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# Vital Statistics: An Introduction to Health Science Statistics by Stephen McKenzie

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Vital Statistics: An Introduction to Health Science Statistics is a new Australian publication. This textbook draws on real world, health-related and local examples, with a broad appeal to the Health Sciences student. It demonstrates how an understanding of statistics is useful both in the real world, and in statistics exams.

Vital Statistics: An Introduction to Health Science Statistics is a relatively small and easy-to-read book that will painlessly introduce or re-introduce you to the statistical basics before guiding you through more demanding statistical challenges.

Written in recognition of Health Sciences courses which require knowledge of statistical literacy, this book guides the reader to an understanding of why, as well as how and when to use statistics.

It explores:

How data relates to information, and how information relates to knowledge.
How to use statistics to distinguish information from disinformation.
The importance of probability, in statistics and in life.
That inferential statistics allow us to infer from samples to populations, and how useful such inferences can be.
How to appropriately apply and interpret statistical measures of difference and association.
How qualitative and quantitative methods differ, and when it’s appropriate to use each.
The special statistical needs of the health sciences, and some especially health science relevant statistics.
The vital importance of computers in the statistical analysis of data, and gives an overview of the most commonly used analyses.

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### Transcript of "Vital Statistics: An Introduction to Health Science Statistics by Stephen McKenzie"

1. 1. 1 ST EDITIONVITALSTATISTICS:AN INTRODUCTION TO HEALTH SCIENCE STATISTICS STEPHEN MCKENZIE
2. 2. VITALSTATISTICS:AN INTRODUCTION TO HEALTH-SCIENCE STATISTICS
3. 3. VITALSTATISTICS:AN INTRODUCTION TO HEALTH-SCIENCE STATISTICS STEPHEN McKENZIE BA(Psych)(Hons) PhD(Psych) Research and Evaluation Ofﬁcer, Healthy Togetherpreventive health initiative, City of Greater Geelong, Victoria With contributed chapters by DEAN McKENZIE BA(Psych)(Hons) PhD(Psych Epidemiology) Senior Research Fellow and NHMRC Postdoctoral Fellow, Monash University, Melbourne, Victoria NHMRC Postdoctoral Fellow and Honorary Fellow, Murdoch Childrens Research Institute, Royal Children’s Hospital, Melbourne, Victoria Sydney Edinburgh London New York Philadelphia St Louis Toronto
4. 4. Churchill Livingstone is an imprint of Elsevier Elsevier Australia. ACN 001 002 357 (a division of Reed International Books Australia Pty Ltd) Tower 1, 475 Victoria Avenue, Chatswood, NSW 2067This edition © 2013 Elsevier AustraliaThis publication is copyright. Except as expressly provided in the Copyright Act 1968 andthe Copyright Amendment (Digital Agenda) Act 2000, no part of this publication may bereproduced, stored in any retrieval system or transmitted by any means (including electronic,mechanical, microcopying, photocopying, recording or otherwise) without prior writtenpermission from the publisher.Every attempt has been made to trace and acknowledge copyright, but in some cases this maynot have been possible. The publisher apologises for any accidental infringement and wouldwelcome any information to redress the situation.This publication has been carefully reviewed and checked to ensure that the content is asaccurate and current as possible at time of publication. We would recommend, however, thatthe reader verify any procedures, treatments, drug dosages or legal content described in thisbook. Neither the author, the contributors, nor the publisher assume any liability for injuryand/or damage to persons or property arising from any error in or omission from thispublication.National Library of Australia Cataloguing-in-Publication DataAuthor: McKenzie, Stephen.Title: Vital statistics : an introduction to health science statistics / Stephen McKenzie ;Dean McKenzie.ISBN: 9780729541497 (pbk.)Subjects: Medical statistics. Health status indicators.Other Authors/Contributors: McKenzie, Dean.Dewey Number: 610.72Publisher: Luisa CecottiDevelopmental Editors: Amanda Lucas and Neli BryantProject Coordinators: Geraldine Minto and Nayagi AthmanathanEdited by Carol NatsisProofread by Tim LearnerCover and internal design by studioemmaIndex by Robert SwansonTypeset by Toppan Best-set Premedia Limited, ChinaPrinted in China by 1010 Printing Int’l Ltd.
