hypothesis in descriptive studies are usually

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A Practical Guide to Writing Quantitative and Qualitative Research Questions and Hypotheses in Scholarly Articles

Edward barroga.

1 Department of General Education, Graduate School of Nursing Science, St. Luke’s International University, Tokyo, Japan.

Glafera Janet Matanguihan

2 Department of Biological Sciences, Messiah University, Mechanicsburg, PA, USA.

The development of research questions and the subsequent hypotheses are prerequisites to defining the main research purpose and specific objectives of a study. Consequently, these objectives determine the study design and research outcome. The development of research questions is a process based on knowledge of current trends, cutting-edge studies, and technological advances in the research field. Excellent research questions are focused and require a comprehensive literature search and in-depth understanding of the problem being investigated. Initially, research questions may be written as descriptive questions which could be developed into inferential questions. These questions must be specific and concise to provide a clear foundation for developing hypotheses. Hypotheses are more formal predictions about the research outcomes. These specify the possible results that may or may not be expected regarding the relationship between groups. Thus, research questions and hypotheses clarify the main purpose and specific objectives of the study, which in turn dictate the design of the study, its direction, and outcome. Studies developed from good research questions and hypotheses will have trustworthy outcomes with wide-ranging social and health implications.

INTRODUCTION

Scientific research is usually initiated by posing evidenced-based research questions which are then explicitly restated as hypotheses. 1 , 2 The hypotheses provide directions to guide the study, solutions, explanations, and expected results. 3 , 4 Both research questions and hypotheses are essentially formulated based on conventional theories and real-world processes, which allow the inception of novel studies and the ethical testing of ideas. 5 , 6

It is crucial to have knowledge of both quantitative and qualitative research 2 as both types of research involve writing research questions and hypotheses. 7 However, these crucial elements of research are sometimes overlooked; if not overlooked, then framed without the forethought and meticulous attention it needs. Planning and careful consideration are needed when developing quantitative or qualitative research, particularly when conceptualizing research questions and hypotheses. 4

There is a continuing need to support researchers in the creation of innovative research questions and hypotheses, as well as for journal articles that carefully review these elements. 1 When research questions and hypotheses are not carefully thought of, unethical studies and poor outcomes usually ensue. Carefully formulated research questions and hypotheses define well-founded objectives, which in turn determine the appropriate design, course, and outcome of the study. This article then aims to discuss in detail the various aspects of crafting research questions and hypotheses, with the goal of guiding researchers as they develop their own. Examples from the authors and peer-reviewed scientific articles in the healthcare field are provided to illustrate key points.

DEFINITIONS AND RELATIONSHIP OF RESEARCH QUESTIONS AND HYPOTHESES

A research question is what a study aims to answer after data analysis and interpretation. The answer is written in length in the discussion section of the paper. Thus, the research question gives a preview of the different parts and variables of the study meant to address the problem posed in the research question. 1 An excellent research question clarifies the research writing while facilitating understanding of the research topic, objective, scope, and limitations of the study. 5

On the other hand, a research hypothesis is an educated statement of an expected outcome. This statement is based on background research and current knowledge. 8 , 9 The research hypothesis makes a specific prediction about a new phenomenon 10 or a formal statement on the expected relationship between an independent variable and a dependent variable. 3 , 11 It provides a tentative answer to the research question to be tested or explored. 4

Hypotheses employ reasoning to predict a theory-based outcome. 10 These can also be developed from theories by focusing on components of theories that have not yet been observed. 10 The validity of hypotheses is often based on the testability of the prediction made in a reproducible experiment. 8

Conversely, hypotheses can also be rephrased as research questions. Several hypotheses based on existing theories and knowledge may be needed to answer a research question. Developing ethical research questions and hypotheses creates a research design that has logical relationships among variables. These relationships serve as a solid foundation for the conduct of the study. 4 , 11 Haphazardly constructed research questions can result in poorly formulated hypotheses and improper study designs, leading to unreliable results. Thus, the formulations of relevant research questions and verifiable hypotheses are crucial when beginning research. 12

CHARACTERISTICS OF GOOD RESEARCH QUESTIONS AND HYPOTHESES

Excellent research questions are specific and focused. These integrate collective data and observations to confirm or refute the subsequent hypotheses. Well-constructed hypotheses are based on previous reports and verify the research context. These are realistic, in-depth, sufficiently complex, and reproducible. More importantly, these hypotheses can be addressed and tested. 13

There are several characteristics of well-developed hypotheses. Good hypotheses are 1) empirically testable 7 , 10 , 11 , 13 ; 2) backed by preliminary evidence 9 ; 3) testable by ethical research 7 , 9 ; 4) based on original ideas 9 ; 5) have evidenced-based logical reasoning 10 ; and 6) can be predicted. 11 Good hypotheses can infer ethical and positive implications, indicating the presence of a relationship or effect relevant to the research theme. 7 , 11 These are initially developed from a general theory and branch into specific hypotheses by deductive reasoning. In the absence of a theory to base the hypotheses, inductive reasoning based on specific observations or findings form more general hypotheses. 10

TYPES OF RESEARCH QUESTIONS AND HYPOTHESES

Research questions and hypotheses are developed according to the type of research, which can be broadly classified into quantitative and qualitative research. We provide a summary of the types of research questions and hypotheses under quantitative and qualitative research categories in Table 1 .

Research questions in quantitative research

In quantitative research, research questions inquire about the relationships among variables being investigated and are usually framed at the start of the study. These are precise and typically linked to the subject population, dependent and independent variables, and research design. 1 Research questions may also attempt to describe the behavior of a population in relation to one or more variables, or describe the characteristics of variables to be measured ( descriptive research questions ). 1 , 5 , 14 These questions may also aim to discover differences between groups within the context of an outcome variable ( comparative research questions ), 1 , 5 , 14 or elucidate trends and interactions among variables ( relationship research questions ). 1 , 5 We provide examples of descriptive, comparative, and relationship research questions in quantitative research in Table 2 .

Hypotheses in quantitative research

In quantitative research, hypotheses predict the expected relationships among variables. 15 Relationships among variables that can be predicted include 1) between a single dependent variable and a single independent variable ( simple hypothesis ) or 2) between two or more independent and dependent variables ( complex hypothesis ). 4 , 11 Hypotheses may also specify the expected direction to be followed and imply an intellectual commitment to a particular outcome ( directional hypothesis ) 4 . On the other hand, hypotheses may not predict the exact direction and are used in the absence of a theory, or when findings contradict previous studies ( non-directional hypothesis ). 4 In addition, hypotheses can 1) define interdependency between variables ( associative hypothesis ), 4 2) propose an effect on the dependent variable from manipulation of the independent variable ( causal hypothesis ), 4 3) state a negative relationship between two variables ( null hypothesis ), 4 , 11 , 15 4) replace the working hypothesis if rejected ( alternative hypothesis ), 15 explain the relationship of phenomena to possibly generate a theory ( working hypothesis ), 11 5) involve quantifiable variables that can be tested statistically ( statistical hypothesis ), 11 6) or express a relationship whose interlinks can be verified logically ( logical hypothesis ). 11 We provide examples of simple, complex, directional, non-directional, associative, causal, null, alternative, working, statistical, and logical hypotheses in quantitative research, as well as the definition of quantitative hypothesis-testing research in Table 3 .

Research questions in qualitative research

Unlike research questions in quantitative research, research questions in qualitative research are usually continuously reviewed and reformulated. The central question and associated subquestions are stated more than the hypotheses. 15 The central question broadly explores a complex set of factors surrounding the central phenomenon, aiming to present the varied perspectives of participants. 15

There are varied goals for which qualitative research questions are developed. These questions can function in several ways, such as to 1) identify and describe existing conditions ( contextual research question s); 2) describe a phenomenon ( descriptive research questions ); 3) assess the effectiveness of existing methods, protocols, theories, or procedures ( evaluation research questions ); 4) examine a phenomenon or analyze the reasons or relationships between subjects or phenomena ( explanatory research questions ); or 5) focus on unknown aspects of a particular topic ( exploratory research questions ). 5 In addition, some qualitative research questions provide new ideas for the development of theories and actions ( generative research questions ) or advance specific ideologies of a position ( ideological research questions ). 1 Other qualitative research questions may build on a body of existing literature and become working guidelines ( ethnographic research questions ). Research questions may also be broadly stated without specific reference to the existing literature or a typology of questions ( phenomenological research questions ), may be directed towards generating a theory of some process ( grounded theory questions ), or may address a description of the case and the emerging themes ( qualitative case study questions ). 15 We provide examples of contextual, descriptive, evaluation, explanatory, exploratory, generative, ideological, ethnographic, phenomenological, grounded theory, and qualitative case study research questions in qualitative research in Table 4 , and the definition of qualitative hypothesis-generating research in Table 5 .

Qualitative studies usually pose at least one central research question and several subquestions starting with How or What . These research questions use exploratory verbs such as explore or describe . These also focus on one central phenomenon of interest, and may mention the participants and research site. 15

Hypotheses in qualitative research

Hypotheses in qualitative research are stated in the form of a clear statement concerning the problem to be investigated. Unlike in quantitative research where hypotheses are usually developed to be tested, qualitative research can lead to both hypothesis-testing and hypothesis-generating outcomes. 2 When studies require both quantitative and qualitative research questions, this suggests an integrative process between both research methods wherein a single mixed-methods research question can be developed. 1

FRAMEWORKS FOR DEVELOPING RESEARCH QUESTIONS AND HYPOTHESES

Research questions followed by hypotheses should be developed before the start of the study. 1 , 12 , 14 It is crucial to develop feasible research questions on a topic that is interesting to both the researcher and the scientific community. This can be achieved by a meticulous review of previous and current studies to establish a novel topic. Specific areas are subsequently focused on to generate ethical research questions. The relevance of the research questions is evaluated in terms of clarity of the resulting data, specificity of the methodology, objectivity of the outcome, depth of the research, and impact of the study. 1 , 5 These aspects constitute the FINER criteria (i.e., Feasible, Interesting, Novel, Ethical, and Relevant). 1 Clarity and effectiveness are achieved if research questions meet the FINER criteria. In addition to the FINER criteria, Ratan et al. described focus, complexity, novelty, feasibility, and measurability for evaluating the effectiveness of research questions. 14

The PICOT and PEO frameworks are also used when developing research questions. 1 The following elements are addressed in these frameworks, PICOT: P-population/patients/problem, I-intervention or indicator being studied, C-comparison group, O-outcome of interest, and T-timeframe of the study; PEO: P-population being studied, E-exposure to preexisting conditions, and O-outcome of interest. 1 Research questions are also considered good if these meet the “FINERMAPS” framework: Feasible, Interesting, Novel, Ethical, Relevant, Manageable, Appropriate, Potential value/publishable, and Systematic. 14

As we indicated earlier, research questions and hypotheses that are not carefully formulated result in unethical studies or poor outcomes. To illustrate this, we provide some examples of ambiguous research question and hypotheses that result in unclear and weak research objectives in quantitative research ( Table 6 ) 16 and qualitative research ( Table 7 ) 17 , and how to transform these ambiguous research question(s) and hypothesis(es) into clear and good statements.

a These statements were composed for comparison and illustrative purposes only.

b These statements are direct quotes from Higashihara and Horiuchi. 16

a This statement is a direct quote from Shimoda et al. 17

The other statements were composed for comparison and illustrative purposes only.

CONSTRUCTING RESEARCH QUESTIONS AND HYPOTHESES

To construct effective research questions and hypotheses, it is very important to 1) clarify the background and 2) identify the research problem at the outset of the research, within a specific timeframe. 9 Then, 3) review or conduct preliminary research to collect all available knowledge about the possible research questions by studying theories and previous studies. 18 Afterwards, 4) construct research questions to investigate the research problem. Identify variables to be accessed from the research questions 4 and make operational definitions of constructs from the research problem and questions. Thereafter, 5) construct specific deductive or inductive predictions in the form of hypotheses. 4 Finally, 6) state the study aims . This general flow for constructing effective research questions and hypotheses prior to conducting research is shown in Fig. 1 .

Research questions are used more frequently in qualitative research than objectives or hypotheses. 3 These questions seek to discover, understand, explore or describe experiences by asking “What” or “How.” The questions are open-ended to elicit a description rather than to relate variables or compare groups. The questions are continually reviewed, reformulated, and changed during the qualitative study. 3 Research questions are also used more frequently in survey projects than hypotheses in experiments in quantitative research to compare variables and their relationships.

