International Journal of Epidemiology Vol. 26, No.

1
© International Epidemiological Association 1997 Printed in Great Britain

Relationship between Prevalence

Rate Ratios and Odds Ratios in
Cross-Sectional Studies
CARLO ZOCCHETTI,* DARIO CONSONNI* AND PIER A BERTAZZI**

Zocchetti C (Institute of Occupational Health, Faculty of Medicine, University of Milan, Milan, Italy), Consonni D and
Bertazzi PA. Relationship between prevalence rate ratios and odds ratios in cross-sectional studies. International Journal
of Epidemiology 1997; 26: 220–223.
Background. Cross-sectional data are frequently encountered in epidemiology and published results are predominantly
presented in terms of prevalence odds ratios (POR). A recent debate suggested a switch from POR, which is easily ob-
tained via logistic regression analysis available in many statistical packages, to prevalence rate ratios (PRR). We thought
it useful to explore the mathematical relationship between PRR and POR and to evaluate the degree of divergence of the
two measures as a function of the prevalence of disease and exposure.
Methods. With the use of some algebra and the common definitions of prevalence of the disease (Pr(D)), prevalence of
the exposure (Pr(E)), PRR, and POR in a 2 ´ 2 table, we have identified a useful formula that represents the math-
ematical relationship between these four quantities. Plots of POR versus PRR for selected values of Pr(D) and Pr(E) are
reported.
Results. Mathematically speaking the general relationship takes the form of a second order curve which can change
curvature and/or rotate around the point POR = PRR = 1 according to the values of Pr(D) and Pr(E), with POR being
always further from the null value than is PRR. The discrepancies are much more influenced by variations in Pr(D) than
in Pr(E).
Conclusions. We think that the choice between POR or PRR in a cross-sectional study ought to be based on epi-
demiological grounds and not on the availability of software tools. The paper offers a formula and some examples for a
better understanding of the relationship between PRR and POR as a function of the prevalence of the disease and the
prevalence of the exposure.
Keywords: prevalence rate ratio, prevalence odds ratio, cross-sectional study, log-linear model

A recent debate in this1–3 and other journals4–9 has
pointed out the interest surrounding cross-sectional
studies and the epidemiological measures used to con-
vey their results. Some authors (see for example1,2,7,8)
have indicated their preference for the use of pre-
valence rate ratios (PRR) against the more frequently
encountered prevalence odds ratios (POR) and others3
have claimed the utility of both depending on many
arguments and/or circumstances.
It is likely that the great availability of computer
programs which produce OR as a standard result of the
fitting of logistic regression models (see for example
10–12
) has increased the use of POR as effect measures
in cross-sectional studies, while the absence of simple
* Clinica del Lavoro «Luigi Devoto», Istituti Clinici di Per-
fezionamento, Milan, Italy.
** Institute of Occupational Health, Faculty of Medicine, University
of Milan, Milan, Italy.
Reprint requests to: Pier A Bertazzi, Institute of Occupational Health,
Faculty of Medicine, University of Milan, Via San Barnaba 8, 20122
Milan, Italy.
220
computer programs for the estimation of PRR has
probably reduced their application. This gap is likely to
reduce13,14 and the selection of appropriate epidemiolo-
gical measures should not be based on the available tools
but on epidemiological grounds.
To add further substance to the discussion, and ex-
pand on some suggestions made by other authors in this
Journal3 we thought it useful to clarify the mathematical
relationships between POR and PRR for a better under-
standing of their performance in different contexts, i.e.
for varying values of the prevalences of the disease and
exposure.
METHODS
If we consider a 2 ´ 2 table deriving from a cross-
sectional study a number of useful quantities can be
easily defined, including: prevalence of the disease
(Pr(D)), prevalence of the exposure (Pr(E)), prevalence
odds ratio (POR), and prevalence rate ratio (PRR)
(Table 1). With the help of some algebra different
 PREVALENCE RATE RATIOS VERSUS ODDS RATIOS 221

