Cancer Screening Health Promotion
Model
CANCER SCREENING HEALTH PROMOTION ENVIRONMENTAL SCAN
ACKNOWLEDGEMENTS
Documents prepared by:
Seema M. Parmar, MHA, PhD(c), Health Promotion Associate
Alberta Health Services, Health Promotion, Disease and Injury Prevention, Screening
Programs, Health Promotion
Rosanna Taylor, MSc. Health Promotion Research Associate
Alberta Health Services, Health Promotion, Disease and Injury Prevention, Screening
Programs, Health Promotion
Documents reviewed by:
Alberta Health Services, Health Promotion, Disease and Injury Prevention, Screening Programs,
Health Promotion
Alison Nelson, Manager
Monica Schwann, Acting Manager
Charlene Mo, Health Promotion Coordinator
Melissa Hyman, Health Promotion Coordinator
Carmen Webber, Health Promotion Coordinator, Screen Test
Alberta Health Services, Health Promotion, Disease and Injury Prevention, Screening Programs
Dr. Huiming Yang, Director, Screening Programs
Dr. Laura McDougall, Medical Lead, Screening Programs
Krista Russell, Manager, ABCSP/ACCSP
MaryAnne Zupancic, Manager, ACRCSP
Brenda Lynch, Manager, Client Program Services
Germaeline van der Lee, Project Coordinator, ACRCSP
Maria Linehan, Project Coordinator, ABCSP/ACCSP
Tammy Burke, Program Assistant, ABCSP/ACCSP
Carolyn Dudley, Program Manager, EPICS, ABCSP/ACCSP
Dr. Lorraine Shack, Research Leader, Public Health Innovation and Decision Support
Acknowledgements:
The authors gratefully acknowledge the following individuals and organizations for their
contribution to the development of various elements of each of the environmental scan documents.
Alberta Health Services, Health Promotion, Disease and Injury Prevention, Screening
Programs, Health Promotion
(Alison Nelson, Monica Schwann, Charlene Mo, Melissa Hyman, Carmen Webber, Amy
Williams, Teresa Earl)
Alberta Health Services, Health Promotion, Disease and Injury Prevention, Screening
Programs, Screening Programs
(Dr. Huiming Yang, Dr. Laura McDougall, Krista Russell, MaryAnne Zupancic, Song Gao,
Patricia Pelton)
Alberta Health Services
(Dr. Lisa Petermann, Dr. Lorraine Shack, Graham Petz, Brianne Lewis, Robyn Sachs,
Jennifer Doole, Vicky Vu)
Helix Designs (James Shrimpton)
Palomino (Lucas Bombardier, Christina Almeida)
ii
Suggested Citation:
Alberta Health Services (2010). Cancer Screening Health Promotion Model. Calgary, Alberta:
Alberta Health Services
This document is current as of December 30, 2010.
For a PDF version of this document, and more information on the environmental scan, please visit
http://www.screeningforlife.ca/healthpromotion
iii
Cancer Screening Health Promotion Model
CANCER SCREENING HEALTH PROMOTION MODEL
Model Background ....................................................................................... 2
Cancer Screening Health Promotion Model ..................................................... 2
Figure 1: Cancer Screening Health Promotion Model ........................................ 3
The “What” component of the CSHP Model ..................................................... 4
The “How” component of the CSHP Model ...................................................... 6
The “Who” component of the CSHP Model ...................................................... 8
The Cancer Screening Health Promotion Environmental Scan ............................ 8
Appendix A: The Ottawa Charter for Health Promotion .................................. 10
Appendix B: The Population Health Promotion Model ..................................... 14
Appendix C: PRECEDE-PROCEED Model ....................................................... 18
References ............................................................................................... 21
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Cancer Screening Health Promotion Model
Cancer Screening Health Promotion Model
Model Background
In April 2009, the Alberta Health Services (AHS) Screening Programs Health Promotion Unit (SPHPU) initiated a Cancer Screening Health Promotion (CSHP) Environmental Scan. The goal of the
CSHP Environmental Scan was to gather and summarize evidence related to the current breast,
cervical and colorectal cancer screening health promotion needs across Alberta. As part of the
CSHP Environmental Scan, a CSHP Model was created as a guide to examine and attend to the
breast, cervical, and colorectal cancer screening needs in Alberta. The model was altered
throughout the course of the environmental scan as information was gathered and new ideas were
generated. The most recent version of the model is presented in this document.
