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THE PRECEDE/PROCEED MODEL
PURPOSE OF MODEL
The PRECEDE model is a framework for the process of systematic development and evaluation of health education programs. An underlying premise of this model is that health education is dependent on voluntary cooperation and participation of the client in a process which allows personal determination of behavioral practices; and that the degree of change in knowledge and health practice is directly related to the degree of active participation of the client. Therefore, in this model, appropriate health education is considered to be the intervention (treatment) for a properly diagnosed problem in a target population.
This model is multidimensional, founded in the social/behavioral sciences, epidemiology, administration and education. As such, it recognizes that health and health behaviors have multiple causations which must be evaluated in order to assure appropriate intervention. The comprehensive nature of PRECEDE allows for application in a variety of settings such as school health education, patient education, community health education, and direct patient care settings.
PROCEED was added to the model in the late 1980s based on L. Green's experience with Marshall Krueter in various positions with the federal government and the Kaiser Family Foundation. PROCEED was added to the framework in recognition of the emergence of and need for health promotion interventions that go beyond traditional educational approaches to changing unhealthy behaviors. The administrative diagnosis is the final planning steps to "precede" implementation. From there "proceed" to promote the plan or policy, regulate the environment, and organize the resources and services, as required by the plan or policy.
The components of PROCEED take the practitioner beyond educational interventions to the political, managerial, and economic actions necessary to make social systems environments more conducive to healthful lifestyles and a more complete state of physical, mental and social well-being for all.
The purpose of the PRECEDE/PROCEED model is to direct initial attention to outcomes rather than inputs. This forces planners to begin the planning from the
outcome point of view. In other words, you as a program planner begin with the desired outcome and work backwards to determine what causes it, what precedes the outcome. Intervention is targeted at the preceding factors that result in the outcome.
The planning process outline in the model rests on two principles:
• The principle of participation, which states that success in achieving change is enhanced by the active participation of members of the target audience in defining their own high-priority problems and goals and in developing and implementing solutions. This principle is derived from the community development root theories and the empowerment education model exemplified by Freire.
• The important role of the environmental factors as determinants of health and health behavior such as media, industry, politics, and social inequities
CIRCUMSTANCES THAT LED TO DEVELOPMENT
Over several decades, many articles have been published with practical implications for health education, but only a few of those have survived long-term analysis and evaluation. Practitioners in various professions have struggled, often without clear guidelines, to systematize their planning, delivery and evaluation of health or educational programs. The PRECEDE/PROCEED framework has been designed to avoid the philosophical trap that has caught previous efforts to codify the practices of health education.
The overriding principle in this approach to health education is that health behavior must be voluntary behavior. Health means different things to different people, serves different purposes for different people, and is more or less important to different people. Because of this it is difficult to justify the imposition of rigid criteria of appropriate health behavior unless a behavior has been judged by society as a whole to be a sufficient hazard to the common good to warrant the curtailment of individual choice.
DESCRIPTION OF THE MODEL:
PRECEDE - the first 5 phases
Phase 1 - Social Diagnosis
Phase 2 - Epidemiological Diagnosis
Phase 3 - Behavioral & Environmental Diagnosis
Phase 4 - Education & Organizational Diagnosis
Phase 5 - Administrative & Policy Diagnosis
PROCEED - the second 4 phases
Phase 6 - Implementation
Phase 7 - Process Evaluation
Phase 8 - Impact Evaluation
Phase 9 - Outcome Evaluation
PHASE 1 - SOCIAL DIAGNOSIS
The focus of this phase is to identify and evaluate the social problems which impact the quality of life of a target population. This requires program planners to gain an understanding of the social problems which affects the quality of life of the patient, consumer, student, or community, as those populations see those problems. This followed by the establishment of a link between these problems and specific health problems which may become the focus of health education. The link is essential in life and, in turn, how the quality of life affects social problems.
Methods used for social diagnosis may be one or more of the following:
• Community Forums
• Nominal Groups
• Focus Groups
• Surveys
• Interviews
• Central location intercept
PHASE 2 - EPIDEMIOLOGICAL DIAGNOSIS helps determine health issues associated with the quality of life. It helps identify behavioral and environmental factors related to the quality of life issues. The focus of this phase is to identify specific health problem and non health factors which are associated with a poor quality of life. Describing these health problems can: 1) help establish relationships between health problems, other health conditions, and the quality of life; 2) lead to the setting of priorities which will guide the focus of program development and resources utilization; and 3) make possible the delineation of responsibilities between involved professionals and organizations and agencies. These priorities are defined as program objectives which define the target population (WHO), the desired outcome (WHAT), and HOW MUCH benefit the target population should benefit, and by WHEN that benefit should occur.