5. 5. Contents Foreword vi Preface vii Acknowledgments viii Reviewers ix1 A fool-resistant introduction to statistics 12 Statistics as information 133 Descriptive statistics 314 Probability 515 Inferential statistics, sampling and hypothesis testing 656 Signiﬁcance testing, beyond signiﬁcance testing and experimental design 797 Measures of differences 1: t-tests and the chi-square test 91 Dean McKenzie and Stephen McKenzie8 Measures of differences 2: analysis of variance (ANOVA) 1139 Measures of association 1: correlation 127 Stephen McKenzie and Dean McKenzie10 Measures of association 2: regression 147 Dean McKenzie and Stephen McKenzie11 Qualitative research methods 16912 Statistics in the health sciences 18513 Reliability, validity and norms 19914 Statistics and the computer 209 Dean McKenzie Index 223 v
6. 6. ForewordStudents of health sciences are commonly required to have a basic under-standing of statistics. For the more mathematically inclined, this will beeasily acquired and there are many existing textbooks that will serve theirneeds well. However, for others learning about statistics will be an oneroustask that may not seem directly relevant to their goal of becoming a healthpractitioner. To make statistics interesting, relevant and accessible for thesestudents is a continuing challenge for their teachers. Having a suitabletextbook that can motivate, inspire and explain complex concepts in plainlanguage would be a big help. This new book by the McKenzie brothersdoes just that. It reflects many years of experience in explaining statisticsto students and practitioners. This textbook is written more in the tradition of popular science ratherthan in the usual textbook style. The authors have considered the needsof future health practitioners, who will be consumers rather than produc-ers of statistics. The text is remarkably free of equations, and, when theyare introduced, they are also explained in simple words. There are lots of illustrative examples from the authors’ own experi-ences of analysing health data, as well as some interesting historical ones.The interest level of the material is another key to its success. Anyonebrowsing through the text is sure to find interesting snippets that will leadthem to want to read more. The humorous tone of the text also standsout as a distinguishing feature and adds to the motivation to keep reading. I hope and expect that this new textbook will infect many healthscience students with the authors’ obvious love of the topic and lead themto want to learn more. In particular, I hope that they see the value ofstatistics to evidence-based professional practice and become better prac-titioners as a consequence. Anthony Jorm PhD DSc Professorial Fellow, Melbourne School of Population Health, University of Melbourne, Victoria vi
8. 8. AcknowledgmentsStephen McKenzie would like to thank his students at Northern TerritoryUniversity (now Charles Darwin University) in 1988 who inspired thisbook’s conception by demonstrating that there was and is a vital need forit. He would also like to thank his brother Dean (first author of Chapters7 and 10, second author of Chapter 9 and author of Chapter 14), every-one at Elsevier who helped produce this book, the manuscript reviewersand others who facilitated this book’s birth by helping transform an ideainto a reality. The responsibility for all opinions and any errors rests solely with theauthor(s) of the requisite chapters. Stephen McKenzie Geelong, September 2012Dean McKenzie was supported by an Australian Government NationalHealth and Medical Research Council (NHMRC) Public Health Training(Postdoctoral) Fellowship. He would like to thank his wife, Maria; hisfamily; his colleagues at the Department of Epidemiology and PreventiveMedicine at Monash University, and at the Centre for Adolescent Health,Murdoch Childrens Research Institute, Royal Children’s Hospital, Mel-bourne; the staff of the Ian Potter Library, Alfred Hospital, and of thelibraries at Monash University, University of Melbourne and Deakin Uni-versity, and of the State Library of Victoria. He would like to thank hisbrother Stephen for inviting him to be a contributor, everyone at Elsevierwho helped to produce this book, the manuscript reviewers and all of histeachers and students. Dean McKenzie Melbourne, September 2012 viii
9. 9. ReviewersAnthony Bedford BAppSci(Mathematics Hons) PhDAssociate Professor, Deputy Head, Learning and Teaching, School ofMathematical and Geospatial Sciences, RMIT University, Melbourne,VictoriaSimon Boag PhDSenior Lecturer, Department of Psychology, Macquarie University,Sydney, New South WalesCB Del Mar MA MB BChir MD FRACGP FAFPHMProfessor of Public Health, Faculty of Health Sciences and Medicine,Bond University, Gold Coast, QueenslandDaniel Exeter BA MA(Hons) PhDSenior Lecturer, The University of Auckland, New ZealandPhil Hider FAFPHM(RACP) FNZCPHMPublic Health Physician, Canterbury District Health Board andUniversity of Otago, Christchurch, New ZealandJohnson Mak PhD FASMARC Future Fellow, Chair in Infectious Diseases, Professor School ofMedicine, Deakin University, Melbourne, VictoriaHead, HIV and Emerging Viruses Laboratory, CSIRO AustralianAnimal Health Laboratory (AAHL), Geelong, VictoriaElizabeth Manias RN MPharm MNursStud PhD FRCNA MPSAMSHPAProfessor, Melbourne School of Health Sciences, The University ofMelbourne, VictoriaJudy Mullan PhDSenior Lecturer, Graduate School of Medicine, University ofWollongong, New South WalesShawn Somerset PhD RPHNAssociate Professor of Public Health, School of Allied and PublicHealth, Australian Catholic University, Brisbane, Queensland ix
