Finally, we're at the point of trying to pull the different models together, and we do this with the help of the PRECEDE Framework. PRECEDE was developed by Lawrence Green, who was actually a professor at Johns Hopkins in the late 70s, and as a renowned health educator. PRECEDE stands for predisposing, reinforcing, and enabling causes in educational diagnosis and evaluation. The word, diagnosis, is a key factor in the framework, encouraging us to understand problems before intervening to use this understanding to select appropriate strategies. In fact, there are five levels of diagnosis, starting with quality of life, moving to specific health and epidemiological diagnosis, what are the disease conditions, and who is affected by them? Behavioral diagnosis, finding out those behaviors which contribute to, or help control a particular disease, and educational diagnosis, which looks at all of these antecedent variables, intermediate variables that we've considered in our different theoretical models, and an administrative diagnosis that uses the information gathered to select appropriate health education, and health promotion strategies. Finally, having done the diagnosis and designed the intervention, the evaluation component kicks in, and one looks to see if having intervened, having chosen strategies, that the antecedent factors, identified through the educational diagnosis change, do attitudes change, do knowledge change, does skills change? Does this result in a change in behavior, people who are behaving in a different way, does their health status improve, and assuming their health status improves, does that have an improvement on the quality of their life? The full picture of the PRECEDE model, involving health promotion and environmental, and policy considerations, is seen in the next slide. We can use our example of guinea worm to carry out the diagnostic process. Quality of life, we find that people in endemic communities have lower economic production, children miss school, there's reduced economic and social opportunities. The epidemiological diagnosis shows us that the disease is prevalent in certain communities that have poor water supply, results in disability, secondary infections, seasonality is an issue, mainly in the dry season in certain parts of West Africa, for example. Again, people are effected, both men, woman, also children who are above the age where they've stopped breast feeding and start drinking pond water, so we can get an idea of who is effected. The behavioral diagnosis identifies specifically two behaviors that contribute to the transmission. If you have a guinea worm ulcer on your leg, and the worm is coming out, ready to expel larva, if you walk into, or wade into, the pond, the larva will be expelled, they'll be swallowed by the cyclops, so wading into the pond with an ulcer is one. On the other end, if one drinks the pond water containing the infected cyclops, the disease cycle will continue. Obviously, alternative to these are behaviors such as filtering water, or even digging a well. The educational diagnosis, why do people carry out these particular behaviors? The educational diagnosis identifies three sets of antecedent factors, these antecedent factors draw on our previous theoretical models and information. One set of factors is called predisposing, these are cognitive affective determinants, things that are already in people's heads, their knowledge about guinea worm, its cause and prevention, their attitudes about water quality and purity, what they expect good water to look like, smell like, taste like. They're perceived efficacy, their self-efficacy in carrying out filtering, their actual perceived efficacy or effectiveness of the filter itself, their knowledge of filtering steps, their preferences or attitudes about alternative methods for cleaning water, these are examples. Not every factor occurs with every population in every community, and this is why it's necessary to do surveys, and research, formative research, before starting a program, to see what are the salient issues in a given population or community. A second set of antecedent factors are known as enabling factors, these are the resources and skills. These may not be clearly spelled out in theoretical models we've talked about before, but they're certainly implied in terms of the environment, people's economic status, they're often refered to as constraints in the Health Belief Model, the cost, access, et cetera. But these are very important issues, because even if a person has an intention to behave in a certain way, as we've seen in Theory of Reasoned Action, even if they have a positive attitude toward the behavior, even if they perceive that other people want them to behave in a certain way, if they lack the funds, the access, the equipment, to carry out the new behavior, they won't, so enabling factors are very important to stress. The third set of factors are reinforcing factors, these, again, come from our theoretical constructs, where we're concerned about perceptions of what other people will think, social norms, observing other people, the influence of the attitudes and behavior of significant others, family members, co-workers, friends, et cetera. Such social influences are, in getting where control would be, who is it that's promoting the use of filters, is it a co-villager, who is also a village health worker that everyone knows, or is it someone from the outside, from the health center? Maybe neighbors purchase, and this can be observed, in the family, the husbands may or may not buy, and also reinforcement comes from the feedback of having carried out the behavior, or watching the results of what other people have done, and so, this has to do with observational learning, and Social Learning Theory, et cetera. The visible results of removing dirt and debris by the filter may be reinforcing, even if people don't see the cyclops being removed. Here again, the next slides look at how the other theoretical models provide information to help us draw out our PRECEDE model, and help us sort out our antecedent, or intermediate variables, into these three broad categories. Predisposing factors, as we noted, Health Belief Model contributes to the issue of knowledge. Perceptions of threat, seriousness and severity, Social Learning Theory, contributes predisposing factors such, as self efficacy, and outcome and value expectancies, and Theory of Reasoned Action contributes to the predisposing section, the attitudes toward the behavior. Concerning reinforcing factors, Health Belief Model contributes cues to action, which may be advice from other people, or observation of what is happening to other people who use the new idea, or who are suffering from the same illness. Recognition of family structure and social group membership, as a modifying factor, also gives us clues to reinforcing factors in a PRECEDE model. In terms of reinforcing factors that are gleaned from use of Social Learning Theory, we can see the social aspects of the broader environment, and specifically observing other key people who are important in a person's life, peers, family members, co-workers. Theory of Reasoned Action has a whole clear section on the influence of perceived social norms, the respect or otherwise of different reference groups. As we said, enabling factors can be discerned less directly, but they are present in these other models. Health Belief Model talks about barriers and facilitators, logistical factors, transport, time, money, and broadly, as a modifying factor, these would be influenced by a person's economic status and occupation. Social Learning Theory would have enabling factors implied in the broader environmental context, such as the economic and political aspects of the environment, and more specifically, as a characteristic of the person, skills would be involved. In Theory of Reasoned Action, enabling factors are not explicitly stated and not as easy to identify. Finally, with PRECEDE model, the important fifth stage is taking this information and matching strategies to the information gathered about the antecedent factors, matching strategies to our educational diagnosis. The idea is that health education and planning health promotion programs should be scientific, should be systematic, the days are past when we can say all media looks nice, lets put a television spot on, people like entertainment, let's do a drama at the market. The idea of choosing a strategy because it's familiar to you or it looks entertaining are gone, that's inappropriate. What we find is that PRECEDE helps us recognize that the predisposing factors are primarily influenced by communication strategies. The idea of people challenging, reassessing their knowledge, attitudes, values, can come through interpersonal media, communication, such as counselling sessions, or mass media, including the use of electronic media, drama, storytelling, the reinforcing factors are best addressed through social support strategies, this may include family counseling, formation of support groups. Our enabling factors can be best addressed by community development, and resource development strategies, skill training, revolving drug funds, community mobilization and fundraising, et cetera. So once we know the primary, or the major underlying causes, so we say not every factor may be operating at the same time, but once we know the major causes, we are in a better position to pick appropriate strategies that are more likely to work, again, our theoretical models provide us with the basic information to fill in our educational diagnosis.
