Section 2. PRECEDE/PROCEED

Learn how to develop a coherent plan that addresses necessary issues and actions using the Precede-Proceed model.

 

• What is PRECEDE-PROCEED?

• Why use PRECEDE-PROCEED?

• How do you use PRECEDE-PROCEED?

If you were a contractor setting out to build a wood-frame house, you wouldn’t just pick up whatever wood you found lying around and begin. You’d consult first with the owner, and start with an idea of the house she wanted – its size, its shape, its features. You’d want a picture of the finished house, and a floor plan as well, with some notes on measurements and materials. You’d plan the construction with her, and set out a process for getting it done. And you’d do all this before you ever picked up a tool, because otherwise the process would be hit-or-miss: she wouldn’t get the house she wanted, and your time would be wasted.

The same is true if you’re developing an intervention to address a health or community issue. It makes no sense to pick an issue at random, and to use whatever service happens to be available to try to address it. You have to consult with the community, understand and analyze community information, your own and others’ observation, and the context of the issue to create an intervention that will actually bring about the changes the community wants and needs.

In the first section of this chapter, we introduced the need for a process for doing health and community work. In this section, we’ll look at PRECEDE-PROCEED, the first of several specific models that may prove helpful to you in carrying out your own work. We’ll examine other models in subsequent sections of this chapter. Then in the last section, we’ll examine some ways in which elements of various models can be combined to respond to your particular situation.

What is PRECEDE-PROCEED?

Like most of the other models we’ll examine in this chapter, PRECEDE-PROCEED was developed for use in public health. Its basic principles, however, transfer to other community issues as well. As a result, we’ll treat it as a model not just for health intervention, but for community intervention in general. And in fact, PRECEDE/ PROCEED focuses on the community as the wellspring of health promotion.

In the latter half of the 20th Century, as medical advances eliminated many infectious diseases, the leading causes of disability and death in the developed world changed to chronic conditions – heart disease, stroke, cancer, diabetes. The focus of health maintenance, therefore, shifted from the treatment of disease to the prevention of these conditions, and, more recently, to the active promotion of behaviors and attitudes – proper diet, exercise, and reduction of stress, for instance – that in themselves do much to maintain health and improve the length and quality of life.

Behind PRECEDE-PROCEED lie some assumptions about the prevention of illness and promotion of health, and, by extension, about other community issues as well. These include:

• 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. PRECEDE-PROCEED should be a participatory process, involving all stakeholders – those affected by the issue or condition in question – from the beginning.
• Health is, by its very nature, a community issue. It is influenced by community attitudes, shaped by the community environment (physical, social, political, and economic), and colored by community history.
• 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.

AIDS has changed the way many people in the US view and practice sex, for instance. In some other countries, it has affected the whole social structure because of the number of orphans it has created, and its impact on the workforce. By the same token, youth violence changes the views and actions of many people who are at no risk of being its victims, and may put a community at an economic disadvantage by making it less attractive to new business or industry. Almost any other issue could serve equally well as an example of the broad reach of community problems (or assets, for that matter).

• Finally, health is more than physical well-being, or than the absence of disease, illness, or injury. It is a constellation of factors – economic, social, political, ecological, and physical – that add up to healthy, high-quality lives for individuals and communities.

This broad perspective on health extends to other community issues. We can define the health of a community as its fitness in many areas, of which citizens’ physical health is only one. Indications of a community’s overall health include how well it:

• Contributes to the stability of families
• Nurtures and supports children
• Fosters lifelong learning
• Provides meaningful work for its citizens
• Invites involvement in the democratic process
• Cares for those who need help
• Protects and sustains the natural environment
• Encourages the arts
• Values and encourages racial and cultural diversity
• Works to promote and maintain safety and physical well-being for its members

PRECEDE and PROCEED are acronyms (words in which each letter is the first letter of a word). PRECEDE stands for Predisposing, Reinforcing, and Enabling Constructs in Educational/Environmental Diagnosis and Evaluation. As its name implies, it represents the process that precedes, or leads up to, an intervention.

PROCEED spells out Policy, Regulatory, and Organizational Constructs in Educational and Environmental Development, and, true to its name as well, describes how to proceed with the intervention itself.

