According to the statistics from Department of Health, Executive Yuan, in 2007,brain attack has been listed as the third of the top ten reasons for death. In Taiwan, the occurrence rate of brain attack on population above 35-year-old is 3/1000. And the total amount of population above 35-year-old is nearly 10,000,000. Then the latest number of occurrence of brain attack is approximately 30,000¡COnce the stroke happens, under such a circumstance, not only the expense of acute care increases but also the long-term medical care expense, the family and social cost will become larger. In view of that, the long-term care plan for stroke patient has been in urgent need. This research, ¡¨Long-distance Community Health Care Nursing Service for Stroke Patients¡¨, which is originated from a plan conducted by a medical center in Southern Taiwan. Based on Andersen¡¦s¡]1968¡^health behavior model as the theoretical structure¡Awe studied 102 patients who had a stroke (including high stroke risk patients)within one year in Kaohsiung. In this study, we applied JMP V6.0¡]SAS Institute, Cary, NC, USA¡^to analyzing case characters¡Aconducting univariate analysis by £q2 analysis and ANOVA. Then we applied multivariate logistic regression analyses to significant variables. We hope to find out the predisposition, enabling factors and need factor from those important predictor variables in ¡§Long-distance Community Health Care and Nursing Service¡¨. We research the differences of stroke patients¡¦ behaviors, providing those research results as the reference materials for related business promotional strategy in future, hoping to advance the quality of long-term care and nursing for stroke patients. In this study, total 102 copies of the questionnaire were sent out and returned, with a return rate of 100%, and 100 copies of questionnaire were effective. The research results show that: 1. Predisposition¡GThere are significant differences on these items--¡§Number of Children¡¨(Demography), ¡§Buddhist¡¨(Religion) and ¡§Those who have a health check within nearly one year¡¨(Health Concept). 2.Enabling factors¡GThere are significant differences on these items--¡¨Monthly Family Income¡¨(Economical factor),¡¨Monthly Balance of Payment¡¨(Economical factor) and ¡§Commercial Insurance¡¨(Insurance resource). 3.Need factors¡GPeople (those who think their health state stay at the average level), Health State (¡§High Blood Pressure and Heart Attack¡¨,¡¨Eye Diseases¡¨, ¡¨Cancer¡¨,¡¨Bone and Muscle¡¨,¡¨Asthma¡¨,¡¨Ears Disease¡¨and ¡¨Neural Diseases¡¨are involved. The behavior research includes ¡§Number of Accepting Medical Treatment per month¡¨(1 to 2 times), ¡§Activity in Daily Life ¡¨¡]ADL¡BIADL-Shopping Ability¡^and ¡§Functional Behaviors¡¨. 4. To sum up, the predisposition, enabling and need factors in this research could partially influence using behaviors¡Ain accordance with Andersen¡¦s inference in health behavior model. In conclusion¡G1.¡¨Long-term Community Health Care and Nursing¡¨ can be applied to stroke patients, which can help patients to build up effective self-management and advance life quality; 2. This service combines Medical Service Chain established by Information-Telegraphic Technology. Currently, blood pressure checking and telephone consultation are most popular service among interviewees, and other kinds of service are under development; 3. Stroke patients with different demographical characters show a great difference on using behaviors; 4. To speak briefly, this service can meet the ideal long-term care and nursing standard for local aging population.

La scoliose idiopathique de l’adolescent (SIA) est le type de déformation musculosquelettique le plus fréquent dans la population pédiatrique, pour une prévalence d’environ 2,0%. Depuis l’arrêt des programmes scolaires de dépistage de la SIA dans les années 1980 au Canada, nous ne disposions d’aucune donnée sur l’utilisation des services de santé par les patients présentant une SIA suspectée. En l’absence de tels programmes, des changements dans les patrons d’utilisation des services spécialisés d’orthopédie pédiatrique sont anticipés. La thèse a donc pour but d’étudier la pertinence de la référence dans ces services des jeunes avec SIA suspectée. Elle est structurée autour de trois principaux objectifs. 1) Valider un instrument de mesure de la morbidité perçue (perception des symptômes) dans la clientèle d’orthopédie pédiatrique; 2) Étudier la relation entre la morbidité perçue par les profanes (le jeune et le parent) et la morbidité objectivée par les experts; 3) Caractériser les itinéraires de soins des patients avec SIA suspectée, de façon à en élaborer une taxonomie et à analyser les relations entre ceux-ci et la pertinence de la référence. En 2006-2007, une vaste enquête a été réalisée dans les cinq cliniques d’orthopédie pédiatrique du Sud-Ouest du Québec : 831 patients référés ont été recrutés. Ils furent classés selon des critères de pertinence de la référence (inappropriée, appropriée ou tardive) définis en fonction de l’amplitude de la courbe rachidienne et de la maturité squelettique à cette première visite. La morbidité perçue par les profanes a été opérationnalisée par la gravité, l’urgence, les douleurs, l’impact sur l’image de soi et la santé générale. L’ensemble des consultations médicales et paramédicales effectuées en amont de la consultation en orthopédie pédiatrique a été documenté par questionnaire auprès des familles. En s’appuyant sur le Modèle comportemental de l’utilisation des