In the public health arena, the term "enabling factors" is recognized most widely as part of Lawrence W. Green's PRECEDE Model and Green and Kreuter's PRECEDE-PROCEED Model of Community Health Promotion Planning and Evaluation. These models provide a series of steps to guide the assessment of the health and quality-of-life needs of individuals and populations, and the planning, implementation, and evaluation of strategies and programs designed to meet those needs. Once a particular health problem has been identified, the process of designing effective strategies to address it involves determining which behaviors lead to, or are otherwise associated with, that health problem. The next step involves ascertaining which factors have the ability to cause each of these behaviors to occur or to inhibit their occurrence. These factors are themselves grouped into three types: predisposing, reinforcing, and enabling factors.
Green originally adapted the term "enabling factor" in 1974 from the concept of "enabling resources" found in Ronald Andersen's Behavioral Model of Families' Use of Health Services (1968). Andersen's model, still used widely in the fields of health services research and health administration, suggests that among the factors that influence use of health services are two categories of enabling resources: community enabling resources (e.g., health personnel and facilities must be available), and personal/family enabling resources (e.g., people must know how to access and use the services and have the means to get to them).
Within the PRECEDE-PROCEED Model, 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.
SKILLS
A person or population may need to employ a number of skills to carry out successfully all of the tasks involved in changing behavior. Skills that people already possess may serve as predisposing factors insofar as they motivate the behavior. In contrast, any skills that still need to be developed are considered to be enabling factors.
New skills may include those involved with determining how to identify, access, and use medical care procedures, facilities, and programs. For example, women who are comfortable using the Internet may be able to follow a number of links to access information about where to receive a screeningmammogram, whereas women who are not able to use the Internet may have a harder time tracking down available services. Women who have never been shown how to perform breast self-examination may feel that they would do it wrong and may therefore not try at all. Similarly, older women who have traditionally let their doctor guide the discussion during office visits may not know how to effectively ask questions about becoming involved in preventive health maneuvers related to breast cancer.
Other skills of importance are those that allow an individual or population to undertake personal action to reduce their risk of disease. For instance, women may not know how to decrease the fat content of their diet or to increase the amount of vegetables they eat so as to reduce their risk of cancer and heart disease. They may not know how to change their cooking patterns to create meals that are healthful while also being tasty enough that their families will eat them.
Finally, skills in changing the environment may be important for behavior change. As an example, women who receive training in advocacy may be effective in securing funding for comprehensive breast cancer screening programs for low-income recipients. Women who are shown how to participate in community development initiatives may gain credibility with ethnic populations and be able to share with them the importance of breast-cancer screening.
HEALTH CARE RESOURCES
A number of health care resources may be implicated if an individual or population is to make a behavior change. These include such things as health care providers, hospitals, public health programs and classes, clinics for those who are sick, and programs for healthy people who are trying to maintain or improve their health. The relative availability, accessibility, and affordability of these resources may either enable or hinder undertaking a particular behavior.
For example, overweight people may need to reduce their risk of heart disease and diabetes by decreasing the amount of fat and sugar in their diet. Toward this end, health care providers or clinics might agree to making themselves available to people who need to be informed about, and who need periodic monitoring of their blood pressure and the levels of sugar and fat in their blood. Accessibility depends on such things as whether people can secure transportation to clinics and doctors' offices and whether the design of these facilities is user friendly for people with physical limitations. Similarly, the affordability of visits to health care providers for testing, and possibly for lifestyle counseling, is influenced by whether people have health-insurance coverage and whether preventive health care procedures such as lifestyles counseling are covered.
COMMUNITY AND OTHER ENVIRONMENTAL CONDITIONS AND RESOURCES
Changing behavior may be easier if aspects of one's environment are supportive of that change. Community resources include such things as the availability of referral services and of centers that sponsor or provide space for public health initiatives or activities. Other important conditions and resources include policy initiatives, the availability of healthful products and alternatives to unhealthful behaviors, and the existence and enforcement of legislation.
As an example, public health practitioners may want people to increase their levels of physical activity. Individuals may have a greater likelihood of becoming involved in regular exercise if such things as parks, recreation centers, and swimming pools are available in their community. They might be more likely to take up regular walking, jogging, rollerblading, or bike riding if their neighborhood is safe and relatively clean. Furthermore, user fees for recreation centers and other sports facilities, and having to pay for child care while exercising, will influence the affordability of exercise options.
If the aim is to reduce tobacco use, people may be encouraged to quit, or at least to reduce their smoking, if there is a ban on smoking in workplaces and in other public spaces. Levying taxes on cigarettes increases their cost and acts as a disincentive to smoking, especially among youth. Laws that prohibit tobacco sales to minors and that eliminate the placing of tobacco vending machines where minors can access them can combine to decrease access to tobacco among youth, and may serve to discourage their experimentation with tobacco. Making nicotine replacement therapy and other smoking cessation aids available, accessible, and relatively low cost may also increase the likelihood that smokers will attempt to quit.
EFFECTIVE USE OF INFORMATION COLLECTED ABOUT ENABLING FACTORS
Key to the success of health-promotion and disease-prevention programs is a determination of which of the requisite skills and resources for changing behavior and the environment people already possess, and which ones are lacking. This involves an organizational assessment of resources and an educational assessment of the necessary skills. Public health practitioners should then consider adding components to their programs or tapping into other sources that teach the necessary skills or that provide the missing resources. They should further identify what organizational actions need to be taken to modify the environment.
To continue with the examples provided above, if the availability of health care providers in a geographical area is minimal or if their business hours are limited, blood pressure as well as blood lipid and sugar testing can be offered periodically during evening and weekend hours in local shopping malls or in mobile units. Providing child care while individuals undergo testing and any follow-up counseling could further increase accessibility. Follow-up counseling could include the provision of information about, and samples of, low-fat cooking, along with referrals for low-cost classes on healthful cooking. If neighborhoods are not adequately safe or clean, or during winter months, walking clubs could be established in shopping malls before stores opened. If vendors are selling tobacco products to youth in the community, interested citizens could be trained to advocate for consistent enforcement of minors' access laws. In all cases, the aim is to render the environment more supportive of and more conducive to behavior change.
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