Motivational interviewing: improving patient education

Factors associated with attendance at a pharmacist-led group diabetes self-management education class and impact on health outcomes

Background

Group education has demonstrated benefits among people with diabetes, including reduced A1C and improved self-monitoring practices. Despite this, attendance rates are low for a variety of reasons, including lack of understanding of potential benefits among patients.

Objectives

The pharmacist-led diabetes self-management education program at a community hospital has low attendance. This project assesses characteristics associated with attendance and compares outcomes among attendees and non-attendees.

Methods

Retrospective data was collected between July 2022 and December 2023. Variables included: age, sex, class attendance, pre- and ≥ 90-day post-class A1C, pre- and post-class BMI, attending pharmacist-led clinic prior to scheduled class, social determinants of health screening survey responses, and diagnosis of depression or anxiety.

Results

103 patients were identified. 53 % attended at least one class out of a series of four. Attendance at the pharmacist-led diabetes clinic (70 % among attendees versus 30 % among non-attendees, p < 0.001) was associated with attendance. Age, gender, concurrent mental health diagnoses (depression and anxiety), and SDOH related needs were not associated with attendance. Baseline A1C was similar for attendees and non-attendees (9.6 vs. 9.7 %, respectively). Post-class A1C was 7.4 % for attendees of at least one class and 8 % for non-attendees. Patients who attended all four classes achieved a mean A1C <7 %.

Discussion

There are many factors that lead to lack of engagement with group education for diabetes. Referral to group education by a pharmacist who has established rapport with the patient and can speak to specific details about benefits of the classes may improve attendance at diabetes group education.

Clients' Perspectives on Patient-Centeredness: a Qualitative Study with Low-Income Minority Women Receiving HIV Care in South Florida

Low-income, minority women living with HIV often experience multiple barriers in care that contribute to suboptimal care outcomes. Medical case managers (MCM) and medical providers are key players involved in care coordination and aid women along the HIV care continuum. The objective of this study was to identify current and potential patient-centered practices that facilitate adherence to medication and retention in care, from the perspective of racially and ethnically diverse women living with HIV. We implemented a qualitative study using semi-structured interviews with 75 African American, Hispanic/Latina, and Haitian women who were enrolled in the Ryan White HIV/AIDS Program in South Florida in 2019. We organized domains of exploration using a patient-centered care framework to identify practices in which providers acknowledged, respected, and responded to clients' preferences, needs, and values. Interviews were analyzed using consensual thematic analysis approach. Findings reflect women valued MCMs who were proactive and directive in care, provided motivation, and aided with navigation of shame, fear, and stigma. Women valued medical providers who upheld simple educational communication. Moreover, women reported that providers who reviewed medical results with clients, incorporated questions about families, and inquired about multiple physical and clinical needs beyond HIV created opportunities for women to feel respected, valued, and in turn, enhanced their involvement in their care. Findings identify specific interpersonal practices that can enhance the ability to better meet the needs of diverse groups of women, specifically those from racial/ethnic minority groups who face multiple sociocultural barriers while in care.

The Impact of Motivational Interview on Self-Efficacy, Beliefs About Medicines and Medication Adherence Among Adolescents with Asthma: A Randomized Controlled Trial

PURPOSE

This study aimed to determine the impact of MI on self-efficacy, beliefs about medicines and medication adherence among adolescents with asthma.

METHOD

This randomized controlled trial conducted on 52 adolescents with asthma referring to the Pediatric Medical Center in Tehran, Iran. They were randomly assigned to the control and intervention groups. The educational intervention consisted of 3 one-hour sessions per week, which was held individually in the areas of medication adherence, beliefs about medicines and self-efficacy. Four validated questionnaires including demographic characteristics, medication adherence, self-efficacy and beliefs about medicines were completed by self-report both before the MI and 40 days after the end of the intervention.

RESULTS

In the baseline, the two groups were homogeneous in terms of demographic characteristics and outcome measures. At the post-test, the mean scores of the three outcome measures in the intervention group were reported higher compared to the scores in the control group (p < 0.05). The difference between the mean scores in medication adherence, beliefs about medicines and self-efficacy in the post-test between the two groups, even with the elimination of the effect pre-test scores, were significant (p < 0.05).

CONCLUSIONS

The results of this study showed that MI can be effective in improving medication adherence, beliefs about medicines, and self-efficacy.

PRACTICE IMPLICATIONS

The primary goal in the treatment of patients with asthma is asthma control by using corticosteroids. MI is one of the interventions that can simultaneously provide motivation, readiness, beliefs about medicine and self-efficacy for behavioral changes (medication adherence) in patients with asthma.

