天津市某城市社区慢性病综合防治效果评估

目的对天津市某社区为期2年的慢性病社区综合防治项目进行效果评估。方法在天津市某社区街道依据自愿参加的原则,滚动式纳入3030名社区居民。依据居民健康情况进行分类,对其中高血压患者、超重且向心性肥胖患者进行血压和体重的综合干预以及随访管理,并于项目结束时进行效果评估。结果参加项目的3030名居民中,一般人群占23.3%、高危人群占35.1%、慢性病患者占41.6%;纳入血压管理1015人、体重管理者739人;对项目全部人群进行终末调查发现,收缩压、舒张压、腰围等指标有所下降,血压控制率提高,差异均有统计学意义（P〈0.05）;参加血压管理的高血压患者,收缩压由管理前的（135.56±15.32）mmHg下降到管理后的（133.73±11.58）mmHg,舒张压由管理前的（84.68±10.00）mmHg下降到管理后的（82.72±7.56）mmHg,血压控制率随随访次数的增加而呈上升趋势;参加体重管理的超重且向心性肥胖者,干预前后腰围、体重和BMI差异无统计学意义（P〉0.05）。结论通过在社区中开展慢性病综合干预项目,参加血压管理、体重管理以及其他项目人群的血压、体重等指标均有所下降,综合干预效果显著。

Evaluation of chronic diseases control and prevention in urban community of Tianjin

Objective To evaluate effect of integrative chronic diseases control and prevention in a community of Tianjin City from 2008. 11 to 2010. 11. Methods 3030 community residents were enrolled in ＂Integrative chronic diseases control and prevention in community project＂ voluntarily. All participants were classified by their health status, and pa- tients of hypertension, overweight, central obesity were given integrative intervention and follow-up visit. Effect of this project was evaluated at the end of the project. Results Among 3030 participants, 23.3% of them were low risk popula- tion, 35. 1% were high risk population and 41.6% were chronic diseases patients, respectively. 1015 participants were joined in blood pressure management and 739 participants were joined in body weight management. At the end of this pro- ject, systolic blood pressure （ SBP）, diastolic blood pressure （ DBP）, waistline were decreased and blood pressure con- trol rate was increased significantly （P 〈 0. 05）. SBP of hypertension patients who participated blood pressure management were decreased from （ 135.56 ± 15. 32） mmHg to （ 133.73 ± 11.58 ） mmHg, DBP were decreased from （ 84. 68 ± 10. 00） mmHg to （82. 72 ±7.56） mmHg （P 〈 0. 05）. With the increasing of visit time, blood pressure control rate were increased. The body weight, waistline and BMI of overweight patients who participated in bodyweight management had no difference before and after intervention （P 〉 0. 05 ）. Conclusion Blood pressure of participants who were joined in blood pressure management are decreased after two years comprehensive intervention. Effect of integrative chronic disea- ses control and prevention are remarkable.