services d’Andersen, les facteurs (dits de facilitation et de capacité) individuels, relatifs aux professionnels et au système ont été considérés comme variables d’ajustement dans l’étude des relations entre la morbidité perçue ou les itinéraires de soins et la pertinence de la référence. Les principales conclusions de cette étude sont : i) Nous disposons d’instruments fidèles (alpha de Cronbach entre 0,79 et 0,86) et valides (validité de construit, concomitante et capacité discriminante) pour mesurer la perception de la morbidité dans la population adolescente francophone qui consulte en orthopédie pédiatrique; ii) Les profanes jouent un rôle important dans la suspicion de la scoliose (53% des cas) et leur perception de la morbidité est directement associée à la morbidité objectivée par les professionnels; iii) Le case-mix actuel en orthopédie est jugé non optimal en regard de la pertinence de la référence, les mécanismes actuels entraînant un nombre considérable de références inappropriées (38%) et tardives (18%) en soins spécialisés d’orthopédie pédiatrique; iv) Il existe une grande diversité de professionnels par qui sont vus les jeunes avec SIA suspectée ainsi qu’une variabilité des parcours de soins en amont de la consultation en orthopédie, et v) La continuité des soins manifestée dans les itinéraires, notamment via la source régulière de soins de l’enfant, est favorable à la diminution des références tardives (OR=0,32 [0,17-0,59]). Les retombées de cette thèse se veulent des contributions à l’avancement des connaissances et ouvrent sur des propositions d’initiatives de transfert des connaissances auprès des professionnels de la première ligne. De telles initiatives visent la sensibilisation à cette condition de santé et le soutien à la prise de décision de même qu’une meilleure coordination des demandes de consultation pour une référence appropriée et en temps opportun. / Adolescent Idiopathic Scoliosis (AIS) is the type of musculoskeletal deformity most frequently encountered in the pediatric population with a prevalence of approximately 2.0%. Since the Canadian school screening programs were discontinued in the 1980s, data detailing health service utilization or typical reference patterns for patients with suspected AIS are no longer available. Without such programs, changes in the utilization patterns of pediatric orthopedic specialized services are anticipated. The thesis therefore aims to study the appropriateness of referral of youths with suspected AIS. It comprises three main objectives: 1) To validate a measurement tool based on perceived morbidity (perception of the symptoms) in the orthopedic pediatric patient population, 2) To study the relationships between morbidity perceived by lay persons (the young patient and his parent), and the objective morbidity determined by medical professionals, 3) To characterize the healthcare service pathways of suspected AIS cases upstream of their first orthopedic consultation in order to define a taxonomy of the pathways and analyse their relationships with the appropriateness of referral. In 2006-2007, an extensive survey conducted in the five clinics serving southwest Quebec recruited 831 patients. They were categorized using criteria for the appropriateness of referral (inappropriate, appropriate or late) based on the amplitude of the main spinal curve and skeletal maturity at the first visit. Lay perceived morbidity was operationalized according to the seriousness, urgency, pain, self-image and general perceived health. Medical and paramedical visits upstream of the pediatric orthopedic consultation were documented with questionnaires to the families. Based on Andersen’s Health Behavior Model, the individual (facilitating and enabling), professional and systemic factors were considered as control variables in the study of associations between perceived morbidity or healthcare trajectories, and appropriateness of referral. The main conclusions of the thesis are: i) Reliable (Cronbach alpha between 0.79 and 0.86) and valid (construct, concurrent and discriminant validity) measurement tools are available to evaluate the perceived morbidity in the French-speaking adolescent population that consults in pediatric orthopedics, ii) Lay stakeholders play an important role in the suspicion of scoliosis (53% of cases) with their perceived morbidity directly related to the objective morbidity, and therefore associated to the appropriateness of referral, iii) The current orthopedic casemix is considered suboptimal with regards to the appropriateness of referral, and the actual mechanisms for reference are in fact responsible for a large number of inappropriate (38%) and late (18%) referrals to specialized pediatric orthopedic services, iv) Adolescents with suspected AIS consult with a wide range of health specialists resulting in a large variety of healthcare pathways upstream of the orthopedic consultation, and v) Continuity of healthcare services, mainly through a regular source of care for the child, is favourable to a reduction in late referrals (OR=0.32 [0.17-0.59]). This thesis is intended to contribute to the advancement of conceptual, empirical and applied knowledge leading to a series of knowledge translation initiatives targeting primary health care providers. Such initiatives have the potential to increase awareness of the condition, to support decision-making as well as to improve the coordination of consultation requests, thus promoting appropriateness and timeliness of referrals.