Application of the PRECEDE-PROCEED Planning Model in Designing an Oral Health Strategy

Application of the PRECEDE-PROCEED Planning Model in Designing an Oral Health Strategy

Catherine J. Binkley1 and Knowlton W. Johnson2

1 Department of Surgical & Hospital Dentistry, University of Louisville, Louisville, KY, USA

2 Pacific Institute for Research & Evaluation, Louisville, KY , USA

Abstract

Background—Although the poor oral health of adults with intellectual and developmental

disabilities (IDD) constitutes a significant health disparity in the United States, few interventions

to date have produced lasting results. Moreover, there is minimal application of planning models

to inform and design a theory-based strategy that has the potential to be effective and sustainable

in this population.

Methods—The PRECEDE-PROCEED planning model is being used to design and evaluate an

oral health strategy for adults with IDD. The PRECEDE component involves assessing social,

epidemiological, behavioral, environmental, educational, and ecological factors that informed the

development of an intervention with underlying social cognitive theory assumptions. The

PROCEED component consists of pilot-testing and evaluating the implementation of the strategy,

its impact on mediators and outcomes of the population under study.

Results—A The PRECEDE assessment and strategy design results are presented including a

conceptual framework and oral health strategy that are linked to social cognitive theory and Health

Action Process Approach. We have developed a strategy consisting of a planned actions, capacity

building, environmental adaptations, and caregiver reinforcement within group homes. The

strategy is designed to increase caregiver self-efficacy, outcome expectancies, and behavioral

capability, and also to create environmental influences that will lead to improved self-care

behavior of the adult with IDD. It is anticipated that this strategy will improve the oral health and

quality of life, including respiratory health, of individuals with IDD. The planned PROCEED

component of the planning model includes a description of an in-process pilot study to refine the

oral health strategy, along with a future randomized controlled clinical trial to demonstrate its

effectiveness.

Conclusions—The application of the PRECEDE-PROCEED planning model presented here

demonstrates the feasibility of this planning model for developing and evaluating interventions for

adults within the IDD population.

Keywords

Oral health; Adults with intellectual and developmental disabilities; PRECEDE-PROCEED planning model; Social cognitive theory; Health Action Process Approach; Oral health strategy

Corresponding Author: Catherine J. Binkley. [email protected].

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The poor oral health of adults with intellectual and developmental disabilities (IDD) living

in community settings constitutes a significant health disparity in the United States (1, 2).

Efforts have been made to develop and evaluate various strategies to improve the oral

hygiene and oral health of this vulnerable population with minimal to moderate success

(3-7). None of these interventions used a planning model or theory-based behavior change

intervention for caregivers of individuals with IDD. To the best of our knowledge there are

only a few reports of how a planning model is used in dental public health (8, 9), but these

reports are not used to develop a theory-based oral health strategy or intervention for

individuals with IDD.

Planning, designing, and evaluating interventions to impact public dental health can be a

challenging and time-consuming undertaking. The National Institute for Dental and

Craniofacial Research (NIDCR) places emphasis on the importance of using intervention

planning models such as PRECEDE-PROCEED, the role of health behavior theory in

developing interventions, and mediators, moderators, and testing for mechanisms of action.

Moreover, the NIDCR strongly encourages investigators “to utilize methods that allow for a

test of mechanisms of action. Mechanisms of action are causal explanations for behavior.

These are distinguished from correlates, predictors, risk and protective factors, etc., which

may be candidate mechanisms, but have not been demonstrated to have a causal link with

the outcome(s) of interest” (http://www.nidcr.nih.gov/Research/DER/bssrb.htm) (10).

The PRECEDE-PROCEED model can be used to design and evaluate an oral health

promotion effort. The PRECEDE component allows a researcher to work backward from the

ultimate goal of the research (distal outcomes) to create a blueprint to instruct the formation

of the intervention or strategy (11). The PROCEED component may lay out the evaluation,

including pilot study and efficacy study methodologies. The model has been used by Watson

and colleagues to design an oral health promotion program in an inner-city Latino

community (12); by Cannick and colleagues to guide the training of health professional

students (13); and by Sato (9) and Dharamsi (14) to analyze attitudes and prediction factors

regarding oral health. Although this planning model has been applied in oral health, there

are others such as RE-AIM (15) and the Stage Model of Behavioral Therapy (16) that

achieve the same goal of organizing the framework for an oral health promotion program. It

is important to remember that planning models are not health behavior theories because they

cannot test mechanisms of action or causal relationships (10).

