Motivational interviewing in a nurse-led outpatient clinic to support lifestyle behaviour change after admission to a stroke unit: a randomized controlled trial

AIMS

Modification of health behaviour is an important part of stroke risk management. However, the majority of people with cardiovascular disease fail to sustain lifestyle modification in the long term. We aimed to evaluate the effectiveness of motivational interviewing to encourage lifestyle behaviour changes after transient ischaemic attack (TIA) or minor ischaemic stroke.

METHODS AND RESULTS 

We performed a randomized controlled open-label phase II trial with blinded endpoint assessment. The intervention consisted of three 15-minute visits in 3 months by a motivational interviewing trained nurse practitioner. Patients in the control group received standard consultation after 1 and 3 months by a nurse practitioner. Primary outcome was lifestyle behaviour change, defined as smoking cessation and/or increased physical activity (30 min/day) and/or healthy diet improvement (5 points at the Food Frequency Questionnaire) at 6 months. We adjusted for age and sex with multivariable logistic regression. Between January 2014 and February 2016, we included 136 patients (of whom 68 were assigned to the intervention group). Twenty-five of 55 patients in the intervention group (45%) and 27 of 61 patients in the control group (44%) had changed their lifestyle at 6 months. We found no effect of motivational interviewing on lifestyle behaviour change after 6 months (aOR 0.99; 95% confidence interval: 0.44-2.26).

CONCLUSION 

Our results do not support the effectiveness of motivational interviewing in supporting lifestyle behaviour change after TIA or ischaemic stroke. However, the overall lifestyle behaviour change was high and might be explained by the role of specialized nurses in both groups.

Patient perspectives on health-related behavior change after transient ischemic attack or ischemic stroke

OBJECTIVE

Unhealthy lifestyle is common among patients with ischemic stroke or TIA. Hence, health-related behavior change may be an effective way to reduce stroke recurrence. However, this is often difficult to carry out successfully. We aimed to explore patients' perspectives on health-related behavior change, support in this change, and sustain healthy behavior.

METHODS

We conducted a descriptive qualitative study with in-depth, semistructured interviews in eighteen patients with recent TIA or ischemic stroke. Interviews addressed barriers, facilitators, knowledge, and support of health-related behavior change framed by the protection motivation theory. All interviews were transcribed and thematically analyzed.

RESULTS

Patients seem unable to adequately appraise their own health-related behavior. More than half of the patients were satisfied with their lifestyle and felt no urgency to change. Self-efficacy as coping factor was the most important determinant (both barrier and facilitator). Fear as threat factor was named as facilitator for health-related behavior change by half of the patients. Most of the patients did not need support or already received support in changing health behavior. Patients indicated knowledge, guidelines, and social support as most needed to support and preserve a healthy lifestyle.

CONCLUSION

This study suggests that patients with recent TIA or ischemic stroke often do not have a high intention to change health-related behavior. The results fit well within the framework of the protection motivation theory. As many patients seem unable to adequately appraise their health behaviors, interventions should focus on increasing knowledge of healthy behavior and improving self-efficacy and social support.

The optimal timing of supporting patients in health-related behavior change after TIA or ischemic stroke: a prospective cohort study to determinants of health-related intention to change over time

The optimal timing of an intervention to support health-related behavior after transient ischemic attack (TIA) or ischemic stroke is unknown. We aimed to assess determinants of patients' health-related intention to change over time. We prospectively studied 100 patients with TIA or minor ischemic stroke. Patients completed questionnaires on fear, response-efficacy (belief that lifestyle change reduces risk of recurrent stroke), and self-efficacy (patients' confidence to carry out lifestyle behavior) for behavior change, at baseline, 6 weeks and at 3 months after their TIA or ischemic stroke. We studied differences between these determinants at each visit by means of Wilcoxon signed-rank tests. Median self-efficacy score at baseline was 4.3 [interquartile range (IQ) 3.9-4.7], median fear 16 (IQ 7-21), and response-efficacy 10 (9-12). Fear was significantly higher at baseline than at 3 months (mean difference 2.0; 95% confidence interval: 0.78-3.9) and started to decrease after 6 weeks. No change in self-efficacy or response-efficacy was found. Since fear significantly decreased over time after TIA or ischemic stroke and self-efficacy and response-efficacy scores remained high, the optimal moment to start an intervention to support patients in health-related behavior change after TIA or ischemic stroke seems directly after the stroke or TIA.

Determinants of intention to change health-related behavior and actual change in patients with TIA or minor ischemic stroke

OBJECTIVE

To assess determinants of intention to change health-related behavior and actual change in patients with TIA or ischemic stroke.

METHODS

In this prospective cohort study, 100 patients with TIA or minor ischemic stroke completed questionnaires on behavioral intention and sociocognitive factors including perception of severity, susceptibility, fear, response-efficacy and self-efficacy at baseline. Questionnaires on physical activity, diet and smoking were completed at baseline and at 3 months. Associations between sociocognitive factors and behavioral intention and actual change were studied with multivariable linear and logistic regression.

RESULTS

Self-efficacy, response efficacy, and fear were independently associated with behavioral intention, with self-efficacy as the strongest determinant of intention to increase physical activity (aBeta 0.40; 95% CI 0.12-0.71), adapt a healthy diet (aBeta 0.49; 95% CI 0.23-0.75), and quit smoking (aBeta 0.51; 95% CI 0.13-0.88). Intention to change tended to be associated with actual health-related behavior change.

CONCLUSION

Self-efficacy, fear, and response-efficacy were determinants of intention to change health-related behavior after TIA or ischemic stroke.

PRACTICE IMPLICATIONS

These determinants of intention to change health-related behavior after TIA or ischemic stroke should be taken into account in the development of future interventions promoting health-related behavior change in these group of patients.

Health education in patients with a recent stroke or transient ischaemic attack: a comprehensive review

Health education aims at the acquisition of skills and attitudes to modify behaviour that influences health, leads to a modification of risk factors and ultimately to a decrease in disability and case fatality from stroke. Health education is an underdeveloped but important aspect of stroke care. Health education could promote compliance and healthy behaviour, improve patients' understanding of their health status and treatment options and facilitate communication. We reviewed the effect of health education in stroke and transient ischaemic attack patients, aiming at feasibility, effectiveness at the level of knowledge, attitude and skills, health behaviour changes and stroke outcome. We also describe the current status of health education for patients with recent coronary artery disease and public health education in stroke. Basic knowledge of stroke and transient ischaemic attack patients of their disease and associated risk factors is not sufficient. This is also observed in patients with coronary artery disease and in the general population. A beneficial effect of health education in stroke and transient ischaemic attack patients on health behaviour, risk reduction or stroke outcome has not been proven. Trials in patients with coronary artery disease, however, have shown that health education could result in a change of lifestyle. No specific method is superior, although the individualised, repetitive and active methods appear more successful. More intervention studies of health education in stroke and transient ischaemic attack patients are needed. Future trials should be large, have a long follow-up, should use an intensive and repetitive approach and involve patients' relatives to induce and maintain a healthy lifestyle.