原著論文Vicious Spiral in Seeking Medical Care: Decision Trajectory of Acute Ischemic Stroke Patients

Vicious Spiral in Seeking Medical Care: Decision

Trajectory of Acute Ischemic Stroke Patients
Lung Chan1, 2, 3, Kai-Ren Chen4
1
Department of Neurology & Stroke Center, Taipei Medical University-Shuang Ho Hospital,
New Taipei City, Taiwan.
2
Department of Neurology, College of Medicine, and 3Taipei Neuroscience Institute, Taipei Medical University,
Taipei, Taiwan.
4
Department of Public Health, College of Medicine, Fu-Jen Catholic University, New Taipei City, Taiwan.

ABSTRACT
Background and Purpose: Studies on medical seeking behavior of acute ischemic stroke patients are
mostly quantitative analysis, and have concluded many causes of delay. We conducted a qualitative study
using semi-structured interviews to identify the circumstances during decision making process to seek
medical help in patients with acute ischemic stroke.
Methods: Twenty patients with acute ischemic stroke and delayed thrombolytic therapy were recruited by
purposeful and theoretical sampling strategies in a single medical center. Their family and/or caregivers
who had involved in decision making were also invited to the interview. We analyzed their experiences of
acute ischemic stroke, including the perception and recognition of the symptoms, and the actions toward the
symptoms in decision-making process to seek appropriate medical help.
Results: Ten males and ten females with age from 41 to 89 years old were recruited. Twelve patients
were minor stoke with NIHSS ≤ 6, and 8 with NIHSS 7-18. Only 5 were illiterate. Hypertension was the
most common underlying disease, followed by diabetes, heart disease, and past cerebrovascular disease
history. Motor system was the most common symptom presentation (85%), followed by subjective sensory
(35%) and other non-specific symptoms in 2 patients (10%). The findings displayed four areas of patients’
experiences including illustrative quotes from twenty in-depth interviews. The decision-making procedure
during acute stroke is a very complex process. Most common initial action toward the symptoms was ‘wait
and see’. We found that individual perception and interpretation of symptoms influenced the course of
decision-making process. Knowledge of stroke only helped to recognize other people’s symptoms, but not
for themselves. The fear of role changes among patients caused them hesitate to admit the fact that they
have had a stroke, and this directly led to a delay in making decisions.
Conclusion: A vicious spiral model was developed to interpret the decision-making process in acute
ischemic stroke patients, who were delayed for thrombolytic therapy. More aggressive health education is
needed to break the vicious spiral in decision-making process. Augmenting patient confidence to receive
prompt acute stroke treatment, and early acceptance of a role exchange should be a principle concept in
future educational programs for such individuals.

Keywords: acute ischemic stroke, delay medical seeking, trajectory, vicious spiral model.

Corresponding author: Kai-Ren Chen, PhD; Department of Public Health, College of Medicine, Fu-Jen Catholic University,
No. 510, Zhongzheng Rd, Xinzhuang Dist., New Taipei City, Taiwan, R.O.C.
E-mail: [email protected]
DOI: 10.6318/FJS.202006_2(2).0006

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 Vicious Spiral in Seeking Medical Care: Decision Trajectory of Acute Ischemic Stroke Patients

