“我知道一点，但我做不了更多”：一项基于COM-B的定性研究，探讨中国住院COMISA患者的CPAP使用与睡眠行为改变

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中文摘要

背景： 共病失眠与睡眠呼吸暂停（COMISA）是一种高度普遍的疾病，与任一单独疾病相比，其健康结局更差、治疗复杂性更高。与单纯阻塞性睡眠呼吸暂停（OSA）患者相比，COMISA患者对持续气道正压通气（CPAP）治疗的接受度和使用率更低，然而这种依从性惩罚背后的主观机制仍知之甚少。关于COMISA患者CPAP使用和睡眠行为改变的定性研究很少，COM-B（能力、机会、动机-行为）模型很少应用于该人群，非西方文化规范对COMISA治疗参与的影响也鲜受关注。
方法： 在中国湖南省一家三级睡眠医学中心开展了一项以COM-B模型和理论域框架（TDF）为指导的描述性定性研究。采用基于住院CPAP依从性（良好 vs. 差）和是否接受简短护士主导的住院CBT-I项目（有 vs. 无结构化CBT-I）的2×2最大变异矩阵，目的性抽样了16例经多导睡眠图确诊的中重度OSA（AHI≥15）且伴有临床显著失眠（ISI≥15）的住院患者。对个体半结构化访谈采用定向内容分析，报告遵循COREQ清单。
结果： 分析在20个编码节点上生成1,160个参考点，综合为与COM-B维度一致的三个主题和九个亚主题。动机占编码数据的最大份额（589个参考点），并揭示了一种“失眠主导”模式，即参与者系统性地将失眠置于OSA之上优先考虑；四种固定的因果归因模式导致患者排除特定治疗；以及一个将污名、年龄相关身份和治疗拒绝联系起来的情绪-身份复合体。在机会维度内，识别出一种“依从性错觉”：一些CPAP依从性良好的住院患者并未将出院后自我管理的动机内化。文化特异性障碍不仅包括农村与CPAP相关的死亡污名，还包括城市强制性宴饮规范。
结论： 住院COMISA患者面临与单纯OSA患者性质不同的行为障碍，需要COM-B指导的个体化评估，而非统一的依从性干预。护理实践应纳入出院前环境筛查、在前两到三晚主动管理CPAP体验，以及跨越农村和城市社会规范的文化敏感方法。行为改变轮为将这些行为诊断转化为有针对性的、护士主导的干预设计提供了系统路径。

英文摘要

BACKGROUND: Co-morbid insomnia and sleep apnoea (COMISA) is a highly prevalent condition associated with worse health outcomes and greater treatment complexity than either disorder alone. Patients with COMISA demonstrate lower acceptance and use of continuous positive airway pressure (CPAP) therapy compared with those who have obstructive sleep apnoea (OSA) alone, yet the subjective mechanisms underlying this adherence penalty remain poorly understood. Qualitative research on CPAP use and sleep behaviour change in patients with COMISA is scarce, the COM-B (Capability, Opportunity, Motivation-Behaviour) model has rarely been applied to this population, and the influence of non-Western cultural norms on COMISA treatment engagement has received little attention.
METHODS: A descriptive qualitative study guided by the COM-B model and Theoretical Domains Framework (TDF) was conducted at a tertiary sleep medicine centre in Hunan Province, China. Sixteen hospitalised patients with polysomnography-confirmed moderate-to-severe OSA (AHI ≥ 15) and clinically significant insomnia (ISI ≥ 15) were purposively sampled using a 2 × 2 maximum variation matrix based on inpatient CPAP adherence (good vs. poor) and receipt of a brief nurse-led inpatient CBT-I programme (with vs. without structured CBT-I). Individual semi-structured interviews were analysed using directed content analysis, with reporting following the COREQ checklist.
RESULTS: The analysis generated 1,160 reference points across 20 coding nodes, synthesised into three themes and nine sub-themes aligned with the COM-B dimensions. Motivation accounted for the largest share of coded data (589 reference points) and revealed a pattern of "insomnia dominance" in which participants systematically prioritised insomnia over OSA, four patterns of fixed causal attribution that led patients to rule out particular treatments, and an emotion-identity complex linking stigma, age-related identity, and treatment rejection. Within the Opportunity dimension, an "adherence illusion" was identified: some inpatients with good CPAP adherence had not internalised motivation for post-discharge self-management. Culturally specific barriers extended beyond rural CPAP-related death stigma to include urban obligatory banquet drinking norms.
CONCLUSIONS: Hospitalised COMISA patients face qualitatively different behavioural barriers from those with OSA alone, requiring COM-B-guided individualised assessment rather than uniform adherence interventions. Nursing practice should incorporate pre-discharge environmental screening, proactive CPAP experience management during the first two to three nights, and culturally sensitive approaches spanning both rural and urban social norms. The Behaviour Change Wheel provides a systematic pathway for translating these behavioural diagnoses into targeted, nurse-led intervention design.