Barriers to Prehospital Emergency Response Behaviors Among First Witnesses of Stroke: A Qualitative Study Guided by the COM-B Model

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Guided by the Capability–Opportunity–Motivation–Behavior (COM-B) model, this study explored theory-informed barriers influencing prehospital emergency response behaviors among first witnesses of stroke. Methods A theory-informed qualitative descriptive study was conducted. Thirteen first witnesses of acute stroke were purposively recruited from a tertiary hospital in eastern China between May and August 2024. In-depth semi-structured interviews were conducted. Data were analyzed using thematic analysis informed by Colaizzi’s analytical procedures and guided by the COM-B model. Results Barriers to prehospital emergency response clustered across the three COM-B domains. Capability-related barriers involved embodied practice constraints, impaired recognition and appraisal of stroke symptoms, insufficient on-site response skills, and limited health literacy. Opportunity-related barriers reflected restricted access to emergency resources, misalignment between health information dissemination and public needs, low trust in emergency medical services, and disruption of immediate social support. Motivation-related barriers encompassed difficulties in cognitive reframing and behavioral commitment, as well as reflective conflicts related to ethical concerns, knowledge–practice gaps, and psychological burden. Conclusions Prehospital emergency response behaviors among first witnesses of stroke are shaped by interacting constraints across capability, opportunity, and motivation. By clarifying the behavioral mechanisms underlying delayed or constrained responses, this study provides a theory-informed basis to guide future intervention development and health system strategies aimed at improving timely prehospital stroke care. COM-B model first witnesses of stroke prehospital emergency response barriers qualitative research Figures Figure 1 Figure 2 Introduction Stroke ranks among the leading causes of mortality and long-term disability worldwide, with its disease burden continuing to rise in parallel with population aging [1, 2]. According to the World Stroke Organization, approximately 14 million people experience a stroke each year, resulting in more than 6.5 million deaths globally [3]. Given its sudden onset and rapid progression, early recognition and timely intervention are critical determinants of clinical outcomes [4–6]. In particular, because stroke treatment is highly dependent on narrow therapeutic time windows, the effectiveness of the prehospital emergency phase plays a pivotal role in determining treatment success [7]. During acute stroke events, first witnesses—including family members, colleagues, or members of the public—are often the earliest individuals to detect abnormal symptoms and initiate emergency responses [8–10]. Their ability to recognize warning signs, interpret the situation, and make prompt decisions directly influences the activation of the emergency care chain and represents a critical behavioral node in stroke management [8, 11, 12]. Although previous studies have emphasized public stroke awareness and patient-related delay factors, the behavioral formation mechanisms of first witnesses in emergency contexts remain insufficiently explored from a systematic and theory-driven perspective [7, 13]. Existing research has largely focused on isolated factors, such as knowledge or attitudes, without adequately accounting for the interactive effects of individual capability, environmental opportunity, and psychological motivation [14]. This fragmented approach limits a comprehensive understanding of the complex barriers that impede timely and appropriate prehospital emergency responses [12]. The Capability–Opportunity–Motivation– Behavior (COM-B) model offers an integrative theoretical framework to address this limitation [15]. The model posits that behavior arises from the dynamic interaction of capability, opportunity, and motivation and has been widely applied in the development and evaluation of health behavior interventions [16–19]. Against this background, the present study focuses on the critical interval between stroke onset and the arrival of professional emergency services. Guided by the COM-B model, this qualitative study systematically explores the barriers influencing whether first witnesses are able to initiate and perform appropriate prehospital emergency response behaviors. By elucidating the behavioral logic underlying first witnesses’ responses, this study aims to provide a theoretical basis for understanding prehospital emergency behavior and to inform the development of multi-level, precision-targeted strategies to promote timely and effective stroke response. Methods Study design This study adopted a theory-informed qualitative descriptive design guided by the COM-B model. A qualitative descriptive approach was employed to generate a comprehensive, low-inference account of barriers experienced by first witnesses of stroke during the prehospital emergency phase, emphasizing participants’ accounts expressed in their own words [20]. Data analysis followed a thematic analytic process, drawing on selected analytical procedures described by Colaizzi to support systematic organization and interpretation of interview data [21]. The COM-B model was used as an analytical lens to guide the interpretation and theoretical integration of the identified themes. Study setting This study was conducted at a tertiary teaching hospital in eastern China. In urban Chinese settings, individuals with suspected acute stroke are typically transferred directly from community or household locations to tertiary hospitals for emergency care [22]. First witnesses often accompany patients throughout the early clinical encounter, providing an appropriate context for retrospective qualitative exploration of prehospital emergency response behaviors [7]. Participants and sampling Participants were recruited between May and August 2024 using purposive sampling to ensure inclusion of information-rich individuals with direct experience of prehospital stroke emergencies. First witnesses were defined as individuals who were present at the onset of stroke symptoms and directly observed the acute event. Inclusion criteria were: (1) provision of written informed consent; (2) direct witnessing of acute stroke onset in another individual; (3) no concurrent participation in other research studies; and (4) no medical or health-related professional background. Exclusion criteria were: (1) being a paid caregiver; (2) apparent cognitive, language, or hearing impairments that could interfere with participation; or (3) withdrawal from the interview before completion. Theoretical framework Barriers to prehospital emergency response behaviors among first witnesses of stroke were conceptualized as factors that hinder timely symptom recognition, activation of emergency medical services, and appropriate action during the critical interval between symptom onset and arrival of professional care. The COM-B model, a core component of the Behaviour Change Wheel developed by Michie and colleagues, served as the overarching theoretical framework [15]. The model conceptualizes behavior as arising from dynamic interactions among capability (psychological and physical), opportunity (physical and social), and motivation (reflective and automatic)(Fig. 1). In this study, the COM-B model informed the organization of codes and the integration of emerging themes during analysis, enabling theory-based mapping of identified barriers across the three behavioral domains. Data collection Interview guide A semi-structured interview guide was developed based on a review of relevant literature and discussions within the research team and was further refined through expert consultation [23, 24]. Pilot interviews were conducted with five first witnesses of stroke to assess clarity, relevance, and comprehensibility. Minor revisions were made accordingly, resulting in the final interview guide[20, 25]. Interview questions were experience-oriented and open-ended, aiming to elicit participants’ authentic accounts rather than impose predefined theoretical assumptions. Core areas included: (1) immediate reactions during acute stroke events; (2) processes of symptom recognition and appraisal; (3) sources and perceived credibility of emergency-related knowledge; (4) perceptions of helping behaviors and willingness to intervene; and (5) perceived barriers, available support, and unmet needs during emergency response. Probing questions were used flexibly to clarify responses and deepen exploration. Interview procedure Data were collected through retrospective, in-depth, semi-structured interviews conducted by two trained qualitative researchers. One researcher served as the primary interviewer, while the second acted as an observer and documented non-verbal behaviors and contextual information. Prior to each interview, participants were informed about the study purpose, procedures, confidentiality, and audio recording, and written informed consent was obtained [26]. Interviews were conducted in quiet, private settings to facilitate open communication, and leading prompts were deliberately avoided. Each participant was interviewed one to two times depending on data richness [24]. Interviews lasted approximately 40–60 minutes and were audio-recorded in full. Field notes were taken during and immediately after interviews to capture contextual details and support data interpretation. Data collection continued until thematic saturation was achieved, defined as the absence of new themes across three consecutive interviews. Data management and analysis All audio recordings were transcribed verbatim within 24 hours of each interview. Dialect expressions or ambiguous wording were independently reviewed by two researchers and verified against audio recordings when necessary. Transcripts were de-identified using participant codes (P1–P13) and stored securely. Data were analyzed using thematic analysis, supported by selected analytical procedures described by Colaizzi to facilitate systematic coding and interpretation [27]. The analytic process involved the following steps: (1) repeated reading of transcripts to achieve immersion; (2) identification of significant statements related to prehospital emergency response; (3) formulation of meanings grounded in participants’ accounts; (4) clustering of meanings into themes through constant comparison; and (5) iterative refinement of themes through team discussion. Two researchers independently conducted coding and theme development. Discrepancies were resolved through discussion and, when necessary, consultation with a third researcher. After themes were generated inductively from the interview data, the COM-B model was applied as an analytical lens to organize themes and map identified barriers onto capability, opportunity, and motivation domains. Researcher reflexivity The research team comprised nursing researchers with formal training in qualitative methods and prior experience in stroke-related research. To enhance reflexivity, interviewers engaged in ongoing reflective discussions throughout data collection and analysis, documenting assumptions, positionality, and key analytical decisions. Regular team meetings were held to critically examine how researchers’ professional backgrounds and theoretical orientation toward the COM-B model might influence data interpretation. Rigor Methodological rigor was ensured in accordance with Lincoln and Guba’s criteria for qualitative research [28]. Credibility was enhanced through pilot interviews, prolonged engagement, analyst triangulation, and member checking of selected transcripts. Transferability was supported by thick description of the study context, participant characteristics, and research procedures. Dependability was strengthened through standardized documentation of data collection and analytic procedures, with independent coding followed by consensus discussion. Confirmability was ensured by maintaining a comprehensive audit trail, including transcripts, coding frameworks, analytical memos, and reflexive notes, enabling transparency and traceability of analytic decisions. Ethical considerations Ethical approval was obtained from the Ethics Committee of Shanghai Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine.This study was conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from all adult participants. For underage participants, assent was obtained from the participant and written informed consent from legal guardians; interviews were conducted in the presence of guardians. All data were anonymized and handled confidentially. Results Participant characteristics A total of thirteen first witnesses of stroke participated in this study. Participants represented diverse social roles, including students, employed individuals, and retirees, and had experienced a range of prehospital witnessing contexts. Interviews with underage participants were conducted in the presence of legal guardians. Detailed participant characteristics are presented in Table 1. Table 1 Demographic characteristics of first witnesses of stroke Participant ID Educational level Health insurance type Household composition Previous emergency response experience Type of stroke witnessed P1 Junior high school Rural health insurance Living with family No Intracerebral hemorrhage P2 Primary school Urban health insurance Living with family No Ischemic stroke P3 Junior college Urban health insurance Living with family Yes Intracerebral hemorrhage P4 Technical secondary school Urban health insurance Living with family No Intracerebral hemorrhage P5 Junior college Urban health insurance Living alone Yes