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Main indicators of work guidance scheme for comprehensive prevention and control demonstration area of chronic non-communicable diseases
1. Knowledge awareness rate: the knowledge awareness rate of chronic diseases in the demonstration area is over 70%; The awareness rate of self blood pressure level reached 70%, and the awareness rate of self blood sugar level reached 30%.

2. The formation rate of healthy behavior: the smoking rate of adult men should be controlled below 60%; The daily salt intake per capita is less than 8 grams; The proportion of adults who exercise more than 6000 steps a day exceeds 35%.

3. Early detection rate of chronic diseases: the registration rate of hypertension and diabetes is not less than 60% of the local survey prevalence rate or the national average prevalence rate; The early diagnosis rate of key cancers in the intervention population is not less than 50%.

4. Chronic disease management rate: the standardized management rate of hypertension and diabetes in the population is not less than 35% and 30% respectively.

5. Control rate of chronic diseases: The control rates of blood pressure and blood sugar of hypertension and diabetes are not less than 30% and 25% respectively.

Second, the demonstration area work content

The demonstration area can creatively determine the work content of this area according to the basic contents put forward in this guiding scheme.

(1) Collect basic data and carry out community diagnosis related to chronic diseases. Collect, integrate and analyze the basic information and data of the demonstration area, and establish the basic information database of the demonstration area. Analyze the epidemic situation and risk factors of major local chronic diseases, determine key target groups and priority areas, and determine main strategies and action measures.

(2) Establish and improve the chronic disease monitoring system. Gradually establish and improve the chronic disease monitoring system covering the whole people in the demonstration area, including at least the basic contents of chronic disease etiology monitoring, tumor registration, cardiovascular and cerebrovascular event reporting, chronic disease risk factor monitoring and basic public health service project information, and continuously improve the monitoring quality. Establish a chronic disease information management platform, and regularly publish information related to the prevention and treatment of chronic diseases in demonstration areas.

(3) extensive health education and health promotion. Give full play to the role of mass media in the prevention and control of chronic diseases, highlight local characteristics, carry out health education and health promotion activities around key contents such as controlling tobacco consumption, promoting reasonable and balanced diet, and promoting fitness activities, and establish a long-term operating mechanism. The basic requirements are as follows:

1. Local major media should set up fixed publicity columns and extensively carry out publicity and education on the prevention and treatment of chronic diseases.

2. Professional institutions for the prevention and treatment of chronic diseases in districts and counties provide health education data templates and core information for primary health service institutions every year, and can meet relevant quantitative requirements.

3. Community neighborhood committees (village committees) conduct health lectures and consultations for residents, set up publicity columns for comprehensive prevention and treatment of chronic diseases, distribute publicity materials related to the prevention and treatment of chronic diseases, and popularize knowledge and concepts on the prevention and treatment of chronic diseases.

4. The school provides health education courses related to chronic diseases for students. Use kindergarten parent-teacher conferences and other forms to hold lectures on reasonable diet and oral health care.

5. The government organizes all sectors of society to actively support and participate in national hypertension day, United Nations Diabetes Day, cancer prevention publicity week, World No Tobacco Day, National Fitness Day, National Healthy Lifestyle Action Day, national love teeth day and other publicity activities.

(4) In-depth promotion of healthy lifestyles for all. Carry out a nationwide healthy lifestyle campaign for the whole people, popularize simple technologies and appropriate tools, and improve residents' self-management and health skills. The basic requirements are as follows:

1. government organizations, multi-sector participation, extensive mass fitness activities,

Encourage the masses to participate in fitness activities extensively. Organs, enterprises, institutions and schools create a supportive environment conducive to sports activities, organize employees to carry out mass fitness activities, implement a workplace exercise and fitness system, and implement sunshine sports for hundreds of millions of students across the country.

2. Promote food nutrition labels, encourage and guide food production enterprises to develop and produce healthy foods with low sugar, low fat and low salt, publicize reasonable dietary knowledge through health education, and scientifically guide people to have a reasonable and balanced diet.

3. The government departments take the lead, and the whole society carries out tobacco control actions to create smoke-free places and units.

4 to create a national healthy lifestyle action demonstration community, demonstration unit, display

Fan canteen or demonstration restaurant.

(5) Pay attention to high-risk groups of chronic diseases and take preventive intervention measures.

1. All kinds of units provide regular physical examinations for employees to find high-risk groups and patients with chronic diseases as early as possible. Set up self-service detection points for health indicators where conditions permit, and provide simple equipment for physical measurement.

2. All kinds of medical institutions at all levels should implement the blood pressure measurement system for people over 35 years old and provide services such as measuring height, weight, waist circumference and blood sugar.

3. Implement management and health guidance for high-risk groups of chronic diseases such as overweight and obesity, normal and high blood pressure, impaired glucose regulation, dyslipidemia and current daily smokers.

4. Carry out dental caries examination focusing on children in conditional areas, fill the dental caries found in children as soon as possible, and seal the pit and fissure for school-age children.