Introduction understanding of their experiences from onset to

the hospital may shed light on the circumstances
Stroke is the fourth most common cause of around patients to make decision to seek medical
death in Taiwan, and is the main cause of disability help and their actions responding to those
1
in adults. It generates innumerable burdens to circumstances.
both the patients and their family. Thrombolysis We used a qualitative research approach
within three hours from the onset of symptoms to explore the trajectory that stroke patients
can successfully reduce the neurological deficit experience from stroke onset to the hospitals with
in acute ischemic stroke patients. 2 However, special focus on their attribution of symptoms
delay to hospital is still prevalent. The median and their delayed actions toward medical care.
time intervals were from 5 to 16 hours in existing We wanted to understand their onset symptoms,
3-7
studies. In Taiwan, up to 74% acute ischemic their attribution to these symptoms, actions took
stroke patients seek medical help in 2-48 hours in accordance to the dynamic progress of stroke
8
and were classified to the delay group. The symptoms, and to understand their trajectory from
median interval between symptom onset and stroke onset to obtaining appropriate medical care.
9
emergency department arrival was 335 minutes.
Less than 1% of the patients can fulfill the criteria
Methods
of thrombolysis in Taiwan. 10 These findings
suggest that the majority of stroke patients arrived To gain an understanding of the individual
at hospitals beyond the critical 3-hour limit for perceptions of stroke symptoms and the dynamic
tissue plasminogen activator (tPA) treatment. Their circumstance for delay in seeking medical help,
decision to contact medical professionals and a qualitative method was employed. This method
the determinants call for great attention, because offers researchers a flexible set of inductive
11
thrombolysis is a time-dependent therapy, the strategies for building native theories from within
determinants of pre-hospital delay have been noted the participants’ own frames of reference. To fully
by many researchers. uncover patients’ experience, semi-structured in-
Extensive quantitative investigations have depth interviews were conducted in the study
been conducted to describe stroke patients’ pre- setting.
hospital delay. Although some inconsistency in With the approval of the Ethics Committees
9, 12, 13
findings exists, several significant factors of the Faculty of Medicine, we conducted this
have been identified. However, why many study in a general hospital in New Taipei City.
stroke patients don’t consider their stroke onset The participants were interviewed while they
symptoms as emergent which needs immediate were hospitalized in either their bedsides or in
medical treatment? How do they perceive their the conference room of the neurology ward. A
stroke presentations? And what are their actions purposive sampling strategy was devised with
toward the stroke symptom before they obtain sampling of participants structured around two
medical care? The previous mentioned theories key dimensions (sex and age) to reflect range
and empirical studies have suggested important and diversity present in the target population.
directions. But, what are patients’ stories? An The cut-point of age levels was 60 years old. We

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 Vicious Spiral in Seeking Medical Care: Decision Trajectory of Acute Ischemic Stroke Patients

recruited patients with confirmed ischemic stroke obtained through discussions within the research
by brain image who were delayed to receive team.
emergent thrombolytic therapy and were able
to communicate in Mandarin or Taiwanese. We
Results
excluded patients who had cerebral hemorrhage,
aphasia, cognitive dysfunction or severe stroke Twenty patients who were delayed for
with unstable vital signs. Patients’ attending hospitalization were successfully interviewed,
physician was informed to screen suitable patients which were delayed from four hours to three days.
and nursing staff gave an information sheet Ten patients were males and ten were females
describing the study to eligible patients and/or their with age from 41 to 89 years old (mean age, 63.3
family members 2-5 days after admission to obtain years). Twelve patients belonged to minor stoke
their written consent. As the decision was made by with NIHSS ≤ 6, and others with NIHSS around
some others other than stroke patients in most of 7-18. The findings display four areas of patients’
7
the situations , family members or caregivers were experiences and include illustrative quotes
also invited to join the interview. from twenty in-depth interviews. To preserve
An interview guide with key issues we wanted anonymity, each participant was given a unique
to address was developed based on significant code throughout the text.
literature and was modified with specialist’s
consensus (Appendix 1). Contents in the interview The Onset Symptoms among
guide included: What was the symptom? What
Stroke Patients
was your interpretation of the symptom? What Motor symptoms including limb weakness,
had you and/or your family done between the facial deviation and slurred speech were the most
symptom onset and medical care obtained? What common symptom presentation. For examples,
made you and your family decides to receive CASE #20: “I went to exercise in the morning on the
medical treatment? Both the patients and/or the 14th. My leg was too weak to walk smoothly. I had
one involved in the decision making process were to drag my leg. My friends said I was a little lame.”
asked to recall their experiences and situation The accidental episode of limb weakness was
during brain attack. noted while some patients fell to the floor or lost
The data being analyzed included interview control over daily activities. For example, CASE #4
verbatim and interviewer’s notes. Preliminary was unable to put his foot into the slipper because
analysis was started from the first case and it was numb. Then he fell down to the floor. Some
finished while saturation of data was achieved by even became unable to open the door and/or
the time 20 interviews had taken place. Based on urinate smoothly.
the Grounded Theory, constant comparison and Some patients lost their control over their
14
inductive approach were applied. The first and motor system around mouth. For example, CASE
second authors carried out the analysis. For each #9: “I felt my tongue twisted while I talked. I asked
interview, they repeatedly read the response of my husband to hear me talk and compare with last
the content to identified categories and themes day carefully. He said that it sounded OK in the
emerging from the data. Common consensus was beginning of the sentence. But it went worse while

