Saxion University of Applied Science
Reacting to stroke
An explorative study regarding
to knowledge and decisions of relatives of older stroke patients at the first stroke TPUGNG 8H DIEU DUONG TAM DONH De eed 1V VIÊN sẽ:.ÿ#L.HQ/Im
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EXPLANATION OF ORIGINALITY
I declare that I, Pham Thi Thu Huong was bor on January, 19th, 1981, in Namdinh city,
Vietnam as the author of this research report This study:
“An exprorative study regarding to knowledge and decisions of relatives of older stroke patients at the first stroke”
was not carried out previuosly If J used research carried out before by others, this is stated in the text The study was done by myself, with the support of my tutors Professor Joy Notter, Ir Ria Lohuis- Heesink and supervisor Mr Pham Thanh Nam
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Pham Thi Thu Huong SUMMARY
Background: Stroke is a major killer with 10% of the deaths worldwide linked to strokes Strokes are more common in adults particularly the elderly but can also affect
children There are certain risk factors associated with stroke, and these include
hypertension, diabetes and alcohol abuse Vietnam is a developing country, where stroke is a major health problem According to the WHO (2005) report regarding Vietnam, strokes are one in ten the leading causes of deaths
Objectives: The aims of this study is development of information for nurses working with the families of patients who have been assessed as being at risk of a stroke based on regarding the experiences and actions of relatives of stroke patients during the time they suspected the person was having a stroke, and whether they had any prior knowledge of stroke
Methods: A quasi-qualitative approach within the positivist paradigm was used The interviewees were the relatives of patients with stroke, who witnessed the stroke happened and/or made the decision to take the patient to hospital The data were collected by using the standardized open-ended interview guide
Results: 20 participants aged from 22 to 71 were recruited to the research At least one of symptoms of stroke was recognized and hypertension as a risk factor was also awared by many respondents But most of them did not understood what a stroke is In the situation when their relatives were suspected of having a stroke, a wide range of reactions of participants was actual Actions at the point of event include looking for a help from medical staff; transfer directly patients to hospital or self-treatment such as keeping the patient in bed then puting on him or her one of antihypertensive Respondents also met obstacle in seeking help such as there was not consensus from other family members or long distance to hospital
Conclusions: The important findings that emerge from this study is the alarming lack of knowledge about stroke A minority of subjects correctly identified the brain as the affected organ in stroke, and ignorance of the warning symptoms and risk factors for stroke was common The deficiency in knowledge about stroke led to inappropriate actions to first stroke of family members Under pressure of the others, expenditure also influence of objective conditions as far distance, lack of emergency medical service, contact to medical staff before hospitalization, people delay and loose the important time to cure the patients
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TOM TAT
Bối cảnh: đột quy được xem là một “kẻ giết người ghê gớm”, chiếm 10% trong tổng số
các ca tử vong trên toàn thế giới Đột quy chủ yếu xảy ra ở người già nhưng cũng có thể có ở trẻ nhỏ Các yếu tố nguy cơ của đột quy bao gồm huyết áp cao, tiểu đường và việc lạm dụng rượu Việt Nam là một nước đang phát triển, nơi mà đột quy là một vấn để sức khoẻ nổi cộm Theo báo cáo của tổ chức Y tế thế giới, đột quy là một trong mười nguyên nhân
gây tử vong hàng đầu tại Việt Nam năm 2005
Mục tiêu: mục tiêu nghiên cứu là bỗ sung thông tin về đột quy cho điều dưỡng, từ đó cung cấp cho người nhà người bệnh có nguy cơ bị đột quy những thông tin cơ bản về đột quy trên cơ sở tìm hiểu những trải nghiệm và phản ứng của người nhà người bệnh tại thời điểm
nghỉ ngờ người đó bị đột quy và tìm hiểu liệu rằng họ có kiến thức về đột quy
Phương pháp nghiên cứu: nghiên cứu sử dụng phương pháp gần định tính, thực chứng Đối tượng nghiên cứu là người nhà người bệnh bị đột quy, những người đã chứng kiến đột
quy xảy ra và/ hoặc đưa ra quyết định đưa người bệnh đến viện Số liệu được thu thập bằng
việc sử dụng bộ câu hỏi mở tiêu chuẩn
Kết quả: 20 người tuổi từ 22 đến 71 được mời tham gia vào nghiên cứu Ít nhất một triệu
chứng của đột quy đã được nhận ra và huyết áp cao được nhiều người tham gia chú ý là một nguy cơ của đột quy Tuy nhiên, phần lớn trong số họ không hiểu đột quy là gì Diễn
biến tâm lý phức tạp và nhiều hành động đã diễn ra để phản ứng lại với đột quy tại thời
điểm họ nghỉ ngờ người thân bị đột quy Các phản ứng bao gồm gọi nhân viên y tế, chuyển
người bệnh đến bệnh viện hay tự điều trị như đỡ người bệnh lên giường và cho uống thuốc
hạ huyết áp Người tham gia cũng gặp cản trở trong việc tìm kiếm giúp đỡ y tế từ các thành viên khác trong gia đình hay do gặp khó khăn khi vận chuyên
Kết luận: một kết quả quan trọng nỗi bật trong nghiên cứu là sự thiếu hiểu biết về đột quy Một tỷ lệ rất nhỏ các thành viên có thể xác định chính xác não là cơ quan bị ảnh hưởng khi
đột quy xảy ra, và sự hạn chế trong việc nhận biết các dấu hiệu cũng như các yếu tố nguy
cơ của đột quy được lưu ý Do thiếu hiểu biết về đột quy, các thành viên trong gia đình đã `
có các phản ứng không phù hợp với đột quy Áp lực của các thành viên khác, vấn đề tài
chính cũng như ảnh hưởng của các điều kiện khách quan như khoảng cách, thiếu phương
tiện cấp cứu, liên lạc với nhân viên y tế tại chỗ trước khi đến viện, họ đã làm chậm trễ và
làm lỡ thời gian cho việc điều trị hiệu quả cho các ca đột quy
Trang 5CPR CT scan EMS MRI PhD TIA WHO Pham Thi Thu Huong LIST OF ABBREVIATION Cardiopulmonary Resuscitation Computer Tomography scanner Emergency Medical System Magnetic Resonance Imaging Doctor of Philosophy
Transient Ischemic Attack World Health Organization
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ACKNOWLEDGEMENTS
I would like to express my great thanks to all institutions: Nuffic of The Netherland; Ministry of Health, Vietnam; Namdinh University of Nursing, Vietnam; Saxion Universities of Applied Sciences, The School of Health, The Netherland and every one who has contributed to and helped me with my training and research
My sincerely thanks should also go to relatives of stroke patients, the medical staff of Cardiovascular department in Namdinh General hospital participated in my study and willingly shared their experiences, views and opinions with me on the research topics Their contributions are invaluable and unforgettable
Especially, I would like to say forever thanks and carve deeply in my heart the most sincere gratitude to my tutors and supervisor Professor Joy Notter, Dr Pham Thanh Nam, Ir Ria Lohuis- Heesink You always give me your hands in my research work by the most effective way and at the same time you encourage me to go further and to
make me more confident
I would like to express many special thanks to: Mr Do Dinh Xuan, PhD, the Rector of Namdinh University of Nursing, Director of the “Jmproving the Qualitive of University and Collage Level Nursing Training in Vietnam” Project in Vietnam side for his support to my study
I would like to gratefully and sincerely thank all professors and lecturers of the School of Health, Saxion University Apply Science, The Netherland who gave me lectures, ideas and comments to complete this research
I also wish to extend my thanks to my colleagues in Fundamental of Nursing department as well as other teachers in Namdinh University of Nursing, Vietnam, where I am working, for their help, encouragement, and especially their willingness to share my work when I am away for training
In particular, I would like to thank Ms Cao Thi Thanh Mai, Dr Tran Quang Huy, PhD, Dr Ngo Huy Hoang and my ANP friends for valuable and useful discussions,
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11 1iHl@HR
LA(81
Pham Thi Thu Huong comments related to research work, as well sharing their experiences with me in many other aspects
I dedicate this thesis and deepest gratitude to my parents who always encourages me to study, and to my parents in law as well as to my family all, especially to my
husband, Nguyen Ba Tam, my son Nguyen Hoang for your love, sympathies,
understanding, encouragement, patience, and, as well your tolerance I understand deeply in my heart that behind this thesis is my own family, without you, I cannot have enough courage and energy to go ahead For that I am very grateful
Thanks to all !
