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Precede-Proceed and Intervention Mapping provide direction to plan, implement, and evaluate effective health programs and interventions. These models use the theories and their constructs/levels to enable successful planning and to develop interventions that address defined health issues for specific target populations. Unlike the theories/models you have examined previously, these models do not attempt to explain or predict behavior. Rather, they allow the planner to systematically create programs utilizing those theoretical constructs to create successful outcomes. These models also provide guidance for the application of theories/models and the development of effective evaluation methods within interventions.

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Trim size: 7in x 9.25in Glanz p05.tex V2 - 06/17/2015 10:27am Page 349 PART FIVE Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved. USING THEORY IN RESEARCH AND PRACTICE Glanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2015). Health behavior : Theory, research, and practice. Retrieved from http://ebookcentral.proquest.com Created from waldenu on 2019-04-21 20:11:08. Glanz p05.tex V2 - 06/17/2015 Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved. Trim size: 7in x 9.25in Glanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2015). Health behavior : Theory, research, and practice. Retrieved from http://ebookcentral.proquest.com Created from waldenu on 2019-04-21 20:11:08. 10:27am Page 350 Trim size: 7in x 9.25in Glanz c18.tex V2 - 06/17/2015 10:25am Page 351 CHAPTER 18 INTRODUCTION TO USING THEORY IN RESEARCH AND PRACTICE The Editors Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved. One of the greatest challenges for public health professionals is to learn to analyze the fit of a theory or model for issues and populations of interest. A working knowledge of a handful of theories, preferably from different levels of intervention (e.g., individuals and communities), and the ways in which they have been applied is a first step. Mastering the challenges of using theories appropriately and effectively is the logical next step. Effective practice depends on marshaling the most appropriate theory (or theories) and practice strategies for a given situation. Theory-based research and evaluation further require designs, measures, and procedures appropriate to the health problem, context, and unique population at hand, as well as the development and implementation of promising or proven interventions. No one theory or model will be right in all cases. Depending on the unit of practice and type of health behavior or issue, different theoretical frameworks will be appropriate, practical, and useful. Often more than one theory is needed to adequately address an issue. For comprehensive health behavior change programs, this is almost always true. It is also evident in the use and description of applied theories found in the professional literature. The preceding sections of this book make clear that theories often overlap, and that some fit easily within broader models. Generally, theories can be used most effectively when they are integrated into a comprehensive planning framework. Such a system assigns a central role Glanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2015). Health behavior : Theory, research, and practice. Retrieved from http://ebookcentral.proquest.com Created from waldenu on 2019-04-21 20:11:08. Trim size: 7in x 9.25in Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved. 352 Glanz c18.tex V2 - 06/17/2015 CHAPTER 18: INTRODUCTION TO USING THEORY IN RESEARCH AND PRACTICE to research as input; it determines the situation and needs of the population to be served, the resources available, and the progress and effectiveness of the program at various stages. Planning is a continuous process in which new information is constantly gathered to build or improve the program. The chapters in Part Five give specific examples of how theories can be combined for greater impact. Chapter Nineteen, by L. Kay Bartholomew and colleagues, describes two welldeveloped planning models, PRECEDE-PROCEED and Intervention Mapping, that can be used to integrate and apply diverse theoretical frameworks. Both models take comprehensive approaches that begin with assessing the problem and population and continue to evaluation, based on a theoretically informed logic model. In Chapter Twenty, Kevin Volpp and his coauthors present the rationale for and the key constructs of applying behavioral economics to health improvement programs. Behavioral economics has roots in classical economics and expected utility theory, blended with a grounding in theories and evidence from psychology and sociology. The authors illustrate the broad applicability of behavioral economics constructs and provide examples of specific applications to interventions to facilitate weight loss and improve medication adherence. In Chapter Twenty-One, J. Douglas Storey and colleagues describe the purpose, key components, and methods of social marketing. They illustrate the application of social marketing in a family health program in Egypt and an ambitious social marketing program in Uganda that addresses the multiple problems of HIV/AIDS, malaria, family planning, and maternal and child health. This chapter provides highlights from each of the remaining chapters in this section, discusses emerging developments and challenges, and comments on the state of the art in the use of theory in health behavior research and practice. Using theory thoughtfully and appropriately is not simple but it can be rewarding. This discussion aims to provoke thought and debate and stimulate further reading, rather than to provide definitive answers or prescriptions for the field. Theory-Based Planning Models In Chapter Nineteen, Bartholomew, Markham, Mullen, and Fernández, describe two models for systematic development of theory- and evidence-based health promotion programs: the PRECEDE-PROCEED Model and Intervention Mapping. They explicitly illustrate the ways that behavior change theories can be applied and incorporated into a systematic planning process and note the challenges of applying the models. As with some of the theories discussed in earlier chapters, using these planning models can be a demanding and laborious process for practitioners and community groups. But when mastered, it can lead to the development of effective, appropriate health behavior change programs. A key premise of this chapter is that while health behavior theories are critical tools, they do not substitute for adequate planning and research. However, theories do help us to interpret problem situations and plan feasible, promising interventions and appropriate program evaluations. Because we can use theories to articulate the assumptions behind Glanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2015). Health behavior : Theory, research, and practice. Retrieved from http://ebookcentral.proquest.com Created from waldenu on 2019-04-21 20:11:08. 10:25am Page 352 Trim size: 7in x 9.25in Glanz c18.tex V2 - 06/17/2015 BEHAVIORAL ECONOMICS 10:25am Page 353 353 Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved. intervention strategies, theories can be helpful in pinpointing intermediate steps that should be assessed in evaluations. The PRECEDE-PROCEED Model has as its raison d’être the systematic application of theory and previous research to assessment of local needs, priorities, circumstances, and resources (Green et al., 1994). Phase 3 of this model focuses on examining factors that shape behavioral actions and environmental factors. Theories help to guide examination of predisposing, enabling, and reinforcing factors for particular behaviors. For example, constructs from the Health Belief Model might help researchers to understand why some women do not get mammograms (see Chapter Five). PRECEDE-PROCEED also can be used in conjunction with the Transtheoretical Model of change to design stage-appropriate health messages (see Chapter Seven). The concepts of priority, changeability, and community preferences should be considered along with analytical and empirical findings about health behavior determinants. For example, health experts concerned with effecting distribution of safe drinking water must understand how people in the recipient communities think about water sources and what beliefs might be amenable to change. These ideas are also consistent with concepts presented in earlier chapters on community engagement and implementation and dissemination. Bartholomew and colleagues also describe Intervention Mapping (IM), a framework for developing theory- and evidence-based health behavior or education programs, and illustrate how IM has been applied. Intervention Mapping (Bartholomew, Parcel, Kok, Gottlieb, & Fernandez, 2011) is composed of five steps that are complementary to the planning phases of the PRECEDE-PROCEED Model. Intervention Mapping can be helpful in guiding program planners toward explicit specifications for using both theory and empirical findings to develop effective health behavior interventions. Behavioral Economics Behavioral economics has its foundations in classical economics and expected utility theory, blended with a grounding in theories and evidence from psychology and sociology. Behavioral economics has received growing attention in recent years, with applications in several fields in which anticipated costs and benefits play a central role: labor markets, wage policies, savings and retirement plans and policies, and organizational behavior (Camerer, Loewenstein, & Rabin, 2004; Diamond & Vartianen, 2007). Its application to health behavior and health care utilization is emerging rapidly, as described in Chapter Twenty. Behavioral economics aims to increase the explanatory power of economics by grounding that approach in psychological and social foundations. It is not a single theory per se, but uses insights from cognitive psychology, sociology, and decision analysis (Camerer et al., 2004). Behavioral economics recognizes that people make decision errors in weighing the costs and benefits of their actions, and that message framing can influence how people react to persuasive communications. Key implications from behavioral economics for health behavior change suggest that incentives can improve health behaviors, but also, importantly, that the way incentives are delivered can matter more than the amount of incentives. This idea, which is also consistent with applied behavioral analysis and Social Cognitive Theory (Chapter Nine), Glanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2015). Health behavior : Theory, research, and practice. Retrieved from http://ebookcentral.proquest.com Created from waldenu on 2019-04-21 20:11:08. Trim size: 7in x 9.25in 354 Glanz c18.tex V2 - 06/17/2015 CHAPTER 18: INTRODUCTION TO USING THEORY IN RESEARCH AND PRACTICE has been used in health behavior intervention research by the chapter authors and others with substantial success. In Chapter Twenty, Volpp, Loewenstein, and Asch report on successful interventions that used incentives and feedback to improve weight loss success and medication adherence. These authors also noted an important limitation: that once incentives were no longer provided, behavior changes were not maintained. This has been a constant in most studies of incentives, which have been used in many programs over the years. Unless behavior change is internally motivated by individuals and not merely a response to a reinforcement, once the incentive has been applied, the desired behavior stops. Behavioral economics does not delve specifically into the arena of habitual behaviors and maintenance, though this is a future direction for researchers in this field. An interesting prospect would be to blend behavioral economics with central tenets of Self-Determination Theory, which posits that maintenance of behaviors over time requires that patients internalize values and skills for change (Ryan & Deci, 2000). Social Marketing Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved. Social marketing is a process that promotes desired voluntary behaviors among members of a target market by offering attractive benefits and/or reducing barriers associated with healthful choices. It involves the adaptation of commercial marketing technologies to promote socially desirable goals. In Chapter Twenty-One, Storey, Hess, and Saffitz take a fresh look at social marketing. They emphasize how social marketing can be applied within a strategic health communication framework and link key theories of health communication and health behavior