Dorien Brouwer

30 PART 1 Chapter 1.1 high fear and intention to increase physical activity after 6 months. [29] Response efficacy was associated with intention to change health behavior in persons at risk of stroke and predicted increase in physical activity in two studies with cardiac patients. [42-44] Similar to our findings intention to change was the key predictor for health-related behavior change in myocardial infarction. [40] In all these studies, self-efficacy appeared to be an important precondition for intention and actual health-behavior change. Self-efficacy has also been identified as the most common and most reliable predictor of exercise in the quantitative literature in a review focusing on psychological factors in uptake and maintenance of physical activity after stroke. [45] The Protection Motivation Theory has also been studied in relation to dietary behavior in patients with coronary artery disease or myocardial infarction in four studies. [29, 40, 42, 43] In line with our study, these four studies found that self-efficacy was an important determinant of behavior intention. In one study fear had an inverse effect on intention to adapt a healthy diet at six months in contrast to our study. [29] To the best of our knowledge, this is the first study that focuses on the determinants of intention to change and actual change in health-related behavior after TIA or ischemic stroke with the Protection Motivation Theory. A few studies explored determinants of health-related behavior in stroke patients based on the Health Belief Model [45] . One study with 42 patients with TIA or stroke showed that stroke seriousness and severity were the most predictive beliefs of behavior change. However, these beliefs were not independently associated with health-related behavior change [46] . Strenghts of our study are that we collected detailed information on potential determinants of intention to change health-related behavior and patient characteristics. Also, this is one of the few studies that focuses on the determinants of actual change in health-related behavior after TIA and ischemic stroke. Our study also has some limitations. First, it was not designed to change health-related behavior, and as a result only a few patients changed their health-related behavior. Therefore, we were not able to assess determinants of actual health-related change. This might partly explain why we only found a trend towards increased health-related behavior in patients with higher intention to change. However, previous studies have shown a gap between intention and actual change in health-related behavior as well. [47] In our study, intention to change predicted 20% of physical activity and dietary behavior change, comparable with previous studies. In a post intentional phase, various factors can compromise or facilitate the translation of intentions into actions. Some of these factors have been identified, such as maintenance of self-efficacy and recovery of self-efficacy as well as action planning and coping planning [48] . Nevertheless much of the behavioral change processes are still unknown.