619645

research-article2015
HEJ0010.1177/0017896915619645Health Education JournalPorter

Article

Health Education Journal

Revisiting Precede–Proceed: A
1­–12
© The Author(s) 2015
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DOI: 10.1177/0017896915619645
ethical health promotion hej.sagepub.com

Christine M Porter
Division of Kinesiology and Health, College of Health Sciences, University of Wyoming, Laramie, WY, USA

Abstract
Background: The Precede–Proceed model has provided moral and practical guidance for the fields of
health education and health promotion since Lawrence Green first developed Precede in 1974 and Green
and Kreuter added Proceed in 1991. Precede–Proceed today remains the most comprehensive and one of
the most used approaches to promoting health.
Objective: A decade after the most recent edition of the model was published in 2005, this paper examines
the model’s theoretical underpinnings, history, and influence on the field of health promotion. Although the
limited evidence for effectiveness of this and other models is discussed briefly, this review focuses on the
socio-ecological and ethical implications of the model.
Approach: Theory and literature review.
Results: Precede–Proceed has promoted public health and health promotion practice in five ethically and
practically important ways: (1) by advancing the ecological perspective on health that, today, has come to
dominate public health practice; (2) by remaining population-centred, rather than focusing on individuals;
(3) by demanding democratic and participatory approaches to health promotion; (4) by setting quality of
life, rather than behaviour change or even health, as the goal for health promotion; and (5) by being deeply
grounded in practice.
Conclusion: Precede–Proceed guides practitioners in bridging health promotion goals of enabling people to
control and improve their own health with larger public health goals of creating the conditions where people
can be healthy. It also provides an ethical guide to promoting health in democratic and participatory ways.

Keywords
Health promotion ethics, health promotion models, health promotion theory, participatory, Precede–
Proceed, socio-ecological approach

Corresponding author:
Christine M Porter, Division of Kinesiology and Health, College of Health Sciences, University of Wyoming, 1000 E.
University Avenue, Dept 3196, Laramie, WY 82071, USA.
Email: christine.porter@uwyo.edu

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2 Health Education Journal 

The Precede–Proceed model for health programme planning and evaluation is widely taught and
used in Anglophone health promotion practice, with well over 1000 published applications
(Green and Kreuter, 2005; Jones and Donovan, 2004; Linnan et al., 2005; Nutbeam et al., 2010;
Trifiletti et al., 2005). Having been first developed in the 1970s, it is also one of the oldest. The
model’s authors, Green and Kreuter, have written extensively about Precede–Proceed, and a
chapter about the model in Glanz et al.’s comprehensive health behaviour and education text
discusses the history and theory of the model in detail (Gielen et al., 2008; Glanz et al., 2008a).
However, Precede–Proceed merits revisiting not only because of its widespread use, but because
it has been a leading force in operationalising both socio-ecological and participatory approaches
to health promotion.
This paper re-examines the model’s theoretical underpinnings and history with a deductive,
retrospective lens. This paper examines the influence of Precede–Proceed on the field, rather than
evaluating its contributions to developing effective health promotion interventions. While the
weak evidence base for this (and most other health promotion models) is briefly discussed, this
paper focuses on ways the authors of Precede–Proceed have provided practical and ethical leader-
ship in guiding health promotion and education practice to attend to social determinants of health
and respect community expertise and priorities. The approach adopted here is based on a deep
reading and review of the model’s development: from a 1974 paper that outlined the early version
of Precede to the four editions of a text that develops, explains and adapts the Precede–Proceed
approach between 1980 and 2005.

Five defining contributions to health promotion

Precede–Proceed provides an eight-phase framework for practitioners to determine, develop,
implement and evaluate health promotion programmes, including the application of health promo-
tion theories systematically within such programmes (see Figure 1) (Gielen et al., 2008; Green and
Kreuter, 2005). The model was first published as an evaluation framework (Green, 1974), then as
Precede (Green et al., 1980) and finally as the full framework in 1991 (Green and Kreuter, 1991).
The different Precede phases (for Predisposing, Reinforcing and Enabling Constructs in Educational
Diagnosis and Evaluation) aim to map educational ‘diagnosis’ and planning. Proceed (Policy,
Regulatory and Organisational Constructs in Educational and Environmental Development) on the
other hand guides socio-ecological assessment and planning.
The model’s authors define the model’s hallmark approaches as being ‘(1) flexibility and
scalability, (2) evidence-based process and evaluability, (3) its commitment to the principle of
participation, and (4) its provision of a process for appropriate adaptation of evidence-based “best-
practices”’ (Green and Kreuter, 2005: 18). In this section, I will expand on these hallmarks to
outline some of the defining theoretical, practical and ethical underpinnings of the Precede–Proceed
health promotion model that differentiate it from other models.
As its authors note, the Precede–Proceed model is a framework that invites and guides health
promoters to choose the theories they feel will best guide them in each phase of their work. A chap-
ter by Gielen et al. (2008) summarises the model this way:

Precede-Proceed can be thought of as a road map and behaviour change theories as the specific directions
to a destination. The road map presents all the possible avenues, whereas the theory suggests certain
avenues to follow. Unlike the theories described in previous chapters, the main purpose of the Precede-
Proceed Model is not to predict or explain the relationship among factors thought to be associated with an
outcome of interest. Rather, its main purpose is to provide a structure for applying theories and concepts
systematically for planning and evaluating health behaviour change programmes. (p. 408)

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Porter 3

Figure 1.  The Precede–Proceed Model for Health Programme Planning and Evaluation.
From Green and Kreuter (2005). Adapted and used with permission from Green and Kreuter (Green, 2015).

One early critique called the model ‘a-theoretical’ (McLeroy et al., 1993: 307). However, as the
model’s authors and others claim in a reply (Green et al., 1994), the model has robust theoretical
and practical underpinnings, though also is designed to help practitioners plan effective pro-
grammes using theory and not to predict or explain the relationships among factors.
Certainly, the model’s theoretical approach is highly eclectic, including explicitly inviting users
to apply individualistic behaviour change theories in Precede phases. Arguably, the framework
unites a collection of theories and, importantly and somewhat uniquely, ethical principles. The
model could be cast as a theoretical and ethical framework that guides practitioners through each
layer of a socio-ecological model of health, with the predictive value being that a more effective,
relevant, comprehensive and democratically determined outcome will result from its use.
Green and Kreuter (1999, 2005) have subtitled the last two editions of their Precede–Proceed
book, ‘an educational and ecological approach’. As this implies, the model draws on two radi-
cally different theoretical traditions – one cognitive and individual and the other structural and
communal – to support comprehensive health programme planning that accounts for multiple lay-
ers of determinants of health.
Five important and defining approaches of Precede–Proceed are that it is:

•• Socio-ecological with particular emphasis on the impact of physical, social and political
environments on population health.
•• Population-centred, rather than focused on individuals; as such it is arguably a public health
theoretical framework, with health behaviour change embedded within it.

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4 Health Education Journal 

•• Participatory, involving citizens in identifying, assessing and addressing their community’s

health and quality of life issues.
•• Quality-of-life focused, rather than behaviour change or even health oriented.
•• Grounded on experience from the field with ongoing revisions and refinements.

Precede–Proceed leads health promoters through the layers of a socio-ecological model, from
individual characteristics to broad socio-political conditions. The framework has been a leader in
encouraging practitioners to view health and individual health behaviours within the overall eco-
system of health determinants and to improve those conditions (Green and Kreuter, 1999; Green
et al., 1996; Kemm, 2015: 61; Richard et al., 2011).
The model’s population, rather than individual, lens on health also relates to its socio-ecological
approach. Green and Kreuter (2005) urge planners to go ‘beyond the clinical, one-on-one aspect
of acute health care’ to consider the relationship between groups of people and their environments
(p. 2). While parts of the model can be applied to individuals, this is not its intent, in contrast with
intrapersonal theories of health behaviour such as the Health Belief Model, the Transtheoretical
Model, and Theory of Planned Behaviour. Assessments in the Precede phases are designed to be
done at the population level. Yet, drawing on Bandura’s (1978) social cognitive theory, Green and
Kreuter (2005) do not subsume personal agency with their population-level perspective, noting
that ‘people learn continuously from their environmental and social surroundings and can develop,
individually or collectively, the knowledge and skills to modify them’ (p. 30). This emphasis
appears in several phases in the use of more agentic, individual theories such as cognitivism and
exchange theories. Green and Kreuter (2005) write,

Without education and a commitment to the open exchange of idea, biases, and assumptions, the process
of planning runs the risk of becoming a manipulative, social engineering enterprise. Without the policy
support for social change, on the other hand, education efforts, shown to be effective on an individual
basis, often prove to be too weak to yield a population-wide benefit. (p. 6)

This passage points to a third defining feature of the model: an emphasis on democracy and the
participation of the ‘target population’ in every phase of assessment, prioritisation, planning,
implementation and evaluation with emphasis on personal agency in ‘democratic social and behav-
ioural change’ (Green and Kreuter, 2005: 6). Here, the authors draw from participatory action
research methods and concepts from Paulo Freire’s (1970) transformation learning theory, includ-
ing conscientisation and cultural invasion versus synthesis.
A fourth feature is its focus on beginning at the end, with the end being a higher quality of life
rather than behaviour change or even health. Starting with the first edition of the Precede model,
the authors define health as an instrumental value; ‘people cherish health because it serves other
ends’ (Green et al., 1980: 18). This view, later enshrined in the Ottawa Charter for Health Promo-
tion (1986), which describes health as ‘resource for everyday life, not the objective of living’, is
widely expanded upon in later editions.
The model is also notable for being strongly grounded. In response to critiques and comments
from practitioners applying the model in the field, the authors have gradually but substantially
changed their model since Green’s inception 40 years ago of what became Precede (Green, 1974;
Green and Kreuter, 1999). Even the early version of the Precede model was ‘rigorously evaluated
[in] “real world” clinical trials’ (Green et al., 1980: 11). As the authors explain in a footnote,

the theoretical grounding and evolution of the model has been influenced as much from its various
applications and the theories brought to bear in those applications as in the original theories and research
that led to the formulation of the model. (Green and Kreuter, 2005: 180–181)

