A Model for Program

Planning in
Health Promotion
PRECEDE - PROCEED

Planning Models: Background

Information
Models serve as frames from which to
build; Provide structure & organization for
the planning process
Many different models
Common elements, but different labels

Background Information (cont.)

No perfect model
Can be used in entirety, parts, & combinations
Three Fs of program planning help with selecting the
appropriate model
Fluidity - steps are sequential
Flexibility - adapt to needs of stakeholders
Functionality - useful in improving health conditions
Categories
Practitioner

driven
Consumer-based

What is PRECEDE/PROCEED?

PRECEDE/PROCEED is a communityoriented, participatory model for creating

successful community health promotion
interventions.

PRECEDE has five phases:

Phase 1: Social diagnosis

Phase 2: Epidemiological diagnosis
Phase 3: Behavioral and environmental
diagnosis
Phase 4: Educational and organizational
diagnosis
Phase 5: Administrative and policy diagnosis

PROCEED has four phases:

Phase 6: Implementation
Phase 7: Process evaluation
Phase 8: Impact evaluation
Phase 9: Outcome evaluation

Assumptions behind
PRECEDE/PROCEED:

Since behavior change is by and large voluntary, health

promotion (and, by extension, the promotion of other
community benefits) is more likely to be effective if its
participatory.
Health and other issues must be looked at in the context
of the community.
Health and other issues are essentially quality-of-life
issues.
Health is itself a constellation of factors that add up to a
healthy life for individuals and communities.

Why use PRECEDE/PROCEED?

A logic model provides a procedural structure for

constructing an intervention.
A logic model provides a framework for critical
analysis.
PRECEDE/PROCEED is participatory, thus assuring
community involvement.
Community involvement leads to community buy-in.
PRECEDE/PROCEED incorporates a multi-level
evaluation, which means you have the chance to
constantly monitor and adjust your evaluation.
The model allows leeway to adapt the content and
methods of the intervention to your particular needs
and circumstances.

How do you use

PRECEDE/PROCEED?

In Phase 1, social diagnosis, you ask the

community what it wants and needs to improve
its quality of life.
In Phase 2, epidemiological diagnosis, you
identify the health or other issues that most
clearly influence the outcome the community
seeks.
In these two phases, you create the objectives
for your intervention.

How do you use

PRECEDE/PROCEED? (cont.)

In Phase 3, behavioral and environmental diagnosis,

you identify the behaviors and lifestyles and/or
environmental factors that must be changed to affect
the health or other issues identified in Phase 2, and
determine which of them are most likely to be
changeable.
In Phase 4, educational and organizational diagnosis,
you identify the predisposing, enabling, and reinforcing
factors that act as supports for or barriers to changing
the behaviors and environmental factors you identified
in Phase 3.
In these two phases, you plan the intervention.

How do you use

PRECEDE/PROCEED? (cont.)

In Phase 5, administrative and policy diagnosis,

you identify (and adjust where necessary) the
internal administrative issues and internal and
external policy issues that can affect the
successful conduct of the intervention.
Those administrative and policy concerns
include generating the funding and other
resources for the intervention.

How do you use

PRECEDE/PROCEED? (cont.)

In Phase 6, implementation, you carry out the

intervention.
In Phase 7, process evaluation, you evaluate the process
of the intervention i.e., you determine whether the
intervention is proceeding according to plan, and adjust
accordingly.
In Phase 8, impact evaluation, you evaluate whether the
intervention is having the intended impact on the
behavioral and environmental factors its aimed at, and
adjust accordingly.
In Phase 9, outcome evaluation, you evaluate whether
the interventions effects are in turn producing the
outcome(s) the community identified in Phase 1, and
adjust accordingly.

Phase 1 - Social Assessment

Assessment means
Identify
Describe
Prioritize

Phase 1 - seeks to subjectively define the QOL

(problems & priorities) of priority population
Self-assessment of needs & aspirations

Phase 2 - Epidemiological
Assessment
Epidemiology - study of the distribution &
determinants of disease
What are the health problems associated
with the desired QOL?
Not all problems health related; If Phase 2
not applicable, skip and move on to Phase
3.

Phase 2: Epidemiological
Assessment
Epidemiological Data:
Mortality
Morbidity
Disability
Fertility
Incidence rates
Prevalence rates

Phase 2: Epidemiological
Assessment

Creating Priorities:
Which

problem has the greatest impact in

terms of death, disease, days lost from work,
rehabilitation costs, disability, family
disorganization, and costs to communities
and agencies for damage repair or loss and
cost recovery?

Phase 2: Epidemiological
Assessment

Creating priorities (continued)

Which

problems are most changeable?

Which problem has the greater potential for
an attractive yield in improved health status,
economic savings and other benefits?

Phase 2: Epidemiological
Assessment

Creating priorities
Are

certain sub-populations such as teenagers,

tourists, elderly, immigrants, at risk?
Which problem is not being addressed by other
agencies in the community?
Is there a need being neglected?
Are any of the problems highly ranked as a
regional or national priority?

Phase 3: Behavioral
Diagnosis

Focuses on behavioral and nonbehavioral causes (personal and

environmental factors) which seem to be
linked to health problems defined in Phase
2

Behavior of Interest May

be
Behavior of the people whose health is in
question, OR
Behavior of those who control resources or
rewards

Community

Leaders

Legislators
Parents
Teachers
Health

Professionals

Environmental or NonBehavioral Factors

Genetic Predisposition
Age
Gender
Existing Disease
Workplace
Adequacy of Health Care Facilities

Environmental Factors
Include

Determinants outside the person that can

be modified to support behavior, health, or
quality of life.
Physical
Social
Economic

Phase 3: Behavioral &

Environmental Diagnosis

Health and environmental factors

identified are the risk factors or risk
conditions that the intervention will be
tailored to affect.

