Full Ebook of Structural Equation Modeling For Health and Medicine 1St Edition Douglas Gunzler Online PDF All Chapter

Structural Equation Modeling for Health
and Medicine 1st Edition Douglas

Gunzler
Visit to download the full and correct content document:
https://ebookmeta.com/product/structural-equation-modeling-for-health-and-medicine-
1st-edition-douglas-gunzler/
More products digital (pdf, epub, mobi) instant
download maybe you interests ...
Handbook of Structural Equation Modeling 2nd Edition

Rick H. Hoyle
https://ebookmeta.com/product/handbook-of-structural-equation-
modeling-2nd-edition-rick-h-hoyle/
Principles and Practice of Structural Equation Modeling

5th Edition Rex B Kline
https://ebookmeta.com/product/principles-and-practice-of-
structural-equation-modeling-5th-edition-rex-b-kline/
Composite Based Structural Equation Modeling Analyzing

Latent and Emergent Variables 1st Edition Jörg Henseler
https://ebookmeta.com/product/composite-based-structural-
equation-modeling-analyzing-latent-and-emergent-variables-1st-
edition-jorg-henseler/
A Beginner s Guide to Structural Equation Modeling 5th

Edition Tiffany A. Whittaker
https://ebookmeta.com/product/a-beginner-s-guide-to-structural-
equation-modeling-5th-edition-tiffany-a-whittaker/
A Primer on Partial Least Squares Structural Equation
Modeling (PLS-SEM), 3rd 3rd Edition Joseph F. Hair
(Jr.)
https://ebookmeta.com/product/a-primer-on-partial-least-squares-
structural-equation-modeling-pls-sem-3rd-3rd-edition-joseph-f-
hair-jr/
Structural Equation Modeling Using R/SAS: A Step-by-

Step Approach with Real Data Analysis 1st Edition Ding-
Geng Chen
https://ebookmeta.com/product/structural-equation-modeling-using-
r-sas-a-step-by-step-approach-with-real-data-analysis-1st-
edition-ding-geng-chen/
Computer Vision for Structural Dynamics and Health

Monitoring 1st Edition Dongming Feng
https://ebookmeta.com/product/computer-vision-for-structural-
dynamics-and-health-monitoring-1st-edition-dongming-feng/
How Modeling Can Inform Strategies to Improve

Population Health Workshop Summary 1st Edition And
Medicine Engineering National Academies Of Sciences
https://ebookmeta.com/product/how-modeling-can-inform-strategies-
to-improve-population-health-workshop-summary-1st-edition-and-
medicine-engineering-national-academies-of-sciences/
In Quest of the Craft Economic Modeling for the 21st

Century 1st Edition Douglas S Meade
https://ebookmeta.com/product/in-quest-of-the-craft-economic-
modeling-for-the-21st-century-1st-edition-douglas-s-meade/
Structural Equation Modeling
for Health and Medicine
Chapman & Hall/CRC Biostatistics Series
Series Editors:
Shein-Chung Chow, Duke University School of Medicine, USA
Byron Jones, Novartis Pharma AG, Switzerland
Jen-pei Liu, National Taiwan University, Taiwan
Karl E. Peace, Georgia Southern University, USA
Bruce W. Turnbull, Cornell University, USA
Recently Published Titles
Bayesian Applications in Pharmaceutical Development
Mani Lakshminarayanan, Fanni Natanegara
Innovative Statistics in Regulatory Science
Shein-Chung Chow
Geospatial Health Data: Modeling and Visualization with R-INLA and Shiny
Paula Moraga
Artifcial Intelligence for Drug Development, Precision Medicine, and Healthcare
Mark Chang
Bayesian Methods in Pharmaceutical Research
Emmanuel Lesaffre, Gianluca Baio, Bruno Boulanger
Biomarker Analysis in Clinical Trials with R
Nusrat Rabbee
Interface between Regulation and Statistics in Drug Development
Demissie Alemayehu, Birol Emir, Michael Gaffney
Innovative Methods for Rare Disease Drug Development
Shein-Chung Chow
Medical Risk Prediction Models: With Ties to Machine Learning
Thomas A Gerds, Michael W. Kattan
Real-World Evidence in Drug Development and Evaluation
Harry Yang, Binbing Yu
Cure Models: Methods, Applications, and Implementation
Yingwei Peng, Binbing Yu
Bayesian Analysis of Infectious Diseases: COVID-19 and Beyond
Lyle D. Broemeling
Statistical Meta-Analysis Using R and Stata, Second Edition
Ding-Geng (Din) Chen and Karl E. Peace
Advanced Survival Models
Catherine Legrand
Structural Equation Modeling for Health and Medicine
Douglas D. Gunzler, Adam T. Perzynski and Adam C. Carle
For more information about this series, please visit: https://www.routledge.com/

Chapman--Hall-CRC-Biostatistics-Series/book-series/CHBIOSTATIS
for Health and Medicine
Douglas D. Gunzler
Population Health Research Institute
Center for Health Care Research and Policy
The MetroHealth System and Case Western Reserve University
Cleveland, Ohio
Adam T. Perzynski
Population Health Research Institute
Center for Health Care Research and Policy
The MetroHealth System and Case Western Reserve University
Cleveland, Ohio
Adam C. Carle
James M. Anderson Center for Health Systems Excellence
Department of Pediatrics
Cincinnati Children’s Hospital Medical Center
University of Cincinnati College of Medicine
Cincinnati, Ohio
and
Department of Psychology
University of Cincinnati College of Arts and Sciences
Cincinnati, Ohio
First edition published 2021
by CRC Press
6000 Broken Sound Parkway NW, Suite 300, Boca Raton, FL 33487-2742
and by CRC Press

2 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN
© 2021 Taylor & Francis Group, LLC
CRC Press is an imprint of Taylor & Francis Group, LLC
Te right of Douglas D. Gunzler, Adam T. Perzynski and Adam C. Carle to be identifed as the authors of the editorial
material, and of the authors for their individual chapters, has been asserted in accordance with sections 77 and 78 of
the Copyright, Designs and Patents Act 1988.
Reasonable eforts have been made to publish reliable data and information, but the author and publisher cannot
assume responsibility for the validity of all materials or the consequences of their use. Te authors and publishers
have attempted to trace the copyright holders of all material reproduced in this publication and apologize to
copyright holders if permission to publish in this form has not been obtained. If any copyright material has not been
acknowledged please write and let us know so we may rectify in any future reprint.
Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced, transmitted, or
utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including
photocopying, microflming, and recording, or in any information storage or retrieval system, without written
permission from the publishers.
For permission to photocopy or use material electronically from this work, access www.copyright.com or contact the
Copyright Clearance Center, Inc. (CCC), 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400. For works that are
not available on CCC please contact mpkbookspermissions@tandf.co.uk
Trademark notice: Product or corporate names may be trademarks or registered trademarks and are used only for
identifcation and explanation without intent to infringe.
ISBN: 9781138574250 (hbk)

ISBN: 9780367742331 (pbk)
ISBN: 9780203701133 (ebk)
Typeset in Palatino
by codeMantra
Contents
Preface............................................................................................................................................ xiii
Acknowledgments...................................................................................................................... xvii
Authors.......................................................................................................................................... xix
Table of Greek Symbols............................................................................................................... xxi
Part I
I ntroduction to Concepts and Principles of Structural
Equation Modeling for Health and Medical Research
1 Introduction and Brief History of Structural Equation Modeling for Health
and Medical Research.............................................................................................................3
1.1 An Overview of the Material in This Textbook......................................................... 3
1.2 Introduction to Structural Equation Modeling.........................................................4
1.2.1 Path Diagrams, Confirmatory Factor Analysis and Path Analysis...........5
1.2.2 How Do Classic Approaches to SEM Analysis Work?................................ 6
1.2.3 First- and Second-Generation SEM................................................................ 6
1.3 Introduction to Causal Assumptions and Path Diagrams.......................................8
1.3.1 A Note about Error Terms in Path Diagrams...............................................9
1.3.2 Path Analysis Model........................................................................................9
1.3.3 Full Structural Equation Model.................................................................... 10
1.4 Brief History of SEM.................................................................................................... 11
1.5 Health and Medical Research Studies...................................................................... 12
1.5.1 SEM in Health and Medicine........................................................................ 13
1.5.2 A Contrarian View of SEMs: Can Causal Claims Be Justified
When Using SEM Approaches?.................................................................... 15
1.6 Conclusions................................................................................................................... 15
References................................................................................................................................ 15
2 Vocabulary, Concepts and Usages of Structural Equation Modeling........................ 17

2.1 Introduction to the Vocabulary, Concepts and Usages of Structural
Equation Modeling�� 17
2.2 Latent Variables............................................................................................................ 20
2.2.1 Factor Analysis................................................................................................ 21
2.2.2 Principal Component Analysis.....................................................................22
2.3 Path Analysis................................................................................................................ 23
2.4 Conducting SEM Analysis in Health and Medicine............................................... 26
2.4.1 Confirmatory Data Analysis for a Single Model........................................ 26
2.4.2 Model Specification........................................................................................ 26
2.4.3 Model Identification....................................................................................... 27
2.4.4 Model Estimation and Evaluation................................................................ 27
2.4.5 Hypothesis Testing......................................................................................... 28
2.4.6 Exploratory Data Analysis, Model Re-specification and Comparison...... 28
2.5 Longitudinal SEM........................................................................................................ 29
2.6 Systems-Based Models................................................................................................ 29
v
vi Contents
2.7 Direct, Indirect and Total Effects.............................................................................. 30

2.8 Subgroup Analysis Using Latent Variable Methodology or
Multigroup Analysis................................................................................................... 31
2.9 An Introduction to MPlus.......................................................................................... 32
2.10 Conclusions.................................................................................................................. 36
References ............................................................................................................................... 36
Part II Theory of Structural Equation Modeling
3 The Form of Structural Equation Models........................................................................ 41

3.1 Introduction to the Form of SEMs ............................................................................ 41
3.2 Path Diagrams .............................................................................................................42
3.3 Mathematical Form of the SEM Framework ...........................................................44
3.3.1 LISREL Approach .......................................................................................... 45
3.3.2 Some Extensions and Special Cases of the LISREL Model...................... 46
3.3.3 Mathematical Form of the MS-Depression Mediation Model................. 47
3.4 Assumptions for the Error Terms............................................................................. 49
3.4.1 Local Independence....................................................................................... 49
3.4.2 Making Distributional Assumptions.......................................................... 49
3.4.3 An Introduction to Skewness and Kurtosis............................................... 49
3.4.4 Distributional Assumptions in the MS-Depression Mediation
Example........................................................................................................... 50
3.5 Mean Structure............................................................................................................ 53
3.5.1 Free Parameters in the MS-Depression Mediation Model.......................54
3.6 Conclusions.................................................................................................................. 56
Appendix................................................................................................................................. 56
References ............................................................................................................................... 58
4 Model Estimation and Evaluation..................................................................................... 61

4.1 Introduction to Model Estimation in SEM .............................................................. 61
4.2 Estimating Model Parameters from Sample Data and Statistics ......................... 62
4.3 Robust Estimation.......................................................................................................63
4.4 Non-normal Data ........................................................................................................65
4.4.1 Outliers............................................................................................................ 67
4.4.2 Floor and Ceiling Effects .............................................................................. 68
4.5 Unstandardized and Standardized Estimates ....................................................... 68
4.6 Missing Data................................................................................................................ 69
4.7 Covariates..................................................................................................................... 71
4.8 MPlus Output for the MS-Depression Example with Covariates........................ 72
4.9 Introduction to Model Fit........................................................................................... 74
4.10 Chi-squared Test Statistic .......................................................................................... 75
4.11 Descriptive and Alternative Fit Indices ...................................................................77
4.12 MPlus Output for Model Evaluation for the MS-Depression Example .............. 79
4.13 Sample Size and Power .............................................................................................. 81
4.14 Conclusions..................................................................................................................83
References ...............................................................................................................................83
Contents vii
5 Model Identifability and Equivalence ............................................................................ 87

5.1 Introduction to Model Identifability ....................................................................... 87
5.2 Underidentifed, Just-Identifed and Overidentifed Models ............................... 89
5.2.1 Assessing Identifability in Illustrative Examples .................................... 89
5.3 Equivalent Models ...................................................................................................... 94
5.3.1 Examples of Equivalent Models .................................................................. 95
5.3.2 Generating Equivalent Models .................................................................... 97
5.4 Conclusions.................................................................................................................. 97
5.4.1 Appendix: Single Indicator Latent Variable............................................... 98
References ............................................................................................................................... 98
Part III Applications and Examples of Structural Equation

Modeling for Health and Medical Research
6 Choosing among Competing Specifcations................................................................. 103
6.1 Introduction to Model Specifcation and Re-specifcation.................................. 103
6.2 Path Diagrams for Making Model Comparisons ................................................. 105
6.3 Nested vs. Non-nested Models ............................................................................... 106
6.4 Chi-square Test of Difference.................................................................................. 107
6.5 Modifcation Indices ................................................................................................. 108
6.5.1 Categorical Outcomes and Modifcation Indices .................................... 110
6.6 Manual Approaches for Model Re-specifcation.................................................. 110
6.7 R2.................................................................................................................................. 112
6.8 Akaike Information Criterion, Bayesian Information Criterion and
Browne-Cudeck Criterion........................................................................................ 113
6.9 Residual Analysis...................................................................................................... 115
6.10 Software-Based Specifcation Searches.................................................................. 115
6.11 Conclusions................................................................................................................ 119
References ............................................................................................................................. 120
7 Measurement Models for Patient-Reported Outcomes and

Other Health-Related Outcomes ..................................................................................... 123
7.1 Introduction to Measurement Models for Patient-Reported Outcomes ........... 123
7.2 Measurement Model with Ordered-Categorical Items ....................................... 124
7.3 Internal Validity and Dimensionality.................................................................... 126
7.4 Multidimensional Models........................................................................................ 128
7.4.1 Cross-Loadings ............................................................................................ 128
7.4.2 Multidimensional Model Development ................................................... 128
7.5 Dimensionality and Bifactor Model Example....................................................... 131
7.5.1 Methods......................................................................................................... 132
7.5.2 Results ........................................................................................................... 132
7.5.3 Dimensionality Discussion ........................................................................ 133
7.6 Factor Scores .............................................................................................................. 134
7.7 Types of Reliability and Validity of Measurement .............................................. 136
7.7.1 Reliability ...................................................................................................... 136
7.7.2 Validity .......................................................................................................... 136
7.7.3 An Illustrative Example Assessing Reliability and Validity of a
Measurement Model.................................................................................... 137
viii Contents
7.8 Formative Constructs ............................................................................................... 138

7.9 Mixed Formative and Refective Constructs......................................................... 140
7.10 Conclusions................................................................................................................ 140
Appendix............................................................................................................................... 141
References ............................................................................................................................. 143
8 Exploratory Factor Analysis.............................................................................................. 147

8.1 Introduction to Exploratory Factor Analysis ........................................................ 147
8.2 Common Factor Model............................................................................................. 147
8.3 Factor Rotation........................................................................................................... 148
8.4 When to Use EFA ...................................................................................................... 149
8.5 Empirical Criteria for Exploratory Factor Analysis ............................................. 150
8.5.1 Descriptive Analysis Prior to Conducting EFA....................................... 150
8.5.2 Determining the Number of Factors to Retain after
Conducting EFA .......................................................................................... 150
8.6 How to Use Subjective Criteria to Help Determine the Optimal Number
of Factors .................................................................................................................... 154
8.6.1 One Factor Model......................................................................................... 154
8.6.2 Classical Depression Theory and the Two and Three
Factor Models........................................................................................154
8.6.3 Research Domain Criteria and the Four Factor Model .......................... 157
8.6.4 Which Model Should We Choose? ............................................................ 158
8.6.5 Evaluating Factor Intercorrelations for Discriminant Validity ............. 158
8.6.6 Developing a Successive Measurement Model for the Four Factor
Solution.......................................................................................................... 159
8.6.7 Second Order Factor Model........................................................................ 160
8.7 Exploratory Structural Equation Modeling .......................................................... 161
8.8 Conclusions................................................................................................................ 163
References ............................................................................................................................. 163
9 Mediation and Moderation............................................................................................... 165

