motivational interviewing: a promising behavioural intervention for dental public health
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Motivational Interviewing: a promising behavioural intervention for dental public health. Rosamund Harrison Division of Pediatric Dentistry [email protected]. Outline. Caries: multifactorial etiology Traditional advice-giving Process of change “Spirit” of MI Principles of MI - PowerPoint PPT PresentationTRANSCRIPT
Motivational Interviewing: Motivational Interviewing: a promising behavioural a promising behavioural
intervention for dental public intervention for dental public healthhealth
Motivational Interviewing: Motivational Interviewing: a promising behavioural a promising behavioural
intervention for dental public intervention for dental public healthhealth
Rosamund HarrisonDivision of Pediatric [email protected]
Rosamund HarrisonDivision of Pediatric [email protected]
OutlineOutline
Caries: multifactorial etiology
Traditional advice-givingProcess of change“Spirit” of MIPrinciples of MIMI and the dental setting
Caries: multifactorial etiology
Traditional advice-givingProcess of change“Spirit” of MIPrinciples of MIMI and the dental setting
Early childhood cariesEarly childhood caries [images courtesy of Dr. Young Tze Kuah]
Early childhood cariesEarly childhood caries [images courtesy of Dr. Young Tze Kuah]
Caries:Caries: no simple causation pathwayCaries:Caries: no simple causation pathway
Complex: multifactorialComplex: multifactorial
“action of genes, environmental factors and risk-conferring behaviours”
“biology, behaviour and genetics do not completely explain caries.”
Fejerskov O. “Changing paradigms in concepts on dental caries: consequences for oral health care.” Caries Res 38: 2004
“action of genes, environmental factors and risk-conferring behaviours”
“biology, behaviour and genetics do not completely explain caries.”
Fejerskov O. “Changing paradigms in concepts on dental caries: consequences for oral health care.” Caries Res 38: 2004
Controlling caries is not just:Controlling caries is not just:
Killing one microorganismImproving tooth resistancePreventing mutation in one geneManaging one environmental factor
Killing one microorganismImproving tooth resistancePreventing mutation in one geneManaging one environmental factor
Fejerskov O. “Changing paradigms in concepts on dental caries: consequences for oral health care.” Caries Res 38: 2004
The main determinants of health
Poverty
Housing
Sanitation
Leisure Facilities
Shopping Facilities
Employment
Work/educational environment
Income
Policy - International
- National
- Local
Commercial Advertising
Social norms
Peer Groups
Social Capital
Cultural Identity
Social network
Diet
Hygiene
Smoking
Alcohol
Injury
Service
Sex
Age
Genes
Biology
Economic, Political & Environmental Conditions
Social & Community Context
Oral Health Related Behaviour
Individual
Oral
Health
Determinants of Determinants of oral healthoral health
Watt 2003
Experience of changing your behaviour?
Experience of changing your behaviour?
Difficulty of changing an Difficulty of changing an existing orexisting or
adopting a new adopting a new behaviour?behaviour?
Difficulty of changing an Difficulty of changing an existing orexisting or
adopting a new adopting a new behaviour?behaviour?
not important:not important: what I am doing is okay and I like to do it!
not confident:not confident: too hard!
not important:not important: what I am doing is okay and I like to do it!
not confident:not confident: too hard!
Listening to parents whose Listening to parents whose children had dental treatment children had dental treatment
under general anesthesiaunder general anesthesia
Listening to parents whose Listening to parents whose children had dental treatment children had dental treatment
under general anesthesiaunder general anesthesia
“Well, I have an experience…we talk to a dentist,
the rate was $100/hr. They gave us a one-
hour long lesson about how to
take care of our child’s teeth…”
Amin M, Harrison R. Pediatr Dent 29: 2007
“Well, I have an experience…we talk to a dentist,
the rate was $100/hr. They gave us a one-
hour long lesson about how to
take care of our child’s teeth…”
Amin M, Harrison R. Pediatr Dent 29: 2007
“At the end, the only thing we got out from it was to chew gum. The
things we got out from it could also be found in the newspaper and
books, so why do we still have to
take that one-hour lesson from the
dentist?”
“At the end, the only thing we got out from it was to chew gum. The
things we got out from it could also be found in the newspaper and
books, so why do we still have to
take that one-hour lesson from the
dentist?”
Advice-givingAdvice-givingAdvice-givingAdvice-giving Describes or
recommends a preferred course of action”
“you should”“you ought to…”
Describes or recommends a preferred course of action”
“you should”“you ought to…”
Advice-giving: two Advice-giving: two elementselements
Advice-giving: two Advice-giving: two elementselements
InformationPersuasion
Telling people what to doundermines autonomy generates resistance
InformationPersuasion
Telling people what to doundermines autonomy generates resistance
Frustrated!!!Frustrated!!!
