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Population Health for Nurses

18.1 Theories and Models to Guide Program Planning

Population Health for Nurses18.1 Theories and Models to Guide Program Planning

Learning Outcomes

By the end of this section, you should be able to:

  • 18.1.1 Apply theoretical framework(s)/models to plan health promotion, disease prevention interventions, and illness management.
  • 18.1.2 Combine knowledge of health determinants with data to plan health promotion and disease prevention interventions for communities and populations.
  • 18.1.3 Assess learning needs across the continuum of care for self-care for health promotion, illness prevention, and illness management.
  • 18.1.4 Examine different approaches to health promotion and disease prevention.

A program is an organized public health action or set of related activities undertaken to achieve an intended outcome (Centers for Disease Control and Prevention [CDC], 2023). The intended outcome meets the assessed needs of individuals, families, groups, populations, or communities to promote health and health equity, prevent illness, reduce health disparities, empower communities, and/or promote social justice. Program planning involves selecting and implementing activities to achieve desired health outcomes. It serves as a blueprint for coordinating resources to implement planned activities.

Program development follows an assessment of community health needs, identification of priority health problems, and diagnosis of specific community health problems. Community health programs should align with the health problems defined in the assessment phase, meet the community’s perceived needs, target the at-risk aggregate identified during the analysis and diagnosis phases, and reduce characteristics of the community that contribute to risk factors listed within the community nursing diagnosis. Assessment, Analysis, and Diagnosis provides a guide to assessment, analysis, and diagnosis of population health programs.

Theoretical Frameworks and Models Used in Program Planning

In collaboration with the program planning team (those individuals and community partners who will provide resources, will implement or evaluate program activities, and will be impacted by the program), the nurse selects a theoretical framework or model to guide program planning. Theoretical frameworks and models provide a systematic method to develop, implement, and evaluate programs for health promotion, disease prevention, and illness management. CHA models, frameworks, and tools discussed in Assessment, Analysis, and Diagnosis include steps for planning programs. These models include comprehensive assessment guidance but do not include specific details to guide program planning. The Healthy Places by Design’s community action model, PRECEDE-PROCEED model, PATCH model, and intervention mapping, described next, provide detailed guidance for program planning. A logic model is a tool used to visually represent a program.

Healthy Places by Design’s Community Action Model

The Healthy Places by Design Community Action Model describes six essential practices for sustained change within communities and outlines an intentional Partner, Prepare, and Progress, or “3P,” Action Cycle. The program planning team considers community context and the six essential practices during all stages of the community action model to enhance the sustainability of actions that promote community health. These include the following:

  • Health equity focus
  • Facilitative leadership
  • Culture of learning
  • Strategic communication
  • Sustainable thinking
  • Community engagement

The 3P Action Cycle includes Partner, Prepare, and Progress stages. Figure 18.2 describes tasks at each stage of the 3P Action Cycle and incorporates the six essential practices.

The components of the 3P action cycle are illustrated in three circles that are connected by double-ended arrows to create a larger circle, showing how each affects and is affected by the others. The components are: Partner, Prepare, and Progress. Partner includes engaging the community and strengthening multidisciplinary coalitions. Prepare includes assess, reassess, and evaluate; prioritize and plan; build capacity; and leverage resources. Progress includes identifying in implementing practical strategies.
Figure 18.2 As part of the Healthy Places by Design’s Community Action Model, the program planning team progresses through the 3P (Partner, Prepare, and Progress) Action Cycle to develop and implement community health programs. (See Healthy Places by Design, 2016; attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Theory in Action

Using the Community Action Model to Improve Infrastructure and Promote Physical Activity

The Tulane University Prevention Research Center established the KidsWalk Coalition to improve walking and bicycling infrastructure. The community program was developed, implemented, and evaluated using the community action model. The team used the 3Ps (Partner, Prepare, Progress) throughout the program.

Read the case study Communities in Action: New Orleans, LA, and then respond to the following questions.

  1. How did the KidsWalk Coalition engage the community and strengthen multidisciplinary coalitions?
  2. What policy and infrastructure progress did the KidsWalk Coalition make?


