUTCOMES:
1. to describe the component of the appropriate screening programme
2. to explain the differences of screening program and diagnostic test
3. to explain the definition of validity and reliability in diagnostic test
4. to explain parameters used to indicate validity and reliability
5. to describe concept of validity and reliability of the continues or categorical data
6. to explain concept of sigle and multiple diagnostic test (simultan and paralel test)
7. to choose ideal diagnostic test in certain situations related to individual and community
context
1. Definition of diagnostic test and screening program
2. Accuracy, validity (sensitivity, specificity, predictive value, and likely hood ratio) and
reliability
ABSTRACTS
Each clinician will diagnose on their patients in either individual or community contexts
with the diagnostic tools or instruments. A good diagnostic instrument will provide the
appropriate information. However, all the diagnostic instruments have an error. This can
be minimized by choosing an instrument that has a higher level of accuracy than others in
accordance with the conditions and purpose of testing. The accuracy of the instruments
can be calculated by comparing it with a gold standard. The accuracy parameter is seen
from the validity and reliability called diagnostic test.
Diagnostic instrument with numerical outcome need to be divided into sick status or not,
to facilitate the intervention. Selecting a reasonable cut-off point will improve the
performance of the test tool. The accuracy of the instrument is strongly influenced by the
prevalence of the disease in community. The accuracy of the instrument is also
determined by the subject who being examined and the person who examined it. Multiple
tests are carried out in parallel or simultaneously to increase the instrument accuracy.
SELF DIRECTING LEARNING

1. Screening program
2. Accuracy (validity and reliability)
3. Sensitivity, specificity, predictive value, likelihood ratio
4. Cut off point
SCENARIO & LEARNING TASK

Case 1
The result of screening test was as bellow;

Ca Cervix (Histo-PA)
CaCx No-CaCx Total
Positive 3.200 1.400 4.600
IVA Negative 150 29.000 29.150
Total 3.350 30.400 33.750
Learning Tasks 1
1. Calculate the sensitivity, specificity, and predictive value of diabetic retinopathy and
Interpret each of your calculation
2. What is the prevalence of Ca Cervix among the population?
3. What is the relation between prevalence and predictive value? What is the relation
with the target group for screening program?
4. When you conduct screening test among reproductive women population, which
prevention you have done: primary, secondary, or tertiary?
Case 2
There was a patient came to the public health centre (PUSKESMAS) with a bleeding
cough since two weeks ago. Dr. Bima suspected that the patient had pulmonary TB
infection. Dr. Bima then referred the patient to sputum examination.
1. Explain about the process of sputum examination at the PUSKESMAS laboratory?

2. Why do sputum examinations be done multiply? what is the purpose?
Case 3
A detailer has come to dr. Arjuna for offering cheap rapid test for anemia. Dr. Arjuna asked
3 tests for trial. Fortunately, Mrs. Drupadi came for consultation of malaise and continuing
dizziness. Dr. Arjuna asked permission from mrs. Drupadi to take the blood sample for
checking anemia. At the same time, he also told her that he wanted to check the rapid test
for anemia.
Using cyan-met HB, the result of hemoglobin was 12.5mg%, while the result of rapid test
respectively was 10.5 mg%; 10.2mg%; and 12.0mg%.
Learning Task 2
If the criteria of anemia was <11 mg%, how you conclude the result of the rapid test for
anemia that just being tried by dr. Arjuna?
Self Assessments:
1. What is the definition of sensitivity?
2. What is the definition of specificity?
3. If the prevalence increases, what other value will also increase?
4. If the prevalence of a certain disease is high, while the sensitivity and specificity are
stable, than ................... will be low.

M O D U L E ~ 15
CONCEPT OF EPIDEMIOLOGIC STUDIES TO
DETERMINE RISK FACTORS OF DISEASES AND
CROSS-SECTIONAL STUDY
Anak Agung Sagung Sawitri, MD., MPH
(Greenberg)

AIMS:
1. To describe the types and application of epidemiology study designs to determine risk
factors of the disease of interest
2. To describe cross sectional & longitudinal study design and to explain the advantages
and disadvantages of cross sectional & longitudinal study to determine risk factors of
diseases.
LEARNING OUTCOMES:
1. To describe and to draw types of epidemiology study designs and their applications
2. To describe advantages and weaknesses of epidemiology study designs
3. To describe and to draw cross sectional and longitudinal study design
4. To explain the advantages and disadvantages of cross sectional and longitudinal study
to determine risk factors of diseases
5. To explain what is prevalence ratio and how to calculate prevalence ratio in cross
sectional study
6. To explain the interpretation of prevalence ratio in cross sectional studies
7. To explain the incidence rate and how to calculate incidence in longitudinal study
8. To explain the interpretation of incidence rate in longitudinal studies
1. Type, application and advantages/weaknesses of epidemiology study designs
2. The cross sectional and longitudinal study design and theirs attributes
3. Timing of measurements: cross sectional and longitudinal design
4. Data collection in cross sectional and longitudinal studies
5. Data analysis in cross sectional studies: prevalence ratio (PR)
6. Data analysis in longitudinal studies: incidence rate
ABSTRACTS
To prevent the disease, determinants or risk factors of the disease must be
understood. To understand determinants or risk factors, epidemiological studies are used.
There are several epidemiological study designs those can be grouped into several ways.
Based on the availability of intervention or not, the study designs can be divided into
intervention or experimental study and observational study. Intervention study is used to
test the efficacy of treatment or prevention of certain disease in a population.
Observational studies can be grouped into two groups based on whether there are
comparison groups or not. Descriptive study is an observational study without comparison
group to study the distribution of the diseases occurrences in a population. Analytic studies
have comparison groups to study risk factors of diseases. Analytic studies can be defined
into three based on the direction of the observation or the measurement of the outcome.
Cross-sectional is when the measurement or the observation of the disease under study
(outcome) is at the same time with the measurement of risk factors. Cohort design is
prospective or effect to cause while case control design when the direction of the
observation is retrospective or cause to effect.
Descriptive studies describe diseases occurrences (“how much or how many”) in
the community based on “who”, “when” and “where” attributes. There are two major
purposes of this study, are for program planning and evaluation and for foundation of
hypothesis testing of analytical studies (experimental, cross-sectional, case-control and
cohort).

Each type of analytical study has advantages and disadvantages. Experimental

study is not possible to be implemented in human when the aim is to study risk factors
(cause) of certain disease but it can be used to study treatment and prevention of certain
disease. It is also the strongest design to test the hypotheses. Major disadvantage of
cross-sectional design is lack of temporal association since outcome (disease) and risk
factors are measured at the same time. Major disadvantages of cohort design are
expensive and take long time especially when the disease incidence is low and the time
between exposure and disease occurrence is long. Case-control design is less expensive
and faster than Cohort, however it has major weakness of information bias and difficult to
match between “case group” and “control group”.
Self-directing learning:
1. Study design of cross sectional and longitudinal studies and their attributes
2. The procedures of cross sectional and longitudinal studies
3. Findings and its interpretation (including crude PR, adjusted PR) as well as
confounding factors in a cross sectional study
4. Findings and its interpretation (including Crude and Specific Incidence Rate)
Case 1.
Please carefully study the article entitles: “Dengue and Other Common Causes of
Acute Febrile Illness in Asia: An Active Surveillance Study in Children”
Learning Tasks 1:
After you carefully read through the article above, please discuss the following
questions:
1. Draw a figure and explain the design of the study.
2. What is the purpose of the study?
3. What are the uses of this study?
4. Does the study use primary or secondary data?
a. What is the source of the numerator?
b. What is the source of the denominator?
5. Explain how researcher calculates and selects the sample!
6. Explain how researcher measures the incidence of dengue!
7. Explain the interpretation of overall incidence of dengue in Asia? What is overall
incidence of dengue in Indonesia? How is Indonesia position in term of incidence of
dengue?
8. See Table 2 Proportion and incidence density of acute febrile episodes in the study
cohort. (p.4). what is the difference between the two incidence?
9. What is the cumulative incidence of fever for the first time in Indonesia?
10. See Table 3 Incidence density of dengue in febrile participants (p.5). What is the
numbers presented in the bracket (i.e. 3.4 (2.4; 4.8)? The denominator is PY, what is
the definition and the strength of PY?
11. How you explain the Figure 2. Frequency of most commonly detected non-dengue
infections in febrile participants?
Case 2.

Please carefully study the article entitles: “Injecting drug use, sexual risk, HIV
knowledge and harm reduction uptake in a large prison in Bali, Indonesia”
Learning Tasks 2:
questions:
1. Draw a figure and explain the design of the study. Provide reasons for your answer.
2. What is the objective of the study?
3. Is there any dependent variable and independent variable? Explain your answer.
4. What is the measurement obtained from this study? Is it prevalence or incidence?
Explain your answer.
5. Does the study use primary or secondary data?
a. What is the source of the numerator?
b. What is the source of the denominator?
6. Observe the Table 2. Self-reported HIV related injecting risk behavior among IDUs in
prison (n¼17) and IDUs on methadone substitution treatment (MST):
a. What is the interpretation of overall prevalence of injecting drugs (17.4%)?
b. What is the interpretation of prevalence of injecting drugs among men
c. Is there any significance difference of median injecting frequency per week
(SD) between all injecting drugs and those who were on MST?
d. Is there any significance difference of solution used at the last week between
all injecting drugs and those who were on MST?
7. What is the weakness of this study?
Case 3.
The following study entitled “Bacterial vaginosis in female facility workers in north-western
Tanzania: prevalence and risk factors” is examining the relationship between several risk
factors to the infection of Bacterial vaginosis.
Look at Table 1

Learning Tasks 3:
1. What is the design of the study? Provide reasons for your answer.
2. Is there any dependent variable and independent variable? Explain your answer.
3. What is the interpretation of BV prevalence based on age characteristics?
4. What is the interpretation of BV prevalence based on literacy?
5. What is measurement used to show relationship between age and BV in this study?

6. How you explain the calculation of the above measurement by using 2x2 table?
Example how to obtain 0.80 on age 20-24 y.o.
7. How to obtain 1.26 on literacy? Explain using a 2x2 table.
8. Look at the Univariate OR: Is there any significant difference of BV based on age
category?
9. Look at the Adjusted OR: Is there any significant difference of BV based on age
category?
10. How you explain the above condition (no 8 and 9)?

M O D U L E ~ 16
EPIDEMIOLOGY STUDY DESIGN:
CASE – CONTROL STUDY
Dr.dr. Gde Ngurah Indraguna Pinatih, MSc., SpGK

(Greenberg, p. 127-136)
AIMS:
At the end of learning this module, students are expected to be able to describe the case-
control study and to explain the advantages and disadvantages of case-control study to
determine risk factors of diseases.
LEARNING OUTCOMES:
1. To describe and to draw case-control study design
2. To explain the advantages and disadvantages of case-control study to determine
risk factors of diseases
3. To explain what is odd ratio (OR) and how to calculate OR
4. To explain the interpretation of OR in a case control study
1. The case-control study design and its attributes
2. Case and control definition
3. Determination of exposure
4. Selection bias in case-control study
5. Matching strategy in case-control study
6. Data analysis in case control: OR and its interpretation
ABSTRACTS
A case-control study is a type of observational research in which subjects are enrolled
based on the presence or absence of a particular disease and are then evaluated to
determine their history of prior exposure to risk factors of interest.
The advantages of this study design are primarily logistical. In particular, rare
disease and those with long latency periods can be studied efficiently. The sample size
required for a case control study tends to be smaller than would be needed for an
alternative design, such as a cohort study. As a result, the expense of conducting a case-
control study may be substantially less than the cost of conducting a cohort study.
Furthermore, reliance on historical information allows rapid completion of case-control
study. The ability to reach a prompt conclusion is particularly important if the disease of
interest is potentially life-threatening.
The disadvantages of case-control studies relate primarily to their susceptibility to
systematic errors. Because cases and controls are sampled separately, it is possible that
these groups may not arise from the same source population. Bias can be introduced into
the study results if exposure status is associated with the likelihood of including cases or

controls into the study. Reliance on subject recall of earlier exposures or the use of
historical records can lead to imprecise or inaccurate classification of exposure.
The decision to conduct a case control study typically is motivated by a desire to
expose the relationship between prior exposure to a specific risk factor and the likelihood
of developing a particular disease. Ideally, the cases and the controls should derive from
a single well-defined source population, such as a state or metropolitan area (population-
based sampling scheme). An attempt may be made to identify all newly diagnosed cases
(incident cases) within the source population, particularly when the disease is rare or the
source population is modest in size. Cases may be identified from hospital record,
surveillance system, death certificates, or other sources. Careful criteria for the presence
of disease must be established to minimize false inclusions or exclusions.
Controls typically are sampled from the population that gave rise to the cases.
Occasionally, for purposes of convenience, hospital-based samples of cases and control
are selected. The hospital-based approach tends to have the advantages of accessibility
to the subjects and cooperative study participants. On the other hand, cases and controls
may derive from dissimilar source populations in a hospital-based study and prior
exposure status might influence the likelihood of inclusion in this type of investigation.
Matching of controls of cases on the basis of known risk factors for the disease of
interest is a common practice in case-control studies. The intent of matching is usually to
decrease the possibility of confounding, or mixing of the effect of exposure to the risk
factors. Matching can increase the statistical precision of estimates and thereby allow a
smaller sample size. On the other hand, matching can be time consuming, and subjects
who are not successfully matched must be discarded from the analysis.
The process of selection of subjects in a case-control study precludes the
estimation of risk (or rates), and the risk ratio therefore cannot be calculated directly from
case-control data. An indirect estimate of the risk ratio, however, can be calculated in a
case-control study. This measure is referred to as the odds ratio and is defined as the
odds of exposure among cases divided by the odds of exposure among cases divided the
odds of exposure among controls. The approach to calculating the odds ratio depends on
whether cases and controls were sampled in an unmatched or matched fashion. In
instance, a point estimate and 95% confidence interval for the odds ratio can be calculated
as a measure of association between prior exposure to the risk factor and occurrence of
disease.

