Motivational interviewing in health settings: a review

Does motivational interviewing have a role in dentistry?

Traditional approaches to health promotion involve clinicians imparting knowledge to patients and 'telling' patients what changes they should make to benefit their health. This so-called 'fixing reflex' can be counterproductive and ineffective, creating unhelpful discord between clinicians and patients. There is little evidence that this approach is wholly effective in bringing about healthier patient behaviours. In contrast, motivational interviewing (MI) is a patient-centred consultation style aimed at developing patient motivation and commitment for a range of health-related behaviours. It focuses on discovering the values, beliefs and goals of patients and encourages clinicians and patients to work together collaboratively, to bring about change and growth. It is an effective, evidence-based approach, even when used as a 'brief intervention' for a few minutes only. This paper discusses how MI can be applied in dental healthcare settings to enhance general and oral health. The evidence available for its use in dentistry is discussed, along with opportunities for training of the dental team in this skill.

Patient-centric care in primary immune thrombocytopenia (ITP): shared decision-making and assessment of health-related quality of life

ABSTRACTImmune thrombocytopenia (ITP), an autoimmune disease characterized by low platelet counts and increased bleeding risk, can impair health-related quality of life (HRQoL), impacting patients' daily lives and mental health. A number of patient-reported outcome (PRO) measures (both generic and specific to ITP) can be used to understand the impact of ITP on HRQoL and generate evidence to guide disease management. As well-developed PRO tools could help in HRQoL assessment, their optimization could help to solidify a patient-centric approach to ITP management. Shared decision-making is a collaborative process between a patient and their healthcare professional in making decisions about care. Treatment decisions based on this shared process between physician and patient are recommended by clinical guidelines. The goal of this narrative review is to discuss treatment decisions with regards to patient-centric ITP management, with a focus on the impact of PRO measures and the process of shared decision-making in practice.

Empowering Families and Providers With a Lifestyle Medicine Approach to Pediatric Obesity

Pediatric overweight and obesity is a complex chronic medical condition with a multitude of contributing factors. Rates are now nearly double what they were before the COVID-19 pandemic and if the current trajectory holds it is anticipated that by 2050 one in every two US children will experience obesity before the age of thirty-five. Pediatric obesity guidelines emphasize referral to intensive health behavior and lifestyle therapy programs, but these are difficult to access. Front line providers caring for children can use a lifestyle medicine approach within the medical home to make lifestyle changes easier. Lifestyle Medicine can promote a family-oriented, weight-neutral approach by (1) Educating and equipping providers to assess readiness to change and providing high-quality motivational interviewing and lifestyle counseling, (2) Equipping patients and their families with tools involving the six lifestyle interventions to optimize health starting an early age, and (3) Offering a longitudinal uniform office approach to effectively prevent, manage and often reverse obesity and related comorbidities through healthy habit change.

Creating and Validating a Questionnaire for Assessing Dentists' Self-Perception on Oral Healthcare Management-A Pilot Study

BACKGROUND AND OBJECTIVES

Questionnaires designed to test knowledge and self-perception can be valuable tools for diagnosing a dentist's understanding of the management and administration of a practice. The objective of this study was to create and authenticate a questionnaire for assessing dentists' self-perception on oral healthcare management developed from discussions with experts in this field.

MATERIAL AND METHODS

In order to create and verify a questionnaire survey, a cross-sectional, descriptive, and analytical study was carried out. Participants' personal information and 31 statements across four categories made up the final questionnaire form. The answers to the questionnaire were in the form of a Likert scale. After refining the initial version, a total of 36 interviews were conducted at dental offices to verify the validity. For the Exploratory Factor Analysis (EFA), we used the Kaiser-Meyer-Olkin (KMO) index, the Bartlett sphericity test, and also Cronbach alpha coefficient for the validity of the questionnaire.

RESULTS

The accuracy of the instrument was measured by intrarater and interrater reliability. For the EFA, all the communalities exceeded the threshold of 0.05. With a Cronbach's alpha coefficient of 0.898, the questionnaire has sufficient internal consistency.

CONCLUSIONS

The questionnaire demonstrates robust reliability and validity, thereby affirming its suitability for its intended purpose.

Nourishing Conversations: Using Motivational Interviewing in a Community Teaching Kitchen to Promote Healthy Eating via a Food as Medicine Intervention

It is well known that dietary choices impact both individual and global health. However, there are numerous challenges at the personal and systemic level to fostering sustainable healthy eating patterns. There is a need for innovative ways to navigate these barriers. Food as Medicine (FM) and Culinary Medicine (CM) are approaches to helping individuals achieve healthier diets that also recognize the potential to alleviate the burden of chronic diseases through healthy eating. Teaching kitchens, which offer an interactive environment for learning nutrition and cooking skills, are valuable educational tools for FM and CM interventions. Motivational interviewing (MI), a type of person-centered counseling, facilitates behavior change and may enhance FM and CM programs involving teaching kitchens. In this commentary, we share our experience with using MI in a community-based CM program at a teaching kitchen. In demonstrating our application of MI principles, we hope to offer an additional strategy for improving dietary quality and delivering nutrition education.

Feasibility and acceptability of C-PRIME: A health promotion intervention for family caregivers of patients with colorectal cancer

PURPOSE

This study aimed to test the feasibility and acceptability of a digital health promotion intervention for family caregivers of patients with advanced colorectal cancer and explore the intervention's preliminary efficacy for mitigating the impact of caregiving on health and well-being.

METHODS

We conducted a single-arm pilot feasibility trial of C-PRIME (Caregiver Protocol for Remotely Improving, Monitoring, and Extending Quality of Life), an 8-week digital health-promotion behavioral intervention involving monitoring and visualizing health-promoting behaviors (e.g., objective sleep and physical activity data) and health coaching (NCT05379933). A priori benchmarks were established for feasibility (≥ 50% recruitment and objective data collection; ≥ 75% session engagement, measure completion, and retention) and patient satisfaction (> 3 on a 1-5 scale). Preliminary efficacy was explored with pre- to post-intervention changes in quality of life (QOL), sleep quality, social engagement, and self-efficacy.

RESULTS

Participants (N = 13) were M = 52 years old (SD = 14). Rates of recruitment (72%), session attendance (87%), assessment completion (87%), objective data collection (80%), and retention (100%) all indicated feasibility. All participants rated the intervention as acceptable (M = 4.7; SD = 0.8). Most participants showed improvement or maintenance of QOL (15% and 62%), sleep quality (23% and 62%), social engagement (23% and 69%), and general self-efficacy (23% and 62%).

CONCLUSION

The C-PRIME digital health promotion intervention demonstrated feasibility and acceptability among family caregivers of patients with advanced colorectal cancer. A fully powered randomized controlled trial is needed to test C-PRIME efficacy, mechanisms, and implementation outcomes, barriers, and facilitators in a divserse sample of family caregivers.

TRIAL REGISTRATION

The Caregiver Protocol for Remotely Improving, Monitoring, and Extending Quality of Life (C-PRIME) study was registered on clinicaltrials.gov, NCT05379933, in May 2022.

Discrimination and social identity processes predict impairment and dysfunction among heavy drinkers

BACKGROUND

Previous research has linked discrimination to poorer health. Yet health risk behaviours such as heavy alcohol consumption are often targeted with stigmatising public health campaigns. The current study sought to establish the link between experiencing discrimination and health outcomes among heavy drinkers, with a focus on exploring the multiple social identity processes that might underpin this relationship.

METHODS

A survey was conducted with 282 people who self-reported consuming alcohol above recommended guidelines. We measured discrimination experienced as a drinker, components of social identification as a drinker (centrality, satisfaction, solidarity, homogeneity, and self-stereotyping), and two health outcomes: psychological distress and severity of alcohol use disorder symptomatology.

RESULTS

Discrimination was a moderate-large predictor of psychological distress and alcohol use disorder symptoms. Three social identity constructs were implicated in the link between discrimination and ill-health: identity centrality and homogeneity positively mediated this relationship while identity satisfaction was a negative mediator. The model explained a large proportion of the variance (39-47%) in health outcomes.

DISCUSSION

Results are interpreted with an emphasis on the need to avoid stigmatising messaging and to prioritise social identity processes to prevent and treat substance use disorders. We further highlight the need for social identity researchers to consider the multidimensional nature of social identities, especially in the context of stigmatised groups.

Health literacy and self-care among patients with chronic kidney disease in a primary care setting

INTRODUCTION

The study objective was to determine the levels of self-care and health literacy (HL) and their associations among patients with chronic kidney disease (CKD).

