Journal of Health Education Teaching Techniques
Vol. 2, No. 2, pp. 1–15
A Section of the PRECEDE–PROCEED Model
and Its Application in Fictional Podunk,
Texas: A Strategy for Preparing Future
Health Education Specialists to Use
Planning Models
Virginia Braly, Texas A&M University
Ann Amuta, Texas A&M University
Elisa Beth McNeill, Texas A&M University
Abstract
This scenario-based teaching technique is used to demonstrate the application of the PRECEDE portion of the PRECEDE–PROCEED model.
Objectives
1.
2.
3.
4.
After completing this guided learning activity, students will be able to
identify sources of health data,
list and describe behaviors that may contribute positively or negatively to
health status,
determine the health behavior most appropriate for an intervention using
a priority matrix, and
state examples of predisposing, reinforcing, and enabling factors.
Primary Audience
This activity is designed for undergraduate students in the field of health
education/promotion and may be extended for graduate students.
Virginia Braly, MS graduate, Texas A&M University, Department of Health and Kinesiology.
Ann Amuta, PhD candidate, Texas A&M University, Department of Health and Kinesiology.
Elisa Beth McNeill, clinical associate professor, Texas A&M University, Department of Health
and Kinesiology. Please send author correspondence to [email protected]
Acknowledgement. The authors would like to thank Dr. Buzz Pruitt for his mentorship and contributions to the development of this manuscript.
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Braly, Amuta, McNeill
Planning models provide health education specialists with an organized
and logical framework for creating health promotion interventions. The PRECEDE–PROCEED model (PPM) is one framework that challenges health education specialists to plan and evaluate health promotion programs by focusing
on the preferred outcome (Crosby & Noar, 2011). In the model, the outcome
of interest is identified first and then used to investigate factors that positively
or negatively impact it (Crosby & Noar, 2011). This backward design is different from other planning models because it is focused on the bigger picture of
enhancing quality of life (Green & Kreuter, 2005; Green & Rabinowitz, 2012).
The model has two distinct phases: PRECEDE steps are diagnostic and the
PROCEED component is evaluative (National Cancer Institute [NCI], 2005).
The PRECEDE portion will be the focus of this teaching technique. PRECEDE
includes “social assessment, epidemiological assessment, behavioral and environmental assessment, educational and ecological assessment, and administrative and policy assessment” (NCI, 2005, p. 40). The PPM can be used to
consider ways to alter people’s behavior and environment at multiple levels by
acting as a template for conceiving, planning, implementing, and evaluating a
community intervention.
Planning models based on theory, such as the PPM, are important tools
used to design health interventions. According to the NCI (2005), “[they] help
practitioners develop programs step by step, integrating multiple theories to
explain and address health problems” (p. 36). Individuals who prepare professional health education specialists should find useful teaching techniques that
enhance students’ abilities to move from simple comprehension of these steps
to more complex evaluative perspectives. Students new to the field of health
education often struggle when attempting to connect the abstract concepts of
PPM with how to transfer them to authentic situations. Students can use systematic problem-solving methods, such as the ones in this teaching technique,
to develop their ability to think abstractly (Prince & Felder, 2013).
Results from research indicate that using collaborative learning strategies
facilitates mastery of concepts and has positive effects on learning outcomes
(Prince, 2004). Collaborative learning occurs when pairs or small groups share
responsibility and authority for achieving learning outcomes (Udvari-Solner,
2012). In smaller groups, students develop deeper understanding of content
and professional competencies including critical thinking, communication
skills, and interpersonal relations. In this teaching strategy, small groups of
students will analyze and discuss the possible health challenges of the hypothetical small town of Podunk, Texas, while systematically working through
the PRECEDE portion of the PPM.