TABLE 1 Notation and definitions used in the text function of POR is of interest, a reverse approach can
be easily developed.
Exposure Total Pr(D) and Pr(E) could range from 0 to 1 while POR
and PRR could extend from 0 to infinity, but due to the
Yes No relationships between these measures some combina-
tions of the values are not permitted because they give
Disease Pr(D) = D1/T rise to, for example, negative or undefined quantities.
Yes a b D1 Pr(E) = N1/ T
No c d D0 POR = (a d) / (b c)
Total N1 N0 T PRR = (a / N1) / (b / N0)
RESULTS
A simple look at formula (1), with a little algebra,
shows that when PRR is equal to one POR will coincide
exactly with PRR irrespective of the values of Pr(D)
relationships between PRR and POR can be estab- and Pr(E), while for all other conditions POR and PRR
lished,3 and a useful resulting formula is the following: will differ. In addition, when PRR is greater than one
POR will be greater than PRR, while when PRR is less
(1 – Pr(E) + PRR Pr(E) – Pr(D)) than one POR will be less than PRR: both these depart-
POR = PRR (1)
(1 – Pr(E) + PRR Pr(E) – PRR Pr(D)) ures from equality greatly depend on the values of
Pr(D) and Pr(E).
The selected formulation enables us to explore the Figure 1 shows the relationship between PRR and
relationship between POR and PRR as a function of POR for selected values of the prevalence of the disease
both the prevalence of the disease and the prevalence of and of the exposure, in a restricted range of PRR values.
the exposure. Implicitly, this choice corresponds to The figure highlights that the relationship is not linear
evaluating how the POR departs from the PRR which is (it is a quadratic curve) and that according to the values
conceptually taken as a reference measure: if PRR as a of Pr(D) and Pr(E) the curve rotates around the value of

