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Tutorial 4

Measures of Association and Impact

In epidemiological research, the occurrence of disease in a group of people exposed to a risk
factor is compared to that observed in an unexposed group in order to establish causal
relationships, and to identify effective interventions. In this way we can quantify the association
between a risk (or protective) factor and a disease (or other outcome).
An important application of epidemiology is to estimate how much disease is caused by a
certain modifiable risk factor. The data on the impact of risk factors or interventions are
essential to assess the effectiveness and cost-effectiveness of interventions. In this chapter, you
will learn about epidemiological measures used to quantify the association between a risk (or
protective) factor and an outcome, and the measures used to assess the impact of a risk factor
or interventions in the population.

1. define risk as it is used in public health practice
2. identify measures of association and risk as they are used in epidemiology
3. interpret relative risk and odds ratios and be familiar with their calculation using two way
two tables
4. interpret the following measures of risk differences: attributable risk, population
attributable risk, and population attributable risk percent.

Measures of Disease Association in Epidemiology

Risk ratio / RR / CIR

Table 1. 2x 2 table

The incidence of disease in the entire population is (a + c)/(a + b + c + d) per year. We define the
risk ratio as:

Since the incidence of disease in the exposed group is a/(a + b) and in the unexposed group is
c/(c + d), the risk ratio can be calculated as:

The risk ratio is used as a measure of aetiological strength (i.e. the strength of association
between risk factor and outcome). A value of 1.0 will be obtained if the incidence of disease in
the exposed and unexposed groups is identical, and there- fore indicates that there is no
observed association between the exposure and the disease, according to the given data. A
value greater than 1.0 indicates a positive association or an increased risk among those exposed
to the factor. A value less than 1.0 means that there is an inverse association or a decreased risk
among those exposed, or in other words, the exposure is protective.

Rate ratio / RR / IDR

The rate ratio is calculated in the same way as the risk ratio, except that the incidence rates in
the exposed and unexposed groups are used:

Odds ratio
The odds ratio is calculated in a similar way to the risk ratio and the rate ratio, in that the odds
in the exposed group are compared with the odds in the unexposed group:

If we use the information from Table 1 above, the odds of disease are the population is
calculated as (a + c)/(b + d). The odds of disease in the exposed group are a/b and in the
unexposed group is c/d, therefore the odds ratio is:

This equation can be simplified by multiplying the top and bottom parts by bd to give:

Odds ratios are usually used in studies where the incidence of the disease of interest is not
known or if the study participants are selected on the basis of their disease status rather than
because of their exposure status. In this case, rather than calculating the odds of disease in the
exposed and unexposed groups, the odds of exposure are calculated in those with and without
disease. This is known as a case–control study.
Activity 1 Skenario dirubah, pertanyaan tetap
An Indonesian Cohort Study of Non-Communicable Diseases followed about 1500 respondent
since 2011 to 2013. This study had an aim to determine the incidence of diabetes mellitus (DM)
and risk factors that influence the occurance of DM. The investigator were interested in the
effect of central obesity on the incidence of DM then divided the participant into two groups
750 respondent who had central obesity and the remain group who had not central obesity.
The investigators recorded 200 new cases of DM over two years of study follow up, 170 in those
who had central obesity and 30 in those who had not central obesity. The number of person-
years at risk was 8350 in the exposed group and 6950 in the unexposed group.

(Adopted Source: Studi Kohor Prospektif Faktor Risiko PTM, Balitbangkes RI)

1. Calculate the risk ratio, odds ratio and rate ratio for the effect of regular exercise on
osteoporosis in these women.

Attributable (absolute) risk

The attributable or absolute risk can give information on how much greater the frequency of a
disease is in the exposed group than in the unexposed group, assuming the association between
the exposure and disease is causal.
Attributable risk measures the difference in frequency of a disease between two groups, not the
magnitude of association between the risk factor and the outcome (as in a relative risk). It is the
risk of disease in the exposed group that is attributable to the risk factor, after taking into
account the underlying level of disease in the population (from other causes). Attributable risk is
also known as risk difference or excess risk.

