关键词: 健康生态学；农村；老年人；高血压；疾病管理

Abstract: Objective: To develop and evaluate a disease management program for elderly hypertensive patients in rural areas, providing a reference for grassroots hypertension management practices. Methods: Based on the health ecology theory, a disease management program for elderly hypertensive patients in rural areas was constructed through literature analysis, semi-structured interviews, and expert consultation. In November 2023, four administrative villages in a county of Zhuzhou were selected by cluster sampling and divided into an intervention group and a control group (2 villages in each group), with a total of 235 elderly hypertensive patients enrolled as the research subjects. The control group received routine chronic disease management, while the intervention group received the newly developed program. Blood pressure, medication adherence, self-management ability, and quality of life were compared between the two groups before the intervention and at 3 and 6 months post-intervention. Results: The trends in blood pressure values over time differed between the two groups of patients (P<0.05). At 6 months after the intervention, the systolic blood pressure of the intervention group was 142.56±9.23 mmHg and the diastolic blood pressure was 81.96±9.19 mmHg, both lower than the control group's 147.63±14.72 mmHg and 85.82±12.14 mmHg, respectively (P<0.05). The trends of medication compliance, quality of life, and self-management ability over time also differed between the two groups of patients (all P<0.05). Conclusion: The disease management program for rural elderly hypertensive patients, constructed based on the health ecology theory, effectively improves blood pressure control, medication adherence, quality of life and self-management ability of elderly hypertensive patients in rural areas.

Key words: health ecology; rural area; the elderly; hypertension; disease management