Cancer Screening Health Promotion Model
The CSHP model and the sources of the various components are presented in Figure 1. The model
is based on the Ottawa Charter for Health Promotion and the Population Health Promotion (PHP)
model 1; however, the CSHP model includes strategic activities used by the AHS SP-HPU and
different factors associated with cancer screening behaviour drawn from the original PHP model
and the PRECEDE-PROCEED model 2. The Ottawa Charter, PHP Model, and PRECEDE-PROCEED
Model are described in Appendices A-C. Like the Ottawa Charter, PHP Model and the PRECEDEPROCEED Model, the CSHP Model emphasizes the need for multiple strategies involving multiple
levels of the population and addressing multiple factors associated with screening in order to
improve cancer screening rates at the population level and reduce inequities.1
2
Cancer Screening Health Promotion Model
Figure 1: Cancer Screening Health Promotion Model
3
Cancer Screening Health Promotion Model
The “What” component of the Cancer Screening Health
Promotion Model
The original PHP model includes determinants of overall health in the “What” component
of the model. 1 Though many of the determinants in the original PHP model are
associated* with cancer screening, not all of the determinants directly promote or prevent
cancer screening. In the CSHP Model, these determinants of health are called “factors
associated with cancer screening”.
There are six categories of factors associated with cancer screening in the CSHP model.
The first three categories - “Genetic and non-modifiable characteristics”, “Behaviour,
Circumstance & Personal History”, and “Socioeconomic & Environmental conditions”encompass the different determinants of health in the original PHP model. These factors
characterize which populations are likely un- or under-screened and who should be
engaged in cancer screening promotion interventions. The last three categories predisposing, enabling, and reinforcing factors- are adapted from the PRECEDE-PROCEED
model.2 While the factors in the first three categories influence overall health, the factors
in these last three categories are specific to cancer screening promotion and practices.
Predisposing, enabling, and reinforcing factors describe why individuals are not screened
or what needs to happen in order for individuals to be screened. These factors are what
cancer screening promotion interventions aim to change.
Table 1 includes examples of the different categories of factors associated with cancer
screening. Additional examples as well as details about the examples included in this
table are provided in the document titled “Factors associated with cancer screening”
available on www.screeningforlife.ca/healthpromotion.
*
Associated means that these factors do not cause screening or prevent screening, but screening rates differ
significantly between populations with these factors and populations without these factors
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Cancer Screening Health Promotion Model
Table 1: Categories of Factors Associated with Cancer Screening: The “What” component
of the Cancer Screening Health Promotion Model
Category
Types of factors
Genetic & Non- Includes inherited
modifiable
characteristics and
characteristics
characteristics of an individual
that cannot be changed.
Behaviour,
Circumstance
and Personal
History
Socioeconomic
and
Environmental
conditions
Predisposing
factors
Enabling
factors
Reinforcing
factors
†
Examples
Family history
Age
Gender
Race or Ethnicity
Includes factors related to an
individual’s general
behaviour, lifestyle, and life
experiences. These factors
may be difficult to modify in
the short-term.
Education level
Length of time in a new country
Marital status
Disability
Health behaviours
Includes factors related to an
individual’s socioeconomic
status and factors related to
the environment in which and
individual lives and works.
These factors are often
difficult to modify in the shortterm.
Income
Employment
Location of neighborhood of residence
Socioeconomic conditions of
neighborhood of residence
Includes modifiable factors
that motivate an individual to
engage in cancer screening
practices such as cancer
screening knowledge,
attitudes, and beliefs.
Knowledge about cancer screening and
cancer screening services
Fear of cancer screening
Expectation of pain
Fatalistic beliefs
Screening as a priority
Perceived benefits, barriers,
susceptibility, and severity†
Includes modifiable factors
that make it possible for an
individual to engage in
cancer screening such as skills,
resources, and policies.
Health insurance (when applicable)
Regular source of health care
Recent physician contact
Factors related to quality, availability,
and accessibility of healthcare services
Includes modifiable factors
that influence an individual
to continue engaging in
cancer screening such as
social influences, incentives,
and positive experiences.
