Health Promotion Planning:

Educational and Ecological Diagnosis

(PRECEDE-PROCEED Framework)

Col Zulfiquer Ahmed Amin

M Phil, MPH, PGD (Health Economics), MBBS
Armed Forces Medical Institute (AFMI)
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.
To improve/ change Behavior and Attitude:

Awareness and education is the “what” of behavior change. The

motivation is what drives us to change. The skills and tools portion
is the “how do I do this?” part, and the culture and environment
part is a conglomeration of environmental changes, policy changes,
and support from others that all help us to be successful.
Health Promotion Planning:
Forecasting and organizing the activities required for
enabling people to increase control over, and to
improve, their health in the context of community.
PROCESS OF ANY HEALTH EDUCATION INTERVENTION
‘PRECEDE-PROCEED Framework’ for Health Promotion Planning:

PRECEDE/PROCEED is a community-oriented, participatory model

for creating successful community health promotion interventions.

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 purpose of the PRECEDE/PROCEED model is to direct initial
attention to outcomes rather than inputs. In other words, a
program planner begins with the desired outcome and work
backwards to determine what causes it, what precedes the
outcome. Intervention is targeted at the preceding factors that
result in the outcome.
The PRECEDE framework was first developed and introduced in the
1970s by Lawrence W. Green and colleagues.

PRECEED is based on the premise that, just as a medical diagnosis

precedes a treatment plan, an educational diagnosis of a problem
of socio-cultural construct is very essential before developing and
implementing the intervention plan.

As its name implies, it represents the process that precedes, or

leads up to, an intervention.

The PRECEDE model is a framework for the process of systematic

development and evaluation of health education programs.
In 1991, PROCEED was added to the framework in recognition of
the emergence of and need for health promotion interventions
that go beyond traditional educational approaches to changing
unhealthy behaviors.

The "proceed" framework is to promote the plan or policy, regulate

the environment, and organize the resources and services, as
required by the plan or policy.

The components of PROCEED take the practitioner beyond

educational interventions to the political, managerial, and
economic actions necessary to make social systems environments
more conducive to healthful lifestyles and a more complete state of
physical, mental and social well-being for all. Hence more
"ecological" methods were needed to identify and influence these
environmental and social determinants of health behaviors.
Assumptions behind ‘PRECEDE/PROCEED’:

• Since behavior change is by and large voluntary,

health promotion is more likely to be effective if it’s
participatory.
• Health and other issues must be looked at in the
context of the community.
• Health and other issues are essentially quality-of-
life issues.
• Health is itself a constellation of factors that add up
to a healthy life for individuals and communities.
The PRECEDE–PROCEED planning model consists of five planning
phases, one implementation phase, and 3 evaluation phases.

PRECEDE phases PROCEED phases

Phase 1 – Social Diagnosis Phase 6 – Implementation
Phase 2 – Epidemiological,
Phase 7 – Process Evaluation
Diagnosis
Phase 3- Behavioral and
Phase 8 – Impact Evaluation
Environmental Diagnosis
Phase 4 – Educational
Phase 9 – Outcome Evaluation
Diagnosis
Phase 5 – Administrative &
Policy Diagnosis
A flow chart of the model, 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 five 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 evaluating the success
of the intervention at addressing each one (The process evaluation in
Phase 7 looks at whether the intervention addressed the concerns of
Phase 4 as planned. The impact evaluation of Phase 8 examines the
impact of the intervention on the behaviors or environmental factors
identified in Phase 2 and 3. And the Outcome evaluation of Phase 9
explores whether the intervention has had the desired quality of life
outcome identified in Phases 1).
Phase 1: Defining the ultimate outcome (Social Diagnosis).
In Phase 1, social diagnosis, we ask the community what it wants
and needs to improve its quality of life.
What outcome does the community find most important?
Eliminating or reducing a particular problem (homelessness)?
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)?

Ask them by:

- Community surveys
- Focus groups
- Phone interviews
- Face-to-face interviews
- Questionnaires in public places
Demand? = Expressed Need
PHASE 2 - EPIDEMIOLOGICAL DIAGNOSIS
Epidemiology is the study of the distribution and determinants of
health-related states or events in specified populations, and the
application of this study to the control of health problems. In Phase
2, we identify the health or health-related issues that most likely
influence the outcome the community seeks.

Examples of Epidemiological data:

- Vital statistics
- Years of Life Loss (YLL)
- Disability
- Prevalence
- Morbidity
- Incidences
- Mortality
Phase 3 - BEHAVIORAL AND ENVIRONMENTAL DIAGNOSIS
This includes identification of non-behavioral causes (personal and
environmental factors) that can contribute to health problems, but
are not controlled by behavior. These could include genetic
predisposition, age, gender, existing disease, climate, and
workplace, the adequacy of health care facilities, etc. Also
assessed are the behaviors which cause health problems in the
target population.
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.

Needle-sharing is a behavior that puts heroin addicts at high risk for

hepatitis and AIDS.

If littering is a common individual behavior, it may have community

consequences that range from the aesthetic (piles of trash creating
an unattractive scene) to health (breeding of mosquitoes in garbage-
strewn lots, water pollution, etc.) to the economic (businesses
unwilling to locate in the community because of its physical
condition).
The Behavioral Matrix
This helps to identify targets where the most effective intervention
measures can be applied.

