Green’s Precede-Proceed Model

The goals of the model are to explain health-related behaviors and environments, and to design and evaluate the interventions needed to influence both the behaviors and the living conditions that influence them and their consequences.

The Precede-Proceed framework for planning is founded on the disciplines of epidemiology; the social, behavioral, and educational sciences; and health administration. Throughout the work with Precede and Proceed, two fundamental propositions are emphasized: (1) health and health risks are caused by multiple factors and (2) because health and health risks are determined by multiple factors, efforts to effect behavioral, environmental, and social change must be multidimensional or multisectoral, and participatory.

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. 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, enabling and reinforcing factors for all of the behaviors, lifestyles, and environments that influence all of the health and quality-of-life issues of interest.

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.

Pender’s Health Promotion Theory

The health promotion model (HPM) proposed by Nola J Pender (1982; revised, 1996) was designed to be a “complementary counterpart to models of health protection.” It defines health as a positive dynamic state not merely the absence of disease. Health promotion is directed at increasing a client’s level of wellbeing. The health promotion model describes the multi dimensional nature of persons as they interact within their environment to pursue health. The model focuses on following three areas:

· Individual characteristics and experiences

· Behavior-specific cognitions and affect

· Behavioral outcomes

The health promotion model notes that each person has unique personal characteristics and experiences that affect subsequent actions. The set of variables for behavioral specific knowledge and affect have important motivational significance. These variables can be modified through nursing actions. Health promoting behavior is the desired behavioral outcome and is the end point in the HPM. Health promoting behaviors should result in improved health, enhanced functional ability and better quality of life at all stages of development. The final behavioral demand is also influenced by the immediate competing demand and preferences, which can derail an intended health promoting actions.

ASSUMPTIONS OF THE HEALTH PROMOTION MODEL

The HPM is based on the following assumptions, which reflect both nursing and behavioral science perspectives:

Individuals seek to actively regulate their own behavior.

Individuals in all their biopsychosocial complexity interact with the environment, progressively transforming the environment and being transformed over time.

Health professionals constitute a part of the interpersonal environment, which exerts influence on persons throughout their lifespan.

Self-initiated reconfiguration of person-environment interactive patterns is essential to behavior changes.

THEORETICAL PROPOSITIONS OF THE HEALTH PROMOTION MODEL

Theoretical statements derived from the model provide a basis for investigative work on health behaviors. The HPM is based on the following theoretical propositions:

Prior behavior and inherited and acquired characteristics influence beliefs, affect, and enactment of health-promoting behavior.

Persons commit to engaging in behaviors from which they anticipate deriving personally valued benefits.

Perceived barriers can constrain commitment to action, a mediator of behavior as well as actual behavior.

Perceived competence or self-efficacy to execute a given behavior increases the likelihood of commitment to action and actual performance of the behavior.

Greater perceived self-efficacy results in fewer perceived barriers to a specific health behavior.

Positive affect toward a behavior results in greater perceived self-efficacy, which can in turn, result in increased positive affect.

When positive emotions or affect are associated with a behavior, the probability of commitment and action is increased.

Persons are more likely to commit to and engage in health-promoting behaviors when significant others model the behavior, expect the behavior to occur, and provide assistance and support to enable the behavior.

Families, peers, and health care providers are important sources of interpersonal influence that can increase or decrease commitment to and engagement in health-promoting behavior.

Situational influences in the external environment can increase or decrease commitment to or participation in health-promoting behavior.

The greater the commitments to a specific plan of action, the more likely health-promoting behaviors are to be maintained over time.

Commitment to a plan of action is less likely to result in the desired behavior when competing demands over which persons have little control require immediate attention. 13. Commitment to a plan of action is less likely to result in the desired behavior when other actions are more attractive and thus preferred over the target behavior.

Persons can modify cognitions, affect, and the interpersonal and physical environment to create incentives for health actions.

THE MAJOR CONCEPTS AND DEFINITIONS OF THE HEALTH PROMOTION MODEL

Individual Characteristics and Experience

Prior related behavior

Frequency of the similar behavior in the past. Direct and indirect effects on the likelihood of engaging in health promoting behaviors.

PERSONAL FACTORS Personal factors categorized as biological, psychological and socio-cultural. These factors are predictive of a given behavior and shaped by the nature of the target behavior being considered.

Personal biological factors

Include variable such as age gender body mass index pubertal status, aerobic capacity, strength, agility, or balance.