Hypotheses are constructed based on the variables identified and as an if-then statement, following the template, ‘If a specific action is taken, then a certain outcome is expected.’ At this stage, some ideas regarding expectations from the research to be conducted must be drawn. 18 Then, the variables to be manipulated (independent) and influenced (dependent) are defined. 4 Thereafter, the hypothesis is stated and refined, and reproducible data tailored to the hypothesis are identified, collected, and analyzed. 4 The hypotheses must be testable and specific, 18 and should describe the variables and their relationships, the specific group being studied, and the predicted research outcome. 18 Hypotheses construction involves a testable proposition to be deduced from theory, and independent and dependent variables to be separated and measured separately. 3 Therefore, good hypotheses must be based on good research questions constructed at the start of a study or trial. 12

In summary, research questions are constructed after establishing the background of the study. Hypotheses are then developed based on the research questions. Thus, it is crucial to have excellent research questions to generate superior hypotheses. In turn, these would determine the research objectives and the design of the study, and ultimately, the outcome of the research. 12 Algorithms for building research questions and hypotheses are shown in Fig. 2 for quantitative research and in Fig. 3 for qualitative research.

EXAMPLES OF RESEARCH QUESTIONS FROM PUBLISHED ARTICLES

• EXAMPLE 1. Descriptive research question (quantitative research)
• - Presents research variables to be assessed (distinct phenotypes and subphenotypes)
• “BACKGROUND: Since COVID-19 was identified, its clinical and biological heterogeneity has been recognized. Identifying COVID-19 phenotypes might help guide basic, clinical, and translational research efforts.
• RESEARCH QUESTION: Does the clinical spectrum of patients with COVID-19 contain distinct phenotypes and subphenotypes? ” 19
• EXAMPLE 2. Relationship research question (quantitative research)
• - Shows interactions between dependent variable (static postural control) and independent variable (peripheral visual field loss)
• “Background: Integration of visual, vestibular, and proprioceptive sensations contributes to postural control. People with peripheral visual field loss have serious postural instability. However, the directional specificity of postural stability and sensory reweighting caused by gradual peripheral visual field loss remain unclear.
• Research question: What are the effects of peripheral visual field loss on static postural control ?” 20
• EXAMPLE 3. Comparative research question (quantitative research)
• - Clarifies the difference among groups with an outcome variable (patients enrolled in COMPERA with moderate PH or severe PH in COPD) and another group without the outcome variable (patients with idiopathic pulmonary arterial hypertension (IPAH))
• “BACKGROUND: Pulmonary hypertension (PH) in COPD is a poorly investigated clinical condition.
• RESEARCH QUESTION: Which factors determine the outcome of PH in COPD?
• STUDY DESIGN AND METHODS: We analyzed the characteristics and outcome of patients enrolled in the Comparative, Prospective Registry of Newly Initiated Therapies for Pulmonary Hypertension (COMPERA) with moderate or severe PH in COPD as defined during the 6th PH World Symposium who received medical therapy for PH and compared them with patients with idiopathic pulmonary arterial hypertension (IPAH) .” 21
• EXAMPLE 4. Exploratory research question (qualitative research)
• - Explores areas that have not been fully investigated (perspectives of families and children who receive care in clinic-based child obesity treatment) to have a deeper understanding of the research problem
• “Problem: Interventions for children with obesity lead to only modest improvements in BMI and long-term outcomes, and data are limited on the perspectives of families of children with obesity in clinic-based treatment. This scoping review seeks to answer the question: What is known about the perspectives of families and children who receive care in clinic-based child obesity treatment? This review aims to explore the scope of perspectives reported by families of children with obesity who have received individualized outpatient clinic-based obesity treatment.” 22
• EXAMPLE 5. Relationship research question (quantitative research)
• - Defines interactions between dependent variable (use of ankle strategies) and independent variable (changes in muscle tone)
• “Background: To maintain an upright standing posture against external disturbances, the human body mainly employs two types of postural control strategies: “ankle strategy” and “hip strategy.” While it has been reported that the magnitude of the disturbance alters the use of postural control strategies, it has not been elucidated how the level of muscle tone, one of the crucial parameters of bodily function, determines the use of each strategy. We have previously confirmed using forward dynamics simulations of human musculoskeletal models that an increased muscle tone promotes the use of ankle strategies. The objective of the present study was to experimentally evaluate a hypothesis: an increased muscle tone promotes the use of ankle strategies. Research question: Do changes in the muscle tone affect the use of ankle strategies ?” 23

EXAMPLES OF HYPOTHESES IN PUBLISHED ARTICLES

• EXAMPLE 1. Working hypothesis (quantitative research)
• - A hypothesis that is initially accepted for further research to produce a feasible theory
• “As fever may have benefit in shortening the duration of viral illness, it is plausible to hypothesize that the antipyretic efficacy of ibuprofen may be hindering the benefits of a fever response when taken during the early stages of COVID-19 illness .” 24
• “In conclusion, it is plausible to hypothesize that the antipyretic efficacy of ibuprofen may be hindering the benefits of a fever response . The difference in perceived safety of these agents in COVID-19 illness could be related to the more potent efficacy to reduce fever with ibuprofen compared to acetaminophen. Compelling data on the benefit of fever warrant further research and review to determine when to treat or withhold ibuprofen for early stage fever for COVID-19 and other related viral illnesses .” 24
• EXAMPLE 2. Exploratory hypothesis (qualitative research)
• - Explores particular areas deeper to clarify subjective experience and develop a formal hypothesis potentially testable in a future quantitative approach
• “We hypothesized that when thinking about a past experience of help-seeking, a self distancing prompt would cause increased help-seeking intentions and more favorable help-seeking outcome expectations .” 25
• “Conclusion
• Although a priori hypotheses were not supported, further research is warranted as results indicate the potential for using self-distancing approaches to increasing help-seeking among some people with depressive symptomatology.” 25
• EXAMPLE 3. Hypothesis-generating research to establish a framework for hypothesis testing (qualitative research)
• “We hypothesize that compassionate care is beneficial for patients (better outcomes), healthcare systems and payers (lower costs), and healthcare providers (lower burnout). ” 26
• Compassionomics is the branch of knowledge and scientific study of the effects of compassionate healthcare. Our main hypotheses are that compassionate healthcare is beneficial for (1) patients, by improving clinical outcomes, (2) healthcare systems and payers, by supporting financial sustainability, and (3) HCPs, by lowering burnout and promoting resilience and well-being. The purpose of this paper is to establish a scientific framework for testing the hypotheses above . If these hypotheses are confirmed through rigorous research, compassionomics will belong in the science of evidence-based medicine, with major implications for all healthcare domains.” 26
• EXAMPLE 4. Statistical hypothesis (quantitative research)
• - An assumption is made about the relationship among several population characteristics ( gender differences in sociodemographic and clinical characteristics of adults with ADHD ). Validity is tested by statistical experiment or analysis ( chi-square test, Students t-test, and logistic regression analysis)
• “Our research investigated gender differences in sociodemographic and clinical characteristics of adults with ADHD in a Japanese clinical sample. Due to unique Japanese cultural ideals and expectations of women's behavior that are in opposition to ADHD symptoms, we hypothesized that women with ADHD experience more difficulties and present more dysfunctions than men . We tested the following hypotheses: first, women with ADHD have more comorbidities than men with ADHD; second, women with ADHD experience more social hardships than men, such as having less full-time employment and being more likely to be divorced.” 27
• “Statistical Analysis
• ( text omitted ) Between-gender comparisons were made using the chi-squared test for categorical variables and Students t-test for continuous variables…( text omitted ). A logistic regression analysis was performed for employment status, marital status, and comorbidity to evaluate the independent effects of gender on these dependent variables.” 27

EXAMPLES OF HYPOTHESIS AS WRITTEN IN PUBLISHED ARTICLES IN RELATION TO OTHER PARTS

• EXAMPLE 1. Background, hypotheses, and aims are provided
• “Pregnant women need skilled care during pregnancy and childbirth, but that skilled care is often delayed in some countries …( text omitted ). The focused antenatal care (FANC) model of WHO recommends that nurses provide information or counseling to all pregnant women …( text omitted ). Job aids are visual support materials that provide the right kind of information using graphics and words in a simple and yet effective manner. When nurses are not highly trained or have many work details to attend to, these job aids can serve as a content reminder for the nurses and can be used for educating their patients (Jennings, Yebadokpo, Affo, & Agbogbe, 2010) ( text omitted ). Importantly, additional evidence is needed to confirm how job aids can further improve the quality of ANC counseling by health workers in maternal care …( text omitted )” 28
• “ This has led us to hypothesize that the quality of ANC counseling would be better if supported by job aids. Consequently, a better quality of ANC counseling is expected to produce higher levels of awareness concerning the danger signs of pregnancy and a more favorable impression of the caring behavior of nurses .” 28
• “This study aimed to examine the differences in the responses of pregnant women to a job aid-supported intervention during ANC visit in terms of 1) their understanding of the danger signs of pregnancy and 2) their impression of the caring behaviors of nurses to pregnant women in rural Tanzania.” 28
• EXAMPLE 2. Background, hypotheses, and aims are provided
• “We conducted a two-arm randomized controlled trial (RCT) to evaluate and compare changes in salivary cortisol and oxytocin levels of first-time pregnant women between experimental and control groups. The women in the experimental group touched and held an infant for 30 min (experimental intervention protocol), whereas those in the control group watched a DVD movie of an infant (control intervention protocol). The primary outcome was salivary cortisol level and the secondary outcome was salivary oxytocin level.” 29
• “ We hypothesize that at 30 min after touching and holding an infant, the salivary cortisol level will significantly decrease and the salivary oxytocin level will increase in the experimental group compared with the control group .” 29
• EXAMPLE 3. Background, aim, and hypothesis are provided
• “In countries where the maternal mortality ratio remains high, antenatal education to increase Birth Preparedness and Complication Readiness (BPCR) is considered one of the top priorities [1]. BPCR includes birth plans during the antenatal period, such as the birthplace, birth attendant, transportation, health facility for complications, expenses, and birth materials, as well as family coordination to achieve such birth plans. In Tanzania, although increasing, only about half of all pregnant women attend an antenatal clinic more than four times [4]. Moreover, the information provided during antenatal care (ANC) is insufficient. In the resource-poor settings, antenatal group education is a potential approach because of the limited time for individual counseling at antenatal clinics.” 30
• “This study aimed to evaluate an antenatal group education program among pregnant women and their families with respect to birth-preparedness and maternal and infant outcomes in rural villages of Tanzania.” 30
• “ The study hypothesis was if Tanzanian pregnant women and their families received a family-oriented antenatal group education, they would (1) have a higher level of BPCR, (2) attend antenatal clinic four or more times, (3) give birth in a health facility, (4) have less complications of women at birth, and (5) have less complications and deaths of infants than those who did not receive the education .” 30

Research questions and hypotheses are crucial components to any type of research, whether quantitative or qualitative. These questions should be developed at the very beginning of the study. Excellent research questions lead to superior hypotheses, which, like a compass, set the direction of research, and can often determine the successful conduct of the study. Many research studies have floundered because the development of research questions and subsequent hypotheses was not given the thought and meticulous attention needed. The development of research questions and hypotheses is an iterative process based on extensive knowledge of the literature and insightful grasp of the knowledge gap. Focused, concise, and specific research questions provide a strong foundation for constructing hypotheses which serve as formal predictions about the research outcomes. Research questions and hypotheses are crucial elements of research that should not be overlooked. They should be carefully thought of and constructed when planning research. This avoids unethical studies and poor outcomes by defining well-founded objectives that determine the design, course, and outcome of the study.

Disclosure: The authors have no potential conflicts of interest to disclose.

Author Contributions:

• Conceptualization: Barroga E, Matanguihan GJ.
• Methodology: Barroga E, Matanguihan GJ.
• Writing - original draft: Barroga E, Matanguihan GJ.
• Writing - review & editing: Barroga E, Matanguihan GJ.

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Research Questions & Hypotheses

Generally, in quantitative studies, reviewers expect hypotheses rather than research questions. However, both research questions and hypotheses serve different purposes and can be beneficial when used together.

Research Questions

Clarify the research’s aim (farrugia et al., 2010).

