HEALTH EDUCATION RESEARCH

Theory & Practice

Vol.6 no.2 1991
Pages 163-171
Conceptual models for health education research and
practice
Jo Anne Earp and Susan T.Ennett
Abstract Introduction
Although conceptual models are frequently used
to illustrate research questions under investiga-
tion, there is a paucity of articles about how to
develop conceptual models or their importance to
health education research and practice. A number
of uses of the term model exist. Therefore, we
describe a conceptual model developed to guide
health education research or practice as a diagram
of proposed causal linkages among a set of
concepts believed to be related to a specific public
health problem. Although informed by the
multicausal models of public health, the concep-
tual models we describe differ from those models
in that they do not incorporate all factors
correlated with an endpoint of interest. Rather
they show only the small part of the causal web
selected for study. Conceptual models differ from
theory in that they are not usually concerned with
global classes of behavior but with specific types
of behavior in specific contexts. They often are
informed by more than one theory, as well as by
empirical findings. Because of the usefulness of
conceptual models in narrowing both research
questions and the targets of intervention, we
advocate the inclusion of the model development
process in public health education research
methods courses.
Department of Health Behavior and Health Education,
School of Public Health, University of North Carolina at
Chapel Hill, Chapel Hill, NC 27599, USA
Over the span of several years, during the annual
process of preparing to teach a basic research
methods course in public health education, the
paucity of articles on why, when and how to
construct conceptual models became all too apparent.
It was not that we lacked examples of such heuristic
devices; historically many articles, some of them
classics in the health services and medical care
research fields, have included conceptual diagrams
of research questions. Social science-minded health
educators usually insist upon the inclusion of such
models in their own, their students and, as reviewers,
their colleagues' research proposals.
Yet we searched the literature in vain for any
article that defined, in simple, public health-relevant
terms, what a conceptual model is, how it differs
from a theory, why it is particularly relevant to public
health and how to go about developing one.
Therefore, each year we decided, once again, to
assign Daniel Horn's (1976) paper, "A Model for
the Study of Public Choice Health Behavior", even
as it was supplanted by newer, perhaps more rele-
vant (although not more elegant) models for
explaining or predicting health behavior (Prochaska
and DiClemente, 1982) or for planning and
implementing health education interventions (Green
et at., 1980). Although not answering specifically
the above questions, the Horn article still did the most
thorough job of illustrating what a model is and
discussing its public health origins.
Using the Horn article and handouts of models
going back almost 25 years to Suchman's (1965)
framework for health behavior, Graham and
Reeder's (1972) "Social Factors in Chronic
Oxford University Press 163

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J.A.Earp and S.T.Ennett
Diseases", which organized the multiple deter-
minants of cancer of the scrotum by levels of
causality, through Anderson et al.'s (1970) model
for medical care and Rosenstock's (1974) health
belief model, we certainly did not lack examples.
However, neither Horn's model nor the handouts
were specific enough to allow students to walk away
from the course able to design their own conceptual
models or even, more basically, to understand why
using a model helped them as both researchers and
practitioners. Hence, we decided to write such an
article ourselves. In it, we discuss how we define
a conceptual model, why we believe conceptual
models are particularly appropriate to public health,
how they aid in planning research or interventions,
how to develop a useful conceptual model, some
barriers to their acceptance and use, and recommen-
dations for learning how to work with conceptual
models.
Definition
Before we describe how to define the term concep-
tual model, we should note that the term model has
many different uses and meanings. Included among
these are: a conceptual framework for organizing and
integrating information; a diagrammatic system of
measurement (i.e. mathematical and statistical
models); and a conceptual structure successfully
developed in one field and applied to some other field
to guide research and practice (i.e. an analogy)
(Marx, 1976). Also, the term model often is used
interchangeably with the term theory or is used to
mean the visual representation of the elements of a
theory.
Our working definition of conceptual model
derives primarily from the first usage. We define a
conceptual model as a diagram of proposed causal
linkages among a set of concepts believed to be
related to a particular public health problem. By
concept (also referred to as a factor or variable), we
mean an abstract term able to be empirically observed
or measured. Hence, a conceptual model, through
concepts denoted by boxes and processes delineated
by arrows, provides a visual picture that represents
a research question under investigation or the present
focus of a specific intervention effort. A conceptual
model can be informed by more than one theory and
conceptualized at multilevels (from micro to macro).