Of particular importance to the PRECEDE-PROCEED planning model is the role of theory

in creating a conceptual framework that guides construction of an intervention and its

evaluation (11). We believe it is important to develop a planned intervention for oral health

that draws from multiple theories. Several behavioral change theories have reportedly been

used in designing oral health intervention strategies. One of the most common is Bandura's

Social Cognitive Theory (SCT), which posits that the process of human adaptation and

change is a dynamic interplay of personal, behavioral, and environmental factors (17). The

literature suggests that interventions designed to impact these three factors are more likely to

produce desired changes in outcomes (17-19). Personal factors may play a major role in a

person's capability to perform behaviors. Environmental factors may hinder a person's

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ability to adequately perform a behavior and impact their self-efficacy (a personal factor) in

performing the behavior of interest. The reciprocal nature of these determinants of human

functioning make it possible to design interventions to impact personal, behavioral, or

environmental factors. Schwarzer's Health Action Process Approach (HAPA) (20, 21) uses

social cognitive constructs, including outcome expectancies and self-efficacy as well as

planned actions, in predicting behavior change. This approach provides a framework for

prediction of behavior and reflects the assumed causal mechanisms of behavior change (21).

HAPA has been used to describe, explain, and predict changes in health behaviors in a

variety of settings (21) including oral health (22).

METHODS

This article presents the application of the PRECEDE-PROCEED Model (23) as a planning

tool for oral health. (11) PRECEDE (Predisposing, Reinforcing, and Enabling Constructs in

Educational Diagnosis) outlines a diagnostic planning process to assist in the development

of targeted and focused public health programs. PROCEED (Policy, Regulatory, and

Organizational Constructs in Educational and Environmental Development) highlights the

implementation and evaluation of the intervention designed in the PRECEDE component.

Although an eight-phase planning model as presented in the literature is being used, we have

tweaked the PROCEED component (phase 5) to include pilot testing for revising the original

strategy before implementing and evaluating the intended processes, impact, and outcomes

of the intervention. Soliciting input from key informants of the community actively involved

with the population of interest is important in all phases of assessment. The Institutional

Review Board of the University of Louisville reviewed the research (11.0338) and approved

the study including all consent forms for the pilot test of the oral health strategy.

PRECEDE Planning Model Component

We used an extensive literature review and informal discussions with selected community

leaders and staff who work with IDD population in a targeted Midwestern city. These

participants consisted of one vice president, one residential director, and three caregivers

working in group homes of one IDD service organization, and two dentists and three dental

hygienists/assistants who work with IDD population. In total, interview data were collected

from 10 IDD and dental care persons. Each of these participants engaged in an informal

discussion that posed questions central to the assessment of phases 1-4. A content analysis

of the literature and discussions produced the results presented later.

Phase 1 – Social Assessment—The PRECEDE portion of the Model begins with

diagnostic activities that identify desirable outcomes or goals of the intervention or ask,

“What can be achieved?” These activities determined the primary or distal outcomes of the

oral health strategy for the individual with disabilities.

Phase 2 – Epidemiological, Behavioral, and Environmental Assessment—We

searched the literature and asked questions of the selected community leaders and healthcare

staff noted above about what problems or issues affect the oral health-related quality of life

for persons with IDD? – OR – What needs to change to achieve optimal oral health for these

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individuals? This phase determined epidemiological, behavioral, and environmental factors

that may well have an impact on the oral health and quality of life of individuals with IDD.

This phase contributed to the identification of the factors that an oral health strategy needs to

impact (mediating outcomes) in order to achieve the primary outcomes.

Phase 3 – Educational and Ecological Assessment—This phase determined factors

that, if modified, would be most likely to result in behavior change and to sustain this

change process. These factors are generally classified as predisposing, enabling, and

reinforcing factors (23). “Predisposing factors are antecedents to behavior that provide the

rationale or motivation for the behavior” (p.415) (24) and include individuals’ existing skills

and self-efficacy. “Enabling factors are antecedents to behavioral or environmental change

that allow a motivation or environmental policy to be realized” (p.415) (24) and may include

new skills, services, resources, and programs. Reinforcing factors are those factors following

a behavior that provide continuing reward or incentive for the persistence or repetition of the

behavior” (p.415) (24) and they include social support, praise, and vicarious reinforcement.

Change theory(ies) for designing the intervention after this assessment includes individual,

interpersonal, and community theories. Individual-level theories are best used to address

predisposing factors, while interpersonal-level theories, such as social cognitive theory,

address reinforcing factors well; community-level theories are most appropriate for

addressing enabling factors. (24).

