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Dr. Rupesh Sahu 
III yr PG 
Community Medicine 
NSCBMC Jabalpur
Descriptive studies 
Identify disease problem in community 
Relate to environment & host factor 
Suggest an etiological hypothesis 
Analytical & experimental studies 
Test the hypothesis derived for observed RELATIONSHIP b/w suspected cause & 
disease
 Definition: the concurrence of two variables more 
often than would be expected by chance.
1. Spurious Association 
2. Indirect Association 
3. Direct (causal)Association 
1. One to one causal association 
2. Multi-factorial causation.
 False association 
 Because of comparison of likes with non likes 
(selection bias)
Characteristic under 
study 
Factor X 
Disease
 To address the question of association, we must 
use approaches that involve explicit comparisons. 
 Comparing the risk of disease in exposed 
population to the risk of disease in non exposed 
populations. 
◦ Ratio of the risks 
◦ Difference in the risks
 A researcher in his observational 
study found that the average serum 
homocysteine among patients of IHD 
was 15 mcg/dl (Normal=10-12 
mcg/dl)!
 Can we say that 
◦ Hyperhomocystenemia causes IHD? 
 Hypothesize that 
◦ Hyperhomocystenemia may have a role in etiology of 
IHD. 
 For final proof there has to be a ‘comparison’. 
 Comparison would generate another summary 
measure which shows the extent of ‘Association’ 
or ‘Effect’ or ‘risk’
 Cause defined as “anything producing an effect or 
a result”. [Webster] 
 Cause in medical textbooks discussed under 
headings like- “etiology”, “Pathogenesis”, 
“Mechanisms”, “Risk factors”. 
 Important to physician because it guides their 
approach to three clinical tasks- Prevention, 
Diagnosis & Treatment. Eg…..
 Prevention: When clinicians periodically checks 
patients BP they are reacting to evidence that HT 
causes morbidity & mortality and that the 
treatment of hypertension prevents MI,CHF & 
stroke. 
 The diagnostic process, especially in infectious 
disease, frequently involves a search for the 
causative agent.
 Belief in a causal relationship underlies every 
therapeutic intervention in clinical medicine. 
 Why give azithromycin for pneumococcal 
pneumonia unless one believes that it will result in 
a cure.
 Sufficient f’s: one that inevitably produces 
disease 
 Necessary f’s: without which disease does not 
occur, but by itself, it is not sufficient to cause 
disease. 
* The factor which can be modified , interrupted 
or nullified is most important.
 Four types possible 
◦ Necessary & sufficient 
◦ Necessary, but not sufficient 
◦ Sufficient, but not Necessary 
◦ Neither Sufficient nor Necessary
 Without that factor, the disease never develops 
(factor is necessary) 
 and in presence of that factor, the disease always 
develops (factor is sufficient). 
 Rare situation. 
Factor A Disease
 Multiple factors are required, often in specific 
temporal sequence. 
Factor A 
Factor B Disease 
Factor C
 Factors independently can produce the disease. 
Factor A 
OR 
Factor B Disease 
OR 
Factor C
•More complex model. 
•Probably most accurately represents causal relationships that 
operate in most chronic diseases 
Factor A Factor B 
Disease 
OR 
Factor C Factor D 
OR 
Factor E Factor F
 A researcher in his observational 
study found the presence of 
Helicobacter pylori in patients of 
duodenal ulcer!
 Can we say that 
◦ H.pylori causes duodenal ulcers? 
 Hypothesize that 
◦ H.pylori may have a role in etiology of duodenal ulcers. 
 For final proof there has to be a ‘comparison’. 
 Comparison would generate another summary 
measure which shows the extent of ‘Association’ 
or ‘Effect’ or ‘risk’
 Needs a research on the lines of ‘hypothesis 
testing’ 
 final establishment of an “exposure - outcome” 
relationship consists of a sequence of steps as 
follows : 
 Step 1: ensure that the results of the study are 
accurate and not “spurious”. 
◦ Correct methods? 
◦ Validity, reliability preserved? 
◦ Bias?
 Step 2a: do statistical results indicate 
association?-p value/ 95% CI. 
