The DOI matches its Crossref record.
PROPORTION OF DISEASE CAUSED OR PREVENTED BY A GIVEN EXPOSURE, TRAIT OR INTERVENTION1
Abstract
The structures of two epidemiologic parameters are explored. One, the “etiologic fraction, ” relates to markers of increased risk, and it is the proportion of disease attributable to the marker and/or to factors associated with it. The other, the “prevented fraction, ” is the equivalent of this for a marker of reduced risk. It is shown that both parameters depend—in different ways—-on the frequency of the marker among cases of the disease, and on the “standardized morbidity ratio” for those with the marker. Point estimation of these parameters is often straight-forward, particularly in case-control studies.
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“ETT has been used in econometrics to evaluate the effectiveness of social programs on their participants (Heckman, 1992) and has long been the target of research in epidemiology, where it came to be known as 'the effect of exposure on the exposed,' or 'standardized morbidity' (Miettinen, 1974; Greenland and Robins, 1986).”
From Causal inference in statistics: An overview (2009) · cites this paper as Miettinen, 1974
In the citing paper
“Population-attributable fractions, adjusted for aforementioned model covariates, were calculated using Miettinen’s formula, aPRs, and weighted prevalence estimates of each health condition and risk behavior by each cumulative ACEs count level”
From Adverse childhood experiences and health conditions and risk behaviors among high school students—Youth Risk Behavior Survey, United States, 2023 (2024) · cites this paper as [11]
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Murray, C. J. L., Ezzati, M., López, A. D., Rodgers, A., & Hoorn, S. V. (2004) · Cited by 5
Miettinen, O. S. (2004) · Journal of Evaluation in Clinical Practice · doi:10.1111/j.1365-2753.2003.00430.x · Cited by 5
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Craun, G. F. (1991) · Springer eBooks · doi:10.1007/978-3-540-46685-7_1 · Cited by 5
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Blindness prevention through control of ocular hypertension: an epidemiological assessment
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“In assessing the overall importance of a risk factor epidemiologists often use another parameter, attributable risk (2, 6).”
BackgroundSjölander, A. (2016) · Wiley StatsRef: Statistics Reference Online · doi:10.1002/9781118445112.stat07873 · Cited by 5
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Assessment and projection of burden of cancer due to tobacco in India till 2025
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Ambrosino, P., Marcuccio, G., Lombardi, C., et al. (2023) · Journal of Clinical Medicine · doi:10.3390/jcm12206490 · Cited by 4
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MethodQuantifying the benefit of screening colonoscopy
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Mediation Analysis with Attributable Fractions
Sjölander, A. (2018) · Epidemiologic Methods · doi:10.1515/em-2017-0010 · Cited by 5
“The AF has been in focus of intensive research, and various estimation techniques have been developed for all common study designs (e.g. Miettinen 1974; Sturmans, Mulder, and Valkenburg 1977; Deubner et al. 1980; Bruzzi et al. 1985; Greenland and Drescher 1993; Sjölander and Vansteelandt 2011)…”
BackgroundMethodAttributable Fraktionen und vorzeitige Todesfälle: Wichtige Klärung von Missverständnissen
Morfeld, P., & Erren, T. C. (2019) · Das Gesundheitswesen · doi:10.1055/a-0915-1359 · Cited by 4
Hiilamo, A., Keski‐Säntti, M., Räsänen, S., et al. (2023) · Journal of Epidemiology & Community Health · doi:10.1136/jech-2023-220283 · Cited by 4
Caru, M., Curnier, D. Y., Dubois, P., Friedrich, M. G., Andelfinger, G., Krajinović, M., Laverdière, C., Sinnett, D., & Périé, D. (2023) · Journal of Physical Activity and Health · doi:10.1123/jpah.2022-0179 · Cited by 4
Olsen, O. (1995) · American Journal of Industrial Medicine · doi:10.1002/ajim.4700270607 · Cited by 4
Can Data Science Inform Environmental Justice and Community Risk Screening for Type 2 Diabetes?
Davis, J. A., & Burgoon, L. D. (2015) · PLoS ONE · doi:10.1371/journal.pone.0121855 · Cited by 4
“In order to characterize the genetic risk the rs13266634 polymorphism confers to homozygous carriers, the population attributable risk (PAR) for each ethnicity was calculated as follows [20,21]:”
MethodA Scaled Sample Space Cube Used to Illustrate Attributable Fractions
Eide, G. E., & Heuch, I. (2006) · Biometrical Journal · doi:10.1002/bimj.200410156 · Cited by 4
“Other terms like population attributable risk (PAR), etiologic fraction (Miettinen 1974) and excess fraction (Greenland and Robins 1988) have also been used for λ; for an overview see Benichou (2000).”
