Original Article

Community Primary Care-Based Hypertension and Diabetes Management Program in Korea: Evaluation of Participating Patients and Doctors


Background: This study was conducted to examine the effectiveness of a community-based primary care program focused on hypertension and diabetes in Korea.

Methods: We selected patients and doctors who participated in the community-based primary care program as study subjects from Aug 2015 to Jan 2016. Patients and physicians completed a survey, and medical records were reviewed to obtain information regarding clinical variables. Change in the baseline recognition of diseases, motivation for changing health behavior, medical services utilization, doctor-patient relationship were assessed after participation in the program.

Results: Both patients and physicians indicated there was improvement in recognition of disease, motivation for changing health behavior, medical services utilization, and doctor-patient relationship (All of recognition scores were above the median point). Patient health behavior such as exercise, smoking, drinking and diet and clinical variables (blood pressure and blood glucose and cholesterol level) also showed significant improvement.

Conclusion: The community-based primary care program was found to be helpful in improving hypertension and diabetes patients’ overall outcomes and their healthcare providers’ behavior.

1. KCDC (2016) 2016 Health Promotion Statistics Year Book I—Korea National Health and Nutrition Examination Survey (KNHANES VII-1) [in Korean].
2. Knoops KT, de Groot LC, Kromhout D, et al (2004). Mediterranean diet, lifestyle factors, and 10-year mortality in elderly European men and women: the HALE project. JAMA, 292:1433-1439.
3. Proia KK, Thota AB, Njie GJ, et al (2014). Team-based care and improved blood pressure control: a community guide systematic review. Am J Prev Med, 47:86-99.
4. Balk EM, Earley A, Raman G, et al (2015). Combined diet and physical activity promotion programs to prevent type 2 diabetes among persons at increased risk: a systematic review for the Community Preventive Services Task Force. Ann Intern Med, 163:437-451.
5. OECD (2012). OECD Reviews of Health Care Quality: Korea 2012.
6. Cho J, Kwon Y, Jung S (2015). Community based health care service design on chronic disease for enhancing primary care and the status of community based primary care project. Korean J Fam Pract, 5:173-178.
7. Pruitt S (2002). Innovative care for chronic conditions: building blocks for action: global report. ed. World Health Organization.
8. Kim H-S, Suh Y, Kim M-S, et al (2019). Effects of Community-Based Primary Care Management on Patients With Hypertension and Diabetes. Asia Pac J Public Health, 31:522-535.
9. Kim HS, Yoo B-N, Lee EW (2018). Evaluation of the national chronic diseases management policy: performance and future directions. Public Health Aff, 2:105-120.
10. Saltman R, Bankauskaite V, Vrangbaek K (2005). Primary care in the driver's seat?: Organizational reform in European primary care. ed. McGraw-Hill Education (UK).
11. Willcox S, Lewis G, Burgers J (2011). Strengthening primary care: recent reforms and achievements in Australia, England, and the Netherlands. Issue Brief (Commonwealth Fund), 27:1-19.
12. Baena CP, Olandoski M, Younge JO, et al (2014). Effects of lifestyle-related interventions on blood pressure in low and middle-income countries: systematic review and meta-analysis. J Hypertens, 32:961-973.
13. Provost S, Pineault R, Grimard D, et al (2017). Implementation of an integrated primary care cardiometabolic risk prevention and management network in Montreal: does greater coordination of care with primary care physicians have an impact on health outcomes? Health Promot Chronic Dis Prev Can, 37:105-113.
14. Pezzin LE, Feldman PH, Mongoven JM, et al (2011). Improving blood pressure control: results of home-based post-acute care interventions. J Gen Intern Med, 26:280-6.
15. Friedberg JP, Rodriguez MA, Watsula ME, et al (2015). Effectiveness of a tailored behavioral intervention to improve hypertension control: primary outcomes of a randomized controlled trial. Hypertension, 65:440-6.
16. Yim J (2012) The effects assessment of chronic care management based on primary clinics for hypertension, diabetes patients, Korea Health Promotion Institute, Jung-gu, Seoul
17. Cheong W, Yim J, Oh DK, et al (2013). The Effect of a Clinic Based Incentive Program on Medication Adherence among Patients with Hypertension or Diabetes Mellitus in Incheon. ed.
18. Seo JR, Bae SS (2011). The Effect of Metabolic Syndrome Management Program in a Public Health Center. ed.
19. WY L (2013). The Second Year Effectiveness Evaluation of the Gwangmyeong-si CVD Patient Registry Project, Korea Centers for Disease Control & Prevention, Cheongju, Chung-cheong bukdo
20. Duclos M, Dejager S, Postel-Vinay N, et al (2015). Physical activity in patients with type 2 diabetes and hypertension–insights into motivations and barriers from the MOBILE study. Vasc Health Risk Manag, 11:361.
21. Shin DS, Kim CJ, Choi Yj (2016). Effects of an empowerment program for self‐management among rural older adults with hypertension in S outh K orea. Aust J Rural Health, 24:213-219.
22. Alefishat EA, Farha RKA, Al-Debei MM (2017). Self-reported adherence among individuals at high risk of metabolic syndrome: effect of knowledge and attitude. Med Princ Pract, 26:157-163.
23. Aucott L, Rothnie H, McIntyre L, et al (2009). Long-term weight loss from lifestyle intervention benefits blood pressure? A systematic review. Hypertension, 54:756-762.
24. Langford AT, Solid CA, Gann LC, Rabinowitz EP, Williams SK, Seixas AA (2018). Beliefs about the causes of hypertension and associations with pro-health behaviors. Health Psychology, 37:1092.
25. Ahn YH, Ham OK (2016). Factors associated with medication adherence among medical-aid beneficiaries with hypertension. West J Nurs Res, 38:1298-1312.
26. Bai G, Zhang J, Zhao C, et al (2017). Adherence to a healthy lifestyle and a DASH-style diet and risk of hypertension in Chinese individuals. Hypertens Res, 40:196.
27. Masala G, Bendinelli B, Occhini D, et al (2017). Physical activity and blood pressure in 10,000 Mediterranean adults: The EPIC-Florence cohort. Nutr Metab Cardiovasc Dis, 27:670-678.
28. Christensen AJ, Howren MB, Hillis SL, et al (2010). Patient and physician beliefs about control over health: association of symmetrical beliefs with medication regimen adherence. J Gen Intern Med, 25:397-402.
29. Sewitch MJ, Abrahamowicz M, Dobkin PL, et al (2003). Measuring differences between patients' and physicians' health perceptions: the Patient–Physician Discordance Scale. J Behav Med, 26:245-264.
IssueVol 51 No 7 (2022) QRcode
SectionOriginal Article(s)
DOI https://doi.org/10.18502/ijph.v51i7.10096
Hypertension Diabetes Primary care Chronic disease Community medicine

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How to Cite
Kim H-S, Yoo B-N, Lee E-J, Lee E-W, Park J-H. Community Primary Care-Based Hypertension and Diabetes Management Program in Korea: Evaluation of Participating Patients and Doctors. Iran J Public Health. 2022;51(7):1618-1628.