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Causal Association : Cause To Effect<br />Dr. Akhilesh BhargavaMD, DHA, PGDHRMProf. Community Medicine &Director-SIHFW, Ja...
Akhilesh Bhargava<br />2<br />Measure of Association-Concepts<br />If ‘more’ disease occurs in a group that smokes compare...
Akhilesh Bhargava<br />3<br />Why study association?<br />Is the first step in establishing a hypothesized causal relation...
Akhilesh Bhargava<br />4<br />From Association to Causation<br />Does the association make biologic sense?<br />An isolate...
Akhilesh Bhargava<br />5<br />All epidemiological hypotheses is based on the concept of association between exposure & dis...
Akhilesh Bhargava<br />6<br />   a relationship between cause & effect may not be always a causal one, for the reason that...
Akhilesh Bhargava<br />7<br />The variable in an association are-<br />Dependent (dv)<br />Independent (iv)<br />Confoundi...
Akhilesh Bhargava<br />8<br />Causes<br />Hypertension			CHD<br />(iv)<br />				Causes<br />Increased				Hypertension<br /...
Akhilesh Bhargava<br />9<br />					  (cv)<br />				      Prematurity<br />Maternal Malnutrition	Low Birth Weight<br />(iv)...
Akhilesh Bhargava<br />10<br />Factors governing association<br />Magnitude of association or strength       of associatio...
Akhilesh Bhargava<br />11<br />Approaches in establishing a causal association-<br />Basic questions are -<br />Is there a...
Akhilesh Bhargava<br />12<br />An association should satisfy confirmatory<br />criteria for causality, like<br />Strength<...
Akhilesh Bhargava<br />13<br />Types of Association<br /><ul><li>Causal</li></ul>Direct causal (iodine deficiency-goiter)<...
Akhilesh Bhargava<br />14<br />E				D (Direct causality)<br />E				D (Indirect causality)<br />		   C<br />E1<br />				D (...
Akhilesh Bhargava<br />15<br /> Two ways to get at the ‘Association’<br />Start with a group of ‘exposed’ and a group of ‘...
Akhilesh Bhargava<br />16<br /><ul><li>Prospective approach; </li></ul>Comparison of the proportion of those developing di...
Akhilesh Bhargava<br />17<br />Measures of Association<br />Standardized Morbidity Ratio (SMR)<br />  Standardized Mortali...
Akhilesh Bhargava<br />18<br />Standardized Morbidity (Mortality) Ratio<br />SMR= Ratio of an ‘observed’ to an ‘expected’<...
Akhilesh Bhargava<br />19<br />Examples of SMR<br />Observed= number of cases of lung cancer deaths actually observed in a...
Akhilesh Bhargava<br />20<br />SMR Example<br />In a city, observed number of deaths by various causes are available by oc...
Akhilesh Bhargava<br />21<br />Prospective Approach: Relative Risk<br />Relative Risk = (30 / 100) / (10 / 100) = 3.0<br />
Akhilesh Bhargava<br />22<br />Relative Risk (RR)<br />Consider incidence rate of lung cancer in heavy smokers and non-smo...
Akhilesh Bhargava<br />23<br />Relative Risk (RR) cont…<br />Relative Risk (RR)= Ratio of the risk of disease in ‘exposed’...
Akhilesh Bhargava<br />24<br />Retrospective Approach:Odds Ratio<br />Odds Ratio = (30 / 10) / (70 / 90) = 3.85<br />If th...
Akhilesh Bhargava<br />25<br />Attributable Risk (Risk Difference)<br />Incidence in exposed –incidence in unexposed <br /...
Akhilesh Bhargava<br />26<br />Ratios are appropriate measures for examining the importance of a given risk factor in the ...
Akhilesh Bhargava<br />27<br />   But suppose we are interested in finding out to what extent a disease can be prevented i...
Akhilesh Bhargava<br />28<br />  RR=<br />       a/ a + b<br />       -----------<br />       c/ c + d<br />RR-1<br />   A...
Akhilesh Bhargava<br />29<br />a  / a + b       120 / 400<br />RR=     ----------- =   ----------   =  6.0<br />          ...
