The PRECEDE-PROCEED model provides a comprehensive structure for assessing health and quality-of-life needs and for designing, implementing, and evaluating health promotion and other public health programs to meet those needs. PRECEDE (Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and Evaluation) outlines a diagnostic planning process to assist in the development of targeted and focused public health programs. PROCEED (Policy, Regulatory, and Organizational Constructs in Educational and Environmental Development) guides the implementation and evaluation of the programs designed using PRECEDE.
PRECEDE consists of five steps or phases (see Figure 1). Phase one involves determining the quality of life or social problems and needs of a given population. Phase two consists of identifying the health determinants of these problems and needs. Phase three involves analyzing the behavioral and environmental determinants of the health problems. In phase four, the factors that predispose to, reinforce, and enable the behaviors and lifestyles are identified. Phase five involves ascertaining which health promotion, health education and/or policy-related interventions would best be suited to encouraging the desired changes in the behaviors or environments and in the factors that support those behaviors and environments.
PROCEED is composed of four additional phases. In phase six, the interventions identified in phase five are implemented. Phase seven entails process evaluation of those interventions. Phase eight involves evaluating the impact of the interventions on the factors supporting behavior, and on behavior itself. The ninth and last phase comprises outcome evaluation—that is, determining the ultimate effects of the interventions on the health and quality of life of the population.
In actual practice, PRECEDE and PROCEED function in a continuous cycle. Information gathered in PRECEDE guides the development of program goals and objectives in the implementation phase of PROCEED. This same information also provides the criteria against which the success of the program is measured in the evaluation phase of PROCEED. In turn, the data gathered in the implementation and evaluation phases of PROCEED clarify the relationships examined in PRECEDE between the health or quality-of-life outcomes, the behaviors and environments that influence them, and the factors that lead to the desired behavioral and environmental changes. These data also suggest how programs may be modified to more closely reach their goals and targets.
Among the contributions of the PRECEDE-PROCEED model is that it has encouraged and facilitated more systematic and comprehensive planning of public health programs. Sometimes practitioners and researchers attempt to address a specific health or quality-of-life issue in a particular group of people without knowing whether those people consider the issue to be important. Other
times, they choose interventions they are comfortable using rather than searching for the most appropriate intervention for a particular population. Yet, what has worked for one group of people may not necessarily work for another, given how greatly people differ in their priorities, values, and behaviors. PRECEDE-PROCEED therefore begins by engaging the population of interest themselves in a process of identifying their most important health or quality-of-life issues. Then the model guides researchers and practitioners to determine what causes those issues—that is, what must precede them. This way, interventions can be designed based not on speculation but, rather, on a clear understanding of what factors influence the health and quality-of-life issues in that population. As well, the progression from phase to phase within PRECEDE allows the practitioner to establish priorities in each phase that help narrow the focus in each subsequent phase so as to arrive at a tightly defined subset of factors as targets for intervention. This is essential, since no single program could afford to address all the predisposing,
Applications of the PRECEDE-PROCEED model in the public health field are myriad and varied. The model has been used to plan, design, implement, and/or evaluate programs for such diverse health and quality-of-life issues as breast, cervical, and prostate cancer screening; breast self-examination; cancer education; heart health; maternal and child health; injury prevention; weight control; increasing physical activity; tobacco control; alcohol and drug abuse; school-based nutrition; health education policy; and curriculum development and training for health care professionals. A searchable bibliography of hundreds of published applications is available on the World Wide Web (www.ihpr.ubc.ca). Also available is an interactive software training program entitled EMPOWER, which illustrates how the model can be used to plan a breast cancer detection program.
LAWRENCE W. GREEN
SHAWNA L. MERCER
Gold, R.; Green, L. W.; and Kreuter, M. W. (1997). EMPOWER: Enabling Methods of Planning and Organizing within Everyone's Research. Sudbury, MA: Jones & Bartlett. CD-ROM and manual.
Green, L. W. (1992). "Prevention and Health Education." In Maxcy-Rosnau-Last: Public Health and Preventive Medicine, 13th edition, eds. J. M. Last and R. B. Wallace. Norwalk, CT: Appleton & Lange.
Green, L. W., and Kreuter, M. W. (1999). Health Promotion Planning: An Educational and Ecological Approach, 3rd edition. Mountain View, CA: Mayfield.