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: ph1010@mails.fju.edu.tw
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
Stroke is the fourth most common cause of
death in Taiwan, and is the main cause of disability
1
in adults. It generates innumerable burdens to
both the patients and their family. Thrombolysis
within three hours from the onset of symptoms
can successfully reduce the neurological deficit
in acute ischemic stroke patients. 2 However,
delay to hospital is still prevalent. The median
time intervals were from 5 to 16 hours in existing
3-7
studies. In Taiwan, up to 74% acute ischemic
stroke patients seek medical help in 2-48 hours
8
and were classified to the delay group. The
median interval between symptom onset and
9
emergency department arrival was 335 minutes.
Less than 1% of the patients can fulfill the criteria
of thrombolysis in Taiwan. 10 These findings
suggest that the majority of stroke patients arrived
at hospitals beyond the critical 3-hour limit for
tissue plasminogen activator (tPA) treatment. Their
decision to contact medical professionals and
the determinants call for great attention, because
11
thrombolysis is a time-dependent therapy, the
determinants of pre-hospital delay have been noted
by many researchers.
Extensive quantitative investigations have
been conducted to describe stroke patients’ pre-
hospital delay. Although some inconsistency in
9, 12, 13
findings exists, several significant factors
have been identified. However, why many
stroke patients don’t consider their stroke onset
symptoms as emergent which needs immediate
medical treatment? How do they perceive their
stroke presentations? And what are their actions
toward the stroke symptom before they obtain
medical care? The previous mentioned theories
and empirical studies have suggested important
directions. But, what are patients’ stories? An
understanding of their experiences from onset to
the hospital may shed light on the circumstances
around patients to make decision to seek medical
help and their actions responding to those
circumstances.
We used a qualitative research approach
to explore the trajectory that stroke patients
experience from stroke onset to the hospitals with
special focus on their attribution of symptoms
and their delayed actions toward medical care.
We wanted to understand their onset symptoms,
their attribution to these symptoms, actions took
in accordance to the dynamic progress of stroke
symptoms, and to understand their trajectory from
stroke onset to obtaining appropriate medical care.
Methods
To gain an understanding of the individual
perceptions of stroke symptoms and the dynamic
circumstance for delay in seeking medical help,
a qualitative method was employed. This method
offers researchers a flexible set of inductive
strategies for building native theories from within
the participants’ own frames of reference. To fully
uncover patients’ experience, semi-structured in-
depth interviews were conducted in the study
setting.
With the approval of the Ethics Committees
of the Faculty of Medicine, we conducted this
study in a general hospital in New Taipei City.
The participants were interviewed while they
were hospitalized in either their bedsides or in
the conference room of the neurology ward. A
purposive sampling strategy was devised with
sampling of participants structured around two
key dimensions (sex and age) to reflect range
and diversity present in the target population.
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
by brain image who were delayed to receive
emergent thrombolytic therapy and were able
to communicate in Mandarin or Taiwanese. We
excluded patients who had cerebral hemorrhage,
aphasia, cognitive dysfunction or severe stroke
with unstable vital signs. Patients’ attending
physician was informed to screen suitable patients
and nursing staff gave an information sheet
describing the study to eligible patients and/or their
family members 2-5 days after admission to obtain
their written consent. As the decision was made by
some others other than stroke patients in most of
7
the situations , family members or caregivers were
also invited to join the interview.
An interview guide with key issues we wanted
to address was developed based on significant
literature and was modified with specialist’s
consensus (Appendix 1). Contents in the interview
guide included: What was the symptom? What
was your interpretation of the symptom? What
had you and/or your family done between the
symptom onset and medical care obtained? What
made you and your family decides to receive
medical treatment? Both the patients and/or the
one involved in the decision making process were
asked to recall their experiences and situation
during brain attack.
The data being analyzed included interview
verbatim and interviewer’s notes. Preliminary
analysis was started from the first case and
finished while saturation of data was achieved by
the time 20 interviews had taken place. Based on
the Grounded Theory, constant comparison and
14
inductive approach were applied. The first and
second authors carried out the analysis. For each
interview, they repeatedly read the response of
the content to identified categories and themes
emerging from the data. Common consensus was
148
obtained through discussions within the research
team.
