In 1991, PROCEED (Policy, Regulatory, and Organizational Constructs in Educational and Environmental Development) was added to the framework to recognize the importance of environmental factors as determinants of health and health behaviors.
As appreciation of the impact of “lifestyle” (that is, patterns of health-related behaviors) on health grew (McGinnis and Foege, 1993; Mokdad and others, 2004), so did recognition that these behaviors, such as smoking and drinking, are influenced by powerful forces outside the individual, such as industry, media, politics, and social inequalities. Thus, more ecological approaches to health promotion were needed to understand and address these larger contextual determinants of health and health behavior (McLeroy, Bibeau, Steckler, and Glanz, 1988; Institute of Medicine, 2001).