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Cancer Screening Health Promotion Model

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CANCER SCREENING HEALTH PROMOTION ENVIRONMENTAL SCAN

ACKNOWLEDGEMENTS

Documents prepared by: Seema M. Parmar, MHA, PhD(c), Health Promotion Associate

Alberta Health Services, Health Promotion, Disease and Injury Prevention, Screening Programs, Health Promotion

Rosanna Taylor, MSc. Health Promotion Research Associate Alberta Health Services, Health Promotion, Disease and Injury Prevention, Screening Programs, Health Promotion

Documents reviewed by: Alberta Health Services, Health Promotion, Disease and Injury Prevention, Screening Programs, Health Promotion

Alison Nelson, Manager Monica Schwann, Acting Manager Charlene Mo, Health Promotion Coordinator Melissa Hyman, Health Promotion Coordinator Carmen Webber, Health Promotion Coordinator, Screen Test

Alberta Health Services, Health Promotion, Disease and Injury Prevention, Screening Programs Dr. Huiming Yang, Director, Screening Programs Dr. Laura McDougall, Medical Lead, Screening Programs Krista Russell, Manager, ABCSP/ACCSP MaryAnne Zupancic, Manager, ACRCSP Brenda Lynch, Manager, Client Program Services Germaeline van der Lee, Project Coordinator, ACRCSP Maria Linehan, Project Coordinator, ABCSP/ACCSP Tammy Burke, Program Assistant, ABCSP/ACCSP Carolyn Dudley, Program Manager, EPICS, ABCSP/ACCSP Dr. Lorraine Shack, Research Leader, Public Health Innovation and Decision Support

Acknowledgements: The authors gratefully acknowledge the following individuals and organizations for their contribution to the development of various elements of each of the environmental scan documents.

Alberta Health Services, Health Promotion, Disease and Injury Prevention, Screening Programs, Health Promotion (Alison Nelson, Monica Schwann, Charlene Mo, Melissa Hyman, Carmen Webber, Amy Williams, Teresa Earl)

Alberta Health Services, Health Promotion, Disease and Injury Prevention, Screening Programs, Screening Programs (Dr. Huiming Yang, Dr. Laura McDougall, Krista Russell, MaryAnne Zupancic, Song Gao, Patricia Pelton)

Alberta Health Services (Dr. Lisa Petermann, Dr. Lorraine Shack, Graham Petz, Brianne Lewis, Robyn Sachs, Jennifer Doole, Vicky Vu)

Helix Designs (James Shrimpton)

Palomino (Lucas Bombardier, Christina Almeida)

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Suggested Citation: Alberta Health Services (2010). Cancer Screening Health Promotion Model. Calgary, Alberta: Alberta Health Services This document is current as of December 30, 2010. For a PDF version of this document, and more information on the environmental scan, please visit http://www.screeningforlife.ca/healthpromotion

http://www.screeningforlife.ca/healthpromotion


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CANCER SCREENING HEALTH PROMOTION MODEL

Model Background ....................................................................................... 2 Cancer Screening Health Promotion Model ..................................................... 2

Figure 1: Cancer Screening Health Promotion Model ........................................ 3 The “What” component of the CSHP Model ..................................................... 4 The “How” component of the CSHP Model ...................................................... 6

The “Who” component of the CSHP Model ...................................................... 8 The Cancer Screening Health Promotion Environmental Scan ............................ 8

Appendix A: The Ottawa Charter for Health Promotion .................................. 10 Appendix B: The Population Health Promotion Model ..................................... 14 Appendix C: PRECEDE-PROCEED Model ....................................................... 18

References ............................................................................................... 21


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Model Background In April 2009, the Alberta Health Services (AHS) Screening Programs Health Promotion Unit (SP-HPU) initiated a Cancer Screening Health Promotion (CSHP) Environmental Scan. The goal of the CSHP Environmental Scan was to gather and summarize evidence related to the current breast, cervical and colorectal cancer screening health promotion needs across Alberta. As part of the CSHP Environmental Scan, a CSHP Model was created as a guide to examine and attend to the breast, cervical, and colorectal cancer screening needs in Alberta. The model was altered throughout the course of the environmental scan as information was gathered and new ideas were generated. The most recent version of the model is presented in this document.

