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Planning and the Professional Preparation
of Health Educators: Implications
for Teaching, Research, and Practice
PE: KEEP THIS? PLEASE DO NOT CITE WITHOUT
PERMISSION
Planning skills are one of the seven essential responsi-
bilities of health educators, according to the National
Commission of Health Education Credentialing pro-
gram; yet little information is available about who pro-
vides training in planning, what type of training is
offered, and what planning models are taught. A survey
of 253 accredited graduate and undergraduate health
education programs (response rate = 56%) was under-
taken to gather information about planning and the
professional preparation of health educators. Results
revealed that planning instructors were primarily full-
time, experienced, and about one half were CHES certi-
fied. Overall, 88% (113/129) of respondents taught the
predisposing, reinforcing, and enabling causes in edu-
cation diagnosis and evaluation/policy, regulatory, and
organizational constructs in education and environ-
mental development model, and 62% (81/131) taught
the planned approach to community health model. Few
planning differences were found at the graduate and
undergraduate levels. Content analysis of 56 course syl-
labi revealed that 80% (45/56) required students to
complete a program plan proposal or document as the
culminating project for the course. Implications for
teaching, research, and practice are discussed. 172
WORDS - NO ACRONYMS
Keywords: planning; professional preparation; training
Health Promotion Practice
2004 Vol. , No. , 1-
DOI: 10.1177/1524839903260946
©2004 Society for Public Health Education
ARTICLE
HEALTH PROMOTION PRACTICE / Month 20XX
Laura A. Linnan, ScD, CHES
Katherine Regan Sterba, MPH
Ann Marie Lee, MPH
Jean Breny Bontempi, PhD, MPH
Jingzhen Yang, MPH
Carolyn Crump, PhD
P
lanning is an essential skill for health educators—
whether they are in academic, research, commu-
nity, worksite, government, or school settings.
One of the seven key essential responsibilities, as speci-
fied in the National Commission for Health Education
Credentialing (NCHEC; 1996) framework, is that health
educators be able to “plan effective health education
programs.” Moreover, each “essential responsibility”
includes a set of core competencies: recruit community
organizations, resource people, and potential partici-
pants for support and assistance; develop a logical
scope and sequence plan for a health education plan;
formulate appropriate and measurable program objec-
tives; and design educational programs consistent with
specified program objectives. The NCHEC is a voluntary
professional certification program that offers national
standards for individual health education practitioners.
An individual who passes the NCHEC national certifi-
cation exam becomes a certified health education spe-
cialist (CHES), which attests to the fact that this individ-
ual has mastered the knowledge and skills required to
accomplish those seven essential responsibilities,
including planning skills.
Because NCHEC is a voluntary professional certifica-
tion program, not all practicing health educators partic-
ipate in this program. Thus, professional preparation
programs are critically important for providing a foun-
dation that will standardize and ensure excellence
among all trained health educators. The Council on
Education for Public Health (CEPH) is recognized by the
Authors’ Note: We would like to the thank faculty and administra-
tors nationwide who took the time to complete this survey, and to
Alison Babb, for crafting the appendix that summarizes the plan-
ning models. Address all correspondence regarding this article
and requests for reprints to Laura A. Linnan, ScD, CHES, Assistant
Professor, Department of Health Behavior and Health Education,
University of North Carolina Chapel Hill School of Public Health,
CB #7440, Chapel Hill, NC 27599-7440; e-mail: linnan@
email.unc.edu
1
U.S. Department of Education as the official accrediting
body for graduate community health education pro-
grams. It is expected that CEPH accreditation “repre-
sents excellence in education that will relate to profi-
ciency in practice” (Council on Education in Public
Health, 2002, n.p.). The graduate competencies were
adopted in 1998 and reflect profession-wide agreement
about the essential skills and competencies of a health
educator. Program planning and evaluation is listed as
one of the 10 essential areas of responsibility of a
trained health educator. Thus, universities that aspire
to CEPH accreditation must demonstrate that their grad-
uate health education curriculum addresses planning
and each of the other nine areas of responsibility.
In addition to variation in individual-level certifica-
tion and program-level accreditation, it is clear that
health educators can choose from a variety of planning
models when designing effective health education pro-
grams. However, little is known about what planning
models are emphasized in graduate and undergraduate
training programs, who is teaching future health educa-
tors about planning, and what type of teaching methods
are commonly used to develop planning skills.
One exception to this dearth of literature is a study
by Goldman and colleagues (Goldman, Rocco, &
Delnevo, 2000) who investigated the use of program
planning models among 155 selected New York City
health educators. The response rate to this mailed sur-
vey was 72.4%, and the majority of respondents were
master’s prepared health educators who worked in aca-
demic settings, had between 1 and 5 years of experi-
ence, and were CHES certified. Approximately 50% of
The Authors
Laura A. Linnan, ScD, CHES, is an assistant professor in
the Department of Health Behavior and Health Education at
the School of Public Health, University of North Carolina at
Chapel Hill.
Katherine Regan Sterba, MPH, is a doctoral student in the
Department of Health Behavior and Health Education at the
School of Public Health, University of North Carolina at
Chapel Hill.
Ann Marie Lee, MPH, is a registered nurse at the UNC
SPELL OUT Hospital Hematology/Oncology Unit in Chapel
Hill, North Carolina.
Jean Breny Bontempi, PhD, MPH, is an assistant professor
in the Department of Public Health at the Southern Con-
necticut State University at New Haven.
Jingzhen Yang, MPH, is a PhD candidate in the Department
of Health Behavior and Health Education at the School of
Public Health, University of North Carolina at Chapel Hill.