The Green and Kreuter PRECEDE-PROCEED model considers social determinants of health and the community environment when planning programs for health promotion (Porter, 2016). PRECEDE stands for Predisposing, Reinforcing, Enabling Constructs in Educational/Environmental Diagnoses, and Evaluation. The four PRECEDE phases are discussed further in Assessment, Analysis, and Diagnosis. PROCEED stands for Policy, Regulatory, and Organizational Constructs in Educational and Environmental Development. PROCEED follows the community assessment and identification of health issues, utilizing that information to guide program planning, implementation, and evaluation, and includes the following four phases:

  1. Implementation: Design and implement the intervention.
  2. Process evaluation: Evaluate the implementation procedure. Is what was planned actually being done?
  3. Impact evaluation: Evaluate whether the intervention has the desired impact on the target population.
  4. Outcome evaluation: Evaluate whether the intervention has produced the desired impact on the problem identified in the PRECEDE phases.

The PROCEED model directs the user to choose an additional tool, such as the PATCH model, when designing interventions. The program team should select evidence-based interventions most likely to achieve program outcomes (Porter, 2016). Implementation and Evaluation Considerations further describes process, impact, and outcome evaluation.

Planned Approach to Community Health Model

The Planned Approach to Community Health (PATCH) model builds on the PRECEDE model to provide a practical approach to community program planning (U.S. Department of Health and Human Services [HHS], 2001). PATCH includes a detailed guide and worksheets to use at each phase; these resources are especially helpful for communities that have little experience with assessment and program planning. PATCH describes five critical elements of community health promotion programming:

  • Participation of community members
  • Use of data to guide program development
  • Development of a comprehensive health promotion strategy
  • Evaluation to provide timely feedback and for program improvement
  • Increase in community capacity for health promotion (HHS, 2001)

Capacity can be increased through relationships within the community, state health departments, universities, and other regional and national levels of organizations that can provide data, resources, and consultation. Capacity refers to the resources and relationships required to implement the program (Public Health Accreditation Board [PHAB], 2022). This chapter describes methods to develop these relationships.

PATCH can be used to plan, conduct, and evaluate health promotion and disease prevention programs and includes the following five phases:

  1. Mobilizing the community
  2. Collecting and organizing data
  3. Choosing health priorities
  4. Developing a comprehensive intervention plan
  5. Evaluating PATCH

The first three phases relate to the CHA and community health improvement plan (CHIP) processes described in Assessment, Analysis, and Diagnosis. The last two phases include development, implementation, and evaluation of community intervention for health promotion. When developing a comprehensive intervention plan, the team considers contributing factors and community-based programs currently being used elsewhere. This includes surveying other agencies and organizations and searching the literature and internet resources regarding current programs related to the identified community problem. PATCH recommends working with systems, such as schools, work sites, and hospitals, starting simple and combining educational, policy, and environmental strategies to enhance the program and make an impact in several ways.

Intervention Mapping

The Intervention Mapping (IM) framework provides a systematic approach to plan community health interventions. The initial steps of IM are based on the PRECEDE model (Fernandez et al., 2019). Table 18.1 describes the six steps of IM and provides examples of tasks that Jamie, the nurse described in the chapter introduction, completed at each step with the program planning team in developing the Kenton Hardin County Family Bike Program (KHCFBP). Logic models, discussed in the next section, are typically used in IM.

