Motivational Interviewing and Diet Modification: A Review of the Evidence

A latent profile analysis based on diet quality and eating behaviours in participants of the PREDISE study characterized by a higher BMI

The aim of this study was to identify eating-related latent profiles based on diet quality and eating behaviours within a population characterized by a body mass index (BMI) of at least 25 kg/m2, and to compare metabolic variables between profiles. This analysis was conducted in a sample of 614 adults (45.6% women; 44.8 ± 12.9 years) from the cross-sectional PREDISE study. Participants completed the Three-Factor Eating Questionnaire, the Intuitive Eating Scale-2, the Regulation of Eating Behavior Scale, and three self-administered 24 h food recalls. Waist circumference, blood lipids, blood pressure, and fasting glucose were measured to identify carriers of the metabolic syndrome. A latent profile analysis was performed, and cases of metabolic syndrome were compared between profiles. A three-profile solution was found. Profile 1 (22.8%) was characterized by lower diet quality, lower self-determined motivation for eating, lower restraint, and higher intuitive eating. Profile 2 (44.5%) was characterized by higher diet quality, higher self-determined motivation for eating, higher restraint, lower disinhibition, and higher intuitive eating. Profile 3 (32.7%) was characterized by intermediate diet quality, higher non-self-determined motivation for eating, higher restraint and disinhibition, and lower intuitive eating. We found fewer cases of metabolic syndrome among participants in profile 2 than in the other profiles (p = 0.0001). This study suggests that a profile characterized by a lower disinhibition and higher levels of restraint, intuitive eating, self-determined motivation, and diet quality is associated with a better metabolic health among individuals with a higher BMI.

MICA: Motivational Interviewing Conversational Agent for Parents as Proxies for their Children in Healthy Eating (Preprint)

Background

Increased adoption of off-the-shelf conversational agents (CAs) brings opportunities to integrate therapeutic interventions. Motivational Interviewing (MI) can then be integrated with CAs for cost-effective access to it. MI can be especially beneficial for parents who often have low motivation because of limited time and resources to eat healthy together with their children.

Objective

We developed a Motivational Interviewing Conversational Agent (MICA) to improve healthy eating in parents who serve as a proxy for health behavior change in their children. Proxy relationships involve a person serving as a catalyst for behavior change in another person. Parents, serving as proxies, can bring about behavior change in their children.

Methods

We conducted user test sessions of the MICA prototype to understand the perceived acceptability and usefulness of the MICA prototype by parents. A total of 24 parents of young children participated in 2 user test sessions with MICA, approximately 2 weeks apart. After parents’ interaction with the MICA prototype in each user test session, we used qualitative interviews to understand parents’ perceptions and suggestions for improvements in MICA.

Results

Findings showed participants’ perceived usefulness of MICAs for helping them self-reflect and motivating them to adopt healthier eating habits together with their children. Participants further suggested various ways in which MICA can help them safely manage their children’s eating behaviors and provide customized support for their proxy needs and goals.

Conclusions

We have discussed how the user experience of CAs can be improved to uniquely offer support to parents who serve as proxies in changing the behavior of their children. We have concluded with implications for a larger context of designing MI-based CAs for supporting proxy relationships for health behavior change.

Optimizing a Just-in-Time Adaptive Intervention to Improve Dietary Adherence in Behavioral Obesity Treatment: Protocol for a Microrandomized Trial

BACKGROUND

Behavioral obesity treatment (BOT) is a gold standard approach to weight loss and reduces the risk of cardiovascular disease. However, frequent lapses from the recommended diet stymie weight loss and prevent individuals from actualizing the health benefits of BOT. There is a need for innovative treatment solutions to improve adherence to the prescribed diet in BOT.

OBJECTIVE

The aim of this study is to optimize a smartphone-based just-in-time adaptive intervention (JITAI) that uses daily surveys to assess triggers for dietary lapses and deliver interventions when the risk of lapse is high. A microrandomized trial design will evaluate the efficacy of any interventions (ie, theory-driven or a generic alert to risk) on the proximal outcome of lapses during BOT, compare the effects of theory-driven interventions with generic risk alerts on the proximal outcome of lapse, and examine contextual moderators of interventions.

METHODS

Adults with overweight or obesity and cardiovascular disease risk (n=159) will participate in a 6-month web-based BOT while using the JITAI to prevent dietary lapses. Each time the JITAI detects elevated lapse risk, the participant will be randomized to no intervention, a generic risk alert, or 1 of 4 theory-driven interventions (ie, enhanced education, building self-efficacy, fostering motivation, and improving self-regulation). The primary outcome will be the occurrence of lapse in the 2.5 hours following randomization. Contextual moderators of intervention efficacy will also be explored (eg, location and time of day). The data will inform an optimized JITAI that selects the theory-driven approach most likely to prevent lapses in a given moment.

RESULTS

The recruitment for the microrandomized trial began on April 19, 2021, and is ongoing.

CONCLUSIONS

This study will optimize a JITAI for dietary lapses so that it empirically tailors the provision of evidence-based intervention to the individual and context. The finalized JITAI will be evaluated for efficacy in a future randomized controlled trial of distal health outcomes (eg, weight loss).

TRIAL REGISTRATION

ClinicalTrials.gov NCT04784585; http://clinicaltrials.gov/ct2/show/NCT04784585.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/33568.

Effect of personal, food manufacturer, and pet health statements made by a veterinarian during a pet wellness appointment on a dog or cat owner's decision to consider changing their pet's diet

OBJECTIVE

To investigate the effect of statements made by veterinarians during a pet wellness appointment on a pet owner's decision to consider changing their pet's diet.

SAMPLE

Pet owners who presented their dogs and cats for wellness examinations from December 2018 to February 2019 to a veterinary medical teaching hospital or an affiliated low-cost community clinic.

PROCEDURES

Pet owners completed part 1 of the survey, which included questions on various pet characteristics (eg, signalment and current diet) and pet owner's degree of satisfaction with their pet's diet, after a veterinary medical student obtained the pet's medical history and examined the pet. At the conclusion of the wellness appointment, owners completed part 2, which included pet owner demographics (eg, gender and highest educational level) and statements regarding personal, food manufacturer, and pet health that could be made by a veterinarian regarding a pet's diet to which owners were asked to react.

RESULTS

84 dog and 36 cat owners completed the survey. Statements based on pet health and personal (veterinarian) preferences were the most and least effective, respectively, on owners to consider changing their pet's diet. Pet owner gender and pet species did not alter the findings. Most (93%) pet owners were at least somewhat willing to change their pet's diet on the basis of a veterinarian's recommendation.

CONCLUSIONS AND CLINICAL RELEVANCE

When a pet's diet is discussed in the context of a pet's health, a primary care veterinarian consulting with a pet owner during a wellness appointment may be most persuasive to the owner for changing their pet's diet.

Motivational Interviewing and Self-care Practices in Adult Patients With Heart Failure: A Systematic Review and Narrative Synthesis

BACKGROUND

Heart failure contributes to frequent hospitalizations, large healthcare costs, and high mortality. Heart failure management includes patient adherence to strict self-care practices (ie, symptom recognition, limiting sodium and fluids, monitoring weight, maintaining an active lifestyle, and medication adherence as well as monitoring other medical conditions). These practices can be difficult to enact and maintain. Motivational interviewing, although not studied extensively in patients with heart failure, may enhance patients' abilities to enact and maintain self-care practices.