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Porter 5

Examining the Precede–Proceed phases

In the most recent edition of Health Programme Planning, the Precede–Proceed model is said to
have eight stages (see Figure 1) (Green and Kreuter, 2005). Precede has four assessment and plan-
ning stages to guide the health promotion partners in selecting what problem to address, examining
its underlying causes, and planning an intervention. Proceed on the other hand includes four imple-
mentation and evaluation phases.
Phase 1, the social assessment and situation analysis, identifies and assesses potential areas for
health action. By engaging the community in this diagnosis, using ‘both objective and subjective’
(Green and Kreuter, 2005: 31) information from multiple sources, the goal is to identify the popu-
lation’s priorities in improving their lives. The authors suggest that community member priorities
are as relevant as the ‘actual’ (quotes theirs) medical or health needs assessed in the next phase
(Green and Kreuter, 2005: 38, 40).
Phase 2, the epidemiological assessment, identifies and prioritises health issues and sets change
objectives. This phase draws heavily from the empirical traditions of the biomedical sciences, but
also mandates ecological approaches for identifying structural barriers to health by assessing the
physical, social, political and economic determinants of health.
Phase 3, the educational and ecological assessment, urges examination of the broader causal
factors behind the social and health issues prioritised in the earlier stages. The authors draw heavily
from several intrapersonal health promotion theories in how to assess these causal factors, particu-
larly the Health Belief Model, Social Cognitive Theory, Theory of Reasoned Action, and the initial
stages of the Transtheoretical Model. Practitioners have also successfully used motivational inter-
viewing (Monteiro et al., 2011; Riegel and Carlson, 2002; Taplin et al., 2000).
The authors group the Phase 3 causal factors into three categories: predisposing, reinforcing and
enabling. Predisposing factors, which include individual knowledge and attitudes, draw most
heavily from the intrapersonal health promotion theories above. Enabling factors are the resources
and skills required to make desired behavioural and environmental changes; for example, the avail-
ability, accessibility and affordability of fresh produce enables or inhibits eating a healthful diet.
Enabling factors often overlap environmental factors identified in the previous stage. The authors
draw on concepts such as social capital, community capacity and collective efficacy and they sug-
gest community organising and social action strategies to identify problems, set goals and effect
structural change. Reinforcing factors are those that follow a behaviour that ‘determine whether the
actor receives positive (or negative) feedback and is supported socially afterward’ (Green and
Kreuter, 2005: 167). They again draw from intrapersonal health promotion and other expectancy
value theories in this part of their model. All three categories of factors should be prioritised and
then addressed in the intervention, which is planned in the next stage.
In Phase 4, the health promotion coalition designs the action plan for meeting the objectives set
in the first three phases, selecting interventions that are most likely to be successful in achieving
each objective and that are within the capacity of the team. For making these choices the model’s
authors suggest some practical tools (e.g. making Gannt charts, using ‘MATCH – Multilevel
Approach to Community Health’ or ‘PATCH – Planned Approach to Community Health’ models).
The authors also recommend conducting an internal policy assessment within the planning organi-
sation to ensure policies align with the intended intervention plan and to gauge political forces
likely to impact implementation; as they put it, ‘some barriers will be essentially attitudinal or
political or reflect power relationships that you cannot politely make a matter of public record in
your formal plan, but you ignore them at the peril of your programme’ (Green and Kreuter, 2005:
225). To aid in assessing political forces, the authors briefly discuss a wide range of organisational
theories and approaches – including exchange, conflict, utilitarian and critical theories – that may
aid in assessing the power relationships at play.

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6 Health Education Journal 

Proceed includes phases 5–8, mainly providing a participatory health promotion spin on
standard project planning, management, implementation and evaluation frameworks. Proceed’s
goal is to make the programme ‘available, accessible, acceptable and accountable’ (Green and
Kreuter, 2005: 245), including being practically feasible for all partners and appropriate to the
population’s needs, aspirations and circumstances. Phase 5 is implementation. Here, the authors
provide guidance by example through three chapters of case studies. Phases 6–8 encompass the
process, impact and outcome evaluations. Although these three evaluation phases are presented
discretely as final phases, the model suggests conducting process evaluation activities in every
phase.