 Step 2b: if not significant p value, may be b/c of 
less power (smaller sample size)- the investigator 
should suggest additional studies using large 
sample (or else, a ‘meta - analysis’ type of study), 
rather than straightaway dismissing the ‘exposure 
- outcome’ association as non - causal.
 Step 3: if statistically significant –evaluate as to 
whether this relationship is due to ‘indirect 
relationship’ with a third variable (confounder)
 In what ci rcumstances can we 
pass f rom [an] observed 
associat ion to a verdict of 
causat ion? Upon what basis 
should we proceed to do so? 
Sir Austin Bradford Hill, 1965
 Step 4: if confounder excluded- now test this 
postulated “causal” relationship on the following 
criteria of “causal association”
 Most Important criteria 
1. Temporality: cause precedes effect 
2. Strength of association: large relative risk 
3. Consistency: repeatedly observed by different 
persons, in different places, circumstances, and times
 Additional supportive criteria 
4. Biological gradient (dose response): larger 
exposures to cause associated with higher rates of 
disease. And reduction in exposure is followed by lower 
rates of disease (reversibility). 
5. Biological plausibility: makes sense, according to 
biologic knowledge of the time. 
6. Experimental evidence: 
7. Other criteria: Analogy(cause & effect relationship 
already established for a similar exposure or disease), 
specificity (one cause lead to one effect), coherence.
 Order of exposure and disease. 
 Interval between exposure and disease. 
◦ E.g. Asbestos has been clearly linked to increased risk of 
lung cancer but the latent period between exposure and 
appearance of cancer is 15-20 yrs. Therefore, if for e.g. 
lung cancer develops after only 3 yrs since the asbestos 
exposure, it is safe to conclude that the lung cancer was 
not a result of this exposure.
 Measured by the Relative risk (or Odds ratio) 
 Stronger the association, the more likely it is that 
the relation is causal.
 Strong evidence for a causal relationship. 
 However, the absence of a dose response 
relationship does not necessarily rule out a causal 
relationship. 
◦ E.g. those cases in which a threshold exist. 
◦ The association b/w DES consumption by mothers and 
vaginal CA in daughters many years later does not 
exhibit this gradient phenomenon.
 If the relationship is causal, we would expect to 
find it consistently in different studies and in 
different populations, even within subgroups of 
populations.
 Refers to coherence with the current body of 
biologic knowledge. 
◦ E.g. In the mid 19th century when a clinician recommended 
hand washing by medical students & teachers before 
attending obstetric units, his recommendations were 
dismissed by medical fraternity as “doesn’t stand to 
reasoning”
What if we waited until the mechanism was known before employing citrus? 
Chapter 2 GerstmanGerstman 33
 Whether the relationship is causal or is the result 
of confounding, the extent to which the 
investigators have taken other possible 
explanations into account & the extent to which 
they have ruled out such explanations are 
important considerations. 
 Helpful supportive evidence for a causal 
association
 If a factor is a cause of a disease , we would 
expect the risk of the disease to decline when 
exposure to the factor is reduced or eliminated.
 Weakest of all the guidelines. 
 When a certain exposure is associated with only 
one disease.
1. Temporality: 
◦ About 11% of chronic gastritis patients will go on to have 
duodenal ulcers over a 10year period. 
2. Strength of relationship: 
◦ H.pylori is found in at-least 90% of patients with duodenal 
ulcers. 
An Australian tribe population lacking duodenal ulcers, it has 
never been found. 
3. Dose response relationship: 
◦ density of H.pylori per square mm of gastric mucosa is 
higher in patients with duodenal ulcer than without it.
4. Replication of findings: 
◦ many observations regarding H pylori have been replicated 
repeatedly. 
5. Biologic plausibility: 
◦ it was difficult to envision a bacterium infecting stomach 
antrum with such high acidity, but it is now recognized that H 
pylori has binding sites on antral cells. 
6. Consideration of alternate explanations: 
◦ data suggest that smoking can increase the risk of duodenal 
ulcer in H pylori infected patients but is not a risk factor in 
patients in whom H pylori has been eradicated.
7. Cessation of exposure: 
◦ long term ulcer recurrence rates were zero after H 
pylori was eradicated using triple antimicrobial therapy, 
compared with a 60-80% relapse rate found in those 
treated with histamine receptor antagonists. 
