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Experimental Observasional
Survey
Experimental Observational
Experimental/interven Observational studies
tion studies involve an allow nature to take
active attempt to its course
change a disease The investigator
determinant measures but does
(exposure/behaviour/ not intervene
progress of a
disease) through
treatment
Deskriptif Analitik
• Menjelaskan • Studi mengenai
frekuensi & distribusi determinants dari
masalah kesehatan masalah kesehatan
terutama berdasarkan
faktor orang, tempat • Menggunakan
dan waktu kelompok
pembanding untuk
melihat hubungan
kausalitas (sebab-
akibat)
SIKLUS PENELITIAN
PENELITIAN DESKRIPTIF
• A descriptive study is limited to a description of the
occurrence & distribution of a disease in a population
• Often the 1st step in epidemiological investigation
• Limited descriptive information in which the
characteristics of a no. of patients with a specific disease
are described but are NOT compared with those of a
reference population makes no attempt to analyze the
links between exposure & effect
• Identifies non-random variations in the distribution of
disease to enable an investigator to generate testable
hypotheses regarding etiology
Studi Cross-sectional
• Tujuan:
– mempelajari angka kejadian suatu
penyakit/masalah kesehatan
– mempelajari hubungan antara suatu faktor
risiko dengan angka kejadian suatu penyakit
• Unit analisa: individual
• Faktor risiko/exposure dan status
penyakit/masalah kesehatan diukur pada saat
yang sama
PENELITIAN KASUS KELOLA
• Begins with selection of cases
• Types of Case-Control:
Hospital-Based
Population based
Case-Control
Mulai dari kasus/disease (OUTCOME) dulu
Exposure (+)
exposure
Cases (D+)
Exposure (-)
vs
Exposure (+)
Controls (D-)
Exposure (-)
ditelusuri ke belakang
timeline 1999 2009
PENELITIAN KOHORT
Begin with a group of people FREE of disease but
classify them into sub-groups:
• Exposed
• Not exposed
Types of Cohort:
Prospective / Concurrent
Retrospective / Historical / Non-concurrent
JENIS PENELITIAN KOHORT
1. CONCURENT (Prospective)
Investigator identifies the original population at
the beginning of study
Exposure & non-exposure are ascertained as
they occur during the study
Outcome is ascertained in the future
Disease (+)
Exposed (E)
outcome
Disease (-)
vs
Disease (+)
Non-exposed (NE)
Disease (-)
dilihat ke depan
timeline 2009 2019
Cohort Retrospektif
Tetap mulai dari EXPOSURE dulu
Disease (+)
outcome
Exposed (E)
Disease (-)
vs
Disease (+)
Non-exposed (NE)
Disease (-)
dilihat ke depan
timeline 1999 2009
Cohort Prospektif
E(+) E(-)
Cohort Retrospektif
E(+) E(-)
Case - Control
D(+) D(-)
Cross Sectional
Exposure & Outcome
Dilihat pd saat b’samaan
D(+) D(-)
E (+) E (-)
• Random error
• Individual biological variation
• Sampling error (chance variation)
• Systematic error
• Selection bias
• Measurement/Observation/Information
bias
Effect of Bias
• A true association may be partially masked
• Under/Over-estimation of association
Controlling Bias
1. Selection Bias:
Minimize DO/LTFU/non-participant
Same diagnostic criteria
2. Observation bias:
Standardized procedures
Objective measurement of exposures/outcomes
Blinding / masking: single, double, triple
Blinding / Masking
• A study technique by which subject(s) /
researcher / statistical analyst does not
know :
– the group to which the subject(s) have
been allocated
– Status of exposure / outcome
– Hypothesis of the study
CONFOUNDING
Faktor lain yang juga berpengaruh pada faktor
penyebab maupun akibat yang sedang diteliti,
sehingga dapat mengacaukan hasil penelitian
