Green’s Precede-Proceed Model

The Man Behind the Precede-Proceed Model: A Short Background of the Theorist

Lawrence W. Green

A. Early Life

Lawrence W. Green is an American specialist in public health education who received

his B.S. in 1962 from the University of California-Berkeley. He then became a Ford
Foundation project associate and a commissioned officer of the US Public Health Service
with the University of California Family Planning Research and Development Project in
Bangladesh, serving from 1963 through 1965. He returned to Berkeley, where he earned his
M.P.H. in 1966 and Dr.P.H. in 1968, both in public health education. From 1968 to 1970, he
was a lecturer and doctoral program coordinator at Berkeley’s School of Public Health.

B. Honors and Awards

He is a past president and distinguished fellow of the Society for Public Health
Education and honorary fellow of the American School Health Association. He is also a
fellow of the American Academy of Behavioral Medicine Research, the Society of
Behavioral Medicine, and the American Academy of Health Behavior and was the first
recipient of the American Academy of Health Behavior Research Laureate Medal.

C. Contribution

Lawrence W. Green is an American specialist in public health education. He is best

known by health education researchers as the originator of the PRECEDE model and the co-
developer of the PRECEDE-PROCEED model, which has been used throughout the world to
guide health program intervention design, implementation, and evaluation. This model has led to
more than 100 published studies, applications, and commentaries on the model in the
professional and scientific literature.

GREEN’S PRECEDE-PROCEED MODEL

 Precede-Proceed Model is a comprehensive structure for assessing health needs for
designing, implementing, and evaluating health promotion and other public health
programs to meet those needs. It is a cost-benefit evaluation framework proposed in 1974 by
Lawrence W. Green that can help health program planners, policy makers and other evaluators,
analyze situations and design health programs efficiently. One purpose and guiding principle of
the PRECEDE–PROCEED model is to direct initial attention to outcomes, rather than inputs. It
guides planners through a process that starts with desired outcomes and then works backwards in
the causal chain to identify a mix of strategies for achieving those objectives.

KEY ASSUMPTIONS

1. Health promotion is more likely effective if it’s participatory.

Since the health-promoting behaviors and activities that individuals engage in are almost
always voluntary, carrying out health promotion has to involve those whose behavior or actions
you want to change. Hence, PRECEDE-PROCEED should be a participatory process, involving
all stakeholders – those affected by the issue or condition in question – from the beginning.

2. Health is, by its very nature, a community issue.

Health and other issues must be looked at in the context of the community. It is
influenced by community attitudes, shaped by the community environment (physical, social,
political, and economic), and colored by community history.

3. Health is essentially quality-of-life issues.

Health is an integral part of a larger context, probably most clearly defined as quality of
life, and it’s within that context that it must be considered. It is only one of many factors that
make life better or worse for individuals and the community as a whole. It therefore influences,
and is influenced by, much more than seems directly connected to it.

4. Health is more than physical well-being , or than the absence of disease, illness, or
injury.

Health itself is a constellation of factors - economic, social, political, ecological, and

physical - that add up to a healthy, high-quality lives for individuals and communities.

CONCEPTS
PRECEDE

Precede stands for Predisposing, Reinforcing, and Enabling Constructs in

Educational Diagnosis and Evaluation. It includes four (4) phases namely: Social Diagnosis,
Epidemiological, Behavioral & Environmental Diagnosis, Educational & Ecological
Diagnosis, and Administrative & Policy Diagnosis

PHASE 1 - SOCIAL DIAGNOSIS

This phase deals with identifying and evaluating the social problems that affect the
quality of life of a population of interest. Social assessment is the "application, through broad
participation, of multiple sources of information, both objective and subjective, designed to
expand the mutual understanding of people regarding their aspirations for the common good".

During this stage, the program planners try to gain an understanding of the social
problems that affect the quality of life of the community and its members, their strengths,
weaknesses, and resources; and their readiness to change. This is done through various activities
such as developing a planning committee, holdin community forums, and conducting focus
groups, surveys, and/or interviews. These activities will engage the beneficiaries in the planning
process and planners will be able to see the issues just as the community sees them.

PHASE 2 - EPIDEMIOLOGICAL, BEHAVIORAL, AND ENVIRONMENTAL

DIAGNOSIS

Epidemiological diagnosis deals with determining and focusing on specific health

issue(s) of the community, and the behavioral and environmental factors related to prioritized
health needs of the community. It may include secondary data analysis or original data collection
— examples of epidemiological data include vital statistics, state and national health surveys,
medical and administrative records, etc.

