For patients with multiple vascular risk factors, lifestyle and behaviour change is one way to reduce risk, however risk factor reduction by addressing lifestyle has been shown to be poorly implemented, with discussion of lifestyle recorded in only 37% of consultations in the Royal College of Physicians sentinel audit for stroke (RCP 2004). It is well documented that patients with chronic diseases inconsistently adhere to secondary prevention advice and strategies (Hillen et al 2000, Mouradian et al 2002, Horne et al 2009). Gilham and Endacott (2010) go as far as to suggest there is little stroke-specific evidence to inform the effectiveness of lifestyle change to modify stroke risk factors after first stroke. However, improving adherence to medications does have the potential to have a major impact on cardiovascular disease prevention (Silcock & Standage 2007). In order to understand how to improve patient adherence to secondary prevention strategies it is important to understand more about why patients make decisions to adhere or non-adhere or why they chose not to undertake a lifestyle modification which may have the potential to reduce their risk of recurrent stroke and vascular events.
Several theories of behaviour change were developed in the 1980’s as more sophisticated health promotion programmes were being considered beyond the simplistic transmission of information which failed to succeed beyond affluent, higher socio-economic sections of the populations (Nutbeam 2000). These programmes focused on developing personal and social skills required to make positive health behaviour choices. Examples of theories of behaviour change include, the theory of planned behaviour (Azjen and Fishbein 1980), social learning theory (Bandura 1986) and updated versions of the health belief model (Lewin 1951 cited by Kritsonis 2004, Becker et al 1974,Glanz 2002). Such theories were developed to go some way to explain the complex relationships between knowledge, beliefs and perceived ‘norms’ and provide guidance on how to develop educational programmes to promote
behavioural change in a set of given circumstances. Few theories have been used to specifically study stroke survivors, however, recently the Cerebrovascular Attitudes and Beliefs Scale (CABS) was designed using the Health Belief Model (HBM) as a framework to understand stroke survivors’ perceptions of their risk of future stroke (Sullivan and Waugh 2007). CABS is still in its’ developmental stage and was therefore not used as a measure of stroke-related health behaviour in this thesis, however, following further development and validity testing, the tool will be extremely useful in the development of interventions for stroke prevention in the future. Despite this progress in stroke, interventions which have relied primarily on communication and education have mostly failed to achieve substantial results in terms of closing the gap in health status between different social and economic groups in society (Nutbeam 2000). Other mechanisms used in chronic illnesses include patient self- efficacy, intention to comply with treatment advice, attitudes and motivation. Theories of reasoned action and planned behaviour have also been used to explain variations in medication adherence such as the Beliefs about Medicines questionnaire (Horne et al 1999) which assesses patient’s beliefs about the necessity of prescribed medications for controlling their illness and their concerns about the potential adverse consequences of taking them.
Subjective risk factor perception is an important component of the motivation to change unhealthy life-styles. As far back at the 1970’s there was clear evidence that demographic variables such as socioeconomic status, gender, ethnicity and age affects the extent to which people adopt preventive health behaviours (Rosenstock 1974). However, it also became clear that health education and financed services were not enough to change health behaviours alone and there was another aspect of human psychological behaviour which affected a patient’s likelihood to undertake preventive action and follow medical advice (Sheeran and Abraham 2003). Lewin (1951) described the idea of ‘valence’, that is the rendering of a behaviour as more or less attractive. This lead to the idea that the likelihood of experiencing a health problem, the severity of the consequences of that problem and the perceived benefits of health behaviour in combination with its potential costs could be key beliefs guiding health behaviour (Lewin 1951).
The HBM is a useful framework for understanding the relationships between health beliefs and health behaviour. The model fundamentally focuses on two aspects of
individuals representations of health and health behaviour, threat perception and behaviour evaluation (Sheeran and Abraham 2003). Threat perception depends upon two beliefs, perceived susceptibility to illness or health breakdown and anticipated severity of the consequences of such illness. Behaviour evaluation consists of two distinct sets of beliefs, those concerning the benefits of recommended health behaviour and those concerning the costs or barriers to enacting the behaviour. The perception of these consequences of behaviour is relevant to stroke survivors and may affect their motivation to change lifestyles or adhere to potentially large additions to current medication levels. The model takes individual perceptions and modifying factors and is able to predict likelihood of action (Glanz et al 2002). The HBM (Glanz et al 2002) focuses on attitudes and beliefs of individuals based on the understanding that a person will take a health-related action from core assumptions, if that person; (1) feels that a negative health condition can be avoided, (2) has a positive expectation that by taking a recommended action, he/she will avoid a negative health condition and (3) believes that he/she can successfully take a recommended health action (i.e. s/he can physically take the medication or take physical activity). In order to change, patients need to understand the consequences of the disease and also their behaviours, in order to initiate the suggested change. The HBM suggests ‘risk perception’ is a key element to understanding how a person becomes motivated to change their behaviour (Glanz et al 2008). Prochaska and Velicer’s (1997) Transtheoretical model of health behaviour change was developed to measure a person’s ‘readiness to change’ and used six stages, 1) pre contemplation (no intention to change), 2) contemplation (thinking about making a change), 3) preparation (intending to make a change in the immediate future 4) action (changing the health behaviour), 5) maintenance (working to prevent a relapse back into unhealthy or risky behaviour and 6) termination ( zero temptation and 100% self-efficacy). The Transtheoretical model uses stages of change to integrate processes and principles of change from different theories of intervention. The model, originally used in smoking cessation rapidly expanded to apply to a broad range of health and mental health behaviours (Prochaska & Velicer 1997). Both models have been integral to the development of studies exploring human behaviour. The HBM is used within this thesis for the development of questions and both theories were used during the development and communication of the intervention in the RCT.
