Efficacy of Motivational Interviewing to Improve Utilization of Mental Health Services Among Youths With Chronic Medical Conditions: A Cluster Randomized Clinical Trial

IMPORTANCE

Despite the high prevalence of anxiety and depression in youths with chronic medical conditions (CMCs), physicians encounter substantial barriers in motivating these patients to access mental health care services.

OBJECTIVE

To determine the efficacy of motivational interviewing (MI) training for pediatricians in increasing youths' use of mental health care.

DESIGN, SETTING, AND PARTICIPANTS

The COACH-MI (Chronic Conditions in Adolescents: Implementation and Evaluation of Patient-Centered Collaborative Healthcare-Motivational Interviewing) study was a single-center cluster randomized clinical trial at the University Children's Hospital specialized outpatient clinics in Düsseldorf, Germany. Treating pediatricians were cluster randomized to a 2-day MI workshop or treatment as usual (TAU). Patient recruitment and MI conversations occurred between April 2018 and May 2020 with 6-month follow-up and 1-year rescreening. Participants were youths aged 12 to 20 years with CMCs and comorbid symptoms of anxiety and depression; they were advised by their MI-trained or untrained physicians to access psychological counseling services. Statistical analysis was performed from October 2020 to April 2021.

INTERVENTIONS

MI physicians were trained through a 2-day, certified MI training course; they recommended use of mental health care services during routine clinical appointments.

MAIN OUTCOMES AND MEASURES

The primary outcome of uptake of mental health care services within the 6-month follow-up was analyzed using a logistic mixed model, adjusted for the data's cluster structure. Uptake of mental health services was defined as making at least 1 appointment by the 6-month follow-up.

RESULTS

Among 164 youths with CMCs and conspicuous anxiety or depression screening, 97 (59%) were female, 94 (57%) had MI, and 70 (43%) had TAU; the mean (SD) age was 15.2 (1.9) years. Compared with patients receiving TAU, the difference in mental health care use at 6 months among patients whose physicians had undergone MI training was not statistically significant (odds ratio [OR], 1.96; 95% CI, 0.98-3.92; P = .06). The effect was moderated by the subjective burden of disease (F2,158 = 3.42; P = .04). Counseling with an MI-trained physician also led to lower anxiety symptom scores at 1-year rescreening (F1,130 = 4.11; P = .045). MI training was associated with longer conversations between patients and physicians (30.3 [16.7] minutes vs 16.8 [12.5] minutes; P < .001), and conversation length significantly influenced uptake rates across conditions (OR, 1.03; 95% CI, 1.01-1.06; P = .005).

CONCLUSIONS AND RELEVANCE

In this study, use of MI in specialized pediatric consultations did not increase the use of mental health care services among youths with CMCs but did lead to longer patient-physician conversations and lower anxiety scores at 1 year. Additional research is required to determine whether varying scope and duration of MI training for physicians could encourage youths with CMCs to seek counseling and thus improve integrated care models.

TRIAL REGISTRATION

German Trials Registry: DRKS00014043.

Health care provider use of motivational interviewing to address vaccine hesitancy in college students

BACKGROUND

Vaccine-preventable diseases significantly influence the health and academic success of college students. Despite the known negative impact of these diseases, vaccination rates routinely fall short of national goals and recommendations. Although vaccination decisions are complex, a recommendation from a health care provider is one of the key motivators for individuals receiving a vaccine. Motivational interviewing (MI), a counseling approach primarily used to address substance abuse, can be applied to other health-related behaviors.

LOCAL PROBLEM

Despite previous quality improvement efforts aimed at increasing vaccine rates for influenza, human papillomavirus (HPV), and meningitis B (MenB), vaccinations at large university health centers have been well below benchmarks set by Healthy People 2020.

METHODS

This study was guided by the Theory of Planned Behavior and included MI training and regular reinforcement for health care providers to address vaccine hesitancy with college students.

RESULTS

Influenza vaccination rates improved, but HPV vaccine rates remained stable and MenB vaccine rates decreased compared with the previous year. Clinicians demonstrated a significant increase in knowledge of MI techniques after a targeted educational intervention. Repeat measures indicate the potential for sustained improvement when ongoing reinforcement is provided.

CONCLUSION

MI can be an effective part of a strategy to increase vaccination rates.