to the effective practice of social marketing. When using social marketing, success is most likely when marketers accurately determine the perceptions, needs, and wants of target markets and satisfy them through the design, communication, pricing, and delivery of appropriate, competitive, and visible offerings. The process is consumer-driven, not only expert-driven. This orientation is consistent with principles of community organization, and its product development approach parallels the innovation development process of diffusion theory. At the same time, it shares an economic perspective with behavioral economics, a field of inquiry that relates individual behaviors to economic variables (Bickel & Vuchinich, 2000). Another parallel between social marketing and behavioral economics is that each is adapted from a more mature and extensive field: social marketing uses some principles from commercial marketing and behavioral economics builds on classic economic theory. Like the PRECEDE-PROCEED Model and Intervention Mapping, social marketing provides a framework to identify what drives and maintains behavior, and what factors might drive and maintain behavior change. It also requires identification of potential intermediaries, channels of distribution and communication, and actual and potential competitors. As the chapter authors indicate, theories of health behavior can help to guide the analytical process in social marketing and aid in the formulation of intervention strategies and materials. The authors explicitly illustrate four theories that contribute to social marketing approaches: the Theory of Planned Behavior, the extended parallel processing model, Social Cognitive Glanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2015). Health behavior : Theory, research, and practice. Retrieved from http://ebookcentral.proquest.com Created from waldenu on 2019-04-21 20:11:08. Theory and its observational learning construct, and Diffusion of Innovations. Because of 10:25am Page 354 Trim size: 7in x 9.25in Glanz c18.tex V2 - 06/17/2015 CROSS-CUTTING PROPOSITIONS ABOUT USING THEORY 10:25am Page 355 355 their focus on understanding consumers (or target audiences) from the consumers’ point of view, social marketing models are robust for use in diverse and unique populations, including disadvantaged groups and ethnic minorities, and in many countries. In fact, it is often thought that social marketing programs tend to be inherently culturally sensitive because they follow a consumer-oriented process. In social marketing it is always important to identify and fulfill demand—that is, to “start where the people are.” Cross-Cutting Propositions About Using Theory Here we offer some key cross-cutting propositions to readers to put the use of health behavior theory in perspective. These ideas are germane to the review and discussion of the chapters in this section and throughout this book. 1. Researchers and practitioners should not confuse using or applying theory with testing theory or developing theory. They are fundamentally different activities even though complementary. 2. Testing the efficacy or effectiveness of theory-based interventions does not constitute testing a theory or theories per se. Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved. 3. It is likely that the strongest interventions will be built from multiple theories. The most replicable and transparent interventions will be built in a way that the contributions of each theory can be understood. 4. When combining theories, it is important to clearly think through the unique contribution of each different theory to the combined model. If this is not done carefully or well, the “new” combined approach may be redundant, overlapping, and hard to interpret in the context of established theories. 5. Rigorous tests of theory-based interventions, including measurements and analyses of mediators and moderators, are the building blocks of the evidence base in health behavior change. 6. Theory use, testing, and development will be enhanced by the use of shared instruments and reporting. The more researchers and practitioners can build on past efforts, the more they are likely to advance the public’s health. We recommend employing adaptations of the protocol concept used in clinical research so that the measures used with particular theories and the ways in which theory is turned into interventions are transparent and accessible. The opportunity to offer online materials to supplement journal publications makes this increasingly feasible. 7. Theory, research, and practice are parts of a continuum for understanding the determinants of behaviors, testing strategies for change, and disseminating effective interventions (see Chapters Sixteen and Nineteen). 8. There is as much to learn from failure as there is to learn from success. Researchers and practitioners who develop and test theory-based interventions should publish their findings when they are negative and when they are positive. Glanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2015). Health behavior : Theory, research, and practice. Retrieved from http://ebookcentral.proquest.com Created from waldenu on 2019-04-21 20:11:08. Trim size: 7in x 9.25in 356 Glanz c18.tex V2 - 06/17/2015 CHAPTER 18: INTRODUCTION TO USING THEORY IN RESEARCH AND PRACTICE 9. There is no substitute for knowing the audience. This applies to the conduct of fundamental research to understand determinants of health behavior as much as it applies to developing health promotion programs for specific individuals, groups, and communities. Participatory research and program design improve the odds of success. The authors of the remaining three chapters in Part Five describe tools, strategies, models, and issues that are critical to consider when applying theories. This section of Health Behavior: Theory, Research, and Practice tackles the complexity of health behavior and health promotion at its multiple levels. A basic theme is that if intervention strategies are based on a carefully researched understanding of the determinants of behavior and environments, and if systematic approaches to tailoring, targeting, implementation, and evaluation are used, the chances are good that programs will be effective. And when they are not effective, then there should be good information about why they did not work. Understanding past failure is critical to future success. Moving Forward Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved. After one becomes familiar with some contemporary theories of health behavior, the challenge is to use them within a comprehensive planning process. Researchers and practitioners can increase the odds of success by examining health and behavior at multiple levels, as articulated in ecological models (Chapter Three). At its simplest, an ecological perspective emphasizes two main options: change people and/or change the environment. The most powerful approaches will use both of these options together (Smedley & Syme, 2000). The activities most directly tied to changing people are derived from individual-level theories like the Health Belief Model, Transtheoretical Model of change, and Integrated Behavioral Model. In contrast, activities aimed at changing the environment draw on community-level theories. In between are Social Cognitive Theory, theories of social support and social networks, and interpersonal communication models. Each of these focuses on reciprocal relations among persons or between individuals and their environments. Theoretical frameworks are guides in the pursuit of successful change efforts, maximizing researchers’ and practitioners’ flexibility and helping them to apply abstract concepts of theory in ways that are most useful in diverse work settings and situations. Knowledge of theory and comprehensive planning systems offers a great deal of help in this pursuit. Other key elements of effective programs are a good program-to-audience match; accessible and practical information; active learning and participant involvement; and skill building, practice, and reinforcement. Strong interventions will often, although not always, be built on theory, yet theory alone cannot lead to effective interventions. Theory helps you to ask the right questions, and effective planning enables you to zero in on the right elements in relation to a specific problem. Still, theory must be turned into effective interventions, and these must be applied with fidelity and evaluated well. A lot happens between theory and behavior change. Effective use of theory for practice and research requires practice, but it can yield important dividends in efforts to enhance the health of individuals and populations. In the end, we should ask ourselves Glanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2015). Health behavior : Theory, research, and practice. Retrieved from http://ebookcentral.proquest.com Created from waldenu on 2019-04-21 20:11:08. whether our work has made a difference. Developing better theories is a means to that end. 10:25am Page 356 Trim size: 7in x 9.25in Glanz c18.tex V2 - 06/17/2015 REFERENCES 10:25am Page 357 357 In the first edition of Health Behavior and Health Education, Irwin M. Rosenstock said, “it would be the height of folly to predict the future needs of health education [and health behavior] research and practice, at least without the assistance of an outstanding California astrologer or the Great Kreskin” (Rosenstock, 1990, p. 405). Times have changed, and indeed, scientific advances and new technology have dramatically altered our lives. Every day, we find ourselves adapting to life with new technologies, which are appearing at an astonishing pace. They have changed our understanding about the health risks we confront, the information we can obtain, day-to-day priorities and worries, relationships, and the ways we communicate. The modern field of health behavior dates back only about eighty years, and progress has accelerated most rapidly in the past thirty years. As the authors of the chapters in this book have shown, many of the early ideas of social and behavioral theorists serve as solid foundations for our work today. To continue to accelerate our progress, we should stand on the shoulders of the pioneers in the field, equip ourselves to be explorers, address today’s problems with new tools, and anticipate the challenges of the future. References Bartholomew, L. K., Parcel, G. S., Kok, G., Gottlieb, N. H., & Fernández, M. E. (2011). Planning health promotion programs: An intervention mapping approach (3rd ed.). San Francisco: Jossey-Bass. Bickel, W. K., & Vuchinich, R. E. (Eds.). (2000). Reframing health behavior change with behavioral economics. Mahwah, NJ: Erlbaum. Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved. Camerer, C. F., Loewenstein, G., & Rabin, M. (Eds.). (2004). Advances in behavioral economics. Princeton, NJ: Princeton University Press. Diamond, P., & Vartianen, H. (Eds.). (2007). Behavioral economics and its applications. Princeton, NJ: Princeton University Press. Green, L. W., Glanz, K., Hochbaum, G. M., Kok, G., Kreuter, M. W., Lewis, F. M., . . . , Rosenstock, I. M. (1994). Can we build on, or must we replace, the theories and models in health education? Health Education Research, 9, 397–404. Rosenstock, I. M. (1990). The past, present, and future of health education. In K. Glanz, F. M. Lewis, & B. K. Rimer (Eds.), Health behavior and health education: Theory, research, and practice. San Francisco: Jossey-Bass. Ryan, R. M., & Deci, E. L. (2000). Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. American Psychologist, 55, 68–78. Smedley, B. D., & Syme, S. L. (Eds.). (2000). Promoting health: Intervention strategies from social and behavioral research. Washington, DC: National Academies Press. Glanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2015). Health behavior : Theory, research, and practice. Retrieved from http://ebookcentral.proquest.com Created from waldenu on 2019-04-21 20:11:08. Glanz c18.tex V2 - 06/17/2015 Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved. Trim size: 7in x 9.25in Glanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2015). Health behavior : Theory, research, and practice. Retrieved from http://ebookcentral.proquest.com Created from waldenu on 2019-04-21 20:11:08. 