PLANNING & EVALUATION I HEALTH PROMOTION-EDUCATION

OEDOJO SOEDIRHAM DEPARTEMEN PKIP-FKM UNAIR SEMESTER 5 A-B 2012/2013

What is PRECEDE-PROCEED?

• The Precede-Proceed model is a framework that helps health program planners, policy makers, and evaluators analyze the situation and design a health program efficiently. This planning model was initiated as a cost-benefit evaluation framework by Dr. Lawrence W. Green. It provides a comprehensive structure for assessing health and quality of life needs and for designing, implementing, and evaluating health promotion and other public health programs to meet those needs.

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What is PRECEDE-PROCEED?

• One purpose and guiding principle of the Precede-Proceed model is to direct initial attention to outcomes rather than inputs. It guides planners through a process that starts with desired outcomes and works backwards in the causal chain to identify a mix of strategies for achieving objectives. The most fundamental assumption of the model is the active participation of its intended audience – that is, the participants will take an active part in defining their own problems, establishing their goals, and developing their solutions.

• In this framework, health behavior is regarded as being influenced by both individual and environmental factors, and hence it has two distinct parts: an “educational diagnosis” (PRECEDE) and an “ecological diagnosis” (PROCEED) 4/27/2020 OEDOJO SOEDIRHAM ([email protected]) 3

What is PRECEDE-PROCEED?

• Like most of the other models we’ll examine in this chapter, PRECEDE-PROCEED was developed for use in public health. Its basic principles, however, transfer to other community issues as well. As a result, we’ll treat it as a model not just for health intervention, but for community intervention in general. And in fact, PRECEDE/ PROCEED focuses on the community as the wellspring of health promotion.

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• In the latter half of the 20 th Century, as medical advances eliminated many infectious diseases, the leading causes of disability and death in the developed world changed to chronic conditions – heart disease, stroke, cancer, diabetes. The focus of health maintenance, therefore, shifted from the treatment of disease to the prevention of these conditions, and, more recently, to the active promotion of behaviors and attitudes – proper diet, exercise, and reduction of stress, for instance – that in themselves do much to maintain health and improve the length and quality of life.

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Behind PRECEDE-PROCEED lie some assumptions about the prevention of illness and promotion of health, and, by extension, about other community issues as well. These include:

1. Since the health-promoting behaviors and activities that individuals engage in are almost always voluntary, carrying out health promotion has to involve those whose behavior or actions

you want to change. PRECEDE-PROCEED should be a participatory process, involving all stakeholders – those affected by the issue or condition in question – from the beginning.

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2. Health is, by its very nature, a community

issue. It is influenced by community attitudes, shaped by the community environment (physical, social, political, and economic), and colored by community history. 4/27/2020 OEDOJO SOEDIRHAM ([email protected]) 7

3. Health is an integral part of a larger context, probably most clearly defined as quality of

life, and it’s within that context that it must be considered. It is only one of many factors that make life better or worse for individuals and the community as a whole. It therefore influences, and is influenced by, much more than seems directly connected to it. 4/27/2020 OEDOJO SOEDIRHAM ([email protected]) 8

4. Finally, health is more than physical well being, or than the absence of disease,

illness, or injury. It is a constellation of factors – economic, social, political, ecological, and physical – that add up to healthy, high-quality lives for individuals and communities. 4/27/2020 OEDOJO SOEDIRHAM ([email protected]) 9

• PRECEDE and PROCEED are acronyms (words in which each letter is the first letter of a word). PRECEDE stands for

P

redisposing,

R

einforcing, and

E

nabling

C

onstructs in

E

ducational/

E

nvironmental

D

iagnosis and

E

valuation. As its name implies, it represents the process that precedes, or leads up to, an intervention.

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• PROCEED spells out

P

olicy,

R

egulatory, and

O

rganizational

C

onstructs in

E

ducational and

E

nvironmental

D

evelopment, and, true to its name as well, describes how to proceed with the intervention itself.

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FIGURE 1

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• • Phase 3: Identifying the predisposing, enabling, and reinforcing factors that can affect the behaviors, attitudes, and environmental factors given priority in Phase 2.

Phase 4: Identifying the administrative and policy factors that influence what can be implemented. 4/27/2020 OEDOJO SOEDIRHAM ([email protected]) 13

• A flow chart of the model (see Fig. 1), developed by its originators, shows a circular process. It starts (on the upper right) with a community demographic and quality-of-life survey, and goes counterclockwise through PRECEDE’s four phases that explain how to conceive and plan an effective intervention.

• PROCEED then picks up with the intervention itself (described here as a health program), and works back through the first five phases, evaluating the success of the intervention at addressing each one (The process evaluation in Phase 6 looks at whether the intervention addressed the concerns of Phase 3 as planned. The impact evaluation of Phase 7 examines the impact of the intervention on the behaviors or environmental factors identified in Phase 2.

