Health & Nutrition:
Human Health

HEALTH EDUCATION PLANNING MODELS -- A REVIEW OF THE LITERATURE - PART II

Health Education Planning Models

1. Assess the needs of the target population.
2. Identify the problem(s).
3. Develop appropriate goals and objectives.
4. Create an intervention that is likely to achieve desired results.
5. Implement the intervention.
6. Evaluate the results.

A model should provide direction and supply a frame on which to build. (McKenzie & Jurs, 1993) Any model should also have its assumptions formally stated at the beginning by its author(s). These assumptions of health education might include but are not limited to: (Bates & Winder, 1984 and McKenzie & Jurs, 1993)

1. Health status can be changed.
2. Disease occurrence theories and principles can be understood.
3. Appropriate prevention strategies can be developed to deal with the identified health problems.
4. An individual's health is affected by a variety of factors, not just lifestyle, such as heredity, environment, and the health care system.
5. Changes in individual and societal health behaviors and lifestyles will affect an individual's health status positively.
6. Health behavior changes occur in stages.
7. Individuals, families, small groups, and communities can be taught to assume responsibility for their health, which in turn changes their health behaviors and lifestyles.
8. Individual responsibility should not be viewed as victim blaming.
9. Health behavior change is a process, not an event.

Some of the Most Common Health Education Planning Models

1. Comprehensive Health Education Model (Sullivan, 1973)

   The Comprehensive Health Education Model (CHEM) has six major steps and several recommended procedures within each one of these steps (See Figure 13a and Figure 13b). The first step, Involve People, includes identifying the target population and also the personnel required to carry out the program, determine their roles, and create working relationships between people in related programs. Step 2, Set Goals, involves outlining appropriate goals that will mirror health status as well as health education practices and resources in the target population. In Step 3, Define Problems, planners determine the gaps between what is and what could be. After these problems have been identified, the planners will need to decide what specific components of the health problem(s) should be tackled. In the fourth step, Design Plans, the design of program plans includes identifying the most appropriate approach; setting program objectives, defining a timetable, activities and resources; conducting a pretest; and developing evaluation procedures. Step 5, Conduct Activities, mainly focuses on obtaining the necessary resources in order to implement the program and then actually implementing the plans. In the last step, Evaluate Results, planners use the program objectives to evaluate the program. The results of this evaluation should provide the data for making later decisions on continuing or changing the program.

2. Model for Health Education Planning (Ross & Mico, 1980)

   The Model for Health Education Planning (MHEP) analyzes planning in six phases (See Figure 14) Under each phase, there are three dimensions, which include the dimensions of content (subject matter), method (steps and techniques) and process (interactions).

   Phase 1 (Initiate) is the beginning of the planning activity. In order to carry out this phase, the planner(s) must 1) understand the target population problem(s) and its system, 2) enter into an initial contract, and 3) make the client aware that a problem or problems exist.

   The second phase, Needs Assessment, involves completing an assessment of the target population's needs. In order to do this, planner(s) should identify how the problem was measured in the past, determine what data needs to be collected now and how best to do this, then collect and analyze the data and finally describe the nature and scope of the problem.

   In Phase 3, Goal Setting, goals should be based on those problems identified in the needs assessment. They should be appropriate and realistic. In addition, input from those who will be affected should be gathered. Strategies should also be developed in this phase for implementing these goals.

   In Phase 4, Planning/Programming, the planner(s) take these agreed upon strategies and translate them into a rational implementation plan or program, design systems and tools for managing the activity, and arrange for commitments among all of those involved.

   The last two phases of MHEP are Implementation (Phase 5) and Evaluation (Phase 6). In Phase 5, the planner(s) offer assistance to facilitators and participants and track the progress. The final phase of Evaluation includes the steps of: 1) clarifying the evaluation measures, 2) collecting and analyzing the evaluation data, 3) providing the necessary feedback and 4) redefining the problem(s) and standards.

3. The PRECEDE Framework (Green, et al., 1980)

PRECEDE is an acronym for Predisposing, Reinforcing, and Enabling Causes in Educational Diagnosis and Evaluation. It has seven phases, which are as follows: (See Figure 15 for a diagram of this model.)