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CHAPTER 1: INTRODUCTION
Namdinh is a small town in the North of Vietnam, where over a half the
people live from agriculture, and coping with a stroke is extremely difficult for them Traditionally, the different generations in a family live together, sometimes this can be two or three, even four generations with young people working and taking care of their parents However, community health care is not good enough for all elderly people particularly those without health insurance, with the result that a stroke will impact on all aspects of family life It is therefore very important for people to be able to recognize the signs and symptoms of stroke and seek help as quickly as possible to try to minimize the long term consequences that can follow a stroke
In Namdinh General hospital, a consideration number of elderly stroke
patients come to the hospital too late for treatment to be effective Their health problems become worse because of complications such as developing pulmonary or urinary infection Many of these patients have little education, and this makes the provision of care more difficult as the patients do not understand what has happened to them In addition, although in the cardiovascular department, most of the patients
have heart diseases, hypertension, or other risk factors for strokes, patients and their
families report that they receive little information from the nurses and other health workers as well In a study led by (Shah, Makinde, & Thomas) (2007) only one quarter of the patients and bystanders considered their doctor or nurse to be a source of stroke information Follow that, a question is emerged invented how far the stroke patients’ family understand about stroke warning symptoms and it’s risk factors However, most research has focused on controlling symptoms and there is a need to identify risk factors for family members, who can then help patients having a first stroke to reach hospital in time for treatment
Internationally, there are many studies concerned with knowledge of stroke symptoms and risk factors for stroke patients (Dearborn & McCullough, 2009; Derex
L, Adeleine P, Nighoghossian N, Honnorat J, & Trouillas P, 2004; Greenlund, et al.,
Trang 10Pham Thi Thu Huong and describe the decision making process they use prior to seeking help for their relative Based on this, an information pack will be developed for nurses to use when working with the family members of those who are at risk of having a stroke Furthermore, a second and equally important objective of the research is secondary prevention (WHO, 2009) to reduce the risk of stroke occurrence, and finally a third objective is to improve the quality of care
Research statement
The development of information for nurses working with the families of patients with high blood pressure, heart disease and/or diabetes who have been assessed as being
at risk of a stroke
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CHAPTER 2: BACKGROUND
A wide range of resources were used to identify research in this field To enhance the search, a range of key words were used including “stroke awareness”, “stroke, qualitative research”, “stroke, burden” or “delay treatment with stroke” The information gained included research into stroke symptoms, risk factors and the impact of delays treatment on the long term outcomes and was used to confirm the need for the study
2.1 Stroke
A stroke is caused by the interruption of the blood supply to the brain, usually because a blood vessel bursts or is blocked by a clot This cuts off the supply of oxygen and nutrients, causing damage to the brain tissue The most common symptom of a stroke is sudden weakness or numbness of the face, arm or leg, most often on one side of the body Other symptoms include: confusion, difficulty speaking or understanding speech; difficulty seeing with one or both eyes; difficulty
walking, dizziness, loss of balance or coordination; severe headache with no known
cause; fainting or unconsciousness
The effects of a stroke depend on which part of the brain is injured and how severely it is affected A very severe stroke can cause sudden death (WHO, 2009) There are two types of stroke The most common type of stroke (over 80% of cases) is caused by a blockage (ischemic stroke), which happens when a clot blocks an artery that carries blood to the brain The second type of stroke (up to 20% of cases) called a hemorrhagic stroke The cause is a bleeding (hemorrhage) into the brain, when a blood vessel bursts (The Stroke Association, 2008)
Risk factors for ischemic stroke comprise both modifiable and nonmodifiable
etiologies Nonmodifiable risk factors include age, race, sex, ethnicity, history of
migraine headaches, sickle cell disease, fibromuscular dysplasia, and heredity
Modifiable risk factors include hypertension (the most important); diabetes mellitus;
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Pham Thi Thu Huong and ventricular enlargement); hypercholesterolemia; transient ischemic attacks (TIAs); carotid stenosis; hyperhomocystinemia; lifestyle issues - excessive alcohol intake, tobacco use, illicit drug use, obesity, physical inactivity Besides, oral contraceptive using is also a cause of stroke (Jauch, Kissela, & Stettler, 2009)
Advances in stroke therapy confirmed that delivering the earliest possible definitive treatment for acute ischemic stroke is a major goal of clinicians caring for stroke patients Subsequent trials demonstrated that shorter time (within 3 hours) to fibrinolysis substantially improved clinical outcome in acute ischemic stroke patients
(Moser, et al., 2006)
2.2 Stroke — a big problem
Stroke is seen as the third most common cause of mortality and a major cause of long-term disability of adults in most countries (American Heart Association, 2005) According to report of the World Health Organization, there were more than 57 million deaths worldwide in 2002, stroke accounted for nearly one in every 10 of all deaths in the world (Johnston, Mendis, & Mathers, 2009) From European countries (Truelsen, et al., 2006), Asia, America; not only white, also black (Kissela, et al., 2004), stroke happen to everyone, in every country However, much of the mortality and functional burden associated with stroke is concentrated in residents of low and
middle-income countries (Johnston, et al., 2009)
Anyone can have stroke, even children and babies, but most people affected are over 65 (The Stroke Association, 2008) Common with risk factors as hypertension, diabetes, alcohol consumption , stroke becomes a big danger for elderly people
Stroke is also a major health problem in Vietnam Stroke prevalence was 6.08 per 1,000 inhabitants in a survey in 1994-1995 in three different regions of southem Vietnam (Lé, et al., 1999) In 2002, according to report of Vietnam for WHO, stroke is one of ten leading causes of mortality (WHO, 2002)
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Reacting to stroke
more in lost productivity and disability The total costs of stroke are predicted to rise
in real terms by 30% between 1991 and 2010 Today, in Vietnam, there is not detail
financial expenditure spent for stroke, but cost maybe similar to UK
2.3 Delay help-seeking decision of stroke patients
In fact, numerous studies confirm a high frequency of delay in presenting to a
hospital after stroke (Becker K, et al., 2001; Derex L, et al., 2004; Shah, et al., 2007)
As the report of Shah and colleagues, treatment delay can be broadly divided into three phases: patient delay (the most significant), prehospital delay, and hospital delay (Shah, et al., 2007) And from 1998, the National Institute of Neurological Disorders and Stroke’s Consensus Development panel on stroke treatment conceptualized the stroke chain of recovery The chain of recovery is a metaphor that describes a series of sequential actions that must take place in a timely fashion to optimize the chances of