8. Specificity of association: 
◦ prevalence of H pylori in patients with duodenal ulcers 
in 90-100% vs found in some patients with gastric 
ulcer/asymptomatic individuals.
9. Consistency with other knowledge: 
◦ H pylori infection prevalence is same in men & women 
in recent years which was believed to be higher in men. 
◦ High prevalence of ulcer disease in latter part of 19th 
century, consistent with high prevalence of H pylori due 
to poor living conditions at the same period.
Association 
Yes No 
Likely Unlikely 
Yes No 
Cause 
Bias in 
selection or 
measurement 
Chance 
Confounding 
Cause
 Agnes M, editor in chief, Webster’s New World Dictionary, 4th edi. 
Cleveland,Ohio: Wiley publishing,Inc,2002 
 Hill AB. The environment and disease: Association or 
causation. Proceedings of the Royal Society of Medicine 
1965; 58: 295-300. 
 Susser MW. What is a cause and how do we know one ? A 
grammar for pragmatic epidemiology. American Journal of 
Epidemiology 1991; 133: 635- 648. 
 Gordis leon, Epidemiology, 4th edition,saunders Elsevier,227-246 
 Fletcher Robert,Clinical Epidemiology,The essentials,4th 
ediction,Lippincott William Wilkins,187-204 
 K Park,21st edition,MS Banarsidas Bhanot, Jabalpur,82-84 
 RajVir Bhalwar, text book of Public Health, AFMC,pune
 Weighing the Evidence 
◦ Its not the total no of guidelines present that is relevant 
to causal inference but rather an assessment of total 
pattern of evidence observed that may be consistent with 
one or more of the guidelines. 
 Grading the Quality of Evidence
 Mervyn Susser (1988) used similar criteria to 
judge causal relationships. 
 In agreement with previous authors, he 
mentioned that two criteria have to be present 
for any association that has a claim to be 
causal: i.e. time order (X precedes Y); and 
direction (X leads to Y).
 Rejection of a hypothesis can accomplished 
with confidence by only three criteria: time 
order, consistency, factual incompatibility or 
incoherence. 
 Acceptance or affirmation can be achieved by 
only four, namely: strength, consistency, 
predictive performance, and statistical 
coherence in the form of regular exposure/effect 
relation.
Association vs causation

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Association vs causation

  • 1. Dr. Rupesh Sahu III yr PG Community Medicine NSCBMC Jabalpur
  • 2. Descriptive studies Identify disease problem in community Relate to environment & host factor Suggest an etiological hypothesis Analytical & experimental studies Test the hypothesis derived for observed RELATIONSHIP b/w suspected cause & disease
  • 3.  Definition: the concurrence of two variables more often than would be expected by chance.
  • 4. 1. Spurious Association 2. Indirect Association 3. Direct (causal)Association 1. One to one causal association 2. Multi-factorial causation.
  • 5.  False association  Because of comparison of likes with non likes (selection bias)
  • 6. Characteristic under study Factor X Disease
  • 7.  To address the question of association, we must use approaches that involve explicit comparisons.  Comparing the risk of disease in exposed population to the risk of disease in non exposed populations. ◦ Ratio of the risks ◦ Difference in the risks
  • 8.  A researcher in his observational study found that the average serum homocysteine among patients of IHD was 15 mcg/dl (Normal=10-12 mcg/dl)!
  • 9.  Can we say that ◦ Hyperhomocystenemia causes IHD?  Hypothesize that ◦ Hyperhomocystenemia may have a role in etiology of IHD.  For final proof there has to be a ‘comparison’.  Comparison would generate another summary measure which shows the extent of ‘Association’ or ‘Effect’ or ‘risk’
  • 10.  Cause defined as “anything producing an effect or a result”. [Webster]  Cause in medical textbooks discussed under headings like- “etiology”, “Pathogenesis”, “Mechanisms”, “Risk factors”.  Important to physician because it guides their approach to three clinical tasks- Prevention, Diagnosis & Treatment. Eg…..
  • 11.  Prevention: When clinicians periodically checks patients BP they are reacting to evidence that HT causes morbidity & mortality and that the treatment of hypertension prevents MI,CHF & stroke.  The diagnostic process, especially in infectious disease, frequently involves a search for the causative agent.
