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Process Models
and PRECEDE
William R. Brieger, MPH, CHES, DrPh
Johns Hopkins University
1
Section A
Process Models
2
Process Models
Ù Field theory—unfreezing behavior
Ù Stages of change
– Transtheoretical model
Ù Adoption of innovations
3
The Next Step in
Force Field Analysis
Ù Field theory
Ù Steps toward
reaching the goal
in force field
analysis
Ù Need to “unfreeze”
the old behavior
Ù Eventually “refreeze”
as a new habit
4
Process Models
Field Theory
Ù Unfreezing
– A conscious recognition that an
existing behavior may no longer be
functional or that a new behavior is
needed
Ù Evaluation
– An effort to understand and
consider the implications of the
change
Continued
5
Process Models
Field Theory
Ù Goal setting
– A decision on trying to change the
nature of the behavior involved and
the circumstances under which the
behavior will be performed
Continued
6
Process Models
Field Theory
Ù Trial/action
– An effort is made to enact the new
behavior/refrain from the old
behavior and at the same time, the
person is taking cognizance of the
problems and benefits encountered
Continued
7
Process Models
Field Theory
Ù Re-freezing
– The new learning has become a
habit or so much a routine part of
an individual’s on-going behavior
as to be taken for granted, selfsustaining
8
Transtheoretical Model
Stages of Change
Ù Precontemplation: No intention to
adopt behaviour in foreseeable future
Ù Contemplation: Not currently, but
thinking about it, may intend
Ù Preparation: Seeking information,
acquiring resources and skills needed
to carry out the behaviour
Continued
9
Transtheoretical Model
Stages of Change
Ù Action: Carrying out the behavior for
some time
Ù Maintenance: Have taken the action
for a considerable period of time
10
Stages for Bed Net Use
Pre-contemplation
Not thinking about buying a net
Contemplation
Considering insect nuisance, seeking
information and advice about where
to buy
Getting money together; plan when
will visit shop; actually purchases
Sleeps under net nightly for some
weeks
Has slept under net for whole rainy
season
Feels hot in dry season, stops
sleeping under net
Preparation
Action
Maintenance
Relapse
11
12
Stages of Change Can Be Measured
Source: CDC Morbidity and Mortality Weekly Report
13
Out-of-School Adolescents in
Southwestern Nigeria
el
ap
se
R
an
ce
M
ai
nt
en
Ac
ti o
n
on
te
m
p.
..
C
on
te
m
pl
at
io
n
Pr
ep
ar
at
io
n
100
80
60
40
20
0
Pr
eC
Percent
Stages of Change in Condom Use
Stage
Rural Female
Rural Male
Urban Female
Urban Male
14
Section B
Diffusion/Adopter Characteristics
15
Diffusion of Innovations
Ù Innovation as a product or idea
Ù Adoption as the process of individual
behavior change
Ù Importance of networks and
information flow in a community
16
Diffusion
120
100
80
60
40
20
0
Innovators early adopt
Early maj.
Fate maj.
Late adopters
17
Adopter Characteristics
Ù Innovators
– Actively seek new information
– Willing to take risks
– Have access to information and
expertise outside the confines of
the community
– Characteristics such as age,
beliefs, occupation at edge or
outside “normal” for community
Continued 18
Adopter Characteristics
Ù Early adopters
– Seek out new information, belong
to organizations with a national
base, either are or have access to
technical experts, have higher
incomes, generally younger, accept
risks.
Continued 19
Adopter Characteristics
Ù The majority
– Receptive to new ideas, but do not
seek them, belong to local groups,
not national associations, source of
information that are valued are
opinion leaders in the early adopter
group, generally average income.
Continued 20
Adopter Characteristics
Ù Late adopters
– Complacent, possibly skeptical,
neighbors and mass media are
sources of information, wait to see
if others are successful with the
innovation, older, security minded,
lower incomes.
