Evaluation Of Effectiveness And Efficiency Of Group Intervention For Hypertensives Based On Community Health Service Center

Essential hypertension (EH) is not only an independent disease, but also an independent risk factor for cardiovascular diseases, which is the "first killer" of human health now. It is estimated that hypertension causes 4.5% of current global disease burden and is as prevalent in many developing countries, as in the developed countries. In China, there were at least about 174 million of people suffered from the hypertension before the end of 2002 and 220 thousands died from hypertension-related diseases annually. The cause losted life year attributed to hypertension was different between male and female, 0.363 years for male and 0.359 years for female respectively. About 2.54 million life years might be lost potentially due to hypertension. Every hypertensive patient led about 11.4 years life lost on average. Moreover, the direct economic burden reached 31.89 billion RMB. So it is one of key public health problems and should be priority for prevention and control.The successful experiences from domestic and international research indicated that the most effective way to control hypertension is the prevention and control based on community, which should adopt combined strategies of "whole population strategy" and "high risk population strategy". At present, there were mainly two types of hypertension management model, first one is grade management model, and second one is self-management model. There were, however, some shortcomings in these two types model, such as lower coverage, poor compliance, and sustainable development et al.Group intervention strategy of diseases is one kind of case management model, which organized persons with or without same disease together, then carried out health education, behaviors rebuilding, therapy, et al. As one intervenor can provide with education to many persons synchronously, and accept the patient's consultation individually, it is a more effective and efficient model, which combines follow-up, management, therapy in integral whole. The aim of present study was to develop and evaluate a group intervention model for hypertensives based on community health service centers.Part I Feasibility analysis of group intervention based on community healthservice center(GICHSC)Quantitive and qualitative methods were used to analyse the data from related departments and population in order to evaluate the feasibility of the group intervention. The results showed that over 20% of the staff in community health service stations(CHSS) was general practitioner(GP). There were not less than one GP in every CHSS, furthermore all of them took part in the training on chronic disease managements. Clinical practice, prevention practice and health protection were their three main routine works, contributing to 39.7%, 17.7%, and 21.7% of total workload respectively. Consultation was the most part of clinical practice, contributing to 71.8% of clinical practice. Follow-up of hypertensive was the most part of prevention practice, contributing to 66.4% of prevention practice. Gerokomy was the most part of health protection, contributing to 81.4% of health protection. Meanwhile, qualitative analysis results showed that hypertensive management was the main work of CHSS. But it was time-consuming, hard-sledding and lower-effectiveness work. In addition, the attitude of the leaders of community health service centers, community committees and patients to the group intervention based on community health service center (GICHSC) was positive. All of them thought implementation of GICHSC in community was feasible. In summary, the ability of GP met the requirement of implementing GICHSC; implementation of GICHSC didn't change the CHSS works, only changed the delivery model of services; furthermore, the providers of health care and patients accepted GICHSC. So implementation of GICHSC in community was feasible.Part II Development of GICHSCLiterature review and audience analysis were used for the development of GIBC. The results indicated that group intervention can apply several kinds of chronic diseases management; contents of the intervention included 4 sections generally: health education, self-management skills training (role play, relax practice), discussion and consultations, individual treatments. It took 40-120 minutes each intervention. Audience analysis showed that patients were interested in medical treatments, adjusting dietary, physical activity and adjusting emotion; and thought them as the key to control blood pressure level. Furthermore, about 20 persons in each group, and the time spent in one intervention within 2 hours were suitable for them. Finally, it was thought more attractive and effective that health professionals teach the contents of interventions. Based on the results, a participatory intervention model was developed aiming at medical treatments, adjusting dietary, physical activity and adjusting emotion, which included 4 sections such as health education, self-management skills training, group discussion, individual treatments in each intervention according to social-cognitive theory.Part III Implementation of GICHSCAccording to participatory research principles, all related departments were invited to take part in whole process. Firstly, related leaders were mobilized thought special topic discussion meeting, and supports from the health administration system were acquired. After meeting, a related policy was established, which defined every department's responsibilities. Then one thousand three hundreds and forty-six patients who wanted to take part in the study were recruited through methods of community mobilization such as community meetings, residents meeting, individual interview, community propaganda et al.. Twenty four GPs and 32 community health workers (CHW) were trained with the topics of GIBC. After then the trained GP and CHW took responsibilities to