As an approach that promotes behavior preparing them, psychological cost of

change through voluntary exchange and
positive reinforcement, social marketing
borrows substantively from behavior change
theory. Behavioral theory offers insights
into the current behavior of target market
members and what might influence or
“worrying” about getting the recommended
number of servings)
• Place: Grocery stores and other points
of purchase (the 5 A Day message and
healthy foods compete against unhealthy

change that behavior. For example, a social
marketer who references Social Cognitive
Theory might examine how self-efficacy
and expectations about the outcome of a
behavior factor into certain health practices
within a target market.
The California 5 A Day Campaign, which
was the model for the national 5 A Day
PART 3
products for space and attention)
• Promotion: Branding the 5 A Day
campaign to increase awareness (e.g.,
using a slogan and compelling images
that are easy to recall)
39
Distribution channels include mass media
advertising, public service announcements,

PUTTING THEORY AND PRACTICE TOGETHER

program,50 employs social marketing to
newsletters, the Internet, magazines, press
increase Californians’ consumption of
conferences, outreach activities, special
fruit and vegetables through strategies
events, and community-based groups, such
such as supermarket point-of-purchase
as churches. Regular monitoring and
interventions, industry promotional support,
evaluation help to assess the reach and
media outreach, and community programs.51
impact of messages; efficient use of time,
Several features of this program have been
labor, and capital resources; and program
well-received.52 First, it has a focused goal:
costs/benefits.
to increase fruit and vegetable consumption
by raising awareness of the health benefits.
PRECEDE-PROCEED
Second, its approach is built on an
PRECEDE-PROCEED is a planning model,
established theoretical framework—the
not a theory. It does not predict or explain
Stages of Change model. Third, messages
factors linked to the outcomes of interest,
were designed and disseminated using
but offers a framework for identifying
consumer-driven communications
intervention strategies to address these
strategies. Fourth, formative research (mall
factors. Developed by Green, Kreuter,
intercept interviews, focus groups, and
and associates,53 PRECEDE-PROCEED
baseline survey data) helped the planners
provides a road map for designing health
to understand their audiences and improve
education and health promotion programs.
messages. Lastly, the program uses the
It guides planners through a process that
four Ps of social marketing:
starts with desired outcomes and works
backwards to identify a mix of strategies
• Product: Consuming more fruits and
for achieving objectives. (See
vegetables each day to minimize the risk
http://lgreen.net/index.html.)
of cancer and improve health status
Because the model views health behavior
• Price: The costs of eating a healthier diet
as influenced by both individual and
(e.g., financial cost of buying fruits and
environmental forces, it has two distinct
vegetables, time cost of shopping for and
parts: an “educational diagnosis”
 (PRECEDE) and an “ecological diagnosis”
(PROCEED). The PRECEDE acronym
stands for Predisposing, Reinforcing,
Enabling Constructs in Educational/
Environmental Diagnosis and Evaluation.
Developed in the 1970s, this component
of the model posits that an educational
diagnosis is needed to design a health
promotion intervention, just as a medical
diagnosis is needed to design a treatment
plan. PROCEDE stands for Policy,
Regulatory, and Organizational Constructs
in Educational and Environmental
40
Development. This element was added
to the framework later, in 1991, to take
into account the impact of environmental
factors on health. Together, these two
THEORY AT A GLANCE
components of the model help practitioners
plan programs that exemplify an
ecological perspective.
PRECEDE-PROCEED has nine steps. The
first five steps are diagnostic, addressing
both educational and environmental issues.
These include: (1) social assessment, (2)
epidemiological assessment, (3) behavioral
and environmental assessment, (4)
educational and ecological assessment, and
(5) administrative and policy assessment.
The last four comprise implementation and
evaluation of health promotion intervention.
These include: (6) implementation, (7)
process evaluation, (8) impact evaluation,
and (9) outcome evaluation. (See Figure 9.)

