• Chapter 2: Planning Models

    • Chapter 2: Planning Models

    Now that you have a basic overview of the program planning process, we can dig a little deeper into how program planning models help us stay on track. Planning models are evidence-based, and are designed to help professionals create public health interventions that are based on a solid foundation. We want to ensure our plans are successful, and a planning model helps us with that. In contrast to medical treatment models, health promotion planning models look at positive improvements. Planning models have changed and evolved over the last decades and continue to evolve today.

    There are many planning models that are available for us to use, but they all provide a basic framework that help us structure our planning, implementation, and evaluation efforts related to the program we deliver in a community. 

    Take the PRECEDE-PROCEED model for example. The PRECEDE portion (Phases 1–4) is an expansion of Planning, and the PROCEED portion (Phases 5-8) includes Implementation and Evaluation. Each model expands on one of the three components (planning, implementing, and evaluating) and places emphasis on that area as you plan for a program. All planning models are designed to help us improve health outcomes in the communities we serve.


    Let’s apply this to something we may be more familiar with. Here’s a hypothetical situation: you are planning your dream vacation. You want it to be fun, worthwhile, and accomplish all the things that are important for you while on the vacation. What would you plan for before you leave? Consider the travel plans to get there, who will go with you, when you can go, what you will bring, how much it will cost, and what activities you will do when you get there. You will be planning all those things before you leave for a trip. Think of these activities like the planning phase of program planning models. 

    After all of that intensive planning, it’s time to actually arrive at your dream vacation destination. But the work isn’t over. 

    Even as you would finally be enjoying all the fun activities you planned so hard for, you would also be implementing your plans, the action part of all your planning, just like the implementation phase of the program planning process. 

    Next, you’re on your way home, thinking back on everything that happened. You are thinking about all the fun things you did, but you are also formulating ideas of new activities you’d like to try next time. It’s also possible that you spent more money on the trip than you budgeted, because you underestimated the expense of some of the fun activities you planned for, or maybe you scrimped too well, and you might have missed out on something you were interested in. This is an evaluation of how the trip went, if it met all your expectations, and how it can be even better next time. Just like you are evaluating your trip, we also evaluate the health programs we implement in a community to determine if the program was successful in improving health outcomes. 

    Just like our travel plans help us enjoy vacations, planning models help us plan for, implement, and evaluate the health programs in the communities we serve. 


    Assessment & Planning Models, Frameworks & Tools

    (Centers for Disease Control and Prevention, 2023)

    Common Elements of Assessment and Planning Frameworks

    Most assessment and planning frameworks include steps or phases that reflect the following actions, some of which may occur simultaneously:

    Organize and plan

    Most tools emphasize the importance of broad stakeholder and community engagement and can be used by any type of lead organization. Frameworks can also be blended to create a model that addresses your particular community’s needs. 

    NOTE: The following list of planning models is not exhaustive, but it reflects some of the most well-defined resources and frequently used models.


    PRECEDE-PROCEED

    (community tool box, n.d.-a, p. 2)

    If you were a contractor setting out to build a wood-frame house, you wouldn’t just pick up whatever wood you found lying around and begin building. First, you’d  consult  with the owner, and start with an idea of the house she wanted – its size, its shape, its features. Then, you’d want a picture of the finished house, and a floor plan as well, with some notes on measurements and materials. Finally, you’d plan the construction with her, and set out a process for getting it done. And you’d do all this before you ever picked up a tool, because otherwise the process would be hit-or-miss: she wouldn’t get the house she wanted, and your time would be wasted.

    The same is true if you’re developing an intervention to address a health or community issue. It makes no sense to pick an issue at random and to use whatever service happens to be available to try to address it. You need to consult with the community, understand and analyze the following: community information, your own and others’ observations, and the context of the issue. From this information you will then create an intervention that will bring about the changes the community wants and needs.

    FIGURE 1. GENERIC REPRESENTATION OF THE PRECEDE-PROCEED MODEL. FROM L. GREEN AND M. KREUTER. (2005). HEALTH PROMOTION PLANNING: AN EDUCATIONAL AND ECOLOGICAL APPROACH (4 TH ED.). MOUNTAIN VIEW , CA : MAYFIELD PUBLISHERS.


    WHAT IS PRECEDE-PROCEED?

    This planning model was developed for public health and can be applied to other community improvement projects as well. Addressing the phases suggested by this model ensures that all necessary steps are taken in formulating, implementing and evaluating an intervention.