Using group-based trajectory modeling to characterize the association of past ACEIs/ARBs adherence with subsequent statin adherence patterns among new statin users

BACKGROUND

Despite well-documented benefits, statin adherence remains suboptimal. Studies have suggested that previous adherence to other chronic medications is a strong predictor of future adherence to newly initiated statins. Group-based trajectory modeling (GBTM) has been applied as a method to longitudinally depict the dynamic nature of adherence.

OBJECTIVES

This study aimed to examine the association between patients' adherence patterns to newly initiated statins and previous adherence trajectories of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) using GBTM.

METHODS

This retrospective cohort study was conducted among continuously enrolled statin initiators using claims data. Patients were included if they had ACEI/ARB use within 1 year before statin initiation (preindex period). Monthly adherence to ACEIs/ARBs was calculated during the preindex period and monthly adherence to statins was assessed 1 year after statin initiation using proportion of days covered (PDC). The monthly PDCs were modeled as a longitudinal response in a logistic GBTM to provide distinct patterns of adherence for ACEIs/ARBs and statins, separately. A multinomial logistic regression was conducted to determine an association between ACEI/ARB adherence trajectories and future statin trajectories, controlling for patient characteristics.

RESULTS

A total of 1078 patients were categorized into 4 distinct statin adherence trajectories: adherent (40.8%), gradual decline (37.4%), gaps in adherence (13.9%), and rapid decline (7.9%). Patients were further categorized into 4 groups on the basis of their distinct past ACEIs/ARBs trajectories: adherent (43%), gaps in adherence (29%), delayed nonadherence (15.2%), and gradual decline (12.8%). In the multinomial logistic regression, patients in the gaps in adherence or gradual decline groups were more likely to follow similar trajectories for future statin use than the adherent trajectory.

CONCLUSION

Previous adherence trajectories of ACEIs/ARBs may predict future adherence patterns for newly initiated statins. Knowledge of past medication-taking behavior could provide valuable information for developing tailored interventions to improve adherence.

The feasibility, acceptability and preliminary efficacy of parent-targeted interventions in vaccination pain management of infants: a pilot randomized control trial (RCT)

Aim: To evaluate the feasibility, acceptability and preliminary efficacy of parent interventions for improving the use of pain management strategies during vaccination of infants, a two-armed pilot randomized control trial (RCT) was conducted. Materials & methods: 151 parents were randomized in two groups: Group 1) 'Be Sweet to Babies' videos and a tip sheet (n = 76); Group 2) As per Group 1 plus a motivational interviewing informed Affirmative Statements and Questions (AS&Q) (n = 75). Results & conclusion: Feasibility was evaluated by success of the recruitment (151 people in a week), rates of completed consent forms (85%), and surveys (59%). Over 94% satisfaction with interventions, processes and 88% intention to recommend the strategies to others determined the acceptability. Preliminary efficacy was evident by over 95% use of pain management strategies following the interventions. Clinical trial registration number: NCT03968432.

A Study Protocol for a Parallel-Designed Trial Evaluating the Impact of Plant-Based Diets in Comparison to Animal-Based Diets on Health Status and Prevention of Non-communicable Diseases-The Nutritional Evaluation (NuEva) Study

Background and Aims: Currently, there is a continuing upward trend for plant-based lifestyles in Germany and Europe. The implementation of vegetarian and vegan lifestyles is characterized by omitting defined food groups such as fish, meat, sausage (vegetarians), or dairy products and honey (vegans). This carries the risk of an undersupply of valuable nutrients. The NuEva study is designed to examine this hypothesis and to evaluate the impact of plant-based diets on health status and disease risk.

Methods: The NuEva study is a parallel-designed trial with at least 55 participants for each diet (vegetarian, vegan, flexitarian [rare meat/sausage consumption, once or twice per week]), and participants who consume a traditional Western diet as the control group. In the screening period critical nutrients are identified for the studied diets by analysis of a broad spectrum of nutrients in the human samples (fatty acids, vitamins, minerals, trace elements, nutrient metabolites).

Results: Based on the data from the screening period, defined menu plans, ensuring an adequate nutrient intake in accordance with the nutritional guidelines are prepared for each group. The plans are adapted and personalized to individual energy requirements based on the basal metabolic rate and physical activity level. The compliance with the NuEva concept and their impact on nutrient status and cardiovascular risk factors are validated during the intervention period of the NuEva study over 1 year. To investigate the impact of the studied diets on the microbiome, feces samples are collected at the beginning and after the 12 months intervention period (follow up: 12 months).

