基于COM-B与CFIR整合模型的基层医生COPD筛查行为影响因素的机制研究

A Study on the Mechanisms of Factors Influencing Primary Care Physicians’ COPD Screening Behavior Based on an Integrated COM-B and CFIR Framework

摘要: 目的：基于能力–机会–动机–行为(COM-B)模型与实施研究综合框架(CFIR)，构建基层医生慢性阻塞性肺疾病(COPD)筛查行为的影响机制模型，探讨影响基层医生开展COPD筛查的关键因素及作用路径，为促进COPD早期筛查策略在基层医疗卫生机构中的有效实施提供理论依据。方法：采用横断面调查设计，采用自行设计的调查问卷收集人口学资料及COPD筛查相关信息，于2026年1月至4月采用便利抽样法抽取参与COPD相关工作的基层医生进行问卷调查。基于COM-B与CFIR整合模型构建结构方程模型(SEM)，采用验证性因子分析(CFA)评价测量模型拟合与结构效度，采用Bootstrap法(5000次重抽样)检验中介效应。结果：共纳入415例基层医生，问卷有效率为96.5%。各潜变量Cronbach’s alpha系数为0.875~0.931，组合信度(CR)均符合测量要求。整体测量模型拟合良好(χ²/df = 1.066, CFI = 0.994, TLI = 0.994, RMSEA = 0.013, SRMR = 0.040)。路径分析显示：二阶潜变量能力(Capability)由COPD知识(β = 0.264, p < 0.001)和自我效能(β = 0.292, p < 0.001)共同正向构成；实施环境(CFIR)显著正向预测实施机会(Opportunity) (β = 0.591, p < 0.001)。能力(Capability)与实施机会(Opportunity)均对COPD筛查行为产生显著直接正向促进作用(β分别为0.902和0.312，p均 < 0.001)，而实施动机对筛查行为的直接影响无统计学意义(β = 0.223, p = 0.113)。Bootstrap中介分析显示，能力在COPD知识、自我效能与筛查行为间发挥显著中介作用，实施机会在实施环境与筛查行为间发挥显著中介作用(均p < 0.001)。结论：基层医生COPD筛查行为可能与个体实施能力及组织实施机会密切相关。促进基层COPD早筛应优先加强实施能力建设，并同步优化筛查流程、资源配置及组织支持，动机强化可作为辅助措施。

Abstract: Objective: Based on the Capability-Opportunity-Motivation-Behavior (COM-B) model and the Consolidated Framework for Implementation Research (CFIR), this study aimed to construct a structural mechanism model of Chronic Obstructive Pulmonary Disease (COPD) screening behavior among primary care physicians (PCPs), exploring key factors and path mechanisms to provide theoretical evidence and strategy insights for scaling up early COPD screening in primary care settings. Methods: A cross-sectional survey was conducted from January to April 2026, enrolling PCPs involved in COPD management using convenience sampling. A self-designed questionnaire was administered to collect demographic data and COPD screening-related information. Structural equation modeling (SEM) based on the integrated COM-B and CFIR framework was developed. Confirmatory factor analysis (CFA) evaluated the measurement model fit, while a bias-corrected Bootstrap method (5000 resamples) tested mediating effects. Results: A total of 415 valid questionnaires were analyzed (effective rate: 96.5%). Cronbach’s alpha for latent variables ranged from 0.875 to 0.931, and Composite Reliability (CR) met standard criteria. The measurement model demonstrated good fit (chi²/df = 1.066, CFI = 0.994, TLI = 0.994, RMSEA = 0.013, SRMR = 0.040). Path analysis revealed that the second-order latent variable “Capability” was positively formed by COPD knowledge (β = 0.264, p < 0.001) and self-efficacy (β = 0.292, p < 0.001); implementation climate (CFIR) directly predicted implementation opportunity (β = 0.591, p < 0.001). Capability and Opportunity both exerted strong direct positive effects on COPD screening behavior (β = 0.902 and 0.312, respectively, both p < 0.001), whereas the direct effect of motivation on behavior was not statistically significant (β = 0.223, p = 0.113). Bootstrap analysis confirmed that capability mediated the effects of knowledge and self-efficacy on behavior, while opportunity mediated the path from implementation climate to behavior (all p < 0.001). Conclusion: Primary care physicians’ COPD screening practices may be closely related to individual capacity and organizational opportunities for implementation. To promote early COPD screening in primary care, priority should be given to strengthening capacity building, while simultaneously optimizing screening processes, resource allocation, and organizational support; motivational reinforcement can serve as a supplementary measure.