The next example of PRECEDE looks at the issue of Sudden Infant Death Syndrome. This was taken from information available recently in MMWR and reports on a basically health education program to try to intervene to reduce rates of Sudden Infant Death in the country. This from the epidemiological diagnosis was found to be most common between 1 and 12 months of age. Again, as we said PRECEDE has an evaluation component, and after the program, it was found that there was a 38% reduction in SIDS death after the intervention, after the program. The primary behavior that was the focus of the program, and it was found to be associated epidemiologically with the condition, was the sleeping position. Prior to intervention, parents placed their children on their stomach to sleep. After intervention, they placed the child on the back. The educational campaign used the phrase back to sleep. And so there was an improvement in the behavior, and this improvement in behavior was linked with the improvement in the incidents of the problem. They also found that there was some decay, reduction in the behavior after some time. This is quite common, if educational interventions are not continually reinforced until people can maintain the new behavior. In looking at the evaluation results, the educational diagnosis reveal that there were two main set of factors that were involved, putting the child to sleep on the back really did not involve particular skills or enabling factors. And this, again, is important to remember when you do your educational diagnosis, not every single factor is going to apply to every single behavior within every group. This is the whole process of diagnosis, to identify the specific factors that are relevant to specific behavior in specific populations. In terms of predisposing factors, they found that there were existing norms in the communities to let children sleep on their stomach. There were attitudes that this was the best. And so, part of their educational strategies in the administrative diagnosis were media or information campaigns to provide people with the information that they needed to let them know the value of the child sleeping on its back. They also found that reinforcing factors were quite important. People did seek advice from family, friends, hospital personnel on childcare, generally, and sleeping in particular. And during the program, of course, the emphasis on getting more advice from these people was there. A particular reinforcing factor was whether there was a grandmother in the home or nearby that people would seek advice from. Also, as a reinforcer, mothers observed how hospital personnel placed babies to sleep. Finally, another reinforcer was the response of the infant itself to the different sleeping positions. Okay, so the social support strategies included using physicians as authority figures in the media campaign, in other words, as significant or important others, opinion leaders. And again training of staff to model the ideal behavior and discuss with mothers what to do. It was important in this particular study to find that there were different ethnic differences in the response to this behavior, and different ethnic differences also in the reinforcing factors. In particular, it was discovered that African Americans had much more family involvement and family support, family as a reinforcing factor involved in childcare. And so, efforts to convince grandmothers and other family members became an especially important strategy with that group. Again, these are the Important issues to consider, that there are differences in different populations about the factors that are considered important. We have a slide that shows the application of the PRECEDE model to oral rehydration. And in this particular case, looking at health worker behavior. As we'll see later in our module on organizational or institutional level, that it's the behavior of health workers that often influence how the organization functions and delivers its services. And then consequently how consumers or community members at the intra-personal level perceive of that service and use it. Okay, we can see in the PRECEDE model that at the epidemiological level the health worker is working toward the same goal of preventing childhood diarrhea. When the child recovers from diarrhea, there's no dehydration, no death. When the diarrhea is prolonged, we do have dehydration, the child can die. Now from the behavioral point of view, the health worker could actually use oral rehydration, salts in the clinic, the health worker could teach the mother to make salt-sugar solution. Or the health worker could prescribe anti-diarrheal drugs, such as kaolin, could prescribe antibiotics. That may have no effect, of course, if much of the diarrhea's of a viral nature. So the question is, what influences the health workers behavior to either promote ORT or to prescribe drugs that would not be effective. Under the predisposing factors we have the health workers' knowledge about diarrhea. Some of them have been to in service training and know about these new ideas. Some haven't been to anything since they finished nursing or medical school many years before that. They have their beliefs about the efficacy of drugs, whether the best drug is a combination thing that includes anti-microbials and anti-diarrheal drugs all at once, or whether they actually believe that ORT is