Motivational interviewing in health care settings. Opportunities and limitations

A low-cost, sustainable intervention for drinking reduction in the HIV primary care setting

Excess drinking poses multiple substantial health risks to HIV-infected individuals. However, no published intervention studies have focused on drinking reduction as the main outcome in HIV primary care patients. An intervention in this setting must place minimal demands on pressured staff and resources. This pilot study tested such an intervention, which consisted of brief Motivational Interviewing (MI) and HealthCall, an automated daily telephone self-monitoring system based on Interactive Voice Response (IVR), designed to extend and enhance the effects of brief MI. Thirty-one patients entered the study, received a 30-minute MI and were instructed in daily use of the IVR system. They received graphical feedback on their daily drinking from the HealthCall database after 30 days. A statistically significant decrease in drinking was found over time, both as reported in daily IVR calls (beta = - 0.01, se 0.01, p=.03) and in follow-up interviews (beta = - 0.04, se 0.12, p=.02) at 60 days. The proportion of daily calls made supported the feasibility of the intervention. The results indicate that HealthCall is acceptable to a disadvantaged HIV patient population, and preliminary data support the efficacy of this intervention in reducing harmful drinking among HIV primary care patients.

The PHLAME (Promoting Healthy Lifestyles: Alternative Models??? Effects) Firefighter Study: Outcomes of Two Models of Behavior Change

OBJECTIVE

PHLAME's (Promoting Healthy Lifestyles: Alternative Models' Effects) objective was to assess and compare two means to promote healthy lifestyles.

METHODS

Prospective trial among 599 firefighters randomized by station to 1) team-centered curriculum, 2) one-on-one motivational interviewing (MI), and 3) controls. Assessment included dietary behavior, physical activity, weight, and general well-being at baseline and 12 months. Program effects were determined using an analysis of covariance (ANCOVA) based approach, and models for relationships were evaluated with path analysis.

RESULTS

Both interventions were acceptable and delivered with high fidelity. The team and MI programs increased fruit and vegetable consumption (P < 0.01 and 0.05, respectively) and general well-being (P < 0.01). Significantly less weight gain occurred in both (P < 0.05). A cross-sectional model was consistent with mediation differing between interventions.

CONCLUSIONS

Both a team-centered and individual-oriented intervention promoted healthy behaviors. The scripted team curriculum is innovative, exportable, and may enlist influences not accessed with individual formats.

Motivational interviewing for pediatric obesity: Conceptual issues and evidence review

Counseling by health care professionals represents a potentially important intervention for the prevention and treatment of pediatric obesity. One promising approach to weight-control counseling in pediatric practice is motivational interviewing. This article explores conceptual issues related to the application of motivational interviewing for the prevention and treatment of pediatric obesity. Given the paucity of studies on motivational interviewing and pediatric obesity, we examine what is known about the application of motivational interviewing to modify diet, physical activity, and other behaviors in children and adolescents. We begin with a brief overview of motivational interviewing, describe some nuances of applying this approach to pediatric overweight, and conclude with research and clinical recommendations.

Motivational Interviewing to Increase Physical Activity in Long-Term Cancer Survivors

BACKGROUND

Physical activity can confer many benefits on cancer survivors, including relief of persistent symptoms related to cancer treatment.

OBJECTIVES

To evaluate the effect of a motivational interviewing (MI) intervention on increasing physical activity (Community Healthy Activities Model Program for Seniors questionnaire) and improving aerobic fitness (6-minute walk), health (Medical Outcomes Study Short-Form 36), and fatigue (Schwartz Cancer Fatigue Scale) in cancer survivors. A secondary purpose was to evaluate whether the effect of MI on physical activities depended on self-efficacy.

METHODS

Fifty-six physically inactive adult cancer survivors (mean=42 months since completion of treatment) were assigned randomly to intervention and control groups. The MI intervention consisted of one in-person counseling session followed by two MI telephone calls over 6 months. Control group participants received two telephone calls without MI content. Outcomes were measured at baseline, 3 months, and 6 months, and were analyzed using multilevel modeling.

RESULTS

The results of the MI intervention explained significant group differences in regular physical activities (measured in caloric expenditure per week), controlling for time since completion of cancer treatment (p<.05). Aerobic fitness, physical and mental health, and fatigue were not different between groups. In the intervention group, individuals with high self-efficacy for exercise at baseline increased their physical activity more than those with low self-efficacy (p<.05). In the control group, increases in physical activity did not depend on self-efficacy.

DISCUSSION

Use of MI may increase physical activity in long-term cancer survivors, especially in persons with high self-efficacy for exercise. Multilevel modeling analysis revealed individual changes that would not have been shown by analysis of group means. Future studies with larger samples or more intense MI interventions may show changes in aerobic fitness, physical and mental health, and fatigue.

Educating physician assistants as agents in cancer control: issues and opportunities

BACKGROUND

Lifestyle factors (eg, smoking, diet) and compliance with screening recommendations play a role in cancer risk, and emerging technologies (eg, new vaccines, genetic testing) hold promise for improved risk management.

METHODS

However, optimal outcomes from cancer control efforts require better preparation of health professionals in risk assessment, risk communication, and implementing health behavioral change strategies that are vitally important to cancer control.

RESULTS AND CONCLUSION

Although physician assistants (PAs) are substantively engaged in cancer-related service delivery in primary care settings, few models exist to facilitate integration of cancer control learning experiences into the curricula used in intense, fast-paced, 24- to 30-month PA training programs.

How can we increase translation of research into practice? Types of evidence needed

This review summarizes key factors that have interfered with translation of research to practice and what public health researchers can do to hasten such transfer, focusing on characteristics of interventions, target settings, and research designs. The need to address context and to utilize research, review, and reporting practices that address external validity issues-such as designs that focus on replication, and practical clinical and behavioral trials-are emphasized. Although there has been increased emphasis on social-ecological interventions that go beyond the individual level, interventions often address each component as if it were an independent intervention. Greater attention is needed to connectedness across program levels and components. Finally, examples are provided of evaluation models and current programs that can help accelerate translation of research to practice and policy.