Examples of Epidemiological data:
• vital statistics
• years of potential life loss
• disability
• prevalence
• morbidity
• incidences
• mortality
From phase 1 and 2 program objectives are created - that is the goal or goals you hope to achieve as a result of implementing this program
Phase 3 - BEHAVIORAL AND ENVIRONMENTAL DIAGNOSIS
This phase focuses on the systematic identification of health practices and other factors which seem to be linked to health problems defined in Phase 2. This includes non-behavioral causes (personal and environmental factors) that can contribute to health problems, but are not controlled by behavior. These could include genetic predisposition, age, gender, existing disease, climate, and workplace, the adequacy of health care facilities, etc. Also assessed are the behaviors which cause health problems in the target population. Another important component of this phase is the determination of the importance and relative changeability of each behavioral cause. It is critical that a behavioral diagnosis is completed for each health problem identified on Phase 2. This will allow all the planners to choose target behaviors which will become the focus of specific educational interventions.
Behavioral Diagnosis is the analysis of behavioral links to the goals or problems that are identified in the epidemiological or social diagnosis.
Environmental Diagnosis is a parallel analysis of factors in the social and physical environment other than specific actions that could be linked to behaviors.
The Behavioral Matrix
This helps to identify targets where the most effective intervention measures can be applied.
More Changeable
More Important
High Priority Quadrant I
Less Important
Low Priority Except for Political Reasons Quadrant III
Less Changeable
More Important
Priority for Innovations Assessment Crucial Quadrant II
Less Important
No Program Quadrant IV
Behavioral Objectives are created from Quadrants 1 and 2 Quadrant 3 is used more for political reasons
Phase 4 - EDUCATIONAL DIAGNOSIS
This phase assesses the causes of health behaviors which were identified in Phase 3. Three kinds of causes are identified - predisposing factors, enabling factors, and reinforcing factors.
The critical element of this phase is the selection of the factors which if modified, will be most likely to result in behavior change. This selection process includes identifying and sorting (positive and negative) these factors in appropriate category, prioritizing factors among categories, and prioritizing with categories. Prioritization of factors is based on relative importance and changeabiltiy. Learning objectives are then developed which focus on these selected factors.
Pinpoints the factors that must be changed to initiate and maintain behavioral change. It is during this phase that specific intervention objectives are created and the intervention itself will be implemented.
Educational and organizational diagnosis looks at the specifics that hinder or promote behaviors related to the health issue.
Predisposing Factors - any characteristics of a person or population that motivates behavior prior to the occurrence of that behavior
• knowledge
• beliefs
• values
• attitudes
Enablers - characteristic of the environment that facilitate action and any skill or resource required to attain specific behavior
• accessibility
• availability
• skills
• laws (local, state, federal)
Reinforces - rewards or punishments following or anticipated as a consequence of a behavior. They serve to strengthen the motivation for behavior.
• family
• peers
• teacher.
Phase 5 - ADMINISTRATIVE AND POLICY DIAGNOSIS
This phase focuses on the administrative and organizational concerns which must be addresses prior to program implementation. This includes the assessment of resources, budget development and allocation, development of an implementation timetable, organization or personnel within programs, and coordination of the program with all other departments, and institutional organizations and the community.
Administrative Diagnosis - the analysis of policies, resources and circumstances prevailing
organizational situations that could hinder or facilitate the development of the health program.
Policy Diagnosis - to assess the compatibility of your program goals and objectives with
those of the organization and its administration; does it fit into the mission statements, rules
and regulations.
Phase 6 - IMPLEMENTATION OF THE PROGRAM
Phase 7 - PROCESS EVALUATION is used to evaluate the process by which the program is being implemented.
Phase 8 - IMPACT EVALUATION measures the program effectiveness in terms of intermediate objectives and changes in predisposing, enabling, and
reinforcing factors.
Phase 9 - OUTCOME EVALUATION measures change in terms of overall objectives and changes in health and social benefits or the quality of life. It takes a very long time to get results and it may take years before an actual change in the quality of life is seen.
KEY TERMS
PRECEDE is an acronym for Predisposing, Reinforcing, Enabling, Causes in, Educational Diagnosis and Evaluation.
PROCEED is an acronym for Policy, Regulatory, Organizational Constructs in Educational and Environmental Development.