PRECEDE has four phases, which we’ll explore in greater detail later in the section:

• Phase 1: Identifying the ultimate desired result.
• Phase 2: Identifying and setting priorities among health or community issues and their behavioral and environmental determinants that stand in the way of achieving that result, or conditions that have to be attained to achieve that result; and identifying the behaviors, lifestyles, and/or environmental factors that affect those issues or conditions.
• Phase 3: Identifying the predisposing, enabling, and reinforcing factors that can affect the behaviors, attitudes, and environmental factors given priority in Phase 2.
• Phase 4: Identifying the administrative and policy factors that influence what can be implemented.

Another premise behind PRECEDE-PROCEED is that a change process should focus initially on the outcome, not on the activity. (Many organizations set out to create community change without stopping to consider either what effect their actions are likely to have, or whether the change they’re aiming at is one the community wants and needs.) PRECEDE’s four phases, therefore, move logically backward from the desired result, to where and how you might intervene to bring about that result, to the administrative and policy issues that need to be addressed in order to mount that intervention successfully. All of these phases can be thought of as formative.

PROCEED has four phases (also to be discussed in more detail later) that cover the actual implementation of the intervention and the careful evaluation of it, working back to the original starting point – the ultimate desired outcome of the process.

• Phase 5: Implementation – the design and actual conducting of the intervention.
• Phase 6: Process evaluation. Are you actually doing the things you planned to do?
• Phase 7: Impact evaluation. Is the intervention having the desired impact on the target population?
• Phase 8: Outcome evaluation. Is the intervention leading to the outcome (the desired result) that was envisioned in Phase 1?

A word about logic models: Although most formal models, like PRECEDE-PROCEED present themselves as the way to structure an intervention or other activity, the word “logic” implies that you should carefully consider your own situation as well as the model. If there are reasons why a particular part of a model might not work for you, it’s reasonable (logical) to change it. While PRECEDE-PROCEED presents a structure that could conceivably work well (and has worked well) in a variety of situations, it’s still important to think about whether all parts of it will work for you.

A flow chart of the model (see Fig. 1), developed by its originators, shows a circular process. It starts (on the upper right) with a community demographic and quality-of-life survey, and goes counterclockwise through PRECEDE’s four phases that explain how to conceive and plan an effective intervention. PROCEED then picks up with the intervention itself (described here as a health program), and works back through the first five phases, evaluating the success of the intervention at addressing each one (The process evaluation in Phase 6 looks at whether the intervention addressed the concerns of Phase 3 as planned. The impact evaluation of Phase 7 examines the impact of the intervention on the behaviors or environmental factors identified in Phase 2. And the Outcome evaluation of Phase 9 explores whether the intervention has had the desired quality of life outcome identified in Phases 1 and 2). Eventually, the process arrives back at the beginning, either having achieved the desired quality of life outcome, or to start over again, incorporating the lessons of the first try. The arrows in the flow chart demonstrate the effects of each phase’s issues on the next one to the right. Since you’re working backwards from the ultimate outcome, effects move to the right. If the chart was demonstrating the direction of analysis, the arrows would point in the opposite direction.

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.

 

• 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.
• Another basic premise of the model is that the purpose of a health program – and by extension, the purpose of any proactive type of community intervention – is to improve the quality of life for individuals and their community, and that the two are largely inseparable. Thus, any intervention should be community-based, and should look at the needs of the community, even if the intervention is aimed at a more specific target group.
• A final premise of any community-based model for intervention is that planning and implementing a community intervention calls for a joint effort among (health and other) professionals and organizations, policy makers, community officials, community leaders, and community members at large, including members of the target population. In order to ensure accurate information and community support, all elements of the community should be involved in the process from the beginning.

Why use PRECEDE-PROCEED?

First, there are good reasons for using some kind of logic model or theoretical framework for any intervention:

• It provides a structure within which to plan your work, so that you’re not simply grasping at straws. As a result, you’re more likely to develop a coherent plan that addresses the necessary issues.
• Most models give you either a guide or a foundation for critical analysis of the issues at hand. That doesn’t guarantee that your analysis will be complete or accurate, but it significantly increases the chances. (See Analyzing Community Problems and Solutions, for more on logical analysis.)