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VanderWeele, T. J. (2012) · Wiley series in probability and statistics · doi:10.1002/9781119945710.ch13 · Cited by 5
Smoking-related disease in a VA hospital
Allen, A. (1988) · Preventive Medicine · doi:10.1016/0091-7435(88)90043-6 · Cited by 4
Has the Cost-effectiveness of Misoprostol Been Underestimated?
Gabriel, S. E. (1995) · Archives of Internal Medicine · doi:10.1001/archinte.1995.00430130142017 · Cited by 4
Apolone, G., Grilli, R. G., Alexanian, A. A., et al. (1990) · Tumori Journal · doi:10.1177/030089169007600311 · Cited by 4
“Chemotherapy in patients with abdominal or distant metastases 72 8 (25) 62 (18) 1 (30)~”
BackgroundMethodModifiable risk factors for anemia among women of childbearing age in sub-saharan Africa (2015–2023)
Seifu, B. L., Negussie, Y. M., Asnake, A. A., Fente, B. M., Asmare, Z. A., Melkam, M., Bezie, M. M., Gebrehana, A. K., Tsega, S. S., & Asebe, H. A. (2025) · BMC Public Health · doi:10.1186/s12889-025-21427-x · Cited by 3
Oliva, J., Trapero‐Bertran, M., & Peña-Longobardo, L. M. (2024) · Drug and Alcohol Dependence · doi:10.1016/j.drugalcdep.2024.112462 · Cited by 3
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Kritik an Population Attributable Fraction bei genauerem Hinsehen nicht gerechtfertigt
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A toolkit for planning and implementing acute febrile illness (AFI) surveillance
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Quantifying work-related social inequalities in life expectancy: a methodological proof of concept
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Sinisterra-Sierra, S., Godoy-Calderón, S., & Pescador‐Rojas, M. (2023) · Mathematical and Computational Applications · doi:10.3390/mca28010012 · Cited by 3
Cole, P. (1975) · PubMed · Cited by 3
Genomewide Screens in Ankylosing Spondylitis
Brown, M. A. (2009) · Advances in experimental medicine and biology · doi:10.1007/978-1-4419-0298-6_11 · Cited by 3
Combining Cross-sectional Data on Prevalence with Risk Estimates from a Prediction Model
König, J., Blettner, M., Wild, P. S., et al. (2014) · Methods of Information in Medicine · doi:10.3414/me13-01-0088 · Cited by 3
Burden of illness attributable to subclinical hypothyroidism in the Spanish population
Donnay, S., Balsa, J. A., Álvarez, J., Crespo, C., Pérez-Alcántara, F., & Polanco, C. (2013) · Revista Clínica Española (English Edition) · doi:10.1016/j.rceng.2013.07.002 · Cited by 3
Rushton, L., Hutchings, S. J., & Straíf, K. (2020) · Springer eBooks · doi:10.1007/978-3-030-30766-0_32 · Cited by 3
Accounting for biases in survey-based estimates of population attributable fractions
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NICHOLSON, D. (1983) · Annals of Internal Medicine · doi:10.7326/0003-4819-99-5-738_1 · Cited by 3
Revisiting the Population Attributable Fraction
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“The parameter (Equation 1) is mathematically equivalent to the population attributable fraction used by Levin 31 and Miettinen, 32 except expressed using potential outcomes.”
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Screening tool for predicting patient aggressive behavior and staff injury at a pediatric hospital
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“Finally, we calculated population attributable fractions (PAFs) using Miettinen’s formula [25].”
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“When adjusted relative risks are available, Miettinen’s formula provides less biased estimates than simpler methods, such as Levin’s equation, by accounting for confounding [11 , 12].”
Expected impact of a public health intervention in the presence of synergistic risk factors
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“The PAF may be expressed as follows [3]:”
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Li, Y., Wang, Y., Fan, M., et al. (2023) · Environmental Science and Pollution Research · doi:10.1007/s11356-023-28539-0 · Cited by 2
Caru, M., Dubois, P., Curnier, D. Y., Andelfinger, G., Krajinović, M., Laverdière, C., Sinnett, D., & Périé, D. (2023) · Journal of Physical Activity and Health · doi:10.1123/jpah.2023-0100 · Cited by 3
Gorgani, F., Sharafkhah, M., Masoudi, S., Poustchi, H., Delavari, A., Sadjadi, A., Roshandel, G., Khoshnia, M., Eslami, L., Rezaei, N., et al. (2024) · International Journal of Cardiology Cardiovascular Risk and Prevention · doi:10.1016/j.ijcrp.2024.200279 · Cited by 2
“The PAF was calculated based on the proportions of participants who had each risk factor and its association with each outcome using the Levin ’ s formula: Where P is the prevalence of the risk factor, and HR is the hazard ratio of the disease risk [9,16].”