10:25am Page 358 Trim size: 7in x 9.25in Glanz c19.tex V2 - 06/19/2015 1:07pm Page 359 CHAPTER 19 PLANNING MODELS FOR THEORY-BASED HEALTH PROMOTION INTERVENTIONS L. Kay Bartholomew Christine Markham Pat Mullen Marı́a E. Fernández Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved. KEY POINTS In the development of interventions to change behaviors and/or environments, a framework or model enables proThis chapter will: gram planners to apply theories of health behavior and • Describe two models for systematic development of theory- and their constructs to address health and health behavior evidence-based health promotion problems. Once factors contributing to desirable change programs: the PRECEDE-PROCEED are understood, the framework can also guide the choice Model and Intervention Mapping. of leverage points to produce that change. The purpose of • Present steps for using planning a framework or model is to guide planners to identify the models to facilitate systematic use of full range of constructs that may be relevant to one or more theory and evidence when designing target behavior(s) and outcomes. Program developers may health promotion interventions. use constructs from multiple theories in describing a prob• Give examples of using the two lem or devising solutions, and they may also use constructs models to integrate theory and evidence into program planning. that are not explicitly theory based (Fishbein et al., 2001; Noar & Zimmerman, 2005). We use the terms framework • Provide two case studies that show and model interchangeably throughout this chapter to the full sequence of using PRECEDE-PROCEED and Intervention mean a structure that elicits a hypothesized set of relationMapping for intervention ships among constructs and one or more behavior(s) or development. environmental factor(s) leading to health outcomes. Health professionals and researchers who develop, implement, and evaluate interventions often approach theory in a way that is fundamentally different from that of researchers interested in theory generation or singletheory testing. A researcher or practitioner who wants to find a solution to a public health problem in a real-world situation will apply a problem-driven, applied behavioral Glanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2015). Health behavior : Theory, research, and practice. Retrieved from http://ebookcentral.proquest.com Created from waldenu on 2019-04-21 20:11:08. Trim size: 7in x 9.25in Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved. 360 Glanz c19.tex V2 - 06/19/2015 CHAPTER 19: PLANNING MODELS FOR THEORY-BASED HEALTH PROMOTION INTERVENTIONS or social science approach using one or multiple theories, empirical evidence, and new research both to assess the problem and to solve or prevent the problem (Buunk & Vugt, 2008). In this problem-focused approach to using theory, the main criteria for success are health outcomes rather than theory testing or development. Intervention planners make many choices (e.g., where in a system to intervene and/or how to intervene) in the development of an intervention, and theories are one tool to enable better choices. Both the PRECEDE-PROCEED Model and Intervention Mapping are tools that help guide the selection of constructs and theories to optimize change in the behavioral and environmental factors that influence health. To develop theory- and evidence-based interventions, researchers and practitioners using PRECEDE-PROCEED and Intervention Mapping can build diagrams depicting logic models. Logic models depict proposed causal relationships among variables related to health problems and their solutions. A logic model of the problem or theory of the problem depicts plausible causal explanations of a problem. A logic model of change, theory of change, or intervention theory refers to a plausible causal pathway of the mechanisms of change proposed for an intervention (Buunk & Vugt, 2008; Glanz, Rimer, & Viswanath, 2008; Rossi, Lipsey, & Freeman, 2004). For example, a logic model (theory) of the problem might depict, with boxes and arrows, the motivational and environmental factors that influence a certain health behavior. In contrast, a logic model (theory) of change would include change methods aimed at factors related to health-promoting behavior change and improved health outcomes. The next two sections describe the PRECEDE-PROCEED Model and Intervention Mapping. Before we describe the steps of these two planning frameworks, it is important to point out several processes that should always be used in health promotion planning and that are explicitly included or implied in both frameworks. From the days of the earliest work on PRECEDE (prior to the addition of PROCEED), many sources of wisdom in health promotion planning have recommended meaningful attention to the participation of stakeholders, in-depth consideration of theories and theoretical constructs, and attention to cultural appropriateness (Green, Kreuter, Deeds, & Partridge, 1980). Ideally, planners will follow principles of collaboration that include striving to understand personal and institutional histories; to promote multiple stakeholder involvement; to recognize diverse members’ expertise; and to promote equity in decision making and shared learning (Israel, Eng, Schulz, & Parker, 2005; Minkler & Wallerstein, 2010; also see Chapter Fifteen). Both PRECEDE-PROCEED and Intervention Mapping can be used with a wide range of theories for describing health problems and devising solutions. The PRECEDE-PROCEED Model The PRECEDE-PROCEED Model, which has been a cornerstone of health promotion practice for more than three decades, can help to guide the process of designing, implementing, and evaluating health behavior change programs (Green et al., 1980; Green & Kreuter, 2005). PRECEDE-PROCEED can be thought of as a road map, and behavior change theories as the specific directions to a destination. The road map presents all the possible avenues, while the theory suggests certain avenues to follow. The map’s main purpose is to provide a structure for Glanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2015). Health behavior : Theory, research, and practice. Retrieved from http://ebookcentral.proquest.com Created from waldenu on 2019-04-21 20:11:08. 1:07pm Page 360 Trim size: 7in x 9.25in Glanz c19.tex V2 - 06/19/2015 1:07pm THE PRECEDE-PROCEED MODEL Page 361 361 applying theories and concepts systematically in the planning and evaluating of health behavior change programs (Gielen et al., 2008). A population-based planning framework that is ecological in its perspective, the PRECEDEPROCEED Model (Green & Kreuter, 1991, 1999, 2005) has been used for planning hundreds of programs (Aboumatar et al., 2012; Buta et al., 2011; Cole & Horacek, 2009; Hazavei, Sabzmakan, Hasanzadeh, Rabiei, & Roohafza, 2012; Li et al., 2009). When developed in the 1970s, PRECEDE began to influence the health education field toward an outcome-focused approach to planning. By this we mean that rather than having people jumping into applying solutions to health problems, PRECEDE-PROCEED promotes in-depth understanding of the community or other population or target audience and its needs, as well as both the proximal determinants of health and quality-of-life problems and the more distant contextual causes. Its use leads to planning interventions that are specifically targeted to these desired outcomes and causes and provides a structure for systematically applying theories and concepts. The first three phases of PRECEDE help planners to develop a logic model (theory) of the problem (Figure 19.1). They guide an analysis of the causes of health problems at multiple ecological levels and help planners focus on determinants of health-related behavior and environment (Gómez, Seoane, Varela-Centelles, Diz, & Takkouche, 2009; Peacock, Pogrel, & Schmidt, 2008). The socioecological model, which focuses on the interrelationships among individuals with their biological, psychological, and behavioral characteristics and their Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved. PRECEDE Phase 4 Administrative and Policy Assessment and Intervention Alignment Health promotion Educational strategies Phase 3 Educational and Ecological Assessment Phase 2 Epidemiological, Behavioral, and Environmental Assessment Predisposing factors Phase 1 Social Assessment Genetics Reinforcing factors Behavior Quality of life Health Policy regulation organization Enabling factors Environment Phase 5 Implementation Phase 6 Process Evaluation Phase 7 Impact Evaluation Phase 8 Outcome Evaluation PROCEED Figure 19.1 PRECEDE-PROCEED Planning Model Glanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2015). Health behavior : Theory, research, and practice. Retrieved from http://ebookcentral.proquest.com Created from waldenu on 2019-04-21 20:11:08. Trim size: 7in x 9.25in 362 Glanz c19.tex V2 - 06/19/2015 CHAPTER 19: PLANNING MODELS FOR THEORY-BASED HEALTH PROMOTION INTERVENTIONS Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved. environments, drives the perspective underlying the importance of including the environment in a logic model of the problem (Bronfenbrenner, 1979; Kok, Gottlieb, Commers, & Smerecnik, 2008; also see Chapter Three). These ecological levels can influence both individual behavior and environments. In an example of children’s consumption of sugar-sweetened beverages, parents’ provision of sodas to their child would be in the interpersonal level of the ecological model; lack of policy concerning sodas in school vending machines would be at the organizational level; social norms for soda consumption, at the community level; and laws restricting sales of oversized sodas at food stores and restaurants, at the societal level. In another example, in a hospital-based study to reduce health care–associated infections, inadequate hand hygiene by health care providers (individual level) and lack of enforcement of hand hygiene guidelines and contaminated environmental surfaces and equipment (organizational level) were all found to contribute to the transmission of multidrug-resistant organisms (Aboumatar et al., 2012). Similarly, in a study of work-related musculoskeletal disorders among supermarket cashiers, prolonged standing at a workstation, lack of managerial compliance to federal ergonomic guidelines, and poor architectural design of the workstation all contributed to work-related health problems (Wasilewski, Mateo, & Sidorovsky, 2007). In the PRECEDE-PROCEED Model Phase 1—social assessment, participatory planning, and situation analysis—planners try to understand the community in which they are working. Community has historically been thought of as a geographic community, but there are many kinds of communities. Even a physical community is a social place in which people share a sense of living or working in a location as well as some common elements of values, culture, norms, language, and problems of health and quality of life. Members of geographic communities may also share common perceptions of boundaries, appropriate representation, and prioritizations of needs. Further, communities, including environmental elements such as the built environment, can contribute to both causes and solutions for health problems. In addition to communities defined partially by physical boundaries, health professionals may be working in communities defined by other sorts of boundaries, such as demographic boundaries (e.g., socioeconomic status, gender, age, and family structure), ethnic boundaries (e.g., Latino, European American, and African American), problem boundaries (e.g., experiencing the same health problem or served by the same agency), or other identity boundaries (e.g., political, behavioral, or religious identity). Intervention planners often use qualitative methods in this phase to collect information and opinions from community members. Using a combination of methods, such as interviews, focus groups, concept mapping (Trochim, Milstein, Wood, Jackson, & Pressler, 2004), and surveys, can be very productive. This phase of PRECEDE-PROCEED is also the time to assure participation of community members, no matter how the community is defined. Community members, including potential intervention implementers and participants, help to ensure that the project addresses issues important to community members, that project findings are locally relevant, and that participating communities develop capacity in intervention development and research. Several theoretical approaches to community engagement and perspectives on community structure and needs can be helpful at this phase (Bartholomew et al., 2011). A few Glanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2015). Health behavior : Theory, research, and practice. Retrieved from http://ebookcentral.proquest.com examples theories20:11:08. that can help with perspectives on communities and needs are systems Created from waldenuof on 2019-04-21 1:07pm Page 362 Trim size: 7in x 9.25in Glanz c19.tex V2 - 06/19/2015 THE PRECEDE-PROCEED MODEL 1:07pm Page 363 363 theories (Goodson, 2009; National Cancer Institute, 2007), theories regarding social networks (Heaney & Israel, 2008), and constructs of social capital and community capacity (Green & Kreuter, 2005; Wendel et al., 2009). Other theories, for example, stakeholder theories (FosterFishman, Nowell, & Yang, 2007) and coalition theories (Butterfoss, Kegler, & Francisco, 2008) can give guidance for community engagement. Table 19.1 shows examples of theories often used in the various phases of PRECEDE-PROCEED. In Phase 2, epidemiological assessment, the planner begins building a logic model of the health problem from right to left, usually starting with descriptions of health problems and Table 19.1 PRECEDE-PROCEED Model as a Structure for Using Theories and Constructs Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved. Examples of Theories and Principles, by Ecological Level Community level Participation and relevance: e.g., stakeholder theory, theories of power, coalition theories Community assessment: e.g., systems theories, social capital, and community capacity Intervention: e.g., community organization, community mobilization, organizational change, Diffusion of Innovations Interpersonal level Social Cognitive Theory Adult learning Interpersonal communication Social networks and social support Phase 2: Epidemiological, Phase 3: Educational Phase 4: Administrative and Phase 1: Social Behavioral, and Environ- and Ecological Policy Assessment and Assessment mental Assessment Assessment Intervention Alignment X X X X X X X X X X X X X X X X Individual level Social Cognitive Theory X X Theories of self-regulation X X Goal setting and planning X Health Belief Model X Transtheoretical Model of X behavior change (Stages of Change) Theory of Reasoned Action Theory of Planned Behavior Information processing Glanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2015). Health behavior : Theory, research, and practice. Retrieved from http://ebookcentral.proquest.com Created from waldenu on 2019-04-21 20:11:08. x Trim size: 7in x 9.25in 364 Glanz c19.tex V2 - 06/19/2015 CHAPTER 19: PLANNING MODELS FOR THEORY-BASED HEALTH PROMOTION INTERVENTIONS Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved. related quality of life in the community. When completed, the model is read from left to right as a causal model of the health and quality-of-life problems. The epidemiological analysis includes health problems and their related quality-of-life impact, behavioral causes of the health problems, and environmental causes of the health problem or risk behavior. Reducing or eliminating health problems should be the intention of a health education or promotion intervention. For example, if premature mortality and morbidity from health care–associated infections are the health problem, loss of productive years and increased health care costs begin to define the quality-of-life issues for the individual and for society. The behavioral analysis typically includes what the at-risk group does that increases risk of experiencing the health problem. In the case of secondary and tertiary prevention, the analysis investigates what individuals do that increases the risk of disability or death from a health problem they already have. For example, lack of adherence to prescribed dietary, physical activity, and medication guidelines is a major barrier to the proper treatment of diabetes and can lead not only to the disease but also to increased disease burden (morbidity or mortality). The environmental analysis includes conditions in the social, physical, and biological environments that influence the health problem directly or through its behavioral causes. In most analyses of health problems, the environment plays a significant and modifiable role in causing the problem, either directly, such as through exposure to lead-based paint or leadcontaminated dust in lead poisoning, or indirectly through behavior, such as lack of smoking bans in the workplace. Several theories are useful when describing behavior and environment. For example, Social Cognitive Theory (see Chapter Nine) focuses on the reciprocal interaction of behavior and environment. Also, some theories are important for specifying the details of the behavior targeted for change. For example, Self-Regulation Theory (Vohs & Baumeister, 2011), theories of goal setting and planning (Gollwitzer & Sheeran, 2006), and the Transtheoretical Model of behavior change (Stages of Change) (Prochaska, 2013; see Chapter Seven) are theories that can help with understanding the steps people engage in to change behavior (see Table 19.1). At this phase, planners can usually begin to describe the problems in the community and their causes with existing data sources (e.g., local, state, and national health surveys; disease registries; and medical claims). Data from these sources are generally available electronically, and many sources provide extensive resources for both access and interpretation (e.g., the National Health Information Center, at www.health.gov/nhic; the National Library of Medicine databases and electronic resources, at www.nlm.nih.gov/databases; and the National Center for Health Statistics, at www.cdc.gov/nchs). In Phase 3, ecological and educational assessment, health professionals explore the factors that produce the behavioral and environmental conditions described in Phase 2. Here, the question is, what antecedent and reinforcing factors encourage the risk behaviors or environmental conditions that cause or contribute to the health problem? Green and Kreuter (2005) describe these factors as predisposing factors, “a person or population’s knowledge, attitudes, beliefs, values, and perceptions that facilitate or hinder motivation for change” (p. 14); reinforcing factors, “the rewards received and the feedback the learner receives from others following adoption of a behavior” (p. 15); and enabling factors, “those skills, resources, Glanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2015). Health behavior : Theory, research, and practice. Retrieved from http://ebookcentral.proquest.com Created from waldenu on 2019-04-21 20:11:08. 1:07pm Page 364 Trim size: 7in x 9.25in Glanz c19.tex V2 - 06/19/2015 THE PRECEDE-PROCEED MODEL 1:07pm Page 365 365 Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved. or barriers that can help or hinder the desired behavioral changes as well as environmental changes” (p. 15). For example, in their hospital-based study to reduce health care–associated infections, Aboumatar et al. (2012) found that antecedent factors such as lack of knowledge and skeptical attitudes about the risk of multidrug-resistant organisms contributed to poor compliance, and Wasilewski et al. (2007) found that employees did not feel susceptible to or believe in the seriousness of musculoskeletal disorders (determinants from the Health Belief Model) (see Chapter Five), and that this was coupled with lack of managerial support and ergonomic problems in the workplace. Describing the determinants of behavior is a process that can benefit significantly from “thinking with theory.” Constructs from the Health Belief Model (perceived severity and susceptibility, barriers and benefits, cues to action, and self-efficacy) (Chapter Five), the Theory of Planned Behavior (attitudes, subjective norms, intention, and perceived behavioral control) (Chapter Six), and Social Cognitive Theory (self-efficacy, behavioral capability, outcome expectations, reinforcement, observational learning, and reciprocal determinism) (Chapter Nine) all address determinants of behavior. These determinants of behavior apply both to the at-risk group and to those agents responsible for environmental conditions (see Table 19.1). The original PRECEDE model had a separate category of nonbehavioral factors, such as the natural history of disease (Green et al., 1980). These were nonmodifiable factors that nevertheless should be considered in a needs assessment because they may influence factors that can be changed. They also may provide the social or biological context for behaviors of an at-risk group or of those who influence environmental conditions. In the current PRECEDEPROCEED model, genetics is in the model as a factor that is not yet (often) modifiable but may be quite important in understanding the health problem and various affected groups (Green & Kreuter, 2005). In Phase 4, administrative and policy assessment and intervention alignment, the question is, what program components and interventions are needed to effect the changes specified in the previous phases? Does this program have the organizational, policy, and administrative capability and resources to develop and implement the program? Green and Kreuter (2005) offer recommendations from the extensive program development literature for “intervention matching, mapping, pooling and patching” (p. 197) at this stage of planning. Specifically, building a comprehensive program requires (1) matching the ecological levels to broad program components; (2) mapping specific interventions based on theory and prior research and practice to specific predisposing, enabling, and reinforcing factors; (3) pooling prior interventions and community-preferred interventions that might have less evidence to support them; and if necessary, (4) patching those interventions to fill gaps in the evidence-based best practices. In the previous phase, theories were mostly helpful to understand why people engage in risky behaviors, why environmental risk factors exist, and why change might occur. In this phase, intervention planners will use theory to apply change methods. A key challenge of creating an intervention that produces change is using theory to target the correct determinants of behavior and environment in the previous phase. At Phase 4, the challenge is to continue to use theory to choose the powerful methods to promote the desired change within an Glanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2015). Health behavior : Theory, research, and practice. Retrieved from http://ebookcentral.proquest.com Created from waldenu on 2019-04-21 20:11:08. Trim size: 7in x 9.25in 366 Glanz c19.tex V2 - 06/19/2015 CHAPTER 19: PLANNING MODELS FOR THEORY-BASED HEALTH PROMOTION INTERVENTIONS organizational and/or political context. Theories of organizational change (Butterfoss, Kegler, & Francisco, 2008) may be especially useful at this stage of the planning process. Moving into final PROCEED phases, the planner prepares for implementation (Phase 5) by developing the necessary training, materials, and resources to support program delivery. Data collected in the first four phases of PRECEDE-PROCEED are used to guide specific inservice content or skills development so that program facilitators have the capacity and resources to implement the proposed program. In Phases 6 to 8, the planner develops data collection plans to conduct process, impact, and outcome evaluations, respectively (Green & Kreuter, 2005). Process evaluation determines the extent to which the program was implemented according to protocol. Impact evaluation assesses change in predisposing, reinforcing, and enabling factors, as well as in the behavioral and environmental factors. Finally, outcome evaluation determines the effect of the program on health and quality-of-life indicators. Typically, the measurable objectives that are written in each phase of PRECEDE-PROCEED serve as milestones against which accomplishments are evaluated. Intervention Mapping Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved. PRECEDE-PROCEED is the foundation for the Intervention Mapping approach to health promotion planning. Intervention Mapping builds on the logic model of the problem developed in PRECEDE and expands on PROCEED to add detail to the process of intervention development. Intervention Mapping focuses on defining determinants of behavioral and environmental change and matching theory-based change methods to the determinants (Bartholomew, Parcel, & Kok, 1998). Intervention Mapping has guided the development of health promotion programs for many different health problems. Recent examples include antiretroviral treatment adherence (de Bruin, Hospers, de Borne, Kok, & Prins, 2005), physical activity (Brug, Oenema, & Ferreira, 2005), smoking (Dalum, Schaalma, & Kok, 2012), obesity (Lloyd, Logan, Greaves, & Wyatt, 2011), cancer screening (Byrd et al., 2012), chronic disease self-management (Detaille, van der Gulden, Engels, Heerkens, & van Dijk, 2010), HIV prevention (Munir, Kalawsky, Wallis, & Donaldson-Feilder, 2013), vaccination (Kok et al., 2011), and sexual and relationship health (Mkumbo et al., 2009; Newby, Bayley, & Wallace, 2011). Others have explicitly used Intervention Mapping to guide community-based participatory research (Belansky, Cutforth, Chavez, Waters, & Bartlett-Horch, 2011); to better understand what specific parts of interventions produce change, that is, the “active ingredients” (Brendryen, Kraft, & Schaalma, 2010; Kok & Mesters, 2011); and to adapt and implement evidence-based interventions (Tortolero et al., 2010). Each step of Intervention Mapping comprises several tasks (Figure 19.2). The completion of the tasks in each step leads to products that inform the subsequent step, and the completion of all steps creates a blueprint, or map, for designing, implementing, and evaluating an intervention. Even though the depiction of Intervention Mapping is one of sequential, cumulative steps, the process is iterative rather than strictly linear. In Step 1 (logic model [theory] of the problem), the developers of Intervention Mapping recommend that the first step of program planning be to use PRECEDE to conduct a Glanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2015). Health behavior : Theory, research, and practice. Retrieved from http://ebookcentral.proquest.com Created from waldenu on 2019-04-21 20:11:08. 