基于CFIR 2.0框架的基层慢性阻塞性肺疾病主动筛查实施机制的质性研究

A Qualitative Study of the Implementation Mechanisms of Proactive COPD Screening in Primary Healthcare Settings Based on the CFIR 2.0 Framework

摘要: 目的：基于实施研究综合框架(Consolidated Framework for Implementation Research, CFIR) 2.0，分析基层医疗机构开展慢性阻塞性肺疾病(Chronic Obstructive Pulmonary Disease, COPD)主动筛查的多层级影响因素及其作用机制，构建基层COPD主动筛查实施机制模型，为推动慢性呼吸系统疾病早期发现服务在基层医疗体系中的整合实施提供理论依据。方法：采用描述性质性研究设计，于2026年3月至6月采用目的抽样法，选取上海市浦东新区社区卫生服务中心及上级协作医院参与COPD筛查相关工作的利益相关者进行半结构式访谈，包括全科医生、家庭医生团队长、护理及公共卫生人员、基层管理者以及呼吸专科支持人员。基于CFIR 2.0框架设计访谈提纲，采用理论指导下主题分析法(framework-informed thematic analysis)进行资料分析，识别影响基层COPD主动筛查实施的关键因素，并分析其作用关系，构建实施机制模型。结果：共纳入19名利益相关者，形成5个一级主题和15个二级编码。基层COPD主动筛查实施障碍具有明显的多层级特征：1) 疾病价值认知不足限制筛查实施动力，疾病早期症状隐匿、筛查获益感知不足及慢病管理任务竞争降低主动筛查优先级；2) 实施者能力不足阻碍筛查资源向临床实践转化，主要表现为高危人群识别、肺功能操作及结果解释、筛查阳性后管理和健康教育能力不足；3) 组织环境支持不足阻碍筛查嵌入日常工作流程，标准化流程、信息化支持、设备运营、人力资源及绩效激励不足增加实施成本；4) 外部环境支持不足影响筛查服务闭环形成，居民肺健康素养不足、无症状人群筛查接受度低以及医联体专科支持不足限制筛查持续运行；5) 多维度实施策略促进筛查模式重构，包括流程数字化嵌入、实操导向能力建设、医护任务重构及医联体闭环支持。基于上述发现，构建“需求与价值认知–组织实施条件–个体能力转化–实施策略调节–筛查服务常态化”的实施机制模型。结论：基层COPD主动筛查实施障碍并非单纯源于设备和技术不足，而是疾病价值认知、组织实施环境、实施者能力及外部协同等多层因素相互作用的结果。推动主动筛查由项目性活动转变为基层常规服务，应从单纯增加设备和开展一次性培训转向流程嵌入、持续能力建设、团队任务重构和医联体闭环支持的综合实施策略。

Abstract: Objective: To explore the multilevel factors influencing the implementation of proactive chronic obstructive pulmonary disease (COPD) screening in primary healthcare settings and their underlying mechanisms based on the Consolidated Framework for Implementation Research (CFIR) 2.0, and to develop an implementation mechanism model for proactive COPD screening, thereby providing a theoretical basis for integrating early detection services for chronic respiratory diseases into primary healthcare systems. Methods: A descriptive qualitative study was conducted from March to June 2026. Purposive sampling was used to recruit stakeholders involved in COPD screening from community health service centers and collaborating tertiary hospitals in Pudong New Area, Shanghai. Participants included general practitioners, family physician team leaders, nurses and public health professionals, primary healthcare administrators, and respiratory specialist support personnel. A semi-structured interview guide was developed based on the CFIR 2.0 framework. Data were analyzed using a framework-informed thematic analysis to identify key factors influencing the implementation of proactive COPD screening in primary healthcare settings, examine their interrelationships, and develop an implementation mechanism model. Results: A total of 19 stakeholders were included, and five overarching themes and 15 subthemes were identified. The implementation barriers to proactive COPD screening demonstrated clear multilevel characteristics. 1) Insufficient perception of disease value limited screening motivation: the insidious nature of early COPD symptoms, limited perceived benefits of screening, and competing chronic disease management priorities reduced the priority given to proactive screening. 2) Insufficient implementer capability hindered the translation of screening resources into clinical practice: major deficiencies were identified in the identification of high-risk populations, pulmonary function testing and interpretation, management of patients with positive screening results, and health education. 3) Inadequate organizational support hindered the integration of screening into routine workflows: insufficient standardized procedures, information technology support, equipment operation and maintenance, human resources, and performance incentives increased implementation costs. 4) Insufficient support from the external environment impeded the formation of a closed-loop screening service: inadequate public awareness of lung health, low screening acceptance among asymptomatic individuals, and insufficient specialist support within healthcare consortiums constrained sustained implementation. 5) Multidimensional implementation strategies facilitated the restructuring of the screening model, including digital integration of screening workflows, practice-oriented capacity building, task redistribution among healthcare professionals, and closed-loop support through healthcare consortiums. Based on these findings, an implementation mechanism model of “needs and value perception - organizational implementation conditions - individual capability translation - implementation strategy modulation - routine screening services” was developed. Conclusion: The barriers to implementing proactive COPD screening in primary healthcare settings are not attributable solely to insufficient equipment and technical resources, but rather result from the interaction of multiple factors, including disease value perception, the organizational implementation environment, implementer capability, and external collaboration. To transform proactive COPD screening from a project-based activity into a routine primary healthcare service, implementation strategies should shift from merely increasing equipment availability and providing one-time training toward integrated approaches involving workflow integration, continuous capacity building, team-based task redistribution, and closed-loop support through healthcare consortiums.