PRECEDE/PROCEED

PRECEDE and PROCEED frame work of Health education diagnosis Planning and evaluation: concept steps and its application in priority PHC programs intervention).

• Facilitated by Murari Ghimire

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

• PRECEDE stands for Predisposing, Reinforcing, and Enabling Constructs in Educational/Environmental Diagnosis and Evaluation. As its name implies, it represents the process that precedes, or leads up to, an intervention.

• PROCEED spells out Policy, Regulatory, and Organizational Constructs in Educational and Environmental Development, and, true to its name as well, describes how to proceed with the intervention itself.

PRECEDE has four phases, which we’ll explore in greater detail later in the section:

Precede-Proceed Model

http://www.lgreen.net/precede.htm

PRECED PROCEED Model

6Evaluation Phase

Planning Phase

Concepts: a health education planning model developed around 1960th by L W Green and with fellow . PRECEDE framework developed by Green , Keurter , Deeds and Pratridge in 1980

It has been adopted and replaced by PRECEDE/PROCEED model by Green , Keurter 1991

Precede have seven phage and precede-Proceed has nine phages

Concepts: a health education planning model developed around 1960th by L W Green and with fellow .

• What is PRECEDE-PROCEED?

• Why use PRECEDE-PROCEED?

• How do you use PRECEDE-PROCEED?

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

• PRECEDE stands for Predisposing, Reinforcing, and Enabling Constructs in Educational/Environmental Diagnosis and Evaluation. As its name implies, it represents the process that precedes, or leads up to, an intervention.

• PROCEED spells out Policy, Regulatory, and Organizational Constructs in Educational and Environmental Development, and, true to its name as well, describes how to proceed with the intervention itself.

What is PRECEDE-PROCEED?• 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 planning of health promotion.

as a historical perspective In the latter half of the 20th 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.

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.)

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 accepted by community .

Cont…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.

Cont..

4. Finally, health is more than physical well-being, or than the absence of disease, illness, or injury . It is a group of factors – economic, social, political, ecological, and physical – that add up to healthy, high-quality lives for individuals and communities.

Planning Perspective Cont….This broad perspective on health extends to

other community issues. Indications of a community’s overall health include how well it:

• Care and supports children • Fosters lifelong learning, • Provides meaningful work for its citizens • Invites involvement in the democratic process • Cares for those who need help • Family structure

Planning Perspective Cont….

• Cares for those who need help • Protects and sustains the natural

environment • Encourages the arts ,Values and encourages

racial and cultural diversity • Works to promote and maintain safety and

physical well-being for its members

PRECEDE , • Phase 1-2 : (Epidemiological and Social

diagnosis) Identifying the ultimate desired result

Phase 3 : Educational disgnosis) Identifying and setting priorities among health or community issues and their behavioral and environmental determinants that stand in the way of achieving that result, or conditions that have to be attained to achieve that result; and identifying the behaviors, lifestyles, and/or environmental factors that affect those issues or conditions.

Phase 4 Educational diagnosis : Identifying the predisposing, enabling, and reinforcing factors that can affect the behaviors, attitudes, and environmental factors given priority in Phase 2

Phase 5 : Identifying the administrative and policy factors that influence what can be implemented.

• PROCEED has four phases (also to be discussed in more detail later) that cover the actual implementation of the intervention and the careful evaluation of it, working back to the original starting point – the ultimate desired outcome of the process. Phase 6 : Implementation – the design and actual conducting of the intervention.

Phase 7 : Process evaluation. Are you actually doing the things you planned to do?

Phase 8 : Impact evaluation. Is the intervention having the desired impact on the target population?

Phase 9 : Outcome evaluation. Is the intervention leading to the outcome (the desired result) that was envisioned in

Why use PRECEDE-PROCEED?

• First, there are good reasons for using some kind of logic model or theoretical framework for any intervention:

• It provides a structure within which to plan your work, so that you’re not simply grasping at straws( hopes) . As a result, you’re more likely to develop a coherent plan that addresses the necessary issues.

Why use PRECEDE-PROCEED?