Results
Twenty patients who were delayed for
hospitalization were successfully interviewed,
which were delayed from four hours to three days.
Ten patients were males and ten were females
with age from 41 to 89 years old (mean age, 63.3
years). Twelve patients belonged to minor stoke
with NIHSS ≤ 6, and others with NIHSS around
7-18. The findings display four areas of patients’
experiences and include illustrative quotes
from twenty in-depth interviews. To preserve
anonymity, each participant was given a unique
code throughout the text.
The Onset Symptoms among
Stroke Patients
Motor symptoms including limb weakness,
facial deviation and slurred speech were the most
common symptom presentation. For examples,
CASE #20: “I went to exercise in the morning on the
14th. My leg was too weak to walk smoothly. I had
to drag my leg. My friends said I was a little lame.”
The accidental episode of limb weakness was
noted while some patients fell to the floor or lost
control over daily activities. For example, CASE #4
was unable to put his foot into the slipper because
it was numb. Then he fell down to the floor. Some
even became unable to open the door and/or
urinate smoothly.
Some patients lost their control over their
motor system around mouth. For example, CASE
#9: “I felt my tongue twisted while I talked. I asked
my husband to hear me talk and compare with last
day carefully. He said that it sounded OK in the
beginning of the sentence. But it went worse while
 Vicious Spiral in Seeking Medical Care: Decision Trajectory of Acute Ischemic Stroke Patients
I kept on talking. My tongue was very taut and it
got twisted while I talk.”
The second category of symptom was sensory
lesion. Seven patients experienced dizziness and
numbness. CASE #14: “This leg was unable to
move…there…also, my hand was numb. I did not
know what’s going on. My head was dizzy, too. I
felt something wrong in my brain. My head was as
dizzy as an earthquake. Then, my leg became soft
and unable to walk anymore.”
Relatively few patients (2 patients) in this
study experienced non-specific symptoms like
blurred vision. For example, CASE #10 said: “It
was on the Tuesday night around 11 o’clock. After
I took a shower, I found my left eye could not see
things…. One eye could see very clearly; the other
was dark.”
Interpretation and attribution of
the symptoms:
Clinically, most patients’ stroke symptoms
were typical symptoms of stroke. However, only
two patients realized the symptoms probably due
to stroke. For example, CASES #9 was quite
sure about the symptoms. “… my sister had
stroke before. I woke up in the morning…and had
slurred speech sounded like (something wrong). I
wondered am I stroke? How comes my tongue got
twisted while I talked?”
Most participants considered their symptoms
were caused by other diseases, especially some
minor diseases which mimicked stroke symptoms.
For example, several patients considered the
symptoms are related to common cold and/or
fatigue. CASE # 4: “I had my limb weakness in
yesterday afternoon which was recovered after
rest. And I had another feeling of limb weakness
this morning…. I thought that the weakness was
due to common cold or fatigue.” CASE #3: “It felt
like cold before hospitalization. Symptoms like
sore-throat, bone soreness and fatigue…just like
common cold.”
Some patients attributed the symptoms to
other diseases such as gastroenteritis, diabetes,
dementia, and back pain, etc. CASE #12: “I kept
sweating….and had nausea. I thought it was
induced by bad food.” CASE # 14: “I felt my right
leg weakness then my right arm numbness at
night. I had no idea for these, but I felt dizzy one
month ago, I thought this was due to diabetics.”
CASE #18 ‘s daughter: “We did not think of stroke.
It appeared to be elderly related like dementia.
Their brain became dull. We did not think it was
stroke related till mouth deviation was noticed.”
CASE #19: “I slipped at bathroom around 8 in the
morning, and then I felt my left limb weakness. I
thought it is due to backache.” And CASE #17’s
daughter: “He was going to sleep and suddenly fell
down to the floor. We thought that might be due to
his spinal spur. The weakness might be induced by
the nerve compression.”
