Objective To understand the need and assessment of hypertensive patients in community in Shanghai for community-based health instructive follow-up, and to provide the evidence for the strategy towards improving the community-based follow-up management on hypertensive patients. Methods 1018 key management hypertensive patients were randomly selected from Hypertensive Follow-up Management System in Changning, Shanghai. They were interviewed face to face with self-planned questionnaire by trained team. Results 97. 3% of the patients had recognized the necessity of the follow up management, and 99. 1% of the patients were satisfied with it; 50. 5% of the patients hoped to be followed up by clinicians, while 26. 0% hoped to be followed up by public health physicians. 49. 9% of the patients hoped to be followed up in Community Health Service Site. 24. 2% hoped to be followed up at home. 8. 8% hoped to be followed by phone. The total awareness rate of hypertension was relatively high, except on the complication of nephropathy (76. 7% ) and the longterm taking medicine (77. 0% ). The scores of knowledge varied in gender, management group, education level and followup methodstatistically significant difference (P < 0.01 or P < 0. 05). Conclusion Patients were considerably satisfied with the follow-up management and remained the explicit need on doctors, follow-up methods and contents.%目的 了解上海市高血压患者对社区高血压随访管理工作的评价和需求,为进一步整改和提高社区高血压随访管理水平提供依据.方法 对上海市长宁区现有的高血压患者随访管理系统中登记在册的高血压重点管理对象中随机抽取1018名高血压患者.采用自行设计调查问卷,由经过培训的调查员对高血压患者进行面对面调查.结果 97.3％的高血压患者认为高血压随访管理工作有必要,99.1％的高血压患者对医生的访视工作满意,50.5％的患者希望临床医生访视,26.0％的患者希望由公共卫生医生,49.9％的患者希望集中到社区卫生服务站点访视,24.2％的患者希望上门访视,8.8％的患者希望电话访视.被管理的高血压患者的总体知识知晓率较高,但对长期高血压易导致肾病和高血压患者血压降到正常仍需吃药这两方面知识的知晓率较低,分别为76.7％和77.0％.不同的年龄组、管理组别、文化程度和访视方式的患者高血压知识得分差异有统计学意义(P＜0.01或P＜0.05).结论 高血压患者对随访管理工作满意度较高,但对随访医生、随访方式和随访内容有进一步的需求.
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