UKURAN ASOSIASI

Tipe ukuran yang digunakan dalam

epidemiologi
• Ukuran asosiasi
– Merefleksikan kekuatan atau besar asosiasi
antara suatu eksposur/faktor risiko dan
kejadian suatu penyakit

– Memasukkan suatu perbandingan frekuensi

penyakit antara dua atau lebih kelompok
dengan berbagai derajat eksposur

– Beberapa ukuran assosiasi digunakan untuk

mengestimasi efek
Basic Question in Analytic Epidemiology

• Are exposure and disease linked?

Exposure Disease
 Ukuran-ukuran asosiasi
• Ukuran rasio (perbandingan relatif)
– rasio dua frekuensi penyakit
membandingkan kelompok terpajan dengan
kelompok tidak terpajan
• Ukuran perbedaan efek (perbandingan
absolut)
– perbedaan antara ukuran frekuensi penyakit
suatu kelompok terpajan dan kelompok yang
tidak terpajan
 Arithmetic

• Suppose you have $2 and I have $1

• Absolute comparisons  made by subtraction
• $2 – $1 = $1
• “I have $1 more than you”
• Relative comparisons  made by division
• $2 ÷ $1 = 2 [$ units cancel out]
• “I have twice as much as you”
 Arithmetic
• Suppose that the 5-year rate of a disease
• in smokers is 2 per 100
• in non-smokers is 1 per 100
• Absolute comparison: (2 per 100) – (1 per 100)
= 1 per 100
• There is one addition case per 100 smokers
• Relative comparison: (2 per 100) ÷ (1 per 100)
= 2 [no units; “per 100” units cancel out]
• Smokers are at twice the risk of non-smokers
 UKURAN ASOSIASI
• Relative :
–RR (relative risk)
• Risk ratio
• Rate ratio
–OR
• Absolute :
–RD (risk difference)
 Measures of Association
• How much greater the frequency
of disease is in one group compared
with another.

• Often presented in the form of a

two-by-two table.
 Two-By-Two Table

Disease
Yes No Total

a b a+b
Yes
Exposure c d c+d

No Total a+c b+d a+b+c+d

 Hypothetical Two-By-Two
Table
Lung cancer
Yes No Total

70 300 370
Yes
Smoking 15 700 715

No
Total 85 1,000 1,085
 Relative Risk (RR)
• Measures how likely the exposed group
will develop a disease compared to the
unexposed group.

RR = incidence in the exposed = a/(a+b)

incidence in the unexposed c/(c+d)
Example: Hypothetical Study
Lung cancer

Yes No Total

Yes 70 300 370

Smoking No 15 700 715

Total 85 1,000 1,085

Relative Risk = 70/(70+300) = 9.0
15/(15+700)

Which means… participants who

smoked were 9 times more likely to
develop lung cancer than those who
did not smoke.
 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.
 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
Perhitungan RR untuk CI
Outcome (+) Outcome (-) Total

E (exposed) a b a+b

NE (unexposed) c d c+d

Total a+c b+d N

(a + b + c + d)

CI pada populasi exposed (E) --- a/(a + b)

RR=
CI pada populasi unexposed (NE) --- c/(c + d)
 THEN, FOLLOW TO SEE WHETHER
Incidence
Disease Disease rates
Totals
Develops Does Not of
Develop Disease

a Incidence in
FIRST, Exposed a b a+b =
a+b exposed
SELECT
Not c Incidence in
Exposed
c d c+d
c+d
=
non-exposed

a
Relative Risk ( RR ) = incidence in exposed a+b
incidence in non-exposed = c
c+d
 Example : A Prospective Study of 3,000 Smokers and 5,000 Non-
smokers to Investigate Smoking and Coronary Heart Disease
(CHD)
THEN FOLLOW UP TO
SEE HOW MANY

Do Not Incidence
Develop
Develop Total per 1,000
CHD per year
CHD
FIRST, Healthy Smokers 84 2,916 3,000 28.0
SELECT
Healthy Non-Smokers 87 4,913 5,000 17.4
 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
Perhitungan RR untuk IR
Outcome (+) Person-time