A systematic review of motivational interviewing in physical health care settings

PURPOSE

Motivational interviewing (MI), a method of augmenting an individual's motivation to change problematic behaviours, is a patient-centred counselling style that seeks to help patients resolve ambivalence about behaviour change. MI has successfully been used in the field of addictions and has recently received increased interest as a means of promoting treatment adherence in physical health care settings. This systematic review is aimed to evaluate the effectiveness of MI interventions in physical health care settings.

METHODS

Electronic databases were searched for articles specifying the use of 'motivational interviewing' in physical health care settings between 1966 and April 2004. Fifty-one relevant abstracts were yielded and data was extracted from eight relevant selected studies.

RESULTS

Eight studies were identified in the fields of diabetes, asthma, hypertension, hyperlipidaemia, and heart disease. The majority of studies found positive results for effects of MI on psychological, physiological, and life-style change outcomes. Problems with research in this area include: small sample sizes, lack of power, use of disparate multiple outcomes, inadequate validation of questionnaires, poorly-defined therapy and training.

CONCLUSIONS

While MI has high face validity across a number of domains in physical health care settings, the general quality of trials in this area is inadequate and therefore recommendations for its dissemination in this area cannot yet be made. More research into MI applied to health behaviour change is urgently required.

Heart disease prevention in women: Promoting exercise

PURPOSE

To reinforce the importance of exercise in reducing heart disease in women and to describe motivational interviewing (MI), an effective and efficient approach to promoting exercise with women in a brief office visit with a nurse practitioner (NP).

DATA SOURCES

Information was obtained from a literature review. Two brief examples from clinical practice are presented.

CONCLUSIONS

Although exercise can reduce the risk of heart disease in women, most women do not exercise enough to achieve a risk reduction. Although health promotion is a key goal of the NP, it can be difficult to incorporate in a busy practice. When time is limited, brief MI interactions can be effective in less than 10 min, and the results surpass those of the traditional advice to exercise.

IMPLICATIONS FOR PRACTICE

MI is an effective approach to exercise counseling that the NP can quickly learn and successfully conduct within the confines of a brief office visit.

Difficulties of smoking cessation in diabetic inpatients benefiting from a systematic consultation to help them to give up smoking

AIM

To assess the value of systematic smoking cessation consultations for diabetic smokers admitted to hospital.

METHODS

All diabetic smokers admitted to the Diabetes Department of Georges Pompidou European Hospital between February 2003 and February 2004 were systematically offered a consultation with a physician specialised in tobacco cessation. Follow-up visits at three, six and nine months were planned.

RESULTS

Of the 306 diabetic patients admitted, 38 (12.4%) were smokers. There were more men than women in the group of smokers and the diabetic smokers were younger than the non-smokers. The smokers had fewer micro-angiopathic complications than the non-smokers, but there was no difference in the frequency of macro-angiopathic complications. The level of nicotine physical dependence was moderate or high for 60% of the smokers. Although all the smokers agreed to the consultation, less than half agreed to drug-based treatments to help them to give up smoking and only 15% returned for the six-month visit. Only one patient had stopped smoking at the six-month visit.

CONCLUSION

This study demonstrates the difficulties in systematic interventions to help diabetic patients to stop smoking. Diabetic smokers probably constitute a specific population for which the barriers to giving up smoking should be explored.

Smoking cessation and depression: current knowledge and future directions

This paper reviews the literature on comorbid smoking and depression. Current models used to explain this co-occurrence are examined, as are treatment options (both psychological and pharmacological). This paper surmises that treatment planning should consider factors that potentially confound treatment efficacy, including the nature of the depressive illness and the patient's smoking profile. Although there is limited research examining the benefits of a stepped-care framework, a tiered treatment format appears to work well, assisting those who require minimal treatment, as well as those who prolonged difficulties. Further research examining a stepped-care framework for smokers at risk of depression is required, as is appropriate training for health practitioners using this model. Further directions for research and practice are also discussed.

Stages of change and transitioning for adolescent patients with obesity and hypertension

When exploring an adolescent patient's readiness to transition his/her health care to adult practice, it is important to understand the processes that allow for change and which promote self-efficacy and self-care. The large numbers of adolescents with hypertension and obesity, possible antecedents to adult kidney disease, require attention be paid to promoting lifestyle changes and adherence to treatment regimens as these patients enter adulthood. Transitioning to adult care is in many cases an externally imposed change, but a young patient's readiness for this change may be amenable to intervention based on the Stages of Change Model. This article reviews the impact of adolescent obesity and hypertension on future health, the application of the Stages of Change Model in health care and specifically with adolescents, and the concept of transitioning for young patients with special health care needs. The authors suggest that the application of the Stages of Change Model, including the use of motivation interviewing and cognitive-behavioral techniques, may encourage lifestyle change and treatment adherence and assist in preparing patients for transition to the adult health care setting.

Predictors of health promotion behavior in women without prior history of coronary heart disease

The purpose of this study was to determine health promotion behavior (HPB) and the best predictors of HPB in women without prior history of coronary heart disease (CHD). The sample included 119 women aged between 35 and 60 years who had no prior CHD history. The women were asked to complete a self-administered survey regarding their demographic data, personal CHD risk factors, HPB, CHD knowledge, and perceived benefits and barriers to CHD risk factor modification. The women in this study did not practice HPB regularly and had low CHD knowledge levels, a high perception level of benefits, and a moderate level of perceived barriers to CHD risk modification. Backward multiple regression analysis demonstrated that smoking history, family history of CHD, CHD knowledge levels, and perceived barriers to CHD risk modification were the best predictors of HPB in women without CHD. Women with fewer perceived barriers to CHD risk modification, higher CHD knowledge levels, and no smoking history or family history of CHD were more likely to practice HPB.