• Research often begins with an interest in a topic, but a deep understanding of the subject is crucial to formulate an appropriate research question.
• Descriptive: “What factors most influence the academic achievement of senior high school students?”
• Comparative: “What is the performance difference between teaching methods A and B?”
• Relationship-based: “What is the relationship between self-efficacy and academic achievement?”
• Increasing knowledge about a subject can be achieved through systematic literature reviews, in-depth interviews with patients (and proxies), focus groups, and consultations with field experts.
• Some funding bodies, like the Canadian Institute for Health Research, recommend conducting a systematic review or a pilot study before seeking grants for full trials.
• The presence of multiple research questions in a study can complicate the design, statistical analysis, and feasibility.
• It’s advisable to focus on a single primary research question for the study.
• The primary question, clearly stated at the end of a grant proposal’s introduction, usually specifies the study population, intervention, and other relevant factors.
• The FINER criteria underscore aspects that can enhance the chances of a successful research project, including specifying the population of interest, aligning with scientific and public interest, clinical relevance, and contribution to the field, while complying with ethical and national research standards.
• The P ICOT approach is crucial in developing the study’s framework and protocol, influencing inclusion and exclusion criteria and identifying patient groups for inclusion.
• Defining the specific population, intervention, comparator, and outcome helps in selecting the right outcome measurement tool.
• The more precise the population definition and stricter the inclusion and exclusion criteria, the more significant the impact on the interpretation, applicability, and generalizability of the research findings.
• A restricted study population enhances internal validity but may limit the study’s external validity and generalizability to clinical practice.
• A broadly defined study population may better reflect clinical practice but could increase bias and reduce internal validity.
• An inadequately formulated research question can negatively impact study design, potentially leading to ineffective outcomes and affecting publication prospects.

Checklist: Good research questions for social science projects (Panke, 2018)

Research Hypotheses

Present the researcher’s predictions based on specific statements.

• These statements define the research problem or issue and indicate the direction of the researcher’s predictions.
• Formulating the research question and hypothesis from existing data (e.g., a database) can lead to multiple statistical comparisons and potentially spurious findings due to chance.
• The research or clinical hypothesis, derived from the research question, shapes the study’s key elements: sampling strategy, intervention, comparison, and outcome variables.
• Hypotheses can express a single outcome or multiple outcomes.
• After statistical testing, the null hypothesis is either rejected or not rejected based on whether the study’s findings are statistically significant.
• Hypothesis testing helps determine if observed findings are due to true differences and not chance.
• Hypotheses can be 1-sided (specific direction of difference) or 2-sided (presence of a difference without specifying direction).
• 2-sided hypotheses are generally preferred unless there’s a strong justification for a 1-sided hypothesis.
• A solid research hypothesis, informed by a good research question, influences the research design and paves the way for defining clear research objectives.

Types of Research Hypothesis

• In a Y-centered research design, the focus is on the dependent variable (DV) which is specified in the research question. Theories are then used to identify independent variables (IV) and explain their causal relationship with the DV.
• Example: “An increase in teacher-led instructional time (IV) is likely to improve student reading comprehension scores (DV), because extensive guided practice under expert supervision enhances learning retention and skill mastery.”
• Hypothesis Explanation: The dependent variable (student reading comprehension scores) is the focus, and the hypothesis explores how changes in the independent variable (teacher-led instructional time) affect it.
• In X-centered research designs, the independent variable is specified in the research question. Theories are used to determine potential dependent variables and the causal mechanisms at play.
• Example: “Implementing technology-based learning tools (IV) is likely to enhance student engagement in the classroom (DV), because interactive and multimedia content increases student interest and participation.”
• Hypothesis Explanation: The independent variable (technology-based learning tools) is the focus, with the hypothesis exploring its impact on a potential dependent variable (student engagement).
• Probabilistic hypotheses suggest that changes in the independent variable are likely to lead to changes in the dependent variable in a predictable manner, but not with absolute certainty.
• Example: “The more teachers engage in professional development programs (IV), the more their teaching effectiveness (DV) is likely to improve, because continuous training updates pedagogical skills and knowledge.”
• Hypothesis Explanation: This hypothesis implies a probable relationship between the extent of professional development (IV) and teaching effectiveness (DV).
• Deterministic hypotheses state that a specific change in the independent variable will lead to a specific change in the dependent variable, implying a more direct and certain relationship.
• Example: “If the school curriculum changes from traditional lecture-based methods to project-based learning (IV), then student collaboration skills (DV) are expected to improve because project-based learning inherently requires teamwork and peer interaction.”
• Hypothesis Explanation: This hypothesis presumes a direct and definite outcome (improvement in collaboration skills) resulting from a specific change in the teaching method.
• Example : “Students who identify as visual learners will score higher on tests that are presented in a visually rich format compared to tests presented in a text-only format.”
• Explanation : This hypothesis aims to describe the potential difference in test scores between visual learners taking visually rich tests and text-only tests, without implying a direct cause-and-effect relationship.
• Example : “Teaching method A will improve student performance more than method B.”
• Explanation : This hypothesis compares the effectiveness of two different teaching methods, suggesting that one will lead to better student performance than the other. It implies a direct comparison but does not necessarily establish a causal mechanism.
• Example : “Students with higher self-efficacy will show higher levels of academic achievement.”
• Explanation : This hypothesis predicts a relationship between the variable of self-efficacy and academic achievement. Unlike a causal hypothesis, it does not necessarily suggest that one variable causes changes in the other, but rather that they are related in some way.

Tips for developing research questions and hypotheses for research studies

• Perform a systematic literature review (if one has not been done) to increase knowledge and familiarity with the topic and to assist with research development.
• Learn about current trends and technological advances on the topic.
• Seek careful input from experts, mentors, colleagues, and collaborators to refine your research question as this will aid in developing the research question and guide the research study.
• Use the FINER criteria in the development of the research question.
• Ensure that the research question follows PICOT format.
• Develop a research hypothesis from the research question.
• Ensure that the research question and objectives are answerable, feasible, and clinically relevant.

If your research hypotheses are derived from your research questions, particularly when multiple hypotheses address a single question, it’s recommended to use both research questions and hypotheses. However, if this isn’t the case, using hypotheses over research questions is advised. It’s important to note these are general guidelines, not strict rules. If you opt not to use hypotheses, consult with your supervisor for the best approach.

Farrugia, P., Petrisor, B. A., Farrokhyar, F., & Bhandari, M. (2010). Practical tips for surgical research: Research questions, hypotheses and objectives.  Canadian journal of surgery. Journal canadien de chirurgie ,  53 (4), 278–281.

Hulley, S. B., Cummings, S. R., Browner, W. S., Grady, D., & Newman, T. B. (2007). Designing clinical research. Philadelphia.

Panke, D. (2018). Research design & method selection: Making good choices in the social sciences.  Research Design & Method Selection , 1-368.

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5.8: Descriptive Research

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Learning Objectives

• Differentiate between descriptive, experimental, and correlational research
• Explain the strengths and weaknesses of case studies, naturalistic observation, and surveys

There are many research methods available to psychologists in their efforts to understand, describe, and explain behavior and the cognitive and biological processes that underlie it. Some methods rely on observational techniques. Other approaches involve interactions between the researcher and the individuals who are being studied—ranging from a series of simple questions to extensive, in-depth interviews—to well-controlled experiments.

The three main categories of psychological research are descriptive, correlational, and experimental research. Research studies that do not test specific relationships between variables are called descriptive, or qualitative, studies . These studies are used to describe general or specific behaviors and attributes that are observed and measured. In the early stages of research it might be difficult to form a hypothesis, especially when there is not any existing literature in the area. In these situations designing an experiment would be premature, as the question of interest is not yet clearly defined as a hypothesis. Often a researcher will begin with a non-experimental approach, such as a descriptive study, to gather more information about the topic before designing an experiment or correlational study to address a specific hypothesis. Descriptive research is distinct from correlational research , in which psychologists formally test whether a relationship exists between two or more variables. Experimental research goes a step further beyond descriptive and correlational research and randomly assigns people to different conditions, using hypothesis testing to make inferences about how these conditions affect behavior. It aims to determine if one variable directly impacts and causes another. Correlational and experimental research both typically use hypothesis testing, whereas descriptive research does not.

Each of these research methods has unique strengths and weaknesses, and each method may only be appropriate for certain types of research questions. For example, studies that rely primarily on observation produce incredible amounts of information, but the ability to apply this information to the larger population is somewhat limited because of small sample sizes. Survey research, on the other hand, allows researchers to easily collect data from relatively large samples. While this allows for results to be generalized to the larger population more easily, the information that can be collected on any given survey is somewhat limited and subject to problems associated with any type of self-reported data. Some researchers conduct archival research by using existing records. While this can be a fairly inexpensive way to collect data that can provide insight into a number of research questions, researchers using this approach have no control on how or what kind of data was collected.

Correlational research can find a relationship between two variables, but the only way a researcher can claim that the relationship between the variables is cause and effect is to perform an experiment. In experimental research, which will be discussed later in the text, there is a tremendous amount of control over variables of interest. While this is a powerful approach, experiments are often conducted in very artificial settings. This calls into question the validity of experimental findings with regard to how they would apply in real-world settings. In addition, many of the questions that psychologists would like to answer cannot be pursued through experimental research because of ethical concerns.

The three main types of descriptive studies are case studies, naturalistic observation, and surveys.

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Case Studies

In 2011, the New York Times published a feature story on Krista and Tatiana Hogan, Canadian twin girls. These particular twins are unique because Krista and Tatiana are conjoined twins, connected at the head. There is evidence that the two girls are connected in a part of the brain called the thalamus, which is a major sensory relay center. Most incoming sensory information is sent through the thalamus before reaching higher regions of the cerebral cortex for processing.

Link to Learning

To learn more about Krista and Tatiana, watch this video about their lives as conjoined twins.

The implications of this potential connection mean that it might be possible for one twin to experience the sensations of the other twin. For instance, if Krista is watching a particularly funny television program, Tatiana might smile or laugh even if she is not watching the program. This particular possibility has piqued the interest of many neuroscientists who seek to understand how the brain uses sensory information.

These twins represent an enormous resource in the study of the brain, and since their condition is very rare, it is likely that as long as their family agrees, scientists will follow these girls very closely throughout their lives to gain as much information as possible (Dominus, 2011).

In observational research, scientists are conducting a clinical or case study when they focus on one person or just a few individuals. Indeed, some scientists spend their entire careers studying just 10–20 individuals. Why would they do this? Obviously, when they focus their attention on a very small number of people, they can gain a tremendous amount of insight into those cases. The richness of information that is collected in clinical or case studies is unmatched by any other single research method. This allows the researcher to have a very deep understanding of the individuals and the particular phenomenon being studied.

If clinical or case studies provide so much information, why are they not more frequent among researchers? As it turns out, the major benefit of this particular approach is also a weakness. As mentioned earlier, this approach is often used when studying individuals who are interesting to researchers because they have a rare characteristic. Therefore, the individuals who serve as the focus of case studies are not like most other people. If scientists ultimately want to explain all behavior, focusing attention on such a special group of people can make it difficult to generalize any observations to the larger population as a whole. Generalizing refers to the ability to apply the findings of a particular research project to larger segments of society. Again, case studies provide enormous amounts of information, but since the cases are so specific, the potential to apply what’s learned to the average person may be very limited.

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Naturalistic Observation

If you want to understand how behavior occurs, one of the best ways to gain information is to simply observe the behavior in its natural context. However, people might change their behavior in unexpected ways if they know they are being observed. How do researchers obtain accurate information when people tend to hide their natural behavior? As an example, imagine that your professor asks everyone in your class to raise their hand if they always wash their hands after using the restroom. Chances are that almost everyone in the classroom will raise their hand, but do you think hand washing after every trip to the restroom is really that universal?

This is very similar to the phenomenon mentioned earlier in this module: many individuals do not feel comfortable answering a question honestly. But if we are committed to finding out the facts about hand washing, we have other options available to us.

Suppose we send a classmate into the restroom to actually watch whether everyone washes their hands after using the restroom. Will our observer blend into the restroom environment by wearing a white lab coat, sitting with a clipboard, and staring at the sinks? We want our researcher to be inconspicuous—perhaps standing at one of the sinks pretending to put in contact lenses while secretly recording the relevant information. This type of observational study is called naturalistic observation : observing behavior in its natural setting. To better understand peer exclusion, Suzanne Fanger collaborated with colleagues at the University of Texas to observe the behavior of preschool children on a playground. How did the observers remain inconspicuous over the duration of the study? They equipped a few of the children with wireless microphones (which the children quickly forgot about) and observed while taking notes from a distance. Also, the children in that particular preschool (a “laboratory preschool”) were accustomed to having observers on the playground (Fanger, Frankel, & Hazen, 2012).