METHODS

This was a cross-sectional, questionnaire-based study conducted in a public primary care setting in Singapore. A total of 289 participants aged 21-80 years with hypertension were recruited. Self-care profiles were measured using the Hypertension Self-Care Profile (HTN-SCP; range 0-240, domain range 0-80). Health literacy was measured using the Short-Form Health Literacy Scale (HLS-SF12; range 0-50, limited literacy ≤33).

RESULTS

The mean self-care score was 182.7 (standard deviation [SD] 23.2). The median HL score was 34.7 (interquartile range [IQR] 31.9-40.3), and 31.1% of participants had limited HL. Self-care was not associated with age, CKD status, household income and education, but was associated with gender and HL score. In the final regression model, lower HL scores (adjusted β = 1.03, 95% confidence interval [CI] 0.7 to 1.36, P < 0.001) and male gender (adjusted β = -5.29, 95% CI -10.56 to -0.03, P = 0.049) were associated with lower self-care scores. The HL scores were associated with self-care domains of self-efficacy (HL: β = 0.30, 95% CI 0.17 to 0.42, P < 0.001), motivation (HL: β = 0.40, 95% CI 0.26 to 0.53, P < 0.001) and behaviour (HL: β = 0.38, 95% CI 0.26 to 0.50, P < 0.001).

CONCLUSION

Thirty-one percent of the participants had limited HL. Self-care was not associated with age, race, CKD status, household income or education. Male gender and limited HL were associated with lower self-care. Self-care was associated with self-efficacy, motivation and behaviour. Future research could focus on more targeted approaches to improve self-care and HL among patients with CKD.

Incorporating technology in research with older bereaved adults: Lessons learned from conducting an internet-based randomized controlled trial

Objective

Digital health interventions (DHI) involve multiple interactions between the user, technology platform, and study team, posing challenges for implementation. This paper describes the lessons learned while implementing an internet-based randomized controlled trial (RCT) for reducing depression symptom burden in older acutely-bereaved adults.

Methods

The RCT was entitled "Widowed Elders' Lifestyle after Loss" (or WELL), which compared the efficacy of a DHI to an enhanced usual care (EUC) for reducing depression symptoms in adults 60+ years who lost their spouse/life partner within the previous 12 months. Participants randomized to the DHI used their own tablet, smartphone, or pc to record the timing and regularity of sleep, meals, and physical activity twice daily, for 12 weeks. The also received weekly health coaching sessions from a clinician certified in motivational interviewing. Participants randomized to the EUC arm received weekly calls from research staff and were assessed on the same schedule as intervention participants. All study procedures were conducted virtually. Methodological and procedural challenges were discussed weekly with study staff and the primary investigator.

Results

Many challenges can be categorized as follows recruiting virtually, obtaining informed consent, training older adults to use technology, and establishing rapport with older adults. Solutions required researcher and interventionist flexibility in adapting to new strategies. For instance, we redesigned the informed consent process to include a user-friendly brochure that enhanced participants' understanding of the RCT and improved our enrollment rate. We also utilized user-engagement in refining an intervention protocol.

Conclusion

We resolved implementation challenges without compromising internal validity via interdisciplinary collaborations with mobile programmers to ensure our technology met the unique and varied needs of aging users. The solutions from this study may promote the recruitment and retainment of older adults in research studies that use technology-based interventions.

Evaluation of the effectiveness of a joint general practitioner-pharmacist intervention on the implementation of benzodiazepine deprescribing in older adults (BESTOPH-MG trial): protocol for a cluster-randomized controlled trial

Background

Deprescribing benzodiazepines and related drugs (BZDR) is a challenge due to a lack of time on physicians' part, a lack of involvement of other health professionals, and the need for adapted tools. This study is based on primary care collaboration, by evaluating the effectiveness of a joint intervention between general practitioners and community pharmacists on the implementation of BZDR deprescribing in older adults.

Methods

This is a cluster randomized controlled trial in which each cluster will be formed by a physician-pharmacist pair. Within a cluster allocated to the intervention, the pharmacist will be trained in motivational interviewing (MI), and will offer the patient 3 interviews after inclusion by the physician. They will base their intervention on validated deprescribing guidelines. The pharmacist will receive methodological support during the first interviews. Interprofessional collaboration will be encouraged by writing reports for the physician after each interview. The following implementation outcomes will be evaluated: acceptability/adoption, appropriateness, cost, and fidelity. They will be measured by means of sociological interviews, observations, logbooks, and cost-utility analysis. Focus groups with physicians and pharmacists will be carried out to identify levers and barriers experienced in this collaboration. Observations will be conducted with pharmacists to assess their approach of the MIs. Effectiveness outcomes will be based on medication (discontinuation or reduction of BZDR) and clinical outcomes (such as quality of life, insomnia or anxiety), assessed by health insurance databases and validated questionnaires.

Discussion

This study will determine whether collaboration in primary care between physicians and pharmacists, as well as training and coaching of pharmacists in motivational interviewing, allows the implementation of BZDR deprescribing in the older adults.This study will provide an understanding of the processes used to implement deprescribing guidelines, and the contribution of collaborative practice in implementing BZDR discontinuation. The cluster methodology will allow to assess the experience of the relationship between the different primary care actors, and the related obstacles and levers.The results obtained will make it possible to produce guidelines on the involvement of community pharmacists in the management of substance abuse in older adults, or even to legislate new missions or care pathways.

Clinical trial registration

ClinicalTrials.gov, identifier, NCT05765656.

Reasons for recovery and readiness to change among adolescents and young adults engaging in self-injury

Background

Non-suicidal self-injury (NSSI) typically begins during adolescence and the process of treatment and recovery can be challenging. We examine NSSI through the lens of the Transtheoretical Model of Change, a framework that views the process of change as five stages, with differing degrees of readiness to change.

Methods

Thirty participants, both adolescents and young adults (14 to 35 years), were recruited from a tertiary care neuropsychiatric hospital. The participants were predominantly female and had self-injured at least once in the last year. They completed the Inventory of Statements about Self Injury, the University of Rhode Island Change Assessment and the Reasons to Stop Self-Injury Questionnaire.

Results

Seventy-three percent were in the contemplation stage with respect to their readiness to change, while the rest were in the pre-contemplation stage. Participants endorsed a range of vulnerability and resilience related reasons to stop injuring; reasons related to self-efficacy, the addictive nature of NSSI, self-efficacy and impact on interpersonal relationships were prominent levers for the recovery process. Preliminary trends indicated that participants in the contemplation stage endorsed reasons to stop self-injuring more strongly than those in pre-contemplation.

Conclusion

The findings carry implications for assessment, the amplification of reasons for recovery and individualized interventions to support the recovery process with individuals who engage in NSSI.

Cognitive Behavioral Therapy Enhances Survival in Cardiac Patients Aged Under 60: 14-YEAR OUTCOMES OF THE BEATING HEART PROBLEMS PROGRAM TRIAL

PURPOSE

To optimize recovery and improve prognosis, people who have had an acute cardiac event (ACE) need support to manage their cardiac risk. In 2008, we conducted a randomized controlled trial (RCT) of Beating Heart Problems (BHP) , an 8-wk group program based on cognitive behavioral therapy (CBT) and motivational interviewing (MI), designed to improve behavioral and mental health. This study investigated 14-yr mortality status for RCT participants in order to evaluate the survival impact of the BHP program.

METHODS

In 2021, mortality data on 275 participants from the earlier RCT were obtained from the Australian National Death Index. Survival analysis was undertaken to investigate differences in survival for participants in the treatment and control groups.

RESULTS

Over the 14-yr follow-up period, there were 52 deaths (18.9%). For those aged <60 yr, there was a significant survival benefit to program participation, with 3% deaths in the treatment group and 13% deaths in the control group ( P = .022). For those aged ≥60 yr, the death rate was identical in both groups (30%). Other significant predictors of mortality included older age, higher 2-yr risk score, lower functional capacity, lower self-rated health, and having no private health insurance.

CONCLUSIONS

Participation in the BHP conferred a survival benefit for patients aged <60 yr but not for participants overall. The findings highlight the long-term benefit of behavioral and psychosocial management of cardiac risk through CBT and MI for those who are younger at the time of their first ACE.

