Dorien Brouwer

133 All determinants have their own influence on behavior change, but also influence each other, which makes the behavior change process more complex. A previous review of stroke survivors’ and family members’ perspectives of lifestyle interventions also found a reciprocal and interrelated nature of social support, knowledge, self-confidence and motivation. [18] Factors can influence behavior change both directly and indirectly. For example, self-efficacy is influenced by fear, and response efficacy can be influenced by knowledge. Some of our results were in line with other studies, like the important role of self-efficacy in behavior change, which had not been studied in patients with TIA or ischemic stroke before. On the other hand, we did not find that stroke severity is a determinant of intention to health-related behavior change, contrary to my expectation that patients who experience disabilities after their stroke in everyday life would be more motivated to change. Although the severity of the ischemic stroke or TIA did not affect the intention to change, some potentially more vulnerable patients were found to have lower self-efficacy. Up to 70% of patients have cognitive impairment after stroke. We expected cognition to influence the behavior change process, as cognition can influence mood, fatigue, activities, strain and eventually life satisfaction of patients after stroke and TIA [19] These cognitive impairments together with the physical disabilities after stroke may hamper health- related behavior change in contrast to patient with other vascular diseases. Surprisingly, in our quantitative study cognition did not influence intention to change. Knowledge on the other hand was identified by patients as the most important factor for behavior change in our qualitative study. I did not expect knowledge to play a prominent role in changing health-related behavior after TIA or ischemic stroke as earlier studies showed that knowledge does not immediately lead to actual change. [20] Possibly, cognition does not directly influence intention, but rather the ability to absorb knowledge of disease, risk factors and a healthy behavior and self-reflection. Stroke and TIA patients therefore did not differ from other vascular patients in that respect. However, in the qualitative study patients did mention physical impairments such as fatigue and pain as barriers for behavior change. Patients also experienced stress and mood problems and environmental barriers including bad weather or mobility problems. These symptoms can also be experienced by patients with other vascular conditions, but the very nature of the neurological impairments, such as muscle weakness, aphasia or coordination disorders, is essentially different. Therefore, I still think that patients after stroke or TIA cannot be supported in health-related behavior change in the same way as other patients with other vascular disorders and deserve a tailored approach that provides due attention to their neurological disabilities.