It is critical that the observer be as unobtrusive and as inconspicuous as possible: when people know they are being watched, they are less likely to behave naturally. If you have any doubt about this, ask yourself how your driving behavior might differ in two situations: In the first situation, you are driving down a deserted highway during the middle of the day; in the second situation, you are being followed by a police car down the same deserted highway (Figure 1).

It should be pointed out that naturalistic observation is not limited to research involving humans. Indeed, some of the best-known examples of naturalistic observation involve researchers going into the field to observe various kinds of animals in their own environments. As with human studies, the researchers maintain their distance and avoid interfering with the animal subjects so as not to influence their natural behaviors. Scientists have used this technique to study social hierarchies and interactions among animals ranging from ground squirrels to gorillas. The information provided by these studies is invaluable in understanding how those animals organize socially and communicate with one another. The anthropologist Jane Goodall, for example, spent nearly five decades observing the behavior of chimpanzees in Africa (Figure 2). As an illustration of the types of concerns that a researcher might encounter in naturalistic observation, some scientists criticized Goodall for giving the chimps names instead of referring to them by numbers—using names was thought to undermine the emotional detachment required for the objectivity of the study (McKie, 2010).

The greatest benefit of naturalistic observation is the validity, or accuracy, of information collected unobtrusively in a natural setting. Having individuals behave as they normally would in a given situation means that we have a higher degree of ecological validity, or realism, than we might achieve with other research approaches. Therefore, our ability to generalize the findings of the research to real-world situations is enhanced. If done correctly, we need not worry about people or animals modifying their behavior simply because they are being observed. Sometimes, people may assume that reality programs give us a glimpse into authentic human behavior. However, the principle of inconspicuous observation is violated as reality stars are followed by camera crews and are interviewed on camera for personal confessionals. Given that environment, we must doubt how natural and realistic their behaviors are.

The major downside of naturalistic observation is that they are often difficult to set up and control. In our restroom study, what if you stood in the restroom all day prepared to record people’s hand washing behavior and no one came in? Or, what if you have been closely observing a troop of gorillas for weeks only to find that they migrated to a new place while you were sleeping in your tent? The benefit of realistic data comes at a cost. As a researcher you have no control of when (or if) you have behavior to observe. In addition, this type of observational research often requires significant investments of time, money, and a good dose of luck.

Sometimes studies involve structured observation. In these cases, people are observed while engaging in set, specific tasks. An excellent example of structured observation comes from Strange Situation by Mary Ainsworth (you will read more about this in the module on lifespan development). The Strange Situation is a procedure used to evaluate attachment styles that exist between an infant and caregiver. In this scenario, caregivers bring their infants into a room filled with toys. The Strange Situation involves a number of phases, including a stranger coming into the room, the caregiver leaving the room, and the caregiver’s return to the room. The infant’s behavior is closely monitored at each phase, but it is the behavior of the infant upon being reunited with the caregiver that is most telling in terms of characterizing the infant’s attachment style with the caregiver.

Another potential problem in observational research is observer bias . Generally, people who act as observers are closely involved in the research project and may unconsciously skew their observations to fit their research goals or expectations. To protect against this type of bias, researchers should have clear criteria established for the types of behaviors recorded and how those behaviors should be classified. In addition, researchers often compare observations of the same event by multiple observers, in order to test inter-rater reliability : a measure of reliability that assesses the consistency of observations by different observers.

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Often, psychologists develop surveys as a means of gathering data. Surveys are lists of questions to be answered by research participants, and can be delivered as paper-and-pencil questionnaires, administered electronically, or conducted verbally (Figure 3). Generally, the survey itself can be completed in a short time, and the ease of administering a survey makes it easy to collect data from a large number of people.

Surveys allow researchers to gather data from larger samples than may be afforded by other research methods . A sample is a subset of individuals selected from a population , which is the overall group of individuals that the researchers are interested in. Researchers study the sample and seek to generalize their findings to the population.

There is both strength and weakness of the survey in comparison to case studies. By using surveys, we can collect information from a larger sample of people. A larger sample is better able to reflect the actual diversity of the population, thus allowing better generalizability. Therefore, if our sample is sufficiently large and diverse, we can assume that the data we collect from the survey can be generalized to the larger population with more certainty than the information collected through a case study. However, given the greater number of people involved, we are not able to collect the same depth of information on each person that would be collected in a case study.

Another potential weakness of surveys is something we touched on earlier in this module: people don’t always give accurate responses. They may lie, misremember, or answer questions in a way that they think makes them look good. For example, people may report drinking less alcohol than is actually the case.

Any number of research questions can be answered through the use of surveys. One real-world example is the research conducted by Jenkins, Ruppel, Kizer, Yehl, and Griffin (2012) about the backlash against the US Arab-American community following the terrorist attacks of September 11, 2001. Jenkins and colleagues wanted to determine to what extent these negative attitudes toward Arab-Americans still existed nearly a decade after the attacks occurred. In one study, 140 research participants filled out a survey with 10 questions, including questions asking directly about the participant’s overt prejudicial attitudes toward people of various ethnicities. The survey also asked indirect questions about how likely the participant would be to interact with a person of a given ethnicity in a variety of settings (such as, “How likely do you think it is that you would introduce yourself to a person of Arab-American descent?”). The results of the research suggested that participants were unwilling to report prejudicial attitudes toward any ethnic group. However, there were significant differences between their pattern of responses to questions about social interaction with Arab-Americans compared to other ethnic groups: they indicated less willingness for social interaction with Arab-Americans compared to the other ethnic groups. This suggested that the participants harbored subtle forms of prejudice against Arab-Americans, despite their assertions that this was not the case (Jenkins et al., 2012).

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Think It Over

A friend of yours is working part-time in a local pet store. Your friend has become increasingly interested in how dogs normally communicate and interact with each other, and is thinking of visiting a local veterinary clinic to see how dogs interact in the waiting room. After reading this section, do you think this is the best way to better understand such interactions? Do you have any suggestions that might result in more valid data?

clinical or case study:  observational research study focusing on one or a few people

correlational research:  tests whether a relationship exists between two or more variables

descriptive research:  research studies that do not test specific relationships between variables; they are used to describe general or specific behaviors and attributes that are observed and measured

experimental research:  tests a hypothesis to determine cause and effect relationships

generalize inferring that the results for a sample apply to the larger population

inter-rater reliability:  measure of agreement among observers on how they record and classify a particular event

naturalistic observation:  observation of behavior in its natural setting

observer bias:  when observations may be skewed to align with observer expectations

population:  overall group of individuals that the researchers are interested in

sample:  subset of individuals selected from the larger population

survey:  list of questions to be answered by research participants—given as paper-and-pencil questionnaires, administered electronically, or conducted verbally—allowing researchers to collect data from a large number of people

Licenses and Attributions

CC licensed content, Original

• Modification and adaptation. Provided by : Lumen Learning. License : CC BY-SA: Attribution-ShareAlike
• Approaches to Research. Authored by : OpenStax College. Located at : http://cnx.org/contents/[email protected]:iMyFZJzg@5/Approaches-to-Research . License : CC BY: Attribution . License Terms : Download for free at http://cnx.org/contents/[email protected]
• Descriptive Research. Provided by : Boundless. Located at : https://www.boundless.com/psychology/textbooks/boundless-psychology-textbook/researching-psychology-2/types-of-research-studies-27/descriptive-research-124-12659/ . License : CC BY-SA: Attribution-ShareAlike

Child Care and Early Education Research Connections

Descriptive research studies.

Descriptive research is a type of research that is used to describe the characteristics of a population. It collects data that are used to answer a wide range of what, when, and how questions pertaining to a particular population or group. For example, descriptive studies might be used to answer questions such as: What percentage of Head Start teachers have a bachelor's degree or higher? What is the average reading ability of 5-year-olds when they first enter kindergarten? What kinds of math activities are used in early childhood programs? When do children first receive regular child care from someone other than their parents? When are children with developmental disabilities first diagnosed and when do they first receive services? What factors do programs consider when making decisions about the type of assessments that will be used to assess the skills of the children in their programs? How do the types of services children receive from their early childhood program change as children age?

Descriptive research does not answer questions about why a certain phenomenon occurs or what the causes are. Answers to such questions are best obtained from  randomized and quasi-experimental studies . However, data from descriptive studies can be used to examine the relationships (correlations) among variables. While the findings from correlational analyses are not evidence of causality, they can help to distinguish variables that may be important in explaining a phenomenon from those that are not. Thus, descriptive research is often used to generate hypotheses that should be tested using more rigorous designs.

A variety of data collection methods may be used alone or in combination to answer the types of questions guiding descriptive research. Some of the more common methods include surveys, interviews, observations, case studies, and portfolios. The data collected through these methods can be either quantitative or qualitative. Quantitative data are typically analyzed and presenting using  descriptive statistics . Using quantitative data, researchers may describe the characteristics of a sample or population in terms of percentages (e.g., percentage of population that belong to different racial/ethnic groups, percentage of low-income families that receive different government services) or averages (e.g., average household income, average scores of reading, mathematics and language assessments). Quantitative data, such as narrative data collected as part of a case study, may be used to organize, classify, and used to identify patterns of behaviors, attitudes, and other characteristics of groups.

Descriptive studies have an important role in early care and education research. Studies such as the  National Survey of Early Care and Education  and the  National Household Education Surveys Program  have greatly increased our knowledge of the supply of and demand for child care in the U.S. The  Head Start Family and Child Experiences Survey  and the  Early Childhood Longitudinal Study Program  have provided researchers, policy makers and practitioners with rich information about school readiness skills of children in the U.S.

Each of the methods used to collect descriptive data have their own strengths and limitations. The following are some of the strengths and limitations of descriptive research studies in general.

Study participants are questioned or observed in a natural setting (e.g., their homes, child care or educational settings).

Study data can be used to identify the prevalence of particular problems and the need for new or additional services to address these problems.

Descriptive research may identify areas in need of additional research and relationships between variables that require future study. Descriptive research is often referred to as "hypothesis generating research."

Depending on the data collection method used, descriptive studies can generate rich datasets on large and diverse samples.

Limitations:

Descriptive studies cannot be used to establish cause and effect relationships.

Respondents may not be truthful when answering survey questions or may give socially desirable responses.

The choice and wording of questions on a questionnaire may influence the descriptive findings.

Depending on the type and size of sample, the findings may not be generalizable or produce an accurate description of the population of interest.

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• Descriptive Research Design | Definition, Methods & Examples

Descriptive Research Design | Definition, Methods & Examples

Published on 5 May 2022 by Shona McCombes . Revised on 10 October 2022.

Descriptive research aims to accurately and systematically describe a population, situation or phenomenon. It can answer what , where , when , and how   questions , but not why questions.

A descriptive research design can use a wide variety of research methods  to investigate one or more variables . Unlike in experimental research , the researcher does not control or manipulate any of the variables, but only observes and measures them.

Table of contents

When to use a descriptive research design, descriptive research methods.

Descriptive research is an appropriate choice when the research aim is to identify characteristics, frequencies, trends, and categories.

It is useful when not much is known yet about the topic or problem. Before you can research why something happens, you need to understand how, when, and where it happens.

• How has the London housing market changed over the past 20 years?
• Do customers of company X prefer product Y or product Z?
• What are the main genetic, behavioural, and morphological differences between European wildcats and domestic cats?
• What are the most popular online news sources among under-18s?
• How prevalent is disease A in population B?

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Descriptive research is usually defined as a type of quantitative research , though qualitative research can also be used for descriptive purposes. The research design should be carefully developed to ensure that the results are valid and reliable .

Survey research allows you to gather large volumes of data that can be analysed for frequencies, averages, and patterns. Common uses of surveys include:

• Describing the demographics of a country or region
• Gauging public opinion on political and social topics
• Evaluating satisfaction with a company’s products or an organisation’s services

Observations

Observations allow you to gather data on behaviours and phenomena without having to rely on the honesty and accuracy of respondents. This method is often used by psychological, social, and market researchers to understand how people act in real-life situations.

Observation of physical entities and phenomena is also an important part of research in the natural sciences. Before you can develop testable hypotheses , models, or theories, it’s necessary to observe and systematically describe the subject under investigation.

Case studies

A case study can be used to describe the characteristics of a specific subject (such as a person, group, event, or organisation). Instead of gathering a large volume of data to identify patterns across time or location, case studies gather detailed data to identify the characteristics of a narrowly defined subject.

Rather than aiming to describe generalisable facts, case studies often focus on unusual or interesting cases that challenge assumptions, add complexity, or reveal something new about a research problem .