This is not to say that you have to use a logic model. There are other ways to approach developing an intervention, many of them outlined in the Community Tool Box. The advantage of PRECEDE-PROCEED and similar models is that they tell you exactly what to do: you follow directions, and you have a procedure for developing an intervention. The disadvantage of these models is that they tell you exactly what to do: if some part of the model isn’t appropriate for your setting or your circumstances, you’ll have to realize that, and change it to fit, or risk a problem. PRECEDE-PROCEED now offers a flow chart or algorithm to facilitate decisions for skipping some steps or phases, thereby tailoring the model to different local situations.

Usually, the originators of the model will tell you that you have to follow it exactly. In fact, that’s rarely the case. If you like the model, you can be sure to include all its elements, but you can still change some of them, change the timing, even change the order to better match the needs of your community. You might also find yourself taking some pieces of one model and grafting them on to another, or reinterpreting a model in light of a particular theoretical framework.

Over and above the use of logic models in general, there are some good reasons for using PRECEDE-PROCEED specifically:

• PRECEDE-PROCEED provides a template for the process of conceiving, planning, implementing, and evaluating a community intervention.
• PRECEDE-PROCEED is structured as a participatory model, to incorporate the ideas and help of the community. That means that its use will provide you with more, and more accurate, information about the issues in question, and with a better understanding of their history and context in the community.
• Community involvement is also a means of building community ownership of the intervention, leading to more community support and a greater chance of success.
• PRECEDE-PROCEED considers the ways in which administrative and policy guidelines can limit or shape an intervention, an area of planning too often ignored.
• PRECEDE-PROCEED incorporates evaluation of the process, the intervention itself, and the final outcome. That allows the intervention to be monitored and adjusted to respond to community needs and changes in the situation, and checks that its accomplishments actually lead to the projected goal.
• Although PRECEDE-PROCEED sets out a strict process, it says much less about content. It leaves plenty of leeway for adapting your intervention’s design and methods to the situation, the needs of the community, etc.

Although these are good reasons to use PRECEDE-PROCEED, they are also good reasons to use some of the other models in this chapter. This is the reason we are presenting several – so that you can decide which among them, if any, makes the most sense to you, and would be best for your circumstances and community. PRECEDE-PROCEED’s greatest strength may be its comprehensive and rigorous structure – it covers all the bases.

How do you use PRECEDE-PROCEED?

Logic models don’t really mean much unless you actually use them in the community. Once you’ve decided that PRECEDE-PROCEED provides a good model for your intervention, how do you translate it into action? We’ll look at each of the nine phases of the model with that question in mind.

PRECEDE: Doing the groundwork. PRECEDE starts by determining the desired outcome for the community, and then works back to what has to be done to obtain that outcome. Each phase moves one step closer to the actual intervention.

Our presentation of the model assumes that, although it was developed for use in public health, it can be used by activists or organizations concerned with any issues that affect the quality of life in a community, as seen in some of the 950 published applications.

Phase 1: Defining the ultimate outcome. The focus here is on what the community wants and needs, which may seem unrelated to the issue you plan to focus on. What outcome does the community find most important? Eliminating or reducing a particular problem (homelessness)? Addressing an issue (race)? >Improving or maintaining certain aspects of the quality of life (environmental protection?) Improving the quality of life in general (increasing or creating recreational and cultural opportunities)?

This phase starts with the collection of demographic data, which is then presented to the community to help citizens decide on priorities. The way to determine what citizens want for their community is to ask them. There are a number of options here, which can be used individually or in combination, including:

• Community surveys
• Focus groups
• Phone interviews
• Face-to-face interviews
• Questionnaires in public places

Rather than just asking them for their opinions about what would improve the community, it’s far more powerful to involve community members in the whole process from the beginning, including them in all phases of the PRECEDE-PROCEED model. While actual applications of the model often tend to be top-down, it is likely to work better if the community has significant input and decision-making power from the beginning.

Phase 2: Identifying the issue. In Phase 2 of PRECEDE, you look for the issues and factors that might cause or influence the outcome you’ve identified in Phase 1 (including supports for and barriers to achieving it), and select those that are most important, and that can be influenced by an intervention. (One of the causes of community poverty, for instance, may be the global economy, a factor you probably can’t have much effect on. As important as the global economy might be, you’d have to change conditions locally to have any real impact.)

It’s important to analyze these issues carefully, and to make sure that you’ve chosen the right ones. What would the elimination of a particular factor make possible, for instance, that isn’t possible already? How does a particular issue create a barrier to the desired outcome? What else do these issues affect, besides the desired outcome?

