Planning Health Promotion Programs

Planning Health Promotion Programs Models for Health Promotion Interventions Starting the Planning Process Assessing Needs Measurement, Measures, Data Collection, and Sampling Mission Statement, Goals, and Objectives Theories and Models Commonly Used for Health Promotion Interventions Interventions

Models for Health Promotion Programs A Generalized Model for Program Planning Understanding and engaging Assessing needs Setting goals and objectives Most planners find occasions when it is not feasible to use a mode in its entirety or when it is necessary to combine parts of different models to meet specific needs and situations. What is mot critical for any student, practicing health educator, or planner is a working knowledge of the basic steps that most planning models have in common. The Generalized Model for Program Planning (McKenzie et al., 2005) outlines these common steps: understanding and engaging, assessing needs, setting goals and objectives, developing an intervention, implementing the intervention, and evaluating the results. Developing an intervention Implementing the intervention Evaluating the results

Selecting a Specific Planning Model to apply will be based on: The preferences of stakeholders (e.g., decision makers, program partners, consumers); How much time is available for planning purposes; How many resources are available for data collection and analysis; The degree to which clients are actually involved as partners in the planning process or the degree to which your planning efforts will be consumer-oriented (i.e., planning is based on the wants and needs of consumers); and Preferences of a funding agency (in the case of a grant or contract award)

Consider Three Important Criteria Fluidity: Steps in the planning process are sequential, or that they build upon one another Flexibility: Planning is adapted to the needs of stakeholders Functionality: the outcome of planning is improved health conditions, not the production of a program plan itself

Common Models Used by Planners in Health Promotion Settings PRECEDE-PROCEED (practitioners-driven) MATCH (practitioners-driven) CDCYNERY (consumer-based planning – health communication planning) SMART (consumer-based planning – social marketing planning)

Precede-Proceed Model The best-known and most often used theory of implementation. It has two major components: PRECEDE, PROCEED, which are comprised of nine phases, or steps (Green & Kreuter, 2005). The first five phases consists of a series of planned assessments that generate information that will be used to guide subsequent decisions. This series of phases involves considerable sifting and sorting and is refereed to as PRECEDE which is an acronym for “predisposing, reinforcing, and enabling constructs in educational/ecological diagnosis and evaluation” (Green & Kreuter, 2005, p. 9). The second component, which consists of last four phases, is marked by the strategic implementation of multiple actions based on what was learned from the assessments in the initial phase. This second component Is named PROCEED “for policy, regulatory, and organizational constructs in educational and environmental development” (Green & Kreuter, 2005, p. 9).

PRECEDE Health promotion Predisposing factors Health education Phase 5: Administrative And policy assessment Phase 4: Educational And ecological assessment Phase 3: Behavioral and Environmental assessment Phase 2: Epidemiological assessment Phase 1: Social assessment Health promotion Predisposing factors Health education Reinforcing factors Behavior And lifestyle Quality of life Health Policy regulation organization Enabling factors Environment Phase 6: Implementation Phase 7: Process evaluation Phase 8: Impact evaluation Phase 9: Outcome evaluation PROCEED

The Nine Phases of the PRECEDE-PROCEED Model Phase 1. Social assessment: assessing both objective and subjective terms of high-priority problems or aspirations for the common good, defined for a population by economic and social indicators and by individuals in terms of their quality of life Phase 2. Epidemiological assessment: delineating the extent, distribution, and causes of a health problem in a defined population Phase 3. Behavioral assessment: Delineating the specific health-related actions that will most likely cause a health outcome. Environmental assessment: systematically assessing factors in the social and physical environment that interact with behavior to produce health effects or quality-of-life outcomes.