Brief history of the model in health promotion

As a field, public health examines the interaction of environment, agents and hosts. In this triad, a
focus on host ‘lifestyles’ was identified through chronic disease research in the 1960s, particularly
in the USA (e.g. Kannel et al., 1961; US Surgeon General’s Advisory Committee on Smoking and
Health, 1964). This focus on individual behaviour and its determinants drove the expansion of
health education into health promotion.
Health education traditionally involved informing individuals about how their behaviours influ-
ence health. Health promotion is marked by preventing disease through the study and change of
both behaviour and environmental influences on behaviour; its emergence as a part of public health
is often dated to the 1974 LaLonde Report (Bell, 2003; Buchanan, 2000). This Canadian policy
document announced that ‘the Government of Canada now intends to give to human biology, the
environment and lifestyle as much attention as it has to the financing of the health care organisa-
tion’ (LaLonde, 1974: 6). Explicitly building on this report (though omitting its emphasis on
equity), the office of the US Surgeon General officially marked a related shift with the first Healthy
People report (Department of Health and Human Services [DHHS], 1979). In parallel, the quest for
understanding the loci of responsibility for and solutions to health was aided by the adaptation of
social and human ecological theory (Bronfenbrenner, 1977) to a socio-ecological model of deter-
minants in health in the late 1980s (McLeroy et al., 1988).1
Health promotion officially came into its own in 1986 with the defining document of the field,
the Ottawa Charter for Health Promotion. This normative charter, which remains the touchstone
and cornerstone for the field, defines health promotion as ‘the process of enabling people to
increase control over, and to improve, their health’. Several papers trace shifts in dominant dis-
courses of the field as a whole from a focus on individual behaviour change to a socio-ecological
approach for empowerment and equity to, today, a population approach located within capitalist
economics (Porter, 2007; Robertson, 1998; Robertson and Minkler, 1994).2
The 40-year history of the Precede–Proceed model unfolded within this history of health pro-
motion. Green began brewing the Precede model in the late 1960s. He was influenced by the socio-
ecological approach of Rogers (1960), who wrote that

the most pressing human health problems and the most probable solutions for them are more and more
involved in the necessity of knowing more about the relationship between man [sic] and his total
environment. Given a basic, genetic start it appears that what happens to man is thenceforth largely
determined by these external forces. (p. vii)

Green later teamed with Kreuter and others to publish the book Health Education Planning: a
Diagnostic Approach (1980), in which the Precede term was coined. The model itself was nearly
identical to that in Green’s 1974 paper, except that it begins with the more positively oriented

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Porter 7

‘quality of life’ rather than a ‘social problem’ diagnosis. Both publications focused on cost-benefit
analysis, but it is the planning model that has since received the spotlight. This ‘pioneering’ (Rissel
and Bracht, 1999: 61) book helped define the scope of what health education means and how to
conduct it, in much of the USA at least.
The original Precede model focuses nearly exclusively on how to help people make voluntary
health behaviour changes through democratic educational methods. This educational piece remains
intact in later models, including participatory methods that the authors call ‘mutual planning and
diagnosis’ (Green et al., 1980: 5). This was progressive for health education at that time and pos-
sibly helped pave the way for the emergence of community-based participatory research in the late
1990s (Israel et al., 1998) as public health’s version of Freirian (1970) participatory action research.
The early Precede model is missing the environmental and socio-ecological analysis and action
developed in later versions. Although briefly referenced under enabling factors, these outer layers
of today’s socio-ecological health model are mainly lumped together as ‘economic, genetic and
environmental factors … acknowledged here because of the power they have, however indirect,
to influence health’ (Green et al., 1980: 13). This reflects and perpetuates the limited scope of the
health education field overall at that time. As the authors of the model note, ‘except on their own
time health professionals usually are not expected (and sometimes are not allowed) to intervene
in non-health matters’ (Green et al., 1980: 37). However, Green and Kreuter foreshadow the
model’s future expansion from health education to health promotion, and from the educational to
the socio-ecological:

… health education is sometimes accused of ‘blaming the victim’, because it appears to place all the
responsibility for protection of health on the individuals whose health is threatened. Recognising the non-
behavioural causes of health problems acknowledges that there are other threats to health beside the
behaviour of the victim. (Green et al., 1980: 54)