OBJECTIVE

The aim of this study was to examine the effectiveness of motivational interviewing on self-care practices in the adult population with heart failure.

METHODS

We conducted a narrative systematic review of peer-reviewed research literature focused on motivational interviewing in adult patients with heart failure. The following databases were searched from database inception to March 2019: MEDLINE, EMBASE, PsycINFO, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, ERIC, Educational Resource Complete, and Scopus. Of 1158 citations retrieved, 7 studies met the inclusion criteria.

RESULTS

Outcomes were focused on self-care adherence (ie, maintenance, management, confidence), physical activity/exercise, and knowledge of self-care. Motivational interviewing has been effectively used either alone or in combination with other therapies and has been used in-home, over the telephone, and in hospital/clinic settings, although face-to-face interventions seem to be more effective. A number of limitations were noted in the included studies.

CONCLUSION

Motivational interviewing is a potentially effective adjunct to enhance self-care practices in patients with heart failure. Further high-quality research is needed to support changes in clinical practice.

Development of a tablet app designed to improve African Americans' screening colonoscopy rates

Compared with other racial/ethnic groups, African Americans have the highest colorectal cancer (CRC) morbidity and mortality rates. It is critical to help improve African Americans' CRC prevention efforts in order to reduce the burden of CRC in this community. The aim of this study was to develop and field test a tablet app, called e-Motivate, designed to improve African Americans' screening colonoscopy rates. The e-Motivate app was field tested, using an iterative approach. The first version of the app, e-Motivate 1.0, was field tested on 20 African Americans over the age of 50. Participants engaged in a think aloud exercise and provided feedback regarding the app's usability and acceptability. The results of the first field test were used to modify the app and develop e-Motivate 2.0. The field test procedures were repeated on a new group of participants (N = 18). The results from the second field test were used to make final modifications to the app. Overall, participants responded positively to the app. Qualitative analyses showed that participants found the app to be easy to use and helpful. Furthermore, descriptive statistics revealed that participants found the app to be highly usable and acceptable, exceeding recommended benchmarks for usability and acceptability. Critiques of the app were used to modify and finalize the intervention. The results from the proposed study suggest that the e-Motivate app is highly feasible and acceptable. The next step in this line of research is to conduct a randomized clinical trial to formally test the efficacy of the e-Motivate app for improving screening colonoscopy rates among African Americans.

Type 2 diabetes remission: How does it work?

Type 2 diabetes mellitus (Type 2 DM) is a chronic disease which rise is closely linked to the obesity epidemic and which requires long-term medical attention to limit the development of its wide-ranged complications. Many of these complications arise from the combination of resistance to insulin action, inadequate insulin secretion, and excessive or inappropriate glucagon secretion. The increasing evidence of its remission state has been discussed in the literature. Here we report on a patient with metabolic syndrome who underwent a structured therapeutic lifestyle changes (TLC) therapy which eventually led to remission of Type 2 DM.

Using Social Marketing to Reduce Salt Intake in Iran

Objectives: WHO has recommended that the average salt intake must be <5 grams per day. However, people consume salt much more in many countries. In this study, we design and implement an intervention based on social marketing model to reduce salt consumption in Yasuj, Iran. Materials and Methods: This study employed a quasi-experimental pretest-posttest with control group design which consisted of a formative research (qualitative-quantitative) and an interventional phase. To collect the qualitative data, six focus group discussions by participating of 66 people were established. The qualitative data were analyzed manually using directed content analysis. In quantitative study, 166 people aged 25-50 years completed a KAP questionnaire, and their average salt intake was determined through measuring sodium in their urine sample. By analyzing the data, marketing mix components were determined for designing an intervention. An educational package (including posters for installing in the kitchen, pamphlets, phone counseling, four educational classes, and brief interventions done by physicians and other health personnel) focused on reducing salt intake and using alternatives was developed. For one month, program was implemented for intervention group. Two months later, KAP survey and measuring the urine sodium were repeated for intervention and control groups. The data was compared for two groups, before and after the intervention by using independent t-test, paired t-tests and repeated measures ANOVA. Results: The qualitative findings showed that most participants agreed that the salt intake was high in Iran. Most of them recommended home-based and family-driven strategies to reduce salt intake, offered using healthier alternatives for salt, and recognized physicians and health care providers in healthcare facilities as the most important to encourage people to reduce salt intake. After the intervention, the mean and standard deviation of KAP were improved significantly in intervention group. The mean salt intake decreased significantly by 3.01 ± 2.38 in the intervention group and repeated measures ANOVA showed significant change over time (P < 0.001) and a significant difference between two groups (P = 0.04)_. Also, the interaction between time and group was significant (P = 0.001). Conclusion: The mean salt intake among the study population was approximately three times more than the level recommended by the WHO. The social marketing-based intervention succeeded in reducing the salt intake of the study subjects by ~3 grams on average.

Effects of Low-FODMAPS Diet on Irritable Bowel Syndrome Symptoms and Gut Microbiome

Patients with irritable bowel syndrome (IBS) suffer from abdominal pain, bloating, and abnormal defecation. Reducing the dietary intake of fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) has been shown to be beneficial in reducing IBS symptoms. However, diet modification plays an important role in the composition of colonic microbiota. Currently, the effects of a FODMAP diet on the composition of the gut microbiome are not known. We conducted a systematic review to determine (1) the effectiveness of low-FODMAPs diet to reduce symptoms of patients with IBS and (2) the association between a low-FOMAPs diet and the composition of gut microbiome. Four electronic databases were searched using key words "IBS" or "irritable bowel syndrome," and "FODMAP" or "FODMAPs" or "fermentable oligosaccharides, disaccharides, monosaccharides, and polyols," and "microbiome." Two reviewers (H.S. and Y.T.L.) selected and reviewed articles according to our inclusion criteria. A total of 87 articles were reviewed and 7 met inclusion criteria. Based on the systematic review, low FODMAPs appear to reduce gastrointestinal symptoms for a least a subset of patients with IBS. However, due to the heterogeneity of reviewed studies, the influence on patients' gut microbiome composition and/or microbiota metabolites requires additional studies.

Effectiveness of Motivational Interviewing on adult behaviour change in health and social care settings: A systematic review of reviews

BACKGROUND

The challenge of addressing unhealthy lifestyle choice is of global concern. Motivational Interviewing has been widely implemented to help people change their behaviour, but it is unclear for whom it is most beneficial. This overview aims to appraise and synthesise the review evidence for the effectiveness of Motivational Interviewing on health behaviour of adults in health and social care settings.

METHODS

A systematic review of reviews. Methods were pre-specified and documented in a protocol (PROSPERO-CRD42016049278). We systematically searched 7 electronic databases: CDSR; DARE; PROSPERO; MEDLINE; CINAHL; AMED and PsycINFO from 2000 to May 2018. Two reviewers applied pre-defined selection criteria, extracted data using TIDIER guidelines and assessed methodological quality using the ROBIS tool. We used GRADE criteria to rate the strength of the evidence for reviews including meta-analyses.

FINDINGS

Searches identified 5222 records. One hundred and four reviews, including 39 meta-analyses met the inclusion criteria. Most meta-analysis evidence was graded as low or very low (128/155). Moderate quality evidence for mainly short term (<6 months) statistically significant small beneficial effects of Motivational Interviewing were found in 11 of 155 (7%) of meta-analysis comparisons. These outcomes include reducing binge drinking, frequency and quantity of alcohol consumption, substance abuse in people with dependency or addiction, and increasing physical activity participation.

