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MEASURES OF HEALTH AND

RELATED EVENTS
Solomon Berhanu
October 14 2016

Outline
Basic Concepts (Introduction )
Measure of frequency
Measure of morbidity
Measure of mortality
Measure of association
Measure of disease impact

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Variable
A characteristic which takes different values in different
persons, places, or things
Any aspect of an individual or object that is measured
(e.g., BP, age, sex, Heart rate, Blood group... takes any
value)
Qualitative
Quantitative
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Variable
Quantitative variable: is one that can be measured in the
usual sense and Convey information regarding amount
E.G: heights of adult males, weights of preschool children
Average, mean, range, proportion are the possible summary
statistics
Qualitative variables: are not capable of being measured in
the sense that height, weight, and age are measured
Convey information regarding characteristics
Can be categorized only
E.g. A medical diagnosis, an ethnic group
Frequency, counting, proportion are the possible summary
statistics
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Measurement
Is the assignment of numbers to objects or events
according to a set of rules
It involves the concept of summarizing phenomena
quantitatively, numeracy
It is the process of specifying and operationalizing a given
concept
Health related event is measured on various levels (scale)
measurement

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Measurement cont
Epidemiology
The study of the distribution of health-related states and
events in populations
Intend to capture not only disease and illness, but
physiologic states such as blood pressure, psychological
measures such as depression score, and positive
outcomes such as disease immunity
The objective of epidemiologic research is to obtain a valid
and precise estimate of the effect of a potential cause on
the occurrence of disease, which is often a binary
(either/or) outcome
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MeasurementLevels/Scales
The most widely used classification of measurement
scales are:
Nominal scale;
Ordinal scale;
Interval scale; and
Ratio scale.

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MeasurementLevels/Scales
Nominal scale
The simplest type of data, in which the values fall into
unordered categories or classes
Consists of naming observations or classifying them into
various mutually exclusive and collectively exhaustive
categories
Uses names, labels, or symbols to assign each measurement
E.g. calculate averages, comparing with the numbers, use mode
as the measure of central tendency
Use Chi-square test
the least powerful(indicates no order or distance)
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MeasurementLevels/Scales
Ordinal scale
Places events in order, but there is no attempt to make the intervals
of the scale equal in terms of some rule
Have all of the requirements of nominal scales but also include the
property of order
Ordinal scales only permit the ranking of items from highest to lowest
Nothing is known about the size of the interval between any two
numerals
Median as measure of central tendency
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MeasurementLevels/Scales
Interval scale
Have all the requirements of ordinal scales with the added benefit
of distance between items
The distance between attributes does have meaning but has no
fixed zero(zero not indicate absence)
And ratio can meaningfully constructed
E.g. T0 210c-20oc=101oc-100oc but one cannot say that the T0 of
60 is twice as warm as the T0 of 30
Mean, standard deviation can be used
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MeasurementLevels/Scales
Ratio scale
Measurement begins at a true zero point and the scale has

equal space
This has the properties of an interval scale together with a fixed

origin or zero point (zero indicates complete absence) and


Ratio can meaningfully constructed. E.g. 60 kg truly is twice as

heavy as that of 30 kg
The highest level of measurement is a ratio scale
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MeasurementLevels/Scales

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Measures of Disease Frequency


Frequency of disease occurrence can be measured in: Absolute terms (absolute count)
Relative terms ( ratios, proportions, and rates)
The most basic measure of disease frequency is a simple count
of affected individuals
Such information is useful for public health planners and
administrators for resource allocation
Does it helpful for comparison?
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Measures of Disease Frequency


The frequency measures we use with dichotomous variables are

ratios, proportions, and rates


All three measures are based on the same formula

x and y are the two quantities that are being compared


10n is a constant that we use to transform the result of the division

into a uniform quantity


The size of 10n may equal 1, 10, 100, 1000 and so on
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Measures of Disease Frequency


Ratio
Is the most important epidemiological tool used for measuring
diseases
Is the quotient of two numbers, a numerator divided by a
denominator
The values of x and y may be completely independent
E.g. comparing sex of children attending Immunization
Male
Female

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Measures of Disease Frequency


Proportion
Quantifies occurrences in relation to the populations
Special type of ratio in which the numerator is included in
the denominator
The result is expressed as a percentage but any scaling
factor can be used
A proportion can range only between 0 and 1, or 0 and
100% inclusive
Example

