UKURAN ASOSIASI

UKURAN ASOSIASI
– Merefleksikan kekuatan atau besar asosiasi
antara suatu pajanan/faktor risiko dan
kejadian suatu penyakit
– Menyertakkan perbandingandua atau lebih
frekuensi penyakit dengan berbagai derajat
pajanan
– Ukuran assosiasi digunakan untuk
mengestimasi efek
 UKURAN ASOSIASI
• Relative :
– RR (relative risk)
• Risk ratio
• Rate ratio
– OR
• Absolute :
– RD (risk difference)
 2 x 2 Tables
Used to summarize counts of disease and exposure
in order to do calculations of association

Outcome
Exposure Yes No Total
Yes a b a+b
No c d c+d
Total a+c b+d a+b+c+d
 Relative Risk
• The relative risk is the risk of disease in the
exposed group divided by the risk of disease in
the non-exposed group

• RR is the measure used with cohort studies

Outcome a
Yes No Total
Risk among a+b
Yes a b a+b
Exposure
the exposed RR =
No c d c+d Risk among c
the unexposed
c+d
 Ukuran-ukuran asosiasi
• Ukuran rasio
– Rasio risiko atau risiko relatif (RR)
Risiko pada kelompok terpajan
RR 
Risiko pada kelompok tidak terpajan

– Rasio Insidens Kumulatif (RIK)

Insidens kumulatif pada kelompok terpajan

RIK 
Insidens kumulatif pada kelompok tidak terpajan
 Ukuran-ukuran asosiasi
• Ukuran rasio
– Rasio rate atau rasio densitas insidens (RDI)
Densitas insidens pada kelompok terpajan
RDI 
Densitas insidens pada kelompok tidak terpajan

– Rasio Prevalens (RP)

Prevalens pada kelompok terpajan

RP 
Prevalens pada kelompok tidak terpajan
 Contoh 5.
Tabel 1. Kaitan antara merokok dan angka insidens stroke dalam
suatu kohort.
Kategori Jumlah kasus Orang-tahun Tingkat
merokok stroke observasi insidens stroke
(lebih dari 8 (per 100.000
tahun) orang tahun)
Tidak pernah
merokok
70 395.594 17,7
Mantan perokok
65 232.712 27,9
Perokok
139 280.141 49,6

Total
274 908.447 30,2
Sumber: diterjemahkan dari:Beaglehole et al. Basic Epidemiology. WHO. 1993. 18.
 Ukuran-ukuran asosiasi
• Dari Tabel 1.
• Hitunglah:
– Rasio rate atau rasio densitas insidens (RDI)
Densitas insidens pada kelompok terpajan
RDI 
Densitas insidens pada kelompok tidak terpajan

49,6
RDI   2,8
17,7
Postmenopausal Hormone Supplement and CHD
CHD Person-years

Ever use 30 54,308.7

Past use 19 24,386.7
Current 11 29,922.0
Never use 60 51,477.5

RR ever use vs never use = (30/54,308.7) / ( 60/51477.5) = 0.5

RR past use vs never use = (19/24386.7) / (60/51477.5) = 0.7

RR current use vs never use = (11/29922.0) / (60/51477.5) = 0.3
 Interpreting Measures
of Association
RR of 1.0 indicates that the occurrence
of disease in the exposed an
unexposed groups are identical:

– No association observed between

exposed and unexposed groups.
 Interpreting Measures
of Association (Continued)

• RR greater than 1.0 indicates a

positive association, or an increased
risk among the exposed.

• RR less than 1.0 means that there is a

decreased risk among the exposed
group.
 Interpretation
• If the RR = 5
– People who were exposed are 5 times more likely to
have the outcome when compared with persons who
were not exposed

• If the RR = 0.5
– People who were exposed are half as likely to have
the outcome when compared with persons who were
not exposed

• If the RR = 1
– People who were exposed are no more or less likely
to have the outcome when compared to persons who
were not exposed
 Ukuran-ukuran asosiasi
• Ukuran rasio
– Rasio odds (Odds ratio = OR)
• Nama lain: Odds relative; rasio kros-
produk

• rasio dua odds yang digunakan dalam

studi kasus-kontrol untuk mengestimasi
rasio rate atau rasio risiko
 Ukuran-ukuran asosiasi
• Odds suatu kejadian
– rasio probabilitas bahwa kejadian terjadi
terhadap probabilitas kejadian tidak terjadi
P
Odds suatu peristiwa 
1 P

P = Probabilitas suatu kejadian terjadi

1–P = Probabilitas suatu kejadian tidak terjadi
OR in case-control and cohort studies

• Cohort study
Ratio of the proportion of exposed
subjects who developed the disease to the
proportion of non-exposed subjects who
developed the disease
• Case-control study
Ratio of the proportion of cases who were
exposed to the proportion of controls who
were exposed
Figure 11-5 A, Odds ratio (OR) in a cohort study. B, Odds ratio (OR) in a case-control study.