As importantly in an applied field, it allows the inclu-
sion of processes or characteristics not grounded in
formal theory, but that represent empirical findings
or the experience of practicing professionals.
As an example, we use a simple model of
compliance that we have used in class (Figure 1).
The concepts in this model are the communication
between a physician and patient, the patient's
understanding of a treatment and the patient's
compliance with a medical regimen. The arrows, by
their directionality, indicate that the communication
between a doctor and patient influences the patient's
understanding of some recommended treatment
which, in turn, influences the patient's compliance.
It is clear from the model that physicianpatient
communication is the predictor variable, or the
'cause', and that compliance is the dependent
variable, or the 'outcome'. As the model is concep-
tualized, the patient's understanding of the regimen
is a mediating variable (i.e. an intervening,
explanatory variable or process between the predictor
variable and the outcome).
Of course, as students are quick to point out, this
is an incomplete and unrealistic model. There are
other factors certain to affect compliance either
directly or indirectly. For example, the degree of
difficulty for the patient in carrying out the regimen,
whether cost is covered by medical insurance, or
particular characteristics of the condition, such as
whether it is symptomless, could affect compliance.
Also, compliance could be affected by factors that
Physician-Patient
Communication
Fig. 1. Simple three-variable conceptual model.
Patient
Understanding
of Regimen
Compliance
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Conceptual models
influence physician-patient communication. For
example, does educational level of the patient or
whether the doctor and patient are of the same gender
affect communication and, in turn, compliance?
Clearly, the model becomes more complex as
variables are added that the investigator feels are
needed to account for the outcome (Figure 2).
Models and the ecological perspective
As health educators we believe an ecological perspec-
tive is needed for understanding and explaining
health-related behaviors. This perspective implies
that behavior results from the interaction of both
Physician &
Patient Gcnden
Physician-Patient
Communication
individual and environmental determinants (McLeroy
et al., 1987). Indeed, virtually any health behavior,
be it patient compliance, smoking, AIDS-related or
any of many others, results from a multitude of
factors arising from biological, psychological, social,
cultural and structural spheres. Thus, in planning
research and intervention efforts, we need to consider
not only individual, microlevel factors, but influen-
tial environmental and social forces that act, in
concert, on individuals who are part of groups.
Health education models frequently reflect this
perspective by including factors at multiple levels of
influence.
The ecological perspective of health education is
Patient
Understanding
of Regimen
Compliance
Fig. 2. Five-vanable conceptual model showing modifying
and confounding variables.
Epidemiologlcal Model
Complexity
of
Regimen
Ecological Model
AGENT
ENVIRONMENT HOST
Fig. 3. MulticausaJ models of public health (from Susser.
1973).
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J.A.Earp and S.T.Ennett
mirrored by the classic public health
agent host environment model and, more
currently, in multicausal models (Figure 3), which
de-emphasize the agent but elaborate on environment
as a web of reciprocal relationships among factors
(MacMahon and Pugh, 1970; Susser, 1973). Yet
these models, while informing how we conceptualize
health problems, are not to be taken as literal
examples of the conceptual models we are advocating
for application to health education research and prac-
tice. Multicausal models of public health illuminate
the complexity of health problems and help our
understanding of the dynamic inter-relationships that
sustain disease, but they pose a dilemma for construc-
ting models that apply to health education research
and practice. With multicausal models it is often
difficult to sort out relationships, much less direc-
tionality or causation. Indeed, that is not their point.
Rather, their purpose is to call attention to the play
of factors at multiple levels, the inevitable interac-
tion among correlates and the fact that such concep-
tions stand in contrast to germ theory or medical
models of causation with their usual unidirectional,
univariate agents of disease causality (Cassel, 1964).
For behavioral-science-trained health educators,
conceptual models must be, at once, both conceived
within the broadly based framework of multicausal
models and more specifically defined when applied
to the explication or solution of problems of interest.
In constructing conceptual models for health educa-
tion research and practice, we must be attentive to
the multiple determinants of health behaviors and the
complex inter-relationships among factors; at the
same time we also must be willing to fix an
'endpoint' or outcome of interest and move back-
wards from it to selected determinants, ruling out
others. Our point is to cut into the multiple levels
and myriad possible determinants, to show only a
small part of the causal chain rather than to depict
the entire causal process. This contrasts with
indeed, it may seem to contradictthe point of
reciprocal interactions that multicausal models show.