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Measures of Disease Frequency


Rate
Measures the occurrence of an event in a population over
time
The time component is important in the definition
Rates are often proportions
Include persons in the denominator who reflect the
population from which the cases in the numerator arose;
Include counts in the numerator which are for the same
time period as those from the denominator
Include only persons in the denominator who are "at risk"
for the event
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Measures of Disease Frequency


Rate = Number of events in a specific period X10n
Pop at risk of these events in a specified Period
It is considered to be a basic measure of disease occurrence
E.g.
100 people followed for 1 year each=100 person-years
10 people followed for 10 years each=100 person years

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Measures of Disease Frequency


There are three types of rates:
Crude rates
Specific rates
Adjusted rates
Crude rates are summary rates based on the actual number
of events (births, deaths, diseases) in the total population
over a given time period
(CBR) and the crude death rate (CDR) are examples
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Measures of Disease Frequency


Crude rates
Advantages:
Actual summary rates
Calculable from minimum information
Widely used despite limitations
Disadvantages:
Difficult to interpret due to variation in composition (e.g.:
age)
Difficult to understand significant differences in risk
between subgroups
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Measures of Disease Frequency


Specific rates: apply to specific subgroups in the population,
such as a specific age group, sex
When calculating specific rates, except for cause-specific
rates, the denominator is the population in that specific group
As a result, specific rates do not add up to a crude rate
The rates apply to homogenous subgroups and
The rates are detailed and useful for epidemiological and
public health purposes but
Burdensome to compare many subgroups of two or more
populations
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Measures of Disease Frequency


Adjusted rates
Are summary rates that have undergone statistical
transformation
Permit fair comparison between groups differing in some
characteristics that may affect risk of disease
For example: age needs adjustment due to its marked effect
on both diseases and death
When comparing the crude death rates of two or more places,
it is impossible to know whether the difference is
due to age composition, age specific death rate or both
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Measures of Disease Frequency


Adjusted rate..
In age adjusted rates the difference is exclusively attributed to
differences in age specific mortality rates
The effect of age composition is artificially removed
Are summary rates, can permit unbiased comparison and are
easy to interpret but
Are fabricated rates, absolute magnitude depends on standard
population and opposing trends in subgroups masked

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Measurement ..adjusted rate cont..


The underlying principle is that we break the data down
into categories of the factor we wish to standardise for (e.g.
age, social class, ethnic group),
And apply category-specific rates to category-specific
population numbers to find out how many events to expect
if those rates had applied

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Measurement ..adjusted rate cont..


Direct method, we will use the age-specific rates from the
group we intend to standardise (the index population),
and apply these to the numbers of people (in the same age
bands) in a standard population
Indirect method, we used age-specific rates from another
standard population and applied these to the population
numbers (in the same age bands) for the group we
intended to standardise (often referred to as the index
population)
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Measures of Disease Frequency


Adjusted rate.Methods of adjustment
There are two methods of adjustment called as direct and
indirect
A. Direct method
Here, the adjusted rate is derived by applying the category
specific rates observed in each of the populations to a
single standard population
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Measures of Disease Frequency


Age-specific mortality rate and age distribution of
two populations, A and B

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Measures of Disease Frequency


To calculate the crude death rate (CDR):
Multiply the ASMR in each age group by the number of
people in the same group; this will give the annual number of
deaths occurring in the specific age group
Add the number of deaths occurring in each age group to
obtain the total number of deaths
Then divide the total number of deaths by the total
population of each area
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Measures of Disease Frequency


To calculate the age-adjusted rate:
Use a standard population for each age group of both areas
Note that the populations of the groups to be compared have to be
equal when standardizing
For example use 1000 as a standard for each age category of both
populations, and you may use one population either A or B as a
standard
Then follow the steps you took when calculating the CDR, but this
time using the standard population
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Example

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Example

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Measures of Disease Frequency


B. Indirect method
This method implies the process of applying the specific rates of
a standard population to a population of interest to yield a
number of "expected" deaths
Commonly, relate the total expected deaths thus obtained to
observed deaths through a formula known as the standardized
mortality ratio (SMR)

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Measures of Disease Frequency


Used to compare two populations, in one of which the ASMR are
not known or are excessively variable because of small numbers
If SMR > 1,
More deaths are observed in the smaller population than would
be expected on the basis of rates in the larger (standard)
population.
If SMR <1
Fewer deaths are observed than expected

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Example

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Direct or indirect which method is best?

