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S h ort Com munic a tio n

Bathtub concept in health sciences: Acomment


Nidhi Dwivedi, Sandeep Sachdeva, Anika Sulania

Department of Community
Medicine, North DMC Medical
College and Hindu Rao
Hospital, NewDelhi, India
Address for correspondence:
Dr.Sandeep Sachdeva,
Department of Community
Medicine, North DMC
Medical College and
Hindu Rao Hospital,
NewDelhi110007, India.
Email:sachdevadr@yahoo.in

Abstract
Bathtub shape has important connotations in public health and the concept could be reflected
in two novel ways:(1) engineering(2) epidemiological model. Typical bathtub curve is a
combination of three failure rates, that is, decreasing, constant, and increasing failure rate,
and different techniques are utilized to reduce these failures. This brief study highlights the
concept of bathtub, related theory, application, and how data modeling could be undertaken
considering bathtub failure rate.
Key Words: Demography, epidemiology, failure rate, hazard, injury, quality control,
mortality, survival

Introduction
Bathtub is known to be linked with human culture,
lifestyle, and socioeconomic flamboyance since historical
era. However, in modern context more so in the
developed world, it is also one of the top sites of
occurrence of injuries among adults. The typical
bathtub has important connotations in public health
and the concept could be reflected in two novel ways:
1. Engineering(hazard rate or bathtub curve)
2. Epidemiological model.

Hazard Rate(BathTub Curve)


High rate of death is noticed during early course of
human life due to risk of birth and fragility and as the
age advances, natural risk of death declines to a steady
state until a period upon which body starts to wear
out. Health(including medical) science has contributed
immensely to extend human lives in last century and a
similar phenomenon is noticed for engineering goods,
electronic components, and assemblies. Most reliability
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engineers are familiar with bathtub curve based on


human life, that is, hazard rate or risks of failure over
time.[1]
The rate at which failure occurs at a certain time interval
say t1, t2 is called failure rate during that interval. It is
defined as the probability that a failure per unit time
occurs in an interval given that failure has not occurred
prior to the interval t1 whereas hazard rate(or hazard
function) is defined as the limit of failure rate as the
length of interval(t1, t2) approaches to zero.[2] Thus, it
is considered as instantaneous failure rate or literally
speaking hazard rate is a subcomponent of failure rate.
Hazard rate indicates the change in failure rate over the
lifetime of a population.[3]
In many situations, factors or covariates affecting an
individuals lifespan vary over time and are referred
as timevarying or timedependent covariates, for
example, in research studies involving age at which
smoker develops chronic disease(s) is dependent upon
type and level of smoking which itself can vary over
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DOI:
10.4103/2349-5006.183689

How to cite this article: Dwivedi N, Sachdeva S, Sulania A.


Bathtub concept in health sciences: A comment. Indian j health
sci 2016;9:117-20.

2016 Indian Journal of Health Sciences|Published by Wolters KluwerMedknow

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Dwivedi, etal.: Bathtub concept in health sciences

time; duration of a marriage may be affected by presence


of children or couples employment status, both of
which can change over time. Astatement showing
lifetime relationship to covariates is incomplete without
considering covariate history, that is, values the
covariate takes over time; a generally useful approach
is to consider hazard function at time t conditional on
previous covariate values. The hazard function can take a
shape of increasing, decreasing, constant, humpshaped,
bathtub, or some other characteristic that describes
failure mechanism.[4] A typical bathtub curve is shown
in Figure1 and considered an important graphical
shape among nonmonotone shapes of the hazard rate
function.[5,6] The other shape, that is, monotone shape
reflects a constantly rising or declining nature of graph.

Typical Theory of BathTub Curve


Bathtub curve is a composite of several failure
distributions and has three fairly distinct periods:
decreasing failure rate for infant mortality; constant
failure rate for useful life; and increasing failure rate for
wearout period.[7]
Decreasing failure rate(infant mortality period)

The bathtub curve displayed above does not depict the


failure rate of a single item, but describes relative failure
rate of an entire population of products over time. If the
slope is followed from start to where it begins to flatten out
can be considered the first period, that is, characterized by
a decreasing failure rate. The weaker units die off leaving
a population that is more rigorous and the items become
less likely to fail as their survival time increases. Most of
the failures during this period are results of identifiable
causes such as a problem in design, manufacture, use of
substandard component, misapplication, or poor quality
control. As such there are four methods to reduce failures
during this period, that is, burnin testing or debugging

testing, environment stress screening, quality control, and


acceptance testing.[8] Process control charts are used to
detect potential problems with a view to detect and prevent
the occurrence of failure.
The constant failure rate period

The infant mortality period is followed by a nearly


constant failure rate known as useful life wherein failure
occurs purely by chance and, therefore, considered most
common time frame for making reliability predictions.
The time when a chance failure will occur cannot be
predicted, additionally, as the failure rate is constant,
this is the only phase in which exponential distribution
can be valid and, therefore, the time between failures
is exponentially distributed. It is pertinent to notice
how the amplitude on the bathtub curve is at its lowest
during this time. The failures of this period results
from the inherent limitations of design and accidents
that occur due to usage or random unforeseen reasons.
Good control on operation and maintenance is the key
to eliminate accidents/failures; however, basic reduction
of failure rate requires a fundamental redesign.[9] It is
worthy of attention that decrease in failure rate during
this period does not result in a proportional increase in
reliability(probability of survival).
Increasing failure rate(wearout period)

The wearout period is characterized by a rapid


increasing failure rate with time. In a device with a
large population of components, the third and final
failure period is characterized by(a) rising failure
rate above that of the constant failure period and(b)
deterioration that causes components to reach the end
of designated useful lives. This stage is a reflection
of old age and to reduce failures it is necessary
to undertake preventive maintenance along with
replacement of dying components. Different statistical
distributions can be used to characterize each phase, for
example, infant mortality period might be represented
by gamma or Weibull, the useful life period by the
exponential, and the wearout period by gamma or
normal distribution.