FIGURE 1 Graphical relationship between prevalence rate ratio (PRR) and prevalence odds ratio (POR) for
selected values of the prevalence of the disease (Pr(D)) and the prevalence of the exposure (Pr(E))
222 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
PRR equal to one and/or changes curvature. In addition,
for the special case of Pr(D) = Pr(E) = 0.5 the POR value
is exactly the square of the corresponding PRR.
If we consider for the sake of comparison as a base-
line the curve which corresponds to a value of Pr(D) =
Pr(E) = 0.5 (black triangles) Figure 1 shows that a de-
crease in the prevalence of the exposure (e.g. Pr(E) =
0.2, black rectangles) will cause an increase in the
curvature of the relationship giving rise to values of
POR which are always greater than the baseline: in par-
ticular they will depart much more from the PRR values
when PRR is greater than one and will approach the
PRR values when PRR is less than one.
If an increase in the prevalence of the exposure is
considered (e.g. Pr(E) = 0.8, white circles) a decrease
in the curvature of the relationship will result, with
POR departing more from the PRR values when PRR is
,1 and approaching them when PRR is .1.
A different result will be obtained if a change in
the prevalence of the disease (instead of a change in the
prevalence of the exposure) is considered: in this situ-
ation a rotation of the curve around the point POR =
PRR = 1 will take place. For example, again with
respect to the curve with Pr(D) = Pr(E) = 0.5, if we con-
sider a decrease of Pr(D) (e.g. Pr(D) = 0.2, white
rectangles) the POR will always be closer to the cor-
responding PRR value, while an increase in the pre-
valence of the disease (e.g. Pr(D) = 0.8, black circles)
will cause a further departure of the POR from PRR:
both the changes do not depend on PRR being greater
or less than one.
In addition, a change in the prevalence of the disease
will affect the POR value much more than a change in
the prevalence of the exposure, as can be seen from
comparison of the white and black rectangle curves in
Figure 1 (or the white and black circle curves).
When the disease is rare (Pr(D) , 0.10) no major
discrepancies emerge between POR and PRR, irrespect-
ive of the prevalence of the exposure. For example, with
Pr(D) = 0.05 and PRR = 2.5 the values of POR range
from 2.71 when Pr(E) = 0.01 to 2.58 when Pr(E) = 0.99,
which are not very different from 2.5, and the differ-
encies tend to diminish as PRR approaches one.
DISCUSSION
Many epidemiological measures can usefully describe
the results of a study, and the selection of the most
appropriate is never obvious.15 In particular, some
authors have pointed out that the odds ratio is a par-
ticularly misunderstood measure,9,15–17 and that the
cross-sectional study requires extensive methodological
discussion.1–8
Cross-sectional data can serve many purposes,18,19 and
the wide range of applications could suggest the use of
different epidemiological measures in different contexts.
For example, cross-sectional data can be used to
estimate incidence density ratios (IDR).18,19 In this situ-
ation it has been shown20 that under some restrictive
assumptions (regarding, for example, the distribution
over time of exposures, covariates, and incidence; mi-
gration among diseased; duration of disease) POR ap-
proximate IDR better than PRR, which means that when
we are dealing with chronic diseases (i.e. long latency
diseases with different follow-up periods for the sub-
jects under observation) the use of POR may be com-
pletely justified.
On the other hand, if risk ratios (RR) are the para-
meters of interest (considering acute diseases, with
follow-up periods similar among subjects) then PRR
should be the measure of choice.19
In other applications we are interested in outcomes
which are not strictly ‘diseases’: consider, for example,
a study with the aim of describing how the proportion
of subjects with a particular condition (e.g. an adducts
level above the median) varies according to some co-
variate(s). In these situations the use of the prevalence
rate (and hence of PRR) as a descriptor of a ‘state’ seems
a more natural and intelligible measure.7
In addition, it has been noted that the usual as-
sumption of similar duration of disease (or prognosis)
between exposed and unexposed subjects may not be
satisfied: a case in point are musculoskeletal disorders
for which duration of symptoms are likely to vary
between exposure groups.5,7 In this situation again the
use of PRR seems warranted.
A further argument against the use of POR is that it
can introduce confounding even when there is none in
terms of prevalence rates.7
In other instances (the ‘sex ratio’, for example) the
odds ratio is a natural epidemiological measure.3
As a further step in the discussion we have explored
the relationship between POR and PRR in order to
understand the most important discrepancies between
them, using a general formula for this relationship as a
function of the prevalence of the disease (Pr(D)) and
the prevalence of the exposure (Pr(E)). The results in-
dicate that the POR is always further away from the null
value than the PRR and that the discrepancies between
POR and PRR strongly depend on both Pr(D) and
Pr(E), with the former being more important from a
quantitative point of view.
With respect to the prevalence of the disease we have
considered values around 0.5 because they are very
common in emerging areas like musculoskeletal dis-
orders5 and molecular epidemiology. In the latter, for
 PREVALENCE RATE RATIOS VERSUS ODDS RATIOS
example, the outcome may be represented by a categor-
ization of a continuous variable, e.g. adducts level or
other biological markers, with the median value being
the cutpoint.21,22 In other areas the most frequent pre-
valence value of the disease and of the exposure can
greatly vary from the presented examples and con-
sequently the discrepancies between POR and PRR
could vary as well. In particular, it is well known that
when Pr(D) is low (less than, say, 0.10) POR and PRR
will be very similar and there will be no practical
reasons to distinguish between them.
We have chosen to describe the relationship between
POR and PRR in terms of the prevalence of the dis-
ease instead of, for example, the prevalence of the
disease among non-exposed subjects3 because in many
cross-sectional studies the exposure status is not a
criterion for selecting subjects into the study.19
We have only addressed point estimates of POR and
of PRR. Statistical aspects, like test of hypothesis or
confidence interval estimation, can easily be included
in the discussion recalling that both measures are de-
fined in the frame of binomial variability. From the
point of view of hypothesis testing (i.e. accepting/reject-
ing the hypothesis that POR or PRR is equal to one) the
two measures give in practice the same answer, whereas
in terms of confidence intervals POR is characterized
by wider intervals which, in other words, means less
precision in the estimates.9
The issue of the discrepancy in point estimation
requires a further comment. When POR and PRR are
considered in their own domain, the two measures do
not need to be compared, but when they are interpreted
as estimators of some ‘risk’ (ratio of risks) a new prob-
lem arises. Suppose, for example, that PRR is equal to
two and POR is equal to four (which is the case when
Pr(D) = Pr(E) = 0.5). Irrespective of their statistical
significance (and confidence intervals), the two values
indicate, from a quantitative point of view, very differ-
ent perspectives of interpretation (a twofold versus a
fourfold risk) which depend only on the choice of a
specific epidemiological measure and not on the sci-
entific question at issue. We should be aware of this
bias, particularly when comparing results of different
studies from the literature.
In summary, irrespective of the preference of different
authors or the habits induced by software tools avail-
ability, we think that POR and PRR have their specific
role with cross-sectional data and that the choice between
them should remain on epidemiological grounds only.
The arguments made above would suggest the use of
PRR instead of POR in most situations. Despite these
considerations POR have played a major role in the
description of the results of cross-sectional studies due
223
mainly to mathematical convenience 17 and the easy avail-
ability of advanced statistical tools (logistic regression,
mainly1,7) which were not so easy to use for the estima-
tion of PRR. This situation is expected to change rapidly
thanks to new software programs (e.g. SAS GENMOD 12).
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