PRECEDE-PROCEED
Encyclopedia
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. 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, an acronym for Predisposing, Reinforcing and Enabling Constructs in Educational Diagnosis and Evaluation) and an “ecological diagnosis” (PROCEED, for Policy, Regulatory, and Organizational Constructs in Educational and Environmental Development). This model is multidimensional, and founded in the social/behavioral sciences, epidemiology, administration and education. The systematic utilization of the framework in a series of clinical and field trials confirmed the utility and predictive validity of the model as a planning tool (e.g. Green, Levine, & Deeds).
In the early 1990’s The National Center for Chronic Disease Prevention and Health Promotion at the Centers for Disease Control and Prevention
(CDC, US Department of Health and Human Services) gave additional national prominence to the PRECEDE model. Dr. Marshall Kreuter, Director of the Division of Chronic Disease Control and Community Intervention and his staff adapted and incorporated PRECEDE within a model planning process offered with federal technical assistance to state and local health departments for work with their coalitions to plan and evaluate health promotion programs. The CDC model was called PATCH, for Planned Approach to Community Health. The relevance of this initiative to the application of PRECEDE and the inspiration for some of the extension of the model to incorporate PROCEED dimensions is detailed in a special issue of the Journal of Health Education .
In 1991, PROCEED was added to the framework in consideration of the growing recognition of the expansion of health education to encompass policy, regulatory and related ecological/environmental factors in determining health and health behaviors. As health-related behaviors such as smoking, and alcohol abuse increased or became more resistant to change, so did the recognition that these behaviors are influenced by factors such as the media, politics, and businesses, which are outside the direct control of the individuals. Hence more ecological methods were needed to identify and influence these environmental and social determinants of health behaviors. With the emergence and rapid growth in the field of genetics, the Precede-Proceed model was revised also in 2005 to include and address the growing knowledge in this field.
Please click on the following link on Dr. Green's website to see a graphical representation of the model.
PHASE 1 - SOCIAL DIAGNOSIS
The first stage in the program planning phase deals with identifying and evaluating the social problems that have an impact on the quality of life of a population of interest. Social assessment is the “application, through broad participation, of multiple sources of information, both objective and subjective, designed to expand the mutual understanding of people regarding their aspirations for the common good”. During this stage, the program planners try to gain an understanding of the social problems that affects the quality of life of the community and its members, their strengths, weaknesses, and resources; and their readiness to change. This is done through various activities such as developing a planning committee, holding community forums, and conducting focus groups, surveys, and/or interviews. These activities will engage the audience in the planning process and the planners will be able to see the issues just as the community sees those problems.
PHASE 2 – EPIDEMIOLOGICAL, BEHAVIORAL, AND ENVIRONMENTAL DIAGNOSIS
Epidemiological diagnosis – Epidemiological assessment deals with determining and focusing on specific health issue(s) of the community, and the behavioral and environmental factors related to prioritized health needs of the community. Based on these priorities, achievable program goals and objectives for the program being developed are then established. Epidemiological assessment may include secondary data analysis or original data collection. Examples of epidemiological data include vital statistics, state and national health surveys, medical and administrative records etc. Genetic factors, although not directly changeable through a health promotion program, are becoming increasingly important in understanding health problems and counseling people with genetic risks. They may be useful in identifying high-risk groups for intervention.
Behavioral diagnosis – This is the analysis of behavioral links to the goals or problems that are identified in the social or epidemiological diagnosis. The behavioral ascertainment of a health issue is understood firstly through those behaviors that exemplify the severity of the disease (e.g. tobacco use among teenagers). Secondly, through the behavior of the individuals who directly affect the individual at risk (e.g. parents of the teenagers who keep cigarettes at home), and thirdly, through the actions of the decision-makers that affects the environment of the individuals at risk (e.g. law enforcement actions that restrict the teen’s access to cigarettes). Once behavioral diagnosis is completed for each health problem identified, the planner is able to develop more specific and effective interventions.
Environmental diagnosis – This is a parallel analysis of social and physical environmental factors other than specific actions that could be linked to behaviors. In this assessment, environmental factors beyond the control of the individual are modified to influence the health outcome. For example, poor nutritional status among school children may be due to the availability of unhealthful foods in school. This may require not only educational interventions, but also additional strategies like influencing the behaviors of the school’s food service managers.
Phase 3 - EDUCATIONAL AND ECOLOGICAL DIAGNOSIS
Once the behavioral and environmental factors are identified and interventions are selected, the planners start to work on selecting factors that if modified, will be most likely to result in behavior change and sustain this change process. These factors are classified as predisposing factors, enabling factors, and reinforcing factors. Predisposing factors are any characteristics of a person or population that motivates behavior prior to or during the occurrence of that behavior. They include an individual’s knowledge, beliefs, values, and attitudes. Enabling factors are those characteristics of the environment that facilitate action and any skill or resource required to attain specific behavior. They include programs, services, availability and accessibility of resources, or new skills required to enable behavior change. Reinforcing factors are rewards or punishments following or anticipated as a consequence of a behavior. They serve to strengthen the motivation for behavior. Some of the reinforcing factors include social support, peer support, etc.
