目的： 评估在内蒙古自治区包头市实施的基于ICCC模型以社区参与为主预防糖尿病视网膜病变(DR)致盲的综合干预进行效果。

方法： 共470例DR患者纳入本研究，并分为对照组和研究组。对照组接受传统以卫生机构主导的慢病管理模式进行干预预防糖尿病视网膜盲，研究组接受基于ICCC模型重新设计的以社区参与为主的综合干预。在干预前的和干预1a后的调查中分别对预防糖尿病视网膜盲所需具备的知晓知识、正确的信念和采取的行为(KAP)进行了测量以评价不同干预策略的效果。使用卡方检验和t检验评价干预效果情况，使用多元线性相关分析对干预效果的影响因素进行分析。

结果： 在基线调查中235名病人进入对照组，235名病人进入研究组。在终末研究中对照组208名病人，研究组216名病人接受了调查。研究组在终末研究中关于糖尿病致盲及预防知识的正确知晓率、正确信念持有率、期望行为采纳率均比基线调查有显著提高，同时均比对照组有显著提高，差异具有统计学意义。多元线性回归分析显示研究组别、受教育水平和糖尿病病程是预防糖尿病盲的知晓情况的影响因素； 研究组别和受教育水平是预防糖尿病盲所采纳的期望行为的影响因素。

结论：在预防糖尿病盲的眼健康管理策略中以社区参与为主的综合管理方法比传统的管理方法具有更好的效果。

METHODS: Totally 470 diabetic patients newly registered within 3mo in local community health center were recruited in the study by random sampling. The control group received conventional public health service from chronic disease management approach with medical organization initiative on diabetic blindness prevention, and study group received comprehensive intervention based on ICCC model with community participation initiative. Informative knowledge, beheld accurate beliefs and acting behavior(KAP)in preventing diabetic blindness were measured in baseline survey before intervention and final survey after 1 y intervention in both groups respectively to evaluate the effect of different eye health management approaches on diabetic blindness prevention. Chi-square test and t-test were used to compare the effect of intervention and multiple linear regression analysis was used for analyzing influencing factors.

RESULTS: With 235 in control group and 235 in study group in baseline survey, and 208 and 216 in final survey. For study group accurate knowledge informative rate, accurate beheld belief rate and desired acting behavior rate in all the items of questions regarding diabetic blindness and its prevention in the final survey were all significant higher than the ones in baseline survey, and were significantly higher than that in control group. Multiple linear regression analysis showed that group type, educational level and DM duration were the influencing factors on the level of the knowledge. Group type, educational level and gender were the influencing factors on the level of beheld belief. Group type and educational level were the influencing factors on the level of acting behaviors in preventing diabetic blindness.

CONCLUSION:Comprehensive intervention with community participation initiative on managing diabetic eye health to prevent diabetic blindness had better performance compared to traditional intervention, thus it is an effective strategy in promoting diabetic eye health among diabetes.