IDD.
Planning, designing, and evaluating interventions to impact public dental health can be a challenging and time-consuming undertaking. The National Institute for Dental and Craniofacial Research (NIDCR) places emphasis on the importance of using intervention planning models such as PRECEDE-PROCEED, the role of health behavior theory in developing interventions, and mediators, moderators, and testing for mechanisms of action. Moreover, the NIDCR strongly encourages investigators “to utilize methods that allow for a test of mechanisms of action. Mechanisms of action are causal explanations for behavior. These are distinguished from correlates, predictors, risk and protective factors, etc., which may be candidate mechanisms, but have not been demonstrated to have a causal link with the outcome(s) of interest” (http://www.nidcr.nih.gov/Research/DER/bssrb.htm) (10).
The PRECEDE-PROCEED model can be used to design and evaluate an oral health promotion effort. The PRECEDE component allows a researcher to work backward from the ultimate goal of the research (distal outcomes) to create a blueprint to instruct the formation of the intervention or strategy (11). The PROCEED component may lay out the evaluation, including pilot study and efficacy study methodologies. The model has been used by Watson and colleagues to design an oral health promotion program in an inner-city Latino community (12); by Cannick and colleagues to guide the training of health professional students (13); and by Sato (9) and Dharamsi (14) to analyze attitudes and prediction factors regarding oral health. Although this planning model has been applied in oral health, there are others such as RE-AIM (15) and the Stage Model of Behavioral Therapy (16) that achieve the same goal of organizing the framework for an oral health promotion program. It is important to remember that planning models are not health behavior theories because they cannot test mechanisms of action or causal relationships (10).
Of particular importance to the PRECEDE-PROCEED planning model is the role of theory in creating a conceptual framework that guides construction of an intervention and its evaluation (11). We believe it is important to develop a planned intervention for oral health that draws from multiple theories. Several behavioral change theories have reportedly been used in designing oral health intervention strategies. One of the most common is Bandura's Social Cognitive Theory (SCT), which posits that the process of human adaptation and change is a dynamic interplay of personal, behavioral, and environmental factors (17). The literature suggests that interventions designed to impact these three factors are more likely to produce desired changes in outcomes (17-19). Personal factors may play a major role in a person's capability to perform behaviors. Environmental factors may hinder a person's ability to adequately perform a behavior and impact their self-efficacy (a personal factor) in performing the behavior of interest. The reciprocal nature of these determinants of human functioning make it possible to design interventions to impact personal, behavioral, or environmental factors. Schwarzer's Health Action Process Approach (HAPA) (20, 21) uses social cognitive constructs, including outcome expectancies and self-efficacy as well as planned actions, in predicting behavior change. This approach provides a framework for prediction of behavior and reflects the assumed causal mechanisms of behavior change (21). HAPA has been used to describe, explain, and predict changes in health behaviors in a variety of settings (21) including oral health (22).