Phase 4 – Intervention Alignment and Administrative and Policy Assessment

Phase 4a – Intervention Alignment: This phase matched appropriate strategies and

interventions with the projected changes and outcomes identified in phases 1-3 (23). Using

assessment results from phases 1-3, the oral health strategy presented in the results section

emerged as our intervention of choice.

Phase 4b – Administrative and Policy Assessment: In this phase, resources, organizational

barriers and facilitators, and policies that were needed for the strategy or intervention

implementation and sustainability were identified (24). The organizational and

environmental systems that could affect the desired outcomes (enabling factors) were taken

into account. The administrative diagnosis assessed resources, policies, budgetary needs,

and organizational situations that could hinder or facilitate the development and

implementation of the strategy or program (25). The policy diagnosis assessed the

compatibility of the oral health strategy with those of the organizations providing services to

individuals with IDD.

PROCEED Planning Model Component

Phase 5 – Pilot Study—Although we did not recognize the inclusion of a pilot study as

essential to the PRECEDE-PROCEED planning model, we believe that it is an important

planning phase. These results and lessons learned are important to revising both the pilot

oral health strategy and its evaluation for an efficacy study. To this end, we have provided a

description of our inprogress pilot study in the results section of this article.

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Phase 6 – Implementation—This phase presents a description of the implementation of

the oral health strategy in an efficacy study. Key roles in the implementation phase are

highlighted.

Phases 7 and 8 – Process and Outcome Evaluation—Our planned efficacy study is

designed as a cluster randomized control trial that includes a process and outcome

evaluation. The study of both the implementation process and outcome achievements is

important. The implementation process assessment should address the amount of

intervention exposure of the oral health strategy (dosage), extent to which an intervention is

implemented as designed (fidelity), and participant appraisal of intervention quality or

usefulness (participant reaction), all of which are discussed in the evaluation literature (26).

In addition, we measured adequacy of implementation by recruiting an expert panel who has

published implementation articles to assess the adequacy of our implementation (27). The

outcome evaluation should be composed of an assessment of oral health strategy direct

effects on outcomes, mediation of outcomes designated as mechanisms of change, and

moderation of contextual factors. Our evaluation plans are highlighted in the results section

of this article.

RESULTS & DISCUSSION

We present the results of the PRECEDE component of the planning model being

demonstrated. The planned PROCEED component is also described.

PRECEDE Phase 1 – Social Assessment

Our social diagnosis began while we were conducting previous studies in long-term care

facilities and in community settings for persons with IDD. During this planning phase, we

solicited input from the community (direct care staff, administrators, and dental

professionals who care for persons with IDD), and they all stated that poor oral health is one

of the greatest unmet health care needs of their population (28). The community was also

becoming aware of the association of aspiration of bacteria from the mouth into the lungs

with respiratory infections, and it wanted to improve oral health and oral health-related

quality of life including respiratory health.

PRECEDE Phase 2 – Epidemiological, Behavioral, and Environmental Assessment

A. Epidemiological Assessment—Historically, children and adults with mild to

profound intellectual and developmental disabilities (IDD) either lived at home or were

placed in large state institutions with fully staffed medical and dental facilities and stable,

well-trained workers. Over the past several decades, a major effort to deinstitutionalize these

individuals and place them in smaller community residences has been successful. Although

overall quality of life may have been improved for this vulnerable population, their access to

dental care has become limited or non-existent, and their oral health has suffered (29). A

majority of persons with IDD are insured by Medicaid, and many dentists either do not

accept Medicaid or do not believe they are adequately trained to treat special-needs patients.

The oral health of this population is compromised not only by the lack of preventive dental

treatment every six months but also by their inability to adequately brush and/or floss their

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own teeth. The oral hygiene provided or supervised by caregivers is thus critical to

maintaining oral health and reducing the need for extensive restoration or extraction of teeth.

Providing oral care for individuals with IDD is challenging, not only because they may have

physical impairments but also because they exhibit uncooperative behaviors (30). Caregivers

often only clean the anterior teeth, ignoring the posterior teeth and causing the posterior

oropharyngeal area to be at risk for colonization with bacteria and infection (31-33).

Swallowing disorders (dysphagia) are common in persons with developmental disabilities,

putting them at risk for aspiration and respiratory infections, a major cause of morbidity and

mortality in this population (34, 35). Similar to what occurs with elderly persons residing in

nursing homes and patients in intensive care units, (36, 37) potentially pathogenic bacteria

colonize the oropharyngeal area of people with IDD. (38) Rigorous oral hygiene can reduce

oral colonization with bacteria and yeasts, thus reducing pneumonia in at-risk individuals

(39, 40).