recovery from stroke (Pepe, Zachariah, Sayre, & Floccare, 1998) In which, detection
of a stroke is the first element that occurs with recognition of the patient’s neurological changes and subsequent seeking of medical care (Herold & Cichon, 2004) Early recognition is essential to providing optimal treatment for a stroke patient In other words, failure in recognition of the symptoms of stroke is the first cause in delaying during acute stroke management (Kwan, Hand, & Sandercock, 2004)
Multiple barriers delay people from accessing medical attention for stroke Some people thought that their neurological symptoms were not serious Others reported postponing medical attention due to concerns about cost of treatment or about bothering their physician (Schreeder, Rosamond, Morris, Evenson, & Hinn, 2000) Living alone and nonuse of emergency ambulance services were the only two common factors associated with a delay in hospitalization in many studies (J D Pandian, et al., 2006)
2.4 Knowledge of stroke
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Reacting to stroke
more in lost productivity and disability The total costs of stroke are predicted to rise in real terms by 30% between 1991 and 2010 Today, in Vietnam, there is not detail financial expenditure spent for stroke, but cost maybe similar to UK
2.3 Delay help-seeking decision of stroke patients
In fact, numerous studies confirm a high frequency of delay in presenting to a
hospital after stroke (Becker K, et al., 2001; Derex L, et al., 2004; Shah, et al., 2007)
As the report of Shah and colleagues, treatment delay can be broadly divided into three phases: patient delay (the most significant), prehospital delay, and hospital delay (Shah, et al., 2007) And from 1998, the National Institute of Neurological Disorders and Stroke’s Consensus Development panel on stroke treatment conceptualized the stroke chain of recovery The chain of recovery is a metaphor that describes a series of sequential actions that must take place in a timely fashion to optimize the chances of
recovery from stroke (Pepe, Zachariah, Sayre, & Floccare, 1998) In which, detection
of a stroke is the first element that occurs with recognition of the patient’s neurological changes and subsequent seeking of medical care (Herold & Cichon, 2004) Early recognition is essential to providing optimal treatment for a stroke patient In other words, failure in recognition of the symptoms of stroke is the first cause in delaying during acute stroke management (Kwan, Hand, & Sandercock, 2004)
Multiple barriers delay people from accessing medical attention for stroke Some people thought that their neurological symptoms were not serious Others reported postponing medical attention due to concerns about cost of treatment or about bothering their physician (Schroeder, Rosamond, Morris, Evenson, & Hinn, 2000) Living alone and nonuse of emergency ambulance services were the only two common factors associated with a delay in hospitalization in many studies (J D Pandian, et al., 2006)
2.4 Knowledge of stroke
Trang 15Pham Thi Thu Huong et al., 1998; Reeves, Hogan, & Rafferty, 2002) Though many guidelines and recommendations for stroke management or specific aspects of stroke care have been published during the last decade (Ringleb, et al., 2008); or information about stroke is also supported to public by mass media (Silver, Rubini, Black, & Hodgson, 2003), it has a little affect on the number of strokes The researchers conducted public opinion polling in 4 communities to track the level of awareness of the warning signs of stroke and to determine the impact of different media strategies Applying stroke information of the Heart and Stroke Foundation, the 5 categories used to capture the warning signs reflect those used by in all of its stroke communications: weakness, paralysis, or numbness, typically on one side of the body; trouble speaking or understanding speech; unusual or severe headache; dizziness, lightheadedness, or falls; and vision problems Unfortunately, only rarely is stroke information derived from general practitioners or books (Ringleb, et al., 2008)
Lack of knowledge of risk factors for stroke may also hamper compliance with stroke prevention practices (Derex L, et al., 2004) Although most people agree that stroke is an emergency, and that they would seek medical help immediately, a large amount of time is lost outside the hospital (Evensona, Rosamonda, & Morrisb 2001) Avoiding delay should be the major aim in the prehospital phase of acute stroke care This has far-reaching implications in terms of recognition of signs and symptoms of stroke by the patients or by relatives or bystanders (Ringleb, et al., 2008) However, medical attention is rarely sought by the patient, in many cases, contact is initially made by a family member — findings of (Zerwic, Young Hwang, & Tucco, 2007), Ringleb and colleagues (2008)
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Reacting to stroke
making capacity of the patients impaired, crucial motivation is belong to their relatives
who have knowledge about stroke
In conclusion, stroke is a major problem all over the world In contrast, knowledge about stroke symptoms or warning signs, stroke risk factors of community is little Specially, in elderly people, who generally have the frequent risk
factors of stroke as hypertension, diabetes, alcohol consumption, and stroke becomes
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Pham Thi Thu Huong
CHAPTER 3: METHODOLOGY
Currently, in Vietnam and in particularly in Namdinh, despite the efforts from the Government and the Ministry of Health to increase the primary care, the prevalence and incidence of stroke has not reduced There is a wealth of information regarding strokes and their symptoms, but very little research has been done to see how these applied in Vietnam, or to translate these into a Vietnamese context The aim of the study was to develop information for relatives , it was therefore important to find an approach that would enable the perceptions of relatives to be explored, and followed the gathered data by identifying areas where information is needed The final step was the development of information for relatives After consideration of all possible research methods it was decided that the processes used in action research would facilitate all the steps given above as this enables change and innovation to occur through the participation of individuals and groups However, action research is a long term cyclic process which continually refines and reviews activities undertaken It is an inquiry sequence that is based on and monitored by recognized research procedures; it usually begins with a formal assessment of the current situation and there are specific data production and analysis phases, all of which are used as a cycle of activities each of which brings about more change and/or innovation The action research cycle can be represented as in Figure 1
Trang 18Reacting to stroke find themselves working on the same topic in a spiral of repeated cycles of improvement (Tripp, 2003) Figure 1: The full action research cycle Then Plan Research Implement Action and Monitor Action First Plan Action Plan Act action thoughtfully (together) Reflect (on Action) Reconnaissance (First Cycle) {A Evaluate Research action action First Produce and Data Review (Research) Process Then (separately | Analyse and together) Data
Study of this cycle shows that although this study differs from most studies using the process in that it has been focused on one issue, developing information, rather than initially changing practice, ultimately the actions of nurses will change when they start to use the information to support patients and families at risk of a stroke Therefore it this study was seen as the first cycle in an overall change designed to bring about improved practice The structure that this approach gives to the series of activities needed to develop the information for relatives is important as it enables nurses and other healthcare professionals to see why aspects of information were included This is seen as crucial, and change is more effective when participants can see the reasons for inclusion Therefore this study will be based on the first cycle of action research, stopping at the point where reflection and evaluation of the