Attributable risk = Incidence in exposed group – incidence in non-exposed group

The attributable fraction can also be calculated from the relative risk (risk ratio or rate ratio) by
using the following formula, which is useful if we do not know the incidence of disease in the
exposed and unexposed groups:

= OR -1/ OR

The attributable fraction is usually used if there is a positive association between the exposure
and the outcome (i.e. the risk or rate ratio is greater than 1). However, if the exposure prevents
the outcome, as in our example of the effect of regular exercise on osteoporosis, the
attributable fraction will be negative, which is difficult to interpret. In such a case, we would
look instead at the risk or rate that is attributed to not being exposed by replacing the
denominator by the risk in the unexposed group. This measure is known as the preventable
fraction in the non-exposed group:
Population attributable (absolute) risk
The same concept can be applied to the population as a whole. It is of benefit to public health if
we can estimate the excess disease present in a population that is due to a particular risk factor,
or estimate the relative importance of different risk factors.

Population attributable risk= incidence in the whole population – incidence in nonexposed


If we do not know the risk of disease in the population, we can still calculate the population
attributable risk, as long as we know the proportion of the population in the exposed group (p):

Population attributable risk= p x attributable risk

Population attributable fraction

We can indicate what proportion of the total risk of the disease in the population is associated
with the exposure. This is expressed as the population attributable fraction (or the population
attributable risk per cent, if multiplied by 100), and indicates the proportion of the disease in the
population that could be prevented if exposure to the risk factor could be eliminated, and the
entire population was unexposed.
This is calculated in a similar way to the attributable fraction:

Activity 2
Between 1951 and 1971, a total of 10,000 deaths were recorded among 34,440 male British doctors (Doll
and Peto 1976). Of these deaths, 441 were from lung cancer and 3191 were from ischaemic heart disease.
Doctors who smoked at least one cigarette per day during this follow-up period were classified as smokers
and the rest as non-smokers. The age-adjusted annual death rates per 100,000 male doctors for lung
cancer and ischaemic heart disease among smokers and non-smokers are given in table 2 below.

Table 2. Cause of death and specific death rates by smoking habits of British male doctors, 1951-71
cause of death annual death rate per 100000 doctors
non smokers smokers
Lung cancer 10 140
Ischaemic heart
413 669
Source: based on Doll and Peto (1976)

1. Calculate an appropriate epidemiological measure to assess the strength of association

between smoking and lung cancer, and smoking and ischaemic heart disease.
a. Which disease is strongly associated with smoking?
b. Reduction in mortality from which disease would have greater public health impact if
there were a reduction in smoking?
c. What assumptions did you make when estimating the impact of a reduction in

2. Assume that the data shown in Table 2 are valid and that smoking causes lung cancer.
a. What percentage of the risk of death from lung cancer is attributable to smoking?
b. If 50% of doctors stopped smoking, by what percentage would the risk of lung cancer
death among the smokers be reduced?

A case–control study was conducted to investigate the risk factors for myocardial infarction (Doll
and Peto 1976). Information on smoking was collected from cases and controls. Current
cigarette smoking, defined as smoking within the past 3 months, was reported by 60 of the 400
myocardial infarction cases and by 40 of the 400 healthy controls.

3. Set up a 2 × 2 table, and estimate the strength of association between current smoking and
myocardial infarction.

Activity 3.
The incidence of tuberculosis and the mid-year population of different ethnic groups in Country
Z, in 2016 are given in Table 3

Table 3. Incidence of tuberculosis and mid year population

Based on ethnic group, in country Z, 2016
Number of new Mid-year Incidance rate Rate ratio
Ethnic group TB cases 2004 population, 2004 100.000
European 2 890 50 900 000
Indian 1 900 2 790 000
Asian 400 1 550 000
Total 5 190 55 240 000

4. Calculate the incidence rate and rate ratio for each group.
a. Which ethnic group is strongly associated with tuberculosis?
b. Why is the number of tuberculosis cases greater in the European group even though
the incidence rate is lower than in the other two groups?

5. 5. The incidence rate for the entire population is 9.39 per 100,000 person-years. Assume
that a targeted intervention has reduced the incidence rate in the Indian and the Asian
groups to the level of that in the European group (5.6 per 100,000 person-years).
a. What percentage of tuberculosis cases in the Indian group would be prevented?
b. What percentage of tuberculosis cases in the whole population would be prevented?