ASSOCIATION AND CAUSATION

CAUSATION
 IF ONE OF THESE ATTRIBUTES SAY A IS THE SUSPECTED CAUSE
 AND THE OTHER SAY B IS A DISEASE THEN WE HAVE REASON
 TO SUSPECT THAT A HAS CAUSED B.
ASSOCIATION

IF TWO ATTRIBUTES SAY A AND B ARE FOUND TO CO-EXIT

MORE OFTEN THAN AN ORDINARY CHANCE.

IT IS USEFUL TO CONSIDER THE CONCEPT OF

CORRELATION.

CORRELATION INDICATES THE DEGREE OF ASSOCIATION

BETWEEN TWO VARIABLES.
 DEFINITIONS (II)
• ASSOCIATION (RELATIONSHIP): STATISTICAL DEPENDENCE BETWEEN TWO OR
MORE EVENTS, CHARACTERISTICS OR OTHER VARIABLES. POSITIVE
ASSOCIATION IMPLIES A DIRECT RELATIONSHIP, WHILE NEGATIVE ASSOCIATION
IMPLIES AN INVERSE ONE. THE PRESENCE OF A STATISTICAL ASSOCIATION ALONE
DOES NOT NECESSARILY IMPLY A CAUSAL RELATIONSHIP.

• CAUSALITY (CAUSATION / CAUSE-EFFECT RELATIONSHIP): RELATING CAUSES

TO THE EFFECTS THEY PRODUCE.
• CAUSE: AN EVENT, CONDITION, CHARACTERISTIC (OR A COMBINATION) WHICH

PLAYS AN IMPORTANT ROLE / REGULAR / PREDICABLE CHANGE IN OCCURRENCE

OF THE OUTCOME (E.G. SMOKING AND LUNG CANCER)

• CAUSES MAY BE “GENETIC” AND / OR “ENVIRONMENTAL” (E.G. MANY NCDS

INCLUDING: DIABETES, CANCERS, COPD, ETC)

 DEFINITIONS (III)

• DETERMINISTIC CAUSALITY: CAUSE CLOSELY RELATED TO EFFECT, AS IN

“NECESSARY” / “SUFFICIENT” CAUSES

• NECESSARY CAUSE: MUST ALWAYS PRECEDE THE EFFECT. THIS EFFECT NEED
NOT BE THE SOLE RESULT OF THE ONE CAUSE

• SUFFICIENT CAUSE: INEVITABLY INITIATES OR PRODUCES AN EFFECT, INCLUDES

“COMPONENT CAUSES”

ANY GIVEN CAUSE MAY BE NECESSARY, SUFFICIENT, BOTH, NEITHER (EXAMPLES)

 DEFINITIONS (IV)
• COMPONENT CAUSES: TOGETHER THEY CONSTITUTE A SUFFICIENT CAUSE FOR

THE OUTCOME IN QUESTION. IN CDS, THIS MAY INCLUDE THE BIOLOGICAL

AGENT AS WELL AS ENVIRONMENTAL CONDITIONS (E.G. TB, MEASLES, ARF/RHD).

IN NCDS, THIS MAY INCLUDE A WHOLE RANGE OF GENETIC, ENVIRONMENTAL AS

WELL AS PERSONAL / PSYCHOSOCIAL / BEHAVIORAL CHARACTERISTICS (E.G.

DIABETES, CANCERS, IHD)

 DEFINITIONS (V)
• PROBABILISTIC CAUSALITY: IN EPIDEMIOLOGY, MOST ASSOCIATIONS ARE RATHER
“WEAK” (E.G. RELATIONSHIP BETWEEN HIGH SERUM CHOLESTEROL AND IHD),
WHICH IS NEITHER NECESSARY NOR SUFFICIENT

• MULTIPLE CAUSES RESULT IN WHAT IS KNOWN AS “WEB OF CAUSATION” OR “CHAIN

OF CAUSATION”

WHICH IS VERY COMMON FOR NONCOMMUNICABLE / CHRONIC DISEASES

 EFFECT MEASURES / IMPACT FRACTIONS

• EFFECT MEASURES (E.G. ODDS RATIO, RISK RATIO) AND IMPACT FRACTIONS
(E.G. POPULATION ATTRIBUTABLE RISK) ARE CLOSELY RELATED TO THE
STRENGTH OF ASSOCIATION

• THE HIGHER EFFECT MEASURES (AWAY FROM UNITY) AND POPULATION

ATTRIBUTABLE RISK (CLOSER TO 100 %) THE MORE THE EXPOSURE IS
PREDICTIVE OF THE OUTCOME IN QUESTION

• E.G. PAR OF 100 % MEANS THAT A FACTOR IS “NECESSARY”

DETERMINISTIC CAUSALITY (I)
DETERMINISTIC CAUSALITY (II)
DETERMINISTIC CAUSALITY (III)
DETERMINISTIC CAUSALITY (V)
DETERMINISTIC CAUSALITY (VI)
 WEIGHING EVIDENCE
• AT INDIVIDUAL LEVEL: CLINICAL JUDGMENT (WHICH MANAGEMENT
SCHEME)