Trang 19the occurred have been presented in table 1
Pham Thi Thu Huong For clarity the activities needed to complete the cycle and the order in which No | Task Methods
1 Define stroke problem in| Discuss the nature of information Cardiovascular department of | needed with experts in the field of
Namdinh general hospital and | cardiovascular care, this includes, the
assess the available information for | project supervisor, the chef nurse in the patients and relatives Cardiovascular department of Namdinh Assess the information given by | general hospital,
nurses to relatives Consensus was that there was a need to develop information for relatives and to educate nurses so that they will use prepared materials
2 | Literature review on components, | Using internet database machine and
evidences of stroke knowledge, | library: Pubmed, Medline,
burden and delay in seeking help in | ScienceDirect, and Google web
case of stroke Limited year 1997 onwards
Keywords: “stroke awareness”, “stroke, qualitative research”, “stroke, burden” or
“delay treatment with stroke”
3 | Gather information from supervisor | Meet with experts and discuss evidence and Dutch Nurse specialist in care | found, Vietnamese policy and how to for CVA /stroke patients make adapt available information to fit
in Vietnamese
4 | Data collection through from 20 Explorative research to gather relatives of stroke patients in| information about experiences and actions Cardiovascular department of relatives of stroke patients during the time they suspected the person was having a stroke To find out whether they had any prior knowledge of strokes
5 Analyze data found and Synthesize | Transcribe and analysis data link with data from step 2 - | findings to literature review to develop draft of information leaflet for relatives 6 | Refine stroke information procedure | Translate draft version into Vietnamese,
through peer-review and expert then delivery this procedure to supervisors and chief nurse to get feedback
7 |Complete the final stroke | Write down in English then translate information procedure into Vietnamese version
8 |Communicate and publish this | Submit leaflet for consideration by research Namdinh hospital, prepare to disseminate by publication, e.g with Vietnamese Nursing Journal and others
one
Table 1: Activities needed to complete the first cycle of action research
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3.1 Study activities
Once the first two steps had been completed, and the literature review prepared, the next major step in this study had to be to find out what people living in Vietnam knew about the signs and symptoms of stroke and whether they know what to do when these arose For this an initial fact finding exercise it was decided to explore
what families of those who had just had a stroke had known prior to the incident, how
they had coped and what decision they had made regarding seeking help and advice This group was selected as it is only when incidents actually happen that the reality of the problem becomes clear, and this group could therefore describe how they had felt and what information would have been helpful beforehand In addition, it was decided that if too long a time had lapsed between the patient’s stroke and the relative being interviewed memory recall could be inaccurate, making it difficult to find out what they knew or how they had reached decisions
It was seen as important to use a method that allowed relatives to answer the key questions in a manner that enabled the researcher to check that they understood the questions and to explore and clarify the responses given Face to face interviews seemed the most appropriate method to use, and the need for discussion confirmed that these would yield more detailed data than a survey However, as there was a need to summarize the data gathered, in a format that facilitated comparisons, semi- structured or unstructured interviews were rejected Instead this part of the study utilized a quasi- qualitative approach which fitted more within the positivist paradigm, using standardized open-ended interview questions to identify knowledge of patients’ relatives about symptoms, causes of stroke as well as the decision making process and attending the hospital
With standardized interview, all interviewees are asked the same basic
questions in the same order (Patton, 2002) One benefit for this approach is that all participants are asked about the key issues in the same way and it is therefore possible to compare responses Moreover, as the questions are pre-determined this can help reduce the effect and bias of the interviewer during data collection and analysis The disadvantages are that there is less flexibility (Notter, 2009) in the interview, regarding particular individuals and circumstances; without care, this approach can constrain naturalness and limit the responses As the study focused on the 11
Trang 21Pham Thi Thu Huong development of appropriate information, rather than focusing only on the actual experiences they had had when their relatives stroke had a stroke, these limits were not seen a barrier to using this approach It was also felt that careful interview techniques can would help minimize these potential problems
3.2 Research area
Namdinh General hospital is the biggest one in Namdinh province It locates in the centre of the city, thus transportation can be relatively easily organized for most of those living in the city However, for those who live in the remote areas reaching the hospital, it is more difficult It is also recognized many of those living in Namdinh prefer be treated in a big hospital in their hometown, and they will therefore find ways to get there The cardiovascular department is an important part of the hospital with six doctors and twenty nurses The most common diseases and problems are high blood pressure, heart disease, stroke, and myocardial infarction
Normally, after initially being admitted into the emergency department, once stable (usually this takes a few days) the patient is transferred to the Cardiovascular department, and it was the right time to meet patients’ relatives and invite them to participate in the study
In Vietnam, although there have been no official statistics, hospital records
indicate that in winter the number of stroke patients is more than that in other seasons At this time, especially, because of cold weather in the north of Vietnam, strokes are more common in elderly people It is thought that this is because the cold weather leads to peripheral circulation constriction, and passive stretching of vessels
in the brain and lung, which can damage them In addition, in cold weather, the
number of red blood, platelet increase, together with increased blood viscosity, a contributory factor in increasing the risk of coronary disease and stroke
3.3 Population and sample
Twenty relatives of elderly patients having the first stroke treated in Cardiovascular department of Namdinh hospital were asked to participate in the study They were persons who witnessed the stroke when it occurred and then made
Trang 22Reacting to stroke
the decision to take the patients to hospital They know the patient’s diagnosis and they take part in caring progress for the patients, for inclusion they need to be able to understand, and respond to questions in Vietnamese
Convenience sampling was used to make a list of participants As the method, “selection of the most readily available persons as participants” (Polit & Beck, 2006) is the suitable representative for this pilot study, Polit and Beck (2006) also wrote that the key aim in qualitative studies is to extract the greatest possible information from the small number of informants in the sample, and a convenience sample may
