329

British Joumal of Health Psychology (2005), 10, 329-358 2005 7fie British Psychological Society www.bpsjournals.co.uk

The use and reporting of cluster analysis in health psychology: A review .

I 1 I ^

Jane Clatworthy *, Deanna Buick , Matthew Hankins * , John Weinman and Robert Home
'Centre for Health Care Research. University of Brighton, UK ^Macmillan Cancer Relief, London, UK ^Department of Psychology. Institute of Psychiatry, King's College, London, UK
Purpose Cluster analysis is a collection of relatively simple descriptive statistical techniques with potential value in health psychology, addressing both theoretical and practical problems. There are many methods of cluster analysis from which to choose. with no ciear guidelines to aid researchers, in the absence of guidelines it is likely that methods already reported by published researchers will be adopted, and so clear reporting of statistical methodology, while always important, is particularly crucial with cluster analysis. The aim of this review is to describe and evaluate the reporting of cluster analysis in healdi psychology publications. Methods. Electronic searches of 18 health psychology journals identified 59 articles using cluster analysis published between 1984 and 2002. Articles were submitted to systematic evaluation against published criteria for the reporting of cluster analysis. Results. Just 27% of the papers reviewed met all five criteria, although 61 % met at least four Details of the similarity measure and the computer program used were most frequently omitted. Furthermore, while researchers usually reported the procedures employed to determine the number of clusters and to validate the clusters, these procedures were often lacking in rigour, and were reported in insufficient detail for replication. Conclusions. The reporting of cluster analysis was found to be generally unsatisfactory, with many studies failing to provide enough information to allow replication or the evaluation of the quality of the research. Clear guidelines for conducting and reporting cluster analyses in health psychology are needed.

It is human nature to classiiy. Classification is an essential means of organizing infonnation, without which we would be unable to make sense of the world around us. Hence, classification systems are fundamental to all sciences: chemists use the periodic table; zoologists, the classification of animals; botanists, the classification of plants;
* Correspondence should be addressed to Jane Oatworthy. Centre for Health Care Research, University of Brighton, 2-3 Turr}pike Piece, Falmer Site. Brighton BNI 9PH. UK (e-mail: j.datwonhy@bton.ac.uk). DOI: 10.1348/135910705X25697

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astronomers, the classification of stars; geologists, rocks and so on. Empirically-based classifications are known as taxonomies and are most commonly identified through the use of cluster analysis (Bailey, 1994). There are many dUferent types of cluster analysis but most share the same basic principle: to group entities on the basis of their similarit>' with respect to selected variables, so that members ofthe resulting groups are as similar as possible to others within their group (high within-group homogeneity) and as different as possible to those in other groups (low between-group homogeneity). Cluster analysis has the potential to address both theoretical and practical problems in health psychology. From a theoretical perspective, cluster analysis is a means of bridging the gap between nomotlietic and idiographic approaches. This is elegantly summarized by Zubin (1938), one ofthe first psychologists to use clustering techniques:
. . .on the one hand, we have a group of ahstract formulations about ihe reUtionship between variables emanating from research lahoraiories. On the other hand, we have individual case histories written by the practitioner. And there is no way of closing the gap between the two approaches to the problems of ihc individual. Perhaps the research workers might he likened to those who cannot see the trees for the foresi. and the individual case workers lo those who cannot see the forest for the tress. Some middle ground must be found, [t may he that the middie ground will partake of the nature of a grouping of the trees into families, such as oak, birch, etc. That is, the research workers will come to grips with the single individual in the form of a gniup of like minded or likestructured individuals. The case worker will he ahle to transcend his limited interest in the specific individual when the latter's relationship to his like-structured sub-group is estahlished. (p. 509)