Ischemic stroke P6 Junior high school Urban health insurance Living with family No Ischemic stroke P7 Junior high school Rural health insurance Living with family No Intracerebral hemorrhage P8 Bachelor’s degree Rural health insurance Living with family No Ischemic stroke P9 Bachelor’s degree Urban health insurance Living alone No Ischemic stroke P10 Senior high school Urban health insurance Institutional care Yes Ischemic stroke P11 Junior high school Rural health insurance Living with family No Intracerebral hemorrhage P12 Senior high school Urban health insurance Living with family No Intracerebral hemorrhage P13 Junior high school Urban health insurance Living with family No Ischemic stroke Note: Urban and rural health insurance refer to China’s public medical insurance systems. Themes and subthemes Guided by the COM-B model, this study identified 7 themes and 17 subthemes related to barriers to prehospital emergency response behaviors among first witnesses of stroke (Table 2). Themes were generated inductively from the interview data and subsequently organized within the COM-B framework to support analytic integration. Table 2 Themes and subthemes COM-B Themes Subthemes Capability Impaired recognition and risk appraisal of stroke symptoms Delayed anticipation of symptom severity Attribution bias in symptom interpretation Limited capacity to enact appropriate emergency actions Physical and situational constraints Inappropriate or improvised response behaviors Lack of professional emergency knowledge Weak integration of emergency knowledge into everyday preparedness Low initiative in acquiring stroke-related emergency knowledge Continued Table 2 Themes and subthemes COM-B Themes Subthemes Opportunity Structural and logistical barriers to timely emergency activation Limited availability or delayed response of EMS Transportation and access constraints Administrative unpreparedness Low contextual salience of stroke-related information in daily life Limited engagement with existing information channels Perceived irrelevance of health education content Fragility of immediate social support networks Shortage of caregiving manpower Lack of emotional and shared decision-making support Motivation Reflective and emotional ambivalence toward emergency intervention Ethical hesitation and fear of liability Distrust in EMS responsiveness Stress-induced cognitive blankness Fear of causing secondary harm Note: “120” refers to the emergency medical service (EMS) system in China. Analytical themes Theme 1. Impaired recognition and risk appraisal of stroke symptoms Participants frequently described difficulty recognizing early stroke manifestations and accurately assessing their urgency. Initial symptoms such as dizziness, slurred speech, limb weakness, or unusual drowsiness were often interpreted as mild, temporary, or attributable to familiar conditions, which reduced the perceived need for immediate action. Delayed anticipation of symptom severity Many participants failed to anticipate the seriousness of early symptoms and delayed activating emergency medical services. “She often has high blood pressure, and dizziness usually goes away after resting for a while. At that time, calling 120 didn’t seem necessary.” (P4) “He was already stuttering and having trouble moving, but I thought it might just be because he was getting older.” (P8) “He kept feeling very sleepy after returning from morning exercise. I thought he just hadn’t slept well. It wasn’t until his leg stopped working and he collapsed that I realized how serious it was.” (P13) Attribution bias in symptom interpretation Participants frequently attributed warning signs to fatigue, medication effects, or pre-existing conditions, which further weakened risk perception. “I never thought it was something wrong with his brain. I just thought he was having a spasm.” (P1) “He said he had a headache and his speech was a bit unclear. I thought it was because he hadn’t slept enough.” (P3) “When I saw her mouth drooping, my first reaction was facial paralysis. She even insisted it was because she hadn’t put in her dentures properly.” (P5) “We had just come back from the emergency department, so I naturally assumed the blood pressure medication hadn’t taken effect yet. I never thought it was a stroke.” (P8) These misinterpretations delayed recognition of stroke and postponed emergency response. Theme 2. Limited capacity to enact appropriate emergency actions Even when participants realized that something serious was happening, many described difficulty translating concern into effective action during the emergency. Physical and situational constraints Embodied limitations, including insufficient strength, advanced age, or environmental barriers, restricted the ability to assist patients. “My husband is quite large, and we live on the sixth floor without an elevator. In the end, we could only manage to carry him downstairs together with the emergency staff.” (P3) “I’m already quite old, and my legs hurt whenever I squat. She collapsed in the bathroom sink, and it took a great deal of effort just to move her a little.” (P4) “I really wanted to help more, but I couldn’t move him at all by myself. I could only wait there until the ambulance came.” (P6) Inappropriate or improvised response behaviors In the absence of clear knowledge, several participants relied on instinctive or experience-based actions that were later recognized as inappropriate. “After calling 120, I immediately pinched his philtrum and put my phone into his mouth to stop him from biting his tongue.” (P1) “He was convulsing badly, and instinctively I kept squeezing his hands and feet and pressing them repeatedly.” (P5) “When he started vomiting and his lips turned blue, I hurriedly pressed on his chest.” (P11) Lack of professional emergency knowledge Participants frequently expressed uncertainty about what actions were appropriate during the critical prehospital period. “I could only help him sit upright and steady him, and then I didn’t know what else to do. I could only wait.” (P3) “I pinched her philtrum and kept calling her name. That was all I dared to do. Anything professional, I didn’t dare try.” (P8) “Only after everything happened did we realize how little professional first-aid knowledge we actually had.” (P13) Theme 3. Weak integration of emergency knowledge into everyday preparedness Participants reported limited engagement with health education prior to the stroke event. Emergency knowledge had not been incorporated into everyday awareness or preparedness. Low initiative in acquiring stroke-related emergency knowledge Many participants stated that they rarely paid attention to health education activities because they believed such issues were irrelevant to their own lives. “I never take part in the community health education activities. I usually just throw the materials away.” (P5) “I always felt that my family members were healthy. I never thought something like this could happen, so I didn’t pay attention to it.” (P7) This lack of proactive learning reduced both recognition speed and confidence during emergencies. Theme 4. Structural and logistical barriers to timely emergency activation Participants described several systemic and environmental barriers that complicated or delayed emergency response. Limited availability or delayed response of EMS Some participants encountered difficulty reaching emergency services. “When I called 120, the line was busy. I had to call repeatedly before it finally went through.” (P1) “The operator told us they still needed to arrange a vehicle and asked us not to hang up.” (P4) Transportation and access constraints Environmental conditions such as traffic congestion and complex residential layouts further delayed hospital arrival. “When the ambulance was on the way to the hospital, it was right during rush hour. A trip that usually takes 20 minutes ended up taking more than 40.” (P4) “That morning the traffic was quite heavy, and there were many cars blocking the hospital entrance.” (P10) “Our residential area is like a maze. The ambulance spent a lot of time trying to locate the building.” (P13) Administrative unpreparedness In moments of panic, some participants forgot essential documents. “In the panic, I even forgot to bring the ID card.” (P11) “We forgot everything. It wasn’t until we arrived at the hospital that I realized we hadn’t brought the insurance card or the ID.” (P13) Theme 5. Low contextual salience of stroke-related information in daily life Participants reported that existing health information rarely entered their everyday cognitive environment. Limited engagement with existing information channels Online health information was often overlooked or overshadowed by entertainment content. “Health information pushed by big data is easy to ignore. On platforms like TikTok, it’s mostly entertaining videos.” (P3) “Face-to-face communication would be much better.” (P3) Perceived irrelevance of health education content Some participants felt that existing health lectures were too specialized or disconnected from their daily lives. “For people like us who work in factories, we don’t understand professional medical knowledge.” (P1) “Most lectures in the community are about dental or orthopedic issues. I hope the topics could be more diverse.” (P4) “For us farmers, many things are hard to understand, and we don’t even know where to learn these things.” (P7) Theme 6. Fragility of immediate social support networks The temporary absence of practical or emotional support during emergencies further complicated response behavior. Shortage of caregiving manpower “I couldn’t manage my spouse by myself. Everyone in the community is elderly, and there was no younger person I could find to help.” (P4) Lack of emotional and shared decision-making support Participants described feeling overwhelmed when facing emergencies alone. “I was the only one at home. After a night shift, I was anxious and helpless.” (P5) “Of course I panicked. Anyone would. I felt completely helpless—neighbors live far away, and there was no one I could call.” (P6) Theme 7. Reflective and emotional ambivalence toward emergency intervention Motivational barriers played a critical role in shaping response behavior. Ethical hesitation and fear of liability Participants expressed concern about legal disputes or being falsely accused when helping others. “If I saw someone collapse on the street, I definitely wouldn’t dare to help.” (P1) “What if I cause harm and get involved in a dispute? The consequences would be hard to predict.” (P3) Distrust in EMS responsiveness Some participants doubted the timeliness of ambulance services and therefore preferred alternative options. “Waiting for 120 would just waste time. I could leave immediately in my own car.” (P5) “I’ve seen cases where it took half an hour for an ambulance to arrive.” (P6) “Sometimes you call an ambulance, and you don’t know when it will arrive.” (P9) Stress-induced cognitive blankness Acute stress during emergencies impaired recall and decision-making. “My mother once taught me some first-aid knowledge, but when my father collapsed, my mind went completely blank.” (P2) Fear of causing secondary harm Concerns about making the situation worse led some participants to avoid intervening beyond calling for help. “I don’t understand medical procedures. When I don’t know what’s going on, I don’t dare act recklessly.” (P1) “I don’t have any medical knowledge. I could only call 120 and not touch her—what if it made things worse?” (P10) Discussion This study provides a theory-informed qualitative analysis of barriers to prehospital emergency response among first witnesses of stroke, using the COM-B model to elucidate the behavioral mechanisms underlying delayed or constrained action (Fig. 2). The findings indicate that prehospital stroke response is not determined by isolated deficits, but rather emerges from dynamic interactions among capability, opportunity, and motivation within time-critical and emotionally charged contexts. Capability-related barriers: Disruption between awareness and action Capability-related barriers constituted a foundational constraint on effective prehospital response. Importantly, these barriers did not primarily reflect an absence of knowledge, but rather a failure to translate cognitive awareness into action under acute stress [7, 12]. Consistent with prior studies highlighting the importance of symptom recognition and rapid emergency activation [29–31], participants in this study frequently normalized or misattributed early stroke manifestations, weakening risk appraisal and delaying response. In addition, many participants reported limited engagement with health education prior to the event, suggesting that stroke-related emergency knowledge had not been sufficiently integrated into everyday preparedness. These findings extend existing literature by demonstrating that knowledge-based education alone may be insufficient. Physical limitations, environmental constraints, and heightened emotional arousal collectively reduced individuals’ capacity to operationalize what they knew in real time. From a COM-B perspective, this reflects a misalignment between psychological capability and situational demands, underscoring the need to move beyond information-oriented education toward experiential learning and skill rehearsal that support behavioral enactment under pressure. Opportunity-related barriers: Structural and social constraints on action Opportunity-related barriers reflected systemic limitations in both physical and social environments. At the level of physical opportunity, restricted access to timely emergency medical services (EMS), transportation barriers, and contextual obstacles (e.g., traffic congestion, location identification difficulties) constrained prehospital response [31–33]. While