In a strategies chapter, they also address the organising and social action methods required to
impact these ‘non-behavioural causes’.
A major contribution of this original model was challenging the limitations of an exclusively
KAP/KAB approach (Knowledge, Attitudes and Practices/Behaviours) to health behaviour change
and KAB’s underlying premise that if only people had the right information they would change
their behaviour. The authors instead emphasise voluntary, democratic behaviour change and draw
on Freire to contest the ‘empty vessel’ approach, in which some ‘health educators behave as if all
they have to do to ensure the success of their programme is to pour health information into the
empty minds of an eagerly awaiting target population’ (Green et al., 1980: 6). They begin to chal-
lenge ‘victim blaming’ – noting that ‘the system may be at fault, rather than the patient’ (Green
et al., 1980: 77). The breadth, depth and force of these arguments grew in the book’s next edition
(Green and Kreuter, 1991).
Over a decade later, in keeping with and perhaps also partly leading broader developments in the
field, Green and Kreuter (1991) explicitly expanded the model’s scope from health education to
health promotion, titling the second edition of their book, Health Promotion Planning: an Educational
and Environmental Approach. This edition looks very similar to the current (fourth) one, adding
environmental assessments and a policy and power analysis. It also adds the Proceed portion of the
model to help users negotiate the more political terrain this expansion encompasses. Among health
promotion models and theories, Precede–Proceed led the way in socio-ecological health assessments
and planning; only relatively recently have socio-ecological models for health been adopted in public
health as a guiding frame for understanding and improving health (Lang and Rayner, 2012), includ-
ing becoming the anchoring concept for US public health goals (US DHHS, 2010).

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8 Health Education Journal 

The third edition (Green and Kreuter, 1999), titled Health Promotion Planning: an Educational
and Ecological Approach, expanded the environmental approach to an even broader ecological one
because, as the authors noted, health promotion with a population focus

… demanded more than merely taking forces outside the person into account in planning programmes. It
demanded an intersectoral, interdisciplinary, and interorganisational strategy for integrating the forces
operating at several levels and in various spheres to support people in their efforts to gain greater control
over the determinants of their health. (p. xxvi)

The revised model also gave increased emphasis to community participation, coalition forma-
tion, capacity building and sustainability, drawing on work published in the interim, such as asset
mapping (Kretzmann and McKnight, 1993). It shifted even further away from a biomedical
approach, marked by calling the Precede phases ‘assessments’ rather than ‘diagnoses’.
The most recent, fourth edition of the book is entitled Health Programme Planning: an Educational
and Ecological Approach (Green and Kreuter, 2005). Shifts include the addition of genetic factors,
suggestions for application shortcuts, and the folding of the assessment of health, behaviour, envi-
ronment and genetics into one phase, thus reducing the model from nine to eight phases. This last
consolidation emphasises viewing these factors as dialectic and reciprocally determined, rather
than dualistic and discrete. The authors also expand the intended application of the model. As the
title signals, they suggest its usefulness not just for health promotion but also for public and popu-
lation health planning. Finally, to make the model ever more grounded, every successive edition
has addressed feedback and critiques from users and has incorporated new best practices and pro-
cesses in its application.

Limitations of health promotion models

Health promotion models and theories generally, the Precede–Proceed model specifically, and this
paper about the model, all have their limitations. The influence of Precede–Proceed on the field is
examined in this paper, as opposed to focusing on evaluations of the predictive value of the model.
However, this section briefly examines the health promotion model evaluation literature.
In an introductory chapter to the Glanz et al. (2008b) health behaviour text mentioned above,
the editors note that ‘theories that gain recognition in a discipline shape the field, help define the
scope of practice, and influence the training and socialisation of its professionals’ (p. 31). In the
same passage, the editors observe that ‘today, no single theory or conceptual framework dominates
research or practice in health promotion and education. Instead, one can choose from a multitude
of theories’ (Glanz et al., 2008b). One possible reason that no single model or theory dominates
practice is that none have proven to be especially effective for promoting health. Some statistical
reviews suggest that the use of health promotion theories and models to plan programmes has little
or even no association with improved outcomes (e.g. Munro et al., 2007; Webb et al., 2010). Some
qualitative reviews suggest that using health promotion theory to plan programmes can lead to bet-
ter health outcomes (Glanz and Bishop, 2010), although cited examples (e.g. Ammerman et al.,
2002; Noar et al., 2007) tend to provide evidence for particular behaviour change techniques (e.g.
tailoring and goal-setting) rather than whole theories or models. For the Precede–Proceed model,
the strongest evidence for effectiveness concerns predisposing, enabling and reinforcing factors
being predictive of – or, at least, highly correlated with – health behaviours (e.g. Aboumatar et al.,
2012; Chang et al., 2005; Polcyn et al., 1991; Tejeda et al., 2009).
Commonly cited practical limitations of the Precede–Proceed approach include the fact that its
comprehensiveness and participation imperative make it time and cost prohibitive to apply in full

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Porter 9

in the real world, while also not providing detailed guidance for each step (Gielen et al., 2008: 417;
MacDonald and Mullett, 2009: 165; Sharma and Romas, 2012: 48). In response, the authors sug-
gest using the model in part, and in tandem with more specific theories.
For those who consider the ethical foundations of the model an asset, a critique could be made
that the authors sometimes use rather technical language to describe (or perhaps to disguise) con-
cepts that were ground-breaking for a model that became mainstream in health. They suggest pri-
oritising health equity using cloaked language about statistical indicators of health problems. They
also use terms standard in health promotion such as ‘target population’ and ‘patient’ that discur-
sively cast people, communities and citizens in passive roles. And they do so even when making
statements, cited above, that were radical in health fields for 1980 such as ‘the system may be at
fault, rather than the patient’, that ‘both objective and subjective’ information should count, and
that a programme being ‘available, accessible, acceptable and accountable’ is as important as it
being measurably effective.

