RESEARCH AND PRACTICE
When Intraclass Correlation Coefficients Go Awry:
A Case Study From a School-Based Smoking
Prevention Study in South Africa
Ken Resnicow, PhD, Nanhua Zhang, MS, Roger D. Vaughan, DrPH, Sasiragha Priscilla Reddy, PhD, Shamagonam James, PhD, and David M. Murray, PhD
It is common when one is conducting public
health interventions to randomize and then
intervene with intact social groups, such as
schools, churches, or worksites, rather than
individuals. Appropriate analysis of such group-
or cluster-randomized trials must account for
the statistical similarity of participants within
these larger units.1,2 Individuals within clusters
may enter the study with greater similarity than
individuals randomly selected from the general
population and they may also respond to an
intervention in a dependent manner. Failure to
account for either source of similarity violates the
basic premise of participant nonindependence
assumed in traditional statistical approaches
and can result in inflated type I error.1,2 Such
within-group similarity is typically captured by
the intraclass correlation coefficient (ICC).
The following metaphor may help concep-
tualize how an ICC can affect sample size. A
zero ICC occurs when 2 completely unrelated
individuals are randomly selected from the
general population. In this case, each person
contributes a full independent observation.
If, however, siblings from the same
household were selected, because of their
shared environment and genetics, depending
on the degree of similarity, this would result in
slightly less than 2 independent observations. If
nonidentical twins were selected, they would
contribute an even lower degree of indepen-
dent observation; identical twins, even less.
In the extreme case, if Siamese twins were
recruited, they would begin to approach the
contribution of a single individual. In most
cluster-randomized studies, the degree of non-
independence within a group is low, but its
impact on overall statistical power can still
be great because of the variance inflation
formulae used to adjust for the ICC.
If the ICC is known before conducting
a trial, sample size requirements can be
1714 | Research and Practice | Peer Reviewed | Resnicow et al.
Objectives. We conducted a group randomized trial of 2 South African school-
based smoking prevention programs and examined possible sources and
implications of why our actual intraclass correlation coefficients (ICCs) were
significantly higher than the ICC of 0.02 used to compute initial sample size
requirements.
Methods. Thirty-six South African high schools were randomly assigned to 1
of 3 experimental groups. On 3 occasions, students completed questionnaires
on tobacco and drug use attitudes and behaviors. We used mixed-effects models
to partition individual and school-level variance components, with and without
covariate adjustment.
Results. For 30-day smoking, unadjusted ICCs ranged from 0.12 to 0.17 across
the 3 time points. For lifetime smoking, ICCs ranged from 0.18 to 0.22; for other
drug use variables, 0.02 to 0.10; and for psychosocial variables, 0.09 to 0.23.
Covariate adjustment substantially reduced most ICCs.
Conclusions. The unadjusted ICCs we observed for smoking behaviors were
considerably higher than those previously reported. This effectively reduced our
sample size by a factor of 17. Future studies that anticipate significant cluster-
level racial homogeneity may consider using higher-value ICCs in sample-size
calculations to ensure adequate statistical power. (Am J Public Health. 2010;100:
1714–1718. doi:10.2105/AJPH.2009.160879)
adjusted upward to account for the reduction in predominantly in the range of 0.02 to 0.04,4
true sample size and statistical power, and our sample size was computed accordingly.
decreasing the chances of type II error. As However, when the study was completed and we
noted by Murray et al.,3 however, it is often examined the actual ICC it turned out to be
difficult to obtain a reliable ICC estimate that is significantly higher than we had anticipated. As
entirely applicable to one’s proposed study. a result, many of our outcomes that would have
Archival ICC estimates are often derived from been statistically significant with the ICC that was
samples, measures, contexts, or study designs originally projected turned out to be null. We felt
that differ from the one proposed, limiting their it would be useful to publish and explain these
utility. Whereas overestimation of the ICC can ICCs to assist other investigators.
lead to an overpowered study and, therefore,
inefficient use of resources, underestimation of METHODS
the ICC can lead to an underpowered study
(i.e., type II error). All public high schools in 2 of South Africa’s
We recently conducted a group randomized 9 provinces, KwaZulu-Natal and the Western
trial of 2 school-based smoking prevention Cape, were enumerated. Because of the sub-
programs designed for South African youths stantially higher smoking rates among ‘‘col-
from 2004 to 2008. In computing our a priori oured’’ youths,5 schools with predominantly
sample-size requirements, we used ICC esti- ‘‘coloured’’ students were oversampled. ‘‘Col-
mates drawn from published school-based oured’’ in South Africa denotes mixed race of
smoking prevention studies, all of which were Black and at least 1 other ethnic/racial ancestry.
conducted in the United States. Prior ICCs were These 2 provinces were selected because the
American Journal of Public Health | September 2010, Vol 100, No. 9

Western Cape has a much higher proportion of
‘‘coloured’’ residents, whereas KwaZulu-Natal
has a predominantly Black African population,
the largest ethnic group in South Africa.