MethodKim, S., & Park, C. Y. (2024) · Nutrition Research and Practice · doi:10.4162/nrp.2024.18.4.554 · Cited by 3
“Population attributable fraction (PAF) was calculated using the following formula provided by Miettinen [47] and Khosravi et al. [48], where P c is the prevalence of multiple high-risk behaviors among deaths, and HR is the adjusted HR for all-cause mortality associated with multiple high-risk…”
MethodHiilamo, A., Jensen, M. R., & Hermansen, Å. (2024) · Journal of Epidemiology & Community Health · doi:10.1136/jech-2024-222915 · Cited by 2
“23 We then use the Miettinen formula to calculate population attributable fractions (PAFs), 24 which measure the extent to which the prevalence of the outcome (payment problems) can be attributed to the exposure (adolescence psychiatric diagnoses).”
Damigou, E., Anastasiou, C. A., Kyrili, K., Barkas, F., Liberopoulos, E. N., Michelis, E., Pitsavos, C. S., Sfikakis, P. P., Tsioufis, C., & Panagiotakos, D. B. (2025) · Frontiers in Cardiovascular Medicine · doi:10.3389/fcvm.2025.1551020 · Cited by 2
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“In addition, for each risk factor, we calculated the population attributable risk (PAR) percentage (20), which was based on the prevalence and relative risk (RR):”
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“In a RCT, where the agent is expected to be preventive, instead of EF one usually uses the prevented fraction (PF) [5,18]:”
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Ogbo, F. A. (2016) · Cited by 2
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ABC of subfertility: male subfertility
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1976: the year epidemiology became Miettinenian
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Attributable mortality due to nosocomial sepsis in Brazilian hospitals: a case–control study
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Hirvelä, L., Keski‐Rahkonen, A., & Sipilä, P. N. (2023) · International Journal of Eating Disorders · doi:10.1002/eat.24013 · Cited by 2
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Fuchs, C., & Berger, V. W. (2004) · Journal of Modern Applied Statistical Methods · doi:10.22237/jmasm/1083370020 · Cited by 2
“The maximum likelihood estimate (MLE) for the AF under the logistic regression model-adjustment (Miettinen 1974; Walter 1975; Bruzzi et al 1985; Greenland 1987; Benichou & Gail 1990; Greenland & Drescher 1993) is obtained by substituting the proper estimates in equation (2) above.”
MethodHoes, A. W. (1992) · RePub (Erasmus University Rotterdam) · Cited by 2
Attributable Fraction in Exposed
Bénichou, J. (2005) · Encyclopedia of Biostatistics · doi:10.1002/0470011815.b2a03006 · Cited by 2
Response Etiologic and prevented fraction in case-control studies of screening
Sasco, A. J. (1988) · Journal of Clinical Epidemiology · doi:10.1016/0895-4356(88)90171-0 · Cited by 2
Huang, C., Lee, Y., Lo, F., et al. (1998) · Experimental and Clinical Immunogenetics · doi:10.1159/000019051 · Cited by 2
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Bénichou, J. (2005) · Encyclopedia of Biostatistics · doi:10.1002/0470011815.b2a03001 · Cited by 2
Ezzati, M. (2016) · Elsevier eBooks · doi:10.1016/b978-0-12-803678-5.00086-2 · Cited by 2
Statistical Methods to Estimate the Impact of Risk Factors on the Disease Load in a Population
Gefeller, O. (1997) · Studies in classification, data analysis, and knowledge organization · doi:10.1007/978-3-642-59051-1_46 · Cited by 2
Ahmed, K. Y., Thapa, S., Kibret, G. D., et al. (2025) · Journal of Global Health · doi:10.7189/jogh.15.04015 · Cited by 1
Ferguson, J. P. (2025) · Annals of Epidemiology · doi:10.1016/j.annepidem.2025.01.008 · Cited by 1
Damigou, E., Florentin, M., Chrysohoou, C. A., et al. (2025) · Annals of Epidemiology · doi:10.1016/j.annepidem.2025.09.007 · Cited by 1
Narisada, A., Umemura, T., Yamanaka, N., et al. (2025) · Environmental Health and Preventive Medicine · doi:10.1265/ehpm.25-00123 · Cited by 1
“The population-attributable fraction (PAF) of people living in detached houses for the risk of BRAs was calculated using Miettinen ’ s formula [22].”