Conclusion: The NuEva study is designed to investigate the impact of common diets on health and disease status, with focus on prevention of cardiovascular diseases. In addition, the effectiveness of the prepared nutritional coaching strategy, ensuring optimal nutrient intake in accordance with the guidelines, is validated during the intervention period of the NuEva study.

Clinical Trial Registration: Registered under ClinicalTrials.gov Identifier no. NCT03582020.

Role of non-specialist nurses in supporting people who misuse drugs

In their practice, nurses are likely to encounter people who misuse drugs, but they may find it daunting to support these patients. While specialist drug treatment services have an important role in providing substitution treatment and talking therapies, referral is not always appropriate for some patients. Non-specialist nurses are well placed to use techniques such as brief interventions and motivational interviewing to engage patients in discussions about their drug misuse and prompt them to consider how they could reduce it. This article defines drug misuse, describes the contributing factors that can lead to it and its associated health issues. It also discusses how non-specialist nurses can manage and provide optimal support for patients who misuse drugs.

Discontinuing Treatment Against Medical Advice: The Role of Perceived Autonomy Support From Providers in Relapsing-Remitting Multiple Sclerosis

BACKGROUND

Long-term medication adherence is problematic among patients with chronic medical conditions. To our knowledge, this was the first study to examine factors associated with nonadherence among patients with relapsing-remitting multiple sclerosis who discontinue disease-modifying treatments against medical advice.

PURPOSE

To examine differences in perceived provider autonomy support between disease-modifying treatment-adherent relapsing-remitting multiple sclerosis patients and relapsing-remitting multiple sclerosis patients who discontinued disease-modifying treatments against medical advice.

METHODS

Self-report questionnaires and a neurologic exam were administered to demographically matched adherent (n = 50) and nonadherent (n = 79) relapsing- remitting multiple sclerosis patients from the Midwest and Northeast USA.

RESULTS

Adherent patients reported greater perceived autonomy support from their treatment providers, F(1, 124) = 28.170, p < .001, partial η2 = .185. This difference persisted after controlling for current multiple sclerosis healthcare provider, education, disease duration, Expanded Disability Status Scale, perceived barriers to adherence, and prevalence of side effects, F(1, 121) = 9.61, p = .002, partial η2 = .074. Neither depressive symptoms, F(1, 124) = 1.001, p > .05, partial η2 = .009, nor the occurrence of a major depressive episode, χ2(1, N = 129) = .288, p > .05, differed between adherent and nonadherent patients.

CONCLUSIONS

Greater perceived autonomy support from treatment providers may increase adherence to disease-modifying treatments among patients who discontinue treatment against medical advice. Results may inform interventions for patients who discontinue treatment against medical advice.

A Motivational Interviewing Intervention by Pharmacy Students to Improve Medication Adherence

BACKGROUND

Diabetes mellitus (DM) patients with comorbid hypertension (HTN) are at a higher risk of developing microvascular and macrovascular DM complications. Through guideline-driven recommendations, angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) are highly recommended for these patients. Unfortunately, medication adherence to these products, though crucial to achieving therapeutic benefit, is frequently suboptimal. Motivational interviewing (MI) is a patient-centered collaborative communication style that is used to strengthen internal motivation for change that may prove effective in enhancing adherence.

OBJECTIVE

To examine the effect of an MI telephone intervention conducted by pharmacy students in improving adherence to ACEIs/ARBs among Medicare Advantage Plan (MAP) patients with both DM and HTN.

METHODS

A prospective study was conducted among patients enrolled in a Texas MAP. Medical claims data were used to identify patients with DM and HTN, and pharmacy claims were observed to recognize those who filled either an ACEI or an ARB during June 2014. Patients with a 6-month proportion of days covered (PDC) < 0.80 in the previous 6 months were determined nonadherent, and 75% of those were randomly selected to serve as potential subjects for the intervention, while 25% were randomly selected to serve as potential subjects for the control group. The intervention was a telephone call by a pharmacy student on rotation at the health plan, and 5 monthly follow-up calls. Before implementing calls, participating students attended a 3-day MI training course, where their proficiency for MI skills was evaluated. Refill data during the 6-month postintervention were evaluated to examine the intervention effect measured on 3 outcomes: PDC; PDC ≥ 0.80 versus < 0.80; and discontinuation versus continuation. Multivariate linear and logistic regression models were constructed to adjust for any imbalances in baseline characteristics, including age, gender, number of other medications, regimen complexity, health low-income subsidy status, prescriber specialty, comorbidities, 6-month previous hospitalization, baseline 6-month PDC, and Centers for Medicare & Medicaid Services risk score.

