# Situation: A nurse at a Barangay Health Station (BHS) runs a monthly health teaching class for adults with hypertension, several of whom smoke. One year after the class, the nurse will do an outcome evaluation as defined in the PRECEDE-PROCEED model. Which measure should she use?

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> subject: Nursing Practice I — Community Health Nursing

## 문제

Situation: A nurse at a Barangay Health Station (BHS) runs a monthly health teaching class for adults with hypertension, several of whom smoke.

One year after the class, the nurse will do an outcome evaluation as defined in the PRECEDE-PROCEED model. Which measure should she use?

## 보기

1. The share of participants with controlled blood pressure **✔ 정답**
2. The participants' average score on a hypertension knowledge test
3. The share of participants who take their medicine daily by pill count
4. The share of participants who cook without added salt, seen on home visits

**정답: 1**

## 해설

In the PRECEDE-PROCEED model, outcome evaluation measures health status and quality of life, such as blood pressure control, stroke, or mortality. Impact evaluation measures short-term change in the predisposing, enabling, and reinforcing factors and in behavior. Taking medicine and cooking without salt are behaviors and knowledge is a predisposing factor, so these are impact measures even when they are measured one year later.

## 심화 해설

In the PRECEDE-PROCEED model, evaluation is divided into three distinct levels, and confusing them is a common trap on licensure exams. The model moves from predisposing, enabling, and reinforcing factors, through behavior and environment, to the final health outcomes. The question asks specifically about outcome evaluation, which sits at the far end of that chain.

Outcome evaluation measures changes in health status and quality of life, not changes in knowledge, attitudes, or behavior. Blood pressure control is a direct health-status indicator. In contrast, knowledge is a predisposing factor, medication adherence and reduced salt use are behaviors, and all of these belong to impact evaluation, even when measured one year after the teaching.

The distinction is not about when you measure, but about what you measure. A knowledge test one year later still measures a predisposing factor. A pill count one year later still measures a behavior. Watch out! Do not let the one-year time frame trick you into choosing an impact measure as an outcome measure.

The PRECEDE-PROCEED model has been applied across chronic disease settings. In type 2 diabetes, meta-analytic evidence shows that interventions built on this model improve HbA1c, which is the diabetes equivalent of blood pressure control in hypertension—a true health outcome [1]. Cross-sectional work using the model also separates predisposing, enabling, and reinforcing factors from the final outcome of glycemic control, reinforcing the same logic: self-efficacy and self-management behaviors are upstream of the health-status endpoint [2].

| Evaluation type | What it measures | Example from this question |
| --- | --- | --- |
| Process evaluation | Implementation of the program itself | Number of classes held, attendance |
| Impact evaluation | Predisposing, enabling, reinforcing factors and behavior | Knowledge score, pill count, salt use on home visits |
| Outcome evaluation | Health status and quality of life | Blood pressure control, stroke, mortality |

The same structure appears in other PRECEDE-PROCEED applications. A discharge-preparation program for colorectal cancer chemotherapy used the model to target knowledge and self-care ability as intermediate factors, with the expectation that these would later translate into better clinical outcomes . Similarly, a hemodialysis education program measured treatment compliance and healthy lifestyle behaviors as impact-level variables, while quality of life served as the outcome-level variable .

When a question asks for an outcome evaluation, look for the option that reflects a change in the disease state itself or in the person's overall well-being. Blood pressure control is the only option here that qualifies. The other three options—knowledge, medication adherence, and dietary behavior—are all legitimate targets of evaluation, but they are impact measures because they represent factors or behaviors that lead to the outcome, not the outcome itself.

Key point! Memorize the sequence: predisposing/enabling/reinforcing factors → behavior and environment → health status and quality of life. Impact evaluation covers the first two links; outcome evaluation covers the last link.References (research sources)

- [1]The efficacy of PRECEDE-PROCEED model-based interventions on HbA1c and self-management in type 2 diabetes patients: a systematic review and meta-analysis.Meta-analysis/systematic reviewTang Y, Soh KL, Gan WY, Zhou J, Soh KG (2025) · DOI: 10.1186/s12889-025-23073-9

- [2]Identification of Factors Associated with Glycemic Control Using the PRECEDE- PROCEED Model in Patients with Type 2 Diabetes: A Cross-Sectional Study.Research articleTu J, Lin G, Zhu F, Xu F, Gao Y, Gan Q, Chen Y, Hu X, Tang R. (2026) · DOI: 10.2147/dmso.s598614

## 임상 시나리오

PRECEDE-PROCEED Evaluation LevelsOutcome vs. Impact in Hypertension Teaching
Outcome evaluation measures health status and quality of life, such as blood pressure control, stroke, or mortality.

Impact evaluation measures predisposing, enabling, reinforcing factors and behavior, such as knowledge scores, medication adherence, or reduced salt use.

CautionThe distinction is about what you measure, not when you measure. A knowledge test or pill count at one year is still an impact measure, not an outcome measure.

## 핵심 개념

- **Outcome evaluation** — Measures changes in health status and quality of life, such as blood pressure control, stroke, or mortality.
- **Impact evaluation** — Measures short-term changes in predisposing, enabling, reinforcing factors and in behavior.
- **Predisposing factor** — A characteristic that motivates behavior, such as knowledge, attitudes, or beliefs.
- **Enabling factor** — A resource or skill that makes a behavior possible, such as access to services or cooking skills.
- **PRECEDE-PROCEED model** — A planning framework that moves from predisposing, enabling, and reinforcing factors through behavior to health outcomes.

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