1. Case-control study design and its attributes
2. The procedures of a case control study
3. Findings and its interpretation (including crude OR, adjusted OR) as well as
confounding factors in case-control study
Case 1.

Please carefully study the article entitles “Effect of potentially modifiable risk factors
associated with myocardial infarction in 52 countries (the INTERHEART study):
case-control study”
Learning Tasks 1:
questions:
1. Draw a figure of the study with its attributes.
2. Was this study hospital based or population based or combination?
3. Explain its dependent and independent variables!
4. Explain its case definition!
5. Explain the source and methods of selecting control from the study!
6. Is the above study part of a match-paired design? Why or why not? Describe three
reasons.
7. Do the cases represent their population? Do the controls represent their population?
8. Are cases and controls comparable? If not, which part is not comparable?
9. How does the researcher control the effect of confounding variables?
10. What is its CRUDE OR? Provide an interpretation!
Case 2.
Carefully examine the following table.
Table 2.1 Use of IUD in sometime pregnant and never pregnant patients and controls in
different age groups
Age Patients Control
group Sometime Never Total Sometime Never Total
(year) Pregnant Pregnant Pregnant Pregnant
IUD No IUD No IUD No IUD No
IUD IUD IUD IUD
≤ 15 0 1 0 7 8 0 0 0 3 3
16-20 13 44 27 93 177 5 19 7 196 227
21-25 26 74 28 87 215 25 131 7 163 326
26-30 20 50 3 19 92 21 86 3 49 159
31-35 7 12 1 3 23 4 21 0 1 26
Total 66 181 59 209 515 55 257 17 412 741
Learning Tasks 2:
After you examined the above table, please calculate the following:
1. What is the CRUDE OR? Please provide an interpretation!

2. Calculate 95% CI (confidence interval) of the CRUDE OR using below formula:
3. 95%it CI
After is =controlled
(OR) expfor
[+ age
1.961/a+1/b+1/c+1/d]
variable, what is its SPECIFIC OR? What is the
interpretation?

4. What is the SPECIFIC OR after being controlled for obstetric history variable? What
is the interpretation?
Case 3:
Carefully read the article entitles: “Risk Factors for Deep Vein Thrombosis and
Pulmonary EmbolismA Population-Based Case-Control Study”
Learning Tasks 3:
Based on the above case, please answer the following questions:
1. What is the dependent (or response) variable of this study?
2. What are the objectives of this study?
3. What are risk factors investigated or what are independent variables of this study?
4. Was this study hospital based or population based?
5. How long the cases were collected?
6. Who was the control group?
7. Regarding which variables cases and control was comparable?
(a) Regarding which variables cases and control was not comparable?
(b)What must be done to control these confounding variables?
8. See Table-2. How do you determine the most dominant risk factors?
9. See Table-2. Which risk factor had the highest OR? What was the 95% CI for this risk
factor?
10. What were the OR and 95% CI of variable nursing home confinement? Explain,
what does it mean?
Self Assessments:
1. What are the advantages and disadvantages of case-control study in determining risk
factors of diseases?
2. Explain what is mean by control by design and control by analysis in a case-control
study!

M O D U L E ~ 17
EPIDEMIOLOGY STUDY DESIGN: COHORT STUDY
dr. Wayan Citra Wulan Sucipta Putri, MPH

(References: Greenberg page 113-123)
AIMS:
To describe cohort study design and to explain the advantages and disadvantages of
cohort study to determine risk factors of diseases.
LEARNING OUTCOMES:
To describe and to draw prospective and retrospective cohort study design
To explain the advantages and disadvantages of cohort study to determine risk factors of
diseases
To explain what is relative risk and how to calculate relative risk
To explain the interpretation of relative risk in cohort studies
1. The cohort study design and its attributes
2. Timing of measurements: prospective and retrospective design
3. Subject selection in cohort studies: exposed and un-exposed groups
4. Data collection incohort studies
5. Data analysis in cohort studies: risk ratio (RR) and attributable risk (AR)
ABSTRACTS
A cohort study is a type of observational investigation in which subjects are classified on
the basis of level of exposure to a risk factor and followed to determine subsequent
disease outcome. Prospective cohort studies are conducted by making all observations
on exposure and disease status after the onset of the investigation. Retrospective cohort
studies involved observations on exposure and disease status prior to the onset of the
study. The retrospective approach offers several pragmatic advantages, but may result in
less accurate and complete information on exposure and disease status.
Cohort studies are statistically efficient for the study of rare exposures because the
exposed individuals can be selectively included in the study. On the other hand, cohort
studies are inefficient for the investigation of slowly developing or rare diseases. The
evaluation of chronic diseases through the cohort approach requires a long follow-up
period and increases the chances that subjects will be lost from the study. The evaluation
of rare diseases with the cohort study approach requires a large sample size and therefore
is expensive and labour intensive.
There are several basic strategies to analyse cohort studies. If data are collected
on the risk of developing an outcome during a specified period, the summary measure of

effect typically is the risk ratio. An alternative approach to contrasting risks is risk
difference, which is the risk among exposed persons minus the risks among unexposed
persons. If the risk difference is divided by the risk among exposed persons, a measure
term the attributable risk percent is derived. The attributable risk percent is an indicator of
the proportion of risk that may be attributable to the exposure. When data in a cohort study
are based on the rate of disease outcome, the standard measure of effect is the rate ratio.

1. Study design of cohort studies and its attributes
2. The procedures of cohort studies
3. Findings and its interpretation (including crude RR, adjusted RR and attributable risk)
as well as confounding factors in a cohort study
Please find sources for case 1 and 3 in https://goo.gl/UocZee
Case 1.
Please carefully study the article entitles: “Association between recent overnight travel
and risk of malaria: a prospective cohort study at three sites in Uganda”
Learning Tasks 1:
questions:
1. Draw a figure of the study design with its attributes.
2. What are the dependent and independent variables of that study?
3. What are the confounding variables of that study?
4. Expain the inclusion and exclusion criteria!
5. How did the researcher control the effect of confounding variables? Is that the way by
design or by analysis?
6. Explain how the researcher did that (no 6)!
7. Why do the researchers choose this study design? Describe two reasons.
8. What is its CRUDE RR of the study? Provide the interpretation!
9. What is its SPECIFIC RR after being controlled for by age group and by study site?
Provide the interpretation!
Case 3:
A study at Stockholm had observed 216 children who received BCG immunization when
they were aged below 6 years and 358 children who did not have BCG immunization since
1989-1992. The study was set up in 1994. In 1995-1996, all children were examined to
find out atopic disease incidence (atopic: a type of allergic disease). The study result
shows that 36% who had BCG immunization and 41% who did not have BCG
immunization are suffering from atopic disease (χ2 = 2.6; p > 0,05).

Learning Tasks 3:
Based on the above case, please answer the following questions:
What is the study design of the case above?
Draw figure of the study with its attributes?
What is the main requirement if we want to choose that design?
What is the RR?
Does the RR in this study also occur in a population? Describe your reasons!
Case 3.
Carefully read the article entitles: “Cancer risk in the relatives of patients with
nasopharyngeal carcinoma—a register-based cohort study in Sweden”
Learning Tasks 3:
questions:
Please draw the study profile/design with its attributes

Where the exposure and the outcome data were obtained from?
What is the dependent and independent variables?
Identify the confounding variables in this study!
What is the crude RR and what does it meanGr?
Self Assessments:
What are the advantages and disadvantages of prospective and retrospective cohort
studies?
Explain the limitation of cohort studies to determine risk factors of diseases?

M O D U L E ~ 18
APPLICATIONS OF CLINICAL TRIALS TO DETERMINE
THE EFFECTIVENESS OF INTERVENTION,
PREVENTION, AND TREATMENT OF DISEASES
dr. Wayan Citra Wulan Sucipta Putri, MPH
(Reference Greenberg, p.91-113 & Gordis, 131-163)
AIMS:
To be able to describe the application of clinical trials to determine the effectiveness of
intervention, prevention, and treatment of diseases.
LEARNING OUTCOMES:
1. To describe and to draw clinical & community trial design
2. To explain the advantages and disadvantages of clinical & community trial to
determine the effectiveness of intervention, prevention, and treatment of diseases
3. To explain the definition, aims, subject determination (enrolment,
inclusion/exclusion criteria, and randomization of intervention and control group)
4. To explain statistical calculation and consideration in clinical trial
5. To explain outcome evaluation strategy (blinding) and how to calculate outcome
6. To explain the interpretation of study outcome
7. To explain ethical consideration in certain clinical trial
8. To explain the differentiation between clinical and community trial
1. The clinical trial design and its attributes
2. Definition of intervention and control group
3. Enrolment, Inclusion and exclusion criteria and randomization strategy
4. Blinding strategy in clinical trial
5. Statistical calculation and its parameters
6. Data analysis in clinical trial and its interpretation
7. Ethical consideration
8. Differentiation of clinical and community trial
ABSTRACTS
Evidence-based medicine can be defined as the integration of current best evidence with
clinical expertise, pathophysiological knowledge and patient preferences to make health
care decisions. Although there are barriers to the practice of evidence-based medicine,
such as the skills and time required in appraising the literature, this approach encourages
effective management of diseases. It can serve to optimize health outcomes and promote
cost-effective management.
Fundamental practice of evidence-based medicine is the ability to critically assess
the design, conduct and analysis of clinical studies. For the purpose of assessing the
comparative benefits of alternative treatment, the randomized controlled clinical trial is the
“gold standard” approach. The evidence-based practitioner, therefore, must be thoroughly
familiar with this research method.

The principal strength of this approach derives from assigning treatment to patients
by randomization, thereby tending to balance the study groups with respect to both
known and unknown prognostic factors.
Before enrolling patient in a clinical trial, the investigation can determine the
baseline and follow-up information that will be required to all subjects. Procedures can
then be put in place to enable the researches to collect data in a fairly complete and
accurate manner. The investigator can also allocate subjects to desire dose level rather
than relying on physicians or patients preference. When blinding of the evaluation or
patients is feasible, the assessment of clinical outcomes is less likely to be influenced by
knowing which treatment was used.
Randomized controlled clinical trial is subject to certain constraints, however.
Restrictive criteria for inclusion of subjects may produce a very homogenous study
population, which may restrict the ability to extrapolate results to patients with other
characteristics. Clinical trial—particularly those involving chronic processes—may require
years of follow-up to determine the outcome of the treatment. A prolonged observation
period leads to higher costs, increases the likelihood that patient will be lost to follow-up,
and delays the time at which a treatment recommendation can be made. The use of
intermediate end points, such as measurement blood glucose levels glycosylated
hemoglobin in the diabetes therapy trial, can help limit the length of required follow-up.
Nevertheless, a definitive conclusion about treatment benefit often requires years of
observation.
Large sample sizes typically are required in clinical trial when the magnitude of
differences in responses between study groups is small. Furthermore, large numbers of
subjects are likely to be required to demonstrate differences between study groups when
there is wide variability in responses to treatment. Increasing the size of the study
population not only raises the cost of a trial but may also lead to pragmatic difficulties in
locating a sufficiently large pool of eligible patients.
Ethical concern may arise in clinical trial if one or more of the treatment options
has serious potential effects or if early suggest-but do not establish- a therapeutic
advantage for one of the treatments. In this situation, a decision must be made about
whether the trial should be continued until a definitive conclusion is reached or should be
terminated early so that all patients have the opportunity to receive the apparently superior
treatment. To minimize the possible influence of real or perceive conflicts of interests, and
external advisory group should review these ethical questions.
An investigator cannot control the behaviour of subjects enrolled in clinical trial.
Even after initial informed consent has been given to participate in clinical trial, a subject
has the right withdraw at any time. Some subject may elect to remain in the trial but not
comply with the assigned regimen. Noncompliance can reduce the statistical power of
clinical trial and thereby lead to a false-negative conclusion. Accordingly, every effort must
be made to achieve maximal compliance with assigned treatment without infringing on the
patients’ right to refuse therapy. Ultimately, treatment decisions should be best on the best
evidence available concerning therapeutic benefit. The standard approach to gathering
this evidence is the randomized controlled clinical trial. Although this type of investigation
labour intensive, time consuming, and expensive it can provide the most convincing
evidence of the superiority of one treatment over another. Through the use of randomized
control clinical trial such as the diabetes therapy study, decisions concerning patient
treatment and care can be based on rigorous scientific information.