Self-perceived barriers to activity participation among sedentary adolescent girls

PURPOSE

Potential barriers to activity participation were surveyed among adolescent girls and corroborated with other reported information.

METHODS

Among 2379 black and white girls enrolled in the NHLBI Growth and Health Study since ages 9 or 10 yr, those reporting weekly activity frequency as "sometimes" or "rarely" were surveyed for three consecutive years from ages 16 or 17 yr. Barriers to activity were assessed using a 10-item questionnaire. Responses were cross-examined with other reported information. Race-specific longitudinal regression examined the impact of barrier scores on activity levels and also potential factors having an impact on barrier scores.

RESULTS

Approximately half of the cohort was screened as "sedentary" with a trend toward an increasing proportion with age. Lack of time was cited by 60% of sedentary girls as the leading barrier to activity participation for all 3 yr. Other frequently cited barriers to activity included "I'm too tired" and "They don't interest me." No differences were seen in hours at work or in household chores between those who cited lack of time and those who did not. Barrier score was a significant predictor of habitual activity scores. For both races, body mass index and "would rather do other things than exercise" were significant predictors of barriers, but work, parental education, TV watching, and childbirth were not significant.

CONCLUSION

Self-reported barriers to activity participation among sedentary girls were shown to be primarily internal and uncorrelated with other corresponding external factors.

Home Visits to Improve Adherence to Highly Active Antiretroviral Therapy

BACKGROUND

Few rigorously designed studies have documented the efficacy of interventions to improve medication adherence among patients prescribed highly active antiretroviral. Data are needed to justify the use of limited resources for these programs.

METHODS

A 2-arm, randomized, controlled trial evaluated the efficacy of a community-based, home-visit intervention to improve medication adherence. Participants were 171 HIV-infected adults prescribed a minimum of 3 antiretroviral agents. The majority had a past or current history of substance abuse. Subjects were randomly assigned to receive home visits for 1 year or usual care. Medication adherence was assessed with Medication Event Monitoring stem caps at 3-month intervals from randomization through 3 months after the conclusion of the intervention.

RESULTS

A larger proportion of subjects in the intervention group demonstrated adherence greater than 90% compared with the control group at each time point after baseline. The difference over time was statistically significant (Extended Mantel-Haenszel test: 5.80, P = 0.02). A statistically significant intervention effect on HIV-RNA level or CD4 cell count was not seen, but there was a statistically significant association between greater than 90% adherence and an undetectable HIV-RNA over time (P < 0.03).

CONCLUSION

Home visits from a nurse and a community worker were associated with medication adherence greater than 90% among a cohort of socially vulnerable people living with HIV/AIDS in northeastern United States.

An exploration of the usefulness of motivational interviewing in facilitating secondary prevention gains in cardiac rehabilitation

Motivational interviewing is a client-centered, directive counseling approach aimed at promoting motivation in clients to change certain behaviors. Its effect is to reduce defensiveness and promote disclosure, engagement, and participation, thereby motivating the client to make behavioral changes. Motivational interviewing marries well with the principles of cardiac rehabilitation (CR) in terms of increasing motivation among CR clients, promoting a client-centered approach and in the cost- and time-effective practices of CR. Very little research has been conducted examining the effectiveness of motivational interviewing in enhancing CR outcomes. This article discusses research that has been conducted in motivational interviewing that relates to the components of CR, provides examples of how motivational interviewing can be applied to CR, and recommends further exploration, development, and investigation of the usefulness of motivational interviewing in the field of CR.

A 2-arm, randomized, controlled trial of a motivational interviewing-based intervention to improve adherence to antiretroviral therapy (ART) among patients failing or initiating ART

RATIONALE AND PURPOSE

Motivational interviewing (MI) is a counseling technique that has been used effectively to change a number of health-related behaviors. We sought to assess the impact on patients' antiretroviral therapy (ART) adherence of a multicomponent, MI-based ART adherence intervention compared with that of an HIV informational control program.

STUDY DESIGN

Two-arm, randomized, controlled trial.

SAMPLE

One hundred forty adult HIV-infected patients attending a large, academic center infectious diseases clinic who were either failing or newly initiating an ART regimen. STUDY ENDPOINTS: (1) Mean adherence level (% of prescribed doses take in the prior month) at the week 12 visit, (2) change in mean adherence, (3) percentage of patients achieving >95% adherence in the third 4-week block, and (4) change in viral load.

MAIN FINDINGS

The MI group's mean adherence improved by 4.5% compared with a decrease in the control group's adherence by 3.83% (P = 0.10). In the treatment group, 29% achieved >95% adherence compared with only 17% in the control group (P = 0.13). When we controlled for ethnicity, the intervention group had 2.75 times higher odds of achieving more than 95% adherence than did the controls (P = 0.045; 95% confidence interval: 1.023, 7.398). Although a number of mediating variables (beliefs about ART, coping style, social support, and goals set) had statistically significant changes in the expected direction in the MI group compared with controls, in the intent-to-treat analysis, the mean adherence at study exit for the intervention group was 76% (SD = 27%) and 71% (SD = 27%) for the control group (P = 0.62).

CONCLUSION

Although not definitive, this study provides some evidence that MI offers an effective approach to improving adherence. Future studies able to build MI into the intervention for longer than 3 months may have a greater impact.

Motivational Interviewing to Promote Sustained Breastfeeding

OBJECTIVE

To explore the feasibility of using motivational interviewing to promote sustained breastfeeding by increasing a mother's intent to breastfeed for 6 months and increasing her breastfeeding self-efficacy.

DESIGN

A longitudinal experimental two-group design with repeated measures was selected to explore the feasibility of using motivational interviewing to promote sustained breastfeeding in primiparous mothers.

SETTING

Three Western rural community hospital sites.

PARTICIPANTS

Convenience sample of 73 primiparous breastfeeding mothers ranging between the ages of 19 and 38, M = 25 (SD = 4.5).