It means we have to limit our scope and fix our focus,
even while being aware of the larger causal web
surrounding our particular research question or
intervention effort. Our conceptual models will
almost certainly not incorporate all the factors that
relate to our endpoint, but will show the relation-
ships for only that small part of the causal web we
have selected for study or have targeted for change.
The relationship between
models and theories
Although the term model is often used loosely to
mean theory, conceptual models and theories are not
the same. Theories consist of one or more general
and logically inter-related propositions offered to
explain a class of phenomena (Bauman, 1980). They
are usually concerned with very general and global
classes of behavior and do not deal directly, as
conceptual models do, with specific types of behavior
in specific contexts. Also, theories generally repre-
sent reality from a discipline-specific perspective, be
that sociological, economic or biological. Because
they are discipline-specific, theories often specify
level-specific causes.
Our concerns in health education virtually dictate
that we cannot apply or test only one theory from
one discipline, nor can we delimit the levels of
causalityhence the usefulness of conceptual
models. In developing conceptual models, we often
draw on a number of theories for help in understand-
ing a specific problem in a particular setting or
context. Furthermore, we draw on empirical findings
and on the knowledge we may have about the specific
topic and context under consideration. Although the
domain of interest of our conceptual models is usually
narrower than that of theories, it is important to note
that models have several similar functions to theories.
Conceptual models are useful for summarizing and
integrating the knowledge we have, defining
concepts, providing explanations for causal linkages
and generating hypodieses.
An important role of theory in model development
is guidance on narrowing the concepts to include in
the model and for help in understanding and predic-
ting relationships. A recent investigation, for
example, of parental influences on adolescent
smoking (Foshee, 1989) was informed by both social
control theory (Hirschi, 1969) and social learning
theory (Bandura, 1971). Social control theory states
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Conceptual models
that the more adolescents are attached to family and
friends, committed to conventional activities, and
believe in the conventional rules of society, the less
likely they are to deviate from conventional behavior.
The behavior of significant others, either family or
friends, is not included in control theory but has been
consistently found to be a strong predictor of adoles-
cent smoking behavior. Social learning theory,
however, states that parents and peers influence
adolescent behavior by providing models to imitate
and by expressing favorable or unfavorable attitudes
toward the behavior. Hence, a new model for predic-
ting adolescent cigarette smoking was proposed that
incorporated processes of both theories (Figure 4).
This example demonstrates the utility of using
theory to provide guidance on the choice of concepts
for investigation and for specifying the relationships
to be expected. It also demonstrates that a single
theory is usually insufficient to incorporate all
variables of interest to conceptual models in health
education. Expecting this to be so, model builders
should be open to using several theories as well as
past research findings. Model building then becomes
a process of invention, subject to modification as new
findings emerge that confirm or redirect how
problems are conceptualized.
Use of models
Susser (1973) describes several uses of public health
models pertinent to our discussion, including
representational, organizing and explanatory func-
tions. As health educators, we also include their
usefulness in planning interventions. The represen-
tational function of models is to present, in a
simplified form, relationships believed to exist. Part
and parcel of conceptual models' representational
function is their usefulness as organizing tools.
According to Susser, they "organize and synthesize
a complex of related factors into coherent forms"
(1973, p. 33). The best models parsimoniously
convey complex information, allowing the viewer to
quickly visualize and grasp complicated relationships.
At their most practical level conceptual models help
to narrow global research topics into specific research
questions, designate variables to be operationalized
under particular conditions and anticipate analytical
approaches before the sample is chosen or the data
collected.
As conceptual models are developed, they serve
an important function in making explicit alternative
routes to the same endpoint. When we construct
models, we inevitably struggle with including some
Commitment
to
Conventional Activities
Belief in
Conventional Rules
of
Society
Fig. 4. Conceptual model incorporating processes from social control theory and social learning theory (Foshee, 1989).
