Lecture 2

Measures of Frequency
and Effect
 Measures of Frequency

• Raw numbers

• Ratios

• Proportions

• Rates
– Incidence
– Prevalence
 Ratio
• A numerical expression which indicates
the relationship in quantity, amount or
size between 2 or more numbers.
• Denominator is never 0
• Usually expressed in the form x:y or x/y
• Example: 55 patients attended Nuffield
Clinic last Friday. Of these, 22 were
males & 33 were females.
• Ratio of M:F = 22:33 or 2: 3
 Proportion
This is a specific type of ratio in which the
numerator is included in the denominator,
and the resultant value is expressed as a
percentage.
Eg. proportion of all Nuffield clinic patients
that were male:
= x / (x + y) x 100
= 22/55 x 100
= 0.4 x 100
= 40%
 Rate
• A rate measures the occurrence of some
particular event during a given period , in
a population.
• It is expressed as:
x/y . 10n per unit of time
• 10n is read as 10 to the nth power
100 = 1
101 = 10
102 = 10 x 10 = 100
103 = 10 x 10 x 10 = 1,000
 Rates
• Rates may be expressed as per 100,
per 1,000, or per 10,000, etc.,
depending on the number of cases in
the denominator.

• The resultant rate should be

expressed as a number that is > 1.0.
 Making Use of Rates
There are 2 main reasons for using rates as
opposed to whole numbers.
• to make meaningful comparisons
• to calculate the number of expected
cases.
Eg. Crude death rate (CDR)
• Age-specific rate (infant mortality rate)
• Cause-specific rate (rate of MI’s)
 Example
Infant mortality rate (IMR) =
Deaths in infants <1 in a year
Live births during the same year

• Infant deaths, Bila District in 1998 = 40

• Infant deaths, Vau District in 1998 = 100

Do you conclude that Vau has a higher infant

death than Bila District?
 Example cont’d
Total livebirths
– Bila District: 2000
– Vau District: 20,000

Therefore IMR for the 2 districts are:

– Bila: 40/2000 = 0.02x1000 = 20 cases per
1000 population

– Vau: 100/20,000 = 0.005x1000 = 5 cases

per 1000 population
 1. Incidence Rate
• Measures the number of NEW cases,
episodes, or events occurring over a
defined period of time.
• Best indicator of whether a condition
is decreasing, increasing, or
remaining static.
• Best measure to use for evaluation
• Two types:
 Cumulative Incidence
 Incidence density
1a. Cumulative Incidence
CI = No. of new cases who get the
disease during a certain period
No. of individuals at risk in the
population at the beginning of the period.
• It is the proportion of healthy individuals
who get the disease during a certain
period of study
• Both the numerator & denominator include
all those individuals who are at the
beginning of the period are free from the
disease & therefore “at risk” to get it.
 Example of CI
The Swedish census from 1960 showed that
there were 3076 males aged 20-64 who were
employed as plastic workers. According to the
Swedish Registry, 11 of those workers
developed brain tumours during the period
1961- 1973. The CI during the 13-year period
is calculated as:
CI = 11/3076
= 0.0036
= 3.6/1000 for the 13 year period.
 1b. Incidence Density
IR = No. of new cases of a disease during given
time period
Total person-time of observation
• Numerator is the number of NEW cases in the
population during the period of study or
observation.

• Denominator is the sum of each individual’s time at

risk or

• Sum of the time that each person remained under

observation & free from disease

• More accurate method of measuring incidence (new

cases) in a population.
 Example of Incidence Density
Total
Development of Disease X observation
period
A X 2
B  2
C X
3
RIP
D 7

E  2
RIP
F 6

1 2 3 4 5 6 7
Years
 Example (con’t)
• 6 healthy individuals who were well at the
beginning of the study period.

• Person A developed disease X 2 years after

entry into the study. Since subjects
contribute “person-time” only while eligible
to develop the disease, the person-time for
‘Person A’ was 2 yrs.

• Persons B,C,D,E,& F contribute 2, 3, 7, 2, &

6 yrs respectively. Patients A & C develop
the disease under study.
 Example (con’t.)
Total NEW cases after 7 yrs of study = 2

Total person-time of observation = 22 person-years

Incidence density = 2/22

= 0.09 cases/person-year
= 9 cases/100 person-years

Cumulative incidence = 2/6

= 0.3333
= 33 cases/100 population
 2. Prevalence

• Measures the all existing cases, (new

and old), episodes, or events occurring
in a population at a specified time.

• 2 types :
• point prevalence
• period prevalence
2a. Point prevalence
- measures the frequency of all current
cases ( old + new ) of a disease at one
point in time in relation to a defined
population.
- the point may be one day, several days, or
even a few weeks….
2b. Period prevalence
- measures the frequency of all current
cases ( old + new) of disease in a
specified period of time , usually
annually, in relation to a defined
population.
 2. Prevalence Rate
Usually refers to “point prevalence” ie.
At a point in time.
P = No. of existing (OLD +NEW) at a given
point in time
Total population at that time

Can be expressed as a percentage

(%) or per 10n ie. 1000, 10,000,
100,000…..
Example of PR
A sample including 1038 women aged 70-74
yrs was selected from the population of
Stockholm. After examination, 70 were
classified as having rheumatoid arthritis.
The prevalence of RA was:
P = 70/1038
= 0.067 = 6.7% or
= 67 cases/ 1000 population (of
women aged 70-74 yrs)
Factors Affecting Prevalence Rate:
PR INCREASED BY:
• Longer duration of the illness
• prolongation of life of patients without
cure
• increase in new cases
• out-migration of healthy people
• in-migration of susceptible people
• improved diagnostic facilities
PR DECREASED BY:
• Shorter duration of disease
• high case-fatality rate
• decrease in new cases
• in-migration of healthy people
• out-migration of cases
• improved cure rate of cases
 Measures of Effect
Difference measures- for absolute comparisons
– Risk difference (RD) or excess risk
– Attributable risk percent (AR%)
– Population attributable risk (PAR)

Ratio measures - for relative comparisons

– Relative risk/ratio
– Odds ratio
– Standardized mortality ratio (type of risk
ratio)