1:07pm Page 366 Trim size: 7in x 9.25in Glanz c19.tex V2 - 06/19/2015 INTERVENTION MAPPING Step Step 1 Logic model (theory) of the problem Step 2 Program outcomes and objectives—logic model (theory) of change Evaluation Step 3 Program plan Step 4 Program production Step 5 Implementation plan Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved. Step 6 Implementation Evaluation plan 1:07pm Page 367 367 Tasks • Establish and work with a planning group. • Describe the context for the intervention, including the population, setting, and community. • Conduct a needs assessment to create a logic model of the problem. • State expected outcomes for behavior and environment. • Specify performance objectives for behavioral and environmental outcomes. • Select determinants for behavioral and environmental outcomes. • Create a logic model of change. • Construct matrices of change objectives. • Generate program themes, components, scope, and sequence. • Choose theory- and evidence-based methods to create change. • Select or design practical applications to deliver change methods. • • • • Refine program structure and organization. Prepare plans for program materials. Draft messages, materials, and protocols. Pretest, refine, and produce materials. • Identify potential program implementers. • State outcomes and performance objectives for implementation. • Construct matrices of change objectives for implementation. • Design implementation interventions. • Write effect and process evaluation questions. • Develop indicators and measures for assessment. • Specify evaluation design. Figure 19.2 Intervention Mapping Overview Source: Adapted from Bartholomew et al., 2011. needs assessment, which will result in the development of a logic model of the problem, as shown in Figure 19.1 and described in Figure 19.2 (Bartholomew et al., 2011). The developers of Intervention Mapping use a modified version of PRECEDE in this step: they combine predisposing and reinforcing factors (Figure 19.1) into one category of personal determinants—those cognitive and emotional factors that lead to either the behavior of the risk group or the behaviors of persons in the environment. Enabling factors (those environmental conditions that make the behavior of the at-risk group either easier or more difficult) are included in the environment box of the logic model. The same theories mentioned earlier in discussing the development of the PRECEDE model are relevant in Step 1 of Intervention Mapping. In Step 2 of Intervention Mapping (program outcomes and objectives—the logic model [theory] of change), health professionals use theory and evidence to describe the targets of change for the intervention. These are hypothesized causal pathways from the planned Glanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2015). Health behavior : Theory, research, and practice. Retrieved from http://ebookcentral.proquest.com Created from waldenu on 2019-04-21 20:11:08. Trim size: 7in x 9.25in 368 Glanz c19.tex V2 - 06/19/2015 CHAPTER 19: PLANNING MODELS FOR THEORY-BASED HEALTH PROMOTION INTERVENTIONS Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved. intervention through the determinants of behavior to the expected health-promoting behaviors of both the at-risk group and the environmental change agents (those individuals who are able to create change in environmental factors) and ultimately to changes in health outcomes. This step builds directly on the previous step. Once the health care professionals who are planning the intervention describe the health problem and its causes, the question becomes, “What needs to change to decrease or eliminate the health problem and the behavioral and environmental risks?” Looking at the logic model of the problem, planners will decide, first, which behavioral and environmental factors are most strongly associated with improvement in health outcomes (relevance) and which are most changeable. For example, in the middle school sexual health education application called It’s Your Game, described later in this chapter, the planners targeted delayed sexual initiation as the main behavioral outcome for the at-risk group. They then analyzed this complex behavior to detail the components of the behavior, termed performance objectives (e.g., to avoid risky situations that might lead to sex). As described earlier for the PRECEDE-PROCEED model, there are theories that are useful for considering what specific behavior should be the target for change whether a planner is thinking of the at-risk group or of those in the environment who can create change. For example, Social Cognitive Theory emphasizes the interaction between person and environment and is congruent with the emphasis of this Intervention Mapping step on the importance of change in both the at-risk group and the environment (see Chapter Nine). Some theories are particularly helpful in specifying the details of the behavior targeted for change. For example, Self-Regulation Theory (Vohs & Baumeister, 2011) and theories of goal setting and planning (Gollwitzer & Sheeran, 2006) guide the planner to break behavior change into the processes of self-monitoring, goal setting, planning, performing, and evaluating strategies—processes that could apply to any behavior. When thinking about the behavior of persons or groups in the environment, such as organizations, political entities, or communities, theories at a higher ecological level can be helpful. These include theories that address social support and social networks (Uchino, 2009; also see Chapter Ten), stage of organizational change (Butterfoss et al., 2008), and community organization (Minkler & Wallerstein, 2004; also see Chapter Fifteen) (see Figure 19.3). The next task in this step is to use theory, empirical evidence, and new data to understand the hypothesized determinants of the behavior changes for the at-risk group and for the environmental agents. These determinants answer the question of why the person at risk or the environmental agent would make a behavior change. We label these as hypothesized because, even though interventions are based on causal assumptions (“if we do x, y will happen”), the factors designated as possible determinants of behavior are often derived from a mix of research types and theories. Planners may have evidence from cross-sectional and longitudinal surveys and experiments as well as from perceptions of their communities and the planning team. They should be skeptical about the causal direction based on cross-sectional studies where behavior and assumed determinants are measured at the same time. It could be possible that the causal direction is reversed or even multidirectional. For example, does depression lead to obesity, or obesity to depression? This question is impossible to answer without longitudinal research. Glanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2015). Health behavior : Theory, research, and practice. Retrieved from http://ebookcentral.proquest.com Created from waldenu on 2019-04-21 20:11:08. 1:07pm Page 368 Trim size: 7in x 9.25in Glanz c19.tex V2 - 06/19/2015 INTERVENTION MAPPING 1:07pm Page 369 369 At-Risk Group Intervention theory-based methods for the at-risk group: What method(s) will affect the change objectives? Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved. Theories that suggest methods of change (e.g., Social Cognitive Theory, Transtheoretical Model of behavior change, information processing) Change objectives: (Personal determinants × Performance objectives): What theory- and evidence-based changes will be causally related to the behavioral outcome? Theories that suggest determinants (e.g., Social Cognitive Theory) Intervention theory-based methods for the environmental agent: What method(s) will affect the change objectives? Change objectives: (Personal determinants × Performance objectives): What theory- and evidence-based changes will be causally related to the environmental outcome? Theories that suggest change methods at the environmental level (e.g., organizational development, policy advocacy) Theories that suggest determinants of the behavior of environmental agents (e.g., Social Cognitive Theory) Behavioral outcomes: What is intended to change in order to produce the desired health outcomes? Theories that suggest components of behaviors (e.g., goal setting and planning) Environmental outcomes: What is intended to change to produce the desired health outcomes? Theories that suggest behavior change components among environmental agents and groups (e.g., stage of organizational change, theories of community organization) Health problems: What changes should the intervention produce in the health problem(s)? Quality of life: What changes should the intervention produce in the quality-of-life issues related to the health problem(s)? Environmental Agent Figure 19.3 Logic Model (Theory) of Change Planners will also use theory to posit factors that may influence the behaviors of interest. In the applied work of thinking about the determinants of behavior, there is no mandate to specify a single theory, and a decision about which theories and/or constructs to include begins with a review of the previous research on factors that have been shown to be related to the behavior of interest. Some of the studies found will be theory-based, and others will be atheoretical. As described earlier regarding the PRECEDE model, several theories are routinely used in health promotion to examine proposed determinants of behavior (e.g., Social Cognitive Theory, the Theory of Planned Behavior/Theory of Reasoned Action, and the Health Belief Model). For example, when Bartholomew and Mullen (2011) conducted a brief review of why dentists did or did not conduct oral cancer screening, they found evidence for the influence of Social Cognitive Theory constructs of skills, knowledge of what to do and how to do it, and self-efficacy. Furthermore, they found that some patient and provider beliefs can be defined by the Social Cognitive Theory construct of outcome expectations—“if I do x, y will happen.” Glanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2015). Health behavior : Theory, research, and practice. Retrieved from http://ebookcentral.proquest.com Created from waldenu on 2019-04-21 20:11:08. Trim size: 7in x 9.25in 370 Glanz c19.tex V2 - 06/19/2015 CHAPTER 19: PLANNING MODELS FOR THEORY-BASED HEALTH PROMOTION INTERVENTIONS Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved. For example, “If I talk to my patients about an oral cancer exam, I will increase their awareness.” So, in reality, we are “thinking harder with theory” at this point than we were in the logic model of the problem discussed earlier. Interpreting some concepts in terms of theory (when justified) even when original studies were not based on theory can be beneficial because the entire theory provides additional constructs that may be added to the model. In addition to logic modeling, a central tool of Intervention Mapping is to create a matrix of the change objectives that specify who and what should change as a result of the intervention. The later section on It’s Your Game shows examples of matrices. Change objectives are the intersection of the performance objectives and the determinants guided by the question, “What has to change in the determinant to bring about the performance objective in the target population?” The answers to this question form the cells of the matrix and are the targets for change in an intervention. In the It’s Your Game example, the