Barriers to prehospital emergency response behaviors among first witnesses of stroke: A qualitative study guided by the COM-B model

OBJECTIVES: Timely prehospital emergency response by first witnesses of stroke is critical for improving patient outcomes, yet the behavioral mechanisms underlying such responses remain poorly understood. Guided by the Capability-Opportunity-Motivation-Behavior (COM-B) model, this study explored barriers influencing prehospital emergency response behaviors among first witnesses of stroke. STUDY DESIGN: Theory-informed qualitative descriptive study. METHODS: Thirteen first witnesses of consecutive patients with acute stroke admitted to a tertiary hospital in eastern China were purposively recruited between May and August 2024. Semi-structured in-depth interviews were conducted. Data were analyzed using thematic analysis informed by Colaizzi's analytical procedures and interpreted using the COM-B framework. RESULTS: Barriers were identified across the capability, opportunity, and motivation domains of the COM-B model. Capability-related barriers included impaired symptom recognition, limited emergency response skills, and inadequate preparedness. Opportunity-related barriers involved restricted access to emergency resources, limited social support, and misalignment between health information and public needs. Motivation-related barriers included emotional distress, fear of causing harm, ethical concerns, and distrust in emergency medical services. These interacting barriers contributed to delayed or constrained emergency responses. CONCLUSIONS: Prehospital emergency response behaviors among first witnesses of stroke are shaped by interacting constraints across capability, opportunity, and motivation. These findings provide a theory-informed basis for developing targeted interventions and health system strategies to improve timely prehospital stroke care.