PURPOSE OF MODEL
The PRECEDE model is a framework for the process of systematic development and evaluation of health education programs. An underlying premise of this model is that health education is dependent on voluntary cooperation and participation of the client in a process which allows personal determination of behavioral practices; and that the degree of change in knowledge and health practice is directly related to the degree of active participation of the client. Therefore, in this model, appropriate health education is considered to be the intervention (treatment) for a properly diagnosed problem in a target population.
This model is multidimensional, founded in the social/behavioral sciences, epidemiology, administration and education. As such, it recognizes that health and health behaviors have multiple causations which must be evaluated in order to assure appropriate intervention. The comprehensive nature of PRECEDE allows for application in a variety of settings such as school health education, patient education, community health education, and direct patient care settings.
PROCEED was added to the model in the late 1980s based on L. Green's experience with Marshall Krueter in various positions with the federal government and the Kaiser Family Foundation. PROCEED was added to the framework in recognition of the emergence of and need for health promotion interventions that go beyond traditional educational approaches to changing unhealthy behaviors. The administrative diagnosis is the final planning steps to "precede" implementation. From there "proceed" to promote the plan or policy, regulate the environment, and organize the resources and services, as required by the plan or policy.
The components of PROCEED take the practitioner beyond educational interventions to the political, managerial, and economic actions necessary to make social systems environments more conducive to healthful lifestyles and a more complete state of physical, mental and social well-being for all.
The purpose of the PRECEDE/PROCEED model is to direct initial attention to outcomes rather than inputs. This forces planners to begin the planning from the
outcome point of view. In other words, you as a program planner begin with the desired outcome and work backwards to determine what causes it, what precedes the outcome. Intervention is targeted at the preceding factors that result in the outcome.
The planning process outline in the model rests on two principles:
• The principle of participation, which states that success in achieving change is enhanced by the active participation of members of the target audience in defining their own high-priority problems and goals and in developing and implementing solutions. This principle is derived from the community development root theories and the empowerment education model exemplified by Freire.
• The important role of the environmental factors as determinants of health and health behavior such as media, industry, politics, and social inequities
CIRCUMSTANCES THAT LED TO DEVELOPMENT
Over several decades, many articles have been published with practical implications for health education, but only a few of those have survived long-term analysis and evaluation. Practitioners in various professions have struggled, often without clear guidelines, to systematize their planning, delivery and evaluation of health or educational programs. The PRECEDE/PROCEED framework has been designed to avoid the philosophical trap that has caught previous efforts to codify the practices of health education.
The overriding principle in this approach to health education is that health behavior must be voluntary behavior. Health means different things to different people, serves different purposes for different people, and is more or less important to different people. Because of this it is difficult to justify the imposition of rigid criteria of appropriate health behavior unless a behavior has been judged by society as a whole to be a sufficient hazard to the common good to warrant the curtailment of individual choice.
DESCRIPTION OF THE MODEL:
PRECEDE - the first 5 phases
Phase 1 - Social Diagnosis
Phase 2 - Epidemiological Diagnosis
Phase 3 - Behavioral & Environmental Diagnosis
Phase 4 - Education & Organizational Diagnosis
Phase 5 - Administrative & Policy Diagnosis
PROCEED - the second 4 phases
Phase 6 - Implementation
Phase 7 - Process Evaluation
Phase 8 - Impact Evaluation
Phase 9 - Outcome Evaluation
PHASE 1 - SOCIAL DIAGNOSIS
The focus of this phase is to identify and evaluate the social problems which impact the quality of life of a target population. This requires program planners to gain an understanding of the social problems which affects the quality of life of the patient, consumer, student, or community, as those populations see those problems. This followed by the establishment of a link between these problems and specific health problems which may become the focus of health education. The link is essential in life and, in turn, how the quality of life affects social problems.
Methods used for social diagnosis may be one or more of the following:
• Community Forums
• Nominal Groups
• Focus Groups
• Surveys
• Interviews
• Central location intercept
PHASE 2 - EPIDEMIOLOGICAL DIAGNOSIS helps determine health issues associated with the quality of life. It helps identify behavioral and environmental factors related to the quality of life issues. The focus of this phase is to identify specific health problem and non health factors which are associated with a poor quality of life. Describing these health problems can: 1) help establish relationships between health problems, other health conditions, and the quality of life; 2) lead to the setting of priorities which will guide the focus of program development and resources utilization; and 3) make possible the delineation of responsibilities between involved professionals and organizations and agencies. These priorities are defined as program objectives which define the target population (WHO), the desired outcome (WHAT), and HOW MUCH benefit the target population should benefit, and by WHEN that benefit should occur.