• Most models give you either a guide or a foundation for critical analysis of the issues at hand. That doesn’t guarantee that your analysis will be complete or accurate, but it significantly increases the chances. for more on logical analysis

• Over and above the use of logic models in general, there are some good reasons for using PRECEDE-PROCEED specifically: • PRECEDE-PROCEED provides a

template for the process of conceiving, planning, implementing, and evaluating a community intervention.

• PRECEDE-PROCEED is structured as a participatory model, to incorporate the ideas and help of the community. That means that its use will provide you with more, and more accurate, information about the issues in question, and with a better understanding of their history and context in the community.

• Community involvement is also a means of building community ownership of the intervention, leading to more community support and a greater chance of success.

• PRECEDE-PROCEED considers the ways in which administrative and policy guidelines can limit or shape an intervention, an area of planning too often ignored.

• PRECEDE-PROCEED incorporates evaluation of the process, the intervention itself, and the final outcome. That allows the intervention to be monitored and adjusted to respond to community needs and changes in the situation, and checks that its accomplishments actually lead to the projected goal.

• Although PRECEDE-PROCEED sets out a strict process, it says much less about content. It leaves plenty of space for adapting your intervention’s design and methods to the situation, the needs of the community, etc.

How do you use PRECEDE-PROCEED? • Logic models don’t really mean much unless

you actually use them in the community. Once you’ve decided that PRECEDE-PROCEED provides a good model for your intervention, how do you translate it into action?

• We’ll look at each of the nine phases of the model with that question in mind.

How do you use PRECEDE-PROCEED? • PRECEDE: Doing the groundwork . PRECEDE

starts by determining the desired outcome for the community, and then works back to what has to be done to obtain that outcome. Each phase moves one step closer to the actual intervention.

• Our presentation of the model assumes that, although it was developed for use in public health, it can be used by activists or organizations concerned with any issues that affect the quality of life in a community, as seen in some of the 950 published applications.

Phase 1: Defining the ultimate outcome . The focus here is on what the community wants and needs, which may seem unrelated to the issue you plan to focus on. What outcome does the community find most important? Eliminating or reducing a particular problem (homelessness)? Addressing an issue ? Improving or maintaining certain aspects of the quality of life (environmental protection)? Improving the quality of life in general (increasing or creating recreational and cultural opportunities)?

Phase 1: Defining the ultimate outcome . • This phase starts with the collection of

demographic data, which is then presented to the community to help citizens decide on priorities. The way to determine what citizens want for their community is to ask them. There are a number of options here, which can be used individually or in combination, including:

• Community surveys • Focus groups • Phone interviews • Face-to-face interviews • Questionnaires in public places

Phase 2: Identifying the issue . In Phase 2 of PRECEDE, you look for the issues and factors that might cause or influence the outcome you’ve identified in Phase 1 (including supports for and barriers to achieving it), and select those that are most important, and that can be influenced by an intervention. (One of the causes of community poverty, for instance, may be the global economy, a factor you probably can’t have much effect on.

Phase 2: Identifying the issue . • It’s important to analyze these issues carefully, and

to make sure that you’ve chosen the right ones. • What would the elimination of a particular factor

make possible, for instance, that isn’t possible already?

• How does a particular issue create a barrier to the desired outcome?

• What else do these issues affect, besides the desired outcome?

• Which are the issues with the most drastic effects? • And how do you define “the most drastic effects?”

Are they economic? Social? Physical?

Phase 3: Environmental and Behavioural diagnosis

Phase 3: Examining the factors that influence behavior, lifestyle, and responses to environment .

Here, you identify the factors that will create the behavior and environmental changes you’ve decided on in Phase 2. (For more on behavior change)

Phase 4 Educational and orga diag…Predisposing factors are intellectual and emotional

“givens” that tend to make individuals more or less likely to adopt healthful or risky behaviors or lifestyles or to approve of or accept particular environmental conditions. Some of these factors can often be influenced by educational interventions. They include:

• Knowledge . You’re more likely, for instance, to avoid sunburn if you know it can lead to skin cancer than if you don’t.

• Attitudes . People who have spent their youth as athletes often come to see regular exercise as an integral part of life, as necessary and obvious as regular meals.