Carolyn Crump, PhD, is a research assistant professor in
the Department of Health Behavior and Health Education at
the School of Public Health, University of North Carolina at
Chapel Hill.
2 HEALTH PROMOTION PRACTICE / 2004
respondents reported having program planning respon-
sibilities. Overall, 98% of these health educators
reported studying planning models, yet less than 47%
reported using any program planning model in their
work. Of those who studied program planning, more
than 70% reported studying about program planning in
graduate school, while less than one third studied
planning as undergraduates.
Goldman and colleagues also reported that
PRECEDE-PROCEED (Green & Kreuter, 1999) or
PRECEDE (alone) (Green, Kreuter, Deeds, & Partridge,
1980) were the top two planning models health educa-
tors reported studying and using. Reported barriers to
using program planning models included lack of time,
resources, money, and knowledge about planning mod-
els. When asked about continuing education interest in
program planning topics, the top three endorsed sub-
jects were evaluation issues, models, and design of
planning efforts. Based on these results, Goldman and
colleagues questioned who was involved in local plan-
ning efforts and why health educators responding to
their survey underutilized planning models. Moreover,
they questioned how well trained and experienced fac-
ulty members were in presenting and/or using the
program planning models they had taught.
The current study attempts to address some of the
important questions raised by Goldman and colleagues,
and to redirect some of these questions to those
involved in professional preparation of health educa-
tors. Here, we focus on the preparation of health educa-
tors, from the perspective of those involved in under-
graduate and graduate training programs nationwide.
The specific aims of the current study are to (a) deter-
mine the extent to which training programs for health
educators offer training in planning and (b) describe
which program planning models are typically being
taught, who is doing the teaching, and how training
about planning fits within the overall training of health
educators. Implications of these study results are dis-
cussed in light of teaching, research, and the practice of
health education.
> METHOD
Sample
The American Association for Heath Education
(AAHE) conducts a survey of institutions offering spe-
cialization in health education every 2 years, creates a
Directory of Institutions and then sells this list to inter-
ested parties for a one-time use fee. The contact person
on the list is either the department chair or the coordi-
nator of the health education program at each univer-
sity. In December 2000, we purchased the AAHE mail-
ing labels from the August 2000 survey. The labels
included 273 contacts at universities offering a special-
ization in health education at the graduate or under-
graduate level. Phone calls to each verified that 20 con-
tacts had no health education program available at their
university, so the original list of 273 was reduced to 253
eligible respondents.
Survey Instrument
A 21-item survey was developed to gather informa-
tion about professional preparation of health educators
related to program planning at the graduate or under-
graduate level. Respondents were asked whether pro-
gram planning was taught as a separate course or as one
component of a more extensive course. If multiple
courses were offered that contained planning informa-
tion, respondents were asked to select the one course at
their institution that contains the most information on
planning and to refer to that course when answering the
remainder of the questionnaire. Details about the length
of the course, training/experience of the primary
instructor, availability of teaching assistants, student
enrollment issues, and the course content were assessed
(the survey instrument is available from the first
author).
To clarify which planning models were covered in
these courses, respondents were given a list of 10 plan-
ning models (plus an “other” write-in option) and asked
to identify which of them were typically covered in
their planning course. Appendix A gives a brief sum-
mary description and key references for each of the 10
planning models: assessment protocol for excellence in
public health (APEXPH), comprehensive health educa-
tion model, effectiveness-based/rational planning, evi-
dence-based/risk factor analysis, intervention mapping,
multilevel approach to community health (MATCH),
model for health education planning (MHEP), planned
approach to community health (PATCH), predisposing,
reinforcing, and enabling causes in education diagnosis
and evaluation (PRECEDE), and predisposing, reinforc-
ing, and enabling causes in education diagnosis and
evaluation-policy, regulatory, and organizational con-
structs in education and environmental development
(PRECEDE-PROCEED). Selection of the 10 models was
based on a literature search of planning models applied
in health education, results from a recent survey of
health educators in New York City (Goldman et al.,
2000), and a consensus development process from
experienced health educators on the research team. Sur-
vey respondents were asked to indicate whether one
planning model was covered more extensively in the
course, and if so, they were asked to list this as the
primary planning model.
Respondents were also asked to clarify their familiar-
ity with and use of the 10 listed planning models for
teaching and practice. This item was operationalized as
0 = I am familiar with and have used this model, 1 = I am
familiar with, but have not used this model, and 2 = I am
NOT familiar with and have NOT used this model.
Respondents were asked to rate the usefulness of each
model for research and for practice, and to rate the
model on appropriateness for undergraduate and gradu-
ate students. The item was operationalized as 0 = No,
Linnan et al. / PLANNING AND PREPARATION OF HEALTH EDUCATORS
1 = Yes, or 2 = No opinion due to lack experience with
the model. To further verify the self-reported informa-
tion, a written copy of the planning course syllabus was
requested as well.
The survey instrument was pretested with three fac-
ulty members who taught program planning in a univer-
sity setting and was reviewed by experienced survey
researchers at the Odum Institute of Social Science
Research, University of North Carolina at Chapel Hill.
Revisions were made to the survey as needed to
improve clarity, ease of response, and completeness
prior to administration.
Survey Administration
Surveys were distributed via mail to eligible AAHE
list members (N = 253) in March 2001. The initial con-
tact included an introductory letter addressed to the
department chair or program coordinator of health edu-
cation at each university. The letter described the study
objectives, requested that the survey be directed to the
person most responsible for teaching about planning,
and provided information about the confidentiality of
the participants’ responses. The initial mailing also
included the written survey instrument, a postage-paid
return envelope, pencil, and contact information for
investigators at the University of North Carolina-Chapel
Hill. Approximately 3 to 4 days after the original mail-
ing, a reminder postcard was mailed; then, 2 weeks after
the postcard mailing, a second letter, survey, and post-
age-paid envelope were mailed to nonrespondents
(Dillman, 2000). Approximately 2 weeks after the sec-
ond mailing, all eligible nonrespondents received a
reminder message by telephone. Two weeks after the
first reminder call, a second reminder call was made,
and an e-mail reminder was also sent to all
nonrespondents whose e-mail addresses were available
in the public domain. As surveys were returned, they
were date stamped, coded, and entered manually into a
Microsoft Access 2000 database by trained project staff.