From a practical perspective, cluster analysis can perform a number of useful functions. The process of taking a heterogenous sample of entities (usually people in health psychology) and forming relatively homogenous groups, serves to organize large quantities of multivariate information. Labels can be assigned to the subgroups, making the data more manageable for the individual researcher, and facilitating communication between researchers. Moreover, cluster analysis has the potential to make a major contribution to applied health psychology research through the identification of groups that might best benefit from interventions or further research. The BPS Division of Health Psychology aims to apply psychology to three areas: the promotion and maintenance of health, improvement to the health care system, prevention of illness and disability, and enhanced outcomes of those who are ill or disabled (BPS Division of Health Psychology, 2000). Cluster analysis can help to identify key targets for these applied initiatives, enabling resources to be allocated in an optimally effective manner. Indeed cluster analysis has been applied to each of these areas of health psychology. In health promotion, cluster analysis has led to the selection of target groups most likely to benefit from specific health promotion campaigns, while also providing information about the types of beliefs or behaviour held by people in these groups, facilitating the development of relevant health promotion material (Abel, Plumddge, & Graham, 2002; Martin. Wyllie, & Casswell, 1992; Maschewsky-Schneider & Greiser, 1989; Wyllie & Casswell, 1993, 1997). In terms of health care development, health care systems need to evolve and develop to meel communities' changing needs while achieving 'best value'. Cluster analysis can assist by identifying groups of people that may benefit from specific services. For example, Hodges and Wotring (2000) used cluster analysis to group 4,758 young people referred to community mental health services in Michigan according to level of function

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in various domains, with the explicit aim of matching services to the specific needs of each group. The authors then developed an algorithm to enable newly-assessed patients to be allocated to the group expected to offer the most appropriate treatment. The major use of cluster analysis in health psychology has been to identify groups of people at risk of developing medical conditions (e.g. Houston, Babyak, Chesney, & Black, 1997; Shaffer, Graves, Swank, & Pearson, 1987) and at risk of poor outcomes (e.g. Brandwin, Trask, Schwartz, 8c Clifford, 2000; Buick, 1997; Chan, 2000; Chan, Lee, & Lieh-Mak, 2000). Identifying these high-risk groups again enables interventions to be developed and targeted appropriately, in a cost effective manner. For example. Weir et al. (2000) used cluster analysis to group hypertensive patients according to adherence to lifestyle change and medication. They identified four patient gn>ups in their sample and considered the type of interventions that might be best suited to each group in order to maximize blood pressure control. While the benefits of classification are clear, appropriate means of forming classifications are not. Although the techniques themselves are fairly simple, there are many methods and procedures from which to choose, with no guidelines to assist researchers in the selection process. In the absence of guidelines, researchers are likely to adopt the methods used by published researchers. As with any research, it is necessary to report the methodology clearly so that others could replicate the study. This is perhaps particularly important with cluster analyses where the potential for variation in methodology is so great. In a popular introductory cluster analysis book, Aldenderfer and Blashfield (1984) list five basic types of information that they believe should be reported following cluster analysis: < r

The computer program It is common practice to state the computer software used for any statistical analysis, and cluster analysis should be no exception. Blashfield (1977) found that given the same data set and the same method of cluster analysis, different computer packages produced different results. Further research is needed to ascertain whether these inconsistencies in computer programs remain today.

The similarity measure Clustering involves grouping people on the basis of their similarity on the chosen variables. There are many methods of assessing similarity, but two methods predominate; squared Euclidean distance and Pearson's correlation. The choice of similarity measure can have a profound impact on the cluster analysis resuhs, as it determines whether the classification is based solely on the pattern of people's scores on the variables of interest, or whether elevation of scores is also taken into account. In health psychology, it is common for the difference in elevation of scores to be considered important to ensure grouping like-minded individuals (e.g. to group people with high anxiety scores separately from people with low anxiety scores). Squared Euclidean distance would be used for this purpose. There are, however, occasions when elevation of scores is not important. Consider a researcher who wished to cluster people according to their response to an atixiety-reducing intervention. Anxiety levels could be assessed before and after the intervention, and people could be grouped according to the similarity in the pattern of their anxiety scores over time. This would enable identification of groups of people showing similar responses to the intervention

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Jane Oatworthy et ai.

