MEASURE OF

ASSOCIATION

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 Measures of Association

• Exposure Outcome

• Is there a relationship between the

exposure and outcome of interest?
 Exposure and Outcome

• A study considers two main factors: exposure

and outcome
• Exposure refers to factors that might influence
one’s risk of disease
• Outcome refers to response of the exposure
Exposure Outcome
contaminated food Diarrhea

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 MEASURE OF ASSOCIATION
Requires comparing two groups: Exposed Vs Unexposed

With outcome Vs Without Outcome

Indications of how more or less likely one is to develop

disease as compared to another

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 TWO-BY- TWO Table /2x2 table

Disease No disease Total

Exposed a b a+b
Non-exposed c d c+d
Total a+c b+d a+b+c+d
 Relative Risk
• Relative Risk or Risk Ratio (RR) compares the risk of
some health-related events (often disease or death) in
two groups, typically in persons exposed to the disease

to those not exposed

RR =

RR = Risk (incidence) in exposed

Risk ( Incidence) in non exposed

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OR

RR

OR= A/C RR= A/A+B

B/D C/C+D

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 EXAMPLE

Table 1: data from a cohort study of oral contraceptive (OC)

use and bacteruria among women aged 16-49 years.

Bacteruria
Yes No Total

Current OC use
Yes 27 455 482
No 77 1831 1908
Total 104 2286 2390

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• Calculate RR??????? Ans:- 1.4
• Interpretation: women who used oral
contraceptive had 1.4 times higher risk of
developing bacteruria when compared to
non-users.

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 INTERPRETATION OF RR
1 = No association between exposure and disease
– incidence rates 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

– example: .5 = half as likely to experience disease

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 ODDS RATIO (OR)

What are odds?

Let p = the probability of an event
1-p = the probability that the event does not
occur
Odds of the event = p/1-p
– If the probability of an event is 0.7, the
odds of winning are 0.7/0.3 = 2.33

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 ODDS RATIO…

• The ratio of the odds of a condition in the exposed compared

with the odds of the condition in the unexposed.
• Usually applied to prevalence studies rather than incidence
studies.

OR Odds of exposed in disease

=
Odds of exposed in non disease

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• Odds Ratio: Odds of case being exposed
Odds of control being exposed
OR = a/c = ad
b/d bc

• Odds- the ratio of the probability of occurrence

of an event to that of nonoccurrence.
• OR indicates the likelihood of having been
exposed among cases relative to controls.

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 EXAMPLE
Table 3: Data from a case-control study of
current oral contraceptive (OC) use and MI
in pre-menopausal female nurses

Myocardial infarction
Yes No Total

Current OC use
Yes 23 304 327
No 133 2816 2949
Total 156 3120 3276

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Calculate OR
OR = ad = (23) (2816) = 1.6
bc (304) (133)
Interpretation: the odds of having MI
is 1.6 times higher among OCP
users as compared to that of the
non OCP users.

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 ATTRIBUTABLE RISK(AR)

• Attributable Risk: Measure of the potential for

prevention of disease if the exposure could be
eliminated (assuming a causal relationship).

• It tells us how many cases of disease in exposed people

could have been prevented by eliminating the exposure.

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 AR…
• AR = Risk in exposed - Risk in unexposed

• Quantify the excess risk in the exposed that can be

attributable to the exposure by removing the risk of
disease that could have occurred anyway due to other
causes.
• Indicates the number of cases of the disease among the
exposed that can be attributed to the exposure itself.

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 AR…
,

Attributable Risk
Incidence

Exp Unexp
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 ATTRIBUTABLE RISK (AR)
AR = Iexposed – Inonexposed

ISM = 84 / 3000
Develop CHD
= 0.028 = 28.0 /
Smoke Yes No 1000
Yes 84 2916 3000 INS = 87 / 5000
= 0.0174 =
No 87 4913 5000 17.4 / 1000

AR = (28.0 – 17.4) / 1000 = 10.6 /

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1000 19
 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
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eliminated. 20
 ATTRIBUTABLE RISK PERCENT
(AR %)

• Estimates the proportion of the disease

among the exposed that is attributable to
the exposure
• The proportion of the disease in the exposed
group that could be prevented by
eliminating the exposure
AR % = (Ie - Io) X 100
Ie

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 ATTRIBUTABLE RISK (AR)
AR = Iexposed – Inonexposed

ISM = 84 / 3000
Develop CHD
= 0.028 = 28.0 /
Smoke Yes No 1000
Yes 84 2916 3000 INS = 87 / 5000
= 0.0174 =
No 87 4913 5000 17.4 / 1000

AR = (28.0 – 17.4) / 1000 = 10.6 /

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1000 22
 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
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 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.

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 POPULATION ATTRIBUTABLE RISK (PAR)

Example: We want to estimate how much of the burden of diabetes

among Ethiopians is attributed to obesity. PAR = Itotal – Inonexposed

Diabetes IT = 1100 / 10000
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) / 1000 = 64.5 / 1000

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 POPULATION ATTRIBUTABLE RISK (PAR)

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

In the general pop, 64.5 of the

110/1000 incident cases of diabetes
are attributed to obesity.

In the general population, 64.5 of the

110/1000 incident cases of diabetes
that occur could be prevented with
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sufficient weight loss. 26
 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

= 0.0455 = 45.5 / 1000
Slim 250 5250 5500

1100 8900 10000

PAR% = (110 – 45.5) / 110 =
58.6%
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 POPULATION ATTRIBUTABLE RISK
PERCENT

PAR% = (110 – 45.5) / 110= 58.6%

In the population, 59% of the cases of diabetes may

be attributed to obesity in the population…

In the population, 59% of the cases of diabetes could

be prevented if sufficient weight lost.

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Summary of Measures of Association

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Summary of Measures of Association

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Possible Outcomes in studying the relationship
between disease and exposure

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 Presence of Association

Relative risk ¹1
1
Odds Ratio ¹1
Attributable
0 risk ¹
0
 Thank you!

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