Codes were created for noncontinuous variables, such
as the degrees conferred and major fields of study of the
primary instructor. Frequencies and other descriptive
statistics on the survey results were completed using
SAS V. 8.2.
Sixty-four syllabi were submitted by respondents
and identified as the “primary course where planning
was taught.” All 64 syllabi were read through for overall
content and key issues of interest to the research team.
An Excel spreadsheet was created to track information
on the following issues: required readings, culminating
projects, main topic/focus of the course, length of
course, and time spent on program planning topics. The
syllabi were rereviewed, and data on each issue was
coded and entered into the spreadsheet. Overall, 86%
(56/64) of the submitted syllabi focused almost exclu-
sively on the topic of program planning and formed the
basis of our comments in this article; the remaining
eight syllabi contained only a small amount of informa-
3
tion on program planning and were not included in the
content analysis.
> RESULTS
Sample Description
Of 253 eligible respondents, 144 completed and
returned the survey for an overall response rate of 56%.
Of those, 131 (90.9%) who completed surveys
responded by mail, 11 (7.6%) by fax, and 4 (2.8%) by e-
mail. Of respondents, 35% (51/144) reported being
either a department chair, program head, or program
coordinator for the health education program. The
majority of respondents reported being faculty members
in the health education department; of those who pro-
vided a response to the item, 51.3% (39/76) were the
primary instructor for the planning course.
Who Teaches Planning?
Of the primary instructors for the program planning
course, 95% (125/132) worked full-time, 43% (57/132)
were tenure track, 74% (89/120) had completed doc-
toral training, 52% (68/118) were CHES certified, and
28% (37/131) of the primary instructors for the plan-
ning course were full professors, 30% (38/131) were
associate professors, 34% (45/131) were assistant pro-
fessors, 5% were instructors (8/131) and less than 1%
were adjunct professors (1/131).
How Does Planning Fit in the
Health Education Curriculum?
of respondents, 63% (86/144) reported that planning
was taught as a separate course, 30% (40/144) stated
that planning principles were taught within a course
focused on more than planning, and 4% (6/144)
reported that no course devoted to or incorporating pro-
gram planning was available at the time of the survey
(missing = 12 respondents). Many program planning
courses had been in place for a length of time: 18 existed
for 20 or more years, 29 existed for between 11 and 19
years, 39 existed for 6 to 10 years, while 30 have been in
place for 5 or fewer years. The average class size was 23
students. An estimated 91% (119/144) of respondents
reported that students enrolled in program planning
courses were health education majors (vs. other degree
programs). Of respondents, 61% reported that under-
graduates were required to take the planning course,
and 46% reported that graduate students were required
to take the planning course (this equals greater than
100% because it was possible for respondents to choose
“all that apply” to the question of whether graduate or
undergraduates were required to take the planning
course).
4 HEALTH PROMOTION PRACTICE / 2004
What Planning Models
Are Typically Taught?
One hundred and thirty-two respondents provided
information about the planning models that were rou-
tinely covered in their courses. Respondents were
invited to check from a list of 10, all models taught in
the primary class where planning was taught. Eighty-
eight percent (113/129) taught PRECEDE-PROCEED,
62% (81/131) taught PATCH, 58% (76/130) taught
PRECEDE (distinct from PRECEDE-PROCEED), 45%
(59/131) taught the comprehensive health education
model, 37% (49/131) taught the model for health educa-
tion planning, 35% (46/131) taught MATCH, 28% (37/
131) taught intervention mapping, 20% (26/131) taught
APEXPH, 17% (22/131) taught evidence-based/risk fac-
tor analysis, and 7% (9/131) taught the effectiveness-
based rational planning model. Of respondents, 65%
(31/48) reported that they teach about other planning
models beyond the 10 named on our list, including, for
example, the model for health education planning and
resource development (MHEPRD), total quality
improvement (TQI), as well as CATCH, CDCYNERGY,
social marketing, and SMART SPELL ALL OUT.
Familiarity and Use of Selected
Planning Models for Teaching/Practice
Wide variation existed in respondent familiarity
with and use of planning models for teaching and prac-
tice. Given a list of 10 planning models, 85.7% of
respondents reported familiarity with and use of the
PRECEDE-PROCEED model in teaching, and 74.6%
reported familiarity with and use for practice. Respon-
dents reported familiarity with and use of other plan-
ning models in teaching and in practice in the following
order: PRECEDE only (77.5% in teaching and 74.6% in
practice), PATCH (61.3% in teaching and 68.6% in
practice), comprehensive health education model
(47.2% in teaching and 39.8% in practice), model for
health education planning (38.5% in teaching and
24.4% in practice), intervention mapping (29.8% in
teaching and 21.7% in practice), MATCH (28.1% in
teaching and 18.5% in practice), evidence-based/risk
factor analysis (19.2% in teaching and 12.9% in prac-
tice), APEXPH (18.6% in teaching and 13.2% in prac-
tice), and effectiveness-based/rational planning (10.9%
in teaching and 9.5%). Thus, respondents indicated
higher levels of familiarity but lower levels of use for
each planning model except PATCH.