Three patients assumed that their symptom
was related to their behavior. CASE#1: “I thought
my facial palsy was related to betel nut chewing
only.” And CASE#15: “I fell twice that night while
I was on my duty as night shift security. I thought
I was just sitting too long which may induce limb
numbness.”
On the other hand, stroke was excluded
if patients regularly conduct healthy behavior.
CASE#11: “I had palpitation and mouth deviation
at night during watching the television…I swim
every morning. People who swim don’t get stroke.”
Actions in Accordance to the
Dynamic Progress of Stroke
Symptoms from Stroke Onset to
Appropriate Medical Care:
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 Vicious Spiral in Seeking Medical Care: Decision Trajectory of Acute Ischemic Stroke Patients
Patients would apply wide-ranging self-care
behaviors after symptom onset. The most notable
actions were rest and/or sleep. CASE #2: “I felt
dizzy and headache with unsteady gait when I
woke up after nap. I smoked … I thought my blood
pressure was high then I sit down and drink some
water.” CASE#17’s daughter: No. He could walk
after got up (from the floor). Therefore, he went to
bed. It was time to go to sleep. CASE#14: I felt my
right leg weakness then my right arm numbness at
night. I thought this was due to diabetics. Then I
went to sleep, I woke up in the morning and I fell,
then I rested until afternoon.
Another self-care behavior before they went
to the hospital was related to the underlying
disease. They would try to take medication to relief
the stroke symptoms. CASE #4: I just took my
medication for blood glucose control. I think it is
glucose related.
Some patients had obvious limb weakness
and/or numbness. They tried to massage, beating or
shaking hand. No matter how they deal with their
symptoms, patients and their family became more
alert and decided to go to the hospital while their
symptoms appeared to get worse and/or persisted
longer than expectation. In CASE #12: I felt
dizzy and then nausea with general weakness on
February 22 afternoon ... The symptom persisted to
th
23 , so I went to the outpatient clinic first, and then
I was transferred to the emergency department.
CASE #7’s Husband: It seems not so serious. She
could still walk around the house. Her symptom
was just one-sided weakness. It seemed like about
to have a mild stroke. I sent her to the emergency
department because her symptoms were getting
more and more obvious.
Decision-Making Trajectory from
Stroke Onset to Appropriate
Medical Treatment
150
In the time course from symptom onset to
reach correct medical assistance, both patients
and their families were involved in a series of
process. After symptom onset, patients and/or their
families observed the progression, made attribution
to the symptoms, took action and evaluated the
effectiveness of the action. All our studied cases
experienced various symptoms and made different
attributions to the symptoms, however, they
decided not to go to the hospitals. This process is
considered the first cycle of decision making about
seeking medical care (Figure 1). The decision
made by either the patient or his/her families. This
cycle proceeded quite fast and ended while the
action 1 had been taken.
If patients or their families had made a quick
correct decision, the delay for appropriate medical
care would be much decreased. Unfortunately,
all the participants took wrong actions, and
entered the second cycle of illness evaluation. For
example, CASE #17 thought that her symptom was
back pain related, so she went to sleep and rest.
However, her symptom persisted after she woke up
and then she called for help. Another patient (CASE
# 18) had stroke history before with limb weakness
sequel. This time the symptoms were not similar to
her previous experience. Her family thought that
the symptoms might be a dementia symptom; they
all thought that stroke must have limb weaknesses.
Therefore, her family decided to wait and rest.
They didn’t call emergency department until they
found the symptoms persisted and become worse.
From the summary of the interpretation, action
or response toward the stroke symptoms of the
patients (Table 1), delay happened when patients
failed to recognize the onset symptoms after the
first decision of action 1, when patients and their
families kept on evaluating the effectiveness of
the action, making second attribution based on
 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
action. The action 2 was taken when the symptoms
persisted, occurred again, or become worse after
the first action was conducted and evaluated as
ineffective. This process was considered the second
cycle of decision making about seeking medical
care (Figure 1), CASE 7 and 9 even entered the
third cycle before making the right decision. In our
study, patients and their families took more than
one day to figure out that their need of medical
care instead of self-care.