such barriers have often been emphasized in rural or resource-limited settings [33], participants’ accounts suggest that opportunity constraints remain salient even in urban contexts. At the level of social opportunity, misalignment between health information dissemination and public needs emerged as a prominent barrier. Existing health education was frequently perceived as overly technical, insufficiently tailored, or delivered through channels that failed to engage diverse occupational and educational groups. Furthermore, although family and community support have been shown to facilitate symptom recognition and decision-making, participants often described a temporary collapse of social support during acute events, leaving witnesses without timely informational or emotional assistance. Together, these findings illustrate how opportunity constraints may undermine prehospital response even when individual capability is present. Motivation-related barriers: Ethical tension and trust deficits Motivation played a pivotal role in determining whether available capability and opportunity were translated into action. At the level of automatic motivation, participants frequently described cognitive blankness and emotional overload during emergencies, limiting retrieval and application of prior emergency knowledge. Fear of causing secondary harm further contributed to hesitation, as some participants preferred to avoid physical intervention due to uncertainty about appropriate actions. This pattern highlights the limited automatization of emergency behaviors among lay populations. Reflective motivation was shaped by ethical concerns, legal uncertainty, and trust deficits. Fear of legal liability, social disputes, or unintended harm discouraged intervention, particularly when assisting strangers. Although legal protections for emergency assistance exist in China (e.g., Article 184 of the Civil Code) [34], limited public awareness and ambiguity in practical application appear to weaken their behavioral impact. In addition, distrust in EMS responsiveness further suppressed motivation to seek professional help. Collectively, these motivational constraints help explain why individuals may possess the capacity and opportunity to act, yet still hesitate in real-world emergency situations. Interaction across capability, opportunity, and motivation Beyond barriers identified within individual COM-B domains, the findings suggest that capability, opportunity, and motivation interact dynamically in shaping first witnesses’ responses during stroke emergencies. Rather than operating independently, constraints in one domain often amplify limitations in others. Capability deficits, such as uncertainty in symptom recognition or lack of confidence in emergency response skills, frequently redirected witnesses toward informal support networks rather than activating emergency medical services. Although these networks may provide reassurance, they are often unreliable and may introduce delays. Motivational perceptions regarding emergency system responsiveness also influenced opportunity choices. Distrust in ambulance response times led some participants to rely on private transportation, which transferred responsibilities for patient handling and monitoring to untrained witnesses and intensified existing capability constraints. In addition, emotional stress and fear of causing harm sometimes produced cognitive blankness that prevented individuals from applying prior knowledge. Taken together, these findings indicate that barriers to stroke response may arise from a reinforcing interaction across capability, opportunity, and motivation, helping explain why knowledge-focused interventions alone often achieve limited behavioral impact. Implications for future research and intervention development Guided by the COM-B model, the findings of this study highlight key leverage points that may inform future intervention development, without presupposing specific implementation strategies. At the level of capability, interventions may need to prioritize experiential and scenario-based approaches that enhance behavioral enactment under stress rather than solely increasing knowledge. At the level of opportunity, system-level efforts to improve EMS accessibility, information alignment, and community-based support may help reduce contextual barriers. At the level of motivation, strengthening public trust in emergency systems and clarifying legal protections may alleviate ethical and psychological constraints on helping behavior. Importantly, these implications are exploratory and theory-informed, serving to clarify intervention logic rather than to prescribe or evaluate specific programs. Limitations and future research directions This study has several limitations. First, as a single-center qualitative study with a relatively small sample, transferability to other settings may be limited. Second, retrospective accounts may be subject to recall bias and post-event reinterpretation. Third, although the COM-B model provided a robust analytical framework, the relative contribution of identified barriers was not quantitatively assessed. In addition, the inclusion of a small number of adolescent participants may have influenced the depth of experiential accounts. Future research should adopt multicenter and mixed-methods designs to examine the prevalence and interaction of COM-B–related barriers across contexts. Quantitative and longitudinal approaches may further elucidate causal pathways and test the effectiveness of theory-informed interventions aimed at improving prehospital stroke response. Conclusion Prehospital emergency response behaviors among first witnesses of stroke are shaped by interacting constraints across capability, opportunity, and motivation. By elucidating the behavioral mechanisms underlying delayed or constrained action, this study advances theory-informed understanding of prehospital stroke response and provides an empirical foundation for future research and intervention development aimed at improving timely emergency care. Abbreviations COM-B: Capability, Opportunity, Motivation–Behavior model; EMS: Emergency Medical Services; ED: Emergency Department. Declarations Contribution of the Paper What is already known • Timely recognition and response by first witnesses is critical to reducing prehospital delay in stroke. • Previous studies have mainly focused on public awareness or patient-related delays. What this paper adds • This study provides a theory-informed analysis of barriers to stroke emergency response using the COM-B model. • Barriers arise from interacting constraints across capability, opportunity, and motivation. Ethics approval and consent to participate This study was approved by the Ethics Committee of Shanghai Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine. All participants provided written informed consent prior to participation. For underage participants, assent was obtained from the participants and written informed consent was obtained from their legal guardians. This study was conducted in accordance with the Declaration of Helsinki. Consent for publication Not applicable. Availability of data and materials The datasets generated and/or analyzed during the current study are not publicly available due to privacy and ethical restrictions but are available from the corresponding author on reasonable request. Competing Interests The authors declare that they have no competing interests. Funding This research was supported by the 2023 Science and Technology Development Project of Shanghai University of Traditional Chinese Medicine (Grant No. 23HLZX05), the 2023 Hospital Management Research Fund of the Shanghai Hospital Association (Grant No. Q2023052), and the 2026 Cohort Construction Project of Shanghai Pudong New Area Guangming Hospital of Traditional Chinese Medicine (Grant No. 2026-PWDL-33). Authors’ contributions C.W. and G.L. conceptualized and designed the study. C.W. and K.X. conducted the literature review and data analysis. C.X. and Y.S. contributed to data collection. H.N. and G.L. supervised the study. C.W. drafted the manuscript. All authors reviewed and approved the final manuscript. Acknowledgements The authors would like to thank all participants for sharing their experiences. References Feigin VL, Brainin M, Norrving B, Martins SO, Pandian J, Lindsay P, et al. World stroke organization: global stroke fact sheet 2025. Int J Stroke . 2025;20(2):132–144. doi:10.1177/17474930241308142. Global, regional, and national burden of stroke, 1990-2016: a systematic analysis for the global burden of disease study 2016. Lancet Neurol . 2019;18(5):439–458. doi:10.1016/S1474-4422(19)30034-1. Parry-Jones AR, Krishnamurthi R, Ziai WC, Shoamanesh A, Wu S, Martins SO, et al. World stroke organization (wso): global intracerebral hemorrhage factsheet 2025. Int J Stroke . 2025;20(2):145–150. doi:10.1177/17474930241307876. Magnusson C, Herlitz J, Sunnerhagen KS, Hansson P, Andersson J, Jood K. Prehospital recognition of stroke is associated with a lower risk of death. Acta Neurol Scand . 2022;146(2):126–136. doi:10.1111/ane.13618. Wu Y, Yang Y, Guo X, Guo D, Lu Y, Li G, et al. Effect of pre-hospital early intervention combined with an in-hospital emergency model in the emergency care of patients with acute stroke. Am J Transl Res . 2022;14(1):672–678. Shkirkova K, Saver JL, Starkman S, Wong G, Weng J, Hamilton S, et al. Frequency, predictors, and outcomes of prehospital and early postarrival neurological deterioration in acute stroke: exploratory analysis of the fast-mag randomized clinical trial. Jama Neurol . 2018;75(11):1364–1374. doi:10.1001/jamaneurol.2018.1893. Busetto L, Stang C, Herzog F, Sert M, Hoffmann J, Purrucker J, et al. "I didn't even wonder why i was on the floor" - mixed methods exploration of stroke awareness and help-seeking behaviour at stroke symptom onset. Bmc Health Serv Res . 2024;24(1):880. doi:10.1186/s12913-024-11276-6. Zachrison KS, Nielsen VM, de la Ossa NP, Madsen TE, Cash RE, Crowe RP, et al. Prehospital stroke care part 1: emergency medical services and the stroke systems of care. Stroke . 2023;54(4):1138–1147. doi:10.1161/STROKEAHA.122.039586. Bakke I, Lund CG, Carlsson M, Salvesen R, Normann B. Barriers to and facilitators for making emergency calls - a qualitative interview study of stroke patients and witnesses. J Stroke Cerebrovasc Dis . 2022;31(10):106734. doi:10.1016/j.jstrokecerebrovasdis.2022.106734. Bhutta ZA, Pathan SA, Puolakka T, Akhtar N, Thomas SH, Harris T, et al. Assessing stroke awareness and behavioural response following the national 'act fast' stroke awareness campaign - insights from a cross-sectional survey in qatar. J Patient Exp . 2024;11:682752093. doi:10.1177/23743735241242717. Tan J, Ramazanu S, Liaw SY, Chua WL. Effectiveness of public education campaigns for stroke symptom recognition and response in non-elderly adults: a systematic review and meta-analysis. J Stroke Cerebrovasc Dis . 2022;31(2):106207. doi:10.1016/j.jstrokecerebrovasdis.2021.106207. Vatsalis T, Papadopoulos D, Georgousopoulou V, Bostantzis P, Rudolf J. Global awareness and response to early symptoms of acute stroke: a systematic literature review. Cureus . 2025;17(2):e78420. doi:10.7759/cureus.78420. Su Y, Qi W, Yu Y, Zhu J, Shi X, Wu X, et al. Analysis of prehospital delay in acute ischaemic stroke and its influencing factors: a multicentre prospective case registry study in china. Stroke Vasc Neurol . 2025;10(5):637–647. doi:10.1136/svn-2024-003535. Teuschl Y, Brainin M. Stroke education: discrepancies among factors influencing prehospital delay and stroke knowledge. Int J Stroke . 2010;5(3):187–208. doi:10.1111/j.1747-4949.2010.00428.x. Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci . 2011;6:42. doi:10.1186/1748-5908-6-42. Madhani A, Finlay KA. Using the com-b model to characterize the barriers and facilitators of pre-exposure prophylaxis (prep) uptake in men who have sex with men. Br J Health Psychol . 2022;27(4):1330–1353. doi:10.1111/bjhp.12605. Yang Y, Gao Y, An R, Wan Q. Barriers and facilitators to exercise adherence in community-dwelling older adults: a mixed-methods systematic review using the com-b model and theoretical domains framework. Int J Nurs Stud . 2024;157:104808. doi:10.1016/j.ijnurstu.2024.104808. Flannery C, McHugh S, Anaba AE, Clifford E, O'Riordan M, Kenny LC, et al. Enablers and barriers to physical activity in overweight and obese pregnant women: an analysis informed by the theoretical domains framework and com-b model. Bmc Pregnancy Childbirth . 2018;18(1):178. doi:10.1186/s12884-018-1816-z. Zhang M, Guo L, Namassevayam G, Wei M, Xie Y, Guo Y, et al. Factors associated with health behaviours among stroke survivors: a mixed-methods study using com-b model. J Clin Nurs . 2024;33(6):2138–2152. doi:10.1111/jocn.17103. Sandelowski M. What's in a name? Qualitative description revisited. Res Nurs Health . 2010;33(1):77–84. doi:10.1002/nur.20362. Webb C. Information point: colaizzi's framework for analysing qualitative data. J Clin Nurs . 1999;8(5):576. Wang Y, Li Z, Gu H, Zhai Y, Zhou Q, Jiang Y, et al. China stroke statistics: an update on the 2019 report from the national center for healthcare quality management in neurological diseases, china national clinical research center for neurological diseases, the chinese stroke association, national center for chronic and non-communicable disease control and prevention, chinese center for disease control and prevention and institute for global neuroscience and stroke collaborations. Stroke Vasc Neurol . 2022;7(5):415–450. doi:10.1136/svn-2021-001374. Kallio H, Pietilä A, Johnson M, Kangasniemi M. Systematic methodological review: developing a framework for a qualitative semi-structured interview guide. J Adv Nurs . 2016;72(12):2954–2965. doi:10.1111/jan.13031. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (coreq): a 32-item checklist for interviews and focus groups. Int J Qual Health Care . 2007;19(6):349–357. doi:10.1093/intqhc/mzm042. Sandelowski M. Whatever happened to qualitative description? Res Nurs Health . 2000;23(4):334–340. doi:10.1002/1098-240x(200008)23:43.0.co;2-g. World medical association declaration of helsinki: ethical principles for medical research involving human subjects. Jama . 2013;310(20):2191–2194. doi:10.1001/jama.2013.281053. Colaizzi PF, Valle RS, King M. Existential phenomenological alternatives for psychology. Psychological Research as the Phenomenologist Views It . 1978;48:71. Guba EG, Lincoln YS. Fourth generation evaluation . Thousand Oaks, CA: Sage Publications; 1989. Amtoft AC, Danielsen AK, Hornnes N, Kruuse C. A qualitative inquiry into patient reported factors that influence time from stroke symptom onset to hospitalization. J Neurosci Nurs . 2021;53(1):5–10. doi:10.1097/JNN.0000000000000557. Mahawish KM, Greenblatt D. Pre-hospital delays in patients experiencing symptoms of acute stroke or transient ischaemic attack. N Z Med J . 2021;134(1542):29–37. Nagao Y, Nakajima M, Inatomi Y, Ito Y, Kouzaki Y, Wada K, et al. Pre-hospital delay in patients with acute ischemic stroke in a multicenter stroke registry: k-plus. J Stroke Cerebrovasc Dis . 2020;29(11):105284. doi:10.1016/j.jstrokecerebrovasdis.2020.105284. Kielkopf M, Meinel T, Kaesmacher J, Fischer U, Arnold M, Heldner M, et al. Temporal trends and risk factors for delayed hospital admission in suspected stroke patients. J Clin Med . 2020;9(8). doi:10.3390/jcm9082376. Zhu Y, Zhang X, You S, Cao X, Wang X, Gong W, et al. Factors associated with pre-hospital delay and intravenous thrombolysis in china. J Stroke Cerebrovasc Dis . 2020;29(8):104897. doi:10.1016/j.jstrokecerebrovasdis.2020.104897. Civil code of the people ’ s republic of china . Beijing: China Democracy and Legal System Publishing House; 2021. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 30 Apr, 2026 Reviewers agreed at journal 23 Apr, 2026 Reviewers invited by journal 21 Apr, 2026 Editor assigned by journal 20 Apr, 2026 Editor invited by journal 25 Mar, 2026 Submission checks completed at journal 24 Mar, 2026 First submitted to journal 24 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9171521","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":631064652,"identity":"f1809aef-6cf9-4668-844a-da046a3497b8","order_by":0,"name":"Chengxia Wei","email":"","orcid":"","institution":"Guangming Hospital of Traditional Chinese Medicine,Pudong New Area,Shanghai,China","correspondingAuthor":false,"prefix":"","firstName":"Chengxia","middleName":"","lastName":"Wei","suffix":""},{"id":631064656,"identity":"fe53c780-db5c-4e41-af14-4ec42a83d77a","order_by":1,"name":"Keying Xu","email":"","orcid":"","institution":"Graduate School, Shanghai University of Traditional Chinese Medicine","correspondingAuthor":false,"prefix":"","firstName":"Keying","middleName":"","lastName":"Xu","suffix":""},{"id":631064664,"identity":"c36ae5b3-dfa8-4dc9-99d9-49f111f1cdd4","order_by":2,"name":"Chen Xu","email":"","orcid":"","institution":"Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China","correspondingAuthor":false,"prefix":"","firstName":"Chen","middleName":"","lastName":"Xu","suffix":""},{"id":631064667,"identity":"f7c6f9ce-3578-41bb-8103-9aca358af6ab","order_by":3,"name":"Yingying Shao","email":"","orcid":"","institution":"Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China","correspondingAuthor":false,"prefix":"","firstName":"Yingying","middleName":"","lastName":"Shao","suffix":""},{"id":631064674,"identity":"4ad43fa7-a72b-4542-beca-8fee0ddc4625","order_by":4,"name":"Hui Ni","email":"","orcid":"","institution":"Guangming Hospital of Traditional Chinese Medicine,Pudong New Area,Shanghai,China","correspondingAuthor":false,"prefix":"","firstName":"Hui","middleName":"","lastName":"Ni","suffix":""},{"id":631064675,"identity":"29be600e-5229-4f71-b2b8-3322b8ad6826","order_by":5,"name":"Gendi Lu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAxUlEQVRIiWNgGAWjYBACAyCW+GAgIcfPzHzwAdFaJGdUWBhLtrMlGxCtRZrnTEWiwXkeMwHitEikX7zB2yaRYHyYwYyBocYmmggtOcUWkm0SeWaHGdIeMBxLy20gQkuahGGbRDFQy3EDxobDRGpJbJNI3NzM2CZBpJb0YxIHzkgkbmBmZiNSC88bZsuGCgljicNszAYJxPjFvj394e0/BnVy/P3nPz74UGNDWAsDAw9SBCYQVg4C7A+IUzcKRsEoGAUjFwAAPvI8HMuQKA8AAAAASUVORK5CYII=","orcid":"","institution":"Guangming Hospital of Traditional Chinese Medicine,Pudong New Area,Shanghai,China","correspondingAuthor":true,"prefix":"","firstName":"Gendi","middleName":"","lastName":"Lu","suffix":""}],"badges":[],"createdAt":"2026-03-19 16:09:49","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9171521/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9171521/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108097643,"identity":"aec920b8-1d43-490a-ba6c-5662a843916d","added_by":"auto","created_at":"2026-04-29 10:15:14","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":197118,"visible":true,"origin":"","legend":"\u003cp\u003eThe COM-B model. Reproduced from Michie et al. [15].\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9171521/v1/13318d82090b5e26ced41671.png"},{"id":108097645,"identity":"cd6de835-2e55-4f33-a16b-a961dd1828ad","added_by":"auto","created_at":"2026-04-29 10:15:15","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":130854,"visible":true,"origin":"","legend":"\u003cp\u003eA COM-B–informed framework for prehospital stroke response\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-9171521/v1/1db81d84981cea399f306703.png"},{"id":108182287,"identity":"eb7f4dd9-dc53-4480-af48-93c960171064","added_by":"auto","created_at":"2026-04-30 08:59:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":690271,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9171521/v1/1f1412cf-1940-4b7f-a560-8828f31ea0b7.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Barriers to Prehospital Emergency Response Behaviors Among First Witnesses of Stroke: A Qualitative Study Guided by the COM-B Model","fulltext":[{"header":"Introduction","content":"\u003cp\u003eStroke ranks among the leading causes of mortality and long-term disability worldwide, with its disease burden continuing to rise in parallel with population aging [1, 2]. According to the World Stroke Organization, approximately 14\u0026nbsp;million people experience a stroke each year, resulting in more than 6.5\u0026nbsp;million deaths globally [3]. Given its sudden onset and rapid progression, early recognition and timely intervention are critical determinants of clinical outcomes [4\u0026ndash;6]. In particular, because stroke treatment is highly dependent on narrow therapeutic time windows, the effectiveness of the prehospital emergency phase plays a pivotal role in determining treatment success [7].\u003c/p\u003e \u003cp\u003eDuring acute stroke events, first witnesses\u0026mdash;including family members, colleagues, or members of the public\u0026mdash;are often the earliest individuals to detect abnormal symptoms and initiate emergency responses [8\u0026ndash;10]. Their ability to recognize warning signs, interpret the situation, and make prompt decisions directly influences the activation of the emergency care chain and represents a critical behavioral node in stroke management [8, 11, 12]. Although previous studies have emphasized public stroke awareness and patient-related delay factors, the behavioral formation mechanisms of first witnesses in emergency contexts remain insufficiently explored from a systematic and theory-driven perspective [7, 13].\u003c/p\u003e \u003cp\u003eExisting research has largely focused on isolated factors, such as knowledge or attitudes, without adequately accounting for the interactive effects of individual capability, environmental opportunity, and psychological motivation [14]. This fragmented approach limits a comprehensive understanding of the complex barriers that impede timely and appropriate prehospital emergency responses [12]. The Capability\u0026ndash;Opportunity\u0026ndash;Motivation\u0026ndash; Behavior (COM-B) model offers an integrative theoretical framework to address this limitation [15]. The model posits that behavior arises from the dynamic interaction of capability, opportunity, and motivation and has been widely applied in the development and evaluation of health behavior interventions [16\u0026ndash;19].\u003c/p\u003e \u003cp\u003eAgainst this background, the present study focuses on the critical interval between stroke onset and the arrival of professional emergency services. Guided by the COM-B model, this qualitative study systematically explores the barriers influencing whether first witnesses are able to initiate and perform appropriate prehospital emergency response behaviors. By elucidating the behavioral logic underlying first witnesses\u0026rsquo; responses, this study aims to provide a theoretical basis for understanding prehospital emergency behavior and to inform the development of multi-level, precision-targeted strategies to promote timely and effective stroke response.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003eStudy design\u003c/h2\u003e\n \u003cp\u003eThis study adopted a theory-informed qualitative descriptive design guided by the COM-B model. A qualitative descriptive approach was employed to generate a comprehensive, low-inference account of barriers experienced by first witnesses of stroke during the prehospital emergency phase, emphasizing participants\u0026rsquo; accounts expressed in their own words [20].\u003c/p\u003e\n \u003cp\u003eData analysis followed a thematic analytic process, drawing on selected analytical procedures described by Colaizzi to support systematic organization and interpretation of interview data [21]. The COM-B model was used as an analytical lens to guide the interpretation and theoretical integration of the identified themes.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eStudy setting\u003c/h3\u003e\n\u003cp\u003eThis study was conducted at a tertiary teaching hospital in eastern China. In urban Chinese settings, individuals with suspected acute stroke are typically transferred directly from community or household locations to tertiary hospitals for emergency care [22]. First witnesses often accompany patients throughout the early clinical encounter, providing an appropriate context for retrospective qualitative exploration of prehospital emergency response behaviors [7].\u003c/p\u003e\n\u003ch3\u003eParticipants and sampling\u003c/h3\u003e\n\u003cp\u003eParticipants were recruited between May and August 2024 using purposive sampling to ensure inclusion of information-rich individuals with direct experience of prehospital stroke emergencies. First witnesses were defined as individuals who were present at the onset of stroke symptoms and directly observed the acute event.\u003c/p\u003e\n\u003ch3\u003eInclusion criteria were:\u003c/h3\u003e\n\u003cp\u003e(1) provision of written informed consent;\u003c/p\u003e\n\u003cp\u003e(2) direct witnessing of acute stroke onset in another individual;\u003c/p\u003e\n\u003cp\u003e(3) no concurrent participation in other research studies; and\u003c/p\u003e\n\u003cp\u003e(4) no medical or health-related professional background.\u003c/p\u003e\n\u003ch3\u003eExclusion criteria were:\u003c/h3\u003e\n\u003cp\u003e(1) being a paid caregiver;\u003c/p\u003e\n\u003cp\u003e(2) apparent cognitive, language, or hearing impairments that could interfere with participation; or\u003c/p\u003e\n\u003cp\u003e(3) withdrawal from the interview before completion.\u003c/p\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003eTheoretical framework\u003c/h2\u003e\n \u003cp\u003eBarriers to prehospital emergency response behaviors among first witnesses of stroke were conceptualized as factors that hinder timely symptom recognition, activation of emergency medical services, and appropriate action during the critical interval between symptom onset and arrival of professional care.\u003c/p\u003e\n \u003cp\u003eThe COM-B model, a core component of the Behaviour Change Wheel developed by Michie and colleagues, served as the overarching theoretical framework [15]. The model conceptualizes behavior as arising from dynamic interactions among capability (psychological and physical), opportunity (physical and social), and motivation (reflective and automatic)(Fig. 1). In this study, the COM-B model informed the organization of codes and the integration of emerging themes during analysis, enabling theory-based mapping of identified barriers across the three behavioral domains.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n \u003ch2\u003eInterview guide\u003c/h2\u003e\n \u003cp\u003eA semi-structured interview guide was developed based on a review of relevant literature and discussions within the research team and was further refined through expert consultation [23, 24]. Pilot interviews were conducted with five first witnesses of stroke to assess clarity, relevance, and comprehensibility. Minor revisions were made accordingly, resulting in the final interview guide[20, 25].\u003c/p\u003e\n \u003cp\u003eInterview questions were experience-oriented and open-ended, aiming to elicit participants\u0026rsquo; authentic accounts rather than impose predefined theoretical assumptions. Core areas included:\u003c/p\u003e\n \u003cp\u003e(1) immediate reactions during acute stroke events;\u003c/p\u003e\n \u003cp\u003e(2) processes of symptom recognition and appraisal;\u003c/p\u003e\n \u003cp\u003e(3) sources and perceived credibility of emergency-related knowledge;\u003c/p\u003e\n \u003cp\u003e(4) perceptions of helping behaviors and willingness to intervene; and\u003c/p\u003e\n \u003cp\u003e(5) perceived barriers, available support, and unmet needs during emergency response.\u003c/p\u003e\n \u003cp\u003eProbing questions were used flexibly to clarify responses and deepen exploration.