Cancer Screening Health Promotion Model The CSHP model and the sources of the various components are presented in Figure 1. The model is based on the Ottawa Charter for Health Promotion and the Population Health Promotion (PHP) model 1; however, the CSHP model includes strategic activities used by the AHS SP-HPU and different factors associated with cancer screening behaviour drawn from the original PHP model and the PRECEDE-PROCEED model 2. The Ottawa Charter, PHP Model, and PRECEDE-PROCEED Model are described in Appendices A-C. Like the Ottawa Charter, PHP Model and the PRECEDE-PROCEED Model, the CSHP Model emphasizes the need for multiple strategies involving multiple levels of the population and addressing multiple factors associated with screening in order to improve cancer screening rates at the population level and reduce inequities.1


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Figure 1: Cancer Screening Health Promotion Model


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The “What” component of the Cancer Screening Health

Promotion Model

The original PHP model includes determinants of overall health in the “What” component of the model. 1 Though many of the determinants in the original PHP model are associated* with cancer screening, not all of the determinants directly promote or prevent cancer screening. In the CSHP Model, these determinants of health are called “factors associated with cancer screening”.

There are six categories of factors associated with cancer screening in the CSHP model. The first three categories - “Genetic and non-modifiable characteristics”, “Behaviour, Circumstance & Personal History”, and “Socioeconomic & Environmental conditions”- encompass the different determinants of health in the original PHP model. These factors characterize which populations are likely un- or under-screened and who should be engaged in cancer screening promotion interventions. The last three categories - predisposing, enabling, and reinforcing factors- are adapted from the PRECEDE-PROCEED model.2 While the factors in the first three categories influence overall health, the factors in these last three categories are specific to cancer screening promotion and practices. Predisposing, enabling, and reinforcing factors describe why individuals are not screened or what needs to happen in order for individuals to be screened. These factors are what cancer screening promotion interventions aim to change.

Table 1 includes examples of the different categories of factors associated with cancer screening. Additional examples as well as details about the examples included in this table are provided in the document titled “Factors associated with cancer screening” available on www.screeningforlife.ca/healthpromotion.

* Associated means that these factors do not cause screening or prevent screening, but screening rates differ significantly between populations with these factors and populations without these factors



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Table 1: Categories of Factors Associated with Cancer Screening: The “What” component of the Cancer Screening Health Promotion Model

Category Types of factors Examples

Genetic & Non-modifiable characteristics

Includes inherited characteristics and characteristics of an individual that cannot be changed.

Family history Age Gender Race or Ethnicity

Behaviour, Circumstance and Personal History

Includes factors related to an individual’s general behaviour, lifestyle, and life experiences. These factors may be difficult to modify in the short-term.

Education level

Length of time in a new country

Marital status

Disability

Health behaviours

Socioeconomic and Environmental conditions

Includes factors related to an individual’s socioeconomic status and factors related to the environment in which and individual lives and works. These factors are often difficult to modify in the short-term.

Income

Employment

Location of neighborhood of residence

Socioeconomic conditions of neighborhood of residence

Predisposing factors

Includes modifiable factors that motivate an individual to engage in cancer screening practices such as cancer screening knowledge, attitudes, and beliefs.

Knowledge about cancer screening and cancer screening services

Fear of cancer screening

Expectation of pain

Fatalistic beliefs

Screening as a priority

Perceived benefits, barriers,

susceptibility, and severity†

Enabling factors

Includes modifiable factors that make it possible for an individual to engage in cancer screening such as skills, resources, and policies.

