中国全科医学 ›› 2023, Vol. 26 ›› Issue (16): 1972-1978.DOI: 10.12114/j.issn.1007-9572.2022.0677

所属专题: 全民健康最新文章合集 高血压最新文章合集

• 论著·基层卫生服务研究 • 上一篇    下一篇


张硕1,2, 付英杰1,2, 常乐乐1,2, 孙晓杰1,2,*()   

  1. 1250012 山东省济南市,山东大学齐鲁医学院公共卫生学院卫生管理与政策研究中心
    2250012 山东省济南市,国家卫生健康委员会卫生经济与政策研究重点实验室(山东大学)
  • 收稿日期:2022-09-19 修回日期:2023-02-14 出版日期:2023-06-05 发布日期:2023-03-16
  • 通讯作者: 孙晓杰

  • 作者贡献:张硕、孙晓杰负责文章的构思与设计;张硕负责论文的撰写和修订;张硕、付英杰、常乐乐、孙晓杰负责资料收集;张硕、付英杰负责数据整理和分析;孙晓杰负责文章的质量控制及审校,并对文章整体负责。
  • 基金资助:
    山东省自然科学基金资助项目--社会资本对农村居家老年高血压患者生命质量的影响路径研究(ZR2019MG013); 山东大学青年交叉科学创新群体--文旅康养产业交叉融合创新研究团队(2020QNQT019)

Qualitative Study of Health Management for Hypertensive Patients in Shandong's Rural Areas Using the Innovative Care for Chronic Conditions Framework

ZHANG Shuo1,2, FU Yingjie1,2, CHANG Lele1,2, SUN Xiaojie1,2,*()   

  1. 1Centre for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan 250012, China
    2NHC Key Lab of Health Economics and Policy Research (Shandong University), Jinan 250012, China
  • Received:2022-09-19 Revised:2023-02-14 Published:2023-06-05 Online:2023-03-16
  • Contact: SUN Xiaojie

摘要: 背景 我国农村地区高血压患病形势十分严峻,农村地区高血压健康管理工作尤为重要。 目的 基于世界卫生组织(WHO)提出的慢性病创新照护(ICCC)框架,总结山东省农村地区高血压健康管理的特点与存在的不足,并提出针对性建议。 方法 根据社会经济发展水平和山东省高血压患病率的地理分布,选取位于山东省菏泽市A县、济南市B区和威海市C市的3家县级疾控中心、9家乡镇卫生院、36个村卫生室作为样本来源地。采用目的抽样法,于2021年6—7月,选取各级高血压项目管理人员、医务人员及高血压患者共计84例为访谈对象,采用半结构式访谈法对其进行"面对面"访谈,了解山东省农村地区高血压健康管理现状。采用NVivo 12软件及由MILES和HUBERMAN提出的"综合法",并围绕ICCC框架宏观、中观、微观3个层面的要素对访谈文本进行编码和分析。 结果 针对山东省农村地区高血压健康管理现状,从宏观、中观、微观3个层面共析出13个一级节点、51个二级节点。在宏观层面,山东省农村地区高血压健康管理总体处于积极的政策环境中,贯彻和落实国家慢性病健康管理相关政策,并对慢性病健康管理进行宣传,但是政策体系框架尚不完善、卫生系统内部的融合程度不佳、高血压健康管理专业人才紧缺、经费支持不到位等问题突出;在中观层面,各医疗卫生机构努力提升医疗服务的连续性,但是在组织和配备家庭医生团队、推广和使用信息系统等方面的工作还有待进一步加强;在微观层面,患者及家庭与家庭医生团队间的配合度,以及两方参与高血压健康管理的积极性还有待提高。 结论 山东省农村地区高血压健康管理工作整体运行情况良好,但仍须:大力发挥政府的领导和监督作用,制定并整合相关政策,推动部门融合;加大经费支持力度,补齐农村地区卫生人力资源相对匮乏和信息化建设较弱的"短板",推进医疗服务高质量发展;重视患者及家庭、卫生服务团队和社区伙伴三方的互动,促进患者自我管理。

关键词: 慢性病创新照护框架, 农村, 高血压, 健康管理, 质性研究, 山东



As the prevalence of hypertension in China's rural areas is very high, hypertension management in these areas is particularly important.


To summarize the characteristics and weaknesses of hypertension management in Shandong's rural areas using the Innovative Care for Chronic Conditions Framework (ICCC) proposed by the WHO, and to put forward targeted recommendations.


According to the socio-economic level and geographical distribution of hypertension prevalence, three county-level centers for disease control and prevention, 9 town health centers and 36 village clinics were selected from A county of Heze, B district of Jinan and C city of Weihai in Shandong Province, from which 84 cases (including individuals responsible for hypertension management programs, medical workers and hypertensive patients) were selected from June to July 2021 using a purposive sampling method to attend a face-to-face semi-structured interview for understanding the status of hypertension management in Shandong's rural areas. NVivo 12 and Qualitative Data Analysis Model proposed by MILES and HUBERMAN, were used to encode and analyse the interview results using the macro-, meso- and micro-level components of the ICCC.


A total of 13 themes and 51 subthemes were derived from the analysis at three levels. At the macro level, the implementation of hypertension management in Shandong's rural areas was generally in a positive policy environment, such as implementing national policies regarding chronic disease management and publicizing chronic disease management, but the policy framework was not complete, the integration within the departments in the health system was poor, and shortages of professional hypertension managers and sufficient financial support were serious. At the meso level, various medical institutions strived to promote the continuity of medical services, but the organization and deployment of family doctor teams and the promotion and use of information systems still needed to be further strengthened. At the micro level, the cooperation between patients and their families and the family doctor team needed to be improved, and the involvement of patients and their families in hypertension management should be enhanced as well.


The implementation of hypertension management in Shandong's rural areas is good generally, but the following efforts should be made for improvements: vigorously strengthening the leadership and supervision role of the government, formulating and integrating relevant policies, and promoting the integration of relevant departments; increasing financial support, and addressing the relatively shortage of health human resources and improving the weakness of informatization construction in rural areas to promote the delivery of high-quality medical services; attaching importance to the interaction between patients and families, health service team and community partners to promote patients' self-management.

Key words: Innovative Care for Chronic Conditions Framework, Rural, Hypertension, Health management, Qualitative research, Shandong