Phase 4 - ADMINISTRATIVE AND POLICY DIAGNOSIS
This phase focuses on the administrative and organizational concerns, which must be addressed prior to program implementation. This includes assessment of resources, development and allocation of budget, looking at organizational barriers, and coordination of the program with all other departments, including external organizations and the community. These are detailed further in Green & Ottoson.
Administrative Diagnosis - to assess policies, resources, circumstances, prevailing organizational situations that could hinder or facilitate the development of the health program.
Policy Diagnosis - to assess the compatibility of the program goals and objectives with those of the organization and its administration; does it fit into the mission statements, rules and regulations that are needed for the implementation and sustainability of the program.
Phase 5 - IMPLEMENTATION OF THE PROGRAM
Phase 6 - PROCESS EVALUATION is used to evaluate the process by which the program is being implemented. That is, this phase determines whether the program being implemented according to the protocol.
Phase 7 - IMPACT EVALUATION measures the effectiveness of the program with regards to the intermediate objectives as well as the changes in predisposing, enabling, and reinforcing factors.
Phase 8 - OUTCOME EVALUATION measures change in terms of overall objectives and changes in health and social benefits or the quality of life. That is, it determines the effect the program had in the health and quality of life of the community.
Lawrence W. Green
Lawrence W. Green is best known by health education researchers as one of the developers of the PRECEDE-PROCEED Model, which has been used throughout the world to guide health program intervention design, implementation, and evaluation and has led to published studies, applications and...
. 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. 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, an acronym for Predisposing, Reinforcing and Enabling Constructs in Educational Diagnosis and Evaluation) and an “ecological diagnosis” (PROCEED, for Policy, Regulatory, and Organizational Constructs in Educational and Environmental Development). This model is multidimensional, and founded in the social/behavioral sciences, epidemiology, administration and education. The systematic utilization of the framework in a series of clinical and field trials confirmed the utility and predictive validity of the model as a planning tool (e.g. Green, Levine, & Deeds).
Brief history and purpose of the model
The PRECEDE framework was first developed and introduced in the 1970s by Green and colleagues. PRECEDE is based on the premise that, just as a medical diagnosis precedes a treatment plan, an educational diagnosis of the problem is very essential before developing and implementing the intervention plan. Predisposing factors include knowledge, attitudes, beliefs, personal preferences, existing skills, and self-efficacy towards the desired behavior change. Reinforcing factors include factors that reward or reinforce the desired behavior change, including social support, economic rewards, and changing social norms. Enabling factors are skills or physical factors such as availability and accessibility of resources or services that facilitate achievement of motivation to change behavior. The model has led to more than 1000 published studies, applications and commentaries on the model in the professional and scientific literature.In the early 1990’s The National Center for Chronic Disease Prevention and Health Promotion at the Centers for Disease Control and Prevention
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention are a United States federal agency under the Department of Health and Human Services headquartered in Druid Hills, unincorporated DeKalb County, Georgia, in Greater Atlanta...
(CDC, US Department of Health and Human Services) gave additional national prominence to the PRECEDE model. Dr. Marshall Kreuter, Director of the Division of Chronic Disease Control and Community Intervention and his staff adapted and incorporated PRECEDE within a model planning process offered with federal technical assistance to state and local health departments for work with their coalitions to plan and evaluate health promotion programs. The CDC model was called PATCH, for Planned Approach to Community Health. The relevance of this initiative to the application of PRECEDE and the inspiration for some of the extension of the model to incorporate PROCEED dimensions is detailed in a special issue of the Journal of Health Education .
In 1991, PROCEED was added to the framework in consideration of the growing recognition of the expansion of health education to encompass policy, regulatory and related ecological/environmental factors in determining health and health behaviors. As health-related behaviors such as smoking, and alcohol abuse increased or became more resistant to change, so did the recognition that these behaviors are influenced by factors such as the media, politics, and businesses, which are outside the direct control of the individuals. Hence more ecological methods were needed to identify and influence these environmental and social determinants of health behaviors. With the emergence and rapid growth in the field of genetics, the Precede-Proceed model was revised also in 2005 to include and address the growing knowledge in this field.