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 Vicious Spiral in Seeking Medical Care: Decision Trajectory of Acute Ischemic Stroke Patients

I kept on talking. My tongue was very taut and it like cold before hospitalization. Symptoms like
got twisted while I talk.” sore-throat, bone soreness and fatigue…just like
The second category of symptom was sensory common cold.”
lesion. Seven patients experienced dizziness and Some patients attributed the symptoms to
numbness. CASE #14: “This leg was unable to other diseases such as gastroenteritis, diabetes,
move…there…also, my hand was numb. I did not dementia, and back pain, etc. CASE #12: “I kept
know what’s going on. My head was dizzy, too. I sweating….and had nausea. I thought it was
felt something wrong in my brain. My head was as induced by bad food.” CASE # 14: “I felt my right
dizzy as an earthquake. Then, my leg became soft leg weakness then my right arm numbness at
and unable to walk anymore.” night. I had no idea for these, but I felt dizzy one
Relatively few patients (2 patients) in this month ago, I thought this was due to diabetics.”
study experienced non-specific symptoms like CASE #18 ‘s daughter: “We did not think of stroke.
blurred vision. For example, CASE #10 said: “It It appeared to be elderly related like dementia.
was on the Tuesday night around 11 o’clock. After Their brain became dull. We did not think it was
I took a shower, I found my left eye could not see stroke related till mouth deviation was noticed.”
things…. One eye could see very clearly; the other CASE #19: “I slipped at bathroom around 8 in the
was dark.” morning, and then I felt my left limb weakness. I
thought it is due to backache.” And CASE #17’s
Interpretation and attribution of daughter: “He was going to sleep and suddenly fell
the symptoms: down to the floor. We thought that might be due to
Clinically, most patients’ stroke symptoms his spinal spur. The weakness might be induced by
were typical symptoms of stroke. However, only the nerve compression.”
two patients realized the symptoms probably due Three patients assumed that their symptom
to stroke. For example, CASES #9 was quite was related to their behavior. CASE#1: “I thought
sure about the symptoms. “… my sister had my facial palsy was related to betel nut chewing
stroke before. I woke up in the morning…and had only.” And CASE#15: “I fell twice that night while
slurred speech sounded like (something wrong). I I was on my duty as night shift security. I thought
wondered am I stroke? How comes my tongue got I was just sitting too long which may induce limb
twisted while I talked?” numbness.”
Most participants considered their symptoms On the other hand, stroke was excluded
were caused by other diseases, especially some if patients regularly conduct healthy behavior.
minor diseases which mimicked stroke symptoms. CASE#11: “I had palpitation and mouth deviation
For example, several patients considered the at night during watching the television…I swim
symptoms are related to common cold and/or every morning. People who swim don’t get stroke.”
fatigue. CASE # 4: “I had my limb weakness in
yesterday afternoon which was recovered after Actions in Accordance to the
rest. And I had another feeling of limb weakness
Dynamic Progress of Stroke
this morning…. I thought that the weakness was
Symptoms from Stroke Onset to
Appropriate Medical Care:
due to common cold or fatigue.” CASE #3: “It felt

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 Vicious Spiral in Seeking Medical Care: Decision Trajectory of Acute Ischemic Stroke Patients