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• And the Outcome evaluation of Phase 9 explores whether the intervention has had the desired quality of life outcome identified in Phases 1 and 2). Eventually, the process arrives back at the beginning, either having achieved the desired quality of life outcome, or to start over again, incorporating the lessons of the first try. The arrows in the flow chart demonstrate the effects of each phase’s issues on the next one to the right. Since you’re working backwards from the ultimate outcome, effects move to the right. If the chart was demonstrating the direction of analysis, the arrows would point in the opposite direction. 4/27/2020 OEDOJO SOEDIRHAM ([email protected]) 15

Change Theories and Principles by Level of Change

• • •

Community level (most appropriate for

enabling factors

):

– – Participation and relevance Community organization – Community mobilization

Interpersonal level ( most appropriate for

reinforcing factors

):

– Social Cognitive Theory – Adult learning – Interpersonal communication

Individual level (most appropriate for

predisposing factors

):

– – Health Belief Model Stages of Change – – – Theory of Reasoned Action Theory of Planned Behavior Information processing 4/27/2020 OEDOJO SOEDIRHAM ([email protected]) 16

• Predisposing factors: – are antecedents to behavior that provide the rationale or motivation for the behavior” – they include individuals’ knowledge, attitudes, beliefs, personal preferences, existing skills, and self-efficacy beliefs.

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• Reinforcing factors: – are those factors following a behavior that provide continuing reward or incentive for the persistence or repetition of the behavior.

– Examples include social support, peer influence, significant others, and vicarious reinforcement.

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•

Enabling factors:

– are antecedents to behavioral or environmental change that allow a motivation or environmental policy to be realized.

– Enabling factors can affect behavior directly or indirectly through an environmental factor.

– They include programs, services, and resources necessary for behavioral and environmental outcomes to be realized and, in some cases, the new skills needed to enable behavior change.

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• • For example, in a community with high teen pregnancy and sexually transmitted disease (STD) rates, community norms and teen attitudes may support the use of contraception, but teens may not have access to confidential reproductive planning services.

In this case, organizational change theories can provide more effective guidance, as they would suggest ways to enable the delivery of services through on-site school-based clinics or other structures. 4/27/2020 OEDOJO SOEDIRHAM ([email protected]) 20

• In another example, planners of a program to promote bicycle helmet use might learn that children find helmets uncomfortable, fear “looking nerdy,” and believe they won’t get hurt on their bikes. These unfavorable attitudes might be best addressed, from a diffusion theory perspective, by emphasizing the relative advantage, compatibility, and observability attributes of helmet use that would be meaningful to children in the community. Drawing also on SCT, these findings would suggest that social influence plays an important role in both predisposing and reinforcing helmet use. Finally, if children’s personal beliefs are that bike riding is not dangerous, application of a theory such as the HBM will help. The model includes the construct of perceived susceptibility, which would be an important predisposing factor for helmet use in this hypothetical example.

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Phase 4: Administrative and Policy Assessment and Intervention Alignment

• • In Phase 4, the planner selects and aligns the program’s components (that is, interventions) with the priority determinants of change previously identified.

Its purpose is to identify resources, organizational barriers and facilitators, and policies that are needed for program implementation and sustainability.

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• • When creating the program plan, it is important to look at two levels of alignment between the assessment of determinants and the selection of interventions (Green and Kreuter, 2005).

First, at the macro level, the organizational and environmental systems that can affect the desired outcomes should be considered. These are interventions that affect enabling factors for environmental change, which in turn support the desired health behavior or health outcome.

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• Second, at the micro level, the focus is on individual, peer, family, and others who can influence the intended audience’s health behaviors more directly. Interventions at the micro level are specifically directed at changing the predisposing, reinforcing, and enabling factors. There are many available strategies, such as mass and small media, counseling, and advocacy, and the “best” strategy is the one that matches the context of the program, the audience’s needs, and the theory of the problem that the PRECEDE-PROCEED diagnosis has uncovered. Typically, successful programs use multiple strategies to have an effective impact on complex health issues.

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• Green and Kreuter (2005) have drawn on a body of literature about program development to offer recommendations for “intervention matching, mapping, pooling and patching” at this stage of planning (Simons-Morton, Greene, and Gottlieb, 1995; D’Onofrio, 2001).

• Specifically, building a comprehensive program requires – (1) matching the ecological levels to broad program components; – (2) mapping specific interventions based on theory and prior research and practice to specific predisposing, enabling, and reinforcing factors, and – (3) pooling prior interventions and community preferred interventions that might have less evidence to support them, and if necessary, – (4) patching those interventions to fill gaps in the evidence-based

best practices.

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Theory and Phase 4.

• • The mapping of interventions to predisposing, reinforcing, and enabling factors is influenced by theoretical considerations similar to those described in Phase 3, focusing mainly on community-level theories (Table 18.1).

Organizational change theory addresses the processes and strategies for creating and sustaining changes in health policies and procedures that influence the success of health promotion programs.

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CASE STUDY: THE SAFE HOME PROJECT

• • • The SAFE Home Project was an intervention trial aimed at reducing in-home childhood injury risk among low-income, urban families.

