Motivational interviewing in health care settings. Opportunities and limitations

Teaching motivational interviewing to first-year medical students to improve counseling skills in health behavior change

OBJECTIVE

To examine the effectiveness of motivational interviewing training on improving medical students' knowledge of and confidence in their ability to counsel patients regarding health behavior change.

SUBJECTS AND METHODS

In the spring of 2002, 42 first-year medical students participated in a counseling course on health behavior change. Three small groups focused on learning and practicing motivational interviewing techniques using brief lectures, interactive class activities, student role-plays, and simulated patients. Students completed an identical precourse and postcourse questionnaire that measured their confidence and knowledge regarding counseling skills in health behavior change.

RESULTS

The medical students reported improved confidence in their understanding of motivational interviewing after participation in the course (very confident, 77%) compared with before the course (very confident, 2%). Each of the 8 confidence items were compared before and after the course using a signed rank test. All comparisons indicated a significant improvement (P < .001) in confidence. Regarding knowledge-based questions, students showed significant improvement; 31% of students answered all the questions correctly before the course, and 56% answered all the questions correctly after the course (P = .004).

CONCLUSION

These results show that teaching motivational interviewing techniques to first-year medical students can enhance student confidence in and knowledge of providing counseling to patients regarding health behavior change.

Applying motivational interviewing to contraceptive counseling: ESP for clinicians

Healthcare providers are in a unique position to address women's risk of unintended pregnancy and sexually transmitted infections (STIs), yet evidence for effective counseling strategies is limited. One approach to developing effective contraceptive counseling methods may be the application of theory-based behavior counseling models. One such model, motivational interviewing (MI), is a promising approach for addressing risk-taking behaviors of many kinds. We propose application of MI to contraceptive counseling. This process, ESP, involves Exploring discrepancies between pregnancy intention and contraceptive use and between risk of STIs and condom use, Sharing information and Promoting behaviors to reduce risk. This model emphasizes the importance of identifying discrepancies between goals and behaviors and supporting women's confidence in using appropriate contraceptive methods

Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure

The National High Blood Pressure Education Program presents the complete Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Like its predecessors, the purpose is to provide an evidence-based approach to the prevention and management of hypertension. The key messages of this report are these: in those older than age 50, systolic blood pressure (BP) of greater than 140 mm Hg is a more important cardiovascular disease (CVD) risk factor than diastolic BP; beginning at 115/75 mm Hg, CVD risk doubles for each increment of 20/10 mm Hg; those who are normotensive at 55 years of age will have a 90% lifetime risk of developing hypertension; prehypertensive individuals (systolic BP 120-139 mm Hg or diastolic BP 80-89 mm Hg) require health-promoting lifestyle modifications to prevent the progressive rise in blood pressure and CVD; for uncomplicated hypertension, thiazide diuretic should be used in drug treatment for most, either alone or combined with drugs from other classes; this report delineates specific high-risk conditions that are compelling indications for the use of other antihypertensive drug classes (angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, beta-blockers, calcium channel blockers); two or more antihypertensive medications will be required to achieve goal BP (<140/90 mm Hg, or <130/80 mm Hg) for patients with diabetes and chronic kidney disease; for patients whose BP is more than 20 mm Hg above the systolic BP goal or more than 10 mm Hg above the diastolic BP goal, initiation of therapy using two agents, one of which usually will be a thiazide diuretic, should be considered; regardless of therapy or care, hypertension will be controlled only if patients are motivated to stay on their treatment plan. Positive experiences, trust in the clinician, and empathy improve patient motivation and satisfaction. This report serves as a guide, and the committee continues to recognize that the responsible physician's judgment remains paramount.

Motivating and helping smokers to stop smoking

Smokers try to quit only once every 2 to 3 years and most do not use proven treatments. Repeated, brief, diplomatic advice increases quit rates. Such advice should include a clear request to quit, reinforcing personal risks of smoking and their reversibility, offering solutions to barriers to quitting, and offering treatment. All smokers should be encouraged to use both medications and counseling. Scientifically proven, first-line medications are nicotine gum, inhaler, lozenge, and patch plus the nonnicotine medication bupropion. Proven second-line medications are clonidine, nicotine nasal spray, and nortriptyline. These medications are equally effective and safe and the incidence of dependence is very small. The proven psychosocial therapies are behavioral and supportive therapies. These are as effective as medications and are effective via individual counseling, group, and telephone formats. The writing of this article was supported in part by Senior Scientist Award DA-00450 from the National Institute on Drug Abuse.

The primary prevention of heart disease in women through health behavior change promotion in primary care

PURPOSE

To summarize recent evidence-based recommendations for physical activity promotion, dietary improvement, and tobacco cessation from the U.S. Preventive Services Task Force (USPSTF) and the Task Force on Community Preventive Services (CTF), and examine their applicability to the primary prevention of cardiovascular disease (CVD) in women through primary care interventions.

METHODS

For the behaviors cited, USPSTF and CTF recommendations and their associated systematic evidence reviews (SERs) were retrieved. Individual articles from the USPSTF healthy diet and physical activity SERs that met our inclusion criteria were systematically examined to determine the applicability of this research to women. We supplemented findings from these sources with comprehensive federal research summaries and SERs from focused searches of systematic review databases relevant to primary CVD prevention in women through healthy behavior change.