The Transtheoretical ModelThe Transtheoretical Model: a framework for understanding
the process of change
“Stages of change”
James Prochaska and Carlo DiClemente
The Transtheoretical ModelThe Transtheoretical Model: a framework for understanding
the process of change
“Stages of change”
James Prochaska and Carlo DiClemente
importance of tailoring intervention to individual’s stage of change
importance of tailoring intervention to individual’s stage of change
MaintenanceMaintenanceActioActionn
PreparationPreparationContemplatiContemplationon
PrecontemplationPrecontemplation Stages of ChangeProchaska et al, 1991
Pre-contemplationPre-contemplation Individual has problem
(may not recognize it) and has no intention of changing
Pre-contemplationPre-contemplation Individual has problem
(may not recognize it) and has no intention of changing
traditional health promotion & health education not designed for such individuals doesn’t match their needs
traditional health promotion & health education not designed for such individuals doesn’t match their needs
ContemplationContemplation Individual recognizes the problem; seriously thinking about changing
ContemplationContemplation Individual recognizes the problem; seriously thinking about changing
more aware of pros; even more aware of cons
balance between costs/benefits of change = ambivalence
stuck here for long time
more aware of pros; even more aware of cons
balance between costs/benefits of change = ambivalence
stuck here for long time
Preparation for changePreparation for change Individual recognizes problem and intends to change behaviour soon.
Some change efforts reported
Preparation for changePreparation for change Individual recognizes problem and intends to change behaviour soon.
Some change efforts reported
intending to take action in immediate future, e.g. consult professional
some significant action in the past year
intending to take action in immediate future, e.g. consult professional
some significant action in the past year
ActionAction consistent behaviour
change
ActionAction consistent behaviour
change
made specific modifications in practices
risk of relapse
made specific modifications in practices
risk of relapse
MaintenanceMaintenance MaintenanceMaintenance
working to prevent relapse
working to prevent relapse
TerminationTermination TerminationTermination
change habitual and embeddedchange habitual and embedded
Stages of change: Remember!Remember!
Stages of change: Remember!Remember!
people move backwards & forwards
if you talk to people expecting them to be further along; expect resistance!
people move backwards & forwards
if you talk to people expecting them to be further along; expect resistance!
Stages of change: Remember!Remember!
Stages of change: Remember!Remember!
parent may not be ready likely won’t say
“I want to change” different stages of
“readiness” = be flexible!
parent may not be ready likely won’t say
“I want to change” different stages of
“readiness” = be flexible!
Applying stages of change to an intervention:
Motivational Motivational InterviewingInterviewing
“M. I.”“M. I.”
William Miller
Stephen Rollnick
Applying stages of change to an intervention:
Motivational Motivational InterviewingInterviewing
“M. I.”“M. I.”
William Miller
Stephen Rollnick
Work with problem drinkers
Miller 1978
Work with problem drinkers
Miller 1978
control group (advice, self-help book)
experimental group (10 sessions)
same improvementbetter than wait-list!
control group (advice, self-help book)
experimental group (10 sessions)
same improvementbetter than wait-list!
predictor of success = therapist empathy
predictor of success = therapist empathy
Motivational Motivational InterviewingInterviewingMotivational Motivational InterviewingInterviewing
directive, patient-centred counseling style for
eliciting behaviour changeby helping patients to
explore and resolve ambivalence
Rollnick and Miller, 1995
directive, patient-centred counseling style for
eliciting behaviour changeby helping patients to
explore and resolve ambivalence
Rollnick and Miller, 1995
Motivational InterviewingMotivational InterviewingMotivational InterviewingMotivational Interviewing
Directive:Directive: practitioner provides some structure
Directive:Directive: practitioner provides some structure
Patient-Patient-centred:centred: patient has opportunity to identify and resolve behaviour change issues
Patient-Patient-centred:centred: patient has opportunity to identify and resolve behaviour change issues
““SPIRIT of MI”SPIRIT of MI”““SPIRIT of MI”SPIRIT of MI”
collaborate negotiatepatient is expertmechanism to
changerespect autonomy
collaborate negotiatepatient is expertmechanism to
changerespect autonomy
First principle of MI:First principle of MI: Express empathyExpress empathyFirst principle of MI:First principle of MI: Express empathyExpress empathy
• see world through client's eyes
• share in client’s experience
• see world through client's eyes
• share in client’s experience
2nd principle of MI:2nd principle of MI: Develop discrepancy2nd principle of MI:2nd principle of MI: Develop discrepancy
How client’s current way of being will not fulfill their goal
How client’s current way of being will not fulfill their goal
3rd principle of MI:3rd principle of MI: “Roll with resistance”“Roll with resistance”3rd principle of MI:3rd principle of MI: “Roll with resistance”“Roll with resistance”
skillful deflection of client resistance
define problems, then develop solutions
skillful deflection of client resistance
define problems, then develop solutions
4th principle of MI:4th principle of MI: Support “self-efficacy”Support “self-efficacy”4th principle of MI:4th principle of MI: Support “self-efficacy”Support “self-efficacy”
you can do this!
no right way others did it,
so can you
you can do this!
no right way others did it,
so can you
Parental efficacy efficacyParental efficacy efficacy
“Parents’ belief in their ability to take action and administer parental control.”