    PRECEDE stands for Predisposing, Reinforcing, and Enabling Constructs in Educational/Environmental Diagnosis and Evaluation. It represents the process that precedes, or leads up to, an intervention.

    PROCEED spells out Policy, Regulatory, and Organizational Constructs in Educational and Environmental Development. It describes how to proceed with the intervention itself.


    WHY USE PRECEDE-PROCEED?

    The benefit of this planning model is that it emphasizes participation by the community involved, for better understanding of the issues and community ownership of the intervention. As a logic model, it provides a structure within which to plan your work and organize your thinking, so that your intervention will be a carefully-planned, coherent whole, rather than brought together in an uncoordinated way. It provides a guide for analyzing the issues involved, choosing the most likely areas that need to be addressed, and how to address them. This model allows for adjustment and the freedom to adapt the structure to whatever content and methods meet the needs of your community.


     HOW DO YOU USE PRECEDE-PROCEED?

    The eight phases are described here, as well as a brief example of using this model.

    PRECEDE is the diagnostic portion of the model. It starts with the idea that the focus of change must be on its desired outcome, and works backward from that outcome to construct an intervention that will bring it about. It has four phases:

    Phase 1: Social diagnosis – determine what the community wants and needs to improve its quality of life.

    Phase 2: Epidemiological diagnosis – determine the health problems or other issues that affect the community’s quality of life. Include the behavioral and environmental factors that must change in order to address these problems or issues. Behavioral factors include patterns of behavior that constitute lifestyles. In considering environmental factors, you should include the physical, social, political, and economic environments.

    Phases 1 and 2 identify the goals of the intervention.

    Phase 3: Educational and organizational diagnosis – determine what to do in order to change the behavioral and environmental factors in Phase 2, taking into account predisposing factors (knowledge, attitudes, beliefs, values, and confidence); enabling factors (availability of resources, accessibility of services, government laws and policies, issue-related skills); and reinforcing factors (largely the influence of significant others in the social environment).

    Phase 4: Designing programs or interventions and the support for them through administrative and policy diagnosis – determine (and address) the internal administrative and internal and external policy factors that can affect the success of your intervention. The former include organizational structure, procedures, culture, and resources; the latter encompass both internal policies and funders’ requirements, oversight agency regulations, state or federal laws, local ordinances, and unstated community policies.

    Phases 3 and 4 set the structure and targets for the planning and design of the intervention.

    PROCEED is the treatment portion of the model, and comprises the implementation and evaluation of the intervention. It consists of four phases:

    Phase 5: Implementation – conduct the intervention.

    Phase 6: Process evaluation – determine whether the intervention is actually taking the actions intended.

    Phase 7: Impact evaluation – determine whether the intervention is having the intended effects on behaviors and/or environment.

    Phase 8: Outcome evaluation – determine whether the intervention brings about the improvements in quality of life identified by the community.

    An important part of the model is that your plan or intervention should be revisited and revised, based on continued analysis and the results of the various evaluations.


    BRIEF EXAMPLE OF A HEALTH PROGRAM USING PRECEDE-PROCEED

    PRECEDE:

    Phase 1: Social diagnosis
    Surveys and town meetings reveal that people in this community want to reverse the recent trend of increasing rates of obesity and overweight.

    Phase 2: Epidemiological diagnosis
    Data from surveys and area agencies show that residents eat few fruits and vegetables and have few places to exercise.

    Phase 3: Educational and organizational diagnosis
    Coalition brings together leaders, agencies and key community members who set goals of developing community gardens, walking trails and bike paths.

    Phase 4: Design of interventions
    Coalition subcommittees plan with local agricultural agencies to set up 2 new community gardens and meet with city park & recreation officials to develop walking trails and bike paths. Coalition sets budget and timeline, recruits volunteers and publicizes the projects.

    PROCEED:

    Phase 5: Implementation
    Development begins of community gardens, walking trails and bike paths, following the timeline that was set by committees.

    Phase 6: Process Evaluation
     Leaders evaluate: How are the committees working together? How are the gardens, trails, and paths progressing?

    Phase 7: Impact Evaluation
    Leaders evaluate: Are people using the garden produce? Are walkers and bikers using the trails and paths?

    Phase 8: Outcome Evaluation
    Final evaluation: have residents’ fruit and vegetable consumption increased? Has physical activity increased? After years of the project, have rates of obesity and overweight leveled or decreased?