We used data supplied by South Africa’s
National Department of Education to catego-
rize schools in these provinces by ethnic com-
position, size, and socioeconomic status (SES).
Schools were considered large if there were
more than 200 8th grade students enrolled
and otherwise they were classified as small.
Schools were then randomly selected within
each ethnicity, size, and SES stratum. The
target sample was 36 schools, or 12 per
experimental group. A total of 39 schools
were approached, of which 3 refused. The 36
public schools recruited from the 2 provinces
(18 per province) were then randomly assigned
to 1 of 3 experimental groups. Group 1 (com-
parison) schools (n =12) received the usual
tobacco and substance use education, which
involves little specific smoking prevention
programming. Group 2 schools (n =12)
received the South African version of the
‘‘Keep Left’’ harm minimization curriculum
beginning in 8th grade and continuing through
9th grade. Group 3 schools (n =12) received
the South African version of the ‘‘Life Skills
Training’’ curriculum beginning in 8th grade
and continuing through 9th grade.
The 2 curricula, each of which comprised 8
units per year for 2 years, were designed to be
taught by life orientation teachers. Life orien-
tation is a separate mandatory topic in South
African schools similar to health education in
the United States that includes student out-
comes for health behaviors and social skills
development. Additional details about the
study and the interventions used can be found
elsewhere.6
The participating schools had 175 eligible
8th grade classes. Classrooms were sampled
randomly from the pool of 175 until approxi-
mately 150 students per school were assessed.
To reach the 150 student quota per school, 123
(70%) classrooms were required. The 123
classes represented 59 unique life orientation
teachers.
Measures
Tobacco and other drug use. The primary
outcome for the intervention was past month
use of cigarettes, defined as any use in the past
September 2010, Vol 100, No. 9 | American Journal of Public Health
RESEARCH AND PRACTICE
30 days. This, as well as secondary outcomes of
lifetime cigarette use, frequent cigarette use
(more than 20 days per month), past-month
marijuana use, past-month binge drinking (de-
fined as consumption of 5 or more drinks
within a few hours), and an index of past-
month illicit drug use were assessed with a self-
report questionnaire adapted from prior
studies conducted in South Africa and else-
where.5,7,8 Each of these indicators was recoded
into a binary variable with 0 =nonuse and
1= use. Because of the low rates of hard or illicit
drug use, we created an aggregate index in-
dicating past month use of either cocaine or
crack, Mandrax (methaqualone), or ‘‘tik’’ (meth-
amphetamine). Use of any 1 of these substances
was coded as ‘‘1’’ for the illicit drug use index.
Psychosocial variables. We assessed per-
ceived harm of ever and regular use of tobacco,
marijuana, and alcohol by using a 3-point
scale with the following response categories
and coding: 1= no harm, 2 = slight harm, and
3 = great harm. The a in our sample for the
ever-use items was 0.73, and a for the regular-
use items was 0.88. Perceived refusal skills for 5
substances (cigarettes, alcohol, marijuana, co-
caine, and inhalable drugs) was assessed by
querying ‘‘Would you be able to say no if
someone tried to get you to use [insert sub-
stance name]?’’ Responses ranged from 1=
definitely would to 5 = definitely would not
(a = 0.97). We assessed attitude toward smok-
ing with a 10-item measure adapted from a
previous South African survey that tapped
positive expectancies of smoking. Sample items
include: smoking helps you cope with stress,
smoking helps you enjoy a party, and smoking
helps people feel more relaxed. Items were
answered on a 4-point scale ranging from 1=
strongly agree to 4 = strongly disagree
(a = 0.88).
Scannable questionnaires were administered
in the classroom by trained research assistants.
Student names were not included in the ques-
tionnaire. Each student was assigned a confi-
dential identifying number, which was pre-
written on his or her questionnaire. Teachers
were asked to vacate the room during the
questionnaire administration.
Assessment schedule. Students completed
questionnaires on 3 occasions: (1) baseline in
the beginning of 8th grade, (2) posttest 1 at the
end of 8th grade, and (3) posttest 2 at the end
Resnicow et al. | Peer Reviewed | Research and Practice | 1715
of 9th grade. For the 2 posttest assessments,
only individuals who were in the school at
the beginning of 8th grade and who had
completed the baseline evaluation were asked
to complete questionnaires.