Physician’s recommendation
Peer or family support
Reinforcement from spiritual leaders
Medical history
Previous cancer screening experiences
From the Health Belief Model {{879 Rosenstock, I.M. 1974;}}
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Cancer Screening Health Promotion Model
The “How” component of the Cancer Screening Health Promotion
Model
The “How”component of the CSHP Model includes categories of strategic activities used by AHS
SP-HPU to promote cancer screening throughout Alberta. The specific activities coordinated by
AHS SP-HPU aim to increase cancer screening at the population level by improving knowledge,
influencing positive attitudes, and increasing cancer screening behaviour (Table 2). Examples of
cancer screening promotion activities within these categories that can be coordinated at the level
of a health unit (e.g. Zone, Primary Care Network, health department etc.) or at the community
level (e.g. neighborhood groups, community service organizations, employers, etc.) are described
in the documents titled “Activities that Promote Cancer Screening” and “Cancer Screening
Promotion Activities in Alberta” available on www.screeningforlife.ca/healthpromotion. There are
six categories of strategic activities in the CSHP Model: Education Resources & Training, Social
Marketing, Communication, Community Action, and Knowledge Management.
Education resources and training includes two types of activities. The first type of activity is the
development and distribution of information resources on cancer screening. These resources
include, but are not limited to, brochures, information and fact sheets, posters, PowerPoint
presentations, and tabletop displays that provide information on breast, cervical, and colorectal
cancer screening. Separate educational resources are created for the public and for healthcare
providers (including physicians, nurses, lab technologists, and mammography technologists). The
second type of activity is training. Training includes sessions and workshops that provide
information on cancer screening to healthcare staff (e.g. nurses, health promoters and educators,
physician etc.), train staff to use the different cancer screening information resources, and/or train
staff on actual screening practices (e.g. Pap test training for registered nurses) so that staff are
able to deliver cancer screening education and services to their clients.
Social marketing activities aim to create an atmosphere that encourages cancer screening by
improving cancer screening knowledge, attitudes, values, and behaviours. Social marketing
integrates key behaviour change theories and concepts (see document titled “Health Promotion
and Behaviour Change Theory” on www.screeningforlife.ca/healthpromotion) with commercial
marketing strategies used in consumer and market research, and product advertising and
promotion.3 Social marketing projects require the use of rigorous research and planning, strategy
design, implementation and evaluation methods.4-8 Social marketing campaigns coordinated by
AHS SP-HPU focus on the specific target age groups for the different cancer screening programs,
health professionals, and known un- or under-screened populations. The AHS SP-HPU works with
professional social marketing and market research organizations to ensure that the consumer and
market research accurately characterizes the target populations and that the marketing methods
and deliverables appropriately reflect the target population’s needs and preferences.
Communication activities examine different modes of connecting with and providing information to
the public and healthcare providers. Examples of communication activities include print
communications (e.g. correspondence letters, articles, and advertisements), online communication
(e.g. websites, emails), and telephone communication (e.g. health information telephone lines).
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Cancer Screening Health Promotion Model
Community Action activities provide support to health units (e.g. Primary Care Networks, AHS
Zones, and health departments) and community groups interested in cancer screening promotion
who are working directly with un- or under-screened populations. These un- or under-screened
populations may not be screened routinely for a number of reasons that require intensive, multipronged, resource-heavy cancer screening promotion interventions to address. AHS SP-HPU aims
to engage these un- and under-screened populations in screening through collaborations with
community-based organizations that bring together the resources and expertise of the different
collaborators. The AHS SP-HPU’s Community Action process involves three phases. The first phase
is using our resources and expertise to assist organizations interested in cancer screening
promotion to meet their needs and objectives. This type of assistance is generally short-term and
conducted as consultations. The second phase is building relationships with community-based
organizations through these consultations in order to assist these groups with planning,
implementing, and evaluating their cancer screening promotion activities. The third phase is where
the community-based organizations collaborate with AHS SP-HPU to implement ongoing and
sustainable cancer screening promotion activities in their communities.