In Phase 1, Social Diagnosis, an assessment of the quality of life is conducted. In this phase, needs assessment techniques are used to determine the quality of life by identifying the social problems in the target population.

In the second phase (Epidemiological Diagnosis), epidemiological data is used to determine what specific health problems are contributing to the social problems previously identified. This data might include mortality, morbidity, fertility, and disability, and their dimensions such as incidence, prevalence, distribution, intensity and duration. Once these health problems are identified, they must be prioritized to determine which ones can be addressed.

In Phase 3 of PRECEDE, Behavioral Diagnosis, the specific health-related behaviors that seem to be associated with the prioritized health problems in Phase 2 are identified. The behavioral causes of the health problem are separated from nonbehavioral causes. An extensive list of behaviors can then be rated in terms of their importance and changeability.

Phases 4 and 5 are combined in Educational Diagnosis. Breaking these phases apart, in Phase 4 the causes of health behavior are assessed by identifying, sorting and categorizing three classes of factors that have the potential to affect health behavior. These three classes include:

1. Predisposing factors - These are the factors that can facilitate or hinder a person's motivation to change. These include many affective traits such as a person's attitudes, values, beliefs and perceptions. Predisposing factors can be thought of as the "personal" preferences that an individual or group brings to an educational experience.

2. Enabling factors - These are the factors which come before the behavior that allow a motivation or aspiration to be realized and include personal skills and resources (which also includes community resources). Barriers created by forces in society are also a part of this class. Examples of some of these barriers include limited access to health care; inadequate resources, income or health insurance; or restrictive laws, rules, regulations and policies.

3. Reinforcing factors - These are factors which occur after the behavior that provide the continuing reward, incentive, or punishment for that behavior and either contribute to its persistence or extinction. Possible factors include both social and physical benefits which may be real, imagined or vicarious rewards.

The second part of the educational diagnosis, Phase 5, is concerned with deciding which factors will be the focus of the intervention and also what educational intervention will be used. This decision will be made based upon the prioritizing of these factors as well as the availability of resources to influence each of them.

Phase 6, Administrative Diagnosis, involves the actual development and implementation of the program. This also includes resource allocation or budgeting.

The final phase of the framework, Evaluation, is not even listed at the end of the model in Figure 15. The authors of this model believe that evaluation should begin early in this planning process and be an ongoing part of that process. The authors indicate three levels at which a health education program can be evaluated:

1. Process evaluation - At this first level of evaluation the main focus is upon professional practice. Quality in health education programming is monitored by such methods as audit, peer review, accreditation, certification, and government or administrative overview of contracts and grants.

2. Impact evaluation - This second level of evaluation concentrates on the immediate impact of the program on knowledge, attitudes and behavior. Cost-effectiveness is one standard of acceptability in impact evaluation.

3. Outcome evaluation - At the third level, outcome evaluation is centered upon mortality and morbidity, such as the incidence and prevalence of the condition(s) affected by the program. Outcome evaluation is a long-term consideration requiring large population samples.

4. Model for Health Education Planning and Resource Development (Bates and Winder, 1984)

   The Model for Health Education Planning and Resource Development (MHEPRD) is not as well-known as some of the models previously discussed, but this model has some very distinguishing characteristics. It separates process from the end results, and its inclusion of the evaluation process throughout the entire model is unique (See Figure 16). There are five major components in the MHEPRD: 1) Health Education Plans, 2) Demonstration Programs, 3) Operational Programs, 4) Research Programs and 5) Information and Statistics. Each one represents an end result of the planning process. As mentioned earlier, the authors do not see evaluation as a separate phase of the model. It plays an integral role in each phase by testing and validating programs assumptions throughout the process.

