金华市社区糖尿病综合防治管理模式探讨

目的：评价糖尿病社区综合防治管理效果。方法：通过设立试点社区和对照社区开展综合防治管理一年半以后，对病人的发现率，对病人和病人家属知信行情况改变以及病人家属对病人的督导率的改变和社区糖尿病管理率的变化进行考评。结果：社区糖尿病的发现病人数（率），社区卫生服务站的糖尿病建档人数和病人管理率，病人和家属的糖尿病防治知识的知晓率，家庭成员对病人督导率均提高，病人生活方式有所变化，病人的规范服药率明显提高。在试点社区和对照社区之间的差异显著。结论：“以卫生行政部门为领导，疾病预防控制机构为中心，医疗机构为诊疗支撑，社区卫生为服务平台，患者家庭为辅助”的社区糖尿病综合防治管理模式有一定效果。

Comprehensive diabetes prevention and management model in communities of Jinhua city

Objective To evaluate the effect of comprehensive diabetes prevention and management in community. Method After comprehensive diabetes prevention and management has been carried on in pilot community and control community for a year and a half, the change of knowledge-belief-behavior of patient and patient＇s family, the rate of patient＇s family supervising patient and the rate of diabetes management were assessed. ResultsThe number of patients found in pilot community increased obviously than that in control community, as well as the rate of diabetes records which were filed in centre of community health service. Higher rate of patients and patients＇ family has knowledge about diabetes prevention in pilot community, and more diabetes patients changed their unhealthy lifestyles and took medicine more normatively. Conclusion The results suggest that carrying out comprehensive diabetes prevention and management model in community is effective.