Inpatient obstetric consultation-liaison services: Meeting unmet needs in perinatal mental health

Obstetric patients are at increased risk for psychological distress and the development or exacerbation of mental illness, particularly in the setting of pregnancy or delivery complications. Inpatient antepartum, labor and delivery, and postpartum hospitalization is an important opportunity for psychiatric support and intervention. The aims of this paper are to review the unmet mental health needs in obstetric inpatient care, examine the current state of obstetric consultation-liaison (OB CL) psychiatry services, present one existing model of such a service at the authors' institution, provide broad recommendations for the structure and implementation of this service, and detail areas of future research within the area of OB CL psychiatry. We argue that the inpatient obstetric setting is a critical space for mental health evaluation, education and intervention, and that dedicated OB CL psychiatry services are a potentially valuable tool in addressing the perinatal mental health crisis.

Oral health promotion in acute hospital setting: a quality improvement programme

Tooth extraction is the most common hospital procedure for children aged 6-10 years in England. Tooth decay is almost entirely preventable and is inequitably distributed across the population: it can cause pain, infection, school absences and undermine overall health status.An oral health programme (OHP) was delivered in a hospital setting, comprising: (1) health promotion activities; (2) targeted supervised toothbrushing (STB) and (3) staff training. Outcomes were measured using three key performance indicators (KPI1: percentage of children/families seeing promotional material; KPI2: number of children receiving STB; KPI3: number of staff trained) and relevant qualitative indicators. Data were collected between November 2019 and August 2021 using surveys and data from the online booking platform.OHP delivery was impacted by COVID-19, with interventions interrupted, reduced, eliminated or delivered differently (eg, in-person training moved online). Despite these challenges, progress against all KPIs was made. 93 posters were deployed across the hospital site, along with animated video 41% (233/565) of families recalled seeing OHP materials across the hospital site (KPI1). 737 children received STB (KPI2), averaging 35 children/month during the active project. Following STB, 96% participants stated they learnt something, and 94% committed to behaviour change. Finally, 73 staff members (KPI3) received oral health training. All people providing feedback (32/32) reported learning something new from the training session, with 84% (27/32) reporting that they would do things differently in the future.Results highlight the importance of flexibility and resilience when delivering QI projects under challenging conditions or unforeseen circumstances. While results suggest that hospital-based OHP is potentially an effective and equitable way to improve patient, family and staff knowledge of good oral health practices, future work is needed to understand if and how patients and staff put into practice the desired behaviour change and what impact this may have on oral health outcomes.

Motivational Interviewing in Primary-Care: Substance Use Disorders beyond AUDIT/DAST

Primary-care settings have a unique advantage to reaching a broad range of the population and the ability to address a wide array of presenting problems, including substance-use. With high rates of substance-use in the United States and low rates of substance-use treatment utilization, the primary-care office is key in assessing and supporting patients in changing substance-use behaviors. Motivational interviewing is a conversational tool physicians can use to highlight intrinsic motivation for change and support specific changes patients want to make. Providers can also apply motivational interviewing to a variety of chronic health care behaviors.

Premature mortality of people with severe mental illness: a renewed focus for a new era

This perspective article applies public health principles to improve the physical health of selected populations with mental disorders. Two preventable adverse outcomes, poorer physical health and premature mortality, are described across mental disorders. Evidence of the lifetime effects of adverse childhood experiences and inequalities is presented: these are the 'causes of the causes'. Seven drivers of physical disorders are illustrated that drive preventable deaths and as doctors, psychiatrists must lead from the front to reverse rising mortality. Evidence supports universal and selective interventions and even the most difficult challenges such as weight gain and opioid misuse are an opportunity for psychiatry to engage with individual patients and their organisations, public health colleagues, health systems and beyond. Interventions complement and do not replace existing clinical practices that reduce self-harm and prevent suicide. Mental health teams already do most of the work in this arena, and the case is made to refocus on physical health with task sharing. The top 10 recommendations within a personalised medicine framework are listed in this paper as a starting point.

A pilot randomized controlled trial on motivational interviewing in return to work after work disability

PURPOSE

Does 15-minute consult using Motivational Interviewing (MI) have a positive effect on (1) time until return to work (RTW) and relapse after work resumption for patients who have been work disabled for longer than 3 months, and (2) can psychological variables (i.e., work-related motivation, work-related psychological needs, quality of life and work ability) explain these results?

METHODS

265 patients were included in a pilot randomized controlled trial, parallel and single blind, with an allocation ratio of 1:1 comparing the consult with MI with the consult as usual group (CAU). There was a 12-month follow up on actual RTW and relapse for both groups. The psychological outcomes were work-related motivation (MAWS), work-related psychological needs (BPNSFS), quality of life (EQ5D5L)) and work ability (WAI). Measurement of these indicators took place at baseline, 1 week after the intervention and 3 months after the intervention.

RESULTS

Patients in the MI group showed faster RTW and had a lower chance of relapse compared to those in the CAU condition. No significant differences were found between MI and CAU for the psychological outcomes.

CONCLUSIONS

Based on our results, there is some evidence that counseling including MI helps work-disabled patients to RTW faster and experience less relapse. However, much remains unknown about the underlying psychological mechanisms explaining this effect. Suggestions are made for the full RCT.

Health motivations and perceived barriers are determinants of self-care behaviour for the prevention of hypertension in a Malaysian community

INTRODUCTION

Self-care behaviour is fundamental in preventing hypertension in the general population. According to the Health Belief Model, health beliefs and perceptions influence the success in adopting disease prevention strategies. While factors influencing hypertension self-care behaviour have been examined previously in patient populations, they have not been assessed in the general community.

METHODS

This was a cross-sectional study conducted between 12 June 2020 to 26 July 2021. An online survey was administered via email and social media to Malaysians in the Selangor and Kuala Lumpur communities. Respondents were over 18 years old, without a formal diagnosis of hypertension. The survey evaluated hypertension knowledge, Health Belief Model constructs, self-care behaviour frequency, and motivators and barriers to self-care behaviour. Multiple linear regression was performed to determine the main predictors of self-care behaviour, and descriptive statistics were used to characterise motivators and barriers of each self-care behaviour.

RESULTS

Only health motivations (β = 0.217, p < 0.001) and perceived barriers (β = 0.571, p < 0.001) significantly influenced self-care behaviour. Maintaining a healthy diet, regular physical activity and blood pressure checks need to be improved in the community, particularly in reducing salt and calorie intake. Lack of time, limited choices and laziness are the biggest challenges that need to be tackled in adopting a healthy diet and an active lifestyle in the community. Many are ignorant towards their health status, therefore, do not prioritize blood pressure screenings, suggesting a need to enhance community blood pressure checks for early diagnosis of hypertension.

CONCLUSION AND IMPLICATIONS

Motivations and barriers were the main determinants of self-care behaviour in the Selangor and Kuala Lumpur community. Targeting these aspects of self-care behaviour should be considered when developing interventions and education programmes tailored to local cultural, environmental and personal factors, to more effectively reduce the hypertension prevalence and burden.

Using the Exploration-Preparation-Implementation-Sustainment (EPIS) Framework to prepare for the implementation of evidence-based practices into adolescent HIV settings

Despite advances in evidence-based practices (EBP) to support HIV prevention and treatment, youth ages 13-24 experience significant disparities in HIV risk and outcomes. An important factor in this disparity is poor EBP implementation, yet implementation research is limited, particularly in youth-serving settings. This study used the Exploration, Preparation, Implementation, Sustainment (EPIS) framework to guide the implementation of four Motivational Interviewing (MI) and MI-framed interventions into youth-serving HIV prevention and treatment settings. Key stakeholders (n = 153) across 13 sites completed pre-implementation interviews. Stakeholders' comments identified two critical factors for effective implementation: fit with the patient population and provider receptivity, including concerns about scope of practice, buy-in, and time. Stakeholders recommended strategies for structuring training, fidelity monitoring, and facilitating implementation including engaging informal leaders, collaboratively developing the implementation strategy, and site-wide implementation. Results highlight the importance of pre-implementation contextual assessment and strategic planning for identifying provider concerns and developing responsive implementation strategies.

Effect of Computer-Tailored Print Feedback, Motivational Interviewing, and Motivational Enhancement Therapy on Engagement in Advance Care Planning: A Randomized Clinical Trial

Importance

There is a tension between clinician-led approaches to engagement in advance care planning (ACP), which are effective but resource-intensive, and self-administered tools, which are more easily disseminated but rely on ability and willingness to complete.

Objective

To examine the efficacy of computer-tailored print feedback (CTPF), motivational interviewing (MI), and motivational enhancement therapy (MET) on completion of a set of ACP activities, each as compared with usual care.

Design, Setting, and Participants

This randomized clinical trial was conducted from October 2017 to December 2020 via telephone contact with primary care patients at a single VA facility; 483 veterans aged 55 years or older were randomly selected from a list of patients with a primary care visit in the prior 12 months, with oversampling of women and people from minoritized racial and ethnic groups. Statistical analysis was performed from January to June 2022.

