Motivational Interviewing: a promising behavioural intervention for dental public health Rosamund Harrison Division of Pediatric Dentistry Rosamund Harrison Division of Pediatric Dentistry

Outline  Caries: multifactorial etiology  Traditional advice-giving  Process of change  “Spirit” of MI  Principles of MI  MI and the dental setting  Caries: multifactorial etiology  Traditional advice-giving  Process of change  “Spirit” of MI  Principles of MI  MI and the dental setting

Early childhood caries Early childhood caries [images courtesy of Dr. Young Tze Kuah]

Caries: Caries: no simple causation pathway

Complex: 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:  Killing one microorganism  Improving tooth resistance  Preventing mutation in one gene  Managing one environmental factor  Killing one microorganism  Improving tooth resistance  Preventing mutation in one gene  Managing 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 oral health Watt 2003

Experience of changing your behaviour?

Difficulty of changing an existing or adopting a new 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 children had dental treatment under 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?”

Advice-givingAdvice-giving Describes or recommends a preferred course of action ” “ you should ” “ you ought to …”

Advice-giving: two elements  Information  Persuasion  Telling people what to do  undermines autonomy  generates resistance  Information  Persuasion  Telling people what to do  undermines autonomy  generates resistance

Frustrated !!!

The Transtheoretical Model The 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

Maintenance Action Preparation Contemplation Precontemplation Stages of Change Prochaska et al, 1991

Pre-contemplation Pre-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

Contemplation Contemplation 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 change Preparation 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

Action Action consistent behaviour change  made specific modifications in practices  risk of relapse  made specific modifications in practices  risk of relapse

MaintenanceMaintenance  working to prevent relapse

TerminationTermination  change habitual and embedded

Remember! Stages of change: 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 !

Remember! Stages of change: 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!

Motivational Interviewing “ M. I. ” Applying stages of change to an intervention: Motivational Interviewing “ M. I. ” William Miller Stephen Rollnick

Work with problem drinkers Miller 1978  control group (advice, self-help book)  experimental group (10 sessions)  same improvement  better than wait-list!  control group (advice, self-help book)  experimental group (10 sessions)  same improvement  better than wait-list!

 predictor of success = therapist empathy

Motivational Interviewing  directive, patient-centred counseling style for  eliciting behaviour change  by helping patients to explore and resolve ambivalence Rollnick and Miller, 1995  directive, patient-centred counseling style for  eliciting behaviour change  by helping patients to explore and resolve ambivalence Rollnick and Miller, 1995

Motivational Interviewing  Directive:  Directive: practitioner provides some structure  Patient-centred:  Patient-centred: patient has opportunity to identify and resolve behaviour change issues

“SPIRIT of MI”  collaborate  negotiate  patient is expert  mechanism to change  respect autonomy  collaborate  negotiate  patient is expert  mechanism to change  respect autonomy

First principle of MI: Express 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 discrepancy How client ’ s current way of being will not fulfill their goal

3rd principle of MI: “ 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: 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

efficacy Parental 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  2822 parents of 3-4 year olds  Parental efficacy (self-belief) and attitudes were strongest predictors of  establishing toothbrushing behaviour and  controlling sugar snacking  2822 parents of 3-4 year olds  Parental efficacy (self-belief) and attitudes were strongest predictors of  establishing toothbrushing behaviour and  controlling sugar snacking

Skills and strategies: more than “ being nice! ”  O  Open-ended questions  allow expression of concerns, problems  A  Affirmations  enhance self-efficacy  R  Reflective listening  active listening  clarifying not just repeating  S  Summarizing  reach joint decisions  O  Open-ended questions  allow expression of concerns, problems  A  Affirmations  enhance self-efficacy  R  Reflective listening  active listening  clarifying not just repeating  S  Summarizing  reach joint decisions

In the dental setting?

Practical application  Time  for training and practice  for follow-up  Short time with family  Not our training!  more “ action-oriented ”  Not easy!  reflective listening  open-ended questions  Time  for training and practice  for follow-up  Short time with family  Not our training!  more “ action-oriented ”  Not easy!  reflective listening  open-ended questions

Principle #1: empathy Show concern  Get parent talking about child  open-ended questions  “ what is it like to be... ’ s Mom? ”  “ tell me more …. ”  “ it must be hard to ….. ”  Get parent talking about child  open-ended questions  “ what is it like to be... ’ s Mom? ”  “ tell me more …. ”  “ it must be hard to ….. ”

Principle #2: Explore discrepancy  Explore discrepancy between what parent wants for child ’ s dental health  straight teeth  no toothaches  Explore discrepancy between what parent wants for child ’ s dental health  straight teeth  no toothaches

 Explore discrepancy between  what parent believes will happen  children have bad teeth  baby teeth not important  too hard to do anything about it  Explore discrepancy between  what parent believes will happen  children have bad teeth  baby teeth not important  too hard to do anything about it

Make a “list” ProsProsConsCons

Principle #3: “ Roll with resistance ”  baby teeth not important  don ’ 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 important  don ’ 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-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

Summarize  “ 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 …”

Summarize  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

Problems 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

SummarySummary  Give copy of menu  Anticipate problems  Encourage contact  Commitment check  “… it is your choice, not mine, to go ahead.  “ if you are unsure, think about it ”  Give copy of menu  Anticipate problems  Encourage contact  Commitment check  “… it is your choice, not mine, to go ahead.  “ if you are unsure, think about it ”

Follow-up  Telephone, , in person, postcard  Important  encouragement  problems  prevent relapse  Telephone, , in person, postcard  Important  encouragement  problems  prevent relapse

Readiness Change Empathy Hope Collaboration Confidence Motivational Interviewing

Thank you!