The Nine Phases of the PRECEDE-PROCEED Model Phase 4. Educational assessment: delineating factors that predispose, enable, and reinforce a specific behavior or that through behavior affect environmental changes. Predisposing factor: “any characteristics of a person or population that motivates behavior prior to the occurrence of the behavior”; Enabling factor: “any characteristics of the environment that facilitates action and any skill or resource required to attain a specific behavior.” Reinforcing factor: “any reward or punishment following or anticipated as a consequence of a behavior, serving to strengthen the motivation for or against the behavior.” Phase 5. Administrative assessment: “an analysis of the policies, resources, and circumstances prevailing in an organization to facilitate or hinder the development of the health promotion program.”

The Nine Phases of the PRECEDE-PROCEED Model Phase 6. Implementation: “the act of converting program objectives into actions through policy changes, regulation, and organization.” Phase 7. Process evaluation: “the assessment of policies, materials, personnel, performance, quality of practice or services, and other inputs and implementation experiences.” Phase 8. Impact evaluation: “the assessment of program effects on intermediate objectives including changes in predisposing, enabling, and reinforcing factors, as well as behavioral and environmental changes.” Phase 9. Outcome evaluation: an “assessment of the effects of a program on its ultimate objectives, including changes in health and social benefits or quality of life.”

Features Complicated at first glance Follows a logic sequence beginning by “identifying the desired outcome, to determine what causes it, and finally to design an intervention aimed at reaching the desired outcome” (McKenzie et al., 2005, p. 18).

An Application Consider a hypothetical example using a school setting Phase 1: planners seek to define the quality of life of the priority population so that the desired outcomes can be identified Involving all parties (teachers, parents, PE teachers, health evaluators, students) in the process of assessing needs. Identifying social indicators: health status, fitness, self-esteem, class attendance, academic performance

An Application (cont.) Phase 2: planners use data to identify and rank health goals or problems that are associated with economic concerns and school conditions Collecting and analyzing data Ranking those health concerns as they related to the quality-of-life issues identified in Phase 1 e.g., overweight and obesity, physical inactivity (through epidemiological assessment) → health status, fitness, self-esteem, school performance

An Application (cont.) Phase 3: planners determines what risk factors or determinants contribute to overweight and obesity, and physical inactivity Lack of rigorous physical activity program? Lack of access to physical activity facilities? Unhealthy school lunch program? Easy access to high carbohydrate/calorie food/drinks?

An Application (cont.) Phase 4: planners conduct educational and ecological assessment Surveying students and teachers about their knowledge of health risk factors Conducting an evaluation of existing programs and environment Observing students’ levels of physical activity. Deciding an appropriate health promotion intervention (comprised of an education component, behavior change, and new policies that promote school-wide physical activity)

An Application (cont.) Phase 5: planners determine what organizational and administrative support and resources are available to carry out the health promotion intervention. Health education built into the curriculum? Hiring a health educator/consultant? Increasing level of intensity in PE? Restructuring school lunch program? More after school physical activity and/or sport programs? More education on promoting healthy nutrition and physical activity habits.

An Application (cont.) Once the availability of program resources is determined, Phase 6, implementation, can begin The evaluation components (Phases 7,8, and 9) of this program will be based on the objectives that were created during assessment phases. Ensure that criteria (standards of acceptability) noted in each objective were clear.

An Application (cont.) e.g., in phase 7 (process evaluation), planners may be concerned with determining the availability of the educational component of the intervention for each student. e.g., in phase 8 (impact evaluation), planners would be interested in evaluating changes in the behavior of the students (e.g., become more active?) and the school environment (e.g., program availability, access to healthy school foods, etc.) As for outcome evaluation, Phase 9, planners may be looking for an overall increase in school-wide physical activity and consumption of healthy food (i.e., low-calorie and nutritious).

The MATCH Planning Model MATCH is an acronym for Multilevel Approach to Community Health By: Simons-Morton, D. G., Simons-Morton, B. G., Parcel, G.S., & Bunker, J.F. (1988). Influencing personal and environmental conditions for community health: A multilevel intervention model. Family and Community Health, 11(2), 25-35.