efficacious. Okay, so all of these issues, their knowledge, beliefs about drugs versus their knowledge and beliefs about oral rehydration are predisposing factors. Reinforcing factors can come from several levels. They may see that their colleagues are prescribing drugs. They may have pressure from representatives from the drug companies. They may even have pressures from community members who are demanding drugs. Or they may hear mother's complaints, say, if I use this salt sugar solution, the sugar will cause my child to have dysentery or another problem. So they may be under pressure from other people to prescribe as opposed to promote ORT. Clearly the enabling factors have to do with the time to teach the mothers, the availability of oral rehydration salts int he clinic. Whether there is a place available in the clinic where the materials can be setup to demonstrate making salt-sugar solution. Or alternatively, whether stocks of these other drugs are available and people want to sell and prescribe them. Next we have to consider what would be the strategies, the educational strategies, to address these factors. Straightforward in-service training program with demonstrations, as well as with support from the scientific literature may help convince health workers to try ORT. These communication strategies would address their predisposing factors. In terms of social support, the importance of the change agents within the health profession. Is it possible for the Pediatrics Association, for example, or the Nursing Association to endorse ORT? On the other hand, would community education of the patients, would the patients change their demands for drugs and put different pressure or less pressure on the health worker for drugs. And then in terms of developmental strategies, setting up special ORT corners and teaching the health workers the skills to make ORT and explain and demonstrate and educate the mothers. So here we have an example of applying this PRECEDE and also our understanding of health behavior to health workers themselves. Another example of PRECEDE, where we're trying to identify the factors relating to breast self-examination. Studies have been done that show that, for example, under predisposing factors high levels of self-confidence or self-efficacy encourage the behavior. Awareness that mammography is a backup, so that if you do find a lump you have somewhere to go, so that knowledge and knowledge of other risk factors such a parity. These are predisposing factors that encourage women. Now again, if we know this information, we can use this in our communication strategies to help women become more aware of the benefits and the risks of reducing potential of breast self-examination. And we can also engage in training programs to help women practice, improve their self-efficacy, self-confidence in performing the new behavior. Other examples of the predisposing factors that research has shown associated with practicing breast self-examination is a desire or willingness or an intention to seek reconstructive surgery should they find that they have cancer. So in other words, taking a positive future outlook on this. And another personal characteristic that predisposes is a higher level of education. As we can see, tying this back with our stages of change, or our adoption-diffusion model, that maybe people who are likely to start up breast self-examination, be innovators, would be highly educated. Other factors to consider that influence positively a woman's desire, willingness to practice breast self-examination, would be the enabling factors. Possessing the actual skill to perform it, knowing exactly the steps to do, where and when, in the shower, what times a month that's appropriate, so having those specific skills are important. Not just the confidence to perform it, but actually being able to perform it correctly. And then having our reinforcing factors, messages from clinician, influence of skills teachers, maybe other issues too of the attitudes and opinions of their close friends and relatives. These again can be transformed into strategies. When we know reinforcing factors, when messages from clinicians have a positive effect, then how can we get them to communicate better with women in the community. Again, if we know that having the skills enhances the likelihood of actually performing it, having adequate time to do it would enhance that, what can we do? How can we help women budget their time to be able to carry this out? How can we arrange training sessions that people will learn the new skills and then ultimately from the practice develop the self-confidence? So PRECEDE most importantly takes our theoretical models and gives us ideas from the variables that come from those models on which strategies would be most appropriate for health education. The next slide looks at how one can integrate PRECEDE as a planning model with stages of change as a process model. With the goal to help us identify factors, or do an educational diagnosis for each stage, and then plan educational programs accordingly to help people move from one stage to the other. Looking at the example of diarrheal diseases, we can find that in the pre-contemplative stage, diarrhea may have started, but the parent has not yet recognized that it's a serious problem. They may believe that diarrhea is common in children, especially in children of the age where they're