Patients would apply wide-ranging self-care In the time course from symptom onset to
behaviors after symptom onset. The most notable reach correct medical assistance, both patients
actions were rest and/or sleep. CASE #2: “I felt and their families were involved in a series of
dizzy and headache with unsteady gait when I process. After symptom onset, patients and/or their
woke up after nap. I smoked … I thought my blood families observed the progression, made attribution
pressure was high then I sit down and drink some to the symptoms, took action and evaluated the
water.” CASE#17’s daughter: No. He could walk effectiveness of the action. All our studied cases
after got up (from the floor). Therefore, he went to experienced various symptoms and made different
bed. It was time to go to sleep. CASE#14: I felt my attributions to the symptoms, however, they
right leg weakness then my right arm numbness at decided not to go to the hospitals. This process is
night. I thought this was due to diabetics. Then I considered the first cycle of decision making about
went to sleep, I woke up in the morning and I fell, seeking medical care (Figure 1). The decision
then I rested until afternoon. made by either the patient or his/her families. This
Another self-care behavior before they went cycle proceeded quite fast and ended while the
to the hospital was related to the underlying action 1 had been taken.
disease. They would try to take medication to relief If patients or their families had made a quick
the stroke symptoms. CASE #4: I just took my correct decision, the delay for appropriate medical
medication for blood glucose control. I think it is care would be much decreased. Unfortunately,
glucose related. all the participants took wrong actions, and
Some patients had obvious limb weakness entered the second cycle of illness evaluation. For
and/or numbness. They tried to massage, beating or example, CASE #17 thought that her symptom was
shaking hand. No matter how they deal with their back pain related, so she went to sleep and rest.
symptoms, patients and their family became more However, her symptom persisted after she woke up
alert and decided to go to the hospital while their and then she called for help. Another patient (CASE
symptoms appeared to get worse and/or persisted # 18) had stroke history before with limb weakness
longer than expectation. In CASE #12: I felt sequel. This time the symptoms were not similar to
dizzy and then nausea with general weakness on her previous experience. Her family thought that
February 22 afternoon ... The symptom persisted to the symptoms might be a dementia symptom; they
th
23 , so I went to the outpatient clinic first, and then all thought that stroke must have limb weaknesses.
I was transferred to the emergency department. Therefore, her family decided to wait and rest.
CASE #7’s Husband: It seems not so serious. She They didn’t call emergency department until they
could still walk around the house. Her symptom found the symptoms persisted and become worse.
was just one-sided weakness. It seemed like about From the summary of the interpretation, action
to have a mild stroke. I sent her to the emergency or response toward the stroke symptoms of the
department because her symptoms were getting patients (Table 1), delay happened when patients
more and more obvious. failed to recognize the onset symptoms after the

Decision-Making Trajectory from first decision of action 1, when patients and their
Stroke Onset to Appropriate families kept on evaluating the effectiveness of
Medical Treatment the action, making second attribution based on

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 Vicious Spiral in Seeking Medical Care: Decision Trajectory of Acute Ischemic Stroke Patients

Table 1. Summary of the interpretation, action or response toward the stroke symptoms
Case First Interpretation First action or Second Second action or More than second
No response Interpretation response interpretation,
action or response
1 Betel nut chewing Observation and rest His son found Visit LMD Self interpretation
induced something wrong that symptom got
severe
2 Hypertension Observation and rest His son found His son brought Transferred to a
something wrong him to a regional medical center
hospital
3 No idea Observation and rest His wife found His sister transferred -
something wrong him to a medical
center
4 Common cold Observation and rest His wife found His friend brought -
something wrong him to a medical
center
5 Denied stroke Observation and rest His wife found His friend brought -
something wrong him to a medical
center
6 Denied stroke Observation and OPD doctor told Transferred to ED -
rest, visit OPD stroke
7 Common cold Observation and rest Her husband felt that Observation Her husband finally
might be common recognized that was
cold, but stroke was stroke and brought
suspected her to ED
8 Diabetes induced Observation and rest Her daughter found Patient wanted to -
something wrong visit LMD, her
daughter brought
her to ED
9 No idea Observation and Her husband found Her husband OPD doctor
rest, wait for her something wrong brought her to OPD transferred her to
husband ED
10 Fatigue Wait and pray Her daughter found Her daughter -
something wrong brought her to ED
11 Denied stroke Observation and rest His son found Patient wanted to -
something wrong visit LMD, his son
brought him to ED
12 Gastroenteritis Observation and OPD doctor told Transferred to ED -
rest, visit OPD stroke
13 Common cold Observation and His friend thought His friend brought His son found
rest, call his friend that he was tire after him some soda something wrong
ball game drink and brought him to
ED
14 Diabetes induced Observation and His son suspected His son brought him -
rest, wait for his son he was stroke to ED
15 Back pain Observation and rest His family found Family brought him -
something wrong to ED
16 Common cold Observation and Her family found Her family brought Transferred to a
rest, visit LMD something wrong her to regional medical center
hospital, where
stroke was told
17 Back pain Observation and restPatient felt that Went o ED -
symptom got severe
18 No decision ability Observation and rest Her family found Her family brought -
something wrong her to ED
19 Back pain Observation and rest Her daughter felt Massage by her Her daughter felt
she was stroke daughter symptom got severe
and called ED
20 Denied stroke Observation and Her family found Her family brought OPD doctor
rest, visit LMD something wrong her to OPD transferred her to
ED
※OPD-outpatient clinic of the hospital; ◎LMD-local medical doctor; #ED-emergency department.