RESULTS

A total of 11 students participated in the intervention implementation. Patients receiving calls were randomly selected from those potential subjects for the intervention arm until a target of 250 was reached; 500 controls were randomly selected from the potential subjects for the control arm. The final cohort included in multivariate models consisted of 743 patients. Patients completing the initial call and at least 2 follow-ups were less likely to discontinue (OR = 0.29; 95% CI = 0.15-0.54; P < 0.001) and more likely to be adherent in the linear regression model (β = 0.0604, P < 0.001) and the logistic regression model (OR = 1.53; 95% CI = 1.02-2.28; P = 0.009). Other factors significantly associated with better adherence included higher baseline PDC and number of medications. Depression status was significantly associated with lower adherence.

CONCLUSIONS

Patients receiving 2 or more calls had significantly better adherence and less discontinuation during the 6 months following initial calls compared with those who did not receive calls. This finding indicates that an MI-based telephone intervention by pharmacy students may be a promising intervention to improve adherence. Future research should examine the sustainability of the intervention effect for longer time periods and its influence on associated clinical outcomes.

DISCLOSURES

This project was supported by the Pharmaceutical Research and Manufacturers of America Foundation (PhRMA). The content is solely the responsibility of the authors and does not necessarily represent the official views of PhRMA. The funding agency was not involved in research design, analysis, or reporting results. Funding was obtained by Abughosh. Holstad provided a consultation regarding the MI guide and provided the MI training. Study concept and design were contributed by Abughosh and Fleming, along with Serna, Esse, and Holstad. Serna, Esse, Mann, Holstad, and Masilamani collected the data, and data interpretation was performed by Abughosh, Wong, and Esse. The manuscript was written by Abughosh, Wong, and Esse and revised by Masilamani and Holstad, along with the other authors.

A Pharmacist Telephone Intervention to Identify Adherence Barriers and Improve Adherence Among Nonadherent Patients with Comorbid Hypertension and Diabetes in a Medicare Advantage Plan

BACKGROUND

Patients with comorbid hypertension (HTN) and diabetes mellitus (DM) are at a high risk of developing macrovascular and microvascular complications of DM. Controlling high blood pressure can greatly reduce these complications. Angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) are recommended for patients with both DM and HTN by the American Diabetes Association guidelines, and their benefit and efficacy in reducing macrovascular and microvascular complications of DM have been well documented. Poor adherence, however, remains a significant barrier to achieving full effectiveness and optimal outcomes.

OBJECTIVE

To examine the effect of a brief pharmacist telephone intervention in identifying adherence barriers and improving adherence to ACEI/ARB medications among nonadherent patients with comorbid HTN and DM who are enrolled in a Medicare Advantage plan.

METHODS

Cigna-HealthSpring's medical claims data was used to identify patients with HTN and DM diagnoses by using ICD-9-CM codes 401 and 250, and at least 2 fills for ACEIs or ARBs between January 2013 and October 2013. Patients who failed to refill their medication for more than 1 day and had a proportion of days covered (PDC) < 0.8 were considered nonadherent and were contacted by a pharmacist by phone to identify adherence barriers. Two outcome variables were evaluated: The first was adherence to ACEIs/ARBs, defined as PDC during the 6 months following the phone call intervention. The second outcome variable was a categorical outcome of discontinuation versus continuation. Discontinuation was defined as not using ACEIs/ARBs during the 6-month post-intervention period. Patients who disenrolled from the plan in 2014 or were switched to another medication commonly used for treating DM and HTN were excluded from further analysis. Descriptive statistics were conducted to assess the frequency distribution of sample demographic characteristics at baseline. Multiple linear regression was conducted to assess the intervention effect on adherence during the 6 months post-intervention using the first outcome of post-intervention PDC, adjusting for baseline PDC and other covariates. Logistic regression was performed to assess the association between medication discontinuation and other baseline characteristics using the second outcome of discontinuation. Other control variables in the models included demographics (age, sex, language), physician specialty (primary care vs. specialist), health plan (low-income subsidy vs. other), Centers for Medicare & Medicaid risk score, Charlson Comorbidity Index, and number of distinct medications.