IM Step Tasks to Complete Example of Tasks Completed by the KHCFPB Program Planning Team
Step 1: Logic Model of the Problem
  • Establish a team consisting of the target population, individuals and groups impacted by the program outcome, and the planning and implementation team.
  • Conduct a CHA.
  • Perform analysis of health, quality of life, behaviors, and environmental conditions that influence health problems.
  • Create a logic model illustrating the problem.
  • Determine program goals. Goals are discussed in detail in Section 18.3.
  • Reviewed CHA, which showed that 70% of county adults were overweight or obese as defined by BMI, only 29% of adults met national physical activity recommendations, 15% of county youth were obese, and only 29% of youth met national physical activity recommendations.
  • The established team included staff from the county health department (director of nursing [DON], fiscal officer), a nurse educator, a YMCA staff member, the county WIC director, and two local bike experts. The team also collaborated with an established county transportation committee that had been looking to add bike paths in the community.
  • Determined program goal—to increase physical activity of program participants through biking and to increase bike safety.
Step 2: Logic Model of Change
  • Identify determinants of the identified health problem by searching the literature, choosing theories, and conducting research, if needed.
  • Select determinants to target during the program.
  • Determine expected outcomes and objectives.
  • Create a logic model of change.
Step 3: Program Design
  • Choose theory and evidence-based change methods.
  • Select or design program delivery methods.
  • Investigated several physical activity programs targeting youth and adults. Finding no biking program targeting youth and adults, the team designed the program based on five evidence-based programs.
  • Created logic model of the program.
Step 4: Program Production
  • Draft messages, materials, and protocols.
  • Pretest, refine, and produce materials.
  • Created participant workbooks and facilitator guides with input from the nurse educator, DON, bike experts, and WIC director.
  • Added the county health department public relations staff to create advertisements.
  • Met with the team to review and refine the plan for implementation.
Step 5: Program Implementation Plan
  • Identify persons who are responsible for the delivery of the program.
  • State outcomes and performance objectives.
  • Implement the program.
  • Identified responsible persons. Bike experts delivered curriculum; volunteers assisted with biking skills and maintenance; DON and nurse educator managed logistics (surveys, forms, snacks, and equipment/time management).
  • Recruited volunteers from a local university to assist with program delivery.
  • Program was implemented.
Step 6: Evaluation Plan
  • Develop evaluation indicators, measures, and questions.
  • Complete evaluation.
  • Used the CDC Framework for Program Evaluation in Public Health.
  • Created evaluations with input from the nurse educator, DON, bike experts, and WIC director.
  • Evaluated participant biking knowledge, helmet use, and amount of time riding prior to, immediately following, and 6 months after the program.
  • Conducted both process and outcome evaluations.
Table 18.1 IM Steps and Associated Tasks

Logic Models

Logic models are tools to visually present the relationships among resources that are used to implement a program, the activities planned, and the program’s intended results (W. K. Kellogg Foundation, 2004). The logic model describes the sequence of events to connect the program’s need with the desired results and shows how human and financial resources contribute to the program. The Logic Model Development Guide provides a step-by-step method to create logic models. Common components of logic models include:

  • Resources: human, financial, organizational, and community needed to operate the program
  • Activities: processes, tools, events, technology, and actions for implementation
  • Outputs: direct products of program activities, such as the number of participants
  • Outcomes: specific changes in participant behavior, knowledge, or skill, usually designated by short-term and long-term
  • Impact: fundamental change as a result of the program, usually within 7 to 10 years

Figure 18.3 provides an example of a logic model developed by Jamie, the community health nurse described in the chapter introduction, and the program development team to visually represent the Kenton Hardin County Family Bike Program.

An example of a logic model provides details regarding the situation to be addressed, and bulleted lists for each of the 5 steps within the model. The 5 steps in order are resources and inputs, activities, outputs, outcomes, and impact.
Figure 18.3 The community health nurse may assist in development of a logic model as a part of program planning. (source: reproduced with permission from Jamie Hunsicker, DNP, RN)

Use Health Determinants and Data to Plan Programs

Community assessment and health determinant data are the basis of effective programs. The first step of program planning, regardless of the framework or model selected, is to review community assessment data related to the identified problem that the program is targeting. This provides a rationale for implementing the program and establishes baseline data for measuring the health problem and evaluating the program.

The nurse also gathers data on determinants of health that contribute to the specific health problem. Determinants of health are combined factors that affect the health of individuals and communities, including individual characteristics and environmental conditions where people are born, live, learn, work, play, worship, and age (CDC, 2019; HHS, n.d.). As discussed throughout this text, those environmental conditions are called social determinants of health (SDOH). Individual determinants include age, sex, genetics, and behaviors, such as physical activity, nutrition, and substance use. SDOH include economic stability, education access and quality, health care access and quality, neighborhood and built environment, and social and community context (HHS, n.d.). Access to safe housing and transportation, employment opportunities, food security, income and socioeconomic status, level of education, air and water quality, and health literacy are all examples of SDOH. See Social Determinants Affecting Health Outcomes for more information.

Theory in Action

Addressing the Social Determinants of Health

This animation describes the influence that SDOH have on health.

Watch the video, and then respond to the following questions.

  1. How do social determinants of health impact health outcomes?
  2. What are some community interventions the nurse could implement that would influence each determinant of health described in the video?

