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ABSTRACT
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Behavioral Epidemiology
THE BEHAVIORAL EPIDEMIOLOGY FRAMEWORK
Phase 1--Establish Links Between Behaviors and Health
Basic epidemiological studies document associations between
behaviors and health. Such documentation provides a rationale for
proceeding to the subsequent phases of behavioral epidemiology
research. Beyond simply documenting that an association exists,
research in Phase 1 also includes dose-response relationships
between the behavior and health outcomes. Such evidence provides key elements from which to derive the population health
guidelines. An example would be developing guidelines for
saturated fat intake based on the dose-response relationship
between amount of saturated fat in peoples' diets and risk of
coronary heart disease.
Phase 2---Develop Methods for Measuring the Behavior
High-quality measures are essential for all stages of research,
so measurement development is positioned as an early stage. This
would include establishing the reliability and validity of extant
measures, developing new measures, and field-testing new tools.
Using improved behavioral measures to refine results of Phase 1
studies is an example of how various phases can have reciprocal
linkages.
Phase 3---Identify Factors That Influence the Behavior
The first purpose of this phase is to describe demographic
correlates of the behavior. Such descriptive epidemiology documents how the behavior varies by sex, age, ethnic group, socioeconomic status, and other variables. Descriptive research is useful for
identifying characteristics of people who are most in need of
intervention. The second purpose of Phase 2 is to test hypotheses
about the correlates, influences, or determinants of the behavior.
Such research includes validating applications of theoretical
models and uses of theory-derived constructs in identifying
modifiable psychological, social, and environmental factors that
may influence the behaviors. This phase requires the explicit and
systematic application and evaluation of behavioral theories (14,15).
Phase 4 - - E v a h a t e Interventions to Change the Behavior
Intervention programs drawing on the knowledge derived
from studies in Phases 1, 2, and 3 need to be developed and tested
systematically. Evaluations can be conducted in efficacy studies
using randomized trials or in effectiveness studies where rigorous
study designs and objective measures may be less readily implemented, but where approximations to "real world" outcomes may
be assessed (10,11). The modifiable factors identified in Phase 3
may be considered potential mediators of intervention effects and
should be targeted for change in intervention trials (16). Phase 4
studies could include "subtraction" designs to decompose effective intervention elements to identify the most cost-effective
strategy, as suggested by Baranowski and associates (16). The
earlier Phase 3 studies can help to identify factors that may and
may not be amenable to change; for example, modifiable factors
relating to food intake and physical activity versus genetic factors
that predispose towards obesity. Identified determinants of the
behaviors may be targeted for intervention. Nonmodifiable genetic
influences might be the targets for awareness raising and for
motivating change in other factors (cigarette smoking, for example) that interact with obesity to increase health risk.
Phase 5mTranslate Research Into Practice
When interventions are shown to be effective in Phase 4, they
have to be used in worksites, schools, health care settings, and
V O L U M E 22, N U M B E R 4, 2000
295
METHOD
Four journals were selected to examine two content fields and
two related but distinct disciplinary perspectives on health behavior research. The journals surveyed were Annals of Behavioral
Medicine, representing an interdisciplinary field; Health Psychology, representing a discipline-specific field; Journal of Nutrition
Education and Tobacco Control, emphasizing intervention research on specific health behaviors. Although this is a small and
selective subset of all possible candidate journals, our purpose was
not to evaluate the state of fields of research but to illustrate how
the behavioral epidemiology framework could be used as part of an
evaluation of journal contents or a grant portfolio.
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A N N A L S OF B E H A V I O R A L M E D I C I N E
TABLE 1
Characteristics of Journals Reviewed
Sallis et ai.
Health Beha~or
Journal
Years
Reviewed
Number of
Articles Coded
1996-1997
1997-1998
1996-1997
1997-1998
79
124
81
63
43%
'17%
mAnn Behav Med
Etiology of
Behavior
RESULTS
Figure 1 shows the distribution of articles in Annals of
Behavioral Medicine and Health Psychology by the behavioral
50%
1%
Interventions
Research to
Practice
15%
0%
10%
20%
30%
40%
50%
60%
FIGURE 1:
Percent of articles in interdisciplinary and
discipline-specific journal, in behavioral epidemiology phases.
B~av'~
i 1 0 %
Health
Measurement ~
6%
4O%
Etiology of Behavior
32%
Interventions
4O%
Researchto Prac6ce
0%
10%
20%
30%
40%
5O%
6O%
FIGURE 2:
Percent of articles in behavior-specific intervention journals, in behavioral epidemiology phases.
