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

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

Catherine J. Binkley1 and Knowlton W. Johnson2

1 Division of Surgical & Sanatorium Dentistry, College of Louisville, Louisville, KY, USA

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

Abstract

Background—Even supposing the heart-broken oral smartly being of adults with intellectual and developmental

disabilities (IDD) constitutes a distinguished smartly being disparity in the United States, few interventions

so far have produced lasting results. Furthermore, there would possibly be minimal application of planning objects

to insist and blueprint a idea-basically basically based completely technique that has the functionality to be effective and sustainable

in this inhabitants.

Systems—The PRECEDE-PROCEED planning mannequin is being ragged to blueprint and review an

oral smartly being technique for adults with IDD. The PRECEDE component involves assessing social,

epidemiological, behavioral, environmental, tutorial, and ecological factors that suggested the

state of an intervention with underlying social cognitive idea assumptions. The

PROCEED component contains pilot-checking out and evaluating the implementation of the technique,

its impact on mediators and outcomes of the inhabitants below gaze.

Outcomes—A The PRECEDE review and technique blueprint results are presented collectively with a

conceptual framework and oral smartly being technique that are linked to social cognitive idea and Health

Motion Direction of Intention. We now have gotten developed a technique consisting of a planned actions, capability

building, environmental adaptations, and caregiver reinforcement within crew properties. The

technique is designed to lengthen caregiver self-efficacy, expectancies, and behavioral

functionality, and likewise to make environmental influences that can lead to improved self-care

behavior of the grownup with IDD. It’s anticipated that this technique will enhance the oral smartly being and

quality of existence, collectively with respiratory smartly being, of people with IDD. The planned PROCEED

component of the planning mannequin comprises an define of an in-job pilot gaze to refine the

oral smartly being technique, along with a future randomized managed clinical trial to demonstrate its

effectiveness.

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

demonstrates the feasibility of this planning mannequin for constructing and evaluating interventions for

adults all the blueprint by blueprint of the IDD inhabitants.

Keywords

Oral smartly being; Adults with intellectual and developmental disabilities; PRECEDE-PROCEED planning mannequin; Social cognitive idea; Health Motion Direction of Intention; Oral smartly being technique

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

NIH Public Procure entry to Creator Manuscript J Knowing Pract Dent Public Health. Creator manuscript; readily available in PMC 2014 October 16.

Published in final edited blueprint as: J Knowing Pract Dent Public Health. ; 1(3): .

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The heart-broken oral smartly being of adults with intellectual and developmental disabilities (IDD) dwelling

in neighborhood settings constitutes a distinguished smartly being disparity in the United States (1, 2).

Efforts had been made to develop and review varied solutions to reinforce the oral

hygiene and oral smartly being of this weak inhabitants with minimal to moderate success

(3-7). None of these interventions ragged a planning mannequin or idea-basically basically based completely behavior switch

intervention for caregivers of people with IDD. To the handiest of our records there are

simplest a number of reports of how a planning mannequin is ragged in dental public smartly being (8, 9), but these

reports are no longer ragged to develop a idea-basically basically based completely oral smartly being technique or intervention for

contributors with IDD.

Planning, designing, and evaluating interventions to impact public dental smartly being would possibly perchance per chance well furthermore be a

troublesome and time-keen enterprise. The Nationwide Institute for Dental and

Craniofacial Research (NIDCR) areas emphasis on the importance of the employ of intervention

planning objects equivalent to PRECEDE-PROCEED, the role of smartly being behavior idea in

constructing interventions, and mediators, moderators, and checking out for mechanisms of action.

Furthermore, the NIDCR strongly encourages investigators “to use solutions that allow for a

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

These are approved from correlates, predictors, threat and protective factors, etc., which

would possibly perchance per chance well be candidate mechanisms, but have no longer been demonstrated to have a causal link with

the tip end result(s) of ardour” (http://www.nidcr.nih.gov/Research/DER/bssrb.htm) (10).

The PRECEDE-PROCEED mannequin would possibly perchance per chance well furthermore be ragged to blueprint and review an oral smartly being

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

closing aim of the research (distal outcomes) to make a blueprint to reveal the formation

of the intervention or technique (11). The PROCEED component would possibly perchance per chance well lay out the review,

collectively with pilot gaze and efficacy gaze methodologies. The mannequin has been ragged by Watson

and colleagues to blueprint an oral smartly being promotion program in an interior-metropolis Latino

neighborhood (12); by Cannick and colleagues to handbook the educational of smartly being professional

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

regarding oral smartly being. Even supposing this planning mannequin has been utilized in oral smartly being, there

are others equivalent to RE-AIM (15) and the Stage Model of Behavioral Treatment (16) that

develop the identical aim of organizing the framework for an oral smartly being promotion program. It

is distinguished to be conscious that planning objects are no longer smartly being behavior theories because they

can not test mechanisms of action or causal relationships (10).

