Unit five:

Measure of strength of association

June, 2017
Hawassa, Ethiopia

1
 Session objectives
 Calculate and interpret Risk Ratio/Relative risk/Cumulative
incidence ratio
 Calculate and interpret Rate Ratio/ Incidence density ratio
 Calculate and interpret Odd Ratio
 Calculate and interpret attributable proportion

2
  “How strong is the relationship between
two factors?”

3
 Content
 Measures of association
 Risk ratio (Relative Risk)
 Rate Ratio
 Odd Ratio

4
 1. Risk ratio
 A risk ratio (RR), also called 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 does so by dividing the risk (incidence proportion, attack

rate) in group 1 by the risk (incidence proportion, attack rate)
in group 2.

 Often, the group of primary interest is labeled the exposed

group, and the comparison group is labeled the
unexposed group.

5
 Method for Calculating risk ratio

Risk of disease (incidence proportion, attack rate) in exposed group

Risk of disease (incidence proportion, attack rate)in comparison group

 A risk ratio of 1.0 indicates identical risk among the two groups.
 A risk ratio greater than 1.0 indicates an increased risk for the
group in the numerator, usually the exposed group.
 A risk ratio less than 1.0 indicates a decreased risk for the
exposed group, indicating that perhaps exposure actually protects
against disease occurrence

6
 EXAMPLES: Calculating Risk Ratios
Example A:
 In an outbreak of tuberculosis among prison inmates in
Hawassa in 1999, 28 of 157 inmates residing on the East
wing of the dormitory developed tuberculosis, compared
with 4 of 137 inmates residing on the West wing.

 Calculate the risk ratio?

 These data are summarized in the two-by-two table so
called because it has two rows for the exposure and two
columns for the outcome.

7
 Table 1.1

8
 Example…
 In this example, the exposure is the dormitory wing (and
the outcome is tuberculosis) illustrated in Table 1.2.
 Table 1.2 Incidence of Mycobacterium Tuberculosis
Infection Among Congregated, HIV-Infected Prison
Inmates by Dormitory Wing— Hawassa, 1999

9
 Example…
 To calculate the risk ratio, first calculate the risk or attack rate for
each group. Here are the formulas:

Attack Rate (Risk)=

 Attack rate for exposed = a / a+b
 Attack rate for unexposed = c / c+d
 For this example: Risk of tuberculosis among East wing residents
= 28 / 157 = 0.178 = 17.8%
 Risk of tuberculosis among West wing residents = 4 / 137 =
0.029 = 2.9%
 The risk ratio is simply the ratio of these two risks:
 Risk ratio = 17.8 / 2.9 = 6.1

10
 Interpretation
 Thus, inmates who resided in the East wing of the dormitory
were 6.1 times as likely to develop tuberculosis as those who
resided in the West wing.

11
 Example B:
 In an outbreak of varicella (chickenpox) in Oregon in 2002,
varicella was diagnosed in 18 of 152 vaccinated children
compared with 3 of 7 unvaccinated children. Calculate the
risk ratio.
 Table 1.3 Incidence of Varicella Among Schoolchildren in
9 Affected Classrooms— Oregon, 2002

12
 Example B:
 Risk of varicella among vaccinated children = 18/152 =
0.118 = 11.8%
 Risk of varicella among unvaccinated children = 3/7 =
0.429 = 42.9%
 Risk ratio = 0.118 / 0.429 = 0.28
 The risk ratio is less than 1.0, indicating a decreased risk or
protective effect for the exposed (vaccinated) children.
 The risk ratio of 0.28 indicates that vaccinated children were
only approximately one-fourth as likely (28%, actually) to
develop varicella as were unvaccinated children.

13
 2. Odds ratio
 An odds ratio (OR) is another measure of association that
quantifies the relationship between an exposure with two
categories and health outcome.
 Referring to the four cells in Table 1.1, the odds ratio is
calculated as
 Odds ratio = (a/b)(c/d)=ad/bc

14
 Odds ratio…
 where
a = number of persons exposed and with disease
b = number of persons exposed but without disease
c = number of persons unexposed but with disease
d = number of persons unexposed: and without disease
a+c = total number of persons with disease (case-patients)
b+d = total number of persons without disease (controls)

15
 EXAMPLE: Calculating Odds Ratios
 Table 1.4 Exposure and Disease in a Hypothetical
Population of 10,000 Persons

16
 Example…
1. Risk ratio=5.0 / 1.0 = 5.0
2. Odds ratio =(100 x 7,920) / (1,900 x 80) = 5.2

 Notice that the odds ratio of 5.2 is close to the risk ratio of
5.0.
 That is one of the attractive features of the odds ratio —
when the health outcome is uncommon, the odds ratio
provides a reasonable approximation of the risk ratio.

 Another attractive feature is that the odds ratio can be

calculated with data from a case-control study, whereas
neither a risk ratio nor a rate ratio can be calculated.

17
 Odds ratio…
 The odds ratio is the measure of choice in a case-control
study

 A case-control study is based on enrolling a group of

persons with disease (“case-patients”) and a comparable
group without disease (“controls”).

