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BEHAVIORAL EPIDEMIOLOGY: A SYSTEMATIC FRAMEWORK TO CLASSIFY PHASES

OF RESEARCH ON HEALTH PROMOTION AND DISEASE PREVENTION 1

James F. Sallis, Ph.D.


San Diego State University

Neville Owen, Ph.D.


University of Wollongong, Wollongong Australia

Michael J. Fotheringham, Ph.D.


Deakin University, Melbourne Australia

ABSTRACT

cancers, human immunodeficiency virus (HIV), and pulmonary


diseases, among others. Here, we describe and apply a framework
through which we aim to clarify and systematize what we see as
the purposes of behavioral epidemiology research. Our aim is to
make more explicit how the contributions of behavioral science
can be brought to bear on ameliorating the leading causes of death
and disability in populations.
"Behavioral epidemiology" is a term that has been used in the
literature since the late 1970s (3-7) but has not yet been
sufficiently clearly defined. A more explicit conceptualization of
the focus, scope, and logic of behavioral epidemiology is needed.
In the context of behavioral medicine research, behavioral epidemiology can be considered a subset of research that studies the
distribution and etiology of health-related behaviors in populations, as contrasted with research on clinical cases. Further,
behavioral epidemiology concerns itself with research that has the
explicit purpose of understanding and influencing healthful behavior patterns, as part of population-wide initiatives to prevent
disease and promote health.
The authors have developed a behavioral epidemiology
framework (8) that sets out to classify a sequence of research
categories about any health-related behavior. The framework
proposes a general sequence of studies that leads to evidence-based
public health interventions, while acknowledging that there is
nonsequential feedback among the phases. It builds on, but is
distinct from, earlier frameworks proposed by Greenwald and
Cullen (9) and of Flay (10) that describe phases--from basic
research through to policy and program implementation----of
chronic disease prevention and health promotion research. Oldenburg, Hardcastle, and Kok (11) described a research framework
focused more specifically on the latter phases--the diffusion and
institutionalization of health behavior change programs. Others
have proposed related frameworks to guide thinking about how to
conceptualize and influence behavior for health protection and
disease prevention outcomes (12,13). These also set out to classify
the different domains of relevant research and its applications.
A fundamental concern of all of these frameworks is improving the understanding of health-related behaviors and using this
knowledge to favorably influence behavior and health in populations. Achieving these goals requires research across the spectrum
of analytic, descriptive, and intervention studies. We argue that this
can be facilitated by the use of a systematic framework to classify
the sequencing of studies. To this end, the proposed behavioral
epidemiology framework (8) describes five main research phases.

Although the term "behavioral epidemiology" has been used


in the literature since the late 1970s, it has not been clearly
defined. A behavioral epidemiology framework is proposed to
specify a systematic sequence o f studies on health-related behaviors, leading to evidence-based interventions directed at populations. The phases are: ]---establish links between behaviors and
health; 2--develop measures o f the behavior; 3--identify influences on the behavior; 4--evaluate interventions to change the
behavior; 5--translate research into practice. Mature research
areas are expected to have more studies in the latter phases. Recent
volumes o f four journals (Annals of Behavioral Medicine, Health
Psychology, Journal of Nutrition Education, Tobacco Control)
were audited, and empirical studies were classified into these
phases. Phase 3 studies were common (identifying influences on
behaviors; 2 7% to 50%), and Phase 2 studies were least common
(measurement; 0% to 15%). Annals of Behavioral Medicine and
Health Psychology were low on Phase 4 (intervention studies; 9%
and 11%, respectively). The Journal of Nutrition Education was the
only journal reviewed that had a substantial number (20%) of
Phase 5 studies (translating research into practice). The behavioral epidemiology framework can be used to evaluate the status of
research on health behaviors and to guide research policies.

(Ann Behav Med 2000, 22 (4):294-298)


INTRODUCTION
A large body of evidence has accumulated on the extent to
which unhealthful behavior patterns are contributing to the chronic
diseases that are the leading causes of death and disability in
industrialized nations (1). The discipline of epidemiology studies
the distribution and etiology of diseases, with the intention of using
the results to inform population-wide prevention efforts (2). Some
limits of traditional epidemiology become apparent when the
diseases have a substantial behavioral etiology, because epidemiologic data do not provide specific guidance on how to change the
behaviors that are implicated in cardiovascular diseases, diabetes,

1 Adrian Bauman and Tom Baranowski contributed to the critique of


terminology. Special thanks to Robert LaForge for his helpful comments
on an earlier draft. Kecia Carrasco contributed to manuscript preparation.
Reprint Address: J. E Sallis, Ph.D., Department of Psychology, San Diego
State University, 6363 Alvarado Court, #103, San Diego, CA 92120.