Motivational Interviewing Adapted to Group Setting for the Treatment of Relapse in the Behavioral Therapy of Obesity. A Clinical Audit

Motivational interviewing (MI) is devised to change unhealthy behaviors by increasing motivation. We adapted MI to a group format for the treatment of relapse during the behavioral treatment of obesity and performed a clinical audit to evaluate its effectiveness in stopping weight regain. The program was structured in seven weekly sessions, plus a 6-month follow-up. Patients (n = 86) completed a questionnaire on motivation to change in both healthy diet and physical activity, and a self-reported measurement of calorie intake and physical activity at baseline, at program end and at 6-month follow-up. The attendance to the program was high, with only 13 patients (15%) not completing the program and 24% not attending the 6-month follow-up. By the end of follow up, the prevalence of patients in either precontemplation or contemplation was reduced from over 60% at enrollment to approximately 20%, whereas the sum of patients in action or maintenance stages was increased from 9.5% in healthy diet and 14% in physical activity to 39.7% and 41.3%, respectively. These changes translated into significant behavioral changes (mean calorie intake, −13%; total physical activity, +125%; sedentary time, −8%) and finally into reduced body weight ( −3%). We conclude that MI programs adapted for groups may be used to stop relapse in individuals following a behavioral intervention for obesity.

Motivational Interviewing in Child Welfare Services: A Systematic Review

Families in the child welfare (CW) system who cannot be engaged in services are at high risk of negative outcomes. As motivational interviewing (MI) has been shown to improve engagement in similar contexts. This study aimed to systematically review MI with CW families as well as MI training with CW workers and social work students training to become CW workers. The review used Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and searched multiple databases in June 2018. In September 2019, the initial search was repeated with additional searches to identify gray literature. Eight studies described the acquisition of MI among CW workers or student trainees, and 11 studies evaluated the impact of MI on families in CW. MI's impact on some family outcomes, such as engagement in services, was mixed, though MI paired with other evidence-based treatments showed positive effects. With regard to training CW workers and students in MI, differences in training duration, intensity, and modality make conclusions difficult, though trainees generally described MI favorably and some studies showed training increased worker empathy and self-efficacy. Importantly, few published studies have evaluated whether MI-trained CW workers impact out-of-home-care placement, and no studies have evaluated their impact on maltreatment.

Teaching motivational interviewing in a blended learning environment

BACKGROUND AND PURPOSE

To describe the implementation of blended learning in teaching motivational interviewing (MI) to third-year pharmacy students and evaluate changes in MI knowledge by assessing students' abilities to recognize and formulate responses using MI skills after the training and, for a subset of students, one year later.

EDUCATIONAL ACTIVITY AND SETTING

The comMIt e-learning program was integrated into a third-year pharmacy communication course. Skills learned in the program were applied and assessed using e-learning quizzes, three in-class practice sessions and a 5-minute final assessment video. In addition, students completed a 22-item pre- and post-survey addressing their abilities to recognize and formulate statements using MI skills. This survey was voluntarily completed again one year later.

FINDINGS

Sixty students completed the training and showed a statistically significant improvement between the pre- and post-surveys. Twenty-seven students voluntarily responded to the survey one year later. While overall performance dropped between the post-survey and the one-year follow-up, students sustained their ability to formulate appropriate MI responses to the open-response questions.

SUMMARY

This study demonstrates that students can successfully learn and retain MI skills using blended learning via the comMIt e-learning program and in-class practice activities.

Student Pharmacists' Use of Patient-Centered Communication Skills During an Introductory Pharmacy Practice Experience

Objective. To assess how Doctor of Pharmacy (PharmD) students use patient-centered communication (PCC) during a community pharmacy introductory pharmacy practice experience (IPPE). Methods. All first-year student pharmacists at the University of Arkansas for Medical Sciences completed a required course in patient-centered communication that included training in motivational interviewing. After subsequently completing their first IPPE, the students submitted written reflections on their use of PCC during the experience. The reflections were de-identified and template analysis was conducted. With this method, predetermined codes are established, and a constant comparison method is used to finalize overarching themes. The students' overall level of reflection was assessed and each reflection was coded. Discrepancies were resolved through in-depth discussion and negotiated consensus. Results. Of the 116 student reflections submitted, 951 codes were applied. Six overarching themes were identified: acknowledgement of motivational interviewing skills/components; philosophy of patient-centeredness; barriers to using PCC or motivational interviewing; benefits from use of PCC; demonstration of good general communication skills; and perceptions of patient encounters. Approximately 46% of students reflected at a level three or higher (ie, personal insight or intended behavior change). Conclusion. First-year student pharmacists successfully used PCC skills during their IPPE. These findings demonstrate the impact that a PCC course can have on students' overall patient-centeredness and highlights barriers that students struggle to overcome. Other pharmacy schools may benefit from implementing a similar PCC course. Activities that reiterate these skills and provide additional opportunities to practice PCC are necessary throughout the curriculum.