not provide the most information — rich sources However, for this subject, where the
participants are all relatives and have recently seen a member of their family have a stroke, using a convenience sample is not a problem
3.4 Data collection
Each interview took about 20 minutes Based on information about stroke of WHO (2009), the Stroke Association (2008) and evidence from studies about stroke symptoms and risk factors awareness, the interview guide was divided into three domains The first part of this gathered demographic information The second and the third part are their experiences and reaction to the stroke with their knowledge/ stroke awareness Each one consists of time of onset of symptoms, nature of initial response, time to contacting healthcare system, symptom recognition, knowledge and attitude about stroke, and barriers to seeking care The questions about behavior have been developed from the research of Shah and colleagues (2007) who studied cognitive behavior with an acute stroke
Data collection procedure
Polit and Beck (2006) point out that knowledge is maximized when the distance between the inquirer and the participants in the study is minimized, therefore a face-to-face approach whereby relatives are interviewed seemed more appropriate This study had arisen because of experiences gained while the researcher was consolidating her clinical practice During the time, it was evident that from the care of stroke patients from their family, unfortunately, undeserving complications happened to the patients, especially, among elderly stroke patients, the development of pressure ulcers Although discussions were held with the nurses to
Trang 23Pham Thi Thu Huong guide and help them to care for the patients, diet for the patients was clearly a problem, with little information being given to relatives Day by day, talk to them, the nurses problems and faculties became more evident, and once their trust was gained, pilot interviews were used to develop the questions for the interview schedule (Notter, 2009)
In addition, two stroke patients’ relatives from the list of patients who met the study criteria asked the questions in interview guide, and then asked how easy they were to understand and answer The researcher used all comments from them and discussed them with the supervisor as well as tutor to finalize the interview guide From these pilots, some questions were changed, but even following the third process, the result was as not good enough as hoped for Therefore cardiovascular experts and the project supervisor were used to again refine the questions
The face to face interviews were conducted in the Cardiovascular department and lasted approximately 20 minutes There were four strengths of this method Firstly, the face to face interview helped to establish good relationship between the researcher and the respondent Secondly, it allowed the researcher to listen as well as to observe the informants during the time of interview For the third point, it permitted more complex questions to be asked than in other types of data collection And prompts were used in this session And finally, it was effective in controlling the answers, the respondent had to complete all inquiries in the interview guide, even they refused to discuss they needed to say no to it Thus, the missing answers were
minimized
In the first meeting, participants was explained about the purpose of the research and why they were being asked to participate The date and place are discussed between researcher and participants for suitability and comfort In collecting data, in stead of name and address of the participants, the codes or numbers were used to make sure the no prejudicial opinions in analyzing data and that all data is anonymised (Polit & Beck, 2006)
Trang 24k ,.Ắừ _Ừ
Reacting to stroke
At the beginning, interviewer presented some information about interview process, for example, what participants and interviewer should do to understand each other During interviewing time, if participants did not understand question, they could ask for repeat or explanation When they were ready, they could sign in informed consent to start interview Next step, each respondent completed general information that related to him/her and his/her relative After that, they were interviewed Ideally,
interview would be place one time In one case, because of an objective reason, the
participant left during interviewing time, the other appointment was made with the rest of interview questions (Patton, 2002) At the end of each interview, researcher asked the thinking or comments of participants to improve in next one
3.5 Data analysis
Data analysis for the standardized open-ended interview was based on five steps with transcribing, familiarization with the data, analysis by question, grouping quotes and interpreting data, respectively (Vocht, 2009) In step one, all of 20 audiotapes were transcribed verbatim (word by word) after the interview was finished F4, an audio/video transcription computer program, was used to facilitate the transcriptions This transcribing activity was also a good starting point of the data analysis, because I could make note while transcribing It was really helpful for me in the second step in which I needed to get familiar with the data Careful arrangement the respondent number on each page and the page number for each transcript and other advice on typing transcripts were noticed at this phase (Notter,
2009; Vocht, 2009)
The aim of the step two was to immerse in the data and to get a sense of the interview as a whole before breaking it into different parts of the next step Thus, I listened to the tapes, reading the transcripts in their entirety for several times and read the notes written immediately after each interview These three activities helped me familiarize with the data (Vocht, 2009)
In step three and step four, after printing all transcriptions, I made important and special quotes in highlight colors so that I could easily notice when interpreting
the data at the final step With group questions for stroke knowledge, actions to
stroke, separately, I made tables with summary words to show all information from
15
Trang 25Pham Thi Thu Huong transcriptions For example, the appearance of stroke symptoms as weakness, numbness, problem with eyes, marked in correlative column and row
Final step, I divided two groups for stroke knowledge and react to stroke In group questions of knowledge about stroke, I found quotes for each question, saw the relationship among them and _ the links between the data as a whole By contrast, for reactions of respondents when they suspected their relatives having a stroke, I conducted stories These told all from the first stroke signs appeared, what they did also their thinking Every participant had each story, but I chose and described some of typical ones
I presented finding and discussion separately, I thought that was a suitable way to show the significant terms in my research results In fact, it was difficult to find comparative information from researches of Vietnam for reaction of relatives to stroke This was one of limitations of my research
3.6 Methodological quality
In this research, qualitative research method, standardized open-ended
interviews were used to collect data, so validity and reliability was defined as instrument to assess the accuracy and rigour of research study To assess the methodological quality the positivist paradigm uses reliability and validity Reliability is the traditional paradigm underlying the scientific approach, which assumes that there is a fixed, orderly reality that can be objectively studies; often associated with quantitative research Validity is the degree to which an instrument measures what it is intended to measure The last one, reliability is the degree of consistency or dependability with which an instrument measures the attribute it is designed to measure (Polit & Beck, 2006)
