城市社区慢性非传染性疾病综合防控建设示范

目的通过城市慢性非传染性疾病综合防治示范社区建设探索以社区为平台，社区卫生服务机构适宜技术用于控制城市社区慢性非传染性疾病发生发展，促进社区参与和提高健康管理水平。方法利用社区卫生服务可及性、连续性、家庭医生服务模式，以社区为基础的一级教育、二级随访、三级治疗分级干预流程和网络；进行信息化条件下社区病例综合管理。结果50～60岁中老年人健康体检结论回顾性评价居民生物危险因素降低了2．87％，其中高血压发生降低了10．99％：高血糖发生降低了2．48％；高血压、糖尿病慢性病新发病例筛查登记下降了17．1％；问卷调查自我血压水平知晓率达到80．4％。结论慢性病的发生和快速发展有效控制除环境因素和生活方式改变外，基层社区卫生服务机构的干预能力是重要的因素，社区的参与配合能够使慢病防控工作做到实处。

Urban communities with chronic non-communicable diseases prevention and control of the construction of demonstration

Objective Through city chronic non-communicable diseases prevention and treatment demonstration community construction community as a platform,community health service institutions appropriate technology is used to control the city of chronic non-communicable diseases in community development,contributing to community participation and improve health management level.Methods For utilizing community health services accessibility,continuity,the family doctor service mode,community-based primary education,two follow-up,treatment of grade three grade intervention process and network;information under the condition of community case management.Results 50~60 old elderly health examination conclusion: retrospective evaluation of residents of biological risk factors decreased by 2.87%,in which hypertension reduced 10.99%;Hyperglycemia occurred decreased 2.48%;hypertension,diabetic chronic disease screening for registration of new cases dropped 17.1%;questionnaire survey;self blood levels of awareness rate reached 80.4%.Conclusion The incidence of chronic diseases and the rapid development of effective control in addition to environmental factors and lifestyle changes,community health service organizations intervention ability is the important factor.Community participation can slow disease prevention and control work done.