Which are the issues with the most drastic effects? And how do you define “the most drastic effects?” Are they economic? Social? Physical?

An industry responsible for pollution that actually or potentially causes health problems may also be the local economic mainstay. Even if the industry has the best of intentions, it may be unable to afford to clean up its operation. The town may be faced with the choice of either losing the jobs and tax base that the industry provides, or continuing to live with a health hazard. What’s more important here, and how do you decide what to focus on? (And is there an answer that isn’t either-or ?)

This kind of situation is by no means universal...but it isn’t particularly unusual, either.

In some cases, the issues you choose to focus on may be directly related to the outcome you’re seeking – building more affordable housing as a way to address homelessness, for instance. In others, you may be trying to affect factors that have just as great an impact on the outcome, but seem further removed from it – e.g., addressing safe streets by providing parenting courses and other services for at-risk families.

Once again, involving stakeholders and other community members here is likely to get you the best information possible about which issues to emphasize, and to keep you from making mistakes based on ignorance of the community’s history or of the relationships among community members.

Phases 1 and 2 are where you develop the long-term goals for your intervention. They tell you what your ultimate desired outcome should be, and what the issue(s) or associated factors may be that influence it. Those are the things you’re ultimately aiming to change.

Most of the factors influencing the issues or outcomes can be classified as behavioral, lifestyle, or environmental.

The behavior referred to here is a specific, observable, often measurable – and usually customary – action. Some behaviors put people or communities at more or less risk for health or other problems.

• Needle-sharing is a behavior that puts heroin addicts at high risk for hepatitis and AIDS.
• Consistent studying usually lessens the risk of school failure for a student.
• If littering is a common individual behavior, it may have community consequences that range from the aesthetic (piles of trash creating an unattractive scene) to health (breeding of mosquitoes in garbage-strewn lots, water pollution, etc.) to the economic (businesses unwilling to locate in the community because of its physical condition). It may also have social consequences, with neighborhood conditions affecting residents’ self-image, and leading eventually to a breakdown of civic responsibility.

A lifestyle is a collection of related behaviors that go together to form a pattern of living. Some lifestyles may put people and communities at risk of health and other problems.

• An example of a high-risk lifestyle that is often mentioned in the popular media is one that includes very little exercise, a diet high in calories and saturated fats, and lots of stress. Such a lifestyle can lead to heart attack, stroke, cardiovascular disease, and other problems associated with obesity, including diabetes.
• A lifestyle that involves gang membership and regular participation in violent acts has both individual consequences (the constant risk of serious injury or death, an arrest record, detachment from others’ humanity) and consequences for the community (people afraid to use the streets, reduced economic activity, scarce resources spent on extra law enforcement, etc).

The environment of a particular issue or problem can refer to the natural, physical environment – the character and condition of the water, air, open space, plants, and wildlife, as well as the design and condition of built-up areas. But it can also refer to the social environment (influence of family and peers; community attitudes about gender roles, race, childrearing, work, etc.), the political environment (policies and laws, such as anti-smoking ordinances, that regulate behavior or lifestyle; the attitudes of those in power toward certain groups or issues), and the economic environment (the availability of decent-wage jobs, affordable housing, and health insurance; the community tax base; global economic conditions).

In general, behaviors, lifestyles, and environmental factors are what an intervention sets out to change. The changes in these areas in turn affect the crucial issues, and lead to the achievement of the final outcome that was identified in Phase 1 of the model.

So how do you choose which behaviors, lifestyles, or environmental factors to focus on? That’s where analysis comes in. What are people doing – or what are the factors in the environment – that lead to, maintain, or prevent the issue or condition you want to change? Using critical thinking and the “But why?” technique, you should be able to narrow it down to a handful. The criteria for choosing a particular target for your intervention are: (a) Is the potential target an important enough factor to have a real effect on the issue, and thus on the quality of life in the community? and (b) Is it likely that the potential target can actually be changed by an intervention that you have the resources to mount?

A classic example of community change through behavior change is that of reducing the incidence of lung cancer and heart disease in a community by convincing smokers to change their behavior – i.e. quit. Fewer smokers mean less secondhand smoke, less time lost from work because of smoke breaks and smoking-related illnesses, fewer low-birth-weight babies, fewer children with asthma and other respiratory ailments, and lower health insurance costs. Altogether, changing smokers’ behavior adds up to an improvement in the overall quality of life for the community.