   In the first phase of the model, Health Education Plans are an end result of a needs assessment which Bates and Winder refer to as a "Policy-Analysis Process" and also an ongoing "Evaluation Process" of Information and Statistics. The plans which are developed in Phase 1 provide the hypotheses to be tested in Phase 2, the "Development Process" where planners create Demonstration Programs. In Phase 3, the "Validation Process," the results of the Demonstration Programs are examined to determine which should be continued and become Operational Programs. This phase also includes the development of an implementation plan that should reflect the experiences learned during the development and validation of the Demonstration Programs. Therefore, this process should yield Operational Programs which are based on sound research, planning and demonstrations. In Phase 4, Implementation of the Operational Programs occurs. The problems that arise during the "Implementation Process" provide the basis for research questions for the program planners. The possible answers to these questions are formulated and tested through appropriate experimentation in their Research Programs. The data that are generated by these experimentations are used for future "Policy Analysis" and planning. The planning process thereby becomes a cycle since it is always building on previous planning. Hopefully, as the process continues, the results should be better organized and more effective health education services.

5. Generic Health/Fitness Delivery System (Patton, Corry, Gettman & Graf, 1986)

   The Generic Health/Fitness Delivery System (GHFDS) was not developed specifically for health education as its name suggests, but it can be easily applied to health education. This goal-oriented planning model has five steps or stages: 1) Needs Assessment, 2) Goal Setting, 3) Planning (choice of strategies to meet goals), 4) Program Implementation (delivery of program) and 5) Evaluation. Each of these steps has two components--education and service. The education component provides a cognitive (awareness, knowledge) experience in each step, while the service component provides a "hands-on" experience. In the visual presentation of the model (See Figure 17), this approach is dynamic and interactive. It provides on-going review and feedback so that the needs of the target population can best be met. Input from the previous step in GHFDS modifies the approach used in delivering the later steps in the model. In addition, feedback from the later steps becomes most useful in modifying the program delivery.

6. Community Wellness Model (Jenkins, 1991)

   In the 1980's at a time when less money was available to fund health services for a population with increasing numbers of sicker, older and uninsured individuals, the University of Georgia Cooperative Extension Service responded with the Community Wellness Model for its rural communities. This is a planning model program designed to help communities use their local resources to find solutions to some very complex health issues. Community Wellness is considered to be a "process-oriented program" which provides the means to "assess, identify, and find workable solutions to community problems." County Extension agents and other leaders (both in the health and non-health sectors) serve as "catalysts" in order to involve members progressively in community problem-solving. Planned health interventions are based on the assessment of specific community health needs. This whole process should empower the community and help to develop a community-wide support system.

   Susan Jenkins, the model's creator, has visualized this process taking place on four different organizational levels. At the beginning, the county Extension agents would conduct programs at the Single Resource Level. These are needed programs that the agent can plan and implement without outside support. In Figure 18 beneath the first stage, Single Resources, there are sample programs, such as stress workshops, listed which meet this requirement. Most of the programs at this level would be self-contained.

   In the second stage, Multiple Resources, programs require that other health agencies or professionals be cooperating and involved with the Extension agent. These programs require more time in planning, organizing and follow-up. In Figure 18 below Multiple Resources, there are examples of these types of programs which require more than one resource. Heading up the list is RISKO. This is an educational computer-assisted program which estimates the participant's chances of suffering from a heart attack or stroke based on eight risk factors which relate directly to a person's lifestyle. This program was introduced by the Extension Service for Georgians about 15 years ago. The Extension agent, working together with health professionals at the health department and/or local hospital, could offer education, counseling, or screening as needed based on this program.

   Stage three of the Community Wellness process moves up to the broader level of Community-Wide Resources. There is even more organizational involvement as the programs become more complex. Organizations collaborate and coordinate by increasing the number of local meetings and networking to expand the organizational structure. Under Community-Wide Resources in Figure 18, Health Fairs lead the list of examples. According to Jenkins' recommendation, anywhere from 15 to 30 organizations could be involved in coordinating a one-day health fair. As members of these organizations learn more about each other and the organizations they represent when completing these Community-Wide programs, the realization will come that much more can be accomplished by working together by eliminating duplication of efforts. As in the previous two stages, a report is written after the program with all cooperating agencies being involved and receiving a copy. At this point, the Extension agent should have taken on the role as a member of "a multi-disciplinary team" rather than as the "initiator" or "organizer" at the start of this process.

   The final, and fourth, stage of the Community Wellness Model focuses on Task Force Resources. At this level, a Community Wellness Council is formed. This Council should be able to function independently as it identifies the health needs of the community, decides on strategies to solve these problems, and then proceeds to implement these solutions. Georgia's Community Wellness Councils are similar to Alabama's Health Councils and Mississippi's Rural Health Coalitions.

