Dorien Brouwer

132 complicated, but also provides opportunities for influencing self-efficacy. Self-management approaches may help to increase self-efficacy for health-related behavior change after TIA or ischemic stroke. However, at present there is a lack of large studies on this subject. Self-efficacy is clearly not the only determinant of health-related behavior change after TIA or ischemic stroke. As the PMT states, coping is needed when a threat is experienced. We therefore added the determinant fear (threat) to the model because we expected it to play a role in health-related behavior change after TIA or ischemic stroke. Fear is often spontaneously reported by patients during regular follow up visit at the outpatient clinic. A meta-analysis of fear studied in different populations and different behaviors showed a significant interaction between threat (fear) and efficacy. [7] In these studies threat only had a motivating effect when high efficacy is present while fear was independently associated with intention to change in our study. Possibly, fear can be counterproductive and can lead to avoidance or denial-based forms of coping which explains the association with low self-efficacy. Response efficacy played a role in health-related behavior change as well. It seems to be a plausible determinant as behavior change is hard to accomplish and patients are only willing to change when they believe that this helps to reduce the risk of new vascular events. In my opinion, response efficacy could be influenced by increasing knowledge about the risk of recurrence and unhealthy behavior. We showed that stroke patients understand what constitutes healthy behavior but seem unable to adequately appraise their own health-related behavior. This finding is in my view very important for daily practice. When patients lack knowledge of risk factors for behavior change strategies one cannot expect them to adequately evaluate their own health-related behavior and to be highly motivated to change. Another possible reason for this inadequate judgement of health-related behavior can be denial. When patients experience anxiety, minimizing the unhealthy behavior and denying the effects of this behavior can be a way to reduce anxiety. As self-efficacy is developed by social persuasion, [8, 9] I expected social support to play a role in building self-efficacy for behavior change after TIA or ischemic stroke as well. However, we found no relation between social support and self-efficacy in the quantitative study. In contrast, in our qualitative study, besides knowledge, social support was indicated as most needed to change behavior. Possibly social support influences self-management in a different way than by improving self-efficacy. It seems plausible that social support influences the motivation to change as it is very hard to accomplish behavior change on your own. In line with this finding social support and knowledge has been found as important factors for changing health-related behavior after stroke in many other studies. [10-17]