motivational interviewing: a promising behavioural intervention for dental public health

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 Dentistryrosha@interchange.ubc.ca

Rosamund HarrisonDivision of Pediatric Dentistryrosha@interchange.ubc.ca

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!