(e.g. reduction in anxiety, increase in anxiety, no change), regardless of their actual anxiety scores. In this instance, a correlation coefficient would be used.
The duster method

Although many different methods of cluster analysis have been developed, the literature focuses almost exclusively on two types; hierarchical agglomerative methods and iterative partitioning methods. Hierarchical agglomerative cluster analysis involves a series of steps, whereby individual cases (people) begin as individual clusters and step-by-step the most similar clusters are joined together, eventually resulting in one cluster containing all cases. Each step is irreversible, so clusters joined at one step cannot be separated later in the clustering process. Hierarchical clustering procedures result in the same ntimber of cluster solutions as there are entities to cluster. Through examination ofthe computer output the researcher is required to decide on the most appropriate number of clusters to describe their data set. There are four main types of hierarchical agglomerative cluster analysis; single linkage (Florek, Lukaszewiez, Perkal, Steinhaus, & Zubrzchi, 1951; Sneath, 1957), complete linkage (Sokal & Michener, 1958), average linkage (Sokat & Michener, 1958) and Ward's method (Ward, 1963). Iterative partitioning methods (e.g. K-means cluster analysis) begin by dividing the entities into the required number of clusters, calculating the cluster centroids and relocating the entities to their nearest cluster centroid. The process of calculating the new cluster centroids and relocating entities continues until all the entities are closer to their own cluster centroid than any other and the solution is therefore stable. Iterative partitioning techniques difler from hierarcliical methods in two key ways. First, the number of clusters is specified by the researcher before the analysis takes place, and therefore otily one cluster solution is given. Second, cases can be moved from one cluster to another during the clustering process to optimize the cluster solution. Milligan (1980) suggested performing a hierarchical method first to determine the number of clusters and the cluster centroids, followed by a K-means cluster analysis to optimize the results.

The procedure used to detennine the number of clusters

When conducting a hierarchical cluster analysis, there will be as many cluster solutions as there are cases to be clustered. The researcher needs to make a decision about which cluster solution to use, using a selection of rules based on heuristics. These rules are sometimes known as 'stopping ailes' as they indicate when the process of clustering from A' to one cluster should be stopped. The most straightforward method of deciding on the number of clusters is to examine both the agglomeration schedule and the dendrogram, (part ofthe cluster analysis output). An inconsistent increase in the dissimilarity measure indicates that the clusters joined at that stage were quite distinct, and that the clustering process should be stopped at one stage prior. This method is fairly subjective since the researcher decides what constitutes an inconsistently large increase in the dissimilarity measure. Everitt (1993) warns that researchers' prior expectations could influence the decision. In an effort to make the decision more objective, formal rules and equations have been derived that can be applied to determine the number of clusters in a sample. Two that were found to perform particularly well in a review of such procedures (Milligan & Cooper, 1985) are the pseudo-/^ statistic (Calitiski & Harabasz, 1974) and the cubic

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clustering criterion (Sarle, 1983). These are not, however, uniformly available across different software packages.
Evidence for the validity of the clusters

