MEASURES OF ASSOCIATION

IN PUBLIC HEALTH
VITRI WIDYANINGSIH
Attributable Risk (AR)
AR = (Risiko pada kelompok terpapar) - (risiko pada kelompok tidak terpapar)
◦ Berapa banyak risiko pada kelompok terpapar disebabkan oleh paparan, (bukan oleh risiko baseline)
◦ Risiko baseline secara teoritis dapat kita ketahui dengan mencari risiko pada kelompok tidak terpapar

Contoh:
◦ Risiko pada kelompok terpapar = 3/100
◦ Risiko pada kelompok tidak terpapar = 1/100
◦ AR = (3/100) – (1/100) = 2/100

◦ Walaupun risiko pada kelompok terpapar sebesar 3/100, 1/100 merupakan risiko baseline,
sehingga risiko yang disebabkan (attributable) oleh paparan adalah 2/100
Attributable Risk
Excess Risk =
Risk Attributable Risk
Attributable Risk =
(Risiko pada paparan+) –
(Risiko pada paparan -)

Relative Risk =
(Risiko pada paparan +) /
(Risiko pada paparan -)

risiko baseline
paparan
Attributable Risk
Excess Risk =
Attributable Risk
Risk
Attributable Risk = 0.78 – 0.5 = 0.33

33% dari penyakit pada kelompok terpapar

disebabkan oleh paparan 33% penyakit
pada kelompok terpapar dapat dikurangi
apabila paparan dihilangkan

Relative Risk = 0.78 / 0.5 = 1.56

risiko baseline
paparan
Relative vs. Attributable Risk
Relative risk merupakan ukuran yang penting untuk menandakan
kekuatan hubungan
◦ Penting untuk menentukan hubungan etiologis/ causal

Attributable risk merupakan ukuran yang penting untuk mengetahui:

“Seberapa besar penyakit tersebut disebabkan oleh paparan?”
◦ Penting untuk klinis dan kesehatan masyarakat
Attributable Risk Fraction (ARF)
ARF = AR / (total risiko pada kelompok terpapar)
◦ Berapa persen (%) risiko pada kelompok terpapar disebabkan oleh paparan?

Pada contoh sebelumnya AR = 2/100, risiko pada kelompok terpapar = 3/100

ARF = (2/100) / (3/100)

ARF = 2/3 = 66%

2% attributable risk, 3% total risk artinya 66% total risiko pada kelompok terpapar
disebabkan oleh paparan
Attributable Risk Fraction
Excess Risk =
Attributable Risk
Risk
Attributable Risk =
(risiko pada paparan +) –
(risiko pada paparan -)

Attributable Risk Fraction =

ARF = AR / (total risiko pada
kelompok terpapar)

risiko baseline
paparan
Attributable Risk Fraction
Ukuran absolut
Excess Risk =
Attributable Risk
Attributable Risk = 0.78 – 0.5 = 0.33

Risk
33% penyakit pada kelompok
terpapar (baik yang sakit atau tidak)
disebabkan oleh paparan
Relatif terhadap risiko
pada kelompok terpapar
group

ARF = 0.33/0.78 = 0.42

42% dari seluruh penyakit pada

kelompok terpapar (hanya pada yang
sakit) disebabkan oleh paparan

paparan
risiko baseline
 Contoh (berkelompok)
Disease + Disease -

Exposure + 6 94 100

Exposure - 2 98 100

8 192 200
Population Attributable Risk
Seberapa besar penyakit yang ada di populasi disebabkan oleh paparan?
Mempertimbangkan prevalensi paparan pada populasi

Excess Risk =
Attributable Risk
Risk
Attributable Risk =
(risiko pada paparan +) –
(risiko pada paparan -)

Population Attributable Risk =

PAR = AR x Prevalensi paparan

risiko baseline
paparan
Population Attributable Risk (PAR)
Contoh
◦ risiko pada kelompok terpapar=3/100, risiko pada kelompok tidak terpapar=1/100
◦ prevalensi paparan=20%
◦ PAR = AR x prevalensi paparan
◦ PAR = (2/100) x 20%
◦ PAR = 0.4%

◦ “ Risiko kanker paru yang disebabkan oleh merokok pada populasi adalah 0.4% (baik terpapar maupun
tidak), bila 20% populasi terpapar rokok.”
Population Attributable Risk Fraction
Berapa % penyakit pada populasi disebabkan paparan?