10. 10. x REVIEWERS David Stanley NursD MSc(HS) BA(Ng) DipHE(Nursing) RN RM Associate Professor, School of Population Health, University of Western Australia, Perth Kerrianne Watt BSc(Hons Psych) PhD Associate Professor, Discipline of Public Health and Tropical Medicine, School of Public Health, Tropical Medicine and Rehabilitation Sciences, James Cook University, Townsville, Queensland
11. 11. To our parents, Diana and Graham,who inspired and began our conceptions, births and creations
12. 12. CHAPTER 1 A FOOL-RESISTANT INTRODUCTION TO STATISTICS (Hardly anything is foolproof.)OBJECTIVESAfter carefully reading this chapter, you will:• recognise that statistical literacy is becoming as important in our increasingly complex age as written literacy• understand the basic purpose and nature of statistics• realise that statistics have interesting uses in the real world, as well as perhaps not quite as interesting uses in classrooms and laboratories• know how to emulate some interesting real-world uses of statistics that deserve to be emulated• know how to avoid some interesting real-world misuses of statistics that deserve to be avoided• understand that statistics are, or can be, our friend. 1
13. 13. 2 VITAL STATISTICS Introduction A lot of otherwise mostly happy people are mostly unhappy about statis- tics. Unfortunately many of these people are working at jobs or enrolled in courses or living lives that involve constant exposure to statistics. This means that there are many millions of people living in statistical discom- fort, misery or denial. There was a time when it was perfectly possible to live a long and fruitful life without any knowledge whatsoever of statistics. Indeed, even now it is rumoured that there are people in the remoter areas of our planet who have enjoyed a basically unchanged lifestyle for more than 40,000 years. Perhaps these fortunate few can still sleep peacefully at night with only the fuzziest notions of normal distributions or arith- metic means, but such people are modern-world outliers — exceptions to the modern norm. There is nothing necessarily wrong with being an outlier. Indeed, if not for the outliers who realised the life-changing potential of fire and the wheel and the computer, we would still be in caves, for better or for worse. Whether or not our foray into technology was a good move is not the point. What is becoming increasingly vital to us all now is the realisation that the flow of information in our increasingly technological age is rapidly getting so complicated that there is a real risk that an underclass of information illiterates is being created. Those of us who missed out on fully learning the language of information at our schools, universities or jobs are now in danger of being distanced from the shared public domain reality that underlies much of our shared lives, in the same way that ordinary illiterates were distanced from information-sharing opportunities when the printing press was invented circa 1440. It has been calculated that a person reading the weekend edition of a major metropolitan newspaper is exposed over that weekend to as much information as a person living several centuries ago was exposed to in their entire lifetime. The recent proliferation of statistics courses and statistical components in non-statistics courses reflects this ever-increasing practical need to keep up with the Information Age Joneses. Vital Statistics will provide you with enough general and health-science-specific statistical knowledge and confidence to safely and happily go as far as you would like to go on the new information superhighway. What statistics really are and how they can help The ever-increasing complexity of the technical demands of life on our modern planet is reflected in the rapidly expanding number of courses that now require some knowledge of statistics. Courses in a wide range of
14. 14. CHAPTER 1: A FOOL-RESISTANT INTRODUCTION TO STATISTICS 3health sciences now routinely require what can seem to at least someintending health professionals to be a formidable understanding of some-times strange and scary concepts. When teaching inferential statistics to first-year health professionstudents at Darwin’s then newly evolved Northern Territory University,it became obvious that it is not easy to persuade health-science students,professionals or indeed anybody else that to be a good health professionalthey need a steady grasp of concepts such as the random samplingdistribution of means. It was easier, however, to convince health-sciencestudents, and others, that the probability theory that underlies therandom sampling distribution of means is actually relevant to virtuallyeverybody. This is true, whether you are a current or impendinggeneral practitioner, specialist, nurse, psychologist, health system admin-istrator or even a professional or amateur gambler — a player of life’sodds. What is the likely evidence-based outcome if my patients get aparticular drug, operation, therapy or case-mix funding system? What isthe likely evidence-based outcome if I get