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 Vicious Spiral in Seeking Medical Care: Decision Trajectory of Acute Ischemic Stroke Patients

Fig. 1. P
 atients and/or their family’s trajectory from stroke onset to access medical care- four representative
cases.

Fig. 2. D
 ecision making chain of medical delay trajectory reported by stroke patients and/or their families.
Patients or their families persisted in making attribution (I-1, 2, 3, 4), action (II-1, 2, 3, 4) and
evaluation (III-1, 2, 3, 4), in order to achieve health.

the residual symptoms and then took their second care (Figure 1), CASE 7 and 9 even entered the
action. The action 2 was taken when the symptoms third cycle before making the right decision. In our
persisted, occurred again, or become worse after study, patients and their families took more than
the first action was conducted and evaluated as one day to figure out that their need of medical
ineffective. This process was considered the second care instead of self-care.
cycle of decision making about seeking medical To overview the whole process of our study

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 Vicious Spiral in Seeking Medical Care: Decision Trajectory of Acute Ischemic Stroke Patients

participants, their experiences from stroke onset related to delay in his stage of illness experience
to medical care seeking appeared to be a cyclic model.15 According to this model, the experience
trajectory (Figure 2). Patients or their families kept of symptoms is the starting point of an illness
in evaluating the symptoms, making attributions, experience. In this stage, patients confront with
taking actions, and evaluating the effectiveness a decision dilemma about whether “something
of the action in order to regain patients’ health is wrong”. Only when patients consider that the
(Figure 2). As the time proceeded (to the right symptoms are related to certain diseases and need
side of Figure 2), the cycle of the spiral trajectory attention, they are more likely to enter the second
was getting smaller. Besides, the time needed to stage. In the assumption of sick role stage, patients’
proceed another cycle was shorter and concrete social obligations are provisionally relinquished.
to reach the target of appropriate medical seeking Patients would receive lay remedies until they feel
behavior. In our study, all patients failed to make the necessity of seeking medical treatment. The
immediate and appropriate medical seeking longer the patients stay in the first and the second
decision. Furthermore, patients and/or their stages, the longer the time between the onset
families took at least two cycles before they made and appropriate medical care. Delay for medical
a correct decision to arrive in the hospitals. Patients treatment is thus resulted.
or their families, as the decision makers, persisted On the other hand, Wolinsky’s General
in making attribution (I-1, 2, 3, 4), action (II-1, Theory of Help Seeking suggests four categories
2, 3, 4) and evaluation (III-1, 2, 3, 4), in order to of determinants which would influence patients’
achieve the target of being healthy. decision for seeking medical help17: (1) the salience
and cognition of the symptoms; (2) persistence and

Discussion disturbance of the symptoms; (3) other demands

and alternative symptoms explanations; and (4)
Delay (or procrastination) has been defined other non-socio-cultural factors (e.g. resource
as being late from symptom onset to medical accessibility and medical expenditure). According
15
treatment. It was categorized into three stages to this theory, patients with symptoms, which are
based on individuals’ psychological assessment more salience, not concordant to their cognitions,
16
process by Safer. In the first stage (i.e. assessment more serious, persistent, great disturbance with
delay), patients don’t seek medical help because their lives, are more likely to make decision for
they are making symptom assessments to figure seeking medical treatments. Otherwise, patients
out if it is disease related. In the second stage are more hesitant to seek medical care and thus the
(illness delay), patients have perceived themselves pre-hospital delay would be prolonged.
as illed whereas they are late for medical treatment The previous theories suggested that personal
because they are making decision about its cognitions about symptoms and situational factors
necessity of medical treatments. The final stage both play important roles in patients’ decision in
(utilization delay) regards the time delayed for seeking medical care. Many empirical studies also
obtaining appropriate medical treatments since echoed these theories. For example, limb weakness
they have decided to seek. was reported only in 26% to 65% of the subjects.18-
21
Suchman proposed another perspective Up to 39% people were unable to identify any

