目的评价高血压、糖尿病患者在自我管理项目实施1年后的效果,为制定慢性病防治策略提供依据。方法 2012年在常州市武进区农村社区中根据自愿报名的原则选取高血压和(或)糖尿病患者518例,并根据社区、年龄、性别等进行匹配,挑选对照组518例。干预组接受《高血压自我管理》和《糖尿病自我管理》课程,对照组接受常规慢性病管理,比较两组慢性病患者在干预1年后各评价指标的变化。结果干预组和对照组干预前各指标间差异均无统计学意义(P>0.05)。干预实施1年后,单纯高血压干预组的收缩压(SBP)[(135.24±19.72)mm Hg]、舒张压(DBP)[(82.07±7.35)mm Hg]均低于对照组干预后[分别为(139.67±20.36)、(85.01±8.67)mm Hg],差异有统计学意义(P<0.05);高血压合并糖尿病干预组的体质指数(BMI)[(25.19±3.10)kg/m2]、SBP[(132.85±19.99)mm Hg]、DBP[(80.78±8.47)mm Hg]、空腹血糖(FPG)[(7.19±2.35)mmol/L]均低于对照组[分别为(25.95±3.02)kg/m2、(136.70±20.12)mm Hg、(83.67±9.73)mm Hg、(7.87±2.72)mmol/L],差异均有统计学意义(P<0.05)。干预后,单纯高血压组和高血压合并糖尿病组血压控制率(分别为64.96%、65.09%)高于对照组(分别为44.02%、43.79%),差异有统计学意义(P<0.05);单纯糖尿病组和高血压合并糖尿病组血糖控制率(分别为48.57%、44.97%)高于对照组(分别为19.05%、19.53%),差异有统计学意义(P<0.05)。结论开展社区高血压和糖尿病自我管理项目较传统的社区慢性病随访和健康教育模式更能改善患者不良的生活方式,建立健康的行为习惯,有效降低血压、血糖水平,提高血压、血糖控制率。 Objective To evaluate the effect of hypertension and diabetes patients self-management project one year after the implementation, to provide basis for the development of strategies for prevention and control of chronic diseases. Methods A total of 518 cases of hypertension and / or diabetes were selected according to the principle of voluntary enrollment in rural community of Wujin District, Changzhou City in 2012. 518 cases of control group were selected according to community, age and gender. The intervention group received courses of “self-management of hypertension” and “self-management of diabetes”, and the control group underwent routine chronic disease management. The changes of each evaluation index of patients with chronic diseases in two groups after one year of intervention were compared. Results There was no significant difference between the intervention group and the control group before intervention (P> 0.05). SBP (135.24 ± 19.72 mm Hg) and DBP (82.07 ± 7.35 mm Hg) in the intervention group were lower than those in the control group after intervention for one year (P <0.05). The body mass index (BMI) [(25.19 ± 3.10) kg / m 2] in hypertensive patients with diabetes mellitus group was significantly higher than that in the hypertensive patients with diabetes mellitus (139.67 ± 20.36 vs 85.01 ± 8.67 mm Hg, respectively) SBP was (132.85 ± 19.99) mm Hg, DBP was 80.78 ± 8.47 mmHg and FPG was 7.19 ± 2.35 mmol / L, respectively, which were lower than that of the control group (25.95 ± 3.02, kg / m2, (136.70 ± 20.12) mm Hg, (83.67 ± 9.73) mm Hg, (7.87 ± 2.72) mmol / L respectively). There were significant differences between the two groups (P <0.05). After the intervention, the blood pressure control rates (64.96%, 65.09%) in hypertension group and hypertension with diabetes mellitus group were higher than those in control group (44.02%, 43.79%, respectively), the difference was statistically significant (P <0.05). The control rate of blood glucose (48.57%, 44.97%, respectively) in simple diabetic group and hypertensive diabetic group was significantly higher than that in control group (19.05% and 19.53%, respectively) (P <0.05). Conclusion Compared with traditional community chronic disease follow-up and health education model, community hypertension and diabetes self-management project can improve patients’ bad lifestyles, establish healthy behaviors, reduce blood pressure and blood sugar level, and increase blood pressure and blood sugar control rate.