married to a particular person,or place all of my meagre house-deposit funds on a particular roulettewheel number?Statistics: what’s in them for me?There are genuine reasons why a working knowledge of statistical conceptswill greatly and practically benefit you as a current or impending health-science professional, and these reasons are even more important than youmay currently realise. A working knowledge of statistical principles willbenefit you far more broadly than just helping you do well in a coursethat officially or unofficially expects you to understand statistics. Under-standing at least the basic principles underlying statistics is a vital modernlife skill that will help you to genuinely understand the information thatwe are all exposed to every day, as well as to understand your professionallyrelevant information. In 1954 Darrel Huff wrote what is probably the world’s only statisticsbook bestseller to date, and it is still in print — the descriptive statisticsclassic How to Lie with Statistics.1 The aim of this book was not to helppeople to use information to lie, but rather how to recognise and thereforebe protected from statistical lies. Disinformation can be an insidiousproblem for us if we do not know what form it takes, and it could evenbe said that there is an epidemic of disinformation infecting our modernworld. In 1954 descriptive statistical literacy was all that you needed fora competitive edge in coping with the information demands of the day.The world and its information complexity have changed, so that now wealso often need to understand inferential statistics, whether we know whatthey are called or not, so keep reading!
15. 15. 4 VITAL STATISTICS The purpose of statistics Being continually exposed to statistics when you do not understand or like them is like being in any other kind of bad relationship. The simplest solution to this common predicament is to change our attitude rather than change what we are in a bad relationship with. If the idea of statistics fills you with terror or sarcasm, do not worry; they have a similar effect on most people and this is probably not the result of some deep flaw in your character or karma. Most of us were inadvertently taught our bad statisti- cal attitude at school, where we (well, many of us) learned to fear math- ematical symbols even more than we feared sarcasm or beatings. This relates to the perfectly sensible survival law that things that are not what they seem tend to be dangerous. This principle applies to the tips of ice- bergs, Trojan horses and sarcasm, as well as to statistics. At one level, both mathematics and statistics seem to be about what they are not. At first glance, statistical symbols such as epsilons and alphas might seem Greek to you, especially if you hail from Athens, but they actually have a saving grace, which probably nobody told you about at school, and that is that, deep down, statistics actually mean something. Statistics exist to help people, including you, understand information. Information is inherently interesting as well as important even to non- statisticians, and it offers you powerful survival, entertainment and edu- cational possibilities. The sound of a nearby twig snapping as you drink from a stream gives you only enough information to want to know more. The sight of a sabre-toothed tiger rushing at you, however, gives you enough relevant information to justify acting. The sight of a wombat or snail approaching you gives you enough relevant information to justify not acting. Statistics as evidence Statistics provides a tool kit that can help us describe and understand information. As such, it can conveniently be divided into two types: descriptive statistics, which consists of aids to the presentation and diges- tion of raw information; and inferential statistics, which uses probability theory to extrapolate information from samples to populations — from a few cases of something to all cases of it. A sample is like a taste of a wine before you buy a whole bottle of it. A population is like the bottle. We all engage in informal inferential statistics continuously, even if we do not have a formal knowledge of it, and fortunately this is usually a painless and often useful procedure. When we make a generalisation about a life experience, we are informally, and often inaccurately, using inferen- tial statistics. If we go to a restaurant twice and like it both times, we often come up with an extrapolation of our sample data along the lines of ‘This is a good restaurant!’. Maybe it is and maybe it is not, and if we keep
