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[目的]了解南京市社区居民社区综合干预前后有关慢病的知识、态度、行为(KAP)的改变情况,探讨健康教育和社区干预在慢病综合防治中的作用。[方法]2004年7月在南京市3个城区和1个郊县分别随机整群抽取1个社区,以社区35岁及以上人群(n=4,293)为研究对象。在完成基线调查的情况下,对4个社区的研究对象实施健康教育、健康促进、临床义诊、定期随访等干预措施,于2007年7月份进行终点调查,整个现场干预和随访期限为3年。[结果]干预前后糖尿病病人的患病知晓率(36%,51.7%),治疗率(33.7%,44.6%),血糖控制率(11.3%,21.6%)显著明显增加。慢病知、信、行水平干预后较干预前均有不同程度的提高。居民定期测量血压率显著提高(13.0%,18.5%,χ2=44.25,P﹤0.01);饮酒比例下降显著(24.3%,17.9%,χ2=47.93,P﹤0.01)。[结论]以社区为基础、以健康教育和健康促进为中心内容的的慢病综合干预措施在当前我国的现实情况下切实可行且行之有效。
[Objective] To understand the changes of knowledge, attitudes and behavior (KAP) about chronic diseases before and after community-based intervention in community in Nanjing, and to explore the role of health education and community intervention in the comprehensive prevention and treatment of chronic diseases. [Method] In July 2004, one community was randomly selected in three urban areas and one suburban area of Nanjing City, respectively. The population aged 35 years and over in the community (n = 4,293) was selected as the research object. At the completion of the baseline survey, end-point surveys were conducted in July 2007 on interventions such as health education, health promotion, clinical volunteer visits and regular follow-up for the four community study subjects. The entire field intervention and follow-up period was 3 years. [Results] The prevalence of diabetes (36%, 51.7%), the treatment rate (33.7%, 44.6%) and the rate of glycemic control (11.3%, 21.6%) were significantly increased before and after intervention. Slow disease knowledge, letter, line horizontal intervention than before intervention were improved to varying degrees. The rate of drinking regularly decreased significantly (13.0%, 18.5%, χ2 = 44.25, P <0.01). The proportion of drinking decreased significantly (24.3%, 17.9%, χ2 = 47.93, P <0.01). [Conclusion] The comprehensive interventions for chronic diseases based on community and centered on health education and health promotion are practical and effective under the current conditions of our country.