Global Health Psychology

University of Padua

3.1 PLANNING HEALTH PROMOTION

PROGRAMS

Roberto De Vogli

Associate Professor, Department of Psychology,

University of Padua

Associate Professor, Public Health Department of Sciences,

University of California Davis
 Outline

•  Health Education and Health Promotion

•  Health Promotion Planning: the PRECEDE-

PROCEED model
What is Health Promotion?
What is Health Education?
 Health Education

“Any combination of learning experiences

designed
to facilitate voluntary actions
conducive to health”

Green & Kreuter, 1998

 Health Promotion

“Combination of educational and socio-environmental

support to actions and conditions leading to health”

»  Green & Kreuter, 1991

 Health Education vs. Health Promotion

Health Education Health Promotion

ä Behavior change ä Socio-environmental

ä Individual responsibility for change
health ä Societal responsibility for
ä  “Victim blaming” health
ä  “System blaming”
 WHO Definition of Health Promotion

“The process of enabling

people to increase control
over their health and its
determinants, and thereby
improve their health.”

Ottawa Charter 1986

 Disease Prevention

“Any intervention that help to prevent diseases”

•  It is defined more specifically according to the

following levels:
–  Primary prevention
–  Secondary prevention
–  Tertiary prevention
 Primary Prevention

•  Activities known to help prevent disease or illness

prior to its occurrence are classified as primary
prevention

•  Measures taken to prevent the disease from

occurring such as:
–  healthy lifestyle habits
–  Immunizations
 Secondary Prevention

•  Specific action taken to enable early detection of a

health problem and to stop or modify the severity
or extent of illness are considered secondary
preventive measures

•  Measures undertaken to facilitate early detection

–  Screenings
–  Diagnostic tests
 Tertiary Prevention

•  Measures to minimize complications or

exacerbation of injury or disease are considered
tertiary preventive measures

•  Rehabilitation, while a treatment modality, can

also be considered as tertiary prevention
–  Rehabilitation Therapy
–  Patient counseling
healthy onset of advanced disability
person symptoms symptoms death
(reversible) (not reversible )

Primary Secondary Tertiary

prevention prevention prevention
screening rehabilitation
case finding
 The Rainbow model

Independent Inquiry into Inequalities in Health report Chairman: Sir Donald Acheson 1998
Health Promotion Means Changing Behavior
at Multiple Levels
A Individual: knowledge, attitudes, beliefs,
personality
B Interpersonal: family, friends, peers
C Community: social networks, standards,
norms
D Institutional: rules, policies, informal
structures
E Public Policy: local policies related to
healthy practices

Source: Adapted from National Cancer Institute, Theory at a Glance: A Guide for Health Promotion (2003),
available online at http://cancer.gov.
 Outline

•  Health Education and Health Promotion

•  Health Promotion Planning: the PRECEDE-

PROCEED model
 What is PRECEDE/PROCEED?

PRECEDE/PROCEED is a community-oriented,
participatory model for creating successful community
health promotion interventions

PRECEDE = Predisposing, PROCEED = Policy,

Reinforcing, and Enabling Regulatory, and
Constructs in Educational/ Organizational Constructs
Environmental Diagnosis and in Education and
Evaluation Environmental
Development
Precede-Proceed Model (Green & Kreuter, 1991)
PRECEDE has 5 phases

Phase 1: Social diagnosis

Phase 2: Epidemiological diagnosis
Phase 3: Behavioral and environmental diagnosis
Phase 4: Educational and organizational
diagnosis
Phase 5: Administrative and policy diagnosis
PROCEED has 4 phases

Phase 6: Implementation
Phase 7: Process evaluation
Phase 8: Impact evaluation
Phase 9: Outcome evaluation
Phase 1: Social Diagnosis

•  Identify social problems (subjectively defined)

affecting quality of life of individuals and
communities
•  Identify priorities of the individuals and
communities
•  First step to promote community participation
Phase 1: Social Assessment

Health educators/promoters must determine the

population’s idea of quality of life through:

–  Needs assessment
–  Discussion groups
–  Focus groups
–  Participatory observation
Phase 2: Epidemiological Diagnosis

•  Identification of the specific health problems that

may contribute to the social problems in phase 1

•  Epidemiological analysis: morbidity, mortality,

disability, major causes of death in the community
(objectively defined)
Phase 2: Epidemiology Assessment

•  Secondary data analysis

•  Writing health objectives:

–  Who is the target of the program?
–  What is the health benefit that target population
will receive?
–  How much benefit should be achieved?
–  When should the benefit be achieved, or for
how long should the program run?
Defining your target population
Aims and objectives
•  Aims are the broad goals associated with improving health
in a particular area
–  reducing the amount of alcohol-related ill health.

