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目的通过对管辖区域内确诊的415例高血压患者施行社区干预,提高高血压患者的随访率、知晓率、控制率,从而更好的控制高血压,降低心血管病的危险性和死亡率。方法对2008年社区内415例高血压患者施行建档、随访、健康教育、指导饮食,运动及行为干扰,规范合理用药等综合措施,观察随访率、知晓率、控制率的变化。结果通过社区高血压综合干预,干预前后比较,高血压随访率、知晓率、控制率的48.4%、62.2%、50.1%上升为97.9%、94.9%、84.5%。结论高血压患者制定个体化健康指导方案,定期随访干预,开展据悉继续教育等综合干预措施是高血压防治工作最有效的手段和高血压病防治的最佳途径。
OBJECTIVE To better control hypertension and reduce the risk of cardiovascular diseases and death rate through community intervention in 415 hypertensive patients diagnosed in jurisdiction and improve the follow-up rate, awareness rate and control rate of hypertensive patients. METHODS: A total of 415 hypertensive patients in the community were enrolled in this study. Follow-up, health education, dietary intervention, exercise and behavioral disturbance, standardized medication and other comprehensive measures were adopted to observe the changes of follow-up rate, awareness rate and control rate. Results The community-based hypertension intervention increased from 48.4%, 62.2% and 50.1% to 97.9%, 94.9% and 84.5%, respectively, before and after the intervention, follow-up rate of hypertension, awareness rate and control rate. CONCLUSIONS: Individualized health guidance programs for hypertension patients and regular follow-up interventions to carry out comprehensive interventions such as continuing education are reported to be the most effective means of prevention and treatment of hypertension and the best way to prevent and control hypertension.