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Measure of morbidity
Used to describe the presence of disease in a population, or
the probability of its occurrence
There are two general types of measures of disease
frequency, incidence (I) and prevalence (P)
Incidence measures new cases of a disease that develop
over a period of time where as
Prevalence measures existing cases of a disease at a
particular point in time or over a period of time
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Measures of Disease Frequency

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Measures of Disease Frequency


Incidence Rates
Expresses the probability or risk of illness in a population
over a period of time
Measure of the frequency of new case of illness, occurs in
a population over a period of time
The choice of time period is arbitrary: We could calculate
incidence in one week, incidence in one month, incidence
in one year, 5 year
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Measures of Disease Frequency

Types of Incidence
Two types of measures of incidence defined by the type of
denominator
1. Incidence based on person at risk
2. Incidence based on person-time units at risk
The Cumulative incidence rate and incidence density or
incidence rate or person-time rate
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Measures of Disease Frequency


Cumulative Incidence (CI)
An incidence rate that is calculated from a population that is more
or less stable, by taking the population at the beginning of the
time period as denominator
The cumulative incidence assumes that the entire population at
risk at the beginning of the study period has been followed for the
specified time interval for the development of the outcome

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Cumulative incidence.
In epidemiologic studies observation on all study units is
not possible-censored observation
Lost to follow up
Death from causes other than the outcome of interest
Different recruitment time/may not develop event of
interest when the study ends.due to shorter period/

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Measures of Disease Frequency


Incidence Density
An incidence rate whose denominator is calculated using

person-time units
The numerator of the incidence density is the number of new

cases in the population


The denominator, however, is the sum of each individuals

time at risk or the sum of the time that each person


remained under observation, i.e., person time denominator
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Measures of Disease Frequency


This is particularly when one is studying a group whose members are

observed for different lengths of time


Specify the time units rate represents the number of cases per person

day, person month or person year

The denominator is measured in person-time units rather than persons,


which account for persons enter after study period, lost during study
period, e.g. 100 people followed for 1 year each=100 person-years

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Measures of Disease Frequency


Basic requirements for calculating incidence rates
Knowledge of the health status of the study population
Time of Onset
Specification of Numerator
Specification of Denominator
Period of Observation

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Measures of Disease Frequency


Prevalence Rate
Is the proportion of persons in a population who have a
particular disease or attribute at a specified point in time or
over a specified period of time
Prevalence measures existing cases of a health condition
and
Is the primary design feature of a cross-sectional study

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Measures of Disease Frequency

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Measures of Disease Frequency


There are two types of prevalence:
Point prevalence, which is most commonly used, and
Period prevalence
But life time prevalence is also additional type of
prevalence

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Measures of Disease Frequency


Point Prevalence
The amount of disease present in a population at a single point
in time
This is not a true rate; rather it is a simple proportion
Point prevalence = All cases of factor of interest at a given time X 10n
Total population

Period prevalence
Requires the assumption of a stable dynamic population for
estimation
Helps to know how much of a particular disease is present in a
population over a longer period
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Measures of Disease Frequency


It measures the proportion of a population that is affected
with a certain condition during a specified period of time
The interval can be a week, month, year, decade, or any
other specified time period

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Measures of Disease Frequency


Lifetime prevalence (cumulative lifetime frequency)
Is the proportion of the population that has a history of a
given disorder at some point in time

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Measures of Disease Frequency


Characteristics of Prevalence
It is useful for planning (e.g. beds, clinics, workforce needs)
It is easy to obtain which need only one measurement
It is impossible to infer causation
High prevalence does not mean high risk rather it could reflect
increased survival (improved care, behavior change - long duration)
Low prevalence does not mean low risk rather it could reflect rapid
fatal or cure process)
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Measures of Disease Frequency


Prevalence is affected by:
o New and effective treatment
o Increased

survival

despite

incidence

unchanged

or

even

decreasing (illness duration)


o Prevalence decreases due to new curative therapy, despite more
people acquiring disease
o Population movement
o Severity of illness and
o Number of new cases
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Measures of morbidity

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Measures of morbidity
Prevalence rate is directly proportional to both incidence rate
and to the average duration of the disease and thus
expressed as
P ~ IR x D
If incidence is high but duration is short, prevalence is
low
If incidence is low but duration is long, prevalence is
high