Firstly, content validity can be considered through literature review or background A lots of studies show that stroke is a big problem for human being over the world In contrary, knowledge about stroke symptoms and risk factors are limited and a large amount of time is lost outside the hospital for treatment Moreover, the role of relatives or bystanders is not concerned in helping patient to hospitalization
This research will find out the reaction of elderly stroke relatives to situation that
Trang 26Reacting to stroke
stroke happened and awareness of them to stroke In Vietnam, retired age in men and women are 60 and 55 respectively, so all participants were over 55 years The interview guide targeted two domains: reaction to the stroke situation and knowledge about stroke The questions about knowledge of stroke were based on stroke definition, symptoms and risk factors presented in background and questionnaire of other studies To make sure the straightforwardness and appropriateness, the questionnaire was pretested in a pilot by two people who met participant criteria Secondly, face validity for approach and instrument is defined by using the judgment of Cardiovascular expert and Neurology expert The opinions of them can be used as an evidence that assumes the efficiency of the interview guide
The pilot was also used to check reliability of questionnaire (using questions in interview guide to ask a small group of people have participant criteria) (Notter, 2009)
3.7 Ethical consideration
Ethical permission for the study, I received from the Namdinh hospital and Namdinh University of Nursing All participants were assured of anonymity and the data were kept confidentially in accordance with data protection requirements Informed consent for all participants and consent for recording were demanded The verbal and written explanation were given to the participants before interview In which, one important thing they should understand was if they do not participate to the study, there was not any impact to the health service for their relative Also nonmaleficence principle was conducted; “researcher’s duty to avoid, prevent or minimize harm to study participants” (Polit & Beck, 2006) Participants were assured that they could withdraw at any time during interviewing process they want (Orb, Eisenhauer, & Wynaden, 2001)
Trang 27Pham Thi Thu Huong CHAPTER 4: FINDINGS Biographic data Age, years n(%) < 50 13 (65) 51-60 2 (10) >60 5 (25) Sex, Male 7 (35) Female 13 (65) Education
Less than junior high 15 (75)
More than junior high 5 (25)
Current professional status Worker 4 (20) Farmer 10 (50) Retired 4 (20) Unemployed 2 (10) Health insurance status of patients Yes 12 (60) No 8 (40) Stroke risk factors of patients TIA 1 (5) Hypertension 9 (45) Cardio disease 1(5) Diabetes 1(5) Table 1 Biographic data from participants N= 20
In total there were 20 participants, the proportion of people in working age was 65% The youngest was a woman at 22 of age and the oldest at 71 A difference between Vietnam and other countries is the women can be retired from 50 of age This was reason I divided 3 level of ages for my participants With different generations in a family live together culture, there was a diversification in participation Respondents were maybe a older wife, a son, a daughter, a daughter- in-law, even a grandchild They were caregivers or witness stroke happened to the patients directly Of the participants, 65% women compares to 35% of men
Trang 28A HC
ibid
Reacting to stroke
Normally, taking care role belongs to female, who are more thoughtful than male This is maybe reason for the higher in proportion of women than men interviewees
There was a notice in education level of respondents A consideration rate (75%) was less then junior high school education level With grand generation, because of the war, it was really difficult for people to complete study progress Unfortunately, it was not small number of youngers who were still too low level (the third year of primary)
In professional status, a half of relatives of elderly stroke patients were farmers, compares to 20% of workers It was rarely meet an intellectual in this case If research time longer, does this status change in ?
In Vietnam, one challenge for health policy maker was health insurance Financial for health insurance was a non small amount of money for low-incomes, especially elderly people There was a consideration rate of older stroke patients without health insurance in rural areas Even though efforts of government to the poor families, providing insurance for everybody is a big problem for the whole society
As self report of family member, nearly a half of stroke patients had stroke risk factor with hypertension However, most of patients were defined high blood pressure at the time hospitalization How many percentage for without medical history for high blood pressure cases were One reason for these was lacking periodic health testing On the other hand, with some situations, they did not take medication frequently, even not care in hypertension case Generally, periodic health checking is not regular habit for all citizen in my country, thus, hypertension also other risk factors for stroke as heart diseases were not detected early And the consequence that it is too late for people recognize the stroke when it happen
4.1 Knowledge about stroke
Trang 29Pham Thi Thu Huong himself” Even, in one case, the forth participant: “It happened with my father in-law by brain vessels ruptured 4-5 years ago” It maybe very hard to promote them find
out to understand more about stroke in their situations
Participant were asked what a stroke was There was a range of responses from the relative of stroke patients, including “blood can not flow to brain” and “the vessels in brain was broken, the shake would effect to central nerve” or “neurological disease” Another gave a more visual answer comparing a stroke to image that “the huge wave makes breaching dyke” Generally, the frequently identified meaning of stroke in responses was the problem in the brain Otherwise,
three fourths of participants could not defined about Stroke, even had not one chance
to see stroke happened Stroke symptoms N,% Motor 15 (75) Language or speech 5 (25) Vision 1 (5) Sensory 5 (25) Others (vomiting, facial dropped, unconsciousness) 6 (30) Death 1(5) Stroke risk factors Alcohol 4 (20) , Stress 1 (5) i High blood pressure 9 (45) Diabetes 1(5) Hypercholesterolemia 1(5) Cardiac disease 1 (5) Age 2 1 (5)
What would you recommend in case of stroke?
First aid before hospital admission 9 (45)
Rapid contact with medical staff 2 (10)
Rapid hospital admission 5 (25)
Unknown 4 (20)
Table 2 Knowledge about stroke, N = 20
The majority of participants (85%) were able to accurately identify at least one symptom of stroke The most frequently identified stroke symptoms were
Trang 30Reacting to stroke
sensory with headache, numbness or dizziness sigh (25%), visual changes (5%) Three individuals (15%) said that they had no prior knowledge of stroke symptoms, and others were not accurate (15%), giving responses such as “red face like that of drinker” or “high temperature” One participant had missing data in response to this question
The most frequently identified risk factors were high blood pressure (45%), alcohol (20%), and hypercholesterolemia or diabetes (5%) Relative of stroke patients’ knowledge about causes of stroke varied from fair to very limited The following quote is an example of a participant’s response that was considered fair understanding of causes
“A lot of people have high blood pressure have stroke Besides, hypercholesterolemia, veins blocked or old age, arteriosclerosis.”
An example of very limited understanding is the following patient’s relative’s response
“A clash (falling down or beat your head somewhere), having crowded or even talk too much.”