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Descriptive Epidemiology

Introduction

The image above illustrates the ten essential functions of public health. Epidemiology plays a particularly important role for three of the functions: monitoring, investigating, and evaluating. The 10 Essential Public Health Services describe the public health activities that all communities should undertake. Public health systems should

• Monitor health status to identify and solve community health problems.
• Diagnose and investigate health problems and health hazards in the community.
• Inform, educate, and empower people about health issues.
• Mobilize community partnerships and action to identify and solve health problems.
• Develop policies and plans that support individual and community health efforts.
• Enforce laws and regulations that protect health and ensure safety.
• Link people to needed personal health services and assure the provision of health care when otherwise unavailable.
• Assure competent public and personal health care workforce.
• Evaluate effectiveness, accessibility, and quality of personal and population-based health services.
• Research for new insights and innovative solutions to health problems.

Disease surveillance systems and health data sources provide the raw information necessary to monitor trends in health and disease. Descriptive epidemiology provides a way of organizing and analyzing these data in order to understand variations in disease frequency geographically and over time, and how disease (or health) varies among people based on a host of personal characteristics (person, place, and time). This makes it possible to identify trends in health and disease and also provides a means of planning resources for populations. In addition, descriptive epidemiology is important for generating hypotheses (possible explanations) about the determinants of health and disease. By generating hypotheses, descriptive epidemiology also provides the starting point for analytic epidemiology, which formally tests associations between potential determinants and health or disease outcomes. Specific tasks of descriptive epidemiology are the following:

• Monitoring and reporting on the health status and health related behaviors in populations
• Identifying emerging health problems
• Alerting us to potential threats from bioterrorism
• Establishing public health priorities for a population
• Evaluating the effectiveness of intervention programs and
• Exploring potential associations between "risk factors" and health outcomes in order to generate hypotheses about the determinants of disease.

Learning Objectives

After successfully completing this unit, the student will be able to:

• Explain the role of descriptive studies for identifying problems and establishing hypotheses.
• Explain how the characteristics of person, place, & time are used to formulate hypotheses in acute disease outbreaks and in studies of chronic diseases.
• Identify case reports and case series and explain their uses and their limitations.
• Describe the design features of an ecologic study and discuss their strengths and weaknesses.
• Explain the concept of ecologic fallacy both in general and in the context of a study. Identify the strengths and limitations of an ecologic study.
• Describe the design features of a cross-sectional study and describe their uses, strengths, and limitations.

Hypothesis Formulation – Characteristics of Person, Place, and Time

Descriptive epidemiology searches for patterns by examining characteristics of person, place, & time . These characteristics are carefully considered when a disease outbreak occurs, because they provide important clues regarding the source of the outbreak.

Hypotheses about the determinants of disease arise from considering the characteristics of person, place, and time and looking for differences, similarities, and correlations. Consider the following examples:

• Differences : if the frequency of disease differs in two circumstances, it may be caused by a factor that differs between the two circumstances. For example , there was a substantial difference in the incidence of stomach cancer in Japan & the US. There are also substantial differences in genetics and diet. Perhaps these factors are related to stomach cancer.
• Similarities : if a high frequency of disease is found in several different circumstances & one can identify a common factor, then the common factor may be responsible. Example : AIDS in IV drug users, recipients of transfusions, & hemophiliacs suggests the possibility that HIV can be transmitted via blood or blood products.
• Correlations: If the frequency of disease varies in relation to some factor, then that factor may be a cause of the disease. Example: differences in coronary heart disease vary with cigarettes consumption.

Descriptive epidemiology provides a way of organizing and analyzing data on health and disease in order to understand variations in disease frequency geographically and over time and how disease varies among people based on a host of personal characteristics (person, place, and time). Epidemiology had its origins in the desire to understand the determinants of acute infectious diseases, but its methods and applicability have expanded to include chronic diseases as well.

Descriptive Epidemiology for Infectious Disease Outbreaks

Outbreaks generally come to the attention of state or local health departments in one of two ways:

• Astute individuals (citizens, physicians, nurses, laboratory workers) will sometimes notice cases of disease occurring close together with respect to time and/or location or they will notice several individuals with unusual features of disease and report them to health authorities.
• Public health surveillance systems collect data on 'reportable diseases'. Requirements for reporting infectious diseases in Massachusetts are described in 105 CMR 300.000 (Link to Reportable Diseases, Surveillance, and Isolation and Quarantine Requirements).

Clues About the Source of an Outbreak of Infectious Disease

When an outbreak occurs, one of the first things that should be considered is what is known about that particular disease. How can the disease be transmitted? In what settings is it commonly found? What is the incubation period? There are many good summaries available online. For example, Massachusetts DPH provides this link to a PDF fact sheet for Hepatitis A, which provide a very succinct summary. With this background information in mind, the initial task is to begin to characterize the cases in terms of personal characteristics, location, and time (when did they become ill and where might they have been exposed given the incubation period for that disease. In sense, we are looking for the common element that explains why all of these people became ill. What do they have in common?

"Person"

Information about the cases is typically recorded in a "line listing," a grid on which information for each case is summarized with a separate column for each variable. Demographic information is always relevant, e.g., age, sex, and address, because they are often the characteristics most strongly related to exposure and to the risk of disease. In the beginning of an investigation a small number of cases will be interviewed to look for some common link. These are referred to as "hypothesis-generating interviews." Depending on the means by which the disease is generally transmitted, the investigator might also want to know about other personal characteristics, such as travel, occupation, leisure activities, use of medications, tobacco, drugs. What did these victims have in common? Where did they do their grocery shopping? What restaurants had they gone to in the past month or so? Had they traveled? Had they been exposed to other people who had been ill? Other characteristics will be more specific to the disease under investigation and the setting of the outbreak. For example, if you were investigating an outbreak of hepatitis B, you should consider the usual high-risk exposures for that infection, such as intravenous drug use, sexual contacts, and health care employment. Of course, with an outbreak of foodborne illness (such as hepatitis A), it would be important to ask many questions about possible food exposures. Where do you generally eat your meals? Do you ever eat at restaurants or obtain foods from sources outside the home? Hypothesis generating interviews may quickly reveal some commonalities that provide clues about the possible sources.

"Place"

Assessment of an outbreak by place provides information on the geographic extent of a problem and may also show clusters or patterns that provide clues to the identity and origins of the problem. A simple and useful technique for looking at geographic patterns is to plot, on a "spot map" of the area, where the affected people live, work, or may have been exposed. A spot map of cases may show clusters or patterns that reflect water supplies, wind currents, or proximity to a restaurant or grocery store.

In 1854 there was an epidemic of cholera in the Broad Street area of London. John Snow determined the residence or place of business of the victims and plotted them on a street map (the stacked black disks on the map below). He noted that the cases were clustered around the Broad Street community pump. It was also noteworthy that there were large numbers of workers in a local workhouse and a brewery, but none of these workers were affected - the workhouse and brewery each had their own well.

On a spot map within a hospital, nursing home, or other such facility, clustering usually indicates either a focal source or person-to-person spread, while the scattering of cases throughout a facility is more consistent with a common source such as a dining hall. In studying an outbreak of surgical wound infections in a hospital, we might plot cases by operating room, recovery room, and ward room to look for clustering.

• Link to more on the outbreak of cholera in the Broad Street area of London
• Link to an enlarged version of Snow's spot map

"Time"

When investigating the source of an outbreak of infectious disease, Investigators record the date of onset of disease for each of the victims and then plot the onset of new cases over time to create what is referred to as an epidemic curve . The epidemic curve for an outbreak of hepatitis A is shown in the illustration below. Begriming in late April, the number of new cases rises to a peak of twelve new cases reported on May 12, and then the number of new cases gradually drops back to zero by May 21. Knowing that the incubation period for hepatitis A averages about 28-30 days, the investigators concluded that this was a point source epidemic because the cluster of new cases all occurred within the span of a single incubation period (see explanation on the next page). This, in conjunction with other information, provided important clues that helped shape their hypotheses about the source of the outbreak.

Video Summary: Person, Place, and Time (10:42)

Epidemic Curves

An "epidemic curve" shows the frequency of new cases over time based on the date of onset of disease. The shape of the curve in relation to the incubation period for a particular disease can give clues about the source. There are three basic types of epidemic curve.

Point source outbreaks (epidemics) involve a common source, such as contaminated food or an infected food handler, and all the exposures tend to occur in a relatively brief period. Consequently, point source outbreaks tend to have epidemic curves with a rapid increase in cases followed by a somewhat slower decline, and all of the cases tend to fall within one incubation period.  The graph above from a hepatitis outbreak is an example of a point source epidemic. The incubation period for hepatitis ranges from 15-50 days, with an average of about 28-30 days. In a point source epidemic of hepatitis A you would expect the rise and fall of new cases to occur within about a 30 day span of time, which is what is seen in the graph below.

Continuous common source epidemics may also rise to a peak and then fall, but the cases do not all occur within the span of a single incubation period. This implies that there is an ongoing source of contamination. The down slope of the curve may be very sharp if the common source is removed or gradual if the outbreak is allowed to exhaust itself. The epidemic curve below is from the cholera outbreak in the Broad Street area of London in 1854 that was investigated by Dr. John Snow. Cholera has an incubation period of 1-3 days, and even though residents began to flee when the outbreak erupted, you can see that this outbreak lasted for more than a single incubation period. This suggests an ongoing source of infection, in this case the Broad Street pump.

Propagated (or progressive source) epidemic . The epidemic curve shown below is from an outbreak of measles that began with a single index case who infected a number of other individuals. (The incubation period for measles averages 10 days with a range of 7-18 days.) One or more of the people infected in the initial wave infected a group of people who become the second wave of infection. So here transmission is person-to-person, rather than from a common source. Propagated epidemic curves usually have a series of successively larger peaks, which are one incubation period apart. The successive waves tend to involve more and more people, until the pool of susceptible people is exhausted or control measures are implemented. This is an ideal example, however; in reality, most of these epidemics do not produce the classic pattern.

For some outbreaks the descriptive information is all that is needed to figure out the source, and control measures can be undertaken rapidly. In other cases, this descriptive information (person, place, and time) helps generate hypotheses about the source, but it isn't obvious what the source is. When this occurs, it is necessary to test the hypotheses by conducting an analytical study, i.e. either a case-control study or a cohort study. This means collecting data and analyzing it in order to identify the source. After the hepatitis outbreak in Marshfield, DPH conducted a case-control study. After an outbreak of Giardia in Milton, MA, a retrospective cohort study was conducted. However, it is important to recognize that you can't test a hypothesis unless you have one to test. So, the descriptive studies that generate hypotheses are essential.

Use the graph below to answer this "Quiz Me."

(Optional) - Two Methods for Creating an Epidemic Curve in Excel

Method 1 - video

Method 2 - video

(Optional) - Steps in the Investigation of a Disease Outbreak

Most outbreak investigations involve the following steps:

• Preparation for the investigation
• Verifying the diagnosis and establishing the existence of an outbreak
• Establishing a case definition and finding cases
• Conducting descriptive epidemiology to determine the personal characteristics of the cases, changes in disease frequency over time, and differences in disease frequency based on location.
• Developing hypotheses about the cause or source
• Evaluating the hypotheses & refining the hypotheses and conducting additional studies if necessary
• Implementing control and prevention measures
• Communicating the findings

Some of these steps may be conducted simultaneously, and the order may vary depending on the circumstances. For example, if new cases are continuing to occur and there are steps that can be taken to control the outbreak and prevent more cases, then certainly control and prevention measures would take top priority.

Optional Additional Resources

General Information on Outbreak Investigations

For an overview of outbreak investigations for foodborne illness see the CDC web page linked here. Other good general sources of information on how to conduct outbreak investigations can be found in the University of North Carolina (UNC) online Focus on Field Epidemiology series. The following links to online articles may be of interest:

Issue #1: Overview of Outbreak Investigations

Issue #2: Anatomy and Physiology of an Outbreak Team

Issue #3: Embarking on an Outbreak Investigation

Issue #4: Case Finding and Line Listing: A Guide for Investigators

Issue #5: Epidemic Curves Ahead with a Focus Flash on Creating an Epidemic Curve in Excel

Issue #6:Hypothesis Generation During Outbreaks

Issue #1: Hypothesis-Generating Interviews

Issue #2: Developing a Questionnaire

Issue #3: Interviewing Techniques

Another good general resource is "Hepatitis in Sparta." This is an online interactive teaching case that thrusts the student into the role of investigator trying to determine the source for an outbreak of hepatitis cases in the town of Sparta.

