Understanding Treatment-Seeking Decisions in Acute Stroke Survivors in Thailand

Background: Many Thai stroke patients are ineligible for reperfusion treatment due to prolonged prehospital delay. Decision delay mainly influences prehospital delay; yet, factors affecting this phase have not been fully explored. Despite the possibility of bystander’s involvement, prior studies have mostly excluded bystanders. Objectives: This study aimed to examine influencing factors of decision delay and to explore the impact of bystanders on treatment-seeking decisions after stroke symptoms. Methods: Based on Leventhal's Common-Sense Model, this cross-sectional correlational study recruited 170 acute stroke patients and 108 bystanders at three hospitals in Khon Kaen, Thailand. Patients and bystanders were interviewed using structural questionnaires with integrating open-ended and verbatim responses. The patient's clinical data were obtained from medical records. Data was analyzed by using descriptive statistics, content analysis, gamma regression, and logistic regression. Results: Treatment-seeking decisions in Thai acute stroke patients included 5 phases (pre-recognition, decision, waiting, transportation, and referral). The median prehospital delay and decision delay were 372 minutes and 120 minutes, respectively. Dyslipidemia, atrial fibrillation, and prior stroke knowledge influenced a short decision delay; whereas, the alternative behaviors of the bystanders and patients rather than seeking treatment were related to the prolonged decision delay. Of 170 patients, 41% had early decision (≤ 1 hour), and 42% had early prehospital time (≤ 4.5 hours). The primary decision-makers included the patients (29%), bystanders (49%), and joint decisions between them (22%), which were insignificantly related to both decision and prehospital delay times. The determinants of the bystanders as primary decision-makers were hemorrhagic stroke, speech problems, advanced age, and low prior stroke knowledge. As a parallel to the patients' factors, only the bystander's action was a strong predictor of a decision within 1 hour and prehospital delay within 4.5 hours. Conclusion: This study confirms decision delay as the primary contributor to prehospital delay and bystanders as the vital persons of treatment-seeking decisions for acute stroke patients. There is a need for a public stroke intervention addressing significant relatives as bystanders. Prospective research should be further conducted in high-risk stroke cases.