8b. The PRECEDE-PROCEED Model of Intervention Planning: An Overview

One of the most comprehensive and widely used frameworks for guiding the development of population health interventions is the PRECEDE-PROCEED Model, which was developed by Larry Green and Marshall Kreuter.¹ The model is depicted in Figure 1.

The PRECEDE-PROCEED model for health program planning and evaluation is widely utilized in the Western world, with over 1000 publications documenting its application to a myriad of health issues.^2,3 It is also one of the oldest models, having initially been developed in the early 1970s as an evaluation framework for health education initiatives.⁴

PRECEDE-PROCEED is premised on the key principle of participation, which states that success in achieving change is enhanced by the active participation of the intended audience in defining their own health-related problems and goals and in developing and implementing solutions. Accordingly, the application of each stage of the model should include efforts to seek input from the priority population(s) an intervention is designed to assist.¹

A unique feature of PRECEDE-PROCEED is that its eight-step planning process begins at the end, focusing on the health-related outcomes of interest. The model then works backwards to determine which combination of intervention strategies will best achieve these objectives.¹

Assessing the Health Issue: the PRECEDE Component (Phases 1-4)

As Figure 1 indicates, the bulk of the intervention planning occurs in the first four stages of the model labelled PRECEDE, which stands for Predisposing, Reinforcing and Enabling Constructs in Educational Diagnosis and Evaluation.¹ I know that seems a bit wordy and confusing, but the significance of that title will become more apparent as we proceed through the model.

Phase 1: Social Assessment

The process begins with what Green and Kreuter call a social assessment.¹ The social assessment step, illustrated in Figure 2, determines people’s perceptions of their own health-related needs and quality of life.

At this stage, population health planners broaden their understanding of the community in which they are working by conducting multiple data-collection activities, such as interviews with key opinion leaders, focus groups with members of the community, observational data gathering, and surveys. As you learned in module 6, the term “community” is typically used to denote a defined geographical area or a group with shared characteristics, interests, values, and norms.

In addition to articulating the community’s needs and desires, a social assessment considers the community’s problem solving capacity, its strengths, resources, and its readiness to change. Your required reading from Chapter 4 of the Planning Health Promotion Programs text provides more detail about the methods used to assess community needs along with some relevant examples.

A social assessment is important for many reasons. First, as you’ve likely come to realize at this point in the course, the relationship between health and quality of life is reciprocal, with each affecting the other. For example, living in poverty is associated with poor health, and being unhealthy makes it more difficult to escape poverty and impoverished living conditions. People value their health not simply as an end unto itself, but because being healthy enables them to achieve other goals such as the enjoyment of work and recreation. By understanding the intended audience’s concerns, the planner is more likely to develop a program that is relevant, which will increase its chances of being well-received and effective.

Phase 2: Epidemiological Assessment

The second step or phase is an epidemiological assessment (see Figure 3).

Health Problems

An epidemiological assessment helps determine which health problems are most important for which groups in the community. In an epidemiological assessment, planners can conduct secondary data analyses using existing data sources such as vital statistics, census data, provincial or national health and labour force surveys, as well as medical, administrative, and consumer data (e.g., junk food consumption).

These various sources of data can provide indicators of morbidity, mortality, and disability in a population and help specify subgroups at particular risk. Subgroups may be characterized by factors such as age, gender, ethnicity, occupation, education, income, family structure, and geographic location.

Sometimes it may be inappropriate to extrapolate from national or provincial data to a smaller region that has unique attributes. In this case, it may be necessary to collect original data. For example, household surveys of a nationally representative sample may have inadequate numbers of respondents from a single province or region to provide reliable information.

Factors Contributing to the Health Problems

The next step of the epidemiological assessment process (see Figure 4) involves assessing factors contributing to the health problem(s) under consideration.

Behavioural factors are those behaviours or lifestyles of individuals at risk contributing to the occurrence and severity of the health problem or to disparities in the distribution of the problem.

Environmental factors are the social, economic, and physical factors external to, and beyond the personal control of, individuals that can be modified to positively affect the health outcome of interest. Modifying environmental factors usually requires strategies other than education or counselling. For example, poor nutrition status among school children is a function of poor dietary behaviours, which in turn is at least partly affected by the availability of unhealthy foods in schools, which is an environmental factor.