Of particular importance to the PRECEDE-PROCEED planning mannequin is the role of idea

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

review (11). We think it is most realistic to develop a planned intervention for oral smartly being

that pulls from a pair of theories. Several behavioral switch theories have reportedly been

ragged in designing oral smartly being intervention solutions. Indubitably one of many most customary is Bandura's

Social Cognitive Knowing (SCT), which posits that the job of human adaptation and

switch is a dynamic interplay of private, behavioral, and environmental factors (17). The

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

blueprint desired adjustments in outcomes (17-19). Private factors would possibly perchance per chance well play a distinguished role in a

person's functionality to carry out behaviors. Environmental factors would possibly perchance per chance well hinder a person's

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capability to adequately carry out a behavior and impact their self-efficacy (a non-public ingredient) in

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

functioning blueprint it probably to blueprint interventions to impact deepest, behavioral, or

environmental factors. Schwarzer's Health Motion Direction of Intention (HAPA) (20, 21) makes employ of

social cognitive constructs, collectively with expectancies and self-efficacy in addition to

planned actions, in predicting behavior switch. This model offers a framework for

prediction of behavior and shows the assumed causal mechanisms of behavior switch (21).

HAPA has been ragged to bellow, repeat, and predict adjustments in smartly being behaviors in a

selection of settings (21) collectively with oral smartly being (22).

METHODS

This text affords the applying of the PRECEDE-PROCEED Model (23) as a planning

instrument for oral smartly being. (11) PRECEDE (Predisposing, Reinforcing, and Enabling Constructs in

Tutorial Diagnosis) outlines a diagnostic planning job to support in the enchancment

of targeted and targeted public smartly being packages. PROCEED (Policy, Regulatory, and

Organizational Constructs in Tutorial and Environmental Pattern) highlights the

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

Even supposing an eight-half planning mannequin as presented in the literature is being ragged, now we have

tweaked the PROCEED component (half 5) to incorporate pilot checking out for revising the distinctive

technique sooner than imposing and evaluating the intended processes, impact, and outcomes

of the intervention. Soliciting enter from key informants of the neighborhood actively eager

with the inhabitants of ardour is distinguished in all phases of review. The Institutional

Overview Board of the College of Louisville reviewed the research (11.0338) and accredited

the gaze collectively with all consent forms for the pilot test of the oral smartly being technique.

PRECEDE Planning Model Ingredient

We ragged an intensive literature review and informal discussions with chosen neighborhood

leaders and workers who work with IDD inhabitants in a targeted Midwestern metropolis. These

contributors consisted of 1 vice chairman, one residential director, and three caregivers

working in crew properties of 1 IDD service organization, and two dentists and three dental

hygienists/assistants who work with IDD inhabitants. In entire, interview records had been unruffled

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

discussion that posed questions central to the review of phases 1-4. A insist analysis

of the literature and discussions produced the implications presented later.

Portion 1 – Social Assessment—The PRECEDE half of the Model begins with

diagnostic actions that name enticing outcomes or targets of the intervention or predict,

“What would possibly perchance per chance well furthermore be executed?” These actions sure the distinguished or distal outcomes of the

oral smartly being technique for the actual person with disabilities.

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

searched the literature and asked questions of the chosen neighborhood leaders and healthcare

workers approved above about what considerations or factors impact the oral smartly being-linked quality of existence

for persons with IDD? – OR – What desires to change to develop optimum oral smartly being for these

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contributors? This half sure epidemiological, behavioral, and environmental factors

which will smartly have an impact on the oral smartly being and quality of lifetime of people with IDD.

This half contributed to the identification of the factors that an oral smartly being technique desires to

impact (mediating outcomes) in whisper to develop the distinguished outcomes.

Portion 3 – Tutorial and Ecological Assessment—This half sure factors

that, if modified, would be perchance to end result in behavior switch and to retain this

switch job. These factors are every on occasion labeled 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 consist of contributors’ reward skills

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

that allow a motivation or environmental policy to be realized” (p.415) (24) and must consist of

current skills, services, sources, and packages. Reinforcing factors are these factors following

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

behavior” (p.415) (24) and they consist of social give a possess terminate to, praise, and vicarious reinforcement.

Commerce idea(ies) for designing the intervention after this review comprises particular person,

interpersonal, and neighborhood theories. Particular person-level theories are handiest ragged to contend with

predisposing factors, whereas interpersonal-level theories, equivalent to social cognitive idea,

address reinforcing factors smartly; neighborhood-level theories are most appropriate for

addressing enabling factors. (24).

Portion 4 – Intervention Alignment and Administrative and Policy Assessment

Portion 4a – Intervention Alignment: This half matched appropriate solutions and

interventions with the projected adjustments and outcomes identified in phases 1-3 (23). The usage of

review results from phases 1-3, the oral smartly being technique presented in the implications half

emerged as our intervention of resolution.

