Dorien Brouwer

Interventions for health-related behavior change At present, only limited and inconsistent data are available on interventions to support patients in health-related behavior change after TIA or ischemic stroke [23,24] . The existing interventions vary from personal education, exercise or lifestyle classes, to motivational counseling (not specified), telephone support, home visits and interviews. [25] The heterogeneity in the applied interventions with regard to content, intensity, type of behavior and durationmakes it difficult to compare these studies. [23] Furthermore, follow-up rates are often short and patients often have physical barriers such as fatigue or pain, lack of knowledge, absent or inadequate social support, and cognitive problems whichmay also affect behavior. [26-30] One of the conclusions based on present knowledge is that the majority of people with cardiovascular disease fail to sustain lifestyle modification in the long-term. [31, 32] Aims and outline of the thesis The aim of my thesis was to study health-related behavior change after TIA or ischemic stroke. It consists of two parts. The first step towards developing a successful intervention is to unravel factors that play a role in the behavior change process after TIA or ischemic stroke. This provides insight into the mechanism of behavioral change in this group and thereby direction on components that the intervention should contain. Therefore, Part 1 of my research focuses on determinants of lifestyle behavior change after TIA or stroke. To gain insight in the process of lifestyle behavior change, we assessed determinants of intention to change health- related behavior and actual change based on the ProtectionMotivation Theory. I describe this study in Chapter 1.1. In this quantitative study, we were unable to examine patients’ subjective perspective of health behavior. We therefore performed a qualitative study with in-depth, semi-structured interviews of patients’ personal experience and view on health behavior change after TIA or ischemic stroke. This study is described in Chapter 1.2. As self-efficacy may play an important role in health-related behavior change, Chapter 1.3 focuses on self-efficacy for health-related behavior change. This part ends with Chapter 1.4 in which I describe the determinants of intention to change health-related behavior over time in order to examine the optimal timing of an intervention to support patients in behavior change. Part 2 focuses on studies supporting patients in health-related behavior change. In Chapter 2.1 I review health education in patients with a TIA or ischemic stroke patients and the effects aiming at feasibility, effectiveness at the level of knowledge, attitude and skills, health behavior changes and stroke outcome. After the assessment of determinants of health-related behavior change, we developed an intervention that we subsequently studied in a randomized clinical trial. Whether motivational interviewing is an effective intervention in supporting patients in health-related behavior change is described in Chapter 2.2. In Chapter 3 and 4, I present a general discussion and a summary of the results presented in this thesis.