Figure 9. The PRECEDE-PROCEED Model

PRECEDE
STEP 5 STEP 4 STEP 3 STEP 2 STEP 1
Administration Educational and Behavioral and Epidemiological Social
and Policy Ecological Environmental Assessment Assessment
Diagnosis Assessment Assessment

Predisposing
Health factors
Promotion

Health Reinforcing Behavior and

education factors lifestyle

Health Quality
of life
Policy
regulation Enabling Environment
organization factors

STEP 6 STEP 7 STEP 8 STEP 9

Implementation Process Impact Outcome
Evaluation Evaluation Evaluation

PROCEED Source: Green LW, Kreuter MW, 1999.

During the diagnostic steps of the model,
practitioners employ various methods to
learn about the community’s perceived and
actual needs, as well as the regulatory
context in which the intervention will
operate. To conduct social assessment, the
practitioner may use multiple data collection
• Enabling factors, which enable persons to
act on their predispositions; these factors
include available resources, supportive
policies, assistance, and services.
• Reinforcing factors, which come into play
after a behavior has been initiated; they

PART 3
activities (e.g., key informant interviews, encourage repetition or persistence of
focus groups, participant observation, behaviors by providing continuing rewards
surveys) to understand the community’s or incentives. Social support, praise,
perceived needs. Epidemiological reassurance, and symptom relief might all
assessment may include secondary data be considered reinforcing factors.
analysis or original data collection to
prioritize the community’s health needs and
In the final diagnostic step of PRECEDE- 41
establish program goals and objectives.
PROCEED, Administrative and Policy
Behavioral and Environmental Assessment
Assessment, intervention strategies reflect

PUTTING THEORY AND PRACTICE TOGETHER

identifies factors, both internal and external
information gathered in previous steps;
to the individual, that affect the health
the availability of needed resources; and
problem. Reviewing the literature and
organizational policies and regulations
applying theory are two ways to map out
that could affect program implementation.
these factors.
(See Table 10.)
In Educational and Ecological Assessment,
The four remaining steps of PRECEDE-
the practitioner identifies antecedent and
PROCEED comprise program
reinforcing factors that must be in place to
implementation and evaluation. Before
initiate and sustain change. Behavior—such
Implementation (Step 6) begins,
as reducing intake of dietary fat, engaging
practitioners should prepare plans for
in routine physical activity, and obtaining
evaluating the process (Step 7), impact
annual mammograms—is shaped by
(Step 8), and outcome (Step 9) of the
predisposing, reinforcing, and enabling
intervention. Process Evaluation gauges the
factors. Practitioners can use individual,
extent to which a program is being carried
interpersonal, or community-level change
out according to plan. Impact Evaluation
theories to classify determinants of behavior
looks at changes in factors (i.e.,
into one of these three categories and rank
predisposing, enabling, and reinforcing
their importance. Because each type of
factors) that influence the likelihood that
factor requires different intervention
behavioral and environmental change will
strategies, classifying them helps
occur. Lastly, outcome evaluation looks at
practitioners consider how to address
whether the intervention has affected health
community needs. The three types of
and quality-of-life indicators.
influencing factors include:
As Table 11 shows, the individual,
• Predisposing factors, which motivate or
interpersonal, and community-level theories
provide a reason for behavior; they include
discussed in this monograph are most
knowledge, attitudes, cultural beliefs, and
useful when applied to PRECEDE-
readiness to change.
PROCEED’s diagnostic steps. Community
 organization relates to Step 1, which may
entail working with communities to identify
their own needs, strengths, resources, and
capacities. Descriptive epidemiology is most
pertinent to Step 2, but community-level
theories may be relevant if the community
helps to choose the health problem that will
be addressed, or to set priorities among
health problems. Theory is most directly
useful when applied to steps 3, 4, and 5,
since these steps call upon the practitioner
to make strategic decisions. By using theory,
the practitioner can make sound choices
42
that are based upon more than just intuition
and personal judgment.
THEORY AT A GLANCE
Theory should guide practitioners’ exam-
ination of predisposing, enabling, and
reinforcing factors. For example, the Health
Belief Model suggests that certain beliefs
might influence women’s decisions about
whether or not to get a mammogram, such
as perceived chances of developing cancer
(perceived susceptibility), or how serious
they believe cancer would be (perceived
severity). Both beliefs constitute
predisposing factors. Other HBM constructs
may identify possible perceived benefits of
and barriers to screening. Receiving