   Data should be gathered throughout the stages of this process to become a part of the assessment of health needs. The Community Assessment should be composed of two parts: 1) the Community Issue Profile (which includes secondary data from county/community and state sources on general characteristics, such as age, poverty and leading causes of death, and life stage characteristics from infants up through the elderly) and 2) the Community Issue Profile (which lists organizations and their programs that are available in the agent's county/community). This assessment should help identify the potential issues as well as possible community resources that could aid in solving these concerns.

   In addition to the assessment, planning and implementation in this process, there must also be provision for evaluation. In Community Wellness, this is done in two stages. The first stage examines the initiation of Community Wellness through the community assessment, the identification of health issues or concerns, and the development of a plan of action by the council and community to meet the community's needs. In the second stage of evaluation, the community will need to prioritize which issues can and need to be addressed in the plan of action, resources that may help with these health issues or concerns, and any changes in the status of health that may occur within the community as a result of these programs.

   In actualizing any model, there will be real world concerns. First, since Extension has traditionally been agricultural in focus, this movement into the health arena did cause some turf concerns in Georgia; however, the anxiety tended to be at the administrative levels of organizations, not at the local level as interaction and trust increased. Secondly, Jenkins noted that the lack of agent continuity in what is basically a "three-to-five-year process" to establish an independent Community Wellness Council can cause a lag in this process until the new agent feels comfortable in this role. A third concern particularly felt by agents is the time and labor that can be required initially, especially with their other responsibilities in the areas of home economics, youth programs, and agriculture. As the community becomes more involved in this process, this should become less of a concern. Fourth, in what was promoted as a collaborative effort, some organizations have become alienated when success was only partially shared among the organizations. All groups should be recognized on reports or other information released on the project. A fifth point is that more training for agents and community leaders is needed to gain the necessary skills for functioning as a group facilitator. Jenkins suggests that grants or special monies might help meet these training needs. Lastly, some health professionals also indicate that this Community Wellness Model increases their already demanding workload. Local resources within the community must be used to their maximum potential to prevent this sense of frustration by health professionals. In order for all the people in a community involved with the Council to withstand the stresses and strains over time, they must concentrate on "communication, collaboration, and common goals" to make an impact on their community's health.

7. PRECEDE-PROCEED Model (Green & Kreuter, 1991)

   At a first glance, this revised model looks much like its earlier version. However, there are changes that make it a more useful model. The title summarizes the phases within the model. PRECEDE has been modified and is now an acronym for Predisposing, Reinforcing and Enabling Constructs in Educational/Environmental Diagnosis and Evaluation. PRECEDE is the diagnostic or needs assessment phase. PROCEED, a new acronym, stands for Policy, Regulatory and Organizational Constructs in Educational and Environmental Development. As a follow-up, PROCEED is the developmental stage of planning and begins the implementation and evaluation process. The new model now contains nine phases or steps. (See Figure 19.) It is much more comprehensive than the 1980 framework and also further subdivides the evaluation component. Similar to PRECEDE, the PRECEDE-PROCEED model begins with the final consequences (or end) and works back to the causes.

   The first phase of this model is also called Social Diagnosis. Similar to the 1980 framework, this model attempts to define subjectively the quality of life (problems as well as priorities) of those in the target population. This is best accomplished by involving individuals in the target population in a self-study of their own needs. These subjective quality of life social indicators could include illegitimacy, welfare, discrimination, happiness, self-esteem along with many other possibilities.

   Phase 2, Epidemiological Diagnosis, is once again the stage where health goals or problems are identified and prioritized Epidemiological data, as well as clinical and investigative data, are used in order to reach these decisions about which health problems are most deserving of scarce resources.

   In Phase 3, Behavioral and Environmental Diagnosis, the behavioral and environmental risk factors that might be linked to the health problems in Phase 2 are determined and ranked. Environmental risk factors are defined as the factors outside an individual that have any affect on behavior, health and quality of life. The ranking or prioritizing of these risk factors can be done by using a 2 X 2 table, as shown in Figure 20. An attempt would be made to identify those behavioral and environmental risk factors that were both important and changeable.