Phase 4 cont…Predisposing factors • Beliefs . These can be mistaken understandings –

believing that anything low in fat is also low in calories – or closely held beliefs based on religion or culture.

• Values . A value system that renounces violence would make a parent less likely to beat a child, or to be physically abusive to a spouse or other family member.

• Confidence . Many people fail to change risky behavior simply because they don’t feel capable of doing so.

Phase 3…..

• Enabling factors are those internal and external conditions directly related to the issue that help people adopt and maintain healthy or unhealthy behaviors and lifestyles, or to embrace or reject particular environmental conditions. Among them are:

• Availability of resources . People with mental health problems, for instance, are much more likely to get help if services are readily available.

• Accessibility of services . Services do no good if they have waiting lists that run into years, or aren’t physically accessible to those who need them. (For more on availability and accessibility of services,

Phase 3…..• Enabling factors

• Accessibility of services . Services do no good if they have waiting lists that run into years, or aren’t physically accessible to those who need them. (For more on availability and accessibility of services,

• Community and/or government laws, policies, priority, and commitment to the issue . Government laws and policies can both force changes in behavior or environment, and underline the importance of those changes.

• Issue-related skills . People who start out with a work ethic and an understanding of the workplace, for instance, are apt to benefit from job placement programs.

• Reinforcing factors , are the people and community attitudes that support or make difficult adopting healthy behaviors or fostering healthy environmental conditions. These are largely the attitudes of influential people: family, peers, teachers, employers, health or human service providers, the media, community leaders, and politicians and other decision makers.

• An intervention might aim at these people and groups – because of their influence – in order to most effectively reach the real target group.

• Phases 2 and 3 comprise the part of the model where the real planning of an intervention has to take place.

• What are you trying to change, and what are the factors that will help to bring that change about?

• Answering these questions should bring you to an understanding of whom and what an intervention should target, who best might conduct the intervention, and what it should look like in order to hit its targets effectively.

Phase 5 administrative and policy diagnosis.

• Phase 5: Identifying “best practices” and other sources of guidance for intervention design, as well as administrative, regulation, and policy issues that can influence the implementation of the program or intervention .

• Phase 5 helps you look at organizational issues that might have an impact on your actual intervention. It factors in the effects on the intervention of your internal administrative structure and policies, as well as external policies and regulations (from funders, public agencies, and others).

Phase 4

• The discussion of the ways in which organizational issues, particularly internal ones, interact with a proposed intervention is one that all too often never takes place.

• For that reason, Phase 4 is particularly important. Such a discussion can avoid mismatches between an organization and its proposed intervention (a strictly hierarchical organization attempting to implement an intervention meant to empower a group with no voice, for instance), or to alert an organization to an internal or external regulation or policy that needs to be changed or circumvented for an intervention to proceed as planned.

• Policy and regulatory issues have to do with the rules and restrictions – both internal and external – that can affect an intervention, and their levels of flexibility and enforcement.

• Internal policies : • Staff members . Organizational policy may treat staff as employees

who take orders, as colleagues who contribute to the work of the organization, or as collaborators who jointly own it. The amount of freedom they have to exercise their creativity and to take initiative probably depends on that policy, which may be unstated.

• Participants . Does organizational policy see participants as “clients” that the organization is doing something to or for, or as partners in a change effort? Does it treat participants respectfully, as equals, or does it condescend or act authoritative?

• How does the organization treat relationships among participants and staff? In some organizations, they may be friendly; in others, strictly professional. (Romantic or sexual relationships raise some ethical questions, and probably need to be considered separately. See “Professional ethics” below.)

• Policy and regulatory issues have to do with the rules and restrictions – both internal and external – that can affect an intervention, and their levels of flexibility and enforcement.

• Internal policies : • Staff members . Organizational policy may

treat staff as employees who take orders, as colleagues who contribute to the work of the organization, or as collaborators who jointly own it. The amount of freedom they have to exercise their creativity and to take initiative probably depends on that policy, which may be unstated.

• Specific practices, methods, or programs . Many organizations maintain policies that suggest or mandate certain ways of carrying out their work.