planning team asked, “What does the intervention have to change in knowledge, skills, and self-efficacy in order for students to avoid situations that might lead to sex?” The matrices are the foundation for decisions about which theory-based change methods (also referred to as techniques; see Michie, Johnston, Francis, Hardeman, & Eccles, 2008) will likely influence change in determinants of the targeted behaviors in both the at-risk group and agents in the environment (see the description of Step 2 for It’s Your Game). In Step 3 (program plan) and Step 4 (program production), planners work from the logic model of change (Step 2) to conceptualize and design the intervention. They make decisions about theory-based change methods, shape their interpretation into a deliverable intervention (Step 3), and then develop the needed materials and messages (Step 4). In Step 3, planners generate possible program themes and major program components. They choose the methods that will be included in the program from the preliminary list of theoretical methods they created as a part of the logic model of change. A theory-based change method is a defined process by which theories postulate, and empiric research provides evidence for, the ways in which interventions can influence change in the determinants of behavior of individuals, groups, or social structures. Determinants of behavior almost always include many factors other than knowledge and awareness; therefore methods must include processes to influence factors other than simple knowledge. Theory-based methods are likely to form a major foundation for an intervention’s active ingredients, because they have been matched directly to the change objectives. Table 19.2 lists a sampling of theory-based change methods and gives definitions for them. For example, the planners guiding the It’s Your Game project (Tortolero et al., 2010) considered many different methods that could influence a change objective, but they ultimately chose a limited number of methods that could be feasibly implemented in the program environment. As planners figure out how to deliver a program and write its content, they must consider parameters for the use of each method. Parameters are theory or research-derived “instructions” for effective use of a method. For example, a role model must be credible to the observer, must demonstrate clearly the skill to be learned, and must be positively reinforced (Bandura, 1986). A planning group must also be very meticulous at this stage, because links between change methods and the determinants of behavior and environment can easily be lost in this crucial Glanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2015). Health behavior : Theory, research, and practice. Retrieved from http://ebookcentral.proquest.com Created from waldenu on 2019-04-21 20:11:08. 1:07pm Page 370 Trim size: 7in x 9.25in Glanz c19.tex V2 - 06/19/2015 INTERVENTION MAPPING 1:07pm Page 371 371 Table 19.2 Samples of Theory-Based Change Methods Theoretical Method (Theory) Determinant: skills and self-efficacy Modeling (Social Cognitive Theory) Reward and reinforcement (Social Cognitive Theory) Guided practice, skills training, and feedback (Social Cognitive Theory; learning theory, goal setting) Determinant: knowledge Imagery (theories of information processing) Advance organizers (theories of information processing) Elaboration (theories of information processing, Elaboration Likelihood Model) Determinant: attitudes Repeated exposure (theories of learning) Self-reevaluation (Transtheoretical Model) Environmental reevaluation (Transtheoretical Model) Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved. Shifting perspective (theories of stigma and discrimination) Determinant: social influence and perceived social norms Provide opportunities for social comparison (Social Comparison Theory) Information about others’ approval (Theory of Planned Behavior/Theory of Reasoned Action) Definition Enabling someone to observe an appropriate model performing the behavior and being reinforced Offering contingent valued consequences (only if the behavior is performed) Prompting individuals to rehearse and repeat the behavior various times, discuss the experience, and provide feedback Providing familiar physical or verbal images as analogies to a less familiar process Presenting an overview of the material that enables a learner to activate relevant schemas so that new material can be associated Stimulating the learner to add meaning to the information that is processed Making a stimulus or message repeatedly accessible to an individual Encouraging combining both cognitive and affective assessments of one’s self-image with and without an unhealthy behavior Encouraging realizing the negative impact of the unhealthy behavior and the positive impact of the healthful behavior Encouraging taking the perspective of the other Facilitating observation of nonexpert others in order to evaluate one’s own opinions and performance abilities Providing information about what others think about the person’s behavior and whether others will approve or disapprove of any proposed behavior change step. One reason for this planning hazard is that the theories used to understand or predict a behavior may offer little or no guidance on how to change determinants related to the behavior. Other theories may be needed for this purpose. For example, the Health Belief Model suggests the importance of perceived susceptibility in predicting action, but offers little guidance about how to change this belief (see Chapter Five). Social Cognitive Theory, in contrast, offers specific methods for affecting change in determinants (see Chapter Nine). These chosen theory-derived change methods are then matched with practical delivery strategies and woven into a coherent program with a defined scope and sequence. The final delivered intervention will often be a multicomponent and possibly multilevel program targeting change in both at-risk groups and environmental agents. Each part of the program may require materials and messages. One challenge of Intervention Mapping Step 4 is translation: optimizing the odds of getting the materials and messages “right” in order to deliver the methods and practical applications as effectively as possible so that the change objectives can be accomplished. Glanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2015). Health behavior : Theory, research, and practice. Retrieved from http://ebookcentral.proquest.com Created from waldenu on 2019-04-21 20:11:08. Trim size: 7in x 9.25in 372 Glanz c19.tex V2 - 06/19/2015 CHAPTER 19: PLANNING MODELS FOR THEORY-BASED HEALTH PROMOTION INTERVENTIONS Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved. In Step 5 (implementation plan), planners have another opportunity to use theory and evidence systematically in program development and implementation. Potentially effective health promotion programs will have no impact if they are not implemented and will not reach as far as desired in the populations for which they are intended if they are not sustained or widely disseminated (Glasgow, Klesges, Dzewaltowski, Estabrooks, & Vogt, 2006). The developers of Intervention Mapping suggest that without a planned dissemination intervention to ensure appropriate adoption, implementation, maintenance, and sustainability, a health promotion program is likely to be less widely used than it could have been, or used with less fidelity (also see Chapter Sixteen). For new programs, demonstration projects, and research projects, the focus of Step 5 is on planning for program use in initial testing of the program’s efficacy or effectiveness. If the program is shown to be effective, then its ultimate degree of impact on public health will depend on populations’ degree of exposure to the program, and developers can use Step 5 to plan for larger program dissemination. In this step, planners repeat the processes of considering needs, performance objectives, and determinants—but this time for the program adopters, implementers, and maintainers. Working with potential adopters and implementers as core members of the planning group from the beginning of a project, in addition to compiling matrices of change objectives in order to fully understand the reasons that they may implement a program, can form the foundation for developing program components that directly affect implementation. In Step 6 (evaluation plan), planners propose process and outcome evaluation methods. The evaluation plan is based on the products from the previous Intervention Mapping steps. A wealth of literature is available from which to learn the basics of program evaluation (Patton, 2008; Rossi et al., 2004; Wholey, Hatry, & Newcomer, 2010). Thinking about the evaluation is a parallel process with program planning, and should begin along with the work on the needs assessment and logic model of the problem. Most evaluation texts (see Rossi et al., 2004; Wholey et al., 2010) include program planning or understanding the program as the first part of the evaluation process. They ask questions about the program’s logic and design to determine evaluability. For example: Is there a need for the program? Have the right target groups been identified? Do stakeholders agree on the program objectives? Is the program theory, that is, the logic model of change, flawed? Have appropriate delivery channels been selected? Such questions are suggested to avoid wasting resources on programs with insufficient planning. Programs that have been developed using a systematic framework such as Intervention Mapping are likely to perform well in this initial step of evaluation. The logic of the intended program effects will be transparent. Once the logic of the program is understood, evaluations determine whether the intervention was successful in meeting program goals and objectives (effects or outcomes evaluation), and why the intervention was or was not successful (process evaluation). Using the output from each Intervention Mapping step, planners determine evaluation questions, indicators and measures, and an appropriate research design to ensure that findings can be appropriately attributed to the program under consideration. The general focus of evaluation questions for each Intervention Mapping step is shown in the following list: Glanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2015). Health behavior : Theory, research, and practice. Retrieved from http://ebookcentral.proquest.com Created from waldenu on 2019-04-21 20:11:08. 1:07pm Page 372 Trim size: 7in x 9.25in Glanz c19.tex V2 - 06/19/2015 APPLYING THE PRECEDE-PROCEED MODEL AND INTERVENTION MAPPING 1:07pm Page 373 373 Step 1: Did the program have an effect on health or quality-of-life factors? Step 2: Did the program have an effect on behavioral and environmental change as specified in the program plan? (Measurement of this change should follow the performance objectives.) Did the program affect the determinants of behavior or environmental conditions? (Measurement of this change should follow the change objectives [on the matrices], organized by determinant.) Step 3: Were the theory-based change methods included in the program appropriate to influence change? Were the theory-based change methods and practical applications implemented as intended in the program design and according to the theoretical guidance for their use? Step 4: Were the program components acceptable to the target population? Step 5: Was the program delivered as intended (with fidelity)? What was the extent of the program’s reach to the intended populations? Applying the PRECEDE-PROCEED Model and Intervention Mapping The following applications illustrate how researchers have used the PRECEDE-PROCEED Model and Intervention Mapping, respectively, as theory- and evidence-based planning models to develop, implement, and evaluate two distinct health promotion interventions. Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved. Application 1: A Youth Mental Health Community Awareness Campaign The Compass Strategy program is an example of an application of the PRECEDE-PROCEED model to develop, implement, and evaluate a successful youth mental health community awareness campaign in Melbourne, Australia. Details of the development process and results from a quasi-experimental trial have been reported elsewhere (Wright, McGorry, Harris, Jorm, & Pennell, 2006). Findings from a population assessment with youth, focus groups with youth affected by mental health disorders and their parents, and consultations with service providers informed the needs assessment and intervention development (Wright et al., 2006). A project development group comprising representatives from key stakeholder groups, including mental health service providers, general practitioners, and local, state, and Commonwealth government departments, reviewed these data and provided ongoing consultation during the implementation and evaluation phases. Social and Epidemiological Assessment Most mental disorders typically first present during adolescence and young adulthood, and they are often characterized by comorbidity (Kessler, Berglund, Demler, Jin, & Walters, 2005). These specific disorders and this age group were considered an important target for improving mental health, as early detection and treatment at the time of first onset have been found Glanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2015). Health behavior : Theory, research, and practice. Retrieved from http://ebookcentral.proquest.com Created from waldenu on 2019-04-21 20:11:08. Trim size: 7in x 9.25in Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved. 374 Glanz c19.tex V2 - 06/19/2015 CHAPTER 19: PLANNING MODELS FOR THEORY-BASED HEALTH PROMOTION INTERVENTIONS to improve long-term outcomes (Kupfer, Frank, & Perel, 1989) and reduce the risk of future illness episodes (Kroll, Harrington, Jayson, Fraser, & Gowers, 1996). The project team found that over a quarter (26%) of Australian youth aged sixteen to twenty-four report having a mental health disorder (Australian Bureau of Statistics, 2008). Related quality-of-life issues include school failure, poor social and family functioning, and high rates of enduring disability (McGorry, 2010). In 2009, the financial cost of mental illness among Australian youth aged twelve to twenty-five was AU$10.6 billion; the value of lost well-being (disability and premature death) was a further AU$20.5 billion (Access Economics, 2009). The team set objectives for increasing rates of early detection and treatment for mental health disorders to lead to better health and quality-of-life outcomes. Previous studies had indicated that recognition of depression, and especially psychosis, was limited, although such recognition is an essential step for effective help seeking (Wright et al., 2005). Help seeking at the earliest possible stage is essential for the early receipt of treatment. However, rates of help seeking were also low, particularly in relation to mood disorders. Thus, based on the literature and focus group findings, the most important and changeable behavioral factors for early detection and treatment were identified as (1) recognition of the problem, (2) seeking help for the problem, (3) delivery of appropriate treatment, and (4) treatment compliance. Given that other agencies were already targeting treatment delivery and compliance, the project development group decided to focus on recognition and help seeking behavior as key behavioral targets for youth. In the environmental assessment, the project development group considered social and physical factors that might influence the health outcome directly or indirectly via behavior. Physical factors, such as the accessibility and availability of mental health services, were already being addressed. Thus social support and social norms associated with youth’s recognition of the problem and with help seeking for mental health services were identified as the key environmental target. Educational and Ecological Based on the literature and findings from the focus groups and youth population survey, the key predisposing factors that impeded recognition and help seeking were limited knowledge of signs, symptoms, and treatment availability; low perceived susceptibility and severity; perceived barriers to help seeking; and stigma related to mental health disorders. Reinforcing factors identified by youth and the literature indicated a role for social support from family, friends, teachers, counselors, and lay leaders. However, focus group data and input from service providers indicated that these social support individuals often faced the same barriers to action as the youth did; they had limited knowledge of signs and symptoms and a perception that youth had low susceptibility. Enabling factors included the need to increase the availability of mental health information and to enhance behavioral skills related to recognition and help seeking (Figure 19.4). Glanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2015). Health behavior : Theory, research, and practice. Retrieved from http://ebookcentral.proquest.com Created from waldenu on 2019-04-21 20:11:08. 1:07pm Page 374 Trim size: 7in x 9.25in Glanz c19.tex V2 - 06/19/2015 Predisposing Factors Knowledge of symptoms and sources of help Perceived barriers to seeking help Behavioral Factors Recognition and help seeking by young people Perceived susceptibility and severity Intervention Media campaign Website Reinforcing Factors Social supports’ knowledge of symptoms and sources Health Target Quality of Life Early identification of depression and psychosis in young people School performance Social and family functioning Financial costs Information line Perceived susceptibility Video ARTICLE I. ENVIRONMENTAL FACTORS Navigator training Social support and social norms associated with recognition and help seeking by young people Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved. Service provider links ARTICLE II. ENABLING FACTORS Availability of mental health information Behavioral skills Figure 19.4 Application of PRECEDE-PROCEED to Youth Mental Health Awareness Source: Adapted from Wright et al., 2006. Glanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2015). Health behavior : Theory, research, and practice. Retrieved from http://ebookcentral.proquest.com Created from waldenu on 2019-04-21 20:11:08. 1:07pm Page 375 Trim size: 7in x 9.25in 376 Glanz c19.tex V2 - 06/19/2015 CHAPTER 19: PLANNING MODELS FOR THEORY-BASED HEALTH PROMOTION INTERVENTIONS Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved. Administrative and Policy Assessment and Intervention Alignment This phase required an analysis of the policies, resources, and circumstances in potential implementation settings that would either impede or facilitate implementation of a youth mental health community awareness campaign. Approximately thirty consultation forums and presentations were conducted with representatives from key service sectors, comprising mental health services, general practitioners, community health services, youth and welfare services, the education sector, and local, state, and Commonwealth government departments. These forums demonstrated support and capacity in the community and in the service systems for a wide-scale initiative. Furthermore, funding was made available for grant application in the context of a new Australian government mental health policy that focused on early intervention and mental health promotion. The intervention comprised six components: a media campaign, website, information line, video, navigator training, and service provider links. Each component was designed to affect the predisposing, reinforcing, and enabling factors identified in the needs assessment. The target audience comprised youth (self, friend, or family member) and adults (primarily parents). Based on the identified predisposing and reinforcing factors and constructs from the Health Belief Model (e.g., perceived susceptibility and severity), the main theme was “Get on top of it before it gets on top of you,” supported by five key messages: youth are particularly susceptible to mental health disorders, symptoms should be taken seriously, the nature of the core symptoms, the importance of getting help early, and directions to information sources. The selection of components was also guided by the Transtheoretical Model (Prochaska & DiClemente, 1983; also see Chapter Seven), in recognition that different individuals will be at different stages of readiness to contemplate mental health issues, and that they will move through these stages at varying rates during the process of recognition and help seeking. The components were pretested with the target audience prior to implementation to assess comprehension, cultural sensitivity, engagement, ease of use, and any potential negative effects. The media campaign involved cinema, radio, local newspaper, and youth magazine advertisements, and newspaper editorials to raise awareness and interest. Print media (posters, brochures, and postcards) were displayed in schools and in recreational, health, and welfare settings and were used as supplements in classroom and counseling activities. The Getontop website provided detailed information about disorders, help seeker tips, and links to local resources. The information line responded to calls 24/7 and provided personalized information and help seeker coaching. The video and accompanying facilitator’s manual were designed for use in classrooms or information sessions; they included scenarios depicting early signs of illness and strategies for help seeking, to stimulate discussion. The navigator program comprised training workshops for lay professionals on basic mental health counseling. Additional service provider strategies focused on facilitating consultation, building strong links between services, updating resources, and providing program updates via newsletters, presentations, and visits. Implementation The campaign ran from May 2001 to May 2003. Each component had its own implementation plan to ensure effective and coordinated delivery. The media campaign targeted high-impact Glanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2015). Health behavior : Theory, research, and practice. Retrieved from http://ebookcentral.proquest.com Created from waldenu on 2019-04-21 20:11:08. 1:07pm Page 376 Trim size: 7in x 9.25in Glanz c19.tex V2 - 06/19/2015 APPLYING THE PRECEDE-PROCEED MODEL AND INTERVENTION MAPPING 1:07pm Page 377 377 periods, such as school holidays, to maximize exposure for youth and parents. Print media, the navigator program, and service provider strategies were delivered primarily during the school semester. Thus the campaign proceeded in waves of intensity with a varying number of components being implemented at any given time. This helped to ensure wide-scale coverage and reduced the risk of message burnout. Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved. Process, Impact, and Outcome Evaluation Process evaluation data were collected to document whether the campaign was being implemented as designed and to allow for real-time adjustments. Program reach and effectiveness were assessed by monitoring hits to the website and calls to the information line. Distribution rates were used to assess the number of media activities, print materials, and service provider materials distributed. During the first fourteen months of the campaign, the website and information line averaged 465 visits and 28 calls per month, respectively; over 7,000 cinema and 195 radio advertisements were aired; twenty-one weeks of youth magazine advertisements and 15 newspaper advertisements (average circulation 20,000 per advertisement) were circulated; and 15,000 postcards, 600 posters, and 20,000 stickers were distributed to schools and/or health care services. The Strategy Compass newsletter was distributed to 532 services, and 157 service providers requested Compass materials. Impact evaluation was conducted using a quasi-experimental design. A cross-sectional telephone survey was conducted before and fourteen months after the start of the campaign. Randomly selected samples of 600 youth aged twelve to twenty-five from the experimental region and 600 youth in the same age range from a comparison region were surveyed at each time point. Outcomes measured included the targeted behaviors (e.g., correct recognition of mental health disorder, and active help seeking) and the predisposing, reinforcing, and enabling factors (e.g., perceived barriers to help seeking, perceived likelihood of discrimination, and helpfulness ratings of professionals and medications), and exposure to mental health campaigns. Among youth in the experimental regions, the campaign had a statistically significant, positive impact on self-identified depression, help seeking for depression in the previous year, correct estimate of the prevalence of mental health disorders, increased awareness of suicide risk, a reduction in perceived barriers to help seeking, and an increased awareness of mental health campaigns, compared to youth in the comparison region. For example, after the campaign, a greater percentage of youth in the experimental regions correctly estimated the prevalence of mental health issues compared to youth in the comparison region (24.7%, vs. 22.8%), and were more likely to