Use of Selected Planning
Models for Research/Practice
Respondents held vastly different opinions about the
usefulness of the 10 selected planning models for
research and for practice. Of respondents, 86% reported
that PRECEDE-PROCEED was the most useful for
research, followed by: PRECEDE only (79.7%), PATCH
(61.1%), intervention mapping (50.5%), model for
health education planning (44.6%), MATCH (41.3%),
comprehensive health education model (39.3%), evi-
dence-based/risk factor analysis (34.8%), effectiveness-
based/rational planning (22.3%), and APEXPH
(19.3%).
The PRECEDE-PROCEED model was also rated high-
est on usefulness for practice (90.8%), followed by
PRECEDE alone (87.9%), PATCH (80.3%), comprehen-
sive health education model (60.0%), model for health
education planning (58.4%), intervention mapping
(52.2%), MATCH (50.9%), APEXPH (34.6%), evidence-
based/risk factor analysis (29.8%), and effectiveness-
based/rational planning (22.2%).
Teaching About Planning
For teaching undergraduate students, respondents
ranked the PRECEDE (only) planning model (85.8%)
and the PRECEDE-PROCEED model (84.5%) as most
appropriate, followed by PATCH (72.8%), the model for
health education planning (62.0%), the comprehensive
health education model (59.6%), and MATCH (51.4%).
For teaching graduate students, respondents reported
PRECEDE-PROCEED (93.9%) as most appropriate, fol-
lowed by PRECEDE only (88.3%), PATCH (74.1%),
model for health education planning (61.6%), interven-
tion mapping (60.0%), the comprehensive health edu-
cation model (58.9%), and MATCH (54.1%). No other
model was endorsed by more than 50% of respondents
on appropriateness for teaching either graduates or
undergraduates.
Review of Course Syllabi
A review of 56 planning course syllabi revealed that
a variety of teaching methods were used: lectures and
discussions, student presentations, course projects, and
assigned readings. of the reviewed courses, 80% (45/56)
required students to complete a program plan proposal
or document as the culminating project for the course.
Of the remaining 11 courses, eight required some other
final project (e.g., needs assessment, program evalua-
tion, development of a health curriculum, or a data
analysis project), and final project status could not be
determined from three course syllabi. Eight percent (5/
56) of courses required that students do a service
learning project.
Of the course syllabi reviewed, 34% (19/56) listed
PRECEDE (Green et al., 1980) as the primary planning
model taught in the course; while the majority that
remained either did not specify a planning model or
covered several planning models. Fifty-seven percent
(32/56) specified that the McKenzie and Smeltzer
(2001) text Planning, Implementing, and Evaluating
Health Promotion Programs was required, whereas 21%
(12/56) of all course syllabi required the most recent
Green and Kreuter (1999) textbook (describes
PRECEDE-PROCEED), and another 13% (7/56) recom-
Linnan et al. / PLANNING AND PREPARATION OF HEALTH EDUCATORS
mended (vs. required) that textbook. Thus, 44 course
syllabi reviewed (from 56) required either the McKenzie
and Smeltzer (2001) or Green and Kreuter (1999) text-
books. The majority of syllabi reviewed also covered all
aspects of the program planning process; had planning
as the primary focus of the course, spent the entire
semester on planning; and required students to com-
plete a culminating project of a program plan proposal.
> DISCUSSION
This survey investigated the professional prepara-
tion of health educators on the subject of program plan-
ning, an essential health educator skill, from the per-
spective of faculty from universities with a health
education specialization. Overall, 63% of respondents
reported that planning was being taught as a separate
course in the curriculum, 30% included program plan-
ning as part of a separate class, and only 4% reported
that no course was offered that included program plan-
ning. Goldman et al. (2000) reported that a majority of
New York City health educators studied program plan-
ning as part of a master’s program. In the current study,
less than one half of all responding program representa-
tives required graduate students to take a planning
course; and only 61% required it of undergraduate stu-
dents. Planning is an essential skill for credentialing
health education specialists, and it is a required compe-
tency that must be addressed if a professional training
program wants to receive CEPH accreditation in gradu-
ate health education training. Although 63% of respon-
dents included planning as a primary focus (e.g., as a
separate course), it is unclear about the extent to which
planning is addressed in the 30% of programs where it
is included as part of a separate class. Determining the
amount of training that is available in these courses
where planning is covered among many topics, and
understanding whether the amount that is covered is
enough to develop essential planning skills, is not clear
from our results. The fact that students who seek out
graduate training in health education often do not com-
plete undergraduate training in a health education pro-
gram (e.g., they may come from a wide range of under-
graduate degree programs) clarifies the danger in not
covering this topic adequately. It appears that the
standardization of training in this important skill area
must be addressed at the graduate and undergraduate
levels.
The vast majority of primary instructors for planning
courses were full-time, had completed doctoral train-
ing, and approximately one half were CHES certified.
The professional preparation of faculty reported to be
the primary instructor for the planning course was
evenly distributed at the full, associate, and assistant
professor levels. When asked about familiarity and
appropriateness of specific planning models for teach-
ing, research, and practice, there was widespread simi-
larity in responses. First, when asked about planning
models typically covered in their courses, three plan-
5
ning models were endorsed by more than one half of
respondents: PRECEDE-PROCEED, PATCH, and
PRECEDE (only). Of these, PRECEDE-PROCEED was
endorsed by 88% of all respondents. These results were
similar to those of Goldman et al. (2000) who reported
that two planning models were studied by more than
one half of the health educators who responded to their
survey: PRECEDE-PROCEED and PRECEDE (only).