21
Communal bed net soaking
22
Factors that Influence Adoption
Ù Characteristics of the innovation
– Cultural congruence
– Complexity/simplicity
– Benefits perceived
– “Trialability” (logistics)
– Competition/ alternatives
23
Factors that Influence Adoption
Ù Adopter factors
– Personal attributes: Age, gender,
education, etc
– Personality: Assertiveness,
submissiveness
Continued
Factors that Influence Adoption
Ù Communication factors
– Type of media: Indigenous,
mass/electronic
– Familiarity with/perceptions of
available media
25
Communication Factors Considered
Radio Use in Rural Nigeria
Ù Education—higher education = more
listening
Ù Gender
– Males listen to specific programs
and news
– Females have it on as background
Continued 26
Communication Factors Considered
Radio Use in Rural Nigeria
Ù Electricity—Listen more if town has
electricity; batteries costly on regular
basis
Ù Message recall—more of outbreak
type—yellow fever; ORT, EPI more
from clinic
27
More Factors that
Influence Adoption
Ù Change agent characteristics
– Homophily/heterophily—
similar/different
– Flaskerund and Liu (1991) found that
when clients and therapists shared a
common language or ethnic origin,
more sessions were held
– Personal attributes: Cultural
competence, listening skills, etc
28
Cumulative Adoption Curve
Guinea Worm Filter Sales Peaked Early
29
Adoption of SSS/ORT
30
Safer Sexual Behaviors
Ù MMWR 40(46): 792–794, 1991
Ù Homosexual-bisexual men and
condom use
Ù Proportion in each stage remained the
same over time—but there was some
progress and some relapse
31
32
Factors Influencing Movement
among Stages
Ù Self efficacy
– Confidence that one can practice
safer sexual behavior even in
difficult circumstances, such as
when under the influence of drugs
or alcohol or in the company of a
new sex partner
– Odds ratio (OR) = 1.5; 95%
confidence interval (CI) = 1.1–2.0
Continued 33
Factors Influencing Movement
among Stages
Ù Perceived peer
support
– OR= 1.4;
95% CI =
1.0–2.0
© Planned Parenthood
Federation of America, Inc.,
Courtesy of Photoshare
34
Relapse Behavior
Ù AIDS rising again in San Francisco,
sounding warning
– The Sun: Saturday, July 1, 2000:
Page 3A
Ù Epidemiology
– The percentage of HIV-positive
cases at anonymous testing centers
nearly tripled between 1997 and
1999 to reach 3.7 percent
Continued 35
Relapse Behavior
Ù Behavior
– Gay men in San Francisco who
reported always using a condom
during sex fell from 70 percent in
1994 to 54 percent in 1999
Ù Antecedent
– New AIDS drugs have made the
disease seem less threatening
36
Section C
The PRECEDE Framework
37
The Acronym
Ù
Ù
Ù
Ù
Ù
Ù
Ù
Predisposing
Reinforcing and
Enabling
Causes in
Educational
Diagnosis and
Evaluation
38
The PRECEDE Framework
An Integration of Theories
Ù
Ù
Ù
Ù
Ù
Ù
Quality of life diagnosis
Health/epidemiological diagnosis
Behavioral diagnoses
Educational diagnoses
Administrative/strategy diagnosis
Evaluation process
39
Precede/Proceed:
Full Picture of a Model
Phase 5
Administrative and
policy diagnosis
Phase 4
Educational and
organizational
diagnosis
Health
Promotion
Predisposing
factors
Health
education
Policy
regulation
organization
Phase 6
Implementation
Reinforcing
factors
Phase1
Phase 2
Phase 3
Social
Behavioral and Epidemiological
diagnosis
diagnosis
environmental
diagnosis
Behavior and
Lifestyle
Health
Enabling
factors
Quality
of Life
Environment
Phase 7
Phase 8
Process evaluation Impact evaluation
Phase 9
Outcome evaluation 40
Guinea Worm Disease
Analysis Using PRECEDE
Ù Quality of life
– Lower economic production,
missed school, and reduced
opportunities
Ù Epidemiological diagnosis
– Prevalence of disease, disability,
and secondary infections
Continued 41
Guinea Worm Disease
Analysis Using PRECEDE
Ù Behavioral diagnoses
– Wading in water with open ulcer
– Drinking water with infected
cyclops
– Alternatively: Filtering water to
prevent
42
Educational Diagnosis
Predisposing Factors (Cognitive/Affective Determinants)
Ù Knowledge of guinea worm cause and
prevention
Ù Attitude about water quality, purity:
“Water has no enemy”
Ù Perceived efficacy: Filter cannot
remove something already in the body
Ù Knowledge of correct use steps
Ù Preference viz: Alternative ways of
“cleaning” water
43
Enabling Factors
Resources and Skills Needed
Ù Skills: Ability to
follow correct use
steps
Ù Supply: Easily
available
Ù Cost: Price of a
bottle of beer
Ù Time: Not take too
long but is repetitive
44
Reinforcing Factors
Social Influences, Feedback Mechanisms
Ù Use promoted
by village health
workers who
were selected
by villagers
Ù Neighbors may
purchase and
use
Continued 45
Reinforcing Factors
Social Influences, Feedback Mechanisms
Ù Husbands
may/may not buy
Ù Visible results
removing
dirt/debris
46
Predisposing Factors
Integrating Theoretical Concepts into Educational Diagnosis
Ù HBM
– Knowledge as a modifying factor
– Perceived threat and its
components of perceived
susceptibility and severity
Continued 47
Predisposing Factors
Integrating Theoretical Concepts into Educational Diagnosis
Ù SLT
– Self-efficacy expectations
