Revisiting Precede-Proceed: A Leading Model For Ecological and Ethical Health Promotion
Revisiting Precede-Proceed: A Leading Model For Ecological and Ethical Health Promotion
Revisiting Precede-Proceed: A Leading Model For Ecological and Ethical Health Promotion
research-article2015
HEJ0010.1177/0017896915619645Health Education JournalPorter
Article
Revisiting Precede–Proceed: A
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© The Author(s) 2015
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DOI: 10.1177/0017896915619645
ethical health promotion hej.sagepub.com
Christine M Porter
Division of Kinesiology and Health, College of Health Sciences, University of Wyoming, Laramie, WY, USA
Abstract
Background: The Precede–Proceed model has provided moral and practical guidance for the fields of
health education and health promotion since Lawrence Green first developed Precede in 1974 and Green
and Kreuter added Proceed in 1991. Precede–Proceed today remains the most comprehensive and one of
the most used approaches to promoting health.
Objective: A decade after the most recent edition of the model was published in 2005, this paper examines
the model’s theoretical underpinnings, history, and influence on the field of health promotion. Although the
limited evidence for effectiveness of this and other models is discussed briefly, this review focuses on the
socio-ecological and ethical implications of the model.
Approach: Theory and literature review.
Results: Precede–Proceed has promoted public health and health promotion practice in five ethically and
practically important ways: (1) by advancing the ecological perspective on health that, today, has come to
dominate public health practice; (2) by remaining population-centred, rather than focusing on individuals;
(3) by demanding democratic and participatory approaches to health promotion; (4) by setting quality of
life, rather than behaviour change or even health, as the goal for health promotion; and (5) by being deeply
grounded in practice.
Conclusion: Precede–Proceed guides practitioners in bridging health promotion goals of enabling people to
control and improve their own health with larger public health goals of creating the conditions where people
can be healthy. It also provides an ethical guide to promoting health in democratic and participatory ways.
Keywords
Health promotion ethics, health promotion models, health promotion theory, participatory, Precede–
Proceed, socio-ecological approach
Corresponding author:
Christine M Porter, Division of Kinesiology and Health, College of Health Sciences, University of Wyoming, 1000 E.
University Avenue, Dept 3196, Laramie, WY 82071, USA.
Email: [email protected]
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2 Health Education Journal
The Precede–Proceed model for health programme planning and evaluation is widely taught and
used in Anglophone health promotion practice, with well over 1000 published applications
(Green and Kreuter, 2005; Jones and Donovan, 2004; Linnan et al., 2005; Nutbeam et al., 2010;
Trifiletti et al., 2005). Having been first developed in the 1970s, it is also one of the oldest. The
model’s authors, Green and Kreuter, have written extensively about Precede–Proceed, and a
chapter about the model in Glanz et al.’s comprehensive health behaviour and education text
discusses the history and theory of the model in detail (Gielen et al., 2008; Glanz et al., 2008a).
However, Precede–Proceed merits revisiting not only because of its widespread use, but because
it has been a leading force in operationalising both socio-ecological and participatory approaches
to health promotion.
This paper re-examines the model’s theoretical underpinnings and history with a deductive,
retrospective lens. This paper examines the influence of Precede–Proceed on the field, rather than
evaluating its contributions to developing effective health promotion interventions. While the
weak evidence base for this (and most other health promotion models) is briefly discussed, this
paper focuses on ways the authors of Precede–Proceed have provided practical and ethical leader-
ship in guiding health promotion and education practice to attend to social determinants of health
and respect community expertise and priorities. The approach adopted here is based on a deep
reading and review of the model’s development: from a 1974 paper that outlined the early version
of Precede to the four editions of a text that develops, explains and adapts the Precede–Proceed
approach between 1980 and 2005.
Precede-Proceed can be thought of as a road map and behaviour change theories as the specific directions
to a destination. The road map presents all the possible avenues, whereas the theory suggests certain
avenues to follow. Unlike the theories described in previous chapters, the main purpose of the Precede-
Proceed Model is not to predict or explain the relationship among factors thought to be associated with an
outcome of interest. Rather, its main purpose is to provide a structure for applying theories and concepts
systematically for planning and evaluating health behaviour change programmes. (p. 408)
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Porter 3
Figure 1. The Precede–Proceed Model for Health Programme Planning and Evaluation.
From Green and Kreuter (2005). Adapted and used with permission from Green and Kreuter (Green, 2015).
One early critique called the model ‘a-theoretical’ (McLeroy et al., 1993: 307). However, as the
model’s authors and others claim in a reply (Green et al., 1994), the model has robust theoretical
and practical underpinnings, though also is designed to help practitioners plan effective pro-
grammes using theory and not to predict or explain the relationships among factors.