Health insurance (when applicable)

Regular source of health care

Recent physician contact

Factors related to quality, availability, and accessibility of healthcare services

Reinforcing factors

Includes modifiable factors that influence an individual to continue engaging in cancer screening such as social influences, incentives, and positive experiences.

Physician’s recommendation

Peer or family support

Reinforcement from spiritual leaders

Medical history

Previous cancer screening experiences

† From the Health Belief Model {{879 Rosenstock, I.M. 1974;}}


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The “How” component of the Cancer Screening Health Promotion

Model The “How”component of the CSHP Model includes categories of strategic activities used by AHS SP-HPU to promote cancer screening throughout Alberta. The specific activities coordinated by AHS SP-HPU aim to increase cancer screening at the population level by improving knowledge, influencing positive attitudes, and increasing cancer screening behaviour (Table 2). Examples of cancer screening promotion activities within these categories that can be coordinated at the level of a health unit (e.g. Zone, Primary Care Network, health department etc.) or at the community level (e.g. neighborhood groups, community service organizations, employers, etc.) are described in the documents titled “Activities that Promote Cancer Screening” and “Cancer Screening Promotion Activities in Alberta” available on www.screeningforlife.ca/healthpromotion. There are six categories of strategic activities in the CSHP Model: Education Resources & Training, Social Marketing, Communication, Community Action, and Knowledge Management.

Education resources and training includes two types of activities. The first type of activity is the development and distribution of information resources on cancer screening. These resources include, but are not limited to, brochures, information and fact sheets, posters, PowerPoint presentations, and tabletop displays that provide information on breast, cervical, and colorectal cancer screening. Separate educational resources are created for the public and for healthcare providers (including physicians, nurses, lab technologists, and mammography technologists). The second type of activity is training. Training includes sessions and workshops that provide information on cancer screening to healthcare staff (e.g. nurses, health promoters and educators, physician etc.), train staff to use the different cancer screening information resources, and/or train staff on actual screening practices (e.g. Pap test training for registered nurses) so that staff are able to deliver cancer screening education and services to their clients. Social marketing activities aim to create an atmosphere that encourages cancer screening by improving cancer screening knowledge, attitudes, values, and behaviours. Social marketing integrates key behaviour change theories and concepts (see document titled “Health Promotion and Behaviour Change Theory” on www.screeningforlife.ca/healthpromotion) with commercial marketing strategies used in consumer and market research, and product advertising and promotion.3 Social marketing projects require the use of rigorous research and planning, strategy design, implementation and evaluation methods.4-8 Social marketing campaigns coordinated by AHS SP-HPU focus on the specific target age groups for the different cancer screening programs, health professionals, and known un- or under-screened populations. The AHS SP-HPU works with professional social marketing and market research organizations to ensure that the consumer and market research accurately characterizes the target populations and that the marketing methods and deliverables appropriately reflect the target population’s needs and preferences. Communication activities examine different modes of connecting with and providing information to the public and healthcare providers. Examples of communication activities include print communications (e.g. correspondence letters, articles, and advertisements), online communication (e.g. websites, emails), and telephone communication (e.g. health information telephone lines).