CONCLUSIONS

We have created a comprehensive map of reviews relating to Motivational Interviewing to signpost stakeholders to the best available evidence. More high quality research is needed to be confident about the effectiveness of Motivational Interviewing. We identified a large volume of low quality evidence and many areas of overlapping research. To avoid research waste, it is vital for researchers to be aware of existing research, and the implications arising from that research. In the case of Motivational Interviewing issues relating to monitoring and reporting fidelity of interventions need to be addressed.

A novel peer-support intervention using motivational interviewing for breastfeeding maintenance: a UK feasibility study

BACKGROUND

In total, 81% of women in the UK start breastfeeding, but fewer than half continue beyond 6 weeks. Peer support in the early postnatal period may encourage women to breastfeed for longer.

OBJECTIVE

To develop a breastfeeding peer-support intervention based on motivational interviewing (MI) for breastfeeding maintenance and to test the feasibility of delivering it to mothers in areas with high levels of social deprivation.

DESIGN

Intervention development and a non-randomised multisite feasibility study.

SETTING

Community maternity services in three areas with high levels of social deprivation and low breastfeeding initiation rates in England and Wales.

PARTICIPANTS

Pregnant women considering breastfeeding. Women who did not plan to breastfeed, who had a clinical reason that precluded breastfeeding continuation or who were unable to consent were excluded.

INTERVENTION

The intervention Mam-Kind was informed by a survey of infant feeding co-ordinators, rapid literature review, focus groups with service users and peer supporters and interviews with health-care professionals and a Stakeholder Advisory Group. It consisted of face-to-face contact at 48 hours after birth and proactive one-to-one peer support from the Mam-Kind buddy for 2 weeks, followed by mother-led contact for a further 2-6 weeks.

MAIN OUTCOME MEASURES

Recruitment and retention of Mam-Kind buddies, uptake of Mam-Kind by participants, feasibility of delivering Mam-Kind as specified and of data collection methods, and acceptability of Mam-Kind to mothers, buddies and health-care professionals.

RESULTS

Nine buddies were recruited to deliver Mam-Kind to 70 participants (61% of eligible women who expressed an interest in taking part in the study). Participants were aged between 19 and 41 years and 94% of participants were white. Intervention uptake was 75% and did not vary according to age or parity. Most contacts (79%) were initiated by the buddy, demonstrating the intended proactive nature of the intervention and 73% (n = 51) of participants received a contact within 48 hours. Follow-up data were available for 78% of participants at 10 days and 64% at 8 weeks. Data collection methods were judged feasible and acceptable. Data completeness was > 80% for almost all variables. Interviews with participants, buddies and health service professionals showed that the intervention was acceptable. Buddies delivered the intervention content with fidelity (93% of intervention objectives were met), and, in some cases, developed certain MI skills to a competency level. However, they reported difficulties in changing from an information-giving role to a collaborative approach. These findings were used to refine the training and intervention specification to emphasise the focus of the intervention on providing mother-centric support. Health-care professionals were satisfied that the intervention could be integrated with existing services.

CONCLUSIONS

The Mam-Kind intervention was acceptable and feasible to deliver within NHS maternity services and should be tested for effectiveness in a multicentre randomised controlled trial. The feasibility study highlighted the need to strengthen strategies for birth notification and retention of participants, and provided some insights on how this could be achieved in a full trial.

LIMITATIONS

The response rate to the survey of infant feeding co-ordinators was low (19.5%). In addition, the women who were recruited may not be representative of the study sites.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

A pilot randomized controlled trial examining the feasibility, acceptability, and efficacy of Adapted Motivational Interviewing for post-operative bariatric surgery patients

OBJECTIVE

Non-adherence to post-operative dietary guidelines contributes to poorer outcomes following bariatric surgery. The current pilot study evaluated the impact of Adapted Motivational Interviewing (AMI) on patients' readiness for change, self-efficacy, and adherence to dietary guidelines following bariatric surgery.

METHODS

A randomized wait-list controlled trial was conducted. Post-operative bariatric patients (N=51) were randomly allocated to receive the single session AMI intervention either immediately (AMI group; n=23), or in 12weeks while continuing to receive standard bariatric care (wait list control [WLC] group; n=28).

RESULTS

Completer analyses (n=44) indicated that participants reported improvements in readiness, confidence, and self-efficacy for change immediately following the AMI intervention. They also reported improvements in binge eating symptomatology and some measures of dietary adherence across the 12-week follow-up period. Significant Group×Time interactions for confidence for change, dietary adherence, and binge eating symptomatology suggest that the AMI group improved on these outcomes whereas the control group did not.

CONCLUSIONS

These preliminary findings suggest that AMI is an acceptable and feasible intervention with the potential to improve bariatric patients' confidence for change and eating behaviors. Future research should examine these results in comparison to routinely collected postsurgery follow-up data to learn more about AMI's efficacy for improving post-surgical adherence.

A systematic review of Motivational Interviewing interventions in cancer patients and survivors

OBJECTIVE

To explore the use of Motivational Interviewing (MI) interventions among cancer patients and survivors, and determine aspects of intervention design that are common across successful MI interventions for this population.

METHODS

We conducted a systematic review of studies addressing behavior change in cancer patients or survivors using Motivational Interviewing techniques. Studies were categorized into three groups based on behavioral outcome; lifestyle behaviors, psychosocial outcomes, and cancer-related symptom management.

RESULTS

We included 15 studies in our analysis. Studies addressed behaviors such as diet, exercise, smoking cessation, cancer-related stress, and fatigue management. Counseling sessions varied in frequency and method of delivery, although telephone-based interventions were common. Trained oncology nurses often delivered MI sessions, and the majority of interventions included quality assessment to verify fidelity of MI techniques.

CONCLUSION

Solid evidence exists for the efficacy of MI to address lifestyle behaviors as well as the psychosocial needs of cancer patients and survivors. More research is needed on the use of MI for self-management of cancer-related symptoms.

PRACTICE IMPLICATIONS

Motivational Interviewing is a promising technique for addressing many types of behavior change in cancer patients or survivors. Intervention design must be sensitive to cancer type, phase of care, and complexity of desired behavior.

Cost-effectiveness of motivational intervention with significant others for patients with alcohol misuse

AIMS

To estimate the incremental cost, cost-effectiveness and benefit-cost ratio of incorporating a significant other (SO) into motivational intervention for alcohol misuse.

DESIGN

We obtained economic data from the one year with the intervention in full operation for patients in a recent randomized trial.

SETTING

The underlying trial took place at a major urban hospital in the United States.

PARTICIPANTS

The trial randomized 406 (68.7% male) eligible hazardous drinkers (196 during the economic study) admitted to the emergency department or trauma unit.

INTERVENTION

The motivational interview condition consisted of one in-person session featuring personalized normative feedback. The significant other motivational interview condition comprised one joint session with the participant and SO in which the SO's perspective and support were elicited.

MEASUREMENTS

We ascertained activities across 445 representative time segments through work sampling (including staff idle time), calculated the incremental cost in per patient of incorporating an SO, expressed the results in 2014 US$, incorporated quality and mortality effects from a closely related trial and derived the cost per quality-adjusted life-year (QALY) gained.