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Measures of morbidity
Uses of Prevalence and Incidence
Prediction of future illness
Incidence - Need to assess causation
Clinical decision making
Prevalence useful in guiding diagnostic and treatment
decisions
Comparisons of health states
Both useful
Compare proportion of population with one disease vs.
another (prevalence)
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Measures of morbidity
Prevalence may be more useful when
Onset of health state not clear
Population at risk difficult/impossible to ascertain
Planning for health resources and facilities

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Measures of morbidity
Limitations of prevalence studies
Prevalence studies favor inclusion of chronic over acute
cases
Disease status and attribute are measured at the same
time; hence, temporal relations cannot be established

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Measures of morbidity
Example
Two surveys were done in the same community 12 months
apart. Of 10,000 people surveyed the first time, 50 had
antibodies to histoplasmosis. Twelve months later, 70 had
antibodies, including the original 50. Calculate
A. The prevalence at the second survey,
B. Compare the prevalence with the 1-yr incidence &

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Measures of morbidity
Answers
A. Prevalence at the second survey:
X = antibody positive at second survey = 70
y = population = 10,000
(X/y) X 10n = 70/10,000 x 1,000 = 7 per 1,000
B. Incidence during the 12-month period:
X = number of new positives during the 12-month period =
70 - 50 = 20
y = population at risk = 10,000 - 50 = 9,950
(X/y) X 10n = 20/9,950 x 1,000 = 4 per 1,000
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Measures of morbidity
Attack Rate
An attack rate is a variant of an incidence rate, applied to a
narrowly defined population observed for a limited time,
such as during an epidemic
The attack rate is usually expressed as a percent, so 10 n
equals 100

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Measures of morbidity
Example
Of 75 persons who attended a School picnic, 46
subsequently developed gastroenteritis
To calculate the attack rate of gastroenteritis we first define
the numerator and denominator:
AR=

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Measures of morbidity
Secondary Attack Rate
It is a measure of the frequency of new cases of a disease
among the contacts of known cases

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Measures of morbidity
Example
Seven cases of hepatitis A occurred among 70 children
attending a child care center. Each infected child came from a
different family. The total number of persons in the 7 affected
families was 32. One incubation period later, 5 family
members of the 7 infected children also developed hepatitis
A. Calculate the attack rate in the child care center and the
secondary attack rate among family contacts of those cases
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Measures of morbidity
Answers
1. Attack rate in child care center:
x = cases of hepatitis A among children in child care center
=7
y = number of children enrolled in the child care center =
70

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Measures of morbidity

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Measurements of Mortality
A mortality rate is a measure of the frequency of occurrence of
death in a defined population
Rates whose denominators are the total population are
commonly calculated using either
The mid - interval population or
The average populationpopulation size fluctuates

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Measurements of Mortality
1. Crude mortality rate (crude death rate):

2. Cause-specific mortality rate:

3. Age-specific mortality rate

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Measurements of Mortality
4. Sex-specific mortality rate

5. Infant mortality rate

6. Neonatal mortality rate

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Measurements of Mortality
7. Post-neonatal mortality rate

8. Fetal death rate

9. Peri-natal mortality rate

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Measurements of Mortality
10. Child mortality rate

11. Under five Mortality rate

12. Case-fatality rate

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Measurements of Mortality
13. Maternal mortality rate

14. Proportionate mortality

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Measurements of Mortality

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Measurements of Mortality
Years of Potential Life Lost and YPLL Rate
Is a measure of the impact of premature mortality on a
population (death occurred before average life expectancy)
It is calculated as the sum of the differences between some
predetermined end point and the ages of death for those who
died before that end point
The two most commonly used end points are age 65 years
and average life expectancy
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Measurements of Mortality
Calculating YPLL from a frequency distribution

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Measurements of Mortality
The Years of Potential Life Lost Rate
It represents years of potential life lost per 1,000
populations below the age of 65 years (or below the
average life expectancy).
Used

to

compare

premature

mortality

in

different

populations

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Measurements of Mortality
Example
Using the motor vehicle injury (MVI) data in Table below, we
will calculate the following:
a. MVI related mortality rate, all ages
b. MVI related mortality rate for persons under age 65 yrs
c. MVI related years of potential life lost
d. MVI related YPLL rate
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Measurements of Mortality

Deaths attributed to motor vehicle injuries (MVI)


and to pneumonia and influenza by age group,
country X, 1997

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Measurements of Mortality
Answers