The cluster analysis process will identify clusters in all data sets, even if the data are homogenous. As Breckenridge (2000) reported, cluster analysis can create as well as reveal structure' (p. 261). There is a need to show first that the clusters are stable, and second, that they are of value to the field of study. There are various methods of determining the stability of the clusters. The most common method is to randomly divide the study sample into two halves and repeat the cluster analysis on each. If the clusters are stable, a similar cluster structure should be found in each half of the sample. An alternative is to repeat the cluster analysis in a different sample drawn from the same population. Jolliffe. Jones, and Morgan (1982) used a process of removing a few variables and rerunning the analysis to see if the clusters were robust. Kos and Psenicka (2000) advocate repeating the cluster analysis with a different clustering method to see if they replicate the same findings, although this approach may be questionable given that the different methods were designed to cluster in different ways. Perhaps the best advice is from Ketchen and Hult (2000) who suggest employing multiple techniques to assess the stability of the clusters. Stability of the clusters is a necessary but not sufficient determinant of validity (Aldenderfer & Blashfield, 1984). The validation of the clusters must include some evidence of their value to thefieldof study, for example, by using inferential statistics to compare the groups on variables that were not included in the clustering process. In health psychology, the aim of the cluster analysis is often not simply to form a taxonomy, but to see if the groups identified are associated with an external variable (predictive validity). For example, Shaffer et al. (1987) grouped medical students on the basis of personality traits to see if the personality clusters would predict incidence of cancer. The provision of these five basic pieces of information might seem straightforward. Preliminary evidence, however, indicates that reporting may not be satisfactory. Blashfield (1980a) examined six cluster analysis articles published in the Joumal of Consulting and Clinical Psychology in 1979 to see how much of this information they provided. He found that two (33%) failed to report the cluster analytic method used, three (50%) failed to report the similarity measure, five (83%) failed to report the computer program, and four (66%) did not adequately describe the procedure used for determining the number of clusters. Not only did the study reveal the poor standards of reporting of cluster analysis, but it also gave insight into the types and appropriateness of methods used. For example, while all but one of the studies attempted to provide some evidence of the validity of the clusters, inadequate procedures for assessing validity were often selected. Punj and Stewart (1983) also encountered weak reporting of cluster analysis when conducting a review of clustering techniques in marketing research. They stated: 'The lack of detailed reporting suggests either an ignorance or a lack of concern for the important parameters of the clustering method used' (p. 136). The aim of this review is to use Aldenderfer and Blashfield's (1984) reporting criteria as a framework to describe and evaluate the reporting of cluster analysis in health psycholog)'. The review serves to identify the cluster analysis methods that are used in health psychology and to highlight any particular areas of weakness in conducting and reporting cluster analyses. '>

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Method

I*

In order to assess the reporting of cluster analysis in health psychology it was decided to conduct a systematic computer database search for peer reviewed health psychology journal articles reporting cluster analysis.
Journal selection

Health psychology is a broad discipline that shares common ground with many other fields (e.g, clinical psychology, occupational psychology, developmental psychology, medicine). Initially electronic databases were searched for any cluster analysis articles that could conceivably fall into the realm of health psychology, but it proved difficult to restrict the search to a manageable number of relevant abstracts. It was, therefore, decided to limit the review to cluster analysis articles published in key' health psychology journals. There were three stages to determining key health psychology journals. First an Ingenta publication search was conducted for any journals containing the words health andpsychology in the title (5 journals). Second, the ISI Joumal Citation Report was examined for any additional journals believed to be primarily health psychology journals with an impact rating >1 (15 journals). Finally, six health psychologists were independently presented with the list of possible journals and were asked to decide whether or not they believed each journal was a key health psychology journal. Wliere reviewers were unfamiliar with the journals they were provided with sample abstracts from the publications to aid their decision. With a majority consensus, 18 journals were selected, listed in Table 1.
Article selection

Articles were identified through electronic searches ofthe PsycINFO, Medline, CINAHL and ISI Web of Science databases. The chosen search terms consisted of the keyword cluster* in combination with each ofthe 18 journal titles (e.g. cluster* in Keyword AND British Journal of Health Psychology in Periodical). The searches were restricted to the period since Aldenderfer's and Blashfield's (1984) published recommendations (1984 2002). The number of articles retrievedfi-omeach database is presented in Table 1. In total, 278 articles were generated from tlie search.
Abstract review

Tliree psychology researchers reviewed all of the abstracts to assess whether they were (a) health psychology and (b) cluster analysis. Following an initial meeting to establish consensus over what 'health psychology' and 'cluster analysis' encompassed, the three psychoiogy researchers independently assessed the abstracts and recorded their decision on the two criteria on a proforma. Full articles were obtained when at least two of the reviewers considered both criteria met, or where it was unclear from the abstract whether the criteria had been met.
Data extraction

A data extraction sheet was compiled to reflect the research questions. The five necessary pieces of information as recommended by Aldenderfer and Blashfield (1984) were recorded (i.e. the computer program, the similarity' measure, the cluster method, the process for deciding on the number of clusters and evidence for the validity of the

Use ond reporting of duster analysis Table 1. Number of articles retrieved from each database for each journal

