MEASURES

OF
ASSOCIATION
IN PUBLIC
VITRI WIDYANINGSIH

HEALTH (2)
 Total 5 people
Risk Vs
Odds Risk Odds
0.80 4.0 ⌂⌂⌂⌂/⌂
0.67 2.0 ⌂⌂/⌂
0.50 1.0 ⌂/⌂
0.20 0.25 ⌂/⌂⌂⌂⌂
0.10 0.11 ⌂/⌂⌂⌂⌂⌂⌂⌂⌂⌂

Conversion: Risk : 4 people developed disease out of 5

people
Odds = Risk/(1-Risk)
Odds : For 4 people who developed disease,
Risk = Odds / (1 + Odds) 1 did not develop disease
Risk Ratio vs Relative
Risk
Risk Ratio (Relative Risk )
◦Risk among exposed/ Risk among unexposed
◦Risk → 1/10 = 0.1
◦“The risk of disease in the exposed group is x (RR) times the risk of disease in the unexposed group.”

Odds Ratio
◦ Odds among exposed/ Odds among unexposed
◦ Same as RR—uses odds instead of probabilities
◦ Odds → 1/10=1:9
◦ “The odds of disease in the exposed group is x (OR) times the odds of disease in the unexposed group.”
Odds Ratio (Pause and do
the calculation)
Hipertensi Total

Obesitas Ya Tidak

Ya 40 60 100

Tidak 5 95 100

Total 45 155 200

Odds Ratio (Pause review your
answer) Hipertensi Total

Obesitas Ya Tidak

Ya 40 60 100

Tidak 5 95 100

Total 45 155 200

Odds Hipertensi untuk obesitas: 40/60 = 0.67

Odds Hipertensi untuk yang tidak obesitas : 5/95 =

0.052
“ Odds hipertensi pada obesitas sebesar
OR = 0.67/0.052 = 12.9 12.9 kali lebih tinggi disbanding odds
hipertensi pada yang tidak obesitas
Odds
Ratio Hipertensi Total

Obesitas Ya Tidak

Ya 40 60 100

Tidak 5 95 100

Total 45 155 200

Odds Hipertensi untuk obesitas: 40/60 = 0.67

Odds Hipertensi untuk yang tidak obesitas : 5/95 =

0.052
“ Odds hipertensi pada obesitas sebesar
OR = 0.67/0.052 = 12.9 12.9 kali lebih tinggi disbanding odds
hipertensi pada yang tidak obesitas
Relative
Risk Hipertensi Total

Obesitas Ya Tidak

Ya 40 60 100

Tidak 5 95 100

Total 45 155 200

Risiko hipertensi pada obesitas : 40/100 = 0.4

Risiko hipertensi pada non obesitas: 5/100 = 0.05
“ Risiko hipertensi pada obesitas sebesar 8
RR = 0.4/0.05 = 8 kali lebih tinggi disbanding Risiko
hipertensi pada yang tidak obesitas
 Berapa nilai hipotesis 0 untuk RR dan OR? (Hipotesis 0 = apabila
tidak ada hubungan antara paparan dengan penyakit)
Pause Kapan nilai OR bisa mendekati nilai RR?

and write Nilai mana yang lebih ekstrim?

down your Apa arti dari OR < 1?

Apa arti dari OR > 1?
answer for Apa arti RR > 1?

discussion Apa arti OR < 1?

 Relative risk merupakan ukuran yang penting untuk menandakan

Relative
kekuatan hubungan
◦Penting untuk menentukan hubungan etiologis/ causal

vs. Attributable risk merupakan ukuran yang penting untuk

Attributab mengetahui: “Seberapa besar penyakit tersebut disebabkan oleh
paparan?”

le ◦Penting untuk klinis dan kesehatan masyarakat

Risk
Risk Difference and
Relative Risk
 Absolute Difference (ARR/ARI)
◦ARR (Absolute Risk Reduction) → for beneficial exposure
(e.i.
vaccine, treatment)
◦ARI (Absolute Risk Increase) → for adverse exposure (i.e.
srik factor, adverse event)
◦On the additive scale
Ris ◦Subtraction

k
◦The difference between 2 risks
◦Example

Differen ◦ 15 out of 100 people in exposed group have disease

(Risk = 0.15)
ce ◦ 5 out of 100 people in unexposed group have disease
(Risk=0.05)
◦Absolute difference = 0.15 – 0.05 = 0.10
Null value=0
 Pause and Review your answer
Kanker Paru Total

Merokok Yes No

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”
More practice → compute RD and
RR (Pause and do the calculation)

Flu Flu Total

Getting Yes No
Vaccine
Yes 5 95 100

No 40 60 100

Total 45 155 200

 Pause and Review your answer
Flu Flu Total

Getting Yes No

Vaccin
e
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
 RRR = 1 – RR

Relative
How much less likely will someone get the disease if they are
treated

Risk
 i.e. used more for beneficial exposures like treatments

Example:
Reductio ◦Risk in treatment group = 20/100 = 0.02
◦Risk in control group= 80/100 = 0.08
n ◦RR= (20/100)/(80/100)=0.25

(RRR)
Pause and do the calculation → compute RR and
RRR Flu Flu Total

Getting Yes No

Vaccin
e
Yes 5 95 100
No 40 60 100
Total 45 155 200
 Pause and review your answer
Flu Flu Total

Getting Yes No

Vaccin
e
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
 ◦ ARR = Risk Difference = Risk1 – Risk2
◦Harmful exposures: ARR = (Risk in exposed) – (Risk in
unexposed)
◦Because risk in exposed is larger (example : virus, smoking)
Absolute ◦Beneficial exposures: ARR = (Risk in unexposed) – (Risk
exposed)
Risk ◦Because risiko in unexposed is larger (example :
treatment,
Reductio vaccine)
Using the previous example:

n ◦Risk in treatment group = 20/100 = 0.20

◦Risk in control group= 80/100 = 0.80

(ARR)
More practice → compute RD
and ARR Flu Flu Total

Getting Yes No

Vaccin
e
Yes 5 95 100
No 40 60 100
Total 45 155 200
 More practice → compute
Flu Flu ARR Total

Getting Yes No

Vaccin
e
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
Pause the video and do the
calculation
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?
Pause the Video and Review your
answer
A large observational cohort study was done in China to
determine if Folic Acid supplementation during pregnancy
(77/111392 = 0.00069)
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 (86/104320 = 0.00082)
were 86 neural tube defects in their children.
 What was the cumulative incidence of neural tube defects
among mothers who took folic acid supplements? 1-RR = 0.16 or 16%
 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?
For every treatment – there’s a trade
off NNT
(for benefit)
NNH
(for harm)
 For beneficial effect

NNT = 1 / ARR or 1 / RD
◦ Number needed to treat in order to prevent one case of the disease

Numbe New example:

r Needed
◦ Risk in treatment group = 10/100
◦ Risk in control group = 20/100

to Treat
◦ ARR=RD = (20/100) - (10/100) = 10/100

(NNT)
◦ 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
 Same thing as NNT— for harmful effect
◦ Commonly used in adverse medication events

Numbe
New example:
◦risiko pada kelompok terpapar= 45/100

r Needed
◦risiko pada kelompok tidak terpapar = 20/100
◦RD=ARR= (45/100) – (20/100) = 25/100 = 0.25

to Harm ◦ NNH = 1/ARR = 1/0.25 = 4

(NNH) ◦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