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Causal Association

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Causal Association

  1. 1. Causal Association : Cause To Effect<br />Dr. Akhilesh BhargavaMD, DHA, PGDHRMProf. Community Medicine &Director-SIHFW, Jaipur<br />
  2. 2. Akhilesh Bhargava<br />2<br />Measure of Association-Concepts<br />If ‘more’ disease occurs in a group that smokes compared to the group that does not smoke, there is an ‘association’ between the disease and smoking<br />If ‘more’ disease occurs in Hindus than in Muslims, there is an ‘association’ between the disease and race<br />If ‘more’ lung cancer deaths occur in certain occupations than others, there is an ‘association’ between occupational exposure characteristics and lung cancer<br />
  3. 3. Akhilesh Bhargava<br />3<br />Why study association?<br />Is the first step in establishing a hypothesized causal relationship<br />Association by itself does not implicate causation<br />
  4. 4. Akhilesh Bhargava<br />4<br />From Association to Causation<br />Does the association make biologic sense?<br />An isolated study or, many studies in different populations find a similar association?<br />Does the association support a dose response, i.e., more exposure is associated with more disease?<br />
  5. 5. Akhilesh Bhargava<br />5<br />All epidemiological hypotheses is based on the concept of association between exposure & disease<br />Primary objective is to see whether an association is causal or not. <br />Presence of an association in no way implies that the relationship is that of a cause & effect.<br />The association means a statistical dependence between two variables i.e. when a change in one variable parallels or coincides with the change in other variable<br />
  6. 6. Akhilesh Bhargava<br />6<br /> a relationship between cause & effect may not be always a causal one, for the reason that <br /> Bias, <br /> Chance & <br /> Confounding may under or over play the association <br />
  7. 7. Akhilesh Bhargava<br />7<br />The variable in an association are-<br />Dependent (dv)<br />Independent (iv)<br />Confounding (cv)<br />Intermediate (im.v)<br />
  8. 8. Akhilesh Bhargava<br />8<br />Causes<br />Hypertension CHD<br />(iv)<br /> Causes<br />Increased Hypertension<br />Salt intake (dv)<br /> Hypertension<br />Obesity (cv) CHD<br />Salt intake Hypertension CHD <br /> causes causes<br /> (Intermediate variable) <br />
  9. 9. Akhilesh Bhargava<br />9<br /> (cv)<br /> Prematurity<br />Maternal Malnutrition Low Birth Weight<br />(iv) (dv)<br /> Maternal Anemia<br /> (intermediate variable)<br />
  10. 10. Akhilesh Bhargava<br />10<br />Factors governing association<br />Magnitude of association or strength of association<br />B. Biological likelihood <br />C. Consistency with other findings<br />D. Time sequence &<br />E. Dose-response relationship<br />
  11. 11. Akhilesh Bhargava<br />11<br />Approaches in establishing a causal association-<br />Basic questions are -<br />Is there an association actually existing<br />Is the association likely to be causal<br />
  12. 12. Akhilesh Bhargava<br />12<br />An association should satisfy confirmatory<br />criteria for causality, like<br />Strength<br />Biological gradient (dose- response relationship)<br />Temporality ( time sequence)<br />Biological plausibility<br />Specificity<br />Consistency &<br />Experimental proof<br />
  13. 13. Akhilesh Bhargava<br />13<br />Types of Association<br /><ul><li>Causal</li></ul>Direct causal (iodine deficiency-goiter)<br />Indirect causal (iodine deficiency-goiter-thyroid adenoma)<br /><ul><li>Non-causal</li></ul>Chance, <br />Numerator analysis alone <br />Bias <br />
  14. 14. Akhilesh Bhargava<br />14<br />E D (Direct causality)<br />E D (Indirect causality)<br /> C<br />E1<br /> D (Independently causal<br />E2<br />E1<br />+ D (conditionally causal)<br />E2<br />(E1 and E2 need to be present<br />simultaneously<br />E= Exposure<br />D= Disease<br />C=Confounding<br />
  15. 15. Akhilesh Bhargava<br />15<br /> Two ways to get at the ‘Association’<br />Start with a group of ‘exposed’ and a group of ‘unexposed’. Determine how many (what proportion) in each group have or develop the disease in question.<br />Start with a group of people with the disease and a group free of the disease. Determine how many (what proportion) in each group has the exposure in question<br />
  16. 16. Akhilesh Bhargava<br />16<br /><ul><li>Prospective approach; </li></ul>Comparison of the proportion of those developing disease in the exposed and the unexposed group constitutes a measure of association (relative risk) between the disease and the exposure.<br /><ul><li>Retrospective approach.</li></ul>Comparison of odds (related to proportion) of having exposure in the disease and the disease-free group constitutes a measure of association (odds ratio) between the disease and the exposure.<br />
  17. 17. Akhilesh Bhargava<br />17<br />Measures of Association<br />Standardized Morbidity Ratio (SMR)<br /> Standardized Mortality Ratio (SMR)<br /> Relative Risk (RR)<br /> Odds Ratio (OR)<br /> Attributable Risk (AR)<br />