9.1 Introduction to Structural Models for Health and Medical Studies ................. 165
9.2 An Introduction to Mediation Analysis ................................................................ 167
9.2.1 Percent Mediated ......................................................................................... 170
9.2.2 Hypothesis Testing for Mediation............................................................. 171
9.3 Classic Approaches for Performing Mediation Analysis.................................... 171
9.4 Computer-Intensive Approaches for Performing Mediation Analysis............. 173
9.4.1 Mediation Analysis with a Small Sample Size ........................................ 175
9.5 Mediation Analysis with a Systems-Based Model............................................... 175
9.5.1 Specifc Indirect Effects and Total Indirect Effects................................. 176
9.5.2 Testing Mediation Effects with the Multiple Mediator Multiple
Outcome MS-Depression and Fatigue Model.......................................... 177
9.6 Noncontinuous Outcomes and Mediators ............................................................ 178
9.7 Causal Mediation Analysis...................................................................................... 179
9.7.1 No Unmeasured Confounding Assumptions for Causal Mediation ... 179
9.7.2 Exposure-Mediator Interaction.................................................................. 180
9.7.3 Binary Outcome, Continuous Mediator Smoking-HIV Viral Load
Example......................................................................................................... 181
9.8 Moderation Analysis ................................................................................................ 183
Contents ix
9.9 Mediation Process Accounting for Moderation.................................................... 185

9.9.1 Mediated Moderation and Moderated Mediation .................................. 186
9.10 Moderation Analysis Using Multigroup Modeling ............................................. 187
9.11 Conclusions................................................................................................................ 189
Appendix............................................................................................................................... 189
References ............................................................................................................................. 190
10 Measurement Bias, Multiple Indicator Multiple Cause Modeling and

Multiple Group Modeling ................................................................................................ 193
10.1 Introduction to Measurement Bias ......................................................................... 193
10.2 Multiple Indicator Multiple Cause Models ........................................................... 195
10.2.1 Illustrative Example of MIMIC Analysis.................................................. 196
10.2.2 Item Response Theory................................................................................. 197
10.3 Multigroup Modeling............................................................................................... 197
10.3.1 Measurement Invariance ............................................................................ 198
10.3.2 Structural, Dimensional and Longitudinal Invariance.......................... 199
10.3.3 Some Practical Considerations about the Steps for Testing for
Measurement Invariance ............................................................................ 200
10.4 MG-MIMIC Analyses ............................................................................................... 200
10.4.1 Methods......................................................................................................... 200
10.4.1.1 Participants.................................................................................... 200
10.4.2 Measures ....................................................................................................... 201
10.4.3 Analytical Approach .................................................................................. 201
10.4.4 Results ........................................................................................................... 201
10.4.4.1 Evaluating Internal Validity ....................................................... 201
10.4.4.2 Evaluating Measurement Bias.................................................... 202
10.4.4.3 Adjusting for Measurement Bias ............................................... 205
10.4.5 Discussion..................................................................................................... 205
10.5 Analysis of Overlapping Symptoms of Co-occurring Conditions .................... 206
10.5.1 Overlapping Symptoms of Multiple Sclerosis and Depression ............ 207
10.6 Conclusions................................................................................................................ 209
References ............................................................................................................................. 210
11 Latent Class Analysis......................................................................................................... 213

11.1 Introduction to Mixture Distributions................................................................... 213
11.1.1 Finite Mixture Modeling ............................................................................ 214
11.2 Introduction to Latent Class Analysis ................................................................... 215
11.2.1 Local Independence..................................................................................... 215
11.2.2 LCA Model for Dichotomous Data ........................................................... 216
11.2.3 Most Likely Latent Class Membership ..................................................... 217
11.3 How to Determine the Number of Latent Classes? ............................................. 217
11.3.1 Empirical Criteria ........................................................................................ 217
11.3.2 Interpretability ............................................................................................. 219
11.4 LCA with Covariates and Distal Outcomes.......................................................... 220
11.5 Some FAQs with LCA in Health and Medical Studies........................................222
11.5.1 Can I Assume Local Dependence among Indicators within Class?.....222
11.5.2 I Can Justify Multiple Solutions, Which Do I Choose? ..........................222
11.5.3 Can I Incorporate Nominal Variables as Covariates in a Latent
Class Model?.................................................................................................223
x Contents
11.5.4 Should One Hold Out a Portion of the Sample as a Validation

Sample or Use the Whole Sample? ............................................................223
11.6 Application of LCA with Binary Indicators: Hepatitis C Transmission
Awareness Example.................................................................................................. 224
11.6.1 LCA for Hepatitis C Transmission Awareness with Covariates........... 226
11.7 Application of LCA with Binary and Ordinal Indicators: Methods of
Tobacco Use Example ............................................................................................... 228
11.8 Extensions of Latent Class Analysis with Longitudinal Data............................ 231
11.9 Conclusions................................................................................................................ 231
References ............................................................................................................................. 232
12 Latent Profle Analysis ...................................................................................................... 235

12.1 Introduction to Latent Profle Analysis ................................................................. 235
12.2 LPA Model.................................................................................................................. 235
12.3 Assumptions Regarding the Variance-Covariance Matrix in LPA ................... 236
12.4 Outliers in LPA .......................................................................................................... 236
12.5 Application of LPA in Adults with Serious Mental Illness and Diabetes......... 237
12.5.1 Descriptive Analysis.................................................................................... 238
12.5.2 LPA Results ................................................................................................... 238
12.5.3 LPA with Auxiliary Variables Using the Five Profle Model................. 242
12.5.4 Is the Five Profle Model Optimal?............................................................ 244
12.5.5 Local Dependencies in LPA for DM-SMI Adults .................................... 244
12.6 Factor Mixture Models ............................................................................................. 244
12.7 Conclusions................................................................................................................ 246
References ............................................................................................................................. 246
13 Structural Equation Modeling with Longitudinal Data ............................................ 249

13.1 Introduction to the Repeated Measures Data and Longitudinal
Structural Equation Modeling ................................................................................ 249
13.2 Basic Longitudinal Path Analysis Models in Health and Medicine ................. 250
13.3 SEM Autoregressive Models ................................................................................... 252
13.4 Longitudinal CFA .....................................................................................................254
13.5 Latent Growth Models ............................................................................................. 255
13.5.1 Path Diagram for a Basic Linear Latent Growth Model......................... 255
13.5.2 Mathematical Form of a Linear Latent Growth Model .......................... 256
13.5.3 Quadratic Latent Growth Model with a Time Invariant Covariate ..... 257
13.5.4 Applications of Latent Growth Models in Health and Medicine ......... 258
13.5.5 Modeling the Trajectory of Depression in Persons Living
with HIV ....................................................................................................... 258
13.6 Multilevel (Hierarchical) Models for Longitudinal Data.................................... 260
13.7 Longitudinal Mediation........................................................................................... 261
13.8 Survival Analysis ...................................................................................................... 262
13.9 Cohort Sequential Modeling Techniques .............................................................. 263
13.9.1 Age-Period-Cohort Analysis ...................................................................... 264
13.9.2 Risk-Period-Cohort Approach.................................................................... 264
13.10 Conclusions................................................................................................................ 265
References ............................................................................................................................. 266
Contents xi
14 Growth Mixture Modeling............................................................................................... 269

14.1 Introduction to Growth Mixture Modeling .......................................................... 269
14.2 Determining the Optimal Number of Latent Trajectories.................................. 270
14.3 Latent Class Growth Analysis................................................................................. 271
14.4 An Applied Example of Latent Class Growth Analysis from the Health
and Retirement Study............................................................................................... 271
14.5 MplusAutomation and Runmplus: Useful Tools for Summarizing
Results for a Series of Latent Variable Mixture Models ...................................... 276
14.5.1 An Applied Example of LCGA for People Living with HIV
Using MplusAutomation ............................................................................ 276
14.6 Conclusions................................................................................................................ 280
References ............................................................................................................................. 280
15 Special Topics ...................................................................................................................... 283

15.1 Introduction to Special Topics for SEM for Health and Medicine ..................... 283
15.2 Challenges in Using Electronic Health Records................................................... 283
15.3 Genetics ...................................................................................................................... 285
15.3.1 SEM for Twin Data....................................................................................... 285
15.3.2 Genome-Wide SEM...................................................................................... 285
15.4 Bayesian SEM............................................................................................................. 286
15.5 Partial Least Squares Structural Equation Modeling (PLS-SEM)...................... 288
15.6 Intensive Longitudinal Data.................................................................................... 289
15.7 Dashboards for Health and Medical Decision Making: The Future of SEM? .... 289
15.8 Conclusions................................................................................................................ 290
References ............................................................................................................................. 290
Index ............................................................................................................................................. 293

Preface
The book came about due to a series of workshops and panels on structural equation
modeling (SEM) we presented at national health services research and medical decision-
making meetings. Our initial workshop goal was to satisfy the curiosity of graduate
students, faculty, industry professionals and other attendees and help them gain a solid
understanding of the introductory principles of SEM. However, it became clear to us dur-
ing both question and answer portions and informal post-lecture discussion that many
attendees still needed a deeper understanding of how to apply these techniques with par-
ticular health and medical studies in mind. The problems and questions from our health
science audience did not follow “linearly” from the typical introductory SEM examples for
the social sciences. A classic example [1] that appears often in SEM introductions, manu-
als and tutorials describes the relationships between alienation and background variables
such as education and occupation. While concepts such as alienation are familiar to many
sociologists and other social scientists, they may be less helpful at the introductory stage
for researchers studying health and medicine.
Health and medical researchers use a wide variety of data sources, including complex
and messy real-world data. Study designs are also highly variable. Translating a concep-
tual model into a formal structural equation model under the boundaries of a study can be
diffcult in practice. Likewise, output from software for the analysis of structural equation
models (SEMs) commonly requires thorough review and interpretation. Careful consid-
eration of theory, logic and prior literature is mandatory (as with all SEM research). Thus,
our workshops and panels over time became adapted to showcase the methods for more
nuanced examples in health and medicine.
We, ourselves, learned SEM in traditional graduate school programs in biostatistics, soci-
ology and psychology. However, countless hours thinking about how to analyze data with
SEM as faculty in departments in schools of medicine over the past decade have shaped
our views and presentation of SEM for this textbook. This collaboration between the three
authors of this textbook is refective of our recommended usages of SEM for health and
medicine. Most of our applications of SEM have been done using a team science approach.
Team science is a collaborative effort from a group of researchers to address a scien-
tifc challenge. In team science a research group leverages the strengths and expertise of
each of the individuals trained in different felds. In a cross-disciplinary (e.g. interdisciplin-
ary, multidisciplinary, transdisciplinary) approach within team science a research group with
expertise in different felds work together to combine or integrate their perspectives with
a purpose in mind (e.g. addressing the research aims of a study). In a multidisciplinary
approach, researchers draw from multiple disciplines to redefne problems and reach solu-
tions. However, the researchers remain within the boundaries of the different disciplines.
An interdisciplinary approach integrates separate disciplines into a coordinated and coher-
ent whole. A transdisciplinary approach transcends the pre-conceived boundaries of the
different disciplines and refers to learning that is authentic and relevant to the real world
[2]. Rather than being confned by traditional ways of thinking about research problems,
learning in the transdisciplinary approach is supported and enriched by them. For exam-
ple, a non-clinician could take part in a comprehensive clinical observership of patients
with a condition under study (e.g. multiple sclerosis or lung cancer), under the supervision
of a clinician, to better understand the emotional, mental and physical symptoms of the
xiii
xiv Preface
condition. The training activity is useful for the later development of a transdisciplinary
conceptual model for persons with the condition under study as well as recommendations
for implementing the analytic results in clinical application [3].
More generally, researchers using SEM in health and medicine can beneft from a team
science approach. The team can work together in designing the study under appropriate
boundaries and make suitable study assumptions. Further, the experts of different disci-
plines under the guidance of a primary investigator (or investigators) can collaboratively
develop conceptual models, specify measurement and structural models, interpret output
and draw ftting study conclusions. In the SEM examples presented throughout this book,
answering diffcult research questions required the integration of perspectives and exper-
tise across disciplines.
Our goal with this textbook is to both introduce SEM and then present illustrative appli-
cations with software that can be used for the analysis of SEMs (e.g. Mplus, AMOS). We
use the nomenclature SEM in this textbook for a diverse set of methods incorporating a
combination of continuous and categorical latent variables.
This textbook presents both a nontechnical overview of topics with introductory
examples and a more intermediate level technical description of SEM with more detailed
examples. We envision this textbook can work on its own to cover topics ranging from
introductory and above for SEM students and researchers in a range of health and medi-
cal departments. Thus we hope that a reader, similar to our course and panel participants,
comes away with an understanding of how to effectively use SEM for their own research
in health and medicine. An understanding, in this sense, includes grasping (1) basic prin-
ciples of SEM and recommended strategies for application in health and medicine and (2)
a sense of how to fexibly and creatively use SEM. We’ve written this book in three parts.
Part I (Chapters 1 and 2) presents a basic overview of SEM for health and medicine.
These chapters introduce the history, vocabulary, concepts and usages of SEM.
Part II (Chapters 3–5) presents the basic theory of SEM using illustrative examples in health
and medicine. These chapters include material on the graphical and mathematical forms of
SEMs and model specifcation, estimation, evaluation, identifcation and equivalence.
Part III (Chapters 6–15) presents applications and examples of SEM for health and medi-
cal studies. In these chapters, there is material on confrmatory factor analysis, exploratory
factor analysis, mediation and moderation analysis, model modifcation, comparison and
specifcation searches, multiple indicator multiple cause and multigroup analysis, mixture
modeling and longitudinal modeling. These chapters include illustrative examples involv-
ing patient reported outcomes data and other health-related outcomes, large observational
studies, randomized controlled trials, clinical risk factors, disease progression and other
commonly occurring phenomena in health and medicine. The book ends with Chapter 15
on a series of special topics relevant for SEM health and medical researchers.
Several of the applied examples in this book focus on depression screening and individ-
uals studied have comorbid conditions (e.g. depression and multiple sclerosis, depression
and HIV). We particularly use the patient health questionnaire (PHQ-9) as a short-item
self-report depression screening tool [4]. As one reads the book, it should be noted that
these are some of the study samples and measures used in our research. The reader should
envision applying the methods for their own research which may involve vastly different
study samples and measures.
It has been a truly rewarding experience in completing this textbook. This achievement
marks an important path traveled in the longer journey to make SEM more accessible for
health and medical researchers. This feld will continue to evolve as funders, research
institutions and companies alike dedicate more resources to population health research.
Preface xv
REFERENCES
1. Wheaton, B., et al., Assessing reliability and stability in panel models. Sociological Methodology,
1977. 8: pp. 84–136.
2. Choi, B.C. and A.W. Pak, Multidisciplinarity, interdisciplinarity and transdisciplinarity in
health research, services, education and policy: 1. Definitions, objectives, and evidence of
effectiveness. Clinical and Investigative Medicine, 2006. 29(6): pp. 351–364.
3. Gunzler, D., et al., Training a nonclinician to become a leader in transdisciplinary clinical research:
Clinical observerships. International Journal of Clinical Biostatistics and Biometrics, 2015. 1(5).
4. Kroenke, K., R.L. Spitzer, and J.B. Williams, The PHQ-9. Journal of General Internal Medicine,
2001. 16(9): pp. 606–613.
Acknowledgments
This book represents collaborative work by the three authors. Financial support for
this study was provided by grants from NIH/NIDDK 1R01DK112905-01A1 (Sehgal and
Gunzler), NIH/NCATS UL1 TR 002548-01 (Konstan), NIH/NIA, R01AG055480 (Dalton
and Perzynski), NIH/NIA R01AG022459 (Sudano), NIH/NIA R01AG024206 (Sudano),
Health Resources and Services Administration H97HA27429-01-00 (Avery), NIH NCI/
FDA R01CA190130 (Flocke), NIH/NIAAA R01AA013302 (Dawson) and NIH/NIMH
R01MH085665 (Dawson and Sajatovic).
The funding agreement ensured the authors’ independence in conceptualizing, design-
ing, writing and publishing this textbook.
We appreciate the contributions from five independent and anonymous reviewers and
Drs. Neal Dawson, Ann Avery, Jarrod Dalton, Farren Briggs, Susan Flocke, Karen Ishler,
Kristen Berg, Nathan Morris, Martha Sajatovic, Richard McCormick and Joseph Sudano.
We are grateful to Rob Hamm and other leaders at the Society for Medical Decision
Making for choosing to offer our SEM short course for many years, to the learners in those
courses who shared their questions and ideas with us, and to Dana Alden who (together
with Kristen Berg and Joseph Sudano) has co-taught with us on many occasions.
We thank Rob Calver, Vaishali Singh and Iris Fahrer from Chapman & Hall and Vijay
Shanker at CodeMantra. We would like to thank all others heavily involved in this process
as well from both the editing and production side.
From author Dr. Douglas D. Gunzler: To my thesis advisor Dr. Xin M. Tu for your
friendship, wisdom and ardent introduction to SEM and mediation analysis. On a
personal note, I would like to specially thank my wonderful wife, Meredith, and chil-
dren, Paige and Jacob, for their all-around patience, love, support and understanding
t hroughout this process.
From Dr. Adam T. Perzynski: To my peers Tanetta Andersson, Chris Burant, Katy Abbott,
Heather Menne, Joshua Terchek and Noah Webster: if not for your friendship and inspir-
ing scholarship, I would not have had anything to offer this book. Thanks to Kyle Kercher
for his enthusiastic (and at times relentless) introduction to SEM in Sociology 509 which
set me on a pathway to contributing to this book. Most of all thanks to my loving family
Maureen, Holly, Sophie and Eddie.
From Dr. Adam C. Carle: I would like to thank Tara J. Carle, Lyla S. B. Carle and Margaret
Carle for their love and unending support. I would also like to thank the sheep and the
dogs for being, well, sheep and dogs.
xvii
Authors
Dr. Douglas D. Gunzler is a tenured Associate Professor of Medicine and Population and
Quantitative Health Sciences in the Population Health Research Institute at the Center for
Health Care Research and Policy, MetroHealth and Case Western Reserve University. He
is a biostatistician with specialties in structural equation modeling (SEM) and longitudinal
data analysis. His research interests lie in the areas of mediation analysis, factor analysis,
mixture modeling, psychometrics, age-period-cohort analysis and their application to both
clinical trials and observational studies in health and medicine. In his research, he is using
SEM for analysis of overlapping symptoms in co-occurring conditions. Dr. Gunzler earned
his PhD from the Department of Biostatistics & Computational Biology at the University
of Rochester in 2011.
Dr. Adam T. Perzynski is a tenured Associate Professor of Medicine and Sociology in the
Population Health Research Institute at the Center for Health Care Research and Policy,
MetroHealth and Case Western Reserve University. He is also the Founding Director
of the Patient Centered Media Lab. His doctoral degree is in sociology, and his current
research interests include novel strategies to eliminate health disparities, outcomes mea-
surement over the life course and research methods. His methodologic expertise spans the
continuum from focus groups and ethnography to psychometrics and structural equation
modeling. His publications span many disciplines and stand out against the backdrop of
a career-long effort to infuse the study of biomedical scientific problems with the knowl-
edge, theories and methods of social science.
Dr. Adam C. Carle is a clinically and quantitatively trained investigator. He is nationally
recognized as an expert in pediatric patient reported outcomes and measurement. He
uses structural equation models (SEM), multilevel models (MLM) and contemporary
test theory (e.g. item response theory – IRT) to advance the methodological science used
to measure health and health-related outcomes from the family and child’s perspective,
investigate the correlates of children and their families’ well-being, and investigate and
eliminate health disparities. Additionally, his work seeks to better understand individual
and contextual variables’ influences on health and health disparities at individual, local,
system, state and national levels. He is a PI, Co-PI or Co-I on numerous federal grants and
has served as a reviewer for federal granting agencies and national foundations. He has
published more than 80 peer-reviewed manuscripts. Most important, he thinks his family
is amazing (including the dogs and sheep).
xix
Table of Greek Symbols
Name Uppercase Lowercase