FINDINGS

From a health system perspective, the incremental cost per patient of adding an SO was $341.09 [95% confidence interval (CI) = $244.44-437.74]. The incremental cost per year per hazardous drinker averted was $3623 (CI = $1777-22,709), the cost per QALY gained $32,200 (CI = $15,800-201,700), and the benefit-cost ratio was 4.73 (95% CI = 0.7-9.66). If adding an SO into the intervention strategy were concentrated during the hours with highest risk or in a trauma unit, it would become even more cost-beneficial.

CONCLUSIONS

Using criteria established by the World Health Organization (cost-effectiveness below the country's gross domestic product per capita), incorporating a significant other into a patient's motivational intervention for alcohol misuse is highly cost-effective.

Laparoscopic Adjustable Gastric Banding (LAGB) Aftercare Attendance and Attrition

BACKGROUND

Regular aftercare attendance following laparoscopic adjustable gastric banding (LAGB) is associated with greater weight loss and fewer post-surgical complications. Despite high reported rates of attrition from LAGB aftercare, the reasons for non-attendance have not been previously explored. The present study aimed to explore patient-reported barriers to LAGB aftercare attendance, and the perceived helpfulness of potential attrition-reducing strategies, in both regular attendees and non-attendees of aftercare.

METHODS

One hundred and seventy-nine participants (107 regular attendees and 72 non-attendees) completed a semi-structured questionnaire, assessing barriers to attrition (101 items) and usefulness of attrition prevention strategies (14 items).

RESULTS

Findings indicate that both regular attendees and non-attendees experience multiple barriers to aftercare attendance. Non-attendees generally reported that barriers had a greater impact on their aftercare attendance. There was evidence for some level of acceptability for attrition-reducing strategies suggesting that LAGB patients may be receptive to such strategies.

CONCLUSIONS

Current findings highlight the importance of assessing barriers to treatment in both attendees and non-attendees. It is proposed that addressing barriers that differentiate non-attendees from attendees may be most effective in reducing attrition from aftercare.

Does motivational interviewing improve retention or outcome in cognitive behaviour therapy for overweight and obese adolescents?

This study aimed to determine whether motivational interviewing improved retention and/or outcome in cognitive behaviour therapy for overweight and obese adolescents (M=14.4, SD=2.0; 52% female). The first 23 participants were allocated to a standard semi-structure assessment interview, the remaining 19 to a motivational interview, prior to commencing the intervention. The groups did not differ at baseline or on anthropometric (weight, BMI, BMI-z-score, waist circumference, waist-hip or waist-height ratio), body composition (percent body fat, fat mass, lean mass) or attrition measures post-treatment or post-maintenance (p>.01). MI did not improve retention or outcome of cognitive behaviour therapy for adolescent overweight and obesity.

Motivational Interviewing Approach Used by a Community Mental Health Team

The current study aimed to (a) evaluate the effectiveness of motivational interviewing, as applied by a community mental health team (CMHT) based in Singapore; (b) reduce hospital admissions and length of hospital stay; and (c) improve global functioning and satisfaction of individuals with mental illness. The current study used a quasi-experimental method. A convenience sample of 120 participants was selected from the caseload of the CMHT. Participants received motivational interviewing sessions at least once every month for 1 year. Data on the number of hospital admissions, length of hospitalization, Global Assessment of Functioning, and patient satisfaction were collected at baseline and 6 and 12 months. Participants who underwent the CMHT services with motivational interviewing were more compliant to treatment, resulting in significant reduction in hospitalization and improvement in functionality. Motivational interviewing is effective in facilitating better illness management for patients in the community. Adoption of the motivational interviewing approach may potentially provide significant benefits for psychiatric support services in the community.

Motivational interviewing targeting diet and physical activity improves adherence to paediatric obesity treatment: results from the MI Values randomized controlled trial

BACKGROUND

Adherence is a challenge in obesity treatment. Motivational interviewing (MI) may promote patient adherence. MI Values is a randomized controlled trial of MI implemented as an adjunct to an adolescent obesity treatment [Teaching Encouragement Exercise Nutrition Support (T.E.E.N.S.)].

OBJECTIVE

Assess effects of MI Values on T.E.E.N.S. attrition and adherence.

METHODS

Participants were randomized to MI (n = 58) or control (n = 41). At weeks 1 and 10, MI participants had brief MI sessions; controls viewed health education videos. All participants continued with T.E.E.N.S. (biweekly dietitian and behavioural support visits; 3 times per week supervised physical activity). Assessments were repeated at baseline, 3 and 6 months. T-tests and chi-square analyses examined T.E.E.N.S. attrition and adherence by group.

RESULTS

Adolescents (N = 99) were primarily African-American (73%) females (74%); age = 13.8 ± 1.8 years, body mass index percentile = 98.0 ± 1.2. Compared with controls, MI participants had greater 3-month adherence overall (89.2% vs. 81.0%, P = 0.040), and to dietitian (91.3% vs. 84.0%; P = 0.046) and behavioural support (92.9% vs. 85.2%; P = 0.041) visits, and greater 6-month adherence overall (84.4% vs. 76.2%, P = 0.026) and to behavioural support visits (87.5% vs. 78.8%, P = 0.011).

CONCLUSIONS

MI enhanced adherence to this obesity intervention. MI Values is the first study to examine the impact of MI on treatment adherence among obese, primarily African-American adolescents.

Mechanisms of change within motivational interviewing in relation to health behaviors outcomes: a systematic review

OBJECTIVE

Motivational interviewing (MI) has been identified as an effective treatment for health behaviors. Understanding the mechanisms of MI could have practical implications for MI delivery. This review is the first to examine mechanisms within MI that affect health behavior outcomes and summarizes and evaluates the evidence.

METHODS

A systematic literature search was conducted in PSYCHINFO, MEDLINE and EMBASE to identify studies that delivered individual MI in the context of health behaviors, excluding addictions, and investigated mechanisms of MI. Effect sizes were calculated.

RESULTS

291 studies were identified and 37 met the inclusion criteria. Few of the 37 studies included, conducted mediation analyses. MI spirit and motivation were the most promising mechanisms of MI. Although self-efficacy was the most researched, it was not identified as a mechanism of MI. Study quality was generally poor.

CONCLUSION

Although this review has indicated possible mechanisms by which MI could influence health behavior outcomes, it also highlights that more high quality research is needed, looking at other possible mechanisms or causal pathways within health behavior outcomes.

PRACTICE IMPLICATIONS

MI spirit possibly plays an important role within MI and may potentially be used to evoke change talk which links to outcomes.

Weight's up? Predictors of weight-related communication during primary care visits with overweight adolescents

OBJECTIVE

Physicians' use of Motivational Interviewing (MI) techniques when discussing weight with adolescent patients is unknown.

METHODS

We coded audio-recorded encounters between 49 primary care physicians and 180 overweight adolescent patients. During weight discussions, we used the MITI 3.0 to assess: Empathy, MI Spirit, open-ended questions, reflections, MI consistent behaviors (e.g., praising) and MI inconsistent behaviors (e.g., confronting). We examined associations of patient and physician characteristics with (1) MI techniques, (2) time discussing weight, and (3) encounter time.

RESULTS

Physicians used more MI consistent techniques with female patients (p=0.06) and with heavier patients (p=0.02). Physicians with prior MI training also used more MI consistent techniques (p=0.04) and asked more open-ended questions (p=0.05). Pediatricians had a higher MI Spirit score than family physicians (p=0.03). Older patient age was associated with physicians spending less time discussing weight-related topics (p=0.04) and higher BMI percentile was associated with physicians spending more time discussing weight-related topics (p=0.01). Increased use of MI inconsistent techniques was associated with longer encounters (p=0.02).