Limitations of this paper

A main limitation of this review is that the links suggested between the ethical and practical impli-
cations of Green and Kreuter’s framework with trends in health promotion and public health are
associational, not necessarially causal. Evidence for causality is limited to, at best, temporal prec-
edence. Other weaknesses are in the limited scope of the paper, including only a truncated review
of histories of the field and, moreover, of the overall socio-political contexts of its development.
Also, the assessment of the very extensive literatures containing weak evidence for the effective-
ness of this (or any other) model in health promotion is partial. Finally, the lens employed to pro-
vide this overview of the model, its development, and its implications for the field is wide and, as
with all perspectives, situated. Others might note different features standing out as worthy of atten-
tion, even if they were to look through the same lens from the same location.

Why the Precede–Proceed model matters

Public health involves ‘ensuring the conditions for people to be healthy’ (Institute of Medicine,
1988) and, within this, health promotion is ‘the process of enabling people to increase control over,
and to improve, their health’ (Ottawa Charter, 1986). However, for a field and a discipline that
should be about enabling control and improving health conditions, health promotion strategies tend
towards highly individualistic behaviour change approaches.3
The Precede–Proceed model embodies public health and health promotion goals and guides
practitioners in reaching them. It allows health promoters to use popular individual health behav-
iour change theories as part of larger strategy for socio-ecological change that improve health
conditions and enables people to control their own health in ways most meaningful to them. The
framework provides a guide to improving health through change in multiple layers of an ecological
model.
The model’s authors have offered not only a practical framework for using multiple theories
in planning health programmes. They have been providing moral leadership in the health promo-
tion field in two ways. First, the authors reject the persistent behaviour change myths of health
promotion – that behaviour change is an end in itself; that information dissemination alone will
lead to behaviour change; and that behaviour change is mainly a function of rational, individual
decision making. Following this model, improved quality of life should be the goal of health work,
with behaviour change and enhanced health simply as means to that end. Effective interventions
should include action on structural factors that influence health. Second, long before the advent of

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10 Health Education Journal 

community-based participatory research in health, the model’s authors had been advocating since
1974 that ‘target populations’ must be intimately involved in identifying, assessing and resolving
their own community health issues. Couching their model in Cartesian, techno-rational terms may
have made this process seem less radical, but also more acceptable in mainstream health promotion
– serving as a Trojan horse, perhaps, for health promotion tackling social determinants of health
more than health behaviour, and for respecting the experience, expertise and priorities of commu-
nity members in determining their own health. If none of these tenets are news today, this may be
in some part due to the leadership offered by this approach. The fact that socio-ecological and
participatory approaches are hardly ubiquitously applied means that the Precede–Proceed model
still has much to offer in guiding health promotion planning and practice.

Funding
The author(s) received no financial support for the research, authorship and/or publication of this paper.

Notes
1. The ‘ecology’ in this ‘socio-ecological’ model implicitly addressed by Precede–Proceed is not ecological
in the natural, biological, ecosystem sense. For a truly ecological lens on public health, see US Surgeon
General John Hanlon’s (1969) work and, more recently, that of Rayner and Lang (2012).
2. Arguably, since this health promotion discourse work, advances in genetics and pharmaceuticals within
this capitalist frame have moved a biology-centred approach to health to the fore. See, for example,
a growing emphasis on ‘personalised medicine’, as in a joint commentary by the Food and Drug
Administration (FDA) and National Institutes of Health (NIH) chiefs in the USA (Hamburg and Collins,
2010).
3. For example, advertisements for the world’s most popular soft drink have aimed to ‘teach the world to
sing in perfect harmony’ since at least 1971 and more recently have emphasised sharing (e.g. ‘Share
happiness’, and ‘Spread happiness, share a Coke’, see http://www.shareacoke.com). Although hardly
health promoting, these messages stress community connections and quality of life, as health promotion
should do. However, health promotion messages about avoiding such beverages simply urge individual
behaviour change (e.g. the humorously disgusting ‘Don’t Drink Yourself Fat’ campaign by the New York
City Department of Health; ‘Rethink Your Drink’ slogans and, more positively but still individualisti-
cally, the Change4Life ‘Smart Swaps’ campaign in the UK [see www.nhs.uk/change4life]). Similarly,
the names of community obesity prevention initiatives in the USA are often behaviour change com-
mands – for example, Shape Up Somerville; Eat Well Play Hard; Get Up Montgomery County and in the
United Kingdom, the Change4Life slogan (‘Eat Well, Move More, Live Longer’) is simply individually
informative.

