model of health planning in health education using preceed proceed model.

1. Models of health education
planning
prepared & presented by:
Sudarshan Gautam
Subash Adhikari
BPH 1st Batch
UCMS

2. Different models or framework
• Classical model – PIE model
• Comprehensive framework – PRECEDE
& PROCEED

3. THE PRECEDE/PROCEED
MODEL
 Originators
Lawrence W . Green
Marshall W. Krueter
 A framework of comprehensive health
promotion/education programme
planning.
 It systematically guides the development
and evaluation of health education
programme.

4. PRECEDE
PRECEDE stands for “Predisposing,
Reinforcing, and Enabling Factors
construct in Educational Diagnosis
and Evaluation.”

5. PROCEED
 PROCEED, which stands for “policy,
regulatory, and organizational
constructs in educational and
environmental development.”

6. PRECEDE
 Look at present outcomes of health habits and
quality of life of the target population
 Ask “WHY?” rather than “HOW?”
 First portion of the model
 Diagnostic phase
 Built on the belief that there is a need to engage in
multidimensional diagnoses to more effectively
determine factors that may influence health status
in the community.
 Begins with desired outcomes and works
backwards to determines what causes it or what
precede the outcomes.

7.  Outcomes focus
INPUTS OUTCOMES
(EDUCATION) (HEALTH)

8. PROCEED
 Implementation & evaluation phase.
 Goes beyond educational interventions to
the political, managerial, and economic
actions necessary to make social system
environments more conducive to
healthful lifestyles and a more complete
state of physical, mental and social well-
being for all

10. PRECEDE
(Diagnostic Part)
•Phase 1-Social Diagnosis
•Phase 2-Epidemiological Diagnosis
(Social Epidemiology 1&2)
•Phase 3-Behavioral & Environmental
Diagnosis
•Phase 4-Educational Diagnosis
•Phase 5-Administrative & Policy
Diagnosis

11. PROCEED
(Implementation & evaluation
part)•Phase 6-Implementation
•Phase 7-Process Evaluation
•Phase 8-Impact Evaluation
•Phase 9-Outcome Evaluation

12. Diagnosis/Situation Assessment….
PRECEEDE framework of diagnosis
systematically assess problems and
factors related to behavior change in
5 different phases.
These systematic and sequential
phases guide programme planners to
understand and identify the problems
and factors to be addressed by health
education program.

13. Phase 1: Social Diagnosis
•Determine people’s perceptions of their
own needs and quality of life.
•Important because of mutual relationship
between health and quality of life
•Links between social problems & specific
health problems used to develop focus for
health education

14. Methodology for social diagnosis
•Interviews with key opinion leaders &
“target” population
•Focus group discussions
•RRA, PRA & PLA
•Observation –participatory & non-
participatory
•Surveys
•Literature Review –secondary information

15. Phase 2-Epidemiological Diagnosis
 Identify which health problems are most
important to population or community that
are contributing to or interacting with QoL
concerns.
 Establish the program goals and objectives.
 Identify specific health problem which are
associated with a poor quality of life.
 Answer “What health problems are
important (measured objectively, rather than
subjectively)?”

16. Contd….
 Establish the relationships between health
problems, other health conditions and quality of
life.
 Establish dimensions for measuring health
problems –indicators for morbidity, mortality, &
disability (Ds).
 set priorities within health problems and within
target population.
 Magnitude of health problem (Incidence,
prevalence), its distribution with time, place and
person and class is identified.
 Methods: population census, national
demographic surveys, other sample surveys, etc.

17. Phase 3-Behavioral & Environmental
Diagnosis
 Focuses on systematic identification of
health practices and other factors which
seem to be linked to health problems defined
in Phase 2.
 These are malnutrition, unsafe sex, unsafe
drinking water and sanitation, indoor air
pollution, tobacco and alcohol consumption,
high cholesterol consumption
 Includes non-behavioral causes (personal and
environmental factors) that can contribute to
health problems, but are not controlled by
behavior.

18. Non-behavioral causes
•Genetic predisposition
•Age
•Sex
•Climate
•Workplace
•Adequacy of health care facilities

19. Phase 3-Behavioral & Environmental
Diagnosis (contd.)
BehaviouralMatrix:
More Important Less Important
More Changeable High
PriorityQuadrant I
Low Priority Except for
Political
ReasonsQuadrant III
Less Changeable Priority for
InnovationsAsses
sment
CrucialQuadrant
II
No ProgramQuadrant
IV

20. Behavior
s
More Important Less Important
More
Changeab
le
• Sleeping with
out bed nets
• Uses of LLINs
• Sleeping on floor or
surface
• Delay in health
seeking
behavior
Less
Changeab
le
• Working in evening
hours
• Outdoor sleeping
• Proper
management of
waste water
Behavioral Matrix for mosquito
control