Interventions

Mailed CTPF generated in response to a brief telephone assessment of readiness to engage in and attitudes toward ACP; MI, an interview exploring ambivalence to change and developing a change plan; and MET, MI plus print feedback, delivered by telephone at baseline, 2, and 4 months.

Main Outcome and Measures

Self-reported completion of 4 ACP activities: communicating about views on quality vs quantity of life, assignment of a health care agent, completion of a living will, and submitting documents for inclusion in the electronic health record at 6 months.

Results

The study included 483 persons, mean (SD) age 68.3 (8.0) years, 18.2% women and 31.1% who were people from minoritized racial and ethnic groups. Adjusting for age, education, race, gender, and baseline stage of change for each ACP, predicted probabilities for completing the ACP activities were: usual care 5.7% (95% CI, 2.8%-11.1%) for usual care, 17.7% (95% CI, 11.8%-25.9%; P = .003) for MET, 15.8% (95% CI, 10.2%-23.6%; P = .01) for MI, P = .01, and 10.0% (95% CI, 5.9%-16.7%; P = .18) for CTPF.

Conclusions and Relevance

This randomized clinical trial found that a series of 3 MI and MET counseling sessions significantly increased the proportion of middle-aged and older veterans completing a set of ACP activities, while print feedback did not. These findings suggest the importance of clinical interaction for ACP engagement.

Trial Registration

ClinicalTrials.gov Identifier: NCT03103828.

Attitudes and experiences towards the application of motivational interviewing by podiatrists working with people with diabetes at high-risk of developing foot ulcers: a mixed-methods study

Background

Podiatrists are key professionals in promoting adequate foot self-care for people with diabetes at high-risk of developing foot ulcers. However, merely informing patients about the advantages of foot self-care is insufficient to realise behavioural change. Motivational interviewing (MI) is a promising person-centred communication style that could help to create a working alliance between healthcare providers and patient to improve foot self-care. This study aims to observe and analyse the application of MI in consultations carried out by MI-trained and non-MI-trained podiatrists with their patients, and explore podiatrists’ attitudes and experiences towards MI.

Methods

Eighteen podiatrists (median age: 28.5 years, 10 female and 8 male) followed a three-day basic training in MI and 4 podiatrists (median age: 38.5 years, 4 female) were not trained in MI. To observe and rate the MI-fidelity in daily clinical practice, audio recordings from the MI-trained and non-MI-trained podiatrists were scored with the Motivational Interviewing Treatment Integrity code. Individual, semi-structed, in-depth interviews were conducted with the MI-trained podiatrists to explore their attitudes towards and experiences with MI. These data sources were triangulated to describe the effect of training podiatrists in MI for their clinical practice.

Results

The MI-trained podiatrists scored significantly higher than the non-MI-trained podiatrists on two of four global MI-related communication skills (empathy, p = 0.008 and change talk, p = 0.008), on one of five core MI-adherent behaviours (affirmation, p = 0.041) and on one of the other behaviour counts (simple reflections, p = 0.008). The podiatrists mainly reported their attitudes and experiences regarding partnership and cultivating change talk, during the interviews. In addition, they also mentioned facilitators and barriers to using MI and indicated whether they experienced MI as having added value.

Conclusions

The MI-trained podiatrists used the principles of MI at a solid beginner proficiency level in their clinical practice in comparison to the non-MI-trained podiatrists, who did not reach this level. This achievement is in accordance with the basic MI-training they received. This multi-method study reveals that podiatrists can be effectively trained in applying MI in daily clinical practice.

Trial registration

Netherlands Trial Register NL7710. Registered: 6 May 2019.

Combining Cognitive Behavioral Therapy for Insomnia and Chronic Spinal Pain Within Physical Therapy: A Practical Guide for the Implementation of an Integrated Approach

Most people who have nonspecific chronic spinal pain (nCSP) report comorbid insomnia. However, in current treatment strategies for nCSP, insomnia is usually not addressed. Considering the bidirectional interaction between pain and sleep and its underlying psychophysiological mechanisms, insomnia may increase the risk of developing adverse physical and psychological health outcomes and should thus no longer be left untreated. As suggested by previous pilot studies, adding cognitive behavioral therapy for insomnia to the contemporary evidence-based biopsychosocial physical therapy approach may also improve pain outcomes in nCSP. This manuscript aims to provide practical guidelines on hybrid physical therapy, including the combination of the following components: (1) pain neuroscience education (eg, to reconceptualize pain) and cognition-targeted exercise therapy (eg, graded exposure to functional daily life movements), and (2) cognitive behavioral therapy for insomnia (sleep psychoeducation, behavioral and cognitive therapy, correction of sleep hygiene, and relaxation therapy) can be deployed for the management of patients who have chronic spinal pain. Impact. Due to the major impact sleep disturbances have on pain and disability, insomnia as a comorbidity should no longer be ignored when treating patients with chronic spinal pain.

Therapeutic Alliance in Web-Based Treatment for Eating Disorders: Secondary Analysis of a Randomized Controlled Trial

Background

In face-to-face therapy for eating disorders, therapeutic alliance (TA) is an important predictor of symptom reduction and treatment completion. To date, however, little is known about TA during web-based cognitive behavioral therapy (web-CBT) and its association with symptom reduction, treatment completion, and the perspectives of patients versus therapists.

Objective

This study aimed to investigate TA ratings measured at interim and after treatment, separately for patients and therapists; the degree of agreement between therapists and patients (treatment completers and noncompleters) for TA ratings; and associations between patient and therapist TA ratings and both eating disorder pathology and treatment completion.

Methods

A secondary analysis was performed on randomized controlled trial data of a web-CBT intervention for eating disorders. Participants were 170 females with bulimia nervosa (n=33), binge eating disorder (n=68), or eating disorder not otherwise specified (n=69); the mean age was 39.6 (SD 11.5) years. TA was operationalized using the Helping Alliance Questionnaire (HAQ). Paired t tests were conducted to assess the change in TA from interim to after treatment. Intraclass correlations were calculated to determine cross-informant agreement with regard to HAQ scores between patients and therapists. A total of 2 stepwise regressive procedures (at interim and after treatment) were used to examine which HAQ scores predicted eating disorder pathology and therapy completion.

Results

For treatment completers (128/170, 75.3%), the HAQ-total scores and HAQ-Helpfulness scores for both patients and therapists improved significantly from interim to post treatment. For noncompleters (42/170, 24.7%), all HAQ scores decreased significantly. For all HAQ scales, the agreement between patients and therapists was poor. However, the agreement was slightly better after treatment than at interim. Higher patient scores on the helpfulness subscale of the HAQ at interim and after treatment were associated with less eating disorder psychopathology. A positive association was found between the HAQ-total patient scores at interim and treatment completion. Finally, posttreatment HAQ-total patient scores and posttreatment HAQ-Helpfulness scores of therapists were positively associated with treatment completion.

Conclusions

Our study showed that TA in web-CBT is predictive of eating disorder pathology and treatment completion. Of particular importance is patients’ confidence in their abilities as measured with the HAQ-Helpfulness subscale when predicting posttreatment eating disorder pathology and treatment completion.

Non-communicable disease prevention in Kosovo: quantitative and qualitative assessment of uptake and barriers of an intervention for healthier lifestyles in primary healthcare

BACKGROUND

Smoking, physical inactivity, low fruit and vegetable consumption, and obesity are common in Kosovo. Their prevention is a priority to relieve the health system of from costly non-communicable disease treatments. The Accessible Quality Healthcare project is implementing a primary healthcare intervention that entails nurse-guided motivational counselling to facilitate change in the domains of smoking, diet, alcohol consumption and physical inactivity for at-risk patients. This study quantitatively assesses the uptake of motivational counselling and the distribution of health behaviours and stages of health behaviour change of the participants according to the intervention, as well as qualitatively describes experiences and perceived benefits of motivational counselling.

METHODS

Study participants (n = 907) were recruited consecutively in 2019 from patients visiting the Main Family Medical Centres in 12 municipalities participating in the Kosovo Non-Communicable Disease Cohort study as part of the Accessible Quality Healthcare project. For the quantitative study, we used baseline and first follow-up data on smoking status, physical inactivity, obesity, fruit and vegetable as well as alcohol consumption, uptake of counselling, and stages for behavioural change. For the qualitative study, in-depth interviews were conducted with a subset of 26 cohort participants who had undergone motivational counselling.

