Dorien Brouwer

134 At present the behavior change process after TIA or ischemic stroke is not completely clear. I showed that even when patients had the intention to change and had a high self-efficacy score and fear was present, there was often no actual change. This might be explained by our finding that more than half of the patients were satisfied with their health-related behavior and felt no urgency to change. Previous studies have shown a gap between intention and actual change in health-related behavior as well. [21] Timing of an intervention to support patients in behavior change After assessing the main determinants of health-related behavior change after TIA or ischemic stroke, we focused on the optimal timing of an intervention to support patients in behavior change. We assessed this by studying change of determinants of health- related behavior intention to change over time. Self-efficacy and response-efficacy did not change over time and remained high. However, fear significantly decreased over time. Persistent high self-efficacy over time suggests that patients do not lose their confidence in behavior change when the stroke or TIA occurred longer ago. In a previous systematic review and meta-analysis of interventions focusing on modifiable behavior factors no difference was found between trials starting before or beyond three months after TIA or ischemic stroke. [22] However, since fear does decrease over months there seems to be a window of opportunity to support patients soon after their stroke. Therefore, in my view, an intervention to support patients in changing health-related behavior should start as soon as possible after the TIA or ischemic stroke. Interventions to change health-related behavior after TIA or ischemic stroke We developed an intervention that we subsequently studied in a randomized clinical trial. I was trained in motivational interviewing and experienced positive effects of this approach during my consultations at the outpatient clinic. Motivational interviewing has been proven effective in adopting health-related behavior in patients with chronic diseases as well as in patients with cardiovascular diseases, in particular in supporting weight loss and reducing alcohol and tobacco intake. [23-25] These effects occur when conversations were short and repeated and may persist at least one year after counseling. [26] Therefore, patients in the intervention group received three consults of fifteen minutes at approximately four weeks, eight weeks and three months after inclusion. In our randomized controlled clinical trial motivational interviewing was not more effective in supporting health-related behavior change after TIA or minor ischemic stroke than conventional support. Although no overall effect of motivational interviewing on health-related behavior change could be found, 50% of the patients in the intervention group stopped smoking after three months compared with 33% in the control group suggesting an effect on smoking behavior. This