Seven individuals (35%) said that they were not aware of any of the causes of stroke One individual believed that “wind or the changing of the weather” is one of direct causes of stroke While another suggested that “go out with sunny [weather], you maybe have stroke”
Answer for question what would you recommend in case of stroke, nine respondents (45%) chose giving life support on the scene before admission to the
2 6
hospital “keep his on the premises, safety”, “massage” or “oil massage” Other said “put a cool towel on his/her forehead, prick on the top of the finger, squeeze one blood drop out, until he or her to be conscious”
According to the participant’s story, this was an experience from Chinese traditional medical doctors Two respondents had the same solution: “take an anti- hypertension tablet” Most of them thought they would wait for blood pressure reducing before taking the patients to hospital By contrast, some participants (25%)
Trang 31Pham Thi Thu Huong would call a taxi or emergency medical system (number of EMS 115) for transferring a stroke victim to the hospital immediately On the other hand, four relatives considered their own decision in seeing a well-known doctor because
“he is a good, experienced doctor Though call a taxi, whether it comes in time or not”
To find out the sources of information about stroke, only three people said they had a chance to know symptoms and risk factors regarded to stroke Separately, several said “I am too busy to watch TV”, even “all year long, I do not come to medical centre one time” Nearly all of relatives of stroke patients did not receive
any information about stroke from mass media, medical staff, etc
4.2 Experiences and actions to strokes
Warning signs for stroke
Warning signs of stroke was defined by what respondents saw or they heard from patients Remembered some days before stroke happened, a respondent concerned
“two weeks ago, sometimes she felt numbness on her right hand and headache (blood pressure raising)”
One more phenomenon that the participant paid attention was
“with her numb hand, everything she took was falling right away (falling eating bowl and chopstick) But it appended for a while, then every sign and symptom regained”
In contrast of the limitation in defining warning signs of stroke as above case, other respondent had experience about transient ischemic attack (TIA), there was change like “became quiet” and “his face looked like a foolish” compared to other days at her father-in-law She said, “the day before, it was cold His hand and leg were tremble”, she guessed he would have problem like what happened two years before “counted 2 years from the last slight stroke”
Trang 32Reacting to stroke
With researcher’s suggestion, other participants remembered patients complain about the numbness, headache or fatigue With the second respondent, however, it was not easy for her to recognize unusual sign at her mother “last afternoon, she complaint light headache, but at dinner, her diet was not problem”
However, these signs were forgotten promptly or imputed to influence of the
weather
“it was cold His hand and leg were tremble”
One individual believed “she was remembering her grandchildren”, because that day was the Tet holiday, the “getting together” day in Vietnam And “she became woozy Sometimes, she did not answer my question, even grouchy”
Stroke happened with symptoms
Several days after, symptoms of stroke appeared and many relatives of stroke patients seemed to have difficulty interpreting these that patients were having as indicating a stroke Results of the research show that the majority of them did not know what was occurring The fourth participant started:
“there is a strange on his face, deformed mouth and bleary-eyes When | lift his hand, it drooped and his whole right side felt really weak He seem make urinary without consciousness I did not know what happened to my father”
The actual symptoms experienced by patients are shown in Table 3
Trang 33Pham Thi Thu Huong Symptoms Frequency Percent n=20 Sensory Headache 2 10 Dizziness 6 30 Numbness 5 25 Speech Slurred speech/dysphasia 15 75 Motor Weakness 12 60 Unbalanced/fell 5 25 Paralysis of limb 2 10
Vision Blurred/vision loss or change 3 15
Others Facial drooping 7 35
Nausea/vomiting 5 25
Loss of consciousness 3 15
Table 3: Signs of stroke recognized by participants
Unlikely to theory, stroke symptoms through the eyes of research respondents were very multiform The first signs of stroke with the first interviewee was “ he maybe felt giddy, could not go into our house, left a sandal on the ground”, or “like
seasick” As the words of an old woman, at the church and beside her family, “all
around seem fall” and she “fell down gradually” One sign which closed person could see at patients was weakness of hands or legs: “his hand and leg were weak”, “one his hand was stiff and he could not keep a spoon” With one man, the circumstance was more slight than all “before going to sleep, my father felt numbness more than normal”
However, stroke signs were ignored in this case
“he thought that because of the changing of the weather After accident in last
year, his hand and leg were sometime numbness”
Through stories of participants, stroke happened to patients with “his voice was change”, “he could not speech any more” and facial drooping were easy to recognize at their relatives In case of the participant sixth: “he said his hand and leg
Trang 34Reacting to stroke
were numb He asked to take to him a phial of oil”, when she saw his face that was out of shape, “J did not know what was disease”
An example of respondent who met difficulty in recognize stroke symptoms: “In the evening the day before, before sleeping, he said he felt tired In that morning, he had stomached, .thirsty, but drink into, he vomited immediately pain at around his navel”
Confusing to other, she helped him by the way to apply hot compresses with roared bran and mugwort
Not only relative of stroke patient had mistake in realization stroke symptoms, but medical staff, even the doctor in hospital did not know exactly what was happening to their patients The patient, an old woman, when she complained acute pain whole of her body and she vomited, one commute health staff guessed based on own experience “she had problem with her eyes thus she vomited like this” Doctors in district hospital and eyed hospital thought her matter was eyes though she vomited times and her hand, leg became weakly
With some cases, stroke took place and patients’ situation really serious “he was convulsive and made urine without control”, the participant twelfth said In case of the one man, after 20 minutes took an anti-hypertension under tongue and an injection, he appeared drooping his mouth, convulsive and urinate
Reatt to stroke
Cope with stroke happened to the patients, react of the relatives who saw directly or not was diversified With the first participant, she “leaded my husband by my hand to took in the bed” and “found a doctor to inject for him”
“I kept him on the premises, did nothing, I called a taxi took him to hospital immediately” another respondent said
Or the decision for directly hospitalization was from a patient: “he felt
uncomfortable and asked taking him to hospital” Besides, some relatives of stroke
Trang 35OO 6G
Pham Thi Thu Huong patients have first aid like oil massage or used ginseng “help her be senses” Especially, one respondent chose anti-hypertension drug for her husband as experience by herself:
“I have high blood pressure too When seeing him red face, I gave him an anti- hypertension drug that was reddish He lied stable, maybe not difficult in breathing”
One notice action was over half of respondents sought for help from medical staff Some of them said “this is an experienced doctor He had taken care of some situations like this” Opinion of a woman: “find a family doctor to inject, if better, stay at home to treat continuously Otherwise, if worse, we would take him to hospital” When doctor or nurse came, they measured blood pressure After defining high blood pressure, doctor advised the family should take the patients to hospital
However, slight signs sometimes were overlooked In one case, after checking, the doctor said that “no matter for him, not need any medication also injection” Because at that time, blood pressure of the patient was 130/80mmHg
Some of medical staff took anti-hypertension drug or injection: “the nurse measured, .blood pressure was 270, dripped drug” And the nurse made careful recommendation to the relative “you should keep her still to monitor After 2 hours, if there is not change), take her to hospital” Others took care of patients without explanation the name of medication to their family, “the doctor said injection for emergency” Checking blood pressure one or more times again before patients hospitalization of some ones, they wanted to make sure there was not problem to the patients on the way transportation On the other hand, two doctors advised the stroke patients’ relative should keep him at home to monitor or for treatment Against advising of some medical staff keeping patients at home, their relative took them to hospital “there were some nearby people had the same problem, so we decided to go to hospital”
Trang 36Reacting to stroke
Patients transporting
Unawareness the dangerous of stroke, two families transported the patients by motor: “our son and me took him to district hospital by motor”, “I called a hug motorbike” Most cases came to hospital by taxi One respondent told his own experience:
“T called 115 service but they did not come, although I waited for a long
time”