RESULTS

Motivational counselling was obtained by only 22% of the eligible participants in the intervention municipalities. Unhealthy behaviours are high even in persons who underwent counselling (of whom 13% are smokers; 86% physically inactive; 93% with inadequate fruit and vegetable consumption; and 61% are obese); only the rate of smoking was lower in those who obtained counselling. Among smokers, over 80% were still in the pre-contemplation phase of behaviour change. More advanced stages of behaviour change were observed among the highly prevalent group of inactive persons and participants with poor dietary habits, among the 5 intervention municipalities. According to the qualitative study results, the participants who obtained motivational counselling were very satisfied with the services but requested additional services such as group physical activity sessions and specialized services for smoking cessation.

CONCLUSIONS

More tailored and additional primary health care approaches in accordance with patients' views need to be considered for the motivational counselling intervention to reach patients and efficiently facilitate lifestyle behaviour change.

Investigating the influence of interaction modality on the communication patterns of spinal cord injury peer mentors

OBJECTIVES

To examine how the quality of spinal cord injury peer mentorship relationships and mentor-mentee behaviors are impacted by interaction modality.

METHODS

Using a within-subjects, repeated measures, experimental design, peer mentors (n = 8) completed two mentoring sessions with a standardized mentee in a telephone and a video chat condition. Measures of therapeutic alliance and autonomy supportiveness were administered following each session. Mentors' leadership behaviors, motivational interviewing skills, and behavior change techniques were compared across conditions. Mentors' and mentees' use of motivational interviewing skills and behavior change techniques were further analyzed using state space grids.

RESULTS

Mentors' therapeutic alliance, autonomy supportiveness, use of leadership behaviors, motivational interviewing skills, and behavior change techniques did not significantly differ across the two conditions (ps > 0.123; Cohen's d range = 0.218-0.619). State space grids analyses revealed that the dynamic structure of mentoring conversations was similar when interactions occurred through the telephone versus video chat.

CONCLUSIONS

Mentors were effective at forming positive, autonomy supportive relationships with mentees in telephone and video chat interaction conditions. Mentors also used leadership/counselling behaviors to a similar extent when interacting through these two modalities.

PRACTICE IMPLICATIONS

Organizations that provide peer mentorship can have confidence in using both telephone and video chat modalitites.

A qualitative study exploring the barriers to attending structured education programmes among adults with type 2 diabetes

BACKGROUND

Diabetes self-management education, a universally recommended component of diabetes care, aims to support self-management in people with type 2 diabetes. However, attendance is low (approx. 10%). Previous research investigating the reasons for low attendance have not yet linked findings to theory, making it difficult to translate findings into practice. This study explores why some adults with type 2 diabetes do not attend diabetes self-management education and considers how services can be adapted accordingly, using Andersen's Behavioural Model of Health Service Utilisation as a framework.

METHODS

A cross-sectional semi-structured qualitative interview study was carried out. Semi-structured interviews were conducted by telephone with 14 adults with type 2 diabetes who had verbally declined their invitation to attend diabetes self-management education in Bath and North East Somerset, UK, within the last 2 years. Data were analysed using inductive thematic analysis before mapping the themes onto the factors of Andersen's Behavioural Model.

RESULTS

Two main themes were identified: 'perceived need' and 'practical barriers'. The former theme explored participants' tendency to decline diabetes education when they perceived they did not need the programme. This perception tended to arise from participants' high self-efficacy to manage their type 2 diabetes, the low priority they attributed to their condition and limited knowledge about the programme. The latter theme, 'practical barriers', explored the notion that some participants wanted to attend but were unable to due to other commitments and/or transportation issues in getting to the venue.

CONCLUSIONS

All sub-themes resonated with one or more factors of Andersen's Behavioural Model indicating that the model may help to elucidate attendance barriers and ways to improve services. To fully understand low attendance to diabetes education, the complex and individualised reasons for non-attendance must be recognised and a person-centred approach should be taken to understand people's experience, needs and capabilities.

Integrating Pediatric Universal Behavioral Health Care at Federally Qualified Health Centers

BACKGROUND

Research supports integrated pediatric behavioral health (BH), but evidence gaps remain in ensuring equitable care for children of all ages. In response, an interdisciplinary team codeveloped a stepped care model that expands BH services at 3 federally qualified health centers (FQHCs).

METHODS

FQHCs reported monthly electronic medical record data regarding detection of BH issues, receipt of services, and psychotropic medications. Study staff reviewed charts of children with attention-deficit/hyperactivity disorder (ADHD) before and after implementation.

RESULTS

Across 47 437 well-child visits, >80% included a complete BH screen, significantly higher than the state's long-term average (67.5%; P < .001). Primary care providers identified >30% of children as having BH issues. Of these, 11.2% of children <5 years, 53.8% of 5-12 years, and 74.6% >12 years were referred for care. Children seen by BH staff on the day of referral (ie, "warm hand-off") were more likely to complete an additional BH visit than children seen later (hazard ratio = 1.37; P < .0001). There was no change in the proportion of children prescribed psychotropic medications, but polypharmacy declined (from 9.5% to 5.7%; P < .001). After implementation, diagnostic rates for ADHD more than doubled compared with baseline, follow-up with a clinician within 30 days of diagnosis increased (62.9% before vs 78.3% after; P = .03) and prescriptions for psychotropic medication decreased (61.4% before vs 43.9% after; P = .03).

CONCLUSIONS

Adding to a growing literature, results demonstrate that integrated BH care can improve services for children of all ages in FQHCs that predominantly serve marginalized populations.

Using Behavioral Science to Address COVID-19 Vaccine Hesitancy Among Cancer Survivors: Communication Strategies and Research Opportunities

Due to cancer survivors’ increased vulnerability to complications from COVID-19, addressing vaccine hesitancy and improving vaccine uptake among this population is a public health priority. However, several factors may complicate efforts to increase vaccine confidence in this population, including the underrepresentation of cancer patients in COVID-19 vaccine trials and distinct recommendations for vaccine administration and timing for certain subgroups of survivors. Evidence suggests vaccine communication efforts targeting survivors could benefit from strategies that consider factors such as social norms, risk perceptions, and trust. However, additional behavioral research is needed to help the clinical and public health community better understand, and more effectively respond to, drivers of vaccine hesitancy among survivors and ensure optimal protection against COVID-19 for this at-risk population. Knowledge generated by this research could also have an impact beyond the current COVID-19 pandemic by informing future vaccination efforts and communication with cancer survivors more broadly.

A video- and feedback-based approach to teaching communication skills in undergraduate clinical dental education: The student perspective

OBJECTIVE

Student evaluation of a communication-education programme that combined patient consultation videos with peer- or expert-based feedback.

METHODS

A self-perception questionnaire was given to undergraduate dental students who had undertaken a curricular communication training and feedback programme, in which each participant was videoed three times during a patient interview or consultation, subsequently receiving either peer (PG) or expert feedback (EG). The questionnaire used feedback programme content to evaluate student perspectives, ascertaining whether the students experienced a gain in knowledge and professional conversational skills, whether videos or feedback helped them improve more and general questions about the structure and content of the curriculum. Differences between feedback groups were analysed (Mann-Whitney U test).

RESULTS

45 participants (peer group: n = 23, expert group: n = 22) took part in the study. The peer group experienced watching their video (38%) and receiving feedback (33%) as their major beneficial aspect to improve communication skills (watching fellow student´s video: 17%, providing feedback: 12%). The expert group experienced the major effect in receiving expert feedback (73%, video watching: 27%). The students said that communication skills should be a core competency in dental education learning outcomes (PG: 4.48 ± 0.67, EG: 4.41 ± 0.67; P > 0.05) and that communication curricula should include video-based feedback (PG: 3.91 ± 0.73, EG: 4.00 ± 0.93; P > 0.05).

CONCLUSION

Watching videos and both receiving and providing peer group feedback were experienced as helpful in improving students' communication skills. These findings suggest that a longitudinal communication curriculum, which includes both video-based peer feedback and correlated self-reflection, is a promising learning approach for dental education.

The evaluation of a physical health promotion intervention for people with severe mental illness receiving community based accommodational support: a mixed-method pilot study

BACKGROUND

Unhealthy lifestyle constitutes a cause of increased morbidity and mortality in people with severe mental illness. The aim of this mixed-method pilot study was to investigate the feasibility and preliminary effectiveness of an intervention to promote a health-conscious lifestyle in comparison to care as usual among people with severe mental illness receiving accommodational support in community settings.