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Measurements of Mortality
c. MVI-related years of potential life lost

1.Calculate the midpoint of each age interval up to age


interval 55-64.
The age group 0 to 4 years is (0 + 4 + 1)/2=2.5 yrs
2. Subtract the midpoint from the end point to determine
the years of potential life lost for a particular age
group
For the age group 0 to 4 years, each death represents
65 minus 2.5, or 62.5 years of potential life lost
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Measurements of Mortality
c. MVI-related years of potential life lost
3. Calculate age-specific YPLL by multiplying the number of deaths in a
given age group by its years of potential life lost
For the age group 0 to 4 years, 1190 deaths x62.5 equals 74,375.0
years of potential life lost
4. Total the age-specific years of potential life lostSum the age specific
YPLL
The total years of potential life lost attributed to MVI in country x in 1997
was 1,441,985 yearssee table below
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Measurements of Mortality

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Measurements of Mortality

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Measures of association
We use measures of strength when we would like to
compare the strength of association between exposed and
unexposed subjects
We use
Incidence rates in prospective studies
Prevalence rates in cross-sectional studies to see the
strength

of

association

between

exposed

and

unexposed individuals
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Measures of association cont


Quantifies the relationship between exposure and disease
among the two groups
Compare disease occurrence in two or more groups of
people whose exposures have differed
Measure of association capable to assess the strength of
association
The risk ratio and the odds ratio

are two fundamental

measures of associations
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Measures of Association

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Measures of Association
Risk Ratio or Relative Risk
Compares the risk of a health event (disease, injury, risk
factor, or death) among one group with the risk among
another group
It indicates the likelihood of developing the disease in
exposed group relative to those who are not exposed
It is the ratio of the risk for one group, say group 1, to the risk
for another group, say group 0
This is the measure of association mostly used in cohort
studies
Its value can be <1, >1, or = 1
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Measures of Association
Referring the prototype two-by-two table presented above
Risk in exposed = a/a+b
Risk in non-exposed = c/c+d
Therefore, RR = a/ a+b

c/ c+d
If the RR >1, there is an association between exposure and

disease and the exposure is associated with an increase of


the frequency of the disease
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Measures of Association
If the RR<1, there is an association between exposure and

disease and the exposure is associated with a decrease of the


frequency of the disease
If the RR=1, there is no effect of being in one group when

compared to the other or the risk of developing disease in the


exposed and non-exposed groups are identical
Interpretation: A relative risk of 5 means that the probability to

develop the disease in the exposed is 5 times the probability to


develop it in the non exposed
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Measures of Association
In general the strength of association can be considered:
High - if the RR is 3.0 or more
Moderate if the RR is from 1.5 to 2.9
Weak if the RR is from 1.2 to 1.4

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Attack rate from food outbreak Exercise

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Relative risk/risk ratio

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Cohort study

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Cohort.

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Interpreting relative risk of a disease

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Exposure-disease cross-tabulated table

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Assume that a researcher is interested to; if age of university


student is a risk factor for sexually transmitted infection(STI)
1. Calculate RR and interpret for each age category using 15-19
age category as reference age groups
2. Calculate proportion of STI in the sample
Age in
completed
years

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15-20
21-25
26-30
>=31

No of
students
with STI
5
5
5
5

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No of
students
with no STI
35
20
10
5

Total

40
25
15
10

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Measures of Association
Odds Ratio (OR)
The word "odds" means the chances of an event to happen
The Odds of an event is the ratio of the event to happen
over the event not to happen
Odds = Number with events
Number without events
The odds ratio (OR) is the ratio of two odds i.e.
The ratio of the odds in the exposed over the odds in the
non exposed is called the Odds Ratio
Is the measure of association in case control/Crosssectional designs
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Applying Concept of Odds


The odds of having the disease is the ratio of the
probability that the disease will occur to the probability that
the disease will not occur
Or
The odds of having the disease can be calculated as the
number of people with the disease divided by the number
of people without the disease
[Note: in the exposure-disease 2x2 table, the odds of
having a disease in the exposed group is the same as the
odds that an exposed person develops the disease]
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Measures of Association
From the above 2x2 table,
OR = a/c
= ad
b/d
bc
The context of OR <1, >1 or = 1 is similar as RR
Interpretation: OR=5 means The odds of outcome among
exposed is 5 times more than non exposed

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Calculating Odds in a Cohort Study

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Calculating Odds in a Cohort Study

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Calculating Odds Ratio in a Case-Control Study

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When Is Odds Ratio a Good Estimate of Relative Risk?


