PRECEDE–PROCEED model
The PRECEDE–PROCEED model is a cost–benefit evaluation framework proposed in 1974 by Lawrence W. Green that can help health program planners, policy makers and other evaluators, analyze situations and design health programs efficiently. 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 then works backwards in the causal chain to identify a mix of strategies for achieving those objectives. A fundamental assumption of the model is the active participation of its intended audience — that is, that 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 has two distinct parts. First is an "educational diagnosis" – PRECEDE, an acronym for Predisposing, Reinforcing and Enabling Constructs in Educational Diagnosis and Evaluation. Second is an "ecological diagnosis" – PROCEED, for Policy, Regulatory, and Organizational Constructs in Educational and Environmental Development. The model is multidimensional and is founded in the social/behavioral sciences, epidemiology, administration, and education. The systematic use of the framework in a series of clinical and field trials confirmed the utility and predictive validity of the model as a planning tool.
Brief history and purpose
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 1990s the National Center for Chronic Disease Prevention and Health Promotion at the Centers for Disease Control and Prevention 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 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 extensions of the model to incorporate PROCEED dimensions was detailed in a special issue of the Journal of Health Education in 1992.
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 of and rapid growth in the field of genetics, the PRECEDE–PROCEED model was revised, in 2005, to include and address the growing knowledge in this field.
Description
The PRECEDE–PROCEED planning model consists of four planning phases, one implementation phase, and 3 evaluation phases.| 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 affect 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 affect 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 beneficiaries in the planning process and planners will be able to see the issues just as the community sees them.Phase 2 – Epidemiological, Behavioral, and Environmental Diagnosis
Epidemiological diagnosis deals with determining and focusing on specific health issue 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 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, or 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 ; secondly, through the behavior of the individuals who directly affect the individual at risk ; and thirdly, through the actions of the decision-makers that affects the environment of the individuals at risk. 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 children may be due to the availability of unhealthful foods in school. This may require not only educational interventions, but also additional strategies such as influencing the behaviors of a school's food service managers.
Phase 3 – Educational and Ecological Diagnosis
Once the behavioral and environmental factors are identified and interventions selected, planners can start to work on selecting factors that, if modified, will most likely result in behavior change, as well as sustain it. These factors are classified as 1) predisposing, 2) enabling, and 3) reinforcing factors.Predisposing factors are any characteristics of a person or population that motivate 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 a 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 that must be addressed prior to program implementation. This includes assessment of resources, development and allocation of budgets, looking at organizational barriers, and coordination of the program with other departments, including external organizations and the community.Administrative diagnosis assesses policies, resources, circumstances and prevailing organizational situations that could hinder or facilitate the development of the health program.
Policy diagnosis assesses the compatibility of program goals and objectives with those of the organization and its administration. This evaluates whether program goals fit into the mission statements, rules and regulations that are needed for the implementation and sustainability of the program.