MAIN OUTCOME MEASURE

Mothers reported the date of their last day of breastfeeding, defined as any breastfeeding during the previous 24-hour period. Breastfeeding behavior was confirmed at each visit by infant test weights.

RESULTS

The motivational interviewing group (M = 98.1 days, SD = 75.2) breastfed longer than the comparison group (M= 80.7 days, SD = 71.9); however, this difference was not significant, t(69) = 0.991, p = .325, Cohen's d = 0.24, related to the variability in the sample.

CONCLUSIONS

Although not a statistically significant difference, the mean number of days that mothers in the intervention group breastfed was 98 days compared to the mean of 81 days by the comparison group; therefore, motivational interviewing may be useful as a strategy to test in a comprehensive intervention plan.

Seizing the 9-month moment: addressing behavioral risks in prenatal patients

OBJECTIVE

Our qualitative study explored prenatal care providers' methods for identifying and counseling pregnant women to reduce or stop smoking, alcohol use, illicit drug use, and the risk of domestic violence.

METHODS

We conducted six focus groups (five with OB/Gyn physicians, one with nurse practitioners and certified nurse midwives), total N=49, using open-ended questions. Investigators analyzed transcripts to identify and describe themes.

RESULTS

Three major themes emerged: (1) specific risk-prevention tactics or strategies exist that are useful during pregnancy; (2) some providers address patients' isolation or depression; and (3) providers can adopt a policy of "just chipping away" at risks. Specific tactics included normalizing risk prevention, using specific assessment techniques and counseling strategies, employing a patient-centered style of smoking reduction, and involving the family.

CONCLUSIONS

Providers generally agreed that addressing behavioral risks in pregnant patients is challenging. Patient-centered techniques and awareness of patients' social contexts help patients disclose and discuss risks.

PRACTICE IMPLICATIONS

Brief but routine assessment and risk reduction messages require little time of the provider, but can make a big difference to the patient, who may make changes later.

A Qualitative Approach to Developing a Patient-Derived Intervention to Increase Exercise in Peripheral Arterial Disease

OBJECTIVE

In designing a patient-physician communication intervention, we explored patients' perceptions of the role of exercise in the treatment of peripheral arterial disease (PAD).

METHODS

We conducted qualitative interviews (5 focus groups and 13 one-on-one interviews) involving 35 patients with known PAD. We analyzed verbatim transcripts for significant dimensions of patients' explanatory models of PAD and exercise, perceptions of patient-physician communication, and other factors that would increase their participation in exercise (ie, walking). We used Atlas.ti software to facilitate data sorting and storage.

RESULTS

Based on 30 emerging codes, we identified primary themes that constitute patients' perceptions of (1) the causes and outcomes of PAD, (2) the importance of patient-physician communication, (3) the impact of PAD on their lives, and (4) the factors that would lead to their exercise participation to treat PAD. From this information, our conceptual model focuses on an intervention plan that includes addressing the known causes of PAD, the patient's behavior prior to the diagnosis of PAD, and the factors that shape a patient's overall assessment of the role of exercise for PAD. An integral aspect of our model is the impact of the physician's perception of PAD coupled with the patient's perception in order to shape the intervention-a partnership between the physician and the patient-that we posit is likely to lead to behavior change.

CONCLUSION

Based on qualitative data analysis, we developed a patient-derived model to influence exercise participation. This model highlights those factors most likely to influence behavior change in patients with PAD. The next step is to enact and assess an intervention based on this model, to increase physical activity in patients with PAD.

Effects of a brief computer-assisted diabetes self-management intervention on dietary, biological and quality-of-life outcomes

OBJECTIVE

There is a need for practical, efficient and broad-reaching diabetes self-management interventions that can produce changes in lifestyle behaviours such as healthy eating and weight loss. The objective of this study was to evaluate such a computer-assisted intervention.

METHODS

Type 2 diabetes primary care patients (n=335) from fee-for-service and health maintenance organization settings were randomized to social cognitive theory-based tailored self-management (TSM) or computer-aided enhanced usual care (UC). Intervention consisted of computer-assisted self-management assessment and feedback, tailored goal-setting, barrier identification, and problem-solving, followed by health counsellor interaction and follow-up calls. Outcomes were changes in dietary behaviours (fat and fruit/vegetable intake), haemoglobin Alc (HbA1c), lipids, weight, quality of life, and depression.

RESULTS

TSM patients reduced dietary fat intake and weight significantly more than UC patients at the 2-month follow-up. Among patients having elevated levels of HbA1c, lipids or depression at baseline, there were consistent directional trends favouring intervention, but these differences did not reach significance. The intervention proved feasible and was implemented successfully by a variety of staff.

CONCLUSIONS

This relatively low-intensity intervention appealed to a large, generally representative sample of patients, was well implemented, and produced improvement in targeted behaviours. Implications of this practical clinical trial for dissemination are discussed.

The Indiana Chronic Disease Management Program

The Indiana Chronic Disease Management Program (ICDMP) is intended to improve the quality and cost-effectiveness of care for Medicaid members with congestive heart failure (chronic heart failure), diabetes, asthma, and other conditions. The ICDMP is being assembled by Indiana Medicaid primarily from state and local resources and has seven components: (1) identification of eligible participants to create regional registries, (2) risk stratification of eligible participants, (3) nurse care management for high-risk participants, (4) telephonic intervention for all participants, (5) an Internet-based information system, (6) quality improvement collaboratives for primary care practices, and (7) program evaluation. The evaluation involves a randomized controlled trial in two inner-city group practices, as well as a statewide observational design. This article describes the ICDMP, highlights challenges, and discusses approaches to its evaluation.

