MEASURES OF ASSOCIATION

AND IMPACT

Presenters,
Mdent, Msc(Microbiology&Immunology, Anatomy,
Physiology,Microbiology Histotechnology). Mmed
(Microbiology &Immunology, Urology and Anaesthesia).

Facilitator: Dr.Mucho
Objectives

At the end of session participants should be

able to:
» Describe measures of association between
risk factors (Exposure) and diseases.
» Interpret measures of Association
» Describe measures of Impact
» Interpret measures of impact
 Introduction
Measure of association (syn. measure of
effect) is a statistic that quantifies the
relationship between an exposure and a
disease| outcome.

Measure of potential impact is a statistic

that quantifies the potential impact of
removing a hazardous exposure.
 To identify any association
 exposures and outcome must first be measured in
quantitative manner.
 Association between exposure and outcome is then
evaluated using measures of association /effect
 The impact of removing an exposure on outcome is
evaluated by computing measures of potential
impact
 Measure of Measure of Measure of
disease frequency association potential impact

•Attributabl
•Relative risk
• Prevalence
•Risk difference e fraction
•
•
Incidence rate
Cumulative incidence
•Rate difference •Population
•Odd ratio
•Odd difference
attributable
fraction
 Terminologies
• Exposure (E)  an explanatory factor; any potential
health determinant; the independent variable

• Disease (D)  the response; any health-related outcome;

the dependent variable
• Prevalence(P): proportion of people in a define
population that has the outcome at a specific point in
time.

• Risk (R): relate the number of new cases to the size of

the population at risk at the beginning of the period
studied
Terminologies
• Rate: relate the number of new cases to
the person-time at risk , taking into
account changes in the size of the
population at risk during follow-up.

• Odds: Is ratio of people who get the

disease to people who do not get the
disease
Prevalence= Number of cases
Total population at time t

Rate = Number of new cases

Total person-time at risk

Risk = Number of new cases

Population initially at risk

Number of new cases in a defined time period

Odds =
Number of non-cases during that period
 Example: Risk V/s Odds
Observe a lecture theatre of 200 students for
1 hour: outcome of interest is sneezing at
least once
- 50 students sneeze during lecture

 The Risk of sneezing is 50/200=0.25(or

25%)

 The Odds of sneezing 50/150=0.33

  Measures of association/effect
Quantifies the extent to which a change in the
value of one variable is related to a change
in the value of another variable
There are two types
1.Ratio measures 2.Difference measures
(Relative measures) (Absolute measure)
 Risk Ratio,  Risk Difference,
 Odds Ratio,  Rate Difference,
 Rate Ratio,  Prevalence difference
 Ratio measures
(Rate ratios, risk ratios, odds ratio)

 Are all ratio measures of effect

 Sometimes used interchangeably
 May also be referred to as relative measures
e.g relative risk
 Have different properties and are derived
from different study types
Can be calculated by the formula
Rate or risk or odds in exposed (r1)
Rate or risk or odds in unexposed (r0)

NOTE
Incidence risk ratio=Risk ratio
Incidence rate ratio=Rate ratio
 RISK RATIO
» Measures the magnitude of the effect of a
risk factor on incidence of disease: the
strength of the association between a risk
factor and a disease.

» Risk in exposed group divided by risk in

unexposed group i.e. RR = Re/Ru = CIe / CIu.
 Example
DISEASE/OUTCOME
DISEASED NON TOTAL
EXPOSURE

DISEASED

EXPOSED
a b a+b

c d c+d
UNEXPOSED
 Risk in exposed
» Relative risk = --------------------
(Risk ratio) Risk in unexposed

a/(a +b)
= c/(c +d)
 Interpretation of risk ratio
If RR is;
 1= No association between Exposure and
outcome
Incidence risk are identical between groups
 > 1= Positive association
Exposed group has higher incidence than non
exposed group
 < 1= Negative association or protective effect
Non exposed group has higher incidence than
exposed group
Example cont..
» Percent of Relative Effect can be calculated as
follows:
» (RR-1) X100%

» So from the above example :