167

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J.A.Earp and S.T.Ennett
concepts and excluding others, and with posing
different relationships between concepts. Some of
diese may be valid alternatives to those selected for
study or intervention. By using models to reason
through alternative explanations before implemen-
ting our research, we have the opportunity to gather
data needed to control confounding factors or to test
these alternative pathways. At the least, we become
aware of potential influences beyond the specific
factors under study.
Finally, conceptual models are extremely useful
for helping identify potential targets of intervention.
Aldiough a model does ot tell us how to intervene,
it does make clear where intervention efforts can be
aimed. The more comprehensive the model, the
greater the number of points and levels of interven-
tion suggested. Depending on where efforts are
focused, we can look at die linkages shown in our
model and speculate on the intervention's effects on
these relationships.
Developing a conceptual model
Using an existing model as a starting point and/or
beginning with a comprehensive inventory of risk
factors, the researcher or intervention planner begins
developing a conceptual model by specifying an
endpoint of interestthe dependent variable,
outcome or target point of intervention. Smoking
initiation, for example, is a different endpoint from
persistent smoking behavior, attitudes toward
smoking or smoking cessation. The model builder
may change or move the endpoint, as the concep-
tual model is fleshed out, to be more proximal to
the predictors selected or more practical. Even
though the endpoint might change, however, the
model development process cannot really start until
some outcome is selected.
Having chosen the endpoint of interest, the model
builder begins by selecting potential correlates and
proceeds by sorting out at least initial relationships
among those concepts. Linkages among concepts are
drawn, based on empirical and theoretical evidence,
as well as on the knowledge one may have about the
specific topic under consideration. Causal explana-
tions are made explicit by the directionality of arrows
connecting concepts. It is at this point that the model
builder usually must begin to pare down a probably-
too-global, too unwieldy, set of concepts to those
particular aspects of the problem that he or she
decides can be realistically addressed in this research
effort or intervention strategy. The choice will be
affected by many considerations: interest, practical
considerations, the relative importance of various
factors or relationships, past research and scientific
merit, and theoretical considerations.
The process of narrowing the concepts in the
model is one of die most difficult steps in its develop-
ment. The investigator is usually forced to accept that
there are alternative routes to the endpoint of interest
or complementary causal pathways to the one(s)
selected for focus. This process of reasoning through
what is important and what to leave in or take out
of the model should make clear to the investigator
or practitioner exactly what is not being investigated.
As noted earlier, this knowledge can be useful in
planning what additional information to gather or for
later suggesting explanations for unanticipated
intervention effects or contradictory research
findings.
The simplicity of die final product usually belies
the difficult work that goes into it. As we hope is
obvious, the process of developing a conceptual
model requires clear understanding of what is being
considered, for the model explicitly lays out concepts
of interest and anticipated relationships even as it
deliberately omits other factors and pathways.
Although the analysis and thought behind concep-
tual models are rarely simple, the conventions for
drawing them are. For models constructed for
research purposes, only concepts that will be opera-
tionally defined and measured are included in the
final model; all other concepts not direcdy considered
are excluded. For models that guide intervention, all
factors targeted by the intervention or expected to
be influenced by it are shown. Because of the usually
greater diversity and number of levels involved,
intervention models often will be more complicated
than diose drawn for research purposes.
Conceptual models generally are read from left to
right or up to down, going from causes to effects.
The direction of causality is indicated with arrows.
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Conceptual models
Antecedent or mediating variables are indicated by
their placement next to other variables. Confounding
variables, variables that affect the dependent variable
and vary with a predictor variable, are shown by a
line or double-headed arrow (if the direction of
causality is not known) drawn from the confounder
to both the dependent and predictor variables. A
variable thought to modify the relationship between
two variables is indicated by an arrow drawn to the
midpoint of the line connecting the two related
variables (Figure 5).
Labels of concepts or variables included in the
model should be succinct; neither operational defini-
tions nor the values of variables are shown. For
example, a model could show that 'peer smoking
behavior' is related to 'adolescent smoking initiation',
but the hypothesis that having more than two
smoking friends is related to earlier smoking initia-
tion, while having two or fewer smoking friends is
not, should not be indicated (Figure 6). Hypotheses
are stated in the text accompanying models, as are
the values of all variables shown in the model.
It can be helpful to remember that constructing a
conceptual model is as much an art as a science.
