13.12: PRECEDE-PROCEED Model
PRECEDE-PROCEED is an acronym that defines the planning and implementation stages of a community health intervention. PRECEDE stands for Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and Evaluation. This model attempts to “reverse engineer” the program, by starting with identifying the desired outcome, and then working backwards from that to design the intervention. While this may certainly sound daunting, it’s really describing a process of assessing the needs and context of the community, including the following phases (summarized from McKenzie et al., 2017, HRSA, 2024, University of Kansas, 2024):
- Phase 1: social assessment and situational analysis. A social assessment identifies the subjective needs of a population, including things like quality of life, perception of safety, and their own goals and aspirations for the community. This requires substantial input from the community members themselves on their own subjective experiences, needs and desires. This might include surveys, telephone or face-to-face interviews, focus groups, or questionnaires. The goal of this phase is to envision the ultimate outcome that the community wants to achieve.
- Phase 2: epidemiological assessment. This level of data collection and assessment involves more objective data, including mortality and morbidity rates, disability status, and behavioral, genetic, and environmental factors that influence health outcomes. Prioritizing health problems in this phase is important, as well as connecting them to the subjective needs and desires of the community (identified in phase 1). Program planners will need to use both scientific evidence and an understanding of the community resources available, as well as the priorities of the community itself, in order to appropriately prioritize health problems. For example, the program planner may identify that rates of type II diabetes are higher in the community than the national average, and community members might therefore benefit from a Diabetes Prevention Program (DPP). However, community members may identify that residential street safety is a much more pressing concern in phase 1. If the program planner tries to “shoehorn” or force their agenda on the community intervention, however well intentioned, it may not be well-received and at worst may lead to public distrust of health interventions.
- Phase 3: educational and ecological assessment. This last level of assessment looks to identify those factors that influence the behaviors, lifestyles, and health risks in the community. These include predisposing, enabling, and reinforcing factors (described earlier). Factors can include a lack of access or resources, an educational or informational gap, environmental influences, policies or something else. Often there are multiple factors that influence a health risk, necessitating multiple components in the intervention to address them.
- Phase 4: health program and policy development. At this stage the program is being designed based on the findings from the previous assessments, along with “best evidence” or “best practice” (using scientific evidence and/or behavioral change theory). The program should be connected back to both the social assessment and the epidemiological assessment, and should focus on those factors that were identified and predisposing, enabling, and/or reinforcing behaviors in phase 3. Another key component of this phase is to do an administrative and policy assessment, which determines two things: whether or not existing resources - including funding and personnel - are available and adequate to implement the program, and if there are any policies (local laws, regulations, etc.) that may influence the program implementation. An example of this might be a program designed to offer exercise sessions in a local park, which would require the program planner to check with the city parks and recreation office to find out if a contract or memorandum of understanding (MOU) is required, if liability insurance is adequate, and if there are any requirements for participants to sign liability waivers or other paperwork. Personnel may need to be hired and trained to lead exercise sessions, and equipment may need to be purchased.
The second part of the model is the acronym PROCEED, which stands for Policy, Regulatory, and Organizational Constructs in Educational and Environmental Development. This is the process of implementing and evaluating the intervention created in the first four phases, and evaluating each different piece (see Figure 13.9 for a diagram of all of the phases together). Once again, there are 4 phases dedicated to this process, outlined below (summarized from McKenzie et al., 2017, HRSA, 2024, University of Kansas, 2024):
- Phase 5: implementation. This is where the intervention actually takes place! Phase 5 might include a pilot program, and/or phasing in process. It may be helpful to use a Gantt chart or other project management tools to ensure that each piece of the program is implemented in the right order. Phases 6 and 7 can be conducted as the program is ongoing, in order to provide valuable feedback that can be used to make the program better.
- Phase 6: process evaluation. Is the program being implemented as planned? This evaluation seeks to determine whether the activities of the intervention are actually being delivered. For example, are health education sessions being offered? Did some need to be canceled? If so, why? What can be done to address problems with the program implementation early on, so that it actually gets completed as promised?
- Phase 7: impact or short-term evaluation. This evaluation addresses the impact that the program is having on knowledge, behaviors, or environmental objectives (see earlier in this chapter for definitions). These might be intermediate or short-term assessments, done in the middle of the program, as well as at the end of it. For example, if the program involves offering health education courses with the objective of improving knowledge about health eating patterns, has that knowledge actually improved for the participants? Do they score higher on a questionnaire about healthy eating? Performing impact assessments while the program is ongoing also helps to identify if changes need to be made to make the program more effective.
- Phase 8: outcome or long-term evaluation. The final assessment should be on the outcome objectives, which are typically the ultimate desired changes to health status for the community. Some of these changes may take years or even decades to be demonstrated. For example, the ultimate desired goal for a community might be a reduction in cardiovascular disease (CVD) rates. However, many of the participants in the community program might not be at risk for developing cardiovascular disease for several years, but the program activities may be helping them to prevent CVD. Sometimes a different marker can be targeted that is associated with the ultimate goal - such as an improvement in cardiovascular fitness, a reduction in body mass index (BMI), or lower blood cholesterol levels - but these will need to be maintained over the years in order to reach the ultimate goal of CVD prevention.
There are several other program models that have proven successful besides those presented here (McKenzie et al., 2017). Ultimately each model is a guide that can be used to provide structure for a program planner. Each of these models highlights the importance of involving the community members themselves in both planning and implementation of the community health intervention, as well as the need for regular assessments of the program to ensure it is actually working to improve the health and lives of the population.