collaboratively finish 7 intensive interventions and 3 times of follow-up interventions in their own work community.Part IV Evaluation of GICHSC1. Evaluation of Effectiveness and Efficiency of GICHSCRandomized control trail based on community was applied to the present study. The quantitive datum got at baseline and post-intervention were analyzed through repeated data analysis methods. And qualitative datum got at post-intervention through focus group interviews were analyzed by contents analysis methods. The results showed as following: GICHSC can improve health status, increase physical energy score, and reduce blood pressure, self-reported score for health were decreased 0.38 scores (higher score represents worse for health), physical energy score were increased 0.27 scores, and 2.5 mmHg and 1.5 mmHg were reduced in systolic blood pressure and diastolic blood pressure respectively. Besides, GICHSC can improve patients' compliance to therapy, medication compliance increased 14.7%, compliance of physical activity increased 9.7%, and dietary compliance increased 10.1% respectively. Furthermore, GICHSC also can increase self-efficacy related to disease managements, the score of self-efficacy were increased 1.76, 0.98, 0.54 in self-efficacy to managing symptoms (SEMS), managing diseases in general (SEMDG), and to physical activities respectively. Finally, GICHSC also can change patients' negative attitude to control blood pressure, increase physician-patient commutations and social supports, reduce bad emotions and worry about health, and increase coping-skill. Although the evaluation indexes mentioned above were improved in control groups, the improvements in intervention groups were more significantly. Qualitative evaluation results indicated that GICHSC can change patients' attitude, increase related knowledge, increase self-efficacy. Meanwhile, it can build supportive environment for the patients, and improve physician-patient relationship. Efficiency analysis indicated it can save 7.0 minutes spend on every visit if physician provide care through GICHSC for 19 patients in one group compared with providing these care to same patients through traditional "one by one" model. All of these results showed that GICHSC is a feasible, effective, and efficient chronic diseases management model.2. Analysis of influencing factors to GICHSCTwo-level linear multilevel model was adopted to analyses the affection of community factors and individual factors to GICHSC. The results indicated that education level, the average monthly income of a family, combining other chronic diseases were the influencing factors to effect of GICHSC without consideration of the datum's hierarchically structured character; but the support of community and the devoted energy of GP were the community factor affecting effect of GICHSC with consideration of the datum's hierarchically structured character, the subjects in the higher community support communities were higher 1.74 scores than the subjects in the lower community support communities after controlling other factors affection respectively, similar condition to the devoted energy of GP, but the score was 4.37. Gender was the individual factor affecting the effect of GICHSC with consideration of the datum's hierarchically structured character. So it was concluded that the collaboration of multi-departments is not only in favor of implementation of intervention model, but also a key factor affecting the effect of GICHSC.3. Path analysis for the effect of GICHSCPath analysis can not only clarify the relationship between independent variables, but also explain the relationship of independent variables and dependent. On the one hand, which can validate the theory of intervention, on the other hand, which can enrich and develop the theory through explaining the relationships different variables quantificationally. the results indicated: 1). Negative emotion, such as worry about health and depressing, were correlated to blood pressure level and self-report health positively, which means the blood pressure was increased and health status deteriorated both with the level of negative emotion aggravation. Negative emotion was affected by social support mainly, social support increased 1unit, the negative emotion decreased 0.413 units, which hinted us that we can reduce negative emotion through increasing social supports.2). Social support not only affects metal health, but also affects physical health, which indirectly affects health through its effect on self-efficacy and behaviors. Social support positively predicted self-efficacy and treatment behaviors, and negatively predicated self-reported health. So, we can increase patients' diseases management self-efficacy and treatment compliance through increasing social supports, then reducing blood pressure and improving health indirectly.3). Self-efficacy is key construct of social-cognitive theory as fundamental to behavior change, which can affect health directly and indirectly. First, it can predict self-reported health directly. Secondly, it indirectly reduced blood pressure through its effect on treatment behaviors, then improving health. Self-efficacy was affected by negative emotion and social support, but the latter' effect was more prominent.4). Bad compliance is one of important factors to uncontrolled blood pressure. Social support, negative emotion, and self-efficacy were the factors affecting compliance, furthermore, self-efficacy' affection was most prominent. Therefore, where the shoe pinches to improve treatment compliance was increasing the patients' self-efficacy.In summary, the results indicated: the group intervention based on community health service center, which was built through feasibility analysis under scientific guidance theory was a more effective, more efficient, and patient-oriented disease management model. It can be applied for hypertensive management as a complementary model for the existing chronic diseases management models.