21. Phase 4-Educational
Diagnosis
 •This phase assesses the causes of
health behaviors which were identified
in Phase 3.
 Three types of causes are identified:
 Predisposing factors
 Enabling factors
 Reinforcing factors

22.  Identifies those antecedent and
reinforcing factors that initiate and
sustain the change process
 Critical element of this phase is
selection of the factors which if
modified, will be most likely to result in
behavior change
 Prioritization of factors is based on
relative importance and changeability

23.  Predisposing factors are the
antecedents that provide the rationale
or motivation for a behavior.
Knowledge
Attitudes
Beliefs

24.  Reinforcing factors are those elements
that appear subsequent to the
behavior and that provide continuing
reward or incentive for the behavior to
become persistent
Social support -reward, or punishment
Peer influence
Significant others’ support

25.  Enabling factors are
psychological/emotional
or physical factors that facilitate
motivation to change behavior:
Programs, services, and resources
necessary for behavioral
Accessibility, availability, skills

26.  Factors are enumerated and rated in
terms of importance and changeability
 •Priority target groups for intervention are
selected
 •Measurable objectives are then written
How many will know, believe, or be able to
do what by when?
How much of what resource will be available
to whom by when?
 Must be driven by a thorough knowledge
of the relevant literature, and
understanding

27.  Methods for educational diagnosis
- secondary data collection
- Primary data collection-
quantitative and qualitative
surveys
-Observations
-FGD, In-depth Interviews etc.
 Participatory methods of data
collection are encouraged.

28. Phase 5-Administrative and Policy
Diagnosis
 Focuses on administrative and
organizational concerns which must
be addressed prior to program
implementation.
 Includes assessment of resources,
evidence-based ground of available
resources, development of
implementation timetable, organization
and coordination with others.

29.  Assess limitations and constraints
 Select the best combination of
methods and strategies
 e.g Analysis of national health policy

30. Administrative Diagnosis
Analysis of policies, resources and
circumstances prevailing
organizational situations that could
hinder or facilitate the development of
the health program.
Policy Diagnosis
Assesses the compatibility of your
program goals/objectives with those of
the organization and its administration

31. Phase 6-Implementation of the
Program
 Planned activities and strategies are
carried out with the target population.
 Includes development and
implementation of action plan, time
table, building commitment,
mobilization of resources, supervision
and monitoring, organization and
coordination with others.

32. Evaluation
•Clear and concise objectives are the
foundation for evaluation
•From two perspective –Health Program and
Health Education program
•Health Education Programs intermediate to
Health Programs
•Three types of evaluation –Diagnostic,
Formative & Summative
•Three areas of evaluation –process, impact
and outcome (some literature outcome as
output, effect and impact)

33. Phase 7-Process Evaluation
•To evaluate the process by which the
program is being implemented
•Ongoing; flow of activities
•Includes effectiveness of planning
meetings, running meetings,
communicating with others who are
involved

34. Phase 8-Impact Evaluation
 Health Education Impact –Change in
Behavioral and environmental
indicators
 Program Impact –Change in
Epidemiological and social indicators

35. Phase 9-Outcome Evaluation
•Outcome may indicate all -output,
effect or impact
•Output –Immediate outcome
•Effect –More qualitative in nature
•Impact –Change in quality of life of the
people

36. USE OF BED NET TO PREVENT
KALA-AZAR
Health Education Plan through
PRECEDE-PROCEED MODEL

37. • Introduction
• Rational of HE Plan
• Social Diagnosis of the problem
• Epidemiological diagnosis
• Behavioral and Environmental
diagnosis
• Behavioral Matrix

38. • Education & Organizational
Diagnosis
• Administrative and policy diagnosis
• Implementation of HE Program
• Evaluation Plan of HE Program

39. Introduction
• Kala-azar (Visceral Leishmaniasis) is a vector
born disease caused by the parasite
Leishmania donovani
• The vector of kala-azar (Leishmania
donovani) commonly known by “Sand Fly”
• Transmitted by the bite of the infected female
sand fly called “Phlebotomus argentipes”

40.  Using Bed Net while sleeping is a
simple preventing measure of Kala-
azar as well as other vector born
diseases likes; JE, Dengue and
Malaria etc
 Environmental, socioeconomic and
health behavior related factors directly
affects the transmission of disease

41. Rational
• KA is considered as a major public health
problem in Nepal with incidence rate:
0.14/10,000 population (DHS Report -2012/13)
• Household behaviors promotes the breeding
and biting from the vectors. Vector’s biting is
an absolute source of disease transmission
• Sand flies (vectors) usually have nocturnal
biting habit