335

Journal American Journal of Health Promotion Annals of Behavioral Medicine Behavioral Medicine British Journal of Health Psychology Health Education and Behavior Health Promotion International Health Psychology Journal of Behavioral Medicine Journal of Health and Social Behavior Journal of Health Psychology Journal of Psychosomatic Research Psychology and Health Psychology, Health and Medicine Psychosomatic Medicine Psychosomatics Psychotherapy and Psychosomatics Social Science and Medicine Sociology of Health and Illness

No. ISI Web PsycINFO Medline of Science CINAHl. replications Total

2 5 4 4 4 0 1 0 7 3 0 0 0 0 0 5

5 5 2
4 4 IB 17

4
4 3 6 5 13 9 1 I

9 8
9 2

4
0

4
1 19 18 1 0 23 0 0 21 10 16 82 0

10
7 29

5 5 3 II
6 21 19 2 2 28 15 0 23 12 18

25
1

1 2 22
9

1
34 8 0 35 15 21

17
9 0

0
19 8 14 23 0

0
0

18
9 9 53 1

0
0

28 0

85 0
Total:

101 1 278

clusters) In addition, general information about the type of study was recorded (e.g. area of health psychology, research aims, types of variables used). One researcher performed the data extraction. Any ambiguous information was discussed with two independent researchers. Information from the data extraction sheets was entered into an SPSS 11 database for computing descriptive statistics.
Results

Of the 278 articles generated by the computer search, 31 were not considered to be health psychology papers, 119 did not use cluster analysis, and 57 were neither health psychology nor used cluster analysis. A further 12 cluster analysis papers were excluded as they used cluster analysis to group variables rather than people.' Brief descriptions of the remaining 59 articles included in the study are presented in Table 2.
How is cluster analysis being used in health psychology?

The 59 studies were divided into the three BPS Division of Health Psychology areas of health psychology research (BPS Division of Health Psychology, 2000). The majority of the studies (80%) fell into the broad category of 'prevention of illness and disability and enhancement of outcomes for those who are ill and disabled'. Three medical areas predominated; cardiac disorders/hypertension (27%), pain (12%) and cancer (12%).
'Although some authors use the term duster analysis in a broad sense to meon both the grouping of entities and variables (e.g. Tryon&c &ailey, 1970). it is more commonly used to mean just tbe grouping of entities (Blashfietd, 19B0b). This review is adopting the laaer, more popular, definition of cluster analysis.

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Ofthe 10 'promotion and maintenance of health' studies, four were concerned with general health promotion, two with alcohol consumption, one with diet, one with smoking, one with stress management and one with safe sex behaviour. The two studies that fell into the category 'analysis and improvement of the health care system and health policy formation' were both concerned with the roles of GPs. For some studies, the goal of the cluster analysis was clearly to advance theory by forming a taxonomy. For example, Wyllie and Casswell (1993) formed a taxonomy of male drinkers, with the hope of informing health promotion efforts in the future. Others used cluster analysis for practical purposes. For example, Griffiths (1999) performed a cluster analysis in order to draw a cluster sample for the main study, while Janman, Jones, Payne, and Rick (1988) chose to use cluster analysis as they had insufficient power to use ANOVA with the number of independent variables in their study By grouping the participants according to the numerous variables, they believed that their results would also be psychologically clearer' (p. 19). Many studies addressed both theoretical and practical issues. For example, Brandwin et al. (2000) formed a taxonomy of cardiac transplant candidates based on scores on personality measures, and then compared the groups on mortality All studies, whether as a specific goal or by default, formed a taxonomy. The variables used to form these taxonomies are listed in Table 2. Unfortunately it was not possible to judge the worth of the taxonomies as many of the cluster analyses were reported in insufficient detail for evaluation.
To what extent do the studies meet Atdenderfer and Blashfield's (1984) recommendations for reporting cluster analysis?