  • 12.  Belief in a causal relationship underlies every therapeutic intervention in clinical medicine.  Why give azithromycin for pneumococcal pneumonia unless one believes that it will result in a cure.
  • 13.  Sufficient f’s: one that inevitably produces disease  Necessary f’s: without which disease does not occur, but by itself, it is not sufficient to cause disease. * The factor which can be modified , interrupted or nullified is most important.
  • 14.  Four types possible ◦ Necessary & sufficient ◦ Necessary, but not sufficient ◦ Sufficient, but not Necessary ◦ Neither Sufficient nor Necessary
  • 15.  Without that factor, the disease never develops (factor is necessary)  and in presence of that factor, the disease always develops (factor is sufficient).  Rare situation. Factor A Disease
  • 16.  Multiple factors are required, often in specific temporal sequence. Factor A Factor B Disease Factor C
  • 17.  Factors independently can produce the disease. Factor A OR Factor B Disease OR Factor C
  • 18. •More complex model. •Probably most accurately represents causal relationships that operate in most chronic diseases Factor A Factor B Disease OR Factor C Factor D OR Factor E Factor F
  • 19.  A researcher in his observational study found the presence of Helicobacter pylori in patients of duodenal ulcer!
  • 20.  Can we say that ◦ H.pylori causes duodenal ulcers?  Hypothesize that ◦ H.pylori may have a role in etiology of duodenal ulcers.  For final proof there has to be a ‘comparison’.  Comparison would generate another summary measure which shows the extent of ‘Association’ or ‘Effect’ or ‘risk’
  • 21.  Needs a research on the lines of ‘hypothesis testing’  final establishment of an “exposure - outcome” relationship consists of a sequence of steps as follows :  Step 1: ensure that the results of the study are accurate and not “spurious”. ◦ Correct methods? ◦ Validity, reliability preserved? ◦ Bias?
  • 22.  Step 2a: do statistical results indicate association?-p value/ 95% CI.  Step 2b: if not significant p value, may be b/c of less power (smaller sample size)- the investigator should suggest additional studies using large sample (or else, a ‘meta - analysis’ type of study), rather than straightaway dismissing the ‘exposure - outcome’ association as non - causal.
  • 23.  Step 3: if statistically significant –evaluate as to whether this relationship is due to ‘indirect relationship’ with a third variable (confounder)
  • 24.  In what ci rcumstances can we pass f rom [an] observed associat ion to a verdict of causat ion? Upon what basis should we proceed to do so? Sir Austin Bradford Hill, 1965
  • 25.  Step 4: if confounder excluded- now test this postulated “causal” relationship on the following criteria of “causal association”
  • 26.  Most Important criteria 1. Temporality: cause precedes effect 2. Strength of association: large relative risk 3. Consistency: repeatedly observed by different persons, in different places, circumstances, and times
  • 27.  Additional supportive criteria 4. Biological gradient (dose response): larger exposures to cause associated with higher rates of disease. And reduction in exposure is followed by lower rates of disease (reversibility). 5. Biological plausibility: makes sense, according to biologic knowledge of the time. 6. Experimental evidence: 7. Other criteria: Analogy(cause & effect relationship already established for a similar exposure or disease), specificity (one cause lead to one effect), coherence.
  • 28.  Order of exposure and disease.  Interval between exposure and disease. ◦ E.g. Asbestos has been clearly linked to increased risk of lung cancer but the latent period between exposure and appearance of cancer is 15-20 yrs. Therefore, if for e.g. lung cancer develops after only 3 yrs since the asbestos exposure, it is safe to conclude that the lung cancer was not a result of this exposure.
  • 29.  Measured by the Relative risk (or Odds ratio)  Stronger the association, the more likely it is that the relation is causal.
  • 30.  Strong evidence for a causal relationship.  However, the absence of a dose response relationship does not necessarily rule out a causal relationship. ◦ E.g. those cases in which a threshold exist. ◦ The association b/w DES consumption by mothers and vaginal CA in daughters many years later does not exhibit this gradient phenomenon.
  • 31.  If the relationship is causal, we would expect to find it consistently in different studies and in different populations, even within subgroups of populations.