RESULTS

In total, 186 hypertensive diabetic patients, nonadherent to ACEIs/ARBs (PDC < 0.8), were included in the study. Of the 186 patients, 87 received the pharmacist phone call intervention. Among these patients, forgetfulness (25.29%) and doctor issues, such as having difficulty scheduling appointments (16.79%), were the most commonly reported barriers. After excluding those who switched from ACEIs/ARBs to another medication, 157 patients were included in the logistic regression model. Of those, 131 had continued using ACEIs/ARBs and were included in the linear regression model. The mean (±SD) post-intervention PDC for the intervention group was 0.58 (±0.26) and for the control group 0.29 (±0.17). Intervention was a significant predictor of better adherence in the linear regression model after adjusting all the other baseline covariates (β = 0.3182, 95% CI = 0.19-0.38, P < 0.001). Other covariates were not significantly associated with better adherence. In the logistic regression model (discontinuation: 26 [yes]/131 [no]) for predicting medication discontinuation, patients who received intervention were more likely to continue using ACEIs/ARBs (OR = 3.56, 95% CI = 1.06-11.86), and those with a higher comorbidity index were less likely to continue using them (OR = 0.72, 95% CI = 0.53-0.99).

CONCLUSIONS

The brief pharmacist telephone intervention resulted in significantly better PDCs during the 6 months following the intervention as well as lower discontinuation rates among a group of nonadherent patients with comorbid HTN and DM. The overall PDC rates in both the intervention and control groups were still lower than the recommended 80%. Improving adherence to clinically meaningful values may require more than a brief pharmacist phone call. Incorporating motivational interviewing techniques with follow-up calls to address adherence barriers may be more influential in forming sustainable behavioral change and enhancing medication adherence.

Parent education for adults with intellectual disability: A review and suggestions for future research

OBJECTIVE

This review evaluates research regarding parent education interventions for adults with an intellectual disability (ID).

METHODS

Electronic database and ancestral searches identified 13 studies published between 1994 and 2012. The results of these studies are discussed in relation to (a) participants and settings; (b) general intervention procedures, (c) programmed antecedent stimuli to occasion parent behaviour; (d) targeted behaviours; (e) programmed consequence(s) for parent behaviour; and (f) the presence of generalization and maintenance strategies.

RESULTS

In the majority of reviewed studies, intervention components lacked operational definitions appropriate for replication and direct observation of child outcomes were often not included as a dependent variable. Also, most interventions did not include steps to promote the generalization of skills to different stimuli or settings although the majority assessed the maintenance of targeted skills.

CONCLUSION

In consideration of these findings, several relevant areas for future research are proposed.

Efficacy of Group Motivational Interviewing in the Degree of Drug Craving in the Addicts Under the Methadone Maintenance Treatment (MMT) in South East of Iran

BACKGROUND

Craving is one of the important factors having an effective role in the addiction relapse. As an important factor in the therapy failure, this clinical phenomenon has to be diagnosed and treated.

OBJECTIVE

The present research aimed at determining the efficacy of group motivational interviewing in the degree of drug craving in the addicts under the Methadone Maintenance Treatment (MMT).

METHOD

This is a quasi-experimental study carried out on 100 addicted men (aged 18-50 years), who were under the MMT in a drug abstinence clinic affiliated with University of Medical Sciences (Iran) in the second half of 2014. The research sample was selected by the availability criteria based on the inclusion and exclusion criteria, and upon matching, it was divided randomly into two groups of 50 (control and treatment). The treatment group first received 5 sessions of group motivational counseling; then it entered the therapy process. The control group received the usual treatment of the drug abstinence clinic. To assess the drug craving degree (in the pretest, 2, 6 and 12 months after the abstinence), the Visual Cue-induced Craving Task, scored 0 to 100, was used. The data were analyzed by the descriptive statistics through independent t-test, and repeated measures analysis of variance.

RESULTS

The means of craving degrees in the control group, 2, 6 and 12 months after the abstinence (73.28 ± 7.52, 65.83 ± 6.69 and 61.25±5.17, respectively) were significantly (p=0.0001) higher than those in the treatment group (68.94 ± 10.53, 40.48 ± 11.78 and 32.51 ± 9.00). Moreover, the mean of retention in the treatment was 9.24 ± 2.45 months in the treatment group that was significantly (p=0.001) higher than the 4.88 ± 3.65 months of retention in the control group.

CONCLUSION

The research results support the fact that motivational interviewing decreases the degree of drug craving, and increases the probability of the addicts' retention in long-term therapeutic abstinence programs. Therefore, the use of such an approach as a pretreatment and a complementary therapy in changing health behaviors is recommended.

Improving Developmental-Behavioral Pediatric care workflow

: Experience and available research suggest that Developmental Behavioral Pediatric (DBP) practice is both complex and variable. Variability involves multiple aspects of DBP care, from activities before the visit (e.g. triage and collecting information) to activities during (e.g. history taking and testing) and after the visit (e.g. care coordination). Together these activities represent workflow, a series of clinical events by which health care is delivered. In complex systems, workflow variation often suggests the presence of inefficiency or inconsistent quality. Given the current environment of increasing health care costs and an increasing focus on quality, DBP practitioners must be mindful of these concepts for the field of DBP to remain viable. In order to characterize current DBP practice and identify common challenges, a workshop was developed with the ultimate goal of identifying potential solutions for improving both quality and efficiency. This paper summarizes the workshop findings and proposes future directions to foster improvements in DBP workflow.