  18. 18. Akhilesh Bhargava<br />18<br />Standardized Morbidity (Mortality) Ratio<br />SMR= Ratio of an ‘observed’ to an ‘expected’<br />If ‘observed’ and ‘expected’ are equal, that is, if SMR=1, there is no association<br />If SMR is different than 1, there is association<br />Remember, association does not implicate causation<br />
  19. 19. Akhilesh Bhargava<br />19<br />Examples of SMR<br />Observed= number of cases of lung cancer deaths actually observed in an occupational group. <br /> Expected= number of lung cancer deaths expected in this group based on general population rates.<br />If observed and expected are equal, there is no reason to suspect that the particular occupation carries higher risk of lung cancer.<br />If, on the other hand, observed is different than the expected, one can infer an ‘association’ between the particular occupation and lung cancer.<br />
  20. 20. Akhilesh Bhargava<br />20<br />SMR Example<br />In a city, observed number of deaths by various causes are available by occupation<br /> Expected number of deaths for each occupation are calculated by applying the citywide rates to each occupation.<br />If number of observed and actual deaths are equal for each occupation, one would not suspect a relationship between occupational characteristics and risk of death for a certain cause.<br />If, on the other hand, for a specific cause of death, some occupations exhibit excess while others exhibit a deficit, an association between occupational characteristics and the specific cause of death would be inferred.<br />
  21. 21. Akhilesh Bhargava<br />21<br />Prospective Approach: Relative Risk<br />Relative Risk = (30 / 100) / (10 / 100) = 3.0<br />
  22. 22. Akhilesh Bhargava<br />22<br />Relative Risk (RR)<br />Consider incidence rate of lung cancer in heavy smokers and non-smokers<br />If the incidence rate is the same for heavy smokers and non-smokers, no association can be inferred between smoking and lung cancer<br />If the incidence rate is higher among heavy smokers RELATIVE to non-smokers, an association would be suggested.<br />Incidence rate can be taken as a measure of risk, and the ratio of the two incidence rates would then be the Relative Risk (RR)<br />
  23. 23. Akhilesh Bhargava<br />23<br />Relative Risk (RR) cont…<br />Relative Risk (RR)= Ratio of the risk of disease in ‘exposed’ and ‘unexposed’<br />RR=1 No association between the exposure and the disease.<br />RR&gt;1  There is an association (risk factor)<br />RR&lt;1  There is an association (protective factor)<br />Farther from the null value the RR is, stronger is the association<br />No matter how strong the association, it can not in and by itself implicate causation<br />
  24. 24. Akhilesh Bhargava<br />24<br />Retrospective Approach:Odds Ratio<br />Odds Ratio = (30 / 10) / (70 / 90) = 3.85<br />If the disease is rare, the odds ratio provides a good approximation of relative risk.<br />However, in the literature, odds ratio and relative risks are (erroneously) considered synonymous.<br />
  25. 25. Akhilesh Bhargava<br />25<br />Attributable Risk (Risk Difference)<br />Incidence in exposed –incidence in unexposed <br />AR is an expression of existence of a cause-effect<br />relationship.<br />An AR value of 0 (Zero) means no association <br />between cause and effect.<br />AR is basically a Ratio<br />
  26. 26. Akhilesh Bhargava<br />26<br />Ratios are appropriate measures for examining the importance of a given risk factor in the etiology of the disease. This is because the ratio provides an indication of how many times is the risk of the disease to a person with the exposure to the factor compared to one who is not so exposed.<br />
  27. 27. Akhilesh Bhargava<br />27<br /> But suppose we are interested in finding out to what extent a disease can be prevented in a population if a particular risk factor was eliminated?<br /> Or suppose we are interested in finding out to what extent is the particular risk factor responsible for the disease in an exposed individual?<br /> The first question pertains to what is known as the population attributable risk (AR )<br /> The second question pertains to what is known as the exposure attributable risk (AR% ).<br />
  28. 28. Akhilesh Bhargava<br />28<br /> RR=<br /> a/ a + b<br /> -----------<br /> c/ c + d<br />RR-1<br /> AR= -------<br /> RR<br /> a d<br /> OR = -----<br />b c<br /> Incidence in Total pop. – Incidence in exposed<br />AR p %= ---------------------------------------- ---------- ----x 100<br /> Incidence in total Pop. <br /> ARIe-Io<br />ARp % =-------- x 100 = ------- x 100<br />IeIe<br />
  29. 29. Akhilesh Bhargava<br />29<br />a / a + b 120 / 400<br />RR= ----------- = ---------- = 6.0<br /> c/ c + d 30 / 600<br /> RR-1 6-1<br />AR= ------- = ------ = 0.83<br /> RR 6<br /> 0.83 0.83<br />AR p % = ------- = ------ = 3.32<br /> 120 / 400 0.25<br /> a d 120 x 570<br />O.R. = ----- = ------------- = 8.14<br /> b c 280 x 30<br />

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