   Phase 4, Educational and Organizational Diagnosis, of this model, like its predecessor, identifies and classifies the predisposing, reinforcing and enabling factors which can potentially influence behavior. These factors have already been described in this document. Once again, priorities must be set, and those ranked highest in these three categories will help to determine the focus of the intervention(s).

   In the fifth step, Administrative and Policy Diagnosis, a determination is made if the capabilities and resources are available to develop and implement the program. Limitations or constraints of resources, policies, abilities and time are assessed. This completes the final phase of PRECEDE (the diagnostic portion) as PROCEED (implementation and evaluation) begins.

   In Phase 6, Implementation, with the proper resources in hand, the appropriate methods and strategies of the intervention are selected.

   Phases 7 (Process Evaluation), Phase 8 (Impact Evaluation) and Phase 9 (Outcome Evaluation) focus, of course, on evaluation and are based upon the earlier phases of the model when the program objectives were outlined in the diagnostic process.

   The first level of evaluation (Phase 7) is referred to as Process Evaluation since the information on the "process" of the program is the first to become available. This is the time to experiment with methods, to pilot new program components, and to solve problems in new materials such as their readability, cultural sensitivity and/or acceptability to the target population.

   In the second level, Impact Evaluation (Phase 8), the immediate effect that the program has on certain target behaviors and their predisposing, enabling and reinforcing factors, or on important environmental factors will be assessed. Phases 3 and 4 of the PRECEDE process should provide the foundation for evaluating program impact.

   At the third and final level, Outcome Evaluation (Phase 9), the health status and quality-of-life indicators which were outlined in the earliest stages of this planning process will be reexamined.

   Whether all three of these final phases are used depends on the evaluation requirements of the program. The resources needed to conduct evaluations of impact and outcome are much greater than those needed to conduct process evaluation.

8. THE PEN-3 MODEL (Airhihenbuwa, 1992)

   The PEN-3 Model was originally developed to be used as a framework for health education and disease prevention in African countries. It has been successfully applied in child survival interventions in these countries. This model consists of three dimensions of health beliefs and behavior that are interrelated and interdependent: 1) Health Education, 2) Educational Diagnosis of Health Behavior and 3) Cultural Appropriateness of Health Behavior. The model is illustrated in categories that form the acronym PEN for each of the three dimensions (See Figure 21).

   The first dimension of the PEN-3 model is Health Education. An explanation for the acronym in this first dimension is:

   P - Person. Health education should be committed to improving the health of everyone. Therefore, individuals should be empowered to make informed decisions which are appropriate to their roles in their families and communities.

   E - Extended Family. Health education should be targeted to not only the immediate family but also to the extended family or kinships. When the program is designed to target a particular member of the family, the individual should become the focus within the context of that person's environment.

   N - Neighborhood. Health education should be committed to promoting health and preventing disease in neighborhoods and communities. Involvement of community members and their leaders is critical to providing culturally appropriate health programs.

   The second dimension of the PEN-3 model is the Educational Diagnosis of Health Behavior. Educational diagnosis has been used by researchers in an attempt to determine what factors affect individual, family and/or community health actions. According to its author, this dimension has evolved from three models in health education: 1) Health Belief Model; 2) Theory of Reasoned Action; and 3) the PRECEDE framework. The factors in the second dimension are:

   P - Perceptions. These are the knowledge, attitudes, values and beliefs that may facilitate or hinder personal motivation to maintain or change health beliefs and/or practices. Two examples of this might be that being overweight is not necessarily associated with a negative body image for many African Americans or that teenage pregnancies among African Americans may, in fact, be desired. Appropriate health education interventions should begin with the person's "perceived" needs and desires rather than those "real" needs as defined by planners.

   E - Enablers. These are societal, systematic or structural influences (forces) that may enhance or create barriers to maintain or change health beliefs and/or practices. These could include available resources, accessibility, referrals, skills or types of services.

   N - Nurturers. These are the reinforcing factors that an individual may receive from significant others. These important others could include extended family, peers, employers, health personnel, religious leaders or government officials.