METHODS

This was a prospective, quasi-experimental, controlled study over four six-month assessment points (t0, + 6 months, + 12 months, + 18 months) with 70 persons with severe mental illness receiving community based accommodational support. Mental health staff members of the housing facilities were trained in Motivational Interviewing and conducted a six-week health course with the intervention group participants in addition to care as usual. Next to the primary outcome - self-rated physical well-being (FEW 16) - anthropometric parameters and unhealthy behaviours (diet, physical activity, alcohol and tobacco consumption, and oral hygiene) were examined. Effectiveness analysis was conducted using mixed-effects regression models with propensity score adjustment to control for selection bias. One year after the end of the intervention, semi-standardized expert interviews were conducted with 12 of these employees and evaluated by content analysis.

RESULTS

The qualitative interviews with mental health staff underline the intervention's feasibility in people with severe mental illness in sheltered housing, and the acceptability of and satisfaction with the intervention among mental health workers. But in this pilot study no superiority of the HELPS intervention compared to routine care could be demonstrated in terms of the investigated outcomes.

CONCLUSIONS

The findings of this pilot study underscore the feasibility and acceptability of health promotion programmes based on Motivational Interviewing and highlight the need to further develop multi-modal programs according to the needs of the target group. Long-term and sustainable support for healthy lifestyles of people with severe mental illness receiving community mental health care requires multi-modal concepts and organisational change.

TRIAL REGISTRATION

DRKS00011659 , date of registration was 2017/02/15; retrospectively registered as date of first enrolment was 2017/01/24.

Supporting autonomy in youth mentoring relationships

The preference for and exercise of autonomous decision-making in adolescence is a normative developmental process. Yet, increased autonomy is associated with both risks and benefits. Connection to others through positive relationships, including mentoring relationships, is one context that predicts healthy autonomous decision-making. In other ways, such relationships can interfere or stifle the development of autonomy. In synthesizing the existing scientific literature on autonomy development and autonomy-supportive practices, we propose a framework for considering the role of mentors in supporting autonomy through five domains of influence: role modeling, encouraging, providing access to resources, relationships, and experiences, advocacy, and conversations about behavior change. We provide suggestions for research and practice.

Improving CPAP Adherence in Adults With Obstructive Sleep Apnea Syndrome: A Scoping Review of Motivational Interventions

Objective: This scoping review aims to provide an accessible summary of available evidence on the efficacy of motivational interventions to increase adherence to Continuous Positive Airway Pressure (CPAP) among patients with Obstructive Sleep Apnea Syndrome (OSAS) and of their specific aspects and strategies by assessing adherence measures. Methods: A literature search was performed in PubMed, Scopus, Medline, PsycINFO, and Web of Science databases using the concepts of "obstructive sleep apnea syndrome," "continuous positive airway pressure," "motivational intervention," and "adherence." Rigorous inclusion criteria and screening by at least two reviewers were applied. Data were extracted to address the review aims and were presented as a narrative synthesis. Results: Search for databases produced 11 randomized controlled trials, all including naïve CPAP users. Findings showed that motivational interventions were more effective than usual care and educational programs in increasing adherence to CPAP, despite results were not always maintained over time across studies. Discussion: To our knowledge, this is the first scoping review of the literature aimed to explore the characteristics and impact of motivational interventions to promote adherence to CPAP in patients with OSAS. More research providing a detailed description of motivational strategies, and testing of their association with positive treatment outcomes via both direct and indirect measures are needed to increase awareness on active mechanisms of change.

Beyond cardioversion, ablation and pharmacotherapies: Risk factors, lifestyle change and behavioral counseling strategies in the prevention and treatment of atrial fibrillation

IMPORTANCE

It has been suggested that atrial fibrillation (AF) is the new cardiovascular disease epidemic of the 21st century. Clinical cardiology has largely focused on AF treatment and associated stroke prevention rather than preventing AF itself. To reduce the global consequences and associated costs of AF, it is critical to now embrace prevention as a priority. Proactively addressing the risk factors for AF and the underlying unhealthy lifestyle habits that contribute to them, using research-based counseling approaches, represents a complementary and adjunctive alternative in combatting this disease burden.

OBSERVATIONS

Encouraging and sustaining patient involvement to reduce AF incidence and improve outcomes begins with screening to identify risk factors, unhealthy lifestyle habits, and characteristics associated with failed attempts at favorably modifying these causalities. Modulators of and common barriers to achieving risk reduction and lifestyle change include self-efficacy, social support, age, sex, marital and socioeconomic status, education, employment, and psychosocial factors such as depression, isolation, anxiety and chronic life stress. Focused behavioral counseling approaches, including assessing the patient's readiness to change, motivational interviewing and using the 5 A's (assess, advise, agree, assist, arrange), along with employing initial downscaled goals to overcome inertia, are proven methodologies to overcome these common barriers to favorably modifying risk factors and unhealthy lifestyle habits.

CONCLUSIONS AND RELEVANCE

To complement and enhance the current armamentarium for the medical management of cardiac arrhythmias, there is an urgent need to proactively address the causative factors triggering new-onset, recurrent and persistent AF. Beyond the counseling skills of highly trained professionals (eg, psychiatrists, psychologists), this narrative review highlights the need for and potential impact on lifestyle modification that non-behavioral scientists, including internal medicine, cardiology, and allied health professionals, can have on the patients they serve.

Impacts of Post-Hospitalization Accessible Health Technology and Caregiver Support on 90-Day Acute Care Use and Self-Care Assistance: A Randomized Clinical Trial

Hospitalized patients often are readmitted soon after discharge, with many hospitalizations being potentially preventable. The authors evaluated a mobile health intervention designed to improve post-hospitalization support for older adults with common chronic conditions. All participants enrolled with an informal caregiver or "CarePartner" (CP). Intervention patients received automated assessment and behavior change calls. CPs received automated, structured feedback following each assessment. Clinicians received alerts about serious problems identified during patient calls. Controls had a 65% greater risk of hospitalization within 90 days post discharge than intervention patients (P = .041). For every 6.8 enrollees, the intervention prevented 1 rehospitalization or emergency department encounter. The intervention improved physical functioning at 90 days (P = .012). The intervention also improved medication adherence and indicators of the quality of communication with CPs (all P < .01). Automated telephone patient monitoring and self-care advice with feedback to primary care teams and CPs reduces readmission rates over 90 days.

Long-term effectiveness of web-based cognitive behavioral therapy for patients with eating disorders

PURPOSE

To evaluate the long-term effectiveness of a web-based therapist-delivered cognitive behavioral therapy (CBT) for patients with eating disorders (ED).

METHODS

We used follow-up data from a randomized controlled trial that evaluated a web-based CBT on ED psychopathology and related health, compared to a waiting list control (WL) condition. As participants of the WL condition started the intervention after their waiting period, follow-up data included participants from both groups. The primary outcome was change from baseline, at 3, 6, and 12-month intervals in ED psychopathology, analyzed using mixed models for repeated measures. Secondary outcomes included body dissatisfaction, BMI, physical health, mental health, self-esteem, quality of life, and social functioning.

RESULTS

The population comprised 212 participants in total, in three subgroups: bulimia nervosa (BN; n = 44), binge eating disorder (BED; n = 83), and ED not otherwise specified (EDNOS; n = 85). Treatment effects were sustained during follow-up, with generally large effect sizes for the reduction of ED psychopathology and body dissatisfaction, and small to moderate effect sizes for physical and mental health, self-esteem, social functioning, and quality of life. Most effects were found for all three subgroups, except for long-term improvements in self-esteem and quality of life among participants with BN and EDNOS.

CONCLUSION

This study showed long-term sustainability of treatment effects up to 1-year post-treatment of a web-based therapist-delivered CBT for patients with various ED.

LEVEL OF EVIDENCE

Level IV, evidence obtained from multiple time series analysis, with intervention.

UNIQUE CLINICAL TRIAL NUMBER

NTR2415-Dutch Trial Registry ( http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2415 ).

Mechanisms associated with increased physical activity in patients undergoing self-management behaviour modification in the randomised PHYSACTO trial

Introduction

In this analysis of the PHYSACTO® study, we assessed the efficacy of a self-management behaviour modification (SMBM) programme to improve physical activity (PA) levels, and the extent to which effects were mediated by readiness to change, motivation and confidence.

Methods

PHYSACTO® was a randomised, partially double-blind, parallel-group, 12-week trial to evaluate the effects of treatment on exercise capacity and PA. COPD patients received placebo, tiotropium 5 µg or tiotropium/olodaterol 5/5 µg, with or without exercise training, all with an SMBM intervention (the Living Well with COPD programme). Changes were assessed in readiness to change (stage of change visual analogue scale [VAS]), motivation (Treatment Self-Regulation Questionnaire [TSRQ]) and confidence (Perceived Competence Scale [PCS]) to engage in PA.