Phase 3: Behavioral &

Environmental Diagnosis
Each factor is rated in terms of its
importance to the health problem
And rated in terms of its changeability

Decision Matrix
More Important

Less Important

More
Changeable

High Priority for

Program Focus

Low Priority Except

to Demonstrate
Change for Political
Purposes

Less
Changeable

Priority for
Innovative
Program;
Evaluation Crucial

No Program

Phase 3: Behavioral &

Environmental Diagnosis

If planners fail at this stage to become

rigorous in identifying and ranking these
factors and how they influence the
outcomes sought, the whole planning
process will collapse under its own weight.

Phase 3: Behavioral &

Environmental Diagnosis
Once target behaviors and conditions are
identified, behavioral objectives are written
Specificity is vital

Phase 3: Behavioral &

Environmental Diagnosis
How many will know, believe, or be able to
do what by when?
How much of what resource will be
available to whom by when?

Phase 4: Educational &

Organizational Diagnosis

Identifies causal factors that must be

changed to initiate and sustain the
process of behavioral and environmental
change identified in Phase 3

Phase 3 - Behavioral &

Environmental Assessment

Behavior of priority population

Determining & prioritizing behavioral &
environmental risk factors or conditions linked to
the health problem
Environmental factors - determinants outside an
individual, that can be modified to support
behavior, health, or QOL
Once identified, must be prioritized

Review of PRECEDE
Model
Predisposing
Factors

Reinforcing
Factors

Enabling
Factors

Phase 4 Educational &

Ecological
Assessment

Predisposing Factors
Knowledge
Attitudes
Values
Beliefs
Perceived Needs and Abilities

Enabling Factors
Environmental and Personal
Resources that impact:
Accessibility, Availability and
Affordability
Programs & Services
Skills
Money & Time
Facilities
Laws

Reinforcing
Positive or Negative Feedback From:
Peers
Family
Health Care Workers
Law Enforcement
The Media
Others

Phase 4: Educational &

Ecological Assessment

After identifying the three types of influencing

factors, assess their relative importance and
changeability
Then related learning and organizational
objectives can be written, and state so that
health promotion programs can focus where
they will do the most good in facilitating
development of or changes in behavior and
environment

Phase 4: Educational &

Ecological Assessment
Theory is applied in this Phase
Predisposing Individual Factors Individual Theories
Enabling Factors Interpersonal Level
Theories
Reinforcing Factors Community Level
and Systems Theories

Phase 5: Administrative and

Policy Diagnosis
Health
Programs

Predisposing
Factors

Health
Education

Reinforcing
Factors

Policy
Regulation
Organization

Enabling
Factors

Phase 5: Administrative and

Policy Diagnosis
Focuses on administrative and
organizational concerns which must be
addressed prior to program
implementation
Includes assessment of resources, budget
development and allocation, development
of implementation timetable, organization
and coordination with others

Phase 5: Administrative
and Policy Diagnosis
Administrative Diagnosis
Analysis of policies, resources and
circumstances prevailing organizational
situations that could hinder or facilitate the
development of the health program Policy
Diagnosis
Assesses the compatibility of your program
goals/objectives with those of the organization
and its administration

Phase 5: Administrative and

Policy Diagnosis
Work in this phase is specific to the
context of the program and the sponsoring
organization(s) and requires political savvy
as much as theoretical or empirical
knowledge
Informed by theories, particularly
community-level theories

Phase 5: Administrative
and Policy Diagnosis
Assess limitations and constraints
Select the best combination of methods
and strategies
Development of organizational and
resource objectives follows

Design a Comprehensive
Intervention

Reducing Drunk and

Drugged Driving by New
Drivers in Montana

What did you include in

your intervention design?
Which Predisposing, Enabling and
Reinforcing Factors did you choose to
change? Why?
What are your impact objectives?

PROCEED Model
Implementation and Evaluation

Phase 6:
Implementation

The act of converting program objectives

into actions through policy changes,
regulation and organization (Green &
Kreuter, 1991, p.432).

Phase 4 - Educational & Ecological

Assessment

Identifies & classifies factors that have potential

to influence behavior or change the environment
Predisposing factors - antecedent; impact
motivation; e.g., knowledge, attitudes , beliefs,
values
Enabling factors - antecedent; barriers & vehicles;
e.g., access, availability
Reinforcing factors - subsequent; feedback &
rewards; e.g., incentives, disincentives
Priorities become focus of intervention

Phase 5 - Administrative &

Policy Assessment
Determine if capabilities & resources
are available to develop & implement
program
Close to the end of PRECEDE & moving
toward PROCEED

Phase 6 - Implementation
Beginning of PROCEED
Selection of methods and strategies of the
intervention, for example, education &/or
other resources
Program begins

Phases 7, 8, & 9 - Evaluation

Process evaluation - measurements of

implementation to control, assure, or improve
the quality of the program
Impact evaluation - immediate observable
effects of program
Outcome evaluation -long-term effects of the
program
Line up with PRECEDE

American Journal of Health Promotion

Predictors of Fat Intake Behavior

Differ Between Normal-weight
and Obese WIC Mothers
Purpose. To determine whether predictors of fat intake behavior were the
same for normal-weight and obese WIC mothers when applying the
PRECEDE-PROCEED model and to identify predictors for each group.
Conclusions. Interventions to modify low-income womens fat intake behavior
might benefit from targeting behavioral predictors that differ with body size.
Messages that emphasize weight control intentions, sensory appeal, and
mood are likely to affect both normal-weight and obese women. Information
about cost of food, availability of time to prepare food, and accessibility to
purchase food is likely to be more effective with obese women.