Motivational interviewing to support antiretroviral therapy adherence: The role of quality counseling
Introduction
Antiretroviral therapy (ART) has helped turn HIV infection in the United States into a relatively manageable, though still serious, chronic disease [1], [2]. Achieving and maintaining the health benefits of this regimen requires near-perfect adherence, which most patients do not achieve [1]. Those with suboptimal adherence have greater morbidity, are more likely to experience treatment failure, and risk developing drug resistant forms of HIV [3], [4], [5], [6], [7]. To support patient adherence, the most recent national guidelines for antiretroviral therapy use recommend that health care providers assess and support patient adherence through routine counseling [1]. Some ART adherence interventions have demonstrated initial success, but more theoretically based research is needed if we wish to better understand why some counseling interventions are more effective than others [8], [9].
One patient-centered approach to improve ART adherence is motivational interviewing (MI). Developed by Miller and Rollnick [10] for the treatment of problem drinkers, MI is an empowering counseling style that helps clients explore and resolve their ambivalence towards making change, thus moving them closer to the desired behavioral goal [11], [12]. The “spirit” of MI is an interpersonal style that adapts and reacts to clients’ statements in a nonjudgmental manner and views the relationship as a partnership. The counselor emphasizes patients’ autonomy, but also guides them towards positive behavior change and patient-identified goals [10]. HIV+ patients report many challenges to achieving adherence to antiretroviral therapy adherence, such as forgetfulness, fear of HIV status disclosure, medication side effects, changes in daily routine, and depression [13], [14], [15]. Pilot studies have found that the MI counseling style is acceptable to HIV+ patients, who consider the sessions helpful in identifying tailored strategies to overcome their difficulties in adhering to ART [16], [17]. In addition, HIV+ patients who received MI in one pilot study had better adherence to antiretroviral therapy than those in a control condition, although only one adherence measure achieved significance [17].
Motivational interviewing experts consider interviewer skill a critical aspect of eliciting client behavior change [18], but published descriptions of the intervention process suggest that MI quality may be inconsistent in practice [19], [20]. Inconsistent treatment fidelity may lead to a false positive or false negative outcome [21]. Indeed, reviewers cannot be sure that an intervention adheres to the MI spirit in the absence of some evidence of treatment integrity [27], [30]. Use of the motivational interviewing skill code (MISC), a structured assessment instrument developed at the University of New Mexico [22], [23], may provide some specifics about the process of MI conducted as a part of an intervention. Despite the web-based availability of this instrument (http://www.motivationalinterview.org), few studies report on the quality of MI sessions conducted in clinical and community settings. In the absence of MISC, researchers report brief descriptions of training length and monitoring activities [24] or offer general assessments of the MI skill of training participants [19], [25], [26]. In contrast, researchers who have used MISC provide some evidence of the extent to which interventions – and interviewers – adhered to the MI spirit and demonstrated a reasonable level of MI skill. A small sample of training studies suggests that changes in MI behaviors post-training do occur, but are modest at best [27], [28], [29], [30], [31].
We present the results of a secondary data analysis of recorded brief MI sessions used during a randomized controlled trial to improve antiretroviral adherence among HIV+ patients attending a university-based infectious disease clinic. This paper has two aims: (a) to evaluate the quality of audiotaped MI sessions using MISC quality measures; (b) to explore whether MISC quality measures are associated with ART adherence. The second aim is based on the hypothesis that MI quality is an important part of the patient behavior change process [18]. To our knowledge, this is the one of the first studies to relate interviewer behaviors and measures of MI quality to patient outcomes other than the positive client statements known as change talk [29], [32].
Section snippets
Intervention description
The participating and communicating together (PACT) study was a randomized controlled trial to test a theoretically based, multicomponent intervention to improve ART adherence among HIV+ patients (PI: Golin). PACT's aims were to: (a) encourage goal-setting and behavior change around ART adherence, and (b) train patients to participate in medical decision-making. The intervention was guided by a conceptual model based on empirical ART adherence research and social cognitive theory [16]. This
Global assessments
Table 1 presents the average scores for the global measures of MI skill by interviewers and participant engagement. The external rater assessed interviewers and participants as above average on all global measures. For interviewer behaviors, the highest ratings were for “genuineness” (5.3) and “warmth” (5.3); the lowest was for “egalitarianism” (4.0). Degree of disclosure was the most highly rated participant dimension; affect expressed by the participant and degree of collaboration between the
Discussion and conclusion
Little published information exists on the quality of motivational interviewing conducted in community and clinical settings. Past studies using the motivational interviewing skill code (MISC) to evaluate MI quality primarily report changes in counseling behavior after workshop training, rather than during the course of an intervention study [27], [28], [29], [31]. Our evaluation reviewed MI quality in practice during an efficacy trial. In this study we used a structured assessment instrument
Acknowledgements
This research was partially supported by a Larry Linn Award to Dr. Golin from the Society of General Internal Medicine and NIMH grant no. K23 MH01862-01. Ms. Thrasher was partly supported by the Larry Linn Award and a National Research Service Award from the Agency for Healthcare Research and Quality sponsored by the Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill (grant no. T32 HS00032). Support for the PACT study was also provided by the
References (43)
- et al.