teething and not respond to that as a serious problem, not contemplate that the child may be at risk. The educational diagnosis that would occur at this stage would be to focus on predisposing factors, such as the knowledge of diarrhea diseases, recognition of the dangers and symptoms. In particularly found in many of our communities that there is no knowledge or understanding of the concept of dehydration. There is no local word for dehydration in many of the local languages. When you use the word the child has dried up, which is a literal translation that some of the health staff use that is interpreted as meaning the child is malnourished. And while diarrhea and malnutrition are related, this is clearly not the concept of dehydration, of loss of fluids. So this is an important finding in terms of the educational diagnosis, that people do not think diarrhea is serious and they don't see the connection. In particular we found that there is even a local disease entity that refers to something fontanelle. And this is believed to be caused if the mother eats plantain during pregnancy and treatment, indigenous treatment, may include in some West African countries turning the child upside down, rubbing certain herbs on the child's head. So this symptom of dehydration is seen as a completely different disease. So this is part of the educational diagnosis at the pre-contemplative stage, showing why people would not necessarily contemplate or consider childhood diarrhea to be serious and need response. Later, if the diarrhea persists or if information is provided and the parent sees that diarrhea may require some response, they may contemplate and consider options to help the child and seek advice. Educational diagnosis in this sense would involve looking at the predisposing factors again, such as knowledge of treatment options, what is available? Many times people look for anti-diarrheals, whether kaolin in the clinic or sometimes chalk or cassava flour or other things like that to stop the diarrhea as an indigenous treatment method. People may or may not be aware of oral rehydration. And as we saw in our explanatory models early in this module, people may ply oral rehydration selectively depending on their perception of the type of diarrheal disease the child has. So again, our educational diagnosis points to the need to communicate with mothers about the different types of treatments and the pros and cons of those. Also at this stage, the role of reinforcers needs to be considered. What are the social norms for treatment? What are the potential support that mothers and other caregivers may receive? People giving advice in the home, existing norms for appropriate treatment for children with diarrhea. In the next stage of change, we have planning and action. And assuming that the previous educational interventions at the contemplation phase have helped the caregiver understand the value of oral rehydration therapy, the caregiver then would begin to assemble the ingredients. Ensure that the child has plenty of other fluids and foods to begin the process of oral rehydration therapy. The educational diagnosis at this stage might consider enabling factors, such as the skills of making homemade salt-sugar solution, the measuring skills, and the availability of different kinds of fluids and foods in the home. And particularly for salt-sugar solution, we found that the availability of sugar in a home is an issue to consider and whether it's available at a nearby kiosk or shop. At this stage also our educational diagnosis would take into account reinforcing factors, who is in the house, who would approve or not. The grandmothers say don't give the child sugar in the fluid, because it will cause another disease, etc. So these factors need to be addressed in terms of health education to ensure that the mother will go ahead and actually use ORT, mix the salt-sugar solution and administer it to the child. And do this during the course of the diarrheal episode. And at the maintenance stage, which comes next, be willing to continue to provide this then every time the child has diarrhea. The educational diagnosis connected with the maintenance stage is particularly focused on reinforcing factors, family support for continuing this, the response of the child to treatment, does the child recover? Sometimes the child remains healthy, but the diarrhea does not actually stop right away. And local expectations of what diarrhea medicines are supposed to do, may be in conflict with oral rehydration. So these are important factors to consider in terms of designing educational interventions to maintain the behavior of oral rehydration throughout the diarrhea episode and in subsequent episodes. The programming implications for looking at a combination of stages of change together with the analysis and planning of PRECEDE, puts our diagnostic abilities to test. Can we identify the different stages? Do we accept that there are multiple antecedent factors, different factors at different stages? Are we aware of different segments of the population, such as in the SIDS example. There may be different social reinforcement in different ethnic groups. And of course, the important thing is that people are at different stages and levels of change. And can we design our programs to meet the needs of people at different stages? And this leads us to the importance of having multi-strategy approaches.
