Dorien Brouwer

131 GENERAL DISCUSSION In my thesis, I have focused on different aspects of health-related behavior change after TIA or ischemic stroke. Before the start of my PhD project, my work at the outpatient clinic strongly motivated me to optimally support patients in changing health-related behavior after TIA or ischemic stroke. It was unknown which interventions are effective, how an intervention should be designed, to which patients it should be applied and at what time the intervention should be started. It was also unclear how these patients assess their own health-related behavior, which factors in their view facilitate or hamper health-related behavior change, and which support they request for changing health-related behavior. In this chapter, I will discuss the main findings of my studies, some methodological issues and implications for daily practice and future research. Determinants of behavior change after TIA or ischemic stroke The first step towards developing a successful intervention is to identify 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 patient group and thereby direction on components that the intervention should contain. Therefore, the first part of my research focused on determinants of health-related behavior change after TIA or stroke. To gain insight in the process of health-related behavior change, we assessed determinants of intention to change health-related behavior and actual change based on the Protection Motivation Theory. We showed that self-efficacy, response-efficacy, and fear were independently associated with intention to change health-related behavior, with self-efficacy as the strongest determinant. In this quantitative study, we were unable to examine patients’ subjective perspective of health behavior. Therefore, we also 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. In this study self-efficacy also appeared to be the most important determinant of behavior change. Patients mentioned self-efficacy both as barrier and facilitator. This finding that s elf-efficacy seems to play the most important role in health-related behavior change after TIA or ischemic stroke is in line with previous studies with other cardiovascular patients and in general populations [1-4] . Our finding that elderly patients, and those with a vascular history, depressive symptoms, higher BMI, less physical activity and increased fear had lower levels of self-efficacy for health-related behavior change suggests that self-efficacy is influenced by several factors. In contrast with earlier studies with patients with vascular disease (coronary heart disease, cerebrovascular disease or peripheral artery disease), we did not find associations between diabetes and smoking and lower levels of self-efficacy. [5, 6] The variety of factors that influence each other makes the behavior change process