    MAPP: Mobilizing for Action through Planning and Partnerships

    (community tool box, n.d.-c, p. 2)

    WHAT IS MAPP?

    Mobilizing for Action through Planning and Participation (MAPP) is a model for developing a healthy community. Its community perspective addresses the community as a whole and makes it flexible enough to be used with any community system. Its basic philosophy is broad community participation in planning and implementation of the initiative. The structure includes visioning, community assessment, issue identification, strategic planning and goal setting, and implementation.

    MAPP emphasizes these 7 principles:


    WHY USE MAPP?

    Compared to other models, MAPP provides a unique and specified set of assessments for the community. The Assessment Phase of MAPP is especially thorough and includes community themes and strengths as identified by community members, the state of the local public health system, the state of the community’s health status, and real or potential forces of change. MAPP uses systems thinking to analyze these assessments, identify key issues, and develop strategies for addressing them.

    If properly realized, MAPP can permanently improve the ways in which individuals and organizations relate and the extent to which the community can control its own health and quality of life.

     

    HOW DO YOU USE MAPP?

    The six phases are described here, as well as a brief example of using this model.


    PHASE 1: ORGANIZE FOR SUCCESS/PARTNERSHIP DEVELOPMENT
    PHASE 2: VISIONING
    PHASE 3: THE ASSESSMENTS

    1. Community Themes and Strengths: thoughts, opinions, concerns, and assets.

    2. Local Public Health System Assessment (LPHSA) uses the National Public Health Performance Standards Program, based on the Ten Essential Public Health Services.

    3. Community Health Status Assessment addresses health and quality of life, to summarize major health issues.

    4. Forces of Change Assessment identifies current and anticipated factors that directly or indirectly affect health.

    PHASE 4: STRATEGIC ISSUES
    PHASE 5: GOALS AND STRATEGIES
    PHASE 6: ACTION CYCLE

    1. Plan for action: organize, develop objectives and establish accountability. Objectives need to be specific, measurable, achievable, relevant, timed, and challenging.

    2. Implementation: review action plans, then implement and monitor.

    3. Evaluation: prepare at the beginning of the MAPP process, focus the evaluation design, gather credible evidence and justify the conclusions.

    4. Share lessons learned and celebrate successes.

    5. Maintain the cycle to continue improving.


     BRIEF EXAMPLE OF USING THE MAPP MODEL:

    PHASE 1: ORGANIZE FOR SUCCESS/PARTNERSHIP DEVELOPMENT

    The community decides they need the MAPP process to address several recent health issues. A coalition is formed of local agencies and concerned individuals. They agree on a series of planning meetings, set ground rules, and choose a coalition leader.

    PHASE 2: VISIONING

    The coalition invites the whole community to participate, and together they identify the vision of a healthier community for all residents, with values of respect, inclusion and communication.

    PHASE 3: THE ASSESSMENTS

    The coalition conducts the 4 recommended assessments. Results show several health issues of concern including teen tobacco use, childhood obesity, drug overdoses, heart disease, and skin cancer.

    PHASE 4: STRATEGIC ISSUES

    The coalition considers all potential health issues to address, according to the established vision and values. They identify the two highest priorities as teen tobacco use and childhood obesity.

    PHASE 5: GOALS AND STRATEGIES

    The coalition forms subcommittees which develop goals and strategies. The Tobacco committee identifies the long-term goal of reducing the rate of teen tobacco use. Strategies include enforcing and monitoring local ordinances that restrict tobacco sales to minors. The Childhood Committee sets a long-term goal of leveling the increase in rate of childhood obesity. Strategies include incorporating lesson plans in elementary schools for games and activities to include healthier snacks and limiting sweet beverages. The coalition develops a report of the plans, and publicizes it through a community newsletter and on their Facebook page, highlighting the work of the two committees.

    PHASE 6: ACTION CYCLE

    A.       The committees form short-term objectives. The Tobacco committee decides the town will hire 2 monitors who will check 10 stores each month for compliance with laws restricting tobacco sales to minors. The Childhood committee decides two health educators will present one healthy snack lesson per month to each class in the elementary school.

    B.       Both committees implement their plans and report back to the coalition.

    C.       The coalition surveys participants. Tobacco compliance was only 30% the first month but has risen to 70% by the second month as the retail stores became aware of the monitoring process. In schools the pre- and post-tests at healthy snack lessons indicate children are now 80% more willing to include carrots and apple slices for snacks.