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
to medical care seeking appeared to be a cyclic
trajectory (Figure 2). Patients or their families kept
in evaluating the symptoms, making attributions,
taking actions, and evaluating the effectiveness
of the action in order to regain patients’ health
(Figure 2). As the time proceeded (to the right
side of Figure 2), the cycle of the spiral trajectory
was getting smaller. Besides, the time needed to
proceed another cycle was shorter and concrete
to reach the target of appropriate medical seeking
behavior. In our study, all patients failed to make
immediate and appropriate medical seeking
decision. Furthermore, patients and/or their
families took at least two cycles before they made
a correct decision to arrive in the hospitals. Patients
or their families, as the decision makers, 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 the target of being healthy.
Discussion
Delay (or procrastination) has been defined
as being late from symptom onset to medical
15
treatment. It was categorized into three stages
based on individuals’ psychological assessment
16
process by Safer. In the first stage (i.e. assessment
delay), patients don’t seek medical help because
they are making symptom assessments to figure
out if it is disease related. In the second stage
(illness delay), patients have perceived themselves
as illed whereas they are late for medical treatment
because they are making decision about its
necessity of medical treatments. The final stage
(utilization delay) regards the time delayed for
obtaining appropriate medical treatments since
they have decided to seek.
Suchman proposed another perspective
related to delay in his stage of illness experience
model.15 According to this model, the experience
of symptoms is the starting point of an illness
experience. In this stage, patients confront with
a decision dilemma about whether “something
is wrong”. Only when patients consider that the
symptoms are related to certain diseases and need
attention, they are more likely to enter the second
stage. In the assumption of sick role stage, patients’
social obligations are provisionally relinquished.
Patients would receive lay remedies until they feel
the necessity of seeking medical treatment. The
longer the patients stay in the first and the second
stages, the longer the time between the onset
and appropriate medical care. Delay for medical
treatment is thus resulted.
On the other hand, Wolinsky’s General
Theory of Help Seeking suggests four categories
of determinants which would influence patients’
decision for seeking medical help17: (1) the salience
and cognition of the symptoms; (2) persistence and
disturbance of the symptoms; (3) other demands
and alternative symptoms explanations; and (4)
other non-socio-cultural factors (e.g. resource
accessibility and medical expenditure). According
to this theory, patients with symptoms, which are
more salience, not concordant to their cognitions,
more serious, persistent, great disturbance with
their lives, are more likely to make decision for
seeking medical treatments. Otherwise, patients
are more hesitant to seek medical care and thus the
pre-hospital delay would be prolonged.
The previous theories suggested that personal
cognitions about symptoms and situational factors
both play important roles in patients’ decision in
seeking medical care. Many empirical studies also
echoed these theories. For example, limb weakness
was reported only in 26% to 65% of the subjects.18-
21
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
patients did not consider their symptoms as stroke
22
related in the study of Williams et al. The other
52% with higher knowledge about stroke symptom
tended to go to hospital earlier. These studies
revealed that people’s knowledge and recognition
about stroke symptoms varied and influence stroke
patients’ decision to seek appropriate medical
treatment.
The motor, sensory and some non-specific
symptoms were reported by the subjects, where
the motor symptoms were the most prevalent
symptoms in our study, and is similar to the
18-21
previous studies . However, all the patients and/
or their families failed to connect their episodes
with stroke. They tended to make comparison
between the onset symptoms with other diseases,
which patients have had. Illness schema plays
an important role in make a right decision.16 In
addition, many patients also tended to attribute
their symptoms to certain diseases induced by their
unhealthy behavior, or they totally did not think of
stroke because they had healthy life style. These
interpretation of illness onset could be misled by
the misconnection between health related behavior
and diseases.
Along with the previous finding, our subjects’
knowledge about stroke is very limited. Low
level of knowledge of stroke symptoms was also
reported in other studies.20, 22 Both patients and/or
families appeared to have very little knowledge of
onset symptoms of stroke and appropriate actions.
17
In Mechanics and Wolinsky’s help seeking theory,
perception of the alarm from their health situation
is the initiation of the behavior. Therefore, patients
and their families were unable to correct perceive
the onset symptom of stroke and consequentially
took correct actions.