Reframing "prevention with positives": incorporating counseling techniques that improve the health of HIV-positive patients

Federal HIV prevention strategy seeks to increase efforts by health care providers to identify and reduce their HIV-positive patients' transmission-related behaviors. Implementation of these recommendations will be hindered if providers perceive these efforts have the potential to harm their relationships with patients. Because transmission-related behaviors (unsafe sex and sharing needles) and the related issues of drug and alcohol use also jeopardize the health of HIV-positive patients, providers can use patient-centered counseling when addressing those behaviors. We suggest efforts to increase provider-delivered transmission-prevention counseling be reframed so that "prevention with positives" includes the goal of protecting HIV-positive patients' health. We review the specific consequences of these risky behaviors on HIV-positive patients' health and review brief counseling strategies appropriate for HIV care providers.

Barriers to Coronary Heart Disease Risk Modification in Women without Prior History of Coronary Heart Disease

PURPOSE

To explore the extent to which women perceive barriers to coronary heart disease (CHD) risk modification and to determine if access to a nurse practitioner (NP) decreases perceived barriers to CHD risk modification.

DATA SOURCES

Surveys completed by 120 women between the ages of 35 and 60 years, with no known history of CHD. The barriers scale was used to examine women's perceived barriers to CHD risk modification.

CONCLUSIONS

Women with access to an NP had less perceived barriers to CHD risk modification.

IMPLICATIONS FOR PRACTICE

NPs are ideally suited to decrease the mortality and morbidity associated with CHD through education strategies and attention to individual barriers women face when attempting to incorporate CHD risk factor modification into their lifestyles.

A programmatic and methodologic review and synthesis of clinic-based risk-reduction interventions for sexually transmitted infections: research and practice implications

The over-arching goal of this article is to systematically review and synthesize empirical findings for sexually transmitted disease risk-reduction programs that were developed and implemented specifically for adolescents seeking health care services at clinical venues. The objective is to examine the reported efficacy of these programs in reducing adolescents' sexually transmitted infection (STI)-associated behavior, in enhancing theoretically and empirically important psychosocial mediators associated with the adoption of STI-preventive behaviors, and, most important, in reducing adolescents' risk of acquiring an STI. In addition, our review assesses program and methodologic characteristics of the studies, determines compliance with standardized reporting guidelines, identifies a subset of program characteristics that are related to efficacy in terms of modifying adolescents' sexual risk behaviors, and examines the research and practice implications of these findings for implementing evidence-based STI risk-reduction programs in clinics.

Examples of implementation and evaluation of treatment fidelity in the BCC studies: where we are and where we need to go

Treatment fidelity plays an important role in the research team's ability to ensure that a treatment has been implemented as intended and that the treatment has been accurately tested. Developing, implementing, and evaluating a treatment fidelity plan can be challenging. The treatment fidelity workgroup within the Behavior Change Consortium (BCC) developed guidelines to comprehensively evaluate treatment fidelity in behavior change research. The guidelines include evaluation of treatment fidelity with regard to study design, training of interventionists, delivery and receipt of the intervention, and enactment of the intervention in real-life settings. This article describes these guidelines and provides examples from four BCC studies as to how these recommended guidelines for fidelity were considered. Future work needs to focus not only on implementing treatment fidelity plans but also on quantifying the evaluations performed, developing specific criteria for interpretation of the findings, and establishing best practices of treatment fidelity.

Training general practitioners in behavior change counseling to improve asthma medication adherence

OBJECTIVE

Adherence to asthma medication regimens is problematic in general practice. We developed and evaluated a communication training for general practitioners (GPs) to help them address medication adherence during routine consultations. This paper describes the development of the training and evaluation results of a pilot study.

METHODS

The training was based on behavior change counseling (BCC), a technique derived from motivational interviewing. We developed a five phases BCC consultation model. Participating GPs answered questions at baseline (T0), directly after (T1) and 4-10 months after (T2) the training that assessed their attitudes and confidence regarding adherence communication. They completed evaluation forms at T1 and T2.

RESULTS

The 19 participating GPs were positive about the course and the feasibility of BCC in GP consultations. Also, after the training, their attitudes and confidence had improved (p<0.05) and all reported to use BCC skills at least sometimes 4-10 months after the training.

CONCLUSION

These positive effects provide us with some hope that the training positively influenced the GP's communication behavior.

PRACTICE IMPLICATIONS

If further data on physician behavior and patient outcomes justify implementation of the training, it would then be worthwhile to also involve practice nurses.

The SPHERE Study. Secondary prevention of heart disease in general practice: protocol of a randomised controlled trial of tailored practice and patient care plans with parallel qualitative, economic and policy analyses. [ISRCTN24081411]

Background

The aim of the SPHERE study is to design, implement and evaluate tailored practice and personal care plans to improve the process of care and objective clinical outcomes for patients with established coronary heart disease (CHD) in general practice across two different health systems on the island of Ireland.

CHD is a common cause of death and a significant cause of morbidity in Ireland. Secondary prevention has been recommended as a key strategy for reducing levels of CHD mortality and general practice has been highlighted as an ideal setting for secondary prevention initiatives. Current indications suggest that there is considerable room for improvement in the provision of secondary prevention for patients with established heart disease on the island of Ireland. The review literature recommends structured programmes with continued support and follow-up of patients; the provision of training, tailored to practice needs of access to evidence of effectiveness of secondary prevention; structured recall programmes that also take account of individual practice needs; and patient-centred consultations accompanied by attention to disease management guidelines.

Methods

SPHERE is a cluster randomised controlled trial, with practice-level randomisation to intervention and control groups, recruiting 960 patients from 48 practices in three study centres (Belfast, Dublin and Galway). Primary outcomes are blood pressure, total cholesterol, physical and mental health status (SF-12) and hospital re-admissions.

The intervention takes place over two years and data is collected at baseline, one-year and two-year follow-up. Data is obtained from medical charts, consultations with practitioners, and patient postal questionnaires.

The SPHERE intervention involves the implementation of a structured systematic programme of care for patients with CHD attending general practice. It is a multi-faceted intervention that has been developed to respond to barriers and solutions to optimal secondary prevention identified in preliminary qualitative research with practitioners and patients. General practitioners and practice nurses attend training sessions in facilitating behaviour change and medication prescribing guidelines for secondary prevention of CHD. Patients are invited to attend regular four-monthly consultations over two years, during which targets and goals for secondary prevention are set and reviewed. The analysis will be strengthened by economic, policy and qualitative components.