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003eInterview procedure\u003c/h2\u003e\n \u003cp\u003eData were collected through retrospective, in-depth, semi-structured interviews conducted by two trained qualitative researchers. One researcher served as the primary interviewer, while the second acted as an observer and documented non-verbal behaviors and contextual information. Prior to each interview, participants were informed about the study purpose, procedures, confidentiality, and audio recording, and written informed consent was obtained [26].\u003c/p\u003e\n \u003cp\u003eInterviews were conducted in quiet, private settings to facilitate open communication, and leading prompts were deliberately avoided. Each participant was interviewed one to two times depending on data richness [24]. Interviews lasted approximately 40\u0026ndash;60 minutes and were audio-recorded in full. Field notes were taken during and immediately after interviews to capture contextual details and support data interpretation.\u003c/p\u003e\n \u003cp\u003eData collection continued until thematic saturation was achieved, defined as the absence of new themes across three consecutive interviews.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003eData management and analysis\u003c/h2\u003e\n \u003cp\u003eAll audio recordings were transcribed verbatim within 24 hours of each interview. Dialect expressions or ambiguous wording were independently reviewed by two researchers and verified against audio recordings when necessary. Transcripts were de-identified using participant codes (P1\u0026ndash;P13) and stored securely.\u003c/p\u003e\n \u003cp\u003eData were analyzed using thematic analysis, supported by selected analytical procedures described by Colaizzi to facilitate systematic coding and interpretation [27]. The analytic process involved the following steps:\u003c/p\u003e\n \u003cp\u003e(1) repeated reading of transcripts to achieve immersion;\u003c/p\u003e\n \u003cp\u003e(2) identification of significant statements related to prehospital emergency response;\u003c/p\u003e\n \u003cp\u003e(3) formulation of meanings grounded in participants\u0026rsquo; accounts;\u003c/p\u003e\n \u003cp\u003e(4) clustering of meanings into themes through constant comparison; and\u003c/p\u003e\n \u003cp\u003e(5) iterative refinement of themes through team discussion.\u003c/p\u003e\n \u003cp\u003eTwo researchers independently conducted coding and theme development. Discrepancies were resolved through discussion and, when necessary, consultation with a third researcher. After themes were generated inductively from the interview data, the COM-B model was applied as an analytical lens to organize themes and map identified barriers onto capability, opportunity, and motivation domains.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003ch2\u003eResearcher reflexivity\u003c/h2\u003e\n \u003cp\u003eThe research team comprised nursing researchers with formal training in qualitative methods and prior experience in stroke-related research. To enhance reflexivity, interviewers engaged in ongoing reflective discussions throughout data collection and analysis, documenting assumptions, positionality, and key analytical decisions. Regular team meetings were held to critically examine how researchers\u0026rsquo; professional backgrounds and theoretical orientation toward the COM-B model might influence data interpretation.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n \u003ch2\u003eRigor\u003c/h2\u003e\n \u003cp\u003eMethodological rigor was ensured in accordance with Lincoln and Guba\u0026rsquo;s criteria for qualitative research [28].\u003c/p\u003e\n \u003cp\u003eCredibility was enhanced through pilot interviews, prolonged engagement, analyst triangulation, and member checking of selected transcripts.\u003c/p\u003e\n \u003cp\u003eTransferability was supported by thick description of the study context, participant characteristics, and research procedures.\u003c/p\u003e\n \u003cp\u003eDependability was strengthened through standardized documentation of data collection and analytic procedures, with independent coding followed by consensus discussion.\u003c/p\u003e\n \u003cp\u003eConfirmability was ensured by maintaining a comprehensive audit trail, including transcripts, coding frameworks, analytical memos, and reflexive notes, enabling transparency and traceability of analytic decisions.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\n \u003ch2\u003eEthical considerations\u003c/h2\u003e\n \u003cp\u003eEthical approval was obtained from the Ethics Committee of Shanghai Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine.This study was conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from all adult participants. For underage participants, assent was obtained from the participant and written informed consent from legal guardians; interviews were conducted in the presence of guardians. All data were anonymized and handled confidentially.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eParticipant characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of thirteen first witnesses of stroke participated in this study. Participants represented diverse social roles, including students, employed individuals, and retirees, and had experienced a range of prehospital witnessing contexts. Interviews with underage participants were conducted in the presence of legal guardians. Detailed participant characteristics are presented in Table 1.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTable 1\u003c/em\u003e\u0026nbsp; Demographic characteristics of first witnesses of stroke\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"635\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParticipant ID\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducational level\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHealth insurance type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHousehold composition\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrevious emergency response experience\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eType of stroke witnessed\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003eP1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003eJunior high school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003eRural health insurance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003eLiving with family\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003eIntracerebral hemorrhage\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003eP2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003ePrimary school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003eUrban health insurance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003eLiving with family\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003eIschemic stroke\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003eP3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003eJunior college\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003eUrban health insurance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003eLiving with family\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003eIntracerebral hemorrhage\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003eP4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003eTechnical secondary school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003eUrban health insurance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003eLiving with family\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003eIntracerebral hemorrhage\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003eP5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003eJunior college\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003eUrban health insurance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003eLiving alone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003eIschemic stroke\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003eP6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003eJunior high school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003eUrban health insurance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003eLiving with family\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003eIschemic stroke\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003eP7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003eJunior high school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003eRural health insurance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003eLiving with family\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003eIntracerebral hemorrhage\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003eP8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003eBachelor\u0026rsquo;s degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003eRural health insurance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003eLiving with family\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003eIschemic stroke\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003eP9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003eBachelor\u0026rsquo;s degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003eUrban health insurance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003eLiving alone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003eIschemic stroke\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003eP10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003eSenior high school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003eUrban health insurance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003eInstitutional care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003eIschemic stroke\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003eP11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003eJunior high school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003eRural health insurance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003eLiving with family\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003eIntracerebral hemorrhage\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003eP12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003eSenior high school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003eUrban health insurance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003eLiving with family\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003eIntracerebral hemorrhage\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003eP13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003eJunior high school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003eUrban health insurance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003eLiving with family\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003eIschemic stroke\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eNote:\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u0026nbsp;Urban and rural health insurance refer to China\u0026rsquo;s public medical insurance systems.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThemes and subthemes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGuided by the COM-B model, this study identified 7 themes and 17 subthemes related to barriers to prehospital emergency response behaviors among first witnesses of stroke (Table 2). Themes were generated inductively from the interview data and subsequently organized within the COM-B framework to support analytic integration.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTable 2\u003c/em\u003e\u0026nbsp; Themes and subthemes\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCOM-B\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eThemes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSubthemes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"6\" valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003eCapability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eImpaired recognition and risk appraisal of stroke symptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003eDelayed anticipation of symptom severity\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003eAttribution bias in symptom interpretation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eLimited capacity to enact appropriate emergency actions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003ePhysical and situational constraints\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003eInappropriate or improvised response behaviors\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003eLack of professional emergency knowledge\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eWeak integration of emergency knowledge into everyday preparedness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003eLow initiative in acquiring stroke-related emergency knowledge\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eContinued Table 2\u003c/em\u003e\u0026nbsp; Themes and subthemes\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCOM-B\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eThemes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSubthemes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"7\" valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003eOpportunity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003eStructural and logistical barriers to timely emergency activation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eLimited availability or delayed response of EMS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eTransportation and access constraints\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eAdministrative unpreparedness\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003eLow contextual salience of stroke-related information in daily life\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eLimited engagement with existing information channels\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003ePerceived irrelevance of health education content\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003eFragility of immediate social support networks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eShortage of caregiving manpower\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eLack of emotional and shared decision-making support\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003eMotivation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003eReflective and emotional ambivalence toward emergency intervention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eEthical hesitation and fear of liability\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eDistrust in EMS responsiveness\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eStress-induced cognitive blankness\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eFear of causing secondary harm\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eNote:\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u0026nbsp;\u0026ldquo;120\u0026rdquo; refers to the emergency medical service (EMS) system in China.