Identifying mediators of healthy lifestyle adoption after stroke: a focus group study using a Theoretical Domains Framework guided analysis.

Abstract

Background: Lifestyle measures in addition to pharmacotherapy are recommended to optimise stroke secondary prevention. Adopting and sustaining good health behaviours after stroke necessitates ongoing motivation, influenced by complex social and cultural factors. This study analysed stroke survivors' experiences of addressing their lifestyle-related risks through a comprehensive theoretical lens addressing cognitive, affective, social, and environmental influences. Patient and public involvement (PPI) enhanced the research quality and transparency.

Methods: Eight focus group discussions (N = 35 stroke participants; N = 3 family members/informal carers) were facilitated using semi-structured questions co-developed with a PPI panel. Purposive sampling ensured adequate representation (e.g. urban/rural location and stroke-related disabilities). Data were first coded and categorised inductively and mapped to the Theoretical Domains Framework (TDF) deductively to identify relevant constructs and theories of behaviour-change.

Results: Participants reported risk reducing lifestyle changes as largely self-directed activities they figured out themselves. Their experiences mapped to 10 of the 14 theoretical domains of the TDF. The most reported behaviour-change mediators discussed were in the domains of Knowledge and Social Influences, seen as encouraging change and supporting emotional reactions. Goals were discussed in a limited way indicating underutilisation. Reminders, reinforcements, and rules to observe for maintaining healthy behaviours, mapping to the Reinforcement and Behavioural Regulation domains, were valued constructs. Psychosocial challenges, emotional responses and cognitive difficulties (Memory, Attention & Decision Processes and Emotions domains) were strongly evident, resonating with the experiences of our PPI contributor and interfacing with behaviour change processes and knowledge uptake. Health-beliefs, self-identity and perceived ability to change behaviour were considered to assert both positive and negative influences on behaviours, mapping to Social/Professional Role & Identity, Beliefs about Consequences and Beliefs about Capabilities domains. 'Know how' was highlighted as largely lacking for behaviour change, with the associated theoretical domains Intentions, Skills, Environmental context & resources to encourage skills development and Optimism about change notably absent from discussions.

Conclusions: The TDF proved a valuable tool to link stroke survivors' secondary prevention experiences and unmet needs with recognised constructs for behaviour-change. Results have important theory-driven implications to guide future interventions designed to support individuals in risk reducing behaviours following stroke.