Antecedent
Variable
Predictor
Variable
Predictor
Variable
Mediating
Variable
Confounding
Variable
Dependent
Variable
Dependent
Variable
Predictor
Variable
Dependent
- Variable
Modifying
Variable
Predictor
Variable
Dependent
Variable
Fig. 5. Types of relationships between variables in conceptual
models.
Making the model visually pleasing helps in making
it readable and understandable. Boxes drawn around
concepts make the model easy to interpret, as do
boldface type, different type fonts and other computer
graphic features. Usually, several attempts are
needed to arrive at a pleasing and meaningful model.
It is probably no coincidence that where the model
builder stumbles in this process is often a good clue
to where conceptual clarity is lacking.
Barriers to developing and using models
We have already alluded to the biggest barrier in
developing conceptual models: clarity and rigor of
thinking are required. Explicating the mechanisms
of action of a set of concepts is very difficult. It
involves learning to 'think small' and learning how
small is small, giving up many favorite concepts to
narrow the scope, and choosing a realistic endpoint
that is still conceptually interesting and defensible.
The outcome first chosen, until one learns from
experience, is usually too gross. For many people,
the initial feedback about this outcome, or other
typical problems encountered in constructing a
model, may not be accompanied by suggested alter-
natives. Without such suggestions, it can be difficult
to make refinements on one's own.
Many health educators are uncomfortable with
developing and using conceptual models because
their exposure to them and experience using them
are limited. When models are taught, the process is
too often truncated at the intellectual level. Students
rarely have the 'hands on' learning experience of
developing and refining a model after being exposed
to a classroom lecture on the model development
process. To our knowledge, no published collection
of public health or health education models exists for
instructors to use with students.
Furthermore, guidelines that point to what is left
out of a model are non-existent. Many people use
the agenthostenvironment or multicausal models
such as PRECEDE (Green et al., 1980) as starting
points for conceptualizing health problems.
However, as McLeroy et al. (1987) note, multicausal
models lack sufficient specificity to guide concep-
tualization of a specific research question or to iden-
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J.A.Earp and S.T.Ennett
Friends' Smoking
Behavior
CORRECT
Tetn Smoking
Initiation
>2 Smoking
Frtenda
S 2 Smoking
Friendj
INCORRECT
Earlier
-Smoking
Initiation
Later
Smoking
Initiation
Fig. 6. Correct conceptual model showing concepts; incorrect model showing values of variables.
tify appropriate and feasible interventions. In fact,
taking a multicausal approach may be paralyzing by
its immensity and tendency to assign equal weights
to all factors. Citing some of the shortcomings of
using the multicausal model to direct disease preven-
tion policy, Tesh (1988) observes that ". . . the
multicausal model easily becomes a rationale for not
taking action" (p. 62) because the maze of connec-
ting links seems to require that prevention policy
attack all causes at once, an impossible strategy.
Recommendations
Our recommendations for learning how to
appreciate, develop and use conceptual models are
first to look at examples of models developed for
health education research or practice and to practice
working with your own. For example, we give
students a health behavior or health education
outcome and have them come up with a list of
correlates of that outcome. They group these
concepts into conceptually similar clusters, name
each cluster, and finally draw arrows to indicate the
connections they think are most logical between their
set of concepts and the outcome. A follow-up assign-
ment involves drawing forth one or two research
questions from the narrowed down model, followed
by posing one or two hypotheses from each ques-
tion, and finally attempting to operationalize the
variables, including specifying their values and the
methods that will be used to measure them.
At a more general or programmatic level, we
suggest that all basic research methods courses, at
least in public health education, avoid simply
teaching data collection methods, research designs
and analytical techniques without putting these
techniques in the context of using conceptual models
to narrow a research area to a defined set of research
questions. This, in turn, may mean we need to re-
evaluate our basic methods courses and/or revamp
our approaches to the teaching of both theory and
methods in public health. Until professors themselves
become more comfortable with the design and use
of conceptual models, it is unlikely that their students
will think about using, much less struggling to
construct, conceptual models to guide their research
or shape their program interventions and strategies.
We hope this article represents one step to advance
these goals.
Acknowledgements
We would like to acknowledge Kathleen
Welshimer's contribution to the development of some
of these ideas. Karl Bauman, Robert Flewelling,
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Conceptual models
Vangie Foshee and Carol Runyan made helpful
comments on an earlier draft of this paper.
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