Ukuran absolut di
Excess Risk = tingkat populasi
Attributable Risk
Risk
Population Attributable Risk =
PAR = AR x prevalensi paparan

% risiko di populasi

PARF = PAR/ total risiko di populasi

risiko baseline
paparan
Population Attributable Risk Fraction
(PARF)
PARF = PAR / total risiko
◦ risiko pada kelompok terpapar=3/100, risiko pada kelompok tidak terpapar=1/100
◦ prevalensi paparan=20%
◦ PAR=(2/100) x 20% = 0.4%
◦ Total risiko = total risiko pada populasi (terpapar+ tidak terpapar) = (3 + 1) / (100 + 100) = 4/200 =
2%
◦ PARF = PAR / Total risiko
◦ PARF = 0.4% / 2% = 20%

◦ 20% dari seluruh penyakit yang ada di populasi disebabkan oleh paparan
or
◦ If we could remove this exposure from this population, we would remove ~20% of the risk of this
disease
PAR and PARF
prevalensi paparan = 30%
Absolute measures

Excess Risk =
Attributable Risk PAR = 0.33 * 0.5 = 0.066

Risk
6.6% of disease in the population is
attributable to the exposure
Relative to risiko
pada kelompok
terpapar group

PARF = 6.6%/64%

10.3% of the total disease in the

population is due to this exposure

paparan risiko baseline

Another PAR example
risiko pada kelompok tidak terpapar = 7/100 = 0.07
risiko pada kelompok terpapar = 21/100 = 0.21
prevalensi paparan=0.5
Risk in total = (0.21+0.07) x 0.5 = 0.14

PAR = RD x Prevalence
RD = 0.21 – 0.07 = 0.14
PAR = 0.14 x 0.5 = 0.07
PARF = 0.07 / 0.14 = 50%
Group Practice

Paparan = tidak pernah memakan ikan

Tidak terpapar = memakan ikan hamper tiap hari
Hitung RR, AR, ARF, PAR, dan PARF untuk populasi ini
Answer
Risiko pada terpapar (Ie)= a/a+b=82/1,631=0.0503, or 5.03 per
Risiko pada tidak terpapar (Iu)= c/c+d= 23/802=0.0287, or 2.87 per 100
Risiko pada semuanya (Ip): a+c/(a+ b+ c+ d)=105/2,433 =0.0432, or 4.32 per 100
RR=Risiko pada terpapar ÷ risiko pada tidak terpapar=
5.03 ÷ 2.87=1.75
AR = 2.16 per 100
ARF = 43%
PAR = 1.45 per 100
PARF = 33.6%
Risk Difference and
Relative Risk
Risk Difference
Absolute Difference (ARR/ARI)
◦ ARR (Absolute Risk Reduction) for beneficial exposure (i.e. vaccine, treatment)
◦ ARI (Absolute Risk Increase) for adverse exposure (i.e. risk factor, adverse event)
◦ On the additive scale
◦ Subtraction
◦ The difference between 2 risks
◦ Example
◦ 15 out of 100 people in exposed group have disease
(Risk = 0.15)
◦ 5 out of 100 people in unexposed group have disease
(Risk=0.05)
◦ Absolute difference = 0.15 – 0.05 = 0.10

Null value=0
 More practice compute RD and RR
Flu Flu Total

Getting Yes No
Vaccine
Yes 5 95 100

No 40 60 100

Total 45 155 200

Risk of getting flu for people who were vaccinated : 5/100 = 0.05
Risk of getting flu for people who were not vaccinated : 40/100 = 0.40
“The risk of Flu in those vaccinated
RD = 0.40 – 0.05 = 0.35 decreased by 35% as the risk of Flu in
people who were not vaccinated”

“The risk of Flu in those vaccinated is 0.125

RR = 0.05/0.40 = 0.125 times as the risk of Flu in people who were
not vaccinated”
ARR vs RRR

Ref: http://www.cche.net/usersguides/ebm_tips.asp
Relative Risk Reduction (RRR)
RRR = 1 – RR
How much less likely will someone get the disease if they are treated
✔ i.e. used more for beneficial exposures like treatments

Example:
◦ Risk in treatment group = 20/100 = 0.02
◦ Risk in control group= 80/100 = 0.08
◦ RR= (20/100)/(80/100)=0.25
 More practice compute RRR
Flu Flu Total

Getting Yes No
Vaccine
Yes 5 95 100

No 40 60 100

Total 45 155 200

Risk of getting flu for people who were vaccinated : 5/100 = 0.05
Risk of getting flu for people who were not vaccinated : 40/100 = 0.40
“The risk of Flu in those vaccinated is
RR = 0.05/0.40 = 0.125 0.125 times as the risk of Flu in people
who were not vaccinated group”