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Community Action activities provide support to health units (e.g. Primary Care Networks, AHS Zones, and health departments) and community groups interested in cancer screening promotion who are working directly with un- or under-screened populations. These un- or under-screened populations may not be screened routinely for a number of reasons that require intensive, multi-pronged, resource-heavy cancer screening promotion interventions to address. AHS SP-HPU aims to engage these un- and under-screened populations in screening through collaborations with community-based organizations that bring together the resources and expertise of the different collaborators. The AHS SP-HPU’s Community Action process involves three phases. The first phase is using our resources and expertise to assist organizations interested in cancer screening promotion to meet their needs and objectives. This type of assistance is generally short-term and conducted as consultations. The second phase is building relationships with community-based organizations through these consultations in order to assist these groups with planning, implementing, and evaluating their cancer screening promotion activities. The third phase is where the community-based organizations collaborate with AHS SP-HPU to implement ongoing and sustainable cancer screening promotion activities in their communities. Knowledge management is defined by the World Health Organization (WHO) as “a set of principles, tools, and practices that enable people to create knowledge, and to share, translate and apply what they know to create value and improve effectiveness.”9 Knowledge management activities aim to bridge the “know-do” gap: the gap that results between what is known about resolving health problems and what is done to resolve health problems. In many cases, solutions to health problems are known, but not applied. Knowledge management aims to encourage creating, sharing, and applying knowledge to improve health.9 AHS SP-HPU uses knowledge management to share what is learned about cancer screening promotion in Alberta with others interested and involved in cancer screening promotion. These learnings also contribute to the foundation of the CSHP model and increase knowledge and understanding of health promotion and cancer screening values, assumptions, and evidence. Connecting the “What” and the “How” The factors described in the categories of Genetic & Non-modifiable characteristics, Behaviour, Circumstance, & Personal History, and Socioeconomic & Environmental Conditions in the “What” component of the CSHP model are used to ensure that all of the activities and deliverables are relevant to and appropriate for the populations the activities are intended to reach. For example, the following are three ways education resources are created to reflect factors associated with cancer screening:

1) Education resources for certain genders, age groups, and/or ethnicities include pictures of individuals of that gender from that age group or ethnicity. If education resources are intended to reach both genders and different age groups and ethnicities, the resources include pictures of males and females of different ages and ethnicities.

2) Language used in the education resources reflects factors related to education levels or cultures/countries of origin. Simplified language is used for individuals with lower literacy or English comprehension levels. Education resources are translated into multiple languages to make the information available to those who do not read English.


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3) Language and formats of education resources and training reflect specific professions and occupations using pictures, models, and language that is used frequently and accepted in that profession.

The factors described in the categories of Predisposing factors, Enabling factors, and Reinforcing factors in the “What” component of the CSHP model are used to determine the format and content of the cancer screening promotion activities and deliverables. For example, activities that aim to change predisposing factors will discuss information related to cancer screening knowledge, attitudes, and beliefs, while activities that aim to change enabling factors will include information to help individuals seek and access cancer screening services. Activities that aim to encourage continued use of cancer screening services will address reinforcing factors such as benefits of ongoing cancer screening.

The “Who” component of the Cancer Screening Health Promotion Model The “Who” component of the CSHP model defines who needs to be reached through cancer screening promotion activities and who should be involved in delivering cancer screening promotion activities. The levels of the population included in the “Who” component of the CSHP Model are almost the same as the levels of the population included in the original PHP model. These are Society, Health Sector/System, Community, Family, and Individual. The original PHP model states Sector/System while the CSHP specifies Health Sector/System. Including the different levels emphasizes the need to involve different levels in overall cancer screening promotion, taking into account who the activities are targeting, what factors the activities are focused on changing, and the types of activities necessary to change these strategies and the resources and expertise of those involved in delivering the cancer screening promotion activities. This can work the other way too, starting with who is involved in delivering the cancer screening promotion activity and their resources and expertise, examining what activities they can successfully deliver, what factors they can effectively change, and who they can successfully reach. AHS SP-HPU aims to influence cancer screening promotion at the Society, Health Sector/System, and Community level. Through the Community Action activities, AHS SP-HPU aims to support and collaborate with different community organizations working to promote cancer screening at the family and individual-level.

The Cancer Screening Health Promotion Environmental Scan

The CSHP Environmental Scan shapes the foundation of the CSHP Model by 1) defining health promotion & cancer screening values and assumptions, and 2) describing evidence from peer-reviewed literature, surveillance data, and experiences related to cancer-screening promotion. During the CSHP Environmental Scan, the CSHP Model was used to determine how determinants of cancer screening and interventions that promote cancer screening could be organized. The determinants of cancer screening were used to identify populations that were potentially un- or


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under-screened for breast, cervical, and/or colorectal cancer in Alberta. The interventions used to promote cancer screening were used to understand what is being done and what can be done to promote screening for breast, cervical, and/or colorectal cancer in Alberta. The study of determinants of cancer screening and interventions that promote cancer screening is necessary to acknowledge who is currently engaged and who needs to be further engaged in cancer screening promotion in Alberta. A description of the Framework for the Cancer Screening Health Promotion Environmental Scan is available on www.screeningforlife.ca/healthpromotion.



