PRECEDE-PROCEED is a planning model designed by Lawrence Green and Marshall Kreuter for health education and health promotion programs. Its overriding principle is that most enduring health behavior change is voluntary in nature. This principle is reflected in a systematic planning process which seeks to empower individuals with understanding, motivation, and skills and active engagement in community affairs to improve their quality of life. This is also practical: Much research shows that behavior change is most likely and lasting when people have actively participated in decisions about it. In the process, they make healthy choices easier by changing their behavior and by changing the policies and regulations which influence their behavior.
FIGURE 4
PRECEDE-PROCEED*
* Source: Green and Kreuter, 1991.
PRECEDE-PROCEED has nine phases, the first five of which are diagnostic: (1) social diagnosis of the self-determined needs, wants, resources, and barriers to them in the target community; (2) epidemiological diagnosis of the health problems; (3) behavioral and environmental diagnosis of the specific behaviors and environmental factors for the program to address; (4) educational and organizational diagnosis of the predisposing, enabling, and reinforcing conditions which immediately affect behavior; and (5) administrative and policy diagnosis of the resources needed and available in the organization, as well as the barriers and supports available in the organization and community.
TABLE 9
PRECEDE-PROCEED as an Organizing Framework for Application of Theory
Diagnostic Phase
THEORY Phase1
Social Diagnosis
Phase 2
Epidemiological Diagnosis
Phase 3
Behavioral & Environmental Diagnosis
Phase 4
Educational & Organizational Diagnosis
Phase 5
Administrative & Policy Diagnosis
Stages of Change x x Health Belief Model x Consumer Information Processing x Social Learning Theory x x Community Organization x x Organizational Change x x Diffusion of Innovations x x
These diagnoses involve research in target communities and the change-initiating organization to identify goals and specific objectives and set priorities among the objectives to be addressed in the program. Each diagnosis identifies objectives and sets priorities among them based on their importance, immediacy, and changeability. The result of all of these diagnoses is a plan with specific objectives and strategies. The assumptions behind the strategies are based on what was learned in the diagnostic phases about key causes and factors contributing to problems or needs; the application of theory, then, is useful in pinpointing which factors to examine within each diagnostic category. The plan leads right back to the end-goal: meeting the community's self-determined needs and wants.
The four remaining phases in PRECEDE-PROCEED are implementation and evaluation (process, impact, and outcome), with emphasis on using the latter to improve the former. Evaluation of the process begins as soon as implementation does, in order to detect problems early so they can be corrected. As implementation proceeds, the planner starts evaluating in the order in which program effects are expected. First, its immediate effects (impacts) are evaluated, in order to determine the extent to which the program needs modification. Finally, when enough time has passed--as specified in the objectives--the ultimate intended effects on morbidity, mortality, and quality of life are assessed. This kind of phased evaluation allows you to see what works and what does not.
To use PRECEDE-PROCEED as an organizing framework for application of theory, it is first important to reflect on which phases have the closest parallels to theories at the individual, interpersonal, and community levels. As Table 1 shows, the application of theories discussed in this guide is clustered around Phases 3, 4, and 5: behavioral and environmental diagnosis; educational and organizational diagnosis; and administrative and policy diagnosis. Community organization also relates to Phase 1, social diagnosis. None of the theories is especially informative for epidemiological diagnosis, where straightforward descriptive epidemiology is most pertinent. Still, community organization might come into play when it comes to setting priorities among existing health problems.
Theory is most likely to be informative during Phase 4 of the planning process suggested by PRECEDE-PROCEED, or the educational and organizational diagnosis. This phase focuses on examining factors that shape behavioral actions, and environmental factors. Behavioral actions--such as reducing intake of dietary fat, engaging in routine physical activity, and obtaining annual mammograms--are shaped by predisposing, reinforcing, and enabling factors, many of which are amenable to change. Environmental factors--such as availability of prevention services, hazardous workplace conditions, and reimbursement for cancer screening--are influenced primarily by enabling factors.
Suppose you were planning chronic disease intervention programs to reduce cancer risk. Those programs can only be effective if they influence the precursors to behaviors (or environments); and to influence those precursors, you must first be able to identify them.
Theories help guide the examination of predisposing, enabling, and reinforcing factors. For example, the Health Belief Model targets certain kinds of beliefs that might lead a woman to get a mammogram, or to avoid one--her perception of her chances of developing cancer (susceptibility), and how serious she thinks cancer would be (severity); both are predisposing factors. Other HBM constructs relate to benefits of and barriers to screening. A potential benefit would be reassurance that she does not have cancer (a reinforcing factor); and the lack of insurance coverage for screening mammography might be a barrier (negative enabling factor). By finding out how important each of these factors is to her behavior, program planners might prioritize the importance of a message (for example, about personal susceptibility) or an administrative intervention (such as providing low- or no-cost screening, or changing insurance coverage). The best way to do this is by gathering information directly from women in that group (market segment); a next-best approach is to learn through reading the research literature on women with similar characteristics.
PRECEDE-PROCEED and Social Marketing are both comprehensive planning systems based on the needs of the people or community to be served. Both start with extensive research and analysis to assess those needs, planning backwards from the needs to steps which will meet them. Both deal with the individuals to be served--(health) consumers--and with others who have resources or influence on them, such as channels of distribution or "intermediaries" and "partners," including community leaders, media decision makers, parents, peers, teachers, and health professionals. Both use this analysis to focus on specific levers which might best influence the desired behavior. Levers are sought among predisposing factors such as motives, reinforcing factors such as rewards, and enabling factors or barriers. Both use this analysis to focus on specific, realistic behavioral objectives which can be measured for evaluation. And both use research to help create and refine the program elements continually. Finally, both provide ample opportunities for the use of multiple theories and methods.
