Planning component

PRECEDE-PROCEED model provides a comprehensive structure for the assessment of health needs of a population for the planning, implementation and evaluation of oral health promotion program. PRECEDE is used for structuring of plan for the targeted intellectual and developmental disabilities (IDD) adult population focused on their oral health. PROCEED model can be used for the implementation and evaluation of the oral promotion program from Binkly’s strategy. ¹

Planning component

Phase 1: Social assessment: In this phase, gerontology nurses would undertake the determination of perception of IDD adult population regarding oral hygiene needs and overall effect of social problems on their quality of life. The nurses would undertake the social needs through literature review, survey and questionnaire, individual interviews, focused group interviews and organizational forums for data collection (both objective and subjective). This phase helps in making the planners aware of the oral health issue that community sees. ^1-2

Phase 2: Epidemiological, behavioural and environmental assessment: This phase deals with the determination and focusing on IDD adults with oral unhygienic health related to community health needs. The primary or secondary data for epidemiological data collection comprises of national health surveys, vital oral health statistics among IDD adults, genetic factors in understanding IDD oral health problems and counselling them. ^1-3

There is poor communication, uncontrolled movements, lack of manual dexterity make it difficult for the IDD adults to maintain oral hygiene. The common behaviours like brushing is also difficult to maintain for them.

The lack of calming atmosphere and oral hygiene devices are the factors that contribute to poor oral hygiene among IDD adults.

Phase 3: Ecological and educational diagnosis: This phase focuses on selected factors like predisposing, enabling and reinforcing as if these factors are modified, it can bring about behaviour change among IDD adults.

In IDD adults, the predisposing factors for poor oral hygiene are feeding problems, swallowing disease and poor functional status that contribute to poor oral hygiene among them. The self-efficacy like oral health hygiene practices and adaptive environmental usage are also predisposing factors. Reinforcing factors include use of rewards or any sort of reinforcement that can be used for behaviour change. Coaching can also be reinforced where dental health coaches motivate IDD adults to undertake tooth brushing and mouth washing. The enabling factors include the dietary supervision, monitoring, availability of oral hygiene products and resources that can facilitate achievement of behaviour change. ^1-3

Phase 4: Administrative and policy assessment: This phase focuses on organizational and administrative concerns that include development of budgets, timeline through Gantt chart, resources assessment and coordination with community and other organizations. The types of personnel like dentists, dental nurses, dental health practitioners and support staff for carrying out the health promotion program. Booklets, educational materials, lecture room, pamphlets, projector and printers, counselling clinic, organizational budget and oral health supplies like toothbrushes, toothpaste, dental brushes and mouthwash solutions.

Social assessment

Oral Health America. Policy Statement and Healthy People 2020 objective of oral health can help to assess the organizational goals and administration. The policy would help to evaluate that program goals are working in accordance with rules, regulations and mission of oral health promotion program that are needed for sustainability of implemented program. ^1-3

Barriers are also identified to behaviour change like attitudes of IDD adults, commitment, motivation, capability, difficulty using a brush, inability to rinse, complexity and familiarity of program along with adequate funding and space. There might also be dysphagia as they have a tendency to gag or choke while tooth brushing.

PROCEED- implementation and evaluation component

Phase 5: Program implementation: For successful implementation of oral health hygiene strategy, capacity-building promotion is required for training skills and supervising of oral hygiene practices for IDD adults. Behaviour management techniques like motivating IDD adults to perform tooth brushing, flossing and mouth washing after having food. Specially designed oral hygiene aids can be given to IDD patients as they lack the ability to perform brushing. This training can be given to dental hygienists, caregivers and gerontological nurses through 20 minutes DVD power point presentation demonstrating behavioural management techniques and oral hygiene practices.

Phase 6: Process evaluation: In this phase, the evaluation of health promotion program is done through fidelity, dosage and participants’ reaction. The amount of intervention exposure of dosage or oral health promotion, extent of implementation of intervention as designed and appraisal of interventions by participants on usefulness or intervention quality (participant reaction).  ^1-2

Phase 7: Impact evaluation: The performance of educators and participants can be evaluated for impact and effectiveness of oral health program with respect to program objectives, predisposing, reinforcing and enabling factors.

Phase 8: Outcome evaluation: This can be done through oral health strategy assessment as it has direct effects on outcomes and mechanisms of behaviour change.

The main contribution of this model in the case study is that it guides the exact way to develop an intervention for oral health promotion. Every assessment step contributes by outlining what exactly needs to be done offering an algorithm or flow chart for oral health strategy. This model also contributes to conducting behaviour change, implement oral hygiene interventions and delivery of oral health promotion program among IDD patients. In the case study, it was observed that IDD patients are unable to maintain oral health hygiene due to feeding and swallowing issues, dysphagia, lack of motivation and low self-esteem. Therefore, this model is helpful in achieving oral health hygiene and behaviour change among IDD adults through their active participation. ³

Epidemiological, behavioural and environmental assessment

Not every phase in the model is important for health promotion. As mentioned above that this model is an exact guide that tells what to do by following directions, therefore model application can vary accordingly. If this model is not suitable in a particular setting or there is risk, resistant to change, few steps can be skipped and tailoring of model can be done suitable to different local settings. In addition, the social, epidemiological, environmental, behavioural, ecological and educational assessments are important phases as it helps to plan the interventions for behaviour change and health promotion. ^3-4

In case of application of this model to any other health issue, the adaption of health promotion program depends on the population type and setting. There are different factors that play a role in health issues and therefore, this model need to be tailored according to the behavioural, social, epidemiological, administrative, policy factors and sensitive to these differences. The model varies in a way where it must be tailored for individual approaches scalable to population approaches at multiple points of intervention.