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Appendix A: The Ottawa Charter for Health Promotion

The Ottawa Charter for Health Promotion was developed by the World Health Organization in 1986 during the First International Conference on Health Promotion, held in Ottawa, Ontario. The following definition of health promotion provided in the Ottawa Charter is used throughout the world to guide health promotion activities.

“Health promotion is the process of enabling people to increase control over, and to improve, their health. To reach a state of complete physical, mental, and social well-being, an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment. Health is, therefore, seen as a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities. Therefore, health promotion is not just the responsibility of the health sector, but goes beyond healthy life-styles to well-being.”10

The Ottawa Charter describes five action areas and three strategies that form the foundation of health promotion. The integration of these different areas and strategies is illustrated by the health promotion emblem, which was introduced at the International Conference on Health Promotion in Ottawa in 1986 and is still in use today (Figure A.1).


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Figure A.1: World Health Organization Health Promotion Emblem


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The emblem includes five sections. The small circle includes three strategies for health promotion. These strategies are to enable everyone to improve their health by ensuring equal opportunities and resources, to mediate the different interests of all sectors to promote a common goal of improving the health of individuals, families and communities, and to advocate for political, economic, social, cultural, environmental, behavioural, and biological changes that promote health. The three wings represent four of the five action areas: 1) “Reorient health services” to focus on health promotion and disease prevention; 2) “Create supportive environments” to ensure healthy living and working conditions; 3) “Develop personal skills” so individuals can make healthy choices and control their own health and environment; 4) “Strengthen community action” so communities can plan and implement health promoting strategies of greatest importance to them. Developing personal skills is part of strengthening community action, which is why they are part of the same wing. This wing breaks the large circle, signifying the need for policy to respond to the changing needs of societies, communities, and individuals.11 The large circle represents “Building healthy public policy”, which involves pursuing the other four action areas and all three strategies.

The AHS SP-HPU uses multiple strategies and approaches to reach targeted

populations, healthcare providers (HCP) including AHS staff, community groups, and

the general public in order to influence positive attitudes, improve knowledge, and

increase cancer screening behaviours. The SP-HPU’s strategic activities fall within six

areas: Health Education, Continuing Education, Health Communication, Social

Marketing, Knowledge Management, and Community Action. These activities are

based on key health promotion principles as outlined in the Ottawa Charter. Table

A.1 shows how the SP-HPU’s strategic activities relate to the five action areas

described in the Ottawa Charter. Further information on the Ottawa Charter for

Health Promotion is available on

http://www.who.int/healthpromotion/conferences/previous/ottawa/en/.

http://www.who.int/healthpromotion/conferences/previous/ottawa/en/


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Table A.1: Relation of Alberta Health Services (AHS) Screening Programs Health Promotion Unit (SP-HPU) Strategic Activities to Ottawa Charter Action Areas

Action Area (Ottawa Charter)

Definition (Ottawa Charter)

Objectives (AHS SP-HPU)

Strategic Activities

(AHS SP-HPU)

Building Public Policy

Ensure that policy developed by all sectors contributes to health-promoting conditions.

Increase policy makers’ awareness and efforts toward

enhancing and integrating cancer screening promotion

Community Action, Knowledge Management

Reorient Health Services

Create systems that focus on the needs of the whole person and invite a true partnership among the providers and users of the services.

