PRECEDE-PROCEED:
Down the Yellow-Brick Road to
Optimal Planning,
Implementation and Evaluation
Lawrence W. Green
University of California at San Francisco
and
Judith M. Ottoson
San Francisco State University
NW Chapter of Society for Public Health Education
Seattle, May 30, 2013
Some Challenges of Planning
Programs in Public Health
• Health behavior & environmental change are
driven by more than knowledge, beliefs, and
attitudes (“motivation”)
• Health behavior & environmental changes
usually must be sustained over long periods to
achieve health benefits
• Communications must be supported by policies
and programs, regulations and organization
• Must adapt programs to different populations
and settings, with sensitivity to their differences
• In summary: the challenges require more than
merely importing and imparting information,
knowledge, or even wisdom…
PRECEDE-PROCEED Model
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Predisposing,
Reinforcing, &
Enabling
Constructs in
Educational/Ecological
Diagnosis &
Evaluation
•
•
•
•
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•
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Policy,
Regulatory &
Organizational
Constructs in
Educational &
Environmental
Development
Green & Kreuter, Health Program Planning, 4th ed., NY, London: McGraw-Hill, 2005.
For bibliography of >1000 published applications, go to www.lgreen.net
Prototype of Causal Models
and Intervention Models
Problem Theory:
Causes (X)>->->->->->Effects
Action Theory Causal Theory:
Intervention
Models:
INPUTS
(educational,
organizational
economic, etc.)
X?
OUTPUTS
(behavioral
change, health,
quality of life,
development)
Different models interpret the content of “X?”
according to different theories (or assumptions)
about causation and control (mediating variables).
Green & Kreuter, Health Program Planning, 4th ed., NY, London: McGraw-Hill, 2005.
Examples of Causal Theories on
Which PRECEDE-PROCEED is Based
• Psychological theories: X includes a behavior, and
its antecedents such as attitudes, beliefs, values,
perceptions, and other cognitive variables
• Socio-cultural theories: X includes social norms,
networks, diffusion, organizational functioning, and
inter-organizational exchange & coalitions.
• Economic theories: X includes consumer behavior
and organizational response to consumer demand;
governmental subsidies or incentives, taxes.
• Pathophysiological theories: X includes organisms
or environmental exposure processes.
Planning & Evaluation Phases
Phase 4a
Intervention
Alignment
Phase 3
Educational &
Ecological
assessment
Phase 2
Epidemiological,
Behavioral and
Environmental Assessment
Phase 1
Social and
Quality of Life
Assessment
Precede Evaluation tasks: Specifying
Health
Program
Phase 4b
Administrative Educational
strategies
& Policy
Assessment
Policy
regulation
organization
Predisposing
measurable objectives and baselines.
Genetics
Reinforcing
Behavior
Health
Quality of
life
Environment
Enabling
Proceed Evaluation Tasks: Monitoring & Continuous Quality Improvement
Input
Process
Phase 5
Implementation
Output
Short-term
impact
Phase 6
Process evaluation
Longer-term
health outcome
Short-term
social impact
Phases 7-8
Impact and outcome evaluation
Long-term
social impact
Phases 2-4 of PRECEDE.
Phase 4: Intervention
Alignment, Administrative
And Policy Assessment
Matching and Mapping
Communications with
Evidence, Theory &
Policy
Direct
Phase 3: Educational
Phase 2: Epidemioand Ecological Assessment logical & Behavioral
Assessment
Predisposing
Knowledge, Attitudes
Beliefs
Cultural Values
Perceptions
Genetics and
Human Biology
Communications
Communications:
Health education,
Training, Political,
Media advocacy
Reinforcing
Influence from parents,
Indirect
Communi- teachers, employers,
peers, etc.
cations
Enabling
Policy, Regulation,
Organization
Availability of
resources
Accessibility
Skills, Restrictions
Behavior
and
Lifestyle
Ecosystem
Environment
Phases 3-4. Intervention Planning
2c. Select Intervention
Approaches
Policy
Advocacy
Phases 4-5:.
Community
Dissemination Development
2b. Select Channels
and Mediators
Community
Leaders
2a. Select Intervention
Objectives
Healthful
policies
Community
Norm Shapers
Healthful
Communities
Community
Organization
Organization
Decision-Makers
Healthful
Organizations
To Influence
Individuals
Individuals at
Risk
Healthful
behavior
Phases 1-2.
Select Health,
Environmental
& Behavioral
Goals
& Implementation
6. Conduct Process
Evaluation
7. Conduct Impact
Evaluation
8. Conduct Outcome
Evaluation
Phases 6-8. Evaluation
*Adapted from Simons-Morton B, Greene W, & Gottlieb N. Introduction to Health
Education & Health Promotion, 2nd ed. Waveland Press, 1995, p.154.
Health Status
From Planning to Implementation & Evaluation
Chapter 5
Phase 3
Planning
PRECEDE
Phases 4+
Intervention Alignment
Administrative
& Policy Diagnosis
Communications:
Health Education
Training
Media Advocacy
Predisposing
Reinforcing
Policy
Regulation
Organization
Enabling
:
PROCEED
Behavior &
Lifestyle
Environment
Evaluation: Process………...Impact……Outcome-->
ALIGNING INTERVENTIONS WITH
EVIDENCE, THEORY, EXPERIENCE,
POLICY, IMPLEMENTATION AND
FORMATIVE EVALUATION
Chapter 5: TURNING THE CORNER FROM
PRECEDE to PROCEED
Green & Kreuter, Health Program Planning: An Educational
and Ecological Approach. 4th ed. NY: McGraw-Hill, 2005; and
building on Green & Lewis, Measurement & Evaluation in
Health Education and Health Promotion. Palo Alto: Mayfield
Publishing Co., 1984.