   The third and most crucial dimension of the PEN-3 Model is the cultural appropriateness of health beliefs. This is essential to developing a culturally sensitive health education program for ethnic minority cultures. The three factors in this final dimensions are:

   P - Positive. These are the perceptions, enablers and nurturers that may cause an individual, family or community to engage in health practices that contribute to improved health status and must be encouraged. These positive health practices are essential to the empowerment of people, families, neighborhoods and communities. One example is the traditional practice of eating green vegetables.

   E - Exotic. These are unfamiliar practices that have no harmful health consequences and therefore do not need to be changed. Programs should address "what is" instead of "what ought to be."

   N - Negative. These are perceptions, enablers and nurturers that may lead individuals, families or communities to follow health practices that are harmful to their health. An example would be unprotected sexual intercourse.

   Health educators should focus on both the positive (empowerment process) and the negative behaviors in a health program. This can lead to a higher level of sensitivity when the planner(s) are selecting the most culturally-appropriate educational intervention.

   There are several phases in the application of this model. In Phase 1 (Health Education), the planner(s) must determine if the emphasis of the program in health education will be for individuals, for the extended family or for the community. Using surveys and/or interviews, in Phase 2 (Education Diagnosis of Health Behavior), the planner(s) should explore the beliefs and practices that are related to perceptions, enablers and nurturers. The third phase (Cultural Appropriateness of Health Behavior) involves categorizing these inherent beliefs and practices as either positive, exotic or negative beliefs. Finally the planner(s) with assistance from others will classify all health beliefs into two groups: 1) the identified health beliefs that are rooted in the cultural patterns and lifestyles of the target community; 2) the identified health beliefs that are newly developed and have only loose or superficial ties with the cultural patterns and lifestyles of the target community. The real challenge for planner(s) is to identify which positive beliefs and practices are supportive of the individual, extended family and neighborhood. The planner(s) must understand the thinking behind stated beliefs and practices to determine appropriate classification and for selection of proper health education strategies.

9. APEXPH and PATCH (Centers for Disease & Prevention, 1993)

   Assessment Protocol for Excellence in Public Health (APEXPH) and Planned Approach to Community Health (PATCH) are two planning processes developed by the Centers for Disease Control & Prevention. These two models differ in what they are designed to accomplish and also in how they are used. Both may be used in the same community. However, it is not recommended that these two processes begin at the same time. An overview of APEXPH will be presented first followed by PATCH.

   1. APEXPH was designed for use by local health departments in meeting the public health needs of their communities. A workbook is available to health departments which is divided into three major parts: Part I - Organizational Capacity Assessment; Part II - The Community Process; and Part III - Completing the Cycle.

      In Part I, Organizational Capacity Assessment, the director of the health department and a team conduct an internal self-assessment and create an action plan for the organization. This plan should set priorities and build on strengths to correct perceived weaknesses in meeting the public's health needs.

      During Part II, a community advisory committee should be formed. This committee identifies and prioritizes health problems which require attention. Health status goals and program objective are also outlined. Depending on the public health objectives, certain community resources are activated. The Community Process should include the collection and analysis of health data, the community's perception of its health status, and the involvement of the health advisory committee throughout the development of a community health plan.

      In Part III, Completing the Cycle, the basic monitoring and evaluation tools must be used to ensure that the Organizational Action Plan (in Part I) and the Community Health Plan (in Part II) are carried out with the desired results. By performing these tasks, the assessment, policy development and assurance functions should become an on-going cycle in the health department (i.e. institutionalized).

   2. PATCH is a process designed to increase a community's capacity to organize its members, collect and use community data, set health priorities, select and implement appropriate interventions, and perform both process and impact evaluations. This model has been described as a "bottom-up" rather than a top-down approach to health education program planning and follows the PRECEDE Model (1980) fairly closely. It is primarily intended for chronic disease prevention and health promotion programs.. Although applicable to either rural or urban settings, in the past PATCH has been used more in rural populations than in urban. Urban and minority populations were less likely to be targeted. There are five phases in this process:

      Phase I: Mobilizing the Community - A community group is formed to define the community, address health issues, and create working groups to carry out the remaining phases.

      Phase II: Collecting and Organizing Data - Data (mortality, morbidity, behavioral, community opinion) are gathered and analyzed. The community group uses these analyses to determine health priorities and program planning. One criticism at this stage was that the gathering and analyzing of data required so much time that several communities involved in this process lost momentum.

