The document discusses various concepts related to establishing causation between factors and diseases in epidemiology. It defines association and how this does not necessarily imply causation. There can be spurious, indirect, or direct causal associations. For a direct causal relationship, a factor must be both necessary and sufficient for a disease - meaning the disease cannot occur without the factor and the factor inevitably causes the disease. However, for many diseases a single factor is not enough to cause it, and multiple factors may interact in complex ways. Various models are discussed to explain multifactorial causation, including the epidemiological triad of agent, host, environment and the web of causation showing interrelationships between multiple predisposing factors. Additional criteria like temporal
The document discusses various concepts related to establishing causation between factors and diseases in epidemiology. It defines association and how this does not necessarily imply causation. There can be spurious, indirect, or direct causal associations. For a direct causal relationship, a factor must be both necessary and sufficient for a disease - meaning the disease cannot occur without the factor and the factor inevitably causes the disease. However, for many diseases a single factor is not enough to cause it, and multiple factors may interact in complex ways. Various models are discussed to explain multifactorial causation, including the epidemiological triad of agent, host, environment and the web of causation showing interrelationships between multiple predisposing factors. Additional criteria like temporal
The document discusses various concepts related to establishing causation between factors and diseases in epidemiology. It defines association and how this does not necessarily imply causation. There can be spurious, indirect, or direct causal associations. For a direct causal relationship, a factor must be both necessary and sufficient for a disease - meaning the disease cannot occur without the factor and the factor inevitably causes the disease. However, for many diseases a single factor is not enough to cause it, and multiple factors may interact in complex ways. Various models are discussed to explain multifactorial causation, including the epidemiological triad of agent, host, environment and the web of causation showing interrelationships between multiple predisposing factors. Additional criteria like temporal
The document discusses various concepts related to establishing causation between factors and diseases in epidemiology. It defines association and how this does not necessarily imply causation. There can be spurious, indirect, or direct causal associations. For a direct causal relationship, a factor must be both necessary and sufficient for a disease - meaning the disease cannot occur without the factor and the factor inevitably causes the disease. However, for many diseases a single factor is not enough to cause it, and multiple factors may interact in complex ways. Various models are discussed to explain multifactorial causation, including the epidemiological triad of agent, host, environment and the web of causation showing interrelationships between multiple predisposing factors. Additional criteria like temporal
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ASSOCIATION AND CAUSATION
The epidemiologist whose primary interest is to establish a "cause and
effect" relationship has to proceeds from demonstration of statistical association to demonstration that the association is causal Association may be defined as the concurrence of two variables more often than would be expected by chance. But association does not necessarily imply a causal relationship. The concept of cause A cause of a disease is an event, condition, characteristic or a combination of these factors which plays an important role in producing the disease. Logically a cause must be preceding a disease. Association can be broadly grouped under three headings: a. Spurious association b. Indirect association c. Direct (causal) association (i) one-to-one causal association (ii) multifactorial causation. a. Spurious association Sometimes an observed association between a disease and suspected factor may not be real. For example, a study in UK of 5174 births at home and 11,156 births in hospitals showed perinatal mortality rates of 5.4 per 1000 in the home births, and 27.8 per 1000 in the hospital births. Apparently, the perinatal mortality was higher in hospital births than in the home births. It might be concluded that homes are a safer place for delivery of births than hospitals. Such a conclusion. is spurious or artifactual, because in general, hospitals attract women at high risk for delivery because of their special equipment and expertise, whereas this is not the case with home deliveries. The high perinatal mortality rate in hospitals might be due to this fact alone, and not because the quality of care was inferior. b. Indirect association Many associations which at first appeared to be causal have been found on further study to be due to indirect association. The indirect association is a statistical association between a characteristic (or variable) of interest and a disease due to the presence of another factor, known or unknown, that is common to both the characteristic and the disease. This third factor (i.e., the common factor) is also known as the "confounding" variable. Since it is related both to the disease and to the variable, it might explain the statistical association between disease and a characteristic wholly or in part. Such confounding variables (e.g., age, sex, social class) are potentially and probably present in all data and represent a formidable obstacle to overcome in trying to assess the causal nature of the relationship. Examples of an indirect association is altitude and endemic goitre endemic goitre is generally found in high altitudes, showing thereby an association between altitude and endemic goitre. We know, that endemic goitre is not due to altitude but due to environmental deficiency of iodine. a common factor {i.e., iodine deficiency) can result in an apparent association between two variables, when no association exists. This amplifies the earlier statement that statistical association does not necessarily mean causation. c. Direct (causal) association (i) One-to-one causal relationship Two variables are stated to be causally related (AB) if a change in A is followed by a change in B. If it does not, then their relationship cannot be causal. This is known as "one-to-one" causal relationship. This model suggests that when the factor A is present, the disease B must result. Conversely, when the disease is present, the factor must also be present. The proponents of the germ theory of disease insisted that the cause must be: a. necessary, and b. sufficient for the occurrence of disease before it can qualify as cause of disease. In other words, whenever the disease occurs, the factor or cause must be present. The cause is termed necessary if a disease cannot develop in its absence; (necessary cause: The cause must be present for the outcome to happen. However, the cause can be present without the outcome happening). The cause is termed sufficient cause when it is not usually a single factor, but often comprises several components, and each sufficient cause has a necessary cause as a component. A cause is termed sufficient when it inevitably produces or initiates a disease; (sufficient cause: If the cause is present the outcome must occur. However, the outcome can occur without the cause being present). In general, it is not necessary to identify all the components of a sufficient cause before effective prevention can take place, since the removal of one component may interfere with the action of the others and thus prevent the disease. the "necessary and sufficient" concept does not fit well for many diseases. Taking for example tuberculosis, tubercle bacilli cannot be found in all cases of the disease but this does not rule out the statement that tubercle bacilli are the cause of tuberculosis. In tuberculosis, it is wellknown that besides tubercle bacilli, there are additional factors such as host susceptibility which are required to produce the disease. The concept of one-to-one causal relationship is further complicated by the fact that sometimes, a single cause or factor may lead to more than one outcome. In short, one-to-one causal relationship, although ideal in disease aetiology, does not explain every situation. (ii) Multifactorial causation: the causal thinking is different when we consider a noncommunicable disease or condition (e.g., CHO) where the aetiology is multifactorial. This situation is exemplified in lung cancer where more than one aetiological factor (e.g., smoking, air pollution, exposure to asbestos) can produce the disease independently. It is possible as our knowledge of cancer increases, we may discover a common biochemical event at the cellular level that can be produced by each of the factors. The cellular or molecular factor will then be considered necessary as a causal factor. In the second model (Factor 1 + 2+ Factor 3 = outcome). A model of multifactorial causation showing synergism the causal factors act cumulatively to produce disease. This is probably the correct model for many diseases. lt is possible that each of the several factors act independently, but when an individual is exposed to 2 or more factors, there may be a synergistic effect. From the above discussion. In biological phenomena, the requirement that "cause" is both "necessary" and "sufficient" condition is not easily reached, because of the existence of multiple factors in disease aetiology. Web of Causation In many diseases, especially noncommunicable diseases, the causative agent may be unknown or uncertain, yet there may be definite This model is ideally suited in the study of chronic disease, where the disease agent is often not known, but is the outcome of interaction of multiple factors. The (web of causation) considers all the predisposing factors of any type and their complex interrelationship with each other which shows a variety of possible interventions that could be taken which might reduce the occurrence of the chronic disease. An example of the Web of causation in reference to ischemic heart disease is given in the accompanying diagram.
