Table of Contents |
In the latter half of the 20th century, many infectious diseases were eliminated due to medical advances. The leading causes of death and disability then changed to chronic conditions like heart disease, stroke, cancer, and diabetes. There was a shift from the treatment of disease maintenance to the prevention of these conditions and, more recently, to the active promotion of behaviors and attitudes like exercise, healthy diet, smoking prevention or cessation, and stress reduction, which do much more to improve the length and quality of life (Community Tool Box, 2014).
Recall that there are phases to program planning and models or frameworks that planners can use to guide community programming to address issues like chronic conditions. In this course, the MAPP model and logic models were previously mentioned as tools to assist in programming. Much of what happens with a community program begins in the preplanning phase. Here, the community assesses priority issues, studies the data from the assessments, recruits partners, considers strategies, decides which program might be best suited to address the identified priorities, and decides how to fund the program. The evaluation of the program was also discussed as a key planning tool so that the effectiveness of the processes and outcomes can be measured and mapped to the goals and objectives established during the preplanning and planning phases.
One commonly used model in community health programming is the PRECEDE-PROCEED model. PRECEDE is an acronym for predisposing, reinforcing, and enabling constructs in educational/ecological diagnosis and evaluation (McKenzie et al., 2017, p. 48). PROCEED is an acronym for policy, regulatory, and organizational constructs in educational and environmental development. Since the PRECEDE model was developed by Dr. Lawrence Green in 1974, and expanded by Dr. Marshall Kreuter to add PROCEED in 1991, hundreds of papers have been published citing evidence of the effectiveness of using this model to improve health outcomes. It is the oldest and most enduring planning model that is used in health promotion (McKenzie et al., 2017, p. 48). Phases 1–4 of the PRECEDE portion of the model are assessments of circumstances surrounding the need for a program or intervention. The results of these assessments lead program planners to diagnose and evaluate the factors that influence health behaviors and conditions before implementing an intervention.
Behind the PRECEDE-PROCEED model are some assumptions about the prevention of illness and health promotion. One assumption is that health-promoting behaviors and activities are always voluntary, as people can choose to lead a healthy lifestyle. Therefore, health promotion activities should target those whose behaviors you want to change, which is to say, those who choose not to participate in healthy lifestyles. This model is intended to be a participatory process that includes partners affected by the issue. Another assumption is that health, by its nature, is a community issue. It is influenced by community attitudes, environment, and community history.
The image below depicts the PRECEDE-PROCEED MODEL graphically. One reason to use this type of logic model is that it is a structure with which to plan the work. The process begins with Phase 1 in the PRECEDE part of the model at the top of the image and continues with the PROCEED part of the model across the bottom, beginning with Phase 5. By using a structure, planners are more likely to develop a coherent plan that targets identified issues. The advantage of a logic model like this one is that it guides planners in exactly what to do; if planners follow the directions, a procedure to develop an intervention will result. However, if some part of the model isn’t appropriate for the setting or the circumstances, adaptation may be needed, or there is a risk of a problem.
The originators of this model indicate that planners must follow the model with fidelity. Fidelity refers to when planners follow a model, or evidence-based program or intervention components, exactly as developed, written, and intended. Adaptation refers to making changes in evidence-based programs where needed to better fit the setting or circumstances while still attempting to implement the program’s core components with fidelity. Adaptations can include changes related to the language, culture, race, religious traditions, or literacy level of the target audience (Nolt & Leviton, 2023).