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnalytical themes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 1. Impaired recognition and risk appraisal of stroke symptoms\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants frequently described difficulty recognizing early stroke manifestations and accurately assessing their urgency. Initial symptoms such as dizziness, slurred speech, limb weakness, or unusual drowsiness were often interpreted as mild, temporary, or attributable to familiar conditions, which reduced the perceived need for immediate action.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDelayed anticipation of symptom severity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMany participants failed to anticipate the seriousness of early symptoms and delayed activating emergency medical services.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;She often has high blood pressure, and dizziness usually goes away after resting for a while. At that time, calling 120 didn\u0026rsquo;t seem necessary.\u0026rdquo; (P4)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;He was already stuttering and having trouble moving, but I thought it might just be because he was getting older.\u0026rdquo; (P8)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;He kept feeling very sleepy after returning from morning exercise. I thought he just hadn\u0026rsquo;t slept well. It wasn\u0026rsquo;t until his leg stopped working and he collapsed that I realized how serious it was.\u0026rdquo; (P13)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAttribution bias in symptom interpretation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants frequently attributed warning signs to fatigue, medication effects, or pre-existing conditions, which further weakened risk perception.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I never thought it was something wrong with his brain. I just thought he was having a spasm.\u0026rdquo; (P1)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;He said he had a headache and his speech was a bit unclear. I thought it was because he hadn\u0026rsquo;t slept enough.\u0026rdquo; (P3)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;When I saw her mouth drooping, my first reaction was facial paralysis. She even insisted it was because she hadn\u0026rsquo;t put in her dentures properly.\u0026rdquo; (P5)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;We had just come back from the emergency department, so I naturally assumed the blood pressure medication hadn\u0026rsquo;t taken effect yet. I never thought it was a stroke.\u0026rdquo; (P8)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThese misinterpretations delayed recognition of stroke and postponed emergency response.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 2. Limited capacity to enact appropriate emergency actions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEven when participants realized that something serious was happening, many described difficulty translating concern into effective action during the emergency.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePhysical and situational constraints\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEmbodied limitations, including insufficient strength, advanced age, or environmental barriers, restricted the ability to assist patients.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;My husband is quite large, and we live on the sixth floor without an elevator. In the end, we could only manage to carry him downstairs together with the emergency staff.\u0026rdquo; (P3)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I\u0026rsquo;m already quite old, and my legs hurt whenever I squat. She collapsed in the bathroom sink, and it took a great deal of effort just to move her a little.\u0026rdquo; (P4)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I really wanted to help more, but I couldn\u0026rsquo;t move him at all by myself. I could only wait there until the ambulance came.\u0026rdquo; (P6)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInappropriate or improvised response behaviors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the absence of clear knowledge, several participants relied on instinctive or experience-based actions that were later recognized as inappropriate.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;After calling 120, I immediately pinched his philtrum and put my phone into his mouth to stop him from biting his tongue.\u0026rdquo; (P1)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;He was convulsing badly, and instinctively I kept squeezing his hands and feet and pressing them repeatedly.\u0026rdquo; (P5)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;When he started vomiting and his lips turned blue, I hurriedly pressed on his chest.\u0026rdquo; (P11)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLack of professional emergency knowledge\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants frequently expressed uncertainty about what actions were appropriate during the critical prehospital period.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I could only help him sit upright and steady him, and then I didn\u0026rsquo;t know what else to do. I could only wait.\u0026rdquo; (P3)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I pinched her philtrum and kept calling her name. That was all I dared to do. Anything professional, I didn\u0026rsquo;t dare try.\u0026rdquo; (P8)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Only after everything happened did we realize how little professional first-aid knowledge we actually had.\u0026rdquo; (P13)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 3. Weak integration of emergency knowledge into everyday preparedness\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants reported limited engagement with health education prior to the stroke event. Emergency knowledge had not been incorporated into everyday awareness or preparedness.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLow initiative in acquiring stroke-related emergency knowledge\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMany participants stated that they rarely paid attention to health education activities because they believed such issues were irrelevant to their own lives.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I never take part in the community health education activities. I usually just throw the materials away.\u0026rdquo; (P5)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I always felt that my family members were healthy. I never thought something like this could happen, so I didn\u0026rsquo;t pay attention to it.\u0026rdquo; (P7)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis lack of proactive learning reduced both recognition speed and confidence during emergencies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 4. Structural and logistical barriers to timely emergency activation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants described several systemic and environmental barriers that complicated or delayed emergency response.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimited availability or delayed response of EMS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSome participants encountered difficulty reaching emergency services.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;When I called 120, the line was busy. I had to call repeatedly before it finally went through.\u0026rdquo; (P1)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The operator told us they still needed to arrange a vehicle and asked us not to hang up.\u0026rdquo; (P4)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTransportation and access constraints\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEnvironmental conditions such as traffic congestion and complex residential layouts further delayed hospital arrival.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;When the ambulance was on the way to the hospital, it was right during rush hour. A trip that usually takes 20 minutes ended up taking more than 40.\u0026rdquo; (P4)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;That morning the traffic was quite heavy, and there were many cars blocking the hospital entrance.\u0026rdquo; (P10)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Our residential area is like a maze. The ambulance spent a lot of time trying to locate the building.\u0026rdquo; (P13)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAdministrative unpreparedness\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn moments of panic, some participants forgot essential documents.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;In the panic, I even forgot to bring the ID card.\u0026rdquo; (P11)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;We forgot everything. It wasn\u0026rsquo;t until we arrived at the hospital that I realized we hadn\u0026rsquo;t brought the insurance card or the ID.\u0026rdquo; (P13)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 5. Low contextual salience of stroke-related information in daily life\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants reported that existing health information rarely entered their everyday cognitive environment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimited engagement with existing information channels\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOnline health information was often overlooked or overshadowed by entertainment content.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Health information pushed by big data is easy to ignore. On platforms like TikTok, it\u0026rsquo;s mostly entertaining videos.\u0026rdquo; (P3)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Face-to-face communication would be much better.\u0026rdquo; (P3)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePerceived irrelevance of health education content\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSome participants felt that existing health lectures were too specialized or disconnected from their daily lives.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;For people like us who work in factories, we don\u0026rsquo;t understand professional medical knowledge.\u0026rdquo; (P1)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Most lectures in the community are about dental or orthopedic issues. I hope the topics could be more diverse.\u0026rdquo; (P4)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;For us farmers, many things are hard to understand, and we don\u0026rsquo;t even know where to learn these things.\u0026rdquo; (P7)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 6. Fragility of immediate social support networks\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe temporary absence of practical or emotional support during emergencies further complicated response behavior.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eShortage of caregiving manpower\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I couldn\u0026rsquo;t manage my spouse by myself. Everyone in the community is elderly, and there was no younger person I could find to help.\u0026rdquo; (P4)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLack of emotional and shared decision-making support\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants described feeling overwhelmed when facing emergencies alone.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I was the only one at home. After a night shift, I was anxious and helpless.\u0026rdquo; (P5)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Of course I panicked. Anyone would. I felt completely helpless\u0026mdash;neighbors live far away, and there was no one I could call.\u0026rdquo; (P6)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 7. Reflective and emotional ambivalence toward emergency intervention\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMotivational barriers played a critical role in shaping response behavior.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical hesitation and fear of liability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants expressed concern about legal disputes or being falsely accused when helping others.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;If I saw someone collapse on the street, I definitely wouldn\u0026rsquo;t dare to help.\u0026rdquo; (P1)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;What if I cause harm and get involved in a dispute? The consequences would be hard to predict.