The theory of planned behaviour was developed from the theory of reasoned action (Ajzen & Fishbein 1975) which is based upon the relationship between attitudes and behaviour and the principle of compatibility (Ajzen 1988). The main theory is based upon the assertion that each attitude and behaviour has four elements, an action, target, context and time. It is thought that the attitudes and behaviour will be most positive when both are measured at the same time in conjunction with the four elements. Hence any particular behaviour consists of (a) an action or behaviour, (b) performed on or toward a target, (c) in a context, (d) at a time or occasion. For example, a person concerned about oral hygiene (a) brushes (b) their teeth (c) in the bathroom (d) every morning after breakfast. This example illustrates how behaviour can be aggregated over a range of occasions. In the study of health behaviours it is the repeat performance of a single behaviour that is useful in predicting future behaviours (Ajzen 1988). The theory was developed further by adding to the model the concept of perceived behavioural control, which is the individuals perception of the extent to which performance of a behaviour is easy or difficult (Connor & Sparks 2003). This theory would be useful in identifying beliefs and values of health that might be influential in changing attitudes towards secondary prevention which may result in improved adherence to strategies, however there has been criticism that communication strategies alone are ineffective in changing attitudes (Connor & Sparks 2003). However the theory gives a greater understanding of how clearly defining an action or behaviour may be useful in changing behaviours in the long- term. Both models have been used to study behaviours in patients with chronic diseases such as diabetes, heart disease and hypertension, however none have been used to specifically predict stroke survivor’s behaviours (Rhodes et al 2005).
Some researchers believe it is possible to improve risk perception in the general public through the provision of information and through awareness campaigns (Kraywinkel et al 2007). However, the stroke population is complex and may require a more targeted strategy to improve their risk perceptions and adherence. Patient- centred strategies may lead to the identification of better tools to improve adherence (Schedlbauer et al 2007, Silcock & Standage 2007) while randomized controlled trials have shown specific health behaviour modification interventions can be successful, such as advice to give up smoking (Law et al 1995) and healthy eating in nurse-led CVD follow-up programmes (Wood et al 2008). However, it remains
unclear what aspects of the programmes influence behaviour besides the added contact with a health professional.
However, other studies have shown brief interventions have little impact on risk factor control and do not appear to have any long-term benefit (McManus et al 2009), however in the short term it has been suggested that patients feel more satisfied with the information provided to them about stroke disease, risk factors and who to contact in the event of problems, therefore at the very least there is evidence of an improvement in patient experience. Specifically targeted programmes may be beneficial to the stroke population if they are individually designed. Some studies (Sudlow et al 1997, Hillen et al 2003, Van Wijk et al 2005) have shown some association between smoking cessation and specific socio-demographic characteristics of stroke survivors such as younger age and males. However, Sienkiewicz-Jarosz (2009) investigated the relationship between degrees of nicotine dependence and smoking abstinence 3 months after ischaemic stroke in order to explore predictors for smoking abstinence after stroke. This study suggests dependent smokers have greater difficulty quitting smoking due to more withdrawal symptoms and stronger nicotine cravings. This is an important factor in identifying specific prevention programmes for individuals, ensuring physiological assistance is provided for those who we can predict will struggle to make behaviour changes more than others.
Notwithstanding these successes, studies to examine if improvements have been made to long-term management of chronic vascular diseases such as coronary heart disease, diabetes and hypertension with the formal introduction of pay-for- performance targets have shown no improvement in blood pressure, blood glucose or cholesterol control (Crawley et al 2009). Indeed, even improved patient knowledge has failed to guarantee higher levels of adherence supporting the opposite view that poor knowledge does not necessarily lead to low adherence (Silcock and Standage 2007). Studies investigating interventions to improve adherence have been unable to identify advantages in any one type of intervention (Schedlbauer et al 2004, Horne et al 2005). The provision of medically accurate information may improve knowledge but may not improve mood or perceived health status and therefore the patient’s own perspectives about stroke and their recovery. Preliminary studies of additional risk factor advice provision have produced disappointing results for lifestyle change
following stroke (Townend et al 2006). It is therefore an important consideration to include individuals’ prior personal experience, beliefs, fears and perceptions prior to developing an intervention if it is to be successful for long term behavioural change.