Understanding the PRECEDE-PROCEED model in this scenario
The PRECEDE-PROCEED framework organizes factors that influence health behavior into three categories: predisposing, enabling, and reinforcing factors. In this furniture factory, the key observation is that both shifts demonstrated similar knowledge acquisition, yet earplug use differed dramatically. The day shift achieved
82% compliance while the night shift reached only
18%. This gap points to a structural barrier rather than a knowledge deficit or motivational difference.
Predisposing factors include knowledge, attitudes, beliefs, and perceived susceptibility. The post-test pass rates were nearly identical—
96% for day shift and
94% for night shift—indicating that both groups understood the risks of noise exposure and the purpose of hearing protection. Knowledge was not the differentiator.
Reinforcing factors involve feedback, rewards, or social support that sustain a behavior. The data note that supervisors seldom wear earplugs on both shifts. If poor role modeling were the primary driver, the day shift would also show low compliance. Since the day shift reached
82% despite the same weak supervisor modeling, this factor cannot explain the night shift's
18% use.
Enabling factors are the resources, skills, or environmental conditions that make a behavior possible. Here lies the critical difference: the stockroom that issues earplugs is open during the day shift but closed during the night shift.
Night workers cannot obtain earplugs even if they intend to wear them, which is a textbook enabling-factor barrier.
Key point! When two groups show equal knowledge but unequal behavior, first check whether the environment allows the behavior to occur. Access to supplies is an enabling factor, not a knowledge or attitude issue.
Why access matters in hearing protection programs
Noise-induced hearing loss is a cumulative and permanent condition. Occupational hearing conservation programs rely on the consistent use of hearing protection devices during exposure to hazardous noise levels. If earplugs are unavailable during an entire shift, even well-informed workers face an impossible choice: work unprotected or improvise with unsafe substitutes. The PRECEDE-PROCEED model directs the nurse to identify which factor category is most modifiable and most directly linked to the observed gap.
The night shift's low compliance is best explained by the closed stockroom because the behavior cannot occur without the necessary resource. This is distinct from a reinforcing factor, which would require a social or reward-based explanation, and from a predisposing factor, which would require a knowledge or attitude deficit.
Watch out! Do not confuse “supervisors seldom wear earplugs” with the primary cause. That observation applies equally to both shifts, so it cannot account for the difference between them. In exam questions, look for the variable that changes between groups.
Applying the model to the nurse's next step
The occupational health nurse should collaborate with management to ensure earplug distribution is available on every shift. Options include keeping the stockroom open during night hours, installing vending machines with hearing protection, or providing each worker with a personal supply. The intervention targets the enabling factor directly.
| Factor category | Definition | Evidence in this scenario | Explains the gap? |
|---|
| Predisposing | Knowledge, attitudes, beliefs | Post-test pass rates: day 96%, night 94% | No — both shifts knowledgeable |
| Reinforcing | Social support, modeling, rewards | Supervisors seldom wear earplugs on both shifts | No — same condition on both shifts |
| Enabling | Resources, access, skills, environment | Stockroom open during day shift, closed during night shift | Yes — only variable that differs |
The correct answer is option 4: an enabling factor, because earplugs cannot be obtained during the night shift. The nurse's priority is to remove the access barrier so that the knowledge workers already possess can translate into protective behavior.