The Epidemiological Triad
In epidemiology, there is a concept known as the “Epidemiological Triad“, which describes the necessary relationship between vector, host, and environment. When all three are present, the disease can occur. Without one or more of those three factors, the disease cannot occur. It’s a very simplistic but useful model. The occurrence and manifestations of any disease, whether communicable or noncommunicable, are determined by the interactions between the agent, the host and the environment, which together constitute the epidemiological triad . Each of these is treated as a separate component, though many epidemiologists consider the agent as part of the biological .environment of man
The causal pie model
An individual factor that contributes to cause disease is shown as a piece of a pie. After all .the pieces of a pie fall into place, the pie is complete, and disease occurs
The individual factors are called component
causes. The complete pie, is called a sufficient cause. A disease may have more than one sufficient cause, with each sufficient cause being composed of several component causes that may or may not overlap. A component that appears in every single pie or pathway is called a necessary cause, .because without it, disease does not occur Component causes A–E add up to sufficient causes I–III. Every sufficient cause consists of different component causes. If and only if all the component causes that constitute the causal pie of a sufficient cause are present, does the sufficient cause exist and does the outcome occur. Hence, the effect of a component cause depends on the presence of its complementary component causes, that is, its complementary set. I, II, and III can be sufficient causes for the same outcome, or for different outcomes, in which case the .outcomes are correlated through the component causes
ADDITIONAL CRITERIA FOR JUDGING CAUSALITY
In the absence of controlled experimental evidence to incriminate the "cause", certain additional criteria have been evolved for deciding when an association may be considered a causal association. An elegant elucidation of these criteria appears in "Smoking and Health" the Report of the Advisory Committee to the Surgeon General of the Public Health Service in US (87). Bradford Hill (88, 89) and others (90) have pointed out that the likelihood of a causal relationship is increased by the presence of the following criteria. 1. Temporal association 2. Strength of association 3. Specificity of the association 4. Consistency of the association 5. Biological plausibility 6. Coherence of the association To judge or evaluate the causal significance of an association, all the above criteria must be utilized, no one of which by itself is self-sufficient, but each adds to the quantum of evidence, and all put together contribute to a probability of the association being causal. 1. Temporal association This criterion centers round the question: Does the suspected cause precede the observed effect? A causal association requires that exposure to a putative cause must precede temporarily the onset of a disease. 2. Strength of association: In general, the larger the relative risk, the greater the likelihood of a causal association. Furthermore, the likelihood of a causal relationship is strengthened if there is a biological gradient or dose-response relationship - i.e., with increasing levels of exposure to the risk factor, an increasing rise in incidence of the disease is found. 3. Specificity of the association: The concept of specificity implies a "one-to-one" relationship between the cause and effect. The requirement of specificity is a most difficult criterion to establish not only in chronic disease but also in acute diseases and conditions. The reasons are: first, a single cause or factor can give rise to more than one disease. Secondly, most diseases are due to multiple factors with no possibility of demonstrating one-to-one relationship. In short, specificity supports causal interpretation but lack of specificity does not negate it 4. Consistency of the association: The association is consistent if the results are replicated when studied in different settings and by different methods. If there is no consistency, it will weaken a causal interpretation. A consistent association has been found between cigarette smoking and lung cancer. 5. Biological plausibility Causal association is supported if there is biological credibility to the association. For example, the notion that food intake and cancer are interrelated is an old one. The positive association of intestine, rectum and breast cancers is biologically logical, whereas the positive association of food and skin cancer makes no biological sense suggesting that strength of association by itself does not imply causality causal. 6. Coherence of the association: A final criterion for the appraisal of causal significance of an association is its coherence with known facts that are thought to be relevant. For example, the historical evidence of the rising consumption of tobacco in the form of cigarettes and the rising incidence of lung cancer are coherent. The fall in the relative risk of lung cancer when cigarette smoking is stopped, and the occurrence of lung cancer from occupational exposure to other carcinogens such as asbestos and uranium and the demonstrated increase in lung cancer risk when workers exposed to these substances also smoked, enhance the significance of a causal association.