Jimma University,

Institute of health,
Faculty of public health,
Department of Epidemiology

Measures of Association and Public Health Impacts

By Mohammed Jihad (BSc, MPHE)

2022

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 Outlines
 Measures of Association
o Risk ratio/ RR
o Rate ratio/ IDR
o OR
 Measures of public health impacts
o AR
o AR%
o PAR
o PAR%
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 Types of association

• Positive/Negative
• Direct/Indirect
• Causal/Non causal

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 Types of association….

• Positive: Occurrence of higher value of a

predictor variable is associated with
occurrence of higher value of another
dependent variable.

Ex: education and suicide

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 Types of association….
• Negative–Occurrence of higher value of a
predictor variable is associated with lower value
of another dependent variable.
Ex – Female literacy and IMR

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 Types of association….
Direct
• Directly associated i.e. not via a known third variable.

Salt intake-------------- Hypertension.

Indirect
• Associated through a known third variable.

Salt intake  Hypertension CAD.

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 Types of association….
Causal
• Independent variable must cause change in dependent

variable.

Ex –salt intake and hypertension

Non-causal

• Non-directional association between two variables.

Ex –alcohol use and smoking

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Cumulative incidence ratio (also
called “risk ratio” or “relative risk”)
• The cumulative incidence ratio (CIR) addresses
the question “by how many times does the risk
in exposed persons exceed that for unexposed
persons?”
• If the CIR is 3, we can say that exposed persons
have 3 times the risk of unexposed persons.
• We can also say that the average exposed
individual has three times the risk of disease as
the average unexposed individual.
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 Cumulative incidence…..
•

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 Example 1.
Exposure = eating a particular food
Disease = gastroenteritis
Exposed C1 = 63 in 88 = 0.7159
Non exposed C0 = 1 in 7 = 0.1429
RR= 0.7159/0.1429 = 5

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 Cumulative incidence…..
• Interpretation: People who ate the meat had a
risk that was 5x high of those who didn’t
• Since the CIR is based on estimates of CI or
risk, the CIR can be estimated directly only
from a cohort study.
• CI provides a direct estimate of an individual's
risk, as may be useful for making clinical
and/or personal decisions.

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Incidence density ratio (also called “rate
ratio”)
• The incidence density ratio (IDR) addresses the
question “how many times does the rate of
disease in exposed persons exceed that in
unexposed persons?”. If the IDR is 3 we can say
that the rate in the exposed is 3 times that in the
unexposed.
• There is not an obvious interpretation at the
individual level, but the IDR is of prime
importance for studies of dynamic populations
and lengthy cohorts.
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 Incidence density…….
•

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 Odds ratio
• The odds ratio (OR) is a ratio of “odds”, which
are transformations of risks or probabilities.
• The ratio of the odds of a condition in the
exposed compared with the odds of the
condition of the unexposed
• Odds ratios are calculated from case-control
studies
• Sometimes it can also be calculated from
prevalence studies
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 Derivation of OR
• Probability of being exposed among cases = a/(a+c)
• Probability of being unexposed among cases = c/(a+c)
• Odds of being exposed among cases = a/c
• Probability of being exposed among controls = b/(b+d)
• Probability of being unexposed among controls = d/(b+d)
• Odds of being exposed among control = b/d

OR = ad/cb

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Measures of Public health impacts
1. Attributable risk: the amount of the risk in
the exposed group that is related to their
exposure.
• Attributable risk is estimated by the
cumulative incidence difference or incidence
density difference:
• AR = I1 – I0

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 Example 2
Exposure = eating a particular food
Disease = gastroenteritis
Risk in exposed R1 = 63 in 88 = 0.7159
Risk in no exposed R0 = 1 in 7 = 0.1429
AR = Risk in R1- Risk in R0 0.7159-0.1429
= .5730 or 57.3% increase of risk