Insert the MATCH Planning Model here

An Application Assumption: Needs assessment is complete Heart disease is the focus of the program we are planning Health Problem Behavioral Risk Factors Environmental Risk Factors Heart disease Lack of exercise Poor eating habits Lack of exercise facilities School lunch program

Phase 1: Goal Selection Heart disease is the leading cause of death Several of the behaviors associated with the disease are changeable Therefore, optimal health-status goal is to reduce the prevalence of heart disease. Target population: elementary school children Health behavioral goals: ↓ sedentary lifestyle and improve eating habits Environmental goals focus on available exercise facilities, school's curriculum with regard to PA and nutrition, School policies that can influence PA and eating habits

Phase 2: Intervention Planning Identify the following elements: the levels of society at which planners plan to intervene; what intervention objectives will be; the mediators with which we will be concerned; what intervention approaches we will take See the Table for Summary

Step 1 Focus of Intervention Step 2 Objectives Step 3 Mediators Step 4 Intervention Approaches Individual students 5th and 6th graders Health behaviors Exercise Eating habits Educational Teaching Positive reinforcement Knowledge Attitudes Skills Behavior Organizational Board of education School administrators Teachers School cafeteria workers Organizational Change Curricula change School lunch menu policy in-service training Programs Practices Policies Resources Knowledge Attitudes Skills Behavior Governmental City council City parks and recreation board workers Political Action Lobbying Policy advocacy Interest-group pressure Programs Practices Policies Resources Knowledge Attitudes Skills Behavior

Phase 3: Program Development Focus on several program components Training teachers for PA and nutrition Training cafeteria workers to create healthier school lunches Soliciting board of education for changes in related to curriculum PE and health education Lobbying the city parks and recreation board for better equipped parks and exercise facilities

Phase 4: Implementation Preparations Planners need to facilitate the adoption, implementation, and maintenance of their program components by preparing those impacted by the program for change Showing these who are affected the possible consequences of no change Programs that have been successful Opinion leaders in the community support the change Planners need to select and , if necessary, training the implementors so they can conduct the in-service sessions for the teachers and cafeteria workers, and prepare those who will be lobbying the city parks and recreation board

Phase 5: Program Evaluation Process evaluation will involve: Examining the success of the implementation of the various program components Quality of the in-service session Pros and cons of the program components Impact evaluation: knowledge, attitudes, and health practices of the students with regard to PA and nutrition, and change in PA facilities at the city park level Outcome evaluation (i.e., ↓ the prevalence of heart disease)?

CDCynergy Planning Model Developed by the Office of Communication at the Cents for Disease Control and Prevention (CDC) (Centers for Disease Control and Prevention, 2003)

CDCynergy Planning Model Use six phases involving multiple steps to help planners acquire a thorough understanding of a health problem Explore a wide range of possible strategies for influencing the problem Systematically select the strategies that show the most promise; Understand the role excommunication can play in planning, implementing, and evaluating selected strategies; Develop a comprehensive community plan

CDCynergy Planning Model Phase 1: Describe Problem Identify and define health problems that may be addressed by your program interventions. Examine and/or conduct necessary research to describe the problems. Assess factors and variables the can affect the project’s direction, including strengths, weaknesses, and threats (SWOT).

CDCynergy Planning Model Phase 2: Analyze Problem List causes of each problem you plan to address. Develop goals for each problem. Consider strengths, weaknesses, opportunities, threats, and ethics of health: (1) engineering, (2) communication/education, (3) policy/enforcement, and (4) community service intervention options. Select the types of intervention(s) that should be used to address the problem(s).

CDCynergy Planning Model Phase 3: Plan Intervention Decide whether communication is needed as a dominant intervention and/or as support for other intervention(s). If communication is used as a dominant intervention, list possible audiences. If communication is to be used to support Community Services, Engineering, and/or Policy/Enforcement interventions, list possible audiences to be reached in support of each selected interventions. Conduct necessary audience research to segment intended audiences. Select audience segment(s) and write communication objectives for each audience segment. Write a creative brief to provide guidance in selection appropriate concepts/messages, settings, activities, and materials.

