Measures of association

in epidemiology
Bony Wiem Lestari
Division of Epidemiology, Department of Public Health
Faculty of Medicine UNPAD
2022
 Objectives:

1. To introduce and compare the relative risk and odds ratio as

measures of association between an exposure and a disease

2. To calculate and interpret the relative risk and odds ratio as

measures of association between an exposure and a disease

3. To introduce the concept of association and causation in

epidemiology
Measures of association
Measures of association
Common measures of association

•Relative risk

•Hazard ratio

•Odds ratio
Introducing the 2x2 Table
• The 2x2 Table (or Contingency Table) is the basis
for calculating associations in epidemiology.
Relative risk
• In the exposed: Cases of disease / Total exposed (A/A+B)
• In the unexposed: Cases of disease / Total unexposed (C/C+D)
• Relative risk: Risk in the exposed (A/A+B) / Risk in the
unexposed (C/C+D)
Hazard ratio
• The Hazard Ratio is like the Relative Risk, except it
introduces the element of follow-up time.
• In the exposed: Cases of disease / Total time period of
exposure
• In the unexposed: Cases of disease / Total time period
when not exposed

• Hazard ratio: Risk over time in the exposed / Risk over

time in the unexposed
Odds ratio
• In those with the disease: Exposed / Unexposed (A/C)
• In those without the disease: Exposed / Unexposed (B/D)
• Odds ratio: The odds of the disease occurring in the exposed
divided by the odds of the disease occurring in the unexposed
(AD/BC)
Odds ratio and relative risk

• Odds Ratios are a good estimation of the Relative

Risk when the disease is rare.

• It tends to exaggerate the magnitude of the

association when the disease is not rare.
Interpreting associations
• Relative Risk, Hazard Ratios and Odds Ratios are interpreted in
essentially the same way:
• An association of 1:
No association
• An association of >1:
The exposure increases the risk of the disease.
• An association between 0 and 1:
The exposure is protective against the disease (i.e.reduces the
risk).
• Often expressed as a percentage reduction, i.e. RR=0.8 is expressed as
“20% reduction in risk”.
Factors influencing associations

✓Random error

✓Bias (systematic error)

✓Confounding (mixing of effects)

✓Effect modification
Random error

• Since studies involve samples drawn from a population

(rather than the entire population itself), there will
always be some random error.

• It can be assessed with p-values and confidence

intervals.
Bias
• Bias is any source of systematic error in the determination
of the association between the exposure and the disease.

• Selection bias: Systematic bias in how subjects are selected

(either into the study or into particular groups within the
study)

• Observation bias / Measurement error: Systematic bias in

how the data are obtained
 Bias in clinical observation

Selection bias Occurs when comparisons are made between

groups of patients that differ in determinants of
outcome other than the one under study.
Measurement bias Occurs when the methods of measurement are
dissimilar among groups of patients
Confounding Occurs when two factors are associated (travel
together) and the effect of one is confused with or
distorted by the effect of the other

Source: Fletcher, Clinical Epidemiology, The Essentials, 6th ed.

Internal and external validity

Source: Fletcher, Clinical Epidemiology, The Essentials, 6th ed.

Confounding
• A “confounder” is a variable that confuses the
relationship between the exposure and the
outcome.
 Confounding

Source: Fletcher, Clinical Epidemiology, The Essentials, 6th ed.

Effect Modification
• Effect modification occurs when the magnitude of the
effect of the primary exposure on an outcome (i.e. the
association) differs depending on the level of a third
variable.
• Computing an overall estimate of association is
misleading.
• One common way of dealing with effect modification is
examine the association separately for each level of the
third variable.
Effect Modification
• Unlike confounding, effect modification is a
biological phenomenon in which the exposure has
a different impact in different circumstances.
References

1. Celentano David D, Szklo M, Gordis epidemiology. 6th ed.

Philadelphia: Elsevier; 2019.
2. Fletcher, Clinical Epidemiology, The Essentials, 6th ed.
Lippincott Williams & Wilkins; 2021.

Any questions:
Please don’t hesitate to contact me at bony.wiem@unpad.ac.id