Personal psychological factors

Include variables such as self esteem self motivation personal competence perceived health status and definition of health.

Personal socio-cultural factors

Include variables such as race ethnicity, acculturation, education and socioeconomic status.

Behavioral Specific Cognition and Affect

PERCEIVED BENEFITS OF ACTION

Anticipated positive out comes that will occur from health behavior.

PERCEIVED BARRIERS TO ACTION

Anticipated, imagined or real blocks and personal costs of understanding a given behavior

PERCEIVED SELF EFFICACY

Judgment of personal capability to organize and execute a health-promoting behavior. Perceived self efficacy influences perceived barriers to action so higher efficacy result in lowered perceptions of barriers to the performance of the behavior.

ACTIVITY RELATED AFFECT

Subjective positive or negative feeling that occur before, during and following behavior based on the stimulus properties of the behavior itself. Activity-related affect influences perceived self-efficacy, which means the more positive the subjective feeling, the greater the feeling of efficacy. In turn, increased feelings of efficacy can generate further positive affect.

INTERPERSONAL INFLUENCES

Cognition concerning behaviors, beliefs, or attitudes of the others. Interpersonal influences include: norms (expectations of significant others), social support (instrumental and emotional encouragement) and modeling (vicarious learning through observing others engaged in a particular behavior). Primary sources of interpersonal influences are families, peers, and healthcare providers.

SITUATIONAL INFLUENCES

Personal perceptions and cognitions of any given situation or context that can facilitate or impede behavior. Include perceptions of options available, demand characteristics and aesthetic features of the environment in which given health promoting is proposed to take place. Situational influences may have direct or indirect influences on health behavior.

Behavioral Outcome

COMMITMENT TO PLAN OF ACTION

The concept of intention and identification of a planned strategy leads to implementation of health behavior.

IMMEDIATE COMPETING DEMANDS AND PREFERENCES

Competing demands are those alternative behavior over which individuals have low control because there are environmental contingencies such as work or family care responsibilities. Competing preferences are alternative behavior over which individuals exert relatively high control, such as choice of ice cream or apple for a snack

HEALTH PROMOTING BEHAVIOR

Endpoint or action outcome directed toward attaining positive health outcome such as optimal well-being, personal fulfillment, and productive living.

Bandura’s Self-Efficacy Theory

The concept of self-efficacy lies at the center of psychologist Albert Bandura’s social cognitive theory. Bandura’s theory emphasizes the role of observational learning, social experience, and reciprocal determinism in the development of personality.

According to Bandura, a person’s attitudes, abilities, and cognitive skills comprise what is known as the self-system. This system plays a major role in how we perceive situations and how we behave in response to different situations. Self-efficacy plays an essential part of this self-system. Bandura's basic principle is that people are likely to engage in activities to the extent that they perceive themselves to be competent at those activities. With regard to education, this means that learners will be more likely to attempt, to persevere, and to be successful at tasks at which they have a sense of efficacy. When learners fail, this may occur because they lack the skills to succeed or because they have the skills but lack the sense of efficacy to use these skills well.

What Is Self-Efficacy?

According to Albert Bandura, self-efficacy is “the belief in one’s capabilities to organize and execute the courses of action required to manage prospective situations” (1995, p. 2). In other words, self-efficacy is a person’s belief in his or her ability to succeed in a particular situation. Bandura described these beliefs as determinants of how people think, behave, and feel (1994).

Since Bandura published his seminal 1977 paper, "Self-Efficacy: Toward a Unifying Theory of Behavioral Change," the subject has become one of the most studied topics in psychology. Why has self-efficacy become such an important topic among psychologists and educators? As Bandura and other researchers have demonstrated, self-efficacy can have an impact on everything from psychological states to behavior to motivation.

Perceived self-efficacy is concerned with people's beliefs in their capabilities to exercise control over their own functioning and over events that affect their lives. Beliefs in personal efficacy affect life choices, level of motivation, quality of functioning, resilience to adversity and vulnerability to stress and depression. People's beliefs in their efficacy are developed by four main sources of influence. They include mastery experiences, seeing people similar to oneself manage task demands successfully, social persuasion that one has the capabilities to succeed in given activities, and inferences from somatic and emotional states indicative of personal strengths and vulnerabilities. Ordinary realities are strewn with impediments, adversities, setbacks, frustrations and inequities. People must, therefore, have a robust sense of efficacy to sustain the perseverant effort needed to succeed. Succeeding periods of life present new types of competency demands requiring further development of personal efficacy for successful functioning. The nature and scope of perceived self-efficacy undergo changes throughout the course of the lifespan.