Strategies to enhance effectiveness of individual based nutrition communications

Lifestyle modifications, including dietary and physical activity, are treatments for many chronic health conditions. Therefore, there is continued interest in improving the quantity and quality of nutrition information provided to the patient by the physician. This paper reviews the evidence to support motivational interviewing and other similar strategies for nutrition communications. Limited but positive data were found.

Some lessons from Swedish midwives' experiences of approaching women smokers in antenatal care

OBJECTIVE

to describe the qualitatively different ways in which midwives make sense of how to approach women smokers.

DESIGN, SETTING AND PARTICIPANTS

a more person-centred national project 'Smoke-free pregnancy' has been in progress in Sweden since 1992. Using a phenomenographic approach, 24 midwives who have been regularly working in antenatal care were interviewed about addressing smoking during pregnancy.

FINDINGS

four different story types of how the midwives made sense of their experiences in addressing smoking in pregnancy were identified: 'avoiding', 'informing', 'friend-making', 'co-operating'.

KEY CONCLUSION

the midwives' story types about how they approached women who smoke illustrated the difficulties of changing from being an expert who gives information and advice to being an expert on how to enable a woman in finding out why she smoked and how to stop smoking.

IMPLICATIONS FOR PRACTICE

health education about smoking that is built on co-operation and dialogue was seen by the midwives as a productive way of working. The starting point should be the lay perspective of a woman, which means that her thoughts about smoking cessation are given the space to grow while she talks.

Cancer prevention among working class, multiethnic adults: results of the healthy directions-health centers study

OBJECTIVES

We analyzed outcomes from a study that examined social-contextual factors in cancer prevention interventions for working class, multiethnic populations.

METHODS

Ten community health centers were randomized to intervention or to control. Patients who resided in low-income, multiethnic neighborhoods were eligible; the intervention targeted fruit and vegetable consumption, red meat consumption, multivitamin intake, and physical activity. Outcomes were measured at 8 months.

RESULTS

The intervention led to significant increases in fruit and vegetable consumption and multivitamin intake and reductions in red meat consumption; no change was found in physical activity levels. The intervention effect was not changed when contextual variables that may function as confounders or effect modifiers (e.g., gender, education, race/ethnicity, respondent and parents' country of birth, and poverty status) were included in the analyses.

CONCLUSIONS

The intervention led to significant improvements in health behaviors among a working class, multiethnic population, regardless of race/ ethnicity and socioeconomic status. Interventions that respond to the social context of working class individuals across racial/ethnic categories hold promise for improving cancer-related risk behaviors.

Motivational interviewing in community-based research: Experiences from the field

Motivational Interviewing (MI) has been established as an effective psychotherapeutic treatment for problem drinking in clinical settings. Consequently, there is a growing interest in applying MI to facilitate change across other health behaviors, such as tobacco use, eating habits, and physical activity in a variety of community-based research settings. These extended applications pose new challenges regarding implementation and evaluation. For instance, investigators must consider how best to train intervention counselors; implement strategies for preserving the MI spirit, despite limited client contact time; incorporate adjunctive strategies that support brief MI sessions; and develop a plan for monitoring and evaluating MI treatment fidelity. This article highlights specific examples of how several behavior change research projects applied MI across a variety of settings and populations, provides lessons learned from our experience as a collaborative workgroup, and offers strategies for consideration in future community-based research.

Role of specialists in common chronic diseases

Consultant care is currently available to only a small proportion of people with chronic illness. How can we enable many more people to benefit from specialist expertise?

Improving Quality of Life in Patients With Heart Failure

Nurses play a major role in assisting patients with chronic diseases manage their symptoms, adhere to treatment, and change behavior. This article describes an innovative behavioral intervention for patients with heart failure. The rationale and theoretical basis for the intervention, implementation, and evaluation of the intervention and its implications for use in clinical practice and further research are presented.

Results of the Healthy Body Healthy Spirit Trial

Healthy Body Healthy Spirit was a multicomponent intervention to increase fruit and vegetable (F & V) consumption and physical activity (PA) delivered through Black churches. Sixteen churches were randomly assigned to 3 intervention conditions. At baseline, 1,056 individuals were recruited across the 16 churches, of which 906 (86%) were assessed at 1-year follow-up. Group 1 received standard educational materials, Group 2 received culturally targeted self-help nutrition and PA materials, and Group 3 received the same intervention as did Group 2 as well as 4 telephone counseling calls based on motivational interviewing (MI) delivered over the course of 1 year. At 1-year follow-up, Groups 2 and 3 showed significant changes in both F & V intake and PA. Changes were somewhat larger for F & V. For F & V, but not PA, there was a clear additive effect for the MI intervention.

Grey lungs and blue moods: smoking cessation in the context of lifetime depression history

OBJECTIVE

To present an overview of the relationship between depression and cigarette smoking and to provide recommendations for clinicians who wish to help patients with a history of depression to stop smoking.

METHOD

English language journal articles published in the last 15 years on clinical material related to depression history, smoking cessation and related health issues were collected via MEDLINE, PsycINFO and Cochrane Library database searches.

RESULTS

Nicotine dependence is associated with increased rates of depression prior to and after taking up smoking as well as increased rates of suicidal ideation. Depression history is associated with increased rates of nicotine dependence, problems with smoking cessation and depression after cessation. While nicotine replacement and counselling are effective for smoking cessation, standard smoking cessation strategies may not pay sufficient attention to the needs of smokers with a depression history. Some antidepressants (bupropion and nortriptyline) are particularly effective for those with a lifetime depression history as they appear to assist with dysphoria during withdrawal and prevent relapse. Psychological and lifestyle strategies, such as motivational interviewing, relaxation exercises and mood charts, assist in mood regulation over and above the standard smoking cessation treatments for smokers with a depression history, who require more attention to relapse of depression and smoking after quitting.