It is possible that the use of planning models might
be limited by a lack of familiarity with more than one or
two planning models. For example, less than one half
the respondents to our survey were familiar with mod-
els other than PRECEDE-PROCEED, PRECEDE (only), or
PATCH. When ranking the usefulness of planning mod-
els for research, only intervention mapping was added
to the original list of the three most familiar planning
models. Yet when usefulness for practice was rated, a
much wider range of planning models was endorsed by
at least one half the respondents, including the compre-
hensive health education model, model for health edu-
cation planning, intervention mapping, and MATCH. It
is unclear why respondents endorsed the usefulness of
these models for practice (vs. for research purposes),
however this would be an interesting topic for more in-
depth investigation among respondents.
Respondents were asked to rate the appropriateness
of various planning models for teaching undergraduates
and graduate students. Six planning models were
deemed appropriate by more than 50% of respondents
for teaching undergraduates, and seven models were
rated appropriate for graduate students. However, for
undergraduates, PRECEDE (only) (85.6%) slightly
edged PRECEDE-PROCEED as the number-one-rated
planning model appropriate for undergraduates;
whereas PRECEDE-PROCEED was endorsed by 94.5%
of respondents as appropriate for graduate students, fol-
lowed closely by PRECEDE (only) and PATCH. Thus,
differences in planning models endorsed as appropriate
for teaching undergraduates (vs. graduates), or for prac-
tice purposes, were relatively minor in the current
study. However, a much smaller number of planning
models were endorsed as appropriate for research pur-
poses. These data, taken together, make it evident that
PRECEDE-PROCEED, PRECEDE (only), and PATCH
were endorsed most often as appropriate across all three
categories: teaching, research, and practice.
Why has PRECEDE-PROCEED become such an
important planning model for the preparation of health
educators? We offer several plausible reasons. First,
PRECEDE-PROCEED has evolved over time, beginning
in the late 1970s, right alongside the evolution of the
field of health education. The original version of this
planning model—PRECEDE—was among the first plan-
ning models to incorporate theory and a systematic pro-
cess into a planning framework. Second, PRECEDE-
PROCEED was developed by health educators for health
educators. The examples used to help students under-
stand the steps in the planning process were taken from
typical health education scenarios, organized around
6 HEALTH PROMOTION PRACTICE / 2004
community, worksite, or school-based settings. Third,
the developers (Green & Kreuter) are leaders in the field
of health education, they have held a variety of influen-
tial academic and practice-based positions, their work/
ideas are respected, and they have published widely in
peer-reviewed journals and have described their plan-
ning model (and its evolution) in three textbook edi-
tions. It appears that the uptake of the PRECEDE model
among those teaching/preparing professional health
educators occurred early in the diffusion curve and has
maintained a steady, consistent level since then.
Fourth, ongoing information and support, along with
revisions/additions to the model, have been made. For
example, at the time of this printing, a fourth edition
PRECEDE-PROCEED planning textbook is under devel-
opment, a Web site, and an instructor guide are in place
to support interested users. Moreover, when PROCEED
was added to the original PRECEDE planning model, a
comprehensive link between planning, implementa-
tion, and evaluation of health education programs was
possible. Researchers may have embraced this planning
framework because it could provide a systematic
approach for identifying testable, theory-linked
research questions about possible determinants of
change at the behavioral and environmental levels.
Although the purpose of this article is not to provide
a critical review of various planning models, nor is this
article designed to recommend certain planning models
over others, it remains clear that nearly 30 years after
the PRECEDE planning model was first introduced, it
remains a dominant force in the preparation of the cur-
rent (and next) generation of professional health
educators.
Given these results, it is interesting that only 19% of
course syllabi reviewed required the purchase of the
Green and Kreuter textbook (focused exclusively on the
PRECEDE-PROCEED planning model), versus 50% that
required the McKenzie and Smeltzer (2001) text (which
is more generalized on planning, implementing, and
evaluating health promotion programs). It may be that
instructors want a text that introduces students to a
greater number of planning models, although even
McKenzie and Smeltzer (2001) acknowledge,
“PRECEDE-PROCEED is a model with which all stu-
dents should become very familiar. It is considered ‘the
model’ by most people in the health profession and has
been the basis for many professional projects at the
national level” (p. 13).
Implications of these results for teaching, research,
and practice are noteworthy. As for teaching, primary
instructors in our survey appear to be well trained, well
established in their programs, and familiar with a num-
ber of planning models. However, the current study
revealed that instructors are less likely to endorse the
usefulness of planning models for practice purposes.
Goldman et al. (2000) found that less than one half of
health educators in their study reported using planning
models in practice. It may be that a disconnect exists
between what is being taught (an ideal planning
approach), and what is practical when it comes to real-
world application of the planning model. This might
occur if instructors are not using real-world examples of
how these models are applied, if the planning models
themselves are overly complex, or if these models
require an unreasonable amount of time to develop,
implement, and/or evaluate. Syllabi review suggests
that primary instructors use a variety of teaching meth-
ods, however it is not possible to judge the quality or the
practicality of the experiences students encounter in
the classroom. Offering ongoing continuing education
opportunities on the use of planning models for faculty
and students at professional meetings or conferences
may be helpful. Self-study programs through the mail or
online (including those offered for CHES credits) would
make these opportunities more accessible to interested
individuals.
At the University of North Carolina-Chapel Hill
School of Public Health, where several of us have taught
(and/or have been students in) the required Planning
Course (HBHE 172) in the Department of Health Behav-
ior and Health Education, we require students to learn
and apply all phases of the PRECEDE-PROCEED plan-
ning process, and to think (and write) critically about
the strengths and limitations of this planning model.