Table 10. Diagnostic Elements of PRECEDE-PROCEED

Planning Step Function Examples of Relevant Theory

1. Social Assessment Assesses people’s views of Community organization

their own needs and quality
of life Community building

2. Epidemiological Documents which health Community-level theories

Assessment problems are most important (If the community helps to
for which groups in a choose the health problem that
community will be addressed)

3. Behavioral/ Identifies factors that Interpersonal theories

Environmental contribute to the health - Social Cognitive Theory
Assessment problem of interest
Theories of organizational change

Community organization

Diffusion of innovations

4. Educational/ Identifies preceding and All three levels of change theories:

Ecological reinforcing factors that must - Individual
Assessment be in place to initiate and - Interpersonal
sustain change - Community

5. Administrative/ Identifies policies, resources, Community-level theories:

Policy and circumstances in the - Community organization
Assessment program’s context that may - Organizational change
help or hinder implementation
reassurance that they do not have cancer
(perceived benefit) might be a reinforcing
factor. Lack of insurance coverage for
screening mammography (perceived
barrier) could be a negative enabling factor.
By exploring the degree to which each of
these factors affects women’s behaviors,
program planners can decide how to focus
program messages for a communications
campaign or strategies for an administrative
intervention (such as providing low- or no-
cost screening or changing insurance
coverage). The best way to verify and rank
explanations offered by theory is to gather
information directly from women in the
target population. Another, less ideal
approach is to learn by reading research
literature on women who share
characteristics with the target population.
Where to Begin: Choosing the
Right Theories
Interventions that evolve from a
comprehensive planning process, build
on prior research, and use health behavior
theories are more likely to be effective.
By investigating what factors influence
the target population’s behavior, including
their social and physical environments,
practitioners gain the raw materials they
need to meet the needs of that population.
Theory helps practitioners to interpret the
findings of their research, making the leap
from facts on a page to understanding the
dynamic interactions between behavior
and environmental context. Systematic
approaches to tailoring, targeting,
implementing, and evaluating programs
provide practitioners with a framework for
translating this insight into actions that
improve health outcomes.
To make appropriate use of theory in a
given situation, practitioners must consider
both the social or health problem at hand
and the context in which the intervention
will take place. Once they have identified
a problem, they can use a planning system
such as social marketing or PRECEDE-
PART 3
PROCEED to identify social science
theories that contribute to their
understanding. These theories can guide
them to potential points of intervention.
Consulting the research literature helps
practitioners to learn about the past
successes or failures of intervention
43
strategies that they consider, and reflect
on whether those strategies are likely to
PUTTING THEORY AND PRACTICE TOGETHER
work for the current situation. Pre-testing
and actively discussing proposed
strategies with the target audience can
also help to determine whether or not they
will be well received.
Table 11. summarizes the focus and key
concepts of each of the eight theories
described in this guide. Refer to this table
to identify theories that help explain and
address a health problem. For example,
several theories could be used to inform the
design of a program to reduce tobacco use
among adolescents. By scanning the
“Focus” column, one can quickly gauge
which theories might apply to a particular
situation. For example, The Stages of
Change model might be very useful, since it
centers on individuals’ readiness to change.
On the other hand, the Health Belief Model
seems less promising, since young people
may be less concerned about long-term
health problems. (In fact, they may not feel
vulnerable to disease at all!) Social
Cognitive Theory could be helpful because it
emphasizes the interplay between personal,
environmental, and behavior factors.
Likewise, Community Organization could
offer perspective on activating young people