Planning models and theories: integrating components for addressing complex challenges

Abstract

The article in this issue by Crosby and Noar 1 provides a useful, detailed overview on the PRECEDE-PROCEED planning model 2. PRECEDE-PROCEED is the most widely used planning model for the development and evaluation of health promotion and policy programs in the world. A check of Dr. Lawrence W. Green's PRECEDE-PROCEED website http://www.lgreen.net/precede.htm lists 960 publications that have used the model, and it should work well for dental health applications. Crosby and Noar provide a well-organized summary and description, as well as lessons learned from implementing the PRECEDE-PROCEED model. Their table provides a useful summary of key components of the model, and readers desiring more information might wish to consult the EMPOWER tool listed on Dr. Green's website. The authors provide an important distinction between theories, which should be testable and falsifiable, and planning models that are more like blueprints that guide actions, but do not provide testable hypotheses. Rather, PRECEDE-PROCEED highlights a sequence of steps and activities that should be conducted to obtain successful and sustainable outcomes. Keys to PRECEDE-PROCEED, as Crosby and Noar describe, are that it is a socio-ecologic model that considers factors at multiple levels from the individual to society; and that a collaborative, community-oriented partnership approach is used to engage relevant stakeholders throughout the process. The PRECEDE-PROCEED model works especially well for complex issues, such as improving dental health, that are multifaceted and involve several interrelated factors including personal behaviors, family and media influences, clinical/dental education and interventions, and larger social and economic factors. Given the complexity of the model, I highlight some additional points to those presented by Crosby and Noar. First, it is not so much the number of activities completed at each step or level of diagnosis and action within PRECEDE-PROCEED that is important. Rather, as with the Chronic Care Model 3, another widely used planning model within medical systems, it is the extent to which these activities are conducted in an integrated fashion and designed to complement and reinforce each other that determines success. It is currently politically correct to say that one employs a partnership approach, but more challenging to “walk one's talk” and to actually treat stakeholders, ranging from citizens and families to health care professionals, to vested interests and those having opposing views, as equal and valued partners. Doing so is one of the “best processes” that is essential to success and Dr. Green's website references assessment strategies for determining the extent to which a project is really community-based and participatory (a useful screening question that is often revealing is to ask, “who controls the budget and makes actual budget decisions?”). Finally, although Crosby and Noar do a nice job of presenting the evaluation aspects of the PROCEED components, these are actually interactive, and to build successful sustainable programs, planners need to adapt to changing circumstances, challenges, and emerging data. The capacity that they rightly emphasize involves the ability to respond to new problems and situations, not simply implementing one's original strategy “with fidelity.”