Moreover, we create an opportunity for students to
work in small groups where they are assigned to study
one other planning model intensively over the course of
the semester. Near the end of the semester, each group
gives a presentation on the assigned planning model—
so that students learn more about other planning mod-
els, their historical development, intended uses, key
components, strengths, and limitations. As a result, stu-
dents learn to work in-depth with the PRECEDE-
PROCEED model to create a program plan over the
course of the semester on a topic of their choice, and to
think critically about that model in relation to five to
seven additional planning models they learned about in
class (see Appendix B for sample questions students
answer as a final reflection on planning approaches).
Implications for the practice of health education are
linked to these teaching implications. In other words, if
students receive better professional preparation around
planning skills, we contend that professional practice
skills will also improve. Thus, continuing education
strategies for students and for experienced profession-
als/faculty members is an important issue for improving
planning practice. Yet Goldman et al. (2000) found that
most health educators are aware of planning models,
however few are using them. Why? Our survey results
do not address this question per se, however respon-
dent rankings on the usefulness of planning models for
practice work was decidedly lower than rankings on the
usefulness of these models for teaching or research. Is it
possible that health educators are forced to react to
health problems or situations instead of taking the time
to plan effectively for how to best react? It may also be
true that practitioners are using pieces of planning mod-
els but not an entire planning model in practice efforts.
Linnan et al. / PLANNING AND PREPARATION OF HEALTH EDUCATORS
More insights into why planning models are
underutilized among practitioners are needed.
As for research implications, the current study gener-
ates a number of questions. For example, should we
advocate for professional preparation that includes an
emphasis on the PRECEDE-PROCEED planning model
to the exclusion of other models? Similar to a number of
respondents to our survey, we believe that offering stu-
dents in-depth training on the use of at least one plan-
ning model, and exposure to a variety of other planning
models, is most desirable. According to our data,
respondents indicate that PRECEDE-PROCEED is likely
to be an important part of the training on planning mod-
els that students receive. However, investigating the
conditions under which certain planning models may
be more or less helpful, and understanding the
strengths and limitations of each planning model, are
all important, researchable questions.
The role of theory in planning approaches also
requires further investigation. Because only approxi-
mately one half (49.1%) of respondents reported that
theory was integrated into their teaching about plan-
ning “a great deal” (data not shown), and most would
agree that developing theory-based interventions is
desirable, why are planning efforts disassociated from
theory in professional preparation? On a related issue, it
would be useful to determine whether (and to what
extent) community-based public health partnerships
(Bruce & McKane, 2000) are addressed during training
about planning. Which planning models are best able to
accommodate partnership approaches (and which are
not)? The field of health education has embraced com-
munity-based partnership approaches, and training
methods that link planning and partnership
development are needed.
This survey has several limitations. First, despite an
aggressive nonrespondent follow-up, the response rate
to this survey was 56%. Thus, we cannot generalize the
results of this survey to all professional health educa-
tion training programs. Second, the list of health educa-
tion training programs compiled by AAHE might not be
complete, or may underrepresent smaller (or newer)
health education training programs. Third, although we
requested that the survey be directed to the person who
best knew about the planning course, it is possible that
the survey respondent did not have complete informa-
tion about the primary planning course offered at that
institution. Despite these limitations, several strengths
of this survey should be acknowledged. This was the
first attempt at a national survey of planning related to
health educator preparation and thus yields new infor-
mation for the field. Second, prior to designing the sur-
vey, a thorough review of published literature on plan-
ning models was undertaken and was used in the
development of the survey items. Finally, course syllabi
submitted by respondents gave our team additional,
more in-depth information about the teaching methods,
materials, and course content offered in these planning
courses.
7
 Effective planning is an essential skill according to
professional health education credentialing programs
and program-level accreditation standards. However, it
appears that a wide degree of variation exists in the pro-
fessional preparation of health educators at the under-
graduate and graduate levels. The CEPH accreditation
process for graduate-level health education programs
acknowledges the importance of planning skills and
requires that programs offer planning as part of a
required curriculum. Only a portion of graduate schools
is CEPH accredited, so not all graduate programs can be
accounted for in this process. Undergraduate programs
in health education receive less oversight. The Society
of Public Health Education (SOPHE)-AAHE Baccalaure-
ate Program Approval Committee (SABPAC) process is
the way that the profession is currently monitoring
undergraduate health education preparation programs.
It is a voluntary process whereby programs undertake a
program self-study based on the seven responsibilities
of health education (NCHEC, 1996), pay a fee, and
receive a site visit by a team of health education profes-
sionals. Brookins-Fisher and Pope (1999) conducted a
study of 17 undergraduate community health education
programs that were approved by SABPAC and found
great variation within the approved programs. Thus,
existing accreditation procedures may need further
specification.
At the present time, we understand that a joint
SOPHE-AAHE Task Force on Accreditation in Health
Education is deliberating on the possibility of CEPH
providing a single accreditation mechanism for commu-
nity/public health education programs at the under-
graduate and graduate levels. We support a standard-
8 HEALTH PROMOTION PRACTICE / 2004
ized accreditation process for graduate and undergradu-
ate programs but recognize that the accreditation pro-
cess alone will not be sufficient to ensure that planning
skills of health educators are improved. In other words,
even if the content of professional preparation becomes
standardized, we believe that quality of professional
preparation must be also addressed. Therefore, we con-
tend that individual health educators will need to take
some responsibility for their professional skills and
experiences in this area. Specifically, we encourage stu-
dents to take a course on planning (or a course where
planning skills are taught); and we advocate for contin-
uing education training of practitioners who may have
had insufficient training in planning models. Although
it is a voluntary credentialing program, we support the
CHES accreditation process to help standardize training
of health educators and offer these types of continuing
education opportunities as an important component of
professional development. We expect that the annual
CHES exam will include questions that test planning
knowledge and skills of those who are applying for pro-
fessional certification. We advocate for teaching meth-
ods that ensure students have the opportunity to criti-
cally think about and apply planning skills learned in
the classroom to real-world practice. If planning skills
set the stage for effective implementation and evalua-
tion efforts, it follows that more attention to the profes-
sional preparation of planning skills and their ongoing
development (for students and experienced
professionals alike) is warranted. We hope this research
will stimulate additional thinking and dialogue on this
important topic.