Coronary Heart Disease Attributable to Psychosocial Stressors at Work
Lavigne‐Robichaud, M., Trudel, X., Talbot, D. C., Milot, A., Pena-Gralle, A. P. B., Mésidor, M., Gilbert‐Ouimet, M., Niedhammer, I., Sultan‐Taïeb, H., Dionne, C. E., et al. (2025) · JACC Advances · doi:10.1016/j.jacadv.2025.102160 · Cited by 6
Li, X., Cao, L., She, W., et al. (2025) · The Cleft Palate-Craniofacial Journal · doi:10.1177/10556656251378598 · Cited by 1
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Preventie van depressie: een overzicht
Cuijpers, P. J., Smit, F., & Beekman, A. T. F. (2010) · Psychologie & gezondheid · doi:10.1007/bf03089341 · Cited by 1
Ruan, Y., Walter, S. D., Gogna, P., Friedenreich, C. M., & Brenner, D. R. (2021) · BMJ Open · doi:10.1136/bmjopen-2020-045410 · Cited by 1
Mitchell, E. A., Zhang, D., Thompson, J., Liu, C., Leversha, A., & Milne, B. J. (2022) · Archives of Disease in Childhood · doi:10.1136/archdischild-2021-323006 · Cited by 1
Inequality in COVID-19 mortality in Quebec associated with neighbourhood-level vulnerability domains
Blaser, C., Gautier, L., Brousseau, É., et al. (2023) · Canadian Journal of Public Health · doi:10.17269/s41997-023-00829-7 · Cited by 1
Defining the Limits of Effectiveness of Contact Tracing in Control of Tuberculosis in Urban Africa
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The Relation of a Woman’s Impaired in Utero Growth and Association of Diabetes During Pregnancy
Chawla, R., Rankin, K., & Collins, J. W. (2014) · Maternal and Child Health Journal · doi:10.1007/s10995-014-1448-5 · Cited by 1
“Lastly, to estimate the percentage of pregnancies complicated by DM attributable to maternal SGA status, assuming a causal relationship, we calculated the adjusted population attributable risk percent (PAR %): adjPAR % = Pc (adjRR-1)/adjRR, where Pc is the RP proportion of women with diabetes who were formerly SGA, an…”
MethodClassical causation research practices and sufficient-component cause model – Appraisal and pitfalls
Alrawahi, A. H. (2022) · Epidemiology Biostatistics and Public Health · doi:10.2427/12576 · Cited by 2
“However, to the best of our knowledge, the sufficientcomponent cause model seems to be a theoretical framework for epidemiology, and its implications on the current classical causation research practices are still not well explored [9].”
BackgroundWändell, P. E., Fredrikson, S., Carlsson, A. C., et al. (2020) · Seizure · doi:10.1016/j.seizure.2020.02.005 · Cited by 1
“8 was estimated in percent for risk factors as prevalence (%) among cases multiplied by HR1/HR [15], using adjusted HRs for the different factors.”
MethodInterrupted X-Suture Prevents Burst Abdomen: Analysis of 5 Randomised Controlled Trials from India
Mishra, P. R., Kumar, S., Mishra, S. R., et al. (2022) · Indian Journal of Surgery · doi:10.1007/s12262-022-03411-6 · Cited by 1
Reporting Risk: From Math to Meaning
Lapointe‐Shaw, L., Babe, G., Austin, P. C., et al. (2022) · Canadian Journal of General Internal Medicine · doi:10.22374/cjgim.v17i4.638 · Cited by 1
Metadata
- Authors
- MIETTINEN, O. S.
- Corresponding author
- MIETTINEN, OLLI S.
- Venue
- American Journal of Epidemiology
- Publisher
- Oxford University Press (OUP)
- Published
- 1974-05
- Volume
- 99
- Issue
- 5
- Pages
- 325-332
- ISSN
- 0002-9262 (ISSN-L)
- 1476-6256
- OpenAlex
- W1953501928
- Cited by
- 1,036
- References
- 0
- Citations by year
- 2026: 24 · 2025: 34 · 2024: 41 · 2023: 35 · 2022: 26 · 2021: 35 · 2020: 39 · 2019: 40 · 2018: 31 · 2017: 22 · 2016: 27 · 2015: 25 · 2014: 28 · 2013: 22 · 2012: 26
- FWCI
- 7.80
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- American Journal of Epidemiology (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Physical Sciences › Mathematics › Statistics and Probability › Statistical Methods in Epidemiology
- Health Sciences › Medicine › Epidemiology › Historical and modern epidemiology studies
- Physical Sciences › Mathematics › Statistics and Probability › Advanced Causal Inference Techniques
- Keywords
- population attributable fraction, prevented fraction, attributable fraction, risk indicators, standardized morbidity ratio, case-control study, disease prevention
- MeSH terms
- Coffee, Coronary Disease, Drinking, Epidemiologic Methods, Humans, Hypercholesterolemia, Hypertension, Models, Theoretical, Morbidity, Myocardial Infarction, Population, Preventive Medicine, Smoking, Statistics as Topic
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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