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 Measures of Public……
2. Population attributable risk [absolute]: the
amount of risk in the population (i.e., in
exposed and unexposed persons taken
together) that is related to exposure.
• PAR = IT –IO
Where
• IO : Incidence among non exposed
• IT : Incidence total
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 Example 2
PAR = Itotal – Inonexposed
Diabetes IT = 1100 / 10000
Weight Yes No = 0.11 = 110 / 1000
Obese 850 3650 4500 INE = 250 / 5500
Slim 250 5250 5500 = 0.0455 = 45.5 / 1000

1100 8900 10000

PAR = (110 – 45.5) / 1000 = 64.5 / 1000

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Interpretation:

• In x population, 64.5 of the 110/1000

incident cases of diabetes are attributed to
obesity …
• In X population, 64.5 of the 110/1000
incident cases of diabetes that occur could
be prevented with sufficient weight loss.

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 Measures of Public……
•

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 AR% = (Iexposed – Inonexposed) / Iexposed =
“Etiologic fraction”
Develop CHD ISM = 84 / 3000
Smoke Yes No = 0.028 = 28.0 / 1000
Yes 84 2916 3000 INS = 87 / 5000
No 87 4913 5000 = 0.0174 = 17.4 / 1000

AR% = (28.0 – 17.4) / 28.0 = 37.9%

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AR% = (28.0 – 17.4) / 28.0 = 37.9%

Among SMOKERS, 38% of the morbidity

from CHD may be attributed to smoking…
Among SMOKERS, 38% of the morbidity
from CHD could be prevented if smoking
were eliminated.

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 Measures of Public……
4. Population attributable Risk Percent (also
often expressed as a percent) [PAF]: the
proportion (percent) of the risk in the
population that is related to the exposure.

PAR% = (Itotal – Inonexposed) / Itotal

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 IT = 1100 / 10000
Diabetes
Weight Yes No = 0.11 = 110 / 1000

Obese 850 3650 4500 INE = 250 / 5500

= 0.0455 = 45.5 / 1000
Slim 250 5250 5500

1100 8900 10000

PAR% = (110 – 45.5) / 110 = 58.6%
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PAR% = (110 – 45.5) / 110 = 58.6%

In x population, 59% of the cases of diabetes

may be attributed to obesity in the
population…
In x population, 59% of the cases of diabetes
could be prevented if x residents lost
sufficient weight.

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 References
• Boogaard, H., Walker, K., Cohen, A.J., 2019. Air pollution: the
emergence of a major global health risk factor. International
Health, 11, pp. 417-421. doi:10.1093/inthealth/ihz078.
• Ebi, K.L., Ogden, N.H., Semenza, J.C., Woodward, A., 2017.
Detecting and Attributing Health Burdens to Climate Change.
Environmental Health Perspectives. 125(8):085004. doi:
10.1289/EHP1509.
• Lee, J.Y., Lee, S.B., Bae, G.N., 2014. A review of the
association between air pollutant exposure and allergic
diseases in children. Atmospheric Pollution Research, 5, pp.
616-629.

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 References
• Rajagopalan, S., Al-Kindi, S.G., Brook, R.D., 2018.
Air Pollution and Cardiovascular Disease: JACC
State-of-the-Art Review. Journal of the American
College of Cardiology, 72, pp. 2054-2070. doi:
10.1016/j.jacc.2018.07.099.
• Schikowski ,T., Adam, M., Marcon, A., Cai, Y.,
Vierkötter, A., Carsin, A.E.,et al., 2014. Association
of ambient air pollution with the prevalence and
incidence of COPD. European Respiratory Journal,
44, pp. 614-626. doi:10.1183/09031936.00132213.
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 Reading List
• Principles of Epidemiology in Public Health
Practice
– https://www.cdc.gov/csels/dsepd/ss1978/lesson1
/section1.html

• Gordis Epidemiology, 6th Edition (Celentano

and Szklo 2019)

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The End!

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