» (1.39-1) X 100% = 39%
» Therefore women who use OC's are 39% more
likely to develop bacteriuria (over 1 year)
compared with women who do not use OC's.
 Protective effects
• Ratio effect measures less than 1 indicate
that the exposure is associated with a lower
risk of the outcome
• Example: comparing vegetarians to meat
eaters
• Risk of obesity among vegetarians=12%
• Risk of obesity among meat-eaters=17.1%
• Risk-ratio=12%/17%=0.7
 Protective effects
• Vegetarians have a lower risk of obesity
• Vegetarians have 0.7 times the risk of
obesity compared to non-vegetarians
• Vegetarians have 30% less obesity
compared to non-vegetarians
 Rate Ratios
» Rate ratios are closely
related to risk ratios
» they are computed as
the ratio of the
incidence rate in an
exposed group divided
by the incidence rate
in an unexposed
 Example
» Consider an example from The Nurses' Health Study.
This prospective cohort study was used to investigate the
effects of hormone replacement therapy (HRT) on
coronary artery disease in post-menopausal women.

» The investigators calculated the incidence rate of

coronary artery disease in post-menopausal women who
had been taking HRT and compared it to the incidence
rate in post-menopausal women who had not taken HRT.
The findings are summarized in the TABLE BELOW
 Summary
Post coronary Person
menopausal heart years of
hormone use disease disease free
follow -up
YES 30 54,308.7

NO 60 51,477.5
 Cont..
» The rate in those using hormones was 30 / 54,308.7 = 55.2 per 100,000
person-years
» The rate in those NOT using hormones was 60 / 51,477.5 = 116.6 per
100,000 person-years.
» So, the rate ratio was 0.47.

» Interpretation: Women who used postmenopausal hormones had 0.47 times

the rate of coronary artery disease compared to women who did not use
postmenopausal hormones.

» (Rate ratios are often interpreted as if they were risk ratios, e.g., post-
menopausal women using HRT had 0.47 times the risk of CAD compared
to women not using HRT, but it is more precise to refer to the ratio of rates
rather than risk.)
Odds Ratio
» The odds ratio is the measure of association for
a case-control study. It tells us how much
higher the odds of exposure is among cases of
a disease compared with controls.
» It compares the odds of exposure to the factor
of interest among cases to the odds of exposure
to the factor among controls.
 Example
DISEASE
Sick Well
EXPOSURE

Exposed a b

Unexposed c d
 Odds Ratio

• = Odds of diseased in exposed group

Odds of diseased in unexposed (control)
Odds ratio = ad/ bc
 Example 2. OR calculation: Incidence of
Hypertension
Hyper by tobaccoTotal
Normo use
tensive tensive

tobacco use 16 34 50

No tobacco 133 298 431

use

OR =
1.05
Interpretation.
» The odds of hypertension in tobacco users
is 1.05 times the odds of hypertension in
non-tobacco users.
Odds Ratio Interpretation
 Why use Odds?
» In case-control studies we don’t know the
incidence of a disease in exposed or
unexposed since we start with diseased
(cases) and non diseased (controls).
» Therefore, we cannot directly calculate
incidence (probability of disease).
» We don’t know the size of the population at
risk of developing the disease of interest
» We use the odds ratio to determine whether
exposure is associated with disease.
Risk ratio vs Odds Ratio
» In a cohort study you can calculate either a risk
ratio or an odds ratio, but in a case-control study:
you can only calculate an odds ratio.
» As the outcomes of interest become more
common, the odds ratio gives estimates that are
increasing more extreme than the risk ratio would
have been. i.e. odds ratios that are greater than
1 will be larger than the corresponding risk ratio,
and odds ratios that are less than 1 will be
smaller than the corresponding risk ratio.
EXAMPLE
DISEASED NON - TOTAL
DISEASED

