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Helth pomotion planning educational and ecological diagnosis (precede-proceed framework)

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Helth pomotion planning educational and ecological diagnosis (precede-proceed framework)

  1. 1. 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)
  2. 2. 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.
  3. 3. 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. To improve/ change Behavior and Attitude:
  4. 4. 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.
  6. 6. 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. ‘PRECEDE-PROCEED Framework’ for Health Promotion Planning:
  7. 7. 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.
  8. 8. 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.
  9. 9. 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.
  10. 10. 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.
  11. 11. PRECEDE phases PROCEED phases Phase 1 – Social Diagnosis Phase 6 – Implementation Phase 2 – Epidemiological, Diagnosis Phase 7 – Process Evaluation Phase 3- Behavioral and Environmental Diagnosis Phase 8 – Impact Evaluation Phase 4 – Educational Diagnosis Phase 9 – Outcome Evaluation Phase 5 – Administrative & Policy Diagnosis The PRECEDE–PROCEED planning model consists of five planning phases, one implementation phase, and 3 evaluation phases.
  12. 12. 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).
  13. 13. 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
  14. 14. Demand? = Expressed Need
  15. 15. 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
  16. 16. 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.
  17. 17. 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).
  18. 18. More Important Less Important More Changeable High Priority Quadrant I Low Priority Except for Political Reasons Quadrant III Less Changeable Priority for Innovations Assessment Crucial Quadrant II No Program Quadrant IV Behavioral Objectives are created from Quadrants 1 and 2 . Quadrant 3 is used more for political reasons The Behavioral Matrix This helps to identify targets where the most effective intervention measures can be applied.
  19. 19. 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.
  20. 20. 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).
  21. 21. 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.
  22. 22. Phase-4. Educational Diagnosis:
  23. 23. Individual Behavior Change Framework
  24. 24. 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.
  25. 25. 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.
  26. 26. 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.
  27. 27. 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.
  28. 28. 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.
  29. 29. ? Precipitating Factor: Factors which are associated with the onset of the disease or condition. eg, Exposure to specific disease agent, or noxious agent.
  30. 30. Examples for ‘Physical Activity’:
  31. 31. Phase-5. Ecological Factors (Administrative and Policy Diagnosis)
  32. 32. 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.
  33. 33. 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.
  34. 34. 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.
  35. 35. Strategy
  36. 36. 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.