Descriptive Epidemiology for Chronic Diseases

The same questions about person, time, and place can be applied to chronic diseases.  Who are the people who have the disease? What are their characteristics? What is their occupation? Where do they live and work? How did disease occurrence vary over time?

Personal Characteristics

Personal characteristics also provide clues about the causes of chronic diseases. Many disease vary in relation to age and gender, but many other characteristics are also important, such as occupation, diet, sexual activity, travel history, and personal behaviors (exercise, smoking, etc.)

Age-specific Rates of Disease

Because so many diseases vary in relation to disease, one frequently sees disease rates categorized this way - so-called "age-specific rates of disease." Mortality rates are very low in the youngest age groups & similar in males and females. In adulthood the mortality rates rise sharply and become higher in males. Although the mortality rate continues to rise into old age, the gender difference begins to narrow. One might describe this as a chronic, progressive disease in which the gender differences raise the question of whether sex hormones play a role, particularly since females begin to catch up after menopause occurs.

Table - Death Rates from Coronary Artery Disease (Age-Specific Rates)

Differences by Race and Ethnicity

In addition to age and gender one might want to examine how disease rates differ with respect to other characteristics, such as race. The table below summarizes. annual mortality rates per 100,000 in whites and blacks in the United States in 1967. Ethnic and racial differences in disease rates sometimes have a genetic basis, e.g., sickle cell anemia in people of African descent or beta thalassemia in people of Mediterranean descent, but in other cases racial differences are due to environmental or socioeconomic factors.

• Link to more on sickle cell anemia
• Link to more on beta thalassemia

Table - Annual Mortality Rates per 100,000 population in the US, 1967

Other Personal Characteristics

Besides age, gender and race/ethnicity, other personal characteristics that might be important to consider are:

• Religious practices, e.g. dietary restrictions or restrictions on drinking alcohol or tobacco use
• Leisure activities, e.g., exercise

Place: Variation by Location

Differences in disease frequency by location provides important clues about the determinants of chronic diseases. Where does the disease tend to occur?

• Does the frequency of disease vary from country to country? Or state to state?
• Does it vary among cities or neighborhoods?
• Does it vary within different parts of a large workplace?

Example 1: Stomach Cancer by Location in the US

These maps show death rates from stomach cancer in females (top) and males (below) in different US counties. The darkness of shading of each county indicates how its stomach cancer rate compares with the national average. The darkest shading indicates rates well above average, and white shading indicates rates below average; the gray shading indicates intermediate levels. Note that rates of stomach cancer tend to be high in counties in the north-central part of the country in both males and females. Investigators speculated that these clusters might correlate with populations of German or Scandinavian descent who have a tradition of eating smoked fish. Could the high rates of stomach cancer be the result of their consumption of smoked fish or other traditional methods of food preservation?

Source: Atlas of Cancer Mortality for U.S. Counties: 1950-1969, TJ Mason et al, PHS, NIH, 1975

Example 2: Differences in Rates of Stomach Cancer in Japan and US

Rates of stomach cancer also vary among countries. Japanese have a higher rate of stomach cancer than Caucasians in California. Is this due to a genetic difference? A dietary difference? The rate among Japanese people diminishes after they move to US, and diminishes even more in their offspring. One possibility is that once the Japanese move here, they begin to shift to an American diet, and this trend is even stronger in their children. Are there important dietary differences? Could consumption of large amounts of smoked fish be a cause of stomach cancer?

Variation in Disease Over Time

• Has the frequency of disease changed over several decades?
• Does frequency of disease vary in a cyclic way that relates to the seasons?
• Has it changed over the course of days?

Changes in disease rate over time can also provide clues for chronic diseases.

Example 1: Annual Mortality from Pulmonary Tuberculosis in England and Wales

Tuberculosis (TB) is one of the great killers of all times. The graph on the right shows the mortality rate from TB from 1855-1955 in England and Wales. The remarkable downward trend began well before the development of antibiotics. The steady improvement was probably a direct result of "the sanitary idea" which resulted in concerted efforts to improve working and living conditions, nutrition, ventilation, and waste management. Also, note the increases in TB mortality that occurred during World War I and World War II. This suggests that nutritional deficiencies, translocation, crowding, and other adverse circumstances associated with war are contributing factors to the causation of TB.

Example 2: Toxic Shock and Rely Tampons

In January 1980 there were several reports of toxic shock syndrome due to infection with Staphylococcus aureus bacteria, and the descriptive epidemiology indicated that the problem was occurring primarily in menstruating women. A CDC task force investigated and eventually traced the outbreak to the introduction of Rely tampons, a super absorbent product marketed by Proctor and Gamble. The monthly cases of toxic shock syndrome in 1980-1981 are shown in the graph below [from A. Reingold et al., Toxic shock syndrome surveillance in the United States, 1980-1981. Ann. Intern. Med 96:875, 1982]. The graph shows that prior to 1978 there were just occasional cases of toxic shock syndrome in the United States. After Rely tampons were introduced in 1978, there was a steady increase in toxic shock cases which peaked at about 125 per month in 1980. Shortly after that, Rely tampons were taken off the market, and the incidence declined sharply.

There were actual two pieces of evidence related to time variations that supported Rely tampons as the cause. First, descriptive epidemiology suggested a link to menstruation, leading doctors to take bacterial cultures from the vagina. This provided a key clue suggesting a link to certain brands of tampons. In addition, the frequency of toxic shock syndrome clearly correlated with the introduction and subsequent removal of Rely tampons from the market.

• Link to more on toxic shock syndrome

Other Factors That Can Produce Changes in Disease Frequency Over Years or Decades

If the frequency of a disease or mortality from a disease changes over time, there are several factors which could be responsible:

• Changes in incidence due to environmental or life-style changes.
• Improvements in diagnosis may increase cases reported even though the incidence may not be changing.
• Changes in record keeping (accuracy) can create what appear to be changes in disease rates.
• Improved treatment may decrease mortality rates
• Changes in the age distribution of a population can produce changes in the overall rate of disease, even though age-specific rates are not changing.

Two Fundamental Types of Study Questions

Specifying the research questions is essential to selection of an appropriate study population, and infinite questions exist. Nevertheless, Keyes and Galea stress two fundamental types of research questions which have important implications selecting an appropriate study design.  

1. Questions whose goal is accurate estimation of population parameters

• What proportion of high school students smoke? Or use drugs?
• What is the frequency of death from coronary artery disease among black and white males and females, and how have those rate changed over the past 20 years?

Questions like these require samples that are representative of the population being studied, that is comparable to the population in their characteristics (and they require adequate sample size in order to minimize sampling error).

2. Questions whose goal is to identify and quantify exposures that have causal effects on health outcomes.

• Does use of cell phones cause cancer?
• Do "brain exercises prevent cognitive decline with advancing age?
• Do childhood vaccinations cause autism?

Questions like these also require an adequate sample size to precisely assess the magnitude of an effect, but they differ from questions aimed at parameter estimation in that that they require making comparisons, e.g., comparing risk between exposed and non-exposed persons. When trying to answer questions like these regarding etiology, it is not so important that the samples be representative of the overall population, but for accurate assessment of the effect the groups being compared must be comparable to each other with respect to other factors that affect the outcome.

Fundamental Study Designs for Both Representative and Purposive Studies

Keyes and Galea identify three fundamental approaches to study design that can be applied regardless of whether one's goal is to take representative samples to estimate population parameters or to take purposive samples in order to determine whether a given exposure or factor causes one or more health outcomes.

• One can study the sample at a particular point in time.
• One can follow the sample forward in time to compare the frequency of health indicators among two or more exposure groups.
• One can examine the retrospective exposure history of a sample.

The second option will only be utilized in analytical studies, which will be covered in a separate module, but the first two options will be seen in the next section describing several types of descritive studies.

Categories of Descriptive Epidemiology

Case reports.

A case report is a detailed description of disease occurrence in a single person. Unusual features of the case may suggest a new hypothesis about the causes or mechanisms of disease.

Example: Acquired Immunodeficiency in an Infant; Possible Transmission by Means of Blood Products

Link to article by Ammann AJ et al: Acquired immunodeficiency in an infant: possible transmission by means of blood products. The Lancet 1:956-958, 1983.

In April 1983 it had not yet been shown that AIDS could be transmitted by blood or blood products. An infant born with Rh incompatibility; required blood products from 18 donors over 8 weeks and subsequently developed unusual recurrent infections with opportunistic agents such as Candida. The infant's T cell count was low, suggesting AIDS. There was no family history of immunodeficiency, but one of the blood donors was found to have died of AIDS. This led the investigators to hypothesize that AIDS could be transmitted by blood transfusion.

Example: Survival after Treatment of Rabies with Induction of Coma.

Link to article by Willoughby R, Jr., et al: N Engl J Med 2005;352:2508-14.

Rabies is almost uniformly fatal once it develops. As of 2005 there had been only four survivors, each of whom received rabies prophylaxis after the bite, but before symptoms developed. Willoughby et al. reported on a 15 year-old girl who rescued and released a bat that had struck an interior window. The bat bit her left index finger. The wound was washed with peroxide, but medical attention was not sought, and no rabies prophylaxis was administered. One month later she began to experience progressive neurological symptoms that were eventually diagnosed as rabies. The mainstay of her treatment was medically induced coma. Eight days later blood tests demonstrated that she had begun to develop an immune response to the rabies virus. Eventually the coma was reversed, and the patient gradually regained consciousness. She had severe neurological deficits, but gradually improved. She was discharged to her home after 76 days. Five months after her initial hospitalization, she was alert and communicative, but had persistent slurred speech and an unsteady gait.

The report by Willoughby et al. is an example of a case report – a detailed description of a single subject. The report is important because it demonstrates that it is possible for victims of rabies to survive, even without post-exposure prophylaxis. However, we have no idea how effective this treatment might be.

Case Series

A case series is a report on the characteristics of a group of subjects who all have a particular disease or condition. Common features among the group may suggest hypotheses about disease causation. Note that the "series" may be small (as in the example below) or it may be large (hundreds or thousands of "cases"). However, the chief limitation is that there is no comparison group. Consequently, common features may suggest hypotheses, but these need to be tested with some sort of analytical study before an association can be accepted as valid.

Example: Pneumocystis carinii pneumonia and mucosal candidiasis in previously healthy homosexual men: evidence of a new acquired cellular immunodeficiency.

Link to article by Gottlieb MS, et al: N Engl J Med 1981;305:1425-1431.

In 1980 –1981 four previously healthy young men were diagnosed with Pneumocystis carinii pneumonia, an unusual "opportunistic" infection that had only been seen in immune compromised people with hereditary disorders or in people with immune compromise due to chemotherapy. The medical histories didn't suggest any preexisting immunodeficiency, but all had decreased immune responses and low T cell counts. These unusual infections suggested the possibility of a previously unknown disease.  It was noted that all four men were sexually active homosexuals, and in the case series which was published in the New England Journal of Medicine the authors speculated that the immune dysfunction was due to a sexually transmitted infectious agent.

This was an extraordinarily important case series (a detailed description of characteristics of a series of people who all have the same disease) that suggested that this new syndrome was associated with sexual activity in male homosexuals. Alerting the medical establishment and proposing a hypothesis was an important milestone in the AIDS epidemic, however, the association could not be securely established based on this small case series. It was not known how many other individuals might be suffering from this new syndrome. It was also not known what the prevalence of homosexuality might be in others with this syndrome or how this might compare to the overall prevalence of homosexuality in the population that gave rise to the cases. As a result, this case series could not securely establish a valid association. Nevertheless, it laid the ground work for subsequent case-control studies and cohort studies (analytic studies) that did establish the risk factors for this disease.

Example: Oral Contraceptives and Hepatocellular Carcinoma?

There had been a number of case reports of liver cancers in young women taking oral contraceptives. A study was undertaken by contacting all of the cancer registries collaborating with the American College of Surgeons. The investigators wanted to collect information on as many of these rare liver tumors as possible across the US.  

Table - Oral Contraceptive Use Among Women Who Developed Liver Cancer

What conclusions can you draw from these data regarding a possible increased risk of liver cancer in woman taking oral contraceptives? Think about it before you look at the answer.

  Answer

Video Summary: Case Reports and Case Series (6:59)

Cross-Sectional Surveys

Cross-sectional surveys assess the prevalence of disease and the prevalence of risk factors at the same point in time and provide a "snapshot" of diseases and risk factors simultaneously in a defined population. For example, US government agencies periodically send out large surveys to random samples of the US population, asking about health status and risk factors and behaviors at that point in time. The Health Interview Survey (HIS) and the National Health and Nutrition Examination Survey (NHANES) are good examples.