    D.       The coalition reviews lessons learned: stores know they are being checked and may pretend to comply. Children in schools may not actually consume healthier snacks. The Tobacco committee decides to make the compliance checks more unexpected. The Childhood committee decides to budget for food samples at the snack lessons.

    E.        Both committees continue the cycle of modifying their short-term objectives and reporting progress to the coalition.


    MAP-IT

    (community tool box, n.d.-d, p. 2)

    WHAT IS MAP-IT?

    The MAP-IT framework is designed to help communities develop local health initiatives. Its phases provide a logical structure to address and resolve local health problems and to build healthy communities. The phases include the following:

    WHY USE MAP-IT?

    MAP-IT emphasizes integrating all stakeholders in a widely-supported, community-owned effort. The efforts start with an assessment of health needs and what resources are available in the community. Plans are developed with timelines, objectives and action steps. MAP-IT allows for adjustment of plans, according to the ongoing evaluation process.

    HOW DO YOU USE MAP-IT?

    The five steps are described here, as well as examples of how the steps in this model have been used.

    STEP 1: MOBILIZE

    Gather key individuals and agencies into a coalition. Aim for broad representation. Engage potential coalition members around issues that are already of concern in the community. Create a vision. Brainstorm potential partners from among likely stakeholders, involving as many different community sectors as possible.

    STEP 2: ASSESS

    Identify real health needs of the community, not just impressions. Gather data about major health issues. Also identify assets and resources of the community and what it has to offer.

    STEP 3: PLAN

    Create an action plan with concrete steps and deadlines. Assign responsibility of what exactly is to be achieved, by whom and by when. Include ongoing data collection for monitoring progress. Create a timeline. Include a communication plan of how to keep the community informed of the projects.

    STEP 4: IMPLEMENT

    Complete assigned tasks according to the plan and timeline. Publicize the efforts in the community. Showcase the accomplishments and acknowledge partners.

    STEP 5: TRACK

    Conduct regular evaluations to measure progress over time, and report back to the coalition.


    EXAMPLES OF HOW MAP-IT HAS BEEN USED:

    Mobilization

    One state formed a partnership with a group of individuals representing a broad sector of both public and private organizations, including members from local departments of health. This group was charged with the responsibility of meeting the state’s public health improvement goals.

    Assessment

    One coalition determined priority health issues through its steering committee, which evaluated health data, sought expert opinions, invited public comments, and conducted an opinion survey of residents. They used a consensus method to limit the scope of its objectives to 4 priority health areas and 4 disease risk factors. The 4 priority health areas included alcohol and drug abuse, cancer, heart disease, HIV and other sexually transmitted diseases. The focal risk factors were lack of access to preventive care, tobacco use, poor nutrition, and lack of physical activity.

    Planning

    To achieve its year 2030 objectives, one health department initiated a Worksite Wellness Council. They focused on increasing health promotion and disease prevention activities in work sites, where most adults spend the majority of their time. The Council set a goal of having 20 percent of its workforce in sites certified by a national Worksite Wellness agency.

    Implementation

    The Office of Healthy Residents in one area is responsible for keeping their Healthy People initiative on track. Staff are available for support and training, particularly coalition building. There is also a mayor’s task force that certifies communities in the Healthy People project. The communities do an assessment and then implement an action plan.

    Tracking Example

    One health department’s statistical and program staff assessed progress and analyzed trends. Based on their trend analysis, staff categorized each objective as “likely to be achieved,” “unlikely to be achieved,” or “uncertain.” They then continued to monitor all objectives and made them part of annual reports.


    Health Cities/Healthy Communities

    (community tool box, n.d.-b, p. 2)

     WHAT IS HEALTHY CITIES/HEALTHY COMMUNITIES? 

    (World Health Organization, n.d.-a)

    "Health is created and lived by people within the settings of their everyday life; where they learn,  work, play, and love." - The Ottawa Charter, 1986.

    This statement is at the heart of the Healthy Settings approach, which has its roots in the WHO Health for All strategy and, more specifically, the Ottawa Charter for Health Promotion. Initiated by WHO in 1986, Healthy Cities have spread rapidly across the world.

    A Healthy City aims to do the following:

    Being a Healthy City depends not only on health infrastructures, but also on a commitment to improve a city's environs and a willingness to forge the necessary connections in political, economic, and social arenas.

    Healthy Cities/Healthy Communities is now used as a philosophical framework for an inclusive, participatory process aimed at raising the quality of life for everyone and creating a truly healthy community.