alpha Α α
beta Β β
gamma Γ γ
delta ∆ δ
epsilon Ε ε
zeta Ζ ζ
eta Η η
theta Θ θ
iota Ι ι
kappa Κ κ
lambda Λ λ
mu Μ µ
nu Ν ν
xi Ξ ξ
omicron Ο ο
pi Π π
rho Ρ ρ
sigma Σ σ
tau Τ τ
upsilon ϒ υ
phi Φ φ
chi Χ χ
psi Ψ ψ
omega Ω ω
xxi
Part I
Introduction to Concepts
and Principles of Structural
Equation Modeling for Health
and Medical Research
1
Introduction and Brief History of Structural Equation
Modeling for Health and Medical Research
1.1 An Overview of the Material in This Textbook

Structural equation modeling (SEM) has its roots in the social sciences [1]. In writing this
textbook, we look to make SEM accessible to a wider audience of researchers across many
disciplines, addressing issues unique to health and medicine. As SEM enthusiasts situ-
ated among clinicians and multidisciplinary researchers in medical settings we provide
a broad, current, on the ground understanding of the issues faced by clinical and health
services researchers and decision scientists.
For the past several years we have given short courses, written statistical tutorials and
authored applied research articles in the feld of SEM. We have noticed in feedback from
students, readers and editors a serious gap in the medical and bioscientifc literature that
makes this type of book fundamental for the felds of SEM, medicine and public health.
Readers will be introduced to a full range of SEM methods within the context of health
and medicine. Prior knowledge of SEM is not required. Readers with an understanding
of the fundamentals of traditional regression analysis will beneft from this book. More
seasoned SEM researchers with a focus on health and medicine will also beneft from it for
the particular applications to health and medical research.
We present an overview of SEM principles, common nomenclature, diagrams and many
real-world examples. We also present some more advanced latent variable approaches appli-
cable to health and medicine, such as modeling to establish measurement invariance, latent
variable mixture modeling and latent growth curve modeling. These techniques are very
useful with a wide range of practical applications. For example, we will cover how to use SEM
with patient-reported outcomes (PROs) and clinician ratings scales as found in both clinical
trial data and electronic health records. Readers of this book will be able to understand the
theory behind SEM, understand modeling guidelines, interpret SEM analyses and under-
stand advantages and limitations of SEM relative to more traditional analytic techniques.
In brief:
• The book covers basic, intermediate and advanced SEM topics.

• Applications are detailed and relevant for health and medical scientists.
• Topics and examples are relevant to both new SEM researchers as well as more
seasoned SEM researchers.
• Substantive issues in health and medicine in the context of SEM are discussed.
• Chapters are referenced with both methodological and applied examples.
• Illustrative fgures and diagrams are included for the examples used.
3
4 Structural Equation Modeling for Health and Medicine
1.2 Introduction to Structural Equation Modeling

Defning structural equation modeling is a great task in itself. There is no straightforward
manner for us to describe SEM to a novice user that will encompass all that it is or allow
one to thoroughly understand what it does and does not do. Metaphorically speaking, we
take the approach of immersing the reader in the water rather than merely getting their
feet wet frst. We provide here a broad view of SEM and focus on the big picture and then
get more and more nuanced throughout the chapters in this textbook. In this context, this
is likely the more comprehensible approach.
Let us begin our general description of SEM with a short segue for clarity to distinguish
between “multivariable” and “multivariate” analysis. Multivariable analysis refers to statis-
tical techniques used to evaluate multiple variables. Multivariate analysis, more specifcally,
refers to statistical techniques that can be used to evaluate multiple dependent variables
simultaneously. “Multivariate” and “multivariable” analysis are somewhat synonymous
terms (both types of analysis can include multiple dependent variables and multiple
independent variables). However, the terminology “multivariable” is typically used in
the context of a multiple regression model with a single dependent variable and multiple
independent variables. Meanwhile, the terminology “multivariate” analysis is commonly
used as defned for analysis with multiple dependent variables at the same time. With that
explanation, we can now provide a broad defnition of SEM.
Defnition: SEM is a very general and fexible multivariate technique that allows relation-
ships among variables to be examined.
Structural equation models (SEMs) are multi-equation models that commonly involve
multiple dependent and independent variables. Variables may play the role of both a
dependent and independent variable in different equations within a structural equation
model (Chapter 2). In practical settings, SEM, among many applications, includes a diverse
set of methods equipped to handle measurement error and evaluate the hypothesized causal
relations among observed and unobserved variables [2]. SEM researchers must differenti-
ate between observed and unobserved variables and understand the concept of measure-
ment error.
Observed variables are variables which are measured and recorded in the data (e.g.
sex, age, height and weight). Unobserved variables are variables that are not directly mea-
sured. Unobserved variables are also called latent variables, latent traits or latent constructs.
Phenomena such as depression, intelligence, perceived pain and happiness may be treated
as latent variables in research studies. In SEM, multiple observed variables are commonly
used as surrogates of a latent variable(s). For example, responses to multiple observed
items from a questionnaire about mental health (multiple observed variables) can be used
to measure a hypothetical construct of mental health (unobserved variable).
Most typically and as theoretically appropriate, an SEM researcher hypothesizes that
multiple observed items infuence the manifestation of the latent variable(s) rather than
the other way around. These causal assumptions will be elaborated on in an illustrative
example in this chapter regarding a latent construct for pain behavior. Causal assumptions
are strong assumptions. Given that one makes these assumptions about the hypothesized
directionality between a set of observed items and latent variable(s), SEM uses the latent
variable(s) to account for measurement error.
Measurement error is the difference between the underlying true values (e.g. mental
health) and the actual values (e.g. a score based on responses to multiple items from a
questionnaire about mental health). Observed measurements, being infuenced by latent
Introduction and History of SEM 5
variables, have measurement error. Latent variables themselves do not have measurement
error associated with them. Measurement error is accounted for in the model of relation-
ships between a latent variable and its indicator variables. Refer to Chapter 2 for more
details about different forms of measurement error.
We have now provided a very basic description of how one typically views a latent vari-
able in SEM. As we have defned it, in summary, SEM is an approach that can model latent
variables and then conduct multivariate regression of latent variables on each other (as
well as observed variables).
1.2.1 Path Diagrams, Confirmatory Factor Analysis and Path Analysis

Latent variables are treated as continuous in what we shall refer to as conventional SEM
(or what are sometimes called frst-generation SEM [3,4]). Later we discuss second-generation
SEM which includes more advanced, related techniques and uses a combination of con-
tinuous and categorical latent variables [3,4]. In this section, we fundamentally describe
the methods included in conventional SEM as a basis.
One way SEM deals with continuous latent variables in practice is through confrmatory
factor analysis (CFA). Factor analyses are approaches to represent the relationships among
multiple observed variables in terms of a smaller number of hypothesized latent variables.
In the context of factor analysis, latent variables are commonly also referred to as factors.
Exploratory factor analysis (EFA) is a data-driven method used to help identify the under-
lying latent variable or variables from a set of observed variables. CFA is used to verify
hypothesized relationships between the latent variables and the set of observed variables.
EFA can also be viewed as a special case of CFA and vice versa. Both EFA and CFA employ
the same common mathematical model under different constraints (Chapter 8).
Exploratory data analysis, such as EFA, is data-driven, while confrmatory data analysis,
such as CFA, is hypothesis-driven (relies on a priori hypothesis). In connection, EFA can
be used to help determine the number of factors to retain and then CFA can be used to
evaluate prespecifed relationships between factors and their indicators. These techniques
(EFA and CFA) can be successively applied on the same set of indicators in different data
(to prevent overftting of the CFA model). We will introduce latent variables and factor
analysis in some more detail in Chapter 2 and then dedicate full chapters to CFA and EFA
(Chapters 7 and 8) in the context of health and medicine.
Full SEM [5] emphasizes not just the measuring of continuous latent variables but the
regression of these latent variables on each other. The term “full” is used in the sense that
in the hypothesized model every observed variable is an indicator of a latent variable and
every variable in the regression analysis is a latent variable. Hypothesized relationships
amongst latent and observed variables in a structural equation model can be illustrated
with a path diagram. A path diagram is a visualization of the conceptual model. A conceptual
model is a general idea of the relationships under study. Another way to think about the
distinction is that path diagrams are usually a reduction or elaboration of a conceptual
model to something that can be both represented and tested in the SEM framework. We
will construct path diagrams for illustrative examples later in this chapter.
Path diagrams can be used to represent full SEMs. Path diagrams can also be used to
represent many special cases of SEMs that are not full including a CFA model or a hypoth-
esized structural equation model in which only observed variables are examined. Path
analysis is a form of regression and multivariate statistical analysis most often used to
evaluate hypothesized causal relationships between observed variables. The SEM frame-
work links together conceptual models, path diagrams, CFA and path analysis.
1.2.2 How Do Classic Approaches to SEM Analysis Work?