APPENDIX A
Brief Description of Selected Planning Models

Model Brief Description

Assessment Protocol Designed by the National Association of County Health Officials (NACHO), with funding from
for Excellence the Centers for Disease Control, APEXPH was released in 1991. It was designed to improve a
in Public Health community’s public health by helping local health officials “assess the organization and
(APEXPH; Dever, management of the health department, provide a framework for working with community
1997) members and other organizations is assessing the health status of the community, and
establish the leadership role of the health department in the community” (NACHO, 1991,
p. 1). APEXPH may easily be used in combination with other planning models.
APEXPH has three major parts:
Part 1: Organizational capacity assessment (conduct an internal self-assessment of the health
department, create a plan of action)
Part 2: The community process (establish a community advisory committee to identify and
prioritize key health problems, collect and analyze health data, set goals and objectives,
and identify local resources)
Part 3: completing the cycle (monitor and evaluate the organizational action plan and the
community health plan; ensure that assessment, policy development, and assurance are
institutionalized)
Comprehensive Developed by Sullivan in the early 1970s, CHEM is an even more elaborate model than its
health education predecessor, model for health education planning (MHEP; described later) (McKenzie &
model (CHEM) Smeltzer, 2001; Sullivan, 1973). The model has six steps, with suggested procedures for
(McKenzie & each. As planners work through the steps, they should consider the specific health problem
Smeltzer, 2001; to be addressed, the interplay of the behaviors involved with that health problem, the best
Sullivan, 1973) practices and limitations of health education, and the resources that will be needed to
conduct the program.
CHEM is composed of six steps:
· involve people
· set goals
· define problems
· design plans
· conduct activities
· evaluate results
Effectiveness-based/ Effectiveness-based/rational planning was developed by Kettner and colleagues in 1990 to
rational planning help social service agencies determine whether their programs make a difference in the
(Kettner, Moroney, & life of their clients. It utilizes an inventory to help program planners identify areas of
Martin, 1990) weakness. Experts and clients identify a demand for services, define program needs, and
clarify the relative need for services within each geographic area. Following this assessment,
the model guides the agency through a process to help remedy program limitations.
The planning model consists of seven steps:
· problem analysis
· needs assessment
· selecting a strategy and establishing objectives
· program design
· management information systems
· budgeting
· program Evaluation
Evidence-based/risk Evidence-based/risk factor analysis was developed by Dever in 1997 to help public health
factor analysis practitioners and health care policy makers make evidence-based recommendations for
(Dever, 1997) population-based preventive health services (Dever, 1997). “This cycle of setting priorities,
setting guidelines, measuring performance, and improving performance, which is dependent
on lifelong learning, is continuous and, therefore, moves the process of evidence-based
public health always to the next level of outcome improvement defined by decisions based
on evidence” (Dever, 1997, p. 86). A unique aspect of the model is that it uses an algorithm
to prioritize health problems mathematically based on the size of the problem, the
seriousness of the problem, and the efficacy of available interventions (Dever, 1997).
The planning model consists of five components:
· lifelong learning
· setting priorities
· setting guidelines
· measuring performance
(continued)

Linnan et al. / PLANNING AND PREPARATION OF HEALTH EDUCATORS 9

APPENDIX A (continued)

Model Brief Description

· improving performance
Intervention Intervention mapping was designed by Bartholomew and colleagues in 2001. The authors
mapping explain that “Intervention Mapping is the product of our frustration in teaching health
(Bartholomew, education student the processes involved in planning an intervention” (Bartholomew et al.,
Parcel,Kok, & 2001, p. xvii). Intervention mapping is intended to be used in combination with existing
Gottlieb, 2001) frameworks and models for needs assessment and evaluation. The goal of the evidence in a
model is to help practitioners apply theory and make decisions based on empirical very
practical manner throughout the planning, implementation, and evaluation stages of an
intervention (Bartholomew et al., 2001). The model uses three core processes and five
fundamental steps to create a map of an intervention.
The three core processes direct the decisions made during the five steps:
· searching literature for empirical findings
· assessing and using theory
· issue approach
· concept approach
· general theory approach
· collecting and using new data
The five fundamental steps:
· identify proximal program objectives
· determine theoretical methods and practical strategies
· design program
· adopt and implement intervention
· monitor and evaluate intervention
Multilevel approach MATCH was developed by Simons-Morton and colleagues in 1995. It is a five-phase planning
to community model that uses a social ecology approach to develop multilevel health education and
health (MATCH) promotion interventions. Although PRECEDE-PROCEED emphasizes needs assessment,
(Simons-Morton, MATCH focuses more attention on program implementation (Simons-Morton et al., 1995).
Greene, & This model is intended to be used after behavioral and environmental risk factors have been
Gottlieb, 1995) determined and key factors to target have been established (Simons-Morton et al., 1995). It
helps the practitioner match intervention objectives with appropriate intervention strategies.