perceive themselves to be at risk for suicide than the other youth were (20.4% vs. 17.8%). Application 2: It’s Your Game. . . Keep It Real It’s Your Game. . . Keep It Real is a sexual health education program for middle school students (Markham et al., 2012; Tortolero et al., 2010) that was developed using Intervention Mapping. School-based programs offer an efficient strategy to reach youth with the aim of reducing Glanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2015). Health behavior : Theory, research, and practice. Retrieved from http://ebookcentral.proquest.com Created from waldenu on 2019-04-21 20:11:08. Trim size: 7in x 9.25in 378 Glanz c19.tex V2 - 06/19/2015 CHAPTER 19: PLANNING MODELS FOR THEORY-BASED HEALTH PROMOTION INTERVENTIONS adolescent risky sexual behaviors that may lead to sexually transmitted infections (STIs), including the human immunodeficiency virus (HIV) and human papillomavirus (HPV), and to teen pregnancy. However, development and delivery of sexual health education programs at the middle school level present several challenges, including the heterogeneity of students’ physical and social development, and community needs and sensitivities regarding sexual health education at this age. This example describes how program planners used the Intervention Mapping process to develop an innovative, theory-based sexual education program that addresses the diverse needs of middle school students. The planning team engaged multiple community partners throughout program development, including members from local medical, religious, and community service organizations, school district personnel, parents, and teenagers. They used several community engagement methods to gain input: (1) formation of a community advisory board and a teen advisory board, (2) use of focus groups with parents and teenagers from the priority population, and (3) use of school district presentations and meetings. These methods helped to ensure program sensitivity to the needs of the priority population (see Chapter Fifteen). Step 1: Logic Model (Theory) of the Problem Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved. The population for the initial It’s Your Game project comprised predominantly African American and Hispanic middle school students attending a large, urban school district in the south-central United States. All students attended middle schools with high participation in the free or reduced-price school lunch program, which is an indicator of low socioeconomic status. Using the PRECEDE model to guide the needs assessment, the team used secondary data sources, empirical literature reviews, and community input to describe health problems and quality-of-life issues related to sexual risk behaviors that may begin in middle school. Minority youth are disproportionately affected both by teen births and STIs (Centers for Disease Control and Prevention [CDC], 2013; Hamilton & Ventura, 2012). Teen pregnancy is a major factor in dropping out of high school and welfare dependency and also in negative outcomes for children of teens (Hoffman, 2006; Shuger, 2012). Examining behavioral factors, the team identified early sexual initiation as a risk factor for STIs and teen pregnancy. Nationally in 2011, 47 percent of high school students reported ever having sex; of these, 40 percent said they did not use a condom at last intercourse, 15 percent had had four or more partners, and 9 percent had experienced dating violence (CDC, Division of Adolescent and School Health, 2013). Other behaviors, such as dating older partners and low health care use, increase the risk of adverse health outcomes (Marin, Kirby, Hudes, Gomez, & Coyle, 2003). Environmental factors, such as low parental communication about sexual health and low parental monitoring and also state policies on minors’ access to health care services (The Guttmacher Institute, 2013) also affect adolescent sexual behaviors. Finally, many psychosocial determinants, such as knowledge, self-efficacy, and outcome expectations, also influence adolescent behavior (Kirby, Lepore, & Ryan, 2005). These findings are evidence of the need for effective sexual education for those in the early years of adolescence. Glanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2015). Health behavior : Theory, research, and practice. Retrieved from http://ebookcentral.proquest.com Created from waldenu on 2019-04-21 20:11:08. 1:07pm Page 378 Trim size: 7in x 9.25in Glanz c19.tex V2 - 06/19/2015 APPLYING THE PRECEDE-PROCEED MODEL AND INTERVENTION MAPPING 1:07pm Page 379 379 Step 2: Program Outcomes and Objectives—Logic Model (Theory) of Change Working from their logic model of the problem, the team developed a logic model of change and matrices of change objectives to guide the program’s content and evaluation. Behavioral and environmental outcomes, descriptions of what middle school youth will do, and what environmental changes will occur as a result of the program are displayed in Table 19.3, along with the details of the specific behaviors students and parents would have to perform to achieve these outcomes (performance objectives). The next task in developing the logic model of change is to use health and empirical research to identify why program participants would accomplish the performance objectives. The planning group for It’s Your Game used Social Cognitive Theory (see Chapter Nine), a literature review, and data from the needs assessment to answer the question, “Why would a participant perform a particular behavior?” The team then developed a matrix of change objectives by asking, “What needs to change related to this determinant to influence this performance objective?” For example: “What needs to change about outcome expectations regarding sexual behavior to decide not to have sex?” Table 19.4 depicts a partial matrix for students and for parents. It displays all the relevant determinants but only three of the performance objectives and related change objectives. Steps 3 and 4: Program Plan and Program Production Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved. The It’s Your Game team selected potential theory-based methods that had been shown to be effective for sex education and matched them to specific change objectives in the matrices (Coyle et al., 1996; Coyle, Kirby, Marin, Gómez, & Gregorich, 2004). These methods comprised information transfer, active learning, modeling, group discussion, persuasive communication, scenario-based risk information, skills training with guided practice, anticipated regret, and goal setting. The team then translated these theory-based change methods into practical program components to be implemented via multiple communication channels and vehicles, including group-based classroom lessons, individual journaling and computer-based lessons tailored by gender and sexual experience, parent-child take-home activities, and parent newsletters. The planners wrote content (messages) appropriate for twenty-four fifty-minute lessons, with twelve lessons in seventh grade and twelve lessons in eighth grade. The computer activities included interactive skills-training exercises, peer role model videos, and real-world-style teen serials with online student feedback to reinforce and supplement activities in the group-based classroom lessons. Each grade level included three take-home activities to facilitate parent-child communication and a parent newsletter. The seventh-grade curriculum was structured to begin with lessons on general decision making or life skills, founded on a self-regulatory, decision-making paradigm or theme: select (students select their personal rules or limits), detect (students recognize challenges to these rules), and protect (students avoid situations that challenge these rules and use refusal skills to protect these rules). These three steps would enable students to keep their game (their life) real (healthy), initially by setting rules for general risk behaviors (e.g., not using drugs Glanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2015). Health behavior : Theory, research, and practice. Retrieved from http://ebookcentral.proquest.com Created from waldenu on 2019-04-21 20:11:08. Trim size: 7in x 9.25in 380 Glanz c19.tex V2 - 06/19/2015 CHAPTER 19: PLANNING MODELS FOR THEORY-BASED HEALTH PROMOTION INTERVENTIONS Table 19.3 Step 2: Behavioral Outcomes, Environmental Outcomes, and Performance Objectives for It’s Your Game. . . Keep It Real Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved. Outcomes Associated Performance Objectives Behavioral outcomes: students will. . . 1. Choose not to have sex. Decide to not have sex. Communicate personal limits regarding sex. Avoid situations that could lead to sex. Refuse to have sex. 2. Use condoms correctly and Make the decision to use condoms. consistently if having sex. Buy or obtain a free condom. Carry condoms. Negotiate the use of a condom with every partner. Use a condom correctly. Maintain condom use with every partner every time you have sex. Make decision to use birth control. 3. Use effective method of Choose appropriate birth control method. contraception along with Negotiate use of birth control method each time you engage in sex. condoms if having sex. Use chosen birth control method effectively and consistently. 4. [For students who have sex.] Make the decision to get tested. Get tested and counseled for Make appointment to get tested by health care provider. HIV, STI, and pregnancy. Keep appointment to get tested. Obtain test results. Obtain and follow through with health care if necessary. Notify partner(s) of test results. Maintain testing behavior over time. 5. Have healthy relationships with Evaluate past, current, and potential relationships. Communicate expectations about healthy relationships. their friends, girlfriends, or Avoid relationships with friends, boyfriends/girlfriends that are not healthy. boyfriends. Get out of relationships with friends, boyfriends/girlfriends that are not healthy. Environmental outcomes: parents will. . . 1....
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Running Head APPLYING THE PRECEDE-PROCEED MODEL

Name
Applying the Precede-Proceed Model
Course
Instructor
Date

1

Applying The Precede-Proceed Model

2

Description of the Precede-Proceed model
PRECEDE-PROCEED is a framework used for program planning and evaluation. The
PRECEDE-PROCEED framework helps program managers identify factors affecting public
health and plan targets for intervention, specify objectives, and criteria for evaluation. The
PROCEED framework provides steps for policy, implementation, and evaluation. The acronym
PRECEDE stands for predisposing, reinforcing, and enabling constructs in educational/
environmental diagnosis and evaluation. The acronym PROCEED stands for policy, regulatory,
and organizational constructs in educational environmental development.
The PRECEDE and PROCEED phases, together, provide a stepped approach for program
planning, implementation, and evaluation. During the PRECEDE phases, priorities are identified,
and objectives are set and establish objects and policy criteria, implementation, and assessment
in the Proceed phases. The PRECEDE-PROCEED framework encourages multidimensional
efforts and involves multiple sectors and levels of the community to effect change. As a model,
PRECEDE-PROCEED posts a system of hypothesized relationships between public health
program processes and outcomes that may be tested in evaluation. The developers of the
framework define program evaluation as the comparison of an object of interest against a
standard of acceptability. Objects of interest include program inputs (human, physical, and fiscal
investments) described in terms of objectives that specify who will have what type of change by
what timeline, implementation processes, impact or intermediate effects, and ultimate effects or
outcomes. Standards of acceptability are program targets of how much and when a change is
expected. Standards may be levels of improvement anticipated by program managers, scientific
standards, historical performance measures, or norms such as state averages. The PRECEDEPROCEED Model integrates evaluation planning and program planning. It provides a process for

Applying The Precede-Proceed Model

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collecting baseline data and program planning that facilitates future measurement and evaluation.
The PRECEDE plan for the program will include social, behavioral, health, environmental, and
educational objectives, as well as program activities, targeted to the objectives. Evaluation is
continuous and integral to the model, incorporat...


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