Stroke is the third cause of death and the leading cause of disability in developed countries. The incidence of stroke rises with increasing age and is expected to further increase the next years. After a TIA or ischemic stroke patients have an increased risk of recurrent stroke and other cardiovascular events. Supporting patients in changing health-related behavior after TIA or stroke may be an effective way to reduce stroke recurrence and is recommended in many guidelines. However, the majority of people with cardiovascular disease fail to sustain lifestyle modification in the long-term. At present, only limited and inconsistent data are available on interventions to support patients in health-related behavior change after TIA or ischemic stroke. Follow-up rates are short and patients often have physical barriers such as fatigue or pain, lack of knowledge, absent or inadequate social support, and cognitive problems which may also affect health-related behavior.
This thesis focuses on health-related behavior change after TIA or minor ischemic stroke. In the Introduction, I describe the background and rationale for the research in this thesis. The thesis consists of two parts. The first part focuses on determinants of health-related behavior change after TIA or ischemic stroke. In Chapter 1.1, I studied determinants of intention to change health-related behavior and actual change. In this prospective study, we aimed to identify factors that play a role in the health-related behavior change process after TIA or ischemic stroke. This can be the first step towards developing a successful intervention. In total, 100 patients with TIA or minor ischemic stroke completed question- naires on behavioral intention and socio-cognitive factors from the Protection Motivation Theory including perception of severity, susceptibility, fear, response-efficacy and self- efficacy. Questionnaires on physical activity, diet and smoking were completed at baseline and at 3 months. Self-efficacy, response efficacy and fear were independently associated with behavioral intention, with self-efficacy as the strongest determinant of intention to increase physical activity (aBeta 0.40; 95% CI 0.12–0.71), adapt a healthy diet (aBeta 0.49; 95% CI 0.23–0.75), and quit smoking (aBeta 0.51; 95% CI 0.13–0.88). We found a trend to increased health-related behavior change in patients with higher intention to change. These determinants of intention to change health-related behavior after TIA or ischemic stroke should be taken into account in the development of future interventions promoting health-related behavior change in these group of patients. In Chapter 1.2, I describe a qualitative study of the determinants of health-related behavior change after TIA or ischemic stroke. We aimed to explore patients’ perspectives on health-related behavior change, support in this change and sustaining healthy behavior. Eighteen patients with recent TIA or ischemic stroke underwent in-depth, semi-structured interviews. Interviews addressed barriers, facilitators, knowledge and support of health-related behavior change framed by the Protection Motivation Theory and Transtheoretical Model. This study showed that these patients understand what constitutes a healthy lifestyle, but seem unable to adequately appraise their own health-related behavior. More than half of the patients were satisfied with their lifestyle and felt no urgency to change. In this study, self-efficacy was the most important determinant for health-related behavior change. It was reported by patients both as barrier and facilitator. Most of the patients stated that they did not need support or already received support in changing health behavior. Patients indicated knowledge, guidelines and social support as most needed to facilitate behavior change and to preserve a healthy lifestyle. This study suggests that increasing knowledge on lifestyle risk factors for ischemic stroke and improving self-efficacy may be important targets for lifestyle interventions after ischemic stroke. As self-efficacy appeared to play an important role we aimed to describe levels of self-efficacy of health-related behavior change and identify correlates of self-efficacy in patients with ischemic stroke or TIA. This study is described in Chapter 1.3.

See dissertation for the complete summary.