1. Clinical trial design and its attributes

2. The procedures of a clinical trial
3. The concept of subject selection, restriction and randomization
4. Statistical calculation and its parameters
5. Findings and its interpretation
Case 1.
Please carefully study the article entitles “Phase III Equivalence Trial of Azithromycin
vs Benzathine Penicillin for Early Syphilis”
https://www.ncbi.nlm.nih.gov/pubmed/20402591
Learning Tasks 1:
questions:
1. What is the study intervention?

2. What is the expected outcome (its dependent variable)?
3. Why did the researcher consider to do this study, or in other words, what is the problem
in the community?
4. Based on clinical trials definition, describe the purpose of this trial.
5. Did somebody do similar study before? Mention the study and researchers who did it.
6. Related to previous study, why did the researcher think it was important to do this
study? What is the difference with the previous study?
7. Describe how researchers design the study, the period, and selected the sites for
study. What considerations were put in place when selected the sites?
8. Describe how the researcher selected the subjects of this study. What are the inclusion
and exclusion criteria? What are the purposes of defining these criteria?
9. Which type of randomization has been done? What is the purpose in doing this?
10. See the Figure 1. Flow of patients through the study. Define which the target,
sampled, and experimental populations is.
11. Describe how the method of intervention was performed?
12. Describe the characteristics of providers who deliver the intervention. How
researchers standardize the intervention?
13. What are the outcomes (dependent variables)? Describe the operational definitions.
14. Based on measurement scale, that dependent variable is part of which type?
15. Is this study using a blind design? What is the purpose to use blind design?
16. Mention parameters used by researchers in the statistical analysis.
17. What is one limitation for this longitudinal study with regard to study subjects?
18. Look at table 2. Phase III Equivalence Trial of Azithromycin vs Benzathine
Penicillin for Early Syphilis (DMID99005); What is the purpose of researchers for
showing the table?
19. What is the main result of this study? Which intervention was more effective?
20. What other outcomes were also resulting from this study?
21. Researchers reported the result as below (Table 4)

How you interpret the result at month 3 and 6 for Intention to Treat and Per Protocol?
22. What are ethical aspects you see from the study?
Case 2.
Family planning services throughout all villages are needed to decrease birth rate in
Indonesia. In Ayodya Province, almost all reproductive couples chose the vasectomy
method. Since the users were high in demand while the doctors in that province were
limited, dr. Nyoman Abimanyu, a surgeon who was also the head of the Provincial Health
Department, trained a group of nurses to be able to conduct vasectomies. With his
authorization for the nurses to do vasectomies, dr. Abimanyu got a lot of criticisms from
other surgeons. Therefore, he thought that it was important to have empiric data from a
research.
In his study, a number of candidate acceptors (candidate users) were vasectomised by
trained nurses, while the other users underwent vasectomies by doctors. Previously, all
candidates were informed whether they would be operated by doctors or trained nurses.
The number of samples was already sufficient and was already sampled randomly to
ensure representatives for their population. The results are as follows: vasectomy failure
on the group operated by nurses was 2% while by doctors was 1.25%. Hematoma
(subcutaneous bleeding) in the nurses’ group was 8% and in the doctors’ group was 5%.
Learning Tasks 2:
1. What are dependent and independent variables in that study?
2. Is the study above an observational or experimental study?
3. What is the intervention?
4. Is that possible to randomize?
5. What randomization can be done?
6. What are the advantages and disadvantages of each randomization method?
7. Is it possible to do cross-over design? If not, why?
8. Is it possible to do blind design?
9. Which blind design can be done?
10. From the result above, what is the conclusion? Which is more effective?
11. If the result is as follows, what is the conclusion? Which one is more effective? The
vasectomy failure in the group operated by nurses is 2% while on the doctor is 1.25%
(p > 0.01). Hematoma (subcutaneous bleeding) in the nurses’ group is 8% and in the
doctors’ group is 5% (p > 0.01).
Case 3.

Please carefully study the article entitles “Operative Compared with Nonoperative
Treatment of Displaced Intra-Articular Calcaneal Fractures”
(https://journals.lww.com/jbjsjournal/Fulltext/2002/10000/Operative_Compared_wit
h_Nonoperative_Treatment_of.1.aspx )
Learning Tasks 3:
questions:
1. What is the study intervention?

2. What is the expected outcome (its dependent variable)?
3. Why did the researcher consider to do this study, or in other words, what is the problem
in the community?
4. Based on clinical trials definition, describe the purpose of this trial.
5. Did somebody do similar study before? Mention the study and researchers who did it.
6. Related to previous study, why did the researcher think it was important to do this
study? What is the difference with the previous study?
7. Describe how researchers design the study, the period, and selected the sites for
study. What considerations were put in place when selected the sites?
8. Describe how the researcher selected the subjects of this study. What are the inclusion
and exclusion criteria? What are the purposes of defining these criteria?
9. Which type of randomization has been done? What is the purpose in doing this?
10. Define which the target, sampled, and experimental populations is.
11. Describe how the method of intervention was performed?
12. Describe the characteristics of providers who deliver the intervention. How
researchers standardize the intervention?
13. What are the outcomes (dependent variables)? Describe the operational definitions.
14. Based on measurement scale, that dependent variable is part of which type?
15. Is this study using a blind design? What is the purpose to use blind design?
16. Mention ALL parameters used by researchers in the statistical analysis.
17. What is one limitation for this longitudinal study with regard to study subjects?
18. What is the main result of this study? Which intervention was more effective?
19. What other outcomes were also resulting from this study?
20. Table 1 presented the overall main result of the study? Please interpret the result.
21. What are ethical aspects you see from the study?
Self Assessments:
1. Describe the application of clinical trials in diagnosis and patient treatment?
2. Describe the design of parallel clinical trials and cross-over trials
4. Explain the purpose and application of parallel clinical trials and cross-over trials
5. Describe the definition and purpose of single blind and double blind study.
6. Describe the definition of informed consent.
7. On the British Medical Journal 2002, the study was conducted to know the effect of
ice consumption to headache with the design study was prospective randomized trial
(Source: UKDI)
Headache (+) Headache (-) Total

Accelerated eating group 20 53 73

Cautious eating group 9 63 72
Total 29 116 145
What is the role of the risk factor?

A. 2,9
B. 2,2
C. 4,4
D. 4,6
E. 6,8
8. On the study of medication that will be use to suppress cholesterol level; the study
procedure was dividing the study group in to two: control and intervention group. Then,
the outcome will be compared for both groups. What is the design of the study?
(Source: UKDI)
A. True experimental
B. Quasi experimental
C. Cross sectional
D. Cohort
E. Descriptive

REFERENCES
Mausner and Bahn, Epidemiology an Introductory text

Kirkwood B.R & Sterne, A.C. (2008), Medical Statistics, Blackwell ScienceLtd. a
Blackwell Publishing Company
Greenberg, R.S. (2004), Medical Epidemiology, 3rded, McGraw-Hill, New York, USA
Gordis, Epidemiology
SPSS V.11.5 Manual
Webb & Bain, Essential Epidemiology
Sastroasmoro, S. dan Ismael, S. (2008), Dasar-Dasar Metodologi Penelitian Klinis,
edisi ke-2, CV Sagung Seto, Jakarta.
Emily and Murphy, Michael J. (2015) Demography and public health. In: Detels,
Roger, Gulliford, Martin, Karim, Quarraisha Abdool and Tan, Chorh Chuan,
(eds.) Oxford Textbook of Global Public Health. Oxford textbooks, 2. 6th ed.,
Oxford University Press, Oxford, UK, pp. 718-735
Bahan SGD (jurnal, hasil penelitian)

ANNEX-1
SUMMARY FILM
And The Band
Played On
SINOPSIS DAN PENJELASAN TAMBAHAN FILM “AND THE BAND PLAYED ON”

 Film ini merupakan kisah nyata yang menceritakan tentang terjadinya wabah suatu
penyakit yang tidak diketahui penyebabnya pada awal tahun 1980.
 Kisah yang mirip dengan film juga diuraikan di Buku Greenberg halaman 1 – 7
(lihat buku reference yang telah dibagikan).
 Dikisahkan dalam film ini bahwa untuk meneliti atau mengungkapkan penyebab
suatu penyakit banyak bidang ilmu yang terlibat, yaitu: ilmu klinik, statistik,
epidemilogi, ilmu sosial, imunologi, virologi, etika dan profesionalime. Juga
banyak aspek yang berperan, yaitu aspek sosial, politik, dan ekonomi.
 Demikian pula dalam pencegahan dan penanggulangannya dikisahkan bahwa
suatu penyakit baru bisa dicegah setelah diketahui determinannya, cara
penularannya, teknologi untuk diagnosanya (alat test), dan banyak aspek yang
berperan antara lain: aspek sosial (stigma pada kelompok gay), politik (rezim yang
berkuasa di pemerintahan), ekonomi (pembiayaan).
 Film dimulai dengan Dr. Don Francis (seorang dokter yang menekuni Bidang
Epidemiologi dan pencegahan)yang diminta oleh Badan Kesehatan Dunia
(WHO)untuk meneliti wabah Ebola di Sungai Ebola (Afrika). Ebola adalah suatu
penyakit yang tingkat kematiannya hampir 100% dan dijumpai pertama kali di Sungai
Ebola.
 Setelah itu, ditunjukkan bahwa dokter dan rumah sakit di Kopenhagen, Denmark
menemukan seorang pasien yang sakit lalu meninggal dimana penyebab penyakit dan
kematiannya tidak diketahui. Yang dijumpai oleh dokter rumah sakit tersebut hanya
T-sel (suatu sel yang membentuk kekebalan tubuh manusia) hampir nol dalam
pemeriksaan lab-nya.
 Selanjutnya bermunculan kasus-kasus serupa yang dijumpai oleh dokter di sejumlah
rumah sakit di Amerika, pasien dengan T-sel amat rendah, dan secara klinis dijumpai
ada semacam tumor kulit (Kaposi Sarcoma), infeksi oleh jamur di mulut pasien,
radang pada otaknya oleh kuman toksoplasmosis. Bakteri ini biasanya dijumpai
pada kucing atau anjing.
 Hampir semua kasus-kasus tersebut diumpai pada kalangan gay di Amerika terutama
Negara Bagian California dan New York. Karena itu, pada saat itu penyakit misterius
tsb disebut saja dengan penyakit gay.
 Kemudian pihak Communicable Diseases Control (CDC) atau lembaga Kementrian
Kesehatan Amerika yang bertanggung jawab terhadap penyakit menular (yang kantor
pusatnya di Atlanta, Negara Bagian Georgia) minta bantuan Dr. Don Francis ikut
dalam Tim untuk meneliti penyakit ini lebih lanjut. Dia dipilih oleh CDC karena Dr. Don
Francis pernah meneliti penularan Hepatitis B dan Wabah Ebola. CDC sama dengan
Dirjen P2M (Penanggulangan Penyakit Menular) di Kementrian Kesehatan RI.
 Dr. Don Francis bergabung dalam Tim CDC bersama-sama dengan pakar ilmu sosial,
statistik, parasitologi, dokter ahli penyakit menular seksual, dll.
 Saat itu kegiatan CDC banyak menemui hambatan karena tidak didukung
pendanannya oleh Pemerintah Pusat Amerika karena penyakit tersebut banyak
dijumpai pada kalangan gay. Partai yang berkuasa saat itu adalah Partai Republik
(dengan Reagan sebagai presidennya) yang ideologi politiknya tidak menyetujui atau
tidak menyukai homosek-sualitas. Sedangkan Partai Demokrat (partai oposisi) tidak