E (exposed) a N1

NE (unexposed) c N0

Total a+c T

IR pada populasi exposed (E) --- a/N1

RR=
IR pada populasi unexposed (NE) --- c/N0
 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
 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
• Ukuran rasio
– Rasio odds (Odds ratio = OR)
• odds untuk satu kelompok dibagi dengan odds
untuk kelompok yang lain
• Mempunyai interpretasi yang sama seperti risiko
relatif
 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
PROSPECTIVE STUDY
THEN, FOLLOW TO SEE WHETHER Incidence
Disease Disease rates
Totals
Develops Does Not of
Develop Disease

a Incidence in
FIRST, Exposed a b a+b a+b = exposed
SELECT c
Not Incidence in
c d c+d c+d =
Exposed = non-exposed

CASE – CONTROL (REPROSPECTIVE STUDY)

FIRST,
SELECT

CASES CONTROLS
( with ( without
disease) disease)
THEN,
MEASURE Were
a b
PAST Exposed
EXPOSURE Were Not
c d
Exposed
Totals a+c b+d
Proportion a b
exposed a+c b+d
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
 The odds ratio (Relative Odds)
In prospective studies, the odds ratio is the ratio of the odds of the exposed people developing
the disease to the odds non-exposed people developing the disease, i.e:

a
b ad a c ad
= : =
c bc b d bc
d

In case-control studies, the odds ratio is the ratio of the odds of the cases having been exposed
to the odds of the controls having been exposed, i.e:

a
c ad a b ad
= : =
b bc c d bc
d
Tabel 1. Tabulasi silang pemajan dan status sakit,
insidens sakit dan Probabilitas odds sakit
pada studi kohort.
Status sakit

Pemajan Sakit Tidak Total Insiden sakit Probabilitas odds sakit

sakit (Risk)
a
+ a b a+b a/(a+b)
ab  a
 a  b
1  
 ab
c
- c d c+d c/(c+d) cd c

 c  d
1  
cd 

Total a+c b+d a+b+c+d

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
Odds Ratio (OR) = Relative
Odds
Odds pemajan untuk kasus
Odds Ratio 
Odds pemajan untuk kontrol
a
c axd
Odds Ratio  
b bxc
d

a x d 650 x 350
Odds Ratio    4,8
bxc 950 x 50
Perokok mempunyai risiko menjadi kasus 4,8 kali dari yang bukan
perokok.
Interpretasinya: odds perokok menjadi kasus 4,8 kali lebih besar
dari odds bukan perokok
 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
The odds ratio ( relative odds) is a good
approximation of the relative risk when :

1.The cases are representative of

all cases with regard to exposure;
2.The controls are representative
of all control with regard to
exposure; =

3.The disease being studied is rare

 Odds Ratio & Risk Ratio
The odds ratio will provide a good estimate of the
risk ratio when:

1. The outcome (disease) is rare a / (a +b )

RR = ------------
D+ D- c / (c +d)
E+ a b If the disease is rare, then
E- c d cells (a) and (c) will be small

OR = (a / c) / (b / d)
a / (a +b ) a / b ad
OR = (ad) / (bc) RR = ------------ = ------ =-- = OR
c / (c +d) c / d bc
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
In a prospective study/cohort study,
the Relative Risk can be calculated
directly

In a retrospective study /case control

study , the RR cannot be calculated
directly, so that the Relative Odds or
ODDS RATIO ( Cross Products Ratio )
is used as an estimate of the RR, when
the risk of the disease is low
 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.
 Incidence Odds Ratio (POR) = 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 (risk ) Ratio    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
 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) 46

 RR < 1 RR = 1 RR > 1
Risk
Risk for disease Risk of disease Risk for disease
comparison
is lower in the are equal for is higher in the
between
exposed than in exposed and exposed than in
exposed and
the unexposed unexposed the unexposed
unexposed

Exposure
reduces disease Exposure
Exposure as a Particular
risk increases
risk factor for exposure is not a
disease risk
the disease? (Protective risk factor
(Risk factor)
factor)
 Measure of
Association

Relative risk Attributable risk

RR OR AR PAR
 Epidemiology Kept Simple

Chapter 8
Measures of Association

Gerstman Chapter 8 (partial) 49

 If it’s not clear…
• Gordis Leon, M.D., M.P.H., Dr.P.H. 2009.
Epidemiolgy. W.B. Saunders Company.
Philadelphia ,Chapter 11

• Epidemiology in Medicine. Henneckens CH,

Buring JE. Edited by Mayrent SL, Chapter 4