Variance Components
For a mixed-effect analysis of variance in
group randomized trials, the total variance for
the dependent variable y is
ð1Þ r2y ¼ r2m þ r2g ;
where r2g reflects the a component of variance
attributable to the groups (which are nested in
condition), and r2m is the variance component
attributable to random variation of the mem-
bers within those groups.
The ICC is calculated as
r2g
ð2Þ ICCm:g ¼ ;
r2m þ r2g
where m:g reflects nesting of members within
groups. In our analysis, g represents the
schools, and m represents students within the
schools. To examine possible reduction in ICC
because of covariates, we used a mixed-effect
analysis of covariance. The ICC is then
calculated as
r2g  x
ð3Þ ICCm:g  x ¼ ;
r2m x þ r2g  x
where r2g  x is the variance component
attributable to the groups adjusting for other
covariates, and r2m x is the variance attributable
to individuals adjusting for covariates.
Covariates in our model included treatment
condition, age, race, gender, urbanicity, pocket
money, and family income.
We estimated variance components by using
SAS version 9.1 PROC MIXED or the SAS
GLIMMIX macro (SAS Institute Inc, Cary, NC),
depending on the variable distribution. For
continuous variables with an assumed Gauss-
ian distribution (e.g., attitude and efficacy
measures) MIXED, which implements the gen-
eral linear mixed model, was used. For binary
variables (i.e., all substance use variables), we
used GLIMMIX specifying a logit link and
binomial error. The GLIMMIX macro itera-
tively calls the MIXED procedure until it
converges on a solution for the fixed effects
and random effects. MIXED and GLIMMIX
provide estimates of the variance attributable
 RESEARCH AND PRACTICE

to school and to residual error; estimates from

GLIMMIX were transformed back to their TABLE 1—Intraclass Correlation Coefficients (ICCs) of Behavioral and Cognitive Measures of
Adolescent Smoking and Drug Use: KwaZulu-Natal and Western Cape, South Africa 2004–2008.
original scale via the inverse link func-
tion.1(p239,240) Although other approaches to Model 2 Versus Model 1,
computing ICCs for binary variables have been Variables Model 1, Raw ICCa Model 2, Adjusted ICCb % ICC Change
proposed,9 by using the above method our
Smoking
results will be more comparable with prior
Lifetime smoking
studies. The ICC estimates are provided both
Baseline 0.198 0.094 –52.5
with (model 2) and without (model 1) covariate
Posttest 1 0.179 0.065 –63.8
adjustment. We compared the improvement of
Posttest 2 0.217 0.064 –70.4
model 2 versus model 1 as a percentage change in
Past 30-day smoking
ð4Þ ICC ¼ ðmodel 2  model 1Þ=model 1 · 100: Baseline 0.123 0.070 –43.2
Posttest 1 0.118 0.051 –56.9
Posttest 2 0.168 0.028 –83.5
RESULTS
Frequent smokingc
Baseline 0.089 0.046 –48.8
A total of 5266 8th grade students com-
Posttest 1 0.087 0.035 –60.0
pleted the baseline survey. According to the
Posttest 2 0.095 0.036 –62.4
school rosters provided, there were 5685
Other drug use
eligible 8th grade students, which equates to
30-day marijuana use
a response rate of 93%. Of these, 4684 (89%)
Baseline 0.049 0.053 9.5
completed at least 1 of the 2 posttest assess-
Posttest 1 0.045 0.035 –22.7
ments. The sample was 51% male, with a mean
Posttest 2 0.095 0.045 –52.5
age of 14.1 years. Approximately 58% of the
30-day binge drinking
sample was Black, 28% were ‘‘coloured,’’ and
Baseline 0.024 0.018 –25.3
14% were White or other. Thirty-day smoking
Posttest 1 0.022 0.012 –45.0
rates at baseline, 1-year follow-up, and 2-year
Posttest 2 0.035 0.022 –36.5
follow-up were 18%, 20%, and 21%, respec-
30-day illicit drug use
tively. Rates by race at baseline were 10%,
Baseline 0.041 0.045 11.0
35%, and 12% for Black, ‘‘coloured,’’ and
Posttest 1 0.029 0.027 –6.9
White or other youths, respectively.