42.  Using of bed net to prevent the risk of
biting during sleeping time is a key
preventing measure of disease
transmission
 Only three-fifths or almost 61% of
households have mosquito nets (NDHS-
2006)

43. Kala-azar Prone 12 districts and Incidence Rate

44. 1. Social Diagnosis of the problem:
• 12 terrai lower land districts of Nepal are considered
as Kala-azar prone districts
• Those who have poor housing condition and poor
sanitation practices, higher chances of getting
disease.
• Socially and economically disadvantaged groups with
high illiteracy and poverty, suffered greater compared
to others. It is the disease of poorest of the poor
• Almost about 50% people are illiterate and 24.7 %
people are below of poverty line in Nepal
• Lack of knowledge about on preventive measures
including use of bed net during sleeping time are the
determining factors for disease transmission

45. 2. Epidemiological diagnosis:Disease causing agent (vector):Sand fly or
Phlebotomus
Argentipes
Population at risk :Almost 8 million (12
districts)
: Higher incidence among
men
Highest risk group :Below the age of 15 years
(>50% in <15 years
of age)
Occupation :High pre. among Farmers
Seasonality of transmission :Epidemic (Rainy &
post-rainy season – 90%
cases occur )
Incidence rate :0.75 in 2011 and
0.14 in 2012
Average case fatality :1.02 percent

46. 3. Behavioral and Environmental diagnosis
(a) Behavior factors for disease incidence and
transmission:
• Sleeping without bed nets
• Outdoor sleeping or sleeping on floor/surface
• Expose of body parts at evening hours
• Traditional animal husbandry practices
• Improper management of waste water
• Delay in health seeking
• Not using of LLINs
Negative
Behaviors

47. • Using Khatiya for sleeping
• Practices of waste-material fumigation
in dusk to drive the vectors
• Sleeping habit on second floor
• Using of bed nets
Positive
Behaviors
Behavior factors for disease incidence &
transmission:

48. (b) Environment conditions for disease
incidence and transmission:
• Paddy field surrounding of houses
• Favorable temperate and climates for vectors
• Poor environmental and housing condition which
is appropriate to vectors for the breeding
• Nocturnal biting habits of the vectors
• Only 61% of households (84% in Tarai and 46%
in Hill) have mosquito net (NDHS’o6)
• Limited number of bed nets in house hold, three in
ten own one net, one in two owns two to three
nets, and one in five owns at least four nets

49. Behavior
s
More Important Less Important
More
Changeab
le
• Sleeping with
out bed nets
• Uses of LLINs
• Sleeping on floor or
surface
• Delay in health
seeking
behavior
Less
Changeab
le
• Working in evening
hours
• Outdoor sleeping
• Proper
management of
waste water
Behavioral Matrix

50. 4. Education & Organizational
Diagnosis:
(a) Predisposing Factors:
• Lack of Knowledge on disease causing,
transmitting agents and preventive ways of
Kala-azar
• False believes and misconceptions about
treatment and prevention of kala-azar
• Negative attitude towards using bed nets.

51. Education & Organizational Diagnosis……
(b) Enabling Factors:
• Poor housing leading to aggravate breeding.
• Lack of affording capacity to use bed net and adopt
other preventive measures
• Inaccessible treatment facilities and costly
• Lack of access on education and communication
• Traditional practices of treating diseases and
superstition
• Less availability of bed-nets
• Lack of acceptable and affordable treating system
• Favorable environment for vectors breeding and
bites

52. Education & Organizational Diagnosis……
(c) Reinforcing Factors:
• Family environment (Less approval of using
bed net by family)
• Use of bed net by role models of
community(teachers)
• Wide spread use of bed net in community
• Bed net promotional advertisement in local
media
• No punishment & reward system for users
and non-users
• Interaction with HWs and teachers

53. 5. Administrative and policy
diagnosis:(a) National, International and Local Responses:
• MOHP considered vector born diseases as priority
one program and has been implementing various
measures for controlling the disease
• The Kala-azar elimination programme has been
expanding after successive piloting at Saptari district
to all 12 epidemic districts by adopting PHC
approach
• Collaboratively implementing the Kala-azar
elimination program by adopting a same protocols
(Miltefosine-oral and rK-39 diagnostic tools) in Nepal,
India and Bangladesh

54. Administrative and policy diagnosis……….
National, International and Local Responses………
• Establishment of sentinel surveillance sites with in the
districts through early warning reporting system
• Providing various anti- Kala-azar services at
community in free of cost, through existing health
networks
• Peripheral level health workers were trained on
appropriate skills required for prevention and control
of vector borne diseases including Kala-azar
• Establishment of Vector Borne Disease Research and
Training Centre (VBDRTC)

55. (b) Disease control and preventive strategies:
• Health education and promotion
• Bi-annual Indoor Residual Spraying (IRS) at 12
endemic districts
• Distribution and promotion of insecticide treated
bed nets (ITBN) and long lasting insecticide bed
nets (LLIBN) per identified household at endemic
areas
• Early diagnosis, prompt and complete treatment
(EDPCT) of Kala-azar cases along with
appropriate laboratory diagnostic facilities
• Training to HPIs, PHOs, DHOs and MOs on Kala-
azar control and management
• Research on the epidemiology of Kala-azar, vector
bionomics and effectiveness of different anti-Kala-
azar drugs.
Administrative and policy diagnosis……….