menentang keberadaan komunitas gay. Permintaan CDC untuk meningkatkan

laboratoriumnya termasuk untuk membeli mikroskop elektron juga menemui
hambatan.
 Penelitian yang pertama kali dilakukan oleh CDC adalah menentukan apakah ini
penyakit menular dan bagaimana cara menularnya.
 Dari data deskriptif dimana hampir semua kasus dijumpai pada kalangan gay dan
dengan penelitian contact tracing, kemudian CDC mendapat petunjuk bahwa penyakit
ini menular melalui hubungan seksual. Contact tracingatau penelusuran kontak
adalah salah satu cara untuk mencari sumber penularan suatu penyakit yang
ditularkan melalui kontak langsung termasuk kontak seksual. Catatan: cara penularan
penyakit SARS diketahui dengan cara penelitian contact tracing. Catatan: Wabah
SARS terjadi tahun 2003 yang bermula di Hongkong kemudian menyebar ke berbagai
negara di dunia.
 Namun selanjutnya CDC menerima laporan bahwa kasus-kasus yang sama juga
dijumpai pada perempuan (migran dari Haiti). Dengan demikian maka penyakit ini
bukan lagi penyakit pada gay.
 Juga ada laporan bahwa dijumpai pada anak-anak penderita hemofilia (penyakit
genetik dimana terjadi kelainan pada sistem pembekuan darah), pasien operasi yang
mendapat transfusi darah. Catatan: penderita hemofilia harus rutin mendapat
transfusi darah.
 Tim CDC semakin bingung karena penyakit ini ternyata bukan saja menular melalui
seksual tetapi juga melalui darah atau produk darah.
 Karena bukan lagi pada gay saja, kemudian tercetus istilah bahwa penyakit ini adalah
suatu Acquired Immunodeficiency Syndrome(AIDS), yaitu suatu syndrome
(kumpulan gejala) yang didapat karena terganggunya kekebalan tubuh..
 Secara kebetulan Dr. Don Francis melihat temannya yang main game di suatu
kantin, dan dia terinspirasi dari game tersebut bahwa ada virus yang menghancurkan
T-sel pasien. Tim CDC kemudian mencurigai bahwa penyebab penyakit ini
kemungkinan suatu virus yang termasuk dalam famili rotavirus. Pada tahap ini,
kemudian penelitian difokuskan untuk bisa menemukan virus tersebut pada pasien.
Pada saat itu pakar yang sedang meneliti rotavirus adalah Robert Gallo (seorang ahli
virology ternama di Amerika Serikat). Saat itu Robert Gallo meneliti rotavirus pada
pasien-pasien leukemia.
 Robert Gallo mengklaim bahwa rotavirus yang dia jumpai adalah penyebab pasien-
pasien Acquired Immunodeficiency Syndrome pada saat itu.
 Karena fasilitas penelitian virus yang saat itu masih terbatas di Amerika, kemudian Dr.
Don Francis (CDC) juga minta bantuan kepada Dr. Luc Montagnier (ilmuwan dan
peneliti di Lembaga Pasteur di Perancis) untuk menemukan virus yang
menyebabkan pasien-pasien AIDS. Saat itu fasilitas di Lembaga Pasteur di Perancis
lebih lengkap dibanding di Amerika.
 Dalam hal inilah terjadi moral hazard (pelanggaran etika dan kelakuan yang tidak
professional) dimana Robert Gallo mengklaim bahwa dirinyalah penemu HIV, padahal
yang menemukan pertama kali adalah Tim dari Lembaga Pasteur di Perancis.
Menemukan suatu virus baru dalam suatu sampel yang diambil dari pasien tidaklah

mudah karena virus harus bisa dibiakkan (dibuat kultur sehingga tidak mati) agar
kemudian bisa dilihat dengan elektron mikroskop.
 Perselisihan antara Robert Gallo dan Lembaga Pasteur hampir dibawa ke pengadilan
(tetapi batal) dan terus berkepanjangan. Karena itu, Panitia Hadiah Nobel dalam waktu
lama tidak memutuskan pemberian hadiah Nobel kepada pihak manapun, tetapi
akhirnya baru diberikan pada tahun 2008 kepada Tim dariLembaga Pasteur di
Perancis setelah HIV dijumpai pada tahun 1984 (setelah 24 tahun).
 Test antibodi pertama untuk mengetahui seseorang tertular HIV dijumpai pertama kali
pada tahun 1984.
Hal-hal lain yang dikemukakan dalam film ini:
 Pencegahan penyakit bisa dilaksanakan ketika cara penularannya telah bisa
dipastikan walaupun kuman penyebabnya (HIV) belum diketemukan secara pasti. Hal
yang sama juga terjadi pada penyakit-penyakit lainnya. Kejadian kolera dengan
penelitian epidemiologi diumpai pada tahun 1854 dan sudah mulai bisa dilakukan
pencegahannya saat itu (dengan konsumsi air bersih), sedangkan kuman kolera baru
dijumpai 30 tahun kemudian. Demikian pula dengan penyakit-penyakit lain (TBC,
polio, dll).
 Upaya pencegahan AIDS yang diusulkan oleh Dr. Don Francis saat itu banyak
menemukan hambatan, baik hambatan politik (partai republik tidak mau memberikan
biaya), hambatan ekonomi (PMI-nya Amerika menolak test pada donor darah karena
biayanya akan amat mahal), hambatan sosial (stigma pada komunitas gay dan
penolakan penutupan tempat sauna/bathhouse yang biasa dipergunakan oleh
komunitas gay untuk berkumpul).
 Dalam film juga ditunjukkan bahwa hambatan yang dijumpai bukan saja dalam hal
pencegahan tetapi juga dalam hal perawatan pasien AIDS. Dokter di salah satu
negara di Eropa dipanggil dan ditegur oleh direkturnya karena banyak merawat
pasien AIDS. Direktur RS mengatakan citra RS-nya tercoreng. Si dokter
menjawab: “Saya tetap akan merawat mereka, dimanapun saya mendapat
tempat”.
 Sampai saat ini Dr. Don Francis berdomisili di California dan banyak melaksanakan
program-program pencegahan.
 Catatan: Dr. MervynSilverman yang dalam film ditunjukan sebagai Kepala Dinas
Kesehatan San Franscisco (Public Health Director) saat itu yang terlambat datang
satu jam dalam pertemuan di bathhouse dan bersusah payah menengahi upaya
penutupan bathhouse komunitas gay, sampai saat ini sering berkunjung ke Bali
karena putrinya menikah dengan seorang pemuda dari suatu desa di Kabupaten
Gianyar.
=====================

ANNEX -2
ARTIKEL KORAN
BALI POST
Bali Post, Senin, 19-6-1995

Dipertanyakan, Pasien Kurang Mampu

Masuk RSUP Denpasar
Denpasar, (Bali Post)
Pihak RSUP Denpasar mempertanyakan pasien kurang mampu masuk RSUP Denpasar
yang jumlahnya cenderung terus meningkat.Munculnya pertanyaan itu, karena dari data
yang ada jumlah pasien yang kurang mampu masuk RSUP justru paling banyak dari
Kabupaten Badung (179 orang), Gianyar (171 orang), dan Tabanan (150
orang).Padahal ketiga daerah ini dinilai sebagai daerah yang memiliki pendapatan
perkapita lebih tinggi dari daerah lainnya di Bali.
Hal tersebut diungkapkan Humas Menurut R, asalkan tempat tidur Sedangkan sebelumnya dari
RSUP Denpasar, Y.H.L., ketika berkelas penuh, sebenarnya Januari-Desember 1994 tercatat
ditemui Jumat (16/6).Dia menilai pasien kurang mampu tidak 606 pasien kurang mampu yang
tidak masuk akal ketiga daerah masalah bagi RSUP. Sebab kalau telah ditolong. Itu berarti 877
yang pendapatan perkapitanya tempat tidur berkelas itu penuh, pasien kurang mampu ditolong
cukup tinggi justru warganya keuntungan dari sana yang akan keringanan biaya perawatannya
paling banyak menyatakan kurang dipakai membantu para pasien oleh RSUP. Dari jumlah tersebut,
mampu. Padahal Daerah Bali kurang mampu yang masuk Kabupaten Badung menempati
yang perekonomiannya dinilai membludak, tentu hal ini akan posisi paling tinggi sebanyak 179
semakin maju, sebagai dampak menjadi masalah, paparnya. orang, menyusul Gianyar 171
pariwisata, jumlah masyarakatnya orang , Tabanan 150 orang,
yang kurang mampu makin sedikit Seleksi Surat Keterangan Karangasem 97 orang, Kodya
Denpasar 75 orang, Klungkung 52
“Apakah mungkin mereka sengaja Baik R dan Y mengharapkan pihak orang, Singaraja 50 oarang,
mengaku kurang mampu dan aparat terkait lainnya, benar-benar Jembrana 43 orang, Bangli 42
gampang mendapatkan surat menyeleksi dalam memberikan orang, Banyuwangi 9 orang,
keterangan kurang mampu dari surat keterangan kurang mampu. Timtim 4 orang, NTB 3 orang, dan
aparat desanya,” kata Y. Sebab, tidak mungkin pihak RSUP NTT 1 orang.
akan mengecek apakah orang itu
Ketika ditanya apakah hal itu benar benar kurang mampu Sementara jumlah tempat tidur
merugikan RSUP yang kini sampai ke desanya. Demikian yang tersedia di RSUP sebanyak
menjadi swadana, Y tidak berani pula pihak terkait, seperti camat, 752 buah, masing-masing VIP A
menjawab.Namun direktur RSUP, Depsos, dan lain-lain, tidak akan 17 buah, VIP B 18 buah, VIP C 15
dr. IGLMR, ketika dikonfirmasi mungkin tahu dengan persis dan Buah, dan sisanya tempat tidur
megatakan hal itu sebenarnya detai keadaan pemohon surat kelas I, II, III, dan biasa.
tidak terlalu berpengaruh terhadap keteragan kurang mampu. “Untuk Sedangkan tarif yang diberikan
keberadaan RSUP.Meskipun kini itu seleksi aparat desa diharapkan untuk tempat tidur berkelas VIP A
menjadi swadana, RSUP tetap lebih ketat lagi dalam Rp 100.000, VIP B Rp 70.000, VIP
mempertahankan fungsi mengeluarkan surat keterangan C Rp 55.000, kelas I Rp 30.000,
sosialnya. kurang mampu.” ujar Y. kelas II Rp 15.000, dan kelas III Rp
4.000 per hari. Dari sinilah
“Jangan hanya mengejar Sejak Januari sampai Juni 1995, keuntungan yang diharapkan
keuntungan belaka, fungsi sosial tercatat 271 pasien kurang mampu dapat membantu para penderita
harus tetap diperhatikan.” Ujarnya. telah dibantu biaya perawatannya kurang mampu yang masuk
oleh pihak RSUP. RSUP.
. Bali Post, Selasa, 20-6-1995

Masalah Pasien Kurang Mampu

DPRD Pertanyakan Keluhan RSUP
Denpasar (Bali Post)
Keluhan RSUP Denpasar tentang terus APN kemudian menambahkan sama saja
meningkatnya jumlah pasien kurang mampu dengan desa tertinggal. ”Belum tentu penduduk
yang datang berobat (Bali Post, 19/6)) di desa tertinggal tergolong kurang mampu.
durasakan sebagai hal yang mengherankan Misalnya Kintamani, di sana banyak
oleh Komisi E DPRD Bali. Karena dalam penduduknya kaya-kaya, ” tandasnya.
kunjungan terakhir Komisi E ke RSUP sekitar
dua bulan lalu, didapat masukan jumlah pasien Baik APN maupun S juga melihat ada hal lain
yang menggunakan kartu miskin menurun, yang perlu dipertimbangkan. Menurut mereka,
bahkan banyak orang yang kurang mampu tidak kesadaran penduduk di Badung, Tabanan, dan
menunjukkan surat keterangan miskin karena Gianyar mungkin lebih tinggi daripada
malu. kabupaten lain. ”Meski tergolong tidak mampu,
tetapi karena daerahnya relatif lebih maju,
Demikian keterangan yang dihimpun Bali Post penduduk di tiga kabupaten itu memiliki
dari beberapa anggota Komisi E DPRD Bali, kesadaran untuk berobat ke rumah sakit
Senin (19/6) kemarin. Ketua Komisi E APN dibanding tempat lain seperti ke dukun.
mempertanyakan, apakah hanya dalam waktu Sebaliknya, penduduk tak mampu di kabupaten
singkat sudah terjadi perubahan. ”Kami akan lain lebih memilih ke dukun. Jadi kelihatannya
mengadakan pertemuan dengan pihak RSUP jumlah penduduk miskinnya lebih sedikit,” tutur
untuk mendapatkan masukan lebih rinci. S.
Mungkin awal Juli nanti sebagai bagian dari
acara rapat koordinasi dengan berbagai instansi Kriteria harus jelas
yang merupakan mitra kerja Komisi E.”
Sebelumnya pihak RSUP juga meminta agar
tegasnya.
aparat desa melakukan seleksi yang lebih ketat
Berkenaan dengan jumlah pasien kurang dalam memberikan surat keterangan miskin.
mampu yang lebih banyak datang dari daerah Karena, menurut Y, tidak masuk akal daerah
yang memiliki pendapatan per kapita tinggi yang pendapatan per kapitanya tinggi memiliki
seperti Badung, Tabanan, dan Gianyar, anggota banyak masyarakat miskin.
Komisi E lainnya, S berpendapat, masalah ini
Terhadap hal ini APN, yang juga Ketua FKP
harus dikaji lebih mendalam.
menegaskan, pemberian surat keterangan
Bisa saja suatu daerah pendapatan per miskin harus mengikuti kriteria yang ada.
kapitanya tinggi tetapi banyak masyarakat yang Berdasarkan kriteria itulah kemudian ditetapkan
tergolong kurang mampu. Mungkin ada apakah seseorang tergolong miskin atau tidak.
kesenjangan pendapatan di mana sebagian ”Saya kira kriteria ini perlu diikuti dalam
kecil masyarakat pendapatannya sangat tinggi mengeluarkan surat keterangan miskin. Jangan
dan sebagian lainnya rendah. Kemudian setelah sampai masyarakat merasa aparat desa pilih
dirata-ratakan pendapatan per kapitanya tinggi,” kasih. Kalau sudah begitu masyarakat bisa
ujarnya. ribut.” ujarnya.