Behavioral Epidemiology
DISCUSSION
The findings of our audit of four selected journals in the
behavioral medicine and health psychology field show how the
Sallis and Owen (8) behavioral epidemiology framework can be
used to characterize the state of an area of research as reflected in
studies published in key journals. The four journals audited had
very different profiles. As expected, the more broad-based journals
representing an interdisciplinary field (Annals of Behavioral
Medicine) and a discipline-specific field (Health Psychology) had
most of their content clustered in the first three phases, primarily
Phases 1 and 3. In the field of behavioral medicine there is an
apparent emphasis on documenting the relation of behavior to
health outcomes, indicating this field is at an early stage of
development. Half of the articles in the issues of Health Psychology reviewed were devoted to examining etiologic factors in
behavior, perhaps reflecting the emphasis on theory-testing in the
field of psychology.
What we report here will naturally reflect the editorial policies
of the journals selected. Editorial policies reflect as well as help to
shape the type of work that is done in each of the relevant fields.
For example, the editorial policies of Journal of Nutrition Education and Tobacco Control explicitly emphasized intervention
studies, and the stated policies were reflected by the substantial
percentage of articles in Phase 4. Ninety percent of articles in these
two journals were in the latter phases, with most being in Phases 3
and 4. The small percent of articles reporting Phase 5 studies in
Tobacco Control was surprising, because of the emphasis on policy
interventions for tobacco control expressed in the journal's editorial statement. In the Journal of Nutrition Education, there clearly
was a strong interest in translating research to practice, suggesting
a mature research field. An alternative explanation is that dissemination and policy studies in the tobacco field were published in
other journals that were not audited.
All four journals devoted 25% to 50% of all articles to Phase 3
research. The consistent emphasis on identifying etiologic factors
may be due to several factors. The complexity of behavioral
etiology and the existence of multiple theories of etiology (14,15)
may require large numbers of studies to produce advances in
understanding. The relative ease of conducting cross-sectional
correlational studies that make up the bulk of the health behavior
literature (17) may help explain the large number of Phase 3
studies. Because Phase 3 studies can inform the development of
interventions evaluated in Phase 4, etiologic studies covering a
variety of variables and populations are needed. On the other hand,
it is not clear that information on variables identified as potential
determinants or mediators is systematically applied in intervention
studies.
Given the well-known difficulties in accurately assessing
behaviors, it was surprising that all four of these behaviorallyoriented journals had low percentages of articles on behavioral
measurement. The low percentage of articles on translating
research into practice (Phase 5) has been observed across many
health behaviors (17).
The generalizability of the present audit is limited by the
inclusion of a small number of journals. Each journal is part of a
larger field whose literature is published in multiple journals. Thus,
it is likely that these exemplar journals do not adequately
characterize the nature and the patterns of scientific activity in their
fields. The inclusion of the two recent volumes, ranging from 63 to
124 articles per journal, should be a sufficient sample to characterize content of these particular journals.
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298
and other fields. These broad fields of study include much content
that may be appropriately described as behavioral epidemiology.
However, the term has the disadvantage of ambiguity, because it is
not clear which specific disciplines or methodological approaches
might be referred to as behavioral science. Therefore, this term also
may not be a promising referent for behavioral epidemiology.
The preferred meaning for the "behavioral" term in behavioral epidemiology may be simply human actions. Behavioral
epidemiology typically is used for studies of the behaviors cited by
McGinnis and Foege (1) and in governmental policy documents,
such as Healthy People 2010 (21) and the Health Goals and Targets
for Australia (22). This use of behavior implies no discipline or
ideology, does not refer to particular methodologies, and has a
common sense meaning. Most importantly, this term accurately
reflects the intent to focus on research and application that is
concerned with behaviors and health (23).
A further limitation of the "behavioral epidemiology" label is
that it may be perceived as not implying interventions as a central
goal. Epidemiology is commonly seen as primarily consisting of
descriptive population studies or analytic studies that focus on
understanding disease causation, without an obvious focus on
interventions. Many epidemiologists would disagree with such a
position and argue that descriptive studies provide the empirical
basis for public health and preventive medicine interventions
(2,24). The current operationalization of the behavioral epidemiology framework may make a contribution by specifically defining the goal of behavioral epidemiology as using empiricallybased behavior change interventions to improve the health of
populations.
Conclusion
Even though the term "behavioral epidemiology" has been
used since the late 1970s (3-7), it has not been explicitly defined.
We have described and applied a framework that we suggest
provides an operational definition of behavioral epidemiology. We
hope the framework may stimulate a shared understanding of the
term and help overcome some inherent ambiguities in the terminology. Our broader purpose of elaborating the behavioral epidemiology framework is to stimulate a more systematic approach to
developing, evaluating, and diffusing behavior change interventions to improve population health. The framework also may help
guide, or at least stimulate debate about, the empirically-based
development of behavior change interventions that have the
potential to improve the health of the population. Given the
fundamental role of behaviors in the etiology of the major sources
of morbidity and mortality in industrialized nations (1), a framework that helps to systematize health behavior research could
make a contribution to improving public health.
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