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American Journal of Epidemiology Vol. 135, No. 8: 926-935
Copyright © 1992 by The Johns Hopkins University School of Hygiene and Public Health

research-article

Assessing the Direction of Causality in Cross-sectional Studies

W. Dana Flanders1,, Lillian Lin1, James L. Pirkle2 and Samuel P. Caudill2

1Emory University School of Public Health Atlanta, GA
2Center for Environmental Health and Injury Control, Centers for Disease Control Atlanta, GA

Reprint requests to W. Dana Flanders, Emory University School of Public Health, Division of Epidemiology, 1599 Clifton Road, Atlanta, GA 30329

Interpretation of observational studies is difficult, particularly in cross-sectional studies, because the direction of cause and effect may be difficult to assess Did the "outcome" affect the measured exposure level, or did the exposure affect the outcome? In this paper, the authors describe a pattern, the "checkmark pattern," which can arise in cross-sectional studies. This pattern is characterized by higher levels of the outcome in an unexposed comparison group than in some subgroups of the exposed. The pattern, if seen in certain types of observational studies, suggests that the "outcome" variable may have affected the measured exposure level. Recognition of the pattern may help the epidemiologist to decipher the causal sequence Two examples illustrate the issues involved. Am J Epidemiol 1992;135:926–35.

causality; cross-sectional studies; epidemiologic methods; public health; observational studies


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