\u0026rdquo; (P3)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDistrust in EMS responsiveness\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSome participants doubted the timeliness of ambulance services and therefore preferred alternative options.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Waiting for 120 would just waste time. I could leave immediately in my own car.\u0026rdquo; (P5)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I\u0026rsquo;ve seen cases where it took half an hour for an ambulance to arrive.\u0026rdquo; (P6)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Sometimes you call an ambulance, and you don\u0026rsquo;t know when it will arrive.\u0026rdquo; (P9)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStress-induced cognitive blankness\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAcute stress during emergencies impaired recall and decision-making.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;My mother once taught me some first-aid knowledge, but when my father collapsed, my mind went completely blank.\u0026rdquo; (P2)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFear of causing secondary harm\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConcerns about making the situation worse led some participants to avoid intervening beyond calling for help.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I don\u0026rsquo;t understand medical procedures. When I don\u0026rsquo;t know what\u0026rsquo;s going on, I don\u0026rsquo;t dare act recklessly.\u0026rdquo; (P1)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I don\u0026rsquo;t have any medical knowledge. I could only call 120 and not touch her\u0026mdash;what if it made things worse?\u0026rdquo; (P10)\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study provides a theory-informed qualitative analysis of barriers to prehospital emergency response among first witnesses of stroke, using the COM-B model to elucidate the behavioral mechanisms underlying delayed or constrained action (Fig.\u0026nbsp;2). The findings indicate that prehospital stroke response is not determined by isolated deficits, but rather emerges from dynamic interactions among capability, opportunity, and motivation within time-critical and emotionally charged contexts.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eCapability-related barriers: Disruption between awareness and action\u003c/b\u003e \u003c/p\u003e \u003cp\u003eCapability-related barriers constituted a foundational constraint on effective prehospital response. Importantly, these barriers did not primarily reflect an absence of knowledge, but rather a failure to translate cognitive awareness into action under acute stress [7, 12]. Consistent with prior studies highlighting the importance of symptom recognition and rapid emergency activation [29\u0026ndash;31], participants in this study frequently normalized or misattributed early stroke manifestations, weakening risk appraisal and delaying response. In addition, many participants reported limited engagement with health education prior to the event, suggesting that stroke-related emergency knowledge had not been sufficiently integrated into everyday preparedness.\u003c/p\u003e \u003cp\u003eThese findings extend existing literature by demonstrating that knowledge-based education alone may be insufficient. Physical limitations, environmental constraints, and heightened emotional arousal collectively reduced individuals\u0026rsquo; capacity to operationalize what they knew in real time. From a COM-B perspective, this reflects a misalignment between psychological capability and situational demands, underscoring the need to move beyond information-oriented education toward experiential learning and skill rehearsal that support behavioral enactment under pressure.\u003c/p\u003e \u003cp\u003e \u003cb\u003eOpportunity-related barriers: Structural and social constraints on action\u003c/b\u003e \u003c/p\u003e \u003cp\u003eOpportunity-related barriers reflected systemic limitations in both physical and social environments. At the level of physical opportunity, restricted access to timely emergency medical services (EMS), transportation barriers, and contextual obstacles (e.g., traffic congestion, location identification difficulties) constrained prehospital response [31\u0026ndash;33]. While such barriers have often been emphasized in rural or resource-limited settings [33], participants\u0026rsquo; accounts suggest that opportunity constraints remain salient even in urban contexts.\u003c/p\u003e \u003cp\u003eAt the level of social opportunity, misalignment between health information dissemination and public needs emerged as a prominent barrier. Existing health education was frequently perceived as overly technical, insufficiently tailored, or delivered through channels that failed to engage diverse occupational and educational groups. Furthermore, although family and community support have been shown to facilitate symptom recognition and decision-making, participants often described a temporary collapse of social support during acute events, leaving witnesses without timely informational or emotional assistance. Together, these findings illustrate how opportunity constraints may undermine prehospital response even when individual capability is present.\u003c/p\u003e \u003cp\u003e \u003cb\u003eMotivation-related barriers: Ethical tension and trust deficits\u003c/b\u003e \u003c/p\u003e \u003cp\u003eMotivation played a pivotal role in determining whether available capability and opportunity were translated into action. At the level of automatic motivation, participants frequently described cognitive blankness and emotional overload during emergencies, limiting retrieval and application of prior emergency knowledge. Fear of causing secondary harm further contributed to hesitation, as some participants preferred to avoid physical intervention due to uncertainty about appropriate actions. This pattern highlights the limited automatization of emergency behaviors among lay populations.\u003c/p\u003e \u003cp\u003eReflective motivation was shaped by ethical concerns, legal uncertainty, and trust deficits. Fear of legal liability, social disputes, or unintended harm discouraged intervention, particularly when assisting strangers. Although legal protections for emergency assistance exist in China (e.g., Article 184 of the Civil Code) [34], limited public awareness and ambiguity in practical application appear to weaken their behavioral impact. In addition, distrust in EMS responsiveness further suppressed motivation to seek professional help. Collectively, these motivational constraints help explain why individuals may possess the capacity and opportunity to act, yet still hesitate in real-world emergency situations.\u003c/p\u003e \u003cp\u003e \u003cb\u003eInteraction across capability, opportunity, and motivation\u003c/b\u003e \u003c/p\u003e \u003cp\u003eBeyond barriers identified within individual COM-B domains, the findings suggest that capability, opportunity, and motivation interact dynamically in shaping first witnesses\u0026rsquo; responses during stroke emergencies. Rather than operating independently, constraints in one domain often amplify limitations in others.\u003c/p\u003e \u003cp\u003eCapability deficits, such as uncertainty in symptom recognition or lack of confidence in emergency response skills, frequently redirected witnesses toward informal support networks rather than activating emergency medical services. Although these networks may provide reassurance, they are often unreliable and may introduce delays.\u003c/p\u003e \u003cp\u003eMotivational perceptions regarding emergency system responsiveness also influenced opportunity choices. Distrust in ambulance response times led some participants to rely on private transportation, which transferred responsibilities for patient handling and monitoring to untrained witnesses and intensified existing capability constraints.\u003c/p\u003e \u003cp\u003eIn addition, emotional stress and fear of causing harm sometimes produced cognitive blankness that prevented individuals from applying prior knowledge. Taken together, these findings indicate that barriers to stroke response may arise from a reinforcing interaction across capability, opportunity, and motivation, helping explain why knowledge-focused interventions alone often achieve limited behavioral impact.\u003c/p\u003e \u003cp\u003e \u003cb\u003eImplications for future research and intervention development\u003c/b\u003e \u003c/p\u003e \u003cp\u003eGuided by the COM-B model, the findings of this study highlight key leverage points that may inform future intervention development, without presupposing specific implementation strategies. At the level of capability, interventions may need to prioritize experiential and scenario-based approaches that enhance behavioral enactment under stress rather than solely increasing knowledge. At the level of opportunity, system-level efforts to improve EMS accessibility, information alignment, and community-based support may help reduce contextual barriers. At the level of motivation, strengthening public trust in emergency systems and clarifying legal protections may alleviate ethical and psychological constraints on helping behavior.\u003c/p\u003e \u003cp\u003eImportantly, these implications are exploratory and theory-informed, serving to clarify intervention logic rather than to prescribe or evaluate specific programs.\u003c/p\u003e \u003cp\u003e \u003cb\u003eLimitations and future research directions\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis study has several limitations. First, as a single-center qualitative study with a relatively small sample, transferability to other settings may be limited. Second, retrospective accounts may be subject to recall bias and post-event reinterpretation. Third, although the COM-B model provided a robust analytical framework, the relative contribution of identified barriers was not quantitatively assessed. In addition, the inclusion of a small number of adolescent participants may have influenced the depth of experiential accounts.\u003c/p\u003e \u003cp\u003eFuture research should adopt multicenter and mixed-methods designs to examine the prevalence and interaction of COM-B\u0026ndash;related barriers across contexts. Quantitative and longitudinal approaches may further elucidate causal pathways and test the effectiveness of theory-informed interventions aimed at improving prehospital stroke response.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003ePrehospital emergency response behaviors among first witnesses of stroke are shaped by interacting constraints across capability, opportunity, and motivation. By elucidating the behavioral mechanisms underlying delayed or constrained action, this study advances theory-informed understanding of prehospital stroke response and provides an empirical foundation for future research and intervention development aimed at improving timely emergency care.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCOM-B: Capability, Opportunity, Motivation–Behavior model;\u003c/p\u003e\n\u003cp\u003eEMS: Emergency Medical Services;\u003c/p\u003e\n\u003cp\u003eED: Emergency Department.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eContribution of the Paper\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhat is already known\u003c/p\u003e\n\u003cp\u003e\u0026bull; Timely recognition and response by first witnesses is critical to reducing prehospital delay in stroke.\u003c/p\u003e\n\u003cp\u003e\u0026bull; Previous studies have mainly focused on public awareness or patient-related delays.\u003c/p\u003e\n\u003cp\u003eWhat this paper adds\u003c/p\u003e\n\u003cp\u003e\u0026bull; This study provides a theory-informed analysis of barriers to stroke emergency response using the COM-B model.\u003c/p\u003e\n\u003cp\u003e\u0026bull; Barriers arise from interacting constraints across capability, opportunity, and motivation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethics Committee of Shanghai Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine.\u003c/p\u003e\n\u003cp\u003eAll participants provided written informed consent prior to participation.\u003c/p\u003e\n\u003cp\u003eFor underage participants, assent was obtained from the participants and written informed consent was obtained from their legal guardians.\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are not publicly available due to privacy and ethical restrictions but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was supported by the 2023 Science and Technology Development Project of Shanghai University of Traditional Chinese Medicine (Grant No. 23HLZX05), the 2023 Hospital Management Research Fund of the Shanghai Hospital Association (Grant No. Q2023052), and the 2026 Cohort Construction Project of Shanghai Pudong New Area Guangming Hospital of Traditional Chinese Medicine (Grant No. 2026-PWDL-33).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eC.W. and G.L. conceptualized and designed the study.\u003c/p\u003e\n\u003cp\u003eC.W. and K.X. conducted the literature review and data analysis.\u003c/p\u003e\n\u003cp\u003eC.X. and Y.S. contributed to data collection.\u003c/p\u003e\n\u003cp\u003eH.N. and G.L. supervised the study.\u003c/p\u003e\n\u003cp\u003eC.W. drafted the manuscript.\u003c/p\u003e\n\u003cp\u003eAll authors reviewed and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank all participants for sharing their experiences.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eFeigin VL, Brainin M, Norrving B, Martins SO, Pandian J, Lindsay P, et al. World stroke organization: global stroke fact sheet 2025. \u003cem\u003eInt J Stroke\u003c/em\u003e. 2025;20(2):132\u0026ndash;144. doi:10.1177/17474930241308142.