Portion 4b – Administrative and Policy Assessment: In this half, sources, organizational

boundaries and facilitators, and insurance policies that had been wanted for the technique or intervention

implementation and sustainability had been identified (24). The organizational and

environmental methods that can impact the desired outcomes (enabling factors) had been taken

into tale. The executive prognosis assessed sources, insurance policies, budgetary desires,

and organizational cases that can hinder or facilitate the enchancment and

implementation of the technique or program (25). The policy prognosis assessed the

compatibility of the oral smartly being technique with these of the organizations offering services to

contributors with IDD.

PROCEED Planning Model Ingredient

Portion 5 – Pilot Explore—Even supposing we did no longer glimpse the inclusion of a pilot gaze as

distinguished to the PRECEDE-PROCEED planning mannequin, we think that it is a truly most distinguished

planning half. These results and lessons realized are most distinguished to revising both the pilot

oral smartly being technique and its review for an efficacy gaze. To this terminate, now we have supplied a

description of our inprogress pilot gaze in the implications half of this article.

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Portion 6 – Implementation—This half affords an define of the implementation of

the oral smartly being technique in an efficacy gaze. Key roles in the implementation half are

highlighted.

Phases 7 and 8 – Direction of and Evaluate—Our planned efficacy gaze is

designed as a cluster randomized adjust trial that contains a job and

review. The gaze of both the implementation job and achievements is

most distinguished. The implementation job review must address the amount of

intervention exposure of the oral smartly being technique (dosage), extent to which an intervention is

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

usefulness (participant response), all of that are discussed in the review literature (26).

Moreover, we measured adequacy of implementation by recruiting an educated panel who has

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

review must be tranquil of an review of oral smartly being technique suppose

results on outcomes, mediation of outcomes designated as mechanisms of switch, and

moderation of contextual factors. Our review plans are highlighted in the implications half

of this article.

RESULTS & DISCUSSION

We repeat the implications of the PRECEDE component of the planning mannequin being

demonstrated. The planned PROCEED component is also described.

PRECEDE Portion 1 – Social Assessment

Our social prognosis started whereas we had been conducting previous research in long-term care

facilities and in neighborhood settings for persons with IDD. Throughout this planning half, we

solicited enter from the neighborhood (suppose care workers, administrators, and dental

mavens who fancy persons with IDD), and they all talked about that heart-broken oral smartly being is one

of the most attention-grabbing unmet smartly being care desires of their inhabitants (28). The neighborhood used to be also

turning into attentive to the affiliation of aspiration of micro organism from the mouth into the lungs

with respiratory infections, and it desired to reinforce oral smartly being and oral smartly being-linked

quality of existence collectively with respiratory smartly being.

PRECEDE Portion 2 – Epidemiological, Behavioral, and Environmental Assessment

A. Epidemiological Assessment—Traditionally, formative years and adults with tranquil to

profound intellectual and developmental disabilities (IDD) both lived at dwelling or had been

positioned in expansive pronounce institutions with completely staffed scientific and dental facilities and stable,

smartly-professional workers. Over the previous several a long time, a distinguished effort to deinstitutionalize these

contributors and put them in smaller neighborhood residences has been a success. Even supposing

total quality of existence would possibly perchance per chance well had been improved for this weak inhabitants, their salvage entry to to

dental care has become miniature or non-existent, and their oral smartly being has suffered (29). A

majority of persons with IDD are insured by Medicaid, and a selection of dentists both attain no longer

accept Medicaid or attain no longer think they are adequately professional to contend with special-desires sufferers.

The oral smartly being of this inhabitants is compromised no longer simplest by the dearth of preventive dental

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

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possess tooth. The oral hygiene supplied or supervised by caregivers is thus excessive to

placing ahead oral smartly being and reducing the need for large restoration or extraction of tooth.

Providing oral fancy contributors with IDD is troublesome, no longer simplest because they would possibly perchance per chance have

bodily impairments but also because they repeat uncooperative behaviors (30). Caregivers

in overall simplest enticing the anterior tooth, ignoring the posterior tooth and causing the posterior

oropharyngeal space to be in anguish for colonization with micro organism and infection (31-33).

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

placing them in anguish for aspiration and respiratory infections, a distinguished cause in the support of morbidity and

mortality in this inhabitants (34, 35). Such as what occurs with elderly persons residing in

nursing properties and sufferers in intensive care objects, (36, 37) presumably pathogenic micro organism

colonize the oropharyngeal space of of us with IDD. (38) Rigorous oral hygiene can decrease

oral colonization with micro organism and yeasts, thus reducing pneumonia in at-threat contributors

(39, 40).

