Running head: FIGHTING ASTHMA USING PRECEDE-PROCEED MODEL 1

Using PRECEDE-PROCEED Model to Control

Asthma Affecting Black and Latino Children

in the Boston Area

Amjad Kamal

MCPHS University
 FIGHTING ASTHMA USING PRECEDE-PROCEED MODEL 2

Overview of Health Issue

The World Health Organization defines asthma as a chronic disease that differs in

severity from one individual to another. The disease consists of frequent attacks resulting in

restricting air flow to the lungs and wheezing (WHO, n.d.). Asthma can be triggered by

environmental factors, such as air pollutants, allergens, dust and other factors that relatively easy

to locate and controlled as explained by the (CDC, 2013). Asthma is disproportionally

distributed among the population, affecting mostly minority groups, and individuals with low

socioeconomic status. Making that a Public Health issue of unequally distributing resources and

burdens between the population which puts the underprivileged individual in a less advantaged

situation providing them with additional challenges and making it harder for their ability to live

normally. Asthma is a disease that is caused by human behavior; therefore, it is the role of the

community as whole to put some effort to control this disease.

Asthma affects children more frequently than adults, as the reported hospitalization of

asthma attaches f children are higher than adults. On the other hand, the mortality rates for adults

are 16 times higher than children as reported by the CDC. The uppermost rate between racial and

ethnic groups belongs to Latinos and black individuals, similarly affecting children more

frequently. Additionally, the rate is increasing rapidly over the years (CDC, 2013). The reason

making asthma a critical problem, and requiring immediate attention and effort to take place to

address this problem, is that asthma is caused by human behavior and misdistribution of

resources resulting in harming individuals, spending too much money in health care costs and

most significantly causing people to lose their lives.

There is a clear difference between Hispanic and black residence in Boston, as they

experience more emergency room visits because of asthma attacks. For a preventable disease,
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that affects people because of environmental disparities and unhealthy living conditions. As

presented in Boston Public Health Commission 2013 report, the dilemma of asthma has a ripple

effect, starting from poverty level and education level, those factors result in poor living

conditions such as expositor to old, dust and proximity to auto repair shops. The existence of

such factors in the environment leads the hospitalization rates to increase compared to other

neighborhoods with more parks and green spaces (Boston Public Health Commission, 2013).

Overview of PRECEDE-PROCEED Model

PRECEDE-PROCEED model aims to evaluate factors that influence an issue, such as

predisposing, reinforcing, enabling factors to shed some light on disparities in the community

and then, it focuses on developing and enforcing a health policy aiming to educate the public and

implement regulations that control the health issue and reduces disparities in the community.

The model also uses different methods of evaluations throughout the implementation of the

model. Areas of evaluation include evaluating the team efficacy, evaluating the immediate

impact and evaluating the outcome. The evaluation process helps to address any areas of

weaknesses and to ensure that the program.

PRECEDE-PROCEED model includes a wide range of applications such as coalition

building, involving the community and providing them with some power to participate in

addressing and fixing the targeted issues to focus on the needs of that community rather than

wasting resources and efforts on other secondary issues that the community does not view as

important. Also, PRECEDE-PROCEED model focuses on planning and building health

education programs which are a key factor to change the community's view of a health problem

and provides them with a solution and ideas to use for the betterment of their lives instead of

waiting for the government to implement changes. The model gives the community the power to
 FIGHTING ASTHMA USING PRECEDE-PROCEED MODEL 4

make their own decisions and provides them with the tools that they need to do so, as for the

latter part of the model, changing or implementing policies comes into effect. The model helps to

get the community of Boston to participate in helping reduce asthma incidence and creating

policies to ensure that the entire Boston community has equal opportunity for health.

The specific population targeted for the application of the model is black and Latino

residents living in the Boston area because they are the most affected population of the disease.

The model focused on educating the affected population about the disease itself, what causes it,

what triggers it, teaching them how to use the inhaled inflammatory medication to decrease

emergency department visits. In addition to teaching them the importance of physical activity

and healthy diet in its role of decreasing the incidence of having an asthma attack. The model

was also applied to eliminate existing barriers in the community such as auto repair shops, bus

stops which are more commonly located in less advantaged communities, and helping to build

more parks and green areas to enhance the quality of the outdoor air.

