Precede-Proceed Revisited

Behavior, Lifestyle, and Social Determinants of Heart Health: From Research to Policy, Planning, Programs &

Services

Lawrence W. Green

Office of Extramural Prevention ResearchPublic Health Practice Program Office

Centers for Disease Control and PreventionU.S. Department of Health & Human Services

York University Forum, Toronto, Feb. 20, 2003

Health Promotion, Health Protection, and Disease Prevention

Social structure,conditions

Culture, lifestyle, attitudes &

policies about risk

Risk behaviors &Environmental exposures

Adversehealth events

Health Promotion

Primary Prevention &Health Protection

Sequelae, Outcomes

Secondary Prevention Tertiary Prevention

Lesson 1. Social determinants operate as background & as distal determinants on most of the proximal determinants of health.

Self-care

Determinants of Health* More Distal More Proximal

Income & social status Gender Education Employment &

working conditions Physical environment Biology & genetic

endowment

Personal health practices & coping skills

Healthy child development

Health & social services Culture Social support networks Social environment

*Tonmyr et al., The population health perspective… Chronic Diseasesin Canada 23:123-129, Fall 2002.

Lesson 2: The Social Determinants Imperative and Opportunity

From tobacco control experience, we know that some work with other sectors and work within the health sector on more distal determinants is essential to long-term success

Many, if not most, social determinants are:– More proximal, and/or– Amenable to health sector intervention, and/or– Amenable to collaboration with other sectors

Achieving Health for All*

*Epp, Jake. Achieving health for all: a framework for health promotion. Ottawa: Minister of Supply and Services, 1986.

AIM

HEALTHCHALLENGES

HEALTHPROMOTIONMECHANISMS

IMPLEMENTATIONSTRATEGIES

REDUCINGINEQUITIES

INCREASINGPREVENTION

ENHANCINGCOPING

SELF-CARE MUTUAL AID HEALTHYENVIRONMENTS

FOSTERINGPUBLIC

PARTICIPATION

STRENGTHENINGCOMMUNITY

HEALTH SERVICES

COORDINATINGHEALTHY PUBLIC

POLICY

ACHIEVING HEALTHFOR ALL

0

1,000

2,000

3,000

4,000

5,000

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990

Num

ber o

f Cig

aret

tes

What is this public health achievement of the 20th Century?What is the evaluation method to judge this an achievement?

35%

22%

0

1,000

2,000

3,000

4,000

5,000

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990

Num

ber o

f Cig

aret

tes

Source: USDA; 1986 Surgeon General's Report

Great Depression

End of WW II

Nonsmokers’Rights

Movement Begins

1st SurgeonGeneral’s Report

Fairness DoctrineMessages on TVand Radio

Federal CigaretteTax Doubles

BroadcastAd Ban

Adult Per Capita Cigarette Consumption and Major Historical Events—United States, 1900-2000

MasterSettlementAgreement

NicotineMedications Available Over the Counter

1st Smoking-Cancer Concern

1st World Conferenceon Smoking and Health

Surgeon General’sReport on EnvironmentalTobacco Smoke

1st Great American Smokeout

Lesson 3: Surveillance--Making Lesson 3: Surveillance--Making Better Use of Natural ExperimentsBetter Use of Natural Experiments Key to establishing baselines & trend lines that can

be projected to warn against neglect Key to putting an issue on the public policy agenda Key to showing change in relation to other trends,

policy and program interventions Key to comparing progress in relation to objectives

and programs, over time and between jurisdictions.

Lesson 4: Evaluation of ecological approaches to prevention on community-wide or province-wide scale should not attempt to isolate the components.

Lesson 5: Comprehensiveness Lesson 5: Comprehensiveness

In trying to isolate the essential components of tobacco control programs that made them effective, none could be shown to stand alone

Any combination of methods was more effective than the individual methods

The more components, the more effective The more components, the better coverage

Cost (US$) Per Year of Life Saved

Smoking cessationLow intensity interventions $100 - 500Brief advice, MD $1,000 - 3,000High intensity interventions $6,000 - 15,000

Common disease prevention $1,500 - 15,000Secondary or tertiary care $20,000 - 100,000

Source: Warner KE. Smoking cessation: Alternative strategies: Financial implications. Tobacco Control , Autumn 1995.