Downloaded from: StudentConsult (on 8 October 2009 11:44 AM)

© 2005 Elsevier
Incidence Odds Ratio (IOR) = Cross Product Ratio
 bila data didasarkan pada kasus-kasus insidens
20 x 990
Incidence Odds Ratio   2,02
10 x 980

20 / 1000 0,02
Incidence proportion Ratio( RR )    2,00
10 / 1000 0,01

Faktor Sakit Tidak sakit Total

Perokok 20 (a) 980 (b) 1000

Bukan 10 (c) 990 (d) 1000

perokok
Total 30 1970 2000
 OR in case-control study
 In case-control study RR cannot be calculated directly
to determine the association between exposure and
disease.
 Don’t know the risk of disease among exposed and un-
exposed since we start recruiting cases and controls
 Can use OR as measure of association between
exposure and disease in a case control study.
Odds Ratio (OR) = Relative Odds = Cross
Product Ratio pada studi kasus kontrol
Odds pemajan untuk kasus
Odds Ratio 
Odds pemajan untuk kontrol

Faktor Kasus Kontrol Total

Perokok 650 (a) 950 (b) 1600
Bukan 50 (c) 350 (d) 400
perokok
Total 700 1300 2000
 Prevalence Odds Ratio (POR) = Cross Product
Ratio  bila data didasarkan pada kasus-kasus
prevalens
650 x 350
Prevalence Odds Ratio   4,8
950 x 50
650 / 1600 0,40625
Prevalence ( proportion) Ratio    3,25
50 / 400 0,125

Faktor Kasus Kontrol Total

Perokok 650 (a) 950 (b) 1600

Bukan 50 (c) 350 (d) 400

perokok
Total 700 1300 2000
Figure 11-6 Example: The odds ratio is a good estimate
of the relative risk when a disease is infrequent.
Downloaded from: StudentConsult (on 8 October 2009 11:44 AM)
© 2005 Elsevier
Figure 11-7 Example: The odds ratio is not a
good estimate of the relative risk when a
disease is not infrequent.
Downloaded from: StudentConsult (on 8 October 2009 11:44 AM)
© 2005 Elsevier
 OR & RR
• Pada penyakit yang jarang terjadi,nilai
Odds Ratio hampir sama dengan nilai
Relative Risk (Risk Ratio). Nilai
Prevalence Odds Ratio hampir sama
dengan nilai Prevalence Proportion Ratio.
• Pada penyakit yang umum terjadi, nilai
Odds Ratio lebih ekstrim dari pada Risk
Ratio.
Interpretation of Odds Ratio
• Relative odds associated with exposure
OR = 1  no association
OR > 1  positive association
OR < 1  negative association

• Size of OR indicates strength of

association
• OR ≈ RR when disease rare (i.e., risk <
5%); when disease not rare, OR still a
valid measure of association
Gerstman Chapter 8 (partial) 31
 Tests of Significance
• Indication of reliability of the association that
was observed

• Answers the question “How likely is it that the

observed association may be due to chance?”

• Two main tests:

1. 95% Confidence Intervals (CI)
2. p-values
 95% CI Example
Disease Odds Ratio 95% CI
Gonorrhea 2.4 1.3 – 4.4
Trichomonas 1.9 1.3 – 2.8
Yeast 1.3 1.0 – 1.7
Other vaginitis 1.7 1.0 – 2.7
Herpes 0.9 0.5 – 1.8
Genital warts 0.4 0.2 – 1.0
Grodstein F, Goldman MB, Cramer DW. Relation of tubal infertility to history of sexually
transmitted diseases. Am J Epidemiol. 1993 Mar 1;137(5):577-84
Interpreting 95% Confidence Intervals
• To have a significant association between
exposure and outcome, the 95% CI
should not include 1.0

• A 95% CI range below 1 suggests less risk

of the outcome in the exposed population

• A 95% CI range above 1 suggests a

higher risk of the outcome in the exposed
population
 p-values
• The p-value is a measure of how likely the
observed association would be to occur by
chance alone, in the absence of a true
association

• A very small p-value means that you are very

unlikely to observe such a RR or OR if there was
no true association

• A p-value of 0.05 indicates only a 5% chance

that the RR or OR was observed by chance
alone
 p-value Example
Disease Odds Ratio 95% CI p-value
Gonorrhea 2.4 1.3 – 4.4 0.004
Trichomonas 1.9 1.3 – 2.8 0.001
Yeast 1.3 1.0 – 1.7 0.04
Other vaginitis 1.7 1.0 – 2.7 0.04
Herpes 0.9 0.5 – 1.8 0.80
Genital warts 0.4 0.2 – 1.0 0.05

Grodstein F, Goldman MB, Cramer DW. Relation of tubal infertility to history of sexually transmitted diseases. Am J Epidemiol. 1993 Mar 1;137(5):577-84
 M e a s u re o f
A s s o c ia t io n

R e la t iv e r is k A t t r ib u t a b le r is k
RR OR AR PAR