The MTCP program was launched with an aim to change the policies of smoking in the community and motivate individuals to quit smoking with provision of tobacco treatment services. The discontinuation of funding was the main reason for the sustainability of this program. Due to the nation-wide recession, there was defunding and termination of this program led to a major health challenge.⁵

In the second paper, Body Project was launched with a hope of eating disorder prevention. However, the mater-level clinicians who were the prime mental health providers in the project have limited experiences in delivering interventions. Moreover, there were time constraints and lack of experience with manualized format that made clinicians leave the project and as a result, there was high turnover. These barriers failed to provide sustainability to the program. ⁶

In the above two cases, funding, time and lack of experience of clinicians led to the failure of the both projects. For the Body Project, the clinicians should have been provided with more time so that they would have not felt rushed and took time to adapt to the changes like conducting more group interviews and recommend others about the program. Although, the clinicians lacked knowledge about project, they valued the intervention aspects. Therefore, it was important to take constructive feedback from them that would have facilitated the delivery of intervention with training for effective time management. As there was limited staff time, there was high clinical turnover, therefore clinical training on time management and dissemination through internet-based approaches would have been an active way and helpful in program sustainability. In the tobacco program, funding is the main issue where it was fruitful to select affordable services that would have grant funding. Re-location of funding, adjustment of staff patterns, assigning of resources for creation of demand for services and adjusting to existing funding would have been useful for the program sustainability.

Ecological and educational diagnosis

The evaluation steps outlined in CDC framework comprises of evaluation of process and outcomes. In process evaluation, the examination of activities, its conduction, progress and sufficient inputs for the activities are done. This step is important for distinguishing a poor program from good one focusing on access, staff competency, dosage and transfer of accountability. Moreover, the outcome evaluation or effectiveness is done through assessing of progress of program outcomes. The changes in the attitudes of people, protective factors, environment and trends in mortality and morbidity greatly evaluate a health promotion program. The PRECEDE-PROCEED model greatly resembles the CDC evaluation framework for health promotion program. ⁷

The process and impact evaluation of promoting preventive behaviours of domestic violence among girls and women was conducted through this model. There is close resemblance of both evaluation processes as the preventive behaviour of domestic violence program was done through evaluation of process, educational objectives and program components like methods, program staff, activities and materials used. ⁸

Community-based youth fitness and nutrition summer camp was also evaluated by PRECEDE-PROCEED model. In implementation step, the supporting organizations, program length, activity duration, frequency and participants grouping was done. The outcome and impact evaluation was addressed through analysis of actual data like efficiency, effectiveness and effort consideration. The designing of program and achievement of desired outcomes with minimum use of resources was measured for program effectiveness using this model. ⁹

Both the programs show similarity with CDC evaluation framework for health promotion as the model used in both programs aligns with the framework.

When the evaluation step is compared to my own experiences, I believe that the PRECEDE-PROCEED model used for the oral health promotion is appropriate. The evaluation steps outlined in CDC is similar to my chosen model and greatly helpful in measuring the effectiveness of oral promotion program for IDD adults.

References

Binkley C, Johnson K. Application of the PRECEDE-PROCEED Planning Model in Designing an Oral Health Strategy. J Theory Pract Dent Public Health. 2013;1(3).

Aldiabat K. Developing Smoking Cessation Program for Older Canadian People: An Application of Precede-Proceed Model. American Journal of Nursing Science. 2013;2(3):33. doi:10.11648/j.ajns.20130203.13.

Popoola T, Mchunu G. Application of PRECEDE-PROCEED model to tackle problems identified with diarrhoea burden among under-5s in Botswana. Int J Nurs Pract. 2015;21:67-70. doi:10.1111/ijn.12328.

Devleesschauwer B, Aryal A, Joshi D et al. Epidemiology of Taenia solium in Nepal: is it influenced by the social characteristics of the population and the presence of Taenia asiatica?. Tropical Medicine & International Health. 2012;17(8):1019-1022. doi:10.1111/j.1365-3156.2012.03017.x.

LaPelle N, Zapka J, Ockene J. Sustainability of Public Health Programs: The Example of Tobacco Treatment Services in Massachusetts. Am J Public Health. 2006;96(8):1363-1369. doi:10.2105/ajph.2005.067124.

Rohde P, Shaw H, Butryn M, Stice E. Assessing program sustainability in an eating disorder prevention effectiveness trial delivered by college clinicians. Behav Res Ther. 2015;72:1-8. doi:10.1016/j.brat.2015.06.009.

Cdcgov. 2011.Introduction to Program Evaluation for Public Health Programs: A Self-Study Guide. Available at: https://www.cdc.gov/eval/guide/cdcevalmanual.pdf. Accessed March 6, 2018.

Soleiman Ekhtiari Y, Shojaeizadeh D, Rahimi Foroushani A, Ghofranipour F, Ahmadi B. The Effect of an intervention based on the PRECEDE- PROCEED Model on preventive behaviors of domestic violence among Iranian high school girls. Iran Red Crescent Med J. 2013;15(1). doi:10.5812/ircmj.3517.

Scholarworksuvmedu. 2016. Application of the precede-proceed model in the evaluation of a community based youth fitness and nutrition summer camp program. . Available at: https://scholarworks.uvm.edu/cgi/viewcontent.cgi?referer=&httpsredir=1&article=1646&context=graddis. Accessed March 6, 2018.