Examples of Epidemiological data:
• vital statistics
• years of potential life loss
• disability
• prevalence
• morbidity
• incidences
• mortality
From phase 1 and 2 program objectives are created - that is the goal or goals you hope to achieve as a result of implementing this program
Phase 3 - BEHAVIORAL AND ENVIRONMENTAL DIAGNOSIS
This phase focuses on the systematic identification of health practices and other factors which seem to be linked to health problems defined in Phase 2. This includes non-behavioral causes (personal and environmental factors) that can contribute to health problems, but are not controlled by behavior. These could include genetic predisposition, age, gender, existing disease, climate, and workplace, the adequacy of health care facilities, etc. Also assessed are the behaviors which cause health problems in the target population. Another important component of this phase is the determination of the importance and relative changeability of each behavioral cause. It is critical that a behavioral diagnosis is completed for each health problem identified on Phase 2. This will allow all the planners to choose target behaviors which will become the focus of specific educational interventions.
Behavioral Diagnosis is the analysis of behavioral links to the goals or problems that are identified in the epidemiological or social diagnosis.
Environmental Diagnosis is a parallel analysis of factors in the social and physical environment other than specific actions that could be linked to behaviors.
The Behavioral Matrix
This helps to identify targets where the most effective intervention measures can be applied.
More Changeable
More Important
High Priority Quadrant I
Less Important
Low Priority Except for Political Reasons Quadrant III
Less Changeable
More Important
Priority for Innovations Assessment Crucial Quadrant II
Less Important
No Program Quadrant IV
Behavioral Objectives are created from Quadrants 1 and 2 Quadrant 3 is used more for political reasons
Phase 4 - EDUCATIONAL DIAGNOSIS
This phase assesses the causes of health behaviors which were identified in Phase 3. Three kinds of causes are identified - predisposing factors, enabling factors, and reinforcing factors.
The critical element of this phase is the selection of the factors which if modified, will be most likely to result in behavior change. This selection process includes identifying and sorting (positive and negative) these factors in appropriate category, prioritizing factors among categories, and prioritizing with categories. Prioritization of factors is based on relative importance and changeabiltiy. Learning objectives are then developed which focus on these selected factors.
Pinpoints the factors that must be changed to initiate and maintain behavioral change. It is during this phase that specific intervention objectives are created and the intervention itself will be implemented.
Educational and organizational diagnosis looks at the specifics that hinder or promote behaviors related to the health issue.
Predisposing Factors - any characteristics of a person or population that motivates behavior prior to the occurrence of that behavior
• knowledge
• beliefs
• values
• attitudes
Enablers - characteristic of the environment that facilitate action and any skill or resource required to attain specific behavior
• accessibility
• availability
• skills
• laws (local, state, federal)
Reinforces - rewards or punishments following or anticipated as a consequence of a behavior. They serve to strengthen the motivation for behavior.
• family
• peers
• teacher.
Phase 5 - ADMINISTRATIVE AND POLICY DIAGNOSIS
This phase focuses on the administrative and organizational concerns which must be addresses prior to program implementation. This includes the assessment of resources, budget development and allocation, development of an implementation timetable, organization or personnel within programs, and coordination of the program with all other departments, and institutional organizations and the community.
Administrative Diagnosis - the analysis of policies, resources and circumstances prevailing
organizational situations that could hinder or facilitate the development of the health program.
Policy Diagnosis - to assess the compatibility of your program goals and objectives with
those of the organization and its administration; does it fit into the mission statements, rules
and regulations.
Phase 6 - IMPLEMENTATION OF THE PROGRAM
Phase 7 - PROCESS EVALUATION is used to evaluate the process by which the program is being implemented.
Phase 8 - IMPACT EVALUATION measures the program effectiveness in terms of intermediate objectives and changes in predisposing, enabling, and
reinforcing factors.
Phase 9 - OUTCOME EVALUATION measures change in terms of overall objectives and changes in health and social benefits or the quality of life. It takes a very long time to get results and it may take years before an actual change in the quality of life is seen.
KEY TERMS
PRECEDE is an acronym for Predisposing, Reinforcing, Enabling, Causes in, Educational Diagnosis and Evaluation.
PROCEED is an acronym for Policy, Regulatory, Organizational Constructs in Educational and Environmental Development.
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