MATCH has five phases, each of which has several steps. The five phases are
· goal(s) selection
· intervention planning
· program development
· implementation preparations
· evaluation
Model for health MHEP was first developed by Mico in 1966 and then later refined into the following six
education phases (Cottrell, Girvan, & McKenzie, 1999; Ross & Mico, 1980). In Phase 1, planners
planning (MHEP) develop an understanding of the target population’s problem, develop a relationship with
(McKenzie & the target population, and create awareness of the problem. Phase 2 involves identifying
Smeltzer, 2001; past assessment efforts, as well as collecting and analyzing new data, to describe the
Ross & Mico, problem. In Phase 3 realistic goals should be set to address the problems identified and
1980;) strategies to achieve the goals should be identified. During Phase 4 these strategies are
translated into an implementation plan. Phase 5 is the actual implementation of the
program, and Phase 6 is the evaluation of the program. The data collected during the
evaluation should inform refinements of the program and process.
Composed of six phases:
· initiate
· needs assessment
· goal setting
· planning and programming
· implementation
· evaluation
Each phase focuses on three dimensions:
· content (subject matter)
· method (steps and techniques)
· process (interactions)
Planned approach to PATCH was developed by the Centers for Disease Control and state and local health
community health departments in the mid-1980s to foster the development of effective community-based
(PATCH) (Wurzback, health promotion programs (Wurzback, 2002). It is often used to involve community
2002) members in planning programs for chronic disease prevention and health promotion
10 HEALTH PROMOTION PRACTICE / 2004
APPENDIX A (continued)

Model Brief Description

(Dever, 1997), and historically it has been used in rural settings. Common users are the
health education and promotion divisions of local, state, and federal government health
agencies or community agencies (Dever, 1997).
The PATCH model encourages collaboration among national, regional, and community
levels of governmental and nongovernmental agencies, through the development of
vertical and horizontal networks (Breckon, Harvey, & Lancaster, 1998). These networks
are created to support community programs, with an emphasis on local ownership
(Breckon et al., 1998) and the enhancement of community capacity (Wurzback, 2002).
The model has five phases:
· mobilizing the community
· collecting and organizing data
· choosing health priorities
· developing a comprehensive intervention plan
· evaluating PATCH
The five critical elements to successful utilization of PATCH:
· Community members participate in the process.
· Data guide the development of programs.
· Participants develop a comprehensive health promotion strategy.
· Evaluation emphasizes feedback and improvement.
· The community capacity for health promotion is increased.
Predisposing, Developed by Green and colleagues (1980) in the late 1970s to identify the antecedent
reinforcing, and behaviors of good health and what precedes those behaviors. This model strongly
enabling causes emphasizes diagnostic strategies, helping ensure that programs concentrate on addressing
in educational problems most closely linked to the desired outcome, improved quality of life (Breckon
diagnosis et al., 1988).
and evaluation First, health problems that have the greatest impact on quality of life must be identified
(PRECEDE) (Phases 1 and 2). Then, working backward, health educators must determine what
(Green, Kreuter, behaviors are linked to the health problem (Phase 3). Next, the causes of the health
Deeds, & behavior(s) just identified are categorized into either predisposing, enabling, or
Partridge, 1980) reinforcing factors (Phase 4). When these factors are known, effective ways to intervene
are considered (Phase 5). Finally, administrative barriers and facilitators are assessed
(Phase 6). The authors do not list evaluation as the last phase because they feel that the
evaluation plan should be created throughout the process of planning the intervention
(Green et al., 1980).
PRECEDE has six phases:
· epidemiological and social diagnosis (1 and 2)
· behavioral diagnosis (3)
· educational diagnosis (4 and 5)
· administrative diagnosis (6)
Predisposing, Although the original PRECEDE model is an excellent diagnostic framework, it does not
reinforcing, and offer much guidance in implementation and evaluation. To address this weakness,
enabling PROCEED was created by Green and Kreuter in the early to mid-1980s. PROCEED
constructs in includes an evaluation of policies, regulations, and organizational factors that may affect
educational/ the intervention (Green & Kreuter, 1999). It also guides the developing a budget and
environmental timeline, garnering resources, and creating an evaluation plan (Breckon et al., 1998).
diagnosis and Together, the PRECEDE-PROCEED model is much more comprehensive than the original
evaluation PRECEDE model.
(PRECEDE)— The modified PRECEDE model has five phases:
Policy, · social diagnosis
regulatory, and · epidemiological diagnosis
organizational · behavioral and environmental diagnosis
constructs in · educational and organizational diagnosis
educational and · administrative and policy diagnosis
environmental PROCEED has four phases:
development · implementation
(PROCEED) · process evaluation
(Green & · impact evaluation
Kreuter, 1999) · outcome evaluation

Linnan et al. / PLANNING AND PREPARATION OF HEALTH EDUCATORS 11

 APPENDIX B
Sample Questions Included in
Final Program Plan Assignment
Final Reflection on the
PRECEDE planning process
This portion of the program planning document is
designed to summarize your critical thoughts about
using PRECEDE/PROCEED to plan, implement, and
evaluate your selected health/social program, and to
compare this process with at least one other planning
model of your choosing. Specifically, answer the fol-
lowing questions in your final reflection effort:
• What are at least three strengths and three limitations
of using the PRECEDE/PROCEED planning process?
• Describe at least one other planning model and
explain how it could have been used to address the
particular health/social problem you addressed.
• What are three strengths and three limitations of this
(other) planning model?
• What are two primary advantages to using this (other)
planning model over PRECEDE/PROCEED?
• What are two important disadvantages to using this
(other) planning process over PRECEDE/PROCEED?
You have recently been hired as a new health educator in a
county health department in a rural county in eastern
North Carolina. Obesity is on the rise among children in
your county and your health director has been asked to
address this issue. She asks you if you would help put the
plan together to address this problem and present it to the
county commissioners in 2 months. If you had the choice
of any planning approach described in class (or one you
create), which one would you use for this real-world prob-
lem . . . and WHY did you choose this approach?
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