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 Vicious Spiral in Seeking Medical Care: Decision Trajectory of Acute Ischemic Stroke Patients

symptom of stroke20. Besides, 48% of the stroke the symptom presentation may lead to different
patients did not consider their symptoms as stroke perception and action. When our participants
22
related in the study of Williams et al. The other presented with a minor motor symptom, they
52% with higher knowledge about stroke symptom imputed the symptom to other minor diseases; they
tended to go to hospital earlier. These studies preferred to ‘wait and rest’; they tried to find out
revealed that people’s knowledge and recognition other reasons to explain it. They sought help only
about stroke symptoms varied and influence stroke when the symptom progress to a threshold or is
patients’ decision to seek appropriate medical noticed by others. This finding again is concord
treatment. with Mechanics and Wolinsky’s help seeking
The motor, sensory and some non-specific theory. 17 They unwillingly call for help only
symptoms were reported by the subjects, where when the symptom progressed to a stage, which
the motor symptoms were the most prevalent affected their daily life activity, and/or out of their
symptoms in our study, and is similar to the tolerance. According to Suchman’s role changes,
18-21
previous studies . However, all the patients and/ denial and acceptance are the main corner stone
or their families failed to connect their episodes of illness experience.16 Misinterpretation of stroke
with stroke. They tended to make comparison symptom by patients or their families may hinder
between the onset symptoms with other diseases, the sick role recognition and delay the medical
which patients have had. Illness schema plays seeking time. Patients’ hesitation may also reflect
an important role in make a right decision.16 In that they are worried to become a burden to their
addition, many patients also tended to attribute family. They expected to postpone the time of
their symptoms to certain diseases induced by their being a sick role.
unhealthy behavior, or they totally did not think of On the other hand, while patients perceive
stroke because they had healthy life style. These the necessity of seeking medical care, their
interpretation of illness onset could be misled by social contexts become influential in obtaining
the misconnection between health related behavior appropriate and timely medical treatment. For
and diseases. example, living alone 4 , stroke happening on
Along with the previous finding, our subjects’ Sunday or at the night time 23 , long distance
knowledge about stroke is very limited. Low from home to hospital, 24 use of ambulance
level of knowledge of stroke symptoms was also transportation4, 7, 23-25 seemed to prolong their time
reported in other studies.20, 22 Both patients and/or to the hospital. Also, the presence of others and
families appeared to have very little knowledge of their ability to make correct decision was found
onset symptoms of stroke and appropriate actions. significantly influence the stroke patients’ arrival
17
In Mechanics and Wolinsky’s help seeking theory, time to medical institutes in previous studies.25
perception of the alarm from their health situation In addition, a number of studies have been
is the initiation of the behavior. Therefore, patients carried out to identify the relationships between
and their families were unable to correct perceive patients’ demographic variables, illness variables
the onset symptom of stroke and consequentially and their time from onset to the hospital. The
took correct actions. outcomes showed some evidence that patients who
From another perspective, the severity of were younger8, 26 and/or females27 were less likely

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 Vicious Spiral in Seeking Medical Care: Decision Trajectory of Acute Ischemic Stroke Patients

to go to hospital earlier. Patients with previous

23, 27
Conclusions
history of diabetes or cardiovascular disease,
and suffered from less serious symptoms8, 10, 26 were Disability after stroke leads to heavy social
more likely to delay for medical treatment. burdens, no one accepts the sick role of stroke
In medical seeking behavior of stroke without protest. Although the high density of
patients, the clinical presentation is the stimulation hospital and high coverage of health insurance
and beginning of the behavior. To interpret the in Taiwan eliminated the difficulty in medical
symptom is an emergent thing to deal with, and assessment, only early recognition and early
finally the action is based on the goal of regaining medical treatment can successfully reduce the
the health role. disability. This qualitative study provides a picture
Analyzing our patients with the proposed to understand the process of patients from stroke
decision making chain, most of them failed in onset to medical care. It is also the first study
making immediately appropriate medical seeking that explores this dynamic process up today. We
decision, and it took at least two cycles in the concluded with a cyclic trajectory to represent
decision chain to reach the target. In the process, patients’ experiences and proposed the following
medical delay also happened in our study. The suggestions.
delay happened in the second interpretation, and
halted by another doctor in the third interpretation
Limitations
while the symptom became more conspicuous.
For example, CASE #12 presented with some This study has been exploratory. The findings
non-specific flu-like symptoms, such as dizziness, of this study and the suggestions made for
nausea and general weakness. He subjectively practice must be treated with some caution as the
thought these were due to gastroenteritis. While study is limited by the small sample of research
the symptom persisted, he called outpatient participants who, although they represent a wide
clinic first and the doctor did not refer CASE #12 range of diversity, are similar in that they had a
to a hospital. He was finally transferred to the well-comprehensive study is needed to compare
emergency department again after his symptoms differences across age, ethnic culture, gender and
became more serious. different religious adherences. The study may
Besides the stroke knowledge of the patient, however indicate some avenues for further inquiry.
family’s knowledge and their subjective perception Conflicts of Interest: None
of the symptom directly influence the time course
in seeking medical help. Most of them reached an
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Appendix 1 Interview guide (Chinese Version)

一、您這次中風是什麼時候發病的? 出現那些症狀? 當時您人在那裡?