Share cancer screening promotion responsibility among community groups, healthcare providers, health service institutions and governments through

increasing collaboration

emphasizing importance of evidence-based practices

Education Resources & Training, Knowledge Management

Create Supportive Environments

Create physical, social, economic, cultural, spiritual environments that recognize the rapidly changing nature of society, particularly in the areas of technology and the organization of work, and that ensure positive impacts on the health of the people

Link people and their environment through

increasing options available for people to control their own health

making healthy choices easier

Community Action, Communication, Social Marketing

Develop Personal Skills

Enable people to have the knowledge and skills to meet life's challenges and to contribute to society

Support lifelong personal learning and development through

providing information on health services

offering health education

enhancing skills

Education Resources & Training, Communication, Social Marketing

Strengthen Community Action

Ensure communities have the capacity to set priorities and make decisions on issues that affect their health

Empower communities through

developing communities’ existing human and material resources

enhancing self-help and social support

increasing flexibility and accessibility of information and learning opportunities

Community Action, Education Resources & Training


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Appendix B: The Population Health Promotion Model

The Population Health Promotion Model, created by Hamilton and Bhatti in 1996 (Figure B.1), addresses the intersection of health promotion and population health. The model combines the action areas defined in the Ottawa Charter for Health Promotion with the determinants of health presented in the 1994 Health Canada report “Strategies for Population Health: Investing in the Health of Canadians” and different levels of action within the population. The Population Health Promotion Model can be used to create a comprehensive action plan to address the health needs of a particular high-risk population or to address the health needs of the entire population regarding a particular health issue. This model is depicted in a 3-Dimensional cube, suggesting that health promotion is a multi-dimensional process, involving and affecting the population at multiple levels (who), using multiple health promotion strategies (how) and addressing various determinants of health within and outside the health sector (what). The levels of action include “the individual; family and friends; community (people linked by a common interest or geographic setting such as a neighborhood, school or workplace); sector/system (education, income support, housing, etc.); and society as a whole”.1. Table B.1 includes the determinants of health as defined by Hamilton and Bhatti. The base of the cube emphasizes the importance of evidence-based decision-making using research studies, experiential knowledge, and evaluation studies as the key sources of evidence. The values and assumptions of the model as described by Hamilton and Bhatti are provided in Table B.2. Further information on the Population Health Promotion Model is available at http://www.phac-aspc.gc.ca/ph-sp/php-psp/index-eng.php.

http://www.phac-aspc.gc.ca/ph-sp/php-psp/index-eng.php


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Figure B.1: The Population Health Promotion Model1


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Table B.1: Determinants of Health 1

Determinant Definition

Income & Social Status

The relative distribution of wealth and social status affect health by determining the degree of control people have over life circumstances and, hence, their capacity to take action.

Social Support Networks Support from families, friends, and communities help people deal with difficult situations and maintain control over life circumstances.

Education

Meaningful and relevant education equips people with knowledge and skills for daily living, enables them to participate in their community, and increases opportunities for employment.

Working Conditions Meaningful employment, economic stability, and a healthy work environment are associated with good health.

Biology & Genetic Endowment

Research in the biological sciences suggests "physiological make-up" as an important health determinant.

Personal Health Practices & Coping Skills

Personal health practices prevent disease and promote self-care. Effective coping skills enable people to be self-reliant, solve problems, and make choices that enhance health.

Healthy Child Development

Positive prenatal and early childhood experiences have a significant effect on subsequent health.

Health Services Availability of preventive and primary care services is related to improved health.


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Table B.2: Values and Assumptions of the Population Health Promotion (PHP) Model1

PHP Model Values & Assumptions

1. Policy and program decision makers agree that comprehensive action needs to be taken on all the determinants of health using the knowledge gained from research and practice.

2. It is the role of health organizations to analyze the full range of possibilities for action, to act on those determinants that are within their jurisdiction and to influence other sectors to ensure their policies and programs have a positive impact on health. This can best be achieved by facilitating collaboration among stakeholders regarding the most appropriate activities to be undertaken by each.

