摘要Objective: This study evaluates the community-based intervention of chronic disease management (CDM) through the Integrated Non-Communicable Diseases Health Post (Posbindu-NCD) conducted by a community of health workers (CHWs) in Indonesia's rural areas.Methods: A cohort retrospective study evaluated 577 par ticipants from Posbindu-NCD in 7 public health centers (PHCs) in 2019. Activities of intervention of CDM for Posbindu-NCD was included, identified risk factors to NCDs, and provided counselling education and other follow-ups based on interviews and measurement results from the five Desk systems that recorded in a medical record as a form of the monthly activity report each the first month, the 6 months, and the 12th month. Results: There were statistically significant differences for alcohol consumed and diabetes mellites ( χ 2 = 10.455; P = 0.001). There were significant differences on gender ( χ 2 = 3.963; P = 0.047), on ethnicity ( χ 2 = 19.873; P < 0.001), and hyper tension. In addition, there were also significant differences on ethnicity ( χ 2 = 15.307; P < 0.001), vegetable consumption ( χ 2 = 4.435; P = 0.035), physical exercise ( χ 2 = 6.328; P = 0.012), and the current diseases of hypercholesterolemia of participants. Furthermore, the survival rate among patients who have overweight, abdominal overweight, hypertension, diabetes mellitus, and hypercholesterolemia increased among par ticipants who regularly visited Posbindu-NCD compared with the non-regularly one. Conclusions: The CDM program's community-based intervention through Posbindu-NCD conducted by CHWs improved survival rates in Indonesia's rural areas. Therefore, this program can be further developed in conducting CDM in the community with the active involvement of CHWs so that the community becomes active regularly in participating in Posbindu-NCD activities in rural areas of Indonesia.