Posttest 2 0.047 0.040 –15.3
As shown in Table 1, for 30-day smoking,
Cognitive variables
the primary outcome for the study, unadjusted
Drug refusal efficacy
ICCs ranged from 0.12 to 0.17 across the 3 time
Baseline 0.128 0.111 –13.0
points. For lifetime smoking, ICCs were in the
Posttest 1 0.113 0.098 –13.3
range of 0.18 to 0.22, whereas for heavy
Posttest 2 0.178 0.172 –2.9
smoking the ICC was consistently around 0.09.
Perceived harm of ever used
After adjustment for covariates, the ICCs for
Baseline 0.181 0.167 –7.8
the 3 smoking variables dropped on average
Posttest 1 0.171 0.088 –48.3
60% (range = –43% to –84%).
Posttest 2 0.201 0.093 –53.7
For 30-day marijuana use, ICC values were
Perceived harm of regular used
in the range of 0.05 to 0.095. For binge
Baseline 0.230 0.202 –12.1
drinking, ICC values were between 0.02 and
Posttest 1 0.090 0.078 –14.1
0.04, and for past month illicit drug use, values
Posttest 2 0.121 0.091 –24.9
ranged from 0.03 to 0.05. After adjustment
Smoking beliefs
for covariates, the average ICC for other drug
Baseline 0.060 0.056 –6.5
use variables declined on average 20%
Posttest 1 0.058 0.040 –29.7
(range =11 to –53%).
Posttest 2 0.075 0.050 –33.6
For perceived harm of ever and regular
substance use, ICC values ranged from 0.17 to Notes. Baseline was the beginning of 8th grade; posttest 1 was at the end of 8th grade; and posttest 2 was at the end of 9th grade.
a
0.20 and 0.09 to 0.23, respectively, across the Model 1 includes school only.
b
Model 2 is adjusted for treatment condition, age, gender, race, urbanicity, pocket money, and family income.
3 time points. For drug resistance efficacy, c
At least 20 days in the past month.
d
values ranged from 0.11 to 0.l8. For the Use of tobacco, marijuana, and alcohol, each assessed separately then combined into aggregate scale.

1716 | Research and Practice | Peer Reviewed | Resnicow et al. American Journal of Public Health | September 2010, Vol 100, No. 9

substance use belief scale, values ranged from
0.06 to 0.07. After adjustment for covariates,
the average ICC of the cognitive variables
declined by 22%.
DISCUSSION
The unadjusted ICCs observed in this project
for smoking behaviors were considerably
higher than those previously reported in US
school-based studies. Typically, school-level
ICCs for smoking, alcohol, diet, and physical
activity behaviors have consistently ranged
from 0.01 to 0.04,3,10–16 although in 1 study,
for a subsample of 11th and 12th graders, an
ICC of around 0.10 was reported for weekly
smoking.10 The covariate-adjusted ICCs for
smoking behaviors in our study, though sub-
stantially reduced, were also considerably higher
than those typically reported in US school-based
studies.
Both the adjusted and unadjusted ICCs
observed in this project for drug use behaviors
other than smoking were slightly higher but
generally close to the values reported previ-
ously in US school-based studies.14 The ICCs for
smoking variables have been reported to be
higher than those of other behaviors.10
The unadjusted and adjusted ICCs for cogni-
tive variables were somewhat higher than those
previously reported.11,14 The ICCs for cognitive
variables within our study were much higher
than the ICCs observed for our behavioral vari-
ables. This pattern is consistent with the existing
literature because ICCs tend to be highest for
knowledge, attitudes, and beliefs; lower for be-
haviors; and lowest for physiological measures.4,11
To determine whether the ICCs we observed
might have been anomalous to our sample, we
computed ICCs from another South African
school-based survey, the 2002 South African
National Youth Risk Behavior Survey (YRBS),8,17
a nationally representative study of South Afri-
can youths in grades 8 through 11. Self-adminis-
tered questionnaires covering a broad range of
risk behaviors were obtained from 10 699 stu-
dents in 188 schools. Additional details of the
study can be found elsewhere.8,17 From these
data, we computed school-level ICCs for several
behaviors that were also assessed in our study.
Similar survey items were used across the 2
studies. For 30-day smoking, the ICC in the
YRBS was 0.08; for 30-day alcohol, 0.09; for
September 2010, Vol 100, No. 9 | American Journal of Public Health
RESEARCH AND PRACTICE
lifetime cocaine or heroin use, 0.09; and for 30-
day marijuana, 0.03. With the exception of
marijuana, the ICCs were again higher than prior
studies, suggesting that our findings may be
robust with regard to South African high-school
substance use behaviors. However, the YRBS
sampling framework entailed approximately 13%
of eligible classrooms as compared with 70% in
the current study. Sampling fewer classrooms per
school tends to yield higher ICCs, so the higher
ICCs in YRBS are perhaps less unexpected than
those observed for our current study.
