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
MI and the dental setting
Early childhood caries
[images courtesy of Dr. Young Tze Kuah]
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
Controlling caries is not just:
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
Determinants of
oral health
Economic, Political
& Environmental
Conditions
Poverty
Social &
Community
Context
Housing
Sanitation
Social norms
Leisure Facilities
Shopping Facilities
Peer Groups
Diet
Employment
Work/educational
environment
Income
Policy - International
Social Capital
Hygiene
Smoking
Cultural
Identity
- National
- Local
Oral
Health
Related
Behaviour
Alcohol
Individual
Sex
Oral
Age
Genes
Health
Biology
Injury
Service
Social network
Commercial Advertising
Watt 2003
Experience of
changing your
behaviour?
Difficulty of changing an
existing or
adopting a new behaviour?
not important: what I am
doing is okay and I like to do it!
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 onehour 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 onehour lesson from
the dentist?”
Advice-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
Frustrated
!!!
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
Action
Preparation
Precontemplation
Maintenance
Contemplation
Stages of Change
Prochaska et al, 1991
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
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
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
Action
consistent behaviour change
made specific
modifications in practices
risk of relapse
Maintenance
working to prevent relapse
Termination
change habitual and embedded
Stages of change: Remember!
people move backwards &
forwards
if you talk to people expecting
them to be further along;
expect resistance!
Stages of change:
Remember!
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 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!
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
Motivational Interviewing
Directive:
practitioner
Patient-centred:
provides some patient has
structure
opportunity to
identify and resolve
behaviour change
issues
“SPIRIT of MI”
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
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
4th principle of MI:
Support “self-efficacy”
 you can do this!
 no right way
 others did it, so
can you
Parental efficacy
“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
Skills and strategies:
more than “being nice!”
Open-ended questions
allow expression of concerns, problems
Affirmations
enhance self-efficacy
Reflective listening
active listening
clarifying not just repeating
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
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…..”
Principle #2:
Explore discrepancy
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
Make a “list”
Pros
Cons
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?”
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
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…”
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?
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
Summary
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, email, in person, postcard
Important
encouragement
problems
prevent relapse
Confidence
Readiness
Change
Empathy
Motivational
Interviewing
Hope
Collaboration
Thank you!