CONCLUSIONS

There is a complex and circular relationship between depression, smoking and medical illness that complicates smoking cessation in those who have a history of depression. Depression-history smokers require a multimodal approach to assist with mood regulation and nicotine withdrawal. Further research is required to identify effective strategies to reduce smoking in this context.

Physical activity promotion in primary care: bridging the gap between research and practice

BACKGROUND

While a growing literature supports the effectiveness of physical activity interventions delivered in the primary care setting, few studies have evaluated efforts to increase physician counseling on physical activity during routine practice (i.e., outside the context of controlled research). This paper reports the results of a dissemination trial of a primary care-based physical activity counseling intervention conducted within the context of a larger, multi-strategy, Australian community-based, physical activity intervention, the 10,000 Steps Rockhampton Project.

METHODS

All 23 general practices and 66 general practitioners (GPs, the Australian equivalent of family physicians) were invited to participate. Practice visits were made to consenting practices during which instruction in brief physical activity counseling was offered, along with physical activity promotion resources (print materials and pedometers). The evaluation, guided by the RE-AIM framework, included collection of process data, as well as pre- and post-intervention data from a mailed GP survey, and data from the larger project's random-digit-dialed, community-based, cross-sectional telephone survey that was conducted in Rockhampton and a comparison community.

RESULTS

Ninety-one percent of practices were visited by 10,000 Steps staff and agreed to participate, with 58% of GPs present during the visits. General practitioner survey response rates were 67% (n =44/66 at baseline) and 71% (n =37/52, at 14-month follow-up). At follow-up, 62% had displayed the poster, 81% were using the brochures, and 70% had loaned pedometers to patients, although the number loaned was relatively small. No change was seen in GP self-report of the percentage of patients counseled on physical activity. However, data from the telephone surveys showed a 31% increase in the likelihood of recalling GP advice on physical activity in Rockhampton (95% confidence interval [CI]=1.11-1.54) compared to a 16% decrease (95% CI=0.68-1.04) in the comparison community.

CONCLUSIONS

This dissemination study achieved high rates of GP uptake, reasonable levels of implementation, and a significant increase in the number of community residents counseled on physical activity. These results suggest that evidence-based primary care physical activity counseling protocols can be translated into routine practice, although the initial and ongoing investment of time to develop partnerships with relevant healthcare organizations, and the interest generated by the overall 10,000 Steps program should not be underestimated.

Healthy Doctors, Healthy Communities

Promoting health and eliminating disease are goals of Healthy People 2010, a national initiative for all communities. Physician-directed interventions that advance these principles are most effective when directed by clinicians who regularly participate in such healthy behaviors themselves. This pilot study describes an 8-week intervention, "Well-being for You and Your Patients," for first-year medical students to experience health behavior change. In the 2-hour sessions, students set goals for changing health behavior in 6 dimensions of wellness; report their progress; and enjoy a 30-minute change-of-pace wellness activity. The authors recommend adapting the course for medical student alumni to facilitate health behavior change with small groups of adults, school-age children, teens, and elders in churches, schools, community health centers, and other community-based organizations. Through continuing medical education and Grand Rounds, residents and physicians in practice could also be trained to implement specific behavioral change strategies.

Preparing residents to counsel about smoking

The objective of this study was to evaluate the effects of an innovative, multicomponent, theory-based educational intervention for pediatric residents on prevention of tobacco use counseling for cessation. Before and 3 months after intervention residents in a large urban midwestern pediatric residency program completed a self-assessment of measures of their attitudes and counseling behaviors. The intervention was a 3-hour multicomponent program including presentations, case discussions, role-plays and support material based on concepts from Motivational Interviewing (MI). Participants reported increased confidence in their ability to counsel, as well as greater frequency of counseling (standardized effect size (d) = 0.57). Residents also reported an increased use of principal components of MI, assessing how important quitting is to patients (d = .66), and how confident patients are in their ability to quit (d = .78). This brief educational intervention taught theory-based counseling techniques to pediatric residents. After the study, participants reported significant increases in their frequency of counseling as well as greater use of the MI principles.

Prevalence of nutrition and exercise counseling for patients with hypertension. United States, 1999 to 2000

OBJECTIVE

To evaluate the prevalence of nutrition and exercise counseling for patients with hypertension.

DESIGN

Cross-sectional survey data from the National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS) for 1999 and 2000.

SETTING

Office-based physician practices and hospital outpatient departments.

PATIENTS/PARTICIPANTS

Patients age 18 or older with a diagnosis of hypertension.

MEASUREMENTS AND MAIN RESULTS

In 1999 and 2000, over 137 million patient encounters had a diagnosis of hypertension. Nutrition and exercise counseling were provided at 35% and 26% of visits, respectively. Patients older than 74 received the least nutrition (28%) and exercise (18%) counseling. Asians and Hispanics were more likely to undergo any lifestyle counseling, while non-Hispanic whites received the least exercise and nutrition counseling. Patients with 2 cardiovascular comorbidities were counseled for diet (53%) and exercise (32%) more than those with 1 (44% and 31%) or none (30% and 23%; P

CONCLUSIONS

While there were significant differences in counseling rates with respect to age, race, comorbidity, and survey cohort, counseling for therapeutic lifestyle changes for patients with hypertension was uniformly suboptimal. Physicians need to recognize the importance of nonpharmacologic treatment in hypertension.

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Key Words

• hypertension
• lifestyle counseling
• national survey

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MESH Headings

• Adolescent
• Adult
• Comorbidity
• Counseling/statistics & numerical data
• Diet
• Exercise
• Female
• Health Care Surveys
• Humans
• Hypertension/epidemiology
• Hypertension/prevention & control
• Life Style
• Male
• Middle Aged
• Practice Patterns, Physicians'/statistics & numerical data
• United States

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Affiliation(s)

Philip B Mellen Section of General Internal Medicine, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
Shana L Palla
David C Goff
Denise E Bonds

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Implementation of a cancer prevention program for working class, multiethnic populations

BACKGROUND

This paper describes the implementation of the Healthy Directions-Health Centers intervention and examines the characteristics of participants associated with completion of intervention activities. Healthy Directions-Health Centers was designed to address social contextual factors relevant to cancer prevention interventions for working class, multi-ethnic populations.