A researcher may theorize a causal model making use of strong causal assumptions. In
the process of model specifcation, a researcher translates the conceptual model into a for-
mal structural equation model and indicates causal paths and directionality between vari-
ables (latent or observed) under study. The plausibility of the hypothesized model under
the model specifcation can be tested using observed data in the SEM framework. Much
emphasis is given in SEM to examining the ft of the model to the data.
There is no statistical methodology in and of itself that can uncover casual relationships
among variables. The classic approaches to SEM analysis use the covariance matrix of the
data to estimate the free parameters (e.g. causal path estimates) in a hypothesized model
under the model specifcation. A free parameter is unknown and of interest to estimate.
Thus, free parameters are also referred to as unknown parameters.
Essentially, the researcher can either supply the raw data itself or covariance matrix data
in available software for conducting these classic approaches to SEM analysis. SEM then
estimates the unknown parameters with the aim of most closely reproducing the covari-
ance matrix. Additionally, a researcher can analyze means in SEM. We will provide details
regarding model estimation in Chapter 4.
A full structural equation model consists of two models [6–8]. These two models are
the measurement model (i.e. CFA) that measures latent variables using multiple observed
variables and a structural model (i.e. path analysis incorporating latent variables) that evalu-
ates the relationships between latent variables. Each regression equation in the structural
model has an error term referred to as a disturbance term. Disturbance terms refect the
residual error in regressing an outcome variable on a predictor (or set of predictors).
In a full structural equation model every variable in the structural model is latent. Most
typically in our own health and medical research a structural equation model is not full,
but still consists of a measurement and structural model. That is, we use a structural model
in which at least one of the variables is latent and at least one of the variables is observed
[9]. Many different models are also a special case of a structural equation model (e.g. linear
regression, ANOVA, CFA and path analysis).
We discuss in more detail the basic vocabulary, history, concepts and usages of SEM for
health and medicine in these frst two chapters of this textbook to help clarify this broad
description of SEM. In Part II of this book we provide more technical details that allow
the reader to represent and evaluate a structural equation model. In Part III, we build off
these fundamentals to apply both frst- and second-generation SEM to address problems
in health and medicine.
1.2.3 First- and Second-Generation SEM

Some researchers (possibly unintentionally) will use the term SEM as an umbrella term
for an extensive list of techniques involving latent variables. Other researchers prefer
to distinguish between SEM as it was originally developed and the larger set of latent
variable models that now coexist with SEM. In this setting, frst-generation SEM applies
to continuous latent variables. However, different approaches described later in this
textbook will use continuous latent variables (e.g. CFA), categorical latent variables (e.g.
latent class analysis and latent profle analysis) or both (e.g. growth mixture modeling).
Second-generation SEM uses a combination of continuous and categorical latent variables
[3]. Second-generation SEM is an expansion of the capacity of frst-generation SEM [10].
If the frst- and second-generation distinction and the particular methods mentioned are
not clear as of yet, these nuances and approaches will become more evident throughout
this textbook.
There are many other extensions of SEM that were developed during the frst- and
second-generations of SEM. SEM was originally derived to only consider continuous
observed variables. We will present many applications of SEM with ordered-categorical
observed variables and/or missing data. Applications of SEM can also involve other types
of data such as count and survival time data. SEM has been extended for analysis with
these other types of variables and data. Applications of SEM can involve either cross-
sectional or longitudinal data. For example, latent growth curve modeling (Chapter 13) is
an application of CFA for longitudinal data. Multilevel modeling (Chapter 13) and multi-
group analysis (Chapters 9 and 10) have also been integrated for use with SEM. Further,
Bayesian approaches have been adapted for SEM in parallel with the development of the
frst- and second-generation of SEM [4].
Beyond just using the methods in a straightforward manner, one has the opportu-
nity to extend these methods and fexibly and creatively apply them to address specifc
research questions. For example, in applying latent growth curve modeling, one can
analyze the antecedents and consequences of change, higher-order models and multiple
growth trajectories related to each other. We will use the term SEM hereafter in this textbook,
unless denoting otherwise, as an umbrella term in reference to these extensions and frst- and
second-generation SEM.
One necessitates a very broad framework to represent and fexibly and creatively apply
the different latent variable methods commonly used in studies in health and medicine.
These approaches (e.g. conventional linear SEM, conventional SEM with nonmetric data,
factor analysis, latent class analysis, growth mixture modeling) can be described as belong-
ing to a family of statistical techniques referred to as general latent variable modeling (GLVM).
When one defnes SEM as broadly as we have in this textbook, the terminology GLVM and
SEM can be viewed as synonymous. GLVM is a unifed latent variable framework that uses
a combination of continuous and categorical latent variables for statistical analysis [11]. The
vision of GLVM is to provide a unifed an organized set of tools for conducting many dif-
ferent types of statistical analysis. The interested reader should refer to Muthén [11] for an
introduction to GVLM.
SEM techniques have many advantages in practice including:
• acknowledging and modeling forms of measurement error;

• modeling of hypothesized causal relationships for analyses of direct and indirect
effects;
• modeling latent variable relationships;
• evaluating multiple equation models in a single analysis;
• fexible techniques for model selection and comparison;
• evaluating measurement equivalence in scales based on group differences by vari-
ables such as sex, race/ethnicity, age, area-level deprivation, language and cross-
cultural factors;
• fexible techniques for understanding longitudinal relationships and subpopula-
tion structures.
These advantages are well-suited to address research questions and theory development
in the medical and health sciences.
1.3 Introduction to Causal Assumptions and Path Diagrams

Researchers using SEM for the purpose of evaluating causal relationships among latent
and observed variables make strong causal assumptions. Causality is a much stronger
assumption and more diffcult to support than association. To illustrate this point, we lead
the reader through an example in Figure 1.1.
Here we present a simplifed, hypothesized model of how disease duration presum-
ably affects pain behavior in people with rheumatoid arthritis. Pain behavior encom-
passes behaviors that commonly suggest to others that an individual is experiencing
pain [12]. In the model, we implement the hypothesis that in people with rheumatoid
arthritis, a longer disease duration leads to an increase in pain behavior via an increase
in infammation. The amount of infammation present can be measured by the erythro-
cyte sedimentation rate.
Figure 1.1 consists of two path diagrams (A and B) to illustrate the hypothesized relation-
ships between variables. Recall, path diagrams are commonly used to visualize a concep-
tual model and represent a structural equation model. Observed variables are represented
by squares/rectangles and latent variables by circles/ovals.
We depict in Figure 1.1a a latent pain behavior variable as the underlying cause of four
observed indicators of pain behavior describing level of movement, facial expressions, pro-
tected body and stopped activity. Figure 1.1b shows the hypothesized cause and effect
relationships between disease duration (an observed variable), infammation (an observed
variable) and pain behavior (a latent variable). Figure 1.1a is a representation of a measure-
ment model, and Figure 1.1b is a representation of a structural model.
The type of model hypothesizing cause and effect relationships among variables
relies on strong causal assumptions that a researcher must make a priori. The researcher
ideally makes these causal assumptions based on logic, theory and prior knowledge
before performing empirical analyses. Between any two measures, causal assumptions
imply both cause and effect and temporal order. A predictor occurs frst in time and
FIGURE 1.1
Path diagrams representing hypothesized model in people with rheumatoid arthritis. (a) Hypothesized latent
variable for pain behavior and (b) Hypothesized causal relationships.
Disease duration and infammation are observed variables while pain behavior is a latent variable. The
amount of infammation present can be measured by the erythrocyte sedimentation rate. Pain behavior is
hypothesized as the underlying cause of observed indicators describing the level of movement (moved slower),
facial expressions, protected body (protected the part of the body that was hurt) and stopped activity.
is hypothesized to be the cause of an outcome that occurs subsequently in time and is

the effect.
Figure 1.1 provides a causal assumption every time an arrow points from one vari-
able (the cause) in the direction of another variable (the effect). One in general assumes
for any one-way arrow; the variable at the end of the arrow is explained in terms of the
variable at the beginning of the arrow. For example, we are making a causal assumption
about the relationship between disease duration, the cause, and infammation, the effect.
Thus this model has been specifed to assume that a longer disease duration leads to an
increase in infammation. We could also make a temporal assumption: frst the partici-
pant had the disease and then as time progresses the participant experiences an increase
in infammation. Since the relationship between disease duration and infammation is
just one causal path in our hypothesized model, we make a causal assumption in every
causal path, seven total, in Figure 1.1. Note that a two-way arrow (instead of a one-way
arrow) is used on a path diagram when one assumes association or correlation between
two variables.
Philosophically, making causal assumptions may be viewed as an idealized process that
is never quite obtainable in practice. In health and medicine as in other sciences, causal
considerations nearly always depend on context. Thus, a causal assumption in one setting
does not necessarily hold in other settings. For example, a causal assumption in a basic sci-
ence application may involve a simple linear relationship between cause and effect, while
in an epidemiological context the same assumption may involve a host, an environment
and an organism as contributors to causation and be interactive and nonlinear. In practice,
researchers rarely expect to observe the “true” relationships between causes and effects.
There may be a single cause or there may be multiple causes, each partially infuencing the
effect of interest.
1.3.1 A Note about Error Terms in Path Diagrams

We did not explicitly show any error terms (i.e. measurement error and disturbance terms)
in the path diagrams in Figure 1.1. In Figure 1.1, there is measurement error associated
with every observed indicator (movement, facial expressions, protected body, stopped
activity) of the latent variable of pain behavior. Disturbance terms are associated with
infammation and pain behavior in the structural model. Error terms are implicit in the
path diagrams in this chapter. We will explicitly show error terms in the path diagrams
in Chapter 2 as we provide more details about measurement error and the symbols com-
monly used in SEM research.
1.3.2 Path Analysis Model

In Figure 1.1, we represented using a path diagram a measurement model and a structural
model with both observed and latent variables. We represent a path analysis model in the
path diagram in Figure 1.2. All variables are observed.
We hypothesize increased intensity of current smoking and sugar consumption
cause a spike in the infammatory marker C-reactive protein (CRP). Elevated CRP lev-
els are then hypothesized to lead to an increase in the number of hospitalizations.
Further, increased intensity of current smoking and sugar consumption are hypoth-
esized to lead to an increase in the number of hospitalizations. We again make strong
causal assumptions for every causal pathway specifed in Figure 1.2. An implicit
assumption we made in Figure 1.2 is that there is no relationship between current
FIGURE 1.2
Path analysis model for hospitalization example.
smoking and sugar consumption (i.e. there is no arrow linking current smoking and
sugar consumption).
1.3.3 Full Structural Equation Model

In Figure 1.3, we represent a full structural equation model in the path diagram.
In the measurement model, hypothesized relationships are examined between latent
variables for emotional intelligence, career adaptability and happiness and their associ-
ated observed items. In the structural model, hypothesized relationships between the
three latent variables are evaluated. Once again, we make strong causal assumptions in
the model represented in Figure 1.3.
FIGURE 1.3
Full structural equation model for happiness example.
Emotional intelligence, career adaptability and happiness are latent variables. Emotional intelligence is hypoth-
esized as the underlying, or latent, cause of scores on observed indicators for self-awareness, self-regulation,
social-awareness and success in relationships. Career adaptability is hypothesized as the underlying cause
of scores on career concern, control, curiosity and confdence. This latent variable of career adaptability was
adapted from Nilforooshan, P. and S. Salimi, Career adaptability as a mediator between personality and career
engagement. Journal of Vocational Behavior, 2016. 94: pp. 1–10. Happiness is hypothesized as the underlying cause
of scores on observed indicators for smile, laugh, content and satisfed.
1.4 Brief History of SEM

Figures 1.1 involves two components in the measurement and structural models. In one
component (A), we use multiple indicators to measure a continuous latent variable. In
the other component (B), we model hypothesized causal relationships among latent and
observed variables. These two main components of the conventional SEM framework have
origins, respectively, within factor analysis and path analysis (see Box 1.1).
Following these origins, SEM has grown due to social scientists and other academics
looking to understand the structure of latent phenomena and relationships among latent
and observed phenomena [1]. As latent variable models have become more complex, the
advancement of latent variable software has played a prominent role in the accessibility
of SEM.
The frst widely distributed latent variable software was LISREL (linear structural rela-
tions; Scientifc Software International, Inc., Skokie, IL, USA) and was developed by Karl
Jöreskog in the 1970s [6,8]. Other specialized software came about in the 1980s such as EQS
(Multivariate Software, Inc., Encino, CA, USA) [15] and LISCOMP, which was later devel-
oped into MPlus [16].
As SEM has become more widely used, many more specialized packages have been
developed such as AMOS [17], in addition to the availability of procedures for ftting SEM
in general-purpose statistical packages such as R (i.e. LAVAAN, OpenMX), SAS (i.e. PROC
CALIS), STATA and Statistica. Many of these software packages are versatile modeling
packages which extend the basic SEM framework to include new types of observed and
unobserved traits, such as categorical traits and time to event traits, and include many
different model estimation methods. Another feature of some of these packages is the
ability to draw a model to run analysis (AMOS is notable in this regard) rather than write
programming syntax.
Kline [9] has written an infuential introductory text on the topic of SEM, accessible
to applied researchers. Bollen [7] provides a comprehensive and thorough overview of
the theoretical underpinnings of SEM. Bollen [7] describes general structure equation
systems, commonly known as the LISREL model as developed by Jöreskog [4]. Brown
[18] has provided an in-depth introduction of CFA. Brown describes the theoretical
BOX 1.1
ORIGIN OF FACTOR ANALYSIS
Charles Spearman [13] is credited with constructing the frst factor model, which
laid the foundations for measuring latent variables within the SEM framework [1]. In
his work he proposed a general ability factor, which he called g, that infuences the
performance on disparate cognitive ability measures [1].
ORIGIN OF PATH ANALYSIS (AND PATH DIAGRAMS)

Sewell Wright [14], a geneticist, was the originator of path analysis. In his work, he
laid out an analytical strategy for imposing a causal structure for describing causal
relationships between measures [1]. He developed path diagrams to graphically
depict the relationships between measures in these types of analyses [1].
framework used for CFA while providing many timely, illustrative examples. In SEM
computing, Byrne [5,17–21] has provided useful resources for researchers for using
SEM in MPlus, EQS (Multivariate Software, Inc., Encino, CA, USA), LISREL, PRELIS
(Scientifc Software International), SIMPLIS (SIMPLIS Technologies, Inc., Portland, OR,
USA) and AMOS (IBM Corporation, Armonk, NY, USA). Further, the MPlus website,
Statmodel.com [16] is flled with manuals and examples to assist an applied researcher
in conducting SEM analysis.
1.5 Health and Medical Research Studies

In this section, we will briefy provide an overview of the different types of research
studies using participants in health and medicine. Then, we go on to describe more gener-
ally the foundation of SEM in health and medicine.
In a research study in health and medicine, a common objective is to acquire information
that helps support or disprove a hypothesis. We describe three common types of studies
in health and medicine: experimental, non-experimental (observational) and quasi-experimental.
The type of study, as we will explain, determines the structure in which a researcher
approaches this objective.
In conducting experimental research, the researcher maintains control over the environ-
ment (i.e. design and setting of the study) and is able to manipulate the boundaries on
the primary independent variable. Experimental research is performed prospectively, and
an intervention is tested in a regulated environment. For example, in a randomized, con-
trolled clinical trial of a new sodium chloride tablet for patients with low sodium level,
each patient is randomly assigned to receive the tablet or a placebo (a binary independent
variable). The patients could be randomized into the treatment arm using stratifcation or
minimization as well as a block design. As a result of the study design (and given a large
enough sample), potential confounders such as age, gender and race should be approxi-
mately evenly distributed at least in theory between tablet and placebo group.
In non-experimental (observational) research (e.g. case-control studies, cohort studies), the
researcher has limited to no control over the study environment and variables under study.
This research can be conducted retrospectively or prospectively from an existing database.
A quasi-experimental study typically involves intervention research or the collection of
multiple measures prospectively, but study participants are not randomly assigned. Survey
studies or clinical research studies with treatment and control groups but no randomiza-
tion (non-equivalent groups) could be categorized as a quasi-experiment. We summarize
these three main types of studies in Table 1.1.
TABLE 1.1
Common Types of Research Studies in Health and Medicine
Study Type Experimental Quasi-experimental Observational
Boundaries/limits Control of environment and No random assignment to Limited to no control over
random assignment to intervention or control environment or variables
intervention or control
Examples Randomized controlled trial Survey research, non- Cohort study, case-control
equivalent group research study
Under ideal circumstances, experimental research might allow a researcher to draw

cause and effect conclusions. Based on our prior example for experimental research, given
strong background knowledge and study results, we might be comfortable stating that
these sodium chloride tablets lead to higher levels of sodium in the population under
study.
Experimental designs often entail high costs to implement for researcher and partici-
pant time and lab facilities. This often limits the number of participants enrolled in an
experimental study. Finding eligible participants meeting inclusion criteria can also be
diffcult. Further, with limited resources and imperfect knowledge, collecting information
about all study confounders and maintaining total control over study conditions are rarely
feasible in practice. Under these limitations, researchers using an experimental design in
practice are often limited in their ability to draw conclusions about causality.
In observational research (and quasi-experiments), multiple strategies are available that
attempt to mitigate the bias of the non-random sample in a comparison study. For example,
propensity matching [22], an approach to balance treatment and control group observa-
tions across covariates, can be used for this purpose. Observational studies, due to the
high possibility of confounding, often have poor internal validity. Similarly, due to pos-
sible confounding and lack of control over the study conditions, researchers conducting
observational studies must confront challenges in establishing causality and poor external
validity.
1.5.1 SEM in Health and Medicine