16. 16. CHAPTER 1: A FOOL-RESISTANT INTRODUCTION TO STATISTICS 5going back to the restaurant, and therefore increasing our sample size,then our inference — our generalisation — will become increasingly moreaccurate. Formal health-science decision making uses a similar common-sense evidence-based principle, and this has been described in an articleon the history of medical decisions as originating in:1. a recognition of the need for data as demonstrable evidence2. the development of probability theory (mainly based on games of chance)3. the development of formal inference procedures.2 There are many examples of the evidence-based process at work in thehealth sciences, and some relevant and interesting examples of these inparticular statistical contexts are provided in the following chapters. Aninteresting evidence-based health-science statistical aperitif to sustain youuntil the main course is an Australian article that reports research, basedon data from 175 countries, on the relationship between economic pros-perity (as measured by gross domestic product, GDP), optimal bodyweight (as measured by a body mass index, BMI) and other factors. It isperhaps commonly assumed that as economic prosperity increases so doesbody weight, but the evidence-based information picture is actually morecomplex, more interesting and potentially more useful to a wide range ofhealth sciences. Most countries do not have an average BMI in the optimalhealthy weight range, and, of a subgroup of economically prosperouscountries, those with more equally distributed prosperity (due to increasedmarket regulation) had fewer people above the optimal weight range.3Some useful statistical tipsBefore consummating your relationship with statistics, it will be useful foryou to know just what ‘statistics’ (singular) actually is, as well as what‘statistics’ (plural) are. Singular ‘statistics’ refers to the science of summaris-ing — describing, drawing conclusions and generalising from data — ina rigorous and orderly fashion. Plural ‘statistics’ refers to particular statis-tical tools that have been developed by the science of statistics and areused in its application. A ‘datum’ is a single observation or measurement: for example, age,sex, hair colour, length of nose, type of medication being taken, footballteam barracked for, or level of a particular neurotransmitter substance inthe brain. A datum, like a wolf, tends to hang out in packs with othersof its kind, and these are known collectively as ‘data’. Information is ofno real use to anyone unless there is some effective means of disseminatingit. To adapt a famous observation by Marshall McLuhan, statistics is themedium and also the message.4 Even though statistics might at least occasionally seem like an infiniteseries of meaningless or even obnoxious arbitrary events, they are also
17. 17. 6 VITAL STATISTICS much more. Statistics, like mathematics and love, contain layers of meaning. Statistical tools allow us to understand information by helping us to summarise and see patterns within it, such as patterns of associations or patterns of differences. Statistics can therefore be our passport to the science and also the art of information management. To gain a working knowledge of the art of statistical science, and the science of statistical art, please read on. Statistics in the health sciences: background Statistics can be enormously helpful to us, whatever our field, and the practical requirements of our field can be a great motivator for us to understand and apply the statistics that are particularly relevant to it. There have been some very special cases of people who have developed or helped to develop statistical methodologies that accelerated the growth of knowledge in their special area of interest. A wheat farmer in the Australian or Canadian or Ukrainian wheat belt might not feel an over- whelming need to understand the principles of statistical analysis, espe- cially in a good year, but such principles are far more relevant and potentially profitable to such farmers than they might realise. It can be useful to remember that statistical tools were devised by real (and often interesting) people, to meet real (and often interesting) needs (Box 1.1). Some real and interesting statistical Box 1.1 needs and the people who met them The great English statistician Sir Ronald Fisher (1890–1962) (Fig 1.1) developed a key statistical technique, called the analysis of variance (ANOVA), directly in response to the strong, if then unrealised, need of wheat farmers for a suitably fertile statistic. ANOVA is a technique that reveals whether apparent differences between group average scores, such as annual wheat yields, are indeed real, and its development directly led to the improvement of world wheat harvests. This great statistical discovery objectively showed whether apparent improvements in wheat yields, based on a series of modifications to wheat-growing practices, were statisti- cally meaningful, and therefore worth introducing into wheat- farming standard practice. ANOVA is described more fully in Chapter 8. Florence Nightingale (Fig 1.2), whose name might be more familiar to you than that of Sir Ronald Fisher, was also inspired by the largely unrealised demands for her profession in the nineteenth century to apply and develop an appropriate and powerfully
18. 18. CHAPTER 1: A FOOL-RESISTANT INTRODUCTION TO STATISTICS 7practical statistical methodology. Florence Nightingale is, of course,a famous health professional, who became known for helpinginjured soldiers and others during the Crimean War. Her enor-mous contribution to humanity in that situation and others wasnot just the result of her great compassion and energy; it was alsodue to her recognition that such qualities can be far more usefulwhen applied in conjunction with a statistical scientist’s ability tosee and meet a need. Fig 1.1 Sir Ronald Fisher, a great statistical pioneer (Courtesy RA Fisher Memorial Trust)Fig 1.2 Florence Nightingale, agreat statistical pioneer (FromBoyd J. Florence Nightingale andElizabeth Blackwell. The Lancet.2009;373(9674), Fig 2.)