1、格林模式健康评估PRECEDE-PROCEEDPRECEDE-PROCEED模式模式19801980年，以美国年，以美国Lawrence W.GreenLawrence W.Green教授为首提出教授为首提出的，所以又称格林模式。的，所以又称格林模式。PRECEDE-PROCEEDPRECEDE-PROCEED模式不仅仅是行为理论模型，更模式不仅仅是行为理论模型，更为健康促进的规划设计、执行及评价提供一个连为健康促进的规划设计、执行及评价提供一个连续的步骤或阶段。续的步骤或阶段。是当代健康教育领域最有代表性、应用最广泛的是当代健康教育领域最有代表性、应用最广泛的过程模式。过程模式。阶段阶段指在
2、教育指在教育/环境诊断和评价环境诊断和评价中的倾向因素，促成因素及强化因素中的倾向因素，促成因素及强化因素 PROCEED PROCEED 阶段：阶段：(指在执行教育和环境干预指在执行教育和环境干预中运用政策、法规和组织的手段。中运用政策、法规和组织的手段。3行为理论行为理论/需求诊断需求诊断健康干预健康干预4行为理论行为理论PRECEDE-PROCEEDPRECEDE-PROCEED模式模式分析程序上：从结果入手，以分析程序上：从结果入手，以的方法进行分的方法进行分析思考；在设计干预计划前对产生结果的重要影析思考；在设计干预计划前对产生结果的重要影响因素作出诊断。响因素作出诊断。模式结构上：
3、考虑了影响健康的模式结构上：考虑了影响健康的因素，帮助因素，帮助规划制定者把这些因素作为重点规划制定者把这些因素作为重点的目标，同的目标，同时产生特定的规划目标和评价标准。时产生特定的规划目标和评价标准。倾向因素倾向因素强化因素强化因素促成因素促成因素6行为生活行为生活方式方式环境环境倾向因素倾向因素强化因素强化因素促成因素促成因素PRECEDE-PROCEED模式实施过程（简要）Binkley and Knowlton W.The outcome evaluation should be composed of an assessment of oral health strategy di
4、rect effects on outcomes,mediation of outcomes designated as mechanisms of change,and moderation of contextual factors.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 design
5、ed(fidelity),and participant appraisal of intervention quality or usefulness(participant reaction),all of which are discussed in the evaluation literature.倾向因素（前置因素）：是指能促进或阻碍人们行为改变动机的因素在应用格林模式前，对教育对象进行高血压知识达标率、高血压健康教育的支持率、卫生活动参与率和高血压控制稳定率等调查通过随访和调查问卷的方式，及时了解教育对象及其家人的反馈意见和建议，找出存在的问题并对原计划进行调整某社区高血压患者1
6、20人，应用格林模式进行健康教育。根据各教育对象存在的不用银色，着重给予健康指导、制定计划PRECEDE-PROCEED模式可分为两个阶段：研究格林模式在社区高血压患者健康教育中的应用效果PRECEDE-PROCEED模式：是指能促进或阻碍人们：是指能促进或阻碍人们行为改变动机的因素行为改变动机的因素包括知识、态度、信念、价值观等包括知识、态度、信念、价值观等以母乳喂养为例以母乳喂养为例 产妇关于母乳喂养益处的知识 有效喂养的技能 母乳喂养的态度 自我效能：是指促成或阻碍健康行：是指促成或阻碍健康行为动机得以实现的因素为动机得以实现的因素包括实现健康行为所必须的技术、资源、服务、包括实现健康行
7、为所必须的技术、资源、服务、社会力量等（客观条件）社会力量等（客观条件）以母乳喂养为例以母乳喂养为例 围产期护理 产假政策 知识信息获取（社区/媒体/课堂）配方奶粉的宣传：是指目标人群在行为改变后所获得的：是指目标人群在行为改变后所获得的各种各种正向正向或或负向负向反馈，这种反馈可以是来自他人反馈，这种反馈可以是来自他人的、也可以是来自自身的，其作用结果可能使得的、也可以是来自自身的，其作用结果可能使得行为维持、发展或减弱。行为维持、发展或减弱。包括社会支持、同伴赞许、亲属肯定与鼓励、实包括社会支持、同伴赞许、亲属肯定与鼓励、实质性奖励、自己对行为后果的感受质性奖励、自己对行为后果的感受以母乳
8、喂养为例以母乳喂养为例 围产期护理 产假政策 知识信息获取（社区/媒体/课堂）配方奶粉的宣传PRECEDE-PROCEEDPRECEDE-PROCEED模式实施过程（简要）模式实施过程（简要）评估目标人群的生活质量并明确影响其生活质量的健康问题 了解目标社区或对象人群的社会环境 确定目标人群的主要健康问题 区分行为与非行为因素/重要行为与不重要行为/高可变性行为与低可变性行为 确认影响目标行为的倾向因素、促成因素和强化因素 组织评估和资源评估PRECEDE-PROCEEDPRECEDE-PROCEED模式实施过程（简要）模式实施过程（简要）通过健康教育和政策法规制定实施健康促进 影响行为生活方
9、式的因素是否得到改变 行为与生活方式是否发生改变 生活质量是否得到改善（发病率）PRECEDE-PROCEEDPRECEDE-PROCEED模式实施过程（简要）模式实施过程（简要）健康领域使用最为广泛、评估最为全面的模式之一，健康领域使用最为广泛、评估最为全面的模式之一，也是社区健康促进和公共卫生干预的有效模式也是社区健康促进和公共卫生干预的有效模式干预对象包括健康者和疾病患者干预对象包括健康者和疾病患者研究方向包括疾病护理、疾病预防、健康保健和健康研究方向包括疾病护理、疾病预防、健康保健和健康需求评估等需求评估等PRECEDE-PROCEEDPRECEDE-PROCEED模式的应用模式的应用
10、慢病管理慢病管理 高血压 冠心病营养性疾病营养性疾病 缺铁性贫血 碘缺乏性疾病妇幼保健妇幼保健 剖宫产 口腔健康其他其他 职业防护 艾滋病 烟草控制等等PRECEDE-PROCEEDPRECEDE-PROCEED模式的应用模式的应用研究方向研究方向应用实例（一）格林模式在社区格林模式在社区高血压患者健康教育中的应用高血压患者健康教育中的应用纪诚 郑昊 姚桐 姜岩石研究目的和对象研究目的研究目的：研究格林模式在社区高血压患者健康教育中的应用效果研究对象：研究对象：某社区高血压患者120人，应用格林模式进行健康教育。在应用格林模式前，对教育对象进行高血压知识达标率、高血压健康教育的支持率、卫生活动
11、参与率和高血压控制稳定率等调查研究方法具体实施流程图具体实施流程图研究方法1.社会诊断社会诊断通过GQOLI-74生活质量评价表，了解患者的生活、学习、工作、社会环境等基本情况2.流行病学诊断流行病学诊断进行健康调查，了解既往病史、家族病史、教育对象高血压达到几级并了解其身体健康状况3.行为与环境诊断行为与环境诊断吸烟、长期饮酒、睡眠不足、肥胖等研究方法4.教育与组织诊断教育与组织诊断分析引起高血压的行为和生活方式的倾向因素、促成因素和强化因素，更确切地了解促进疾病生成的原因，更有针对性更有效地进行护理干预5.管理与政策诊断管理与政策诊断6.实施教育计划实施教育计划根据各教育对象存在的不用银色
12、，着重给予健康指导、制定计划研究方法7.健康教育过程评价健康教育过程评价通过随访和调查问卷的方式，及时了解教育对象及其家人的反馈意见和建议，找出存在的问题并对原计划进行调整8.健康教育效果评价健康教育效果评价通过随访和调查问卷的方式，对教育对象进行高血压知识达标率、高血压健康教育的支持率、卫生活动参与率、高血压控制稳定率和不良习惯转变率等调查9.健康教育的结果评价健康教育的结果评价教育结束后，对照计划进行随访，了解教育对象的长、短期目标的完成情况，并根据情况随时修改目标，应用CQOLI-74生活质量评价进行评估应用实例（二）Application of the PRECEDE-PROCEED