Motivational Interviewing: A High-Yield Interactive Session for Medical Trainees and Professionals to Help Tobacco Users Quit

Introduction

Motivational interviewing (MI) is a collaborative patient-focused counseling technique that is effective in promoting smoking cessation but is not consistently taught/practiced in training.

Methods

This training session was implemented in a pediatric residency training program and also given four times to pediatric practitioners as part of a 2-day tobacco training sponsored by the American Academy of Pediatrics (AAP). Pediatric residents (N = 33) participated in a 1-hour interactive session focused on addressing tobacco. Knowledge was assessed with pre- and 6-month postsurveys. Retention of skills was evaluated between 6 and 9 months posttraining by resident performance on two scenarios with standardized patients, which was scored utilizing the Behavior Change Counseling Index (BECCI), by two MI-trained physicians. AAP trainees (N = 115) participated in tobacco trainings with a session dedicated to MI; sessions were evaluated by pre- and posttests.

Results

Residents who completed the session (n = 12) performed significantly better on eight of 10 items of the BECCI and on the overall BECCI score (p < .001) compared with those who had not completed the session (n = 12). Feedback on AAP training sessions (N = 115) indicated that practitioners felt able to perform MI and incorporate MI into practice. The percentage of trainees who felt comfortable counseling about tobacco doubled from pre- to posttraining.

Discussion

A hands-on MI training session provided pediatric residents and practicing clinicians with knowledge and skills to address tobacco use with patients/families. The session is easily incorporated into different training environments.

Cost and cost-effectiveness of computerized vs. in-person motivational interventions in the criminal justice system

INTRODUCTION

Although substance use is common among probationers in the United States, treatment initiation remains an ongoing problem. Among the explanations for low treatment initiation are that probationers are insufficiently motivated to seek treatment, and that probation staff have insufficient training and resources to use evidence-based strategies such as motivational interviewing. A web-based intervention based on motivational enhancement principles may address some of the challenges of initiating treatment but has not been tested to date in probation settings. The current study evaluated the cost-effectiveness of a computerized intervention, Motivational Assessment Program to Initiate Treatment (MAPIT), relative to face-to-face Motivational Interviewing (MI) and supervision as usual (SAU), delivered at the outset of probation.

METHODS

The intervention took place in probation departments in two U.S. cities. The baseline sample comprised 316 participants (MAPIT = 104, MI = 103, and SAU = 109), 90% (n = 285) of whom completed the 6-month follow-up. Costs were estimated from study records and time logs kept by interventionists. The effectiveness outcome was self-reported initiation into any treatment (formal or informal) within 2 and 6 months of the baseline interview. The cost-effectiveness analysis involved assessing dominance and computing incremental cost-effectiveness ratios and cost-effectiveness acceptability curves. Implementation costs were used in the base case of the cost-effectiveness analysis, which excludes both a hypothetical license fee to recoup development costs and startup costs. An intent-to-treat approach was taken.

RESULTS

MAPIT cost $79.37 per participant, which was ~$55 lower than the MI cost of $134.27 per participant. Appointment reminders comprised a large proportion of the cost of the MAPIT and MI intervention arms. In the base case, relative to SAU, MAPIT cost $6.70 per percentage point increase in the probability of initiating treatment. If a decision-maker is willing to pay $15 or more to improve the probability of initiating treatment by 1%, estimates suggest she can be 70% confident that MAPIT is good value relative to SAU at the 2-month follow-up and 90% confident that MAPIT is good value at the 6-month follow-up.

CONCLUSIONS

Web-based MAPIT may be good value compared to in-person delivered alternatives. This conclusion is qualified because the results are not robust to narrowing the outcome to initiating formal treatment only. Further work should explore ways to improve access to efficacious treatment in probation settings.