CONCLUSION

Physicians' weight discussions vary based on adolescent and physician characteristics. Importantly, not using MI lengthened encounter time.

PRACTICE IMPLICATIONS

Physicians might consider using MI techniques more and attempt to use these equally with all adolescents.

Motivational interviewing with parents of overweight children: study design and methods for the NOURISH + MI study

There is an urgent need for innovative approaches to pediatric obesity treatment. There is also a demand for targeted strategies that reduce attrition and improve treatment adherence. Intervening exclusively with parents of overweight children is a novel approach with demonstrated efficacy in reducing child body mass index (BMI) percentile. Motivational interviewing (MI), a brief communication style for exploring and resolving ambivalence about behavior change, might enhance treatment engagement when implemented as part of obesity interventions. The aim of this report is to provide the rationale and methods for a novel study of MI with parents in the treatment of their children's overweight. We designed and are currently implementing NOURISH+MI, a randomized controlled trial examining the feasibility and efficacy of an adjunct values-based MI intervention, implemented within a culturally-tailored parent intervention for overweight children ages 5-11 years, NOURISH(+) (Nourishing Our Understanding of Role modeling to Improve Support and Health). Specifically, we are randomly assigning 60 parents to this adjunctive treatment, and investigating if adding two MI sessions prior to the NOURISH(+) group intervention will enhance treatment effects. We will be able to compare NOURISH+MI participants with those from the two NOURISH(+) treatment conditions (NOURISH(+) and control). We hypothesize that children whose parents participate in NOURISH+MI will demonstrate lower attrition and greater adherence with NOURISH(+), ultimately leading to greater treatment effects, compared with children whose parents are randomized to NOURISH(+) or a control group. Findings will contribute to the emerging literature examining the efficacy of MI within pediatric obesity interventions.

The Cardiovascular Intervention Improvement Telemedicine Study (CITIES): rationale for a tailored behavioral and educational pharmacist-administered intervention for achieving cardiovascular disease risk reduction

BACKGROUND

Hypertension, hyperlipidemia, and diabetes are significant, but often preventable, contributors to cardiovascular disease (CVD) risk. Medication and behavioral nonadherence are significant barriers to successful hypertension, hyperlidemia, and diabetes management. Our objective was to describe the theoretical framework underlying a tailored behavioral and educational pharmacist-administered intervention for achieving CVD risk reduction.

MATERIALS AND METHODS

Adults with poorly controlled hypertension and/or hyperlipidemia were enrolled from three outpatient primary care clinics associated with the Durham Veterans Affairs Medical Center (Durham, NC). Participants were randomly assigned to receive a pharmacist-administered, tailored, 1-year telephone-based intervention or usual care. The goal of the study was to reduce the risk for CVD through a theory-driven intervention to increase medication adherence and improve health behaviors.

RESULTS

Enrollment began in November 2011 and is ongoing. The target sample size is 500 patients.

CONCLUSIONS

The Cardiovascular Intervention Improvement Telemedicine Study (CITIES) intervention has been designed with a strong theoretical underpinning. The theoretical foundation and intervention are designed to encourage patients with multiple comorbidities and poorly controlled CVD risk factors to engage in home-based monitoring and tailored telephone-based interventions. Evidence suggests that clinical pharmacist-administered telephone-based interventions may be efficiently integrated into primary care for patients with poorly controlled CVD risk factors.

No identifiable Hb1Ac or lifestyle change after a comprehensive diabetes programme including motivational interviewing: a cluster randomised trial

OBJECTIVE

To study the effectiveness of a comprehensive diabetes programme in general practice that integrates patient-centred lifestyle counselling into structured diabetes care. Design and setting. Cluster randomised trial in general practices.

INTERVENTION

Nurse-led structured diabetes care with a protocol, record keeping, reminders, and feedback, plus training in motivational interviewing and agenda setting.

SUBJECTS

Primary care nurses in 58 general practices and their 940 type 2 diabetes patients with an HbA1c concentration above 7%, and a body mass index (BMI) above 25 kg/m². Main outcome measures. HbA1c, diet, and physical activity (medical records and patient questionnaires).

RESULTS

Multilevel linear and logistic regression analyses adjusted for baseline outcomes showed that despite active nurse participation in the intervention, the comprehensive programme was no more effective than usual care after 14 months, as shown by HbA1c levels (difference between groups = 0.13; CI 20.8-0.35) and diet (fat (difference between groups = 0.19; CI 20.82-1.21); vegetables (difference between groups = 0.10; CI-0.21-0.41); fruit (difference between groups = 20.02; CI 20.26-0.22)), and physical activity (difference between groups = 21.15; CI 212.26-9.97), or any of the other measures of clinical parameters, patient's readiness to change, or quality of life.

CONCLUSION

A comprehensive programme that integrated lifestyle counselling based on motivational interviewing principles integrated into structured diabetes care did not alter HbA1c or the lifestyle related to diet and physical activity. We thus question the impact of motivational interviewing in terms of its ability to improve routine diabetes care in general practice.

Minimal improvement of nurses' motivational interviewing skills in routine diabetes care one year after training: a cluster randomized trial

BACKGROUND

The effectiveness of nurse-led motivational interviewing (MI) in routine diabetes care in general practice is inconclusive. Knowledge about the extent to which nurses apply MI skills and the factors that affect the usage can help to understand the black box of this intervention. The current study compared MI skills of trained versus non-trained general practice nurses in diabetes consultations. The nurses participated in a cluster randomized trial in which a comprehensive program (including MI training) was tested on improving clinical parameters, lifestyle, patients' readiness to change lifestyle, and quality of life.

METHODS

Fifty-eight general practices were randomly assigned to usual care (35 nurses) or the intervention (30 nurses). The ratings of applying 24 MI skills (primary outcome) were based on five consultation recordings per nurse at baseline and 14 months later. Two judges evaluated independently the MI skills and the consultation characteristics time, amount of nurse communication, amount of lifestyle discussion and patients' readiness to change. The effect of the training on the MI skills was analysed with a multilevel linear regression by comparing baseline and the one-year follow-up between the interventions with usual care group. The overall effect of the consultation characteristics on the MI skills was studied in a multilevel regression analyses.

RESULTS

At one year follow up, it was demonstrated that the nurses improved on 2 of the 24 MI skills, namely, "inviting the patient to talk about behaviour change" (mean difference=0.39, p=0.009), and "assessing patient's confidence in changing their lifestyle" (mean difference=0.28, p=0.037). Consultation time and the amount of lifestyle discussion as well as the patients' readiness to change health behaviour was associated positively with applying MI skills.

CONCLUSIONS

The maintenance of the MI skills one year after the training program was minimal. The question is whether the success of MI to change unhealthy behaviour must be doubted, whether the technique is less suitable for patients with a complex chronic disease, such as diabetes mellitus, or that nurses have problems with the acquisition and maintenance of MI skills in daily practice. Overall, performing MI skills during consultation increases, if there is more time, more lifestyle discussion, and the patients show more readiness to change.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN68707773.

Effectiveness of peer-led self-management coaching for patients recently diagnosed with Type 2 diabetes mellitus in primary care: a randomized controlled trial

AIMS

To study the effectiveness of a peer-led self-management coaching intervention in recently diagnosed patients with Type 2 diabetes.