Knowledge management is defined by the World Health Organization (WHO) as “a set of
principles, tools, and practices that enable people to create knowledge, and to share, translate
and apply what they know to create value and improve effectiveness.”9 Knowledge
management activities aim to bridge the “know-do” gap: the gap that results between what is
known about resolving health problems and what is done to resolve health problems. In many
cases, solutions to health problems are known, but not applied. Knowledge management aims to
encourage creating, sharing, and applying knowledge to improve health.9 AHS SP-HPU uses
knowledge management to share what is learned about cancer screening promotion in Alberta
with others interested and involved in cancer screening promotion. These learnings also contribute
to the foundation of the CSHP model and increase knowledge and understanding of health
promotion and cancer screening values, assumptions, and evidence.
Connecting the “What” and the “How”
The factors described in the categories of Genetic & Non-modifiable characteristics, Behaviour,
Circumstance, & Personal History, and Socioeconomic & Environmental Conditions in the “What”
component of the CSHP model are used to ensure that all of the activities and deliverables are
relevant to and appropriate for the populations the activities are intended to reach. For
example, the following are three ways education resources are created to reflect factors
associated with cancer screening:
1) Education resources for certain genders, age groups, and/or ethnicities include pictures of
individuals of that gender from that age group or ethnicity. If education resources are
intended to reach both genders and different age groups and ethnicities, the resources
include pictures of males and females of different ages and ethnicities.
2) Language used in the education resources reflects factors related to education levels or
cultures/countries of origin. Simplified language is used for individuals with lower literacy
or English comprehension levels. Education resources are translated into multiple
languages to make the information available to those who do not read English.
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Cancer Screening Health Promotion Model
3) Language and formats of education resources and training reflect specific professions and
occupations using pictures, models, and language that is used frequently and accepted in
that profession.
The factors described in the categories of Predisposing factors, Enabling factors, and Reinforcing
factors in the “What” component of the CSHP model are used to determine the format and
content of the cancer screening promotion activities and deliverables. For example, activities that
aim to change predisposing factors will discuss information related to cancer screening
knowledge, attitudes, and beliefs, while activities that aim to change enabling factors will include
information to help individuals seek and access cancer screening services. Activities that aim to
encourage continued use of cancer screening services will address reinforcing factors such as
benefits of ongoing cancer screening.
The “Who” component of the Cancer Screening Health Promotion
Model
The “Who” component of the CSHP model defines who needs to be reached through cancer
screening promotion activities and who should be involved in delivering cancer screening
promotion activities. The levels of the population included in the “Who” component of the CSHP
Model are almost the same as the levels of the population included in the original PHP model.
These are Society, Health Sector/System, Community, Family, and Individual. The original PHP
model states Sector/System while the CSHP specifies Health Sector/System. Including the
different levels emphasizes the need to involve different levels in overall cancer screening
promotion, taking into account who the activities are targeting, what factors the activities are
focused on changing, and the types of activities necessary to change these strategies and the
resources and expertise of those involved in delivering the cancer screening promotion activities.
This can work the other way too, starting with who is involved in delivering the cancer screening
promotion activity and their resources and expertise, examining what activities they can
successfully deliver, what factors they can effectively change, and who they can successfully
reach.
AHS SP-HPU aims to influence cancer screening promotion at the Society, Health Sector/System,
and Community level. Through the Community Action activities, AHS SP-HPU aims to support and
collaborate with different community organizations working to promote cancer screening at the
family and individual-level.
The Cancer Screening Health Promotion Environmental Scan
The CSHP Environmental Scan shapes the foundation of the CSHP Model by 1) defining health
promotion & cancer screening values and assumptions, and 2) describing evidence from peerreviewed literature, surveillance data, and experiences related to cancer-screening promotion.
During the CSHP Environmental Scan, the CSHP Model was used to determine how determinants
of cancer screening and interventions that promote cancer screening could be organized. The
determinants of cancer screening were used to identify populations that were potentially un- or
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Cancer Screening Health Promotion Model
under-screened for breast, cervical, and/or colorectal cancer in Alberta. The interventions used
to promote cancer screening were used to understand what is being done and what can be done
to promote screening for breast, cervical, and/or colorectal cancer in Alberta. The study of
determinants of cancer screening and interventions that promote cancer screening is necessary to
acknowledge who is currently engaged and who needs to be further engaged in cancer screening
promotion in Alberta.
