Measurements in research

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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

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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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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The frequency measures we use with dichotomous variables are

All three measures are based on the same formula

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

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

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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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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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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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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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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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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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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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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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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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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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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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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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Age-specific mortality rate and age distribution of

two populations, A and B

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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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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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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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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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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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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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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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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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Incidence Density

An incidence rate whose denominator is calculated using

person-time units

The numerator of the incidence density is the number of new

The denominator, however, is the sum of each individuals

remained under observation, i.e., person time denominator

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

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

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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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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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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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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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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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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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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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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Prevalence is affected by:

o New and effective treatment

o Increased

survival

despite

incidence

unchanged

or

even

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):

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Measurements of Mortality

4. Sex-specific mortality rate

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Measurements of Mortality

7. Post-neonatal mortality rate

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Measurements of Mortality

10. Child mortality rate

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Measurements of Mortality

13. Maternal mortality rate

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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

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

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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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

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

the frequency of the disease

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Measures of Association

If the RR<1, there is an association between exposure and

frequency of the disease

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

exposed and non-exposed groups are identical

Interpretation: A relative risk of 5 means that 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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Cohort study

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Cohort.

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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

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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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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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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Measures of Association

Exercise : calculate RR and OR and interpret

the results

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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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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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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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Population is a mix of exposed and non-exposed groups

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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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Calculate RD and interpret from the table

AR = 23 _ 133

327

2949

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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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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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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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

11/10/16

135

Possible outcomes in studying the relationship

No association between exposure and disease

AR=0,

Positive

RR=1

association

between

exposure

and

disease

(more

AR>0, RR>1

Negative association between exposure and disease

(more

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

11/10/16

136

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