Details of the cluster analysis methodology reported are presented in Table 3Seventy-three percent of studies failed to meet all of Aldenderfer and Blashiield's criteria (see Fig, 1). The criteria least often met were reporting the similarity measure and computer program used.
The computer program

Almost half of the studies failed to report the program used. Of those that did report the software, SPSS was used more than twice as often as any other type of statistical software.
The similarity measure

Fifty-three percent of the studies foiled to report the similarity measure used. The remaining studies all reported using Euclidean distance or squared Euclidean distance.
The duster method

Four studies failed to report the cluster method. A further nine studies only broadly defined the clustering method as a type of hierarchical method. Hierarchical methods were used in 45 studies, whilst iterative partitioning techniques (K-means) were used in 32 studies (see Fig. 2). The most frequently reported hierarchical method was Ward's method, used in 24 studies. Fourteen studies used a hierarchical method followed by K-means, but only six of these appeared to have used the recommended technique of using the cluster centroids from the hierarchical clustering as the starting seeds for the K-means analysis (Milligan, 1980). Instead, the

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1. Computer software 2. Similarity measure 3. Cluster mettiod 4. Method of selecting no. clusters 5. Evidence of cluster validity Met all five criteria 0 10 20 30 40 50 60 70 80 90 100

Percentage of studies Figure I . The percentage of studies meeting each of Aldenderfer and Blashfietd's reporting criteria.

majoiity had only used the hierarchical cluster analysis to determine the number of clusters for the K-means analysis. Inconsistencies in cluster analysis terminology' were readily apparent. For example, six of the studies used the average linkage method but it was reported under four different najnes (average linkage, average linkage betweengroups, between-group average and unweighted pair-group method). Similarly, five researchers referred to K-means cluster analysis by the computer program s algorithm name (e.g. FASTCLUS, Quick Cluster), necessitating further investigation to decipher the actual method used,
TTie procedures used to determ}r)e the number of groups in the data

Ten studies (17%) did not report how the number of clusters was established. In addition, many studies selected questionable methods of determining the number of clusters. For example, eight studies chose cluster solutions that had sufficiently large numbers of people in each group, seven studies automatically chose the same number of clusters as found in previous similar research, and seven studies chose the cluster solution that facilitated interpretation. One study (Barsky & Wyshak. 1989) reported that the number of clusters was chosen 'arbitrarily' (p. 4l6). The most common method, however, was to look for an inconsistently large jump in the similarit)' measure between joined clusters (37% studies), either by examining the agglomeration schedule, the dendrogram or both. None of the authors provided the relevant section ofthe agglomeration schedule or dendrogram for the reader to assess. Eight studies used the more formal rules ofthe cubic clustering criterion and/or the F statistic. Again though, minimal information was provided, with no studies giving the actual cubic clustering criterion or f-statistic figures.
The validation procedures

Five studies failed to show any evidence of validating the cluster solution. Several studies made unsuccessful attempts to validate the cluster solution (e.g. attempting to repeat tht* cluster structure a few years later or to repeat the cluster structure in a different sample). Less than half of the studies addressed both the stability and external validity of the clusters (36%).

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In terms of cluster stability, 17 of the studies (29%) repeated the analysis is split halves of the sample or in a different sample drawn from the same population. Five smdies (8%) attempted to display stability- by finding consistent results across different hierarchical clustering methods, althougli, with the exception of Shapiro, Rodrigue, Boggs, and Robinson (1994), this was poorly reported (perhaps because there was limited overlap between the methtxis). In terms of validity, nine of the studies (15%) reported concurrent validity as the clusters were In line with the findings of previous research or expert opinion. Forty-nine of the studies (83%) used extemal variables to validate the cluster solution, either by comparing the groups on extemal variables (usually ANOVA) or predicting group membersliip from extemal variables (discriminant fLmction analysis), For many this was the primary goal of their investigation (e.g. to see if group membership could predict another variable) while for others the comparison was purely to validate the cluster structure. Of concem were the number of studies conducting ANOVA (17 studies) or discriminant function analysis (10 studies) using the variables that were used to form the clusters. Although these can give an indication of the relative contributions of the different variables to the cluster solution or the degree of separation of the clusters, the actual statistics are meaningless. The clusters have been purposely created to be as different as possible on the selected variables, hence it is unsurprising that ANOVA tests indicate significantly differences between the groups on those variables or that group membership can be predicted from the variable scores. Aldenderfer and Blashfield (1984) state,'. . .the perfonnance of these tests is useless at best and misleading at worst' (p. 6S). One of the few papers that gave a clear explanation of the limited value of tests was that of Mulry, Kalichman, Kelly Ostrow, and Heckman (1997), stating that, 'Significance tests on the variables used to create the clusters coukl not be used to validate the cluster solution; such analyses merely indicate whether (and how) clusters differ on each clustering variable' (p. 62). Most studies, however, gave no explanation of how the results of these tests should be interpreted, while some made ambiguous or incorrect statements about their value; for example, Kaluza (2000) wrote, 'ANOVAs indicated that the three clusters differed reliably in terms of mean scores for each coping scale' (p. 427).

