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[目的]提高居民高血压、糖尿病知识的知晓率,患者的治疗率和控制率,为农村地区高血压、糖尿病综合防治工作提供参考依据。[方法]2009～2011年,在胶南市农村地区抽取部分35岁以上常住居民进行高血压、糖尿病高危人群筛查,发现高危人群和患者,建立电子健康档案,进行强化教育和个性化随访干预,对干预效果进行分析。[结果]2009～2011年累计筛查≥35岁人群221 514人,高血压高危人群检出率为38.03%,糖尿病高危人群检出率为22.11%;高血压患病率为25.19%,糖尿病患病率为7.72%。干预前后分别调查1 280人,高血压知识知晓率干预前为30.47%,干预后为63.28%(P<0.01);糖尿病知识知晓率干预前为24.38%,干预后为43.91%(P<0.01)。干预前调查,高血压患者1 027例的治疗率为20.16%,血压控制率为12.17%;糖尿病患者442例的治疗率为37.10%,血糖控制率为23.53%。2012年3月,高血压患者16 883例的治疗率为57.70%,血压控制率为32.70%;糖尿病患者6 566例的治疗率为61.10%,血糖控制率为45.37%。干预后与干预前比较,高血压患者的治疗率与血压控制率均有明显提高(P<0.01);糖尿病患者的治疗率与血糖控制率均有明显提高(P<0.01)。[结论]在农村居民中开展高血压、糖尿病高危人群筛查、健康促进和个性化干预,可以提高居民高血压、糖尿病知识的知晓率和患者的治疗率与控制率。
[Objective] To improve the awareness of hypertension and diabetes among residents, the treatment rate and control rate of patients, and provide a reference for the prevention and control of hypertension and diabetes in rural areas. [Methods] From 2009 to 2011, some residents above 35 years old in rural areas of Jiaonan City were selected to screen high-risk population of diabetes and high-risk population. The high-risk population and patients were found, electronic health records were established, intensive education and personalized follow- The effect of intervention is analyzed. [Results] Totally 221 514 people aged ≥35 years were screened from 2009 to 2011. The detection rate of high risk population of hypertension was 38.03%. The detection rate of high risk population of diabetes was 22.11%. The prevalence of hypertension was 25.19% The prevalence was 7.72%. Before and after the intervention, 1,280 persons were investigated before and after the intervention, respectively. The awareness rate of knowledge about hypertension was 30.47% before intervention and 63.28% after intervention (P <0.01). The awareness of diabetes was 24.38% before intervention and 43.91% after intervention (P <0.01) . Before intervention, the treatment rate of 1 027 hypertensive patients was 20.16% and the blood pressure control rate was 12.17%. The treatment rate of 442 diabetic patients was 37.10%, and the blood glucose control rate was 23.53%. In March 2012, the treatment rate of 16 883 hypertensive patients was 57.70% and the blood pressure control rate was 32.70%. The treatment rate of 6 566 diabetic patients was 61.10%, and the blood glucose control rate was 45.37%. Compared with before intervention, the treatment rate and blood pressure control rate were significantly increased in patients with hypertension (P <0.01). The treatment rate and blood glucose control rate in patients with diabetes mellitus were significantly increased (P <0.01). [Conclusion] To carry out screening, health promotion and individualized intervention of high risk population of hypertension and diabetes in rural residents can improve the residents’ awareness of hypertension and diabetes and the treatment rate and control rate.