Application of the PRECEDE-PROCEED

Planning Model in Designing an Oral Health

Strategy

Sabin Thapa
Sanjita Shahi
Background
• The poor oral health of adults with intellectual and developmental
disabilities (IDD) living in community settings constitutes a significant
health difference in the United States.
• Efforts have been made to develop and evaluate various strategies to
improve the oral hygiene and oral health of this vulnerable population
with minimal to moderate success.
• None of these interventions used a planning model or theory-based
behavior change intervention for caregivers of individuals with IDD.
• The PRECEDE-PROCEED model can be used to design and evaluate an
oral health promotion effort.
• The PRECEDE component allows a researcher to work backward from
the ultimate goal of the research (distal outcomes) to create a
blueprint to instruct the formation of the intervention or strategy.
• The PROCEED component may lay out the evaluation, including pilot
study and efficacy study methodologies.
Method
• Application of the PRECEDE-PROCEED Model as a planning tool for
oral health.
• PRECEDE outlines a diagnostic planning process to assist in the
development of targeted and focused public health programs.
• PROCEED highlights the implementation and evaluation of the
intervention designed in the PRECEDE component.
• PRECEDE Planning Model Component
• Phase 1 - Social Assessment
• Phase 2 - Epidemiological, Behavioral, and Environmental Assessment
• Phase 3 - Educational and Ecological Assessment
• Phase 4 - Intervention Alignment and Administrative and Policy Assessment
• PROCEED Planning Model Component
• Phase 5 - Pilot Study
• Phase 6 - Implementation
• Phases 7 and 8 - Process and Outcome Evaluation
Results
• A The PRECEDE assessment and strategy design results are presented
including a conceptual framework and oral health strategy that are
linked to social cognitive theory and Health Action Process Approach
• The planned PROCEED component of the planning model includes a
description of an in-process pilot study to refine the oral health
strategy, along with a future randomized controlled clinical trial to
demonstrate its effectiveness
PRECEDE Model Component
PRECEDE Phase 1 - Social Assessment
• Solicited input from the community ; stated that poor oral health is one of the
greatest unmet health care needs of their population.
• Association of aspiration of bacteria from the mouth into the lungs with
respiratory infections.
• Improve oral health and oral health-related quality of life including respiratory
health
PRECEDE Phase 2 - Epidemiological, Behavioral, and Environmental
Assessment
A. Epidemiological Assessment
• Children and adults with mild to profound IDD lived at home or were placed in large
state institutions
• Overall QOL may have been improved for this vulnerable population, access to
dental care has become limited or non-existent
• lack of preventive dental treatment every six months but also by their inability to
adequately brush and/or floss their own teeth
• Providing oral care with IDD is challenging
• Caregiver behavioral capacity reduced disparity and imperative for improving health
B. Behavioral Assessment
• physical, behavioral, and cognitive disabilities that negatively impact their
ability to perform their own oral hygiene practices
• do not prioritize brushing or flossing their teeth on a regular basis and often
do not know how to perform these practices optimally
• caregivers also play a key role in shaping the behavior of adults with IDD
C. Environmental Assessment
• First, physical environment in group homes is frequently not conducive to
optimal oral hygiene practices.
• Second, there were no policies or procedures in place concerning oral health
or oral hygiene practices
PRECEDE Phase 3 - Educational and Ecological Assessment
A. Predisposing Factors
• Self-efficacy : “people's judgments of the capabilities to organize and execute
courses of action required to attain designated types of performances”
• Outcome expectancies : “a person's estimate that a given behavior will lead to
certain outcomes”
• Behavioral capability : someone's actual ability to perform a behavior in real-
life situations
B. Enabling Factors
• Planned action : enabling factor that has been shown to impact caregiver
behavior and is a key construct of the Health Action Process Approach
• Capacity building : process through which the abilities to do certain things are
obtained, strengthened, adapted, and maintained over time
• Environmental adaptation : utilizing oral hygiene aids, may also improve
caregiver behavioral capability and the oral health of adults with IDD
C. Reinforcing Factors
• coaching and monitoring oral health practices
• caregiver self-efficacy, outcome expectancies, behavioral capabilities, and
environmental influences
• a web-based monitoring system
PRECEDE Phase 4a - Intervention Alignment
• Four-component for oral health strategy
• planned action
• capacity building
• environmental adaptations
• reinforcement activities
PRECEDE Phase 4b - Administrative and Policy Assessment
• Administrative assessment need the following key factors:
1. support of the organizations that provide community services for the individual
residents with IDD
2. behavioral contracts with the Directors of Residential Services of these organizations
to delineate the roles and responsibilities of these key individuals
• In policy assessment the following would be needed:
1. a randomized controlled trial to produce evidence of impact on oral health outcomes,
2. implementation of a monitoring policy by the organization providing services for the
adults with IDD
3. preliminary evidence of the sustainability of the strategy
PROCEED Model Component
• PROCEED 5 - Pilot Study
• Participants: Caregivers and adults with IDD
• Designed to assess:
• Dosage
• Implementation fidelity and,
• Participant reactions
• Duration: 1 month
• PHASE 6 - Implementation of the Oral Health Strategy

• Four major activities:

• Negotiation of behavioral contract with caregivers to participate.
• Design of strategy to promote capacity building in the caregivers.
• Find and evaluate adaptive devices and/or behavioral strategies and
• Assist the caregivers in selecting and assessing reinforcements.
• PHASE 7 – Process Evaluation
• Produce frequency and percentages for all process measures. (dosage,
fidelity, and participant reaction)
• Experts panel for inferential analysis
• Perform bootstrap analysis to increase confidence.
• T- statistics
• PHASE 8- Outcome Evaluation
• Produce outcome data for caregivers and adults with IDD.
• To answer research questions about intervention direct effects, a three-level
hierarchical linear model (HLM) random intercept regressions will be used.
• For dichotomous outcomes Hierarchical non-linear modeling (HNLM).
• Multilevel structural equation model (MSEM) procedures for assessment of
mediating and moderating effects.
Conclusion
• The application of the PRECEDE-PROCEED planning model presented
here demonstrates the feasibility of this planning model for
developing and evaluating interventions for adults within the IDD
population.
Reference
• Binkley, C. J., & Johnson, K. W. (2013). Application of the PRECEDE-PROCEED
Planning Model in Designing an Oral Health Strategy. Journal of Theory and
Practice of Dental Public Health, 1(3), http://www.sharmilachatterjee.com/ojs-
2.3.8/index.php/JTPDPH/article/view/89.