Lesson 6: Effectiveness and benefit may increase with intensity, but cost-utility and cost-effectiveness often decline. Intensity limits reach. -->Issue of inequalities.

Estimated Efficacy (6-month quit rates),Reach (number using), and Impact of

Main Cessation StrategiesIntervention Ef

%Reach #using US

ImpactU.S.

ImpactB.C.

None (unaided) 3 22,800,000 684,000 7,600Rx NRT 14 2,500,000 280,000 3,111OTC NRT 14 6,300,000 560,000 6,222Behavioral 24 395,000 94,800 1,053Inpatient Rx 32 500 160 2

Lesson 7: Cost-benefit and cost-effectiveness depend as much on the reach as on the efficacy of interventions.

Change in Per Capita Cigarette ConsumptionChange in Per Capita Cigarette ConsumptionCalifornia & Massachusetts versus Other 48 States, 1984-1996California & Massachusetts versus Other 48 States, 1984-1996

-25

-20

-15

-10

-5

0

5

Perc

ent R

educ

tion

Other 48 States California Massachusetts

1984-1988 1990-1992 1992-1996

What Worked? Making Better What Worked? Making Better Use of “Natural Experiments”Use of “Natural Experiments”

Comprehensive program Comprehensive program andand tax increases in CA tax increases in CA and MA resulted in: and MA resulted in: – 2 - 3 times faster decline in adult smoking prevalence2 - 3 times faster decline in adult smoking prevalence– Slowed rate of youth smoking prevalence compared Slowed rate of youth smoking prevalence compared

to the rest of the nationto the rest of the nation– Accelerated passage of local ordinancesAccelerated passage of local ordinances

Similar, though later, experience in OR & AZ, Similar, though later, experience in OR & AZ, and in population segments of FLand in population segments of FL

Components of Components of Comprehensive Comprehensive Tobacco Control ProgramsTobacco Control Programs

Community Programs Community Programs Statewide ProgramsStatewide Programs Chronic Disease Chronic Disease

ProgramsPrograms School ProgramsSchool Programs EnforcementEnforcement

Counter-MarketingCounter-Marketing Cessation ProgramsCessation Programs Surveillance and Surveillance and

EvaluationEvaluation Administration and Administration and

ManagementManagement

Lesson 8: The Ecological Lesson 8: The Ecological ImperativeImperative

Need to address the problem at all levelsNeed to address the problem at all levels– IndividualIndividual– Organizational, institutionalOrganizational, institutional– CommunityCommunity– State, regionalState, regional– National, internationalNational, international

Need to make these levels of intervention Need to make these levels of intervention mutually supportive and complementarymutually supportive and complementary

Percent Reductions in Per Capita Cigarette Percent Reductions in Per Capita Cigarette Consumption Attributable to Non-Price Public Consumption Attributable to Non-Price Public

Health InterventionsHealth Interventions

Dollars Per Capita Annual Spending on Programs

0$2

$4

$6

$8

$10

80%

60%

40%

20%

Red

uctio

n in

Sta

te C

onsu

mpt

ion

70%

20%

55%

Lesson 9: Threshold SpendingLesson 9: Threshold Spending

A critical mass of personal exposure is A critical mass of personal exposure is needed for individuals to be influencedneeded for individuals to be influenced

A critical mass of population exposure is A critical mass of population exposure is necessary to effect detectable community necessary to effect detectable community responseresponse

A critical distribution of exposure is A critical distribution of exposure is necessary to reach segments of the necessary to reach segments of the population who are less motivatedpopulation who are less motivated

$0 $2 $4 $6 $8 $10 $12

Massachusetts

California

Arizona

Oregon

NCI/ RWJF

NCI

CDC/ RWJF

CDC

Per Capita Spending on TobaccoPrevention and Control--FY1997

Dollars Per Capita

Lesson 10: The Environmental Lesson 10: The Environmental ImperativeImperative

Environments provide opportunities Environments provide cues Environments enable choices Social environments reinforce positive

behavior and punish negative behavior Legal penalties and financial incentives can

be built into environments

100-Percent Smokefree Ordinances, by Year of Passage

1985 1986 1987 1988 1989 1990 1991 1992*0

24

6

810

12

14

16

18WorkplaceRestaurantRestaurant and Workplace

Number ofOrdinances

Year* Through September 1992.Source: National Institutes of Health, National Cancer Institute (1993). Smoking and Tobacco Control - Monograph 3. Major Local Tobacco Control Ordinates in the U.S. US Dept. of Health and Human Service. Public Health Service, National Institutes of Health. NIH Publ. No. 93-3532.