CDCynergy Planning Model Phase 4: Develop Intervention Develop and test concepts, messages, settings, channel-specific activities, and materials with intended audiences. Finalize and briefly summarize a communication implementation plan. The plan should include: Background and justification, including SWOT and ethics analyses Audiences Communication objectives Messages Settings and channels for conveying your messages Activities (including tactics, materials, and other methods) Available partners and resources Tasks and timeline (including persons responsible for each task, date for completion of each task, resources required to deliver each task, and points at which progress will be checked) Internal and external communication plan Budget Produce materials for dissemination

CDCynergy Planning Model Phase 5: Plan Evaluation Determine stakeholder information needs Decide which types of evaluation (e.g., implementation, reach, effects) are needed to satisfy stakeholder information needs. Identify sources of information and select data collection methods. Formulate an evaluation design that illustrates how methods will be applied to gather credible information. Develop a data analysis and reporting plan. Finalize and briefly summarize an evaluation implementation plan. The plan should include: Stakeholder questions Intervention Standards Evaluation methods and design Data analysis and reporting Tasks and timeline (including persons responsible for each task, date for completion of each task, resources required to deliver each task, and points at which progress will be checked Internal and external communication plan Budget

CDCynergy Planning Model Phase 6: Implement Plan Integrate, execute, and manage communication and evaluation plans. Document feedback and lessons learned. Modify program components based on feedback. Disseminate lessons learned and evaluation findings.

SMART Planning Model SMART – Social Marketing Assessment and Response Tool (Neiger, 1998; Neiger Thackeray, 2002). Central focus of SMART is consumers SMART is composed of seven phases.

The Phases of SMART Phase 1: Preliminary Planning Integrate, execute, and manage communication and evaluation plans. Document feedback and lessons learned. Modify program components based on feedback. Disseminate lessons learned and evaluation findings.

The Phases of SMART Phase 2: Consumer Analysis Segment and identify the priority population. Identify formative research methods. Identify consumer wants, needs, and preferences. Develop preliminary ideas for preferred interventions and communication strategies.

The Phases of SMART Phase 3: Market Analysis Establish and define the market mix. Assess the market to identify competitors (behaviors, messages, programs, etc.), allies (support systems, resources, etc.), and partners.

The Phases of SMART Phase 4: Channel analysis Identify appropriate communication channels. Assess options for program distribution. Determine how channels should be used. Identify communication roles for program partners.

The Phases of SMART Phase 5: Develop Interventions, Materials, and Pretest Develop program interventions and materials using information collected in consumer, market, and channel analysis. Interpret the marketing mix into a strategy that represents exchange and societal good. Pretest and refine the program.

The Phases of SMART Phase 6: Implementation Communicate with partners and clarify involvement. Activate communication and distribution strategies. Document procedures and compare progress to time lines. Refine the program.

The Phases of SMART Phase 7: Evaluation Assess the degree to which the priority population is receiving the program. Assess the immediate impact on the priority population and refine the program as necessary. Ensure the program delivery is consistent with established protocol. Analyze changes in the priority population.

Other Planning Models A Systematic Approach to Health Promotion (Healthy People 2010) (USDHHS, 2000) Mobilizing for Action through Planning and Partnerships (MAPP) (NACCHO, 2001) Healthy Communities (USDHHS, 2001) Assessment Protocol for Excellence in Public Health (APEX-PH) (NACCHO, 1991) SWOT (Strengths, Weaknesses, Opportunities, Threats) Analysis (Johnson, Scholes, & Sexty, 1989). The health Communication Model (NCI; 2002) Healthy Plan-It (CDC, 2000)

Summary Various planning models with the PRECEDE-PROCEED model the most popular one in health promotion They all share common characteristics Seek to understand and engage community members, assess needs, set goals and objectives, develop an intervention, implement the intervention, and evaluate the results (back to the Generalized Model, Slide #3)

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