Engaging families through motivational interviewing

Helping parents change key behaviors may reduce the risk of child maltreatment. However, traditional provider-centered approaches to working with the parents of pediatric patients may increase resistance to behavioral change. Motivational interviewing (MI) is a patient-centered communication technique that helps address problems of provider-centered approaches. In this article, evidence for use of MI to address several risk factors for child maltreatment is reviewed, including parental substance abuse, partner violence, depression treatment, harsh punishment, and parental management of children's health. Fundamental components of MI that may be incorporated into clinical practice are presented.

Training in motivational interviewing in obstetrics: a quantitative analytical tool

OBJECTIVE

To examine whether a 3-day training course in motivational interviewing, which is an approach to helping people to change, could improve the communication skills of obstetric healthcare professionals in their interaction with obese pregnant women.

DESIGN

Intervention study.

SETTING

The Region of Southern Denmark.

METHODS

Eleven obstetric healthcare professionals working with obese pregnant women underwent a 3-day course in motivational interviewing techniques and were assessed before and after training to measure the impact on their overall performance as well as the effect on specific behavioral techniques observed during interviews.

FINDINGS

With a few exceptions, the participants changed their behavior appropriate to the motivational interviewing technique. The participants made more interventions towards the principles of motivational interviewing (adherent and nonadherent interventions). Furthermore, the participants asked fewer closed and more open questions before training in motivational interview. In the assessment of proficiency and competency, most of the participants scored higher after the training in motivational interviewing.

CONCLUSIONS

Training in motivational interviewing improves healthcare professionals' proficiency and competency when communicating with obese pregnant women, albeit that the effect was not universal.

Hispanic Overweight and Obese Children

Through Value Enhanced Nutrition Assessment and other techniques, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) engages clients to set their own nutrition goals. A case series of 30 Hispanic children (2-4.5 years) at ≥85th body mass index (BMI) percentile and their caregivers were followed through an urban WIC clinic. The dyads received either standard counseling ( n = 15) or motivational interviewing (MI; n = 15) by one bilingual WIC nutritionist during 4 regularly scheduled visits over 6 months. Repeated measurements of anthropometric data, dietary patterns, and physical activity were obtained at each visit. Longitudinal bivariate analyses of caregiver concerns and goal selection were conducted along with mean comparisons of anthropometric and food frequency measures. Participation in counseling sessions as rated by the nutritionist was assessed by comparing Wilcoxon rank-sum scores. After counseling, children lost an adjusted mean weight of 0.878 kg (95% confidence interval = 0.280-1.717). A decline in median BMI of more than 3 percentiles ( P = .042) was observed with both counseling approaches. Caregiver-reported vegetable intake of children increased an average of one additional serving in the MI-counseled group by visit 3 ( P = .013) despite MI recipient caregivers being scored as significantly more distracted than standard WIC participants in the first visit ( P = .036). MI is a viable option for WIC counseling to improve diet and health outcomes in participants, particularly in addressing child BMI status and vegetable intake. Public health professionals should examine scalability of the MI approach among larger samples of WIC participants and other innovative techniques to improve client focus during counseling.

Feasibility of using actigraphy and motivational-based interviewing to improve sleep among school-age children and their parents

Inadequate sleep occurs in 25% of our nation's children; poor sleep is associated with physical, cognitive, and social consequences. Developing good sleep hygiene in middle childhood is important, because habits typically extend to adolescence and adulthood; yet, there has been little research on sleep interventions for school-age children. The purpose of this study was to determine the feasibility of a developmentally tailored, motivation-based intervention (MBI) focused on improving sleep behaviors in school-age children aged 8-11. Nine parent-child dyads participated in an 8-week protocol utilizing MBI and comparisons of objective (actigraphy) and subjective (sleep diaries) data. Results suggest that parent and children are able to identify a target behavior to change and complete the protocol. Further, preliminary evidence indicates that sleep patterns change using MBI. Future research will be directed toward comparative effectiveness testing and exploring ways in which it can be adapted and incorporated into school nursing practice.

Barrier removal in increasing physical activity levels in obese African American women with disabilities

BACKGROUND

This pilot study examined the effectiveness of a telephone-based intervention to increase physical activity in obese African American women with mobility disabilities by targeting the removal of barriers to participation.