Tobacco Vending Machine Ordinances

1985 1986 1987 1988 1989 1990 1991 1992*

0

2040

60

80100

120

140

160

180Total BanPartial Ban

Number ofOrdinances(Cumulative)

Year* Through September 1992.Source: National Institutes of Health, National Cancer Institute (1993). Smoking and Tobacco Control - Monograph 3. Major Local Tobacco Control Ordinates in the U.S. US Dept. of Health and Human Service. Public Health Service, National Institutes of Health. NIH Publ. No. 93-3532.

Lesson 11: The Educational Lesson 11: The Educational ImperativeImperative

Public awareness of risks and benefitsPublic awareness of risks and benefits Public interest in lifestyle optionsPublic interest in lifestyle options Public understanding of behavioral stepsPublic understanding of behavioral steps Public attitudes toward the options & stepsPublic attitudes toward the options & steps Public outrage at the conditions that have Public outrage at the conditions that have

put them at risk or in dangerput them at risk or in danger Personal and political actionsPersonal and political actions

Lesson 12: The Evidence-Based Lesson 12: The Evidence-Based Imperative: The Need to Bridge...Imperative: The Need to Bridge...

““best practices” indicated by research to their application best practices” indicated by research to their application in practice in underserved areasin practice in underserved areas

““best practices” from research to the most appropriate best practices” from research to the most appropriate adaptations for special populationsadaptations for special populations

The success of individual behavior changes of the The success of individual behavior changes of the affluent to the system changes needed to reach the less affluent to the system changes needed to reach the less affluent, less educated…affluent, less educated…

University-based, investigator-driven research to University-based, investigator-driven research to practitioner- & community-centered researchpractitioner- & community-centered research

Breaking the Intervention-Based Research and Planning Habit

1. Select off-the-shelf 1. Select off-the-shelf Intervention or Intervention or Service to be StudiedService to be Studied

2. Assess Response2. Assess Responseto the Intervention orto the Intervention orServiceService

3. Increase Dose3. Increase Doseor Increase Demandor Increase Demand

4. Evaluate Response to the4. Evaluate Response to theIntervention or ServiceIntervention or Service

Strengthening Population-based, Strengthening Population-based, Diagnostic Planning Approaches*Diagnostic Planning Approaches*

1. Assess Needs & Capacities 1. Assess Needs & Capacities of Populationof Population

2. Assess 2. Assess Causes, Set Causes, Set Priorities & Priorities & ObjectivesObjectives

3. Design & 3. Design & ImplementImplementProgramProgram

4. Evaluate 4. Evaluate ProgramProgram

*Procedural models, such as PRECEDE, PATCH, Intervention Mapping. SeeGreen & Kreuter, Health Promotion Planning, 3rd ed., Mayfield, 1999.

Reassess causesReassess causes

RedesignRedesign

Uses of Evidence in Population-Based Planning Models

1. Assess Needs & Capacities of Population

2. Assess Causes (X) & Resources

3. Design & ImplementProgram

4. Evaluate Program

Reconsider X

D. Program Evidence

Evidence fromResearch

From previous evaluations (D1)

Evidencefrom communityor population

A.B.

C. Evidence from R&D and Exp’tal. Studies

D2

Surveillance, Planning and Evaluating for Policy and Action: PRECEDE-PROCEED MODEL*

Quality of life

Phase 1 Socialassessment

Health

Phase 2Epidemiological assessment

Healtheducation

Policyregulation

organization

HealthProgram

Phase 5Administrative &policy assessment

Output Longer-termhealth outcome

Short-termsocial impact

Short-term impact

ProcessInput Long-termsocial impact

Phase 6Implementation

Phase 7Process evaluation

Phase 8Impact evaluation

Phase 9Outcome evaluation

Predisposing

Reinforcing

Enabling

Phase 4Educational &

ecologicalassessment

Behavior

Environment

Phase 3Behavioral &environmentalassessment

*Green & Kreuter, Health Promotion Planning, 3rd ed., 1999.