  • 32.  Refers to coherence with the current body of biologic knowledge. ◦ E.g. In the mid 19th century when a clinician recommended hand washing by medical students & teachers before attending obstetric units, his recommendations were dismissed by medical fraternity as “doesn’t stand to reasoning”
  • 33. What if we waited until the mechanism was known before employing citrus? Chapter 2 GerstmanGerstman 33
  • 34.  Whether the relationship is causal or is the result of confounding, the extent to which the investigators have taken other possible explanations into account & the extent to which they have ruled out such explanations are important considerations.  Helpful supportive evidence for a causal association
  • 35.  If a factor is a cause of a disease , we would expect the risk of the disease to decline when exposure to the factor is reduced or eliminated.
  • 36.
  • 37.  Weakest of all the guidelines.  When a certain exposure is associated with only one disease.
  • 38. 1. Temporality: ◦ About 11% of chronic gastritis patients will go on to have duodenal ulcers over a 10year period. 2. Strength of relationship: ◦ H.pylori is found in at-least 90% of patients with duodenal ulcers. An Australian tribe population lacking duodenal ulcers, it has never been found. 3. Dose response relationship: ◦ density of H.pylori per square mm of gastric mucosa is higher in patients with duodenal ulcer than without it.
  • 39. 4. Replication of findings: ◦ many observations regarding H pylori have been replicated repeatedly. 5. Biologic plausibility: ◦ it was difficult to envision a bacterium infecting stomach antrum with such high acidity, but it is now recognized that H pylori has binding sites on antral cells. 6. Consideration of alternate explanations: ◦ data suggest that smoking can increase the risk of duodenal ulcer in H pylori infected patients but is not a risk factor in patients in whom H pylori has been eradicated.
  • 40. 7. Cessation of exposure: ◦ long term ulcer recurrence rates were zero after H pylori was eradicated using triple antimicrobial therapy, compared with a 60-80% relapse rate found in those treated with histamine receptor antagonists. 8. Specificity of association: ◦ prevalence of H pylori in patients with duodenal ulcers in 90-100% vs found in some patients with gastric ulcer/asymptomatic individuals.
  • 41. 9. Consistency with other knowledge: ◦ H pylori infection prevalence is same in men & women in recent years which was believed to be higher in men. ◦ High prevalence of ulcer disease in latter part of 19th century, consistent with high prevalence of H pylori due to poor living conditions at the same period.
  • 42. Association Yes No Likely Unlikely Yes No Cause Bias in selection or measurement Chance Confounding Cause
  • 43.  Agnes M, editor in chief, Webster’s New World Dictionary, 4th edi. Cleveland,Ohio: Wiley publishing,Inc,2002  Hill AB. The environment and disease: Association or causation. Proceedings of the Royal Society of Medicine 1965; 58: 295-300.  Susser MW. What is a cause and how do we know one ? A grammar for pragmatic epidemiology. American Journal of Epidemiology 1991; 133: 635- 648.  Gordis leon, Epidemiology, 4th edition,saunders Elsevier,227-246  Fletcher Robert,Clinical Epidemiology,The essentials,4th ediction,Lippincott William Wilkins,187-204  K Park,21st edition,MS Banarsidas Bhanot, Jabalpur,82-84  RajVir Bhalwar, text book of Public Health, AFMC,pune
  • 44.  Weighing the Evidence ◦ Its not the total no of guidelines present that is relevant to causal inference but rather an assessment of total pattern of evidence observed that may be consistent with one or more of the guidelines.  Grading the Quality of Evidence
  • 45.  Mervyn Susser (1988) used similar criteria to judge causal relationships.  In agreement with previous authors, he mentioned that two criteria have to be present for any association that has a claim to be causal: i.e. time order (X precedes Y); and direction (X leads to Y).
  • 46.  Rejection of a hypothesis can accomplished with confidence by only three criteria: time order, consistency, factual incompatibility or incoherence.  Acceptance or affirmation can be achieved by only four, namely: strength, consistency, predictive performance, and statistical coherence in the form of regular exposure/effect relation.

Editor's Notes

  1. Red : most important criteria Green: give additional support to causal reasoning