Causality assumptions are made by a researcher through a synthesis of logic, theory
and prior knowledge. Causal relationships among latent and observed variables can
therefore be conceptually hypothesized with clinical expert judgment. Experimental,
quasi-experimental and observational studies can all make use of SEM analyses.
Traditionally, in health and medicine, SEM researchers have used survey data or ran-
domized trial data for measuring latent variables and evaluating causal relationships
among the latent and observed variables under study. Clinical trial data has given rise to
mediation studies using SEM. In mediation, we consider an intermediate variable, called
the mediator, that helps explain how or why an independent variable infuences an outcome
[7,9,23–25]. Mediation can further our understanding of the pathology of a disease and the
workings behind an effective treatment. Mediation studies may also help us identify alter-
native, more effcient intervention strategies. In the protocol of a RCT, mediation is often
a secondary aim. As a result, a common limitation of mediation studies in this context is
that RCTs are randomized for the intervention, but not for the levels of the mediator in
each treatment arm.
Health services researchers have increasingly seen the potential for using SEM for obser-
vational studies of large existing electronic registries and cohort studies. Technology has
evolved to where many hospitals and institutions routinely collect clinical information on
large and diverse populations. These observational databases hold important advantages
to decision scientists in the availability of big data with extensive demographic and clinical
information on a diverse range of patients. Many such large retrospective cohort studies
do not involve hypotheses revolving around any intervention. Instead, these types of stud-
ies evaluate complex relationships between clinical factors, sociodemographic characteris-
tics, disease states and health outcomes for a population under study.
In Figure 1.4, a path diagram depicts a web of observed and unobserved variables
for the relationship between risk factors (heath-related and demographic variables and
social determinants) and cardiovascular events. This complex model involves many
hypothesized causal relations, each of which should be supported by sound logic, theory
and prior evidence, as well as other statistical considerations. Competent scientists could
disagree about which paths should be included, and how the model should be specifed.
In this respect, SEM can be seen as creating a practical scientifc dialogue that engages
researchers in processes of specifying and testing models. Models like the one shown in
Figure 1.4 are not intended to intimidate a novice SEM researcher. This is an advanced
example for learning to apply SEM to complex problems in health and medicine. In this
book, we work our way through a series of smaller examples intended to launch readers
into investigating ever more complex and interesting questions and relationships.
It is important to recognize that there are many applications of SEM that do not involve
performing regression to evaluate hypothesized causal relationships in confrmatory data
analysis. Exploratory factor analysis (Chapter 8) and latent class analysis (Chapter 11) are
both techniques commonly used in health and medicine for more exploratory data analy-
sis. Many researchers also use SEM to revise a model. That is, they use quantitative and
subjective criteria to test an initial specifed model against alternative modifed models
with the intentions of developing the “best” model for the data (Chapter 6). Hypothesized
associations are also commonly evaluated using SEM.
FIGURE 1.4
Hypothesized relationships between risk factors and cardiovascular event.
Obesity, mental health, social support and self-effcacy are latent variables. Mental health is hypothesized as the
underlying, or latent, cause of scores on observed indicators for emotional, psychological and social well-
being. Social support is hypothesized as the underlying cause of scores on objective support, subjective
support and support-seeking behavior. These three domains can be measured using the Social Support Self-
Rating Scale developed by Xiao (Reference: Xiao, S., The theoretical basis and research applications of “Social
Support Rating Scale”. Journal of Clinical Psychiatry, 1994. 4(2): pp. 98–100). Self-effcacy is hypothesized as the
underlying cause of scores on observed indicators for self-confdence, accuracy of self-evaluation, taking
calculated risks and accomplishment. Here, obesity is hypothesized as the underlying, or latent, effect of
scores on observed indicators of waist circumference, waist/hip ratio and body mass index (BMI). We have
not specifed all potential paths of interest, including correlations, in this diagram due to visual complexity.
For example, in practice many implied pairwise correlations would be reasonable like SES and smoking. SES,
socioeconomic status.
Conducting analyses of SEMs in health and medicine often does not go strictly accord-
ing to “rules of thumb” or follow linearly from “textbook” examples. The researcher
should carefully take account of prior expert knowledge, make reasonable assumptions,
weigh in on oftentimes conficting empirical evidence from multiple tests and indices, and
draw reasonable conclusions. Throughout this book, we describe examples and the SEM
decision-making involved in this type of research.
1.5.2 A Contrarian View of SEMs: Can Causal Claims Be

Justified When Using SEM Approaches?
We have explicitly stated that researchers necessitate strong, a priori theories to substanti-
ate causal relations. We have mentioned that the classic approaches to SEM analysis use
the covariance matrix of the data to estimate the unknown parameters (e.g. causal path
estimates) in a model. A criticism of SEM that it cannot avoid is that some claim the sam-
ple covariance matrix may not be a suffcient statistic to capture causal relations. There is
nothing magical about the multivariate statistical techniques used in SEM that allow one
to evaluate causal relations. Carefully reasoned, referenced and tested assumptions are
necessary foundations for hypotheses and theories of causality. Aforementioned, one does
not have to make causal assumptions when using SEM. One can make assumptions about
associative relationships. Even for the SEM contrarian, the statistical techniques used in the
SEM framework can be used for a wide range of univariate and multivariate analysis tasks.
1.6 Conclusions
In this chapter, we provided an overview of the material covered in this book. Briefy, we
defned and described SEM and the components of SEM. The strong implications when
one makes causal assumption were stressed in this chapter. We discussed the roots and
history of SEM including the history of latent variable software and recommendations of
classic introductory textbooks depending on the needs of a reader. We provided a back-
ground of three common types of health and medical studies, experimental, observational
and quasi-experimental, and a foundation for the use of SEM in health and medicine.
References
1. Tarka, P., An overview of structural equation modeling: Its beginnings, historical develop-
ment, usefulness and controversies in the social sciences. Quality and Quantity, 2017. 52(1):
pp. 1–42.
2. Bollen, K.A. and M.D. Noble, Structural equation models and the quantifcation of behavior.
Proceedings of the National Academy of Sciences, 2011. 108(Supplement 3): pp. 15639–15646.
3. Muthén, B., Second-generation structural equation modeling with a combination of categorical
and continuous latent variables: New opportunities for latent class–latent growth modeling.
2001.
4. Kaplan, D. and S. Depaoli, Bayesian structural equation modeling, in Handbook of structural
equation modeling, R.H. Hoyle, Editor. 2012, New York: The Guilford Press, pp. 650–673.
5. Byrne, B.M., Structural equation modeling with Mplus: Basic concepts, applications, and program-
ming. 2013, Abingdon: Routledge.
6. Joreskog, K. and D. Sorbom, LISREL 8 user’s reference guide. 1996, Chicago, IL: Scientifc Software
Chicago.
7. Bollen, K., Structural equations with latent variables. 1989, New York: Wiley.
8. Jőreskog, K.G. and M. Thiilo, Lisrel: A general computer program for estimating a linear struc-
tural equation system involving multiple indicators of unmeasured variables. ETS Research
Report Series, 1972.
9. Kline, R.B., Principles and practice of structural equation modeling, fourth edition. 2016, New York:
Guilford Press.
10. Fan, Y., et al., Applications of structural equation modeling (SEM) in ecological studies: An
updated review. Ecological Processes, 2016. 5(1): p. 19.
11. Muthén, B.O., Beyond SEM: General latent variable modeling. Behaviormetrika, 2002. 29(1):
pp. 81–117.
12. Cunningham, N.R., et al., Development and validation of the self-reported PROMIS pediatric
pain behavior item bank and short form scale. Pain, 2017. 158(7): p. 1323.
13. Spearman, C., “General Intelligence,” objectively determined and measured. The American
Journal of Psychology, 1904. 15(2): pp. 201–292.
14. Wright, S., Correlation and causation. Journal of Agricultural Research, 1921. 20(7): pp. 557–585.
15. Bentler, P.M., EQS structural equations program manual, 1989. Los Angeles, CA: BMDP Statistical
Software Pages.
16. Muthén, L.K. and B.O. Muthén, Mplus: The comprehensive modeling program for applied researchers:
User’s guide. Eighth edition. 1998–2017, Los Angeles, CA: Muthén & Muthén.
17. Arbuckle, J., Amos 6.0 user’s guide. 2005, Chicago, IL: Marketing Department, SPSS Incorporated.
18. Brown, T.A., Confrmatory factor analysis for applied research. 2014, New York: Guilford
Publications.
19. Byrne, B.M., Structural equation modeling with AMOS: Basic concepts, applications, and program-
ming. 2013, Abingdon: Routledge.
20. Byrne, B.M., Structural equation modeling with EQS: Basic concepts, applications, and programming.
2013, Abingdon: Routledge.
21. Byrne, B.M., Structural equation modeling with LISREL, PRELIS, and SIMPLIS: Basic concepts,
applications, and programming. 2013, Hove: Psychology Press.
22. Rosenbaum, P.R. and D.B. Rubin, The central role of the propensity score in observational
studies for causal effects. Biometrika, 1983. 70(1): pp. 41–55.
23. Gunzler, D., et al., Introduction to mediation analysis with structural equation modeling.
Shanghai Archives of Psychiatry, 2013. 25(6): pp. 390–394.
24. Baron, R.M. and D.A. Kenny, The moderator–mediator variable distinction in social psycho-
logical research: Conceptual, strategic, and statistical considerations. Journal of Personality and
Social Psychology, 1986. 51(6): p. 1173.
25. MacKinnon, D., Introduction to statistical mediation analysis. 2012, Abingdon: Routledge.
2
Vocabulary, Concepts and Usages of
2.1 Introduction to the Vocabulary, Concepts and

Usages of Structural Equation Modeling
We view conventional SEM as a framework consisting of three core components: conceptual
model, path diagram and system of linked regression-type equations to capture the relationships
among observed and unobserved variables [1,2]. We will present these three core compo-
nents in an illustrative example below. However, before discussing the form of conven-
tional SEMs in technical detail (i.e. path diagrams and mathematical representation of
SEMs) (Chapter 3), we introduce vocabulary, concepts and usages of SEM in this chapter.
In Figure 2.1, we hypothesize in a conceptual model the manner in which a wellness
program lowers anxiety and body mass index (BMI) based on prior scientifc knowledge.
In the example in Figure 2.1, the conceptual model, path diagram and mathematical
equations interrelate for evaluating a wellness program in study participants. The math-
ematical equations in SEM can also be referred to as structural equations.
Traditional regression models, conducted sequentially, allow for testing associations
between the wellness program and different outcomes. However, the SEM approach is
used since (1) we are interested in examining both if and how this program works and (2) our
analyses involve a latent variable anxiety. Conclusions drawn from the results of the more
nuanced SEMs could have broad implications for refning the program and/or implement-
ing the program in different settings.
We are interested in evaluating hypothesized causal relationships in our model corre-
sponding to Figure 2.1. These causal paths were hypothesized via logic, theory and prior
evidence. For some associated or correlated measures, we may not make causal assump-
tions. In our example, calorie intake and weekly exercise are not specifed as causally
related. We hypothesize that they are associated.
One consequence of the nature of hypothesized causal relationships in the SEM frame-
work is that a single variable can act as both a cause and an effect. For example, in Figure 2.1,
calorie intake and weekly exercise are both causes of anxiety and BMI. Calorie intake and weekly
exercise are also both effects in relation to the wellness program. Standard statistical lan-
guage to describe a variable as solely an independent or dependent variable is inadequate.
Calorie intake and weekly exercise are both independent variables in relation to anxiety and
BMI and dependent variables in relation to wellness program. In SEM, variables may be
divided into two classes: exogenous and endogenous [1].
Endogenous variables act as a dependent variable in at least one of the equations in a
structural equation model, while exogenous variables are always independent variables.
17
FIGURE 2.1
Model of wellness program.
The covariance between calorie intake and weekly exercise is represented in the model-implied covariance
matrix and does not appear in the mathematical equations in this fgure. See Chapter 4 for more details about
the model-implied covariance matrix. In this fgure we have omitted the measurement model (model of the
infuence of anxiety on the observed indicators of anxiety) and focused on the structural model. While left out
of the model, a covariance between anxiety and BMI might be theoretically reasonable and could potentially be
added at the discretion of a research team. See Chapter 3 for more details regarding the mathematical equations.
Briefy, here ˜ 0 , ˜ 1 , ˜ 2 and ˜ 3 are intercepts, ˜ 1 , ˜ 2 , ˜ 3 and ˜ 4 are slopes relating endogenous variables to
each other, and ˜ 1 , ˜ 2 , ˜ 3 and ˜ 4 are slopes relating the endogenous variables to the sole exogenous variable
(wellness program). D0 , D1 , D2 and D3 are error terms.
In other words, an endogenous variable is an effect in relation to at least one other vari-
able, while an exogenous variable is always the cause and never an effect. Another way
to phrase this is that the values of exogenous variables are determined by things out-
side/not within the model, whereas the values of endogenous variables are determined by
things within the model. In Figure 2.1, anxiety, BMI, calorie intake and weekly exercise are all
Vocabulary, Concepts and Usages of SEM 19
endogenous variables while wellness program is an exogenous variable. In the path diagram
in Figure 2.1, the sole exogenous variable is the variable with no arrows pointing into it,
and thus, its variation is not explained by other variables in the model.
Researchers commonly use simple sets of symbols from SEM notation to translate a con-
ceptual model into a path diagram (as in Figure 2.1). Table 2.1 displays some of the most
commonly used symbols and vocabulary, as well as the meaning, for researchers using
SEM. We will use these symbols and vocabulary throughout this book.
The reader should take Table 2.1 with some fexibility. Throughout the SEM literature,
there are sometimes variations in the general nomenclature.
TABLE 2.1
Commonly Used Symbols and Vocabulary for SEM Researchers
Symbol or Vocabulary Meaning
Oval or circle
a Latent variable
Rectangle or square Observed variable
Arrows with direction between variables A and B 1. A causes B

A is the cause and B is the effect
1. A ˜ B
2. A causes B and B causes A
2. A  B (or A ˜ B and B ˜ A)
There is a reciprocal relationship (feedback
loop) between A and B
Curved (or sometimes straight) double-sided arrows between A is correlated with B
variables A and B
(or A ˜ B)
Exogenous variable An independent variable that is only a causal

variable and never an effect. Exogenous
variables are of external origin to the model
Endogenous variable A dependent variable (or effect) in at least one
of the equations of a structural equation
model. Endogenous variables are of internal
origin to the model
(Continued)
TABLE 2.1 (Continued)

Commonly Used Symbols and Vocabulary for SEM Researchers
Symbol or Vocabulary Meaning
Measurement model The measurement model explicitly models the
relationship between latent variables and the
directly observed variables that refect or form
the underlying constructs
Structural model The structural model explicitly models the
hypothesized causal relationships among
endogenous and exogenous variables
e or more formally ˜ or ˜ “e” is used as the symbol for measurement
error. Measurement error is the difference
between an observed value and the true value.
Latent variables measure the true concept by
handling the measurement error in the
observed items in the measurement model
D or more formally ˜ “D” is the symbol used for a disturbance term.
A disturbance term is an unobservable (latent)
variable that is the residual error from
regressing an outcome on a predictor (or
predictors) in a structural model
a Measurement error and disturbance terms are also sometimes displayed in small circles.
2.2 Latent Variables

