Design-Ignoring versus Design-Respecting World Models for Epidemiology

World models for epidemiology learn from records shaped by study designs, including assignment, sampling, measurement, and related processes. A model may therefore reconstruct observed trajectories while learning an intervention contrast that depends on how records were collected. We formalize study design as constraints on a world model’s latent-world interface, action mechanism, observation likelihood, and target readout. This distinguishes design-respecting models, which encode these constraints, from design-ignoring models, which fit selected records without relating assignment and observation to the intended intervention question. Using a large scale cluster-randomized test-negative trial, we hold the latent structure and fitting settings fixed and compare a design-ignoring case-count model with a design-respecting test-negative observation model. Both models achieve comparable factual reconstruction. Yet across 500 paired resampling experiments at 80%, 60%, and 40% relative sampling intensity, median contrast changes are −19.96%, −41.06%, and −60.98% for the design-ignoring model, versus −0.95%, −3.00%, and −5.32% for the design-respecting model. The same qualitative separation holds when sampling also varies across clusters. Thus, factual reconstruction alone does not establish design alignment; testing whether fitted contrasts preserve design-implied observation-process invariances provides a sharper evaluation.