Dia menambahkan, ”Kami sebagai wakil rakyat

juga menghimbau agar pihak RSUP tetap
mengutamakan fungsi sosialnya dibandingkan
masalah administrasi. ”Bagaimanapun
masyarakat miskin tetap harus dibantu. Kalau
ada masyarakat miskin terlanjur datang ke
rumah sakit, apakah harus ditolak? Saya kira
tidak. RSUP perlu mementingkan aspek sosial
daripada urusan administrasi.” ujarnya.
Direktur RSUP dr. IGLMR menegaskan,

peningkatan jumlah pasien tidak mampu
sebenarnya tidak berpengaruh terhadap
keberadaan RSUP asalkan tempat tidur
berkelas penuh. RSUP yang kini memiliki status
swadana, lanjut dia, tetap mengutamakan aspek
sosialnya. (jas)

Study Guide Community-Based Practice 2018
Bali Post, Jumat, 23 September 1983
KORBAN KANKER TERBANYAK PENDUDUK

PEDESAAN, TINGKAT SOSEK RENDAH – Perlu
Penyebarluasan Pencegahan Lewat PKK dan Media Massa
Denpasar (Bali Post). Korban ”Masalah pemberantasan seperti Sulsel, cara pengobatan
kanker terbanyak penduduk penyakit kanker yang semakin dilakukan dengan memakai
pedesaan, kaum Ibu dan anak- tumbuh, menjadi semakin ramuan dedaunan pada kanker
anak. Data di RSUP Sanglah penting. Lebih-lebih dikaitkan payudara, seperti daun ”siput
menunjukkan dari 296 kasus dengan upaya meningkatkan kuning” dicampur ”kumis
yang diteliti, ternyata 87,50 kesejahteraan umum.” ujar kucing” dan ”kapur sirih”
persen penderita dari golongan rektor. ditambah air digunakan untuk
petani, 5,07 persen pegawai, mengompres payudara yang
4,73 persen pedagang. Sisanya Rektor IBO juga menghimbau diserang oleh tumor. Di Sulsel
2,7 persen tidak diketahui dilakukan pengawasan yang juga dilakukan pengobatan
profesinya. Data tersebut baik lewat pelayanan dengan menggunakan besi pijar
memberi petunjuk golongan wisatawan, seperti pengawasan disertai mantra-mantra,
masyarakat yang tingkat sosial kesehatan, kebersihan pengobatan dengan pijat,
ekonominya rendah paling lingkungan dan kebersihan dengan kekuatan batin, mediasi
banyak diancam jiwanya oleh makanan dan minuman di bar dll.
penyakit ganas itu. dan restauran.
Seminar yang menarik
Data tersebut terungkap dalam Tempe Bosok perhatian besar itu
seminar di auditorium unud, menampilkan delapan
Dr. DNS mengungkapkan salah
Kamis, 22/9 yang pembicara yakni Prof. Dr. IGPA
satu penyebab timbulnya
diselenggarakan dalam rangka mengenai ’Kanker Masalah
kanker adalah virus cendawan
dies natalis Unud ke-21. Kita:, dr. IBCM ”Beberapa
kuning beracun yang terdapat
informasi kanker buah dada”,
Tindakan pencegahan lebih dalam oncom, tempe bosok,
dr. IGPS ”Kanker rahim”, dr. WS
baik daripada pengobatan yang kecap, kacang, kool, kelapa,
”Beberapa aspek Kanker
sampai saat ini belum berhasil ketela, dll. Juga disebabkan
Nasofaring di RSUP Sanglah”,
diselesaikan secara tuntas. oleh faktor keturunan, ujar dr.
dr. DSN ”Kanker Hati”, dr. AH
Pengobatan hanya untuk AH, disamping zat-zat kimia, zat
”Kanker Darah pad Anak-anak”,
memperpanjang penundaan warna merah, perekat, iradiasi.
dr. GRT ”Kanker Mata yang
kematian. Ganas”.Seminar
Pengobatan dilakukan dalam
berbagai tingkat, yakni antara dikoordinasikan oleh panitia
Dalam hubungan tersebut,
lain dengan pembedahan, penyelenggara diketuaidr. IBT.
rektor Unud, dr. IBO dalam
sambutannya pada acara radiasi, kombinasi bedah, diikuti
pembukaan seminar radiasi dan kemoterapi yang
menyarankan pengetahuan lazimnya dilakukan sebagai
tentang kanker dan cara tindakan paliatif.
pencegahannya disebarluaskan
Prof. Dr. IGPA menyinggung
kepada masyarakat, misalnya
terdapatnya pengobatan kanker
melalui kaum Ibu sebagai juru
secara tradisional seperti
penerangnya di masing-masing
menggunakan ”ketela
rumah tangga. Penyebarluasan
gendruwo” di salah satu rumah
ini juga penting disalurkan lewat
sakit di Jakarta Barat. Di
PKK dan media massa.
beberapa daerah lainnya
Udayana University Faculty of Medicine, MEU Page 96

ANNEX -3
ARTIKEL JURNAL
1. Dengue and Other Common Causes of Acute Febrile Illness in Asia: An
Active Surveillance Study in Children (Module – 15)
2. Injecting drug use, sexual risk, HIV knowledge and harm reduction
uptake in a large prison in Bali, Indonesia (Module – 15)
3. Effect of potentially modifiable risk factors associated with myocardial

infarction in 52 countries (the INTERHEART study): case-control study
(Module – 16)
4. Risk Factors for Deep Vein Thrombosis and Pulmonary EmbolismA

Population-Based Case-Control Study (Module – 16)
5. Association between recent overnight travel and risk of malaria: a

prospective cohort study at three sites in Uganda (Module -17)
6. Cancer risk in the relatives of patients with nasopharyngeal

carcinoma—a register-based cohort study in Sweden (Module-17)
7. Phase III Equivalence Trial of Azithromycin vs Benzathine Penicillin for

Early Syphilis (Module-18)
8. Operative Compared with Nonoperative Treatment of Displaced Intra-

Articular Calcaneal Fractures (Module-18)
97
SKILL LAB
DATA ANALYSIS USING COMPUTER
TOPICS:
- Skill Lab 1: Data Entry Structure, Data Entry, Data
Cleaning, DataTransformation
- Skill Lab 2: Presenting and Describing Data
- Skill Lab 3: Correlation and Regression, Hypothesis

Testing of Categorical and
Interval Data
SKILL LAB MANUAL

BLOCK COMMUNITY-BASED PRACTICE
98
Skill Lab 1
Preparing Data Entry Structure
Before preparing structure of data entry, please recall types and classification
of data and variables, and structure of variables regarding to data entry.
1. To make data entry structure consisting of number, variable name, variable type,
width, decimal, variable labels, value labels, and missing values
a. Use the variables in Annex 1 (Data collection form) to make data entry structure and
Annex 2 (Data skill lab) for data entry practice.
b. Open SPSS program,  click Variable View.  Make the variables structure (name,
type, width, decimal, variable labels, value labels, and missing values), beginning
with variable: nomor, nama, area . . . . . . . . etc.  (Refer to variable structure for data
entry).
c. Save the file you just made, make your own folder and give the name of this file.
d. Notice the variables Pengetahuan_pre (knowlegde before intervention) and
Pengetahuan_post (knowledge after intervention)! These variables are a pair (two) of
variables of one individual (examination of body weight level before and after
intervention). It is important to remember in-paired or dependent tests such as paired
test e.g.: paired-sample test, matched-pair test.
2. Data entry. To practice, use the data Annex 2 ….  Type the data of variables for ten
recods only.
3. Data cleaning. A very important step that must be done before data analysis.
Think of the errors which might occur during data entry. It can be shown by looking for
the minimum, maximum, or extreme values, and the average values of the variables.
What should the minimum, maximum, and the mean values of numeric variables be, and
what the normal values of the variables are. Just think about it!
a. Open skill lab raw.sav file, …  look at the value labels of every variable. Numeric
variable doesn’t have value labels, … Write the minimum and maximum values of all
categorical variables and the anticipated mean for numerical variables.
b. In this case, to some extent data analysis will be done.
Method: Open skill lab raw.sav file (if it hasn’t so). For numeric variable, use the menu
Analyze, Descriptive Statistics, …  choose and click Descriptives..., 
click and move variables to be analyzed to the [Variable(s)] box.  Click
[Options...] box,  leave [Descriptives: Options] window (mean, minimum,
and maximun had been marked),  click [Continue] box and [OK] box to
finish the process.
Watch the results ………. Note if there is any extreme values that might be
incorrect (below the minimum or above the maximum values), or whether the
mean is in between or out of the range of normal value (eg. the mean of BB
above 150 cm).
c. For categorical variable ………  look for frequencies of the categories
Method: Open skill lab raw.sav file (if it hasn’t so).
Use and click the menu: Analyze, Descriptive Statistics,  choose and click
Frequencies…,  click and move variables to be analyzed to the
[Variable(s)] box.  Click [Statistics] box  Click minimum and maximum in
99
the [Dispersion] box,  click [Continue] box and [OK] box to finish the
process  See the results ………. Take note if there are any values beyond
the value labels.
Of point b and c, take note of the variables that have incorrect values and the values
supposed to be incorrect.
d. To display the incorrect data
Method: Open Skill Lab Raw.sav file (if it has not be opened yet).
Use the menu: Data, choose Select Cases…, click if condition is satisfied
in the [Select] box,  click if and  type the condition of the incorrect data
to be looked for in the blank box in the [Select cases] window.
 To display the incorrect data use and click the menu: Analyze, Reports,
choose and click Case Summaries…, type the specification of data to be
displayed in the [Variables] box of the [Summarized cases] window, e.g.
variable’s name, record number, etc.  Click [OK] box to finish the process.
Specifications of the data will make easier to find the incorrect data to be
corrected.
e. Data correction
Method: Open skill lab raw.sav file (if it hasn’t so).
Use and click the menu: Data View …….  place cursor on the variable
column of the incorrect data.  Use the menu: Edit, Finds…,  type the
incorrect value of the data in the [Find what] box,  click Find next, …..
cursor will move to the incorrect data, ….  replace the incorrect data with
the correct value.
f. Save this corrected file for further analysis!
4. Data Transformation (Grouping)
In some cases, it’s very important to transform numeric variable to catego-rical variable,
even categorical variable to other categorical variable of difference categories.
For instance: age can be grouped into several categories of five-year inter-vals, formal
educational level to three categories, e.g. high, middle, and low level of education.
Another example, to make an indicator (composite index) based on two or more
variables, e.g. BMI (body mass index) based on BW (body weight) and H (height).
A new variable must be made based on some existing variables. This new variable can be
numeric or categorical. BMI is a numeric variable and can be trasformed to categorical
variable.
a. To make a new categorical variable from quantitative/interval data or nume-ric/interval
variable. Make a note of categorical value. ….......  Use the menu: Transform,
Recode, Into Different Variables…. (Use Skill Lab Raw.sav file).
Method: Open skill lab.sav file.
Use and click the menu: Transform,  choose Recode,  choose and click
Into Different Variables…,  choose and move the variable to be recoded
to [Input Variabel:] box, ....  type the new variable name in the [Output
Variabel:] box, .... click Change, ....  click Old and New Values, ….  give
a new code/value (must be integer) for every new category.
To practice:  transform variables pendidikan to tk_pendidikan, umur to
Klp_umur, hb to anemia, based on the following classi-fication!
- pendidikan to tk_pendidikan (two categories): 1. Low education (tdk
pernah sekolah-SMP); 2. High Education (SMA –PT)
100
- umur to Klp_umur (three categories): 1. 6-8 y.o; 2. 9-10 y.o; 3. 11-12 y.o
- hb to anemia (two categories): 1. Anemia (≤ 11 g/dL); 2. Normal (> 11
g/dL).
 Edit these new variable structures (type, width, decimal, label, and
values).
b. To make composite index
To make an indicator of obesity using BMI (Body Mass Index) based on tb (tinggi badan,
height) and bb (berat badan, body weight).
Furthermore, BMI can be transformed to categorical variable as described before (1. <
17,0: kurang BB tingkat berat, severe underweight, 2. 17,0-18,5: kurang BB tingkat
ringan, mild underweight, 3. 18,5-25,0: normal, 4. >25-27,0: kelebihan BB tingkat ringan,
mild obesity, 5. >27,0: kelebihan BB tingkat berat, severe obesity). Formula: BMI = BB
(kg)2/TB (m)2.
Remember that BMI formula for TB is in metre; therefore you need to compute
the TB in cm into m.
Use and click the menu: Transform, click Compute..., Compute Variable
window will appear, .... type TBmetre (new variable name) in the [Target
Variable:] box, .... type the equation (TB/100) in the [Numeric Expression]
box  click [OK] box
Then continue to compute BMI variable:
Use and click the menu: Transform,  click Compute...,  Compute
Variable window will appear, ....  type BMI (new variable name) in the
[Target Variable:] box, ....  type the equation to compute BMI in [Numeric
Espression] box (BB/TBmetre2), ....  click and move variable BB to the
[Numeric Expression:] box, ....  click (“/”) (devide symbol), ....  click (“(”)
(left bracket), ....  click and move variable tbmetre to the [Numeric
Expression:] box, .... click (*) (star symbol), ....  click and move variable
tbmetre to the [Numeric Expression:] box, ....  click (“)”) (right bracket),
then ....  click [OK] box to finish the process. ....  A new variable (imt) has
been created containing the results of the calculation of the equation just
made. .....  Edit the new variable structure, BMI (type, width, decimal,
label, and values).
Skill Lab 2
a. Presenting and Describing Data