56. 6. Implementation Plan of
Health Education Program:
“Use of bed net to Prevent Kala-azar”

57.  Goal: To improve health status of Kala-
azar risk population of Siraha
district.
 General Objective :
To increase the use of bed nets
during sleeping time to prevent Kala-
azar.

58. Specific objectives:
At the end of Health Education Program:
• 90% participants will be able to list mode of
transmission of Kala-azar(K)
• 90% participants will be able to explain the
importance of using bed net (K)
• 80% participants will be able to differentiate the
ordinary bed nets and LLINs (K)
• 60% participants will adopt any types of bed nets
based on their needs or capacities (P)

59. Contents of HE session
• Introduction of Kala-azar
• Mode of transmission of Kala-azar
• Importance of using bed nets
• Various types of available bed nets
• Difference between ordinary net and LLINs

60. Target Audience:
Mothers group members
Male farmers group members
Community forest users groups
Female Community Health Volunteers
(FCHVs)

61. HE Methods :
• Brainstorming
• Lecture
• Group Discussion
• Demonstration
HE media/Materials:
• Flip chart: How to use bed net properly & life
cycle of sand flies
• Posters /Pamphlets relating to importance of
using bed nets
• Multimedia: LCD, Lap-Top
• Materials for demonstration (Plain bed net and
LLIBN net)

62. Human and other resources plan:
• Health educators team from TU, MMIHS , BPH
students
• District Public Health Officer and District
Supervisors from DHO, Siraha
• Local health facilities' staffs
• Local INGOs /NGOs and staffs
• Transportation will be managed from MMIHS,
Nakkhu
• Budget and other necessary materials will be
made available from EDCD and PSI

63. H.E Topic Target groups Methods and
Media
Resource
person
Location Date and
duration of
session
• Introduction of
kala-azar and its
mode of
transmission
 FCHVs
 Mothers
groups
members
 Male farmers
groups
member
 Forest
consumer’s
groups
 Brain storming
 Lecture
 Group
discussion
 Flip chart &
poster
 Multimedia
 BPH
students
 Local
HWs
 Saurya
English
Boarding
School ,
Siraha-7
1st March,
2014,
(20 minutes)
 Importance of
using bed net
 Same as
above
 Same as above  Same as
above
 Same as
above
1st March,
2014,
(20 minutes)
 Discussion and Q/A session at the end of health education session of 1st day 20 minutes
 Various types of
bed net
available at
market
 Same as
above
 Same as above  Same
as above
 Same as
above
2nd March,
2014 (20
minutes)
 Introduction and
demonstration
ITBN/LLIN and
differences
between
ordinary net and
 Same as
above
 Demonstration
of available bed
nets
 Same
as above
 Same as
above
2nd March,
2014 (35
minutes)

64. EVALUATION OF THE
PROGRAME

65. 1. Process evaluation
• Plan of health education program
• Materials identification, preparation, uses
• Using of TL method and medias
• Arrangement and allocation of necessary
resources
Techniques of process evaluation
Pre and Post training evaluation
Regular monitoring of sessions and feedback
in post session.
Question/ Answer
Tools for process evaluation
(checklist, questionnaire)
7. Evaluation Plan

66. Process Indicators
 No. of health education session conducted
 No. of supervision conducted
 No. of review meeting conducted
 Number of participants attended HE
session

67. 2. Impact evaluation
 Assesses the changes in the KAP
that occurred in the participants as a
result of the Intervention.
Techniques of Impact evaluation
 Household survey
 Observation
 Pre test/post test (assessment of
knowledge)

68. Impact indicator
• % of participants able to explain importance
of using bed net
• % of participants able to list mode of
transmission of Kala-azar
• % of participants able to differentiate the
ordinary bed nets and LLINs/ITBN
• % of participants adopting any types of bed
nets

69. 3. Outcome Evaluation
Identifying the changes in the health status of
the participating group
Long-term effects of the program

70. Outcome Indicator
 Incidence of Kala-azar
 Prevalence of Kala-azar
Source of data : HP register; Hospital
records; VDC profile