A description of the Framework for the Cancer Screening Health Promotion Environmental Scan is
available on www.screeningforlife.ca/healthpromotion.
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Cancer Screening Health Promotion Model
Appendix A: The Ottawa Charter for Health Promotion
The Ottawa Charter for Health Promotion was developed by the World Health Organization in
1986 during the First International Conference on Health Promotion, held in Ottawa, Ontario. The
following definition of health promotion provided in the Ottawa Charter is used throughout the
world to guide health promotion activities.
“Health promotion is the process of enabling people to increase control over,
and to improve, their health. To reach a state of complete physical, mental, and
social well-being, an individual or group must be able to identify and to realize
aspirations, to satisfy needs, and to change or cope with the environment. Health
is, therefore, seen as a resource for everyday life, not the objective of living.
Health is a positive concept emphasizing social and personal resources, as well as
physical capacities. Therefore, health promotion is not just the responsibility of the
health sector, but goes beyond healthy life-styles to well-being.”10
The Ottawa Charter describes five action areas and three strategies that form the foundation of health
promotion. The integration of these different areas and strategies is illustrated by the health promotion
emblem, which was introduced at the International Conference on Health Promotion in Ottawa in 1986
and is still in use today (Figure A.1).
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Cancer Screening Health Promotion Model
Figure A.1: World Health Organization Health Promotion Emblem
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Cancer Screening Health Promotion Model
The emblem includes five sections. The small circle includes three strategies for health
promotion. These strategies are to enable everyone to improve their health by ensuring equal
opportunities and resources, to mediate the different interests of all sectors to promote a
common goal of improving the health of individuals, families and communities, and to advocate
for political, economic, social, cultural, environmental, behavioural, and biological changes that
promote health. The three wings represent four of the five action areas: 1) “Reorient health
services” to focus on health promotion and disease prevention; 2) “Create supportive
environments” to ensure healthy living and working conditions; 3) “Develop personal skills” so
individuals can make healthy choices and control their own health and environment; 4)
“Strengthen community action” so communities can plan and implement health promoting
strategies of greatest importance to them. Developing personal skills is part of strengthening
community action, which is why they are part of the same wing. This wing breaks the large
circle, signifying the need for policy to respond to the changing needs of societies, communities,
and individuals.11 The large circle represents “Building healthy public policy”, which involves
pursuing the other four action areas and all three strategies.
The AHS SP-HPU uses multiple strategies and approaches to reach targeted
populations, healthcare providers (HCP) including AHS staff, community groups, and
the general public in order to influence positive attitudes, improve knowledge, and
increase cancer screening behaviours. The SP-HPU’s strategic activities fall within six
areas: Health Education, Continuing Education, Health Communication, Social
Marketing, Knowledge Management, and Community Action. These activities are
based on key health promotion principles as outlined in the Ottawa Charter. Table
A.1 shows how the SP-HPU’s strategic activities relate to the five action areas
described in the Ottawa Charter. Further information on the Ottawa Charter for
Health Promotion is available on
http://www.who.int/healthpromotion/conferences/previous/ottawa/en/.
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Cancer Screening Health Promotion Model
Table A.1: Relation of Alberta Health Services (AHS) Screening Programs Health Promotion
Unit (SP-HPU) Strategic Activities to Ottawa Charter Action Areas
Action Area
(Ottawa
Charter)
Building Public
Policy
Definition
(Ottawa Charter)
Ensure that policy
developed by all sectors
contributes to healthpromoting conditions.
Create systems that focus on
the needs of the whole
Reorient
person and invite a true
Health Services
partnership among the
providers and users of the
services.