9 2000 by The Society of Behavioral Medicine.

294

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

broader community environments before they can impact the


population's health (9). In addition to evaluating efforts to disseminate programs, research in this phase could identify determinants
of program adoption. Phase 5 is related to the Oldenburg,
Hardcastle, and Kok (I1) "Innovation Development" phase that
includes descriptive research on methods for dissemination, adoption, implementation, and maintenance of behavior change interventions. The Oldenburg et al. (11) "Institutionalization" phase
involves studies that evaluate the extent to which policies or
interventions are implemented and maintained.
Each phase of the behavioral epidemiology framework builds
upon the previous phases. Studies in Phases 2 and 3 develop a
basic understanding of the behaviors identified as important to
health in Phase 1 by traditional epidemiology studies. Phase 4
research targets groups at risk and evaluates theoretically- and
empirically-based approaches to behavior change, based on research in Phase 3. Phase 5 makes explicit the need to diffuse
interventions found to be effective in Phase 4. However, this
apparently linear sequence also includes several feed-back and
feed-forward elements. For example, epidemiological evidence
from Phase 1 can impact directly on public policy (Phase 5). The
availability of valid and reliable measures (Phase 2) can directly
influence decisions about the feasibility of field evaluations (Phase
4). Politically-driven health policy initiatives (Phase 5) can stimulate new research at some or all of the preceding stages in the
framework. Probably the most compelling nonlinear element is
that as behaviors are better defined and measured (Phase 2),
relationships to health outcomes (Phase 1) can be specified more
clearly through analyses using more refined measures or subcomponents of behaviors.
Although the framework can accommodate various interactions among phases, the main purpose of the five phases is to
describe a rationally-ordered sequence of studies. By basing
intervention on empirically-identified determinants and by studying the diffusion of programs with documented effectiveness, the
scarce resources available for behavioral epidemiology research
may be used more efficiently. The behavioral epidemiology
framework may be used to assess the level of development of a
topic of study. Research in younger areas of inquiry would be
concentrated in the earlier stages, to provide a foundation for
intervention work. Mature fields would be expected to have more
studies in the latter phases (i.e. Phases 4 and 5), that represent the
application of findings from studies in earlier phases.
To illustrate the utility of the framework for assessing topics
of study in the domains relating to health protection and disease
prevention, recent volumes of four journals were audited, empirical studies were classified into the five phases, and the distribution
of studies across the phases are reported.

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

Annals of Behavioral Medicine


Health Psychology
Journal of Nutrition Education
Tobacco Control

1996-1997
1997-1998
1996-1997
1997-1998

79
124
81
63

43%
'17%
mAnn Behav Med

' Health Psych


Measurement

Two years of the most recently available volumes of each of


the four selected journals were audited (see Table 1). Empirical
studies were classified into the phases, and the percent of studies in
each phase are reported.

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

Coding Categories and Rules


Empirical studies, reviews, meta-analyses, and position papers that addressed one or more health behaviors, psychological
variables, or social variables were classified according to the
behavioral epidemiology framework.
Phase 1 (Establish links between behaviors and health)
included studies dealing with the relation between a behavioral,
psychological, or social variable and health (including mental
health) outcomes.
Phase 2 (Develop methods for measuring the behavior)
included studies describing or evaluating a measure of relevant
behavioral variables of the type that are identified in Phase 1
studies.
Phase 3 (Identify factors that influence the behavior) included
studies assessing correlates, moderators, or mediators of behavioral, psychological, or social variables. It could be a crosssectional or prospective population study or a laboratory experiment.
Phase 4 (Evaluate interventions to change behavior) included
efficacy or effectiveness evaluations of interventions that were
intended to change behavioral, psychological, or social variables
related to health. The outcome could be behavioral or a biological
marker of the behavioral variable. Quality of the study design was
not considered.
Phase 5 (Translate research into practice) studies dealt with
the question of how to disseminate behavioral interventions. Such
studies included descriptive research that might inform dissemination, adoption, implementation, and sustainability of behavior
change interventions in different settings (11). Studies categorized
as Phase 5 could evaluate the extent to which policies or
interventions were implemented and maintained (11).
Two other categories were used. "Other behavioral articles"
addressed health-related behaviors but could not be classified into
any of the phases. "Nonbehavioral articles" did not directly
address behavioral, psychological, or social variables.
The coding rules were: (a) editorials and commentaries
without extensive references were not coded; (b) if the paper fit
into multiple categories, the highest phase was coded; (c) if the
paper dealt with measurement of behavior, Phase 2 was coded; (d)
if the paper dealt with measurement of potential influences or
determinants, Phase 3 was coded; and, (e) if the paper dealt with
measurement of factors related to dissemination, Phase 5 was
coded.

