Dorien Brouwer

INTRODUCTION “How can we support patients in changing their lifestyle after a TIA or minor ischemic stroke?” My PhD project started with this question. Each year over 400 patients visit our outpatient clinic after a transient ischemic attack (TIA) or ischemic stroke. As neurovascular nurse practitioner I want to be able to reduce the risk of recurrent stroke or TIA not only by prescribing medication, but also by promoting health-related behavior. During the past fifteen years I have done my best to optimally support these patients, but at times have experienced a sense of powerlessness in guiding the patients to adopt more healthy behavior. It has struck me that some patients quit smoking immediately whereas others tell me “that the stroke isn’t bad enough to stop smoking”. Which factors play a role and how can the nurse practitioner support patients in this process? As very little was known about factors that played a role, effective interventions and the optimal timing of an intervention, I decided to study health-related behavior change after TIA or ischemic stroke. Health-related behavior change after stroke Stroke is the third cause of death and the leading cause of disability in developed countries. [1] The incidence of stroke rises with increasing age and is expected to increase further the next years. [2] After a TIA or ischemic stroke patients have an increased risk of recurrent stroke and other cardiovascular events. [3, 4] Risk factors for recurrent cardiovascular events can be classified into three major groups: non-modifiable risk factors such as age, sex, ethnicity, and family history; medically modifiable risk factors including hypertension, hyperlipidemia, and diabetes and behaviorally modifiable risk factors like cigarette smoking, physical activity and diet. [5] In patients with coronary artery disease, the benefits of lifestyle management on vascular risk factors as well as the risk of vascular death and myocardial infarction have been demonstrated. [6-8] However, the majority of these patients failed to sustain health-related behavior change in the long-term. 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. [9-11] Models for behavior change The process of behavior change is complex and has been described in several models. I used two of these models in my thesis. The first is Roger’s revised Protection Motivation Theory (PMT) [12] that describes socio-cognitive factors that play a role in individuals’ motivation to change or not to change their health-related behavior (Fig. 1). The PMT has shown to be an useful model for predicting health-protective intentions and behavior changes in