Discussion
This study has revealed a need for improvement in the way cluster analysis is reported in health psychology publications. Using a strict interpretation of Aldenderfer and Hlashfield's (1984) five basic criteria, only 27% of the studies reported the cluster analyses in sufficient detail: 61%, however, met at least four of the criteria. Reporting the similarity measure used was the criterion least often met. Where it was stated, Euclidean distance and squared Euclidean distance were exclusively the measures of choice. One would expect Euclidean distance to be popular as psychologists are often interested in differences in elevation between people's score. A few studies, however, conducted cluster analysis on repeated measurements of variables over different time points (e.g. smoking frequency over 7 years, Soldz & Cui, 2002; anxiety and depression over 10 years, Arefjord, Hallarakeri, Havik, & Maeland, 1998; change in physical health over I year, Dewetal., 1998). In these situationsacorrelation measure of similarity, which focuses on the pattem of the variables (i.e. change over time), might have been useful. It is unclear whether Euclidean distance/squared Euclidean distance are consistently being selected because they arc indeed the most appropriate measures of similarity, because

Use ond report/ng of duster analysis

353

researchers look to what has been conducted in the past, or because they are the default setting for SPSS. Four studies failed to report the cluster analysis method, the most fundamental detail of the cluster analysis. Nine more studies only brcjadly defined the clustering method as a type of hierarchical method. Different hierarchical methods can produce profoundly different results (Romesburg, 1984) therefore it is essential that more detail is given if the study is to be replic-able. Amongst those who did speciiy the cluster method used, two methods dominated; K-means cluster analysis and Ward's method. It is not clear why these methods were used so much more than the others. Monte Carlo studies^ have generally found that they perform well (Milligan, 1981) but also report similar results for other methods (e.g. average linkage, complete linkage). Unfortunately, no single cluster analysis method can be recommended as Monte Carlo studies have generated confiicting results depending on the type of data used. Eurther research is needed to determine which method of cluster analysis is most appropriate for health psychology research. It was interesting, however, that Miiligan's (1980) recommendation of conducting a hierarchical cluster analysis to determine the number of clusters and appropriate starting seeds, followed by a K-meatis analysis to 'fine-tune' the results has so rarely been followed. Indeed, just six studies used this procedure, which is perhaps a reflection of the difficulty of obtaining such an analysis. The review has highlighted the lack of consistency in cluster analysis terminology used within health psychology, with the same cluster methods being reported under different names. There is a need to establish a standard terminology to avoid confusion. As reported by Punj and Stewart (1983), the problem lies not only in cluster analysis texts using different terms for the same methods, but also in computer programs developing their own names for methods (e.g. 'Quick Cluster' in SPSS and 'FASTCLUS' in SAS). It is important that researchers report the actual clustering method, not just the computer software's name, to enable comparison hetween studies and to facilitate replication. Although the majority of studies stated how the number of clusters had been determined (83%), the quality of this reporting was generally poor. Details of procedures used were usually reduced to simplistic statements (e.g. 'the number of clusters was determined by looking for a large increase in the similarity measure), with no description of the criteria used. No study included a dendrogram or section of the agglomeration schedule to support the decision. Similarly, none of the eiglit studies using the F-statistic or cubic clustering criterion reported the statistical values for these measures. It is luidear why researchers have not included such important information. It may simply be hecause they are following the lead of previous researchers or that publishers consider the intbmiation superfluous. This issue needs to be addressed: when reporting other statistical tests it would be unacceptable for researchers to state the overall finding but present no figures. In some studies, when the method for selecting the number of groups was stated, it was of questionable value. Forexample, eight studies chose the number of clusters on the basis of avoiding small groups. There is little point in continuing clustering until small distinct groups are merged with larger ones. The small groups may represent important groups of individuals with extreme beliefs that warrant attention. Altematively, they may be outliers that can be excluded from the atiaiysis. Fdelbrock (1979) has ai^ued tliat it is not essential to classify everybody in psychology. He suggests that an algorithm that classifies fewer people but does it accurately is more desirable that one that classifies