The nurse should incorporate health determinants into program planning for several reasons. First, SDOH account for 50 to 80 percent of health outcomes (Whitman et al., 2022; Zhang & Fornili, 2023). Health outcomes are strongly predicted by social and economic factors, followed by health behaviors, clinical care, and the physical environment (Hood et al., 2016). Poor social and economic conditions influence access to health care and an individual’s ability to make healthy choices. For example, healthy food may be unaffordable or unavailable within the community. Additionally, individuals living in impoverished neighborhoods are more likely to experience an unsafe environment, low educational attainment, discrimination, and racism, all of which are associated with chronic stress. The constant release of stress hormones damages body systems and increases the risk of health problems. Second, federal health care programs and organizations have made addressing the SDOH a priority (De Lew & Sommers, 2022). The U.S. Department of Health and Human Services strategy to address the SDOH aims to improve

  • data by increasing the collection of SDOH data and increasing data sharing among systems;
  • connections between the health care systems, social services, and communities; and
  • collaborations and partnerships among government organizations that impact health.

Finally, the nurse and program planning team direct program interventions toward reducing risk of disease. Because SDOH play a significant role in the development of disease, interventions should be directed at those SDOH impacting the community (Figure 18.4). Targeting several aspects of determinants of health enhances the likelihood that the program will achieve goals to reduce risk factors, promote health, and prevent illness.

In the KHCFBP example, the public health nurse, Jamie, and the bike program planning team identified determinants of physical activity via biking. Individual determinants of bike riding included motivation and confidence, knowledge of bike safety, and experience with biking and biking skill. Social determinants of bike riding included the ability to purchase bike equipment, the safety of sidewalks and streets, and social support (Hunsicker, 2020). In this instance, program planners decided to target all determinants except sidewalk and street infrastructure because the likelihood of influencing infrastructure changes was low during this program.

The determinants of physical activity and active living are shown in a circle, with each determinant shown as a ring in the circle. Starting from the inside, the first ring is individual determinants, which includes age, skills, motivations, beliefs, and gender. The next ring is social environment, which includes income, equity, social support, social cohesion, and culture. The next ring is built environment, which includes urban design, green space, land-use patterns, and transport. The final ring is natural environment, which includes weather, topography, air, water.
Figure 18.4 Determinants of physical activity include factors in the natural, built, and social environments such as weather, urban design, green space, and culture as well as individual determinants like motivation, beliefs, age, and skills. (See Dahlgren, 1995; attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Assess Learning Needs Across the Continuum of Care

Effective and relevant community health programs aim to meet community needs by filling the gap between program participants’ knowledge and what is known about a health problem. To understand learning needs, the nurse must assess the target population before the development of program activities. Learning assessments provide perspective regarding the community’s educational needs and guide the choice of program activities to meet them. Therefore, assessment of learning needs and education is essential to community health programs.

Theory in Action

Using Health Education to Reduce Opioid Overdoses

The Naloxone Education Empowerment Distribution (NEED) program was a successful program that has since been completed. It provided education to first responders, local pharmacies, and interested community members. The NEED program trained, certified, and provided community members with education and skills to successfully administer naloxone to prevent opioid overdose. Although it is not currently active, this evidence-based program can be revisited or used as an intervention to reduce opioid overdose deaths in the future.

Watch the video, and then respond to the following questions.

  1. What learning needs do you think were identified before the implementation of the NEED program?
  2. How do you think the assessment of learning needs led to the development of the program?

The nurse can use several methods to assess learning needs. The CHA provides an overview of community learning needs. A comprehensive CHA includes community perspectives via survey collection, focus groups or interviews, and statistical data on health outcomes. Analysis of this data gives the nurse a picture of the community’s learning needs. The nurse also assesses the target population’s health literacy at both the community and participant level before program implementation, allowing the nurse to direct activities at the level of participant health literacy. Another method to assess the target population’s learning needs is to include them in the program planning process. Members of the target population can provide their perspective, indicate what information is important to them, and clarify knowledge, skill, or attitude deficits. Assessment, Analysis, and Diagnosis discusses CHA and health literacy in more detail.

Approaches to Health Promotion and Disease Prevention

The nurse and program planning team consider health promotion and disease prevention theories during program development because these theories help explain health behavior and factors contributing to health problems. These theories direct the program planning team to choose interventions that support behavior change. The health belief model (HBM), transtheoretical model, and social cognitive theory (SCT) are common health promotion and disease prevention approaches used during program planning and implementation. Health Promotion and Disease Prevention Strategies provides a detailed overview of each theory. This chapter applies these theories to community nursing practice.