    Two basic premises underlying the Healthy Cities/Healthy Communities concept are a comprehensive view of health and community issues, which covers a broad range of factors that contribute to a healthy community; and a commitment to the active promotion of a healthy community, rather than the treatment of problems. 

    By addressing the social and other determinants of health and community issues (including the Ottawa Charter’s list of peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice, and equity), and by creating appropriate policy and environments, encouraging social action, providing personal skills, and reorienting services to a more wide-ranging approach, communities can foster citizen empowerment and equity.

     WHY USE HEALTHY CITIES/HEALTHY COMMUNITIES?

    While a Healthy Cities/Healthy Communities process should involve everyone, some particularly important participants include local government and officials; those affected by the issue(s); those who will actually administer and implement the initiative, or whose lives or jobs will be affected by it; any organizations that will be expected to work together; and opinion leaders.

    HOW DO YOU USE HEALTHY CITIES/HEALTHY COMMUNITIES?

    There is no step-by-step procedure. Both the content and the structure of the process depend upon your community’s needs and on community decisions.

    The 10 important components of a Healthy Cities/Healthy Communities process are as follows:

    1. Create a compelling vision: define the efforts to be made, based on shared values.

    2. Embrace a broad definition of health and well-being as not just physical health but including peace, shelter, education, income, food, a stable ecosystem, sustainable resources, social justice and equity.

    3. Address quality of life for all groups and communities.

    4. Engage diverse citizen participation and be citizen-driven. Include participants from all racial, ethnic and socio-economic groups, and all walks of life.

    5. Seek multi-sectoral membership and widespread community ownership. Include all sectors of the community – government, the business and non-profit communities, health care, education, faith communities, cultural institutions and the arts, target populations, and ordinary citizens

    6. Acknowledge the social determinants of health and the interrelationship of health with other issues (housing, education, peace, equity, social justice).

    7. Address issues through collaborative problem-solving. Conflicts should be viewed as opportunities, and people should be helped to work together to reach creative solutions.

    8. Focus on change of systems, the ways in which the community operates, and the attitudes, assumptions, and policies behind the way the community operates.

    9. Build capacity using local assets and resources. All communities have real and potential strengths that should be identified and included in a Healthy Cities/Healthy Communities effort.

    10. Measure and benchmark progress and outcomes. Monitor and evaluate the effort to be sure that it’s effective. Regularly monitoring what you’re doing allows you to spot and correct inadequacies in goals, methods, and communication before they derail your initiative.


    Examples of WHO’s efforts in Healthy Cities/Healthy Communities:

    Improving Health Literacy

    (World Health Organization, n.d.-b)

    By improving people’s access to health information, and their capacity to use it effectively, health literacy becomes critical to empowerment. Improving health literacy in populations provides the foundation on which citizens are enabled to play an active role in improving their own health, engage successfully with community action for health, and push governments to meet their responsibilities in addressing health and health equity. Meeting the health literacy needs of the most disadvantaged and marginalized societies will particularly accelerate progress in reducing inequities in health and beyond.

    Mozambique

    (World Health Organization, n.d.-c)

    60-year-old Raquelina Mazuze is proud of her contribution to the fight against polio as a social mobilizer in her native Mozambique. Following the recent outbreak of Wild poliovirus type 1 in the country, she has been helping to prepare her community for a forthcoming vaccination drive, which aims to protect nearly 4 million children in the four most at-risk provinces. Having been involved in the health sector for decades, Raquelina also spends her days encouraging older people around her to stay active, eat healthily and to keep serving their community, just as she does.

    Partners commit to improve Maternal, Newborn and Child Health

    (World Health Organization, 2023)

    At a meeting of the Network for improving quality of care for Maternal, Newborn and Child Health (MNCH) held in Accra, Ghana, ten global partners resolved to strengthen collaboration towards improving maternal, newborn, and child health through sustained quality of care at all levels of the health system. This meeting was aimed at engaging with the champions from the government and implementing partners and other stakeholders to build on five years of efforts to integrate quality of care in health systems and maternal, newborn, and child health interventions.



    References


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    World Health Organization. (2023, March 23). Global partners commit to improve Maternal, Newborn and Child Health. World Health Organization. https://www.afro.who.int/countries/ghana/news/global-partners-commit-improve-maternal-newborn-and-child-health

    This content is provided to you freely by BYU-I Books.

    Access it online or download it at https://books.byui.edu/pubh_390_readings/chapter_2_planning_models.