The P.E.R. Assessment
So, the problem is childhood obesity.
You have identified two key behaviors in your community setting that relate to childhood obesity. You have assessed what environmental factors might be influencing these behaviors. You have prioritized which behaviors and environmental factors are most important and changeable, and have written specific objectives for these. Now it's time to dig a little deeper and assess the predisposing, enabling, and reinforcing factors that impact the behavioral and environmental changes you've identified.
We'll call this the P.E.R. assessment for short.
The P.E.R. assessment is a tool to help you identify particular factors to target for creating the behavioral and environmental changes you have prioritized. The core P.E.R. assessment question is: What factors must be changed to initiate or sustain the desired behavioral or environmental changes you've identified? These factors will become the immediate targets for your behavioral and/or environmental change interventions.
This assessment is all about identifying the causes of the behaviors and environmental conditions you hope to change. Your intervention is more likely to be successful if you target underlying causes rather than symptoms.
These causal factors generally fall into one of three categories: predisposing factors, enabling factors, and reinforcing factors.
Let's consider these one at a time. As we do, start thinking about what P.E.R. factors affect or explain the behaviors and environmental characteristics you have prioritized. This is both an art and a science because the relative importance of P.E.R. factors will likely vary from community to community.
Predisposing factors are the circumstances and situations that exist before a given behavior occurs. They provide the reason or motivation for that behavior. These factors include an individual's knowledge, attitudes, beliefs, values, and self-efficacy.
Self-efficacy has gained increased recognition in recent years. Self-efficacy is an individual's belief in his or her ability to make the desired behavioral change.
In short, predisposing factors relate to what individuals know, believe, and feel.
Let's consider an example about TV watching. Factors that might predispose a person to watch TV include believing that programs can be educational and knowing that she finds it relaxing. Factors that might predispose her against watching might be valuing silence or believing that watching TV is a waste of time.
Predisposing factors tend to relate most directly to individual behaviors, although cumulatively, individual beliefs and values also impact the social environment through social norms or standards for behavior. Predisposing factors are often addressed through communication with the target audience. Examples of communication methods include information dissemination, verbal persuasion, and modeling.
Enabling factors are the skills, resources, and barriers that help or hinder a given behavioral or environmental change. These factors include availability of resources, accessibility of resources; laws, rules, regulations, and policies; and skills of individuals.
For example, factors that enable a child to watch an average of 4 hours of TV a day range from having a TV in her bedroom (which makes it available and accessible) to larger socioeconomic factors that lead parents to use television as a babysitter, like fear of letting their children play outside because of crime levels or the need to work more than one job.
Many enabling factors are characteristics of the environments in which individuals and families live, work, and play. They include the factors within the built, social, economic, and policy environments, so changing them tends to require an intervention method that includes community organizing.
Reinforcing factors are feedback, positive or negative, that follows a particular behavior.
Reinforcing factors include the perceived attitudes of peers, parents, teachers, community leaders, doctors, etc., toward the behavior; the individual's physical or emotional changes and feelings after the behavior; economic impacts of the behavior; advertising and mass media feedback; and perceived social acceptance.
For example, imagine a middle school girl who reads books all the time. Factors reinforcing her reading include the attitudes of her parents who praise her. Factors that would reinforce her stopping might include the attitudes of her friends who think she's a nerd. The pleasure she feels when reading reinforces her reading, although the cost of new books may discourage her from reading more often.
Messages from advertising and the mass media may be supportive. Teachers may also offer ice cream or pizza parties to reward readers. (These food rewards may reinforce reading, but they also reinforce poor eating habits as children learn to eat for reasons other than hunger.) Perceived social acceptance also encourages or discourages particular health behaviors; in the case of this girl, if she thinks her peers are more likely to accept or even admire her for being a bookworm, that will reinforce her behavior, but if she fears they won't it would discourage her from reading.
Reinforcing factors tend to be addressed through communication with individuals and organizations who can provide feedback to the individuals in the target audience. A program targeted toward parents to get them to work with their children to set aside a half-hour for reading is an example of an intervention program designed to reinforce as well as to enable reading in children. Reinforcing factors can also be influenced through community organizing aimed at changing the policy environment.
Reference: Green LW, Kreuter MW. Health Program Planning: An Educational and Ecological Approach, 4th ed. New York, NY: McGraw-Hill; 2005