The project took place in a pediatric continuity clinic that provided medical care to children living in one of the most impoverished areas of Baltimore City.

This case study describes the application of PRECEDE-PROCEED to the planning, implementation, and evaluation of the project.

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• •

Social and Epidemiological Assessment (Phases 1 and 2)

Injuries occurring in the home and their associated impact on quality of life were defined at the outset (Figure 18.2). This injury focus was driven, in part, by the availability of evidence supporting an injury initiative, professional interest and expertise of the research team, data to support home injuries as a significant public health problem, and the availability of known, effective safety products to minimize injuries.

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• • • The first two phases of PRECEDE-PROCEED—the social and epidemiological assessment—relied heavily on a review of the literature and data on injuries among the intended audience. The prevalence of injuries among children in the local area was documented with a one-year analysis of the hospital database. Input from parents was solicited to confirm that injury prevention was an important topic to families.

Informal surveys in the clinic waiting room were used to ask parents about “things that concern you as a parent,” and child health and safety issues were frequently mentioned.

When asked specifically to rank childhood injury in terms of its overall importance, about half the parents identified it as among their “most important” concerns.

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• These two phases in the process were conducted without drawing on any specific behavior change theory. However, the principles of participation and relevance were used. Parents were engaged in the program planning process through the informal survey in this phase, as well as in subsequent phases.

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Behavioral, Environmental, Educational, and Ecological Assessment (Phases 2 and 3)

• Based on the literature and advice from pediatricians, the most important and most changeable behavioral factors associated with in-home injuries in preschool-age children were found to be a cluster of behaviors, commonly referred to as “childproofing” (Wilson and others, 1991). For falls, burns, and poisonings, this included six safety practices: using stair gates, not using baby walkers, having working smoke alarms, turning down the hot water temperature to less than 125 degrees, keeping poisonous substances locked away, and having syrup of ipecac in the home. (At the time this research was conducted, syrup of ipecac was recommended as a poison-prevention strategy for homes with young children.

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Administrative and Policy Assessment and Implementation (Phases 4 and 5)

• Three distinct yet related interventions were identified: – (1) enhancing pediatricians’ injury-prevention counseling, – (2) developing a clinic-based safety resource center, and – (3) conducting home visits. Administrative and policy aspects of implementing these interventions are described here.

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• •

Enhanced Pediatric Counseling.

Pediatric residents completed five hours of training that covered developmentally appropriate injury-prevention topics (falls, burns, poisonings) to discuss with parents, as well as specific communication skills to use for greater success in improving parents’ adoption of safety behaviors. As a result of the training, residents were expected to provide enhanced anticipatory guidance on injury prevention as a routine part of well-child care.

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•

On-Site Safety Resource Center.

• The safety resource center was intended to reduce barriers of access to and costs of safety supplies—the enabling factors identified in earlier diagnostic phases.

• However, predisposing factors were also addressed because education was provided by a trained health educator at the center. The objectives of the center were to increase the accessibility and affordability of home safety supplies for low income families; to provide personalized, skills-oriented education that reinforces and supplements pediatric advice about child safety, and to elevate the priority given to injury prevention in medical care settings. Parents who came to the Children’s Safety Center received personalized home safety risk assessments and education, and could purchase safety products at reduced cost.

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• Many administrative and organizational constraints surfaced during the planning for this intervention component: space in the clinic for the center; renovation costs for the space, staffing, selecting, and stocking of supplies and educational materials, and access to the center by families who did not receive care in the clinic. A full year of planning was devoted to these issues before the center opened in March 1997 (Mc- Donald and others, 2003).

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• The principles of participation and relevance were high priorities for developing the Children’s Safety Center. Focus groups with parents were conducted to obtain their ideas about the role of the center, the supplies it should carry, and its operating policies and procedures. The notion of “empowerment” also influenced this component of the project. The clinic’s Parent Advisory Board was consulted about plans for the center, and also for the home visit component (described next). Because pediatric residents made referrals to the center, their input was solicited to shape the policies and procedures of the center.

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Home Visits.

• The third intervention—home visits—addressed another recognized enabling factor: skills to adopt childproofing practices. Home visits were conducted by community health workers (CHW), who described and demonstrated appropriate safety practices (such as changing a smoke alarm battery, testing the water temperature) and then allowed mothers to practice and master these skills. The CHWs did not actually install products, due to liability concerns. Throughout the visit, efforts were made to emphasize predisposing factors, such as perceptions of injury risk and seriousness. The CHWs also reinforced education that may have been provided by the pediatrician or health educator in the Children’s Safety Center.

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• The administrative and organizational aspects of implementing this intervention were challenging. Time and commitment from administrative staff were required for training, supervising, and providing for the safety of the CHWs. It was especially important to develop a mechanism to make referrals for housing code violations, because poor housing quality had been identified by parents as a barrier to implementing safety practices.

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• Community empowerment and capacity building were supported by employing health workers from the community where the families lived. Moreover, the tasks of the CHW were informed by the SCT constructs of role modeling and self-efficacy.

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