A meta-analysis of motivational interviewing process: Technical, relational, and conditional process models of change

OBJECTIVE

In the present meta-analysis, we test the technical and relational hypotheses of Motivational Interviewing (MI) efficacy. We also propose an a priori conditional process model where heterogeneity of technical path effect sizes should be explained by interpersonal/relational (i.e., empathy, MI Spirit) and intrapersonal (i.e., client treatment seeking status) moderators.

METHOD

A systematic review identified k = 58 reports, describing 36 primary studies and 40 effect sizes (N = 3,025 participants). Statistical methods calculated the inverse variance-weighted pooled correlation coefficient for the therapist to client and the client to outcome paths across multiple target behaviors (i.e., alcohol use, other drug use, other behavior change).

RESULTS

Therapist MI-consistent skills were correlated with more client change talk (r = .55, p < .001) as well as more sustain talk (r = .40, p < .001). MI-inconsistent skills were correlated with more sustain talk (r = .16, p < .001), but not change talk. When these indicators were combined into proportions, as recommended in the Motivational Interviewing Skill Code, the overall technical hypothesis was supported. Specifically, proportion MI consistency was related to higher proportion change talk (r = .11, p = .004) and higher proportion change talk was related to reductions in risk behavior at follow up (r = -.16, p < .001). When tested as two independent effects, client change talk was not significant, but sustain talk was positively associated with worse outcome (r = .19, p < .001). Finally, the relational hypothesis was not supported, but heterogeneity in technical hypothesis path effect sizes was partially explained by inter- and intrapersonal moderators.

CONCLUSIONS

This meta-analysis provides additional support for the technical hypothesis of MI efficacy; future research on the relational hypothesis should occur in the field rather than in the context of clinical trials. (PsycINFO Database Record

Motivational interviewing education: Creation and assessment of a learning module implemented among advanced pharmacy practice students

BACKGROUND AND PURPOSE

The purpose of this prospective nonrandomized study (quasi-experimental), pre-/post-intervention design was to implement and assess a formal orientation training program for Advanced Pharmacy Practice Experience (APPE) students focusing on skills related to motivational interviewing (MI).

EDUCATIONAL ACTIVITY AND SETTING

Students were assessed on their knowledge, perceived ability, and perceived need to incorporate MI in practice using a pre-/posttest. Ability was assessed via student-conducted patient interviews, and performance was compared to published standards. Satisfaction with the training program was reviewed using a Likert scale questionnaire. Fourteen APPE students from three colleges of pharmacy were enrolled based on pre-assigned community experience placement. Students participated in a didactic training phase consisting of on-line knowledge acquisition and assessments. A modeling phase was implemented with role-play experiences and simulated video assessments. A shadowing phase was incorporated consisting of students observing a preceptor prior to independently conducting patient interviews. Interactions were audio recorded and reviewed by a preceptor with verbal and written feedback provided twice monthly using a standardized rubric.

FINDINGS

Data revealed statistically significant improvements in all categories of the pre-/posttest. MI ability results showed statistically significant improvements as well. Performance scores were higher than goal values in video simulated assessments. Overall student satisfaction with the training program was 4.3 out of 5.

DISCUSSION AND CONCLUSIONS

Data suggests the training program increased students understanding and ability to perform MI in patient interviews. High quality of student performance is also suggested due to trained students' post scores being higher than goal values published by scoring manual.

Treatment fidelity of brief motivational interviewing and health education in a randomized clinical trial to promote dental attendance of low-income mothers and children: Community-Based Intergenerational Oral Health Study "Baby Smiles"

BACKGROUND

Fidelity assessments are integral to intervention research but few published trials report these processes in detail. We included plans for fidelity monitoring in the design of a community-based intervention trial.

METHODS

The study design was a randomized clinical trial of an intervention provided to low-income women to increase utilization of dental care during pregnancy (mother) or the postpartum (child) period. Group assignment followed a 2 × 2 factorial design in which participants were randomly assigned to receive either brief Motivational Interviewing (MI) or Health Education (HE) during pregnancy (prenatal) and then randomly reassigned to one of these groups for the postpartum intervention. The study setting was four county health departments in rural Oregon State, USA. Counseling was standardized using a step-by-step manual. Counselors were trained to criteria prior to delivering the intervention and fidelity monitoring continued throughout the implementation period based on audio recordings of counselor-participant sessions. The Yale Adherence and Competence Scale (YACS), modified for this study, was used to code the audio recordings of the counselors' delivery of both the MI and HE interventions. Using Interclass Correlation Coefficients totaling the occurrences of specific MI counseling behaviors, ICC for prenatal was .93, for postpartum the ICC was .75. Participants provided a second source of fidelity data. As a second source of fidelity data, the participants completed the Feedback Questionnaire that included ratings of their satisfaction with the counselors at the completion of the prenatal and post-partum interventions.

