Dorien Brouwer

136 than the information from the patients themselves. Therefore, we were unable to verify the patients’ claims about their health-related behavior. Furthermore, motivational interviewing seemed so promising that we started our RCT before the results of the first study were fully known. As a result, we did not specifically focus on determinants of health-related behavior change after TIA or ischemic stroke in the intervention group. On the other hand, this study provided ample useful information, such as the importance of involvement of nurses in supporting health-related behavior change after TIA or ischemic stroke. In our prospective cohort study and randomized clinical trial, I experienced a high percentage of drop outs (32%). This high drop out rate of patients in secondary prevention programs after TIA or ischemic stroke has also been found in other studies with similar patients. [30] In my qualitative study, the majority of patients felt no need for support or already received support in changing health-related behavior. This possibly explains the high percentage of patients that did not complete the program. Implications for daily practice In daily practice, one could start by paying more attention to the determinants of health- related behavior change after TIA or ischemic stroke. Screening of patients with unhealthy behavior for depression and anxiety to prevent these two factors from negatively influencing the behavior change process can be a first step. Furthermore, patients with depression or anxiety may need more attention in programs supporting health-related behavior changes as these factors should be treated before or during the behavior change process. Fear of a recurrent stroke may be used as an opportunity to motivate patients to change their health-related behavior. It can be discussed during consultation at the outpatient clinic and be related to health-related behavior change. Response efficacy could possibly be affected by increasing knowledge. As patients mentioned knowledge as an important requirement for behavior change they need proper information about risk factors and those with a low motivation deserve more attention and education. Relatives should be involved in interventions to change health-related behavior after TIA or ischemic stroke, by giving them the same information as the patients and making them aware of the importance of social support in the behavior change process. At present, I would not recommend active measurement of the determinants of health-related behavior change in daily practice. In my opinion there is not yet enough evidence for interventions improving self-efficacy or response efficacy for health-related behavior change after TIA or stroke. Future research Future research should focus on interventions modifying the determinants of health- related behavior change after TIA or ischemic stroke. As patients identified knowledge, guidelines and social support as most needed factors to change and to preserve healthy