Changing smokers’ behavior fits both criteria described above. It has a profound effect on the issue and on the general quality of life; and it is often responsive to change, because of many smokers’ desire to quit, general knowledge about the dangers of smoking, the cost of tobacco products, community support, and already-existing strategies and smoking-cessation groups that can be incorporated relatively cheaply into an intervention.

Phase 3: Examining the factors that influence behavior, lifestyle, and responses to environment. Here, you identify the factors that will create the behavior and environmental changes you’ve decided on in Phase 2.

The terms “healthful behavior” and “risky behavior” below refer not only to physical health, but to any behavior that’s advantageous or harmful to the individual and/or the community, and is likely to have a significant effect on their quality of life.

Predisposing factors are intellectual and emotional “givens” that tend to make individuals more or less likely to adopt healthful or risky behaviors or lifestyles or to approve of or accept particular environmental conditions. Some of these factors can often be influenced by educational interventions. They include:

• Knowledge. You’re more likely, for instance, to avoid sunburn if you know it can lead to skin cancer than if you don’t.
• Attitudes. People who have spent their youth as athletes often come to see regular exercise as an integral part of life, as necessary and obvious as regular meals.
• Beliefs. These can be mistaken understandings – believing that anything low in fat is also low in calories – or closely held beliefs based on religion or culture – as the old saying goes, “Spare the rod and spoil the child,” so it’s important to physically punish your children for mistakes or misdeeds.
• Values. A value system that renounces violence would make a parent less likely to beat a child, or to be physically abusive to a spouse or other family member.
• Confidence. Many people fail to change risky behavior simply because they don’t feel capable of doing so.

Enabling factors are those internal and external conditions directly related to the issue that help people adopt and maintain healthy or unhealthy behaviors and lifestyles, or to embrace or reject particular environmental conditions. Among them are:

• Availability of resources. People with mental health problems, for instance, are much more likely to get help if services are readily available.
• Accessibility of services. Services do no good if they have waiting lists that run into years, or aren’t physically accessible to those who need them.
• Community and/or government laws, policies, priority, and commitment to the issue. Government laws and policies can both force changes in behavior or environment, and underline the importance of those changes.
• Issue-related skills. People who start out with a work ethic and an understanding of the workplace, for instance, are apt to benefit from job placement programs.

Reinforcing factors, are the people and community attitudes that support or make difficult adopting healthy behaviors or fostering healthy environmental conditions. These are largely the attitudes of influential people: family, peers, teachers, employers, health or human service providers, the media, community leaders, and politicians and other decision makers. An intervention might aim at these people and groups – because of their influence – in order to most effectively reach the real target group.

Phases 2 and 3 comprise the part of the model where the real planning of an intervention has to take place. What are you trying to change, and what are the factors that will help to bring that change about? Answering these questions should bring you to an understanding of whom and what an intervention should target, who best might conduct the intervention, and what it should look like in order to hit its targets effectively.

Phase 4: Identifying “best practices” and other sources of guidance for intervention design, as well as administrative, regulation, and policy issues that can influence the implementation of the program or intervention. Phase 4 helps you look at organizational issues that might have an impact on your actual intervention. It factors in the effects on the intervention of your internal administrative structure and policies, as well as external policies and regulations (from funders, public agencies, and others).

Design issues: “Matching, mapping, pooling, and patching.” or “Selecting, designing, blending, and supporting interventions.”

The discussion of the ways in which organizational issues, particularly internal ones, interact with a proposed intervention is one that all too often never takes place. For that reason, Phase 4 is particularly important. Such a discussion can avoid mismatches between an organization and its proposed intervention (a strictly hierarchical organization attempting to implement an intervention meant to empower a group with no voice, for instance), or to alert an organization to an internal or external regulation or policy that needs to be changed or circumvented for an intervention to proceed as planned.

Administrative issues include organizational structure, procedures, and culture; and the availability of resources necessary for the intervention.