Create
Supportive
Environments
Develop
Personal Skills
Strengthen
Community
Action
Create physical, social,
economic, cultural, spiritual
environments that recognize
the rapidly changing nature
of society, particularly in the
areas of technology and the
organization of work, and
that ensure positive impacts
on the health of the people
Enable people to have the
knowledge and skills to
meet life's challenges and to
contribute to society
Ensure communities have
the capacity to set
priorities and make
decisions on issues that
affect their health
Objectives
(AHS SP-HPU)
Increase policy makers’
awareness and efforts
toward
enhancing and integrating
cancer screening
promotion
Share cancer screening
promotion responsibility
among community groups,
healthcare providers, health
service institutions and
governments through
increasing collaboration
emphasizing importance
of evidence-based
practices
Link people and their
environment through
increasing options available
for people to control their
own health
making healthy choices
easier
Support lifelong personal
learning and development
through
providing information on
health services
offering health education
enhancing skills
Empower communities through
developing communities’
existing human and material
resources
enhancing self-help and
social support
increasing flexibility and
accessibility of information
and learning opportunities
Strategic
Activities
(AHS SP-HPU)
Community Action,
Knowledge
Management
Education
Resources &
Training,
Knowledge
Management
Community Action,
Communication,
Social Marketing
Education
Resources &
Training,
Communication,
Social Marketing
Community Action,
Education
Resources &
Training
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Cancer Screening Health Promotion Model
Appendix B: The Population Health Promotion Model
The Population Health Promotion Model, created by Hamilton and Bhatti in 1996 (Figure
B.1), addresses the intersection of health promotion and population health. The model
combines the action areas defined in the Ottawa Charter for Health Promotion with the
determinants of health presented in the 1994 Health Canada report “Strategies for
Population Health: Investing in the Health of Canadians” and different levels of action
within the population.
The Population Health Promotion Model can be used to create a comprehensive action
plan to address the health needs of a particular high-risk population or to address the
health needs of the entire population regarding a particular health issue. This model is
depicted in a 3-Dimensional cube, suggesting that health promotion is a multi-dimensional
process, involving and affecting the population at multiple levels (who), using multiple
health promotion strategies (how) and addressing various determinants of health within
and outside the health sector (what).
The levels of action include “the individual; family and friends; community (people linked
by a common interest or geographic setting such as a neighborhood, school or workplace);
sector/system (education, income support, housing, etc.); and society as a whole”.1. Table
B.1 includes the determinants of health as defined by Hamilton and Bhatti. The base of
the cube emphasizes the importance of evidence-based decision-making using research
studies, experiential knowledge, and evaluation studies as the key sources of evidence.
The values and assumptions of the model as described by Hamilton and Bhatti are
provided in Table B.2.
Further information on the Population Health Promotion Model is available at
http://www.phac-aspc.gc.ca/ph-sp/php-psp/index-eng.php.
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Cancer Screening Health Promotion Model
Figure B.1: The Population Health Promotion Model1
15
Cancer Screening Health Promotion Model
Table B.1: Determinants of Health 1
Determinant
Definition
Income & Social Status
The relative distribution of wealth and social status
affect health by determining the degree of control
people have over life circumstances and, hence, their
capacity to take action.
Social Support Networks
Support from families, friends, and communities help
people deal with difficult situations and maintain
control over life circumstances.
Education
Meaningful and relevant education equips people with
knowledge and skills for daily living, enables them to
participate in their community, and increases
opportunities for employment.
Working Conditions
Meaningful employment, economic stability, and a
healthy work environment are associated with good
health.
Biology & Genetic
Endowment
Research in the biological sciences suggests
"physiological make-up" as an important health
determinant.
Personal Health Practices
& Coping Skills
Personal health practices prevent disease and promote
self-care. Effective coping skills enable people to be
self-reliant, solve problems, and make choices that
enhance health.
Healthy Child
Development
Positive prenatal and early childhood experiences
have a significant effect on subsequent health.
Health Services
Availability of preventive and primary care services is
related to improved health.
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Cancer Screening Health Promotion Model
Table B.2: Values and Assumptions of the Population Health Promotion (PHP) Model1
PHP Model Values & Assumptions
1. Policy and program decision makers agree that comprehensive action needs to
be taken on all the determinants of health using the knowledge gained from
research and practice.
2. It is the role of health organizations to analyze the full range of possibilities for
action, to act on those determinants that are within their jurisdiction and to
influence other sectors to ensure their policies and programs have a positive
impact on health. This can best be achieved by facilitating collaboration among
stakeholders regarding the most appropriate activities to be undertaken by
each.
3. Multiple points of entry to planning and implementation are essential. However,
there is a need for overall coordination of activity.