Best Practices vs. Best
Processes
• Best practices are interventions recommended
on the basis of systematic reviews of evidence
from controlled studies that substantiate their
efficacy in the situations in which they were
tested, but not necessarily their effectiveness in
other populations and circumstances.
• Best processes are methods such as those of
PRECEDE and the matching of evidence-based
interventions to align and adapt them to the
needs of a particular population and setting.
Green & Kreuter, Health Program Planning: An Educational and Ecological Approach. 4th ed.
NY: McGraw-Hill, 2005.
Emergence of a Sedentary Society
2.3
1.8
Millions of
Person-Miles in
Automobiles,
1970-1990
800 k-calories/day
decrease in 20 years
1.4
60% of kids walked to school in 1970. 13% do now
5:06
6:07
7:04
3000
2200
Hours of TV
Viewed Daily
1960-1992
58%
Percent of
Workforce in
Sedentary
Occupations,
1950-1996
45%
36%
1970
Source: Schroeder, 2003
1990
Change in Per Capita Cigarette Consumption
California & Massachusetts vs Other 48 States, 1984-1996
Percent Reduction
5
0
-5
-10
-15
-20
-25
Other 48 States
California
1984-1988
1990-1992
Massachusetts
1992-1996
http://www.cdc.gov/tobacco
The Adaptation Process
The Adaptation Guide, CDC, Div of HIV/AIDS Prevention., 2010.
www.cdc.gov/hiv/topics/evaluation/health_depts/guidance/strathandbook/chapter4.htm
Sources & Uses of Evidence & Theory in
Population-Based Planning & Evaluation
Models*
Evidence
from community
or population
4. Evaluate
Program
Program Evidence
& Effectiveness Studies,
and use of Theory
1. Assess Needs & Capacities
of Population
Evidence from
Etiologic Research
Reconsider X
3. Design &
Implement
Program
2. Assess Causes (X)
& Resources
Evidence from
Efficacy Studies,
and Use of
Theory to Fill
Gaps
*Green & Kreuter, Health Program Planning. 4th ed. NY: McGraw-Hill, 2005, Fig. 5-1.
PROGRAM
EVALUATION
STANDARDS
Yarbrough, D.B., Shulha, L.J., Hopson, R.K., and Caruthers, F.W.
(2011). The program evaluation standards: A guide for evaluators
and evaluation users (3rd ed.). Thousand Oaks, CA: Sage.
http://www.jcsee.org
http://www.jcsee.org/program-evaluation-standards/program-evaluation-standards-stateme
Public Health Core
Functions and Essential Services
Community Tool Box
http://ctb.ku.edu
Evaluation is…...
… the systematic assessment of the operation and/or
outcomes
of a program or policy, compared to a set of explicit or
implicit
standards as a means of contributing to the improvement
of the program or policy
Weiss, p4
The Program Evaluation
Standards
• Key features
– Standards identify and define evaluation quality
– Guide evaluators and evaluation users in pursuit
of evaluation quality
– “laws” vs voluntary, consensus
• Revised 2011
– Clarifications
– Now fifth standard of evaluation accountability
• Trade-offs among standards
The Program Evaluation
Standards
• Utility -- The utility standards support high quality evaluation use
through attention to all aspects of an evaluation
• Feasibility -- The feasibility standards encourage evaluation to be
effective and efficient.
• Propriety -- The propriety standards are intended to ensure that an
evaluation will be proper, fair, legal, right, acceptable, and just.
• Accuracy -- Accuracy is the truthfulness of evaluation
representations, propositions, and findings, which is achieved through
sound theory, methods, designs, and reasoning.
• Evaluation Accountability -- Documenting and improving
evaluation accountability requires similar efforts to those required for
program accountability, i.e., an evaluation of the evaluation
(metaevaluation)
Utility Standards
The utility standards support high quality
evaluation use through attention to all
aspects of an evaluation
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U1: Evaluator credibility
U2: Attention to stakeholders
U3: Negotiated purposes
U4: Explicit values
U5: Relevant information
U6: Meaningful processes & products
U7: Timely & appropriate communicating &
reporting
U8: Concern for consequences and influence
Feasibility Standards
The feasibility standards are intended to ensures that
an evaluation will be realistic, prudent, diplomatic,
and frugal
• F1: Project
management
• F2: Practical
procedures
• F3: Contextual viability
• F4: Resource use
Propriety Standards
The propriety standards are intended to ensure that an evaluation
will be conducted legally, ethically, and with due regard for the
welfare of those involved in the evaluation, as well as those
affected by its results
• P1: Responsive & inclusive
orientation
• P2: Formal agreements
• P3: Human rights & respect
• P4: Clarity and fairness
• P5: Transparency & disclosure
• P6: Conflicts of interest
• P7: Fiscal responsibility
Accuracy Standards
…intended to ensure that an evaluation will reveal and convey
technically adequate information about the features that
determine worth or merit of the program being evaluated.
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A1: Justified conclusions and decisions
A2: Valid information
A3: Reliable information
A4: Explicit program & context descriptions
A5: Information management
A6: Sound design & analysis
A7: Explicit evaluation reasoning
A8: Communication & reporting
Evaluation Accountability
Standards
Accountability refers to the responsible use of resources to
produce value. In program evaluation, this requires an evaluation
of the evaluation.
• E1: Evaluation
documentation
• E2: Internal metaevaluation
• E3: External metaevaluation
Trade offs Among Standards
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Utility vs accuracy
Accuracy vs Feasibility
Feasibility vs utility
Propriety vs nothing
Evaluation Standards:
So What?
• Power of knowing what counts as “good”
evaluation
• Know where to find standards:
ww.jcsee.org
• Rationale for explaining evaluation tradeoffs
• Accountability