References
Aboumatar H, Ristaino P, Davis RO, et al. (2012) Infection prevention promotion program based on the
Precede model: Improving hand hygiene behaviors among healthcare personnel. Infection Control and
Hospital Epidemiology 33: 144–151.
Ammerman AS, Lindquist CH, Lohr KN, et al. (2002) The efficacy of behavioral interventions to modify
dietary fat and fruit and vegetable intake: A review of the evidence. Preventive Medicine 35: 25–41.
Bandura A (1978) The self system in reciprocal determinism. American Psychologist 33: 344–358.
Bell S (2003) The development of modern health promotion. In: MacDonald TH (ed.) The Social Significance
of Health Promotion. New York: Routledge, pp. 18–28.
Bronfenbrenner U (1977) Toward an experimental ecology of human development. American Psychologist
32: 513–531.
Buchanan DR (2000) An Ethic for Health Promotion. New York: Oxford University Press.
Chang M, Baumann L, Nitzke S, et al. (2005) Predictors of fat intake behavior differ between normal-weight
and obese WIC mothers. American Journal of Health Promotion 19: 269–277.

Downloaded from hej.sagepub.com at UNIV CALIFORNIA SAN DIEGO on January 11, 2016
Porter 11

Department of Health and Human Services (DHHS) (1979) Healthy People: The Surgeon General’s Report
on Health Promotion and Disease Prevention. Washington, DC: DHHS.
Freire P (1970) Pedagogy of the Oppressed. New York: Continuum.
Gielen AC, McDonald EM, Gary T, et al. (2008) Using the Precede-Proceed planning model to apply health
behavior theories. In: Glanz K, Rimer BK and Lewis FM (eds) Health Behavior and Health Education:
Theory, Research, and Practice. 4th ed. San Francisco, CA: Jossey-Bass, pp. 407–433.
Glanz K and Bishop DB (2010) The role of behavioral science theory in development and implementation of
public health interventions. Annual Review of Public Health 31: 399–418.
Glanz K, Rimer BK and Viswantah K (2008a) Health Behavior and Health Education: Theory, Research, and
Practice. 4th ed. San Francisco, CA: Jossey-Bass.
Glanz K, Rimer BK and Viswantah K (2008b) Theory, research and practice in health behavior and health
education. In: Glanz K, Rimer BK and Lewis FM (eds) Health Behavior and Health Education: Theory,
Research, and Practice. 4th ed. San Francisco, CA: Jossey-Bass, pp. 23–40.
Green LW (1974) Toward cost-benefit evaluations of health education: Some concepts, methods, and exam-
ples. Health Education Monographs 2(Suppl. 1): 34–64.
Green LW and Kreuter MW (1991) Health Promotion Planning: An Educational and Environmental
Approach. Mountain View, CA: Mayfield Publishing.
Green LW and Kreuter MW (1999) Health Promotion Planning: An Educational and Ecological Approach.
Mountain View, CA: Mayfield Publishing.
Green LW and Kreuter MW (2005) Health Program Planning: An Educational and Ecological Approach.
New York: McGraw-Hill.
Green LW and Kreuter MW (2015) Precede-Proceed. Available at: www.lgreen.net/precede.htm (accessed
13 December 2015).
Green LW, Kreuter MW, Deeds S and Partridge K (1980) Health Education Planning: A Diagnostic Approach.
Palo Alto, CA: Mayfield.
Green LW, Glanz K, Hochbaum G, et al. (1994) Can we build on, or must we replace, the theories and models
in health education? Health Education Research 9: 397–404.
Green LW, Richard L and Potvin L (1996) Ecological foundations of health promotion. American Journal of
Health Promotion 10: 270–281.
Hamburg MA and Collins FS (2010) The path to personalized medicine. New England Journal of Medicine
363: 301–304.
Hanlon J (1969) An ecologic view of public health. American Journal of Public Health 59: 4–11.
Institute of Medicine (1988) The Future of Public Health. Washington, DC: National Academies Press.
Israel BA, Schulz AJ, Parker EA, et al. (1998) Review of community-based research: Assessing partnership
approaches to improve public health. Annual Review of Public Health 19: 173–202.
Jones SC and Donovan RJ (2004) Does theory inform practice in health promotion in Australia? Health
Education Research 19: 1–14.
Kannel W, Dawber T, Kagan A, et al. (1961) Factors of risk in the development of coronary heart disease–six
year follow-up experience. The Framingham Study. Annals of Internal Medicine 55: 33–50.
Kemm J (2015) Health Promotion: Ideology, Discipline, and Specialism. Oxford: Oxford University Press.
Kretzmann J and McKnight J (1993) Building Communities From the Inside Out: A Path Toward Finding and
Mobilizing a Community’s Assets. Evanston, IL: The Asset-Based Community Development Institute,
Institute for Policy Research, Northwestern University.
LaLonde M (1974) A New Perspective on the Health of Canadians: A Working Document. Ottawa, ON,
Canada: Minister of Supply and Services.
Lang T and Rayner G (2012) Ecological public health: The 21st century’s big idea? British Medical Journal
345: E5466.
Linnan LA, Sterba KR, Lee AM, et al. (2005) Planning and the professional preparation of health educators:
Implications for teaching, research, and practice. Health Promotion Practice 6: 308–319.
MacDonald M and Mullett J (2009) Dilemmas in health promotion evaluation: Participation and empower-
ment. In: Potvin L, Anderson LM, Hall M, et al. (eds) Health Promotion Evaluation Practices in the
Americas. New York: Springer, pp. 149–178.

