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10-Measures of Risk and Association

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10-Measures of Risk and Association

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kazemhadi2001
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16/11/2023

Measures of Risk and Association

Saad Ibrahim Al-Ghabban*


*Department of Family and Community Medicine, College of Medicine, University of Al-Ameed,
Karbala, Iraq

Measures of risk and association (1)


Risk is Probability of occurrence or like hood to develop disease (health event) in time, and
association is the statistical relationship between two (or more) variables. The measures of risk and
association are:
1. Absolute risk
2. Relative risk (RR)
3. Attributable risk (AR)
4. Attributable risk percentage (AR %)
5. Odds ratio (OR)
1. Absolute risk
The incidence of a disease in a population is termed the absolute risk. Absolute risk can indicate
the magnitude of the risk in a group of people with a certain exposure, but because it does not
take into consideration the risk of disease in non-exposed individuals, it does not indicate
whether the exposure is associated with an increased risk of the disease.
𝐴𝑏𝑠𝑜𝑙𝑢𝑡𝑒 𝑅𝑖𝑠𝑘 = 𝐼𝑛𝑐𝑖𝑑𝑒𝑛𝑐𝑒
2. Attributable risk
Attributable risk (Excess risk) is the degree of risk of developing the condition that is attributable
to that characteristic. It is the rate of a particular condition among people who have a particular
characteristic minus the rate of the condition among people who do not have the characteristic
𝐴𝑡𝑡𝑟𝑖𝑏𝑢𝑡𝑎𝑏𝑙𝑒 𝑟𝑖𝑠𝑘 = 𝐼𝑛𝑐𝑖𝑑𝑒𝑛𝑐𝑒 𝑖𝑛 𝑒𝑥𝑝𝑜𝑠𝑒𝑑 𝑔𝑟𝑜𝑢𝑝 − 𝐼𝑛𝑐𝑖𝑑𝑒𝑛𝑐𝑒 𝑖𝑛 𝑛𝑜𝑛 − 𝑒𝑥𝑝𝑜𝑠𝑒𝑑 𝑔𝑟𝑜𝑢𝑝
If, for example, the rate of a condition is 20 per 100,000 in heavy smokers and 15 in nonsmokers,
the risk attributable to smoking = 20 per 100,000 minus 15 per 100,000, or 5 per 100,000.
It measures the proportion of the disease that could be prevented by eliminating the exposure in
the exposed group (attributable fraction, etiologic fraction) & if exposure is preventive
(preventive fraction). Attributable Risk is a measure of the public health impact of risk factor on
disease & is used to assess the impact of eliminating a risk factor.

Table 1. Interpretation of attributable risk

3. Attributable risk percentage (AR%)


The attributable risk percent also known as the attributable proportion, is a measure of the public
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16/11/2023

health impact of a causative factor. The calculation of this measure assumes that the occurrence
of disease in the unexposed group represents the baseline or expected risk for that disease. It
further assumes that if the risk of disease in the exposed group is higher than the risk in the
unexposed group, the difference can be attributed to the exposure. Thus, the attributable
proportion is the amount of disease in the exposed group attributable to the exposure. It
represents the expected reduction in disease if the exposure could be removed (or never
existed).(2)

𝐼𝑛𝑐𝑖𝑑𝑒𝑛𝑐𝑒 𝑖𝑛 𝑒𝑥𝑝𝑜𝑠𝑒𝑑 𝑔𝑟𝑜𝑢𝑝 − 𝐼𝑛𝑐𝑖𝑑𝑒𝑛𝑐𝑒 𝑖𝑛 𝑛𝑜𝑛 𝑒𝑥𝑝𝑜𝑠𝑒𝑑 𝑔𝑟𝑜𝑢𝑝


𝐴𝑅% = ∗ 100
𝐼𝑛𝑐𝑖𝑑𝑒𝑛𝑐𝑒 𝑖𝑛 𝑒𝑥𝑝𝑜𝑠𝑒𝑑 𝑔𝑟𝑜𝑢𝑝
4. Relative risk (RR):
It is a ratio that measures the risk of disease among the exposed to the risk of disease among non-
exposed; it compares the rate of a condition in one group with its rate in another group.

