【作者】 李星明；

【导师】 黄建始；

【作者基本信息】 中国协和医科大学 ， 流行病学与卫生统计学， 2009， 博士

【摘要】 背景高血压防治已成为我国欠发达地区农村重要的公共卫生问题。高血压控制受复杂的生物一心理一社会多方面因素的影响,主要来自病人、医务人员和卫生服务管理者等方面。高血压规范化管理方案包括患者早期发现,依据高血压防治指南对患者进行评估和分层,通过随访开展药物和非药物干预及定期开展效果评价等内容。理论上,该方案是一个解决我国农村高血压问题行之有效的方法;实践上,国内外已证明针对高血压危险因素的规范化管理在改善病人健康状况、纠正患者的不良生活方式以及提高控制率等方面效果良好。高血压规范化管理主要是在国内外经济较发达地区城市及农村开展的,目前尚未见到在欠发达地区农村运用规范管理方案开展的高血压防治研究报告。目的1.确认影响欠发达地区农村高血压管理效果的可干预的危险因素;2.根据上述危险因素,设计符合当地卫生实际的规范化管理方案并实施干预;3.评价规范化管理对患者与高血压防治有关的知识、信念和行为等指标的影响;4.对干预方案的实施效果进行综合评价,内容包括患者的疾病负担、临床指标、生活质量、满意度等指标;5.全面分析影响干预效果的因素,为欠发达地区农村高血压管理方案的完善及政策制定提供循证建议。研究方法以甘肃省民勤县为研究现场,采用流行病学研究方法开展研究。首先,在文献综述和定性调查的基础上,确认影响欠发达地区农村高血压患者管理效果的因素,设计调查问卷和高血压管理方案,并开展第一次横断面调查;其次,将调查乡镇分为试验组和对照组,对试验组患者开展健康教育和定期的随访管理,对照组患者则按常规工作对待;第三,实施规范化管理6个月后,采用定量调查和定性访谈等方式评价管理效果,通过第二次横断面调查,对试验组与对照组干预前后的危险因素变化情况及干预效果进行评估,评估内容包括患者的知识、信念和行为等与高血压防治有关的危险因素指标,及其产生的疾病负担、生活质量、临床指标、血压水平变化趋势、干预组满意度等结果指标,并分析影响高血压干预效果的因素;最后,采用SWOT分析,根据定性和定量调查结果分析该类地区今后全面开展该项工作所面临的内部和外部环境因素,并为欠发达地区农村高血压规范化管理方案完善及政策制定提供循证建议。结果在校正了基线信息的不均衡后,经对结局资料进行统计学检验,发现:试验组在正常血压值、成人正常食盐日摄入量、高血压预防和控制、高血压会导致冠心病等方面的知识知晓率高于对照组;试验组在35岁以上成人应每年测血压、吃盐多等危险因素会导致高血压、血压正常后就停药和无不舒服感觉时就停药等方面的信念正确率高于对照组;试验组在采取定期测量血压、按医嘱服药、调理膳食、保持情绪稳定、控制体重、戒烟限酒以及体育活动等行为的流行率要高于对照组;试验组服药依从性得分和心理状况得分显著高于对照组;试验组在因高血压导致的直接费用、卧床天数以及不能劳动天数等方面较对照组显著降低;试验组生活质量各维度得分较对照组显著提高;试验组高血压控制率较对照组显著提高。在不同随访阶段,试验组血压水平呈逐渐下降的趋势,但在第三、四次随访时略有回升;试验组体重指数和发生心脑血管疾病事件的相对危险度与对照组相比无统计学差异。试验组回答满意和很满意的比例为99.28%。干预组医生和患者定性调查结果除验证了上述结果的真实性外,还发现干预措施对改善医患关系和提高医生慢性病管理能力等方面有显著效果。影响高血压控制效果的因素有:患者的健康信念得分、基线期收缩压水平、是否接受干预措施、服药依从性得分和是否联合用药等。影响患者服药依从性的因素有:患者的健康信念得分、干农活的类型、每天动物油摄入量、是否了解药物副作用、是否知道随访医生名字和是否接受干预措施等因素。定性调查还发现,患者的经济状况和社会文化环境、卫生人力等因素也在不同程度上影响着管理的效果。结论1.干预措施对提高患者的健康知识知晓率、健康信念正确率具有显著的效果,对提高患者定期测量血压、服药依从性和心理自我调节行为、减少重体力劳动等行为流行率具有良好的效果,而对改善患者的吸烟、饮酒、膳食摄入等行为收效甚微。2.干预措施对于减轻高血压疾病负担、改善生活质量、提高控制率具有显著效果,能逐步降低患者血压水平,但是干预措施对超重和肥胖的干预效果较差。证明在欠发达地区农村,以乡镇卫生院医务人员为主体的初级卫生保健力量在高血压规范管理方案的指导下,通过对高血压患者开展主动的随访和健康教育,是有明显的干预效果。3.定性和定量调查发现了影响该地区高血压控制效果和患者服药依从性的各种因素,涉及患者的健康信念、生活行为、社会环境、卫生服务和干预活动等方面。4.综合上述研究结果,通过SWOT分析对本地区今后开展高血压危险因素管理的优势、劣势、机会和威胁进行了全面分析,并提出相应的政策建议。本研究是国内首次在欠发达地区农村开展的系统的高血压患者危险因素干预和效果评价,并建立了一套完整的干预方案和效果评价指标体系;首次从定性和定量的角度,全面分析了影响该地区高血压管理效果的因素,并根据研究结果提出了加强欠发达地区农村高血压管理的循证建议。更多还原

【Abstract】 BackgroundThe prevention and treatment of hypertension have been an important public health issue of rural area in the underdeveloped regions. And the hypertension control is affected by various aspects of complicated biologic-psychological-social factors, which mainly come from patients, medical staff and health administrators. The standardized intervention protocol for hypertension factor(SIPHF) is theoretically regarded as a feasible method to address the hypertension issue in rural area of China, which include the early identification of patients, the stratification and evaluation of the patients based the related guidelines, pharmacy therapy and non-pharmacy intervention to patients by follow-up. In practice, evidence from home and abroad shows that the SIPHF plays an important role in improving the healthy status of patients, modifying their unhealthy life style, enhancing their control rate. However, most of researches on SIPHI are conducted in the developed communities of rural and urban area, but have not been carried out in rural area of the underdeveloped rural regions in China.Objectives1.To identify the modified risk factors that affecting the effect of SIPHF in the underdeveloped rural area.2.To design and implement the SIPHF according to the local status of health