Swick and Broadway. J of Instructional Psychology 24: 1997
“Parents’ belief in their ability to take action and administer parental control.”
Swick and Broadway. J of Instructional Psychology 24: 1997
Familial and cultural perceptions and beliefs of oral hygiene and dietary practices among ethnically and socio-economically diverse groups.
Adair P, Pine C et al. Community Dental Health 2004:21
Familial and cultural perceptions and beliefs of oral hygiene and dietary practices among ethnically and socio-economically diverse groups.
Adair P, Pine C et al. Community Dental Health 2004:21
2822 parents of 3-4 year oldsParental efficacy (self-belief)
and attitudes were strongest predictors of establishing toothbrushing
behaviour and controlling sugar snacking
2822 parents of 3-4 year oldsParental efficacy (self-belief)
and attitudes were strongest predictors of establishing toothbrushing
behaviour and controlling sugar snacking
Skills and strategies:more than “being nice!”
Skills and strategies:more than “being nice!”
OOpen-ended questionsallow expression of concerns, problems
AAffirmationsenhance self-efficacy
RReflective listeningactive listeningclarifying not just repeating
SSummarizingreach joint decisions
OOpen-ended questionsallow expression of concerns, problems
AAffirmationsenhance self-efficacy
RReflective listeningactive listeningclarifying not just repeating
SSummarizingreach joint decisions
In the dental setting?In the dental setting?In the dental setting?In the dental setting?
Practical applicationPractical applicationPractical applicationPractical applicationTime
for training and practicefor follow-up
Short time with familyNot our training!
more “action-oriented”Not easy!
reflective listeningopen-ended questions
Timefor training and practicefor follow-up
Short time with familyNot our training!
more “action-oriented”Not easy!
reflective listeningopen-ended questions
Principle #1: empathy Show concernPrinciple #1: empathy Show concern
Get parent talking about childopen-ended questions
“what is it like to be ...’s Mom?”
“tell me more….”“it must be hard to…..”
Get parent talking about childopen-ended questions
“what is it like to be ...’s Mom?”
“tell me more….”“it must be hard to…..”
Principle #2: Explore discrepancyPrinciple #2: Explore discrepancy
Explore discrepancy between what parent wants for child’s dental health straight teethno toothaches
Explore discrepancy between what parent wants for child’s dental health straight teethno toothaches
Explore discrepancy between what parent believes will happen
children have bad teethbaby teeth not importanttoo hard to do anything about it
Explore discrepancy between what parent believes will happen
children have bad teethbaby teeth not importanttoo hard to do anything about it
Make a “list”Make a “list”Make a “list”Make a “list”
ProsProsProsPros ConsConsConsCons
Principle #3:“Roll with resistance”Principle #3:“Roll with resistance”
baby teeth not importantdon’t argue or disagree
“dentists used to think…”“do bad teeth run in your family?”
“tell me about other children’s teeth?”
baby teeth not importantdon’t argue or disagree
“dentists used to think…”“do bad teeth run in your family?”
“tell me about other children’s teeth?”
Principle #4:Support self-efficacyPrinciple #4:Support self-efficacy
you are a really good mother!you are doing
a great job of being a mom
being here today is a good sign
you are a really good mother!you are doing
a great job of being a mom
being here today is a good sign
SummarizeSummarize
“Tell me again what you want for ………’s teeth”
Transition to a menu“I have spoken with other mothers and these are some ideas that they had about good teeth…”
“Tell me again what you want for ………’s teeth”
Transition to a menu“I have spoken with other mothers and these are some ideas that they had about good teeth…”
SummarizeSummarize
Using the menu“worked for other mothers; may not work for you”
focus on the behaviour that parent is most likely to change
Ideas of your own?
Using the menu“worked for other mothers; may not work for you”
focus on the behaviour that parent is most likely to change
Ideas of your own?
Identify potential problems and solutions
Identify potential problems and solutions
Problems and solutionsProblems and solutionsProblems and solutionsProblems and solutions
“What might go wrong?”“Who can help?”“Other good things that might
happen when you……….”stop giving bottle when child wakes = sleep through night
“What might go wrong?”“Who can help?”“Other good things that might
happen when you……….”stop giving bottle when child wakes = sleep through night
SummarySummarySummarySummary
Give copy of menuAnticipate problemsEncourage contactCommitment check
“…it is your choice, not mine, to go ahead.
“if you are unsure, think about it”
Give copy of menuAnticipate problemsEncourage contactCommitment check
“…it is your choice, not mine, to go ahead.
“if you are unsure, think about it”
Follow-upFollow-up
Telephone, email, in person, postcard
Important encouragement problemsprevent relapse
Telephone, email, in person, postcard
Important encouragement problemsprevent relapse
Readiness
Change
Empathy
Hope
Collaboration
Confidence
Motivational Motivational InterviewingInterviewing
Thank you!