Formative evaluation & baselines for outcome evaluation

InterventionMapping&Tailoring

Monitoring & Continuous Quality Improvement

Towards an Integrated Model*

FRAMINGFRAMING FOCUSINGFOCUSING EVALUATINGEVALUATING

Population Health

Models of Change

Best Practices

Dissemination

Policy

Analysisand

Interpretation

SocialEcology

Health PromotionPlanning

CommunityPartnering

LifeCourse

*A.Best, D.Stokels, L.Green, et al., AJHP, in press.

Components of an Integrated Model

Social Ecology - How do we see the problem?

Life Course Health Development - How do people and their health needs change?

Health Promotion Planning & the Precede-Proceed Model - How do we plan & promote change?

Community Partnering - How do we work together?

CIHR Knowledge TranslationKT Research Cycle

Research

Research

Open Competition

Research

Knowledge Priority Setting

Use

Evaluation of Uptake

Research Priorities

Research

Knowledge Synthesis

Expertise

Knowledge Distribution

& ApplicationExpertise

CommunicationMarketingTraining

Dissemination Model

Tends to linear, one-way communication Presumes centrally defined needs Limited, inconsistent impact Incomplete monitoring and evaluation

capacity Disciplines and literatures isolated Lack of systems thinking

Evidence-Advocacy-Policy-Practice Cycle*

Agenda Setting

AdvocacyEvidence

Surveillanceand

Evaluation

Commitment to Develop Policy

and Action

ConsultationTo frame policy and action planTo build support

Endorsement•All agencies with capacity to act orContribute (coalition)

Uptake & Outcomes•Government•Professionals•Communities

Assessment of Need•Inequalities

•Refine programs

ExtramuralResearch

ExternalAdvocacy

*Adapted from Australia Commonwealth Dept of Health, 2001

“Best Practices”Diffusion researchDissemination

The Lenses of Health The Lenses of Health Professionals and Lay People Professionals and Lay People

“ “Objective”Objective” Indicators Indicators of Healthof Health

SubjectiveSubjectiveIndicatorsIndicatorsof Healthof Health

ProfessionalProfessional LaypersonLayperson

LW Green, Inst of Health Promotion Research, Univ. British Columbia, Vancouver, BC V6T 1Z3Adapted from Yukon Bureau of Statistics, Whitehorse, 1995

Understanding Differences Among Understanding Differences Among Public’s Perception of Needs, the Public’s Perception of Needs, the Health Sector’s Assessments, and the Health Sector’s Assessments, and the Political AssessmentsPolitical Assessments

““ActualActualneeds”needs”

Public’sPublic’sperceived needs,perceived needs,

prioritiespriorities

Resources,Resources,feasibilities,feasibilities,

policypolicy

BB

CC

DDAAAA

EE

LW Green, Inst of Health Promotion Research, Univ. British Columbia, Vancouver, BC V6T 1Z3

Strategies to Reconcile Strategies to Reconcile Perceived & Actual Needs, & Perceived & Actual Needs, & ResourcesResources

Participatory Research Participatory Research

AAA

Community Community mobilizationmobilization& organizational& organizationaldevelopmentdevelopment

Health EducationHealth Education

(advocacy)(advocacy)

LW Green & MW Kreuter, Health Promotion Planning: An Educational and Ecological Approach, 1999.

Definition of Definition of Participatory Research Research (www.ihpr.ubc.ca/guidelines.html)

----Systematic investigation...Systematic investigation...--Actively involving people in a learning process...--Actively involving people in a learning process...--For the purpose of social action (new services, resource --For the purpose of social action (new services, resource

allocation, regulation or policy) conducive to [their/their allocation, regulation or policy) conducive to [their/their constituents’] health or quality of life.constituents’] health or quality of life.

--What Participatory Research is not...--What Participatory Research is not...--not just involving people more intensively as subjects of --not just involving people more intensively as subjects of researchresearch