– Outcome and value expectancies
Ù TRA
– Attitudes towards the behavior
48
Integrating: Reinforcing Factors
Ù HBM
– Cues to action as advice from
significant others and observations
of what is happening to others
– Family structure and social group
memberships as modifying factors
Continued 49
Integrating: Reinforcing Factors
Ù SLT
– Social aspects of the environment
– Observational learning of key
others—For example, peers, family
members
Ù TRA
– Attitude toward reference groups
– Perception of social norms
50
Integrating: Enabling Factors
Ù HBM
– Barriers/facilitators as logistical
factors
– Economic status, occupation as
modifying factors
Continued 51
Integrating: Enabling Factors
Ù SLT
– Economic and political aspects of
the environment
– Skills as a person characteristic
Ù TRA
– Not explicitly stated
52
Strategy Diagnosis
Matching Antecedent Factors with Strategies
Ù Communication strategies
– Predisposing factors
– Mass, interpersonal media,
counseling, values clarification
Ù Social support strategies
– Reinforcing factors
– Support groups, peer education,
family counseling
Continued 53
Strategy Diagnosis
Matching Antecedent Factors with Strategies
Ù Resource development strategies
– Enabling factors
– Skills training, community
development, advocacy
54
55
Sudden Infant Death
Syndrome
Ù SIDS
educational
campaign
Ù “Back to Sleep”
Source: First Candle/SIDS Alliance, 800-221-7437
56
Sudden Infant Death
Syndrome
Ù Based on
evidence that the
behavior of
placing an infant
on its back for
sleeping reduces
risk of SIDS
Ù Next need to
analyze the
behavior
Source: First Candle/SIDS Alliance, 800-221-7437
57
Admin Diag
Ed Diag
Communication:
‘Back to Sleep’
media campaign
provided info on
sleeping position
Predisposing:
ÙNorms, accepted
practices to let infants
sleep on stomach
ÙAttitude that
sleeping on stomach
is best
Social Support:
ÙMedia campaign
used physicians
and nurses as
authority figures
ÙStaff Training so
model proper way
to put infant to
sleep
Reinforcing:
ÙAdvice from family,
friends, hospital staff.
ÙGrandmother in
home
ÙObserving hospital
staff put baby on back
ÙInfant’s own
responses to sleeping
position
Developmental:
NA
Enabling:
Not Applicable
Beh Diag
Sleeping Position
Prior – 30-70%
parents place
infants on
stomach to sleep
After – reductions
to 24%
Decay within
months
Differential: less
effective if mother
age 20-29, Afr
Am, low income,
inner-city, live
south, mid-Atlan
Epid Diag
Post-hoc
application
of PRECEDE
to SIDS
Program
SIDS
Most common age
1-12 months.
Eval: reduced
38% after
intervention
Non-Behavioral:
Age of child,
maternal age, cold
weather, low birth
weight
58
59
Educational Diagnosis and
Breast Self-Examination
Ù Predisposing factors
– High levels of self-confidence to
perform BSE
– Awareness of mammography as a
backup diagnostic tool
– Knowledge of risk factor—
especially parity
Continued 60
Educational Diagnosis and
Breast Self-Examination
Ù Predisposing factors
– Desire to seek reconstruction of the
breast should surgery be
necessary
– Education level: higher the level
the more likely
Continued 61
Educational Diagnosis and
Breast Self-Examination
Ù Enabling factors
– Skill in doing BSE at right time of
month
– Adequate time to do BSE
Ù Reinforcing Factors
– Messages from clinicians
– Influence of skills teacher
62
Integrating PRECEDE and Stages
Childhood Diarrhea
Ù Precontemplative
– Diarrhea has started in child but is
not recognized as serious yet by
parent/caregiver
Continued 63
Integrating PRECEDE and Stages
Childhood Diarrhea
Ù Educational diagnosis
– Focus on predisposing factors such
as knowledge of diarrhea disease,
dangers and recognition of
symptoms, attitude toward
seriousness, and value in taking
action instead of passive observing
64
Precede and Stages
Ù Contemplative
– Parent considers option to help
child, seeks advice
Ù Educational diagnosis
– Again, look at predisposing factors,
including knowledge of options and
procedures as well as perception of
personal capabilities to undertake
ORT
Continued 65
Precede and Stages
– Consider role of reinforcers: Social
norms and support from potential
advice givers
Ù Planning and action
– The parent/caregiver begins to
prepare appropriate home fluids
and feedings
Continued 66
Precede and Stages
Ù Educational diagnosis
– Enabling factors, such as skills and
availability of fluids and foods, are
important here
– Reinforcing factors: Who else in
household approves or not
Continued 67
Precede and Stages
Ù Maintenance
– Parent continues to provide ORT
throughout diarrhea episode and
extra food afterwards
– Parent uses ORT next time child
has a diarrhea illness
Continued 68
Precede and Stages
Ù Educational diagnosis
– Attention on reinforcing factors
such as family support, attitude of
spouse and elders, health worker
encouragement, and other parents
to serve as models
69
Programming Implications
Ù Putting diagnostic abilities to test
– Multiple antecedent factors
– Various segments of the population
– Different levels/stages of change
Ù Multi-strategy approach
70