Application of PRECEDE-PROCEED Model to Target Asthma

Phase 1 – Social Assessment

The first phase measures the community's perception of issues that they face and think

needs to be addressed through coalition building, influencing different members and

organizations in the community to solve the issues thrifting their community (Sharma, 2017).

The community of Boston agrees that asthma is a threatening issue to their community, attesting

to that, Boston Children’s Hospital released several videos showing members of Boston

community sharing their struggle about asthma and how this disease prevents them from living

their normal lives (Boston Children’s Hospital, 2013). In one video, the 13 years old Nathalye
 FIGHTING ASTHMA USING PRECEDE-PROCEED MODEL 5

Terrero, explains that asthma prevents her from playing sports having to take her asthma inhaler

before she starts playing and then having to cut her practice short to take another dose. The ten

years old Jeremiah Lopez, says the same thing, asthma attacks, wheezing and chest pain

influence his performance (Boston Children’s Hospital, 2013). Not different from other cases,

ten years old Thomas Smith expresses his frustration with having to go to the hospital every time

he has an asthma attack, getting a lot of medication and IV’s (Boston Children’s Hospital, 2013).

Social assessment phase of PRECEDE-PROCEED model focuses on involving the community

even before the planning process by interviewing some of the community members and

assessing the issues and their extent as well as the readiness of the community members for the

change (Sharma, 2017).

Phase 2 – Epidemiological Assessment

The epidemiological assessment phase, including descriptive and analytical

epidemiology, focuses on examining secondary analysis of epidemiological data. The phase

encompasses examining some of the existing literature and viewing the perception of community

leaders regarding the issue of asthma affecting Boston (Sharma, 2017).

The descriptive epidemiology, which examines morbidity and the morbidity rates related

to the issue, shows that asthma is one of the most significant chronic illnesses affecting all

individual's despite their age. According to the Centers for Disease Control, asthma affects more

than 235 million people worldwide, 25 million of the cases are in the United States, resulting in

3,447 deaths as of 2007, and the estimated cost for hospital care related to asthma consists of $56

billion annually (CDC, 2013). For black children under the age of 6, in 2012, over 60

emergency department visits per 1,000 residents has been recorded, and 55 visits for Latino

children, compared to 15 visits for white children.

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The analytical epidemiology, which inspects behaviors and environmental aspects related

to the issue, represents that as of 2012, 25.1% of black residents in Boston live under the poverty

level, with the median income of is $37,385. For Latinos, the median income is $27,461 with

34.4% under the poverty level, compared to whites with a median income of $70,644 and 15.2%

living under the poverty level (BPHC, 2013). Per Gern et al. (2009), allergens, dust, low indoor

air quality all trigger asthma and cause wheezing and difficulty breathing.

Phase 3 – Educational and Ecological Assessment

PRECEDE-PROCEED model focuses on involving the community in the entire process

of targeting the health issue; therefore, the model examines motivational factors to get the

community members actively participating in eliminating asthma risk from their community. The

educational and ecological assessment phase also looks at the available resources before

implementing the intervention. The different factors that are assessed during this phase include

predisposing factors, enabling factors, and reinforcing factors (Sharma, 2017). Community

mobilization and community participation both function as predisposing factors. According to

Sharma (2017), community mobilization which is getting Boston community members active

and motivation them to participate in planned activities to improve the status of their

communities' health, and community participation, which is getting the community members to

participate in the planning process to improve the health and eliminate asthma form the

community (Sharma, 2017). Both of those factors work as an incentive to get the community of

Boston active, and it motivates them to participate as they develop the feeling of control over

their health issue, and they can actively see that their opinions and decisions are incorporated in

the intervention.
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Boston Children’s Hospital, Boston Public Health Commission, policy makers, other

grassroots organizations, and stakeholders are enabling factors, as they work together, actively

looking for a solution to the asthma issue affecting disadvantaged neighborhoods in Boston.

Reinforcing factors consist of the resources available in the community of Boston to target

asthma (Sharma, 2017). Some of the resources include Breathe Easy at Home programs which

focuses on providing healthy and clean living spaces for disadvantaged Boston residents aiming

to reduce asthma triggers in the environment (Reid et al., 2014). Also, Boston Pediatric Asthma

Program at Massachusetts General Hospital focuses on diagnosing and managing asthma as well

as providing comprehensive asthma education for patients and their families on ways to control

asthma. They also aim to engage children in activities to control asthma to reduce the need for

medication (Massachusetts General Hospital, 2017).