Results

PA was increased in all patients with complete PA data at Week 12 (n=262; +6038 steps·week⁻¹, p<0.001). Significant increases were observed in patients' readiness to change (VAS 0.7 [0.6–0.8]), autonomous regulation (TRSQ 0.2 [0.1–0.3]) and confidence (PCS 0.5 [0.3–0.6]) (all p<0.01). Of note, 23% of the total effect of SMBM on steps·week⁻¹ was found to be mediated by increases in readiness to change, 5% by TSRQ autonomous regulation and 12% by PCS.

Conclusion

Our study demonstrated that an SMBM programme delivered to COPD patients increased PA, mediated by an improvement of three key hypothesised mechanisms of change: readiness to change, autonomous motivation and confidence. For the first time, this study shows that an SMBM programme can be successful in altering the mechanisms of change targeted by the intervention.

Self-management improves motivation and confidence to engage in physical activity in COPD patients in PHYSACTOhttps://bit.ly/2MKoPSy

Evaluation of a Motivation-Based Intervention to Reduce Health Risk Behaviors among Black Primary Care Patients with Adverse Childhood Experiences

BACKGROUND

Considerable evidence suggests that greater attention should be paid to the impact of trauma among low-income, racial/ethnic minority patients living in urban communities. The goal of this article is to evaluate a 2-session, motivational intervention designed to motivate a change in health risk behaviors among low-income, self-identified Black/African American patients with adverse childhood experiences (ACEs).

METHODS

Qualitative self-reported data described helpful aspects of the intervention and those that could be improved. Eligible participants with 1 or more ACEs being seen in a community-based clinic were interviewed by a mental health clinician researcher for 2 in-person sessions scheduled 1 month apart. Content analysis was performed using a general inductive approach to identify core themes.

RESULTS

In total, 36 of 40 participants completed both sessions, with the majority reporting a high rate of satisfaction. Participants emphasized the importance of talking with a trained professional who could listen without judgment, understand patient challenges, clarify patient goals, and facilitate behavior change plans. Suggestions for improvement included modifying structure and content, enhancing clinic environment, improving linkages to behavioral health, and increasing communication and collaboration with clinicians.

CONCLUSION

Participant evaluation data gathered for this study suggest that through the practice of asking, listening, and accepting, clinicians can help patients who have been exposed to childhood adversity better understand themselves and promote healthy coping behaviors. This study provides preliminary data on the needs of underserved patients that can be utilized to develop and deliver health promotion interventions using a trauma-informed approach in community-based clinics.

Motivational Interviewing Confidence and Perceived Competence Among Undergraduate and Graduate Dietetics Students

BACKGROUND

Motivational interviewing (MI) aligns with the scope of practice and competency standards for Registered Dietitian Nutritionists; however, few dietitians receive adequate training. Furthermore, little is known about MI training within dietetics curricula.

OBJECTIVE

The objective of this study was to determine differences in undergraduate and graduate-level dietetics students' confidence and perceived competence before/after taking a MI course.

METHODS

A 38-item pre-postsurvey was completed by students enrolled in a Basic and Advanced MI course at Utah State University. The survey included demographic questions and questions related to confidence and perceived competence using MI techniques. Paired t-tests were used to compare pre/post results and analysis of variance was used to compare groups.

RESULTS

Increased confidence and perceived competence were observed for Basic MI students (n = 72) (P < .0001) and Advanced MI students (n = 32) (P < .0001) after course completion. In the presurvey, Advanced MI students had higher confidence in 5 of 14 MI skills, higher competence in 2 of 11 MI skills, and higher overall MI competence scores (P = .008) than Basic MI students. Following completion of the course, Advanced MI students had higher overall MI confidence scores (P = .03).

CONCLUSIONS

Students' confidence and perceived competence with using MI increased after taking a college-level MI course. Incorporating MI courses into dietetics curricula may be an effective way to increase confidence and perceived competence of using MI techniques and therefore improving communication between dietitians and patients.

Improving community health and social care practitioners' confidence, perceived competence and intention to use behaviour change techniques in health behaviour change conversations

Community health and social care practitioners play an increasingly important role in the health promotion agenda, but lack confidence in having effective health behaviour change (HBC) conversations with members of the public. This study reports the development and evaluation of a training intervention based on health psychology to improve health and social care practitioner self-rated confidence, competence and intention to use five behaviour change techniques (BCTs) in their HBC conversations. A 2-day behavioural science interprofessional skills training course plus online learning module was designed for health and social care staff across North East Scotland, teaching five evidence-based BCTs (e.g. Action Planning), plus person-centred communication skills. Participants rated confidence, competence and future intention to use the BCTs on likert scales (1-10) pre-course and post-course, and provided acceptability data. 177 participants aged 20-64 took part, qualitative and quantitative data suggested that the course had high acceptability. Paired samples t tests (n = 120 with complete data) showed significant improvements in confidence, competence and intention following the course, which remained significant with a conservative analysis (n = 174) assuming no change for missing data. Perceived competence in Action Planning increased most during the course (mean change 3.09). In conclusion, health psychology-based skills training can improve practitioner confidence, competence and intention to use evidence-based BCTs; further evaluation is needed to assess practice change.

Home-Based Cardiac Rehabilitation: A SCIENTIFIC STATEMENT FROM THE AMERICAN ASSOCIATION OF CARDIOVASCULAR AND PULMONARY REHABILITATION, THE AMERICAN HEART ASSOCIATION, AND THE AMERICAN COLLEGE OF CARDIOLOGY

Cardiac rehabilitation (CR) is an evidence-based intervention that uses patient education, health behavior modification, and exercise training to improve secondary prevention outcomes in patients with cardiovascular disease. CR programs reduce morbidity and mortality rates in adults with ischemic heart disease, heart failure, or cardiac surgery but are significantly underused, with only a minority of eligible patients participating in CR in the United States. New delivery strategies are urgently needed to improve participation. One potential strategy is home-based CR (HBCR). In contrast to center-based CR services, which are provided in a medically supervised facility, HBCR relies on remote coaching with indirect exercise supervision and is provided mostly or entirely outside of the traditional center-based setting. Although HBCR has been successfully deployed in the United Kingdom, Canada, and other countries, most US healthcare organizations have little to no experience with such programs. The purpose of this scientific statement is to identify the core components, efficacy, strengths, limitations, evidence gaps, and research necessary to guide the future delivery of HBCR in the United States. Previous randomized trials have generated low- to moderate-strength evidence that HBCR and center-based CR can achieve similar improvements in 3- to 12-month clinical outcomes. Although HBCR appears to hold promise in expanding the use of CR to eligible patients, additional research and demonstration projects are needed to clarify, strengthen, and extend the HBCR evidence base for key subgroups, including older adults, women, underrepresented minority groups, and other higher-risk and understudied groups. In the interim, we conclude that HBCR may be a reasonable option for selected clinically stable low- to moderate-risk patients who are eligible for CR but cannot attend a traditional center-based CR program.

Cardiac rehabilitation: Appraisal of current evidence and utility of technology aided home-based cardiac rehabilitation

Cardiac rehabilitation (CR) is an evidence-based intervention that uses exercise training, health behaviour modification, medication adherence and psychological counselling to improve secondary prevention outcomes in patients with cardiovascular disease. CR programs reduce morbidity and mortality rates in adults with ischemic heart disease, following coronary intervention, heart failure, or cardiac surgery. These are significantly underused, with only a minority of eligible patients participating in CR in India. Novel delivery strategies and CR endorsement by healthcare organizations are urgently needed to improve participation. One potential strategy is home-based CR (HBCR). Differing from centre-based CR services, which are provided in a medically supervised facility, HBCR relies on remote coaching with indirect exercise supervision. It is provided mostly or entirely outside of the traditional centre-based setting and could be facilitated by the aid of technology and web based applications. The purpose of this appraisal is to identify the core components, efficacy, strengths, limitations, evidence gaps, and research necessary to guide the future delivery of HBCR. This appears to hold promise in expanding the use of CR to eligible patients. Additional research and demonstration projects are needed to clarify, strengthen, and extend the HBCR evidence base for key subgroups, including older adults, women, underrepresented minority groups, and people in remote and rural areas. HBCR may be a reasonable option for a selected group of patients and could be a game changer in low- and middle-income countries who are eligible for CR.