Application of the Health Belief Model

The nurse and program planning team use the health belief model (HBM) to design health promotion and disease prevention strategies. The HBM states that an individual is ready for health change if they

  • believe they are susceptible to the health problem,
  • believe the health problem has serious consequences,
  • believe taking action will reduce their risk of the health problem,
  • believe the benefits of change outweigh the costs,
  • are exposed to factors that prompt change, and
  • are confident in their ability to make a change.

The nurse and program planning team apply the HBM by first assessing the perceptions of the target population. This enables the team to develop activities that align with the population’s needs. For example, if an individual or group does not believe they are susceptible to the health problem, the program would provide education on risks of the health problem. If an individual or group lacks confidence in their ability to make a change, the program would provide training to increase skill and confidence. For example, Jamie and the KHCFBP planning team aimed to increase participants’ biking confidence and skill. They developed education on bike maintenance and safety and activities to practice biking skills to meet that aim.

Theory in Action

Applying the HBM in Community Programs

Community health nurses used the HBM to plan and evaluate community health programs. The M-PACT, Men’s Prostate Awareness Church Training, was a partnership between the local faith community, community members, and the Maryland School of Health. The project goal was to increase informed decision-making for prostate cancer screening among Black men who attend church.

Watch the video, and then respond to the following questions.

  1. What were the needs and concerns of the Black men who participated in the program?
  2. What specific activities did the M-PACT program use to meet participants’ needs?
  3. How did each activity correspond to the HBM?

Application of the Transtheoretical Model

The nurse and program planning team use the transtheoretical model to influence the change process. According to this model, individuals move through the following five stages when making health behavior changes:

  • Precontemplation—no intention to make a change within the next 6 months
  • Contemplation—intends to act within the next 6 months
  • Preparation—intends to act within the next 30 days and has taken steps to plan for change
  • Action—changes behavior for less than 6 months
  • Maintenance—changes behavior for more than 6 months

The first step in applying the transtheoretical model to determine where participants fall within the five stages. The nurse and program planning team then develop activities that align with the stage of change. For example, if the program targets tobacco users in the precontemplation stage, activities would include personalized messages and education regarding the risks of tobacco use. If the program targets tobacco users in the preparation stage, activities would include assistance with setting attainable goals and education on resources to quit.

Theory in Action

Applying the Transtheoretical Model

Community health providers use the transtheoretical model to determine individual readiness for change and interventions to match readiness for change. Most often this model has been used to assist individuals in quitting unhealthy behaviors, such as tobacco, alcohol, or other drug use, or to start healthy behaviors, such as exercise. The video applies the transtheoretical model to treatment of youth who use alcohol or other drugs (AOD).

Watch the video, review the Treatment Matching Tip Sheet, and then respond to the following questions.

  1. What program activities align with individuals who have AOD problems in the preparation stage?
  2. How is motivational interviewing used in the contemplation stage?

Application of Social Cognitive Theory

The nurse and program planning committee using social cognitive theory (SCT) recognize that the social environment influences health behaviors. SCT concepts include the following:

  • Reciprocal determinism—interaction among the individual, behavior, and environment
  • Behavioral capacity—knowledge and skill of the individual to perform a health behavior
  • Expectations—anticipated outcomes of a behavior
  • Self-efficacy—confidence in changing behavior and overcoming barriers to behavior
  • Observational learning/modeling—watching another’s behavior and outcomes leading to behavioral change
  • Reinforcements—response to a behavior that increases or decreases the likelihood of that behavior

The first step in applying SCT involves assessing individual or group knowledge, skills, expectations, and confidence and the social environmental factors influencing the health problem. The program planning team plans activities to enhance participants’ likelihood of adopting a new health behavior based on the SCT concepts. For example, a nutrition education program may model creating a healthy shopping list based on a budget, enhance participant confidence by having them participate in cooking classes, and reinforce healthy choices through verbal praise.

Theory in Action

Applying SCT to Reduce Risk of Obesity

Community health providers recognize that health behaviors are influenced by the social environment. Los Angeles Universal Preschool uses SCT to teach healthy habits with the aim of reducing childhood obesity in low-income minority preschool populations.

Watch the video, and then respond to the following questions.

  1. What determinants of obesity did the preschool teacher influence through purposeful intervention?
  2. What interventions highlight the concepts of SCT?

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