From another perspective, the severity of
154
the symptom presentation may lead to different
perception and action. When our participants
presented with a minor motor symptom, they
imputed the symptom to other minor diseases; they
preferred to ‘wait and rest’; they tried to find out
other reasons to explain it. They sought help only
when the symptom progress to a threshold or is
noticed by others. This finding again is concord
with Mechanics and Wolinsky’s help seeking
theory. 17 They unwillingly call for help only
when the symptom progressed to a stage, which
affected their daily life activity, and/or out of their
tolerance. According to Suchman’s role changes,
denial and acceptance are the main corner stone
of illness experience.16 Misinterpretation of stroke
symptom by patients or their families may hinder
the sick role recognition and delay the medical
seeking time. Patients’ hesitation may also reflect
that they are worried to become a burden to their
family. They expected to postpone the time of
being a sick role.
On the other hand, while patients perceive
the necessity of seeking medical care, their
social contexts become influential in obtaining
appropriate and timely medical treatment. For
example, living alone 4 , stroke happening on
Sunday or at the night time 23 , long distance
from home to hospital, 24 use of ambulance
transportation4, 7, 23-25 seemed to prolong their time
to the hospital. Also, the presence of others and
their ability to make correct decision was found
significantly influence the stroke patients’ arrival
time to medical institutes in previous studies.25
In addition, a number of studies have been
carried out to identify the relationships between
patients’ demographic variables, illness variables
and their time from onset to the hospital. The
outcomes showed some evidence that patients who
were younger8, 26 and/or females27 were less likely
 Vicious Spiral in Seeking Medical Care: Decision Trajectory of Acute Ischemic Stroke Patients
to go to hospital earlier. Patients with previous
23, 27
history of diabetes or cardiovascular disease,
and suffered from less serious symptoms8, 10, 26 were
more likely to delay for medical treatment.
In medical seeking behavior of stroke
patients, the clinical presentation is the stimulation
and beginning of the behavior. To interpret the
symptom is an emergent thing to deal with, and
finally the action is based on the goal of regaining
the health role.
Analyzing our patients with the proposed
decision making chain, most of them failed in
making immediately appropriate medical seeking
decision, and it took at least two cycles in the
decision chain to reach the target. In the process,
medical delay also happened in our study. The
delay happened in the second interpretation, and
halted by another doctor in the third interpretation
while the symptom became more conspicuous.
For example, CASE #12 presented with some
non-specific flu-like symptoms, such as dizziness,
nausea and general weakness. He subjectively
thought these were due to gastroenteritis. While
the symptom persisted, he called outpatient
clinic first and the doctor did not refer CASE #12
to a hospital. He was finally transferred to the
emergency department again after his symptoms
became more serious.
Besides the stroke knowledge of the patient,
family’s knowledge and their subjective perception
of the symptom directly influence the time course
in seeking medical help. Most of them reached an
appropriate medical organization without correct
recognition and interpretation of the symptoms,
which may reflect the problem that education to the
people whose family is at high risk, is inadequate.
Conclusions
Disability after stroke leads to heavy social
burdens, no one accepts the sick role of stroke
without protest. Although the high density of
hospital and high coverage of health insurance
in Taiwan eliminated the difficulty in medical
assessment, only early recognition and early
medical treatment can successfully reduce the
disability. This qualitative study provides a picture
to understand the process of patients from stroke
onset to medical care. It is also the first study
that explores this dynamic process up today. We
concluded with a cyclic trajectory to represent
patients’ experiences and proposed the following
suggestions.
Limitations
This study has been exploratory. The findings
of this study and the suggestions made for
practice must be treated with some caution as the
study is limited by the small sample of research
participants who, although they represent a wide
range of diversity, are similar in that they had a
well-comprehensive study is needed to compare
differences across age, ethnic culture, gender and
different religious adherences. The study may
however indicate some avenues for further inquiry.
Conflicts of Interest: None
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 Vicious Spiral in Seeking Medical Care: Decision Trajectory of Acute Ischemic Stroke Patients

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: ph1010@mails.fju.edu.tw

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