What is PRECEDE-PROCEED?

Like most of the other models well 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, well 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: 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 colored by community history. 3. Health is an integral part of a larger context, probably most clearly defined as quality of life , and its 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.

AIDS has changed the way many people in the US view and practice sex, for instance. In some other countries, it has affected the whole social structure because of the number of orphans it has created, and its impact on the workforce. By the same token, youth violence changes the views and actions of many people who are at no risk of being its victims, and may put a community at an economic disadvantage by making it less attractive to new business or industry. Almost any other issue could serve equally well as an example of the broad reach of community problems (or assets, for that matter).

4. Finally, health is more than physical well-being, or than the absence of disease, illness, or injury . It is a constellation of factors economic, social, political, ecological, and physical that add up to healthy, high-quality lives for individuals and communities. 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 communitys overall health include how well it: y y y y y Contributes to the stability of families Nurtures and supports children Fosters lifelong learning, Provides meaningful work for its citizens Invites involvement in the democratic process

y y y y y

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 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 well explore in greater detail later in the section: Phase 1 : Identifying the ultimate desired result Phase 2 : 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 3 : Identifying the predisposing, enabling, and reinforcing factors that can affect the behaviors, attitudes, and environmental factors given priority in Phase 2. Phase 4 : Identifying the administrative and policy factors that influence what can be implemented. 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 theyre aiming at is one the community wants and needs.) PRECEDEs 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. Phase 5 : Implementation the design and actual conducting of the intervention. Phase 6 : Process evaluation. Are you actually doing the things you planned to do? Phase 7 : Impact evaluation. Is the intervention having the desired impact on the target population? Phase 8 : Outcome evaluation. Is the intervention leading to the outcome (the desired result) that was envisioned in Phase 1? A word about logic models: Although most formal models, like PRECEDE-PROCEED present themselves as the way to structure an intervention or other activity, the word logic implies that you should carefully consider your own situation as well as the model. If there are reasons why a particular part of a model might not work for you, its reasonable (logical) to change it. While PRECEDE-PROCEED presents a structure that could conceivably work well (and has worked well)

in a variety of situations, its still important to think about whether all parts of it will work for you.

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 PRECEDEs 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 phases issues on the next one to the right. Since youre 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 Preceed-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.

The PRECEDE-PROCEED model applies a medical perspective to public health, even though its focus is health promotion, rather than treatment of disease. Just as a medical diagnosis precedes treatment, the model assumes that a far-reaching diagnosis should precede a public health intervention. A diagnosis suggests a treatment (an intervention), which is closely monitored for process (Is the patient getting the treatment prescribed?), impact (Is the treatment having the hoped-for impact on the symptoms?), and outcome (Does the treatment cure the patient, or have the desired effect on her overall health?). A premise of the model is that a diagnosis should start with the desired end result and work backwards to determine what needs to be done to bring about that result. Another basic premise of the model is that the purpose of a health program and by extension, the purpose of any proactive type of community intervention is to improve the quality of life for individuals and their community, and that the two are largely inseparable. Thus, any intervention should be community-based, and should look at the needs of the community, even if the intervention is aimed at a more specific target group. A final premise of any community-based model for intervention is that planning and implementing a community intervention calls for a joint effort among (health and other) professionals and organizations, policy makers, community officials, community leaders, and community members at large, including members of the target population. In order to ensure accurate information and community support, all elements of the community should be involved in the process from the beginning.