resources based on the risk factors related to the intervention effect.3.To evaluate the intervention effect of SIPHF, including the indicators on the knowledge, belief and behavior related to hypertension intervention.4.To evaluate the overall intervention effect of SIPHF, including disease burden, clinical outcome, life quality and patients’ satisfaction.5.To comprehensively analyze the affecting factors on intervention effect, in order to provide evidence-based suggestions for SIPHF improvement and policy-making in the underdeveloped rural area of China.MethodsMinqin County in Gansu Province was selected as the experimental field, and clinical trial was conducted for the whole process of research design. Firstly, based on literature review and qualitative surveys, the modified risk factors that affecting the effect of hypertension management in the underdeveloped rural area were identified, the specific questionnaire and SIPHF were developed, and the first cross-sectional study was conducted. Secondly, the surveyed population were then divided into intervention group and control group, and periodic health education and following up were conducted to the intervention group for six months; Thirdly, the second cross-sectional study was conducted to evaluate the effect of intervention by qualitative and quantitative survey, the indicators include the knowledge awareness rate and the right belief rate for hypertension control, and the behavior prevalence related to hypertension intervention, the disease burden, the life quality and clinical outcomes resulted from hypertension, the dynamic tendency of blood pressure and the patients’ satisfaction. And the factors related to the effect of hypertension management was evaluated; Finally, SWOT analysis was conducted to evaluate the factors affecting the intervention process and effect, based on the results of qualitative and quantitative surveys on the factors related to effect of the intervention, and to provide evidence-based suggestions for SIPHF improvement and policy-making in the underdeveloped rural area in China.ResultsAfter disequilibrium of baseline information was modified, the statistics tests for information of final survey showed that the intervention group had better awareness than the control group, including the normal blood pressure, the normal salt intake amount each day for an adult, the coronary heart diseases resulting from hypertension, the knowledge related to hypertension prevention and control. The intervention group had better belief than the control group, including measuring blood pressure each year for the person above 35 years old, too much salt intake and other factors leading to hypertension, quitting drug therapy when the pressure becomes normal and the uncomfortable feeling disappears. The intervention group had better behavior prevalence than the control group, including measuring blood pressure periodically, drug therapy compliance, reasonable diet and mental balance, controlling weight, quitting smoking, restricting drinking, and the score of drug compliance, psychological health status and life quality. The intervention group had less amount of disease burden than the control group, including the direct medicine cost, days lying-in-bed and unable to work. And the intervention group had higher blood control rate than the control group.During the follow-up period, the tendency of blood pressure of intervention group showed an