4. Health problems may affect certain groups more than others. However, the
solution to these problems involves changing social values and structures. It is the
responsibility of the society as a whole to take care of all its members.
5. The health of individuals and groups is a combined result of their own health
practices and the impact of the physical and social environments in which they
live, work, pray, and play. There is an interaction among people and their
surroundings. Settings, consisting of places and things, have a physical and
psychological impact on people's health.
6. In order to enjoy optimal health, people need opportunities to meet their
physical, mental, social, and spiritual needs. This is possible in an environment
that is based on the principles of social justice and equity and where
relationships are built on mutual respect and caring, rather than power and
status.
7. Health care, health protection and disease prevention initiatives complement
health promotion. Comprehensive approaches will include a strategic mix of the
different possibilities for action. Meaningful participation of people in the
development and operationalization of policies and programs is essential for
them to influence the decisions that affect their health.
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Cancer Screening Health Promotion Model
Appendix C: PRECEDE-PROCEED Model
The CSHP Model includes predisposing, enabling, and reinforcing factors, which were
originally described in the PRECEDE-PROCEED Model. This model outlines the necessary
steps during the design, implementation and evaluation stages of a health promotion
intervention (Figure C.1). Like the Population Health Promotion Model, the PRECEDEPROCEED model emphasizes the multiple determinants of health and the need for multisectoral strategies to promote behavioral, social, and environmental change.2 The model
uses concepts from epidemiology, health care administration, and the social, behavioural,
and educational sciences. The model emphasizes a participatory approach involving the
target populations in identifying key health or quality-of-life issues and the factors that
influence these issues. The goal of the model is to have a clear understanding of the
problem based on evidence as opposed to speculation. This evidence-base is also
consistent with the Population Health Promotion Model.
The PRECEDE-PROCEED model includes two components and nine phases. The nine phases
are described in Table C.1. The first five phases are part of the PRECEDE component of
the model. These phases create a foundation for the PROCEED component. The PROCEED
component includes the actual design, implementation and evaluation of the intervention
using what was learned in the PRECEDE component.
Further information on the PRECEDE-PROCEED Model is available at
http://www.lgreen.net/precede.htm.
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Cancer Screening Health Promotion Model
Figure C.1: PRECEDE-PROCEED Model2
Predisposing Reinforcing Enabling Constructs in Educational Diagnosis and Evaluation
Policy Regulatory Organizational Constructs in Educational and Environmental Development
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Cancer Screening Health Promotion Model
Table C.1: Description of steps in the PRECEDE-PROCEED Model2, 12
Step
PROCEED
PRECEDE
Step 1: Social Diagnosis
Purpose
Understand community’s
perceived needs
Prioritize community’s
Step 2: Epidemiological
health needs; Establish
Diagnosis
program goals and
objectives
Identify factors internal
Step 3: Behavioural &
and external to the
Environmental Diagnosis
individual that affect the
health problem
Determine predisposing
(knowledge, attitudes,
beliefs), enabling (skills,
resources, access,
Step 4: Educational &
policies), and reinforcing
Organizational Diagnosis
(social influences,
incentives, positive
experiences) factors
necessary to initiate and
maintain change
Establish availability of
necessary resources and
Step 5: Administration &
organizational policies
Policy Diagnosis
and regulations that
could affect program
implementation
Step 6: Implementation of Intervention
Assess extent to which
Step 7: Process Evaluation intervention is carried out
as planned
Assess changes in
predisposing, enabling,
and reinforcing factors
Step 8: Impact Evaluation
that predict likelihood of
desired behavioural and
environmental changes
Assess desired changes to
Step 9: Outcome
health and quality-of-life
Evaluation
indicators.
Examples of Methods
Key informant interviews,
focus groups, participant
observations, surveys
Primary and secondary
data analysis
Review of literature and
theory
Use available evidence
and individual,
interpersonal, communitylevel change theories to
identify and classify factors
Data and evidence from
previous four steps and
knowledge of organization
policies and resources
Prior to implementation,
design evaluation
framework including
indicators and methods of
measuring indicators for
each step.
20
Cancer Screening Health Promotion Model
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Cancer Screening Health Promotion Model
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