13、Planning Model in Designing an Oral Health StrategyCatherine J.Binkley and Knowlton W.JohnsonJ Theory Pract Dent Public HealthBackgroundBackgroundAlthough the poor oral health of adults with intellectual and developmental disabilities(IDD)constitutes a significant health disparity in the United Stat
14、es.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.MethodsMethodsThe PRECEDE-PROCEED planning model is being used to
15、 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 PROCEE
16、D component consists of pilot-testing and evaluating the implementation of the strategy,its impact on mediators and outcomes of the population under study.PRECEDE Planning Model PRECEDE Planning Model ComponentComponentPhase 1 Social AssessmentPhase 1 Social AssessmentThe PRECEDE portion of the Mode
17、l 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,Phase 2-Epide
18、miological,Behavioral,and Environmental Assessmentand Environmental AssessmentWe 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 n
19、eeds to change to achieve optimal oral health for these 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
20、an oral health strategy needs to impact(mediating outcomes)in order to achieve the primary outcomes.Phase 3 Educational and Ecological AssessmentPhase 3 Educational and Ecological AssessmentThis phase determined factors that,if modified,would be most likely to result in behavior change and to sustai
21、n this change process.These factors are generally classified as predisposing,enabling,and reinforcing factors“Predisposing factors are antecedents to behavior that provide the rationale or motivation for the behavior and include individuals existing skills and self-efficacy.“Enabling factors are ant
22、ecedents to behavioral or environmental change that allow a motivation or environmental policy to be realized”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 repet
23、ition of the behavior”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 inter
24、personal-level theories,such as social cognitive theory,address reinforcing factors munity-level theories are most appropriate for addressing enabling factors.Phase 4 Intervention Alignment and Phase 4 Intervention Alignment and Administrative and Policy AssessmentAdministrative and Policy Assessmen
25、tPhase 4a-Intervention Alignment(调整)This phase matched appropriate strategies and interventions with the projected changes and outcomes identified in phases 1-3.Using assessment results from phases 1-3,the oral health strategy presented in the results section emerged as our intervention of choice.Ph
26、ase 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.The organizational and environmental systems that could affect the desired out
27、comes(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 t
28、he oral health strategy with those of the organizations providing services to individuals with IDD.PROCEED Planning Model PROCEED Planning Model ComponentComponentPhase 5-Pilot StudyPhase 5-Pilot StudyAlthough we did not recognize the inclusion of a pilot study as essential to the PRECEDE-PROCEED pl
29、anning 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 in progress pilot study in the results section of
30、this article.Phase 6-ImplementationPhase 6-ImplementationThis 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 Phases 7 and 8 Process and Outcome EvaluationEval
31、uation 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 exposu
32、re 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.In addition,we measured adequacy of implementation
33、 by recruiting an expert panel who has published implementation articles to assess the adequacy of our implementation.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.谢谢！