EXPOSED 60 108 168

NOT EXPOSED 45 341 386

 Measures of difference
• Estimate the excess risk /absolute risk
caused by exposure in the exposed group
 Risk difference (RD)
 The risk difference focuses on absolute
effect of the risk factor, or the excess risk
of disease in those who have the factor
compared with those who don't ( i.e.
Estimate the excess risk caused by
exposure in the exposed group)
= "Excess risk"
= Attributable risk
• Risk difference= Riskexposed - Risk unexposed
 Rate difference
» Analogous to the risk
difference, the rate
difference is
calculated by (IRe) = incidence rate
subtracting the among the exposed
incidence rate in the subjects
unexposed group (IRu) is the incidence
from the incidence rate among unexposed
rate in the group with subjects
the exposure.
EXAMPLE
» Consider an example from The Nurses' Health
Study. This prospective cohort study was used to
investigate the effects of hormone replacement
therapy (HRT) on coronary artery disease in post-
menopausal women. The investigators calculated the
incidence rate of coronary artery disease in post-
menopausal women who had been taking HRT and
compared it to the incidence rate in post-menopausal
women who had not taken HRT. The findings are
summarized in this table:
 Example
Post |with Person
menopausal coronary years of
hormone use heart disease free
disease follow -up
YES 30 54,308.7

NO 60 51,477.5
» The rate in those using hormones was 30 /
54,308.7 = 55.2 per 100,000 person-years
» The rate in those NOT using hormones was 60 /
51,477.5 = 116.6 per 100,000 person-years.
» Rate difference= 55.2-116.6= -61.4

» Interpretation: Women who used postmenopausal

hormones had 61.4 less cases of coronary artery
disease per 100,000 person-years compared to
women who did not use postmenopausal
hormones.
Relative measures VS Absolute measures

» Provides
Relative Risk two perspective in the same info
Risk difference
i.e risk ratios, rate ie. absolute risk
ratios & odds ratio
Provides a measure Provides a measure of the
of the strength of the public health impact of the
association btn a risk factor and focuses on the
# of cases that could
factor and a disease potentially be prevented by
outcome eliminating the risk factor
Measures of Public Health Impact
Options for comparing disease frequencies
(Revision)

1. Ratio of two independent measures of disease

frequency. (RR and OR).

2. Difference between a measure in an exposed group and

a measure in unexposed (or less exposed) comparison
group)

3. Proportion by which the exposure of interest is estimated

to be potentially responsible for the measure of disease
frequency in the exposed group or in the entire
population from which the exposed group is drawn.
Options for comparing disease frequencies (Ratio,
revision)

Association measures (compare exposed vs. unexposed)

Relative risk
Cohort studies
Can calculate incidence

Odds ratio
Case-control study & cross sectional study.

Indicate: Strength of association between exposure &

outcome
Options for comparing disease frequencies
(Today)

 Compare disease frequency by calculating:

Absolute Comparison (Difference)

Proportion

 Measures of public health impact

Still comparing occurrence of disease between exposed & unexposed or between the whole
population & unexposed group
 Why study measures of impact
 Place an association between exposure and
outcome in meaningful public health context.

 Trying to address the Q:

What is the proportion of disease that will be reduced by
eliminating or controlling a particular exposure?

Quantifies expected reduction in disease occurrence if

harmful exposure could be eliminated
 Why study measures of impact
 Measure preferred by policy makers

Try to estimate the number of people who will be spared the

consequence of the exposure (exposed & population)

Answer so what Q especially for the decision

makers
 Four measures of PH
Impact
 Attributable risk (AR) Number

 Attributable risk percent (AR%) Percentage

 Population attributable risk (PAR) Number

 Population attributable risk percentage (PAR

%)
Percentage
 Measures of Public Health
Impact

All have Important Assumption

They all assume (require) that a cause-effect

relationship exists between the exposure and
the outcome
 Measures of PH
Impact
 Proportion  Absolute
 Attributable risk %/  Attributable risk /
attributable fraction
risk difference/
of the exposed/
excess risk (for
etiological fraction of exposed group)
the exposed
 Population
attributable risk  Population attributable
percentage risk (total population)

» Proportion of cases
» Number of cases attributed
» attributed to exposure
1. Attributable risk (Risk difference/
excess risk)

 Excess risk of disease in those exposed

compared to those non-exposed
AR= Ie – Io

 RD is both a measure of association and

measure of impact
(Unexposed group represent baseline risk for disease even
when the exposure is not present)
Example attributable risk
(Risk difference)

