Table 1 Inclusion and exclusion criteria

Diagnosed with primary hypertension /type 2 diabetes and has been on medications for more than 1 month.^a

Aged 35–75.

Has lived in the intervention/control areas for more than 2 years, no records of moving within the last year.

Has his/her records on the chronic disease management information system of township health centre or village clinic.

Has accepted the chronic disease service provided by township health center or village clinic.

Is willing to participate in the project and has a preferable compliance, cognition and receptivity.

Has serious complications related to diabetes or hypertension.

Has been diagnosed with secondary hypertension.

Has been diagnosed with any other serious disease.

Is pregnant or has psychiatric problems.