Motivational interviewing to support antiretroviral therapy adherence: The role of quality counseling

https://doi.org/10.1016/j.pec.2005.06.003Get rights and content

Abstract

Objective

Although research linking motivational interviewing (MI) to behavior change exists, few studies report on MI's quality or explore how it may influence effectiveness. We studied MI quality and adherence to antiretroviral therapy (ART) in the context of a randomized, controlled trial.

Methods

We used a structured instrument to code MI sessions and then correlated ART adherence (measured by electronic bottle cap monitor and pill count data at study exit) with specific counseling behaviors and the proportion of interactions that achieved quality benchmarks.

Results

The sample (n = 47) was predominantly male (79%), minority (90%), had a mean age of 40, and averaged 79% adherence at exit. On three of five benchmarks, most MI sessions achieved the targeted quality level: 100% achieved them for MI-consistent statements; 85% for complex reflections; 63% for reflections to questions ratio; 44% for global therapist rating; 19% for using open-ended questions. ART adherence was positively associated with the ratio of reflections to questions (r = .39, p = .02), affirming statements (r = .38, p = .02), and negatively associated with closed-ended questions (r = −.33, p = .04).

Discussion

Good quality MI can be conducted within the structure of a controlled trial but was generally not associated with ART adherence.

Conclusion

Documenting treatment fidelity is critical to judging the efficacy of MI-based interventions.

Practice implications

Regular feedback and close monitoring are needed to maintain MI quality.

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

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