Drug-resistance genotyping in HIV-1 therapy: the VIRADAPT randomised controlled trial
Lancet
(1999) - et al.
Patient adherence to HIV medication regimens: a review of published and abstract reports
Patient Educ Couns
(2002) - et al.
Motivational interviewing in health settings: a review
Patient Educ Couns
(2004) - et al.
Using motivational interviewing to promote adherence to antiretroviral medications: a pilot study
J Assoc Nurses AIDS Care
(2003) - et al.
MET meets the real world: design issues and clinical strategies in the Clinical Trials Network
J Subst Abuse Treat
(2002) - et al.
Teaching motivational interviewing to first-year medical students to improve counseling skills in health behavior change
Mayo Clin Proc
(2004) - et al.
An evaluation of workshop training in motivational interviewing for addiction and mental health clinicians
Drug Alcohol Depend
(2004) - et al.
Using distance education to promote the transfer of motivational interviewing skills among behavioral health professionals
J Subst Abuse Treat
(2004) - et al.
Assessing competence in the use of motivational interviewing
J Subst Abuse Treat
(2005) Guidelines for using antiretroviral agents among HIV-infected adults and adolescents: recommendations of the Panel on Clinical Practices for Treatment of HIV
MMWR
(2002)
Selected measures of access to and utilization of treatment and prophylaxis for HIV-infected persons
HIV/AIDS Surveillance Suppl Rep
Declining morbidity and mortality among patients with advanced human immunodeficiency virus infection. HIV Outpatient Study Investigators
N Engl J Med
Adherence to protease inhibitor therapy and outcomes in patients with HIV infection
Ann Intern Med
Predictors of optimal virological response to potent antiretroviral therapy
AIDS
Association between adherence to antiretroviral therapy and human immunodeficiency virus drug resistance
Clin Infect Dis
Antiretroviral adherence interventions: a review of current literature and ongoing studies
Top HIV Med
Motivational interviewing: preparing people for change
Motivational interviewing in service to health promotion
Art Health Promot
Factors affecting adherence to antiretroviral therapy
Clin Infect Dis
A prospective study of predictors of adherence to combination antiretroviral medication
J Gen Intern Med
Adherence to antiretroviral therapy by human immunodeficiency virus-infected patients
J Infect Dis
Cited by (39)
Does the quality of safetalk motivational interviewing counseling predict sexual behavior outcomes among people living with HIV?
2017, Patient Education and CounselingCitation Excerpt :MI practitioners utilize techniques such as reflective listening, open-ended questions, and affirming statements to develop rapport, raise awareness of ambivalence, and elicit behavior change in clients, and avoid MI inconsistent techniques such as advising without permission, directing, or warning which may interfere with rapport-building and hinder behavior change [7]. MI has demonstrated effectiveness in improving health behaviors among people living with HIV, including increasing ARV medication adherence [8–14], reducing substance use, and reducing risky sexual behaviors such as condomless sex [8,10,16–19]. The SafeTalk intervention is one MI-based secondary HIV prevention program that significantly reduced HIV-infected patients’ condomless sex with at-risk partners in comparison with an attention control arm [16].
Effective Patient-Provider Communication in Pediatric Obesity
2016, Pediatric Clinics of North AmericaCitation Excerpt :Given the importance of change talk to patient outcomes, a primary focus of current MI research is identifying the specific provider communication behaviors that predict change talk and patient outcomes. Studies of MI provider communication behavior have confirmed that communication techniques consistent with the MI framework (ie, MI-consistent communication [MICO], illustrated in Table 1) are associated with increased patient change talk54,77,78 and improved patient outcomes.79 However, a methodologic limitation of many studies is the reliance on frequency counts of communication behaviors and correlational analytical techniques which limit causal inference.
The Relationship Between Baseline Drinking Status, Peer Motivational Interviewing Microskills, and Drinking Outcomes in a Brief Alcohol Intervention for Matriculating College Students: A Replication
2013, Behavior TherapyCitation Excerpt :Therefore, it is important to investigate how these behaviors relate to treatment outcomes, especially as these are lower-order skills that can be more easily learned by entry-level providers. For example, the use of more open questions has been related to a more positive client-therapist interaction rating while a high number of closed questions has been related to negative client outcomes (Catley et al., 2006; Thrasher, Golin, Earp, Tien, Porter, & Howie, 2006). These studies have also demonstrated that a higher ratio of reflections to questions was related to positive treatment outcomes, with reflective statements positively associated with client change talk and therapist-client interaction rating.
Fidelity to Motivational Interviewing and subsequent cannabis cessation among adolescents
2011, Addictive BehaviorsCitation Excerpt :MI process variables derived from validated measures have also been investigated in relation to subsequent behavioral outcomes. Thrasher et al., (2006) identified some relationships between MISC variables and adherence to antiretroviral therapy 8 weeks later. The effects of questions and reflections have been evaluated, with some evidence of impact on 3-month alcohol outcomes in brief intervention among university students (Tollison et al., 2008).
Comparison of motivational interviewing with acceptance and commitment therapy: A conceptual and clinical review
2011, Behavioural and Cognitive Psychotherapy