當時知道這樣子就是中風嗎?
1. 知道那您覺得中風除了這些症狀之外，還有那些症狀?
2.不知道
(1) 那您當時覺得那些症狀是怎麼回事?
(2)後來您怎麼知道那些症狀就是中風的症狀呢?
(3)那您現在知道的中風症狀有那些?
【目的 1】了解受訪者此次中風時之主要症狀及當時之主觀詮釋。
【目的 2】了解受訪者對中風症狀之認知與認知來源。
二、您出現這些症狀後，有立即看醫師嗎?
(一)有
1. 到那裡看醫師? 什麼科別? 為什麼選擇到那裡看醫師?
2. 從發病到入院， 大約過了多久? 這中間您或家人試過那些 方法使症狀改善?
【目的 3】了解立即就醫者之就醫選擇及自我處理之方式。
【目的 4】了解立即就醫者之疾病延遲及使用延遲。
(二)沒有
1. 您沒有立即看醫師之原因是什麼?
2. 您發病到決定看醫師，大約過了多久? 這中間您或家人試過那些方法使症狀改善?
3. 後來決定看醫師的原因又是什麼呢?
4. 後來您到那裡看醫師? 什麼科別? 為什麼選擇到那裡看醫師?
5. 自決定看醫師至入院， 大約過了多久? 到院前您或家人做了那些處理?
【目的 3】了解未立即就醫者之就醫選擇及自我處理之方式。
【目的 4】了解未立即就醫者之評估延遲、疾病延遲、及使用延遲。
三、您這次中風，心裡是否感到很意外? 為什麼?
(一)不會為什麼?
(二)會為什麼?
【目的 5】了解受訪者心中對中風之危險因子之認知。
四、您知道目前醫院提供給您的是什麼治療方法嗎?
您知道中風的治療方法有那些嗎? 您如何得知這些方法?
【目的 6】了解受訪者對中風治療方法之認識
五、中風以後對您及家人的生活有何影響?
【目的 7】了解中風對病患及家人之衝擊。

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 Vicious Spiral in Seeking Medical Care: Decision Trajectory of Acute Ischemic Stroke Patients

急性缺血性中風患者的就醫決策軌跡

陳龍 1, 2, 3、陳凱倫 4
1
臺北醫學大學-部立雙和醫院神經科、 2中風中心、 3臺北神經醫學中心
4
輔仁大學醫學院公共衛生學系

摘　要
背景及目的：腦血管疾病一直是國人十大死亡原因之一。急性梗塞型中風可於發病4.5小時內靜脈
注射血栓溶解治療法，但大多病患無法於「黃金治療時間」內趕到醫院，錯失接受治療的良機。
方法：本研究採質性研究，以深度訪談法探討20位急性梗塞性腦中風住院病患從發生症狀到就醫過
程的行為模式。
結果：整個就醫過程是由症狀詮釋、反應行動及成效評估的循環所合成，而多數病患的就醫過程是
由兩個或以上的循環構成。第一次的循環是個人內在的思路，對行動、反應的成效評估是本身或其
家屬、朋友認定，第二及第三次循環的症狀詮釋及反應行動大多由非本人進行。 循環所須時間隨
著整個就醫過程有縮短之傾向。
結論：本研究提出一個針對急性梗塞性腦中風病患的就醫行為模式。就醫時程會因為經過的循環次
數愈多而變長，且病患及其家屬對腦中風的詮釋正確與否乃影響就醫時程的關鍵。建議未來應針對
中風高危險族群及其家人提供更清楚之教育介入，以減少就醫延遲之發生。

關鍵詞：急性缺血性腦中風、延遲、就醫行為、軌跡

通訊作者：陳凱倫　輔仁大學醫學院公共衛生學系
E-mail: [email protected]

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