This paper examines the application of the PRECEDE-PROCEED planning model to the development of an oral health intervention for adults with intellectual and developmental disabilities (IDD) living in group home settings. Developed by Larry Green and Marshall Kreuter, the model's eight phases are traced from social and epidemiological assessment through educational, ecological, administrative, and policy assessment, culminating in implementation and outcome evaluation. The paper highlights barriers to oral health care in this population — including Medicaid limitations, caregiver knowledge gaps, and environmental constraints — and outlines enabling and reinforcing factors that can improve oral hygiene outcomes. Statistical approaches including hierarchical linear modeling and multilevel structural equation modeling are also discussed.
The paper exemplifies model application writing: it takes a well-established theoretical framework and works through each component sequentially, linking scholarly citations to each phase. This technique shows evaluators that the writer can operationalize theory rather than merely describe it.
The paper opens with a conceptual overview of the PRECEDE-PROCEED model and its historical origins, then moves phase by phase through the eight-stage planning process. A concise summary table at the end recaps each phase's purpose. The references section cites primary empirical sources alongside the foundational model literature, reflecting graduate-level engagement with the field.
The PRECEDE-PROCEED model, like any other planning model, is used in public health; however, its primary principles connect to broader community issues as well. During the 20th century, as medical advances eliminated most infectious diseases, the leading causes of death and disability shifted to chronic conditions such as stroke, diabetes, cancer, and heart disease. Health maintenance efforts then changed focus from disease treatment to prevention of such conditions (Morgan et al., 2012). More recently, active promotion of healthy attitudes and behaviors — including exercise and stress minimization — has improved both the span and quality of life.
The PRECEDE-PROCEED model is one of the most detailed and widely used frameworks guiding the development of population health interventions. Larry Green and Marshall Kreuter established the framework, which is primarily used within the Western world, where it has been applied to multiple health issues. It is also one of the oldest frameworks for health education and planning initiatives (Binkley & Johnson, 2013). The framework is founded on the critical principle of participation, which stipulates that change is enhanced through the active participation of targeted audiences in identifying their health-related issues and in implementing and developing solutions. Accordingly, applying any particular stage of the model should encompass attempts to gather input from the priority populations that the intervention is designed to help.
One of the unique features of the PRECEDE-PROCEED model is its eight-stage planning process that begins at the end, centralizing on health-associated outcomes of interest. The model then works backward to establish the combination of intervention strategies that can best achieve those objectives. At this stage, population health planners broaden their understanding of the community in which they work by carrying out several data collection activities — including focus group interviews, interviews with key opinion leaders and community members, surveys, and observational data gathering (Binkley & Johnson, 2013). "Community," as used in this context, refers to a group or geographical area with shared values, norms, and characteristics.
Adults with mild to severe intellectual and developmental disabilities (IDD) were historically placed within institutions or group homes equipped with well-staffed dental and medical facilities and workers with advanced training. Efforts to transition individuals to smaller community residences and remove them from institutions have been largely successful. However, even though such initiatives improved their general health, access to dental health care has become limited or unavailable for many, and oral health has been negatively affected.
Medicaid covers most adults with intellectual and developmental disabilities, yet most dentists do not accept Medicaid for treating patients with special needs. As a result, oral health is further compromised by individuals' inability to properly floss their teeth and by the absence of semiannual preventive dental care. Since individuals with IDD may exhibit diverse uncooperative behaviors and some develop physical impairments due to aging, providing oral care becomes particularly challenging (Binkley & Johnson, 2013). Moreover, many individuals neglect the posterior teeth during cleaning and focus only on the anterior teeth, placing the posterior oropharyngeal area at risk for bacterial infection and colonization.
Individuals with IDD are also prone to swallowing disorders, exposing them to greater risk of respiratory and aspiration infections as well as significant mortality and morbidity. As with patients in intensive care units and residents of nursing homes, pathogenic bacteria can colonize the oropharyngeal area of adults with IDD.
Furthermore, while social initiatives are needed to increase the number of dentists treating this population, individuals with IDD must also be supported in maintaining their own oral hygiene (Binkley & Johnson, 2013). Theoretical strategies and interventions that address behavioral capabilities in providing oral health support may reduce disparities and improve the quality of life and health of this population.
Adults with intellectual and developmental disabilities often have cognitive, physical, and behavioral challenges that negatively affect their ability to maintain oral hygiene. Those with mild disabilities who are capable of performing oral hygiene routinely may still fail to prioritize tooth brushing or may be unaware of how to perform such practices optimally. Those with moderate to severe disabilities may be only partially able to carry out oral hygiene tasks and frequently require supervision or assistance from caregivers to properly clean their teeth.
As with caregivers of very young children, caregivers of adults with IDD play a critical role in shaping oral health behavior, particularly for those with a mental age below that of a 5-year-old child (Binkley & Johnson, 2013). Generally, adults with disabilities do not attain good oral health independently. However, according to Shaw and colleagues, when individuals with IDD are encouraged, motivated, and supervised by caregivers, their oral hygiene improves.
The physical environment of group homes is often not conducive to good oral hygiene. Tools typically available for oral hygiene consist of over-the-counter toothbrushes that may be inadequate for addressing residents' specific disabilities. Research findings indicate that there are usually no formal procedures or policies to guide oral hygiene or oral health practices in these settings (Grant et al., 2004). The enactment of oral health policies and procedures by institutions that manage group homes would provide all caregivers with clear expectations and guidelines for their performance.
In addition, most caregivers are responsible for providing meals to residents during the week and all meals over the weekend. Consequently, they have significant influence over what residents drink and eat while in care (Binkley & Johnson, 2013). They also have the responsibility to ensure that an appropriate diet is available to minimize the risk of tooth decay.
Predisposing factors include outcome expectancies, behavioral capabilities, and self-efficacy. Studies have shown that providing caregivers with training on how to deliver oral hygiene care to residents with IDD has a modest but meaningful effect on improving oral health outcomes.
Enabling factors for individuals with intellectual disability disorders that may affect mechanisms for improving oral health include capacity building, environmental adaptation, and planned action. Planned action has been found to influence caregiver behavior and is a critical construct of the Health Action Process Approach. Capacity building refers to the process of strengthening, adapting, maintaining, and acquiring abilities to perform tasks over time (Binkley & Johnson, 2013). Environmental adaptation involves the use of specialized oral hygiene tools — such as modified toothbrush handles for individuals with limited grip or poor coordination, multi-surface brushes, mouth props, flavored toothpaste, dental floss alternatives, and powered toothbrushes — which can enhance caregivers' behavioral capabilities as well as the oral health of individuals with IDD.
Reinforcing desired behavior is an essential construct within cognitive theory, as it promotes the sustaining and repetition of a behavior. Monitoring oral health practices and components-coaching can affect behavioral capabilities, caregiver self-efficacy, environmental influences, and outcome expectancies (Binkley & Johnson, 2013). According to research findings, ongoing coaching of residents and caregivers is vital to the long-term success of oral health strategies (Grant et al., 2004). In addition to coaching, a web-based monitoring system may enhance the capacity to provide consistent, constructive reinforcement to caregivers over time.
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