Effect of depression on health behavior among myocardial infarction survivors in the United States

Introduction

The purpose of this study was to evaluate the effect of depression on health behavior among myocardial infarction (MI) survivors.

Methods

This retrospective, cross-sectional study used publicly available 2015 Behavioral Risk Factor Surveillance System (BRFSS) data. Our study sample includes adults aged 50 years or older who completed the 2015 BRFSS survey and reported having MI. The BRFSS participants with a yes response to the question, Has a doctor, nurse, or other health care professional ever told you that you had a heart attack, also called a myocardial infarction? were identified as MI survivors. The presence or absence of depression among MI survivors was identified using a similar question. Health behaviors, the dependent variable of this study, included physical activity, smoking status, alcohol use, body mass index, last flu immunization, last physical checkup, last blood cholesterol check, heavy drinking, and vegetable and fruit consumption. Univariate (χ² tests) and multivariable (binomial logistic regression) analyses were used to assess the differences in health behaviors between MI survivors with or without depression.

Results

Our final study sample consists of 20 483 older adults with MI among whom 5343 (26.19%) reported having depression. Multivariable analyses reveal MI survivors with depression are more overweight, have less physical activity, and have higher likelihood of smoking but less odds of consuming alcohol compared to MI survivors without depression.

Discussion

In this nationally representative sample of adults aged over 50 years in the United States, MI survivors with depression exhibited poorer health behaviors compared to those without depression.

Partners in School: An Implementation Strategy to Promote Alignment of Evidence-Based Practices Across Home and School for Children with Autism Spectrum Disorder

When parents and teachers align their practices across home and school, it may optimize services for children with autism spectrum disorder (ASD). Partners in School is a multi-faceted implementation strategy designed to improve ASD services in schools. The goal is to increase parents' and teachers' use of evidence-based practices (EBPs) and to align those EBPs across settings. We piloted Partners in School with 49 parent-teacher dyads to assess administration and the factors associated with reported fidelity to the model. Specifically, we measured the number of intervention steps both parents and teachers completed (reported alignment) and the characteristics associated with intervention alignment. Partners in School involves parent-teacher participation in a pre-consultation interview, an in-person consultation meeting, active implementation of the same EBPs in their respective settings, and a post-consultation interview. Parents and teachers also completed surveys pre- and post-consultation. On average, parents and teachers completed approximately five EBP steps on their own in their respective settings (i.e., at home or at school). Of these five steps, parents and teachers both completed three of the same EBPs steps, on average. Different factors were related to reported alignment for parents versus teachers; however, a similarity noted for both parents and teachers was that communication variables were associated with reported alignment. Our findings indicate the important role of communication in aligning stakeholders for ASD service delivery models.

Social robots as treatment agents: Pilot randomized controlled trial to deliver a behavior change intervention

Social robots are increasingly demonstrating effectiveness as low-intensity behavior change agents. Key targets for these behavioral interventions include daily lifestyle behaviors with significant health consequences, such as the consumption of high-calorie foods and drinks ('snacks'). A pilot randomized controlled trial using a stepped-wedge design was conducted to determine the efficacy of a motivational intervention by an autonomous robot, to help reduce high-calorie snacks. Twenty-six adults were randomized to receive Immediate or 4-week Delayed treatment, with assessments at Baseline and Weeks 4 and 8. The treatment comprised motivation enhancement and self-management training using mental imagery (Functional Imagery Training). A significant condition by time effect for snack episode reduction was obtained, F(2, 32.06) = 4.30, p = .022. The Immediate condition significantly reduced snacking between Baseline and Week 4 (d = -1.06), while the Delayed condition did not (d = -0.08). Immediate participants maintained their improvement between Weeks 4 and 8 (d = -0.18), and Delayed participants then showed a significant fall (d = -1.42). Overall, 'Immediate' participants decreased their snack episodes by 54% and 'Delayed' decreased by 62% from Baseline to Week 8, and an average weight reduction of 4.4 kg was seen across over the first 2 weeks of treatment. Four weeks after starting the intervention, both conditions had significant increases in perceived confidence to control snack intake for time duration, specific scenarios and emotional states (d = 0.61 to 1.42). Working alliance was significantly correlated with reduced snack episodes. The pilot's results appear to suggest that the robot-delivered intervention may be as effective as a human clinician delivering a similar intervention. The robot-delivered pilot achieved similar snack episode reduction in the first four weeks (FIT-R, 55%) when compared with the human-delivered version by a trained clinician (FIT-H, 49%). Overall, the results provide preliminary evidence for an autonomous social robot to deliver a low-intensity treatment on dietary intake without the need for human intervention. Future trials should extend the deployment of the robot-delivered intervention protocol to other low-intensity behavioral outcomes.

Effectiveness of behaviour change techniques on lifestyle interventions of patients with a high risk of developing cardiovascular disease. Using a qualitative approach

This study aimed to identify key active ingredients on the maintenance of behaviour change for lifestyle interventions of patients with a high risk of developing cardiovascular disease (CVD) who participated in a MOtiVational intErviewing InTervention (MOVE IT) randomised control trial (RCT). A process evaluation was carried out using focus groups. Twenty-six participants of the MOVE IT RCT were purposively recruited and split into six focus groups. Four groups had attended six or more sessions of the intensive phase (completers) and two groups had withdrawn before the end of the intensive phase or had not attended any sessions (non-completers). Focus groups were audio recorded, transcribed verbatim and analysed inductively using thematic analysis. Three overall themes were generated from the six focus groups: (a) long-term benefits from diet and physical activity education, (b) group versus individual structure and adherence and (c) impact on health beliefs and risk of CVD. A fourth theme was generated from the two groups of non-completers only: (d) need for professional rapport building and feedback. We found that the key active ingredients for effective behavioural change in lifestyle interventions are having well-developed rapport between facilitators and patients; and providing alternative forms of feedback to encourage maintenance of behaviour change. Furthermore, such programmes also need to have established and strong relationships with associated health professionals (i.e. the General Practitioner) to increase participation and maintenance of engagement.

The Effects of Home Exercise in Older Women With Vertebral Fractures: A Pilot Randomized Controlled Trial

BACKGROUND

Regular exercise is advocated in osteoporosis guidelines to prevent fractures. Few studies have evaluated the effect of exercise on functional performance, posture, and other outcomes that are important to patients after vertebral fractures.

OBJECTIVE

This pilot study will explore the effect of home exercise versus control on functional performance, posture, and patient-reported outcome measures.

DESIGN

This study was a parallel 2-arm pilot feasibility trial with 1:1 randomization to exercise or attentional control groups.

SETTING

This study took place in 5 Canadian and 2 Australian academic or community hospitals/centers.

PARTICIPANTS

This study included 141 women ≥65 years of age with radiographically confirmed vertebral fractures.

INTERVENTION

A physical therapist delivered exercise and behavioral counseling in 6 home visits over 8 months and monthly calls. Participants were to exercise ≥3 times weekly. Controls received equal attention.

MEASUREMENTS

Functional performance, posture, quality of life, pain, and behavior-change outcomes were assessed at baseline and after 6 (questionnaires only) and 12 months. Adherence to exercise was assessed by calendar diary. All t tests examined between-group mean differences (MD) in change from baseline in intention-to-treat and per-protocol analyses.

RESULTS

There was a small effect of exercise on 5 times sit-to-stand test versus control (MD = -1.58 [95% CI = -3.09 to -0.07], intention-to-treat; MD = -1.49 [95% CI = -3.12 to 0.16], per-protocol). There were no other major or statistically significant MDs for any other measured outcomes after follow-up. Adherence declined over time.

LIMITATIONS

Treatment effects on variables may have been underestimated due to multiple comparisons and underpowered analyses.

CONCLUSIONS

Our exploratory estimate of the effect of exercise on functional leg muscle strength was consistent in direction and magnitude with other trials in individuals with vertebral fractures. Declining adherence to home exercise suggests that strategies to enhance long-term adherence might be important in future confirmatory trials.

Precision Medicine in Lifestyle Medicine: The Way of the Future?

Precision medicine has captured the imagination of the medical community with visions of therapies precisely targeted to the specific individual's genetic, biological, social, and environmental profile. However, in practice it has become synonymous with genomic medicine. As such its successes have been limited, with poor predictive or clinical value for the majority of people. It adds little to lifestyle medicine, other than in establishing why a healthy lifestyle is effective in combatting chronic disease. The challenge of lifestyle medicine remains getting people to actually adopt, sustain, and naturalize a healthy lifestyle, and this will require an approach that treats the patient as a person with individual needs and providing them with suitable types of support. The future of lifestyle medicine is holistic and person-centered rather than technological.