3. Multiple points of entry to planning and implementation are essential. However, there is a need for overall coordination of activity.

4. Health problems may affect certain groups more than others. However, the solution to these problems involves changing social values and structures. It is the responsibility of the society as a whole to take care of all its members.

5. The health of individuals and groups is a combined result of their own health practices and the impact of the physical and social environments in which they live, work, pray, and play. There is an interaction among people and their surroundings. Settings, consisting of places and things, have a physical and psychological impact on people's health.

6. In order to enjoy optimal health, people need opportunities to meet their physical, mental, social, and spiritual needs. This is possible in an environment that is based on the principles of social justice and equity and where relationships are built on mutual respect and caring, rather than power and status.

7. Health care, health protection and disease prevention initiatives complement health promotion. Comprehensive approaches will include a strategic mix of the different possibilities for action. Meaningful participation of people in the development and operationalization of policies and programs is essential for them to influence the decisions that affect their health.


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Appendix C: PRECEDE-PROCEED Model

The CSHP Model includes predisposing, enabling, and reinforcing factors, which were originally described in the PRECEDE-PROCEED Model. This model outlines the necessary steps during the design, implementation and evaluation stages of a health promotion intervention (Figure C.1). Like the Population Health Promotion Model, the PRECEDE-PROCEED model emphasizes the multiple determinants of health and the need for multi-sectoral strategies to promote behavioral, social, and environmental change.2 The model uses concepts from epidemiology, health care administration, and the social, behavioural, and educational sciences. The model emphasizes a participatory approach involving the target populations in identifying key health or quality-of-life issues and the factors that influence these issues. The goal of the model is to have a clear understanding of the problem based on evidence as opposed to speculation. This evidence-base is also consistent with the Population Health Promotion Model.

The PRECEDE-PROCEED model includes two components and nine phases. The nine phases are described in Table C.1. The first five phases are part of the PRECEDE component of the model. These phases create a foundation for the PROCEED component. The PROCEED component includes the actual design, implementation and evaluation of the intervention using what was learned in the PRECEDE component.

Further information on the PRECEDE-PROCEED Model is available at http://www.lgreen.net/precede.htm.

http://www.lgreen.net/precede.htm


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Figure C.1: PRECEDE-PROCEED Model2

Predisposing Reinforcing Enabling Constructs in Educational Diagnosis and Evaluation

Policy Regulatory Organizational Constructs in Educational and Environmental Development


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Table C.1: Description of steps in the PRECEDE-PROCEED Model2, 12

Step Purpose Examples of Methods PR

EC

ED

E

Step 1: Social Diagnosis Understand community’s perceived needs

Key informant interviews, focus groups, participant observations, surveys

Step 2: Epidemiological Diagnosis

Prioritize community’s health needs; Establish program goals and objectives

Primary and secondary data analysis

Step 3: Behavioural & Environmental Diagnosis

Identify factors internal and external to the individual that affect the health problem

Review of literature and theory

Step 4: Educational & Organizational Diagnosis

Determine predisposing (knowledge, attitudes, beliefs), enabling (skills, resources, access, policies), and reinforcing (social influences, incentives, positive experiences) factors necessary to initiate and maintain change

Use available evidence and individual, interpersonal, community-level change theories to identify and classify factors

Step 5: Administration & Policy Diagnosis

Establish availability of necessary resources and organizational policies and regulations that could affect program implementation

Data and evidence from previous four steps and knowledge of organization policies and resources

PR

OC

EED

Step 6: Implementation of Intervention

Step 7: Process Evaluation Assess extent to which intervention is carried out as planned

Prior to implementation, design evaluation framework including indicators and methods of measuring indicators for each step.

Step 8: Impact Evaluation

Assess changes in predisposing, enabling, and reinforcing factors that predict likelihood of desired behavioural and environmental changes

Step 9: Outcome Evaluation

Assess desired changes to health and quality-of-life indicators.


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