Dorien Brouwer

41 Patient perspectives on health-related behavior change PART 1 Background Stroke is the third cause of death and the first cause of disability in developed countries [1] . The incidence of stroke rises with increasing age and is expected to increase further the next years [2] . Transient Ischemic Attacks (TIA’s) can be seen as a warning sign and require urgent evaluation to prevent a stroke. [3] As recurrence rates are high [4] , risk factor and health behavior management is of great importance. Interventions promoting a healthy lifestyle after TIA or ischemic stroke may be an effective way to reduce stroke recurrence and are strongly recommended in many guidelines. [5-7] Recommended lifestyle behaviors to prevent recurrence after TIA or ischemic stroke includes regular physical exercise (more than 30 minutes of moderate or intense activity a day), healthy diet, stop smoking and no excessive use of alcohol. However, at present, only limited and inconsistent data are available on interventions to support patients in health-related behavior change after TIA or ischemic stroke. [8-13] Health-related lifestyle change after ischemic stroke and TIA is difficult to carry out successfully and the majority of people fail to sustain lifestyle modification in the long- term. [14, 15] Patients’ knowledge about risk factors for ischemic stroke or TIA is often poor [16] and even when patients believe that their lifestyle is related to their stroke, they did not change their smoking or excessive alcohol drinking habits. [17] Patients experience physical barriers such as pain, fatigue balance problems or fear of falling. Reported mental barriers include lack of motivation or social support and boredomwhich contributed to persistent smoking. Also environmental barriers like bad weather, bad roads and costs of healthy foods were experienced as barriers for behavior change. [18] The process of behavior change is complex and has been described in several models. Roger’s revised Protection Motivation Theory (PMT) [19] describes cognitive factors that play a role in individual’s motivation to change or not to change health-related behavior. Similar to other models including the Health Belief Model, Theory of Planned Behavior and the Transtheoretical Model, this theory assumes that behavior change is a consequence of behavioral intention to change. An intention to change only develops when a threat is perceived and a coping response is available. We showed that fear of recurrence, self- efficacy (patients confidence to carry out lifestyle behavior) and response efficacy (believe that lifestyle behavior change reduces risk of recurrent ischemic stroke) are determinants of intention to change health behavior after TIA or ischemic stroke. [20] Understanding of patients’ perspectives of these determinants of health-related behavior change after TIA or ischemic stroke can facilitate the development of successful behavior change strategies.