The health questionnaires you are asked to fill out when you go to a new physician or being processed for a new job, or prior to entry into military service are similar to cross-sectional surveys in that they ask about the health problems that you have (heart disease? diabetes? asthma?) and your current behaviors and risk factors (e.g., How old are you? Do you smoke? What is your occupation?).

Cross-sectional surveys ask people their current status with respect to both exposures and diseases. This results in two main disadvantages.

• The temporal relationship between exposure and disease outcomes can be unclear, i.e., which came first.
• Cross-sectional studies tend to identify prevalent cases of long duration , since people who die quickly or recover quickly or who are no longer employed in a particular occupation are less likely to be identified.

Consider the following example in which a survey was conducted among white male farm workers. The survey asked many questions, but among them were the questions: "Have you been told you have coronary heart disease (CHD)?" And "How would you classify your level of physical activity?" The table below summarizes the findings. 

Table - Current Coronary Heart Disease Among Male Farm Workers

Note that the investigators did not follow these subjects over a period of time, so they did not assess the "incidence" of heart disease. Instead, they asked the subjects questions designed to determine the prevalence of heart disease, i.e., the proportion of the study population that had heart disease at this particular point in time. When they divided the sample into physically active and inactive farmers and computed the prevalence of heart disease in each of these, they found that CHD was much more prevalent among the inactive farmers. However, this was a cross-sectional study that related the prevalence of disease to the prevalence of activity at a point in time. They did not follow subjects over time to track the development of heart disease (i.e., the incidence). Consequently, the temporal relationship between the risk factor of interest (physical inactivity) and the outcome (CHD) is unclear. Had the farmers been physically active prior to developing CHD? Or, did they begin to limit their physical activity after they developed CHD? Consequently physical inactivity could have been either a cause of heart disease, or it could have been a consequence of CHD.

Large cross-sectional surveys are important for monitoring health status and health care needs of the population over time, and they are sometimes useful for suggesting possible associations between risk factors and diseases. However, the temporal relationship between the risk factor and disease is frequently unclear. Under these circumstances, they can generate hypotheses, but these associations need to be tested by appropriate analytical studies.

However, note that under some circumstances, the temporal relationship is clear on a cross-sectional survey. For example, if one conducted a survey of salaries of male and female professors to see if gender was associated with salary inequities, we could regard this as an analytical study, because it is clear that gender was established long before salary level. In this situation the temporal relationship between the "exposure" of interest (gender) and outcome (salary paid) is clear; we know that gender was established before the salary was negotiated. So, in a sense cross-sectional studies (and ecological studies can be thought of as an intermediate category between descriptive and analytic studies.

Video Summary on Cross-Sectional Surveys (8:25)

Ecological Studies (Correlational Studies)

These studies are distinguished by the fact that the unit of observation is not a person; rather it is an entire population or group. In essence, these studies examine the correlation between the average exposure in various populations with the overall frequency of disease within the populations.

In the study below investigators used commerce data to compute the overall consumption of meat by various nations. They then calculated the average (per capita) meat consumption per person by dividing total national meat consumption by the number of people in a given country. There is a clear linear trend; countries with the lowest meat consumption have the lowest rates of colon cancer, and the colon cancer rate among these countries progressively increases as meat consumption increases.

Note that in reality, people's meat consumption probably varied widely within nations, and the exposure that was calculated was an average that assumes that everyone ate the average amount of meat. This average exposure was then correlated with the overall disease frequency in each country. The example here suggests that the frequency of colon cancer increases as meat consumption increases. The characteristic of ecological studies that is most striking is that there is no information about individual people. If the data were summarized in a spread sheet, you would not see individual level data; you would see records with data on average exposure in multiple groups .

Morgenstern notes that, "Individual­ level variables are properties of individuals, and ecologic variables are properties of groups. To be more specific, ecologic measures may be classified into three types:

• Aggregate measures are summaries (e.g. means or proportions) of observations derived from individuals in each group (e.g. the proportion of smokers or median family income).
• Environmental measures are physical characteristics of the place in which members of each group live or work (e.g. air-pollution level or hours of sunlight). Note that each environmental measure has an analogue at the individual level, and these individual exposures, or doses, usually vary among members of each group, though they may remain unmeasured.
• Global measures are attributes of groups or places for which there is no distinct analogue at the individual level. Unlike aggregate and environmental measures (e.g. population density, level of social disorganization. or the existence of a specific law).

Morgenstern goes on to note: "Ecologic study designs may be classified on two dimensions: (a) whether the primary group is measured (exploratory vs analytic study); and (b) whether subjects are grouped by place (multiple-group study), by time (time-trend study), or by place and time (mixed study). Despite several practical advantages of ecologic studies, there are many methodologic problems that severely limit causal inference, including ecologic and cross-level bias, problems of confounder control, within-group misclassification, lack of adequate data, temporal ambiguity, collinearity, and migration across groups."

For a detailed review of ecologic studies see follow the link to an article by Morgenstern H: Ecologic Studies in Epidemiology: Concepts, Principles, and Methods. Annual Review of Public Health 1995;16:61-81.

To see an extraordinary example of an ecologic study, play the video below created by Hans Rosling. This is a magnificent example that examines the correlation between income and life expectancy in the countries of the world over time. It is also a terrific example of a creative, engaging, and powerful way to display a vast quantity of data.

Advantages of Ecological Studies:

• The data required is frequently readily available. Commerce data can be used to estimate a population's total consumption of products (possible risk factors) such as meat, tobacco, fish, etc. So, these studies are quick & inexpensive.
• The " correlation coefficient " or an "r" value provides a measure of how closely the observed data points conform to a straight line. Some authors say that the "r" value is a measure of the association between the risk factor and the disease, but this is incorrect. The slope of the line would be a measure of the strength of association.  (See the course spreadsheet "Epi_Tools. XLSX" for a worksheet that calculates correlation coefficients). The value of a correlation coefficient is from +1 (a perfect positive correlation) and –1 (a perfect negative correlation). See the tabbed activity below for examples.

Limitations of Ecological Studies: It is important to bear in mind that the exposure in correlational studies is the average exposure for an entire population or group. This results in major limitations:

• Since you don't have any information about the risk factor status or the outcome status of individual people, you can't directly link the risk factor to the disease, i.e., it is not clear that the people who ate the most meat were the ones who got colon cancer. This is sometimes referred to as "ecological bias" or the "ecological fallacy."
• Another limitation is that there is no effective way of taking into account, or adjusting for, other factors that influence the outcome (confounding factors). As a result, an apparent correlation, or the lack of a correlation could be misleading. For example, one might find a strong correlation between the average number of hours of TV viewing & the rate of coronary artery disease among different countries. However, this doesn't necessarily mean that TV per se is a risk factor for CAD. There may be a number of other differences between the populations that are associated with higher rates of TV viewing: e.g., greater industrialization, less exercise, greater availability of processed foods and saturated fat, and so forth. And conversely, the lack of a correlation doesn't necessarily imply that there is no association.
• Since the exposure levels represent average exposure in a large number of people, correlational studies can mask more complicated relationships, as illustrated below.

When a correlational study compared per capita alcohol consumption to death rates from coronary heart disease in different countries, it appeared that there was a fairly striking negative correlation.

However, a meta-analysis of prospective cohort studies which determined mortality rates in subjects for whom they had estimates of individual alcohol consumption, showed that there was actually a "J" shaped relationship. The people who drank the most actually had the highest mortality rates; moderate drinkers had the lowest mortality. This relationship was masked in the correlational study, because of the small percentage of people who have more than three drinks per day.

Adapted from: Di Castelnuovo A, Costanzo S, et al.: Alcohol Dosing and Total Mortality in Men and Women:  

An Updated Meta-analysis of 34 Prospective Studies. Arch Intern Med. 2006;166(22):2437-2445.

  Video Summary for Ecological Studies (7:48)

Summary & Self-Check

Descriptive studies are useful for:

Other Resources

• University of North Carolina (UNC) -Torok M and Anderson M: "Focus on Field Epidemiology: Volume 5; Issue 5:Introduction to Public Health Surveillance."
• University of North Carolina (UNC) - Anderson M: "Focus on Field Epidemiology: Volume 5; Issue 6: Public Health Surveillance Systems".
• Trifonov V, Khiabanian H, Rabadan R: Geographic Dependence, Surveillance, and Origins of the 2009 Influenza A (H1N1) Virus. Perspective article in: N. Engl. J. Med. 2009;361(2):115-119.  
• Scallan E, Hoekstra RM, Angulo FJ, et al. Foodborne Illness Acquired in the United States - Major Pathogens. Emerging Infectious Diseases 2011;17(1):7-15. [Volume 17, Number 1, January 2011, pages 7-15]
• Marsden-Haug N, Foster VB, Gould PL, Elbert E, Wang H, Pavlin JA. Code-based syndromic surveillance for influenzalike illness by International Classification of Diseases, ninth revision. Emerg Infect Dis, Feb. 2007;13(2):207-216.

Module 2: Research and Ethics in Abnormal Psychology

Descriptive research and case studies, learning objectives.

• Explain the importance and uses of descriptive research, especially case studies, in studying abnormal behavior

Types of Research Methods

There are many research methods available to psychologists in their efforts to understand, describe, and explain behavior and the cognitive and biological processes that underlie it. Some methods rely on observational techniques. Other approaches involve interactions between the researcher and the individuals who are being studied—ranging from a series of simple questions; to extensive, in-depth interviews; to well-controlled experiments.

The three main categories of psychological research are descriptive, correlational, and experimental research. Research studies that do not test specific relationships between variables are called descriptive, or qualitative, studies . These studies are used to describe general or specific behaviors and attributes that are observed and measured. In the early stages of research, it might be difficult to form a hypothesis, especially when there is not any existing literature in the area. In these situations designing an experiment would be premature, as the question of interest is not yet clearly defined as a hypothesis. Often a researcher will begin with a non-experimental approach, such as a descriptive study, to gather more information about the topic before designing an experiment or correlational study to address a specific hypothesis. Descriptive research is distinct from correlational research , in which psychologists formally test whether a relationship exists between two or more variables. Experimental research goes a step further beyond descriptive and correlational research and randomly assigns people to different conditions, using hypothesis testing to make inferences about how these conditions affect behavior. It aims to determine if one variable directly impacts and causes another. Correlational and experimental research both typically use hypothesis testing, whereas descriptive research does not.

Each of these research methods has unique strengths and weaknesses, and each method may only be appropriate for certain types of research questions. For example, studies that rely primarily on observation produce incredible amounts of information, but the ability to apply this information to the larger population is somewhat limited because of small sample sizes. Survey research, on the other hand, allows researchers to easily collect data from relatively large samples. While surveys allow results to be generalized to the larger population more easily, the information that can be collected on any given survey is somewhat limited and subject to problems associated with any type of self-reported data. Some researchers conduct archival research by using existing records. While existing records can be a fairly inexpensive way to collect data that can provide insight into a number of research questions, researchers using this approach have no control on how or what kind of data was collected.

Correlational research can find a relationship between two variables, but the only way a researcher can claim that the relationship between the variables is cause and effect is to perform an experiment. In experimental research, which will be discussed later, there is a tremendous amount of control over variables of interest. While performing an experiment is a powerful approach, experiments are often conducted in very artificial settings, which calls into question the validity of experimental findings with regard to how they would apply in real-world settings. In addition, many of the questions that psychologists would like to answer cannot be pursued through experimental research because of ethical concerns.

The three main types of descriptive studies are case studies, naturalistic observation, and surveys.

Clinical or Case Studies

Psychologists can use a detailed description of one person or a small group based on careful observation.  Case studies  are intensive studies of individuals and have commonly been seen as a fruitful way to come up with hypotheses and generate theories. Case studies add descriptive richness. Case studies are also useful for formulating concepts, which are an important aspect of theory construction. Through fine-grained knowledge and description, case studies can fully specify the causal mechanisms in a way that may be harder in a large study.

Sigmund Freud   developed  many theories from case studies (Anna O., Little Hans, Wolf Man, Dora, etc.). F or example, he conducted a case study of a man, nicknamed “Rat Man,”  in which he claimed that this patient had been cured by psychoanalysis.  T he nickname derives from the fact that among the patient’s many compulsions, he had an obsession with nightmarish fantasies about rats. 

Today, more commonly, case studies reflect an up-close, in-depth, and detailed examination of an individual’s course of treatment. Case studies typically include a complete history of the subject’s background and response to treatment. From the particular client’s experience in therapy, the therapist’s goal is to provide information that may help other therapists who treat similar clients.