PRECEDE–PROCEED Model
3
Objectives
The Podunk, TX activity is designed for two 50-minute class sessions. After
completing this activity, students will increase skills associated with using the
PRECEDE portion of the PPM by
• identifying three sources of data related to health (Step 2);
• using action verbs to list and describe six or more behaviors that may
contribute positively or negatively to health status (Step 3);
• identifying four health behaviors to place into a priority matrix to determine the behavior most appropriate for an intervention (Step 4);
and
• stating two or more examples each of predisposing, reinforcing, and
enabling factors (Step 6).
Objectives in the Podunk, TX activity are designed to align with the Certified Health Education Specialist competencies (National Commission for
Health Education Credentialing, 2010). (See Table 1 for further alignment explanation.)
Table 1
Alignment of Steps in Podunk, TX Activity With the Certified Health Education
Specialist Responsibilities and Competencies
Certified Health Education Specialist competency
Location within
activity
1.2.1: Identify sources of data related to health
Step 2
1.4.1: Identify factors that influence health behaviors
Step 3
1.4.3: Identify factors that enhance or compromise health
Step 3
1.7.3: Prioritize health education needs
Step 4
1.6.4: Assess social, environmental, and political conditions that
may impact health education
Step 6
Materials and Resources
•
•
•
Podunk, TX handout per student (Figure 1)
National Commission for Health Education Credentialing competencies alignment applied to this teaching technique (Table 1)
Assessment rubric (Table 2)
Primary Audience
This activity is designed for undergraduate students in the field of health
education/promotion, and it may be extended to graduate students for independent application (see Extension for Graduate Students under Procedure
section).
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Braly, Amuta, McNeill
Procedure
Day 1
1. Read aloud the Podunk, TX scenario (page 1 of Figure 1). Distribute the
Podunk, TX handout (Figure 1) to each student, and divide the class into
groups of three or four.
2. Read aloud the introduction and Step 1 instructions in Figure 1. Re-create
the continuum on the board in the classroom. Have the students indicate
where the teacher should mark the C (current health status of the Podunk
youth) and P (potential health status of the Podunk youth) to represent
the average mark for the class. Ask the class their reasoning for each placement. Expect students to place the P closer to the optimal health end than
the C, indicating there is room for improvement in the health status of the
youth. If students do not place the P closer to the optimal health, a discussion should follow to evaluate why the students do not see the potential for
improvement.
3. Read aloud the Step 2 instructions in Figure 1.
4. Lead a discussion by calling on students to report their responses. Potential
student responses may include local or state health department, Centers for
Disease Control and Prevention website, and U.S. Census Bureau. Students
also may suggest focus groups, community leaders, or a needs assessment.
5. Read aloud the Step 3 instructions in Figure 1. Clarify what a behavior is—
an action the participant is taking/doing—and ask students to use action
verbs when listing behaviors. This distinction is important to note because
health education specialists cannot change teen pregnancy on its own, but
the behavior of teens engaging in unprotected sex can be changed. Encourage students to list as many behaviors and environmental factors as possible (not just the minimum of six and two, respectively).
6. Have the students discuss their responses to Step 3 in Figure 1 in their
small groups, and then ask students to share in a class discussion.
a. Potential student responses for behaviors may include the following:
• spending a lot of time outside, walking a lot (hunting);
• experiencing low levels of stress (slower paced lifestyle), experiencing high levels of social support;
• drinking alcohol, chewing tobacco;
• recklessly carrying/storing weapons, fighting, racing;
• having poor eating habits, having a sedentary lifestyle ;
• engaging in unprotected sex;
PRECEDE–PROCEED Model
•
•
•
•
5
using the convenience store for after-school snacks;
riding ATVs near the power plant;
participating in high-risk sports, being at risk for farming accidents; and
being less educated on health issues.
b. Potential student responses for environmental factors include the
following:
• lack of health services,
• lack of health education/promotion,
• close proximity to power plant, and
• close proximity of convenience store to the high school.
7. Read aloud the Step 4 instructions in Figure 1. Have students discuss their
responses to Step 4 in their small groups, and then ask students to share in
a class discussion. There is no right or wrong answer; however, the students
need to justify why they placed each behavior in the respective box.