Certainly, the model’s theoretical approach is highly eclectic, including explicitly inviting users
to apply individualistic behaviour change theories in Precede phases. Arguably, the framework
unites a collection of theories and, importantly and somewhat uniquely, ethical principles. The
model could be cast as a theoretical and ethical framework that guides practitioners through each
layer of a socio-ecological model of health, with the predictive value being that a more effective,
relevant, comprehensive and democratically determined outcome will result from its use.
Green and Kreuter (1999, 2005) have subtitled the last two editions of their Precede–Proceed
book, ‘an educational and ecological approach’. As this implies, the model draws on two radi-
cally different theoretical traditions – one cognitive and individual and the other structural and
communal – to support comprehensive health programme planning that accounts for multiple lay-
ers of determinants of health.
Five important and defining approaches of Precede–Proceed are that it is:
•• Socio-ecological with particular emphasis on the impact of physical, social and political
environments on population health.
•• Population-centred, rather than focused on individuals; as such it is arguably a public health
theoretical framework, with health behaviour change embedded within it.
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4 Health Education Journal
Precede–Proceed leads health promoters through the layers of a socio-ecological model, from
individual characteristics to broad socio-political conditions. The framework has been a leader in
encouraging practitioners to view health and individual health behaviours within the overall eco-
system of health determinants and to improve those conditions (Green and Kreuter, 1999; Green
et al., 1996; Kemm, 2015: 61; Richard et al., 2011).
The model’s population, rather than individual, lens on health also relates to its socio-ecological
approach. Green and Kreuter (2005) urge planners to go ‘beyond the clinical, one-on-one aspect
of acute health care’ to consider the relationship between groups of people and their environments
(p. 2). While parts of the model can be applied to individuals, this is not its intent, in contrast with
intrapersonal theories of health behaviour such as the Health Belief Model, the Transtheoretical
Model, and Theory of Planned Behaviour. Assessments in the Precede phases are designed to be
done at the population level. Yet, drawing on Bandura’s (1978) social cognitive theory, Green and
Kreuter (2005) do not subsume personal agency with their population-level perspective, noting
that ‘people learn continuously from their environmental and social surroundings and can develop,
individually or collectively, the knowledge and skills to modify them’ (p. 30). This emphasis
appears in several phases in the use of more agentic, individual theories such as cognitivism and
exchange theories. Green and Kreuter (2005) write,
Without education and a commitment to the open exchange of idea, biases, and assumptions, the process
of planning runs the risk of becoming a manipulative, social engineering enterprise. Without the policy
support for social change, on the other hand, education efforts, shown to be effective on an individual
basis, often prove to be too weak to yield a population-wide benefit. (p. 6)
This passage points to a third defining feature of the model: an emphasis on democracy and the
participation of the ‘target population’ in every phase of assessment, prioritisation, planning,
implementation and evaluation with emphasis on personal agency in ‘democratic social and behav-
ioural change’ (Green and Kreuter, 2005: 6). Here, the authors draw from participatory action
research methods and concepts from Paulo Freire’s (1970) transformation learning theory, includ-
ing conscientisation and cultural invasion versus synthesis.
A fourth feature is its focus on beginning at the end, with the end being a higher quality of life
rather than behaviour change or even health. Starting with the first edition of the Precede model,
the authors define health as an instrumental value; ‘people cherish health because it serves other
ends’ (Green et al., 1980: 18). This view, later enshrined in the Ottawa Charter for Health Promo-
tion (1986), which describes health as ‘resource for everyday life, not the objective of living’, is
widely expanded upon in later editions.
The model is also notable for being strongly grounded. In response to critiques and comments
from practitioners applying the model in the field, the authors have gradually but substantially
changed their model since Green’s inception 40 years ago of what became Precede (Green, 1974;
Green and Kreuter, 1999). Even the early version of the Precede model was ‘rigorously evaluated
[in] “real world” clinical trials’ (Green et al., 1980: 11). As the authors explain in a footnote,
the theoretical grounding and evolution of the model has been influenced as much from its various
applications and the theories brought to bear in those applications as in the original theories and research
that led to the formulation of the model. (Green and Kreuter, 2005: 180–181)
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Proceed includes phases 5–8, mainly providing a participatory health promotion spin on
standard project planning, management, implementation and evaluation frameworks. Proceed’s
goal is to make the programme ‘available, accessible, acceptable and accountable’ (Green and
Kreuter, 2005: 245), including being practically feasible for all partners and appropriate to the
population’s needs, aspirations and circumstances. Phase 5 is implementation. Here, the authors
provide guidance by example through three chapters of case studies. Phases 6–8 encompass the
process, impact and outcome evaluations. Although these three evaluation phases are presented
discretely as final phases, the model suggests conducting process evaluation activities in every
phase.