Application of BathTub Curve

Figure 1: Bath tub curve (engineering model)

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Usefulness of bathtub curve concept is well recognized in


several fields including:
1. Reliability and quality control: Hazard curve is used
in risk identification, risk assessment, analysis and
evaluation of risk associated with exposure and its
control

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Dwivedi, etal.: Bathtub concept in health sciences

2. Demography: The pattern of hazard could be utilized


to calculate model age at death, life expectancy and
compression of mortality etc
3. Survival analysis: Hazard curve helps in making
prediction about risk of future infectious disease;
gives idea about the quality of clinical treatment as it
indicates survival of patient after treatment; it is also
helpful in ascertaining usefulness of new method and/
or supremacy over current techniques
4. Health and Hospital Management/Disaster
Management: Concept is applicable in emergency
department of a hospital and also in situation of
disaster
5. Actuarial sciences: Hazard curve is used to decide
payment and policy-administration systems and assist
in death classification system.

Modeling
In public health, some of the known popular models
that easily capture our attention are primary care
model, DOTS(tuberculosis) model, and more recently
AIIMS(Delhi) like model which have definitive
strengths and known weakness/limitations, but overall
found to be useful and hence stands replicated in country.
In contrast, modeling in statistical essence highlights
the entire process involved from goal definition, study
design, and data collection to scientific use. In any field
be it medical, social science, or engineering, researcher
always deals with data and seeks to draw a general
conclusion from a sample of observation with an eye
on population rather than the sample itself.
A statement in mathematical terms representing a
relationship between a dependent and nondependent/
predictor variable(s) is referred to as a model. It is
basically a description of data generating mechanism,
a simplification of complex reality, and refers to
the construction of hypothesis. Statistics is largely
considered a part of mathematics with a slight
difference notably that mathematical model is based
on deterministic distribution whereas statistical model
are probabilistic in nature. For illustration, all the
factors affecting the survival of cancer patients are
listed according to their importance and weightage
contribution with certain assumptions. The survival
may depend upon primary factors such as age, stage/
extent of disease and rate of cell cloning. These
factors are called as parameters, and statistical model
could very well predict the probability of survival at a
particular time for a set of parameters. The statistical
model not only reveals relationship of parameters with

Indian Journal of Health Sciences Jan-Apr 2016 Vol 9 Issue 1

survival, but also provides simultaneous effect of all


the parameters.
These models are particularly useful when investigator
by intuitive means cannot see the relationship between two
or more facts of data set. The models, thus, constructed
are put through graphical and numerical checks before
acceptance and subsequently parameters are estimated
using data in hand across various levels. The estimated
model is useful to elucidate new understanding, derive
new predictions/forecasts(e.g.weather) or optimum
therapeutic solutions, to test hypothesis, to derive
confidence interval, lead to causal inference, and so on. To
sumup, statistical models are useful in data analysis:(1) as
a summary;(2) as a predictor; and(3) as a simulator, etc.
The hazard function is an important characteristic
of a lifetime distribution and is of interest in most
applications indicating the way risk of failure varies
with age or time. Prior information about the shape
of hazard function can help to guide model selection.
Finally, if factors affecting an individuals lifespan
vary over time, it is often essential to approach
modeling through hazard function, for example,
survival/life time data. Various statistical models
used for analyzing survival data are exponential
distribution, Weibull distribution, gamma, lognormal,
inverseGaussian distribution, etc. In the field of
health sciences, exponential and Weibull distributions
are frequently used.
The Weibull distribution could be written as


f (x| , ) =  x ( -1) exp x x > 0, > 0, > 0

where is scale and is shape parameter of the


distribution. If <1, distribution provides decreasing
hazard rate shape whereas >1 indicates increasing
behavior and = 1 reduces the model to wellknown
constant hazard rate exponential family. [10] Thus,
Weibull distribution accommodates all three shapes of
hazard rate in the form of bathtub.

Figure 2: Epidemiological bath tub

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Dwivedi, etal.: Bathtub concept in health sciences

Epidemiological bath tub

References

If we consider incidence and prevalence of a phenomenon


as being related to a bathtub[Figure2], the incidence
would be represented by water flowing into the tub and
the prevalence by the water in the tub(pool of cases).
The prevalence pool is affected by individuals leaving the
population(e.g.death), which can be viewed as the drainage
from the tub. The water supply itself would be individuals
coming into the population(e.g.births). The usefulness of
incidence and prevalence rate as a health status indicator
is welldocumented(WHO). These indicators are public
health management tools useful in reflecting situation with
regard to magnitude, distribution, and control of diseases;
identifications of potential highrisk population; efficacy
of preventive and therapeutic interventions; planning,
budgeting, and administration; and research purpose.

1.

Financial support and sponsorship

Nil.
Conflicts of interest

There are no conflicts of interest.

120

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