More Important Less Important

Low Priority Except for
High Priority
More Changeable Political Reasons
Quadrant I
Quadrant III
Priority for Innovations
No Program
Less Changeable Assessment Crucial
Quadrant IV
Quadrant II

Behavioral Objectives are created from Quadrants 1 and 2 . Quadrant 3 is used

more for political reasons
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.
An example of a high-risk lifestyle that is often mentioned in the
popular media is one that includes very little exercise, a diet high in
calories and saturated fats, and lots of stress. Such a lifestyle can
lead to heart attack, stroke, cardiovascular disease, and other
problems associated with obesity, including diabetes.
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).
Phase 4 - EDUCATIONAL DIAGNOSIS
In Phase 4, Educational Diagnosis, we identify the Predisposing,
Enabling, and Reinforcing factors that act as supports for or barriers
to changing the behaviors and environmental factors.

The critical element of this phase is the selection of the factors

which if modified, will be most likely to result in behavior change.
This selection process includes identifying and sorting (positive and
negative) these factors in appropriate category, prioritizing factors
among categories, and prioritizing with categories. Prioritization of
factors is based on relative importance and changeability. Learning
objectives are then developed which focus on these selected
factors.
Phase-4. Educational Diagnosis:
Individual Behavior Change Framework
Predisposing factors:
A predisposing factor to disease is a substance, event, characteristic
or condition that influences the susceptibility or resistance to
diseases or health-related events. Predisposing factors include age,
sex, people's knowledge, attitudes, beliefs, values, self-efficacy,
behavioral intentions, existing skills, hereditary conditions and
lifestyle factors. For example, common non-modifiable risk factors
for heart disease include being male and having a family history of
heart disease. Modifiable lifestyle factors include smoking, obesity
and poorly controlled diabetes.
Predisposing Factors:
- Knowledge. Avoid sunburn if we know it can lead to skin cancer.
- Attitudes. People who have spent their youth as athletes often
come to see regular exercise as an integral part of life, as
necessary and obvious as regular meals.
- Beliefs. These can be mistaken understandings – believing that
anything low in fat is also low in calories – or closely held beliefs
based on religion or culture – the Bible says “Spare the rod and
spoil the child,” so it’s important to physically punish your
children for mistakes or misdeeds.
- Values. A value system that renounces violence would make a
parent less likely to beat a child, or to be physically abusive to a
spouse or other family member.
- Confidence. Many people fail to change risky behavior simply
because they don’t feel capable of doing so.
Enabling factors:

Enabling factors are defined as factors that make it possible (or

easier) for individuals or populations to change their behavior or
their environment. Enabling factors include resources, conditions
of living, societal supports, and skills that facilitate a behavior's
occurrence. Those internal and external conditions that help
people adopt and maintain healthy or unhealthy behaviors and
lifestyles, or to embrace or reject particular environmental
conditions.

Enablers:
- Availability of resources.
- Accessibility to services: Services do no good if they have
waiting lists that run into years, or aren’t physically accessible
to those who need them.
- Issue-related skills.
Reinforcing factors: The people and community attitudes that
support or make difficult adopting healthy behaviors or fostering
healthy environmental conditions. This is also aggravating factor.
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.
Reinforces - Rewards or punishments following or anticipated as
a consequence of a behavior. They serve to strengthen the
motivation for behavior:
- Family
- Peers
- Teacher.
- Leaders
- Religious Imams
- Healthcare Providers.
? Precipitating Factor:
Factors which are associated with the onset of
the disease or condition. eg, Exposure to specific
disease agent, or noxious agent.
Examples for ‘Physical Activity’:
Phase-5. Ecological Factors (Administrative and Policy Diagnosis)
ADMINISTRATIVE AND POLICY DIAGNOSIS

In Phase 5, administrative and policy diagnosis, we identify (and

adjust where necessary) the internal administrative issues and
internal and external policy issues that can affect the successful
conduct of the intervention.

Administrative Diagnosis - Analysis of resources and circumstances

prevailing organizational situations that could hinder or facilitate
the development of the health program.

Policy Diagnosis - To assess the compatibility of our program goals

and objectives with those of the organization and its administration
in terms of policy, rules and regulations.
Phase 6 - IMPLEMENTATION OF THE PROGRAM :
In Phase 6, implementation, we carry out the planned health
intervention.

Phase 7 - PROCESS EVALUATION:

The process evaluation in Phase 7 looks at whether the
intervention addressed the concerns of Phase 4 as planned.
Measures the program effectiveness in terms of intermediate
objectives and changes in predisposing, enabling, and reinforcing
factors.
Phase 8 - IMPACT EVALUATION:
The impact evaluation of Phase 8 examines the impact of the
intervention on the behaviors, environmental or
epidemiological factors identified in Phase 2 and 3. Here, we
evaluate whether the intervention is having the intended impact
on the behavioral and environmental factors it’s aimed at, and
adjust accordingly.

Phase 9 - OUTCOME EVALUATION

In outcome evaluation, we evaluate whether the intervention’s
effects are in turn producing the outcome(s) the community
identified in Phase 1, and adjust accordingly.

It takes a very long time to get results and it may take years
before an actual change in the quality of life is seen.
Strategy
 Conclusion:

Purpose of PRECEDE-PROCEED Framework is to

make a sound Health Promotion Planning and
materialize the needs of the community by
Educational Intervention and policy support.