Perhaps to prevent the children’s kidding, this service does not answer to calling from a cellphone and not all of citizen know this rule
Emergency department admission
Data related to the time of symptom onset and emergency department admission were available for 19 patients (one participant was unable to pinpoint the time of symptom onset- stroke happened at night) The range of time delay was from 4 to 120 hours Delay was then categorized into less than 2 hours or greater than 2 hours, for the purposes of statistical analyses One participant was unable to identify the time of symptom onset, but he clearly identified that their delay was longer than 2 hours; therefore, data from all 20 patients could be used in analyses These findings support the need for the development of literature for relatives as the delay in seeking medical help has to be a cause for concern, and will affected the treatment and recovery of the patient
There were a lot of things contributing to delay patients hospitalization Beside difficulties in recognition stroke symptoms, respondents met the obstacle from other members in their family: “they said even if took him to hospital, he could not recover” Similarly to other families: “recently, a lot of elderly people who were living near my house had a stroke They were been on first aid before taking to hospital” In addition, to the woman in a family, when the Tet holiday came, she must prepare numerous of things for all “at the end of the year, Tet was coming, Ido not want to take him yet” Moreover, the financial issue is also a problem for poor
Trang 37Pham Thi Thu Huong people before deciding hospitalization In case out of health insurance cover, she did not want to be admitted to the hospital: “she worried about the money” because in her house, there was only two women living together One more difficulty for people to react to stroke was long distance from their home to hospital: “from my house to district hospital is 10 km” With the fifteenth participant, distance was 32km_ for “ took her to province hospital directly” In their mind, at the bigger hospital, “the machine and equipment are more modern” At this time, in Vietnam, CT scan and MRI machines are only available in big hospital
Not only delay outside the hospital, the treatment of the patients was postponed in the hospital On the way came to hospital, the patient vomited and it had alcohol smell, “at dinner, he drank a tiny teacup of wine” At the hospital, “they suspected the reason was wine” and kept him to monitor instead of caring him as a emergency though stroke signs were rather clear Even patient was transferred through two hospitals, but her disease was not defined and she lost two days be
treated for stroke
In Vietnam, for those living in rural area, it is not easy to access the health care system, as one relative of a male stroke patient, the daughter-in-law told in tears:
“three days before, he was very quiet and seemingly sad The day before, I saw his hand quivered, I intended to ask my husband take him to hospital However, on Sunday, at 5pm, he fell down at the edge of our farm Entered home, he still understood when we called but has a slurring in speech and facial drooping At that moment, he could not move on his foot himself My husband and I tried to find out some pharmacies where I could tell them what happened to my father-in-law, hopefully they would sell us the needed medications Unfortunately, we couldn’t I also found the doctor or nurse, but it’s too late (11h pm), so they did not want to go to see my father, they told us take him to hospital but our relative did not agree with this, they were afraid of the brain vessels would be broken on the way arrived hospital This is a probably legitimate reason because the distance from my house to province hospital is about 10km with only bumpy road, so we decided to wait at home till next morning”
One typical example of the delay time in seeking help, from warning signs to stroke symptoms became more serious, the respondent had lost 4 days to help his
Trang 38st ee
Reacting to stroke
mother A 32 year old man an accountant with certificate of secondary level, the knowledge about stroke was really limited
“five days before, in late afternoon, she complained about headache
Her mouth was not normal, but her eating of her was not influenced There was change in her voice, in general, was not fluently In addition, one of her hand and leg were numb and weak However, these signs last only in the afternoon, they totally disappeared next morning”
The appearance of these symptoms in the Tuesday (the next day) and two days after, prolong 7 to 10 hours each day, made the family worried As the patient’ son said, several years ago, his mother had a vertigo, she got better with a kind of traditional herb In the third day, when the situation of the woman got worse, (she still was able to walk by herself), he also thought these were vestibule disorder symptoms, so he found help from a traditional medical doctor Contrary to their hope, the doctor did not give acupuncture to the patient after checking her Until his mother vomit repeatedly and could not speak any more, he decided to take her to hospital
In contrast to these difficulties in accessing the health care system of the women in the first case, other participant experienced what are considered to be classic stroke symptoms but did not immediately seek medical help A male participant reported
“after lunch, my father felt his hand and leg weighty He had a sensation of numbness on his hand and difficult in waking He went to bed and had the feeling of dizziness as seasick At that time, there was change in his voice J though these were symptoms of stroke but not serious I roasted bran, absinth and duckweed to apply compresses for him Around 3pm, I called a medical staff, he took blood pressure (220/90 mmHg) for him and put him ona tablet After 3 hours, he checked blood pressure again, I remembered 170 mmHg approximately Next morning, when he complained of more numbness, we took him to emergency department by taxi.”
The findings about natural remedies was not unusual with participants hoping
that the remedies would be sufficient to resolve problems However, it also revealed that in some instances like the last one above, even where professionals were
consulted they did not always see the need of urgent transfer to hospital Therefore
Trang 39Pham Thi Thu Huong the provision of a leaflet to not only relatives but also for the nurses to be used as the basis of education for this group
Participants were asked for thinking about the long term outcome of stroke as expenditures, communicative relationship, work or fear, the most common senses were worry and nervousness as the following comments illustrated:
“This is not a simple disease, one-two days, to prolong to cold feet.” ““ We must take care of him untill to the day he dead.”
One women reported
“.afraid of the loneliness after he goes away”
Others gave examples of the fear that the patient would no longer be able to work, particularly for those living in rural areas:
“ stay in hospital one week, the result from cultivating one hectare is empty.” This example illustrates that the problems extend beyond the patient, with attendance for care needed at the hospital two people are unable to work, both the patient and the career There are long term potential problems with this, fields left uncultivated mean loss of income for the whole family, so increasing the financial burden for the whole family that arises following a stroke
Trang 40Reacting to stroke
CHAPTER 5: DISCUSSION
5.1 Knowledge about strokes
Although some of respondents defined brain as the affected organ in stroke, the explanation about mechanism and cause of stroke was very limit None of them could give any information about common kinds of stroke The difference between ischemic stroke and hemorrhage stroke is a complex issue, not of all can understand particularly, even among medical staff
The most common warming symptoms identified by family members in my study was weakness or numbness The rate of respondents who mentioned weakness of one side of the body as a symptom of stroke was comparable with other studies from Northwest India (J D Pandian, et al., 2005) and Michigan (Reeves, et al.,
2002) However, it not always happen Sometimes, stroke appears with the
imbalance in standing or the serious headache, even only dropping on the face These signs are ignored or confused easily to others diseases for people without stroke knowledge According to recommendation from Stroke Associations, stroke happens when patients have experience with one of five symptoms (Appendix B), that more simple for people to remember and define a stroke
The proportion of subjects who named hypertension as a risk factor was similar to observations from Cincinnati, Ohio (49%), Australia (31.8%), and Michigan (32.3%) (Pancioli, et al., 1998; Reeves, et al., 2002; Sug Y S, Heller RF, Levi C, Wiggers J, & PE, 2001) Can be seen that the rate of respondents who had positive answers for other risk factors, such as diabetes, smoking, and high cholesterol, were much lower as compared with other studies (Pancioli, et al., 1998; Parahoo K, et al., 2003; Reeves, et al., 2002; Sug Y S, et al., 2001) Only one participant believed heart disease was reason for stroke though they were treated in Cardiovascular department Just explain for the result is there was lacking in transmitting information about stroke from medical staff One notice point from the result of the research, although all of patients and a half of respondents were elderly, they rarely know that old age is one of risk factor for stroke