Develop CHD
Yes No

Smoke Yes 84 2916 3000

No 87 4913 5000

Calculate risk difference or attributable risk

and intepret the results
 Example
1
(Risk difference)
 Incidence CHD smokers
84/3000 = 0.028
28 per 1,000
 Incidence CHD non-smokers (background risk)
87/5,000 = 0.0174
17.4 per 1,000

AR/RD = (28-17.4)/1,000 = 10.6 per 1,000

 Attributable risk (meaning)

Number of cases of the disease among

EXPOSED that are attributed to the
exposure
or
Incidence of disease / Number of cases of the
disease among EXPOSED that can be
eliminated if the exposure is eliminated
Assume: smoking is causal associated with CHD
 Example 2

 Data from a cohort study of smoking and

hypertension

Hypertension
Smoking Yes No Total

Yes 120 280 400

No 30 570 600
Total 150 950 1000
 AR, example
2
 AR = 0.30 – 0.05  25 per 100
Among smokers, 25 of the 30 per 100
incident cases of hypertension are
attributed to the fact these women smoked

Among smokers, potentially 25 of the 30 per

100 incident cases of hypertension that
occurred could be prevented if they
stopped smoking
Attributable risk percentage
Attributable risk percent (%)
 Attributable fraction of the exposed (AF) or
etiological fraction of the exposed

 Provides answers to:

 What proportion of cases or disease among the

exposed …
 can be attributed to the exposure?
 could be avoided by eliminating the exposure?
 How to calculate AR
%

AR% = (Incidence exposed – Incidence unexposed )

Incidence exposed

= (RR - 1)/RR

Synonyms
Attributable fraction among the exposed
Etiologic fraction (EF) of the exposed
Example
1
(AR % or etiological fraction)

Develop CHD
Incidence
Yes No

Smoke Yes 84 2916 3000 Ie

=0.028
No 87 4913 5000 Io =
0.0174

Calculate attributable risk percent and intepret

the results
 AR
%
 Incidence CHD smokers
28 per 1,000
 Incidence CHD non-smokers (background risk)
17.4 per 1,000

AR % = (28-17.4)/28 *100
= 37.9%
Example
2
(AR % or etiological fraction)

Develop Hypertension
Incidence
Yes No

Smoke Yes 120 280 400 Ie =0.30

No 30 570 600 Io =
0.05

Calculate attributable risk percent and

intepret the results
 Example 2: AR%
 Incidence hypertension in smokers
30 per 100
 Incidence hypertension in non-smokers (background
risk)

5 per 100

AR % = (30-5)/30 *100
= 83.3% (Intepretation??)
 Example 2: AR
%
 AR% 83.3%

 Among smokers: 83% of the morbidity due to

hypertensive may be attributed to
smoking

 Among smokers: 83% of the morbidity due to

hypertension could be prevented if smoking
was eliminated
 Use of AR and AR%
 Relevant when making decisions for
individuals
e.g. In evaluating to participate in dangerous sport
you weight AR of injury vs. pleasure of
participation or motorcycle driving and accidents

 Interesting to clinicians
Population Measures (PAR, PAR
%)
 Compare whole population in the study and
unexposed group

 Impact: what proportion of disease in

the total population would be prevented
if exposure is eliminated?

 Valuable concept for public health worker

 Example (PAR, PAR
%)
 We know how to eliminate smoking in our city (in
relation to lung cancer).
 Approach major, with effective way and a plan to
eliminate smoking, we need her to fund the
program
 She is delighted but asks ”what will the impact of your
smoking cessation program be on lung cancer incidence
rate in our city or in the whole population?”
 Population Impact
Measures
(PAR, PAR%)

 Interest to policy makers (answer the

question ’so what’)

 Of interest to those who wants to fund

preventive programs or if you have
competing problems
How is the program going to change the burden of disease in the entire
community, not just in exposed individuals
 PAR and PAR%
Formula
 PAR (Population attributable risk)
(Incidence in population – Incidence in non-exposed)
(Ip - Io)

 PAR %
(Incidence in population – Incidence in non-exposed)
(Incidence in total population)
 PAR and PAR%

 Example

We want to estimate how much how

much of the burden of diabetes among
a certain city (Tampa) is attributed by
obesity
Example
(PAR)
1
Diabetes
Yes No
Obese 850 3650 4500
Weight
Slim 250 5250 5500
1100 8900 10,000

