Community Stroke Service and Hunter Stroke Service, Community and Aged Care Services,

1. Patient readiness for risk-reduction education and lifestyle change following Transient Ischemic Attack Community Stroke Service and Hunter Stroke Service, Community and Aged Care Services, Greater Newcastle Sector, Hunter New England Local Health District N.Geldens, G.Crowfoot, A.Sweetapple, G.Vyslysel, G.Mason, C.English and H.Janssen

2. Sponsors NSW Health (NSW Health EMC Fellowship) Priority Research Centre for Stroke & Brain Injury University of Newcastle Early Career Researcher Equipment Grant Nancy and Vic Allen Stroke Prevention Grant 2018

3. Community Stroke Team Matilda McIntosh Speech Pathologist 02 49855247 Simone Owen Speech Pathologist 02 49855247 Anjelica Carlos Physiotherapist 02 49855246 Anne Sweetapple Team Leader, Occupational Therapist 02 49855245 Heidi Janssen Physiotherapist 02 49214037 Email HNELHD-CommunityStroke@hnehealth.nsw.gov.au

4. Collaborators – HNE LHD/UoN/HMRI/Planet Fitness • Prof Chris Levi - Director of HNE LHD Research Translation Centre and Stroke Specialist at John Hunter Hospital, HNE LHD • A/Prof Coralie English- Associate Professor in Physiotherapy, University of Newcastle (UoN) and Priority Research Centre for Stroke Rehabilitation and Brain Injury (PRC Stroke Rehab and Brain Injury) • Ms Suzanne Tunny - Manager Connecting Care- HNE LHD • Ms Jennifer Rutherford - Clinical Business Analyst, Clinical Telehealth - HNE LHD • Ms Kathryn Jacobson - Community Health Strategy- HNE LHD • Dr Carlos Garcia-Esperon – Department of Neurology, John Hunter Hospital, HNE LHD and Hunter Medical Research Institute, University of Newcastle, Newcastle, Australia. • Prof Neil Spratt, Associate Professor in Biomedical Science, UoN and PRC Stroke and Brain Injury, UoN, Stroke Specialist at John Hunter Hospital, HNE LHD • Dr Gary Crowfoot, Stroke Nurse Researcher, UoN • Planet Fitness, Lambton NSW • A/Prof Michael Pollack, Director of Hunter Stroke Service (HSS) & Rehabilitation Physician, HNE LHD • Ms Michelle Russell, Stroke Research Nurse, John Hunter Hospital Neurology Department, HNE LHD • A/Prof Andrew Searles, Health Research Economist, Hunter Medical Research Institute (HMRI) School of Medicine and Public Health, Faculty of Health and Medicine, UoN • Professor John Attia, Academic Director, School of Medicine and Public Health, Faculty of Health and Medicine, UoN • Ms Louise-Anne Jordan - Service Manager of the Clinical Stroke Stream – HNE LHD • Mr Jonathan Holt - Senior Manager Community Services Director Allied Health –GNS-CACS, HNE LHD • Ms Derene Anderson - General Manager- GNS-CACS, HNE LHD

5. Background Transient Ischemic Attack (TIA) – symptoms of stroke resolving in 24hrs TIA patients at risk of having another CVE event  ~15% risk within 5 yrs 90% of stroke cases are attributable to potentially modifiable risk factors (lifestyle choices)1 1. O’Donnell- (INTERSTROKE), Lancet 2016; 388:761-75

6. Problem Current management (GP and TIA clinic) • medical mx, investigations, medications + ‘advice’ on lifestyle risk factors • no support to modify lifestyle • little to no education re. TIA vs stroke

7. Evidence – Why we can not not do it! Behaviour change programs • ↓ SBP, ↓ fasting glucose & insulin and ↑HDL1 • ↓ odds of CVEs2 • ↑ physical activity3 Inactivity • 2nd highest modifiable risk attributed to stroke (1st being HTN) 4 • physical activity - independent risk factor5 UNMET NEED • D’Isabella et al. 2017, Clinical Rehabilitation 2017 • Lawrence et al., PLoS One. 2015;10(3) • Faulkner et al. J Stroke Cerebrovasc Dis. 2013;22(8) • O’Donnell et al. - (INTERSTROKE), Lancet 2016; 388:761-75 • National Vascular Disease Prevention Alliance. 2012.