• AT POPULATION LEVEL: EPIDEMIOLOGICAL JUDGMENT (WHICH

INTERVENTION)
• WHEN WEIGHING EVIDENCE FROM EPIDEMIOLOGICAL STUDIES, WE
USE “CAUSAL CRITERIA” (USUALLY APPLIED TO A GROUP OF
ARTICLES, TO DEAL WITH CONFOUNDING) E.G. HILL’S / SUSSER’S
CRITERIA, WHICH WERE PRECEDED BY KOCH’S POSTULATES (ON
INFECTIOUS DISEASES)
 HENLE-KOCH'S POSTULATES (1877,1882)
KOCH STATED THAT FOUR POSTULATES SHOULD BE MET BEFORE A CAUSAL
RELATIONSHIP CAN BE ACCEPTED BETWEEN A PARTICULAR BACTERIAL PARASITE
(OR DISEASE AGENT) AND THE DISEASE IN QUESTION. THESE ARE:

1. THE AGENT MUST BE SHOWN TO BE PRESENT IN EVERY CASE OF THE DISEASE BY

ISOLATION IN PURE CULTURE.
2. THE AGENT MUST NOT BE FOUND IN CASES OF OTHER DISEASE.
3. ONCE ISOLATED, THE AGENT MUST BE CAPABLE OF REPRODUCING THE DISEASE
IN EXPERIMENTAL ANIMALS.
4. THE AGENT MUST BE RECOVERED FROM THE EXPERIMENTAL DISEASE
PRODUCED.
 HILL'S CRITERIA (1897 - 1991)
THE FIRST COMPLETE STATEMENT OF THE EPIDEMIOLOGIC CRITERIA OF A CAUSALITY IS
ATTRIBUTED TO AUSTIN HILL (1897 - 1991). THEY ARE:

1. CONSISTENCY (ON REPLICATION)

2. STRENGTH (OF ASSOCIATION)

3. SPECIFICITY

4. DOSE RESPONSE RELATIONSHIP

5. TEMPORAL RELATIONSHIP (DIRECTIONALITY)

6. BIOLOGICAL PLAUSIBILITY (EVIDENCE)

7. COHERENCE

8. EXPERIMENT
CONSISTENCY (I)
 CONSISTENCY (II)
• META-ANALYSIS IS AN GOOD METHOD FOR TESTING CONSISTENCY. IT
SUMMARIZES ODDS RATIOS FROM VARIOUS STUDIES, EXCLUDES BIAS

• CONSISTENCY COULD EITHER MEAN:

• EXACT REPLICATION (AS IN LAB SCIENCES, IMPOSSIBLE IN

EPIDEMIOLOGICAL STUDIES)

• REPLICATION UNDER SIMILAR CIRCUMSTANCES (POSSIBLE)

STRENGTH OF ASSOCIATION
EXPRESSIONS OF STRENGTH OF ASSOCIATION
• QUANTITATIVELY:
• EFFECT MEASURE (OR, RR): AWAY FROM UNITY (THE
HIGHER, THE STRONGER THE ASSOCIATION)
• P-VALUE (AT 95% CONFIDENCE LEVEL): LESS THAN 0.05 (THE
SMALLER, THE STRONGER THE ASSOCIATION)
• QUALITATIVELY:
• ACCEPT ALTERNATIVE HYPOTHESIS: AN ASSOCIATION
BETWEEN THE STUDIED EXPOSURE AND OUTCOME EXISTS
• REJECT NULL HYPOTHESIS: NO ASSOCIATION EXISTS
DOSE-RESPONSE RELATIONSHIP (I)
DOSE-RESPONSE RELATIONSHIP (II)
TIME-ORDER (TEMPORALITY, DIRECTIONALITY)
TIME ORDER
SPECIFICITY OF OUTCOME
SPECIFICITY OF
EXPOSURE
 COHERENCE
• THEORETICAL: COMPATIBLE WITH PRE-EXISTING THEORY

• FACTUAL: COMPATIBLE WITH PRE-EXISTING KNOWLEDGE

• BIOLOGICAL: COMPATIBLE WITH CURRENT BIOLOGICAL KNOWLEDGE FROM OTHER

SPECIES OR OTHER LEVELS OF ORGANIZATION

• STATISTICAL: COMPATIBLE WITH A REASONABLE STATISTICAL MODEL (E.G. DOSE-

RESPONSE)
BIOLOGICAL COHERENCE (I)
BIOLOGICAL COHERENCE (II)
 SUSSER'S CRITERIA (I)

• MERVYN SUSSER (1988) USED SIMILAR CRITERIA TO JUDGE CAUSAL

RELATIONSHIPS.

• IN AGREEMENT WITH PREVIOUS AUTHORS, HE MENTIONED THAT TWO

CRITERIA HAVE TO BE PRESENT FOR ANY ASSOCIATION THAT HAS A CLAIM TO
BE CAUSAL: I.E. TIME ORDER (X PRECEDES Y); AND DIRECTION (X LEADS TO Y).
 SUSSER’S CRITERIA (II)
• REJECTION OF A HYPOTHESIS CAN ACCOMPLISHED WITH CONFIDENCE BY
ONLY THREE CRITERIA:

 TIME ORDER,

 CONSISTENCY,

 FACTUAL INCOMPATIBILITY

 INCOHERENCE.
ACCEPTANCE OR AFFIRMATION CAN BE ACHIEVED BY ONLY FOUR, NAMELY:

 STRENGTH,

 CONSISTENCY,

 PREDICTIVE PERFORMANCE,

 STATISTICAL COHERENCE IN THE FORM OF REGULAR EXPOSURE/EFFECT

RELATION.
COMPARISON OF CAUSAL CRITERIA