Objective: To discuss the effects of continuous and normative community hypertension health management. Methods:Cluster sampling method was used to implement the hypertension grading management of registered residents in Outang Commu-nity, Wuxi city since January 2008. Detailed information were recorded for patients'general condition, living and exercise hab-its or drug taking behaviors, through the way of questionnaires, telephone follow - up and random visits in each year. Inde-pendent samples t test used to find out the main influencing factors of hypertension control rate in 2008 and 2009, and based on the results, intervention was provided in the last three years. After the intervention, the change of influencing factors and man-agement effect were evaluated by using chi square test. Results: After five years health intervention, hypertension control rate influencing factors have been effectively controlled, differences were significant before and after intervention (P < 0. 05), the most obvious changed factors of living habits were exercise and salt condition ( χ2 values were 422. 736 and 171. 94, P <0. 05), drug taking behaviors were obviously improved (χ2 values were 406. 952, 197. 949 and 552. 778, P < 0. 05); The hy-pertension control rate of Outang Community were obviously increased from 35% in 2008 to 64% in 2012, difference were sig-nificant (P < 0. 05). Conclusion: These data suggest that the targeted, continuous and normative community hypertension health management and intervention has beneficial effects on blood pressure control and in reducing variable influencing factors. The intervention not only can adjust the patients daily living habits, but also can improve the drug behaviors, so it has an im-portant and guidance meaning for other community in the management of chronic diseases.%目的：探讨连续、规范社区高血压健康管理的成效。方法文章采取整群抽样的方法,自2008年1月开始对无锡市藕塘社区户籍居民实施高血压分级管理,每年通过问卷调查、电话回访和随机走访等方式详细记录患者的一般情况、生活习惯、运动和服药行为等信息。独立样本 t 检验阐述该社区2008年及2009年的高血压控制率的主要影响因素,并在后续3年的管理中给予重点干预。管理结束后通过卡方检验来评估高血压患者关键影响因素的变化情况及管理效果。结果经过5年的健康干预,藕塘社区的高血压控制率影响因素均得到有效控制,干预前后对比具有统计学意义(P <0.05),其中生活方式中改变最明显的为患者运动情况和摄盐情况(χ2分别为422.736和171.94,P<0.05),服药行为均得到显著改善(χ2分别为406.952、197.949和552.778,P <0.05)；藕塘社区的高血压控制率由2008年的35%提升至2012年的64%,差异具有统计学意义(P <0.05)。结论通过有针对性的、连续规范的社区高血压健康管理与干预,可以有效地降低和改善高血压的可变影响因素。调整患者日常生活方式的同时改进其服药行为的规律性,对指导和管理其他社区慢性疾病亦有重要的指导意义。
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