Directly observable phenomena, such as height or weight, are routinely captured by a
single measure. Measurable (directly observed) variables are also called manifest variables.
Researchers may not have a single observed measure that adequately describes phenom-
ena such as depression, pain behavior, happiness or anxiety. Multiple measures are often
used to obtain reliable estimates, particularly for self-report or rater administered sur-
vey questionnaires. Medical researchers and practitioners alike need reliable and valid
measures in order to understand symptoms, conditions and other clinically relevant mea-
sures that cannot be quantifed directly. Variables that are not directly observed are con-
sidered latent variables and are also regularly labeled latent traits and/or latent constructs.
Latent variable analyses can be useful for assessing the measurement properties of clinical
screening, assessment and symptom scales.
A primary usage of latent variables is for representing a common factor refected by mul-
tiple indicators (i.e. items). To measure a latent variable, one can use indicators on a multiple-
item scale that presumably measure(s) the underlying variable. Responses to these items
are directly observed and may provide a reasonable estimate of the underlying variable.
Measurement error contained in the observed responses must also be accounted for in order
to more accurately represent the relationship between the latent construct and observed
responses. In this setting, measurement error is the difference between the observed value
and the true value. In Figure 2.2, we illustrate that the nine items of the PHQ-9 may provide
a reasonable estimate of an underlying latent variable of depression [1–4].
Since latent variables are unobserved, they do not have a natural metric or measure-
ment scale. For this reason, this metric must be assigned to them. Assigning a metric also
contributes to resolving a problem of lack of model identifcation. The metric can be set by
Vocabulary, Concepts and Usages of SEM 21
FIGURE 2.2
Latent construct of depression using the items of the patient health questionnaire (PHQ)-9.
Depression is hypothesized as the underlying cause of nine observed items describing symptoms of anhedonia,
depressed mood, sleep disturbance, fatigue, appetite changes, feelings of worthlessness (guilt), concentration
diffculties, psychomotor disturbances and thoughts of self-harm. Arrows pointing toward each of the nine
items at the bottom of the fgure represent measurement error.
assigning the latent variable a mean and variance. We introduce model identifcation later
in this chapter and dedicate most of Chapter 5 to the topic.
Measurement error terms are also unobserved. However, measurement error terms are
not a part of the causal process; thus, there are various ways to represent such error terms in
a path diagram as related to continuous observed variables. We represent the measurement
error terms in Figure 2.2 using arrows (edges) at the bottom of the path diagram directionally
pointing toward each of the nine items. Other common representations of these error terms
would be to include a freestanding symbol (not included in a circle or oval as symbolic of a
latent variable), such as e or ˜ or ˜ , with a subscript unique to each item (such as subscripts
1–9), at the end of each edge. Another representation, such as in the AMOS software pack-
age, includes circles with numbered measurement error terms (i.e. e1, e2, …, e9) inside. These
error terms could also simply be implied in the model and left out of the path diagram.
Measurement error can be either random or systematic. Random measurement error varies
from one measurement to another in an unpredictable manner. When we use the terminol-
ogy “measurement error” throughout this textbook, we are referring to random measure-
ment error unless denoted otherwise. Systematic measurement error is predictable and
constant. Systematic measurement error is also known as bias and leads to incorrect model
estimates. An entire group has the same error from the true value across measurements of
a fxed magnitude and direction. For example, gender disparities in how a questionnaire
is flled out lead to a form of systematic measurement error in scoring the questionnaire
across men and women. We specifcally discuss systematic measurement error and how to
identify and account for it in SEM in Chapter 10.
Conventionally, latent variables in SEM analyses appear as refective constructs, such as
depression in Figure 2.2, where the latent trait infuences the indicators. In formative con-
structs, indicators infuence the latent trait. In health and medicine, latent variables for
physical health conditions such as obesity (Chapter 1, Figure 1.4) reasonably could be
considered a formative construct based on clinical characteristics, such as waist circum-
ference, waist–hip ratio and BMI. However, including formative variables in SEMs is an
application that requires special care (Chapter 7).
2.2.1 Factor Analysis

Factor analysis (FA) is a technique for investigating whether a latent variable or vari-
ables underlie a set of item responses [5–9]. If there are multiple latent variables under-
lying the item responses, FA is also used to evaluate the relationships among the latent
variables [5–9]. Exploratory factor analysis (EFA) [6,10] is typically used as an investiga-
tive technique to identify the number of latent variables that underlie a set of item
responses. One commonly uses EFA to describe the factor structure that is consis-
tent with the data and leads to the most meaningful substantive interpretation of
groups of questions or indicators. Confirmatory factor analysis (CFA) [5] is an analytic
technique used to study the relationships between multiple indicators and a latent
variable or variables. CFA is the most widely used technique for specifying latent
variables in the measurement model within the SEM framework. Recall, the measure-
ment model is used to evaluate the relationships between latent variables and their
measurements.
The CFA model is in itself a special case of a structural equation model. Though his-
torically EFA was not typically an SEM procedure, it can be classifed as a more gen-
eral latent variable procedure and is available for use in many SEM software packages.
Aforementioned in Chapter 1, EFA can also be viewed as a special case of CFA and vice
versa as both techniques employ the same common mathematical model under different
constraints (Chapter 8).
Many health and medical researchers use both EFA and CFA in subsequent analyses
(see Figure 2.3). EFA is useful for helping to determine the factor structure among multiple
indicators. CFA is useful for testing and evaluating the measurement properties of a pre-
determined factor structure and then modifying this structure as indicated. Most often a
researcher performing EFA and CFA in succession will do so using two separate samples.
Otherwise, one is likely overftting the model in confrming a factor structure that was
determined by optimizing empirical criteria with the same data. A data set can be ran-
domly split into two data sets for conducting EFA and then CFA. Alternatively, one could
fnd two similar data sets for this purpose.
2.2.2 Principal Component Analysis

Principal component analysis (PCA) is a variable reduction technique that sometimes is mis-
taken for factor analysis. While FA explains the correlations (variances and covariances)
among a set of variables (e.g. items), PCA explains the variance only. Therefore, these two
techniques are different approaches and have different applications. To elaborate further,
PCA does not have a causal interpretation. A principal component is a linear combination
of weighted observed variables. These principal components are uncorrelated. Properly
specifed factors, as previously mentioned, do have a causal interpretation. Multiple latent
factors in a factor analytic solution can be correlated or uncorrelated.
Use CFA to
evaluate the
measurement
Consider any properties of the
pertinent theory factors. CFA can
(previous literature, also be used to
Use EFA to help expert knowledge) modify the factor
determine the in modifying the structure as
factor structure of a factor structure as indicated.
set of indicators. indicated.
FIGURE 2.3
Step diagram for using exploratory and confrmatory factor analysis in succession for health and medical
research.
A subsequent step is to evaluate for group differences (e.g. differences for males and females or across age
groups) across the factor structure using multiple indicator multiple cause (MIMIC) modeling or multigroup
confrmatory factor analysis. See Chapter 10 for a discussion of these techniques.
Another random document with
no related content on Scribd:
afraid? Hear my crying, O Lord; incline thine ear to my calling, my
King and my God, for unto Thee do I make my prayer.’ With these
and other verses of the Psalms the enemy was at length put to flight;
Albinus completed his prayer and went to rest.[64] At that time only
one of his disciples, Waltdramn by name, who is still alive, was
watching with him; he saw all this from a place of concealment, a
witness of this thing that took place.”
St. Martin himself once had a meeting with the devil[65]. There
came into his cell a purple light, and one stood in the midst thereof
clad in a royal robe, having on his head a diadem of gold and
precious stones, his shoes overlaid with gold, his countenance
serene, his face full of joy, looking like anything but the devil. The
devil spoke first. “Know, Martin, whom you behold. I am Christ. I am
about to descend from heaven to the world. I willed first to manifest
myself to thee.” Martin held his tongue. “Why dost thou doubt,
Martin, whom thou seest? I am Christ.” Then the Spirit revealed that
this was the devil, not God, and he answered, “The Lord Jesus did
not predict that He would come again resplendent with purple and
diadem. I will not believe that Christ has come, except in the form in
which He suffered, bearing the stigmata of the Cross.” Thereupon
the apparition vanished like smoke, leaving so very bad a smell that
there was no doubt it was the devil. “This account I had from the
mouth of Martin himself,” Sulpicius adds.
“The father used a little wine, in accordance with the apostle’s
precept, not for the pleasure of the palate, but by reason of his bodily
weakness.[66] In every kind of way he avoided idleness; either he
read, or he wrote, or he taught his disciples, or he gave himself to
prayer and the chanting of Psalms, yielding only to unavoidable
necessities of the body. He was a father to the poor, more humble
than the humble, an inviter to piety of the rich, lofty to the proud, a
discerner of all, and a marvellous comforter. He celebrated every day
many solemnities of masses[67] with honourable diligence, having
proper masses deputed for each day of the week. Moreover, on the
Lord’s day, never at any time after the light of dawn began to appear
did he allow himself to slumber, but swiftly preparing himself as
deacon with his own priest Sigulf he performed the solemnities of
special masses till the third hour, and then with very great reverence
he went to the public mass. His disciples, when they were in other
places, especially when they assisted ad opus Dei, carefully studied
that no cause of blame be seen in them by him.
“The time had come when Albinus had a desire to depart and be
with Christ. He prayed with all his will that if it might be, he should
pass from the world on the day on which the Holy Spirit was seen to
come upon the apostles in tongues of fire, and filled their hearts.
Saying for himself the vesper office, in the place which he had
chosen as his resting-place after death, namely, near the Church of
St. Martin, he sang through the evangelic hymn of the holy Mary with
this antiphon[68], ‘O Key of David, and sceptre of the house of Israel,
who openest and none shutteth, shuttest and none openeth, come
and lead forth from the house of his prison this fettered one, sitting in
darkness and the shadow of death.’ Then he said the Lord’s Prayer.
Then several Psalms—Like as the hart desireth the water-brooks. O
how amiable are Thy dwellings, Thou Lord of hosts. Blessed are
they that dwell in Thy house. Unto Thee lift I up mine eyes. One
thing I have desired of the Lord. Unto Thee, O Lord, will I lift up my
soul.
“He spent the season of Lent, according to his custom, in the most
worthy manner, with all contrition of flesh and spirit and purifying of
habit. Every night he visited the basilicas of the saints which are
within the monastery of St. Martin,[69] washing himself clean of his
sins with heavy groans. When the solemnity of the Resurrection of
the Lord was accomplished, on the night of the Ascension he fell on
his bed, oppressed with languor even unto death, and could not
speak. On the third day before his departure he sang with exultant
voice his favourite antiphon, ‘O key of David,’ and recited the verses
mentioned above. On the day of Pentecost, the matin office having
been performed, at the very hour at which he had been accustomed
to attend masses, at opening dawn, the holy soul of Albinus is[70]
released from the body, and by the ministry of the celestial deacons,
having with them the first martyr Stephen and the archdeacon
Laurence, with an army of angels, he is led to Christ, whom he
loved, whom he sought; and in the bliss of heaven he has for ever
the fruition of the glory of Him whom in this world he so faithfully
served.”
The Annals of Pettau enable us to fill in some details of Alcuin’s
death. Pettau was not far from Salzburg, and therefore the
monastery was likely to be well informed. Arno of Salzburg, Alcuin’s
great admiration and his devoted personal friend, would see to it that
in his neighbourhood all ecclesiastics knew the details. The seizure
on the occasion of his falling on his bed was a paralytic stroke. It
occurred, according to the Annals from which we are quoting, on the
fifth day of the week on the eighth of the Ides of May, that is, on May
8; but in that year, 804, Ascension Day fell on May 9, so that for the
eighth of the Ides we must read the seventh of the Ides. The seizure
took place at vesper tide, after sunset. He lived on till May 19,
Whitsunday, on which day he died, just as the day broke.
“On that night,” to return to the Life, “above the church of the holy
Martin there was seen an inestimable clearness of splendour, so that
to persons at a distance it seemed that the whole was on fire. By
some, that splendour was seen through the whole night, to others it
appeared three times in the night. Joseph the Archbishop of Tours
testified that he and his companions saw this throughout the night.
Many that are still sound in body testify the same. To more persons,
however, this brightness appeared in the same manner, not on that
but on a former night, namely, on the night of the first Sunday after
the Ascension.
“At that same hour there was displayed to a certain hermit in Italy
the army of the heavenly deacons, sounding forth the ineffable
praises of Christ in the air; in the midst of whom Alchuin[71] stood,
clothed with a most splendid dalmatic, entering with them into
heaven to minister with perennial joy to the Eternal Pontiff. This
hermit on that same day of Pentecost told what he had seen to one
of the brethren of Tours, who was making his accustomed way to
visit the thresholds of the Apostles.[72] The hermit asked him these
questions,—‘Who is that Abbat that lives at Tours, in the monastery
of the holy Martin? By what name is he called? And was he well in
body when you left?’ The brother replied, ‘He is called Alchuin, and
he is the best teacher in all France. When I started on my way hither,
I left him well.’ The solitary made rejoinder, with tears, that he was
indeed enjoying the very happiest health; and he told him what he
had seen at day-break that day. When the brother got back to Tours,
he related what he had heard.
“Father Sigulf, with certain others, washed the body of the father
with all honour, and placed it on a bier. Now Sigulf had at the time a
great pain in the head, but being by faith sound in mind, he found a
ready cure for his head. Raising his eyes above the couch of the
master, he saw the comb[73] with which he was wont to comb his
head. Taking it in his hands he said, ‘I believe, Lord Jesus, that if I
combed my head with this my master’s comb, my head would at
once be cured by his merits.’ The moment he drew the comb across
his head, that part of the head which it touched was immediately
cured, and thus by combing his head all round he lost the pain
completely. Another of his disciples, Eangist by name, was
grievously afflicted with immense pain in his teeth. By Sigulf’s advice
he touched his teeth with the comb, and forthwith, because he did it
in faith, he received a cure by the merits of Alchuin.
“When Joseph, the bishop of the city of Tours, a man good and
beloved of God, heard that the blessed Alchuin was dead, he came
to the spot immediately with his clerks, and washing Alchuin’s eyes
with his tears, he kissed him frequently. He advised, moreover, using
wise counsel, that he should not be buried outside, in the place
where the father himself had willed, but with all possible honour
within the basilica of the holy Martin, that the bodies of those whose
souls are united in heaven should on earth lie in one home. And thus
it was done. Above his tomb was placed, as he had directed, a title
which he had dictated in his lifetime, engraved on a plate of bronze
let into the wall.”[74]
The simple epitaph, apart from the title, ran thus:—
“Here doth rest the lord Alchuuin the Abbat, who died in peace on
the fourteenth of the Kalends of June. When you read, O all ye who
pass by, pray for him and say, The Lord grant unto him eternal rest.”
CHAPTER III
The large bulk of Alcuin’s letters and other writings.—The main dates of his life.
—Bede’s advice to Ecgbert.—Careless lives of bishops.—No parochial system.—
Inadequacy of the bishops’ oversight.—Great monasteries to be used as sees for
new bishoprics, and evil monasteries to be suppressed.—Election of abbats and
hereditary descent.—Evils of pilgrimages.—Daily Eucharists.
We in the diocese of Bristol have a special right to study and to