The risk of flu is reduced by vaccine by

RRR = 1 - 0.125 = 0.875
87.5% on a relative scale
Absolute Risk Reduction (ARR)
◦ ARR = Risk Difference = Risk1 – Risk2
◦ Harmful exposures: ARR = (Risk in exposed) – (Risk in unexposed)
◦ Because risk in exposed is larger (example : virus, smoking)
◦ Beneficial exposures: ARR = (Risk in unexposed) – (Risk exposed)
◦ Because risiko in unexposed is larger (example : treatment, vaccine)

Using the previous example:

◦ Risk in treatment group = 20/100 = 0.20
◦ Risk in control group= 80/100 = 0.80
 More practice compute ARR
Flu Flu Total

Getting Yes No
Vaccine
Yes 5 95 100

No 40 60 100

Total 45 155 200

Risk of getting flu for people who were vaccinated : 5/100 = 0.05
Risk of getting flu for people who were not vaccinated : 40/100 = 0.40
“The risk of Flu in those vaccinated
RD = 0.40 – 0.05 = 0.35
decreased by 35% as the risk of Flu in
people who were not vaccinated”

The risk of flu is reduced by vaccine by 35%

ARR = 0.40 – 0.05
on an additive scale
Absolute vs. relative differences
$$$ example:
◦ Person A has a quarter; person B has a nickel
◦ Absolute differences: person A has $0.20 more than person B
◦ Relative differences: person A has five times as much money than person B
Another:
◦ Person C has a penny—compare B and C
◦ Absolute difference: person B has $0.04 more than person C
◦ Relative difference: person B has five times as much money than person B

NOTE: same relative difference in two examples, but different absolute

differences
Group practice
A large observational cohort study was done in China to determine if Folic Acid supplementation
during pregnancy would reduce the incidence of neural tube defects in the newborns. In two
southern provinces a total of 111,392 women took folic acid during their pregnancy and there
were 77 neural tube defects in their children. A total of 104,320 women in the same provinces
did not take folic acid and there were 86 neural tube defects in their children.
▪ What was the cumulative incidence of neural tube defects among mothers who took folic
acid supplements?
▪ What was the cumulative incidence of neural tube defects among mothers who did not take
folic acid supplements?
▪ What is the Relative Risk Reduction (RRR) associated with folic acid supplements for neural
tube defects?
Answers
(77/111392 = 0.00069)

(86/104320 = 0.00082)

1-RR = 0.16 or 16%

Practice
A large observational cohort study was done in China to determine if Folic Acid supplementation
during pregnancy would reduce the incidence of neural tube defects in the newborns. In two
southern provinces a total of 111,392 women took folic acid during their pregnancy and there
were 77 neural tube defects in their children. A total of 104,320 women in the same provinces
did not take folic acid and there were 86 neural tube defects in their children.
What was the cumulative incidence of neural tube defects among mothers who took folic acid
supplements?
What was the probability of neural tube defects among mothers who did not take folic acid
supplements?
What is the Relative Risk (RR) associated with folic acid supplements for neural tube defects?
What does it means?
What is the Relative Risk (OR) associated with folic acid supplements for neural tube defects?
What does it means?
What is the Relative Risk Reduction (RRR) associated with folic acid supplements for neural tube
defects? What does it means?
What is the Absolute Risk Reduction (ARR) associated with folic acid supplements for neural
tube defects? What does it means?
For every treatment – there’s a trade
off
NNT
(for benefit)
NNH
(for harm)
Number Needed to Treat (NNT)
For beneficial effect
NNT = 1 / ARR or 1 / RD
◦ Number needed to treat in order to prevent one case of the disease

New example:
◦ Risk in treatment group = 10/100
◦ Risk in control group = 20/100
◦ ARR=RD = (20/100) - (10/100) = 10/100

◦ NNT = 1/ARR = 1/(10/100) = 1/0.1 = 10

◦ Since each person taking this treatment reduces their risk by 10%, if 10 people are treated, on average, we will
prevent 1 case of the disease
◦ So, NNT=10
Number Needed to Harm (NNH)
Same thing as NNT— for harmful effect
◦ Commonly used in adverse medication events

New example:
◦ risiko pada kelompok terpapar= 45/100
◦ risiko pada kelompok tidak terpapar = 20/100
◦ RD=ARR= (45/100) – (20/100) = 25/100 = 0.25
◦ NNH = 1/ARR = 1/0.25 = 4

◦ Since each person who was exposed increases their risk by 25%, if 4 people are exosed , on average, we
will cause 1 case of the disease
◦ NNH = 4