Monday, December 3, 2018

Threats to Study Validity


Statistical Conclusion Validity
Statistical conclusion validity refers to the appropriate use of statistics for data analyses.  Examples of threats to statistical conclusion validity include:

1.  Low statistical power
2.  Violated assumptions of statistical tests
3.  Error rate
4.  Reliability of outcome measure procedures/tests

I have discussed reliability of outcome measures in a previous 
post.  I will be discussing statistical power, statistical test violations, and error rate in future posts.

Internal Validity
Internal validity refers to the potential for confounding factors to interfere with the relationship between the independent and dependent variables.  I have divided threats to internal validity into three categories.

1.  Single-Group Threats
2.  Multiple-Group Threats
3.  Social Threats  

Single-group threats include:  a) history, b) maturation, c) attrition, d) testing, e) instrumentation, and f) regression.

History is where the observed study results may be explained by events or experiences (confounding variables), other than the intervention/treatment.  For example, participation in other physical activities may effect the outcome of an exercise training study.

Maturation is a threat that is internal to the individual participant.  It is possible that mental or physical changes occur within the study participants that could account for the study results, simply due to the passage of time.  For example, a study that investigates the effect of a treatment on pain in patients with an acute orthopaedic injury may observe an improvement in pain due to the normal healing process and not the treatment.

Attrition (also referred to as drop-outs, withdraw, and experimental mortality) is a threat related to participants withdrawing from a study before it is completed.  If participants withdraw from a study, randomization is negatively impacted and data analyses cannot be performing on all pre-treatment and post-treatment data.

Testing (especially multiple testing) can have a potential effect on a dependent measure.  The effect of conducting multiple tests can result in improvement in an outcome measure that is due to a testing effect and not the effect of an intervention.  Because of this potential testing effect, researchers should use tests that are considered reliable.

Instrumentation is a possible threat if an instrument is unreliable and provides data that are unstable and prone to measurement error.  Observed changes seen between observation points (ie. pre-test and post-test) may also be due to changes in the testing procedure, including the instrument that is being used to collect data.

Regression (or regression toward the mean) is also related to the reliability of a test.  When an unreliable test is used for data collection, a statistical phenomenon sometimes occurs when extreme pre-intervention scores (for example, very high or very low scores) regress toward the group mean at post-intervention.  Again, a reliable test minimizes the threat of regression.  Previous research has identified this statistical phenomenon.


Multiple-group threats to internal validity are related to any variables other than the experimental intervention that can have an impact of the post-intervention difference in outcomes between the groups (sometimes referred to as selection interaction), making the groups not comparable.  Below is a description of different selection interaction threats.

The threat of selection-history is when one group of study participants has different experiences than the other group and these different experiences can influence the outcome of the study.  

Selection-maturation occurs when the experimental group experiences changes in the dependent variable at a different rate than the control or comparison group.  For example, a group of 2-year-old children are likely to experience a different rate of change in development than a group of 10-year-old children.

Selection-testing is when pre-intervention testing affects the groups differently.

Selection-instrumentation occurs when the test (outcome measurement procedures) are performed differently between the groups.

Selection-regression is a concern when participants are assigned to groups based on extreme scores.
Social threats to internal validity refer to the social pressures in the research context that can lead to post-intervention differences that are not directly caused by the treatment.  The following are possible social threats to internal validity.
Social threats can occur because study participants in one group are aware of the treatment that the other group is receiving.  Below are examples of socials threats.

Diffusion or imitation of treatment occurs when a comparison or control group learns about the treatment that the experimental group receives and tries to imitate the treatment.   

Compensatory rivalry is where the comparison or control group knows which intervention that the experimental group is receiving and develops a competitive attitude toward the experimental group.  

Compensatory equalization of treatments occurs when the one(s) who are delivering the experimental treatment administer the treatment to the control or comparison group because the treatment is considered more favorable for treating the study participants.

Resentful demoralization can be thought of the opposite of compensatory rivalry.   For example, the comparison or control group discovers the treatment that the experimental group is receiving.  In this case, instead of developing a rivalry, the comparison group becomes resentful and thus, post-intervention outcome scores may be lower.  Such an impact may be observed when subjective outcome measures (like a questionnaire) are being used.  This threat can result in false, exaggerated differences between groups, making the treatment appear more effective than it actually is.

Construct Validity of Cause and Effect
Construct validity are abstract behaviors or events than cannot be directly observed, but can impact the interpretation of the cause-and-effect relationship.  The threat related to construct validity that I would like to discuss is experimental bias.  This threat occurs when biases are introduced into a study by investigators or the study participants.  For example, participants may desire to fulfill the expectations of the investigators.  Thus, the participants "try harder" to perform better on post-intervention outcomes or adhere more strictly to the study protocol.  Investigators can incorporate this type of bias by making study participants aware of their expectations.  This phenomenon is often referred to as the Hawthorne effect.  Click on the following link for the history of the Hawthorne effect.

External Validity

The findings of a clinical research study must be translational to environments outside of a “lab” in order to be applicable.  External validity is related to the degree to which the results of a study can be generalized beyond the laboratory environment.  I will discuss three threats to external validity.

1.  Interaction of Treatment and Selection
2.  Interaction of Treatment and Setting
3.  Interaction of Treatment and History

When designing a clinical research study, investigators should include a sample of study participants from a target population.  The threat of interaction of treatment and selection concerns when the treatment does not apply to the entire target population.  For example, consider a study that includes a sample of patients with chronic low back pain.  The study findings may indicate that an intervention was effective for treating the sample of study participants.  However, sub-classifications of patients with chronic low back pain exist (patients have chronic low back pain with different causes).  So, the treatment may not be applicable for every patient with chronic low back pain.

The threat of interaction of treatment and setting occurs when the findings of a study cannot be applied to an environment outside the “lab”.  For example, a treatment may be shown to be effective in a controlled laboratory, but the clinical environment is significantly different and therefore, the results of the study cannot be observed at another site.  This threat can be minimized by replicating the study at multiple locations to determine if the study findings are observed in various settings.

The threat of interaction of treatment and history concerns the ability to generalize the findings of a study to different points in time.  For example, the findings of an older study may have indicated that a drug was effective for reducing hypertension, however the study did not control for confounding variables such as diet and exercise.  Since the results of more recent studies provide evidence that diet and exercise can improve hypertension, the findings of the older study may not presently apply.

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