Unlike previous editions, the most recent (2005) version of PRECEED-PROCEDE acknowledges the importance of biological and genetic factors and their potential modifiability.¹

Phase 3: Educational and Ecological Assessment

After selecting the appropriate behavioural and environmental factors for intervention, phase 3 identifies the factors that must be in place to initiate and sustain the change process. These factors, which are depicted in Figure 5, are classified as predisposing, reinforcing, and enabling and they collectively influence the likelihood that the desired behavioural and/or environmental changes will occur. 

Predisposing factors are antecedents to behaviour that provide the rationale or motivation for the behaviour. They include knowledge, attitudes, beliefs, personal preferences, existing skills, expectations, and self-efficacy.

Reinforcing factors are those factors following a behaviour that provide continuing reward or incentive for the persistence or repetition of the behaviour. Examples include social support, peer influence, and vicarious reinforcement.

Enabling factors are defined as antecedents to behaviour that allow a motivation to be realized. Enabling factors can affect behaviour directly or indirectly through an environmental factor. They include programs, services, policies, and resources necessary for behavioural and environmental outcomes to be realized and, in some cases, new skills that are needed to enable health behaviour change.

As is the case with all previous steps, the process of identifying predisposing, reinforcing, and enabling factors should be driven by a knowledge of the research literature, with input from the intended audience through their direct participation in the planning process or through consultation mechanisms such as surveys or focus groups.¹

Developing Goals and Objectives for Population Health Interventions

Equipped with data on a community’s health problem, population health planners are now ready to develop goals and objectives.

A program/intervention goal is a broad statement of the intervention strategy’s ultimate benefit (e.g., to improve family health and quality of life by reducing infant mortality). For example, the goals of the Pan-Canadian Public Health Network are: “to protect and promote the health of Canadians; to promote the importance of public health in the development of a sustainable Canadian Health System; and to improve health outcomes and reduce health inequalities.”⁵

Well-written program objectives should answer the question, “how much of what health outcome should happen to whom by when?” For example, “to reduce infant mortality among Indigenous Canadians by 20% by the year 2030” is an example of an outcome objective. Sometimes less specific objectives are written to address the shorter-term results that need to occur in order to realize longer term changes in morbidity and mortality (e.g., “to increase awareness of the household risks associated with falls among seniors in Calgary”). Measurable program objectives are essential to guide the allocation of program resources and to evaluate the success of an intervention.

One of the key challenges in writing specific objectives is setting realistic change targets. For example, if you want to reduce food insecurity in Nunavut you may wonder if it’s reasonable to set a reduction target of five, ten, or fifteen percent? Community health status data, literature on evidence-based best practices for population health interventions, and national, provincial, or regional/local public policy documents addressing particular health issues are usually good starting points for guidance in setting reasonable targets for change.

Phase 4: Intervention Alignment

The delineation of the intervention strategies and final planning for their implementation is the fourth stage of the PRECEDE-PROCEED model (see Figure 6). Its purpose is to identify policies, resources, and circumstances prevailing in the strategy’s organizational/community context that could facilitate or hinder strategy implementation.

Now we are ready to PROCEED with Implementation and Evaluation (Phases 5-8)

Green and Kreuter define the PRO in PROCEED as follows:

• Policy is the set of objectives and rules guiding the activities of an organization or administration;
• Regulation is the act of implementing policies and enforcing rules or law; and
• Organization is the bringing together and coordination of resources necessary to implement a strategy.¹

At this stage, intervention strategies are selected based on previous steps, and planners must assess the availability of necessary resources such as time, people, and funding. Barriers to implementation, such as staff commitment or lack of space should be assessed and plans to address them put in place. In addition, any organizational policies and regulations that could affect program implementation should be considered and planned for accordingly.

At this point, the population health strategy is ready for implementation (See Figure 7).

Data collection plans should be in place for evaluating the process, impact, and outcome of the program, the final three steps in the PRECEDE-PROCEED model.

• Typically, process evaluation determines the extent to which the program was implemented according to protocol.
• Impact evaluation assesses change in predisposing, reinforcing and enabling factors as well as behavioural and environmental factors (e.g., changes in knowledge, beliefs, attitudes, intentions and social and environmental barriers/supports).
• Finally, outcome evaluation determines the effect of the program on health and quality of life indicators (changes in behaviour, morbidity, and mortality).

Generally, measurable objectives that are written at each step of the model serve as milestones against which accomplishments are evaluated.¹