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.

epidemiology phases. Both journals had relatively low and similar


percentages of articles in Phases 2, 4, and 5, indicating limited
coverage of behavioral measurement, intervention, and diffusion
research. Notably, only 2% of the Health Psychology articles
addressed diffusion of interventions. These journals differed in
their emphases on Phases 1 and 3. In Annals of Behavioral
Medicine, almost half of the audited articles were on relations
between health and behavior, whereas 50% of Health Psychology's
articles examined etiology of the behaviors.
The distribution of articles from Journal of Nutrition Education and from Tobacco Control, as shown in Figure 2, was very
different. The majority of studies were in Phases 3 and 4, and the
percentages were similar for Journal of Nutrition Education and
Tobacco Control. There were few or no studies in Phases 1 and 2.
All journals were high on Phase 3 (etiologic) studies, ranging
from 27% to 50%. All journals were low on Phase 2 (measurement) studies, ranging from 0% to 15%. Annals of Behavioral
Medicine and Health Psychology were very low on Phase 4
(intervention) studies, at 9% and 11%, respectively. The Journal of
Nutrition Education was the only journal with a substantial
proportion (20%) of Phase 5 studies (translate research into
practice).

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.

VOLUME 22, NUMBER 4, 2000

297

Using the behavioral epidemiology framework to assess the


state of a field of research could be useful for a variety of purposes.
Auditing a particular journal could inform that journal's editorial
board about the breadth of coverage shown by recent published
research. While considering the current goals of the journal,
editorial boards could then make empirically-based decisions
about whether to change acceptance policies or whether to solicit
or discourage manuscripts on specific types of studies. Clusters of
journals that represent the literature on specific health behaviors
could be reviewed to characterize the state of research in these
fields. Such results could be fed back to researchers to encourage
studies that would be more likely to move the field forward.
Funding agencies could similarly code the studies in their portfolios to assess emphasis and balance across the five phases. Such a
review could be part of a broader effort to identify areas of
weakness that need to be remedied through targeted solicitations.
As research in a subfield matures, the distribution of studies
across the phases of the framework would be expected to change.
Establishing the association between the behavior and health
outcomes, along with developing adequate measures, should be the
focus of early research, though continued progress in these areas
could also be valuable. Etiologic and intervention studies should
dominate a field in early maturity. When effective interventions are
developed, Phase 5 studies to diffuse those interventions should
become a priority. Periodic reassessment of journals and research
portfolios could determine whether a field of study is evolving or
stagnating. Although the behavioral epidemiology framework can
be used to assess the types of studies that are being conducted, it
does not evaluate methodological, theoretical, or conceptual
quality, or the innovation demonstrated by the research. The
combination of the behavioral epidemiology framework with
formal guidelines for methodological rigor such as those now used
for evidence-based medicine (17) could result in more informative
evaluations.

Critique of the Term "Behavioral Epidemiology"


The purpose of the present paper was to operationalize the
concept of behavioral epidemiology and illustrate the utility of the
proposed framework for guiding research. However, the term
itself, "behavioral epidemiology," can be criticized as imprecise or
even inappropriate. For example, "epidemiology" is the study of
the distribution and etiology of disease in populations. In the
proposed framework, Phase 1 deals with the etiology of disease,
but the remainder of the phases are not explicitly related to disease.
Thus, it can be argued that epidemiology may be a misleading term
for the present framework.
The modifier "behavioral" has several shortcomings. First, it
does not alter the meaning of epidemiology, although "behavioral
epidemiology" does imply a focus on behaviors related to the
health of the population. Second, it is not clear whether behavior
refers to behaviors themselves, behavioral psychology, or behavioral science defined more broadly. Behavioral psychology (18)
provides methods for measuring and changing behaviors and has
been applied to health behavior change in populations (19,20).
However, its concepts and methods are not universally accepted;
there are other effective approaches to behavior change (15); and
behavioral psychology may offer limited guidance concerning the
diffusion of interventions (20). It may be that behavioral psychology is too limited to serve as an appropriate referent for behavioral
epidemiology.
"Behavioral science" is a more inclusive term that can
encompass psychology, sociology, anthropology, communication,

298

ANNALS OF BEHAVIORAL MEDICINE

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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