Calculate population attributable risk and

intepret the results
 Population Attributable Risk Percent (PAR
%)
Population etiological fraction

 PAR expressed as a percentage of total

risk in population
 PAR% is affected by prevalence of disease
in whole population

PAR% 
I population- I unexposedx
Ipopulation
100
Example population attributable risk %
(PAR % or population etiological fraction)

Diabetes
Yes No

Weight Obese 850 3650 4500

Slim 250 5250 5500
1100 8900 10,000

Calculate population attributable risk

percentage and intepret the results
Assumption: obesity is causal related to diabetes
 Example 3
(PAR % or population etiological fraction)

Develop Hypertension
Incidence
Yes No

Smoke Yes 120 280 400 Ie =0.30

No 30 570 600 Io =
0.05

Calculate Population Attributable Risk

percent and intepret the results
 Example 3: PAR%
 Incidence hypertension in total population
150/ 1000
15 per 100
 Incidence hypertension in non-smokers (background
risk)

5 per 100

PAR % = (15-5)/15 *100

= 66.6% (Intepretation??)
 Example 3: PAR%
 PAR% 66.6%
 In the total population: 67% of the hypertension
can be attributed to smoking

 67% of the hypertension cases in the

population could be prevented if smoking was
eliminated

AR = 83.3%; PAR = 66.6% why???

 Relative Risk vs. Attributable
risk
 Relative risk:
 Measure of strength of association.
 Indicator used to assess possibility of a causal
relationship

 Attributable risk:
 Measure of the potential for prevention of disease if
the exposure could be eliminated (assuming a causal
relationship)
 Use of RR vs. Attributable
risk/PAR
 Relative risk:
 Etiology

 Attributable risk:
 Policy decisions
 Funding decisions (e.g. prevention programs)
Example compare fast driving vs drinking
and driving in causing accidents

 What proportion of automobile-related

deaths in the population & in the
exposed group are due to fast driving?

 What proportion of automobile-related

deaths in the population & in the
exposed group are due to driving while
drunk?
 Population Attributable Risk %:
Fast driving (Prev: 2000 /10000= 20%)
Dead Not dead

Fast 100 1900 2000

Slow 80 7920 8000 Risk unexposed=80/8000=0.010

180 9820 10000 Risk overall=180/10000=0.018

PAR%=
(Risk overall-Risk unexposed)/Riskoverall

= (0.018 - 0.010) / 0.018

= 44%
Population Attributable Risk%:
Driving while drunk (Prev: 300 /10000= 3%)

Dead Not dead

Drunk 45 255 300

Not
Drunk 135 9565 9700 Risk unexposed=135/9700=0.014

1809820 10000 Risk overall=180/10000=0.018

PAR=(Risk overall-Risk unexposed)/Riskoverall

= (0.018 - 0.014) / 0.018

= 22%
 Summary
Driving Fast Driving while Drunk

Relative risk 5.0 10.7

Risk difference 4% 13.6%

Attributable risk % 80% 91%

% all drivers with

20% 3%
risk (prevalence)
Population
44% 22%
attributable risk
Where will you put your money to have the
greatest impact for reducing automobile-related
deaths?
 QUESTION??

Where will you put your money

to have the greatest impact for
reducing automobile-related
deaths?
 End
 Measure of Measure of
Question
association impact

How much the

RR / OR Yes No
association could
be?

What is the excess risk

Risk difference Yes Yes between exposed and
unexposed persons?

What proportion of the

exposed persons had an
Attributable risk % No Yes
outcome presumably due
to the exposure?

What proportion of
Population attributable persons in the total
No Yes
Risk% population had the
outcome presumably
because of the exposure?
 REFERENCES
» Beaglehole et al. Basic epidemiology.WHO,Geneva,
1993. Chapter 2, pp14-30
» Last JM. A dictionary of epidemiology (4th Edition).
Oxford: OUP, 2001
» Kleinbbaum DG et al. Epidemiologic research. New
York: Van Nostrand Cia, 1982. Chapter 8
» Rockhill B, Newman B, Weinberg C. Use and misuse
of population attributable fractions. AmJ Public
Health 1998; 88; 15-19