The Role of Self-Efficacy

Virtually all people can identify goals they want to accomplish, things they would like to change, and things they would like to achieve. However, most people also realize that putting these plans into action is not quite so simple. Bandura and others have found that an individual’s self-efficacy plays a major role in how goals, tasks, and challenges are approached.

People with a strong sense of self-efficacy:

View challenging problems as tasks to be mastered. Develop deeper interest in the activities in which they participate. Form a stronger sense of commitment to their interests and activities. Recover quickly from setbacks and disappointments.

People with a weak sense of self-efficacy:

Avoid challenging tasks. Believe that difficult tasks and situations are beyond their capabilities. Focus on personal failings and negative outcomes. Quickly lose confidence in personal abilities (Bandura, 1994).

Sources of Self-Efficacy

How does self-efficacy develop? These beliefs begin to form in early childhood as children deal with a wide variety of experiences, tasks, and situations. However, the growth of self-efficacy does not end during youth, but continues to evolve throughout life as people acquire new skills, experiences, and understanding (Bandura, 1992).

According to Bandura, there are four major sources of self-efficacy.

1. Mastery Experiences

"The most effective way of developing a strong sense of efficacy is through mastery experiences," Bandura explained (1994). Performing a task successfully strengthens our sense of self-efficacy. However, failing to adequately deal with a task or challenge can undermine and weaken self-efficacy.

2. Social Modeling

Witnessing other people successfully completing a task is another important source of self-efficacy. According to Bandura, “Seeing people similar to oneself succeed by sustained effort raises observers' beliefs that they too possess the capabilities master comparable activities to succeed” (1994).

3. Social Persuasion

Bandura also asserted that people could be persuaded to belief that they have the skills and capabilities to succeed. Consider a time when someone said something positive and encouraging that helped you achieve a goal. Getting verbal encouragement from others helps people overcome self-doubt and instead focus on giving their best effort to the task at hand.

4. Psychological Responses

Our own responses and emotional reactions to situations also play an important role in self-efficacy. Moods, emotional states, physical reactions, and stress levels can all impact how a person feels about their personal abilities in a particular situation. A person who becomes extremely nervous before speaking in public may develop a weak sense of self-efficacy in these situations. However, Bandura also notes "it is not the sheer intensity of emotional and physical reactions that is important but rather how they are perceived and interpreted" (1994). By learning how to minimize stress and elevate mood when facing difficult or challenging tasks, people can improve their sense of self-efficacy.

Health- Belief Model

History and Orientation

The Health Belief Model (HBM) is a psychological model that attempts to explain and predict health behaviors. This is done by focusing on the attitudes and beliefs of individuals. The HBM was first developed in the 1950s by social psychologists Hochbaum, Rosenstock and Kegels working in the U.S. Public Health Services. The model was developed in response to the failure of a free tuberculosis (TB) health screening program. Since then, the HBM has been adapted to explore a variety of long- and short-term health behaviors, including sexual risk behaviors and the transmission of HIV/AIDS.

Core Assumptions and Statements

The HBM is based on the understanding that a person will take a health-related action if that person:

1. Feels that a negative health condition can be avoided,

2. Has a positive expectation that by taking a recommended action, he/she will avoid a negative health condition

3. Believes that he/she can successfully take a recommended health action.

The HBM was spelled out in terms of four constructs representing the perceived threat and net benefits: perceived susceptibility, perceived severity, perceived benefits, and perceived barriers. These concepts were proposed as accounting for people's "readiness to act." An added concept, cues to action, would activate that readiness and stimulate overt behavior. A recent addition to the HBM is the concept of self-efficacy, or one's confidence in the ability to successfully perform an action. This concept was added by Rosenstock and others in 1988 to help the HBM better fit the challenges of changing habitual unhealthy behaviors, such as being sedentary, smoking, or overeating.

Table from “Theory at a Glance: A Guide for Health Promotion Practice" (1997)

Concept Definition Application

Perceived Susceptibility

One's opinion of chances of getting a condition

Define population(s) at risk, risk levels; personalize risk based on a person's features or behavior; heighten perceived susceptibility if too low.