Frequency Distribution Tables and Graph
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Tables and graphs can be used to present data/variables. Use narration to describe the
conclusion of the table and graph. One-way tables can be used to present categorical
variables. While association of two or more categorical variables can be presented
using cross-tables.
Graph/chart presentation can be used for either categorical or numeric variables, single
or associations of two or more variables.
Narration is used to describe the conclusion as depicted by the table or graph, e.g.
frequencies, mean, minimum and maximum values, modus, etc.
For those purposes, tables or cross-tables and graphs are needed to be made. Conclusions
of the tables and graphs are presented narratively such as some values depicted by the
tables and graph (average and spread).
1. Presentation of discrete quantitative data is the same as categorical data (qualitative
variable)
a. To make frequency distribution tables, to calculate average and spread, e.g.: mean,
minimum and maximum values, SD, modus, percentiles, etc., use the menu: Analyze,
Descriptive Statistics, Frequencies….
Method: Open skill lab.sav file (if it hasn’t so).
Use and click the menu: Analyze,  choose Descriptive Statistics, 
choose and click Frequencies...,  chose and move the variable(s) to be
analysed (lama_absen) to the [Variable(s):] box in the Frequencies window.
- Leave Display frequency tables (had been marked)
- For statistics option, ....  click [Statistics...] box, …..  choose the
appopriate statistics in the [Percentile Values, Central Tendency,
Dispersion] box in the [Frequencies: Statistics window].
- For graph options, ....  click [Charts...] box, …..  choose the appopriate
chart options in the [Chart Type] box, e.g.: bar, pie, or histogram (with
normal distribution) in the [Frequencies: Charts] window.
 click [Continue] and [OK] box to finish the process.
b. For quantitative data (continuous), calculate the mean, minimum, and maxi-mum values,
SD; use the menu: Analyze, Descriptive Statistics, …...  choose and click
Descriptives…
Use and click the menu: Analyze,  choose Descriptive Statis-tics, 
choose and click Descriptives…,  choose and move the variable(s) (hb)
to be analysed to the [Variable(s):] box.
- For descriptive statistics,  click [Options] box, …..  choose and marked
() the appropriate statistics in the [Dispersion] box, e.g.: mean, minimum,
maximum, and SD) in the [Descriptive: Option] window. .....  Click
[Continue] and [OK] box to finish the process.
c. For more statistics options, including trimmed mean, outliers, CI (Confidence Interval),
percentiles, normality test, plot, etc.: …..  use the menu: Analyze, Descriptive
Statistics, Explore…
Method: Open Skill Lab.sav file (if it hasn’t so).
choose and click Explore...,  [Explore] window will be displayed. Choose,
click and move the variable(s) will be analysed (hb) to the [Dependent List:]
box, ….. Leave [Display] box (Both had been marked), .....  click
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[Statistics...] box for statistic options (e.g. descriptives, outliers), …..  click
[Conti-nue] box. ....  Click [Plots...] box (for graph options: Boxplots,
Descriptive, Normality Plots with Test) .....  click [Continue] box. ..... 
Click [OK] box to finish the process.
Normality test of data is required in hypothesis test, e.g.: T-test, Analysis of
Variance, Correlation, and Multiple Regression.
2. Cross tabulation is used to analyze the association of two categorical variables (dicotomous
or multicotomous). It can be descriptive or analytic analysis. If the variables can be
classified as dependent or independent variables, the depen-dent variable should be
placed as column variable and the independent variable as row variable. Row, column, and
total percentages should be considered according to the methodological design. …..  use
the menu: Analyze, Descriptive Statistics, Crosstabs…
choose and click Crosstabs...,  [Crosstabs] window will be displayed, .....
 choose and move the variables to be analysed (choose jenis_kelamin as
row variable and keluhan_sakit as column variable), .....  choose and move
the variable jenis_kelamin to Row(s): box, and the variable keluhan_sakit
to Column(s): box, …..  click the [Statis-tics...] box (for statistic options:
statistic test, association),  click [Continue] box (Return to [Crosstabs]
window), …..  click the [Cells...] box (for persentage options: row, column,
and total percentages). To display the chart, .....  click Display clustered
bar charts. .....  click [OK] box to finish the process.
B. Presenting and Describing Data

Continued: Frequency Distribution Tables and Charts
1. To Make Several Types of Charts
Other software such as Microsoft Office (Microsoft Word) can be used to make charts. It is
more variative and practical, easier, and yields better results.
The type of charts to be used to present the data depends on the type of data/variables
and the number of variables. Based on these, the appropriate type of charts should be
thought about.
a. One categorical or numeric (discrete) variable: use bar, pie, line chart, histogram.
(Bar, pie chart, and histogram, can be made in the chart options of frequency distribution
analysis).
Use and click the menu: Graphs,  choose and click the type of graphs
(Bar..., Line..., Pie..., Area..., Histogram..., etc.), ....  Bar... for example. 
[Bar Charts] window will be displayed. .....  Click the type of chart ( click
Simple), ....  click Summaries for groups of cases in [Data in Chart Are]
box, ....  click the [Define] box, .... [Define Simple Bar: Summaries for
group of cases] window will be displayed  click N of cases or % of cases
options in the [Bar Represent] box to display value labels, ....  choose and
move the variable (choose paritas) for the chart to the [Category Axis:] box,
……  click OK to finish the process.
b. Two or more variables:
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- Two categorical variables …..  choose bar chart (clustered or stacked), type:
Summaries for groups of cases for displaying data in Persentage;
You need make two categorical variabels (if it hasn’t so). For example
transform the lama_absen variable and categorized it into <3 and >3.
Transform hemoglobin variable into anaemia (<11 g/dl) and not anaemia (11
g/dl and above)
Use and click the menu: Graphs,  choose and click Bar…  [Bar Charts]
window will be displayed. .....  Click the type of chart ( click Clustered or
Stacked,), ....  click Summaries for groups of cases in [Data in Chart
Are] box, ....  click the [Define] box, .... [Define Simple Bar: Summaries
for group of cases] window will be displayed  click N of cases or % of
cases options in the [Bar Represent] box to display value labels, .... 
choose and move grouping variable (lama_absen= <3 & >3) for the chart to
the [Category Axis:] box, ....  choose and move anemia to [Define
Clusters by:] box), .... click OK to finish the process.
. . . . . . Follow this procedure to practice making the other charts. Other example
is graph of age (year) with Hb (anemia/not anemia). First, you need to transform
the continuous variabel in to categorical
The process is almost similar . . . . . . . . .
- More than two variables (one categorical variable for X axis, and two numeric
variables for Y axis) …..  choose bar chart (Clustered or Stacked), type:
Summaries of separate variables to display Mean);
Use the menu: Graphs,  choose Bar..., and click Clustered or Stacked
 click Define,  choose variables for the graph, …..  (choose and
move age (categorical variable) into Category Axis: box, and
Pengetahuan_pre and Pengetahuan_pos into Bar Represent Box. ....
click [OK] box to finish the process.
- Two continuous or ordinal variables for X and Y axis respectively …..  choose
scatter diagram (type: simple).
Use the menu: Graphs,  choose Scatter/Dot...,  [Scatter/ Dot]
window will be displayed, and click Simple, .....  click [Define] box,
[Simple Sacatterplot] window will be displayed, .....  choose the variable
for the graph, …..  (choose Pengetahuan_pre for X axis and
Pengetahuan_post for Y axis). ..... click [OK] box to finish the process.
- Two variables, one categorical variable for X axis and one quantita-tive
(continuous/discrete) variable for Y axis…….  choose boxplot (type: simple,
 choose and click Summaries for groups of cases for Data in Chart Are options).
*) If two numeric variable will be displayed separately,  choose Clustered, and click
Summaries of separate variables in the [Data in Chart Area] box.
Use the menu: Graphs,  choose and click boxplot...,  [Boxplot]
window will be displayed, .....  click Simple for chart option, and click
Summaries for groups of cases in the [Data in Chart Are] box, ..... 
klik Define,  choose variable for the chart, ……..  (choose and move
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Pengetahuan_pre or Pengetahuan_pos into [Variable:] box, and

jenis_kelamin into Category Axis: box). ....  Click [OK] box to finish the
process.
Method*): Open Skill Lab.sav file (if it hasn’t so).
Use the menu: Graphs,  choose and click boxplot..., ..... [Boxplot]
window will be displayed, .....  click Clustered for chart option, and click
Summaries of separate variables in the [Data in Chart Are] box, .....
 klik [Define] box,  choose variable for the chart, ……..  (choose
and move Pengetahuan_pre and Pengetahuan_pos into [Variable:] box,
and jenis_kelamin into [Category Axis:] box). ....  Click [OK] box to
finish the process.
- One numeric variable for Y Axis, one categorical variable as grouping variable for Y
Axis, and one categorical variable for X Axis …….  choose boxplot (type:
clustered, and click Summaries for groups of cases for Data in Chart Area
options).
Use the menu: Graphs,  choose boxplot...,  [Boxplot] window will be
displayed, .....  click Clustered for chart type,  click Summaries for
groups of cases options in [Data in Chart Are] box, .....  click Define,
 choose the variable for the chart to be made, …  (choose and move
jenis_kelamin into [Category Axsis:] box, .....  choose and move
alamat into [Define Clusters by:] box, and Pengetahuan_pre or
Pengetahuan_pos into Variable box). ....  Click [OK] box to finish the
process.
- Two numeric variables for Y Axis, and one categorical variable for X Axis,  choose
boxplot (type: clustered, and Summaries of separate variables for Data in Chart
Area options). (Choose lama_absen for X Axis, and Pengetahuanpre and
Pengetahaun_pos for Y Axis).
Use the menu: Graphs,  choose boxplot...,  [Boxplot] window will be
displayed, .....  click Clustered for type of chart, .....  click Summaries
of separate variables options in [Data in Chart Are] box, .....  click
Define,  choose the variables for the chart to be made, …..  choose
and move alamat into [Category Axis:] box, and Pengetahuanpre and
Pengetahuanpos into [Boxes Represent:] box. .....  Click [OK] box to
finish the process.
2. Graph Editing for Better Presentation