METHODS

Severely obese (mean body mass index [BMI] = 49.1 kg.m²) African American women (n = 33) with mobility disabilities completed a 6-month telephone-based physical activity coaching intervention.

RESULTS

The major environmental/facility barriers at preintervention were cost of the program (66.7%), lack of transportation (48.5%), not aware of fitness center in the area (45.5%), and lack of accessible facilities (45.5%). The major personal barriers were pain (63.6%), don't know how to exercise (45.5%), health concerns (39.4%), don't know where to exercise (39.4%), and lack of energy (36.4%). Despite only two personal barriers being significantly lower at posttest (don't know where to exercise and don't know how to exercise) (p < 0.01), total exercise time increased from < 6 minutes/day to 27 minutes/day at posttest (p < 0.001), and total physical activity time (structured exercise, leisure, indoor and outdoor household activity) increased from 26 minutes/day to 89 minutes/day at posttest (p < 0.001).

CONCLUSIONS

Interventions aimed at increasing physical activity participation among obese African American women with mobility disabilities should start with increasing their awareness/knowledge on where and how to exercise. Other reported barriers (e.g., cost, transportation, finding an accessible facility, health concerns, pain) may not be as critical to alter/remove as identifying where participants can exercise (i.e., home, outdoors, gym) and providing them with a variety of routines that can be performed safely in their desired setting.

Facilitating medication adherence in patients with multiple sclerosis

This article reviews adherence to medication in multiple sclerosis (MS) patients from the perspective of nurse and social worker authors. It reviews data on patient adherence and offers practical, evidence-based strategies that health-care providers can use to facilitate adherence. In addition, it examines how emerging MS therapies may affect patient adherence and associated interventions. To promote adherence, interventions need to incorporate new and creative approaches. A proactive approach includes assessing patient needs and lifestyle before the start of medication and selecting the most appropriate disease-modifying therapy for each individual patient. Including multidisciplinary expertise and services in the treatment plan can be part of a comprehensive, holistic approach to helping patients and families. Optimization of health-care provider roles is likely to facilitate improved adherence.

The quality of the face-to-face counselling in paediatric ambulatory tonsillectomy: parental point of view

The objective of this study was to examine parental opinion on the quality of preoperative face-to-face counselling about the child's preoperative fasting. Families, whose child was admitted for ambulatory tonsillectomy were randomly assigned to the study groups (n = 116; 58/58). The intervention group received the information with face-to-face counselling, and the control group in written form. The parents assessed (visual analogue scale) the level of clarity, intelligibility and adequacy of the information, how well they had understood the meaning and the implementation of the child's preoperative fast, as well as their own skills and success to implement the child's fast. The parents in the intervention group felt that the information was significantly clearer, more intelligible and adequate and that they succeeded well. Face-to-face counselling is an effective way to educate the parents.

What do changes in inflammatory bowel disease management mean for our patients?

Treatment goals in Crohn's disease are evolving beyond the control of symptoms. A treat-to-target approach to management that features earlier initiation of TNF antagonist therapy will enable resolution of objective parameters of inflammation. The decision to initiate anti-TNF therapy should be based on a patient-specific assessment of risks and benefits. This paradigm necessitates a complex process, influenced by multiple factors that include the quality of data available, physicians' and patients' knowledge of the data, and the preferences and values of patients, physicians and society. The potential 'opportunity cost' resulting from a delay in initiation of effective therapy, a consideration that has been neglected in the past, must also enter into the equation. Our evolving approach to the management of Crohn's disease challenges patients to participate in the decision-making process and to become an active partner in their care. Ideally, this evolution should occur within the context of an enduring physician/patient relationship that is based on mutual trust. Motivational communication provides a useful technique to improve dialogue and collaboration between healthcare professionals and patients, and may help to engage and motivate patients to commit to managing their disease.

Development and implementation of a health behavioral counseling curriculum for physician assistant cancer education

A health behavioral counseling curriculum grounded in Motivational Interviewing and the Transtheoretical Model of behavior change was developed to enhance knowledge and clinical skill among physician assistant (PA) students in managing cancer risk behaviors. A literature and curriculum review informed course content, teaching strategies, and learning activities. The course was evaluated over two pilot years. Students demonstrated increased knowledge and skills regarding the basic principles of the intervention models. The course was integrated into the pre-clinical year of PA training and will be disseminated, beginning with a faculty development workshop for all PA training programs in Texas, USA.