The cause of the higher ICCs in our study
merits explication. A likely contributing factor is
the relative ethnic homogeneity of South African
schools; 24 of our schools comprised at least
70% of students from 1 racial group, and race in
South Africa is strongly associated with substance
use.5,7,18,19 This is in part because of unique
cultural attitudes among Black Africans about
smoking and drug use, and socioeconomic dis-
parities that exist in South African society. Race
was included as a covariate in the multivariable
model, which led to a significant reduction in the
ICC. Prior ICC estimates were derived from US
studies. Although most US studies comprised
predominantly White populations, in 2 US stud-
ies African Americans tended to have equal or
even lower ICCs than Whites.11,13
Because our ICCs were generally as high
at baseline as they were at 1-year and 2-year
follow up, it appears the school-level homo-
geneity driving the ICCs was present at
randomization rather than an artifact of post-
randomization effects such as variable teacher
implementation, differential drop out, or com-
mon intervention response. Plus, intervention
group was included as a covariate. Thus, it
does not appear that the intervention gener-
ated the ICCs.
The impact of these ICCs in our study was
severe. When we assumed approximately 100
students per school and used the standard
design effect formula,20 our ICC effectively
reduced our sample size by a factor of 17 for 30-
day smoking outcomes and even moreso for
psychosocial outcomes. In other words, for sig-
nificance testing the ICC-adjusted sample size
was essentially one seventeenth of or smaller
than the sample size actually measured. The
study could then be considered a case of possible
type II error. We had assumed in our sample size
calculations an ICC of around 0.02.
Resnicow et al. | Peer Reviewed | Research and Practice | 1717
Alternatively, the study was powered to
detect a between-group difference in 30-day
smoking of 6% to 7%, which we did not attain.
Nonetheless, if clustering is ignored and the
data are analyzed on the individual level, some
of our behavioral effects and almost all psy-
chosocial effects would have been significantly
different for either or both of the intervention
groups versus the control group.
Our findings suggest that when one is
projecting sample size needs for cluster ran-
domized studies, either observational or in-
tervention, empirical ICCs derived from the
actual target population may be required.
Extrapolation of ICCs from other studies, par-
ticularly in which the social context may differ,
can lead to substantially inaccurate sample size
estimates. Future studies that anticipate signif-
icant cluster-level racial homogeneity for out-
comes that are race-dependent may consider
using higher value ICCs in sample size calcu-
lations to ensure adequate statistical power.
This may also be the case for other socio-
demographic variables. And as recommended
by Murray et al.12,13,14,21 and substantiated by
our findings, inclusion of covariates that might
drive the ICC in outcome analyses can minimize
the ICC’s impact on power. j
About the Authors
Ken Resnicow and Nanhua Zhang are with the University
of Michigan School of Public Health, Ann Arbor. Roger
D. Vaughan is with the Department of Biostatistics,
Columbia University, New York, NY. Sasiragha Priscilla
Reddy and Shamagonam James are with the Medical
Research Council of South Africa, Cape Town. David
M. Murray is with the Division of Epidemiology, College
of Public Health, Ohio State University, Columbus.
Correspondence should be sent to Ken Resnicow, PhD,
University of Michigan, School of Public Health, 109
Observatory (SPHI), Ann Arbor, MI 48109-2029 (e-mail:
kresnic@umich.edu). Reprints can be ordered at
http://www.ajph.org by clicking the ‘‘Reprints/Eprints’’ link.
This article was accepted on August 15, 2009.
Contributors
K. Resnicow, S. P. Reddy, and S. James were responsible
for the design of the study, collection and analysis of
data, and preparation of the article. N. Zhang, R. D.
Vaughan, and D. M. Murray were responsible for
designing the statistical analysis plan, interpreting data,
and preparing the article.
Acknowledgments
Sole funding for the project was provided by the National
Institutes of Health Fogarty International Center to K.
Resnicow (grant TW005977).
 RESEARCH AND PRACTICE

Human Participant Protection 15. Murray DM, Stevens J, Hannan PJ, et al. School-level
Active written consent was obtained from parents. This intraclass correlation for physical activity in sixth grade
study was approved by the institutional review board or girls. Med Sci Sports Exerc. 2006;38(5):926–936.
ethics committee of the University of Michigan and the 16. Murray DM, Phillips GA, Bimbaum AS, Lytle LA.
Medical Research Council of South Africa Intraclass correlation for measures from a middle school
nutrition intervention study: estimates, correlates, and
applications. Health Educ Behav. 2001;28(6):666–679.
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