make much of the letters of Alcuin. Our own great historian, William
of Malmesbury, had in the library of Malmesbury from the year 1100
and onwards an important collection of these letters, from which he
quotes frequently in support of the historical statements which he
makes. More than that, we know of some of the letters of Alcuin only
from the quotations from them thus made by William in this diocese
some 800 years ago. This is specially stated by Abbat Froben, of
Ratisbon, who edited the letters of Alcuin 140 years ago.
The letters of Alcuin are addressed to an emperor, to kings,
queens, popes, patriarchs, archbishops, dukes, and others; so that
of Alcuin’s political importance there can be no question. As to his
learning, William of Malmesbury pays him the great compliment of
naming him along with our own Aldhelm and with Bede. “Of all the
Angles,” he says,[75] “of whom I have read, Alcuin was, next to the
holy Aldhelm and Bede, certainly the most learned.”
Alcuin was born in Northumbria in or about the year 735. He left
England to live in France in 782, returned for a time in 792, and left
finally in 793. He died in 804. We can thus see how he stands in
regard of date to those with whom we have dealt in former lectures.
Aldhelm and Wilfrith died in 709, only about a quarter of a century
before Alcuin’s birth. Bede died, according to the usual statement[76],
in 735, the year of Alcuin’s birth. Boniface was martyred in Holland in
755, when Alcuin was twenty years old.
As in the case of Gregory and of Boniface, who have been the
subjects of the last two courses of lectures, the letters of Alcuin are
the most important—or among the most important—sources of
information for the history of the times. The letters are 236 in
number, and they fill 373 columns of close small print in the large
volumes of Migne’s series. The letters of Boniface are not half so
numerous, and they occupy considerably less than one-third of the
space in the same print.
The letters of Alcuin, great as is their number and reach, form but
a small part of his writings. His collected works are six times as large
as his letters. His commentaries and treatises on the Holy Scriptures
are much more lengthy than his collected letters, more than two-
thirds as long again. His dogmatic writings are not far from half as
long again as his letters. His book on Sacraments and kindred
subjects is about two-thirds as long as his letters. His biographies of
saints, his poems, his treatises on teaching and learning, are all
together nearly as long as the letters; and there is almost the same
bulk of works which are attributed to him on evidence of a less
conclusive character.
Put briefly, this was his life. He was a boy at my own school, the
Cathedral School of York, a school which had the credit of educating,
800 years later, another boy who made a mark on history, Guy
Fawkes. The head master in Alcuin’s time was Ecgbert, Archbishop
of York and brother of the reigning king of Northumbria; and the
second master was Albert, Ecgbert’s cousin, and eventually his
successor in the chief mastership and in the archbishopric. Alcuin
succeeded to the practical part of the mastership on Ecgbert’s death
in 766, the new archbishop, Albert, retaining the government of the
school and the chief part of the religious teaching. In 778 Alcuin
became in all respects the head master of the school, and in the end
of 780 Albert died, leaving to Alcuin the great collection of books
which formed the famous library of York.
Alcuin had for some years travelled much on the continent of
Europe, and he was well acquainted with its principal scholars. They
were relatively few in number, learning having sunk very low on the
continent, while in Northumbria it had been and still was at a very
high level. Alcuin had also made acquaintance with Karl, not yet
known as Karl der Grosse, Carolus Magnus, Charlemagne, the son
of Pepin, king as yet of the Franks, emperor in the year 800, a man
about seven years younger than Alcuin. On a visit to the continent in
781 he again met Karl, who proposed to him that he should enter his
service as master of the school of his palace, and practically minister
of education for all parts of the vast empire over which Karl ruled. In
782 he joined Karl, having obtained leave of absence from the
Northumbrian king Alfweald, Archbishop Ecgbert’s great-nephew,
and from the new archbishop, Eanbald I. From that time onwards he
was Karl’s right-hand man, in matters theological as well as
educational; and in some matters of supreme political importance
too. The leave of absence lasted some nine or ten years; at the end
of that time Alcuin came back for a short time, but he soon after
terminated his official connexion with York, and spent the rest of his
life in the dominions of Karl.
Archbishop Ecgbert, Alcuin’s master, had been a friend of the
venerable Bede. The only occasion on which we know that Bede left
his cloister was that of a visit to Ecgbert at York, shortly before
Bede’s death, if he died in 735. We have it from Bede himself that he
had promised another visit to York in the following year, but was too
ill to carry out his promise. Failing the opportunity of long
conversations on the state of the Province of York, which
corresponded to the bishoprics of York, Lindisfarne, Hexham, and
Whithern, Bede set down his thoughts on parchment or tablets, and
sent them to his friend. This Letter of Bede to Ecgbert is by very far
the most important document of those times which has come down
to us; both because of the remarkable mass of information contained
in it, which we get from no other source, and because of the large
and broad views of ecclesiastical policy which it sets forth. It was no
doubt the advice and warnings of Bede that led Ecgbert to create the
educational conditions which developed the intellect of the most
intellectual man of his times, the subject of these lectures. Inasmuch
as it seems probable—indeed, is practically certain—that the
distressful state of Northumbria was the final cause of Alcuin’s
abandonment of his native land, it will be well to summarize the main
points of Bede’s dirge. We should bear in mind the fact that we are
reading a description by an ecclesiastic, a man keenly devoted to the
monastic life; and that the date is that of the year of Alcuin’s birth. It
tells us, therefore, something of the setting in which Alcuin found
himself in early boyhood.
Ecgbert had only become Bishop of York in the year of Bede’s visit
to him, 734. York was not as yet an Archbishopric; it was raised to
that dignity in Ecgbert’s time. Some writers call Paulinus Archbishop,
because a pall was sent to him by Gregory; but the pall did not reach
England till after Paulinus had run away from York.
Bede thinks it necessary to urge Ecgbert very earnestly to be
careful in his talk. He does not suppose that Ecgbert sins in this
respect, but it is matter of common report that some bishops do; that
they have no men of religion or continence with them, but rather
such as indulge in laughter and jests, in revellings, drunkenness, and
other pleasures of loose life; men who feast daily in rich banquets,
and neglect to feed their minds on the heavenly sacrifice.
There were in 735 sixteen bishops’ sees in England, held in the
south by Tatuin of Canterbury, Ingwald of London, Daniel of
Winchester, Aldwin of Lichfield, Alwig of Lindsey, Forthere of
Sherborn, Ethelfrith of Elmham[77], Wilfrid of Worcester, Wahlstod of
Hereford, Sigga of Selsey, Eadulf of Rochester; and in the north by
Ecgbert of York, Ethelwold of Lindisfarne, Frithobert of Hexham, and
Frithwald of Whithern. We may, probably, narrow Bede’s censure to
Lindisfarne and Hexham, if he really did, as some assume, refer to
his own parts. As a Northumbrian myself, I think that a long-headed
man like Bede, a Northumbrian by birth, more probably referred to
bishops of the parts which we now know as the Southern Province.
Alcuin’s letters, however, show that in his time there was much that
needed improvement in the case of northern bishops as well as
southern.
A bishop in those days had to do the main part of the teaching,
and preaching, and ministering the Sacraments, throughout the
diocese. Bede points out that Ecgbert’s diocese was much too large
for one man to cover it properly with ministrations. He must,
therefore, ordain priests, and appoint teachers to preach the Word of
God in each of the villages; to celebrate the heavenly mysteries; and
especially to attend to sacred baptism[78]. The persons so appointed
must make it their essential business to root deep in the memory of
the people that Catholic Faith which is contained in the Apostles’
Creed, and in like manner the Lord’s Prayer. Those of the people
who do not know Latin are to say the Creed and the Lord’s Prayer
over and over again in their native tongue; and this rule is not for the
laity only, but also for clergy and monks who do not know Latin. For
this purpose, Bede says he has often given translations of these two
into English to uneducated priests; for St. Ambrose declared that all
the faithful should say the Creed every morning, and the English
practice was to chant the Lord’s Prayer very often. How much we of
to-day would give for just one copy of Bede’s Creed and Lord’s
Prayer in English![79]
Ecgbert’s position in the sight of God, Bede says, will be very
serious if he neglects to do as he advises, especially if he takes
temporal gifts or payments from those to whom he does not give
heavenly gifts. This last point Bede presses home with affectionate
earnestness upon the “most beloved Prelate”. “We have heard it
reported,” he says, “that there are many villages and dwellings, on
inaccessible hills and in deep forests, where for many years no
bishop has been seen, no bishop has ministered; and yet no single
person has been free from the payment of tribute to the bishop; and
that although not only has he never come to confirm those who have
been baptized, but there has been no teacher to instruct them in the
faith or show them the difference between good and evil. And if we
believe and confess,” he continues, “that in the laying on of hands
the Holy Spirit is received, it is clear that that gift is absent from
those who have not been confirmed. When a bishop has, from love
of money, taken nominally under his government a larger part of the
population than he can by any means visit with his ministrations in
one whole year, the peril is great for himself, and great for those to
whom he claims to be overseer while he is unable to oversee them.”
Ecgbert has, Bede tells him, a most ready coadjutor in the King of
Northumbria, Ceolwulf, Ecgbert’s near relative, his first cousin, whom
Ecgbert’s brother succeeded. The [arch]bishop should advise the
King to place the ecclesiastical arrangements of the Northumbrian
nation on a better footing. This would best be done by the
appointment of more bishops. Pope Gregory had bidden Augustine
to arrange for twelve bishops in the Northern Province, the Bishop of
York to receive the pall as Metropolitan. Ecgbert should aim at that
number. It may here be noted that in this year of grace 1908 there
are still only nine diocesan bishops in the Northern Province, besides
the archbishop, and five of these nine have been created in the
lifetime of some of us. Bristol knows to its heavy cost that Ripon was
the first of the five.
But Bede points out, and here we come to very interesting matter,
that the negligence of some former kings, and the foolish gifts of
others, had left it very difficult to find a suitable see for a new bishop.
The monasteries were in possession everywhere. It may be
remarked in passing that all over the Christian parts of the world
monasteries existed, even in those early times, in very large
numbers. We know the names, and the dates or periods of
foundation, of no less than 1481 founded before the year 814, in
various parts of the world; and the actual number was very much
larger than that, from what we know of the facts, especially in the
East. In the time of Henry VIII, besides the monasteries which had
been suppressed by Wolsey, Fisher, and others, as also the large
number of alien priories suppressed at an earlier date, and besides
all the ecclesiastical foundations called hospitals and colleges, more
than 600 monasteries remained in this land to be suppressed.
There being, then, no lands left to endow bishoprics, there was, in
Bede’s opinion, only one remedy; that was, the summoning of a
Greater Council, at which an edict should be issued, by pontifical
and royal consent, fixing upon some great monastery for a new
episcopal seat. To conciliate the abbat and monks, the election of the
bishop-abbat should be left to them. If it should prove necessary to
provide more property still for the bishop, Bede pointed out that there
were many establishments calling themselves monasteries which
were not worthy of the name. He would like to see some of these
transferred by synodical authority for the further maintenance of the
newly-created see, so that money which now went in luxury, vanity,
and intemperance in meat and drink, might be used to further the
cause of chastity, temperance, and piety. Here in Bristol, with
Gloucester close at hand, we need no reminder of the closeness of
the parallel between Bede’s advice in 735 to King Ceolwulf and the
actual course taken in 1535 by King Henry, and carried to completion
by him in 1540-2, in the foundation of six new bishoprics on the
spoils of as many great monasteries. Nor need it be pointed out that
Bede’s proposal to suppress small and ill-conditioned monasteries
was a forecast of the original proposal of Henry VIII.
Bede then proceeds to speak with extreme severity of false
monasteries. It appears that men bribed kings to make them grants
of lands—professedly for monasteries—in hereditary possession,
and paid moneys to bishops, abbats, and secular authorities, to ratify
the grants by their signatures; and then they made them the
dwellings of licentiousness and excess of all kinds. The men’s wives
set up corresponding establishments. Bede urged the annulment of
all grants thus misused: again we seem to hear a note prophetic of
eight hundred years later. To so great a pitch had this gone, that
there were no lands left for grants to discharged soldiers, sons of
nobles, and others. Thus it came to pass that such men either went
beyond sea and abandoned their own country, for which they ought
to fight, or else they lived as they could at home, not able to marry,
and living unseemly lives. If this was allowed to go on, the land
would be unable to defend itself against the inroads of the
barbarians. Bede’s prophecy to that effect came crushingly true in
Alcuin’s time, not fifty years after it was written. And here again we
have a remarkable forecast of Henry VIII’s avowed purpose in the
suppression of monasteries, that he must have means to defend his
land against invasion. Thus the three arguments of Henry VIII,
namely, that lands and money were needed for more soldiers and
sailors, that lands and money were needed for more bishoprics, and
that many of the religious houses did not deserve that name, were
carefully set out by one whom we may call a High-Church
ecclesiastic, eight hundred years before Henry.
On two of the points mentioned by Bede in connexion with
monasteries, it may be well to say a little more by way of illustration.
The two points are, the hereditary descent of monasteries, and the
principle on which the election of the abbat should proceed. To take
the second first,—Bede is very precise on this point. He says that
when a monastery is to be taken as the seat of a bishop, licence
should be given to the monks to elect one of themselves to fill the
double office of abbat and bishop, and to rule the monastery in the
one character and the adjacent diocese in the other. We should have
thought it would have been better to leave them free to elect some
prominent churchman from the outside, than to limit their choice to
one of themselves. And the exception for which arrangement was
made points in the same direction of limitation. If they have not the
right man in their own monastery, at least they must choose one
from their own family, or order, to preside over them, in accordance
with the decrees of the Canons. This strictness was traditional in
Northumbria. The great founder of monastic institutions in the
Northern Church, Benedict Biscop, who founded Monk Wearmouth
in 674 and Jarrow in 685, was very decided about it. He would not
have an abbat brought in from another monastery. The duty of the
brethren, he said, when speaking to his monks on his own imminent
decease, was, in accordance with the rule of Abbat Benedict the
Great, and in accordance with the statutes of their own monastery of
Wearmouth—which he had himself drawn up after consideration of
the various rules on the Continent from the statutes of the seventeen
monasteries which he liked best of all that he had seen—to inquire
carefully who of themselves was best fitted for the post, and, after
due election, have him confirmed as abbat by the benediction of the
bishop. There is a great deal to be said in favour of this course, and
there is a great deal to be said for more freedom of election. The
case which comes nearest to it in our English life of to-day is that of
the election of the Master of a College in one of the two Universities.
In Cambridge the election—in two cases the appointment—is in
every case open, in the sense that it is not confined to the Fellows of
the College, and in very recent times there have been several cases
of the election of a prominent man from another College, to the great
advantage of the College thus electing.
The other point is of much wider importance, namely, the
hereditary descent of monasteries and of their headship. Our
Northumbrian abbat Benedict was very decided here also. The
brethren must not elect his successor on account of his birth. There
must be no claim of next of kin. He was specially anxious that his
own brother after the flesh should not be elected to succeed him. He
would rather his monastery became a wilderness than have this man
as his successor, for they all knew that he did not walk in the way of
truth. Benedict evidently feared that a practice of hereditary
succession to ecclesiastical office might spring up. No doubt he had
seen at least the beginning of this in foreign parts. It was no
visionary fear, for in times rather later we have examples of
ecclesiastical benefices, and even bishoprics, going from father to
son, and that in days of supposed celibacy. We have plenty of
examples of monasteries descending from mother to daughter later
on in England; and in Bede’s own time he mentions without adverse
remark that the Abbess of Wetadun (Watton, in East Yorkshire)
persuaded Bishop John of Hexham to cure of an illness her
daughter, whom she proposed to make abbess in her stead. Alcuin
himself, as we have seen,[80] tells us quite as a matter of ordinary
occurrence, not calling for any remark, that he himself succeeded
hereditarily to the first monastery which he ruled, situated on Spurn
Point, the southern promontory of Yorkshire. We cannot doubt that
the evils naturally arising, in some cases at least, from hereditary
succession to spiritual positions, had much to do with the
intemperate suppression of the secular clergy and the enforcement
of clerical celibacy. In considering the question as it concerned the
times of Alcuin, we must bear in mind that we are dealing with times
very long before the development of the idea of feudal succession.
It is interesting to note that the earliest manuscripts of the Rule of
St. Benedict which are known to exist do not definitely lay down the
precise rule that the person elected to an abbacy must be a member
of the abbey or at least of the same order. The Rule was first printed
in 1659 by a monk of Monte Cassino; and this print was carefully
collated throughout with a manuscript of the thirteenth century at Fort
Augustus for the edition published by Burns and Oates in 1886.
Chapter 64 is as follows, taking the translation annexed to the Latin
in that edition, though it does not in all cases give quite the force of
the original.
“In the appointing[81] of an abbot, let this principle always be
observed, that he be made abbot whom all the brethren with one
consent in the fear of God, or even a small part of the community
with more wholesome counsel, shall elect. Let him who is to be
appointed be chosen for the merit of his life and the wisdom of his
doctrine, even though he should be the last of the community. But if
all the brethren with one accord (which God forbid) should elect a
man willing to acquiesce in their evil habits, and these in some way
come to the knowledge of the bishop to whose diocese that place
belongs, or of the abbots or neighbouring Christians, let them not
suffer the consent of these wicked men to prevail, but appoint[82] a
worthy steward over the house of God, knowing that for this they
shall receive a good reward, if they do it with a pure intention and for
the love of God, as, on the other hand, they will sin if they neglect it.”
We hear a good deal in our early history of kings and great men
renouncing the world and entering the cloister. Bede shows us the
darker side of this practice. Ever since king Aldfrith died, he says,
some thirty years before, there has not been one chief minister of
state who has not provided himself while in office with a so-called
monastery of this false kind, and his wife with another. The layman
then is tonsured, and becomes not a monk but an abbat, knowing
nothing of the monastic rule. And the bishops, who ought to restrain
them by regular discipline, or else expel them from Holy Church, are
eager to confirm the unrighteous decrees for the sake of the fees
they receive for their signatures. Against this poison of covetousness
Bede inveighs bitterly; and then he declares that if he were to treat in
like manner of drunkenness, gluttony, sensuality, and like evils, his
letter would extend to an immense length.
It may be well to mention here another religious practice which
had two sides to it, the practice of going on pilgrimage. Anglo-Saxon
men and women had a passion for visiting the tombs of the two
princes of the Apostles, Peter, whose connexion with Rome is so
shadowy up to the time of his death there, and Paul, their own
Apostle, the teacher of the Gentiles, whose connexion with Rome is
so solid a fact in the New Testament and in Church history. Bede
tells us that in his times many of the English, noble and ignoble,
laymen and clerics, men and women, did this. As a result of the
relaxed discipline of mixed travel, a complaint came to England,
soon after, that the promiscuous journeyings on pilgrimage led to
much immorality, so that there was scarcely a town on the route in
which there were not English women leading immoral lives.
There is one striking passage in Bede’s unique letter which shows
us how great were the demands of the early Church upon the
religious observances of the lay people; while it shows with equal
clearness the inadequacy of the response made by the English of
the time. The passage will complete our knowledge of the state of
religion among our Anglian forefathers towards the end of Bede’s
life. It refers to the bishop’s work among the people of the world,
outside the monastic institutions. The bishop must furnish them with
competent teachers, who shall show them how to fortify themselves
and all they have against the continual plots of unclean spirits, by the
frequent use of the sign of the Cross, and by frequent joining in Holy
Communion. “It is salutary,” he says to Ecgbert, “for all classes of
Christians to participate daily in the Body and Blood of the Lord, as
you well know is done by the Church of Christ throughout Italy, Gaul,
Africa, Greece, and the whole of the East. This religious exercise,
this devoted sanctification, has, through the neglect of the teachers,
been so long abandoned by almost all the lay persons of the
province of Northumbria, that even the more religious among them
only communicate at Christmas, Epiphany, and Easter. And yet,” he
continues, “there are innumerable persons, innocent and of most
chaste conversation, boys and girls, young men and virgins, old men
and old women, who without any controversy could communicate on
every Lord’s Day, and indeed on the birthdays of the holy apostles
and martyrs, as you have seen done in the holy Roman and
Apostolic Church.” The Church History of early times has a great
deal of practical teaching for the church people of to-day.
If the life of religious people in the monasteries and in the world
was thus tainted and slack, we can imagine what the ordinary
secular life was likely to be. There was terrible force in Bede’s
suggestion that a nation so rotten could never withstand a hostile
attack of any importance. Archbishop Ecgbert certainly did all that he
could to bring things into order; and he wisely determined that the
very best thing he could do to pull things round was to get hold of the
youth of the nation, and train them with the utmost care in the way
that they should go. This leads us on to the rise or revival of the
Cathedral School of York.
CHAPTER IV
The school of York.—Alcuin’s poem on the Bishops and Saints of the Church of
York.—The destruction of the Britons by the Saxons.—Description of Wilfrith II,
Ecgbert, Albert, of York.—Balther and Eata.—Church building in York.—The
Library of York.
It is usual to reckon the year 735 as the beginning of the great