8. Read aloud the Step 5 instructions. Lead a class discussion about the priority behavior each student group identified by asking the following questions:
a. “Based on what we hypothesized is affecting the youth’s health in
Podunk, is it better to design an intervention that increases positive
behavior, decreases negative behavior, or both?” Any response is appropriate as long as the students provide justification, demonstrating
they have critically thought about their choice. A potential student
response may be, “Depending upon the behavior, promoting positive
behaviors may be more motivational than discouraging negative behaviors.”
b. “Why do we choose the behavior that is most changeable and most
important for our intervention? Why not take on a more challenging
one?” A potential response could be that time and resources call for
a focused approach with a measurable impact, necessitating that the
most changeable and important behavior be targeted.
Day 2
9. Recap with the students on the material covered from Day 1 (Figure1). For
example, “Now that we have determined the health status of the youth of
Podunk, identified resources for gathering epidemiological information,
listed health-enhancing and hindering behaviors, prioritized those behaviors, and identified a behavior to target (Step 5 in Figure 1, social and epidemiological assessments, and behavioral and environmental diagnosis),
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Braly, Amuta, McNeill
we will now determine factors that influence the behavior (educational and
ecological assessment and administrative and policy assessment).”
10. Read aloud the Step 6 instructions in Figure 1. Small groups discuss predisposing, reinforcing, and enabling factors and then share in a class discussion.
a. Potential student responses for predisposing factors, using the behavior of chewing tobacco as an example, may include (a) negative factors such as the individual likes how it feels, is addicted, thinks it is a
normal part of life, thinks it looks cool, may have limited knowledge of
the health implications of the behavior and (b) positive factors such as
tobacco causes bad breath and turns teeth yellow. The negative factors
described would be considered undesirable and, therefore, are more
likely to discourage the behavior. The converse is true for positive factors.
b. Potential student responses for reinforcing factors, using the behavior
of chewing tobacco as an example, may include (a) negative factors
such as the coach gives everyone on the baseball team dip, the individual’s dad dips while on the farm, tobacco use is not frowned upon,
there is peer pressure to dip and (b) positive factors such as kids are
fearful because their friend was diagnosed with lip cancer and girls
may think the behavior is gross. Negative reinforcing factors function
to normalize the behavior and promote it as acceptable. The converse
is true for positive reinforcing factors.
c. Potential student responses for enabling factors, using the behavior of
chewing tobacco as an example, may include (a) negative factors such
as tobacco is readily available, individuals are allowed to carry tobacco
on campus, tobacco is sold to minors, individuals are unaware of resources for cessation and (b) positive factors such as tobacco is expensive and laws currently exist to prohibit the sale of tobacco to minors.
Negative enabling factors function to facilitate the performance of the
behavior, and the converse is true of positive enabling factors.
11. Read aloud the Step 7 instructions in Figure 1. Discuss the influence programs (a) and policies (b) may have on the identified target behavior. Potential student responses may include (a) the Grow Your Health program
and the child care program at the high school and (b) the existence of a law
to prevent sale of chewing tobacco to minors.
PRECEDE–PROCEED Model
7
12.Conclude the lesson by emphasizing how the PRECEDE portion of the
PPM represents the first half of the planning model—the assessment phase
of planning a health promotion intervention.
Extension for Graduate Students
To take the guided experience of Podunk, TX further, continue to Step 8 by
reading the instructions aloud. This step encompasses designing intervention
strategies to target predisposing, reinforcing, and enabling factors that were
identified in Step 6. Ask the students to create an intervention strategy to target
each factor.
a. Potential student responses, using the behavior of chewing tobacco,
may include the following:
i. Health Behavior to Target: Decrease the number of youth who
chew tobacco
ii. Identified Predisposing Factor: Chewing tobacco makes one look
cool
1. Intervention Strategy: Implement a “Who Would You Want
to Date?” campaign with pictures showing the aesthetic effects
of chewing tobacco.
iii. Identified Reinforcing Factor: Peer pressure to chew tobacco
1. Intervention Strategy: Implement a “How to Say No” to tobacco program
iv. Identified Enabling Factor: A lack of chewing tobacco cessation
resources
1. Intervention Strategy: Implement a campaign about available
resources and how to use them.
