Causal and associational language in observational health research: a systematic evaluation

Noah A Haber*, Sarah E Wieten, Julia M Rohrer, Onyebuchi A Arah, Peter W G Tennant, Elizabeth A Stuart, Eleanor J Murray, Sophie Pilleron, Sze Tung Lam, Emily Riederer, Sarah Jane Howcutt, Alison E Simmons, Clémence Leyrat, Philipp Schoenegger, Anna Booman, Mi-Suk Kang Dufour, Ashley L O'Donoghue, Rebekah Baglini, Stefanie Do, Mari De La Rosa TakashimaThomas Rhys Evans, Daloha Rodriguez-Molina, Taym M Alsalti, Daniel J Dunleavy, Gideon Meyerowitz-Katz, Alberto Antonietti, Jose A Calvache, Mark J Kelson, Meg G Salvia, Camila Olarte Parra, Saman Khalatbari-Soltani, Taylor McLinden, Arthur Chatton, Jessie Seiler, Andreea Steriu, Talal S Alshihayb, Sarah E Twardowski, Julia Dabravolskaj, Eric Au, Rachel A Hoopsick, Shashank Suresh, Nicholas Judd, Sebastián Peña, Cathrine Axfors, Palwasha Khan, Ariadne E Rivera Aguirre, Nnaemeka U Odo, Ian Schmid, Matthew P Fox

*Corresponding author for this work

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We estimated the degree to which language used in the high profile medical/public health/epidemiology literature implied causality using language linking exposures to outcomes and action recommendations; examined disconnects between language and recommendations; identified the most common linking phrases; and estimated how strongly linking phrases imply causality. We searched and screened for 1,170 articles from 18 high-profile journals (65 per journal) published from 2010-2019. Based on written framing and systematic guidance, three reviewers rated the degree of causality implied in abstracts and full text for exposure/outcome linking language and action recommendations. Reviewers rated the causal implication of exposure/outcome linking language as None (no causal implication) in 13.8%, Weak 34.2%, Moderate 33.2%, and Strong 18.7% of abstracts. The implied causality of action recommendations was higher than the implied causality of linking sentences for 44.5% or commensurate for 40.3% of articles. The most common linking word in abstracts was "associate" (45.7%). Reviewers’ ratings of linking word roots were highly heterogeneous; over half of reviewers rated "association" as having at least some causal implication.
Original languageEnglish
Article numberkwac137
Pages (from-to)2084-2097
Number of pages14
JournalAmerican Journal of Epidemiology
Issue number12
Early online date4 Aug 2022
Publication statusPublished - 1 Dec 2022


  • Causal language
  • Association
  • Causal inference
  • Obeservational study


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