Carlo studies of cluster anaiysis involve generating artificial data sets with a known cluster structure and applying different methods of cluster anatysii to see which me^od recovers the predetermined cluster structure most accurately.

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Jane Clatworthy et al.

everybody' but makes misclassifications. It is acceptable to select, for example, a six cluster solution and then choose only to focus on the four largest groups if justification is given. Seven studies attempting to replicate a cluster structure found in previous research automatically selected the same number of clusters that were fc>uiid previously, without considering ifa more appropriate clustering solution existed in the data. This biases their results in favour of replicating previous finding. It would be more appropriate to independently select the number of clusters on the basis of one of the recommended stopping rules' and only then compare the findings with those found in previous research. Seven studies chose the number of clusters that allowed for the most meaningful explanation. With so many cluster solutions to choose from it is probable that some will be conducive to more desirable explanations than others. There is little point in conducting research if the results are to be biased in favour of researchers' expectations. It is essential that more objective methods of determining the number of clusters are used. While all but five studies reported some form of validation, less than half addressed both cluster stability and external validity. All cluster analyses will provide clusters, whether true groups exist in the data or not, therefore thorough validation is the most important part of the clu.ster analysis procedure. On a more positive note, most studies did validate the clusters against external variables and reported a wide range of applications of cluster analysis in health psychology. For example, to help identily predietore of anxiety and depression in the partners of those with myocardial infarction (Arefjord et al., 1998). to explore the relationship between dental fear and response to fear-reducing interventions (Litt. Kalinowski, & Shafer. 1999) and to explore the relationship between coping style and impact of rheumatoid arthritis (Newman, Fitzpatrick, Lamb, & Shipley, 1990). It is clear that cluster analysis has immense ptHential in health psychology as a means of addressing both theoretical and practical problems. The restriction of this review to key health psychology journals was a major but necessary limitation of this study. The review has certainly not identified all cluster analysis articles in the tield of health ps>'cho!og)' since 1984 because many articles would have been published in journals not included in the review. It will also undoubtedly have missed some cluster analysis articles published in the selected journals because the statistical methodology used is often not reported in the key words or abstract and therefore the term cluster might not have been detected in the electronic search. This review has, however, served to gain insight into the current use of cluster analysis in health ps7cholc>gy Although over half of the studies met four ofthe five reporting criteria, it is important to remember that unless all five criteria are met. a given study is not reported in sufficient detail for replication. Moreover, evaluation ofthe quality of a study may not be possible. This .study has not only identified some problems with the way duster analysis is reported but aiso potentially serious problems with the underlying methods used. There is a need for clear guidelines to assist health psychologists wishing to conduct cluster analysis, since the contradictory and bewildering literature may deter researchers from using what might be a valuable technique. Moreover, without such guidelines, a tautologous situation may arise whereby researchers try many different methods. If the theoretical and practical value of cluster analysis is to be realized, it is clear that a more principled approach to conducting and reporting these techniques is required.

Use and reporting of cluster analysis 355

Acknowledgements
We wish to thank Richard Jenkins for assistance with the journal selection and reviewing the abstracts. In addition we would like to thank Vanessa Cooper and Sue Hall for assistance with selecting the journals used in the review. Finally, thanks to the anonymous reviewers for their invaluable advice.
:
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