Description of the model
The Precede-Proceed planning model consists of four planning phases, one implementation phase, and 3 evaluation phases.Please click on the following link on Dr. Green's website to see a graphical representation of the model.
| PRECEDE Phases | PROCEED Phases |
|---|---|
| Phase 1 - Social Diagnosis | Phase 5 - Implementation |
| Phase 2 – Epidemiological, Behavioral & Environmental Diagnosis | Phase 6 - Process Evaluation |
| Phase 3 - Educational & Ecological Diagnosis | Phase 7 - Impact Evaluation |
| Phase 4 - Administrative & Policy Diagnosis | Phase 8 - Outcome Evaluation |
PHASE 1 - SOCIAL DIAGNOSIS
The first stage in the program planning phase deals with identifying and evaluating the social problems that have an impact on the quality of life of a population of interest. Social assessment is the “application, through broad participation, of multiple sources of information, both objective and subjective, designed to expand the mutual understanding of people regarding their aspirations for the common good”. During this stage, the program planners try to gain an understanding of the social problems that affects the quality of life of the community and its members, their strengths, weaknesses, and resources; and their readiness to change. This is done through various activities such as developing a planning committee, holding community forums, and conducting focus groups, surveys, and/or interviews. These activities will engage the audience in the planning process and the planners will be able to see the issues just as the community sees those problems.
PHASE 2 – EPIDEMIOLOGICAL, BEHAVIORAL, AND ENVIRONMENTAL DIAGNOSIS
Epidemiological diagnosis – Epidemiological assessment deals with determining and focusing on specific health issue(s) of the community, and the behavioral and environmental factors related to prioritized health needs of the community. Based on these priorities, achievable program goals and objectives for the program being developed are then established. Epidemiological assessment may include secondary data analysis or original data collection. Examples of epidemiological data include vital statistics, state and national health surveys, medical and administrative records etc. Genetic factors, although not directly changeable through a health promotion program, are becoming increasingly important in understanding health problems and counseling people with genetic risks. They may be useful in identifying high-risk groups for intervention.
Behavioral diagnosis – This is the analysis of behavioral links to the goals or problems that are identified in the social or epidemiological diagnosis. The behavioral ascertainment of a health issue is understood firstly through those behaviors that exemplify the severity of the disease (e.g. tobacco use among teenagers). Secondly, through the behavior of the individuals who directly affect the individual at risk (e.g. parents of the teenagers who keep cigarettes at home), and thirdly, through the actions of the decision-makers that affects the environment of the individuals at risk (e.g. law enforcement actions that restrict the teen’s access to cigarettes). Once behavioral diagnosis is completed for each health problem identified, the planner is able to develop more specific and effective interventions.
Environmental diagnosis – This is a parallel analysis of social and physical environmental factors other than specific actions that could be linked to behaviors. In this assessment, environmental factors beyond the control of the individual are modified to influence the health outcome. For example, poor nutritional status among school children may be due to the availability of unhealthful foods in school. This may require not only educational interventions, but also additional strategies like influencing the behaviors of the school’s food service managers.
Phase 3 - EDUCATIONAL AND ECOLOGICAL DIAGNOSIS
Once the behavioral and environmental factors are identified and interventions are selected, the planners start to work on selecting factors that if modified, will be most likely to result in behavior change and sustain this change process. These factors are classified as predisposing factors, enabling factors, and reinforcing factors. Predisposing factors are any characteristics of a person or population that motivates behavior prior to or during the occurrence of that behavior. They include an individual’s knowledge, beliefs, values, and attitudes. Enabling factors are those characteristics of the environment that facilitate action and any skill or resource required to attain specific behavior. They include programs, services, availability and accessibility of resources, or new skills required to enable behavior change. Reinforcing factors are rewards or punishments following or anticipated as a consequence of a behavior. They serve to strengthen the motivation for behavior. Some of the reinforcing factors include social support, peer support, etc.
Phase 4 - ADMINISTRATIVE AND POLICY DIAGNOSIS
This phase focuses on the administrative and organizational concerns, which must be addressed prior to program implementation. This includes assessment of resources, development and allocation of budget, looking at organizational barriers, and coordination of the program with all other departments, including external organizations and the community. These are detailed further in Green & Ottoson.
Administrative Diagnosis - to assess policies, resources, circumstances, prevailing organizational situations that could hinder or facilitate the development of the health program.
Policy Diagnosis - to assess the compatibility of the program goals and objectives with those of the organization and its administration; does it fit into the mission statements, rules and regulations that are needed for the implementation and sustainability of the program.
Phase 5 - IMPLEMENTATION OF THE PROGRAM
Phase 6 - PROCESS EVALUATION is used to evaluate the process by which the program is being implemented. That is, this phase determines whether the program being implemented according to the protocol.
Phase 7 - IMPACT EVALUATION measures the effectiveness of the program with regards to the intermediate objectives as well as the changes in predisposing, enabling, and reinforcing factors.
Phase 8 - OUTCOME EVALUATION measures change in terms of overall objectives and changes in health and social benefits or the quality of life. That is, it determines the effect the program had in the health and quality of life of the community.