Study Design and Sampling in Whitehall Studies

This article discusses the study design and sampling methods used in the Whitehall I and II studies, which focused on the relationship between job control and coronary heart diseases. It also explores the similarities and differences between the two studies and suggests conducting a similar study in Australia to address the challenges of an aging population.

PUBH6005: Epidemiology
Study design, sampling and population risk assignment
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PART 1
Answer to question 1
Whitehall I study sampling frame: The sampling method used in Whitehall study I was a
randomized sampling method where the survey conducted, consisted of the male civil servant
population living in London between 1967 and 1969.
Whitehall II study sampling frame: The sampling method used in the Whitehall II study was a
disproportionate random stratified sampling method, where different age groups were considered
of a total population of both men and women civil servants working in London offices, having
unequal intervals.
The following are the age ranges used for each phases of the Whitehall II study:
Phase 1: 35 to 55 years
Phase 2: 37 to 60 years
Phase 3: 39 to 64 years
Phase 4: 42 to 65 years
Phase 5: 45 to 69 years
Phase 6: 48 to 71 years
Phase 7: 50 to 74 years
Phase 8: 53 to 76 years

Phase 9: 55 to 80 years
Answer to question 2
The Whitehall I study done by Marmot et al. in the year 1978, clarified that men and women
population with a lower job control have higher risks of coronary heart diseases. The survey was
held in two different occasions three years apart. Statistics showed that the individuals with low
job control at the two occasions have an odds ratio of 1.93, compared to individuals with high
job control. The study also stated that the risk of developing coronary diseases is independent of
social support at work and the job demands. The men having the lowest job grade were seen to
have 3-6 times more mortality due to coronary heart diseases than the men belonging to the
highest grade of employment. The study noticed that the men belonging to the lowest paid
groups exhibit similar characteristics like shorter heights, heavier compared to their height, high
blood glucose content, high blood pressure, almost no leisure time or health exercises and
increased habit of nicotine abuse, which in turn increased their susceptibility towards coronary
heart diseases. In the 2001 Whitehall study II done by Breeze et al., it was examined that the
socio-economic status of individuals, having poor health and lacking proper exercise have higher
tendencies of developing coronary heat diseases like angina or heart attack. The resurvey is
similar to the Whitehall I study and yielded similar results, having age as an extra concluding
factor. Thus, a steady relation was drawn between the poor health, poor physical performance
deteriorating mental health and the employment grade. The 2008 Whitehall II study by Chandola
et al., was based on the resurvey of both male and female civil servants ranging from ages 35 to
80 years, consisting of a wide range of people having different exposure to work stress,
behavioral risk factors, heart rates, level of cortisol rise in mornings, angina, and even non-fatal

myocardial infractions. It was found that the accumulation of work stress could be linked with
the increase in the level of cortisol in the morning.
Answer to question 3
The Whitehall study I focused on the male population of civil servants living in London between
the years 1967 and 1969. Whereas, the Whitehall study II is mainly focused on both the male and
female population of civil servants living in London, belonging to different age groups having
unequal intervals. The three studies more or less depict the same scenario, which suggests that
the occurrence of coronary diseases is more in individuals belonging to the lower socio-
economic status and having low job control than individuals belonging to the top of the
hierarchy. The three studies mention that the working class or the individuals with the lower job
security and control are seen to have characteristic features like stunted growth, heavier
compared to their height, high blood pressure, almost no leisure time or health exercises, high
blood glucose content and increased habit of nicotine abuse, which make them easily susceptible
to coronary heart diseases. Thus, from these three papers, the conclusion drawn states that the
lower the job control, the greater their risk to develop coronary heart diseases.
Answer to question 4
It would be more reasonable to conduct an identical study in Australia using the existing cohort
like the 45 and up study cohort as the Australia has been facing the challenge of an increase in
their ageing population. With the advancement in the medical processes, and the decrease in the
mortality rate, there will be a steady increase in the ageing population, aged above 65 years, in
Australia. The country should be ready for the new challenges it would need to face with the
upcoming issue, especially in the healthcare sector. This study will help in the realization of the

increase in the ageing population and also help focus on the areas that would need immediate
attention like the improvement in the healthcare procedures, old-age homes, economic support
for the elderly and more. This study will help determine the factors which are likely to be
responsible in affecting the health of the elderly – substance abuse, diet, availability of proper
healthcare, socio—economic, environmental and cultural factors. It needs to incorporate
determinants for healthy ageing like quality of life, disease risk, susceptibility to infections,
medical care availability, physical care availability and more. Thus, a cohort study needs to be
conducted which will help understand the disease, its causative factors and will also help
establish a link between the threat factors and their health outcomes. The research needs to be in
a sufficient scale and can be done by the randomized sampling method, where the total
population will be aged more than 65 years. The research should be long term so that it can
accurately track the impact of health interventions and other policies, in order to facilitate
healthy ageing. Thus, the 45and up study would help create an accurate population-level
database which would help in the efficient usage of healthcare services and properly account the
amounts of deaths and the occurrences of the common fatal diseases in the chosen population.
PART II
Answer to question 1
Study design – RCT (Randomized controlled trial)
To find out the causal relationship between smoking and lung cancer, a randomized controlled
trial can be done, as in this method there is a control group and a test group, where the subjects
are randomly selected (Lucas & Rodney Harris, 2018). The purpose of the trial is likely to help
decrease the likelihood of risks or benefits the researchers might identify while a trial. The