𝐼𝑛𝑐𝑖𝑑𝑒𝑛𝑐𝑒 𝑖𝑛 𝑒𝑥𝑝𝑜𝑠𝑒𝑑 𝑔𝑟𝑜𝑢𝑝


𝑅𝑅 =
𝐼𝑛𝑐𝑖𝑑𝑒𝑛𝑐𝑒 𝑖𝑛 𝑛𝑜𝑛 𝑒𝑥𝑝𝑜𝑠𝑒𝑑 𝑔𝑟𝑜𝑢𝑝
For example, if the death rate from tuberculosis is 10 per 100,000 in males and 5 per 100,000 in
females, then the relative risk of dying from tuberculosis is twice as great for males as for
females. (10 per 100,000 / 5 per 100,000 = 2)
Both relative and attributable risks are frequently used in cohort study.
For the interpretation of relative risk, consider the following Table 2
Table 2. Interpretation of relative risk

Table 3 shows the Analysis of cohort study using the general format and notation for a
two-by-two table
Table 3. Analysis of cohort study
Disease
Present (+) Absent (-) Incidence
Exposed a b a/ (a + b)
Not exposed c d c/ (c+ d)
[𝑎(𝑎 + 𝑏)]
RR =
[𝑐/ (𝑐+ 𝑑)]
AR = [𝑎(𝑎 + 𝑏)] - [𝑐/ (𝑐 + 𝑑)]
[𝑎(𝑎 + 𝑏)] − [𝑐/ (𝑐 + 𝑑)]
𝐴𝑅% = ∗ 100
[𝑎/ (𝑎 + 𝑏)]
Table 4 and Figure 1 show an example for calculation and Interpretation of the relative risk;

Table 4. Calculation of the relative risk

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Figure 1 Interpretation of the relative risk

5. Odds ratio (OR)(3, 4)


An odds ratio (OR) is another measure of association that quantifies the relationship between an
exposure with two categories and health outcome. Odds ratio is frequently used in case control
studies and can be used in cross sectional study. It is the ratio that measures the odds of exposure
for cases compared to controls; Odds of exposure = number exposed / number unexposed. Odds
ratio is the Odds of exposure for cases divided by the Odds of exposure for controls.

𝑂𝑑𝑑𝑠 𝑜𝑓 𝑒𝑥𝑝𝑜𝑠𝑢𝑟𝑒 𝑓𝑜𝑟 𝑐𝑎𝑠𝑒𝑠


𝑂𝑑𝑑𝑠 𝑟𝑎𝑡𝑖𝑜 =
𝑂𝑑𝑑𝑠 𝑜𝑓 𝑒𝑥𝑝𝑜𝑠𝑢𝑟𝑒 𝑓𝑜𝑟 𝑐𝑜𝑛𝑡𝑟𝑜𝑙𝑠

𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑝𝑒𝑟𝑠𝑜𝑛𝑠 𝑒𝑥𝑝𝑜𝑠𝑒𝑑 𝑎𝑛𝑑 𝑤𝑖𝑡ℎ 𝑑𝑖𝑠𝑒𝑎𝑠𝑒 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑝𝑒𝑟𝑠𝑜𝑛𝑠 𝑒𝑥𝑝𝑜𝑠𝑒𝑑 𝑏𝑢𝑡 𝑤𝑖𝑡ℎ𝑜𝑢𝑡 𝑑𝑖𝑠𝑒𝑎𝑠𝑒
OR= ( 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑝𝑒𝑟𝑠𝑜𝑛𝑠 𝑢𝑛𝑒𝑥𝑝𝑜𝑠𝑒𝑑 𝑏𝑢𝑡 𝑤𝑖𝑡ℎ 𝑑𝑖𝑠𝑒𝑎𝑠𝑒) / ( 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑝𝑒𝑟𝑠𝑜𝑛𝑠 𝑢𝑛𝑒𝑥𝑝𝑜𝑠𝑒𝑑: 𝑎𝑛𝑑 𝑤𝑖𝑡ℎ𝑜𝑢𝑡 𝑑𝑖𝑠𝑒𝑎𝑠𝑒})

For the interpretation of odds ratio, consider the following Table 5

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Table 5. Interpretation of odds ratio

Table 6shows the Analysis of case-control study using the general format and notation for a two-by-
two table
Table 6. analysis of case-control studies
Exposure
Exposed Not exposed
Odds of exposure

Cases a b a/b
Controls c d c/d

Table 7, Figure 2, and Figure 3 show example for calculation and Interpretation of the odds ratio
respectively.

Table 7. Calculation of the odds ratio

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16/11/2023

Figure 2. Interpretation of the odds ratio

Figure 3. Interpretation of the odds ratio


For the strength of the association as concluded by relative risk dds ratio consider Table 6

Table 8. Strength of the association

References:
1. Charles Faselis. USM LE Step 1 • Behavioral Science. 2013.
2. CDC. Principles of Epidemiology _ Lesson 3 - Section 6. Measures of Public Health Impact. 2012.
3. Michael Harris GT. Medical Statistic Made Easy: Taylor & Francis e-Library; 2004.
4. CDC. Principles of Epidemiology _ Lesson 3 - Section 5. Measures of Association. 2012.

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