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Measures of Public Health Impact

This document discusses measures used to quantify the public health impact of exposures, including attributable risk (AR), attributable risk percent (AR%), population attributable risk (PAR), and population attributable risk percent (PAR%). It defines each measure and provides examples of how to calculate them from epidemiological data. It also distinguishes between relative risk and attributable risk and discusses how these measures can inform public health interventions and prevention policies.

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71 views

Measures of Public Health Impact

This document discusses measures used to quantify the public health impact of exposures, including attributable risk (AR), attributable risk percent (AR%), population attributable risk (PAR), and population attributable risk percent (PAR%). It defines each measure and provides examples of how to calculate them from epidemiological data. It also distinguishes between relative risk and attributable risk and discusses how these measures can inform public health interventions and prevention policies.

Uploaded by

Blackstar
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PPT, PDF, TXT or read online on Scribd
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Measures of Public

Health Impact
Learning Objectives:

1. Calculate and interpret measures of public


health impact:
--- Attributable risk
--- Attributable risk percent
--- Population attributable risk
--- Population attributable risk percent
2. Differentiate between attributable risk and
relative risk.
3. Differentiate between high-risk and
population-based approaches to disease
prevention.
Measures of Public Health Impact

• Attributable Risk (AR) Number


• Attributable Risk Percent (AR%) Percentage
• Population Attributable Risk (PAR) Number
• Population Attributable Risk Percent
(PAR%) Percentage
Measures of Public Health Impact

IMPORTANT!

They all assume (require) that a cause-


effect relationship exists between the
exposure and the outcome.
Relative Risk vs. Attributable Risk

Relative Risk: Measure of the strength of


association, and indicator used to
assess the 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).
Relative Risk vs. Attributable Risk

Relative Risk:
• Etiology
Attributable Risk:
• Policy decisions
• Funding decisions
(e.g. prevention programs)
Measures of Public Health Impact

Attributable Risk:
Refers to EXPOSED persons.
Population Attributable Risk:
Refers to both EXPOSED and
NONEXPOSED persons.
Attributable Risk (AR)

Among the EXPOSED:


How much of the disease that occurs can
be attributed to a certain exposure?
AR
AR%
This is of primary interest to the practicing
clinician.
Attributable Risk (AR)
AR = Iexposed – Inonexposed = “Risk Difference”

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
(background risk)

AR = (28.0 – 17.4) / 1000 = 10.6 / 1000


Attributable Risk (AR)
AR = (28.0 – 17.4) / 1000 = 10.6 / 1000

Among SMOKERS, 10.6 of the 28/1000


incident cases of CHD are attributed
to the fact that these people smoke …
Among SMOKERS, 10.6 of the 28/1000
incident cases of CHD that occur
could be prevented if smoking were
eliminated.
Attributable Risk Percent (AR%)
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
(background risk)

AR% = (28.0 – 17.4) / 28.0 = 37.9%


Attributable Risk Percent (AR%)
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.
Discussion Question

If 38% of the morbidity from CHD is due


to smoking, it seems as if we found many
factors causally related to CHD,
the attributable risk for all factors
combined could exceed 100%
How can this be?
Sufficient Sufficient Sufficient
Cause I Cause II Cause III

U U U

A B A E B E

Accounts for Accounts for Accounts for


50% of dx cases 30% of dx cases 20% of dx cases

If we can prevent any of the factors:


U = 100% reduction in disease occurrence
A = 80% reduction in disease occurrence
B = 70% reduction in disease occurrence
E = 50% reduction in disease occurrence
Discussion Question

If we can prevent any of the factors:


U = 100% reduction in disease occurrence
A = 80% reduction in disease occurrence
B = 70% reduction in disease occurrence
E = 50% reduction in disease occurrence
(U + A + B + E) =300%

Hence, because of multi-factorial etiology and


multiple sufficient causes (mechanisms), the
sum of the individual ARs for each causal
factor can exceed 100%.
Population Attributable Risk (PAR)
Among the EXPOSED and NONEXPOSED
(e.g. total population):
How much of the disease that occurs
can be attributed to a certain exposure?
PAR
PAR%
This of interest to policy makers and those
responsible for funding prevention
programs.
PAR and PAR%

Example:
We want to estimate how much of
the burden of diabetes among
Karachites is attributed to obesity.
PAR and PAR%

CAUTION!
In order to calculate PAR and PAR%, we
have to be reasonably sure that the
results of the study can be generalized
to the population of Karachi

(e.g the incidence rates drawn from the


sample approximate the incidence rates
in the entire population).
Population Attributable Risk (PAR)
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 (background risk)

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


Population Attributable Risk (PAR)

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

In Karachi, 64.5 of the 110/1000 incident


cases of diabetes are attributed to
obesity …
In Karachi, 64.5 of the 110/1000 incident
cases of diabetes that occur could be
prevented with sufficient weight loss.
Population Attributable Risk Percent
PAR% = (Itotal – Inonexposed) / Itotal

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

Obese 850 3650 4500 INE = 250 / 5500


Slim 250 5250 5500 = 0.0455 = 45.5 / 1000
(background risk)
1100 8900 10000
PAR% = (110 – 45.5) / 110 = 58.6%
Population Attributable Risk Percent
PAR% = (110 – 45.5) / 110 = 58.6%

In Karachi, 59% of the cases of diabetes


may be attributed to obesity in the
population…
In Karachi, 59% of the cases of diabetes
could be prevented if Karachi
residents lost sufficient weight.
Measures of Public Health Impact
NOTE!
Both attributable and population
attributable risks should be cautiously
interpreted.
In reality, even if an exposure is causal,
we do not know whether it truly
contributed to disease occurrence in
all exposed persons -- in some
exposed persons, other causal factors
may have been entirely responsible.
Calculating Measures of
Public Health Impact
(Case-Control Studies)
Measures of Public Health Impact

 They are based on measures of incidence.

 We can calculate incidence measures from


case-control studies only under special
circumstances.
 Therefore, the AR and PAR cannot usually
be calculated from case-control data.
 However, for most case-control studies, we
can calculate the AR% and PAR%.
AR% (Case-Control Studies)

(OR – 1)
AR% = ----------- x 100
OR
Example: AR% (Case-Control Studies)
Case-control study to evaluate the impact of
smoking as related to bladder cancer.

Bladder Cancer
(160 / 90)
Smoke Yes No OR = ------------
Yes 160 120 (120 / 200)
No 90 200 = 2.96
Example: AR% (Case-Control Studies)
Question: Among smokers, what proportion
(percent) of bladder cancer cases can be
attributed to their smoking habit?

(OR – 1)
AR% = ----------- x 100
OR

AR% = ((2.96 – 1) / 2.96) x 100 = 66.2%


Example: AR% (Case-Control Studies)
 66% of bladder cancer cases among
smokers can be attributed to their
smoking.
 66% of bladder cancer cases among
smokers could be prevented if they
had never taken up smoking.
(Assuming there is a causal
association between smoking and the
development of bladder cancer).
Issues in Prevention Policy
An important question in prevention is
whether the approach should target
specific groups known to be at high
risk, or extend to the general
population as a whole.
This depends largely on the nature of
the exposure/disease relationship,
and the distribution of the exposure
in the population.

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