18
 Odds ratio…
 Often, the size of the population from which the case-
patients came is not known.

 As a result, risks, rates, risk ratios or rate ratios cannot

be calculated from the typical case-control study.

 However, you can calculate an odds ratio and interpret it

as an approximation of the risk ratio, particularly when
the disease is uncommon in the population.

19
 Measures of Public Health Impact
 This is an indirect method of estimating the effect of reducing
or eliminating a causal factor.

 This will determine the relative benefit of public health

interventions.

20
 Attributable Risk (AR) or Risk Difference (RD)
 Provides information about the absolute effect of the
exposure or the excess risk of disease in those exposed
compared with those non exposed
AR = Ie – Io

 In a cohort study, AR is calculated as the difference of

cumulative incidences (risk difference) or incidence density
(rate difference) depending on the study design

 For example, calculate AR in the study of OC use and bacteruria:

21
 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

22
  AR=27/482 – 77/1908 = 0.01566 = 1566

 Thus, the excess occurrence of bacteruria among OC users

attributable to their OC use is 1566 per 100,000.

 AR is used to quantify the risk of disease in the exposed

group that can be considered attributable to the exposure by
removing the risk of disease that would have occurred
anyway due to other causes (the risk in the non-exposed).

23
 4. Attributable proportion (AP)
 The attributable proportion, also known as the attributable
risk percent, is a measure of the public 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.

24
 Attributable proportion…
 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).

 Appropriate use of attributable proportion depends on a

single risk factor being responsible for a condition. When
multiple risk factors may interact (e.g., physical activity and
age or health status), this measure may not be appropriate.

25
 Method for calculating attributable proportion

Risk for exposed group – risk for unexposed group X 100

Risk for exposed group
=
RR-1 X 100 or OR-1 X 100
RR OR

26
 EXAMPLE: Calculating Attributable Proportion
 In another study of smoking and lung cancer, the lung cancer
mortality rate among nonsmokers was 0.07 per 1,000 persons per
year.

 The lung cancer mortality rate among persons who smoked 1–14
cigarettes per day was 0.57 lung cancer deaths per 1,000 persons
per year. Calculate the attributable proportion.

 Attributable proportion = (0.57 – 0.07) / 0.57 x 100% = 87.7%

 Given the proven causal relationship between cigarette smoking

and lung cancer, and assuming that the groups are comparable in
all other ways, one could say that about 88% of the lung cancer
among smokers of 1-14 cigarettes per day might be attributable to
their smoking.
27
 5. Population Attributable Risk (PAR)
 Is the risk in total population minus risk in the non-exposed.
Estimate the excess rate of disease in the total study
population that is attributable to the exposure.

 PAR = Risk in population - Risk in unexposed

28
 Exercise 1
 Using data from one of the classic studies of pellagra by
Goldberger, we will calculate the risk ratio of pellagra for
females versus males. Pellagra is a disease caused by dietary
deficiency of niacin and characterized by dermatitis, diarrhea,
and dementia. Data from a comparative study such as this one
can be summarized in a two-by-two table.

29
 Exercise 1…
 To calculate the risk ratio of pellagra for females versus males,
we must first calculate the risk of illness among females and
among males.
 Risk of illness among females =a/a+b=46/1484= .031
 Risk of illness among males =c/c+d=18/1419=.013
 Therefore, the risk of illness among females is .031 or 3.1%
and the risk of illness among males is .013 or 1.3%.

30
 Exercise 1…
 In calculating the risk ratio for females versus males, females
are the group of primary interest and males are the
comparison group. The formula is:

 Risk ratio=3.1/1.3=2.4

 The risk of pellagra in females appears to be 2.4 times higher

than the risk in males.

31
 Exercise 2
 In the same study, the risk of pellagra among mill workers
was 0.9%. The risk among those who did not work in the
mill was 4.4%. The relative risk of pellagra for mill workers
versus non mill workers is calculated as
 Relative risk = risk ratio = 0.9%/4.4% = 0.2
 The risk of pellagra in mill workers appears to be only 0.2 or
one-fifth of the risk in non-mill workers.
 In other words, working in the mill appears to protect against
developing pellagra.

32
 Exercise 3
 For example, the data in Doll and Hill study provide death
rates from lung cancer taken from the classic study on
smoking and cancer by Doll and Hill.

 Using these data we will calculate the rate ratio of smokers of

1-14 cigarettes per day to nonsmokers. The “exposed group”
is the smokers of 1-14 cigarettes per day.

 The “unexposed group” is the smokers of 0 cigarettes per day.

33
34
 Exercise 3
 Rate ratio = 0.57 / 0.07 = 8.1

 The rate of lung cancer among smokers of 1-14 cigarettes is

8.1 times higher than the rate of lung cancer in nonsmokers.

35
 Exercise 4
 Using data in Doll and hill physicians follow up study ,
calculate the following rate ratios. Enter the ratios in Table
(slide 35)

 Discuss what the various rate ratios show about the risk for
lung cancer among cigarette smokers.
 a. Smokers of 15-24 cigarettes per day compared with
nonsmokers
 b. Smokers of 25+ cigarettes per day compared with
nonsmokers

36
 Thank you!!!

37