MAIN FINDINGS

The USPSTF strongly recommends primary care interventions for tobacco cessation. Strong CTF recommendations for multicomponent systems supports for clinicians, telephone support for quitters, and reduced patient costs for effective cessation therapies guide complementary approaches to assist clinicians. The USPSTF recommends intensive behavioral dietary counseling by specialists for high-risk CVD patients, but found insufficient evidence to recommend for routine healthy diet or physical activity promotion in primary care. The evidence base for these recommendations generally applies to women. Better reporting of gender and minority subgroup outcomes will assist more in-depth understanding of potential differences in either the processes or outcomes of behavior change interventions.

CONCLUSIONS

Primary care clinicians, including obstetrician-gynecologists, can contribute to preventing CVD in women through implementing credible evidence-based recommendations for clinical interventions in tobacco and healthy diet. Researchers can further our understanding of gender-specific issues in healthy behavior interventions by reporting process and outcome data for gender and minority subgroups.

Risk communication in practice: the contribution of decision aids

As patients want to participate more in decision making, and as the range of medical options expands, clinicians are challenged to improve their communication of risk and supportive skills. Are practitioners' counselling skills up to the job?

Motivating health: strategies for the nurse practitioner

PURPOSE

To provide the nurse practitioner (NP) with a practical prescription for acquiring expertise in health behavior change using integrated principles from the transtheoretical model of change and motivational interviewing.

DATA SOURCES

Extensive literature review of current theory and research on health behavior change.

CONCLUSION

Expertise in motivating health behavior change is essential to effective health promotion and to the NP role.

IMPLICATIONS FOR PRACTICE

Lifestyle choices are principal contributors to the leading causes of death and most chronic diseases in the United States. Traditional health behavior interventions are often ineffective in motivating and sustaining lifestyle change.

Preventing falls in older people: risk factors and primary prevention through physical activity

Falls among older people represent a major public health issue, which can in part be tackled through an integrated falls service combining both primary and secondary prevention. Many falls can be prevented following comprehensive assessment to identify risk factors and to plan interventions to eliminate them or ameliorate their effect. Community nursing staff are well placed to undertake such risk assessments and can instigate programmes of primary prevention designed to reduce the likelihood of a person falling. Increased physical activity among older people represents one element of a prevention programme. While this is beneficial for the older person's general health and well-being, certain types of exercise can also be used to reduce falls in individuals with muscle weakness, reduced mobility and balance problems. With the exception of balance training the evidence base related to exercise and falls prevention is patchy; Carter et al (2001) suggest that as yet there is insufficient evidence to suggest an optimum exercise programme for falls prevention. Each person should therefore be individually assessed and the results used to identify what type of exercise they might benefit from in order to address a specific risk factor. Once an appropriate form of exercise has been identified, practitioners should put the older person in contact with a physical activity coordinator to assist them in accessing an exercise programme.

Health education: a case for resuscitation

Health education is the component of health promotion designed to achieve learning related to health or illness. While often described by other names, an educational element features in nearly all health promotion activities. Unlike most other public health actions, it focuses on voluntarism and frequently on the individual. Health education and the resources devoted to it grew rapidly in the latter half of the 20th century. However, in the 1970s, many health educators started to question its value. They criticized it as being excessively concerned with disease, victim blaming, politically naive and increasing health inequalities. While promoting knowledge and skills for health was included as one of the five principles of health promotion in the World Health Organization's Ottawa charter, it received much less attention than the other four principles. Health education was also criticized as being ineffective. Methods for evaluating health education are hotly contested but there is evidence that some education interventions are effective. Current health strategies continue to advocate prevention through health education, and workers in many different settings are expected to ensure that health education is provided. These front-line educators should be able to look to those who specialize in health promotion to support their educational activities. This paper argues that the worth of health education compared with other forms of health promotion has been grossly underestimated and it is time to re-assert its importance.

Understanding people who smoke and how they change: a foundation for smoking cessation in primary care, part 2

The purpose of this 2-part article is to develop an understanding of people who smoke and how they change as a foundation for the delivery of smoking cessation interventions in primary care. Central to our approach is the transtheoretical model of change (TMC). The TMC is an evidence-based model of behavior change that has been developed and tested during the past 2 decades by Prochaska and his colleagues in the context of smoking cessation. We use a review of the literature, in-depth interviews of people who successfully quit smoking, and our experience applying the TMC in the context of primary care and a smoking cessation clinic to explore the clinical work of smoking cessation. This is part 2 of the article "Understanding People Who Smoke and How They Change: A Foundation for Smoking Cessation in Primary Care." Part 1 describes the theoretical information known about smoking cessation: why smoking is a powerful behavior, the scientific background of the TMC, and the building-block constructs of the TMC. The first section of part 2 is a review of the Public Health Service clinical practice guideline, Treating Tobacco Use and Dependence, published in 2000. The second chapter of part 2 is a discussion of clinical assessments and strategies for working with smokers grounded in the Public Health Service practice guideline, our understanding of people who smoke, and the TMC. Woven throughout are transcripts of interviews with 4 people in which they describe their experiences smoking and their pathways to cessation.