RESULTS

Coding indicated counselor adherence to MI protocol and variation among counselors in the use of MI skills in the MI condition. Almost no MI behaviors were found in the HE condition. Differences in the length of time to deliver intervention were found; as expected, the HE intervention took less time. There were no differences between the overall participants' satisfaction ratings of the HE and MI sessions by individual counselor or overall (p > .05).

CONCLUSIONS

Trial design, protocol specification, training, and continuous supervision led to a high degree of treatment fidelity for the counseling interventions in this randomized clinical trial and will increase confidence in the interpretation of the trial findings.

Steps to Growing Up Healthy: a pediatric primary care based obesity prevention program for young children

BACKGROUND

Leading medical organizations have called on primary care pediatricians to take a central role in the prevention of childhood obesity. Weight counseling typically has not been incorporated into routine pediatric practice due to time and training constraints. Brief interventions with simple behavior change messages are needed to reach high-risk children, particularly Latino and Black children who are disproportionately affected by obesity and related comorbidities. Steps to Growing Up Healthy (Added Value) is a randomized controlled trial testing the efficacy of brief motivational counseling (BMC) delivered by primary care clinicians and the added value of supplementing BMC with monthly contact by community health workers (CHW) in the prevention/reversal of obesity in Latino and Black children ages 2-4 years old.

METHODS/DESIGN

Mother-child dyads (targeted n = 150) are recruited for this 12-month randomized trial at an inner-city pediatric primary care clinic and randomized to: 1) BMC delivered by clinicians and nurses at well, sick, and WIC visits with the goal of reducing obesogenic behaviors (BMC); 2) BMC plus monthly phone calls by a CHW (BMC + Phone); or 3) BMC plus monthly home visits by a CHW (BMC + Home). During BMC, the medical team facilitates the selection of a specific goal (i.e., reduce sugar sweetened beverage consumption) that is meaningful to the mother and teaches the mother simple behavioral strategies. Monthly contacts with CHWs are designed to identify and overcome barriers to goal progress. Dyads are assessed at baseline and 12 months and the primary outcome is change in the child's BMI percentile. We hypothesize that BMC + Phone and BMC + Home will produce greater reductions in BMI percentiles than BMC alone and that BMC + Home will produce greater reductions in BMI percentiles than BMC + Phone.

DISCUSSION

Steps to Growing Up Healthy will provide important information about whether a brief primary care-based intervention that utilizes a motivational interviewing and goal setting approach can be incorporated into routine care and is sufficient to prevent/reverse obesity in young children. The study will also explore whether monthly contact with a community health worker bridges the gap between the clinic and the community and is an effective strategy for promoting obesity prevention in high-risk families.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01973153.

Unintended effects of training on clinicians' interest, confidence, and commitment in using motivational interviewing

BACKGROUND

Improving clinicians' interest, confidence, and commitment in using evidence-based treatment (EBT) is often an aim of training clinicians in EBT. However, the degree to which these areas actually improve through training and what their relationship is to treatment integrity is unknown.

METHOD

Using data from a multi-site study (Martino et al., 2010) comparing three methods of clinician training in motivational interviewing (MI), changes in interest, confidence, and commitment over time and their relationship to MI adherence and competence were assessed using mixed-effects regression models. Individual patterns of change were examined through cluster analysis.

RESULTS

Interest, confidence, and commitment declined over time across training conditions with two distinct patterns: 76% clinicians largely maintained strong interest in MI over time with only slight decreases in confidence and commitment (the "maintainers"), while 24% began with lower initial interest, confidence, and commitment, which subsequently declined over time (the "decliners"). Interest and commitment were not associated with MI adherence and competence; confidence was associated with increased competence in the use of advanced MI strategies. However, decliners demonstrated greater use of MI-inconsistent techniques than maintainers overall (d=0.28).

CONCLUSIONS

Training in MI may have an unintended consequence of diminishing clinicians' interest, confidence, or commitment in using MI in practice. While attitudinal variables in this study show mixed relationships to MI integrity, they may have some utility in identifying less enthusiastic participants, better preparing them for training, or tailoring training approaches to meet individual training needs.