Behavioral diagnosis is the analysis of behavioral links to the goals or problems that are
identified in the social or epidemiological diagnosis.The behavioral ascertainment of a health
issue is understood, firstly, through those behaviors that exemplify the severity of the disease
(e.g tobacco use among teenagers); secondly, through the behavior of the individuals who
directly affect the individual at risk (e.g. parents of teenagers who keep cigarettes at home); and
thirdly, through the actions of the decision-makers that affects the environment of the individuals
at risk (e.g. law enforcement actions that restrict teens' access to cigarettes). Once behavioral
diagnosis is completed for each health problem identified, the planner is able to develop more
specific and effective interventions.
 Environmental diagnosis is a parallel analysis of social and physical environmental
factors other than specific actions that could be linked to behaviors.In this assessment,
environmental factors beyond the control of the individual are modified to influence the health
outcome. For example, poor nutritional status among children may be due to the availability of
unhealthful foods in school. This may require not only educational interventions, but also
additional strategies such as influencing the behaviors of a school's food service managers.

PHASE 3 - EDUCATIONAL AND ECOLOGICAL DIAGNOSIS

Once the behavioral and environmental factors are identified and interventions selected,
planners can start to work on selecting factors that, if modified, will most likely result in
behavior change, as well as sustain it. These factors are classified as 1) predisposing, 2)
enabling, and 3) reinforcing factors.

Predisposing factors any characteristics of a person or population that motivate behavior

prior to or during the occurrence of that behavior. They include an individual's knowledge,
beliefs, values, and attitudes.

Enabling factors are those characteristics of the environment that facilitate action and any
skill or resource required to attain specific behavior. They include programs, services,
availability and accessibility of resources, or new skills required to enable behavior change.

Reinforcing factors are rewards or punishments following or anticipated as a

consequence of a behavior. They serve to strengthen the motivation for a behavior. Some of the
reinforcing factors include social support, peer support, etc.

PHASE 4 - ADMINISTRATIVE AND POLICY DIAGNOSIS

This phase focuses on the administrative and organizational concerns that must be
addressed prior to program implementation. This includes assessment of resources,
development and allocation of budgets, looking at organizational barriers, and coordination of
the program with other departments, including external organizations and the community.

Administrative diagnosis assesses policies, resources, circumstances and prevailing

organizational situations that could hinder or facilitate the development of the health program.
On the other hand, policy diagnosis assesses the compatibility of program goals and objectives
with those of the organization and its administration. This evaluates whether program goals fit
into the mission statements, rules and regulations that are needed for the implementation and
sustainability of the program.
PROCEED

Proceed stands for Policy, Regulatory, and Organizational Constructs in Educational

and Environmental Development. It involves four (4) phases namely: Implementation of the
Program, Process Evaluation, Impact Evaluation, and Outcome Evaluation.

PHASE 5 - IMPLEMENTATION OF THE PROGRAM

Design intervention, assess availability of resources, and implement program and

interventions.

PHASE 6 - PROCESS EVALUATION

This phase is used to evaluate the process by which the program is being
implemented. This phase determines whether the program is being implemented according to
the protocol, and determines whether the objectives of the program are being met. It also helps
identify modifications that may be needed to improve the program.

PHASE 7 - IMPACT EVALUATION

This phase measures the effectiveness of the program with regards to the
intermediate objectives as well as the changes in predisposing, enabling, and reinforcing
factors. Often this phase is used to evaluate the performance of educators.

PHASE 8 - OUTCOME EVALUATION

This phase measures change in terms of overall objectives as well as changes in

health and social benefits or quality of life. That is, it determines the effect of the program in
the health and quality of life of the community.

BASIC MODEL OF LEARNING

PRECEDE-PROCEED provides a template for the process of conceiving, planning,

implementing, and evaluating a community intervention. It is structured as a participatory
model, to incorporate the ideas and help of the community.
Figure 1: GENERIC REPRESENTATION OF THE PRECEDE-PROCEED MODEL. FROM L.
GREEN AND M. KREUTER. (2005). HEALTH PROMOTION PLANNING: AN EDUCATIONAL
AND ECOLOGICAL APPROACH (4 TH ED.). MOUNTAIN VIEW , CA : MAYFIELD
PUBLISHERS.

APPLICATION TO HEALTHCARE

1. The PRECEDE-PROCEED model applies a medical perspective to public health,

even though its focus is health promotion, rather than treatment of disease.

Just as a medical diagnosis precedes treatment, the model assumes that a far-reaching
diagnosis should precede a public health intervention. A diagnosis suggests a treatment (an
intervention), which is closely monitored for process (Is the patient getting the treatment
prescribed?), impact (Is the treatment having the hoped-for impact on the symptoms?), and
outcome (Does the treatment cure the patient, or have the desired effect on her overall health?).
A premise of the model is that a diagnosis should start with the desired end result and work
backwards to determine what needs to be done to bring about that result.