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What is the “golden standard” for assessing population-based interventions?—problems of dilution bias
  1. L Lindholma,
  2. M Roséna,b
  1. aDepartment of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden, bCentre for Epidemiology, National Board of Health and Welfare, Stockholm, Sweden
  1. Dr Rosén, Centre for Epidemiology, National Board of Health and Welfare, S-106 30 Stockholm, Sweden (mans.rosen{at}


OBJECTIVES To identify different types of dilution bias in population-based interventions and to suggest measures for handling these methodological problems.

DESIGN Literature review plus analysis of data from a population-based intervention against cardiovascular disease in a Swedish municipality.

MAIN RESULTS The effects of an intervention on mortality and morbidity were much more diluted by non-intervening factors, dissemination to areas outside the intervention area, social diffusion, population mobility and time than by using intermediate outcome measures.

CONCLUSIONS Theoretically, changes in scientifically well documented risk factors, for example, intermediate outcome measures, should be preferred to using morbidity or mortality as outcome measures.

  • population-based interventions

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  • Funding: the work has been funded by the National Board of Health and Welfare in Sweden and the County Council of Västerbotten, Sweden.

  • Conflicts of interest: none.