PHE 425 Module 2 PRECEDE Worksheet Example

Working Backward From a Toothache: PRECEDE-PROCEED for Children's Tooth Decay on the Cumberland Plateau

[Student Name]

Southern New Hampshire University

PHE 425: Programming Planning in Public Health

Module Two Worksheet

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

Working Backward From a Toothache: PRECEDE-PROCEED for Children's Tooth Decay on the Cumberland Plateau

PRECEDE-PROCEED asks planners to begin with the result a community wants and work back to its causes before designing anything (Green & Kreuter, 2005). The first four phases, the PRECEDE half, diagnose the problem; the last four, the PROCEED half, put the program in place and judge it. This worksheet applies each phase to tooth decay among children in a composite county of about 24,000 people on Tennessee's Cumberland Plateau, where six elementary schools serve roughly 2,100 children.

Phase 1: Social Assessment

Two listening sessions with 31 parents and a short survey of teachers asked what bothers families about children's teeth. The answers were consistent. Children miss school or come home early with toothaches, some cannot concentrate in class, and parents described long drives and missed work to reach a dentist. Several parents said a child had been embarrassed to smile. The quality-of-life concern the program will speak to is therefore school attendance and comfort, not teeth as such.

Teachers added a second concern: children with dental pain are sent to the nurse, and the nurse loses time she would spend on chronic conditions such as asthma and diabetes.

Phase 2: Epidemiological Assessment

A screening of 318 third graders found 76 (23.9%) with untreated decay and 92 (28.9%) with a sealant on at least one permanent molar. CDC's analysis of national survey data put sealant prevalence at 38.7% for children from low-income homes, and among those children the ones lacking sealants averaged close to triple the first-molar decay of those who had them (Griffin et al., 2016). The county's sealant rate is therefore about ten points below an already low national figure, and its decay rate is high. Most decay in children of this age begins in the pits and grooves of the molars, the surfaces sealants protect.

Behavioral and Environmental Factors

The behaviors linked to decay include few preventive dental visits, frequent sugary drinks and irregular brushing. The environment matters as much. Only one dentist in the county accepts Medicaid, the nearest pediatric dentist is 45 minutes away, and many rural homes draw from private wells with no added fluoride. Of these, missed preventive care is the most important and the most changeable through a program, because sealants can be brought to the child.

Phase 3: Educational and Ecological Assessment

The model sorts the factors behind behavior into three groups. Table 1 lists what the listening sessions and the school nurse reported.

Table 1. Factors behind missed sealants

Note. Enabling factors appear to matter most.

The consent form stands out. In last year's one-school pilot, only 38% of forms came back signed, so most eligible children were never seen. A program that does not fix the form will not reach the children it was built for.

Phase 4: Administrative and Policy Assessment

The health department employs one public health hygienist and could add a second with grant funds. Portable chairs, lights and curing units would need to be bought or borrowed. The school district allows health services during the school day with signed consent, and principals at four of the six schools have already agreed to host. Gooch et al. (2009) reported that the evidence supports placing sealants on sound and early decayed surfaces after a visual check and providing them even when follow-up cannot be assured, which keeps the program simple enough for a school setting. Billing Medicaid for sealants placed at school would help sustain it.

Setting Priorities

Green and Kreuter (2005) advise rating each factor on two questions: how important is it to the problem, and how changeable is it by a program? Rating the factors in Table 1 this way gives a clear order. Consent form return is both highly important and highly changeable, so it comes first. Access to sealants is highly important and changeable if the program brings them to school. The belief that back teeth matter less is important but slower to change, so it becomes a message folded into the consent materials rather than a campaign of its own. The shortage of Medicaid dentists is important but largely outside the program's reach in the short term; the program can still keep a referral list and send results home so children with decay are directed to care.

Sugary drinks and brushing remain on the list. They matter, but the evidence and the parents' own priorities point first to sealants and the barriers around them, so those behaviors are left for a later phase or a partner program, such as the school nutrition office.

Phase 5: Implementation

The program will visit each school twice a year, sealing first molars in second graders and second molars in sixth graders, and will send consent forms home in several ways, including through the school's text messaging system.

Phases 6 to 8: Process, Impact and Outcome Evaluation

Process evaluation will track consent forms returned and children sealed at each school. Impact evaluation will measure sealant prevalence among third and seventh graders at the next screening. Outcome evaluation will look at untreated decay and parent-reported school absences for dental pain over three years. A Cochrane review found that resin sealants reduce decay on the biting surfaces of permanent molars compared with no sealant (Ahovuo-Saloranta et al., 2017), so the impact measure is a reasonable stand-in for the longer-term outcome.

Reflection

Working backward changed where I expected the program to focus. I began thinking about teaching children to brush. The model pointed to a consent form and a missing dentist. That is the value of doing the phases in order.

I expect the later milestones to keep returning to this table.

References

Ahovuo-Saloranta, A., Forss, H., Walsh, T., Nordblad, A., Mäkelä, M., & Worthington, H. V. (2017). Pit and fissure sealants for preventing dental decay in permanent teeth. Cochrane Database of Systematic Reviews, 2017(7), Article CD001830. https://doi.org/10.1002/14651858.CD001830.pub5

Gooch, B. F., Griffin, S. O., Gray, S. K., Kohn, W. G., Rozier, R. G., Siegal, M., Fontana, M., Brunson, D., Carter, N., Curtis, D. K., Donly, K. J., Haering, H., Hill, L. F., Hinson, H. P., Kumar, J., Lampiris, L., Mallatt, M., Meyer, D. M., Miller, W. R., . . . Zero, D. T. (2009). Preventing dental caries through school-based sealant programs: Updated recommendations and reviews of evidence. Journal of the American Dental Association, 140(11), 1356-1365. https://doi.org/10.14219/jada.archive.2009.0070

Green, L. W., & Kreuter, M. W. (2005). Health program planning: An educational and ecological approach (4th ed.). McGraw-Hill.

Griffin, S. O., Wei, L., Gooch, B. F., Weno, K., & Espinoza, L. (2016). Vital signs: Dental sealant use and untreated tooth decay among U.S. school-aged children. MMWR Morbidity and Mortality Weekly Report, 65(41), 1141-1145. https://doi.org/10.15585/mmwr.mm6541e1