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目的探讨以家庭为单位联合社区医疗网络对高血压病进行群体和个人管理相结合管理模式下高血压的生存质量和社会支持情况。方法以三水西南街道康华、布心、沙头、园林、文峰东等5个居委为主要试点,在知情同意的基础上筛选检出的原发性高血压个体300人300户家庭,按综合医院负责指导培训和负责高血压重症;社区医院负责轻症管理、建档、健康教育、随访、转诊;高血压群组和家庭成员互相协助、督促的综合管理模式,随访观察1年后评价患者在干预前后的生存质量。结果经以家庭为单位的各级医疗网络联合干预后,高血压患者生存质量在生理职能、身体疼痛、一般健康、精力、社会功能和精神健康等6个维度中,均比干预前得分高,差异具有统计学意义(P<0.05);而生理功能、情感职能两项,干预前后没有发生明显差异(P>0.05)。社会支持评价在综合干预后主观支持和社会支持总分有明显提升,差异有统计学意义,而客观支持和对支持的利用度偏低,干预前后无明显差异。结论建立综合医院为指导,社区医院负责轻中症治疗、随访、宣教,高血压群组和家庭成员互相协助、配合、督促,群体管理和个人自我管理相结合的综合医院-社区医院-高血压家庭群组-家庭户-个人的管理模式能提高高血压患者的生存质量。
Objective To explore the quality of life and social support for hypertension in a community-based and community-based medical network with a combination of group and individual management of hypertension. Methods A total of 300 families of 300 individuals with essential hypertension were screened out on the basis of informed consent from 5 neighborhood committees including Kanghua, Buxin, Shatou, Garden and Wenfengdong in Sanshui Southwest Street. , According to the general hospital is responsible for the guidance and training and is responsible for severe hypertension; community hospital is responsible for the management of mild, build files, health education, follow-up, referral; hypertension group and family members to each other, supervise the integrated management model, follow- Years after the evaluation of patients in the quality of life before and after intervention. Results After the joint intervention of family-level medical network, the quality of life of hypertensive patients was higher than those before intervention in six dimensions of physical function, body pain, general health, energy, social function and mental health, (P <0.05). However, there were no significant differences in physiological function and emotional function before and after intervention (P> 0.05). Social support evaluation in the comprehensive intervention subjective support and social support score has improved significantly, the difference was statistically significant, and objective support and utilization of support is low, no significant difference before and after intervention. Conclusions The establishment of a general hospital is the guide. The community hospital is responsible for the treatment of mild to moderate disease, follow-up, mission, hypertensive group and family members to help each other, cooperate, supervise, group management and personal self-management combined general hospital - Community Hospital - Hypertension Family group - family - individual management model can improve the quality of life of hypertensive patients.