Method: Double-click the chart will be edited,  click the part/component of chart to be
edited,  chose the appropriate menu to edit the com-ponent of the chart. Just
do the same process for the other component ….. (Trial and Error, patient .......
are absolutely required).
For black and white printing, using pattern will be better than using color for fill
color, and dash style will be better than line color.
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Skill Lab 3
A. Correlation and Regression
Linear Correlation
Coefficient correlation (r) is an indicator of association of two numeric or interval
variables. The values ranged between -1 and +1. The number depics the strength of the
association, while the – or + values depict the direction of the association. The data
should be normally distributed. If it isn’t so, non-parametric analysis should be choosen
(Remember Pearson coefficient correlation and Spearman rho).
1. Coefficient correlation. It doesn’t show the causal-effect association or classify the
variables to neither dependent nor independent variables. To com-pute coefficient
correlation, choose the menu: Analyze, Correlate, Bivariate…
Choose the menu: Analyze,  Correlate,  choose and click Bivariate..., 
choose and move the variables will be analysed into [Variables:] box, (umur,
Hb, BB, and TB), .....  in the [Correlation Coefficients] box,  choose and
click Pearson (if the data are normally distributed), or Kendall’s tau-b or
Spearman (if the data are not normally distributed), ..…  click Options for
statistic options, .....  [Bivariate Correlation Options] window will be
displayed, .....  click the appropriate statistics in the [Statistics] box. .... 
Click [OK] box to finish the process.
2. Regression, is used to predict the value of one dependent variable (Y) based on one or
more independent variables (X or X1, X2, X3.......). The variables must be numeric or ordinal.
The term Multiple Regression is used if the independent variables are more than one. To
predict the value of Y variable based on the change in value of one or more X variables,
choose the menu: Analyze, Regression, Linear…
. . . . Not to be discussed in this lecture . . . . Only for who is intrested in.
Method: Open skill lab.sav.sav file (if it hasn’t so).
Choose the menu: Analyze,  choose Regression,  choose and click
Linear...,  [Linear Regression] window will appear. .....  Choose and move
the dependent variable into [Dependent:] box, and the independent variable(s)
into [Independent(s):] box (more than one variables for multiple regression) …..
 click [Statistics:] box for statistic options, .....  choose and click the
appropriate statistic options in the [Linear Regression: Statistics] window …..
 click [Plots:] box, .....  click the appropriate options, ….. Then click [OK]
box to finish the process.
Equation: Y = a + b1X1 + b2X2 + b3X3.........
a = intercept
b = slope (regression coefficient)
B. Significancy Test for Categorical Data

There are three types of Significancy Tests for Categorical Data: single proportion for one
dicotomous variable, two proportions of two dicotomous variables, and more than two
proportions. Two proportions of two dicotomous variables in the form of 2 by 2 table (four-fold
table), the larger contingency tables if the categories are more than two.
1. Significancy Test for Single Proportion (Nonparametrik: Binomial test). This
significancy test is used to test a single proportion of one dicotomous vari-able (can be
106
multicotomous and specify the cut point; cut point must be one of the categories).  Use
the menu: Analyze, Nonparametric Test, Binomial…
Use menu Analyze,  choose Nonparametric Tests,  choose and click
Binomial...,  choose and move the variabel to be analyzed (choose anemia)
to the [Test Variable Lists:] box, …..  type the specified test proportion in the
[Test Proportion:] box, .....  in the [Define Dichotomy:] box, .....  choose
and click Cut Point (misal=12) type the specified category as cut point in the
box. .....  Then click [OK] box to finish the process.
2. Significancy Test for Two Proportion (independent and paired test): four-fold table and
larger contingency table
Remember the condition required for Chi-square test:
- Significancy test for 2 by 2 table, if the condition does not meet the require-ment. If it
is so, what should be done for a larger contingency table.
- The significancy test for 2 by 2 table for dependent sample or paired sam-ple.
- Remember the expected frequency less than 5, 2-test, McNemar test, Fisher’s Exact
Test, regroup of column or row.
- Recall the placement of dependent and independent variables, row and column
percentages related to the methodology design.
a. Independent significancy test for two proportions (two dicotomous vari-ables). 
Use menu: Analyze, Descriptive Statistics, Crosstabs…
Use menu: Analyze,  choose Descriptive Statistics, .....  choose and
click Crosstabs...,  [Crosstabs] window will be displayed, .....  choose
and move alamat (independent variable) to [Row(s):] box, and
keluhan_sakit (dependent variable) to [Column(s):] box, .....  click
[Statistics] box, .....  [Crosstabs: Statistics] window will be displayed,
……  choose and click Chi-square (for statistical test) and Risk (for: RR
and OR), .....  click [Continue] box (Return to [Crosstabs] window), .....
click [Cells] box, …..  [Crosstabs: Cell Display] window will be
displayed, …..  click Row and Column to display Row and Column
Percentages. .....  Then click [Continue] and [OK] box to finish the process.
- Output: Chi-Square Test, …..  See p (Asymp Sig.) of Chi-Square or
Yate’s Continuity Correction (for less than 20 sam-ples).
- See Expected Frequency that less than 5. If more than 20% of the total
cells, …….  use p (Exact Sig.) of Fisher’s Exact Test.
- Risk Estimate, …….  use Odds Ratio for case-control design (OR),
or for Cohort (RR) of risk factor and not risk factor for Cohort design.
b. Dependent significancy test for two proportions (two dicotomous vari-ables, paired
sample test).  Use menu: Analyze, Descriptive Statistics, Crosstabs
Use menu: Analyze,  use Descriptive Statistics, .....  choose and click
Crosstabs...,  [Crosstabs] window will be displayed, ..… choose and move
the paired variables, one variable to [Row(s):] box, and the other variable to
[Column(s):] box, …..  click [Statistics:] box, .....  [Crosstabs:
Statistics] window will be displayed, ..…  click McNemar (for statistical
test), …. click [Continue] box (Return to [Crosstabs] window), .....  click
107
[Cells:] box, …..  click Row or Column (to display Row or Column
Percentages). .....  Then click [Continue] and [OK] box to finish the
process.
SPSS Program doesn’t provide facility to compute OR for depen-dent sample
or paired-sample test. OR can be easily computed manually using the
equation: OR = b/c.
C. Significancy Test for Interval Data
Statistical test for two samples mean, independent and dependent or paired- sample
test
1. Remember the condition required for the test (normality distribution of the data).
2. Use non-parametric test if the condition does not meet the requirement.
3. For independent-samples T test, read the Levene test to make conclu-sion of the
results.
Variable consideration: dependent or test variable should be numeric or interval, and the
independent variable should be dicotomous variable.
Recall normality test of data, 1-Sample K-S and Explore
a. Test the normality of BBpre using non-paramtric Kolmogorov-Smirnov test,  Use menu:
Analyze, Nonparametric Tests, 1-Sample K-S….
Use and click menu: Analyze,  choose Nonparametric Tests,  choose and
click 1-Sample K-S...,  [One-Sample Kolmogorov-Smirnov Test] window
will be displayed, .....  choose and move the test variable (choose umur) to
[Test Variable List:] box, …..  click Normal in the [Test Distribution] box.
.....  Then click [OK] box to finish the process.
b. Normality test based on grouping variable, .....  Use and click menu: Analyse,
Descriptive Statistics, Explore...
Method: Open skill lab.sav file (if it hasn’t so)
Use and click menu: Analyze,  choose Descriptive Statistics, .....  choose
and click Explore...,  [Explore] window will be displayed, .....  choose and
move the test variable (umur) to the [Dependent List:] box, and grouping
variable (area) to the [Factor List:] box, ..…  leave the Display box, .... 
click the [Statistics] box, .....  [Explore: Statistics] window will be displayed,
.....  click the appropriate statistics options, ....  click [Continue] box, ..... 
click the Plots box, .....  [Explore: Plots] window will be displayed, ..…  click
the appropriate options (the most important is Normality plots with test, and
Power estimation), ....  click [Continue] box, and [OK] box to finish the
process.
c. Use Levene test for equality of variances testing. It doesn’t need to do this separately,
because it has been included in T test.
d. Whatever the result was, normal or not, assume that the data is normally distri-buted and
it is not normally distributed), …..  go further to T-test. Assume that the distribution of the
data is normal  1) Use and click menu: Analyze, Compare Means, One-Sample T
Test… (for a single mean test), 2) Use and click menu: Analyze, Compare Means,
Independent-Samples T Test ….. (for independent-samples), and 3) Paired-Samples T
Test… (for dependent/pair-ed-samples).
1. Statistical Test for One-Sample T Test
108
This significancy test is used to test the mean of a sample compared with a specified value
(standard or determined by the investigator).
Method: - One-Sample T Test
Open skill lab.sav file (if it hasn’t so).
Use and click menu: Analyze, choose Compare Means, .....  choose and
click One-Samples T Test...,  [One-Sample T Test] window will be
displayed. .....  click and move the test variable (BB) to the [Test
Variable(s):] box, .....  type the standard value (or determined by the
investigator; example=15kg ) in the [Test Value] box, ……  leave the
Options box, and .....  click [OK] box to finish the process.
2. Statistical test for two-samples mean, independent and paired-sample test

- If the data is normally distributed
Method: - Independent-Sample T-Test.
Open skill lab.sav file (if it is not already open).
click Independent-Samples T Test..., [Independent-Samples T Test]
window will be displayed, .....  choose and move the test variable (BB) to
the [Test Varible(s):] box, and the grouping variable (alamat) to the
[Grouping Variabel:] box, ..…  click [Define Group...] box, .....  [Define
Groups] window will be displayed, .....  type code of categories (must be
integer) of the grouping variable in Group 1 and Group 2 box respectively,
......  click [Continue] box, ..... and then, .....  click [OK] box to finish the
process.
Method: - Paired-Samples T Test.
Use and click menu: Analyze, choose Compare Means, .....  click Paired-
Samples T Test...,  [Paired-Samples T Test] window will be
displayed,..…  choose and move the paired-variables (Pengetahuanpre
and Pengetahuanpost) to [Paired Variables:] box, .....  and click OK to
finish the process.
- If the data is not normally distributed, use nonparametric test
Use and click menu: Analyze, Nonparametric Tests,  choose [2 Inde-pendent
Samples…] (for 2 independent samples) or [2 Related Sam-ples…] (for 2 dependent
samples or paired-samples).
Method: - Nonparametric Test for 2 Independent Samples.
Use and click menu: Analyze, choose Nonparametric Tests, ....  choose
and click 2 Independent Samples...,  choose and move the test variable
(Pengetahaunpre) to the [Test Varible(s):] box, and grouping variable
(alamat) to the [Grouping Variable:] box, ...  click Define Group, and
type the code of categories of grouping variable in Group 1 and Group 2
box respectively,  click Continue, …  choose and click Mann-Whitney
U in Test type: box, …  click OK to finish the process.
Method: - Nonparametric Test for 2 Related Samples.
and click 2 Related Samples...,  choose and move the paired-variables
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to be tested (Pengetahuanpre and Pengetahuanpost) to [Test Pair(s)

List:] box, ..…  choose and click Wilcoxon in [Test type:] box, …  click
OK to finish the process.
3. Statistical test for three or more samples mean, independent and paired sample test
(NOT TO BE DISCUSSED), ....... just for who are interested in.
- If the data is normally distributed
Method: - One-Way ANOVA.
click One-Way ANOVA..., [One-Way ANOVA] window will be displayed, .....
 choose and move the test variable (Hb) to the [Dependent List:] box,
and the factor variable (klp_umur) to the [Factor:] box, ..…  click [Post
Hoc...] box, .....  [One-Way ANOVA: Post Hoc Multiple Comparisons]
window will be displayed, .....  click Bonferoni or other options in the
[Equal Variances Assumed] box, and Tamhane’s T2 or other options in
the [Equal Variances Not Assumed] box, ......  click [Continue] box
(Return to [One-Way ANOVA] window. .....  Click [Options] box, ..... 
[One-Way ANOVA: Options] window will be displayed, .....  click
Descriptive and Homogeneity of Variance Test in the [Statistics] box,
Then, .....  click [Continue] and [OK] box to finish the process.
- If the data is not normally distributed, use nonparametric test
Use and click menu: Analyze, Nonparametric Tests,  choose [K Independent
Samples…] (for 2 independent samples) or [2 Related Samples…] (for 2 dependent
samples or paired-samples).
Method: - Nonparametric Test for 3 or more Independent Samples.
and click K Independent Samples...,  [Test for Several Independent
Samples] window will be displayed, .....  choose and move the test
variable (Hb) to the [Test Varible(s):] box, and grouping variable
(klp_umur) to the [Grouping Variable:] box, ...  click [Define Range...]
box, .....  [Several Independent Samples: Define Range] will be
displayed, .....  and type the minimum and maximun range of grouping
variable in the [Minimum] and [Maximum] box respectively, .....  click
Continue (Return to the [Test for Several Independent Samples] window,
...  click [Options...] box, .....  [Several Independent Samples:
Options] will be displayed, .....  click Descriptive and Quartile in the
[Statistics] box, .....  click Continue (Return to the [Test for Several
Independent Samples] window, …  choose and click Kruskal-Wallis H
in Test type: box, …  click OK to finish the process.
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Annex 1.
Data Collection Questionnaire and Data Entry Structure
DATA COLLECTIONS QUESTIONNAIRE
KUESIONER PENELITIAN RISIKO KEJADIAN INFLUENSA LIKE ILLNESS PADA SISWA SEKOLAH DASAR
1. Nomor Identitas:
I. IDENTITAS RESPONDEN
1. Nama :.........................
2. Umur :.........................
3. Jenis Kelamin :.........................
4. Kelas :.........................
111
5. Pendidikan Orang tua/Wali :.........................

