Background Low-income Chinese women aged 60 years and older are more likely to have multiple non-communicable diseases (NCDs). Neither the independent healthcare system nor the social work system based on the communities is equipped to address their complex needs of health and daily care. The objective was to design and evaluate a social worker-led self-management program for older community-dwelling women with NCDs. MethodsA total of 144 and 138 subjects were recruited in the intervention and control groups from 10 communities in Guangzhou, China. The intervention group was designed as follows: each community recruited two social workers to carry out an NCD self-management program. A health care professional assisted social workers to complete six weekly two-hour sessions. The control group had no extra intervention. The evaluation was conducted at baseline and 12-months follow-up. Outcomes included changes in weight, blood pressure, fasting plasma glucose (FPG), lipid profile, self-management behaviors, and NCD-related knowledge. Results After 12 months, participants had gained 3.6 and 6.6 kg (P=0.025 for between-group difference) in the intervention and control groups, respectively. NCD-related knowledge increased by 15.4% and 11.3% (P<0.001 for between-group difference). The intervention group had a greater increase in self-reported exercise (87% to 95%) than the control group (81% to 85%) (P difference=0.031). General linear regression analysis showed that the intervention effects were significant for FPG (P=0.013) and total cholesterol (TC) (P=0.046).ConclusionsA social worker-led NCD self-management program successfully promoted NCD-related knowledge and decreased metabolic risk factors in low-income Cantonese women.Trial registrationChinese Clinical Trial Registry:Evaluation on effectiveness of Non-communicable Disease Self-management models led by social organization. ChiCTR1800015659. Registered 13 April 2018 - Retrospectively registered, http://www.chictr.org.cn/showproj.aspx?proj=15005