Patients, persons or partners? Involving those with chronic disease in their care

Self-care management is essential for effective chronic disease management. Yet prevailing approaches of healthcare practitioners often undermine the efforts of those who require on-going medical attention for chronic conditions, emphasizing their status as patients, failing to consider their larger life experience as people, and most importantly, failing to consider them as people with the potential to be partners in their care. This article explores two approaches for professional-patient interaction in chronic disease management, namely, patient-centred care and empowering partnering, illuminating how professionals might better interact with chronically ill individuals who seek their care. The opportunities, challenges, theory and research evidence associated with each approach are explored. The advantages of moving beyond patient-centred care to the empowering partnering approach are elaborated. For people with chronic disease, having the opportunity to engage in the social construction of their own health as a resource for everyday living, the opportunity to experience interdependence rather than dependence/independence throughout on-going healthcare, and the opportunity to optimize their potential for self-care management of chronic disease are important justifications for being involved in an empowering partnering approach to their chronic disease management.

Clinical utility of varenicline for smokers with medical and psychiatric comorbidity

Chronic obstructive pulmonary disease (COPD) is a costly and deadly disease afflicting an estimated 210 million people and accounting for 5% of all global deaths. Exposure to cigarette smoke is the greatest risk factor for COPD in the developed world. Smoking cessation improves respiratory symptoms and lung function and reduces mortality among patients with COPD. Cigarette smokers with COPD and other co-morbid conditions such as cardiovascular disease and psychiatric illnesses should receive comprehensive tobacco treatment interventions incorporating efficacious pharmacotherapies. Varenicline, an α₄β₂ nicotinic acetylcholine receptor partial agonist, is the newest and most effective drug currently available to promote smoking cessation. In conjunction with behavioral interventions and clinical monitoring for potential side effects, varenicline offers great hope for reducing smoking-attributable death and disability.

Improving treatment seeking among adolescents with depression: understanding readiness for treatment

PURPOSE

To examine readiness for treatment among adolescents with depression in primary care.

METHODS

This article draws upon data from 184 depressed patients, aged 13 to 17, who participated in the Teen Depression Awareness Project. Adolescents were screened assessed along a number of domains at baseline and 6 months.

RESULTS

Seventy-eight percent of the depressed teens acknowledged they had a problem with depression, yet only 25% were currently getting any sort of counseling or treatment for depression. A total of 40.8% of depressed adolescents were "ready" to get care, whereas 26.6% were "unsure" and 32.1% were "not ready." Significant differences among these groups were observed for race/ethnicity and household income. Adolescents in the ready group also had more depressive symptoms and lower MHI-5 scores. Being in the ready group versus being "unsure" was a significant predictor of service use at the 6-month follow-up, as was the average number of days impaired and overall mental health functioning. Race, gender, and age were not significant predictors of readiness, yet average number of depressive symptoms was significantly associated with greater readiness.

CONCLUSIONS

Because teens in primary care settings are not seeking mental health treatments even when depression is detected, providers should be mindful that adolescents may be at different stages of recognition and readiness for treatment. Teens who are less ready for care may need follow-up primary care visits or consultation to help them become more active in seeking care.

Is office-based counseling about media use, timeouts, and firearm storage effective? Results from a cluster-randomized, controlled trial

OBJECTIVE

The objective of this study was to determine whether patients' families' violence-prevention behaviors would be affected by their primary care practitioner's use of a violence-prevention clinical intervention during the routine well-child examination.

METHODS

In this cluster-randomized, controlled trial (2002-2006), 137 Pediatric Research in Office Settings practices were randomly assigned and initiated patient recruitment for either an office-based violence-prevention intervention or a control group (educational handout on literacy promotion provided). Primary caregivers of children who were aged 2 to 11 years and presented for a well-child visit were surveyed at baseline and 1 and 6 months. Practitioners were trained to (1) review a parent previsit summary regarding patient-family behavior and parental concern about media use, discipline strategies, and children's exposure to firearms, (2) counsel using brief principles of motivational interviewing, (3) identify and provide local agency resources for anger and behavior management when indicated, and (4) instruct patient-families on use of tangible tools (minute timers to monitor media time/timeouts and firearm cable locks to store firearms more safely where children live or play). Main outcomes were change over time in self-reported media use <120 minutes per day, use of timeouts, and use of firearm cable locks.

RESULTS

Generalized estimating equation analysis revealed a significant effect at 6 months for decreased media use and safer firearm storage. The intervention group compared with the control group showed an increase in limiting media use to <120 minutes per day. There was no significant effect for timeout use. There was a substantial increase in storing firearms with cable locks for the intervention group versus a decrease for the control group.

CONCLUSIONS

This randomized, controlled trial demonstrated decreased media exposure and increased safe firearm storage as a result of a brief office-based violence-prevention approach.