The PRECEDE component of the framework focuses on planning and includes four phases. PRECEDE Phase 1 is social assessment, which means identifying the social problems and needs of a population and determining the desired quality of life outcomes related to education, employment, and social support. Phase 2, the epidemiological assessment, helps determine health issues that contribute to the social problems identified in the first phase. This includes analyzing data on disease prevalence, mortality rates, and other health indicators. This includes CHNA data. Phase 3, the educational and ecological assessment, refers to analyzing behavioral and environmental factors that influence health. It includes identifying predisposing factors (knowledge, attitudes, and beliefs), enabling factors (resources and skills), and reinforcing factors (social support and rewards) that affect health behaviors. The final phase of PRECEDE, Phase 4, is the administrative and policy assessment and intervention alignment, which involves identifying policies, resources, and organizational structures that can support or hinder the development and implementation of the health program or intervention (Rural Health Information Hub, 2011). These phases of PRECEDE collectively help in creating a comprehensive understanding of the community’s health needs and the factors that influence them, which is essential for designing effective health promotion programs or interventions. Recall that PRECEDE is an acronym for predisposing, reinforcing, and enabling constructs in educational/ecological assessment and evaluation. It is imperative to understand these factors to understand and apply the model effectively.
Predisposing factors are elements that influence an individual’s motivation to engage in a particular behavior, whether healthy or unhealthy, like smoking or physical activity. In the context of health behavior, an antecedent to a predisposing factor refers to something that comes before and influences the development of that predisposing factor. Predisposing factors represent “why” individuals might engage in a future health behavior and include knowledge, which is what individuals know about the health issue. Essentially, an antecedent is prior condition or event that shapes the predisposing factors, which in turn affect individuals’ motivation to engage in a particular health behavior.
EXAMPLE
Cultural norms can be an antecedent to beliefs about health behaviors and early childhood experiences that might shape attitudes toward physical activity.
Also, beliefs are predisposing factors that refer to what individuals believe to be true about the health issue and its consequences. Values, another predisposing factor, refers to the importance individuals place on health and related behaviors, and perceptions are how individuals perceive their ability to perform the behavior and the potential outcomes. These factors are crucial because they shape the initial willingness or reluctance of individuals to adopt healthy or unhealthy behaviors. Understanding them helps in designing effective health promotion interventions that address these underlying motivations.
IN CONTEXT
Predisposing Factors to Teen Tobacco Use
There are several predisposing factors that can influence the health behavior of teen tobacco use. They include parental influence, which suggests that teens are more likely to start smoking if their parents smoke or have nicotine dependence. Peer pressure refers to having friends who smoke, which can significantly increase the likelihood of a teen starting to smoke. Teens from lower socioeconomic backgrounds are also predisposed to start smoking. Mental health conditions such as depression and anxiety can predispose teens to tobacco use as a coping mechanism. Exposure to smoking through media exposure (e.g., movies and social media) can also predispose teens to tobacco use. Poor academic performance, weight concerns, and low self-esteem can also predispose teens to tobacco use. Understanding these predisposing factors can help in creating strategies to prevent teen smoking (Bramlet, 2015).
Enabling factors are those that facilitate or hinder the adoption of healthy or unhealthy behaviors. These are factors that make it easier or harder (the “how” antecedent for the behavior) for individuals to adopt and maintain healthy or unhealthy behaviors. Some examples are access to health care services, the availability of resources, affordability, skills and knowledge, social support, policies and regulations, and the physical environment. They facilitate or hinder the actual performance of the behavior.
EXAMPLE
Having a nearby gym (enabling factor) makes it easier to exercise regularly.Cultural attitudes and norms can either support or discourage healthy behaviors. For example, cultures that value physical fitness may have higher rates of exercise. The difference between predisposing factors and enabling factors is that predisposing factors are about “why” an individual might engage in a health behavior (motivation and intention), while enabling factors are about the “how” (practical means and resources to perform the behavior).