METHODS

Randomized controlled trial of recently diagnosed patients with Type 2 diabetes from 54 participating general practices. The intervention group received three home visits by an experienced peer (expert patient) who adhered to the recommended treatment and lifestyle guidelines. Together with their expert patient, participants set feasible goals and these were evaluated in the next visit. Participants in the control group received care as usual. At baseline, 3 months and 6 months post-intervention, participants completed a questionnaire measuring changes in self-efficacy, coping, physical activity, dietary habits, psychological well-being, depressive symptoms and diabetes related distress.

RESULTS

In total, 327 patients were eligible for inclusion in the study of which 133 consented to participate. In participating patients, self-efficacy, coping and saturated fat intake improved significantly over time. Analyses of participants with low self-efficacy at baseline (25th percentile: 44) revealed a significant time × group difference, F = 3.71; P = 0.03. Participants who reported low psychological well-being at baseline increased substantially throughout the study (F = 23.84; P < 0.01) but no significant time × group differences were found.

CONCLUSIONS

A peer-led self-management coaching programme for recently diagnosed patients with Type 2 diabetes improved self-efficacy of patients experiencing low self-efficacy shortly after diagnosis.

Motivational interviewing in health care: results of a brief training in endocrinology

BACKGROUND

Despite the importance of lifestyle change in disease management and the growing evidence supporting motivational interviewing (MI) as an effective counseling method to promote behavioral change, to date there are few published reports about MI training in graduate medical education.

OBJECTIVE

The study aimed to pilot the feasibility and effectiveness of a brief MI training intervention for endocrinology fellows and other providers.

METHODS

We used a pretest/posttest design to evaluate a brief MI training for 5 endocrinology fellows and 9 other providers. All participants completed subjective assessments of perceived confidence and beliefs about behavioral counseling at pretest and posttest. Objective assessment of MI was conducted using fellows' audiotaped patient encounters, which were coded using a validated tool for adherence to MI before and after the training. Paired t tests examined changes in objective and subjective assessments.

RESULTS

The training intervention was well received and feasible in the endocrinology setting. At posttest, participants reported increased endorsement of the MI spirit and improved confidence in MI skills. Objective assessment revealed relative improvements in MI skills across several domains. However, most domains, as assessed by a validated tool, did not reach competency level after the training intervention.

CONCLUSIONS

Although more intensive training may be needed to develop MI competence, the results of our pilot study suggest that brief, targeted MI training has short-term efficacy and is well received by endocrinology fellows and other providers.

The role and influence of 'champions' in a community-based lifestyle risk modification programme

This article describes the training and implementation of the Waist Disposal Challenge in service clubs in Western Australia in 2009-2010. Ninety-three Champions from 52 clubs were trained to deliver educational presentations to 1100 peers and facilitate a BMI competition among 764 peers. Champions reported significant improvements in their knowledge and confidence to motivate their peers to make changes to their diet and physical activity with 82% of participants completing the BMI competition and on average 58% experiencing and sustaining a BMI reduction for 12 months. It is evident that the Champions had influenced the uptake and success of the intervention.

Adherence behavior in the prevention and treatment of cardiovascular disease

Adherence is critical to the overall management of individuals at risk for and with cardiovascular disease. It forms an interplay between the patient, provider, and health care system and includes barriers that have been encountered within all 3 domains. Improving adherence to exercise, diet, and medication as well as focusing on addictive disorders such as smoking cessation requires patient, provider, and health care system approaches. The use of the cognitive/behavioral elements of health behavior change and communication strategies such as motivational interviewing and coaching serve to enhance overall adherence. Continuous quality improvement initiatives at the system level of change also increase the likelihood that teams will succeed in helping individuals change their behavior. Cardiac rehabilitation programs offer a unique opportunity for health care professionals to play a key role in supporting individuals through the health behavior change process.

Diabetes care practice patterns of recent pharmacy graduates

PURPOSE

The objective of this project was to determine the amount and type of clinical skills and diabetes education provided by recent pharmacy school graduates.

METHODS

Six hundred and one graduates were e-mailed a link to an online survey. Subjects were asked to report how frequently they either educate patients on diabetes self-care activities or perform diabetes-related patient care skills and to rate their ability to do so as poor, fair, good, or excellent.

RESULTS

Data from 155 (25.8%) respondents were analyzed. The most commonly reported clinical activity was changing medication, followed by interpreting blood glucose patterns, medication management therapy, and interpreting laboratory results. Subjects reported educating patients more on the signs and symptoms of hypoglycemia, blood glucose monitoring, and diet information relative to other topics. The majority of subjects rated their skills as good or excellent.

CONCLUSION

Pharmacists reported the most commonly performed diabetes-related clinical skill was changing medication and they most often educate patients about hypoglycemia and blood glucose monitoring. Subjects, who rated themselves poor/fair in these skills, preferred active learning strategies to enhance their ability.

Promoting nurse interventionist fidelity to motivational interviewing in a diabetes self-care intervention

We describe interventionist training procedures for a pilot intervention study that tested the effects of a nurse-delivered Motivational Interviewing (MI) intervention on diabetes self-care among adults diagnosed with type 2 diabetes mellitus. It reports on findings from MI fidelity assessments. Training consisted of didactic workshops plus practicum. Fidelity of MI was assessed using the MI Treatment Integrity (MITI) Scale. Fidelity assessments were conducted on 18 (25%) audiotaped MI sessions, which were randomly selected from a total of 72 sessions with 26 participants. Scores of the MITI were in the proficient and competent range. Results suggest that training strategies were sufficient to promote satisfactory interventionist fidelity to MI.

Reducing excessive gestational weight gain: lessons from the weight control literature and avenues for future research

Excessive gestational weight gain is a prevalent problem and an independent predictor of future obesity in both mothers and offspring. Intervention research to prevent excessive gestational weight gain is still in its infancy but results to date have been quite modest. Research in weight control outside of pregnancy over the past 30 years has been more robust and identified several key components of effective programs, including use of caloric restriction, daily diet self-monitoring, self-weighing, behavior therapy and ongoing patient-provider contact. The aim of this article is to summarize intervention components shown to be effective in promoting successful weight control outside of pregnancy and explore potential applications in pregnancy. Available evidence suggests that the strategies shown to be effective for weight control outside of pregnancy may also promote better weight control in pregnancy, but several lines for future investigation remain.

Predictors of weight loss communication in primary care encounters

OBJECTIVE

Evidence suggests that physicians' use of motivational interviewing (MI) techniques helps patients lose weight. We assessed patient, physician, relationship, and systems predictors of length of weight-loss discussions and whether physicians' used MI techniques.

METHODS

Forty primary care physicians and 461 of their overweight or obese patients were audio recorded and surveyed.

RESULTS

Weight-related topics were commonly discussed (nutrition 78%, physical activity 82%, and BMI/weight 72%). Use of MI techniques was low. A multivariable linear mixed model was fit to time spent discussing weight, adjusting for patient clustering within physician. More time was spent with obese patients (p=.0002), by African American physicians (p=.03), family physicians (p=.02), and physicians who believed patients were embarrassed to discuss weight (p=.05). Female physicians were more likely to use MI techniques (p=.02); African American physicians were more likely to use MI-inconsistent techniques (p<.001).

CONCLUSION

Primary care physicians routinely counsel about weight and are likely to spend more time with obese than with overweight patients. Internists spend less time on weight. Patient and systems factors do not seem to influence physicians' use MI techniques.

PRACTICE IMPLICATIONS

All physicians, particularly, male and African American physicians, could increase their use of MI techniques to promote more weight loss among patients.