Assessment Technique
Using the assessment rubric (Table 2), evaluate learning expectations of
group members throughout the activity. The rubric may be shared with students prior to instruction and activity to ensure they are aware of the formal
grading criteria for the activity.
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Braly, Amuta, McNeill
Welcome to Podunk, Texas! This imaginary “sleepy” town of 15,000 residents, the
county seat of Boonies County, is located in Central Texas. In this small town community,
places for shopping, dining, and nightlife are limited compared to a big city. However, residents enjoy their local businesses, which include the town Y-Mart, Dairy Princess drivein burger joint, Murphy’s gas station/convenience store (which doubles as a beer joint at
night), and Papa Joe’s Pool Hall.
Residents can shop for groceries and produce at the local minimarket located at the
southernmost end of town. In the middle of the community, you’ll find the town square,
which has a small park and shops offering clothing, furniture, and home improvement
items. The town’s only high school, located near Murphy’s on the northernmost side of
town, serves as a hub for community activities. Many of Podunk’s residents work as farmers and ranchers, or they are employed at the fertilizer plant located about 10 miles outside
of town. Entertainment for the youth of Podunk primarily consists of participating in the
county fair and rodeo, raising livestock for show, hunting, fishing, and playing on the high
school’s sports teams. Youth are also encouraged to participate in Grow Your Health, a farmto-market agriculture program offered by the local 4-H chapter.
Recently, local government officials have begun to recognize the need to promote
the health and well-being of the community, specifically of the youth. There has been an
atmosphere of unease among residents since a 17-year-old Podunk High baseball player
was diagnosed with lip cancer earlier this year. Although a law exists to prevent minors
from purchasing tobacco, it is rarely enforced in Podunk. Additionally, some community
members were displeased to hear that the high school had to create a child care program
due to the increased number of teen pregnancies among students. Even the predominantly
overweight city council members have acknowledged the increased rate of obesity among
residents, including adolescents. It has become clear that action to enhance the health of
Podunk youth is a priority.
Recognizing the need for specialized help, local government officials have allotted
funds to hire a health education specialist for the first time in the city’s history. This move
came against a backdrop of opposition from an outspoken minority in the community that
would rather see the tax dollars spent elsewhere. Nevertheless, the contract was announced,
and you were hired. Your job description is ambiguous—put simply, “…make a positive
impact on the health of the youth of Podunk.”
Figure 1. Podunk, TX student handout.
PRECEDE–PROCEED Model
9
You spent the first few weeks on the job becoming acquainted with the community,
getting to know the “movers and shakers” of the county, and thinking about how
you will make a difference in the youth’s health. Now it is time to start planning your
intervention.
Step 1 – Social Assessment:
A. Place a C on the continuum line that best represents the location of
what you believe is the current health status of the Podunk youth.
B. Next, using a P, mark where you believe the potential state of
health could be for the youth of Podunk. Be prepared to justify your
reasoning.
Optimal Health -----------------------------------------------------------Minimal Health
Step 2 – Epidemiological Assessment: Now that you have an idea of
the current health status of the youth of Podunk, the next step is to find
resources that can provide factual information about the health issues
that affect Podunk adolescents. List at least three credible sources of
information.
1.
2.
3.
Figure 1 (cont.)
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Braly, Amuta, McNeill
Step 3 – Behavioral/Environmental Diagnosis: Now that you have
a better understanding of the health issues that adolescents face
(from researching the sources you identified in Step 2), list at least six
behaviors and two environmental factors that you believe may impact
the health status of Podunk youth. Behaviors and environmental factors
may be positive (health enhancing) or negative (health compromising).