•  Objectives are more specific, they identify the actual

changes that you wish to see by the end of your
intervention.

•  Objectives are SMART:

S - Specific
M - Measurable
A - Achievable
R - Realistic
T – Time bound
Writing health objectives

Examples:
–  Reduce all-cause mortality rate of homeless
people in California by 10 percent in 5 years
–  By the end of the intervention, maternal mortality
rate in Tegeta will decrease from 250 per 100,000
to 200 per 100,000
–  Prevalence of lung cancer in Ho Chi Minh City will
be reduced by 35 percent by the end of the next
year
Phase 3: Behavioral and Environmental
Diagnosis

•  This phase identifies the behavioral and

environmental risk factors for the health problems
that were identified in Phase 2.

- List of behavioral risk factors that influence health

- List of socio-environmental risk factors that
influence health
Phase 3: Behavioral Assessment

•  Writing behavioral objectives:

–  What behavior in the target population is expected to

change?
–  How much of the behavior is expected to change?
–  By when is the behavior expected to change?

E.g. By the end of the program (10 years), smoking

prevalence among teenagers living in Ho Chi Minh City
will be reduced by 35 percent
Phase 3: Environmental Assessment

•  Writing environmental objectives:

–  What environmental factor will change?

–  By how much should this factor change?
–  By when in the timeline of program should this change
occur?

E.g. By the end of the program (10 years), smoking will

be prohibited in all public spaces of Ho Chi Minh City
Phase 4: Educational Assessment

•  Identify three general areas of factors that influence

behavior:

•  Predisposing factors

•  Reinforcing factors

•  Enabling factors
Phase 4: Predisposing Factors

Exist within the individual

•  Demographic variables (age, gender, socio-economoc

status, marital status, ethnicity)

•  Knowledge (knowledge of the health consequences of

HIV/AIDS, means of transmission of HIV, role of
exercise in decreasing depression)

•  Attitudes and beliefs (perceived risk, stereotypes,

perceived severity, perceived barriers)
Phase 4: Reinforcing Factors

May provide reward or discourage behaviors

•  Peer pressure/influence

•  Social factors (stigma, social norms and cultural

values)

•  Significant others (e.g. parents)

Phase 4: Enabling Factors

May effect behavior through environmental factors (e.g.

barriers to behavior change)

•  Availability of resources (e.g. availability of mosquito nets,

green areas, fast food restaurants, condom distributors)

•  Accessibility of resources (e.g. access to healthcare

facilities, water and sanitation, transportation)

•  Cost (e.g. price of cigarettes, user fees for healthcare)

Phase 4: Educational Assessment

•  Selecting predisposing, enabling, and reinforcing

factors to focus on in your program:
–  Identify and sort factors into three categories
–  Set priorities in these categories
–  Establish priorities in these categories
Phase 4: Educational Assessment

•  Writing educational objectives:

–  Write for each predisposing, enabling, and
reinforcing factor.

E.g. By the end of the program (10 years), at least 80%

of teenagers in Ho Chi Minh City will be adequately
aware of the health consequences (tobacco knowledge
test, baseline 20%)
 Hierarchy of objectives
•  GOAL
–  To promote sexual health among adolescents living in the Veneto Region (Italy)

•  HEALTH OBJECTIVE
–  To reduce the prevalence of HIV among high school students living in Veneto by 5% in 5 years

•  BEHAVIORAL OBJECTIVE:
–  To increase the percentage of Veneto’s high school students who use condom up to 70% in a 3
years (baseline 40%)

•  SOCIO-ENVIRONMENTAL OBJECTIVE
–  To increase the number of condom distributors around high schools in Veneto by 30% in 3 years

