| Objective: To understand the current status of standardized management of hypertensive patients aged 35 years and above in China,and to explore the impact of standardized management on knowledge,behavior,drug treatment and blood pressure control of hypertension patients.To investigate the barriers and facilitators in the implementation of hypertension health management service specification by using the method of implementation science,and to provide evidence for improving the hypertension management policy in basic public health services in China.Methods: The study adopted the form of quantitative survey and qualitative interview to carry out field investigation: 1.Quantitative survey: Hypertensive patients aged 35 years and above in 16 regions of 8 provinces in 2018 were included in the survey of "The Management Evaluation Study of Chronic Disease Patients in National Basic Public Health Service Project".Questionnaire survey and physical measurement information were collected.SPSS 25.0 software was used for quantitative data analysis to analyze the current status of standardized management of hypertensive patients and its impact on management effect.2.Qualitative interview: This part was based on the research in 2018.The standardized management rate of hypertension patients in 8 provinces was calculated and ranked according to the standardized management rate,and the top one provinces and the bottom one provinces were selected as project sites.In combination with the "WHONCNCD Implementation Research" project,an online survey was conducted in 4 regions of 2 provinces in China from October to November 2022.The interview outline was designed according to the Consolidated Framework for Implementation Research(CFIR).In-depth interviews and focus group discussions were used to conduct qualitative surveys among leaders of primary health commission,primary disease control and prevention personnel,managers of primary medical institutions and medical staff of primary medical institutions.SPSS 25.0 and NVivo 11.0 software were used for quantitative and qualitative data analysis.Using the method of implementation science,the barriers and facilitators of hypertension management in primary care were discussed mainly from the perspective of supply side.Results: 1.Quantitative survey: A total of 5562 hypertensive patients aged 35 years and older were included.In 2018,the rate of standardized management of hypertensive patients aged 35 years old and above in 16 regions of 8 provinces of China was 64.7%,the rate of good knowledge awareness was 39.5%,the rate of current smoking was 10.9%,the rate of drinking was 15.9%,the rate of moderate salt intake was 52.7%,the rate of moderate oil intake was 55.4%,and the rate of good dietary diversity score was 63.8%.The rate of physical inactivity was 58.1%,the rate of drug treatment was 88.6%,and the rate of blood pressure control was 58.4%.The rate of better knowledge,drinking,moderate salt intake,moderate oil intake,good dietary diversity score,physical inactivity,blood pressure control and systolic blood pressure in the standardized management group were better than those in the non-standardized management group(46.7% vs 26.7%,14.5% vs 19.3%,54.9% vs47.9%,56.4% vs 54.2%,68.1 % vs 56.7%,54.4% vs 58.7%,(138.43±14.90)mm Hg vs(141.53±17.21)mm Hg,P < 0.05).After adjusting for demographic characteristics such as gender,age,region,marital status,education level,annual per capita household income,medical insurance,and duration of illness,standardized management was positively associated with better knowledge(OR=2.21,95%CI:1.53～3.18),better dietary diversity(OR=1.89,95%CI:1.55～2.30),drug treatment(OR=1.49,95%CI: 1.14～1.93),and blood pressure control(OR=1.73,95%CI:1.53～1.95)(P<0.05).2.Qualitative interview:(1)4 leaders of primary health commissions,4 primary disease control and prevention personnel,4 primary medical institution managers and 16 primary medical staff from 4 regions of 2 provinces in China were interviewed.(2)A total of 22 themes were identified,namely:(1)7 themes for primary health commission leadership: policy making,financial investment,medical insurance,information system on hypertension,technical guidelines/programs,local support,and main challenges;(2)Four themes for primary disease control personnel: hypertension management related work content,encouraging and publicizing measures for hypertension management,cooperating institutions/individuals,challenges and opportunities brought by the epidemic;(3)Six themes for managers of primary health care institutions: accessibility of equipment and drugs,availability of health services and resources,management measures and needs,capacity building,organizational characteristics and culture,challenges and opportunities brought by the epidemic;(4)five themes for primary health care workers: awareness toward the guidelines/interventions,attitudes toward the guidelines/interventions,practice and skills of the guidelines/interventions,personal characteristics,challenges and opportunities brought by the pandemic.(3)Based on the CFIR structure and substructure,the barriers and facilitators of hypertension management were identified: A total of 13 barriers and 31 facilitators were developed.Barriers included: Problems in practice,poor health awareness of patients,difficulty in communication with patients,low coverage of health services,low financial investment,imperfect information system,large floating population,lack of staff,lack of time,less drugs,less advanced equipment,lack of substantive guidance and training,lack of tacit cooperation of colleagues;Facilitators include: Participation in policy making,reference to other policies and regulations,diverse access to norms,diverse ways to understand intervention,indicators and data of implementation effect,better measures,medical insurance guarantee system,local support mechanism,supervision and assessment system,establishment of effective contact mechanism,high health service coverage,spiritual reward,economic reward,teamwork,supervision mechanism,incentive mechanism,the accessibility of basic equipment and essential drugs,full-time personnel management,regular business training,harmonious working relationship,ways to solve problems,leadership support,knowledge reserve and update,self-execution ability,multi-department cooperation,printing and distributing pamphlets related to service specifications,releasing electronic information related to the specifications,describing the content of the specifications on the bulletin board,and placing specifications on electronic screens content,leadership participation in decisionmaking,selection of specific implementers responsible.Conclusion: 1.Quantitative survey : The standardized management of hypertension patients aged 35 and above in 16 districts of 8 provinces in China has made some progress,but there is still room for improvement.There is a certain correlation between standardized management and higher blood pressure control,better knowledge and behavioral lifestyle changes in hypertensive patients.2.Qualitative interview: Grassroots hypertension management has done well in terms of policy formulation,medical insurance,local support,measures to encourage and publicize hypertension management,cooperative institutions/individuals,management work measures,capacity building,organizational characteristics and culture,knowledge,belief and practice in guidelines/interventions,etc.,and needs to be strengthened in terms of funding,information systems on hypertension,technical guidelines/programs,access to equipment and drugs,availability of health services and resources,work needs,and personal characteristics.In the future policy making,addressing the identified barriers and reasonably absorbing the facilitators will help improve the hypertension management policy in basic public health services in China,so that the hypertension management in primary care can be put into practice more effectively. |
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