METHODS

Ten community health centers were paired and randomly assigned to intervention or control. Patients who resided in low income, multi-ethnic neighborhoods were approached for participation. This study targeted fruit and vegetable consumption, red meat consumption, multi-vitamin intake, and physical activity. The intervention components consisted of: (1) a brief study endorsement from a clinician; (2) an in-person counseling session with a health advisor; (3) four follow-up telephone counseling sessions; and (4) multiple distributions of tailored materials.

RESULTS

Among the 1,088 intervention group participants, 978 participants (90%) completed at least five out of six intervention activities. Participants who missed clinical appointments were less likely to complete all components of the intervention. Participant characteristics that predicted receipt of clinician endorsement differed from characteristics that predicted completion of health advisor activities. Low acculturation did not present a barrier to delivery of the intervention once the participant was enrolled.

CONCLUSIONS

Collection and reporting on process evaluation results can help explain variations in program implementation.

Motivational interviewing in health settings: a review

There is evidence that patient-centred approaches to health care consultations may have better outcomes than traditional advice giving, especially when lifestyle change is involved. Motivational interviewing (MI) is a patient-centred approach that is gathering increased interest in health settings. It provides a way of working with patients who may not seem ready to make the behaviour changes that are considered necessary by the health practitioner. The current paper provides an overview of MI, with particular reference to its application to health problems.

Mothers' and clinicians' perspectives on breastfeeding counseling during routine preventive visits

BACKGROUND

Recent national statistics indicate that, despite increases in the proportion of mothers who initiate breastfeeding, the proportion that continue to breastfeed their infants through 6 months of age remains below the Healthy People 2010 goal of 50%. National professional organizations recommend that clinicians routinely counsel mothers about the benefits of breastfeeding. Little is known, however, about the counseling provided during these visits and how mothers and their clinicians perceive breastfeeding counseling.

OBJECTIVES

We sought to describe mothers' and clinicians' perspectives on breastfeeding counseling during routine preventive visits and identify potential gaps in communication about breastfeeding and management practices.

METHODS

We conducted a prospective cohort study of low-risk mother-newborn pairs and their clinicians in a large multispecialty group practice. The participating mothers completed telephone interviews at 4 and 12 weeks postpartum, and their data were linked with their obstetric and pediatric clinicians' responses to a cross-sectional mailed survey conducted during the same time period. Overall, response rates were 63% for mothers (n = 429) and 82% for clinicians (obstetric clinicians: n = 54; pediatric clinicians: n = 67).

RESULTS

Of the 429 low-risk mother-newborn pairs in the study, 61% were white, 16% were black, 10% were Hispanic, and 8% were Asian, with a mean (SD) age of 32.7 (5.1) years. At 4 weeks postpartum, 319 mothers (74%) were either exclusively or mixed breastfeeding. According to the interviews, few mothers discussed breastfeeding duration with their obstetric clinicians during their prenatal visits (15%) or with their pediatric clinicians during their infants' 2-week preventive visit (24%). Among 164 mothers whose obstetric providers said they usually or always discuss breastfeeding duration during prenatal visits, only 26 (16%) of the mothers reported that the topic was discussed with them (22% agreement; kappa = -.004). Among those mothers whose pediatric clinicians said they usually or always discuss breastfeeding duration during the 2-week preventive visit, only 25% of the mothers reported that the topic was discussed (32% agreement; kappa =.05). Many of the mothers had either returned to work by 12 weeks (29%) or planned to return to work within the next few months (43%). Although nearly all the obstetric (91%) and pediatric (97%) clinicians reported that they usually or always discuss whether a mother plans to continue breastfeeding after returning to work, only approximately half (55%) of the mothers seen by the clinicians reported that the topic was discussed. Overall, few mothers reported discussing with their clinicians specific ways to continue breastfeeding after returning to work.

CONCLUSION

Mothers' reports of breastfeeding advice given during routine preventive visits identified several areas in which unintentional communication gaps may occur, including specifics about breastfeeding duration and methods of breastfeeding after returning to work. Developing approaches to enhance communication with mothers during routine preventive visits could improve the support of breastfeeding.

Anosognosia in individuals with schizophrenia: toward recovery of insight

This paper addresses the growing evidence that lack of insight, or unawareness of illness in people with schizophrenia, may actually be a medically based condition known as anosognosia. Major explanatory models and related research findings are discussed. A case scenario is presented, as well as current perspectives regarding assessment of insight and alternative treatment approaches. Implications for further research, nursing education, and practice also are included. With better understanding of the characteristics and treatment of diminished insight in individuals with schizophrenia, nurses can better assist clients to recover helpful insight that enables them to take an active role in managing their symptoms and problems.

Brief motivational interviewing to improve adherence to antiretroviral therapy: development and qualitative pilot assessment of an intervention

Because successful HIV treatment requires exceptional adherence to antiretroviral therapy (ART), interventions to improve ART adherence are essential. We developed and pilot-tested an intervention to improve ART adherence, based on brief motivational interviewing (MI), which has successfully improved selected health behaviors but has not been tested for ART adherence. We administered the 15- to 30-minute MI session to 20 HIV-positive adults and assessed its usefulness and relevance. Then, we content-analyzed the session for HIV care issues and strategies most salient to patients in the MI session. During the session, all participants chose an HIV-care-related topic that they wanted to discuss, and talked about issues, barriers, and facilitators related to their topic. Most participants (70%) developed strategies to help improve their health. Questions asked after the MI session revealed that almost all (95%-100%) participants found the session useful and helpful. This theoretically based, empowering health counseling approach for HIV-positive persons warrants further research.