Bivariat vs Multivariat
(confounding)
a / (a+b)
RR = -------------
c / (c+d)
Non- c d c+d
Exposed (-)
TOTAL a+c b+d n
Example RR in COHORT
CHD(+) CHD (-) TOTAL
Levels of risk
Incidence due
to exposure
50
Incidence not Background
due to exposure risk
0
Exposed Not Exposed
• Therefore:
Total risk of disease = Background risk + Additional risk
in E person due to exposure
ATTRIBUTABLE RISK
• AR = Ie – I0
b (r - 1)
• AR = ----------------
b (r – 1) + 1
b = proporsi populasi terpapar
r = resiko relatif
ARTI ATTRIBUTABLE RISK
• Memperkirakan besarnya kontribusi suatu
faktor risiko/keterpaparan dalam
menimbulkan penyakit atau mencegah
penyakit itu bila faktor risiko tersebut
dihilangkan
• Menunjukkan besarnya kontribusi suatu
faktor tertentu terhadap timbulnya penyakit
• Disebut juga Risk Difference (RD)
• Penting dalam praktek klinik maupun
kesehatan masyarakat
Pemahaman Attributable Risk
• Therefore OR = a/c = ad
b/d bc
• Bila angka kejadian penyakit kecil sehingga
“a” sangat kecil dibandingkan “b” maka dpt
dianggap (a+b)≈b mis (5+100)≈100
• Demikian pula lebih sedikit dijumpai orang yg
tidak terpapar yg menderita penyakit itu,
sehingga dapat dianggap (c+d)≈d
a a
• Maka RR ≈ OR a+b b ad
=
c c bc
c+d d
Example where OR ≈ RR
Disease No Disease Total
• RR = (200/10000) : (100/10000) = 2
Sample
2. Numerik :
i. Histogram : data kontinu
ii. Frekuensi poligon : > 2 kelompok data
iii. Ogive : data kumulatif (cakupan)
iv. Line diagram : tren, unsur waktu, diskrit
Bar Diagram
90
80
70
60
50 East
40 West
North
30
20
10
0
1st Qtr 2nd Qtr 3rd Qtr 4th Qtr
Pie Diagram
1st Qtr
2nd Qtr
3rd Qtr
4th Qtr
Line Diagram
100
90
80
70
60 East
50 West
40 North
30
20
10
0
1st Qtr 2nd Qtr 3rd Qtr 4th Qtr
Ukuran Tengah
Ukuran ringkasan yang dapat mewakili data yang
diukur atau disurvei
• Data Katagorik : proporsi (%)
• Data Numerik :
i. Mean x (rata2) : terpengaruh nilai ekstrim
• Arithmetic (rata-rata hitung)
• Geometric (rata-rata ukur)
ii. Mode : nilai yang paling sering muncul
iii. Median : nilai tengah yang membagi data menjadi 2
bagian yang sama
Ukuran Tengah Var.Numerik
• Mean = 62,14 kg No BB (kg)
Total / n 435/7 1 65
• Mode = 65 kg 2 60
3x 65 kg 3 55
4 65
• Median = 65
5 65
Urutkan dulu:
6 70
55,55,60,65,65,65,70
7 55
Ukuran Variasi
• Untuk melihat seberapa jauh data menyebar :
homogen / heterogen
• Katagorik : proporsi (%)
• Numerik :
i. Range (rentang) : max - min
ii. Varians (S2)
iii. Standard deviasi (S)
iv. Koefisien variasi (S/x)
Pengambilan Sample
1. Non-random:
i. Convenient
ii. Consecutive
iii. Judgmental/Purposive
iv. Accidental
v. Quota
2. Random:
i. Simple Random Sampling (SRS)
Undi / tabel / komputer (epitable)
ii. Stratified sampling
iii. Cluster Sampling
iv. Multistage
v. PPS (Probability Proportionate to Size)
POPULASI
Stratified
Sampling
S
T
Strata 1 R
A
T
I Antar strata Heterogen
Strata 2
F Dalam strata homogen
I
K
A
Strata 3 S
I
POPULASI
Cluster
Sampling
CLUSTER
Contoh pemilihan secara PPS:
Misalnya 1 Desa terdiri dari 6 RW (45 RT) dimana:
• RW 01 = 10 RT; RW 02 = 8 RT; RW 03 = 6 RT;
RW 04 = 9 RT; RW 05 = 7 RT; RW 06 = 5 RT
2. Var. tergantung:
• = Var. dependent
• = Outcome
• Mrpk penyakit atau sesuatu yg diduga sbg akibat
Penelitian
Var. independent Var. dependent
(sebab/exposure) akibat/outcome
Contoh:
Kebiasaan merokok CA Paru
Merokok a b
Tdk Merokok c d
Uji statistik utk analisis bivariat
Var. Dep Var. Dep
Katagorik Numerik
N { l ad – bc l – 0,5N }2
c2 =
(a+b)(c+d)(a+c)(b+d)
Set O E (O – E)2/E
2. Asosiasi epidemiologik
Hill’s Criteria of Causality
Kuat/tidaknya suatu asosiasi epidemiologik
tergantung besar/kecilnya bias (internal validity)