Dorien Brouwer

82 Chapter 1.4 PART 1 Discussion In this study we found that fear significantly decreases during three months after TIA or ischemic stroke. Patients with TIA or ischemic stroke have high self-efficacy and response efficacy scores for health-related behavior change and these do not vary over time. This suggests that confidence in changing health behavior capacities and the believe that this change can prevent a new stroke are still high at three months. However, fear decreased after three months suggesting that the best time to start the intervention may be directly after the stroke or TIA and at least within three months. To the best of our knowledge, this is the first study that focusses on changes in determinants of health-related behavior change after TIA or ischemic stroke. Self-efficacy has been studied before in patients with vascular disease (coronary heart disease, cerebrovascular disease or peripheral artery disease). [23, 25] In those studies, comparably high self-efficacy levels were found, but the self-efficacy was not monitored over time. Response efficacy for behavior change has not been described in patients with TIA or ischemic stroke before. Fear seems moderate (with a median of 16 on a scale of 32) and decreased strongly within 3 months after stroke or TIA. Fear started to decrease after six weeks. During this period, patients often undergo additional examinations to assess the underlying etiology at different medical specialists. This might lead to uncertainty and fear. Possibly patients also adopt to the uncertainty, which lowers the fear. We could not compare our findings with those of others as fear in relation to behavior change has not been studied quantitatively or in patients with TIA or stroke before. Fear of a recurrent stroke has been found in several other studies. [28-30] and this can possibly be used as an opportunity to motivate patients to change their health-related behavior in order to reduce risk of recurrence. [21] In two small studies with stroke patients fear was mentioned by patients as a motivating factor to change health behavior. [10, 28] . Previous studies in patients with coronary artery syndrome have shown that the majority of patients who quit smoking successfully stopped immediately after the event. [31] Perceived feeling of a life-threatening disease seems to play a role in this process. [32] The European Society of Cardiology (ESC) guidelines recommend to seize this opportunity by addressing the issue of smoking before discharge. [33] These guidelines also recommend that support for cessation of smoking is initiated for all smokers during hospital admission and is continued for a prolonged period after discharge. Although there is no evidence for this approach in stroke patients, it seems reasonable to assume that this advice can also be effective after ischemic stroke or TIA. Strengths of our study are that it is the first to focus on determinants of health behavior change after TIA or ischemic stroke over time. Also, we collected detailed information