Integration of motivational interviewing into practice in the national exercise referral scheme in Wales: a mixed methods study

BACKGROUND

Though motivational interviewing (MI) has demonstrated efficacy in a range of behaviour change settings, effectiveness will require successful integration into everyday practice. This study examines implementers' views on delivering MI within an exercise referral scheme and consistency of consultations with MI before and after a 2-day workshop.

METHOD

Semi-structured interviews were conducted with 27 exercise professionals and 10 area coordinators delivering the Welsh National Exercise Referral Scheme (NERS), and the MI trainer. Eleven professionals provided consultation recordings before and 6-months after training, coded for fidelity using the Behaviour Change Counselling Index.

RESULTS

The workshop was well received by most, triggering increased recognition of potential motivational roles of consultations. However, some cited difficulties combining MI with structured data gathering activities, whilst a minority rejected MI, seeing current practice as effective, or MI as unnecessary because patients were ready to change. Although limited aggregate improvement in practice was observed, substantial improvements were observed in some individuals. Comments on the need for further practice or training were widespread.

CONCLUSIONS

Efforts to implement MI should ensure that training and structures to provide monitoring and feedback are in place and that activities incorporated within consultations are compatible with MI delivery.

Motivational interviewing to improve weight loss in overweight and/or obese patients: a systematic review and meta-analysis of randomized controlled trials

Motivational interviewing, a directive, patient-centred counselling approach focused on exploring and resolving ambivalence, has emerged as an effective therapeutic approach within the addictions field. However, the effectiveness of motivational interviewing in weight-loss interventions is unclear. Electronic databases were systematically searched for randomized controlled trials evaluating behaviour change interventions using motivational interviewing in overweight or obese adults. Standardized mean difference (SMD) for change in body mass, reported as either body mass index (BMI; kg m(-2) ) or body weight (kg), was the primary outcome, with weighted mean difference (WMD) for change in body weight and BMI as secondary outcomes. The search strategy yielded 3540 citations and of the 101 potentially relevant studies, 12 met the inclusion criteria and 11 were included for meta-analysis. Motivational interviewing was associated with a greater reduction in body mass compared to controls (SMD = -0.51 [95% CI -1.04, 0.01]). There was a significant reduction in body weight (kg) for those in the intervention group compared with those in the control group (WMD = -1.47 kg [95% CI -2.05, -0.88]). For the BMI outcome, the WMD was -0.25 kg m(-2) (95% CI -0.50, 0.01). Motivational interviewing appears to enhance weight loss in overweight and obese patients.

Telephone Lifestyle Coaching: Is It Feasible as a Behavioural Change Intervention for Men?

This study assessed the feasibility of a telephone lifestyle coaching intervention for middle aged and older men in a service club setting and evaluated its impact on behavioural change in terms of BMI, physical activity, dietary habits, self-reported quality of life and stages of change. Forty participants from Rotary clubs in Western Australia participated in this pilot intervention. Findings showed significant improvements in lifestyle risk modification indicators. Participants were very satisfied with the interaction with their coaches and rated highly the telephone as a medium for coaching. Findings suggested that telephone coaching was a feasible means of delivering a lifestyle intervention in a ‘real-world’ setting for a hard to reach population group.

Tailored print communication and telephone motivational interviewing are equally successful in improving multiple lifestyle behaviors in a randomized controlled trial

Background

Computer tailoring and motivational interviewing show promise in promoting lifestyle change, despite few head-to-head comparative studies.

Purpose

Vitalum is a randomized controlled trial in which the efficacy of these methods was compared in changing physical activity and fruit and vegetable consumption in middle-aged Dutch adults.

Methods

Participants (n = 1,629) were recruited via 23 general practices and randomly received either four tailored print letters, four motivational telephone calls, two of each type of intervention, or no information. The primary outcomes were absolute change in self-reported physical activity and fruit and vegetable consumption.

Results

All three intervention groups (i.e., the tailored letters, the motivational calls, and the combined version) were equally and significantly more effective than the control group in increasing physical activity (hours/day), intake of fruit (servings/day), and consumption of vegetables (grams/day) from baseline to the intermediate measurement (week 25), follow-up 1 (week 47) and 2 (week 73). Effect sizes (Cohen’s d) ranged from 0.15 to 0.18. Participants rated the interventions positively; interviews were more positively evaluated than letters.

Conclusions

Tailored print communication and telephone motivational interviewing or their combination are equally successful in changing multiple behaviors.

Electronic supplementary material

The online version of this article (doi:10.1007/s12160-010-9231-3) contains supplementary material, which is available to authorized users.

A values-based Motivational Interviewing (MI) intervention for pediatric obesity: study design and methods for MI Values

To reduce pediatric obesity in clinical settings, multidisciplinary behaviorally-based treatment programs are recommended. High attrition and poor compliance are two difficulties frequently encountered in such programs. A brief, empathic and directive clinical intervention, Motivational Interviewing (MI), might help address these motivational and behavioral issues, ultimately resulting in more positive health outcomes. The efficacy of MI as an adjunct in the treatment of pediatric obesity remains relatively understudied. MI Values was developed to implement within an existing multidisciplinary treatment program for obese, ethnically diverse adolescents, the T.E.E.N.S. Program (Teaching, Encouragement, Exercise, Nutrition, Support). T.E.E.N.S. participants who consent to MI Values are randomized to either MI or an education control condition. At weeks 1 and 10 of T.E.E.N.S. participation, the subset of participants assigned to the MI condition engages in individual MI sessions and control participants view health education videos. All MI sessions are audiotaped and coded to monitor treatment fidelity, which has been satisfactory thus far. Participants complete comprehensive assessments at baseline, 3- and 6-month follow-ups. We hypothesize that MI participants will demonstrate greater reductions in Body Mass Index (BMI) percentile, improved diet and physical activity behaviors, better compliance with T.E.E.N.S., and lower attrition than participants in the control group. We present study design and methods for MI Values as well as data on feasibility of recruitment methods and treatment integrity. At study completion, findings will contribute to the emerging literature examining the efficacy of MI in the treatment of pediatric obesity.

Reducing cardiovascular disease risk in sedentary, overweight women: strategies for the cardiovascular specialist

PURPOSE OF REVIEW

To describe the issue of cardiovascular disease in women, and to discuss evidence-based strategies for promoting lifestyle changes to reduce risk in sedentary, overweight women.

RECENT FINDINGS

Given a recent focus on long-term risk of cardiovascular disease, particularly for women, lifestyle change is especially important. Within practices, motivational interviewing holds promise as an effective counseling approach. Cardiologists may also refer women to evidence-based community programs designed to change diet and physical activity behaviors.

SUMMARY

Increasing fitness, improving food intake, and weight control are key elements in prevention. Ideally, motivational interviewing and community-based programs will work synergistically, with health messages and change efforts mutually supported in both settings.

Capability and clinical success

Better outcomes for chronic diseases remain elusive because success depends on events outside the control of the health care system: patients' ability to mange their health behaviors and chronic diseases. Among the most powerful influences on self-management are the social and environmental constraints on healthy living, yet the clinical response to these environmental determinants is poorly developed. A potential approach for addressing social determinants in practice, as well as planning and evaluating community responses, is the capability framework. Defined as the real opportunity to achieve a desired lifestyle, capability focuses attention on the material conditions that constrain real opportunity and how opportunity emerges from the interaction between personal resources and the social environment. Using examples relevant to chronic disease and behavior change, we discuss the clinical application of the capability framework.