IN CONTEXT
Enabling Factors of Teen Tobacco Use
In the context of teen smoking, enabling factors are elements that make it easier or harder for teens to start and continue smoking. One of these enabling factors is access to cigarettes; teens who can easily obtain cigarettes from stores, friends, or family members are more likely to start smoking. Lack of enforcement of tobacco laws is also an enabling factor. Weak enforcement of laws that prohibit the sale of tobacco to minors can make it easier for teens to purchase cigarettes. Teens from lower socioeconomic backgrounds may have higher smoking rates due to stress, lack of resources for healthy alternatives, and targeted marketing (product marketing directed specifically at teens) by tobacco companies. Schools and communities without strong antismoking policies or programs may inadvertently enable smoking by not providing adequate education or support for prevention. Parents who smoke and leave cigarettes around the house or who do not keep track of their cigarettes enable teen smoking by providing easy access to cigarettes and by not setting clear expectations. Friends who smoke can provide access to cigarettes, making it easier for teens to start smoking. Addressing these enabling factors is crucial to designing effective interventions to reduce teen smoking. By understanding and mitigating these factors, communities can create environments that discourage smoking and support healthier choices for teens.
Reinforcing factors are elements that follow a behavior and provide continued reward or incentive for maintaining a healthy or unhealthy behavior. These include social support like encouragement and assistance from family, friends, and peers. These are largely about the people and community attitudes that support or make it difficult to adopt healthy or unhealthy behaviors. Financial incentives or benefits that promote the desired behavior are also reinforcing factors. Changing social norms are shifts in societal expectations and attitudes that support the behavior change, also reinforcing healthy or unhealthy behavior. An intervention might target the people and groups involved in social norms or societal expectations. These factors play an important role in ensuring that the behavior change is sustained over time (Community Tool Box, 2014).
IN CONTEXT
Reinforcing Factors of Teen Tobacco Use
Reinforcing factors related to teen smoking include elements that either encourage or discourage the continuation of smoking among teens. Positive reinforcement from peers who do not smoke can encourage teens who smoke to quit and support teens who have not started. If family members smoke or have a permissive attitude toward smoking, teens may feel supported in their behavior. The same is true for not smoking. If family members do not smoke, and their attitude toward smoking is that it’s harmful, then teens may feel supported in their behavior and attitude not to smoke.
There are some disadvantages to using the PRECEDE-PROCEED model. It is resource intensive, which means that implementing the model requires significant resources, including time, money, and personnel. This can be challenging for organizations with limited budgets. The model relies heavily on data collection and analysis to inform each of the phases, which is difficult in settings where data are scarce or hard to obtain. However, accurate and comprehensive data are crucial for the model’s effectiveness. Finally, there is sometimes too much emphasis on implementing programs and too little on designing interventions that strategically meet the needs of the community. Despite these disadvantages, the PRECEDE-PROCEED model remains a valuable tool for systematic health program planning and evaluation.
Source: THIS TUTORIAL WAS AUTHORED BY SOPHIA LEARNING. PLEASE SEE OUR TERMS OF USE.
Disclaimer: The use of any CDC and United States government materials, including any links to the materials on the CDC or government websites, does not imply endorsement by the CDC or the United States government of us, our company, product, facility, service, or enterprise.
REFERENCES
Bramlet, K. (2015). Teen smoking: 4 risk factors to watch for. The University of Texas MD Anderson Cancer Center. www.mdanderson.org/publications/focused-on-health/FOH-teen-smoking-risk-factors.h18-1589835.html
Community Tool Box. (2014). PRECEDE/PROCEED. ctb.ku.edu/en/table-of-contents/overview/models-for-community-health-and-development/precede-procede/powerpoint
McKenzie, J. F., Neiger, B. L., & Thackeray, R. (2017). Planning, implementing & evaluating health promotion programs (7th ed.). Pearson Education.
Nolt, K. L., & Leviton, L. C. (2023). Fidelity and adaptation of programs: Does adaptation thwart effectiveness? American Journal of Evaluation, 44(3), 322–334. doi.org/10.1177/10982140221138604
Rural Health Information Hub. (2011). PRECEDE-PROCEED model. www.ruralhealthinfo.org/toolkits/health-promotion/2/theories-and-models/precede-proceed