      Phase III: Choosing Health Priorities and Target Groups - Health priorities are identified, existing community resources, policies and programs are identified, target groups are selected, and objectives for the community are set by the community group. It has been recommended from studies of communities where PATCH has been implemented that a community capacity assessment should be conducted before the community needs assessment.

      Phase IV: Choosing and Conducting Interventions - Target groups are involved in the design and implementation of health intervention activities. Volunteers are recruited and trained, and these planned interventions are conducted.

      Phase V: Evaluating PATCH Process and Interventions - Just like Phase I, this phase is an on-going part of this process. The impact of the intervention activities, as well as the impact of the process of PATCH, upon the community should both be evaluated.

      Other suggestions for improving the PATCH process include:

      • technical assistance should be provided throughout a project, not just at the beginning by CDC.
      • at least one full-time community coordinator should be funded.
      • multiple interventions centered around one chronic condition at a time should be stressed.
      • institutionalization of the program must be emphasized.

10. Formative Evaluation, Consultation, and Systems Technique (Goodman and Wandersman, 1994

    FORmative Evaluation, Consultation, and Systems Technique (FORECAST) is a system of formative evaluation designed to aid in the development, planning, and implementation of community health projects. Formative evaluation would be any evaluation that produces information used in the developing stages of a health education program in order to improve it. This systematic analysis of the program provides ongoing information to affect decision-making, action on policy, allocation of resources, and program operations. In this process, the evaluators would be most effective by providing "frequent feedback" on the development of the project. This may require years of feedback since some community health programs are in a contant state of development after their initial start-up. FORECAST has previously been applied to community-based program initiatives in South Carolina with the aim of &quto;preventing and reducing alcohol, tobacco, and other drug abuse."

    Goodman and Wandersman suggest that the lack of a desirable health project outcome could be due to inadequate implementation of the project (Type III error) instead of faulty premises upon which the intervention is based. Even when no Type III error occurs and the project is implemented as intended, the project may need refinement as its constructs face "practical and real world constraints."

    In order to provide a steady stream of feedback during project development, FORECAST is composed of four components: 1) models (diagrams of the project), 2) markers (milestones which indicate whether the project is developing according to the models), 3) measures (materials which indicate whether the markers have been achieved), and 4) meaning (the minimum level of attainment for each measure used to interpret the developmental successes of the project.)

    For the first component, FORECAST used two types of models: 1) a model of the problem, which is a diagram of the "perceived" causes and effect of the health issue or concern that the project is to undertake and 2) a model of the project's proposed action, which is a diagram of the program response to relieve or reduce this health concern.

    In Figure 22, a model of the problem for alcohol and other drug abuse is outlined. The center box identifies many factors that contribute to a person's susceptibility to alcohol and other drug abuse, such as individual (personality/disposition), family, or community influences. This model of the problem strongly indicates that the interventions must also occur on multiple levels if the number of risk behaviors are to be decreased. Therefore, the model of project action should also be focused on the individual, the family, and the community.

    The community development approach in the model of project action (Figure 23) is consistent with the social ecology outlook of the model of the problem (Figure 24).

    Two evaluators are assigned the task of developing both a model of the problem and a model for project action by reviewing the project proposal. These evaluators work independently on both of these diagrams, and then confer with each other upon completion of the two models. After the evaluators have reconciled any differences in their models, they meet with the project staff and community participants to review and refine these models once again. This collaborative process should hopefully contribute to project ownership of these models and set the stage for the development of the project markers.

    This model relies heavily on consultation since evaluators work in partnership with project staff, community members, and any other participants in developing a FORECAST evaluation. It is considered to be a system technique since the evaluators continue to monitor the project's development and encourage adjustments as needed to follow the model of project action. Where changes in the original plan are necessary, evaluators can document any such changes. This technique also provides a way of anticipating (forecasting) how these modifications in a project's planned development may have an impact on the entire operation. If the impact of these alterations is unsatisfactory, "mid-course corrections" can be made.

Prepared by:
Carol Campbell
Health Curriculum Research Assistant
Mississippi Cooperative Extension Service
10/95