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!