Phase 4 – Administrative and Policy Assessment, and intervention alignments

The resources for the intervention, limitations, policies are measured during this phase

(Sharma, 2017). One of the applications of PRECEDE-PROCEED model is policy development,

which is developing a policy ensuring the reduction of the health issue affecting the community

of Boston (Sharma, 2017). Some of the policies that play a role in reducing the incidence of

asthma in Boston include adopting regulations that ensure the quality of the indoor environment

and air. Asthma is a chronic respiratory disease triggered by environmental factors such as mold,

dust mites, dander, cockroaches, some chemicals, passive or active smoking, and other factors.

Breathe Easy at Home program aims to reduce the incidence of asthma as well as the

hospitalization rate of asthma attacks by helping families to recognize and treat asthma riggers as

well as it helps them to develop an asthma action plan with a health care provider, and providing

them with instructions on how to use the medication correctly. The program works closely with
 FIGHTING ASTHMA USING PRECEDE-PROCEED MODEL 8

agencies, such as the Boston Housing Authority and Boston Inspectional Services Department,

and it provides home visits to Boston children and adults with asthma to make sure that the

homes of those patients are healthy. In addition to providing the patents with educational tools

about the causes and triggers of asthma, how to use asthma medications, and information about

smoking cessation (Reid et al., 2014)

Some of the limitations of implementing such policy that aims to cover all affecting

neighborhoods in Boston, includes the high cost of implementation and monitoring and time

restrictions, as it can be challenging to arrange home visits to all affected asthma patients and to

spend some time with them to evaluate their health status and knowledge level of asthma. It is

also difficult to revisit those individuals in the future to measure the improvement rate that they

achieved over time.

Phase 5 – Implementation

The implementation phase consists of effecting the policy detailed in the previous phase

after getting the required approvals from legislators and officials in Boston and assessing the

limitations and the attitude of the community members and lawmakers to measure their

willingness to participate in the program (Sharma, 2017). In this phase, it is important to lobby

for the required policy, by trying to influence policymakers to consider implementing the desired

policy and going through all the required steps of that such as developing policy analysis in order

to address the issue of asthma that is affecting the community (Sharma, 2017). After lawmakers

approved the policy, steps can be taken afterward to implement the policy itself and measuring

the progress actively as well as the barriers and limitations that were not accounted for at first.
 FIGHTING ASTHMA USING PRECEDE-PROCEED MODEL 9

Phase 6 – Process Evaluation

The phase of process evaluation examines how the policies were implemented as well as

examining if the policies were implemented as intended looking for any limitations or

discrepancies along the way. This phase also evaluates the team’s adequacy in implementing the

intervention and measures the extent that the team recognizes the berries and limitations of the

program (Sharma, 2017). Evaluating the process is critical, as it allows to evaluate team

members and their efficacy to ensure that the program is implemented as intended and all the

limitations and barriers are effectively addressed.

Performing a 360 Degree Feedback is helpful during at this phase because it does not

only provide each team member with feedback on their performance from their supervisor, but

from their coworkers and from community members as well, which makes it helpful to

understand areas for improvement from every stakeholder's point of view (Toegel & Conger,

2003). The 360 Degree Feedback evaluation behaviors and skills, it aims to assist each team

member to understand their strengths and weaknesses and to understand areas in need of

improvement (Toegel & Conger, 2003). The 360 Degree Feedback can be used to measure the

quality of the work team members are providing and if the community members are satisfied

with the work. It also measures the professionalism of the team and their knowledge of the

intervention and the population they are helping.

Phase 7 – Impact Evaluation

During this phase, the immediate impact of the intervention is measured, as this phase

focuses on examining the impact of the policy in reducing the incidence of asthma in Boston by

looking once again at the predisposing factors, enabling factors and reinforcing factors (Sharma,
 FIGHTING ASTHMA USING PRECEDE-PROCEED MODEL 10

2017). The immediate effect of the intervention can be measured through surveillance,

evaluation, and feedback from the community members. By creating a network of

communication between hospitals, clinics, pharmacies and schools to track and report any

hospitalization case form asthma, the prescription and selling of asthma medications, and

reporting any school or work days or activities missed due to an asthma attack. Measuring the

rates of health care utilization for any asthma-related incidents, and comparing the results with

the data collected before the intervention will help measure the immediate impact of the

intervention and it will help show any improvements or drawbacks in the intervention. Another

area to focus on is measuring the immediate impact of the program on the community members

and their knowledge of asthma triggers and causes after the program is implemented.

