Measures of association

By Samuel D.(MPH)
 Objectives
By the end of this chapter you will be able to:

 Organize disease frequency data into a two-by-two table.

 List common measures of association and measures of

public health impact

 Calculate and interpret absolute and relative measure of

comparison and describe their use

 Measures of association
Association
 Statistical relationship between two or more variables

Epidemiologic Measure of Association

 Quantifies or expresses the strength of the relationship
between an "exposure" and “outcome” of interest as
compared to another

Requires comparing two groups:

 Indications of how more or less likely one is to develop

disease

 Exposed Vs Unexposed
 With outcome Vs Without Outcome
 Measures of association….
Exposure examples

 in usual sense

 ingestion of contaminated food

 droplets from someone with active pulmonary tuberculosis

 Behaviors

 sharing needles, drinking alcohol, multiple sexual partner etc

 Treatment

 intervention - education program

 Trait -genotype
 Measures of association
….
Outcome

 Disease : e.g., malaria, TB, diabetes

 Event: e.g., injury from land mine, car accident

 Condition: e.g., blindness

 Death

 Other
 Measures of association….
 Types of measures:

 Relative difference: risk ratio, rate ratio, odds ratio

► based on the ratio of two measures of disease frequency

exposed / unexposed

 Absolute difference: risk difference, rate difference

► difference between two measures of disease frequency

exposed – unexposed
 Epidemiologic data are often presented in the form of a two-
by- two table (four-fold or contingency table)

 Generally we can have r-by-c table-(row by column)

 Measures of
association….
Presentation of data in a two-by-two
table
Disease
Yes No Total
Exposure a b
Yes a+b
No c D c+ d

Total a+c b+d a+b+c+

d
What is every letter and summation of letters stand for? Think for a
while and compare your attempt with the provided
 Measures of
Cells association….
A= Exposed, and diseased
B= Exposed, Not diseased
C= Not exposed, but diseased

D= Not exposed, Not diseased

Marginal totals
a+b= Exposed
c+d= Non-exposed
a+c= Diseased
b+d= Non-diseased
Grand total
n = a+b+c+d
 Measures of association….
Presentation of data in a two-by-two table

In cohort studies with variable lengths of follow-up, a variation

of the two-by-two table is used for data presentation, since the

numbers of person-time units for exposed and non-exposed

subjects are provided rather than the total numbers of

individuals in each group.

 Presentation of data in a two-by-two
table
Diseas
e Yes No Person-time units
Exposure
ye PY1
s
N
PY2
o
a+ -
PY=person- c
year
 How strong is the association?

Relative risk (Risk ratio)

 Indicate the likelihood of developing the disease in
the exposed group relative to those who are not
exposed

 used for longitudal study

For a cohort study with count data RR = Ie = a/(a+b)
Io c/(c+d)
 Example
Table 1: data from a cohort study of oral
contraceptive (OC) use and bacteruria among
women aged 16-49 years
Bacteruria
Current OC use Total
Yes No
Yes 27 455 482

No 77 1831 1908

Total 104 2286 2390

Calculate RR and interprate it?

 Example
RR = a/(a+b) = 27/482 =1.4
c/(c+d) 77/1908

Interpretation –
OC usershad 1.4 times riskof developing bacteruria than
nonusers
OC users were 40 percent (i.e 1.4 minus the null value of 1.0)
MORE likely to develop bacteruria than nonusers.

OR 60% LESS likely to develop bacteruria among OC users.

 Examples
Table 2: Data from a cohort study of postmenopausal hormone
use and coronary heart disease among female nurses

Coronary heart disease

Yes No Person-years
Postmenopausal
hormone use
Yes 30 - 54,308.7

No 60 - 51,477.5

Total 90 - 105,786.2
 Example cont…

RR = Ie =IDe = a/PY1 = 30/54,308.7 = 0.5 Io = IDo c/PY2

60/51,477.5
Interpretation: women who used postmenopausal
hormones had
0.5 times, or only half, the riskof developing coronary
heart
disease compared with nonusers.
 Example cont…
RR= 1 indicates no association
RR > 1 indicates a positive association, or an increased risk
among those exposed to a factor.

