0:32
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.
2:52
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.
4:00
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.
5:42
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.
7:41
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.
11:00
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.
11:39
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.
16:54
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.
17:48
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.
18:28
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?