摘要
Abstract
Aim: To evaluate the effect of health management and disease management in community chronic non -communicable disease (NCD) integrated intervention , and explore working mechanism and management pattern of NCD inte -grated intervention that can sustainably develop at the basic level . Methods: The cluster sampling was adopted to select res -idents aged above 35 years and regular follow-up visiting was performed. Research of improving behavior and controlling the risk factors with group intervention and individual intervention was performed . ReSUltS; After intervention, the level of diastole pressure (t = 0. 540 , P = 0. 025 ) , hypertension patient blood pressure control rate (χ2 = 16.819,P<0.001), high risk group proportion (χ2 =46. 891 , P < 0. 001) , new hypertension crowds proportion ( χ2 = 20. 390 , P < 0. 001) , smoking rate( χ2 =3. 904 , P = 0. 048 ) , overweight obese crowd proportion ( χ2 =3. 873 , P = 0. 049 ) , NCD patient knowing rate (X2 = 50. 798 , P < 0. 001) , taking medicine rate (χ2 = 9. 466 , P = 0. 002) , controlling rate (χ2= 7. 893 , P = 0. 005 ) , blood4at abnormity rate of high risk group and NCD patients showed to be significantly declined (χ2 =9. 998 , P = 0. 002). The full proportion of physical training level of high risk group and NCD patients showed to be significantly improved (χ2 = 7. 326, P =0. 007). Conclusion; Health management and disease management in community chronic non -communicable disease integrated intervention is feasible and effective .关键词
社区/健康管理/疾病管理/慢性非传染性疾病/评价Key words
community / health management/ disease management/ chronic non -communicable disease / assessment分类
医药卫生