\u003c/li\u003e\n \u003cli\u003eGlobal, regional, and national burden of stroke, 1990-2016: a systematic analysis for the global burden of disease study 2016. \u003cem\u003eLancet Neurol\u003c/em\u003e. 2019;18(5):439\u0026ndash;458. doi:10.1016/S1474-4422(19)30034-1.\u003c/li\u003e\n \u003cli\u003eParry-Jones AR, Krishnamurthi R, Ziai WC, Shoamanesh A, Wu S, Martins SO, et al. World stroke organization (wso): global intracerebral hemorrhage factsheet 2025. \u003cem\u003eInt J Stroke\u003c/em\u003e. 2025;20(2):145\u0026ndash;150. doi:10.1177/17474930241307876.\u003c/li\u003e\n \u003cli\u003eMagnusson C, Herlitz J, Sunnerhagen KS, Hansson P, Andersson J, Jood K. Prehospital recognition of stroke is associated with a lower risk of death. \u003cem\u003eActa Neurol Scand\u003c/em\u003e. 2022;146(2):126\u0026ndash;136. doi:10.1111/ane.13618.\u003c/li\u003e\n \u003cli\u003eWu Y, Yang Y, Guo X, Guo D, Lu Y, Li G, et al. Effect of pre-hospital early intervention combined with an in-hospital emergency model in the emergency care of patients with acute stroke. \u003cem\u003eAm J Transl Res\u003c/em\u003e. 2022;14(1):672\u0026ndash;678.\u003c/li\u003e\n \u003cli\u003eShkirkova K, Saver JL, Starkman S, Wong G, Weng J, Hamilton S, et al. Frequency, predictors, and outcomes of prehospital and early postarrival neurological deterioration in acute stroke: exploratory analysis of the fast-mag randomized clinical trial. \u003cem\u003eJama Neurol\u003c/em\u003e. 2018;75(11):1364\u0026ndash;1374. doi:10.1001/jamaneurol.2018.1893.\u003c/li\u003e\n \u003cli\u003eBusetto L, Stang C, Herzog F, Sert M, Hoffmann J, Purrucker J, et al. \u0026quot;I didn\u0026apos;t even wonder why i was on the floor\u0026quot; - mixed methods exploration of stroke awareness and help-seeking behaviour at stroke symptom onset. \u003cem\u003eBmc Health Serv Res\u003c/em\u003e. 2024;24(1):880. doi:10.1186/s12913-024-11276-6.\u003c/li\u003e\n \u003cli\u003eZachrison KS, Nielsen VM, de la Ossa NP, Madsen TE, Cash RE, Crowe RP, et al. Prehospital stroke care part 1: emergency medical services and the stroke systems of care. \u003cem\u003eStroke\u003c/em\u003e. 2023;54(4):1138\u0026ndash;1147. doi:10.1161/STROKEAHA.122.039586.\u003c/li\u003e\n \u003cli\u003eBakke I, Lund CG, Carlsson M, Salvesen R, Normann B. Barriers to and facilitators for making emergency calls - a qualitative interview study of stroke patients and witnesses. \u003cem\u003eJ Stroke Cerebrovasc Dis\u003c/em\u003e. 2022;31(10):106734. doi:10.1016/j.jstrokecerebrovasdis.2022.106734.\u003c/li\u003e\n \u003cli\u003eBhutta ZA, Pathan SA, Puolakka T, Akhtar N, Thomas SH, Harris T, et al. Assessing stroke awareness and behavioural response following the national \u0026apos;act fast\u0026apos; stroke awareness campaign - insights from a cross-sectional survey in qatar. \u003cem\u003eJ Patient Exp\u003c/em\u003e. 2024;11:682752093. doi:10.1177/23743735241242717.\u003c/li\u003e\n \u003cli\u003eTan J, Ramazanu S, Liaw SY, Chua WL. Effectiveness of public education campaigns for stroke symptom recognition and response in non-elderly adults: a systematic review and meta-analysis. \u003cem\u003eJ Stroke Cerebrovasc Dis\u003c/em\u003e. 2022;31(2):106207. doi:10.1016/j.jstrokecerebrovasdis.2021.106207.\u003c/li\u003e\n \u003cli\u003eVatsalis T, Papadopoulos D, Georgousopoulou V, Bostantzis P, Rudolf J. Global awareness and response to early symptoms of acute stroke: a systematic literature review. \u003cem\u003eCureus\u003c/em\u003e. 2025;17(2):e78420. doi:10.7759/cureus.78420.\u003c/li\u003e\n \u003cli\u003eSu Y, Qi W, Yu Y, Zhu J, Shi X, Wu X, et al. Analysis of prehospital delay in acute ischaemic stroke and its influencing factors: a multicentre prospective case registry study in china. \u003cem\u003eStroke Vasc Neurol\u003c/em\u003e. 2025;10(5):637\u0026ndash;647. doi:10.1136/svn-2024-003535.\u003c/li\u003e\n \u003cli\u003eTeuschl Y, Brainin M. Stroke education: discrepancies among factors influencing prehospital delay and stroke knowledge. \u003cem\u003eInt J Stroke\u003c/em\u003e. 2010;5(3):187\u0026ndash;208. doi:10.1111/j.1747-4949.2010.00428.x.\u003c/li\u003e\n \u003cli\u003eMichie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. \u003cem\u003eImplement Sci\u003c/em\u003e. 2011;6:42. doi:10.1186/1748-5908-6-42.\u003c/li\u003e\n \u003cli\u003eMadhani A, Finlay KA. Using the com-b model to characterize the barriers and facilitators of pre-exposure prophylaxis (prep) uptake in men who have sex with men. \u003cem\u003eBr J Health Psychol\u003c/em\u003e. 2022;27(4):1330\u0026ndash;1353. doi:10.1111/bjhp.12605.\u003c/li\u003e\n \u003cli\u003eYang Y, Gao Y, An R, Wan Q. Barriers and facilitators to exercise adherence in community-dwelling older adults: a mixed-methods systematic review using the com-b model and theoretical domains framework. \u003cem\u003eInt J Nurs Stud\u003c/em\u003e. 2024;157:104808. doi:10.1016/j.ijnurstu.2024.104808.\u003c/li\u003e\n \u003cli\u003eFlannery C, McHugh S, Anaba AE, Clifford E, O\u0026apos;Riordan M, Kenny LC, et al. Enablers and barriers to physical activity in overweight and obese pregnant women: an analysis informed by the theoretical domains framework and com-b model. \u003cem\u003eBmc Pregnancy Childbirth\u003c/em\u003e. 2018;18(1):178. doi:10.1186/s12884-018-1816-z.\u003c/li\u003e\n \u003cli\u003eZhang M, Guo L, Namassevayam G, Wei M, Xie Y, Guo Y, et al. Factors associated with health behaviours among stroke survivors: a mixed-methods study using com-b model. \u003cem\u003eJ Clin Nurs\u003c/em\u003e. 2024;33(6):2138\u0026ndash;2152. doi:10.1111/jocn.17103.\u003c/li\u003e\n \u003cli\u003eSandelowski M. What\u0026apos;s in a name? Qualitative description revisited. \u003cem\u003eRes Nurs Health\u003c/em\u003e. 2010;33(1):77\u0026ndash;84. doi:10.1002/nur.20362.\u003c/li\u003e\n \u003cli\u003eWebb C. Information point: colaizzi\u0026apos;s framework for analysing qualitative data. \u003cem\u003eJ Clin Nurs\u003c/em\u003e. 1999;8(5):576.\u003c/li\u003e\n \u003cli\u003eWang Y, Li Z, Gu H, Zhai Y, Zhou Q, Jiang Y, et al. China stroke statistics: an update on the 2019 report from the national center for healthcare quality management in neurological diseases, china national clinical research center for neurological diseases, the chinese stroke association, national center for chronic and non-communicable disease control and prevention, chinese center for disease control and prevention and institute for global neuroscience and stroke collaborations. \u003cem\u003eStroke Vasc Neurol\u003c/em\u003e. 2022;7(5):415\u0026ndash;450. doi:10.1136/svn-2021-001374.\u003c/li\u003e\n \u003cli\u003eKallio H, Pietil\u0026auml; A, Johnson M, Kangasniemi M. Systematic methodological review: developing a framework for a qualitative semi-structured interview guide. \u003cem\u003eJ Adv Nurs\u003c/em\u003e. 2016;72(12):2954\u0026ndash;2965. doi:10.1111/jan.13031.\u003c/li\u003e\n \u003cli\u003eTong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (coreq): a 32-item checklist for interviews and focus groups. \u003cem\u003eInt J Qual Health Care\u003c/em\u003e. 2007;19(6):349\u0026ndash;357. doi:10.1093/intqhc/mzm042.\u003c/li\u003e\n \u003cli\u003eSandelowski M. Whatever happened to qualitative description? \u003cem\u003eRes Nurs Health\u003c/em\u003e. 2000;23(4):334\u0026ndash;340. doi:10.1002/1098-240x(200008)23:4\u0026lt;334::aid-nur9\u0026gt;3.0.co;2-g.\u003c/li\u003e\n \u003cli\u003eWorld medical association declaration of helsinki: ethical principles for medical research involving human subjects. \u003cem\u003eJama\u003c/em\u003e. 2013;310(20):2191\u0026ndash;2194. doi:10.1001/jama.2013.281053.\u003c/li\u003e\n \u003cli\u003eColaizzi PF, Valle RS, King M. Existential phenomenological alternatives for psychology. \u003cem\u003ePsychological Research as the Phenomenologist Views It\u003c/em\u003e. 1978;48:71.\u003c/li\u003e\n \u003cli\u003eGuba EG, Lincoln YS. \u003cem\u003eFourth generation evaluation\u003c/em\u003e. Thousand Oaks, CA: Sage Publications; 1989.\u003c/li\u003e\n \u003cli\u003eAmtoft AC, Danielsen AK, Hornnes N, Kruuse C. A qualitative inquiry into patient reported factors that influence time from stroke symptom onset to hospitalization. \u003cem\u003eJ Neurosci Nurs\u003c/em\u003e. 2021;53(1):5\u0026ndash;10. doi:10.1097/JNN.0000000000000557.\u003c/li\u003e\n \u003cli\u003eMahawish KM, Greenblatt D. Pre-hospital delays in patients experiencing symptoms of acute stroke or transient ischaemic attack. \u003cem\u003eN Z Med J\u003c/em\u003e. 2021;134(1542):29\u0026ndash;37.\u003c/li\u003e\n \u003cli\u003eNagao Y, Nakajima M, Inatomi Y, Ito Y, Kouzaki Y, Wada K, et al. Pre-hospital delay in patients with acute ischemic stroke in a multicenter stroke registry: k-plus. \u003cem\u003eJ Stroke Cerebrovasc Dis\u003c/em\u003e. 2020;29(11):105284. doi:10.1016/j.jstrokecerebrovasdis.2020.105284.\u003c/li\u003e\n \u003cli\u003eKielkopf M, Meinel T, Kaesmacher J, Fischer U, Arnold M, Heldner M, et al. Temporal trends and risk factors for delayed hospital admission in suspected stroke patients. \u003cem\u003eJ Clin Med\u003c/em\u003e. 2020;9(8). doi:10.3390/jcm9082376.\u003c/li\u003e\n \u003cli\u003eZhu Y, Zhang X, You S, Cao X, Wang X, Gong W, et al. Factors associated with pre-hospital delay and intravenous thrombolysis in china. \u003cem\u003eJ Stroke Cerebrovasc Dis\u003c/em\u003e. 2020;29(8):104897. doi:10.1016/j.jstrokecerebrovasdis.2020.104897.\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eCivil code of the people\u003c/em\u003e\u003cem\u003e\u0026rsquo;\u003c/em\u003e\u003cem\u003es republic of china\u003c/em\u003e. Beijing: China Democracy and Legal System Publishing House; 2021.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"emmd","sideBox":"Learn more about [BMC Emergency Medicine](http://bmcemergmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/emmd","title":"BMC Emergency Medicine","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"COM-B model, first witnesses of stroke, prehospital emergency response, barriers, qualitative research","lastPublishedDoi":"10.21203/rs.3.rs-9171521/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9171521/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003eTimely prehospital emergency response by first witnesses of stroke is critical for patient outcomes, yet the behavioral mechanisms shaping such responses remain poorly understood. Guided by the Capability\u0026ndash;Opportunity\u0026ndash;Motivation\u0026ndash;Behavior (COM-B) model, this study explored theory-informed barriers influencing prehospital emergency response behaviors among first witnesses of stroke.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eA theory-informed qualitative descriptive study was conducted. Thirteen first witnesses of acute stroke were purposively recruited from a tertiary hospital in eastern China between May and August 2024. In-depth semi-structured interviews were conducted. Data were analyzed using thematic analysis informed by Colaizzi\u0026rsquo;s analytical procedures and guided by the COM-B model.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eBarriers to prehospital emergency response clustered across the three COM-B domains. Capability-related barriers involved embodied practice constraints, impaired recognition and appraisal of stroke symptoms, insufficient on-site response skills, and limited health literacy. Opportunity-related barriers reflected restricted access to emergency resources, misalignment between health information dissemination and public needs, low trust in emergency medical services, and disruption of immediate social support. Motivation-related barriers encompassed difficulties in cognitive reframing and behavioral commitment, as well as reflective conflicts related to ethical concerns, knowledge\u0026ndash;practice gaps, and psychological burden.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions\u003c/b\u003e\u003c/p\u003e \u003cp\u003ePrehospital emergency response behaviors among first witnesses of stroke are shaped by interacting constraints across capability, opportunity, and motivation. By clarifying the behavioral mechanisms underlying delayed or constrained responses, this study provides a theory-informed basis to guide future intervention development and health system strategies aimed at improving timely prehospital stroke care.\u003c/p\u003e","manuscriptTitle":"Barriers to Prehospital Emergency Response Behaviors Among First Witnesses of Stroke: A Qualitative Study Guided by the COM-B Model","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-29 10:15:10","doi":"10.21203/rs.3.rs-9171521/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-04-30T07:57:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"25275371455130021069337980394149417199","date":"2026-04-23T10:55:59+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-21T09:44:55+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-20T08:00:21+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-25T08:09:45+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-24T09:16:13+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Emergency Medicine","date":"2026-03-24T09:12:27+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"emmd","sideBox":"Learn more about [BMC Emergency Medicine](http://bmcemergmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/emmd","title":"BMC Emergency Medicine","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ced3978d-935c-4c61-9412-dcfec54560c5","owner":[],"postedDate":"April 29th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-04-30T07:57:19+00:00","index":68,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-29T10:15:10+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-29 10:15:10","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9171521","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9171521","identity":"rs-9171521","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}