社区高血压高危人群管理规范的制定与论证

Development and Validation of the Management Guideline for the High-risk Population of Hypertension in Community

目的:遴选社区高血压高危人群管理规范的要素及具体内容,为制定高危人群管理规范提供参考。方法:系统评阅国内外管理规范相关的文件和文献194篇,运用边界分析法、项目管理理论归纳管理规范的要素;围绕确定的要素,系统评阅国内外相关文献121篇,结合偱证决策原则和专家咨询,从必要性、可操作性等角度遴选各要素的具体内容。结果:社区高血压高危人群管理规范应包括管理目标、管理主体、管理客体、管理方法和内容、管理时间和频次、管理评估、管理流程等7个要素。高危人群的管理目标是“提高健康知识知晓率和高血压相关知信行水平,降低高血压发生率”;管理机构为社区卫生服务中心(站);管理方法包括健康教育、同伴教育、自我管理、创造健康环境和随访管理5类,管理内容涵盖高血压相关知识和信念、血压的监测和管理、危险因素的监测和控制3类。各要素内容的必要性、社区适宜性和可操作性的认可度高,评分均在4分以上(满分5分)。结论:社区高血压高危人群管理规范具有良好的系统性和完整性,一定程度弥补了高血压高危人群管理领域的不足;规范中明确的操作流程对有效管理社区高血压高危人群具有重要参考价值。

Objective: To select the elements of the community management norms for individuals at risk for hypertension, as well as the specific content, and to provide references for the development of management norms for individuals at risk for hypertension. Methods: A total of 194 documents and literature related to management norms at home and abroad were systematically reviewed, and the elements of management norms were identified using boundary analysis and project management theory. A systematic review of 121 pieces of domestic and foreign literature was conducted with a focus on the elements. Boundary analysis was used in conjunction with the evidence-based decision-making principle and expert consultation, the specific contents of each element were chosen based on their necessity and operability. Results: A total of 7 elements of management norms for individuals at risk for hypertension were identified, including management objectives, management subjects, management objects, management measures and contents, management time and frequency, management evaluation, and management process. The management objectives of standardized management of high-risk population were to improve the awareness rate of health knowledge and the level of hypertension related knowledge, attitude and behavior, and to reduce the incidence of hypertension. The management organization were community health service centers and their subordinate stations. The management measures included health education, peer education, self-management, healthy environment development and follow-up management. The management contents were defined as hypertension related knowledge and attitude, blood pressure monitoring and management, and risk factor monitoring and control. The recognition of the necessity, community appropriateness, and operability of each element’s content is high, all of which were rated higher than 4 points(full marks 5 points).Conclusion: The management norms for individuals at risk for hypertension developed by this study is systematic and complete, which partially makes up for the shortcomings in the field of management of high-risk population of hypertension.The clear operation process may guide to effective implementation of managing high-risk population of hypertension in community.