Case studies are generally a single-case design, but can also be a multiple-case design, where replication instead of sampling is the criterion for inclusion. Like other research methodologies within psychology, the case study must produce valid and reliable results in order to be useful for the development of future research. Distinct advantages and disadvantages are associated with the case study in psychology.

A commonly described limit of case studies is that they do not lend themselves to generalizability . The other issue is that the case study is subject to the bias of the researcher in terms of how the case is written, and that cases are chosen because they are consistent with the researcher’s preconceived notions, resulting in biased research. Another common problem in case study research is that of reconciling conflicting interpretations of the same case history.

Despite these limitations, there are advantages to using case studies. One major advantage of the case study in psychology is the potential for the development of novel hypotheses of the  cause of abnormal behavior   for later testing. Second, the case study can provide detailed descriptions of specific and rare cases and help us study unusual conditions that occur too infrequently to study with large sample sizes. The major disadvantage is that case studies cannot be used to determine causation, as is the case in experimental research, where the factors or variables hypothesized to play a causal role are manipulated or controlled by the researcher. 

Single-Case Experimental Designs

The lack of control available in the traditional case study research strategy led researchers to develop more sophisticated methods, such as single-subject research, which provides the statistical framework for making inferences from quantitative case-study data.

Figure 1 . Antipsychotics are the treatment of choice in managing schizophrenia and other psychotic disorders. Several major trials have been conducted examining the clinical difference between typical antipsychotics and atypical antipsychotics and how the selection may affect the quality of life.

The single-case experimental design  (sometimes called  single-participant research designs ), is particularly useful for studies of treatment effectiveness.  In  single-case experimental designs ,  the same  research participant  serves as the subject in both the experimental and control conditions.  One of the most common forms of the single-case experimental design is the A-B-A-B design, or  reversal design ,  reflecting the alternation between conditions, or phases A and B. The  AB design is a two-part or phase design composed of a baseline (“A” phase) with no changes, and a treatment or intervention (“B”) phase.  If there is a change, then the treatment may be said to have had an effect. However, it is subject to many possible competing hypotheses, making strong conclusions difficult. The A-B-A-B design, or reversal design, is a variant on the AB design. It introduces ways to control for the competing hypotheses and allows for stronger conclusions. T he reversal design (ABAB) is the most powerful of the single-subject research designs because it shows a strong reversal from baseline (“A”) to treatment (“B”) and back again. In an ABAB design, researchers observe behaviors in the “A” phase, institute treatment in the “B” phase, and then repeat the process. If the variable returns to baseline measure without treatment and then resumes its effects when reapplied, the researcher can have greater confidence in the efficacy of that treatment. However, many interventions cannot be reversed for ethical reasons (e.g., involving self-injurious behavior like smoking).  It may be unethical to end an experiment on a baseline measure if the treatment is self-sustaining and highly beneficial and/or related to health. Control condition participants may also deserve the benefits of research once all data has been collected. It is a researcher’s ethical duty to maximize benefits and to ensure that all participants have access to those benefits when possible.

Figure 2. The investigator looks for evidence that the change in the observed behavior occurred coincident with treatment. If the problem behavior declines whenever treatment is introduced (during the first and second treatment phases) but returns (is “reversed”) to baseline levels during the reversal phase, the experimenter can be reasonably confident the treatment had the intended effect.

Link to Learning: Famous Case Studies

Some well-known case studies that related to abnormal psychology include the following:

• Harlow— Phineas Gage
• Breuer & Freud (1895)— Anna O.
• Cleckley’s case studies: on psychopathy ( The Mask of Sanity ) (1941) and multiple personality disorder ( The Three Faces of Eve ) (1957)
• Freud and  Little Hans
• Freud and the  Rat Man
• John Money and the  John/Joan case
• Genie (feral child)
• Piaget’s studies
• Rosenthal’s book on the  murder of Kitty Genovese
• Washoe (sign language)
• Patient H.M.

Naturalistic Observation

If you want to understand how behavior occurs, one of the best ways to gain information is to simply observe the behavior in its natural context. However, people might change their behavior in unexpected ways if they know they are being observed. How do researchers obtain accurate information when people tend to hide their natural behavior? As an example, imagine that your professor asks everyone in your class to raise their hand if they always wash their hands after using the restroom. Chances are that almost everyone in the classroom will raise their hand, but do you think hand washing after every trip to the restroom is really that universal?

This is very similar to the phenomenon mentioned earlier in this module: many individuals do not feel comfortable answering a question honestly. But if we are committed to finding out the facts about handwashing, we have other options available to us.

Suppose we send a researcher to a school playground to observe how aggressive or socially anxious children interact with peers. Will our observer blend into the playground environment by wearing a white lab coat, sitting with a clipboard, and staring at the swings? We want our researcher to be inconspicuous and unobtrusively positioned—perhaps pretending to be a school monitor while secretly recording the relevant information. This type of observational study is called naturalistic observation : observing behavior in its natural setting. To better understand peer exclusion, Suzanne Fanger collaborated with colleagues at the University of Texas to observe the behavior of preschool children on a playground. How did the observers remain inconspicuous over the duration of the study? They equipped a few of the children with wireless microphones (which the children quickly forgot about) and observed while taking notes from a distance. Also, the children in that particular preschool (a “laboratory preschool”) were accustomed to having observers on the playground (Fanger, Frankel, & Hazen, 2012).

Figure 3 . In naturalistic observation, psychologists take their research into the streets, homes, restaurants, schools, and other settings where behavior can be directly observed.

It is critical that the observer be as unobtrusive and as inconspicuous as possible: when people know they are being watched, they are less likely to behave naturally. For example, psychologists have spent weeks observing the behavior of homeless people on the streets, in train stations, and bus terminals. They try to ensure that their naturalistic observations are unobtrusive, so as to minimize interference with the behavior they observe. Nevertheless, the presence of the observer may distort the behavior that is observed, and this must be taken into consideration (Figure 1).

The greatest benefit of naturalistic observation is the validity, or accuracy, of information collected unobtrusively in a natural setting. Having individuals behave as they normally would in a given situation means that we have a higher degree of ecological validity, or realism, than we might achieve with other research approaches. Therefore, our ability to generalize the findings of the research to real-world situations is enhanced. If done correctly, we need not worry about people modifying their behavior simply because they are being observed. Sometimes, people may assume that reality programs give us a glimpse into authentic human behavior. However, the principle of inconspicuous observation is violated as reality stars are followed by camera crews and are interviewed on camera for personal confessionals. Given that environment, we must doubt how natural and realistic their behaviors are.

The major downside of naturalistic observation is that they are often difficult to set up and control. Although something as simple as observation may seem like it would be a part of all research methods, participant observation is a distinct methodology that involves the researcher embedding themselves into a group in order to study its dynamics. For example, Festinger, Riecken, and Shacter (1956) were very interested in the psychology of a particular cult. However, this cult was very secretive and wouldn’t grant interviews to outside members. So, in order to study these people, Festinger and his colleagues pretended to be cult members, allowing them access to the behavior and psychology of the cult. Despite this example, it should be noted that the people being observed in a participant observation study usually know that the researcher is there to study them. [1]

Another potential problem in observational research is observer bias . Generally, people who act as observers are closely involved in the research project and may unconsciously skew their observations to fit their research goals or expectations. To protect against this type of bias, researchers should have clear criteria established for the types of behaviors recorded and how those behaviors should be classified. In addition, researchers often compare observations of the same event by multiple observers, in order to test inter-rater reliability : a measure of reliability that assesses the consistency of observations by different observers.

Often, psychologists develop surveys as a means of gathering data. Surveys are lists of questions to be answered by research participants, and can be delivered as paper-and-pencil questionnaires, administered electronically, or conducted verbally (Figure 3). Generally, the survey itself can be completed in a short time, and the ease of administering a survey makes it easy to collect data from a large number of people.

Surveys allow researchers to gather data from larger samples than may be afforded by other research methods . A sample is a subset of individuals selected from a population , which is the overall group of individuals that the researchers are interested in. Researchers study the sample and seek to generalize their findings to the population.

Figure 4 . Surveys can be administered in a number of ways, including electronically administered research, like the survey shown here. (credit: Robert Nyman)

There is both strength and weakness in surveys when compared to case studies. By using surveys, we can collect information from a larger sample of people. A larger sample is better able to reflect the actual diversity of the population, thus allowing better generalizability. Therefore, if our sample is sufficiently large and diverse, we can assume that the data we collect from the survey can be generalized to the larger population with more certainty than the information collected through a case study. However, given the greater number of people involved, we are not able to collect the same depth of information on each person that would be collected in a case study.

Another potential weakness of surveys is something we touched on earlier in this module: people do not always give accurate responses. They may lie, misremember, or answer questions in a way that they think makes them look good. For example, people may report drinking less alcohol than is actually the case.

Any number of research questions can be answered through the use of surveys. One real-world example is the research conducted by Jenkins, Ruppel, Kizer, Yehl, and Griffin (2012) about the backlash against the U.S. Arab-American community following the terrorist attacks of September 11, 2001. Jenkins and colleagues wanted to determine to what extent these negative attitudes toward Arab-Americans still existed nearly a decade after the attacks occurred. In one study, 140 research participants filled out a survey with 10 questions, including questions asking directly about the participant’s overt prejudicial attitudes toward people of various ethnicities. The survey also asked indirect questions about how likely the participant would be to interact with a person of a given ethnicity in a variety of settings (such as, “How likely do you think it is that you would introduce yourself to a person of Arab-American descent?”). The results of the research suggested that participants were unwilling to report prejudicial attitudes toward any ethnic group. However, there were significant differences between their pattern of responses to questions about social interaction with Arab-Americans compared to other ethnic groups: they indicated less willingness for social interaction with Arab-Americans compared to the other ethnic groups. This suggested that the participants harbored subtle forms of prejudice against Arab-Americans, despite their assertions that this was not the case (Jenkins et al., 2012).

Think iT Over

Research has shown that parental depressive symptoms are linked to a number of negative child outcomes. A classmate of yours is interested in  the associations between parental depressive symptoms and actual child behaviors in everyday life [2] because this associations remains largely unknown. After reading this section, what do you think is the best way to better understand such associations? Which method might result in the most valid data?

A-B-A-B design:  an experimental design in which the a person is given treatment, or experimental condition (B), to compare against the baseline (A), and this repeats in order to determine effectiveness

clinical or case study:  observational research study focusing on one or a few people

correlational research:  tests whether a relationship exists between two or more variables

descriptive research:  research studies that do not test specific relationships between variables; they are used to describe general or specific behaviors and attributes that are observed and measured

experimental research:  tests a hypothesis to determine cause-and-effect relationships

generalizability:  inferring that the results for a sample apply to the larger population

inter-rater reliability:  measure of agreement among observers on how they record and classify a particular event

naturalistic observation:  observation of behavior in its natural setting

observer bias:  when observations may be skewed to align with observer expectations

population:  overall group of individuals that the researchers are interested in

sample:  subset of individuals selected from the larger population

single-case experimental design:   when the same  research participant  serves as the subject in both the experimental and control conditions

survey:  list of questions to be answered by research participants—given as paper-and-pencil questionnaires, administered electronically, or conducted verbally—allowing researchers to collect data from a large number of people

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• Slatcher, R. B., & Trentacosta, C. J. (2011). A naturalistic observation study of the links between parental depressive symptoms and preschoolers' behaviors in everyday life. Journal of family psychology : JFP : journal of the Division of Family Psychology of the American Psychological Association (Division 43), 25(3), 444–448. https://doi.org/10.1037/a0023728 ↵
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Cause of Disease and Causal Inference

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One of the major focuses of epidemiology is to find the causes of diseases or events. Understanding the causes of diseases is important not only for correct diagnoses and treatments but also for effective prevention and control strategies. Therefore, cause of disease and causal inference—the process by which we identify the cause of disease are essential in both clinical and preventive medicine. In epidemiology, cause and causal inference are used to explore the etiology of or risk factors for diseases as well as their impact on the development of disease at the population level, which can provide unique insights into the etiology of the disease and lead to a population-level understanding of the disease. This chapter describes the epidemiologic concept of cause and the approaches to causal inference.

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Rothman KJ, Greenland S (2005) Causation and causal inference in epidemiology [J]. Am J Public Health 95(Suppl 1):S144–S150

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Ye, L. (2023). Cause of Disease and Causal Inference. In: Wang, C., Liu, F. (eds) Textbook of Clinical Epidemiology. Springer, Singapore. https://doi.org/10.1007/978-981-99-3622-9_9

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