Even supposing social initiatives that be conscious of accelerating the selection of dentists who will contend with

special-desires sufferers are wanted, it remains the purview of the caregiver to supervise and/or

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

caregiver's behavioral functionality in offering oral smartly being give a possess terminate to would possibly perchance per chance well decrease disparities and

shall be crucial for bettering smartly being and quality of existence in this inhabitants.(28, 41)

B. Behavioral Assessment—We sure key behavioral factors of the actual person

with IDD that impact mechanisms impacting their oral smartly being and quality of existence. Other folks

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

capability to carry out their very possess oral hygiene practices at an optimum level (42). Those with tranquil

incapacity, who are in a position to performing their oral hygiene, recurrently attain no longer prioritize

brushing or flossing their tooth on a smartly-liked foundation and in overall attain no longer know easy carry out

these practices optimally. Those with moderate to profound disabilities would possibly perchance per chance well be in a local to

partially carry out their oral hygiene, but they in overall require support and/or supervision

supplied by caregivers to adequately enticing their tooth. Also, as a end result of their emotional and

unpredictable episodes, because the caregivers name them, all IDD persons would possibly perchance per chance well repeat

uncooperative and/or resistant behaviors on event that cease them from participating

in oral hygiene practices usually.

Love the folk of very young formative years, caregivers also play a key role in shaping the

behavior of adults with IDD, who recurrently have a psychological age decrease than that of a 5-300 and sixty five days-

ragged child without incapacity. Adults with disabilities every on occasion attain no longer develop an acceptable

no longer unusual of oral smartly being on their very possess. On the different hand, Shaw and colleagues demonstrated that if

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

hygiene would possibly perchance per chance well furthermore be improved (43). Caregiver behavior in the blueprint of give a possess terminate to of the grownup with

IDD oral smartly being, coupled with the caregiver's self-efficacy in promoting the grownup's self-care

behavior, must reinforce the residents’ oral hygiene practices.

C. Environmental Assessment—We identified environmental boundaries or influences

that are key factors in social cognitive idea. First, the bodily atmosphere in crew

properties is always no longer conducive to optimum oral hygiene practices. Supplies readily available for

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oral hygiene in overall consist of simplest over-the-counter toothbrushes, which is perchance no longer sufficient

to contend with the residents’ disabilities.

2nd, our review of the social atmosphere in the crew properties sure that there

had been no insurance policies or procedures in put relating to oral smartly being or oral hygiene practices.

Implementation of insurance policies and procedures linked to oral smartly being by the organizations that

prepare the crew properties would provide all caregivers with guidelines for and expectations

of their performance. We chanced on that every person caregivers are accountable for making ready both

breakfast or dinner all the blueprint by blueprint of the week, and on weekends they must prepare all meals and/or

possess terminate the residents out to lunch. As such, they are the distinguished persons accountable for

determining what the residents explain and drink whereas of their care and they delight in the

responsibility of ensuring the provision of an acceptable weight loss program in the crew dwelling setting to

decrease the threat of tooth decay.

PRECEDE Portion 3 – Tutorial and Ecological Assessment

A. Predisposing Components—We identified skill factors which must be modified

to develop adjustments in caregiver behavior. We identified these factors per discussions

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

self-efficacy, expectancies, and behavioral functionality-would possibly perchance per chance well be most distinguished because

merely offering training to caregivers in oral hygiene provision for dependent persons

has been proven to be minimally effective in bettering oral smartly being (5, 44).

Self-efficacy is outlined as “of us's judgments of the capabilities to rearrange and develop

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

efficacy in oral hygiene, or the perceived capability or self belief of a person to carry out

good-looking tooth brushing and flossing, has been proven to be most distinguished in previous oral smartly being

research (Forty five-forty eight). Caregivers reported to us that they had records of the importance of oral

smartly being but talked about that they had been no longer snug supervising or helping the residents in oral

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

or supervising young formative years's oral hygiene would possibly perchance per chance well furthermore be a stable predictor of parental/caregiver

oral hygiene give a possess terminate to (49, 50).

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

sure outcomes” (p.193) (51) or beliefs in regards to the prospect and payment of behavioral

choices. Caregiver psychosocial factors, equivalent to expectations of heart-broken oral smartly being of their

residents/shoppers, would possibly perchance per chance well serve as a barrier to optimum oral hygiene behavior (52-54).

expectancies would possibly perchance per chance well be impacted by contributors seeing love contributors carry out the behavior

and/or encouragement to them that they are in a position to performing the behavior (55, 56).

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

of the behavior by the caregivers would possibly perchance per chance well impact their expectancies of offering oral

smartly being give a possess terminate to.

Behavioral functionality is outlined as someone's exact capability to carry out a behavior in exact-existence

cases. A caregiver must know what oral smartly being give a possess terminate to behavior is and have the talents to

carry out it. Casual interviews conducted with caregivers (suppose care workers) in the crew

properties printed that they received virtual