Downloaded from hej.sagepub.com at UNIV CALIFORNIA SAN DIEGO on January 11, 2016
12 Health Education Journal 

McLeroy KR, Bibeau D, Steckler A, et al. (1988) An ecological perspective on health promotion programs.
Health Education and Behavior 15: 351–377.
McLeroy KR, Steckler A, Simons-Morton B, et al. (1993) Social science theory in health education: Time for
a new model? Health Education Research 8: 305–312.
Monteiro S, Jancey J, Howat P, et al. (2011) The protocol of a randomized controlled trial for playgroup
mothers: Reminder on Food, Relaxation, Exercise, and Support for Health (REFRESH) program. BMC
Public Health 11: 648.
Munro S, Lewin S, Swart T, et al. (2007) A review of health behaviour theories: How useful are these
for developing interventions to promote long-term medication adherence for TB and HIV/AIDS? BMC
Public Health 7: 104.
Noar SM, Benac CN and Harris MS (2007) Does tailoring matter? Meta-analytic review of tailored print
health behavior change interventions. Psychological Bulletin 133: 673–693.
Nutbeam D, Harris E and Wise W (2010) Theory in a Nutshell: A Practical Guide to Health Promotion
Theories. North Ryde, NSW, Australia: McGraw-Hill.
Ottawa Charter (1986) Ottawa charter for health promotion. Health Promotion International 1: iii–iiv.
Polcyn MM, Price JH, Jurs SG, et al. (1991) Utility of the Precede Model in differentiating users and nonusers
of smokeless tobacco. Journal of School Health 61: 166–171.
Porter C (2007) Ottawa to Bangkok: Changing health promotion discourse. Health Promotion International
22: 72–79.
Rayner G and Lang T (2012) Ecological Public Health: Reshaping the Conditions for Good Health. Oxon:
Routledge.
Richard L, Gauvin L and Raine K (2011) Ecological models revisited: Their uses and evolution in health
promotion over two decades. Annual Review of Public Health 32: 307–326.
Riegel B and Carlson B (2002) Facilitators and barriers to heart failure self-care. Patient Education and
Counseling 46: 287–295.
Rissel C and Bracht NF (1999) Community needs, resources and readiness: Building on strengths. In: Bracht
NF (ed.) Health Promotion at the Community Level: New Advances. Thousand Oaks, CA: SAGE,
pp. 59–82.
Robertson A (1998) Shifting discourse on health in Canada: From health promotion to population health.
Health Promotion International 13: 155–166.
Robertson A and Minkler M (1994) New health promotion movement: A critical examination. Health
Education Quarterly 21: 295–312.
Rogers ES (1960) Human Ecology and Health: An Introduction for Administrators. New York: Macmillan.
Sharma M and Romas JA (2012) Theoretical Foundations of Health Education and Health Promotion.
Sudbury, MA: Jones & Bartlett Learning.
Taplin SH, Barlow WE, Ludman E, et al. (2000) Testing reminder and motivational telephone calls to increase
screening mammography: A randomized study. Journal of the National Cancer Institute 92: 233–242.
Tejeda S, Thompson B, Coronado GD, et al. (2009) Predisposing and enabling factors associated with mam-
mography use among hispanic and non-hispanic white women living in a rural area. Journal of Rural
Health 25: 85–92.
Trifiletti LB, Gielen AC, Sleet DA, et al. (2005) Behavioral and social sciences theories and models: Are they
used in unintentional injury prevention research? Health Education Research 20: 298–307.
US Department of Health and Human Services (2010) Healthy People 2020: Framework. Washington, DC:
Office of Disease Prevention and Health Promotion.
US Surgeon General’s Advisory Committee on Smoking and Health (1964) Smoking and Health: Report of
the Advisory Committee to the Surgeon General of the Public Health Services. Washington, DC: US
Department of Health, Education and Welfare.
Webb TL, Joseph J, Yardley L, et al. (2010) Using the internet to promote health behavior change: A system-
atic review and meta-analysis of the impact of theoretical basis, use of behavior change techniques, and
mode of delivery on efficacy. Journal of Medical Internet Research 12: e4.

Downloaded from hej.sagepub.com at UNIV CALIFORNIA SAN DIEGO on January 11, 2016