6. Pekerjaan Orang tua/Wali :.........................
7. Alamat rumah :.........................
II. HASIL PEMERIKSAAN FAKTOR RISIKO

1. Hasil pemeriksaan Hb : . . . . . . . . mg%
2. Hasil pemeriksaan TB : . . . . . . . . cm
3. Hasil pemeriksaan BB : . . . . . . . . kg
4. Apakah dalam sebulan terakhir mengalami keluhan flu? (Ya/Tidak)
5. JIka Ya, kapan mulai merasakan keluhan tersebut? (tanggal: . . . . . . . . . . . . . . . . )
6. Apa saja gejala yang dirasakan:
a. Demam (Ya/Tidak)
b. Batuk (Ya/Tidak)
c. Pilek (Ya/Tidak)
d. Sesak Nafas (Ya/Tidak)
7. Apakah dengan sakit tersebut, adik pergi berobat ke layanan kesehatan? (Ya/Tidak)
8. dst…
DATA ENTRY STRUCTURE

Format variabel
Name Type Width Deci- Label Values Missing
mals
ID No. urut
nama Nama
umur Umur
jenis_kelamin 1=laki-laki
2=perempuan
kelas
pendidikan_ortu Tingkat 1=Tidak Pernah sekolah
pendidikan 2=Tidak tamat SD
formal 3= SD
terakhir 4= SMP
112
5=SMA
6=PT
alamat alamat 1=Denpasar
tempat 2=Luar Denpasar
tinggal
Pekerjaan Pekerjaan 1= Tidak Bekerja
ibu 2=Bertani/berkebun/berternak
3= lainnya
Hb Kadar Hb
anak
BB BB dalam
kg
TB Tinggi
badan
dalam cm
keluhan_sakit 1=Ya
2=tidak
onset tanggal
mulai
gejala
gejala_demam 1=ya
2=tidak
gejala_batuk 1=ya
2=tidak
gejala_pilek 1=ya
2=tidak
gejala_sesaknafas 1=ya
2=tidak
Pengisian:
- Name (nama variabel), satu kata maksimal 8 huruf jika SPSS versi 12 atau di bawahnya, tidak boleh
ada tanda baca, kecuali tanda (_).
- Type (ingat jenis variabel: numeric/string atau teks, date).

- Width (jumlah digit atau angka yang diperlukan termasuk tanda baca, koma/titik).
- Decimals (jumlah desimal atau jumlah digit di belakang koma, untuk variabel numerik).
- Label (jelas).
- Values (jelas).
- Missing (biasa dipergunakan angka 9, sesuaikan dengan jumlah digit).
113
Annex 2. Skill lab data
114
STUDENT PROJECT
SEARCHING, ANALYSIS, AND INTERPRET STUDY RESULT
TOPICS:
Descriptive longitudinal, cross sectional
Analitic cross sectional
Case Control
Cohort
Clinical & Community Trial
Diagnostic Test
115
STUDENT PROJECT
Abstract
Epidemiologic approaches are utilised to understand the distribution and risk factor of disease,
also to know the effectiveness of an intervention. The understanding of these concepts assist
doctors in diagnosing, developing evidence based therapy and determining the prognosis of
the disease. In community, a doctor is expected to utilise these concepts to tackle health
problems.
This student project aims to help student to gain better understanding about epidemiologic
approaches and the specific attributes in each approach.
Learning task:
1. Each group need to conduct search on scientific publication that using one of the
epidemiology approach (see assignment table for each group).
2. Pay attention on the timeline of this student project
3. Each group need to consult and get approval from the planners on the topic
4. Pay attention on the specific tasks for each approach. Discuss it with your group.
5. Develop short report, maximum 10 A4 pages
6. Make 8 copies of your group reports and submit them to dr. Citra timely
7. Presentation of the student project will be conducted randomly on day 20th of CBP
block, at the PLENARY SESSION (See the presentation guide)
8. Assessment will be conducted based on several criteria (See evaluation guide)
a. Appropriateness of the answer to the task
b. Participation in group work will be proved by clear job description for each
group member. (dominated work will receive negative mark)
c. Student project will contribute 15% of total CBP block mark.
Table 1. Group assign and epidemiologic approach
No SGD Class Approach Planners

1 I, II Regular Study Descriptive Cross Sectional Facilitator
English
2 III Regular Study Descriptive Longitudinal Facilitator
English
3 IV, XII Regular Study Analytic Cross Sectional Facilitator
English
4 V Regular Study Case Control Facilitator
English
5 VI Regular Study Case Control (Matched Pair) Facilitator
English
6 VII Regular Study Cohort Prospective Facilitator
English
7 VIII Regular Study Cohort Retrospective Facilitator
English
116
8 IX Regular Study Clinical Trial Facilitator

English
9 X Regular Study Community Trial Facilitator
English
10 XI Regular Uji Diagnostik Facilitator
English
Table 2. Student Project Timeline
No Date/week Activities Penanggungjawab

1 Week II Searching and consultation with Planners Planners
2 Week II Discussion with group The chief of SGD
3 Week III Report writing The chief of SGD
4 Week IV Report submission to KMKP The chief of SGD & Block
Coordinator
5 Week IV Develop presentation slide The chief of SGD
6 Week IV Presentation Block Coordinator
Table 3. Task for each approach
No Design Task
1 Observational study: cross sectional, case control, cohort (source: STROBE Statement)
Introduction  Explains the study background
 Explains the specific objective of the study
 Explains the study hypothesis (if available)
Method  Explains the study design and describe important element of the study
 Develops study profile
 explains the setting, location, relevant date include recruitment period,
exposure, follow up and data collection method
 Participant:
(a) Cohort study—describes eligibility criteria, sources, and selection
method. Explain the follow up method
(b) Case-control study—describes eligibility criteria, sources and
method to select case and control. Explain the rational in selecting
case and control.
© Cross-sectional study— describes eligibility criteria, sources, and
selection method
(d)Cohort study— For matched studies, explains the matching criteria,
the number of exposed and unexposed group.
(e) Case-control study—For matched studies, explains the matching
criteriaand number of control per case
117
 Explains the definition of outcome, exposure, predictor, potential

confounder and effect modifier. Explain the diagnostic criteria (if
available)
 Explains how to determine sample size
 Explains all statistical methods including methods to control
confounding variables
Cohort study—if available, explains how to resolve loss to follow-up
Case-control study—if available, explains how to match between case
and control that was done
Cross-sectional study—if available, explains analytical method that
have done related to sample selection
Result  Explains main result of the study
2 Clinical Trial : (source: CONSORT Statement)
Introduction  Explains the background of the study
 Explains the specific purpose of the study
 Explains the hypothesis
Methods  Describe the trial design and the attributes including ration allocation
 Developa study profile completely including the attributes
 Explains the criteria of eligibility for the participant
 Explains the settings and location where data collected
 Explains the intervention given to each group, including the possibility
of repetition and real of the intervention
 Explains specific measurement from primary and secondary outcome
 Explains how to determine sample size
 If available, explains about analytical interim that was done
 Explains the randomization methods
 Explains the randomization type and details of the restrictions if
available
 Described the procedure that was done until intervention given
 Explains who did the randomization, who did the subject inclusion and
and who determine subject allocation for intervention/placebo? Was it
done blinded?
 Explains the statistical method used to compare the primary and
secondary outcome
Result &  For every primary and secondary outcome, explains the result and
Discussion significance
 Explains the study limitation, how to resolve bias source, whether any
precision problems
 Explains about generalisability (external validity, applicability) of the
result; if available
3 Diagnostic Test
Introduction  Explains the background of the study
 Explains about the special purpose of the study
 Explains the hypothesis (if available)
Method  Explains the study design and important part related to the study
design
118
 Develop the study profile

 Explains about the relevant setting, location, and date including
recruitment period, exposure, follow up and data collection
 Participant: explains the eligibility criteria, source and selection method
 Explains the definition of gold standard and diagnostic test. Please
explains the diagnostic criteria if available.
 Explains how to determine the sample size
Presentation guideline:
1. Presentation slides:
 Maximum 10 slides
 Maximum 12 sentences/point per slide, minimum font size 20, font type ARIAL/TIMES
NEW ROMAN/CALIBRI
 Minimum animation, simple background
2. Presentation time maximum 12 minutes, followed by 10 minutes discussion
3. Each group will have chance to present their SP as planners will chose presenters
randomly.
4. Please ensure to input all group slides to the computer before the presentation session
begin, and name them as SGD 1, SGD 2 and so on, and put them in to one folder namely:
Student Project Community Based Practice – English/Regular Class
Assesment guideline
No Assesment items Maximum mark

1 Appropriate answer 60
2 Group work 20
3 The ability to answer questions 20
Total mark 100
The mark for study project is an average of marks from planners who assess every SGD
groups. The study project mark contribute 15% of total CBP evaluation.
119

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Study Guide Community-based Practice

Udayana University Faculty of Medicine, DME 1

Curriculum of Community Based Practice 4

Skill Lab Facilitators 10

Skill Lab Time Table 21

Annex 1 Film Summary “And the band played on” 89

Annex 2 Artikel Koran Bali Post 93

Annex 3 Artikel jurnal 98

Skill Lab (1-3) 99

Student Project: Searching, analysis, and interpreting study result 117

Udayana University Faculty of Medicine, DME 2

Udayana University Faculty of Medicine, DME 3

Competency Instructional Learning Objectives Topics

Use community Demonstrate ability a) Describe several Determinants of

Udayana University Faculty of Medicine, DME 4

Competency Instructional Goals Learning Objectives Topics

Demonstrate ability a) Explain Measurements

k) Explain the Pattern of

Udayana University Faculty of Medicine, DME 5

p) Be able to manage, Surveillance

Demonstrate ability a. Describe Methods to

Udayana University Faculty of Medicine, DME 6

control and cohort

Analyze and a. Be able to apply the Screening of

Udayana University Faculty of Medicine, DME 7

No Name Department Phone

4 Dr. dr. Susy Purnawati, M.KK Physiology 08123989891 A-4 A.2.12

6 dr. IGN Sri Wiryawan, M.Repro Histology 082341768888 A-6 A.2.14

8 Clinical A-8 A.2.16

9 Anatomy A-9 A.2.20

Udayana University Faculty of Medicine, DME 8

English Class (Class B)

2 Clinical B-2 B.2.10

4 Anatomy B-4 B.2.12

6 dr. Nila Wahyuni, M.Fis Physiology 087862324209 B-6 B.2.14

7 dr. I Gede Sastra Winata, M.Biomed, B-7 B.2.15

8 Internal B-8 B.2.16

9 dr. I Wayan Gede Sutadarma, M.Gizi Biochemistry 082144071268 B-9 B.2.20

Skill Lab Facilitators

Udayana University Faculty of Medicine, DME 9

11 dr. Dwi Ariawan, S.Ked PH-PM 081339798632

Days/date Time Activity Venue Conveyer

Introductory lecture Class Room (CR) dr. Ni Luh Putu

2 10.00 – 10.50 Independent Learning

Udayana University Faculty of Medicine, DME 10

Days/date Time Activity Venue Conveyer

Udayana University Faculty of Medicine, DME 11

Days/date Time Activity Venue Conveyer

Udayana University Faculty of Medicine, DME 12

Days/date Time Activity Venue Conveyer

10.00 – 11.50 Independent Learning

14 08.00 – 08.50 SGD (Topic-17) DR

Udayana University Faculty of Medicine, DME 13

Days/date Time Activity Venue Conveyer

15 08.00 – 11.50 Student Project Presentation CR 4.02 Team Teaching

Udayana University Faculty of Medicine, DME 14

Days/date Time Activity Venue Conveyer

Introductory lecture Class Room (CR) dr. Ni Luh Putu

Introductory lecture Class Room (CR)

08.00 – 08.50 SGD (Topic-1) Discussion Room dr. Ni Luh Putu

3 10.00 – 10.50 Independent Learning

Udayana University Faculty of Medicine, DME 15

Days/date Time Activity Venue Conveyer