Marshall Kreuter on "Why a systematic model?"

Any health problem has multiple causes. There’s social, economic, biological, behavioral, environmental policy related reasons, environmental reasons why a certain health problem exists, so to begin with they are very complicated. So the reason you need a systematic model or systematic approach is you have to be able to ask what Larry Green and I for example call the four basic epidemiologic questions- What’s the problem?; Who has it?; why do they have it?; What are we going to do about it? And as you go through the processes that answer those questions it reveals information that enables you to make choices. And you have to make choices because you can’t do everything, and there are so many problems-which ones do you choose? And I think you need a process to do that. So a systematic process like the PRECEDE-PROCEED Model helps a person get their head around those issues so they can eventually come to a focus and target a specific program to eliminate a health problem.

Let’s take the words PRECEDE, PROCEED. Each is an acronym. PRECEDE means Predisposing, Reinforcing and Enabling Constructs for Ecological Diagnosis and Evaluation. Basically what that means is that if you are going to approach a community or a group or a population and you want to do a health program that has health promotion, education, prevention in it, then the word ecological diagnosis means kind of we were talking before about the complexity, you have to take into account that complexity and weigh all those issues. And once you determine from input both from the scientific side and the community side what it is we want to address then we have to ask that earlier question “well why is it we have it” and we go through various processes to determine what are the circumstances. Is it a lack of knowledge? It could be. Is it a lack of cultural phenomenon that says this isn’t really a part, the power is elsewhere. Is it access to services? And as we tease out the answers to those questions, then it becomes obvious that here are gaps. Here are knowledge and information that we don’t have. Here are beliefs that are held that get in the way of behavioral action. Here are environmental circumstances or conditions or services that don’t exist that ought to. And then once we pinpoint those then we ask the question “what’s the best way to get them in place?” Do we need policy? Do we need organizational strategies? Do we need educational campaigns? And in most instances it turns out that you need a combination of these things. And that’s logical because you have, it’s a fairly complicated picture.

Now that’s the PRECEDE part. So you start at a point  that’s “what’s the problem?” and you figure out what it is and then when you PROCEED, which stands for, if I can get it right, Policy, Regulatory and Organizational Constructs in Environmental and Educational Development is that you move forward and apply all these things and I think the key issue with regard to PRECEDE-PROCEED, if somebody was to say “what’s the key issue here?” is that the planning process requests of, requires, demands of the practitioner that he or she document what it is they’re trying to do. And as they document those become actually markers for evaluation So as you march through the application part built in to the process are the indicators of how well you’re doing. And finally the reality is this- I’ve been in public health for forty years and I’ve been involved in programs in the United States, in China and all over. Not once have I ever seen a program that started in year one and was described here—we look at it again in year four and it looks like in year four what we planned in year one. That just doesn’t happen. And what does happen is things change. Access to service change, staff change, environmental circumstances, [Hurricane] Katrina happens and so what happens is if you have markers of evaluations which are built into the first part of the process its feedback—it tells you “oops this isn’t working, let’s make this fine tune adjustment.” And that’s the way human beings solve problems. They don’t solve them on a straight course. They solve them by adjusting to circumstances. And this kind of planning model gives you, I think, the opportunity to make the fine tune corrections that really make something work over time.

Social Marketing, the way it’s presented in CDCynergy fits in nicely to that portion of the model that requires greater detail on the descriptions of the population so that you know what it is people want to do. It’s the description of, it’s the application of those research processes that enable you to define population more clearly, more sharply, find out what motivates people, how are they likely to respond. If you want to get more women to a clinic and they don’t seem to be going to the clinic, you use social marketing research techniques in order to get that kind of information. It’s very consistent with the overall model and it is a specific area that deals with the ability to tailor messages so that people can respond in a very prompt and desirable way, particularly with respect to behaviors, organizational behaviors, or individual behaviors. So it fits into the middle of the model. It actually fits into the PRE- Predisposing, Reinforcing and Enabling factors. Many theories- Social learning theory; in the case of clinical circumstances the Health Belief Model fit in as well and social marketers use those theories to frame the questions they are going to ask the population to deal with. So social marketing is the analytic portion- the social research that goes into social marketing is the research portion and the application portion would be the actual creation of the communication messages.