the most pressing human health problems and the most probable solutions for them are more and more
involved in the necessity of knowing more about the relationship between man [sic] and his total
environment. Given a basic, genetic start it appears that what happens to man is thenceforth largely
determined by these external forces. (p. vii)
Green later teamed with Kreuter and others to publish the book Health Education Planning: a
Diagnostic Approach (1980), in which the Precede term was coined. The model itself was nearly
identical to that in Green’s 1974 paper, except that it begins with the more positively oriented
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Porter 7
‘quality of life’ rather than a ‘social problem’ diagnosis. Both publications focused on cost-benefit
analysis, but it is the planning model that has since received the spotlight. This ‘pioneering’ (Rissel
and Bracht, 1999: 61) book helped define the scope of what health education means and how to
conduct it, in much of the USA at least.
The original Precede model focuses nearly exclusively on how to help people make voluntary
health behaviour changes through democratic educational methods. This educational piece remains
intact in later models, including participatory methods that the authors call ‘mutual planning and
diagnosis’ (Green et al., 1980: 5). This was progressive for health education at that time and pos-
sibly helped pave the way for the emergence of community-based participatory research in the late
1990s (Israel et al., 1998) as public health’s version of Freirian (1970) participatory action research.
The early Precede model is missing the environmental and socio-ecological analysis and action
developed in later versions. Although briefly referenced under enabling factors, these outer layers
of today’s socio-ecological health model are mainly lumped together as ‘economic, genetic and
environmental factors … acknowledged here because of the power they have, however indirect,
to influence health’ (Green et al., 1980: 13). This reflects and perpetuates the limited scope of the
health education field overall at that time. As the authors of the model note, ‘except on their own
time health professionals usually are not expected (and sometimes are not allowed) to intervene
in non-health matters’ (Green et al., 1980: 37). However, Green and Kreuter foreshadow the
model’s future expansion from health education to health promotion, and from the educational to
the socio-ecological:
… health education is sometimes accused of ‘blaming the victim’, because it appears to place all the
responsibility for protection of health on the individuals whose health is threatened. Recognising the non-
behavioural causes of health problems acknowledges that there are other threats to health beside the
behaviour of the victim. (Green et al., 1980: 54)
In a strategies chapter, they also address the organising and social action methods required to
impact these ‘non-behavioural causes’.
A major contribution of this original model was challenging the limitations of an exclusively
KAP/KAB approach (Knowledge, Attitudes and Practices/Behaviours) to health behaviour change
and KAB’s underlying premise that if only people had the right information they would change
their behaviour. The authors instead emphasise voluntary, democratic behaviour change and draw
on Freire to contest the ‘empty vessel’ approach, in which some ‘health educators behave as if all
they have to do to ensure the success of their programme is to pour health information into the
empty minds of an eagerly awaiting target population’ (Green et al., 1980: 6). They begin to chal-
lenge ‘victim blaming’ – noting that ‘the system may be at fault, rather than the patient’ (Green
et al., 1980: 77). The breadth, depth and force of these arguments grew in the book’s next edition
(Green and Kreuter, 1991).
Over a decade later, in keeping with and perhaps also partly leading broader developments in the
field, Green and Kreuter (1991) explicitly expanded the model’s scope from health education to
health promotion, titling the second edition of their book, Health Promotion Planning: an Educational
and Environmental Approach. This edition looks very similar to the current (fourth) one, adding
environmental assessments and a policy and power analysis. It also adds the Proceed portion of the
model to help users negotiate the more political terrain this expansion encompasses. Among health
promotion models and theories, Precede–Proceed led the way in socio-ecological health assessments
and planning; only relatively recently have socio-ecological models for health been adopted in public
health as a guiding frame for understanding and improving health (Lang and Rayner, 2012), includ-
ing becoming the anchoring concept for US public health goals (US DHHS, 2010).
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8 Health Education Journal
The third edition (Green and Kreuter, 1999), titled Health Promotion Planning: an Educational
and Ecological Approach, expanded the environmental approach to an even broader ecological one
because, as the authors noted, health promotion with a population focus
… demanded more than merely taking forces outside the person into account in planning programmes. It
demanded an intersectoral, interdisciplinary, and interorganisational strategy for integrating the forces
operating at several levels and in various spheres to support people in their efforts to gain greater control
over the determinants of their health. (p. xxvi)
The revised model also gave increased emphasis to community participation, coalition forma-
tion, capacity building and sustainability, drawing on work published in the interim, such as asset
mapping (Kretzmann and McKnight, 1993). It shifted even further away from a biomedical
approach, marked by calling the Precede phases ‘assessments’ rather than ‘diagnoses’.
