中山古镇农村社区慢性非传染性疾病综合防治模式研究

探索适合农村社区慢性非传染性疾病(慢性病)预防与控制的工作模式,切实提高慢性病的防治水平。通过基线调查及专题调查,了解本社区主要慢性病的流行状况及其危险因素,针对这些危险因素进行综合性的干预试验,并监测其变化、评价其效果。开创了“政府领导、部门协作、社区搭台、卫生唱戏”的良好格局,基本形成了以社区力量为主导,健康教育与健康促进为中心内容,基层医院医生对人群进行高血压及慢性病危险因素筛查为起点,高血压患者分级管理为主要内容的充分体现患者-高危人群-全人群策略和个人-家庭-社区三位一体的临床预防服务与社区卫生服务相结合的一体化慢性病防治模式。

On comprehensive prevention mode of chronic non-infectious diseases in Guzhen township, Zhongshan city

The purpose of this study is to explore the suitable mode of prevention and control of chronic non infectious diseases, to increase the level of prevention and cure. Through base line and special investigation, find out the main prevailing status and risk factors, and take overall intervening trial to overcome the risk factors,check the change and evaluate the effect. The trial starts a good situation of "government inducement, department cooperation, community join, health act", form an overall mode of preventing and curing chronic non infectious disease.This mode's main content are: community being as the main unit, health education and health promotion being as main content, rural hospital surveying community residents to find out the main risk factors of hypertension and chronic diseases, and supervise the hypertension patients by grade. This mode take strategies of patients high risk population public combination,person family community combination, and clinic prevention service and community health service combination.