• The organizational structure may be hierarchical, democratic, collaborative, or some combination, and may be more or less rigid or flexible within each of those categories. It should be appropriate to the design of the intervention (e.g., allowing for staff decisions in the field in a gang outreach program), and flexible enough to make adjustments when necessary.
• Organizational procedures are the ways in which the organization actually carries out its work. In order for an intervention to be successful, those procedures have to focus on its goals, rather than on internal convenience or traditional methods. An intake procedure, for instance, should be designed to be as easy and un-embarrassing for participants as possible – otherwise it can be a barrier to participation.
• The organizational culture. Organizations are social groups that develop cultures of their own. Those cultures often dictate, among other things, how staff members interact with one another, how program participants are treated, and how the organization views its work and its mission. (Is it just a job, or is it God’s work?) They also usually determine the fit between an organization and an intervention.
• The resources available for the intervention include not only money – although that’s certainly important – but time, personnel, skills, and space. Now is the time to pinpoint any gaps in resources beforehand, and work to close them. Thus, finding funding and/or the right staff people may be a good part of this phase.

Policy and regulatory issues have to do with the rules and restrictions – both internal and external – that can affect an intervention, and their levels of flexibility and enforcement.

Internal policies:

• Staff members. Organizational policy may treat staff as employees who take orders, as colleagues who contribute to the work of the organization, or as collaborators who jointly own it. The amount of freedom they have to exercise their creativity and to take initiative probably depends on that policy, which may be unstated.
• Participants. Does organizational policy see participants as “clients” that the organization is doing something to or for, or as partners in a change effort? Does it treat participants respectfully, as equals, or does it condescend or act authoritative?

How does the organization treat relationships among participants and staff? In some organizations, they may be friendly; in others, strictly professional. (Romantic or sexual relationships raise some ethical questions, and probably need to be considered separately. See “Professional ethics” below.)

• Specific practices, methods, or programs. Many organizations maintain policies that suggest or mandate certain ways of carrying out their work.
• Collaboration. Some non-profits make it a point of policy to collaborate as much as possible, while others rarely, if ever, work with other organizations.
• Professional ethics. Many organizations expect staff members to adhere to a code of professional ethics – either an internal one, or one set out by a professional association – that governs confidentiality, inappropriate relationships, abuse of position, reporting (or non-reporting) of specific kinds of illegal behavior, etc. There may be organizational regulations about these areas as well.

External policies and regulations that might affect an intervention can come in a variety of forms:

• Funders’ requirements. These may apply to the intervention itself, or they may place restrictions on anything the organization can do, even those areas – such as, perhaps, this intervention – that aren’t funded directly by the funder in question.
• Oversight agency regulations. The organization may be subject to the authority of a state or federal agency whose regulations affect the intervention.
• State or federal laws, or local ordinances
• Unstated community policies. Certain actions may simply be unacceptable to the majority of the community, to coalition partners, etc.

PROCEED: Implementing and evaluating the intervention .

Phase 5: Implementation. At this point, you’ve devised an intervention (largely in Phases 3 and 4), based on your analysis. Now, you have to carry it out. This phase Involves doing just that – setting up and implementing the intervention you’ve planned.

The final three phases take place as the intervention continues, and serve to help you monitor and adjust your work to make it as effective as possible.

Phase 6: Process Evaluation. This phase isn’t about results, but about procedure. The evaluation here is of whether you’re actually doing what you planned. If, for instance, you proposed to offer mental health services three days a week in a rural area, are you in fact offering those services?

Phase 7: Impact Evaluation. Here, you begin evaluating the initial success of your efforts. Is the intervention having the desired effect on the behavioral or environmental factors that it aimed at changing – i.e., is it actually doing what you expected?

Phase 8: Outcome Evaluation. Is your intervention really working to bring about the outcome the community identified in Phase 1? It may be completely successful in every other way – the process is exactly what you planned, and the expected changes made – but its results may have no effect on the larger issue. In that case, you may have to start the process again, to see why the factors you focused on aren’t the right ones, and to identify others that might work.

Some outcomes may not be apparent for years or decades. Lifestyle changes made by young people to stave off heart disease and stroke, for instance, usually won’t reveal their health benefits until those people are well into middle age. If you know that an outcome may not show itself for a long time, you may just have to be patient and continue to monitor the process and impact of your intervention, with the belief that the eventual outcome will become apparent in time.

Phases 6-8 call for formal evaluations of each phase, with controlled studies and detailed findings, but most Community Tool Box users probably don’t have the resources for that, and shouldn’t expect to do it. That doesn’t mean you shouldn’t evaluate, however.