Tobacco use cessation and weight management among motor freight workers: results of the gear up for health study

OBJECTIVES

To present the results of a study of a worksite-based intervention to promote tobacco use cessation and improve weight management among motor freight workers.

METHODS

This study used a pre-test/post-test, non-randomized design to assess the effectiveness of a four-month intervention that addressed the social context of the work setting. We evaluated 7-day tobacco quit prevalence among baseline tobacco users, and successful weight management, defined as no weight gain in workers with BMI <25 at baseline and any weight loss among overweight and obese workers.

RESULTS

At baseline, 40% were current tobacco users, and 88% had a BMI of 25 or greater. Of 542 workers invited to participate, 227 agreed to participate and received at least the first telephone call (42%). Ten-month post-baseline, baseline tobacco users who participated in the intervention were more likely to have quit using tobacco than non-participants: 23.8% vs. 9.1% (p = 0.02). There was no significant improvement in weight management.

CONCLUSIONS

Incorporating work experiences and job conditions into messages of health behavior change resulted in significant tobacco use cessation among participating motor freight workers.

Peer-based behavioural strategies to improve chronic disease self-management and clinical outcomes: evidence, logistics, evaluation considerations and needs for future research

The diagnosis of a chronic disease such as diabetes generally evokes strong emotions and often brings with it the need to make changes in lifestyle behaviours, such as diet, exercise, medication management and monitoring clinical and metabolic parameters. The diagnosis thus affects not only the person diagnosed but also the family members. Chronic illnesses are largely self-managed with approximately 99% of the care becoming the responsibility of patients and their families or others involved in the daily management of their illnesses. While the responsibility for outcomes, such as metabolic control and chronic complications, are shared with the health care team, the daily decisions and behaviours adopted by patients clearly have a strong influence on their future health and well-being. While diabetes self-management education is essential, it is generally not sufficient for patients to sustain behaviours and cope with a lifetime of diabetes. Peers have been proposed as one method for assisting patients to deal with the behavioural and affective components of diabetes and to provide ongoing self-management support. This paper first describes effective behavioural strategies in diabetes, based on multiple studies and/or meta-analyses, and then provides examples of their use by peers or in peer-based programmes in diabetes. A comprehensive search using the MEDLINE and Cinahl databases was conducted. Key search terms included peer mentors, peer leaders, peer educators, lay health workers and community health workers. Studies that clearly identified behavioural strategies used by peers were included.

Primary care nurses struggle with lifestyle counseling in diabetes care: a qualitative analysis

Background

Patient outcomes are poorly affected by lifestyle advice in general practice. Promoting lifestyle behavior change require that nurses shift from simple advice giving to a more counseling-based approach. The current study examines which barriers nurses encounter in lifestyle counseling to patients with type 2 diabetes. Based on this information we will develop an implementation strategy to improve lifestyle behavior change in general practice.

Method

In a qualitative semi-structured study, twelve in-depth interviews took place with nurses in Dutch general practices involved in diabetes care. Specific barriers in counseling patients with type 2 diabetes about diet, physical activity, and smoking cessation were addressed. The nurses were invited to reflect on barriers at the patient and practice levels, but mainly on their own roles as counselors. All interviews were audio-recorded and transcribed. The data were analyzed with the aid of a predetermined framework.

Results

Nurses felt most barriers on the level of the patient; patients had limited knowledge of a healthy lifestyle and limited insight into their own behavior, and they lacked the motivation to modify their lifestyles or the discipline to maintain an improved lifestyle. Furthermore, nurses reported lack of counseling skills and insufficient time as barriers in effective lifestyle counseling.

Conclusions

The traditional health education approach is still predominant in primary care of patients with type 2 diabetes. An implementation strategy based on motivational interviewing can help to overcome 'jumping ahead of the patient' and promotes skills in lifestyle behavioral change. We will train our nurses in agenda setting to structure the consultation based on prioritizing the behavior change and will help them to develop social maps that contain information on local exercise programs.

Elements of External Validity of Tools for Health: An Intervention for Construction Laborers

Purpose.

To examine the external validity of an efficacious tailored smoking cessation and nutrition improvement telephone intervention.

Design.

Comparison of characteristics of participants and nonparticipants (representativeness); examination of the extent of intervention implementation.

Setting.

Cancer center collaboration with a labor union.

Subjects.

Unionized construction laborers.

Intervention.

Tailored feedback report, telephone counseling, and supplementary educational materials focused on smoking cessation and improved nutrition.

Measures.

Background survey identifying socio-demographic and behavioral characteristics; process evaluation data; and final efficacy survey to determine participant satisfaction.

Analysis.

Cross-classification and the X2 test of homogeneity were used with categorically measured variables comparing participants and nonparticipants. We compared the means in the two groups for continuously scaled measures using the Student t-test and investigated the multivariable association of the characteristics of participation with a multiple logistic regression. For process data we present frequencies, percentages, and means.

Results.

Characteristics associated with participation included self-efficacy to change fruit and vegetable consumption (p = .0009) and self-identification with union's problems (p = 0.05). Eighty-six percent of non-smokers and 61% of smokers completed between 1 and 4 counseling sessions. Over one-half of non-smokers (61%) and smokers (53%) completed 4 or more calls and more smokers (34%) than non-smokers (11%) completed the 5+ sessions.

Conclusions.

These results provide a snapshot of characteristics of construction laborers to whom this intervention can be generalized and indicators of feasibility necessary for translating research into practice.

Feasibility of using motivational interviewing in a Swedish pharmacy setting

Objectives

Motivational interviewing (MI) is widely established as an effective counselling approach for many lifestyle issues, but is largely untested in pharmacy settings. The aim of this study was to identify factors that impact on the feasibility of using MI with pharmacy clients in routine community pharmacy work in Sweden.

Methods

Interviews were conducted with 15 pharmacists at two pharmacies after they had participated in manual-based MI skills training and used MI with clients for 6 months. The pharmacists were offered hands-on training from ‘pilot pharmacists’ who had received more MI training and were involved in assembling the manual that adapted MI for use in pharmacies. Three focus groups with the pharmacists and five individual interviews with pharmacists in leading positions were conducted. Data were interpreted from a phenomenological perspective.

Key findings

Pharmacists who had previously participated in education that included elements similar to MI felt this facilitated their use of MI. Pharmacists experienced many difficulties associated with the practical application of MI, including initiating and concluding client conversations. The opportunity to decide on appropriate clients and/or health-related behaviours for counselling was an important facilitator. The pharmacists believed the physical environment of the pharmacies was favourable for MI use, but they experienced time limitations when there were many clients on the premises. The organisational context in which MI was applied affected the pharmacists' attitudes to using MI.

Conclusions

There are several factors to take into consideration in the implementation of MI in pharmacies.

A self-management concept for men at the community level: the 'Waist' Disposal Challenge

The Waist Disposal Challenge consisted of a health intervention at the community level to bring about a reduction in body mass index (BMI) and is delivered at three levels: educational presentations on nutrition and exercise; monthly monitoring of BMI competition; telephone lifestyle coaching with follow-ups. Twenty-three Rotary Clubs participated in Western Australia in 2007-08 (750 Rotarians). The significant to moderate decreases in BMI are an encouraging indication that such community based-projects for men at-risk of developing chronic disease may influence the way health services reorient their community programmes to suit the health psychology of middle-aged to older men.