method or technique is important as random allocations are done here and all the intervention
groups are given similar treatment and not just the experimental treatment. The randomness of
the selection process reduces the chance of biasness during allocation and selection of the
subjects and tests. Thus, this results in a more accurate test result. However, even though it is
accurate, to have a proper, unbiased trial, the population size has to be huge and also the test
duration has to be for a longer time, otherwise results may not denote the condition accurately.
The ethical consideration for such a trial is that in order to run an RCT, there needs to be at least
two credible and appropriate treatment options that are chosen for the comparison. In the given
case, clinicians might feel that there are insufficient evidences present to run trials comparing
novel chemotherapy with the usual surgical treatments (Allmark & Tod, 2016). Thus,
randomized trials could be properly executed if only there is an investigation of fringe cases or in
comparing treatments with marginal variations found in the lung cancer treatment. Therefore,
here the test subjects will be allowed to smoke and the control will be allowed to choose
healthier methods instead, and then compared to find the rates of susceptibility of the two groups
for lung cancer.
Answer to question 2
Study design – Longitudinal study
To help investigate the association between overeating or binge eating and their adverse effects
on physical and on mental health, a longitudinal study will be the most suitable one. The study
will focus on the adolescent and adult population living in a given area say United States
(Sonneville et al., 2013). The advantages of using the longitudinal study or approach for this is
that it is considered to be more effective in determining the different variable patterns in the

given time period, for any given case (van Weel, van Weel-Baumgarten & Mold, 2019). This
method ensures a more valid and proper outcome when compared to a cross-sectional study. The
disadvantages, however, are similar to the previous study method – they too would require a
large sample size and a large time frame. According to the above given case, Studies are likely to
show that among a large cohort study of the adolescents and young adults, binge eating or
excessive eating is more common among females than males. Thus, the act of binge eating could
not be directly associated with the increase in the usage of drugs, however, the stress for which
the subjects are seen to binge eat, might lead the subjects to abuse substances. The ethical
considerations would be the encouragement of the best subjects in overeating, which can in turn
cause detrimental effects on their health.
Answer to question 3
Study design – Meta-analytic methods can be used to quantitatively synthesize the study results
and Linear regression needs to be used to understand the mental and physical effects of staying
in an asylum.
This method utilizes statistical methods consisting of the combination of evidences and thus
allows the accurate analysis of the situation. This is a very simple method and is very intuitive to
understand and use. However, the method, is very sensitive towards the data anomalies and can
easily turn out to give incorrect interpretations. This method will thus allow the researchers
understand the factors which can significantly affect the mental health of asylum seekers after a
long-term detention (Newman, Proctor & Dudley, 2013). The paper can talk about the different
changes in health seen before entering an asylum and after spending a significant time in there.

Answer to question 4
Study design – Experimental design
To examine the association between the use of prenatal folic acid supplements during pregnancy
and the subsequent risk of autistic disorder in children, one might incorporate an experimental
study design method. Supplements during pregnancies like prenatal folic acid, can be used to
reduce the risk of defects in the neural tube of children. However, it is yet to be decided whether
they can determine whether these supplements can protect against other neurodevelopmental
disorders (Surén et al., 2013). The reason why this method is chosen is due to its ability to
interpret clearly, the clinical performance of different products and in this case, can also help
find the amount of plasma drug level in different formulations. This method uses a control group
and can be converted into a field experiment, but can also be found to be highly expensive.
Answer to question 5
Study design – Experimental study and Clinical trial
To study the reception of a drug administered to elderly people suffering from Alzheimer’s, one
can use the experimental study method along with clinical trials in order to monitor the
effectivity of the drug. In the elderly population, falls is very common, especially in the
population who are cognitively impaired. Out of all the medications prescribed for this disease,
some are beneficial while others are harmful and cause a deleterious effect on their health.
Experiments like the testing of new anti-Alzheimer’s drugs are encouraged to follow
experimental and clinical methods of trial, in order to produce better and accurate results, as the
types of medications for Alzheimer’s patients based on falls are very limited (Epstein, Guo,
Farlow, Singh & Fisher, 2013). The other concern that can be solved using this method is

inability to understand the co-morbidities of Alzheimer’s and thus might contribute in reducing
improper and unnecessary medical treatments (Andersen, Viitanen, Halvorsen, Straume &
Engstad, 2011). The importance of the experimental design study involves their role in
determining the bioavailability of a product, bioequivalence studies, level of drug in the plasma,
and also the clinical performance of the drug compared to other anti-Alzheimer’s drugs in the
market. For this case, the most important aspect of this study, is that it opens a scope for field
experimentation and use of the control group. However, there are also certain disadvantages of
this. They are generally very expensive, which can become a huge issue while conducting the
tests and study for a long period of time. For this, the elderly people, showing similar signs of
Alzheimer’s and their different stages of onset, will be administered the same drugs, having the
same dosage (Yiannopoulou & Papageorgiou, 2012). Their progress in suppressing the signs and
preventing the disease, thus can be accurately found using this method.

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