Although social initiatives that focus on increasing the number of dentists who will treat

special-needs patients are needed, it remains the purview of the caregiver to supervise and/or

provide oral hygiene. Thus, theoretically sound strategies or interventions that address the

caregiver's behavioral capability in providing oral health support may reduce disparities and

could be imperative for improving health and quality of life in this population.(28, 41)

B. Behavioral Assessment—We determined key behavioral factors of the individual

with IDD that affect mechanisms impacting their oral health and quality of life. Individuals

with IDD have physical, behavioral, and cognitive disabilities that negatively impact their

ability to perform their own oral hygiene practices at an optimal level (42). Those with mild

disability, who are capable of performing their oral hygiene, frequently do not prioritize

brushing or flossing their teeth on a regular basis and often do not know how to perform

these practices optimally. Those with moderate to profound disabilities may be able to

partially perform their oral hygiene, but they often require assistance and/or supervision

provided by caregivers to adequately clean their teeth. Also, due to their emotional and

unpredictable episodes, as the caregivers call them, all IDD persons may exhibit

uncooperative and/or resistant behaviors from time to time that prevent them from engaging

in oral hygiene practices regularly.

Like the parents of very young children, caregivers also play a key role in shaping the

behavior of adults with IDD, who frequently have a mental age lower than that of a 5-year-

old child without disability. Adults with disabilities generally do not achieve an acceptable

standard of oral health on their own. However, Shaw and colleagues demonstrated that if

these IDD persons are supervised, encouraged, and motivated by caregivers, their oral

hygiene can be improved (43). Caregiver behavior in the form of support of the adult with

IDD oral health, coupled with the caregiver's self-efficacy in promoting the adult's self-care

behavior, should improve the residents’ oral hygiene practices.

C. Environmental Assessment—We identified environmental barriers or influences

that are key factors in social cognitive theory. First, the physical environment in group

homes is frequently not conducive to optimal oral hygiene practices. Materials available for

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oral hygiene usually include only over-the-counter toothbrushes, which may not be adequate

to address the residents’ disabilities.

Second, our assessment of the social environment in the group homes determined that there

were no policies or procedures in place concerning oral health or oral hygiene practices.

Implementation of policies and procedures related to oral health by the organizations that

manage the group homes would provide all caregivers with guidelines for and expectations

of their performance. We found that all caregivers are responsible for preparing either

breakfast or dinner during the week, and on weekends they must prepare all meals and/or

take the residents out to lunch. As such, they are the primary persons responsible for

determining what the residents eat and drink while in their care and they hold the

responsibility of ensuring the availability of an appropriate diet in the group home setting to

reduce the risk of tooth decay.

PRECEDE Phase 3 – Educational and Ecological Assessment

A. Predisposing Factors—We identified potential factors that may need to be modified

to effect changes in caregiver behavior. We identified these factors based on discussions

with our community leaders and a review of the literature. These social cognitive factors-

self-efficacy, outcome expectancies, and behavioral capability-may be important because

merely providing education to caregivers in oral hygiene provision for dependent persons

has been shown to be minimally effective in improving oral health (5, 44).

Self-efficacy is defined as “people's judgments of the capabilities to organize and execute

courses of action required to attain designated types of performances” (17, p. 391). Self-

efficacy in oral hygiene, or the perceived ability or confidence of an individual to perform

good tooth brushing and flossing, has been shown to be important in previous oral health

studies (45-48). Caregivers reported to us that they had knowledge of the importance of oral

health but stated that they were not comfortable supervising or assisting the residents in oral

hygiene procedures. The literature reports that parental/caregiver self-efficacy in supporting

or supervising young children's oral hygiene can be a strong predictor of parental/caregiver

oral hygiene support (49, 50).

Outcome expectancies are defined as “a person's estimate that a given behavior will lead to

certain outcomes” (p.193) (51) or beliefs about the likelihood and value of behavioral

choices. Caregiver psychosocial factors, such as expectations of poor oral health in their

residents/clients, may serve as a barrier to optimal oral hygiene behavior (52-54). Outcome

expectancies may be impacted by individuals seeing like individuals perform the behavior

and/or encouragement to them that they are capable of performing the behavior (55, 56).

Demonstrations of oral health behaviors by a dental hygienist and the subsequent modeling

of the behavior by the caregivers may impact their outcome expectancies of providing oral

health support.

Behavioral capability is defined as someone's actual ability to perform a behavior in real-life

situations. A caregiver must know what oral health support behavior is and have the skills to

perform it. Informal interviews conducted with caregivers (direct care staff) in the group

homes revealed that they received virtual