School of York, and Archbishop—or rather, as he then was, Bishop
—Ecgbert as its originator. But it seems clear that we must carry its
beginnings further back, and count as its originator a man who filled
a much larger place in the world than even Ecgbert, archbishop as
he became, and brother of the king as he was. When Wilfrith, the
first Englishman to appeal to Rome, was put into the see of York by
Theodore of Canterbury in 669, his chaplain and biographer,
Stephen Eddi, tells of four principal works which, between that year
and 678, his chief accomplished. The first was the restoration of the
Cathedral Church of York, which had fallen into decay during the
time when Lindisfarne was the seat of the Bishop of Northumbria.
The second was the building of a noble church at Ripon for the
people of the kingdom of Elmete, which Edwin, the first Christian
king of Northumbria, had conquered from the Romano-Britons;
corresponding to the West Riding of Yorkshire and parts of
Lancashire, a portion of the great British kingdom of Rheged, at the
court of which the bard Taliessin had sung. The fourth was the
building of a still more noble church at Hexham, to be the
ecclesiastical centre of the northern part of Northumbria, replacing
Lindisfarne in that character. And the third in order was the
establishment of a School, no doubt at York, as that was his
episcopal seat, and he himself was the chief teacher. The world
credits William of Wickham with the invention of the idea of a public
school in the modern sense of the word; but seven hundred[83] years
before him Wilfrith had grasped the idea and put it into practice at
York. This is what his chaplain tells us. The secular chiefs, the
noblemen, sent their sons to him to be so taught that when the time
of choice came they would be found fit to serve God in the ministry, if
that was their choice, or to serve the king in arms if they preferred
that career. We must certainly reckon the year 676, or thereabouts,
as the date of foundation of the school at York, Wilfrith as its founder,
and its principle that of the modern public school, which is supposed
to give an education so liberal that whatever career its alumnus
prefers he will be found fitted for it. The first scholars of the school of
York entered, some of them, the ministry, as learned clerks; others,
the army, as fit to be soldiers. It was still so when I went to that
school sixty-four years ago. The school is older than Winchester by
seven hundred years, and older than Eton by seven hundred and
sixty-five.[84] Bede’s strong appeal to Ecgbert led to the revival of the
school after the natural decay from which good institutions suffer in
times of ecclesiastical and civil disorder, and we date the continuous
life of the school from him. It was an interesting coincidence, that
men saw in the year 735 the revival of the school and the birth of its
most famous pupil, assistant master, and head master. We may now
turn to that man, whose early lot was cast in a state of society, lay
and clerical, such as that described in scathing terms by Bede; and
who was the first-fruits of the remedy which Bede had suggested. As
a link between Bede and Alcuin we may have in mind a pretty little
story about Bede which we find in a letter of Alcuin’s some fifty or
sixty years after Bede’s death.
Alcuin is writing to the monks of Wearmouth. He Ep. 274. Before
tells them how well he remembers what he saw at a.d. 793.
Wearmouth long years ago, and how much he was
pleased with everything he saw. He encourages them to continue in
the right way by reminding them of the virtues of their founders. “It is
certain,” he writes, “that your founders very often visit the place of
your dwelling. They rejoice with all whom they find keeping their
statutes and living right lives; and they cease not to intercede for
such with the pious judge. Nor is it doubtful that visitations of angels
frequent holy places; for it is reported that our master and your
patron the blessed Bede said, ‘I know that angels visit the canonical
hours and the congregations of the brethren. What if they should not
find me among the brethren? Would they not have to say, Where is
Bede? Why does he not come with the brethren to the appointed
prayers?’”
To us in England, and especially to those of us who are North-
countrymen, nothing that Alcuin wrote has a higher interest than his
poem in Latin hexameters on the Bishops and Saints of the Church
of York. By the Church of York Alcuin evidently meant the Church of
Northumbria, although his account of the prelates dwells chiefly on
the archbishops of his time. Considering his long sojourn in France,
it was fitting that the manuscript of this famous poem should be
discovered at a monastery near Reims, the monastery of St.
Theodoric, or Thierry according to the later spelling. A great part of
the poem is in the main a versification of Bede’s prose history of the
conversion of the North to Christianity, and an adaptation of Bede’s
metrical life of St. Cuthbert. On this account the French transcriber
from the original omitted about 1100 of the 1657 lines of which the
poem consists, and only about 550 lines were originally printed by
Mabillon in the Acta Sanctorum. When our own Gale was preparing
to publish it, he got the missing verses both from the St. Theodoric
MS. and also from a MS. at Reims itself. Both manuscripts
disappeared long ago, probably in the devastations of the French
Revolution[85].
The poem describes the importance of York in the time of the
Roman occupation of Britain, the residence, as Alcuin tells us, of the
dukes of Britain, and of sovereigns of Rome. York was, in fact, the
imperial city; it shared with Trèves the honour of being the only
imperial cities north of the Alps. He speaks eloquently of its beautiful
surroundings, its flowery fields, its noble edifices, its fertility, its
charm as a home. This part of the poem inclines the reader to settle
in favour of York the uncertainty as to the place of Alcuin’s birth. One
graphic touch, and the use of a special Latin name for the river Ouse
which flows through the middle of the city, goes to the heart of those
who in their youth have fished in that river—
Hanc piscosa suis undis interluit Usa.

He goes on to speak of the persistent inroads of the Picts after the
withdrawal of the Roman troops. Inasmuch as the sixth legion was
quartered at York, and all of the other three legions in Britain were
withdrawn before the sixth, it may be claimed that York was the last
place effectively occupied by the Roman troops. This indeed is in
itself probable, since York was in the best position for checking the
attempts of the Picts to reach the central and southern parts of
Britain. He describes how the leaders of the Britons sent large bribes
to a warlike race, to bring them over to protect the land, a race, he
says, called from their hardness Saxi, as though Saxons meant
stones.[86] The eventual conquest of the Britons by the Saxons
evidently had Alcuin’s full sympathy. The Britons were lazy; worse
than that, they were wicked; for their sins they were rightly driven
out, and a better race entered into possession of their cities. We
would give a great deal to have had from Alcuin a few words of
tradition about some details of the occupation of York by the Angles,
and of the fate of the British inhabitants. Alcuin’s words would
suggest that their fate was a cruel one, but we do not know anything
of it from any source whatsoever. One of his remarks strikes us as
curious, considering that the Britons were Christians and their
conquerors were pagan: the expulsion, he says, was the work of
God, that a race might enter into possession who should keep the
precepts of the Lord. Clearly Alcuin held a brief for his ancestors of
some five generations before his birth. He writes also in a rather
lordly way of the kingdom of Kent, as though Northumbria was the
really important province in the time of King Edwin, as indeed it
unquestionably was. Edwin was the most prominent personage in
England, the Bretwalda, at the time of the conversion of
Northumbria. All that Alcuin says of Edwin’s young wife Ethelburga,
and of the kingdom of Kent whence she came, is this: “He took from
the southern parts a faithful wife, of excellent disposition, of
illustrious origin, endowed with all the virtues of the holy faith.” We
shall have, at a later stage, to remark upon the silence with which
Wessex also was treated by Alcuin.
It is quite true that the facts of the greater part of the poem are
taken from Bede. But it is of much interest to note the selection

Full Ebook of Structural Equation Modeling For Health and Medicine 1St Edition Douglas Gunzler Online PDF All Chapter

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Full Ebook of Structural Equation Modeling For Health and Medicine 1St Edition Douglas Gunzler Online PDF All Chapter

Uploaded by

Copyright:

Available Formats

Structural Equation Modeling for Health

and Medicine 1st Edition Douglas

Handbook of Structural Equation Modeling 2nd Edition

Principles and Practice of Structural Equation Modeling

Composite Based Structural Equation Modeling Analyzing

A Beginner s Guide to Structural Equation Modeling 5th

Structural Equation Modeling Using R/SAS: A Step-by-

Computer Vision for Structural Dynamics and Health

How Modeling Can Inform Strategies to Improve

In Quest of the Craft Economic Modeling for the 21st

For more information about this series, please visit: https://www.routledge.com/

and by CRC Press

© 2021 Taylor & Francis Group, LLC

CRC Press is an imprint of Taylor & Francis Group, LLC

ISBN: 9781138574250 (hbk)

2 Vocabulary, Concepts and Usages of Structural Equation Modeling........................ 17

2.7 Direct, Indirect and Total Effects.............................................................................. 30

Part II Theory of Structural Equation Modeling

3 The Form of Structural Equation Models........................................................................ 41

4 Model Estimation and Evaluation..................................................................................... 61

5 Model Identifability and Equivalence ............................................................................ 87

Part III Applications and Examples of Structural Equation

7 Measurement Models for Patient-Reported Outcomes and

7.8 Formative Constructs ............................................................................................... 138

8 Exploratory Factor Analysis.............................................................................................. 147

9 Mediation and Moderation............................................................................................... 165

9.9 Mediation Process Accounting for Moderation.................................................... 185

10 Measurement Bias, Multiple Indicator Multiple Cause Modeling and

11 Latent Class Analysis......................................................................................................... 213

11.5.4 Should One Hold Out a Portion of the Sample as a Validation

12 Latent Profle Analysis ...................................................................................................... 235

13 Structural Equation Modeling with Longitudinal Data ............................................ 249

14 Growth Mixture Modeling............................................................................................... 269

15 Special Topics ...................................................................................................................... 283

Index ............................................................................................................................................. 293

Name Uppercase Lowercase

1.1 An Overview of the Material in This Textbook

• The book covers basic, intermediate and advanced SEM topics.

1.2 Introduction to Structural Equation Modeling

1.2.1 Path Diagrams, Confirmatory Factor Analysis and Path Analysis

1.2.2 How Do Classic Approaches to SEM Analysis Work?

1.2.3 First- and Second-Generation SEM

• acknowledging and modeling forms of measurement error;

1.3 Introduction to Causal Assumptions and Path Diagrams

is hypothesized to be the cause of an outcome that occurs subsequently in time and is

1.3.1 A Note about Error Terms in Path Diagrams

1.3.2 Path Analysis Model

1.3.3 Full Structural Equation Model

1.4 Brief History of SEM

ORIGIN OF PATH ANALYSIS (AND PATH DIAGRAMS)

1.5 Health and Medical Research Studies

Under ideal circumstances, experimental research might allow a researcher to draw

1.5.1 SEM in Health and Medicine

1.5.2 A Contrarian View of SEMs: Can Causal Claims Be

2.1 Introduction to the Vocabulary, Concepts and

Rectangle or square Observed variable

Arrows with direction between variables A and B 1. A causes B

Exogenous variable An independent variable that is only a causal

TABLE 2.1 (Continued)

2.2 Latent Variables

2.2.1 Factor Analysis

2.2.2 Principal Component Analysis

We in the diocese of Bristol have a special right to study and to