Include examples of both in your grid.
Health enhancing (+)
Health compromising (-)
Behaviors:
Behaviors:
Environmental factors:
Environmental factors:
Step 4 – Behavioral/Environmental Diagnosis continued: Choose
one behavior from Step 3 that meets the indicated criteria for each
space in the prioritizing grid. Include justification for your reasoning.
Highly Important
Behavior:
High Changeability Justification:
Behavior:
Lesser Changeability Justification:
Figure 1 (cont.)
Less Important
Behavior:
Justification:
Behavior:
Justification:
PRECEDE–PROCEED Model
11
Step 5: List the one behavior from the prioritizing grid in Step 4 that
you found is the most important and most changeable.
Step 6 – Educational and Ecological Assessment: Identify factors
that predispose, reinforce, or enable the teenagers of Podunk to the
behavior you identified in Step 5. Explain how each factor influences
the behavior.
Identify two or more factors that predispose the behavior. Explain your reasoning.
Predisposing factors are characteristics that motivate or provide reason for a behavior;
they include knowledge, attitudes, cultural beliefs, and readiness to change (National
Cancer Institute, 2005, p. 41).
Now, identify two or more factors that reinforce the behavior. Explain your reasoning.
Reinforcing factors are events, actions, or individuals that encourage repetition or
persistence of behavior by providing continuing rewards or incentives such as social
support, praise, reassurances (National Cancer Institute, 2005, p. 41).
Figure 1 (cont.)
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Braly, Amuta, McNeill
Finally, identify two or more factors that enable the behavior. Explain your reasoning.
Enabling factors are factors that allow persons to act on their predispositions; these
factors include available resources, supportive policies, assistances, and services
(National Cancer Institute, 2005, p. 41).
Step 7 – Administrative and Policy Assessment: Identify existing
programs and policies in Podunk that contribute to the health of the
youth.
Programs:
Policies:
The people who participated in this activity include:
_______________________________________
_______________________________________
_______________________________________
_______________________________________
Figure 1 (cont.)
PRECEDE–PROCEED Model
13
Extension for Graduate Students
Step 8 – Design Intervention Strategies: In the chart below, list the behavior from
Step 5 that you believe is most important and most changeable under the Health
Behavior to Target section. Next, choose one predisposing, reinforcing, and enabling
factor that influences the behavior. Describe an intervention strategy that would
target each factor. An example is provided.
Step 8 Example
Health behavior to target: Increase youth participation in physical activity
Type of
enabling
factor
Predisposing
Identified factor
Deficiency in skills needed to
use the equipment at the local
YMCA
Intervention strategy
Train a group of students on
how to use the gym equipment.
Have these students serve as
peer educators who can teach
other students during an open
gym night community event.
Health behavior to target:
Type of
enabling
factor
Predisposing
Reinforcing
Enabling
Figure 1 (cont.)
Identified factor
Intervention strategy
Braly, Amuta, McNeill
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Table 2
Assessment Technique
All
indicators
present
1
Missing
50% or
fewer
indicators
0
0
Missing
51% or
more
indicators
Teachers’s
total:
Teacher’s
rating
A Planning Model for Podunk, Texas:
A Place You Want to Live
2
1
Group members’ names:
Learners identified three or more sources of credible data related to the topic
(Step 2)
2
Assessment criteria
Learners used action verbs to list six or more behaviors and two environmental
factors that may negatively or positively impact the target population (Step 3)
0
0
1
1
2
2
Learners identified four behaviors appropriate to represent the criteria of
the prioritizing grid and provided a justification for selecting each behavior
identified (Step 4)
Learners stated two or more examples of each predisposing factors,
reinforcing factors, and enabling factors that influence the behavior of the
target population (Step 6)
Total: 8 points possible
8 = A (100%)
7 = B (87.5%)
6 = C (75%)
5 = D (62.5%)
4 or more = F
PRECEDE–PROCEED Model
15
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