• Collaboration . Some non-profits make it a point of policy to collaborate as much as possible, while others rarely, if ever, work with other organizations.

• Professional ethics . Many organizations expect staff members to adhere to a code of professional ethics – either an internal one, or one set out by a professional association – that governs confidentiality, inappropriate relationships, abuse of position, reporting (or non-reporting) of specific kinds of illegal behavior, etc. There may be organizational regulations about these areas as well.

• External policies and regulations that might affect an intervention can come in a variety of forms:

• Funders’ requirements . These may apply to the intervention itself, or they may place restrictions on anything the organization can do, even those areas – such as, perhaps, this intervention – that aren’t funded directly by the funder in question.

• Oversight agency regulations . The organization may be subject to the authority of a state or federal agency whose regulations affect the intervention.

• State or federal laws, or local ordinances • Unstated community policies . Certain actions may

simply be unacceptable to the majority of the community, to coalition partners, etc.

ADMINISTRATIVE ISSUE

• Administrative issues include organizational structure, procedures, and culture; and the availability of resources necessary for the intervention.

• The organizational structure may be hierarchical, democratic, collaborative, or some combination, and may be more or less rigid or flexible within each of those categories. It should be appropriate to the design of the intervention (e.g., allowing for staff decisions in the field in a gang outreach program), and flexible enough to make adjustments when necessary.

Phase 5 ADMINISTRATIVE ISSUE

• Organzational procedures are the ways in which the organization actually carries out its work. In order for an intervention to be successful, those procedures have to focus on its goals, rather than on internal convenience or traditional methods. An intake procedure, for instance, should be designed to be as easy and unembarrassing for participants as possible – otherwise it can be a barrier to participation.

• The organizational culture . Organizations are social groups that develop cultures of their own. Those cultures often dictate, among other things, how staff members interact with one another, how program participants are treated, and how the organization views its work and its mission. (Is it just a job, or is it God’s work?) They also usually determine the fit between an organization and an intervention.

• The resources available for the intervention include not only money – although that’s certainly important – but time, personnel, skills, and space. Now is the time to pinpoint any gaps in resources beforehand, and work to close them. Thus, finding funding and/or the right staff people may be a good part of this phase

CONT..

Phase 6: Implementation . At this point, you’ve devised an intervention (largely in Phases 3 and 4), based on your analysis. Now, you have to carry it out. This phase Involves doing just that – setting up and implementing the intervention you’ve planned.

• The final three phases take place as the intervention continues, and serve to help you monitor and adjust your work to make it as effective as possible.

CONT..

• Phase 7 : Process Evaluation . This phase isn’t about results, but about procedure. The evaluation here is of whether you’re actually doing what you planned. If, for instance, you proposed to offer mental health services three days a week in a rural area, are you in fact offering those services?

CONT…

Phase 8: Impact Evaluation . Here, you begin evaluating the initial success of your efforts. Is the intervention having the desired effect on the behavioral or environmental factors that it aimed at changing – i.e., is it actually doing what you expected?

CONT…

Phase 9: Outcome Evaluation . Is your intervention really working to bring about the outcome the community identified in Phase 1? It may be completely successful in every other way – the process is exactly what you planned, and the expected changes made – but its results may have no effect on the larger issue. In that case, you may have to start the process again, to see why the factors you focused on aren’t the right ones, and to identify others that might work.

CONT…

Some outcomes may not be apparent for years or decades. Lifestyle changes made by young people to stave off heart disease and stroke, for instance, usually won’t reveal their health benefits until those people are well into middle age. If you know that an outcome may not show itself for a long time, you may just have to be patient and continue to monitor the process and impact of your intervention, with the belief that the eventual outcome will become apparent in time.

In Summary• PRECEDE-PROCEED provides a logic model that can serve as

the basis for an individual, one-time intervention or a decades-long community development program or project. Although designed for health programs, it’s adaptable to other community issues as well. As with many models, it’s meant to be a guide, not a prescription.

PRECEDE-PROCEED is community-based and participatory, founded on the premise that changes promoting health (and other community issues) are largely voluntary, and therefore need the participation of those needing to change and others who might influence them or be influenced by them.