The most recent, fourth edition of the book is entitled Health Programme Planning: an Educational
and Ecological Approach (Green and Kreuter, 2005). Shifts include the addition of genetic factors,
suggestions for application shortcuts, and the folding of the assessment of health, behaviour, envi-
ronment and genetics into one phase, thus reducing the model from nine to eight phases. This last
consolidation emphasises viewing these factors as dialectic and reciprocally determined, rather
than dualistic and discrete. The authors also expand the intended application of the model. As the
title signals, they suggest its usefulness not just for health promotion but also for public and popu-
lation health planning. Finally, to make the model ever more grounded, every successive edition
has addressed feedback and critiques from users and has incorporated new best practices and pro-
cesses in its application.
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Porter 9
in the real world, while also not providing detailed guidance for each step (Gielen et al., 2008: 417;
MacDonald and Mullett, 2009: 165; Sharma and Romas, 2012: 48). In response, the authors sug-
gest using the model in part, and in tandem with more specific theories.
For those who consider the ethical foundations of the model an asset, a critique could be made
that the authors sometimes use rather technical language to describe (or perhaps to disguise) con-
cepts that were ground-breaking for a model that became mainstream in health. They suggest pri-
oritising health equity using cloaked language about statistical indicators of health problems. They
also use terms standard in health promotion such as ‘target population’ and ‘patient’ that discur-
sively cast people, communities and citizens in passive roles. And they do so even when making
statements, cited above, that were radical in health fields for 1980 such as ‘the system may be at
fault, rather than the patient’, that ‘both objective and subjective’ information should count, and
that a programme being ‘available, accessible, acceptable and accountable’ is as important as it
being measurably effective.
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10 Health Education Journal
community-based participatory research in health, the model’s authors had been advocating since
1974 that ‘target populations’ must be intimately involved in identifying, assessing and resolving
their own community health issues. Couching their model in Cartesian, techno-rational terms may
have made this process seem less radical, but also more acceptable in mainstream health promotion
– serving as a Trojan horse, perhaps, for health promotion tackling social determinants of health
more than health behaviour, and for respecting the experience, expertise and priorities of commu-
nity members in determining their own health. If none of these tenets are news today, this may be
in some part due to the leadership offered by this approach. The fact that socio-ecological and
participatory approaches are hardly ubiquitously applied means that the Precede–Proceed model
still has much to offer in guiding health promotion planning and practice.
Funding
The author(s) received no financial support for the research, authorship and/or publication of this paper.
Notes
1. The ‘ecology’ in this ‘socio-ecological’ model implicitly addressed by Precede–Proceed is not ecological
in the natural, biological, ecosystem sense. For a truly ecological lens on public health, see US Surgeon
General John Hanlon’s (1969) work and, more recently, that of Rayner and Lang (2012).
2. Arguably, since this health promotion discourse work, advances in genetics and pharmaceuticals within
this capitalist frame have moved a biology-centred approach to health to the fore. See, for example,
a growing emphasis on ‘personalised medicine’, as in a joint commentary by the Food and Drug
Administration (FDA) and National Institutes of Health (NIH) chiefs in the USA (Hamburg and Collins,
2010).
3. For example, advertisements for the world’s most popular soft drink have aimed to ‘teach the world to
sing in perfect harmony’ since at least 1971 and more recently have emphasised sharing (e.g. ‘Share
happiness’, and ‘Spread happiness, share a Coke’, see http://www.shareacoke.com). Although hardly
health promoting, these messages stress community connections and quality of life, as health promotion
should do. However, health promotion messages about avoiding such beverages simply urge individual
behaviour change (e.g. the humorously disgusting ‘Don’t Drink Yourself Fat’ campaign by the New York
City Department of Health; ‘Rethink Your Drink’ slogans and, more positively but still individualisti-
cally, the Change4Life ‘Smart Swaps’ campaign in the UK [see www.nhs.uk/change4life]). Similarly,
the names of community obesity prevention initiatives in the USA are often behaviour change com-
mands – for example, Shape Up Somerville; Eat Well Play Hard; Get Up Montgomery County and in the
United Kingdom, the Change4Life slogan (‘Eat Well, Move More, Live Longer’) is simply individually
informative.
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