Once you have identified factors that might underlie the behavioral and environmental factors you have prioritized, you need to sort them into predisposing, enabling, and reinforcing factors and to prioritize these.
Let's try it, using the Nick and Miguel case study as an example.
In this assessment, you will organize the complex array of causative factors into a meaningful framework so that you can address them systematically.
So, consider the factors--both behavioral and environmental--that you have prioritized for change. Follow these P.E.R. assessment steps to identify the underlying factors that affect or explain the target behavior and environmental factors. Involve other professionals and members of the target audience in the identification process.
Step one, identify the P.E.R. factors influencing the behavior or environmental characteristic of interest. Brainstorm a list of them from what you know from research and experience in the community.
Step two, sort them into predisposing, enabling, and reinforcing factors. Don't agonize over the categories—some might fit into more than one. Settle for a rough breakdown. Note that some of the enabling factors might be the same as the environmental factors you identified earlier.
Step three, prioritize the P.E.R. factors both between categories and within each category. If your goal is to impact environmental conditions, enabling factors will usually be the most important. For prioritizing within each category, consider both the importance and the changeability of each factor.
Step four, set change objectives that address the top-ranked factor in each P.E.R. category. These objectives will become the basis of your action plan.
Sometimes you will also need to do a higher level P.E.R. assessment of your top-ranked factors to ensure that your intervention is addressing the deeper underlying causes of the problem, not just symptoms.
Let's try this with an example drawn from our case study about Nick and Miguel.
1. Identify P.E.R. Factors
Anita, the nutrition professional in our case study, and her collaborators have decided to focus on overconsumption of sweetened beverages as the behavior of interest to help prevent childhood obesity.
So their first step is to identify factors that might be influencing sweetened beverage consumption at school. These include:
- Kids like the taste of sweetened beverages.
- Kids know soda is unhealthy.
- Sweetened beverages are widely available in vending machines in schools.
- Kids believe soda will make them overweight.
- Their parents may not approve of drinking soda.
- Kids have money, perhaps lunch money, to buy drinks.
- Kids see lots of ads for these drinks.
- Most of the other kids drink sweetened beverages.
- Kids enjoy drinking them.
- Unsweetened beverages, such as fruit juice and water, are not widely available in schools.
2. Sort P.E.R. Factors
As the second step, they need to sort these into predisposing, enabling, and reinforcing categories.
The predisposing factors are what children know, believe, and feel about drinking sweetened beverages: They like the taste, they believe soda may make them overweight, and they know it's unhealthy.
The enabling factors make it possible for children to drink sweetened beverages: They have the money to buy them and the vending machines that make them available are everywhere. Also, the lack of access to unsweetened beverages from vending machines makes it hard for them to buy alternative drinks.
The reinforcing factors provide the feedback to children after they drink sweetened beverages: They enjoy drinking them, even though they know their parents do not approve. Also, they see many children drinking these drinks and lots of ads for them--this behavior is the norm.
Each P.E.R. factor might work for or against the behavior. Also, the factors may vary in importance or direction according to the target audience.
When identifying the P.E.R. factors, it is crucial that you view the behavior from multiple perspectives including that of the target audience, in this case, the youth. Remember that a lack of available and affordable healthy choices can create barriers as much as having unhealthy options readily available.
3. Prioritize P.E.R. Factors
Once you have a fairly comprehensive list of the factors affecting your target behavior, the next step is to set some priorities. You cannot tackle all of these factors at once, so you need to decide which P.E.R. factors to address and in what order, both between categories and within each category.
Generally speaking, it is best to think first about the enabling factors, particularly the environmental ones. The enabling factors in the environment tend to have greater impact on the behavior of the target audience than predisposing or reinforcing factors. That said, a successful intervention will eventually need to target all three categories of P.E.R. factors, including predisposing and reinforcing factors.
Now, to decide which factors to tackle first, you need to prioritize the factors within the enabling, predisposing, and reinforcing categories. Consider two criteria for prioritizing factors within these categories. One is the importance of each factor. How common, urgent, and necessary is the factor for behavioral change? The other is its changeability. Do you and your team have the capacity to change the factor? Base your priorities on professional judgment and the research literature. Knowledge of the community is also important.
In planning a comprehensive intervention program, ideally begin with the most important and changeable enabling factor and then consider the most important and changeable predisposing factor, and finally move to the most important and changeable reinforcing factor.
For example, Anita's team has made an enabling environmental factor, reducing the availability of sweetened beverages from vending machines at Baker Middle School, their first priority. Another enabling factor, kids having money, is common but not easily changed, so they ranked this lower.
Later, her team might want to address the predisposing and reinforcing factors they find are the most important and changeable. For example, they might try to increase children's familiarity with and preference for other beverages as a way of decreasing their preferences for sweetened beverages.
4. Set Change Objectives
Finally, set change objectives for each of the factors that you have decided to address in your intervention.
The enabling environmental factor Anita's group has prioritized is the availability of sweetened beverages in vending machines in schools. This is both an enabling factor and an environmental characteristic that influences overconsumption of sweetened beverages.
Anita's intervention objective is to decrease by 30% the number of sweetened beverages sold in vending machines in Baker Middle School in two years.
But why are sweetened beverages so readily available in vending machines in schools? Addressing this question requires us to assess the factors that predispose, enable, and reinforce this situation.
5. Conduct Higher Level P.E.R. Assessment.
In other words, we need to do a higher level P.E.R. assessment to understand the factors that make sweetened beverages so readily available in vending machines in schools. This may seem like a lot of extra work, but your intervention is much more likely to be successful if it addresses underlying causes of problems rather than symptoms. Unless the intervention addresses the causes of the wide availability of these beverages in schools, it is unlikely to be successful.
Let's consider some of the factors we might come up with if we followed the same set of P.E.R. assessment steps for this higher-level analysis.
Factors enabling the widespread presence of vending machines might include that school policies don't address uncarbonated sweetened drinks, that the schools need the funds, and that the machines are heavily marketed to school administrations.
Factors predisposing schools to have the machines include what the adults and kids believe and feel about the vending options. For example, parents may think that fruit drinks are a healthier option than soda, and kids may enjoy buying from a machine. Also, school staff may feel powerless to influence vending options in the school. On the other hand, the school board is concerned about the rising rates of obesity.
Factors that reinforce the use and therefore availability of the vending machines include that kids get positive feedback when they buy beverages from a vending machine since they get a portable drink and don't have to spend as much time in the lunch line. A reinforcing factor working against the vending machines is cost.
Now, having listed and categorized the factors, let's set some priorities. Considering importance and changeability, the lack of school policies about all sweetened beverages should perhaps be our top-ranking enabling factor. Since federal regulations now require schools to create and sustain wellness policies, this factor is one that is likely to be changeable. (Note that this factor is also a characteristic of the policy environment.)
With this as a priority we need to specify an objective. For example, this might be that the school administration will adopt and implement a school wellness policy that limits the availability of sweetened beverages in vending machines by a given date.
This objective helps provide an even more specific focus as we develop our action plan to address childhood obesity in our community setting. Keep in mind that changing this policy may require additional interventions that address factors predisposing and reinforcing the lack of school policies related to sales of sweetened beverages.
Reference: Green LW, Kreuter MW. Health Program Planning: An Educational and Ecological Approach, 4th ed. New York, NY: McGraw-Hill; 2005