•  EDUCATIONAL AND ECOLOGICAL/POLICY OBJECTIVES

–  PREDISPOSING FACTORS:
•  To increase the proportion of Veneto’s high school students who know how HIV is transmitted
from 20% (baseline) to 85% (HIV Knowledge Scale) in 2 year
•  To decrease the proportion of Veneto’s high school students who believe in stereotypes
related to HIV by 70% (HIV Student Attitude Scale) in 2 year
–  REINFORCING FACTOR:
•  To decrease the percentage of parents of Veneto’s high school students who believe in
stereotypes related to HIV by 70% (HIV Parents Attitude Scale) in 3 years
–  ENABLING FACTOR:
•  By the end of the third year, establish a regional policy for placing condom distributors around
high schools in Veneto
Phase 5: Administrative and
Policy Diagnosis

•  Identify the policies, resources, and circumstances in the

organization that could hinder or facilitate program
implementation.

•  Assessments of the availability of necessary time, staff,

and resources is conducted.

•  Barriers and opportunities (alliances) to implementation

are identified
Phase 5: Administrative and Policy
Assessment

•  Developing a budget and a time-table:

–  A budget should justify all personnel and all tasks to
be undertaken during program development and
delivery.
–  It must show all direct costs (salaries, fringe benefits
of staff)
–  Indirect costs (space, utilities, rent)
–  Evaluation materials, etc.
 GANTT DIAGRAM
TRIMESTRI

ATTIVITA’ 1 2 3 4 5 6 7 8

Programmazione

Costituzione gruppo lavoro

Analisi situazione attuale

Sviluppo manuale (pari)

Sviluppo manuale (insegn.)
Sviluppo strumenti valutaz.

Coinvolgimento scuole
Formazione insegnanti
Formazione leaders dei pari

Questionario pre-test
Intervento nelle classi
Questionario post-test

Analisi dei risultati

Phase 6: Implementation

•  Program is implemented according to the plans

in Phase 5.
Precede-Proceed Model (Green & Kreuter, 1991)
Phase 7-9: Evaluation

•  Phase 7: Process evaluation

•  Phase 8: Impact evaluation
•  Phase 9: Outcome evaluation
What is evaluation (in health promotion)?

Systematic application of research procedures to

assess the design, implementation and
effectiveness of health promotion interventions
Phase 7: Process Evaluation

•  Utilized to assess:
–  Coverage (did the program reach the target
population?)
–  Delivery of services (have program activities been
delivered as planned?)
–  Resources expended (what human and economic
resources have been used to carry out program
activities?)
–  Degree of satisfaction with program activities
 Fine-tuning evaluations

•  Reappraising objectives and outcomes (feasibility)

•  Program replanning & redesign

–  Identifying medium term problems and design
modifications of the program activities
Phase 8: Impact Evaluation

•  Immediately following the conclusion of the

program

•  Assesses:
–  Knowledge change
–  Attitudes change
–  Behavior change
–  Environmental change
Phase 9: Outcome Evaluation

•  Long Term

•  Assesses:
–  Health status
–  Quality of life
GROSS = NET + CONFOUNDING + DESIGN
OUTCOME EFFECT FACTORS EFFECT
EFFECT
EVALUATION DESIGNS

•  Experimental designs

•  Quasi-experimental designs

•  Full-coverage designs
Experimental designs

•  Randomization
–  Selection of subjects to be included in the experimental
or control group is unsystematic, unpredictable or
random in order or arrangement

x1--------- I ------------x2 (EXPERIMENTAL GROUP)

r
y1-----------------------y2 (CONTROL GROUP)
Quasi-experimental designs

•  No randomization

x1--------- I ------------x2 (EXPERIMENTAL GROUP)

y1-----------------------y2 (CONTROL GROUP)

Full-coverage designs

•  Cross-sectional design at the end of the

intervention
-------- I ----------x1

•  Before-and-after design
x1-------- I ----------x2

•  Time-series analysis
x1---x2---x3---x4--- I ---x8---x9---x10
Group Exercise on the PRECEDE-PROCEED Model

•  Groups of 4 or 5 people

•  Select a health problem

•  Develop an idea of health promotion program on

the basis of the PRECEDE-PROCEED model by
filling out the sequence of selected steps adapted
from the PRECEDE-PROCEED model

•  Group representatives report to the class