If you were a contractor setting out to build a wood-frame house, you wouldn’t just pick up whatever wood you found lying around and begin. You’d consult first with the owner, and start with an idea of the house she wanted – its size, its shape, its features. You’d want a picture of the finished house, and a floor plan as well, with some notes on measurements and materials. You’d plan the construction with her, and set out a process for getting it done. And you’d do all this before you ever picked up a tool, because otherwise the process would be hit-or-miss: she wouldn’t get the house she wanted, and your time would be wasted. The same is true if you’re developing an intervention to address a health or community issue. It makes no sense to pick an issue at random, and to use whatever service happens to be available to try to address it. You have to consult with the community, understand and analyze community information, your own and others’ observation, and the context of the issue to create an intervention that will actually bring about the changes the community wants and needs. In the first section of this chapter, we introduced the need for a process for doing health and community work. In this section, we’ll look at PRECEDE-PROCEED, the first of several specific models that may prove helpful to you in carrying out your own work. We’ll examine other models in subsequent sections of this chapter. Then in the last section, we’ll examine some ways in which elements of various models can be combined to respond to your particular situation. 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. 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:
This broad perspective on health extends to other community issues. We can define the health of a community as its fitness in many areas, of which citizens’ physical health is only one. Indications of a community’s overall health include how well it:
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:
Another premise behind PRECEDE-PROCEED is that a change process should focus initially on the outcome, not on the activity. (Many organizations set out to create community change without stopping to consider either what effect their actions are likely to have, or whether the change they’re aiming at is one the community wants and needs.) PRECEDE’s four phases, therefore, move logically backward from the desired result, to where and how you might intervene to bring about that result, to the administrative and policy issues that need to be addressed in order to mount that intervention successfully. All of these phases can be thought of as formative. 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.
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. 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. Figure 1. Generic representation of the Precede-Proceed Model. From L. Green and M. Kreuter. (2005). Health Promotion Planning: An Educational and Ecological Approach (4 th Ed.). Mountain View , CA : Mayfield Publishers.
Why use PRECEDE-PROCEED?First, there are good reasons for using some kind of logic model or theoretical framework for any intervention:
Over and above the use of logic models in general, there are some good reasons for using PRECEDE-PROCEED specifically:
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. 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 (race)? >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)? 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:
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. As important as the global economy might be, you’d have to change conditions locally to have any real impact.) 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?
In some cases, the issues you choose to focus on may be directly related to the outcome you’re seeking – building more affordable housing as a way to address homelessness, for instance. In others, you may be trying to affect factors that have just as great an impact on the outcome, but seem further removed from it – e.g., addressing safe streets by providing parenting courses and other services for at-risk families. Once again, involving stakeholders and other community members here is likely to get you the best information possible about which issues to emphasize, and to keep you from making mistakes based on ignorance of the community’s history or of the relationships among community members.
Most of the factors influencing the issues or outcomes can be classified as behavioral, lifestyle, or environmental. The behavior referred to here is a specific, observable, often measurable – and usually customary – action. Some behaviors put people or communities at more or less risk for health or other problems.
A lifestyle is a collection of related behaviors that go together to form a pattern of living. Some lifestyles may put people and communities at risk of health and other problems.
The environment of a particular issue or problem can refer to the natural, physical environment – the character and condition of the water, air, open space, plants, and wildlife, as well as the design and condition of built-up areas. But it can also refer to the social environment (influence of family and peers; community attitudes about gender roles, race, childrearing, work, etc.), the political environment (policies and laws, such as anti-smoking ordinances, that regulate behavior or lifestyle; the attitudes of those in power toward certain groups or issues), and the economic environment (the availability of decent-wage jobs, affordable housing, and health insurance; the community tax base; global economic conditions). In general, behaviors, lifestyles, and environmental factors are what an intervention sets out to change. The changes in these areas in turn affect the crucial issues, and lead to the achievement of the final outcome that was identified in Phase 1 of the model.
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.
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:
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:
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.
Phase 4: 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 4 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). Design issues: “Matching, mapping, pooling, and patching.” or “Selecting, designing, blending, and supporting interventions.” 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. Administrative issues include organizational structure, procedures, and culture; and the availability of resources necessary for the intervention.
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:
External policies and regulations that might affect an intervention can come in a variety of forms:
PROCEED: Implementing and evaluating the intervention . Phase 5: 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.
Phase 6: 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? Phase 7: 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? Phase 8: 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. 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.
At any point in the PROCEED continuum, you should be prepared to revisit your analysis. If you find a gap between your planning and reality, or if you realize that your intervention isn’t achieving the results you aimed at, you should go back to the PRECEDE part of the model, try to determine what needs to be changed, and adjust what you’re doing accordingly. The point of evaluation is not to see whether you pass some kind of test – it’s to make sure that your intervention brings about the outcome that the community wanted or needed in the first place. In SummaryPRECEDE-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. 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 cobbled 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. 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. 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. It has four phases: Phase 1: Social diagnosis – determine what the community wants and needs to improve its quality of life. Phase 2: Epidemiological diagnosis – determine the health problems or other issues that affect the community’s quality of life. Include also the behavioral and environmental factors that must change in order to address these problems or issues. Behavioral factors include patterns of behavior that constitute lifestyles. In considering environmental factors, you should include the physical, social, political, and economic environments. Phases 1 and 2 identify the goals of the intervention. Phase 3: Educational and organizational diagnosis – determine what to do in order to change the behavioral and environmental factors in Phase 3, taking into account predisposing factors (knowledge, attitudes, beliefs, values, and confidence); enabling factors (availability of resources, accessibility of services, government laws and policies, issue-related skills), and reinforcing factors (largely the influence of significant others in the social environment). Phase 4: Designing programs or interventions and the support for them through administrative and policy diagnosis – determine (and address) the internal administrative and internal and external policy factors that can affect the success of your intervention. The former include organizational structure, procedures, culture, and resources; the latter encompass both internal policies and funders’ requirements, oversight agency regulations, state or federal laws, or local ordinances, and unstated community policies. Phases 3 and 4 set the structure and targets for the planning and design of the intervention. PROCEED is, in medical terms, the treatment portion of the model, and comprises the implementation and evaluation of the intervention. It consists of four phases: Phase 5: Implementation – conduct the intervention. Phase 6: Process evaluation – determine whether the intervention is actually taking the actions intended. Phase 7: Impact evaluation – determine whether the intervention is having the intended effects on behaviors and/or environment. Phase 8: Outcome evaluation – determine whether the intervention ultimately brings about the improvements in quality of life identified by the community as its desired outcome. An unstated but important part of the model is that, at any point, your plan or intervention can and should be revisited and revised, based on continued analysis and the results of the various evaluations. |
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