Perceived Severity

One's opinion of how serious a condition and its consequences are

Specify consequences of the risk and the condition

Perceived Benefits

One's belief in the efficacy of the advised action to reduce risk or seriousness of impact

Define action to take; how, where, when; clarify the positive effects to be expected.

Perceived Barriers

One's opinion of the tangible and psychological costs of the advised action

Identify and reduce barriers through reassurance, incentives, assistance.

Cues to ActionStrategies to activate "readiness"

Provide how-to information, promote awareness, reminders.

Self-EfficacyConfidence in one's ability to take action

Provide training, guidance in performing action.

Conceptual Model

What Is the Health Belief Model?

The Health Belief Model (HBM) is a tool that scientists use to try and predict health behaviors. Originally developed in the 1950s, and updated in the 1980s, it is based on the theory that a person's willingness to change their health behaviors is primarily due to the following factors:

Perceived SusceptibilityPeople will not change their health behaviors unless they believe that they are at risk.

Perceived SeverityThe probability that a person will change his/her health behaviors to avoid a consequence depends on how serious he or she considers the consequence to be.

Perceived BenefitsIt's difficult to convince people to change a behavior if there isn't something in it for them.

Perceived BarriersOne of the major reasons people don't change their health behaviors is that they think that doing so is going to be hard. Sometimes it's not just a matter of physical difficulty, but social difficulty as well. Changing your health behaviors can cost effort, money, and time.

The Health Belief Model, however, is realistic. It recognizes the fact that sometimes wanting to change a health behavior isn't enough to actually make someone do it, and incorporates two more elements into its estimations about what it actually takes to get an individual to make the leap. These two elements are cues to action and self efficacy.

Cues to action are external events that prompt a desire to make a health change. They can be anything from a blood pressure van being present at a health fair, to having a relative die of cancer. A cue to action is something that helps move someone from wanting to make a health change to actually making the change.

In my mind, however, the most interesting part of the Health Belief Model is the concept of self efficacy -- an element which wasn't added to the model until 1988. Self efficacy looks at a person's belief in his/her ability to make a health related change. It may seem trivial, but faith in your ability to do something has an enormous impact on your actual ability to do it. Thinking that you will fail will almost makes certain that you do.

The Health Belief Model (HBM) is a psychological model that attempts to explain and predict health behaviors by focusing on the attitudes and beliefs of individuals. The HBM was developed in the 1950s as part of an effort by social psychologists in the United States Public Health Service to explain the lack of public participation in health screening and prevention programs. Since then, the HBM has been adapted to explore a variety of long- and short-term

health behaviors, including sexual risk behaviors and the transmission of HIV/AIDS. The key variables of the HBM are as follows (Rosenstock, Strecher and Becker, 1994):

Perceived Threat: Consists of two parts: perceived susceptibility and perceived severity of a health condition.

Perceived Susceptibility: One's subjective perception of the risk of contracting a health condition,

Perceived Severity: Feelings concerning the seriousness of contracting an illness or of leaving it untreated (including evaluations of both medical and clinical consequences and possible social consequences).

Perceived Benefits: The believed effectiveness of strategies designed to reduce the threat of illness.

Perceived Barriers: The potential negative consequences that may result from taking particular health actions, including physical, psychological, and financial demands.

Cues to Action: Events, either bodily (e.g., physical symptoms of a health condition) or environmental (e.g., media publicity) that motivate people to take action. Cues to actions is an aspect of the HBM that has not been systematically studied.

Other Variables: Diverse demographic, sociopsychological, and structural variables that affect an individual's perceptions and thus indirectly influence health-related behavior.

Self-Efficacy: The belief in being able to successfully execute the behavior required to produce the desired outcomes. (This concept was introduced by Bandura in 1977.)

"The Health Belief Model (HBM) was one of the first models that adapted theory from the behavioral sciences to health problems, and it remains one of the most widely recognized conceptual frameworks of health behavior. It was originally introduced in the 1950s by psychologists working in the U.S. Public Health Service (Hochbaum, Rosenstock, Leventhal, and Kegeles). Their focus was on increasing the use of then-available preventive services, such as chest x-rays for tuberculosis screening and immunizations such as flu vaccines. They assumed that people feared diseases, and that health actions were motivated in relation to the degree of fear (perceived threat) and expected fear-reduction potential of actions, as long as that potential outweighed practical and psychological obstacles to taking action (net benefits)."

Rabe, Blazel Edve Marie T.

IIBSN3