When the cases "studied are representative of all people with
the disease in the population from which the cases were
drawn, with regard to history of the exposure
When the controls "studied are representative of all people
without the disease in the population from which the cases
were drawn, with regards to history of exposure
When the disease being studied is not a frequent one (rare
disease)
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When OR~RR

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When OR~RR? Disease infrequent

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OR # RR, If disease is common

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Interpreting Odds Ratio of a Disease

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Measures of Association
Exercise : calculate RR and OR and interpret
the results

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Measures of Public Health Impact


Is used to place the association between an exposure and
an outcome into a meaningful public health context
Measure of association quantifies the relationship between
exposure and disease (begins to provide insight into causal
relationships)
Measures of public health impact reflect the burden that an
exposure contributes to the frequency of disease in the
population
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Measures of Public Health Impact


Common measures of public health impact includes;
Attributable Risk (AR),
Attributable Risk Percent (ARP),
Population Attributable Risk (PAR), and
Population Attributable Risk Percent (PARP)

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Measures of Public Health Impact


Attributable Risk (AR) / Risk Difference (RD)
AR is a measure of association that provides information
about the absolute effect of the exposure
It tells the excess risk of disease in those exposed
compared with those who are not exposed
The null value of the risk difference is 0, whereas the null
value of the risk ratio is 1
Calculated in randomized clinical trial, cohort, and crosssectional studies, but not in case-control studies

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Attack Rates from Food-Borne Outbreak Exercise

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118

Risk in Exposed and Non-Exposed Groups

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Risk in Exposed and Non-Exposed Groups

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Example: Cohort Study

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Attributable Risk in Smokers

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Proportion Attributable Risk in Smokers

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Risk in the Total Population


Population is a mix of exposed and non-exposed groups

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Attributable Risk in the Total Population

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Attributable Risk in the Total Population


If the incidence in the total population is unknown, it can be
calculated if we know:
Incidence among smokers
Incidence among non smokers
Proportion of the total population that smokes

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Attributable Risk in the Total Population

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Attributable Risk in the Total Population

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Attributable Risk in the Total Population

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Attributable Risk in the Total Population

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Lung Cancer, CHD Mortality in Male British Physicians

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Measures of Public Health Impact


Calculate RD and interpret from the table
AR = 23 _ 133
327

2949

=0.02523 =2523 per 100,000 OC users


Interpretation: The excess occurrence of myocardial infection
among OC users attributable to their OC use is 252 per 100,000
OC users
In a population of 100,000 OC users, 7034 would be expected to
develop myocardial infection, 2523 of those who developed
myocardial infection being related to OC use & the remainder,
4511, to other factors
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Measures of Public Health Impact


Example: Research was conducted to assess the association
between cigarette smoking and death from lung cancer. The
following findings were obtained:
AR = 89 per 100,000 per year
Prevalence rate of cigarette smoking = 20 %
PAR = 17.8 per 100,000 per year
Incidence in total Population 24.8 per 100000 per year
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Measures of Public Health Impact


Interpretation:
In a population of 100,000 smokers, 89 deaths from lung
cancer per year could have been avoided by preventing
them from smoking (this refers to AR)
In a general population of 100,000 with a prevalence rate
of cigarette smoking of 20 %, about 18 deaths from lung
cancer per year would be prevented by eliminating
cigarette smoking (this refers to PAR)
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Measures of Public Health Impact


Population Attributable Risk Percent (PAR %)
PAR % =
PAR
X 100
Incidence rate in total population
E.g. PAR = 17.8 per 100,000 per year
Mortality rate in non-smokers = 7 per 105
Mortality rate in the total population = 24.8 /10 5 / yr
PAR % = 17.8 per 105 per year X 100 =71.8%
24.8 per 105 per year
72% of deaths from lung cancer occurring in the general
popn could be prevented by eliminating cigarette
smoking
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Measures of Association summary


Possible outcomes in studying the relationship
No association between exposure and disease
AR=0,
Positive

RR=1
association

between

exposure

and

disease

(more

exposure, more disease)


AR>0, RR>1
Negative association between exposure and disease

(more

exposure, less disease)


AR<0 (negative), RR <1(fraction)
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