Phase 8 – Outcome Evaluation

The final phase of PRECEDE-PROCEED model goes back again to measure the

descriptive epidemiology (Sharma, 2017). Measuring morbidity and mortality rates of asthma in

Boston to measure the outcome of the intervention, then comparing the findings with the

previous data measured on the second phase to help determine the efficacy of the program and

help determine if the intervention is effective or is there any areas for further improvement. This

phase can be conducted with a collaboration with the CDC or with BPHC as it would save

money for the program and ensure the accuracy of the data.

Conclusion and Recommendation

Some of the limitation that is possible to arise during while applying the program

including managing resources efficiently to guarantee the success of the program. The model

requires substantial resources, from financial, to human resources as well as time. For the model
 FIGHTING ASTHMA USING PRECEDE-PROCEED MODEL 11

to function correctly, the team must be highly motivated, and they must have adequate resources

to provide educational material and design educational programs for the community. Also,

funding is required to get the planned policy on the ground regarding promoting and

implementing it. As well as the model is time-consuming, as it starts being empowering the

community, mobilizing them, and implementing the intervention, not mentioning the time it

takes for the policy is in place. The proposal attempts to address many areas, making it difficult

to ensure that the program is fictional and it is harder to predict the outcome of the program. It is

also challenging to have sufficient funding for the program.

The aim of this intervention is not only to reduce the incidence of asthma in

disadvantaged neighborhoods in Boston, but it also intends to develop the social norms of the

community of Boston by creating acceptance for the healthy behaviors that are adopted for

example controlling indoor environmental triggers of asthma such as mold and pet dander also

participating in activities that help reducing asthma attacks without the need to rely on asthma

medications alone (Sharma, 2017). The intervention also aims to create acceptance of the health

policy in which the community members would agree to the home visits and welcome the

educational interventions of the program.

 FIGHTING ASTHMA USING PRECEDE-PROCEED MODEL 12

References

Asthma. (n.d.). Retrieved November 20, 2017, from http://www.who.int/respiratory/asthma/en/

Broadcast Boston Children's. (2013). Retrieved November 27, 2017, from

http://www.childrenshospital.org/broadcast-boston-childrens

CDC's National Asthma Control Program (Rep.). (2013). Retrieved October 13, 2017, from

CDC website: https://www.cdc.gov/asthma/pdfs/investment_americas_health.pdf

Gern, J. E., Visness, C. M., Gergen, P. J., Wood, R. A., Bloomberg, G. R., Oconnor, G. T., . . .

Busse, W. W. (2009). The Urban Environment and Childhood Asthma (URECA) birth

cohort study: design, methods, and study population. BMC Pulmonary Medicine, 9(1), 1-

15. doi:10.1186/1471-2466-9-17

Massachusetts General Hospital. (2017). MGHfC Pediatric Asthma Program. Retrieved

December 2, 2017, from

http://www.massgeneral.org/children/services/treatmentprograms.aspx?id=1582

Place Matters (Rep.). (2013). Retrieved November 18, 2017, from Boston Public Health

Commission website: http://www.bphc.org/whatwedo/health-equity-social-justice/tools-

and-resources/Documents/PlaceMatters-Update-04-13.pdf

Reid, M., Fiffer, M., Gunturi, N., Ali, A., Irish, D., & Sandel, M. (2014). Breathe Easy at Home:

A Web-Based Referral System Linking Clinical Sites with Housing Code Enforcement

for Patients with Asthma. National Environmental Health Association, 76(7), 36-40.

Retrieved December 2, 2017, from

https://www.cityofboston.gov/news/uploads/5823_4_20_33.pdf.
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Sharma, M. (2017). Theoretical foundations of health education and health promotion (3rd

ed). Burlington, MA: Jones & Bartlett Learning. ISBN - 978-1-284-10494-3

Toegel, G., & Conger, J. A. (2003). 360-Degree Assessment: Time for Reinvention. Academy of

Management Learning & Education, 2(3), 297-311. doi:10.5465/amle.2003.10932156