Tutorial 8

Effect and impact of public health intervention

Application of Attributable Risk

Overview
In epidemiological research, the occurrence of disease in a group of people exposed to a risk
factor is compared to that observed in an unexposed group in order to establish causal
relationships, and to identify effective interventions. In this way we can quantify the association
between a risk (or protective) factor and a disease (or other outcome). An important
application of epidemiology is to estimate how much disease is caused by a certain modifiable
risk factor. The data on the impact of risk factors or interventions are essential to assess the
effectiveness and cost-effectiveness of interventions. In this chapter, you will learn about the
value of knowing risk that is attributable to a specific exposure and assess portion of the risk
due to exposure and predict impact on the disease incidence when a causal risk factor is
removed;

Objective
1. Explain the value of knowing the risk that is attributable to a specific exposure
2. Introduce students to the methods for calculating and interpreting attributable risks
3. Calculate the attributable risks to assess the fraction and portion of the risk due to exposure
and predict the impact on the incidence of disease when a causal risk factor is removed

Activity 1 (Before Class Session)

Read assigned article: Impact of Maternal Depression on Infant Nutritional Status and Illness:
A Cohort Study

Activity 2
Answers questions below:
a. Why might maternal depression increase risk for malnutrition and illness?

b. What epidemiologic study design was used to test the hypothesis?

c. How was the study implemented?

d. What were the results of the study?

e. For what potential confounders did the investigators account?

f. What does the relative risk of 2.0 mean for “low birth weight” in Table 1 (column “stunted at
12 months”)?

g. What does the relative risk of 0.5 mean for “maternal financial empowerment” in Table 1
(column “stunted at 12 months”)?

h. What characteristic shown in Table 1 had the strongest association with stunted at 12
months of age?

i. What does the relative risk of 2.5 mean for “maternal depression” in Table 1 (column
“stunted at 12 months”?

j. What does the following statement mean? “Although the relative risks were attenuated, the
relation between exposure to born from prenatally depressed mothers and stunted
remained significant after adjustment for all covariates.”

k. Complete table below:

Exposure – Maternal
Stunted at 12 months Normal at 12 months Total
Depression
Exposed (prenatally depressed
45 B 129
mothers)

Unexposed (prenatally non-

A C 136
depressed mothers)

Total 64 D 265
l. Based on above table, what is the probability that infants, regardless of their mothers
psychologically, would be stunted during the study?

m. Calculate the risk of stunted at 12 months of age among infants exposed to have prenatally
depressed mothers?

n. Calculate the risk of stunted at 12 months of age among infants unexposed to have
prenatally depressed mothers?

o. Calculate the risk ratio:

p. How much of the risk of stunted among infants of prenatally depressed mothers is due to
born from prenatally depressed mothers? What does it mean?

What does the difference mean?

q. What percent of the incidence of stunted among infants who have depressed mothers is due
to having depressed mothers? What does it mean?

r. How much of the total incidence of stunted at 12 months of age among all infants is due to
born from prenatally depressed mothers?

This question was aimed to learn the impact of reducing depression among pregnant woman
on the entire population, those who were exposed to born from prenatally depressed
mothers as well as those who were not.

Above questions (k – p) aimed to learn the impact of reducing depression among pregnant
 woman on only those infants who were exposed to born from prenatally depressed
mothers.

s. What proportion of the incidence of stunted at 12 months is due to having depressed

mothers in the total population of infants?

t. Based on the result above, as a master of public health what would you do for the public
health action?