RR < 1 indicates negative association, which means the

exposure is preventive
In general the strength of association can be considered:

High - if the RR is 3.0 or more

Moderate – if the RR is from 1.5 to 2.9 Weak – if the

RR is from 1.2 to1.4

 Odds ratio(OR)
In case control study RR can be estimated by calculating the
ratio of the odds of exposure among the cases to that among
the controls
OR = a/c = ad
b/d bc
OR indicates the likelihood of having been exposed among
cases relative to controls
Risk = the chances of something happening / the chances of all things
happening
Odds = the chances of something happening /the chances of it not
happening
 Odds ratio…
Example:
Table 3:Data from a case-control study of current oral
contraceptive (OC) use and MI in pre-menopausal female
nurses.
Myocardial infarction
Yes No Total
Current OC use
Yes 23 304 327
No 133 2816 2949
Total 156 3120 3276
 Odds ratio…
OR = = (23)(2816) =
ad 1.6
bc (304)(133)

Interpretation: womenwho were current OC usershad

a
risk of MI 1.6 times that of nonusers
 Odds ratio…
OR is a valid estimator of RR if:
 Cases are incident and drawn from a known and
defined population
 Controls are drawn from the samedefined population
and would have been in the case group if they had the
disease;

 Controls are selected in an unbiased way

 the disease is rare

What is the excess risk among
exposed individuals?
 Attributable risk(AR)
Definition:
 The amount of disease that canbe attributed to a
certain exposure.
 Places exposure–disease associations from public health
perspective
 Quantifies expected reduction in disease occurrence if
harmful exposure could be eliminated
 It is calculated as risk difference (RD)

 Risk Difference = Risk in exposed - Risk in non-exposed

= A / (A + B) – C / (C + D)
 Example
Table 1: data from a cohort study of oral contraceptive
(OC) use and bacteruria among women aged 16-49 years

Bacteruria
Yes No Total

Current OC use
Yes 27 455 482
No 77 1831 1908
Total 104 2286 2390
 Attributable risk(AR)….
AR=27/482 - 77/1908 = 0.01566 = 1566/105
Interpretation: The excess occurrence of
Bacteriuria among OC users attributable to their
OC use is 1566 per 100,000.
 Attributable Risk…
Relative Risk: (Multiplicative)

RR=Ie / Io

(strength, cause ?

)
Attributable Risk: (Additive)

AR=Ie-Io

(impact?).
 Attributable Risk…
 The interpretation of the AR is dependent on the assumption
that a cause- effect relationship exists between exposure and
disease

AR=0 - no association

AR > 0 indicates

I. the number of cases of the disease among the exposed

that can be attributable to the exposure itself, OR

II. alternatively, the number of cases of the disease among the

exposed that could be eliminated if the exposure were
eliminated

 Thus, the AR can be useful as a measure of the public health

impact of a particular exposure
 Presence of associations

Relative risk 1
Odds Ratio 1

Attributable risk 0
What proportion of cases is attributed to the
actual exposure among exposed people?
 Attributable Risk Percent (AR%)
AR% is an attributable risk expressed as a percentage of risk
in exposed

What is the proportion of disease among the exposed which "X" can

be attributed to the exposure?

Synonyms

 Attributable proportion

Attributable fraction

Etiologic fraction (EF)

AR% = AR x 100 = (Ie – Io) x 100

Ie Ie
 AR%….
 For most case-control studies, the AR cannot be calculated
 It is, however, possible to calculatethe AR% using the
following formula

AR% = (OR – 1) x 100

OR
Example:From the data on OC useand MI, the OR of MI
associated with current OC use was 1.6,

yielding AR% of 37.5%

 AR%...
nearly 38% of MIs among young women who used OCs could
be attributable to that exposure or could be eliminated if they
were to stop using OCs

 If the exposure is preventive, so that Ie is less than Io, the

AR is meaningless.

 However, an analogous measure, the Preventive Fraction

(PF), can be defined

PF = Io – Ie
Io
What is the excess risk among the
general population that is due to
exposure of interest?
 Population Attributable Rate or Risk (PAR)

• estimates the excess rate of disease in the total study

population that is attributable to the exposure.

• helps to determine which exposures have the most

relevance to the health of a community

• PAR = IT - I
o

• Alternatively PAR = (AR) (Pe) e=proportion of the population that is exposed

 PAR…
• Example: the PAR of bacteruria associated with OC use
(Table 1) is:
• PAR = IT - I = 104/2390 – 77/1908 = 316/105/year
o

• Or alternatively

PAR = (AR) (Pe) = 1566/105 X (482/2390) =316/105/year

• Thus, if OC use were stopped, the excess annual incidence

rate of bacteruria that could be eliminated among women
in this study is 316 per 100,000.
What proportion of cases is attributed to
the actual exposure among the general
population?
 Population Attributable Risk Percent (PAR%)
• expresses the proportion of disease in the study
population that is attributable to the exposure and thus
could be eliminated if the exposure were eliminated.

• PAR% = PAR x 100

IT
 Example
Table 1: data from a cohort study of oral contraceptive
(OC) use and bacteruria among women aged 16-49 years
Bacteruria
Yes No Total

Current OC use
Yes 27 455 482
No 77 1831 1908
Total 104 2286 2390
 PAR%…
• For example: in the cohort study of OC use and
bacteruria (Table 1)

• PAR% = 316/105 x 100 = 7.3%

4351.5/105
• Thus, if OC use causes bacteruria, about 7
percent of all the bacteruria in the study
population could be prevented if OC use were
eliminated.