• In Summary

A major reason to use PRECEDE-PROCEED is that it is a logic model.

• As a result, it will provide a structure within which to plan your work, and organize both your thinking and your actions, so that your intervention will be a carefully-planned, coherent whole, rather than duplicating together.

• As a logic model, it also provides a guide for analyzing the issues involved, and choosing both the most likely areas to address and the most likely avenues to address them.

• In Summary

There are also reasons to use PRECEDE-PROCEED specifically.

• First, it’s a participatory model. By involving the community, it will both bring more and better ideas about issues and resolving them, and build community ownership of the intervention. Second, since it includes multi-level (ecological) planning and evaluation, PRECEDE-PROCEED builds in monitoring of the intervention, allowing for adjustment and greater effectiveness. And finally, the model allows the freedom to adapt the structure to whatever content and methods meet the needs of your community.

• In Summary

PRECEDE is the diagnostic portion of the model. It starts with the idea that the focus of change must be on its desired outcome, and works backward from that outcome to construct an intervention that will bring it about.

PRECED PROCEED and PHC Program (PIE)Planning

implementation and evaluation

Facilitated by Murari Pd Ghimire

Precede-Proceed Model

http://www.lgreen.net/precede.htm

PRECED PROCEED Model

61Evaluation Phase

Planning Phase

• Planning and Assessment Model– Green and Kreuter (2005)

• Widely Used

Predisposing

• Explains as “in one’s head”– Perceptions, attitudes, values, knowledge, beliefs,

self-efficacy• Find out what these are ……– Own data– General info

• Develop lessons to address “problematic” areas

Predisposing Example-Nutrition

• You find out that typical students at your grade level believe that skim or 1% milk is not as healthy as whole and would taste bad

• Need to develop a strategy to address the beliefs– Nutrition label comparison– Milk fat display– Low fat milk challenge

Reinforcing

• Internal or external factors• Rewards and feedback received from others following

adoption of a behavior• May encourage or discourage• Internal too e.g. pain, pleasure• External-generally considered to be attitudes, behaviors,

support-levels of persons or institutions influential to our population in interest e.g. family members, teachers, employers, church; also media messages

Reinforcing Example-Nutrition

• Fast food advertisements– “looks good”– Healthy claims– promotions

• Need to develop awareness of advertising techniques– Knowledge of advertising purpose and use of

“tricks”– Analysis of fast food ads advertisements– Use of techniques to create ad for health choices

Enabling

• Availability, accessibility, policy/regulation enforcement/existence, skills

• Skills, resources, barriers that can help or hinder desired behavior as well as environmental change

• Created mainly by social forces or systems• Includes facilities and community resources;

existence and enforcement of laws, policies, & statutes; skills required for a desired behavior to happen

Enabling Example-Nutrition

• School cafeteria only serves whole milk and has ice cream available every day.

• Need to decrease accessibility and availability• Work to include/change to low fat and skim milk• Work to decrease ice cream availability to one day• Have students develop milk/ice cream policy suggestion that

would improve ability to make healthy choices

PHC Elements• The ultimate goal of primary health care is better health for

all. WHO has identified five key elements to achieving that goal: 1. reducing exclusion and social disparities in health (universal

coverage reforms);2. organizing health services around people's needs and

expectations (service delivery reforms);3. integrating health into all sectors (public policy reforms);4. pursuing collaborative models of policy dialogue (leadership

reforms); and5. increasing stakeholder participation.

PHC Elements

five key elements PHC: 1. reducing exclusion and social disparities in health –

Application of Social assessment phase 1 and administrative and policy assessment phase 5 of PRECED model

2. organizing health services around people's needs and expectations – Educational and ecological assessment phase 4 PRECED model

3. integrating health into all sectors – Implementation phase 6 PROCEED model

PHC Elements

five key elements PHC: 4. pursuing collaborative models of policy

dialogue – Application of policy assessment phase 5 of PRECED model

5. increasing stakeholder participation. Process evaluation of PROCEED model phase 7

•Thank you