increasing decline in general, but there is a bit rising during the third and fourth interview. There was no statistical difference between the intervention group and control group for the BMI and Relative Risk of cardiovascular and cerebrovascular events, and 99.28% of the intervention group showed quite satisfaction and satisfaction for the intervention. The qualitative survey among doctors and intervened patients testified authenticity of the above results, but showed there were some other effect achieved, including improving relationship between doctors and patients, the chronic disease management ability of the medical staff.The multi-variable analysis showed such factors related to the control rate, including the score of health belief, the baseline information of systolic pressure, whether being intervened or not, the score of drug compliance and the combined usage of drugs. The factors related to drug compliance including the score of health belief, the type of labor, the intake amount of animal oil, the awareness of side-effect of the drug, the awareness of the names of doctors in charge of following up, whether being intervened or not. The qualitative survey showed there were some other factors related to the effect of intervention, including the economy status of patients, the social and cultural circumstance of patients and human resource of medical staff.ConclusionsThe major contribution of the study include:1.The intervention measures had a significant effect on improving the awareness rate of related knowledge, the right belief rate, and had favorable impact on improving the proportion of measuring blood pressure periodically, the drug compliance, the mental balance, decreasing hard physical labors, but had little impact on the change of smoking, drinking, and various meal intake.2.The intervention measures had significant effect on decreasing the disease burden, improving the quality life and control rate, making the blood pressure decline steadily, but had little impact on the overweight and obesity. All these results showed that the active following up and health education, conducted by medical staff of township hospitals, directed by the SIPHF, can produce significant effect.3.The factors that affecting the control effect and drug compliance in that area were found by qualitative and quantitative surveys, including the health belief, the life style, social-cultural-economic factors of the patients, and the health care service and intervention measures, and the corresponding suggestions were then put forward, based on the identified issues.4.Combined with the effect and related factors summarized in above sections, SWOT analysis was finally conducted to evaluate the strength, weakness, opportunities and threats of developing the intervention for hypertension patients’ risk factors in rural area, and the corresponding suggestions for the policy making were then put forward.This study is the first one in China to carry out the SIPHF and effect evaluation for risk factors intervention of hypertension patients, and one series of complete intervention protocol and evaluating indicator system framework was established for SIPHF in the underdeveloped rural area. This study is also the first one in China to analyze the factors attribute to the effect of SIPHF in that area, and the evidence-based suggestions to strengthen the hypertension management in underdeveloped rural area were then put forward.更多还原