(six) to strengthen the prevention and treatment of chronic diseases at the grassroots level and standardize the management of patients with chronic diseases. Implement the national basic public health service standards, strengthen the standardized management of patients with chronic diseases, and improve the management rate of hypertension and diabetes in communities. Establish a chronic disease management information system to evaluate the effect of chronic disease management. Strengthen the self-management function of patients with chronic diseases and popularize the mode of "self-management group for patients with chronic diseases". It is used for chronic patients such as hypertension, diabetes, and stroke recovery period. , community neighborhood committees (village committees) and workplaces as a unit, organize patients to understand chronic diseases, exchange prevention and treatment experience, and gradually improve the self-management ability of patients with chronic diseases.

Third, safeguard measures.

(1) Organize leaders. Establish a leading group for comprehensive prevention and control of chronic diseases in the demonstration area and establish a multi-sectoral cooperation mechanism. The main leaders of the local government are the group leaders, and the heads of development and reform, finance, health, social security, publicity, education, civil affairs, sports, culture, youth league committees, trade unions, women's federations, disabled persons' federations and other relevant departments are members. The leading group has an office, which is responsible for work planning and planning, organization and implementation, coordination and management, supervision and inspection, and assessment. According to the needs of the work, organize regular leading group meetings, supervise and urge the implementation of the responsibilities of relevant departments, coordinate and solve the problems and difficulties existing in the implementation process, and ensure the smooth development of all work. A technical guidance expert group composed of experts in related fields has been set up in the demonstration area, which is responsible for technical guidance and decision-making consultation.

The Ministry of Health shall exercise unified leadership and management over the work of national demonstration zones, and organize regular inspection, supervision and evaluation. The Ministry of Health set up a demonstration area work office, which is located in China Center for Disease Control and Prevention; The provincial health administrative department shall, according to the work guidance plan, be responsible for organizing the establishment of the demonstration area for comprehensive prevention and treatment of chronic diseases within its jurisdiction; Provincial centers for disease control and prevention are responsible for technical guidance, quality control, supervision and training; The county health administrative department shall perform relevant duties under the leadership and support of the leading group of the demonstration area.

(2) Financial guarantee. The work of the demonstration area must be included in the agenda of the local government and included in the government's work tasks. The funds for the prevention and treatment of chronic diseases are included in the local fiscal budget and special funds are arranged. Establish a funding guarantee mechanism for comprehensive prevention and treatment of chronic diseases led by the government and supported by social forces to ensure the long-term sustainable development of chronic disease prevention and treatment.

In order to promote the establishment of demonstration zones in various places, the Ministry of Health will give appropriate financial support to national demonstration zones in the form of transfer payment projects.

(3) Policy guarantee. The government and relevant departments should introduce relevant policies to support the comprehensive prevention and control of chronic diseases, including media propaganda, advocating reasonable diet and low-salt diet, advocating physical exercise, strengthening tobacco control, and providing convenience for early diagnosis, early treatment and two-way referral for high-risk groups and patients with chronic diseases.

(4) Capacity building. Strengthen the construction of chronic disease prevention and control team, and set up a professional department for chronic disease prevention and control in the disease prevention and control center of the demonstration area; Grassroots medical and health institutions have special personnel responsible for the prevention and treatment of chronic diseases. District and county medical institutions have the task of preventing and treating chronic diseases.

Establish a guidance and training system, and district and county medical institutions and disease prevention and control institutions regularly provide standardized training and technical guidance for grassroots medical and health institutions in their respective jurisdictions. County-level medical institutions and primary medical and health institutions have established counterpart assistance and guidance relations to improve the comprehensive prevention and treatment ability and diagnosis and treatment technology level of primary health personnel.

Four. Monitoring and evaluation

The office of the leading group of the demonstration area shall formulate a supervision and inspection system, and regularly organize supervision, inspection and evaluation of the prevention and treatment of chronic diseases in the demonstration area.

The health administrative department at a higher level regularly or irregularly conducts on-site supervision and inspection of the demonstration area, evaluates the prevention and control measures and effects of the demonstration area, and timely reports the supervision and evaluation results.

Referring to the "Evaluation Framework of National Demonstration Zone for Comprehensive Prevention and Control of Chronic Non-communicable Diseases" formulated by the Ministry of Health (see annex), various localities have formulated implementation, supervision and evaluation plans for the comprehensive prevention and control of chronic diseases in their own regions.

Verb (abbreviation of verb) acceptance and management

Encourage all localities to actively carry out the work of comprehensive prevention and control demonstration zones for chronic diseases. In accordance with the principle of voluntary and step-by-step declaration, the Ministry of Health will organize an assessment of the demonstration areas recommended by the provincial health administrative departments in accordance with the Assessment Framework for National Comprehensive Prevention and Control of Chronic Noncommunicable Diseases (Annex), and those who pass the assessment will be named as national demonstration counties (cities, districts) for comprehensive prevention and control of chronic diseases, and will be announced. All provinces (autonomous regions and municipalities) may refer to the standards of national demonstration zones and name provincial demonstration zones according to actual conditions.

National demonstration counties (cities, districts) for comprehensive prevention and treatment of chronic diseases implement dynamic management, and the named demonstration counties (cities, districts) are evaluated regularly. Those who fail to pass the examination shall be rectified within a time limit, and those who fail to meet the requirements after the rectification period shall be disqualified from the title of National Demonstration Zone.