It’s a relatively simple matter, for instance, to keep records and to examine them to find out whether your process was carried out as planned, or simply to look at what you are doing to see whether it matches what you intended to do. The same is true for the other stages of evaluation. Don’t worry if you can’t do a formal study...but don’t let evaluation go, either. It’s an important part of the process.

Remember also that evaluation is ongoing throughout the work. It takes place while the intervention is being implemented, not afterwards. The whole point of evaluation of each phase of the model is to adjust or change what you’re doing in that phase, if necessary, to make it more effective.

At any point in the PROCEED continuum, you should be prepared to revisit your analysis. If you find a gap between your planning and reality, or if you realize that your intervention isn’t achieving the results you aimed at, you should go back to the PRECEDE part of the model, try to determine what needs to be changed, and adjust what you’re doing accordingly. The point of evaluation is not to see whether you pass some kind of test – it’s to make sure that your intervention brings about the outcome that the community wanted or needed in the first place.

In Summary

PRECEDE-PROCEED provides a logic model that can serve as the basis for an individual, one-time intervention or a decades-long community development program or project. Although designed for health programs, it’s adaptable to other community issues as well. As with many models, it’s meant to be a guide, not a prescription.

PRECEDE-PROCEED is community-based and participatory, founded on the premise that changes promoting health (and other community issues) are largely voluntary, and therefore need the participation of those needing to change and others who might influence them or be influenced by them.

A major reason to use PRECEDE-PROCEED is that it is a logic model. As a result, it will provide a structure within which to plan your work, and organize both your thinking and your actions, so that your intervention will be a carefully-planned, coherent whole, rather than cobbled together. As a logic model, it also provides a guide for analyzing the issues involved, and choosing both the most likely areas to address and the most likely avenues to address them.

There are also reasons to use PRECEDE-PROCEED specifically. First, it’s a participatory model. By involving the community, it will both bring more and better ideas about issues and resolving them, and build community ownership of the intervention. Second, since it includes multi-level (ecological) planning and evaluation, PRECEDE-PROCEED builds in monitoring of the intervention, allowing for adjustment and greater effectiveness. And finally, the model allows the freedom to adapt the structure to whatever content and methods meet the needs of your community.

PRECEDE is the diagnostic portion of the model. It starts with the idea that the focus of change must be on its desired outcome, and works backward from that outcome to construct an intervention that will bring it about. It has four phases:

Phase 1: Social diagnosis – determine what the community wants and needs to improve its quality of life.

Phase 2: Epidemiological diagnosis – determine the health problems or other issues that affect the community’s quality of life. Include also the behavioral and environmental factors that must change in order to address these problems or issues. Behavioral factors include patterns of behavior that constitute lifestyles. In considering environmental factors, you should include the physical, social, political, and economic environments.

Phases 1 and 2 identify the goals of the intervention.

Phase 3: Educational and organizational diagnosis – determine what to do in order to change the behavioral and environmental factors in Phase 3, taking into account predisposing factors (knowledge, attitudes, beliefs, values, and confidence); enabling factors (availability of resources, accessibility of services, government laws and policies, issue-related skills), and reinforcing factors (largely the influence of significant others in the social environment).

Phase 4: Designing programs or interventions and the support for them through administrative and policy diagnosis – determine (and address) the internal administrative and internal and external policy factors that can affect the success of your intervention. The former include organizational structure, procedures, culture, and resources; the latter encompass both internal policies and funders’ requirements, oversight agency regulations, state or federal laws, or local ordinances, and unstated community policies.

Phases 3 and 4 set the structure and targets for the planning and design of the intervention.

PROCEED is, in medical terms, the treatment portion of the model, and comprises the implementation and evaluation of the intervention. It consists of four phases:

Phase 5: Implementation – conduct the intervention.

Phase 6: Process evaluation – determine whether the intervention is actually taking the actions intended.

Phase 7: Impact evaluation – determine whether the intervention is having the intended effects on behaviors and/or environment.

Phase 8: Outcome evaluation – determine whether the intervention ultimately brings about the improvements in quality of life identified by the community as its desired outcome.

An unstated but important part of the model is that, at any point, your plan or intervention can and should be revisited and revised, based on continued analysis and the results of the various evaluations.