Defining conceptual boundaries of knowledge attitudes and practices to improve validity in public health research

Abstract Research based on the Knowledge–Attitudes–Practices (KAP) framework has substantially contributed to the understanding of health-related behaviors at the population level and has been widely used in the design and evaluation of public health programs and policies. However, conceptual precision in the definition and measurement of its domains is critical to preserving the validity and interpretability of findings. This comment examines a recurrent methodological limitation in KAP-based research: the lack of clear conceptual boundaries between knowledge, attitudes, and practices. Drawing on recent examples from different areas of health research, it illustrates how the inclusion of heterogeneous content within a single domain—including knowledge, behaviors, intentions, and contextual factors—can lead to conceptual overlap, misclassification bias, and difficulties in interpreting relationships between variables. It further highlights that psychometric procedures, such as factor analysis, do not necessarily resolve these ambiguities when a clear conceptual foundation is lacking in instrument development. We argue that strengthening the conceptual and methodological coherence of the KAP framework—through explicit definitions, clear criteria for item classification, and appropriate validation processes—is essential to improve comparability across studies and the overall quality of the evidence generated. In this context, a precise delineation of KAP domains is crucial for producing more robust and actionable evidence to inform public health interventions, strategies, and policy development.