8. Our aims- develop a behaviour change program • based in a community gym • ↑ stroke knowledge (TIA, risk factors & FAST) • Health Behaviour Change Australia approach • identify individual risk factors • ↑ time mod - vigorous physical activity (MVPA) (& sustain it!) ↓ risk of cardiovascular events

9. Aim Explore patient health journeys & experiences with risk-reduction education and lifestyle change following TIA (& mild stroke)

10. Aim (continued) (i) experience of event & associated risk-factor management (ii) knowledge about TIA, recurrent risk & modifiable risk factors (iii) readiness for risk-reduction education & advice, and (iv) willingness to attend a secondary prevention program

11. Methods acute neurovascular clinic (rapid risk clinic- TIA patients) (tertiary referral hospital Hunter New England Local Health District, NSW) single, recorded, semi-structured telephone interview inductive thematic analysis, - ‘data-driven’ approach to thematic analysis Braun & Clarke’s 6-phase approach to thematic analysis (i) familiarisation with the data, (ii) generating initial codes, (iii) searching for themes, (iv) reviewing themes, (v) defining and naming themes, & (vi) producing the report

12. Results

13. Results • “what the hell happened?” • “I mustn’t have been quite ready” • “what should I be doing?” and 4. “we all see it in different ways.”

14. 1. “what the hell happened?” “Just wanting to know what the hell happened, because I’ve never been like that before” (P6) “in limbo . . . just waiting to find out what happened and what’s going to happen . . . no one’s found a cause yet” (P7) “Since then we have certainly researched it a bit online . . . I’d never even heard of a TIA” (P5)

15. 2. “I mustn’t have been quite ready” “They tried to give me a lot of information but . . . it went in my head and out again” (P6) “I probably didn’t take it on board . . . most probably didn’t even hear the words really” (P3) “There was a shortlist of about five or six things . . . a couple that affect me and I can’t even think what they were” (P5) “Anywhere from two days to a week after . . . definitely [would be] in a state of mind and ready to really take it in and sort of understand what you’re being told” (P5) “The fact that all my tests came up clear . . . I didn’t heed the warning” (P3)

16. 3. “what should I be doing?” “I don’t know what else I should be doing . . . where else should I go?” (P10) “When I didn’t hear back I thought . . . everything must be fine” (P9) “…just needs to be more information about strokes, leading up to strokes and post strokes, what to expect and what not to expect, programs to follow” (P3)

17. 4. “we all see it in different ways.” “I think sometimes talking to people is a good idea . . . it’s better than trying to read it yourself as you mightn’t understand half of it . . . we’re all sort of gifted with different things” (P6) …….a need to “get the message across more forceful” (P3)

18. Community based secondary prevention program (location) “It would depend where it’s at and how I could get there” (P4) (time commitment)“I would be interested but I would want to know the timing of it” (P10) (effects) “Not at this stage . . . it would be a different story if I still had on-going effects and a lot more concern”(P5) “I don’t know . . . I’m getting to what they call the old bloke” (P6)

19. Community based secondary prevention program (knowledge) “I sort of wasn’t totally convinced that my TIA was a warning of a stroke . . . I obviously didn’t put much importance on it” (P3) (complexity of trying to get people to change) “I don’t know whatit would have taken for me to switch the light on” (P3)

20. Conclusions – influencing factors • readiness for risk-reduction education & lifestyle change after TIA: • knowledge • perception of their event • social and environmental factors • format, content and timing of education & advice • consider factors in development & delivery of secondary prevention lifestyle interventions

21. S+SLAM-TIA Service change + Supporting Lifestyle and Activity Modification after TIA Evaluating the effectiveness of implementation of a behaviour change program at a service and patient level SLAMMED NSW Health EMC Research Fellowship 2017-2019 HNE LHD Clinical Research Fellowship 2017-2019

22. Non-randomised controlled trial utilising mixed methods Recruited to date control = 17 and intervention =17

23. Study outcomes

24. Contact details Keen to collaborate? Heidi.Janssen@hnehealth.nsw.gov.au @slootal Ph: 02 40420417 PRCSBI @StrokeBrainPRC